The increased demand for primary care services expected to result from the Affordable Care Act (ACA) may be felt strongly in rural areas. While studies have found that the quality of care delivered to rural patients is as good or better than that available in urban areas, the belief persists that top-quality primary care is only available in big cities. But a new study appearing in the National Rural Health Association's Journal of Rural Health finds few meaningful differences between rural and urban primary care physicians on key measures of professionalism, including their attitudes about participation in quality care improvement. The study did find differences in the likelihood of physicians' knowing a colleague who was impaired or incompetent, in their confidence evaluating new information and in several aspects of their interactions with patients.
"In terms of professional beliefs and behaviors, we found that rural and urban doctors are more alike than they are different," says study leader Eric G. Campbell, PhD, director of Research at the Mongan Institute for Health Policy at Massachusetts General Hospital (MGH) and professor of Medicine at Harvard Medical School. "Despite our results and other evidence, the perception still exists that rural primary care is not as good as that available in cities. So we needed to learn more about the factors driving that misperception and the role it may play in the continuing shortage of rural physicians in the U.S."
Campbell and his co-authors note that, while smaller rural communities may have disadvantages in terms of fewer training options, rural primary-care physicians are significantly more likely to participate in activities such as quality improvement in their practices and hospitals. The fact that rural physicians are more likely to have personal as well as professional relationships with their patients may give them a better sense of environmental and lifestyle factors that affect patients' health but also could lead to challenges when professional responsibilities conflict with patient expectations and perceptions.
This study was designed to determine whether there were significant differences between primary care rural and urban physicians in terms of professional beliefs and in their interest and participation in quality improvement activities. The survey was sent to almost 3,000 practicing physicians randomly selected from an American Medical Association database, almost 2,000 of whom responded. The current report analyzes responses from 840 family practitioners, internists or general pediatricians. Based on ZIP code information, 127 respondents practiced in rural communities, while the other 713 were from urban areas.
There were no significant differences between rural and urban physicians' attitudes regarding participation in quality improvement activities and the importance of open communication with patients, including reporting any errors in their care. Rural physicians were more likely to participate in error-reduction initiatives, in reviews of other physicians' records, and to feel prepared to contribute to quality improvement efforts. They also were more likely to agree that physicians should discuss the costs of care with their patients and to report having added Medicaid or uninsured patients to their patient panels during the preceding year.
"Rural physicians are dedicated to providing high-quality care and committed to supporting safety-net patients," says Anne Kirchhoff, PhD, MPH, corresponding author and an assistant professor of Pediatrics at the University of Utah. "The Affordable Care Act should help more rural primary care providers receive payments for care they currently provide without charge. But as the Medicaid expansion is limited to only half the states, many rural providers will still shoulder a disproportionate cost burden compared with urban physicians."
Although both urban and rural physicians agreed on the importance of reporting colleagues who were incompetent or in some way impaired, rural physicians were significantly more likely to indicate actually knowing about such individuals. Similar percentages of both rural and urban doctors felt prepared to deal with impaired or incompetent colleagues. Rural physicians were more likely to report having fulfilled patient requests for brand-name drugs when less expensive generics were available – a common measure of wasteful medical practice – and were less likely to feel prepared to evaluate new medical information.
"Our findings suggest a deep and broad agreement among primary care physicians on the key tenets of medical professionalism, regardless of the location of their practices," says Campbell. "However we are concerned that, while rural physicians are more likely to know an impaired physician, most of them do not feel prepared to deal with such colleagues. Although rural physicians were more likely to talk to their patients about the costs of their care, they may not be as drug-cost-conscious as they could be. And many don't feel prepared to evaluate new clinical information. We need to further explore the implications of these findings, particular since a significant number of the patients enrolling in new ACA-sponsored health plans will be from rural areas."
Gary Hart, PhD, director and professor at the Center for Rural Health, University of North Dakota School of Medicine and Health Sciences, is also a co-author of the Journal of Rural Health report. The study was supported by a grant from the Institute on Medicine as a Profession at Columbia University.
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $775 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, transplantation biology and photomedicine.
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