When I opened the doors of my rural general surgery practice in 2003, I thought I had the right formula: offer compassionate, high quality care using advanced technology and sound ethical principles. Serve all patients that need care, regardless of resources or socioeconomic status. And stay abreast of cutting-edge techniques with ongoing education and research, allowing rural patients the same access to first-rate medicine as city dwellers enjoyed.

I believed that if I followed this formula, my community would benefit and my small practice would grow proportionate to my efforts.

But achieving success as a rural doctor proved less straightforward than my simple equation predicted.

One problem was that practice expenses mounted at an astonishing pace. Just one example: in the first two years of my practice, the health insurance premiums I paid for my employees and my family increased by 50%. Despite the fact that there were no chronic health problems or major claims among our young group, Blue Shield of California hiked our premiums quicker than my business could grow.

Another threat to the survival of practices like mine comes from a curious payment formula that Medicare applies to doctors in rural California counties. Dubbed the “Sustainable Growth Rate,” it pays higher fees for the same services in areas where the costs of doing business are higher. That sounds reasonable, but it’s not: Physicians with higher operating costs tend also to have wealthier patient populations, disproportionately many of whom have private insurance coverage. The private insurers, in turn, pay rates that are up to 60% higher than Medicare’s. That means doctors whose patients are rural, poor, and often uninsured have a much harder time making ends meet.

The ultimate challenge to keeping my doors open came from an unexpected source—a large number of patients. I became busier, my workdays grew longer, and patient appointments multiplied at a near-exponential rate.

Yet each month my bookkeeping showed only a weak improvement in the “bottom line.” Despite significantly increased expenses associated with caring for many more patients, the practice revenue increased only slightly. In some months, despite the new patients, revenues were flat; if I spent a few days at a medical education conference instead of at the office, expenses exceeded receipts.

How could this be? My patients, over 60% of whom were women I evaluated or treated for breast cancer, seemed pleased with their care. They brought me gifts like crates of raisins or fresh-picked oranges from the fields that surround my office. I opened stacks of thank-you cards from family members and received glowing reports from the doctors who had referred their patients to my care. The number of new patients I saw grew more rapidly than I had predicted.

The ultimate challenge to keeping my doors open came from an unexpected source—a large number of patients.

The surprising answer came when I audited my own books. I had hired a medical billing service to deal with the extraordinarily complex world of Medicare, Medi-Cal, HMOs, PPOs and private health insurance carriers. The rules were ever-changing and inconsistent, requiring the full-time attention of a small army of professionals trained in coding, billing, preauthorizations, copays, deductibles, exclusions, allowances and denials. After wading through a mountain of billing statements that challenged the limits of my intellect (and tolerance for frustration), a clear explanation emerged: Medi-Cal, the State of California’s version of Medicaid, was my practice’s Achilles heel.

Medi-Cal aims to provide healthcare coverage for our state’s low-income individuals and families. What it also does, alas, is destroy the viability of medical practices across California, particularly in small rural communities like mine.

Medi-Cal payment rates for physicians—still based on guidelines from 1969—have increased only once in the past twenty years, on August 1^st, 2000. Despite skyrocketing increases in practice expenses for every individual California physician, the State of California ranks 42^nd in medical reimbursement rates.

The situation for rural doctors is further exacerbated by population characteristics. We serve in counties with higher levels of poverty and unemployment, and an overall lack of economic opportunity compared with more affluent communities on the coast. We provide emergency, preventive and elective healthcare for proportionately larger numbers of undocumented immigrants (assisted, when we can navigate them, by more than two dozen Medi-Cal programs that specifically provide care for “persons with unsatisfactory documentation”). With higher numbers of residents uninsured or underinsured by programs like Medi-Cal and Healthy Families, the burden for their care falls on an ever-smaller number of physicians struggling to meet expenses.

Faced with Medi-Cal reimbursement rates for office visits that often do not even cover the cost of keeping the office open during that visit—yes, I have actually received an $11 check from Medi-Cal for services rendered—many doctors simply stop accepting such patients into their practices. As a consequence, the doctors who do still care for these patients face an unworkable financial situation. A dilemma inevitably arises—the same dilemma that prompted me to audit my own books: do I stop accepting poor patients or do I continue caring for them until my medical practice goes under?

There had to be another way, I reasoned. I was one of the only surgeons accepting women with breast cancer—but without resources—in central California. Patients came to me from a 70-mile radius around the small south Fresno County town where I practice. To close my doors to these women, or else close the doors of my practice entirely, would be a blow to the ideals that had led me to choose rural medicine in the first place. For frightened women with a potentially lethal disease and few options for care, the cost would be far greater.

About two years ago, I took note of a phenomenon surfacing in cities where some of my colleagues practiced. Doctors who were not plastic surgeons started introducing cosmetic procedures into their practices. Cosmetic procedures are not covered by insurance or government programs—they are done for patients with disposable income, who pay a substantial premium for the privilege of looking their medically-enhanced best.

My general surgery practice is now a little schizophrenic. Beautiful women wanting to be more beautiful enter my office alongside women whose main desire is to survive the tumor that threatens their lives.

I was skeptical but fascinated. Internists who injected Botox, relaxing wrinkles and leaving happy, line-free patients in their wake, were part of a larger trend. Obstetricians rejuvenated aging faces with pulses of laser light, removing brown spots and smoothing complexions. In the hands of family practice physicians, lasers also targeted unwanted hair follicles, relieving Hirsutism and encouraging interesting trends in body hairlessness. Technology had propelled the aesthetic realm as it had every other discipline in medicine. Collagen injections were replaced by new, safer synthetics, allowing dermatologists to fill wrinkles and plump lips to Angelina-like proportions.

Having seen “Desperate Housewives,” I wasn’t sure I wanted to participate in this particular arena. But the lucrative nature of these purely cosmetic procedures (without the hassle factor and regular denials associated with health insurance carriers) prompted me to investigate further: could vanity subsidize breast cancer treatment?

For six months, I attended every cosmetic training course and seminar within a five-hour drive from my office. I even flew to Las Vegas twice (An ironically popular venue for aesthetic education, I learned), despite a California-bred aversion to the cigarette smoke that seemed to accompany every oxygen molecule in that city. A generous colleague in southern California invited me to visit his celebrity-filled plastic surgery practice. He and his glamorous staff taught me the subtleties of laser treatments and wrinkle injections, demonstrating on grateful patients who regularly flew in from surrounding states for his expertise. There was artistry and skill in catering to the vain. I made my decision and have not looked back.

So, my general surgery practice is now a little schizophrenic. Beautiful women wanting to be more beautiful enter my office alongside women whose main desire is to survive the tumor that threatens their lives. Rather than seeking enhancement, they fear the loss of part or all of a breast from surgery—or their hair from chemotherapy afterwards.

To me, they are as beautiful as their counterparts seeking relief from wrinkles, age spots and hair. They want to live, an attitude more attractive than can be created by a syringe or light source.

In rural central California, a broken healthcare system threatens to collapse under the weight of bureaucracy and misplaced priorities, and women’s lives are valued less than the pretty packaging in which they are wrapped. Yet the doors of my office remain open. In vanity, there is hope.

Linda Halderman is a Board-Certified General Surgeon practicing in rural south Fresno County. A version of this article first appeared on www.victorhanson.com.