What's in a definition?

Can J Rural Med 1996; 1 (2): 55

This uncertainty has many practical consequences, one of which touches our desire to send this journal out to physicians who are engaged in the practice of rural medicine. Who are they, and how do we find them?

It turns out that the mailing of our first issue stumbled into this semantic quagmire. A Canada Post definition of rural was used, and copies were mailed only to physicians with a "0" strategically placed in their postal codes. This filter correctly identified addresses in the most rural areas of the country but missed everyone else, including many GP anesthetists who may regret that they missed our feature article on ambulatory epidural anesthesia in rural areas, by Dr. Stuart Iglesias of Hinton, Alta., and the accompanying editorial, by Dr. Joanne Douglas, clinical professor and head of the Division of Obstetric Anaesthesia at the British Columbia Women's Hospital and Health Centre, Vancouver, BC. Either may be ordered directly from the authors or through CJRM. The full text of CJRM, volume 1, number 1, including these articles, can be accessed via the Internet at: ../../cjrm/vol-1/issue-1.htm.

So to those folks in Renfrew, Ont., in Hinton, Alta., and in Dauphin, Man. (among many others), unquestionably practitioners of rural medicine, an apology and a hope that with this issue we have been able to refine our aim.

Aside from how it has affected CJRM and its targetted audience, many more substantive concerns hinge on the definition of rural. It is important to identify the features that describe practices that we conveniently group under the moniker "rural" so that we can understand the issue of recruitment and retention, provide the necessary training and, in the end, provide the health care that is appropriate to rural communities. Physicians simply cannot be tossed into a rural area and be expected to "do the best they can." Issues of fundamental justice and of fiscal equity hinge on clear definitions.

Yet a definition of rural, as it applies to medicine, remains elusive. Distance from a major centre is not itself a reliable indicator. A practice 40 km from Toronto may function in a significantly different manner from one located 40 km from Red Deer. Transport time in good weather has been used by some as a definition, as has the presence or absence of key specialty or subspecialty facilities. However, these in isolation are not a full description since weather varies with the season, and specialty availability, at times, seems just as unpredictable. The level of responsibility assumed by rural physicians is widely seen as a defining concept, but even in this area there may be great interphysician variability (even in clearly rural regions), and responsibility itself is difficult to quantify.

The medical needs of rural communities must be explicitly defined, parameters of practice clearly spelled out and training provided to match the skills required. To do this effectively we must be able to define rural.

CJRM will be exploring the topic in greater depth in a forthcoming issue, and we are interested in broadening the discussion within and outside the rural community. If you have a clear idea of what rural means to you, share it with us. I have a feeling that the answer will come from those who know rural medicine the best, rural doctors themselves.