Rural physicians say backup is the shortage that breaks the system
For rural physicians, the most fragile part of the job is not always salary. It is the knowledge that when a colleague leaves, another clinician may not be there to absorb the workload safely.
A national workforce survey presented at the MGMA 2026 Annual Conference found 65% of current rural clinicians lacked adequate specialist and colleague backup, a deficit that outstripped compensation concerns. In the same survey, 42% said pay did not fairly reflect their scope, call burden and workload. The gap between those two figures matters because it points to a deeper retention problem: rural clinicians are not only weighing income, but also whether their practice can function without constant strain.
The survey, Rural Healthcare Specialty Priorities, was based on an August 2026 online sample of 227 respondents with rural experience, including 168 clinicians and 59 administrators. Helen Falkner of Jackson Physician Search and Pamela Ograbisz, DNP, FNP-BC, FAANP, of LocumTenens.com and LT Telehealth discussed the findings during a conference session moderated by MGMA Senior Editor Chris Harrop.
The workforce data read less like a snapshot than an alarm bell. Among current rural clinicians, 59% said they were at least somewhat likely to leave their position within two years. For those who lacked adequate backup, that figure climbed to 67%. In practice, the problem compounds quickly: if one physician departs, the remaining team is often forced to stretch into unfamiliar territory, delay care, or send patients elsewhere.
Thin coverage has become the default in many specialties
Respondents separated local coverage into three categories: adequate, local but thin, and alternative or absent. The middle category captured the reality of much of rural medicine. It means a service is technically present, but one resignation, one maternity leave, one illness, or one reduction in hours can push the practice into crisis.
Family medicine was rated adequate by only 21% of respondents, while 68% called it local but thin. Internal medicine landed at 76% local but thin. General surgery and obstetrics-gynecology each came in at 61% local but thin. Majorities also said losing local access would have significant consequences for pediatrics, emergency medicine and family medicine, with the strongest concern seen in pediatrics at 77%, emergency medicine at 74% and family medicine at 70%.
The clinical logic is straightforward. When the nearest specialist is stretched thin or absent, the family physician becomes the default triage point, care coordinator and stopgap for problems that would normally move downstream to another clinician. That shift increases the chance of delays, burnout and clinical drift beyond the physician’s usual scope.
One sentence from the session captured the problem with blunt precision: rural services are often one physician departure away from collapse.
Obstetric care shows how quickly access can unravel
Ob-gyn stood out for all the wrong reasons. Only 7% of respondents rated local ob-gyn coverage as adequate. The survey also noted that 146 physicians have stopped delivering babies since the end of 2020 or announced plans to do so in 2026.
Obstetric care is uniquely vulnerable because the service depends on a full team, not just a single physician. Falkner described sustainable call as one in three to one in four, while many rural units are operating at one in two. That difference is more than a scheduling inconvenience. It changes whether clinicians can recover between overnight emergencies, maintain safe decision-making and stay in practice long enough to preserve the service.
Falkner said candidates also want modern resources and support, including robotic capability, backup anesthesia, neonatal intensive care support, pediatric support and emergency C-section coverage. The challenge is self-reinforcing: thin coverage makes recruitment harder, recruitment delays intensify burnout among the clinicians who remain, and the cycle keeps tightening.
Ograbisz described rural Georgia communities where women must drive 75 miles for obstetric care. The consequence is immediate and human, not abstract. Pregnant patients who are already overwhelmed by a new pregnancy and a new baby may face long travel for routine prenatal visits, urgent concerns or delivery itself. In that setting, access is not a policy term. It is the difference between timely care and a road trip under stress.
Backup, APP teams and telehealth are helping — but unevenly
When respondents were asked what could work over the long term for a coverage decision within 12 months, 68% rated permanent physician recruitment as viable. Physician plus advanced practice provider teams ranked second at 55%, and they placed first in psychiatry at 85%. Telehealth was viewed as strongly viable in psychiatry as well, with 70% support, but majorities judged it not viable for ob-gyn, emergency medicine or general surgery.
That split fits the clinical demands of each specialty. Psychiatry can often be delivered effectively through a virtual model because many assessments, medication adjustments and follow-up visits do not require hands-on procedures. Emergency medicine, general surgery and obstetrics depend on physical presence, rapid intervention and procedural backup. Telehealth can extend reach, but it cannot substitute for a surgeon in the operating room or an obstetric team ready for an emergent delivery.
Ograbisz argued that physician-APP models can improve efficiency when they are built around real workflow rather than used as a cosmetic fix. She described a cardiothoracic surgery group that expanded APP roles from the operating room into the intensive care unit and inpatient floor, allowing surgeons to remain in the OR while APPs followed patients through recovery. In that model, the added clinicians do not replace physicians; they free physicians to work at the top of their license while extending continuity across the care pathway.
Former rural clinicians would come back if the system changed
The report suggests rural medicine still has a pull. Among former rural clinicians, 45% said they would be very or somewhat likely to consider rural practice again. Their top conditions were competitive compensation at 47% and better specialty coverage and colleague backup at 45%. Current rural clinicians gave the same two answers the highest priority, each at 49%.
Former clinicians also said inadequate backup was the second most common reason they left, at 31%, just behind workload or burnout at 33%. Those numbers point to a retention problem rooted in daily operations, not just recruitment messaging.
Falkner described one practical fix in Glendive, Montana, where an ob-gyn search had remained open for three years. Instead of waiting for a full-time recruit who did not exist, the hospital built a model around three ob-gyns working 10 shifts a month each. One physician from a traditional practice in Billings was hired on a schedule that gave her full-time pay and benefits without the full-time grind. Two of the three physicians are now in place, and the community has ob-gyn coverage again.
Retention now depends on planning for call, coverage and communication
The report’s first recommendation is to treat backup and call as part of the coverage plan, with budgets that include cross-coverage and specialist support rather than assuming those pieces will appear later. In rural medicine, the staffing model and the coverage model are the same problem.
Falkner also stressed that communication with physicians has to continue after the contract is signed. Emerging coverage gaps do not always announce themselves as vacancies. They often begin as schedule strain, rising resentment, more after-hours calls or a clinician quietly taking on work that should belong to someone else.
The most revealing finding in the survey may be the simplest: rural physicians are still willing to stay, and many are still willing to return. But they want a practice structure that lets them do the job without carrying the entire service line on their backs. When backup disappears, retention becomes harder, patient access worsens, and the next vacancy arrives faster than leadership expects.