Reflections of rural primary care physicians on the impact of the COVID-19 pandemic: a qualitative study

Abstract

Background

Rural physicians tend to develop deep relationships with their patients and communities; however, few studies have evaluated the impact of the COVID-19 pandemic on relationships of physicians working in rural primary care clinics. We aimed to collect reflections of primary care physicians to understand their experiences during the pandemic and the impact on their relationships with patients, other physicians, clinic staff, and their communities.

Methods

Interviews with primary care physicians practicing in rural Wisconsin used open-ended questions about experiences during the pandemic and the impact of the pandemic on their work and relationships, coping and well-being, and resources of their rural clinics. Interviews were recorded, transcribed, and de-identified for thematic qualitative analysis.

Results

Twelve physicians were interviewed between October 3, 2022 and April 7, 2023. Experiences varied by the phase of the pandemic, especially changes in the work of physicians (e.g., working in the hospital), adapting to telemedicine, implementing mitigation strategies, and addressing vaccine hesitancy. These experiences impacted physicians’ relationships with patients and their communities, especially when addressing vaccine hesitancy, mitigation strategies (e.g., masking), and misinformation. Some relationships were strengthened by shared experiences, such as clinic staff working together to meet challenges. Other relationships, however, were strained by social distancing and many physicians reported a loss of camaraderie with colleagues attributed to isolation and virtual meetings replacing in-person activities. Challenges for rural clinics included lack of resources (e.g., staff shortages), limited broadband access, and difficulties transferring patients to tertiary care centers.

Conclusions

Physicians working in rural primary care clinics described a myriad of experiences during the pandemic. Difficulties in addressing vaccine hesitancy and misinformation about the pandemic were consistently identified as negatively affecting relationships with patients and some staff. Fewer in-person interactions with colleagues negatively impacted relationships, although the ability to connect with others through virtual methods was viewed positively. Future work could address the loss of collegiality and increasing isolation among clinicians attributed to continued use of virtual tools and increased remote work.

Background

The COVID-19 pandemic has had far-reaching effects on the health care system and may have disproportionally affected rural communities in the US [1, 2]. Although some reports have addressed the impact of the pandemic on rural primary care physicians, many studies were conducted outside the US, including Canada [3, 4], Japan [5], Brazil [6], and other countries [7, 8]. Available literature describes burnout among healthcare workers and negative aspects of the pandemic [3, 9,10,11] with fewer reports on the impact of the pandemic on physicians’ relationships with patients, colleagues, clinic staff, and communities [12]. Rural clinicians are often deeply connected to their patients and communities and build these relationships over time by fostering trust, respect, and understanding between themselves, their patients, and community members [13,14,15,16]. Rural primary care physicians serve as integral and trusted members of their communities, and may expand their roles beyond their clinics to serve as medical advisors to schools, businesses, and community organizations to foster overall well-being of the people they serve [15, 16].

Given the roles of physicians working in rural communities, the pandemic presented unique challenges in dealing with a deadly disease with limited resources as well as misinformation or lack of information about the coronavirus and vaccines [3, 17]. Changes during the pandemic including implementation of telemedicine, social/physical isolation, and masking strained physicians’ relationships; however, factors such as camaraderie built by working with colleagues through a difficult time and staying connected with others virtually had a positive impact on some relationships [3, 12]. Although not unique to healthcare in rural areas, clinic disruptions during the pandemic including nursing staff leaving the workforce, being furloughed, needing sick time for COVID-related illness, financial stressors, and remote work likely contributed to increased physician stress and reduced sense of well-being [1, 10,11,12, 18,19,20,21].

This project was a qualitative assessment of the experiences of rural physicians working in Wisconsin during the pandemic. Overall, the study aimed to use reflections of primary care physicians to understand the impact of their experiences during the COVID-19 pandemic on relationships with patients, other physicians, clinic staff, and their communities.

Methods

Specific aims were to: (1) Learn about the experiences of rural family physicians during the COVID-19 pandemic and how it affected their relationships; (2) Explore coping mechanisms that physicians used during the pandemic; and (3) Investigate the impact of the pandemic on resources and clinic staffing. A conceptual framework of phenomenology, the study of lived experiences, was used [22, 23].

