The Great Healthcare Divide

Rural vs Urban

Photo by Domino Studio on Unsplash

If you’re traveling across America this Summer, particularly if you’ll be going through the vast rural expanse of this amazing country, I have a bit of advice. Before you hit the road, make sure you know where the hospitals are and what resources they have.

This is especially true if you or members of your party have particular medical needs. Because the hard reality is that America has a growing healthcare divide. And that divide is between rural and urban.

I think that television dramas have given people the perception that all hospitals have all things. I mean, when you need a heart transplant, you show up to the ER and they find it and put it in, right? Most people recognize (I hope) that such a situation is mere fiction. But other things we might expect just aren’t available once you’re 30 miles, 60 miles or more out of the city.

Most hospitals that are not teaching or referral centers have no neurology (except by telemedicine visit) or neurosurgery. Time sensitive care for strokes or ruptured aneurysms, care for head injuries and spinal injuries cannot be done locally. In addition they rarely have cardiologists on site and almost never have cardiothoracic or vascular surgeons. Coronary arteries won’t be opened, bypass surgeries and abdominal aneurysm repairs won’t be performed; at least not as fast as we know they should be done. When these services are needed, patients go by ambulance or sometimes helicopter (when weather permits).

Have a complicated surgical procedure and think it might be nice to travel and recuperate? Nice idea, but make sure your surgeon clears it. Lots of small hospitals have either no surgeon or limited surgical capacity. And they don’t like to try and manage complications from surgeries they don’t do themselves (bariatric surgeries for weight loss are a good example). Some procedures require very specific instruments and very specific training. Oh, they’ll do their best, but it’s better to be close to your own doctor until the dust settles.

Many small hospitals lack other critically important specialties and equipment. For instance, they often have no ophthalmologist. Severe eye injuries, detached retinas, perforated globes, acute glaucoma, all such things have to transferred elsewhere, generally at least an hour away; often several. This is always a potential tragedy given that we humans are visual creatures, our world is vision oriented and we have an enormous amount of territory in our brains dedicated to sight.

Small hospitals usually don’t have oral/maxillofacial surgery. Even a dentist on call is a rarity. Severe facial fractures, even displaced or broken teeth, have to be go elsewhere. (Even by private car, it’s still a transfer to another town.) Or those things wait until morning when offices open up. (I wrote about teeth recently as regards the value of dental nerve blocks.)

It wasn’t until later in my career that I realized how vitally important it is to have a urologist (a surgeon who operates on the urinary tract). Many patients have malignancies, enlarged prostates or kidney stones, that obstruct the flow of urine. More than painful, this can be deadly. Retained urine becomes infected urine. This turns into bacteria in the blood, then sepsis (the state of poor blood perfusion to organs due to infection) and can be fatal. Sepsis is a very common cause of death in hospitals and we have many initiatives in place against it. But when you need a surgeon, you need a surgeon. In particular, a surgeon to get that urine out. (So much of medicine is plumbing!)

Traveling and pregnant? Obstetric deserts are growing. I just wrote about this in Emergency Medicin News. https://journals.lww.com/em-news/fulltext/2024/06000/the_growth_of_maternity_deserts.8.aspx

Because many pregnant women are covered by Medicaid, small hospitals in particular find that labor and delivery units are a financial loss. Don’t count on that hospital off of the highway to have an obstetrician; much less a neontal nursery. (This whole thing is especially problematic in a time when we’re struggling with falling birth rates and need to encourage people to have children!)

Not only so, even pharmacies are limited (and often closing) in small towns. That important medication refill, insulin for instance, may not be available until morning. https://apnews.com/article/pharmacy-rural-drugstore-access-closures-425c785b5f244115543d54001311ef33

And of course, another terrifying reality is that some counties in America have no ambulances to call in case of emergency. https://www.npr.org/sections/health-shots/2021/07/05/1012418938/rural-ambulance-services-at-risk-as-volunteers-age-and-expenses-mount. Even those that do often can’t spare an ambulance to take a very sick patient to another facility.

What we’re seeing across the country is the steady collapse of rural healthcare and the closure of small hospitals. https://www.usnews.com/news/healthiest-communities/slideshows/states-with-the-most-rural-hospital-closures

Those that remain open in rural areas often have limited specialty capacity. Not only due to financial issues, but because we have insufficient numbers of many specialties. This is true of procedural specialists like the various species of surgeon, but also of gastroenterologists, cardiologists, intensive care specialists, pediatric specialists and many others. These physicians tend to congregate in large centers where they can do many procedures and be paid commensurate to their skills. (And the amount of time they took not being paid well in training.)

And perhaps worst of all, primary care physicians seem to be going the way of the dinosaur. The low pay and busy lifestyles of their critical work is a disincentive, and systems now put more PAs and NPs into those roles. I believe this is often done unfairly as the job requires too wide a scope of knowledge to be practiced unsupervised by non-physicians With physician oversight? Absolutely.

The genesis of all of these closure, all of these limitations in facilities and physicians, would be a long post indeed. But I write this as warning. Whether you are traveling through rural America or have decided to live there (generally a pleasant move mind you), it’s really important to be aware of the limitations that exist in those areas when it comes to both routine and emergency healthcare.

America needs to reset its priorities (ditto Canada as I understand it), and find creative ways to make medical care for rural citizens as excellent and up-to-date as anything experienced by urban citizens.

And anyone living, working or traveling outside the range of large urban and suburban hospitals just needs to be careful and aware. Because the help you expect may not be available when it matters most.

(Oh, be sure to take your medication lists and a summary of your health problems as most electronic medical records system in the country don’t talk to one another. Especially those in small, rural hospitals which can’t afford high-dollar systems.)

So enjoy your summer, enjoy your travel and be careful out there! Rural America is magnificent and worth your time and tourism dollars.

PS This may be a good time to consider buying travel medical evacuation insurance, some of which will work for domestic as well as rural transports when you need to get home or to a higher level of care. Here are two links on the topic:

https://www.forbes.com/advisor/travel-insurance/medical-evacuation-coverage/

https://tinyurl.com/4duyf8bk