Urgent and emergency family physicians in rural communities.

Health reform and the Affordable Care Act have triggered a renewed interest in strengthening access to primary care services, with a focus on ensuring that the nation has appropriately trained physicians practicing where they are needed. There are about 80 primary care physicians per 100,000 people the United States. Not surprisingly, rural areas have a much lower physician-to-population ratio than urban areas and a higher proportion of generalists. The number and types of physicians needed for optimal health outcomes is key to implementing the triple aim of improving population health, the experience of care, and costs. Understanding scopes and patterns of practice and settings where family physicians provide care provides a reference point in moving toward full access to high-quality care across the nation. Described in a policy brief in this issue of the Journal of the American Board of Family Medicine, staff from the American Board of Family Medicine and The Robert Graham Center analyzed data collected from 22,000 family physicians who passed the Maintenance of Certification examination for Family Physicians between 2008 and 2012. They found that 6.7%—almost 1500 of the recertifying family physicians—spend at least 80% of their time in urgent or emergency care settings. There was an association between greater rurality and a higher percentage of family physicians providing any care in emergency settings. Family physicians account for one half to two thirds of all physicians in rural areas, and the number of specialists diminishes with greater isolation. This presumably leads to a wider scope of practice to address multiple clinical issues and to provide accessible, comprehensive, continuous, coordinated care that is the promise of family medicine. Training and deploying the physician workforce to provide services when and where they are needed is complex and varies across regions and circumstances. Because this analysis reveals that rural family physicians spend a substantial proportion of their time in urgent and emergent settings compared with their urban counterparts, attention to the practice environments and patterns, along with the patient population, is particularly relevant. Scrutiny of the multiple interrelated factors that contribute to the finding of a greater number and percentage of rural compared with urban family physicians practicing in urgent and emergent care may provide perspective on these findings. Factors include, but are not limited to, specialty knowledge, attitudes, and skills of family physicians; workforce needs in underserved and rural locations; available communication and referral networks; and patient demographics in urgent and emergent settings. In addition, the range of health care requirements, including the need for urgent and emergency care in rural settings, offers a wide range of employment opportunities for family physicians that are not available in metropolitan areas. The flexibility of family physicians is important in providing a broad range of services in response to local needs because patients are not limited to a specific age group, sex, or organ-related complaint.With training in behavioral and social issues related to health, family physicians are well positioned to address the variety of problems that present in urgent and emergent settings. A significant percentage of emergency visits are for ambulatory care–sensitive conditions, making family physicians exceptionally well prepared. Because family physicians are more likely to provide emergency care in rural settings From The Robert Graham Center, Washington, DC. Funding: none. Conflict of interest: none declared. Corresponding author: Kathleen Klink, MD, The Robert Graham Center, 1133 Connecticut Ave NW, Suite 1100, Washington, DC 20036 (E-mail: [email protected]).