Primary care physicians practicing in rural areas of Wisconsin during the COVID-19 pandemic (i.e., since March 2020) were eligible to participate. Potentially eligible physicians identified through the Wisconsin Research and Education Network (WREN) were invited to participate by email. Information about the study was included in the WREN monthly newsletter to facilitate recruitment. The Wisconsin Urban-Rural Classification (WURC) System was used to confirm rurality of practice locations [24]. Physicians practicing in urban areas were excluded from the study. The project was reviewed by the University of Wisconsin-Madison Institutional Review Board’s (IRB).

Virtual or in-person semi-structured interviews with physicians were conducted between October 2022 and April 2023. Using open-ended questions, primary care physicians were asked to discuss the impact of pandemic experiences on their relationships with their patients, colleagues, and communities (Additional file 1). Participants were asked about the impact of the pandemic on relationships and strategies that helped them and their clinic staff cope with the pandemic. Interview questions did not mention burnout or stress, but physicians were asked about their well-being. Each interview was to last approximately one hour.

Interviews were recorded, transcribed, and de-identified. Two independent coders (MFH, KM) read the transcripts line-by-line and created draft codebooks using iterative thematic analysis. The independently-created codebooks were reviewed and discussed by the two coders. The codebooks were condensed and edited to create a main codebook (Additional file 2) that was used to code transcripts for thematic analysis using NVivo software (version 14; Lumivero, Denver, CO). We defined thematic saturation as the point at which no new themes were observed. Quotes could be assigned to more than one code.

Results

Twelve physicians were interviewed (nine women, three men; Table 1). Eleven interviews were virtual and one was in person. Although we used semi-structured interviews, all participants provided answers to every question. Physicians practiced in ten counties in rural Wisconsin. Despite the small number of semi-structured interviews, we believe we reached thematic saturation within the first ten interviews given the lack of emergence of new themes.

Table 1 Characteristics of participants, N = 12

Experiences and relationships (Aim 1)

Theme 1: the work of rural primary care physicians changed quickly and dramatically

Experiences varied by different phases of the pandemic

The early pandemic was experienced by some physicians as a time of clinic closures and a slowdown in work. The initial lack of knowledge about SARS-CoV-2 was associated with fear, anxiety, and uncertainty. As patients in their communities became infected with the coronavirus, physicians described the situation as a “war zone” and a time of a rapid-fire and steep learning curve for themselves and their staff. Perceptions of healthcare workers changed during the pandemic, from being perceived as heroes to being viewed negatively. As coronavirus vaccines become more available, the focus shifted from addressing patients who were vaccine eager to those who were vaccine hesitant. Once clinics returned to in-person visits, physicians observed how decreases in preventative care due to patients not being seen in clinics led to worse patient outcomes.

“…the first time in my career where actually we didn’t do what we’re supposed to do, which is take care of people.” (Participant #3).

“The beginning of the pandemic was like, adrenaline all the time.” (Participant #10).

“All of a sudden, in a matter of 2 or 3 days, we had to learn how to provide telehealth with video. We had to try to interface with our patients where it was very difficult for them at that time.” (Participant #9).

“…At one point, I was a hero. People would come and just clap. And then we got to the point where we were ‘assaulting’ them when we asked to have them have a covid swab. We had people calling the cops on us.” (Participant #3).

“And then it became very, very busy in the hospital because (A), we didn’t know how to treat it, (B), we weren’t vaccinated yet, and (C), obviously, there was a surge with a lot of people getting it.” (Participant #9).

Shifting work from clinics to hospitals increased the burden on primary care physicians

As rates of coronavirus infections increased, many physicians shifted work from clinics to hospitals. Some needed to re-gain comfort with in-patient care and be re-trained on use of ventilators. Some physicians were outside of their comfort zone when working in a COVID-19 unit. Many took on more shifts/work during coronavirus surges. Working in a Covid unit carried the fear of bringing the disease back to their families, especially during initial surges when less was known about how the virus was spread and before vaccines were available.

