The Rural vs Urban Practice Decision

Abstract

THE ELECTORAL MAP OF 2000-WITH ITS COASTAL BLUE EDGES AND POINtillist urban centers set against great swaths of red-told many political and economic stories. Attitudes toward rural life often reveal a complex mixture of affection and disdain, ideas about neighborliness and isolation, simplicity and provincialism. In his recent essay, "One Nation, Slightly Divisible," David Brooks argues that the differences between rural and urban America may be merely superficial, exemplified in consumer preferences such as Wal-Mart vs Pottery Barn. 1 Although I agree with his assertion that the two locales possess unique "sensibilities," there are important differences in rural vs urban health care. While 20% of Americans live in rural areas, only 9% of the nation's physicians practice there. Poverty-a principal health risk factor in any geographic locale-is more prevalent in rural areas and is often related to increased rates of chronic disease and greater numbers of uninsured citizens. 2 Rural residents have fewer physicians and nurses per capita and increased transportation barriers; they visit a physician less often and later in the course of their illness than do urban residents. 2 This issue of MSJAMA explores the question of whether there are two US health care delivery systems, one urban and one rural. Differences between urban and rural health care exist on a continuum defined by many variables. Susan Blumenthal and Jessica Kagen provide an epidemiologic background in which to consider important differences and markers between rural and urban health. Hilda Heady explores some of the monetary inequities embodied in rural vs urban reimbursement policies. Terry Meden and colleagues describe how distance from a tertiary care center may be related to decisions about mastectomy for rural women with stages I and II breast cancer. Although Roe vs Wade made abortion legal in the United States, this right may be moot in many rural settings. Trude Bennett explores some of these barriers to prenatal care, family planning, surgical contraception, and other reproductive health care services in rural areas. To address the chronic geographic maldistribution of physicians, Howard Rabinowitz and Nina Paynter outline the constructs that inform medical students' decision to become generalists or specialists and correlatively to practice in a rural vs an urban setting. These inequities in rural vs urban health care delivery are based in structural, economic, and cultural differences. Through increased awareness, research, education, and preventive public health measures, congress, and ultimately communities and the health care providers who serve them, may begin to lessen the degrees of difference.

Trends in Emergency Department Use by Rural and Urban Populations in the United States

“…27 , 28 Rural EDs may be serving as the most immediately accessible source of health care for rural communities. This finding is consistent with the documented intractable rural primary care shortage, 5 misdistribution of primary care favoring urban centers, 29 and rapid rural primary care physician turnover, 30 all of which may contribute to increased ED use. Previous studies suggest that poor primary care access is associated with increased ED use, 31 , 32 with rural patients less likely to have a primary care follow-up visit and more likely to have an ED visit following an inpatient admission.…”

Understanding the professional satisfaction of hospital trainees in Australia

“…Employer and college professional support may be needed for trainees early in their training period. Interestingly, our study's finding that trainees in non‐metropolitan settings have a positive professional experience challenges any perceptions that rural training is associated with lower‐quality training and more limited experience . We also found that some trainee specialty colleges were significantly associated with satisfaction (trainees in pathology or radiology, and obstetrics and gynaecology were most satisfied, whereas those in psychiatry, and emergency and ICU medicine were least satisfied).…”

Challenges and Experiences of Young Medical Specialists in Establishing Private Clinical Practice

“…On the other hand, physicians practicing in urban areas may have more access to colleagues with different subspecialties, as well as sophisticated medical facilities. [14] Most cities have large conglomerate hospital systems with sites around the catchment area, which adds flexibility in terms of traveling from 1 area to another. The downside is possible compartmentalization of practice and tight competition as more subspecialists tend to cluster in urban areas.…”