Notes from the Urban/Rural Divide: Health Care, Part II

Over two years ago, back towards the start of my ongoing intermittent series on urban and rural issues in the United States, I explored some of the issues revolving around rural health care. In a nutshell, we don’t have access to the same quality and stability of care as those in urban areas and we face a lot of obstacles like lack of specialists, long transport times, difficulty getting time off for treatment, and, sometimes, getting even the most basic of care. Without access to primary care providers, rural residents often end up in the emergency room when routine medical issues explode because they weren’t seen to at an early stage, and we also have serious deficits in terms of health education and interventions that could help with preventative care and improving the health of rural populations—all while we work in risky environments like logging sites and farms.

About one in five residents of the United States live in rural communities, yet less than 10% of care providers work in said communities, creating a critical mismatch between patients and doctors. Lots of people need care, but care providers aren’t always available to provide it, and when they do, they need to provide it rapidly and practice a very broad scope of medicine, operating in full awareness of the fact that their patients don’t have as many options as urban dwellers.

When an urban resident sees a primary care physician with a complaint about fatigue, swollen lymph nodes, and anemia, that doctor might run some quick bloodwork and then immediately refer that patient to a hematologist or leukemia specialist. The provider is well aware that the scope of the treatment needed by the patient is such that an oncologist could better provide it. In rural areas, though, primary care providers have to balance broad education in a number of specialties to provide care that advances beyond the basic, sometimes playing the role of specialist because they know their patients can’t access a specialist.

Thus an orthopaedic surgeon can’t afford to focus on, say, joint replacements, but might one day see a patient with a complex joint replacement that could really benefit from attention provided by someone with extensive experience in that area. A primary care provider becomes a pulmonologist for a patient with asthma, while a nurse practitioner offers extensive gynecological and prenatal care because other options simply are not available, despite efforts to recruit doctors to rural areas, improve availability of clinicians, and expand the scope of options.

For patients, there are a lot of access issues, like the long dirt roads in rural areas that can isolate people, making it hard to get care. With petrol prices rising, some patients quite simply can’t afford to go to the doctor, and for those who can’t drive themselves, neighbours might be in the same situation; the errand might need to be combined with another mission to town, which might not be for days or weeks. Meanwhile, the patient’s condition grows even worse over time. Home care for patients who need infusions, monitoring, and other extensive care is often hard to provide, and some rural residents are forced to move to access treatment. If, of course, they can afford to move.

Equalising these health care problems in rural US communities is a huge and pressing issue, and some of the most promising potential for reform actually comes from tools designed to improve medical care in the Global South, illustrating that some issues are more universal than people like to pretend.

Telemedicine is an obvious example; if patients could consult with doctors both at home and in community clinics, they could access high-quality care in a remote location. (This, of course, requires upgrading rural internet access to reasonable standards.) This can be particularly useful for situations like mental health counseling, where patients might struggle to get and access treatment, but a counselor offering remote services could be a fantastic fit, especially for psychiatric crises.

Surgical robots are another example, as we see more and more successful cases of remote surgery. That same orthopaedic surgery above could change radically with the patient’s surgeon supervising while a remote physician performs the delicate surgery using a robot, giving the patient a high-quality reconstructed joint and a better chance at a great outcome. At the same time, the patient’s surgeon could take advantage of the opportunity to learn more about joint replacements and advanced surgical technique.

Rural physicians are already taking advantage of minitraining programmes to familiarise them with formerly speciality-focused issues in order to improve the scope and quality of care they offer their patients. Such continuing education provides lots of opportunities, but it’s not necessarily supported across the board. Government agencies and regional medical groups may or may not be able to provide funding support for such training, let alone coverage to allow a doctor to leave a practice for a training seminar. This, too, needs to change: physicians who want to take some time to learn about new options for their patients should be able to do so with full support.

The fact that rural medicine in the US hasn’t been made more of a priority is indicative of larger overall disdain for rural issues. While people live, work, and need medical care in rural communities across the country, their issues are often ignored, particularly when it comes to medical care. In an era when the fault lines of the health care system are being exposed and more and more people are talking about how to fix this fundamentally broken and terrifyingly poorly managed system, the elision of rural issues is notable, and troubling.

We deserve a seat at the table too.