“In order to keep everything staffed fully, some people had to take a lot more call and I was one of those people.” (Participant #6).

“…definitely a change. I would say, probably worked maybe double the shifts that I usually work in the hospital, compared to normal.” (Participant #7).

“Whenever I had an exposure to someone with COVID, like someone in the hospital, I was always so worried about am I going to bring this home to my kids.” (Participant #11).

Implementing mitigation strategies presented challenges

Difficulties with patient, colleague, and community acceptance of mitigation strategies were reported. The acceptance or lack of acceptance of mitigation strategies overlapped across several topics, such as relationships with schools and clinic staff. The impressions of mitigation strategies by patients and communities varied with the phase of pandemic. For example, access to coronavirus vaccines was initially challenging, but the situation evolved as early adapters were vaccinated and attention shifted to patients who were vaccine hesitant. Recommendations for quarantine and social isolation had a negative impact on relationships. Schools changing to virtual learning was disruptive, especially for physicians with children of school age who continued to work in clinics during the pandemic. Some physicians served as medical advisors for school districts in their communities. Although some had positive experiences, other physicians reported that school administrators disregarded medical advice about mitigation practices. Patients and community members had mixed responses to mask mandates, but some clinic staff recognized the value of continuing to wear masks even after the pandemic. Wearing masks, however, contributed to feelings of isolation and access to sufficient resources, e.g., personal protective equipment (PPE), required time and effort by clinic staff.

“At first, our rate of vaccination for our at-risk population was extremely high…It was one of the higher in the state and then there is a community just north of us and their rate was like red. We were green and they were red… And because of our clinic, our vaccination rate was extremely, extremely high.” (Participant #10).

“Obviously there were struggles with virtual school and online learning.” (Participant #8).

“There were two years where I didn’t see people’s faces. I had so many patients who were new to me, who I had never seen their face. And we just got to take our masks off two weeks ago, and I didn’t stop smiling all day. And I was so happy to see people’s faces again.” (Participant #12).

Experiences with telemedicine were mixed

Experiences with telemedicine were mixed with both positive and negative impressions (Table 2). Despite challenges in adapting to telemedicine, physicians recognized the value of telemedicine and acknowledged that this technology would continue to be embedded in their practices.

Table 2 Positive and negative perceptions of telemedicine

Addressing vaccine hesitancy was difficult and exhausting

Addressing vaccine hesitancy was described as difficult, time-consuming, exhausting, and emotionally draining. Physicians tended to change their approach to discussions about coronavirus vaccines over time with some physicians eventually spending less effort with patients deemed not likely to get vaccinated. The theme of vaccine hesitancy overlapped with politics and misinformation.

“I feel like I’m fighting a battle all the time to talk to people about vaccines.” (Participant #7).

“…one of the other things that still is really pervasive is vaccine hesitancy and those conversations continue to go on, on a daily basis, in clinic. And are emotionally exhausting and frustrating.” (Participant #5).

“I assume certain patients of mine that may be hard line in their politics…This person is probably not going to want to get a vaccine today. Then I asked them and they say, ‘Well, what do you recommend, doc.’ And they’re willing to do it. We have to try to just be as patient centered as we can despite feeling that emotional exhaustion.” (Participant #5).

“Dane county is highly, highly vaccinated, and those physicians are maybe not having to have that conversation quite as often. But when you look at us in a rural community,…my appointments just took forever during the heat of the pandemic when the vaccines are coming out because you’re constantly addressing misinformation and constantly trying to help patients to feel like they have an understanding of what’s going on.” (Participant #7).

Theme 2: beliefs about and implementation of mitigation strategies had a strong impact on relationships

Many relationships were strained although some were maintained or strengthened

Multiple factors were mentioned as having an impact, either positive or negative, on relationships. Vaccine hesitancy, misinformation about the pandemic, mitigation strategies, and political views were reported as straining or negatively impacting relationships, especially relationships with patients. Views on virtual tools were mixed as virtual meetings helped maintain connections both professionally and personally; however, virtual meetings and the inability to meet in person were reported to contribute to loss of connectivity in relationships and feelings of being more socially isolated (Table 3). Some relationships with staff were strengthened by working through difficult times together. Physicians found ways to connect with colleagues and family/friends despite physical distancing (e.g., virtual meetings or creating text groups).

