There is a revolution going on in the treatment of acute strokes right now. It involves a specialist performing a sophisticated procedure called an endovascular thrombectomy wherein a tiny wire is threaded into a cerebral artery to remove an obstructing clot and restore blood flow to the downstream brain tissue. The endovascular thrombectomy will become the standard of care for acute clot-based strokes. But it is only available at certified stroke centers, almost all of which are located in cities.
This inequity is a particular challenge for those who live in rural areas. Physicians have coined the phrase “time is brain” to reflect just how time-sensitive the restoration of blood flow is to the successful treatment of a stroke. In cities, the time lapse between the onset of a stroke and an endovascular thrombectomy can be an hour or two. In rural areas, the procedure is often out of the question due to the long distances between patients and treatment centers.
Over the last five decades, our nation has witnessed the net migration of people from rural areas to cities, a trend that has accelerated with the millennial generation. Doctors, nurses and other healthcare professionals have followed. The result is that sophisticated medical expertise has become concentrated in cities. For many city residents, access to extraordinary care has never been easier.
Sophisticated medical expertise and access to extraordinary care have become concentrated in cities.
People who live in cities also benefit from proximity to local emergency medical services, which have professional staffs and transport times measured in minutes versus the hours that are the operating reality of volunteer-based rural EMS.
Even so, you won’t always enjoy better healthcare in the city. Between the ambulance and access to the latest and greatest critical care is the emergency room, where every patient—the nonurgent, moderately ill and truly critical—are assessed, triaged and treated. If you are not critically ill or injured, it’s easy to fall into no-man’s-land: too sick for the local urgent care clinic but not sick enough for immediate admission to a critical care bed.
This situation is especially prevalent in cities during the winter flu season, when ER waiting times can approach 8 to 10 hours. If you are actually sick enough to be admitted, you have a good chance of spending a day or two on a gurney in the ER hallway because there are no beds available upstairs. They’ve been reserved for sicker people and/or prescheduled surgical cases.
Your best strategy for health in a city environment is therefore twofold: Live in or near a city that has teaching hospitals with large multidisciplinary medical teams, and avoid the emergency room as much as possible.
To achieve the latter, you should do your best to live a healthy lifestyle (less alcohol, more exercise, a Mediterranean diet) while also engaging a committed primary care physician. Since primary care has been chronically underfunded for almost two decades now, this may prove challenging; there has been an ongoing exodus of physicians out of primary care for the last decade. I recommend that you consider enrolling in a concierge/membership-based medical practice if you cannot find a committed doctor who takes your insurance. (Full disclosure: I am the CEO of one.)
Their air polluted and their ERs overcrowded, cities can be stressful places to live. But for most of us, the relatively easy access to cutting-edge healthcare is worth the tradeoff.
CENTERS OF EXCELLENCE
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Very few of the nation’s 5,800 acute care hospitals are certified as providing state-of-the-art stroke care. Almost all are in urban centers, and most are the only such hospital in the city. But a handful of cities have more than one hospital with the certification. Below are the six cities with five or more such hospitals.