Access to primary care is the top-ranking health priority for rural areas (Gamm et al., 2003). Across the health sector, primary care is highly valued as the key mechanism for meeting the majority of health care needs of most individuals. Primary care practices provide essential care for a wide range of health problems; guide patients through the health system, including referrals; foster an ongoing relationship between clinicians and patients (and their families); support disease prevention, management, and health promotion; and build bridges to the local community (IOM, 1996). Shortages in the supply of primary care providers directly affect not only the health status of individuals, but also the rest of the providers in the delivery system.

In rural areas, as in urban, the bulk of health care services are provided in primary care practice settings in the local community, such as small private practices, community health centers, and rural health clinics. The main differences between rural and urban providers are the health professionals engaged in primary care and the scope of practice; the actual structure of urban and rural practice settings tends to be similar.

Primary Care Clinicians

Rural primary care providers are more likely than urban to be family physicians or generalists with a broad scope of practice, and a greater proportion are more likely to be midlevel professionals (e.g., nurse practitioners, physician assistants). The scope of practice for rural physicians can include primary care subspecialties such as pediatrics, obstetrics and gynecology, gerontology, internal medicine, and general surgery for certain procedures, as well as the traditional primary care services for episodic care, preventive care, and chronic disease management. Because certain specialty services are unavailable in rural areas, many rural physicians also provide services characteristic of specialty practice, such as intensive care (51.4 percent), emergency department care (58 percent), and specialist procedures (e.g., sigmoidoscopy [29 percent]) (Phillips and Green, 2002). Some midlevel practitioners provide services in specialist areas as well.

Following is a summary of the presence of these providers in rural practices. As this discussion is limited to clinicians having the greatest contact with patients, pharmacists also are included, but allied health professionals (e.g., laboratory technicians and radiologists) are not. Providers of emergency care, mental health and substance abuse services, and dental care are

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