From the WONCA President: Rural Rocks

November, 2012


This is not a column about remote geology. Rather, it is about the unique and extraordinary work of family doctors in more isolated settings. A common pattern is that younger people in a society flock to the cities for jobs. This results in rural communities with a significantly greater percent of the aged and their greater health care needs. While about half the world’s population lives in rural areas, a much smaller proportion of health care professionals are located in those areas. This disproportion is even greater when it comes to the distribution of physicians. Family doctors however, do a better job of distributing themselves to better meet the needs of the people. For example, in the United States, family doctors are the only physicians distributed geographically in the same proportion as the general population.

I reflected recently on this while driving in the early morning hours from Duluth, Minnesota, USA to Thunder Bay, Ontario, Canada. I was headed to the WONCA Rural Conference on Health, which is convened every few years at locations around the world. In prior years, other commitments made it impossible for me to attend previous conferences – this was to be my first global rural health conference. Even this year, it was not easy. The preceding afternoon, I had to be at an important meeting at the National Institutes of Health (NIH) in Washington, DC, USA to discuss research funding for multiple morbidities like depression and diabetes. It was important that primary care was at that table.

The NIH meeting meant that I had to fly into Duluth late in the evening and arrived at the hotel at 01.00. It was a short time in bed as I needed to arise at 03.00 to fulfill my opening duties in Thunder Bay, a 3.5 hour drive and 1 time zone away. Friends who had lived in the area got me excited about the prospect of a beautiful drive along Lake Superior, enjoying the fall colors as leaves changed to yellow, orange, and red in this heavily wooded region. Unfortunately, there was not much to see driving in the dark, but more on that later.

Even though I was in Thunder Bay for only 28 hours, it was an amazing experience. More than 800 registrants from around the world were in attendance. The conference was a mix of plenary sessions and small group workshops. There were presentations from every continent. Distances were bridged with some speakers joining by videoconference. Much of the discussion focused on the considerable need for more health care professionals in rural communities. The conference was most inclusive: trainees and experienced clinicians; practitioners, teachers, researchers, and administrators; patients; nurses, doctors, and other professionals. A special effort was made to focus on the needs of indigenous people. Participants were able to visit rural health care sites and see firsthand the incredible potential of distributive education. Special congratulations go to Professor Roger Strasser, conference host and Dean of the Northern Ontario School of Medicine, and Professor Ian Couper, chair of the WONCA Working Party on Rural Health. Their vision and planning made for a memorable and successful conference.

The conference confirmed my belief that there is something special about rural practice and practitioners. I believe that rural practitioners come closest to achieving the principal aims of primary care. Barbara Starfield taught that the two aims and assets of primary care are continuity and comprehensiveness. After observing patient care by hundreds of family doctors, both rural and urban, in more than 50 countries, I have concluded that rural practitioners tend to provide greater continuity of care and more comprehensive services. I do not know whether those choosing rural practice do so because they seek to provide greater continuity and comprehensiveness or whether the limited resources in rural settings compel them to do so. I suspect it may be a combination of both reasons, as well as other reasons perhaps (desire for rural lifestyle, return to rural roots, etc.).

By way of full disclosure, I must confess that I am biased on this issue. My 30 years as a family doctor have been spent practicing in communities with fewer than 2500 people. I think those experiences have taught me a few things. In rural communities, health care professionals lean on each other for mutual support – it is more about performance (“who does what best”) rather than pedigree (“who has what credentials”). Rural professionals also understand the importance and value of leveraging their relationships with patients and community leaders to improve the health and well being of their communities. Perhaps the relative lack of resources in rural settings provides greater clarity about individual responsibility and community priorities.

Before entering practice, I spent a dozen years studying at university and training in urban areas with metropolitan populations ranging between 0.5 and 15 million people. I learned, and the literature confirms, that large urban centers represent a collection of small communities that may be defined by proximity, ethnicity, religion, or common interests. For example, studies of lifelong New Yorkers show that most of them spend the majority of their lives residing, working, dining, and recreating within a several block area. So, in a sense, urban areas are like rural areas from an individual’s perspective. It is just that in urban settings there are many more sub-communities to choose from that are defined more by affiliations and interests, and less by geography. This creates more opportunities to express individual preferences, but more challenges for social cohesion.

Thus, I have concluded that rural practitioners can teach all of us a great deal about what health care does, and should, look like. In rural settings, the more obvious connections between individual professional actions and community impact show us more clearly the importance of primary care and its core values of continuity and comprehensiveness. Similarly, the resource constraints of rural practice can foster innovations that will serve all of us well, but only if we listen carefully and learn from what rural professionals say and do. We have to pay attention.

My drive in the dark to Thunder Bay focused my attention on the road ahead. Caught at times in the headlight beams were a number of deer poised to jump from the roadside, and even a young male moose. As the sun emerged over the tree tops, the sky became a glorious orange-red. The effort of the long, intensely focused, and tiring drive contrasted with the beauty of the vista. It reminded me that in rural practice the journey is never easy, but it is worth it.

Professor Rich Roberts
World Organization of Family Doctors