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msJAMA
January 2, 2002

The Rural vs Urban Practice Decision

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JAMA. 2002;287(1):113. doi:10.1001/jama.287.1.113-JMS0102-7-1

Americans living in rural areas have more health problems than their urban peers, yet there are fewer medical services available to them.1 A major part of the disparity between rural and urban health care is the longstanding shortage of physicians in rural areas. Although 20% of the US population lives in rural areas, only 9% of physicians practice there, and only 3% of recent medical school graduates plan to do so.2,3 Thus, it is important to understand why physicians choose to practice in rural vs urban areas.

There are a number of known predictors of choice of rural primary care, including rural background, freshman medical student plans for family practice, and receiving a National Health Service Corps scholarship.4 Women are slightly less likely to practice rural medicine than men, although this is not true for women who enter medical school committed to rural family practice.3,4 Spousal influence and economic issues also play a role in physicians' decisions about where to practice.1,3 During medical school, taking a rural clinical rotation is the strongest predictor of a later decision to practice in a rural setting. 1,3,4 However, since most medical schools are located in urban areas, the vast majority of students have their clinical training there, while few have clinical experiences in rural areas. Overall, medical schools with special admissions programs and those with extensive rural curricula have been more successful in producing rural physicians, as have residency programs with rural training tracks, 4,5 although collectively these programs are too small to eliminate the US rural physician shortage.

Physicians' decisions about where to practice are also related to their choice of specialty. Most urban physicians are not generalists, while a higher proportion of rural physicians are generalists.3 Family physicians are the only specialty group that distributes itself proportionally to the population in rural and urban areas.3 Thus, the size of the future rural physician workforce may be threatened by the trend of US medical students to increasingly train in non-generalist specialties and subspecialties,6 which persists despite evidence that provision of primary care is related to improved health outcomes.7

Physicians also decide on practice locale based on personal issues such as their perceptions of lifestyle, economics, and type of practice. While the characteristics that comprise rural life are viewed as desirable to some, the same variables may dissuade others. Physicians attracted to rural areas often cite their desire to raise a family in a rural setting as crucial to their decision. They may also value participation in outdoor activities, lower crime rates, less traffic, and living in a closely knit community. Physicians selecting urban practice may be drawn by the cultural amenities of urban living, the variety of restaurants, entertainment, goods and services, and cultural and ethnic diversity. Although the average income of rural physicians is lower than that of their urban peers, this is due to the greater proportion of generalists in rural areas.8 Among family physicians, for example, net income in rural vs urban areas is virtually identical.8 Because the cost of housing is substantially lower in most rural areas, this can result in a higher standard of living for many rural physicians. Many physicians in rural areas, however, work more hours than their urban counterparts.8

The scope of medical practice in rural areas is frequently more diverse than in urban areas. Rural family physicians, for example, often deliver more infants, have broader hospital privileges, and make house calls. Rural physicians also retain more clinical independence in their practice. On the other hand, some rural physicians may experience professional isolation, with less access to colleagues and medical resources.1

For medical students contemplating practice location, as with deciding on specialty choice, real world clinical experiences and role models facilitate decision-making and allow students to evaluate their own practice, lifestyle, and financial needs. In order to obtain a broad-based foundation, students should consider obtaining clinical experience in both urban and rural settings.

References
1.
Phillips  DMDunlap  PG Physician Recruitment and Retention.  Washington, DC National Rural Health Association1998;
2.
Jolly  PHudley  DM AAMC Data Book: Statistical Information Related to Medical Education.  Washington, DC Association of American Medical Colleges1998;
3.
Council on Graduate Medical Education (1998), Physician Distribution and Health Care Challenges in Rural and Inner City Areas.  Rockville, MD US Dept of Health and Human Services
4.
Rabinowitz  HKDiamond  JJMarkham  FWPaynter  NP Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;2861041- 1048Article
5.
Rosenthal  TCMcGuigan  MHOsborne  JHolden  DMParsons  MA One-two rural residency tracks in family practice: are they getting the job done? Fam Med. 1998;3090- 93
6.
American Academy of Family Physicians, 2001 Match Information Sheet.  Kansas City, Mo American Academy of Family Physicians2001;
7.
Starfield  B Primary Care: Concepts, Evaluation, and Policy.  New York, NY Oxford University Press1992;
8.
Wright  GE The economics of rural practice. Geyman  JPNorris  TEHart  LGeds.Textbook of Rural Medicine New York, NY McGraw-Hill2001;
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