BACKGROUND The purposes of this study were to determine the extent to which exercise stress testing is performed by family physicians; whether rural physicians are more likely to utilize exercise stress testing than their urban counterparts; and what factors influence their decisions. METHODS A random sample of 211 practicing members of the Nebraska Academy of Family Physicians was surveyed. Responses were received from 163 (77%). To ensure independence, if two or more subjects were members of the same group practice, one was randomly assigned to the study, for a total of 125 respondents available for analysis. Questionnaire items included performance of exercise stress tests, population base, and distance to the nearest specialist who performed the test. Respondents were classified as urban, rural, or frontier, based on population per square mile in their county. RESULTS Seventy-three of the 125 respondents (58%) reported that they perform exercise stress testing. Physicians in rural or frontier counties were twice as likely to perform the test as urban physicians (P < .001). Similar results were found for distance to the closest specialist who performs exercise stress tests (P < .001) and reported population base (P < .01). Of those performing the procedure, 42 (58%) indicated they had learned it during residency, whereas 15 (21%) were self-taught or had learned from a colleague. CONCLUSIONS Family physicians in rural Nebraska are significantly more likely to perform exercise stress testing than those in urban areas and much more likely to do stress testing than previous national studies indicate. National guidelines should acknowledge the need for family physicians to perform exercise tests and promote training in this procedure.