Table 3 Sub-themes pertaining to relationships

Pandemic misinformation or disbeliefs caused disconnection

Physicians had to deal with patients, colleagues, and community members who believed misinformation about the pandemic and/or did not believe that the pandemic was real. These views were reported as being linked to politics and many physicians felt that there was little that they could do to change patients’ beliefs.

“Even when some of the folks, who pushed back against that in a very public way, died of Covid, it was amazing to see that there were still people in that part of the community and those people’s families that didn’t identify with the fact that they died from Covid…That part was mind blowing.” (Participant #12).

“It really divided my patients in my mind into the believers and the non-believers.” (Participant #1).

“Just those disconnects in the community that I serve where it didn’t seem like people were taking it seriously, were so anti-mask, and you were just fighting this rhetoric constantly. It was exhausting.” (Participant #5).

“I remember having to talk to his daughter on the phone several times and how this was really traumatic for her. They were saying, ‘why can’t we give him ivermectin.’ It was a trying experience for them.” (Participant #8).

“We did our best we always tried, but you left that that situation feeling like, just totally defeated as a physician. How do you help that patient when they don’t believe what you’re saying?” (Participant #7).

Coping mechanisms (Aim 2)

Theme 3: despite challenges, rural physicians adapted to do what needed to be done for their patients

Physicians exhibited resilience and commitment to care for their patients, even though their well-being suffered

The pandemic was a time when the spirit of service was important as physicians continued to do their best to care for patients, even when it was uncomfortable. They had support from colleagues and, conversely, developed new ways to support and stay in touch with colleagues.

“Colleagues that I asked to do things that they hadn’t done before − and they did it. I mean, they just stepped up and they did it. And they may not have wanted to and I’m certainly sure they weren’t comfortable with it, but they did it.” (Participant #3).

The well-being of physicians suffered during the pandemic, although they may not have realized the impact of the pandemic at the time given the focus on caring for patients in a time of crisis. Some reported that they felt that they were not always able to give great care, which negatively impacted their well-being. Being there for patients was important to well-being and not always knowing the answers about the pandemic was stressful. Because of the pandemic, some physicians re-examined their priorities around work-life balance.

“…this is third-world medicine now. That’s a comment my partners and I have made to each other on several occasions. Like we are giving worse care than what we had been giving. I think most people feel like that. It’s probably been worse care because of access and because of those kind of issues.” (Participant #12).

“It’s interesting, I think reflecting back on how we’ve really come a long way in getting back to doing preventative medicine after a long time where patients weren’t getting cancer screenings. We weren’t doing so much of what we consider primary care to be: evidence-based medicine.” (Participant #5).

Multiple coping strategies were mentioned including:

• Using virtual platforms to connect with others, despite drawbacks of virtual communications.

• Venting with colleagues.

• Taking advantage of outdoors in rural areas.

• Support from family; although family members increased stress if they accepted misinformation.

• Scheduling mental health days.

• Exercise and usual coping mechanisms.

“There was a lot of commiserating with other physicians and nurses. I think, thank God, in the rural setting, there’s a much tighter sense of community.” (Participant #12).

The experiences during the pandemic were profound

Experiences with patients highlighted profound effects on physicians interviewed.

“It’s the first time I’ve had patients die at home because they wouldn’t come get medical care. I have a patient that I’m helping him through his grief, because his spouse stayed at home for 3 days with her chest pain and she died. It just, it breaks my heart.” (Participant #3).

“I spent a lot of time talking to him about what my thoughts were about the vaccine and why he should actually get the vaccine…And he said, ‘well, you know what? You’re my doctor. You think it’s a good idea. I’m going to.’… So he got his vaccine. Then I saw him in clinic at a follow up… And he said ‘I am the only living member of my family. Everyone else in my family got Covid and died.’ So all of his siblings had COVID and died. His parents were dead, and he was now the only living member of his family and he 100% attributed it to getting the vaccine.” (Participant #7).

