While I have my biases, I really do not think big city doctors are better than rural ones. One might define a better doctor as one who knows more medicine, makes obscure diagnoses, provides good patient care, provides good service to their community, sees more patients, saves lives, have high levels of patient satisfaction, know more up to date treatments or current medical literature, etc.
I have worked in hospitals of every size. I am currently working in emergency medicine in a small town with few specialty services available. We have one doctor on duty and a back-up doctor available. In the last week, I have seen many patients who would have died without immediate medical care – including a baby one week old in heart failure and cardiogenic shock secondary to undiagnosed diGeorge’s syndrome, a three year old who nearly drowned in a swimming pool, some severe strokes and heart attacks, several car accident patients with intracranial bleeding who required neurosurgery, etc.
In a big hospital, these patients would immediately be assessed by a trauma team of five or six doctors and residents plus lots of designated nursing staff. In our hospital, these cases are handled by the one doctor and two nurses in the department who intubate the patient, start IVs, secure the airway, get ECGs, blood gases, X-rays, diagnose life and limb threatening conditions (in a facility with no CT available), put in catheters and lines, organize fluid, interpret all test results, call in the back-up doctor, arrange for transfer if needed, etc., etc.
The one doctor needs to know a lot of medicine since the specialty services (orthopedics, pediatric ER, traumatologists) that exist in the city are not available. You cannot get away with not keeping up to date on the general medical literature. You need to make a correct presumptive diagnosis quickly and accurately, treat all the major diagnoses, and do a lot of things quickly that in a bigger centre would be done by many people.
A city doctor usually has better access to subspecialty expertise, more staff, more diagnostic imaging, better labs, more staff and help, etc. In this setting, you do not need to know as broad a spectrum of medicine and can thus delve deeper into the literature and know things in more depth. It is thus not surprising that specialists can make more obscire diagnoses, but this is not needed for the majority of patients.
In any city where there is a good pediatric hospital, parents will feel more comfortable when their children get treatment there, even for routine diagnoses. When I send my patients to the city for follow-up or for specialist consult, they often complain “you sent me all this way and they didn’t do anything different”. But without specialty back-up, I would hardly ever try to talk a patient out of going to see the city specialist if the patient is determined to do so – since I don’t have their expertise over ANY narrow subject area.
It grinds my gears when a big city ICU tells me that a patient is “too sick” (as if management in a small hospital with no ICU or specialists will be more optimal in a critical patient), or a specialist does not want to see a sick patient purely since it would put them out of their routine. This happens fairly often.
City practice is more attractive to many doctors than rural practice – perceived better lifestyle, more academia, easier for spouse to get job, more prestigious, better hours, etc. City doctors can easily refer patients. I know many internists in the city who do not keep current with ACLS (basic guidelines for managing a heart attack) since “I’ve not had to manage a code in years – the resident does it”; or city emergency doctors who leave all intubation to the RTs and anesthesiologists. A rural doctor has to know all these things and uses them frequently. You could argue that you need better marks/residency training to GET a job in a prestigious hospital. I’m not sure if this is true, but I am sure the real education and learning starts AFTER residency and by dealing with tough situations.
I have seen a lot of patients misdiagnosed and mismanaged by city doctors – and am sure the reverse is true too. I have had patients who refused to admit they had, for example, Huntington’s chorea, because they went to a “expert specialist” clinic in the city every year for an executive physical, had a million tests done by specialists who did lots of tests (ka-ching!) but didn’t examine the patient. In practice, it is easy in the city to not need to use certain skills since there are so many other people sround who have those skills. It is also easy in ANY practice to not want to spend the immense time needed to keep up to date, and it is easier to keep up to date over one or two fields than in primary practice where very broad knowledge is required.
All of our above patients did well, even though our hospital is poorly funded and lacks good back-up. I would argue one doctor who can fulfill the role of many doctors is at least as useful as a specialist who can diagnose obscure conditions – but much depends on the patient you are talking about. Bad doctors with poor bedside manner or who are overworked or not up to date exist in bith the city and country. The definition of a good doctor differs from patient to patient and is not encapsulated fairly by “latest medical treatments” or “obscure diagnosis” which most folks do NOT need. I make most of my diagnoses with access to few tests and only X-rays and ultrasound and believe this lack of being able to depend on these things has made me a pretty good diagnostician – but if you have something weird and wonderful I’d probably miss it… but would hopefully have referred you to a “better” doctor who wouldn’t… if a timely referral is possible!
