Re: Physician and Advanced Practice Clinician Burnout in Rural and Urban Settings

In the article “Physician and Advanced Practice Clinician Burnout in Rural and Urban Settings,” Harry et al report a result of no significant difference in rates of burnout between urban and rural physicians and advanced practice clinicians (APCs) within their Upper Midwest health care system.¹ The article’s definitions of rural and urban, while based on the Veteran Health Administration’s (VHA) interpretation of the US rural-urban commuting area (RUCA) codes, do accurately stratify urban and rural health clinicians and therefore may misrepresent their respective rates of burnout for each. The authors mention that their findings refute prior claims that practicing in a rural setting may increase burnout compared with an urban setting. Their miscategorized data may steer efforts away from initiatives to decrease rates of physician burnout in rural locations.²

The authors coded rurality using the VHA RUCA codes. The VHA uses RUCA code 1 for urban areas, while RUCA codes 2 to 10 correspond to rural areas.³ Other governmental organizations, such as the US Census Bureau and United States Department of Agriculture’s Economic Research Service (USDA-ERS), interpret these codes differently. The US Census Bureau states that “urban areas” contain 50,000 or more people.⁴ The USDA-ERS includes detailed descriptions for each of the 10 RUCA codes. Codes 1 to 3 do not refer to population size at all; Code 4 refers to a “micropolitan area core…within an urban cluster of 10,000 to 49,999.” ⁵ US agencies are using RUCA codes differently to define rurality differently. Had the authors used the USDA-ERS categorizations of RUCA codes, for example, they might have found significant results regarding burnout experiences between rural and urban areas. Unfortunately, the authors did not include individual respondents’ information, making it impossible to explore alternative groupings of the data which could yield a significant difference in burnout rates between urban and rural clinicians.

While it is tempting to follow the rural-urban classification patterns of a large organization such as the Veterans Health Administration, inaccurately categorizing the data may steer efforts away from initiatives to decrease rates of physician and APC burnout in rural locations. I encourage the authors to reanalyze the data using the interpretation of rural and urban definitions discussed in this letter to determine if a significant difference in burnout exists.