Participants were able to identify silver linings

When asked about silver linings of the pandemic, telehealth was often mentioned as providing flexibility for both clinicians and patients, and in allowing work from home. Some other mitigation strategies were continued after the pandemic, such as masking to reduce risk of respiratory infections by clinic staff. Some physicians mentioned that relationships were closer as colleagues faced the struggles of the pandemic together. Hospitals and clinics were willing to step up to care for patients, despite demanding conditions. Another silver lining reported was that learning from this pandemic could help prepare for the next one.

Resources and clinic staffing (Aim 3)

Theme 4: physicians reported that rural clinics had fewer resources and were given lower priority than their urban counterparts

Participants identified factors unique to rural practices

Some physicians indicated that they returned to clinics faster than their urban counterparts noting that their patients in rural communities expected their clinic to meet all of their medical needs. Many patients in rural areas had longstanding relationships with their clinics and were not comfortable traveling to urban areas for care, which was another reason for re-opening faster than in urban areas.

Limits on resources were noted as being unique to rural clinics, e.g., rural clinics did not seem to get vaccines as fast as urban areas. Rural areas have challenges with telehealth because of limited internet access and bandwidth, which was problematic for clinics and physicians working from home. Clinic closures and high demands during disease spikes strained rural areas that already had limited resources. Hospital beds in rural areas are limited, which caused stress during coronavirus infection surges. Physicians expended energy and time to overcome challenges with transfers of seriously ill patients from their rural clinics. The limited resources in rural areas were reported to widen disparities between rural and urban health care.

“We couldn’t get them anywhere. I remember one time we had to call like 26 hospitals to find a bed for these patients.” (Participant #11).

“This frustration of having a patient that takes all of your time, when you’re the only clinician in the hospital, and then spending that time and spending the hospital resources calling 17 facilities to try to get them to go somewhere. Or have the ER call you about a patient that you know you shouldn’t be accepting in your facility, because of the resources you don’t have. But they’ve called 30 hospitals in a four-state radius, and they can’t get anybody to take the patient.” (Participant #12).

Rural clinics were impacted by staff turnover, shortages, and retirements

Some staff turnover was related to mitigation strategies (i.e., not wanting to be vaccinated). Some clinics had loyal staff who came back after layoffs. The impact of staff retirements was mixed with some staff retiring early and some postponing retirement because they were needed during the pandemic.

“We didn’t have staff and so now we’re already tasked overloaded in medicine anyway…We’ve had ads running for months and months and haven’t had anybody apply.” (Participant #3).

“Now the biggest issue is that we’re understaffed. Our volumes in the outpatient clinics certainly went down during Covid, but now they’re back where they were before and then some. We are really busy in our clinics as an outpatient clinic and those patients are sicker, the demand is higher.” (Participant #7).

“I remember one of my partners coming to me and just sitting in my chair and saying, ‘I did everything you asked. I helped with this. I did that. I did this. I did that. Now, I’m going to retire. Yeah, we’re through the pandemic. I’m done.’ “ (Participant #3).

Discussion

Physicians who practice in rural settings have been described as being deeply connected to their patients and communities, with strong physician-patient relationships cited as a motivator to serve rural communities [13,14,15,16]. Relationships between physicians and rural residents are built over time through trust, respect, and understanding [25]. Rural physicians are important community members through leadership in fostering wellness and involvement in community affairs [16, 26]. Providing the medical care needed by their community despite being pushed to the limits of their usual scope of practice has been defined as a component of clinical courage of rural physicians [7, 27].

The COVID-19 pandemic caused widespread disruptions in health care as well as daily life. Through semi-structured interviews, we collected reflections on the COVID-19 pandemic by primary care physicians working in rural Wisconsin to better understand their experiences and impact on relationships. We used the framework of phenomenology and applied qualitative methods to analyze interview transcripts and identify themes that represent the core meaning of the reported lived experiences [22, 23]. As with other investigations, experiences varied by phases of the pandemic with the onset of the pandemic described as caring for patients in a time of uncertainty, fear, and anxiety [4, 8, 12]. These results are not unique to physicians as nursing professionals, pharmacists, and other healthcare professionals report similar experiences [11, 28, 29]. Changes with progression of the pandemic included adapting to virtual technologies, implementing mitigation strategies, working in hospitals to manage surges of SARS-CoV-2 infections, and addressing coronavirus vaccine hesitancy.

