In my medical school, as with most medical schools in North America, we spend our first two years in lectures and our last two years in clinic/on hospital wards managing patients. Our first practical rotation, rural practice, begins during the summer between 2nd and 3rd year.
In rural practice, we work one on one with a family doctor for a month in their rural community. A reality about practicing medicine in a rural community is that you cannot be a jerk...because you will quickly go out of business. The same can be said to some degree about practicing medicine anywhere, but in small towns everyone knows everyone...and they all talk.
During my rural rotation, I met an internist who was constantly complaining about the lack of business in his town. I started thinking that small towns couldn't support specialists because there just weren't enough people that required specialized care. Then I met two of the other internists in the same community, who were telling me that they needed more internists to help with their ridiculous patient load.
Why was there a discrepancy? Turns out the first internist lacked interpersonal skills. He would seem disinterested in patients when he was meeting with them and he would criticize the family doctors, who are the physicians who actually refer patients to him. This meant that the family docs didn't refer their patients to him, which was fine by the patients because they didn't want to be referred to him either.
Now this scenario could happen anywhere, but it will happen much more quickly in a small town where everyone knows everyone. In a big city word doesn't travel as fast and a rude doctor is more likely to be able to maintain his practice, but if you're in a small town...best to be nice if you want to work...