I read your question as if you were asking about starting a practice in the country, and then I reread it and realized you might not care about whether you're working for someone else or not. Well, I'm gonna go ahead and just leave my initial response since I spent a few minutes typing it:
I'm a medical student, but I have asked this question several times to family physicians. Even the "old timers" I spoke with who had started their own practices back in the day were contemplating selling their practice to a large hospital system so they didn't have to deal with the business side of things anymore. Starting out on your own in a small town and hiring a staff to do your billing, labs, front desk work, etc. has a modern day cost that is prohibitive. The reason is that it takes too much staff to handle all the paperwork. For example, the rural doc I shadowed this summer had one partner, 2 NP's, 1 nurse, at least five MA's, several front desk people, and an office manager. That's a ton of salary overhead, even without the NP's or office manager.
Let's say that you want to do a low-overhead type of practice. The options are essentially opening a direct primary care practice that is cash-only, a concierge practice of a similar but more expensive nature, or having a hybrid of direct and typical practice. These arrangements cut out the overhead because they take cash and don't deal with insurance and medicare, so there's often few employees per physician. The physicians often take fewer patients, depending on the model, and utilize a membership-based payment system to ensure financial stability. If you choose to do this, you need to find people willing to pay monthly for your fees, and truly rural areas simply don't have that kind of cash. Yes, you can google examples of people who have done it, but it's very difficult to do in a rural area.
Despite my saying this, I also would love to practice in a rural setting, and I'm trying to investigate some good ways to do it.
So -- having had a rural practice I will tell you to be watchful about this --- most people have the idea that a rural practice will either be like Marcus Welby, M.D. or "Doc" on Gunsmoke or Michael J. Fox in "Doc Hollywood" -- while it can, in my experience, it's not.
So -- for my bias -- I need things to do/go see -- sitting on a porch watching paint dry or wheat grow is not my idea of a good time -- unless that porch is attached to a Tex-Mex restaurant and I'm in a party of 12 having a beer or 3, eating copious amounts of spicy food and eyeballing NYLs ---
The rural town I was at had about 6 physicians in it already but the county held around 35K people, had a small critical access hospital and 3-4 nursing homes and no pediatricians -- was recruited into the area by the hospital -- long story short, it wound up being more inpatient/ICU than I wanted to do and the clinic was more of a medicare/Medicaid clinic since everyone with insurance was going to the next county over as the hospital system over there was larger and "better". The cash pay patients were already being seen by a long time doc -- in the first month, I saw about 20 patients and then went down to 3-4/week -- and yes, I was on the local radio station, CoC, spoke to senior groups, took unassigned ER patients/hospital patients, etc.
So, I closed the practice and sought other opportunities in the burbs....
If you're looking for long term patient relationships, that can be done but it's beginning to be a thing of the past -- most patients go where their insurance will let them or they can find a doc that will give them what they want -- there are some that are truly interested in improving their health/quality of life but most (gross generalization here) want to be band-aided so they can continue the behaviors that got them there in the first place -- and in the case of uncontrolled DM/HTN, most get upset if you either a) decide they need insulin -- needles and blood sugar checks and carb counting ==no fun or b) suggest TLC == I gotta change == fewer tacos than I usually eat == not conducive to my lifestyle
I realize I'm being Debbie Downer but I had an idealistic view of helping people and learned the hard way -- now, every day I run across someone who is truly greatful for what I do to help them -- and that's what keeps me going --