Effects of increased workload, infection risk, limited resources, and strained personal relationships on the mental health of rural physicians during the pandemic have previously been reported [3, 4, 8]. Addressing vaccine hesitancy and misinformation about the pandemic was emotionally draining and negatively impacted relationships with patients and some clinic staff. Similar findings in urban areas indicate that vaccine hesitancy has increased clinician workloads and contributed to burden of care [30]. Another public health challenge is that rural residents have been observed to be less likely than urban residents to have complied with mitigation strategies, such as masking, working from home, or avoided dining at restaurants or bars [31], which may be linked to support for politicians who downplayed the severity of the pandemic [32]. Participants in our study reported that some relationships with staff and colleagues were strengthened by a sense of working together to meet challenges. Previous work shows that strong relationships with their colleagues and communities and collegial support were integral in addressing challenges of the pandemic [7, 8]. Despite positive effects on some relationships with colleagues, the pandemic was also associated with decreased feelings of camaraderie among physicians and increased feelings of isolation at work due to physical distancing, remote work, and fewer in-person meetings [12].

Negative and positive aspects of telehealth were described such as lack of internet access, limited bandwidth in rural areas, and convenience in terms of less travel for telehealth visits. For example, acceptance of telehealth by patients in a rural Midwestern family medicine clinic was poor and patients indicated that telehealth was less effective for relationship building [33]. New initiatives and legislative policies are needed to improve broadband access and support telehealth within rural Wisconsin [18, 34].

Forty-six of 72 Wisconsin counties are considered to be rural with rural residents accounting for approximately 30% of the population of Wisconsin [35, 36]. Lack of resources [1, 2], staffing shortages, and challenges in patient transfers during surges in coronavirus infections were reported as particularly challenging in rural environments. Our participants reported that rural clinics re-opened faster than their urban counterparts in order to serve their patients who expected their clinic to meet al.l of their medical needs. Many patients in rural areas had longstanding relationships with their clinics and were not comfortable traveling to urban areas, especially during the pandemic. The need for rural residents to travel farther to clinics and closures of rural hospitals, including those in Wisconsin, continue to be barriers to access to care [36, 37]. Funding and policy changes are needed to address shortages of resources and access to health care experienced by rural communities [38].

Limitations

These results are reflections of the lived experiences of a small number of physicians who practiced in rural Wisconsin during the pandemic. Despite the small sample size, we believe thematic saturation was reached as determined by the use of NVivo coding to recognize the lack of new themes or insights emerging from analysis of transcripts. The interviews were conducted approximately two and a half years after the onset of the pandemic, which may have limited recall on events and experiences. Furthermore, the structure and sequence of our questions may have prompted recall on certain topics leaving other topics unaddressed. The participants worked in ten counties across Wisconsin and although many similarities in experiences during the pandemic were observed, local differences among communities may not have been recognized. Clinicians in individual practices or smaller rural health care systems had more autonomy to make decisions, but may have had fewer resources than clinics within larger health care systems. Our results from Wisconsin physicians may not be generalizable to rural areas of other states. Furthermore, our cohort had more women than men, which may have indicated a participation bias as female physicians have been historically been less likely to practice in rural areas than men [39].

Conclusions

Overall, our results highlight the commitment of primary care physicians to care for their patients in the face of unprecedented challenges. This work expands our understanding of the far-reaching impact of the pandemic on physicians practicing in rural areas. Physician-patient relationships were often affected by patient and community members’ beliefs about mitigation strategies, especially negative views of the coronavirus vaccine and masking. Despite challenges, changes implemented during the pandemic, such as the use of telemedicine, were viewed as silver linings. Future work may address the loss of camaraderie and increasing isolation among clinicians attributed to the use of virtual tools and increased remote work.