Canadian Journal of Rural Medicine

 

In search of a definition of "rural"

James Rourke, MD, CCFP(EM), MClSc, FCFP, FAAFP

Rural General Practitioner/Family Physician, Goderich, Ont.; Associate Professor (part-time), Department of Family Medicine, University of Western Ontario, London, Ont.; Director, Southwestern Ontario Rural Medicine Education, Research and Development Unit, London

Can J Rural Med vol 2 (3):113

Correspondence to: Dr. James Rourke, 53 North St., Goderich ON N7A 2T5

© 1997 Society of Rural Physicians of Canada

Rural is a perspective, dependent on person, place and contxAs such, the definition and meaning of "rural practice" will vary considerably, depending on whether the person is a rural patient trying to access care, a rural doctor or other rural health worker, a researcher or a government planner. Trying to define rural practice quantitatively is an ongoing problem, and numerous attempts have been made to do so.

In general terms, rural practice can be defined as practice in nonurban areas, where most medical care is provided by a small number of general practitioners/family doctors with limited or distant access to specialist resources and high technology health care facilities. In Canada, communities of up to 10 000 people are often classified as rural.[1,2] By this definition and according to 1991 census information, 31.6% of the Canadian population lives in rural areas.[3] In contrast, only 11.3% of doctors practise in these rural areas (18.6% of general and family practitioners and 3.8% of specialists).[4] Other countries have different geographic definitions of rural.[5­7]

The practice of medicine becomes more challenging as distances from urban areas and isolation increase, while local resources decrease. The Faculty of Rural Medicine, Royal Australian College of General Practitioners, defines "remote rural practice" as "practice in communities more than 80 km or one hour by road from a centre with no less than a continuous specialist service in anesthesia, obstetrics and surgery and a fully functional operating theatre."[8] The Rural Committee of the Canadian Association of Emergency Physicians defines "rural remote" as "rural communities about 80­400 km or about one to four hours transport in good weather from a major regional hospital" and "rural isolated" as "rural communities greater than about 400 km or about four hours transport in good weather from a major regional hospital."[9] An agreement between the Ontario Ministry of Health and the Ontario Medical Association identifies communities of fewer than 10 000 people, greater than 80 km from a regional centre of more than 50 000 people as "specified" or "isolated" communities. Physicians in these communities qualify for additional funding for continuing medical education, assistance with locum tenens and, in some cases, direct salaried funding rather than fee-for-service.[10]

Definitions such as these, however, fail to include or measure the depth and variety of rural practice and the many factors important to recruitment and retention of rural physicians. There is a clear need to develop a more comprehensive index of rural practice.

Indices

The paper in this issue by Eugene Leduc ("Defining rurality: a General Practice Rurality Index for Canada," page 125 ) presents a preliminary model that measures 6 community variables in an effort to quantify rural practice. These variables are distance from the closest advanced referral centre, distance from the closest basic referral centre (or advanced referral centre if closer), drawing population, number of GPs, number of specialists and presence of an acute care hospital.

Other rural practice indices have been developed. The proposed British Columbia Northern and Isolation Allowance Program measures 5 medical isolation factors (number of GPs, number of specialists in the geographic area, distance from a regional referral hospital, exceptional circumstances and doctor:population ratio) and 2 living factors (remoteness from a major population centre and size of the community) (Dr. Geoffrey Appleton, Terrace, BC: personal communication, 1997).

The New Zealand Rural GP Network Rural Ranking Scale measures 7 variables: travelling time from the office to the base hospital, availability of ambulance services, on-call for motor vehicle accidents, travelling time to nearest GP colleague, travelling time to visit most distant patient, on-call duty and number of regular peripheral clinics. The Midland Health (New Zealand) Rural Practice Questionnaire includes 6 additional variables: number of GPs working within 10 to 30 minutes travel time, proportion of patients living more than 30 minutes away from the office, travelling time from the office to the nearest urban centre of more than 30 000 people, socioeconomic status of the practice population, population density of the area served by the practice and ratio of GPs to population (Dr. Martin London, Rural Health Professional Resource Team, Christchurch School of Medicine, Christchurch, New Zealand: personal communication, 1997).

