Getting sick can be a far bigger headache for rural Americans than for city-dwellers. Both the number of doctors and the proportion of under 65s on health insurance are lower, while patchy transport coverage often makes it harder to get to clinics. All of this means health outcomes tend to be worse — the death rate in rural areas is 830.5 per 100,000 people, compared to 703.4 per 100,000 in cities.
A part of the rural-urban divide is due to remoteness — health services in the US countryside are spread further apart than in cities, while transport services are more stretched and earnings lower.
But the report, published in July, argues that a bigger fault may be the way rural care is organised. US doctors and the clinics they run are too specialised; for rural healthcare to improve, it needs generalists and coordinated primary care.
Deeper or broader?
The authors argue that, from as early as 1910, healthcare in the US has focused on training specialist doctors over general practitioners.
The result is more research and “science-based” medicine, which requires “technologies available primarily in densely populated areas.” While this works well in cities, where residents are able to travel between specialist clinics, in rural areas it’s far less effective.
Instead, rural areas should develop a system of integrated health services delivered by generalist clinicians who are able to deal with a wide range of problems, the report argues. This approach is known as “primary care”.
When primary care is provided, outcomes are better. The report’s authors cite research which shows that adults who had a primary care doctor as their main physician were 19% less likely to die prematurely than one with a subspecialist doctor, at 33% lower annual healthcare cost.
Those lower costs partly reflect generalist doctors’ ability to keep patients out of hospital by dealing with many non-serious conditions before they worsen.
But care is lacking in America’s rural areas. Non-metropolitan residents are one of the “largest medically underserved groups in the US”, according to the report. Some 20% of the total US population lives outside of cities, but only 9% of primary care providers serve these areas.
The Robert Graham Centre, a population and healthcare research institute, estimates that 52,000 more primary care physicians are needed by 2025. Because of the trend towards specialists, not enough primary carers are being trained, widening the gap. That limits the supply of rural doctors overall: the specialists that emerge gravitate towards hospitals and research institutes, most of which are in metropolitan areas.
And the few rural hospitals there are find it difficult to attract new blood, often missing out on the funding needed to train junior doctors.
Changing this will require a shift in education and better planning, the report says.
While current training values hard science skills and mathematical ability, rural primary care practice requires soft skills, empathy and the ability to understand rural people’s life patterns and needs.
For primary care to function effectively, services have to work together, which means data sharing between different clinics. This would allow healthcare workers to see patterns in their communities’ health and make early interventions before unhealthy behaviour develops into full-blown illness.
But although Electronic Health Records (EHRs) are now the norm across rural healthcare providers, to be of any use workers need data and IT skills, which are “often scarce in rural communities”.
Rural hospitals need both systemic changes, and a workforce. Perhaps more importantly, rural-healthcare needs more of a presence in higher education, so that healthcare can be “aligned with the health needs of Americans”. When health workers live and train in rural areas, they’re more likely to stay. The emphasis on specialisation detracts from primary care. Specialties such as pediatrics should only be included in primary care programs if they’re shown not to detract from primary care. Otherwise, the drain of doctors to cities will continue. — Anoush Darabi
(Picture credit: Flickr/ U.S. Department of Agriculture)