What is Rural?

In the morningRural Medical Education Director's Executive Summary

Mission of the College of Medicine:
“The Florida State University College of Medicine will educate and develop exemplary physicians who practice patient-centered health care, discover and advance knowledge, and are responsive to community needs, especially through service to elder, rural, minority, and underserved populations.”

Mission of the Department of Family Medicine and Rural Health:
“The mission of the FSUCOM Department of Family Medicine and Rural Health is to teach, serve, and advocate for people and communities, in a person-centered way, through innovative and exceptional service, particularly to rural, elderly, minority and underserved populations; and to produce exemplary physicians who understand and embrace the values of family medicine.”

What is Rural?

The Florida State University College of Medicine was created by the Florida legislature with the passage of House Bill 1121 in June 2000. It was the clear intent that this school have a significant focus on rural health. The word “rural” appears 15 times in the bill, including statements throughout the bill that defined various priorities of the College, such as: the school will have “a principal focus on recruiting and training medical professionals to meet the primary health care needs of the state, especially the needs of the state’s elderly, rural, minority, and other underserved citizens”; “the College of Medicine shall be dedicated to: preparing physicians to practice primary care, geriatric, and rural medicine”; “provide broad-based clinical instruction in both rural and urban settings for students”; and “during the third and fourth years, the curriculum shall follow a distributed, community-based model with a special focus on rural health.” With the word rural such a prominent part of our identity as a medical school, we are routinely asked, “What is rural?”

Generally speaking, the definition of rural varies depending on several factors. These include:
• the group providing the definition (e.g., the Census, the Office of Budget and Management)
• the intended goals or interests of the group providing the definition (e.g., economic relationships between communities), and
• the population studied (e.g., medical students).
The FSU-COM definition was intentionally created to be broad and inclusive so as to encompass as many accepted standard definitions as possible.

For the sake of reporting our rural experiences, we have chosen to count as “rural” those educational experiences that meet any one of the rural definitions below.

1. The Florida Office of Rural Health (Florida Department of Health) – County Level
Defines rural at the county level based on a census population density of less than 100 persons per square mile. Using this definition in 2010, 30 of the 67 counties in Florida are considered rural (3 fewer than the 2000 census).

2. The Federal Definitions - Table 1:

Definition Definition Description Geographic Unit Used
U.S. Census Bureau:
Urban and Rural Areas
The Census Bureau’s classification of rural consists of all territory, population, and housing units located outside of urbanized areas and urban clusters. Urbanized areas include populations of at least 50,000, and urban clusters include populations between 2,500 and 50,000. The core areas of both urbanized areas and urban clusters are defined based on population density of 1,000 per square mile and then certain blocks adjacent to them are added that have at least 500 persons per square mile. Census Block and Block Groups
Economic Research Service, U.S. Department of Agriculture & WWAMI Rural Health Research Center: Rural-Urban Commuting Areas (RUCAs) This classification scheme utilizes the U.S. Census Bureau’s urbanized area and cluster definitions and work commuting information. The RUCA categories are based on the size of settlements and towns as delineated by the Census Bureau and the functional relationships between places as measured by tract-level work commuting data. This taxonomy defines 33 categories of rural and urban census tracts. Census Tract, ZIP Code approximation available
U.S. Office of Management and Budget (OMB): Core Based Statistical Areas (i.e., Metropolitan and Nonmetropolitan areas) A metropolitan area must contain one or more central counties with urbanized areas. Nonmetropolitan counties are outside the boundaries of metropolitan areas and are subdivided into two types, micropolitan areas and noncore counties. Micropolitan areas are urban clusters of 10,000 or more persons. County
Economic Research Service, U.S. Department of Agriculture: Rural-Urban Continuum Codes (Beale Codes) This classification scheme distinguishes metropolitan counties by the population size of their metropolitan area, and nonmetropolitan counties by degree of urbanization and adjacency to a metropolitan area or areas. All counties and county equivalents are grouped according to their official OMB metropolitan-nonmetropolitan status and further subdivided into three metropolitan and six nonmetropolitan groupings. County
Economic Research Service, U.S. Department of Agriculture: Urban Influence Codes This classification scheme subdivides the OMB metropolitan and nonmetropolitan categories into 2 metropolitan and 10 nonmetropolitan categories. Metropolitan counties are divided into two groups by the size of the metropolitan area. Nonmetropolitan-micropolitan counties are divided into three groups by their adjacency to metropolitan areas. Nonmetropolitan-noncore counties are divided into seven groups by their adjacency to metropolitan or micropolitan areas and whether they have their “own town” of at least 2,500 residents.


Office of Rural Health Policy, U.S. Department of Health and Human Services: RUCA Adjustment to OMB Metropolitan and Nonmetropolitan Definition This method uses RUCAs 4-10 to identify small towns and rural areas within large metropolitan counties. In addition, census tracts within metropolitan areas with RUCA codes 2 and 3 that are larger than 400 square miles and have population density of less than 30 people per square mile are also considered rural. Census Tract

Coburn AF, MacKinney AC, McBride TD, Mueller KJ, Slifkin RT, and Wakefield MK (March 2007). Choosing Rural Definitions: Implications for Health Policy. Issue Brief #2. Rural Policy Research Institute Health Panel. http://www.rupri.org/Forms/RuralDefinitionsBrief.pdf  Accessed 3/3/16.

3. The FSU College of Medicine (FSU-COM) –
As a part of COM training, students are sent to Marianna and Immokalee in Florida, and Thomasville in Georgia. Though these areas may not be considered rural by definition, they serve a large population of rural and underserved patients. As such, the COM has decided to classify patients seen in these training sites as “rural” even though they may not fit one of the classifications above. For example, in Immokalee, some of the census tracts do not meet the definition of rural (due to residents commuting to Naples, and Ft. Myers), though other adjacent tracts do meet the definition by having a RUCA code of 4 or more.

We recognize that new definitions of rural may emerge over time and/or existing definitions may be modified. Further, updates to the census, new data sets, or other changes may necessitate periodic revisions, i.e., changes in areas of the state that are recognized as rural as population increases or decreases. We will update our definition to reflect these changes.

Historical Data Recorded By FSU-COM Students
Although definitions may change over time, if an area was rural at the time a student recorded an educational/training experience there, it will be recorded as rural for that student even though the current definition may be in conflict with that data.

A full data base of rural experiences by our medical students is maintained by the University. Also a relatively robust list of Alumni and where they practice is maintained. Thank you for your interest.

Kerwyn Flowers, DO
Director of Rural Medical Education
Department of Family Medicine and Rural Health

For questions concerning FSU-COM, our Rural Mission, or other rural queries, please contact one of the following:

Doug Carlson
Director of Public Affairs and Communication

Kerwyn Flowers, DO
Director of Rural Medical Education
Department of Family Medicine and Rural Health