Rural areas said to have enough doctors

Health care access and quality in rural areas is generally on par with that of urban areas, according to research recently published in Health Affairs. The study stands in stark contrast to the widespread perception that there's a critical shortage of rural physicians. Coincidentally, rural medical care is the theme of the August Academic Medicine, which in its opening editorial states the shortage of medical care in rural communities is one aspect of the physician work-force debate that most agree exists.

However, James Reschovsky, PhD, lead author of the Health Affairs study and a senior health researcher at the Center for Studying Health System Change, says his research shows that barring those who live in health professional shortage areas, those who live in rural areas aren't necessarily hard-pressed to find medical care.

"I think the perception of inadequate supply has a lot to do with the fact there are fewer physicians in rural areas relative to the population, but that's not to say there aren't enough physicians in rural America to meet the need," Dr. Reschovsky said. "The results don't dispute the fact that there are certain areas in rural America that have an inadequate number of physicians, but it's a very small percentage of the rural population that actually lives in medically underserved areas."

Dr. Reschovsky's nationwide survey of patients and physicians found little difference between rural and urban perceptions of access and quality of care. The single exception was mental health care, which was difficult to find in rural areas, according to respondents.

The survey asked patients whether they had any unmet medical need, whether they had put off getting needed care, and whether they had a usual source of care. It found that rural respondents were only slightly more likely to report delayed care -- long identified as an indication of access. The average number of days to get in to see a primary care physician did not differ significantly between rural and urban patients, but rural patients reported longer waits for appointments with specialists.

In the physician survey, rural doctors were less likely than their urban peers to report problems obtaining hospital admissions, ancillary services and diagnostics imaging, and there was little difference in their ability to obtain patient referrals to high-quality specialists. However, rural physicians were much more likely to report problems obtaining inpatient mental health services.

Answers to questions about quality relied solely on physician and patient perceptions, not objective standards. Rural physicians were more confident than their urban counterparts about their ability to provide quality care. When doctors were asked if it was possible to provide high-quality care to all their patients or if they had adequate time to spend during typical patient visits, more rural physicians said yes than did their urban peers. Rural patients also gave more positive responses than urban individuals about their trust in their physicians' ability to meet their medical needs, their doctors' thoroughness and how well their doctor explained things.

The surveys were conducted during 2000 and 2001, and approximately 12,500 physicians and 60,000 individuals were interviewed.

While most rural residents had adequate access to care, the survey confirmed that rural populations have a higher tendency to be uninsured or to lack the financial resources to seek out care. Removing this barrier to care, Dr. Reschovsky said, should be the focus of future policy decisions.

"The answer to that problem is expanding health insurance coverage or increasing the incomes of rural Americans," he said.

Cuts to programs like Medicaid would hurt rural areas more than urban ones, according to the study, and subsides for rural health care should be focused on areas with a demonstrated need, while broader programs might be appropriate when focused on specific areas like mental health care.

From another angle

Howard Rabinowitz, MD, director of the Physician Shortage Area Program at Jefferson Medical College of Thomas Jefferson University in Philadelphia, has a different take.

Jefferson has been training family physicians for rural Pennsylvania for almost 30 years, and the program's success in graduating physicians who actually make a career out of rural medicine is highlighted in the August Academic Medicine.

Dr. Rabinowitz says there's a shortage of primary care physicians in rural counties, and as medical schools begin to ramp up expansion plans in response to predictions of a physician shortage, he is concerned that studies like the one from the Center for Studying Health System Change will send the wrong message.

"This study was very well done, but I would have to come to different conclusions," Dr. Rabinowitz said.

Comparing rural care to urban may just be demonstrating that urban areas have an excess of physicians, he said, or that affluent, urban residents are demanding more care because they can afford it. Rural patients may see their access as adequate because rural physicians will work the hours necessary to fit them in, he said.

"When you are a doctor in a small town, you know everybody," Dr. Rabinowitz said. "You're not going to not see patients because they don't have insurance. You're not going to say you're going home because you've seen enough patients for the day."

This generation of physicians would rather avoid long work days so when they do practice in rural areas, they prefer sharing the load with a partner, Dr. Rabinowitz said. Saying the rural work force is adequate could make the situation worse instead of better, he said.

"This sends the message that we don't need more rural doctors, and I think if you talk to people in rural areas, you'll see it's a huge issue."