I've worked small city ER, and rural clinic and ambulance, as well as air ambulance. Overall, I prefer the rural setting. It really is a matter of personal preference. Here's my take: All the really definitive care is in the metro centers. You won't be sending a patient from the rural ER to cath lab or surgery. You may not even get to initiate stuff like thrombolytic care in some places. BUT, in the rural setting you initiate the critical steps before handing the patient to a transport team for the trip to definitive care. In the rural setting it is harder to keep up some skills; but when you get to use them, your actions are decisive in their effect to stabilize a patient and keep them going till they get to a higher level of care. In the rural setting you have fewer people to fall back on if something doesn't work as planned. So the limitations can be frustrating, and it is harder to stay sharp and up-to-date; but you provide a unique service. Of course, the environment is a big plus in the rural setting as well. Personally, I think the best route is for a provider to get the exposure and experience of the big city for a few years, and then take that to the boonies.