Any index of rural practice should reflect where rural doctors live, what they do and what degree of professional isolation and support they have. When looking at any detailed index, it is useful to see how it examines the depth and variety of rural practice under the 3 headings of community and lifestyle factors, the nature of practice, and professional isolation and support. It is also important to see how these factors are weighted in any index.

Community and lifestyle factors (where rural doctors live)

In the smaller, more distant communities, educational facilities, spousal job opportunities, religious and cultural access, and the potential mate pool for unmarried physicians are all less available. Transportation for these activities is both time-consuming and expensive. Any index of rurality therefore must include both the size of the community and the distance from or ease of access to larger urban centres as key markers for these important social and family considerations.

The nature of rural practice

A practical definition of rural practice, used by the Faculty of Rural Medicine, Royal Australian College of General Practitioners, is "medical practice outside of urban areas where the location of practice obliges some general/family practitioners to have or acquire procedure or other skills not usually required in urban practice."[8]

Each rural setting has its own special challenges. In the smallest, most remote settings, help is a long time and distance away. This places immense strain on limited local resources and on the physician, particularly when serious emergencies occur. In larger rural communities, those equipped with a small active hospital, the rural general practitioner/family doctor's scope of practice, in addition to office-based family practice, house calls and nursing home visits, often includes extensive hospital-based medicine.[11] This usually includes emergency medicine shifts, direct care of in-hospital patients, obstetric deliveries and sometimes GP anesthesia. Acquiring and maintaining the necessary knowledge and skills is a daunting challenge.

The few existing rural specialists, predominately general surgeons, as well as internists, radiologists and a scattering of others, also generally need a broader scope of practice than their urban colleagues.[11] For example, the comprehensive rural general surgeon may perform not only common general surgery, but also plastic, orthopedic and gynecologic procedures and cesarean sections.[12­14]

Ideally, all physicians in the community maximize their complementary skills and interests as part of a group responsibility to meet the needs of the community. This approach may be important in encouraging female physicians to bring their talent and skills to rural practice while providing the kind of flexibility to allow different lifestyle choices.[15] Appropriate organization, funding, support and cooperation are necessary for this approach to work well.

The rural health care context is only beginning to be considered at academic and government levels. The population served by rural doctors has distinct characteristics and determinants of health.[8,16­18] Too often, preventive health care, patient education and counselling are given a low priority or are simply not done because of the time constraints of too few doctors providing care to too many patients. In underdeveloped settings, public health activities take on special importance for rural doctors.

Professional isolation and support

Although all rural areas suffer from professional isolation relative to urban practice, the smallest, most remote communities pose particular challenges in terms of both professional isolation and lack of resource support.[1] This factor must have particular weighting in any index of rurality. Even though the nature of practice may be similar in 2 very different geographic settings, the distance to referral sources may be dramatically different. The presence of a local hospital and its level of resources, including any specialists, and the distance to more advanced referral care and specialist support services are factors affecting professional isolation.

Advances in information technology have made it easier for all rural doctors to access information and continuing medical education, but they do not replace the need for programs to support rural physicians so that they can attend conferences and other educational forums, including intensive short-term traineeships.

The number of doctors available to share the workload and on-call duty is an important variable contributing directly to the sustainability of working conditions. Balancing on-call and case load can be problematic, especially for anesthesia, obstetrics and emergency work. Because rural specialists are often one-of-a-kind in any location, they frequently have the greatest burden of on-call.

In rural practice, professional boundaries are more difficult to maintain, as patients often include people known in other roles, such as neighbours, colleagues, hospital staff and personal friends.[19­21] These complex relationships form part of the richness and challenge of rural practice.

