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.

Do Faster-Trained Physicians Fill the Gaps? Geographic Concentration of Emergency Medicine physicians with different postgraduate training in Ontario Canada

“…This coupled with our previous result on the number of areas where these physicians are located suggests that equity of access to emergency physicians has deteriorated in Ontario over our period of observation. This evidence that emergency medicine trained physicians are increasingly concentrating in highly urbanized environments is consistent with other evidence from the US that suggests similar agglomeration over time 20 .…”

“…This may relate to the portability of the degree that CCFP(EM) and family physicians both have. Whereas the other physician types in our sample usually work in hospital settings, family physicians can work in outpatient settings 20 . This means they can more readily move to places that they prefer, such as urban settings.…”

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

“…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, misdistribution of primary care favoring urban centers, and rapid rural primary care physician turnover, all of which may contribute to increased ED use. Previous studies suggest that poor primary care access is associated with increased ED use, 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 .…”

Mental health and substance use clinical risk factors associated with emergency department and emergency medical services involvement among decedents of suicide by poisoning

“…There may be three key reasons for this increased ED involvement. First, in rural settings, lack of local mental health services,1 2 workforce staffing concerns, such as primary care personnel shortages, and reduced primary care personnel retention37 38 may lead to EDs serving as the only source of MH/SUD care in the time of an emergent psychiatric situation 39 40. Second, social isolation, stigma towards mental healthcare and treatment, lack of recognition of MH/SUD problems and availability of resources for treating suicide attempts (eg, naloxone administration for opioids, clinician-based stigma towards patients presenting with MHSUD and timeliness of care) are barriers for seeking MH/SUD in rural communities,41–44 which may further explain the notable rises in suicide-related trends in rural communities and increased ED involvement.…”