Conclusions

Coming up with a comprehensive definition of "rural" is not an easy task. General practice rurality indices, such as the one described by Dr. Leduc in this issue, can provide a quantitative measure of rural practice. They need to be assessed by how well they reflect where rural doctors practise (community and lifestyle factors), what these doctors do, what professional isolation and support they experience, and how these 3 main considerations are weighted.

Acknowledgements: I thank Prof. Roger Strasser, Dr. Ian Park and Dr. Leslie Rourke for their thoughtful input and the rural doctors who attended the "Definition of Rural Practice" interest group session, chaired by Dr. Eugene Leduc, at the Rural/Remote Area Medicine Conference in Banff on Apr. 3, 1997, for their lively discussion of this topic.

References

  1. Report of the Advisory Panel on the Provision of Medical Services in Underserviced Regions. Ottawa: Canadian Medical Association; 1992.
  2. Rourke J. Perspectives on rural medical care in Ontario. Can Fam Physician 1991;37:1581-1584,1647.
  3. Urban areas. Population and dwelling counts. Ottawa: Statistics Canada; 1992. p. 62 (Table 3).
  4. Sanmartin CA, Snidal L. Profile of Canadian physicians: results of the 1990 Physician Resource Questionnaire. Can Med Assoc J 1993;149(7):977-84.
  5. Rourke JTB, Strasser R. Education for rural practice in Canada and Australia. Acad Med 1996;71(5):464-9.
  6. Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. Which medical schools produce rural physicians? JAMA 1992;268(12):1559-65.
  7. American College of Physicians. Rural primary care. Ann Intern Med 1995;122(5):380-90.
  8. Strasser R. Rural general practice: is it a distinct discipline? Aust Fam Physician 1995;24(5):870-6.
  9. Rural Committee, Canadian Association of Emergency Physicians (Thompson J, chair). Recommendations for the management of rural, remote and isolated emergency health care facilities in Canada. Ottawa: Canadian Association of Emergency Physicians; 1997. p. 12.
  10. Rourke JTB. The politics of rural medical care: forces for change. Ont Med Rev 1994;61(8):17-22.
  11. Rourke J. Small hospital medical services in Ontario. Part 1: Overview. Can Fam Physician 1991;37:1589-94.
  12. Rourke J. Small hospital medical services in Ontario. Part 5: General surgery services. Can Fam Physician 1991;37:1897-1900.
  13. Blanchard RJW. Nontertiary surgery in Manitoba: comparison of provincial and teaching-hospital data. Can J Surg 1992;35(5):531-5.
  14. Chiasson PM, Henshaw JD, Roy PD. General surgical practice patterns in Nova Scotia: the role of the "generalist" general surgeon. Can J Surg 1994;37(4):285-8.
  15. Rourke LL, Rourke J, Brown JB. Women family physicians and rural medicine. Can the grass be greener in the country [editorial]? Can Fam Physician 1996;42:1063-7 [French version, Can Fam Physician 1996;42:1077-82].
  16. Rosenblatt RA, Moscovice IS. Rural health care. Toronto: John Wiley & Sons; 1982.
  17. Cox J. Rural general practice [editorial]. Br J Gen Pract 1994;44:388.
  18. Rousseau N. What is rurality? In: Cox J, editor. Rural general practice in the United Kingdom. London: Royal College of General Practitioners; 1995. p. 1-4.
  19. Rourke JTB, Smith LFP, Brown JB. Patients, friends, and relationship boundaries. Can Fam Physician 1993;39:2557-64.
  20. Rourke L, Graham S, Brown JB. Establishing personal and professional boundaries: the challenge for physicians in small communities. Ont Med Rev 1996;63(5):74-5.
  21. Rourke J, Rourke L, Goertzen J, Brown JB, Smith L. Physician­
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Table of contents: Volume 2, Issue 3