Rural Medicine: Caring for your neighbors in small places

AT THE VALLEY Professionals Community Center in Clinton, Indiana — population 4,800 — IU School of Medicine students Maddie Wright and Andrew Gauger enter an exam room for a postpartum visit with a young mother and her 13-day-old baby.  

They ask her questions about her healing and her newborn’s feedings. They listen to her concerns. Although not yet MDs, but clad in their white coats, Wright and Gauger are the medical professionals in the room. 

It’s an intentional approach employed by their preceptor, Angela Hatfield, MD, a family physician in Clinton, an adjunct clinical assistant professor, and the family medicine clerkship site leader at IU School of Medicine-Terre Haute. 

“I’ve had some students tell me that they’ve never been alone in a room with a patient before, so I make it a very purposeful decision to allow the students one-on-one time with patients,” Hatfield said. “The way you learn to build rapport and create that relationship with the patient is by practicing how to talk to a stranger until they’re not a stranger anymore.” 

To Hatfield, a Clinton resident who has been practicing in the area since her 2015 graduation from IU School of Medicine, there are few strangers here. When she rounds as a hospitalist at Clinton’s Union Hospital, she rarely needs to take a patient history: She knows nearly everyone in town. 

“I joke that I subspecialized in the Wabash Valley,” she said. 

Hatfield, who completed her medical school rotations and family medicine residency in the area, embodies the vision for the School of Medicine’s Rural Medical Education Program, which began in 2008. In fact, Hatfield started down that track a year earlier, in 2007, when she entered the Rural Health Program at Indiana State University. The unique partnership with IU School of Medicine is a pipeline program for rural Indiana high school students to earn a bachelor’s degree and then matriculate into medical school if they meet specific academic and Medical College Admission Test requirements. 

Across the nation, most physicians train in urban centers and tend to stay there, where pay and access to resources are better. That leaves many rural counties with only a handful of primary-care physicians and even fewer specialists. Studies show the best hope for keeping doctors in rural America is to recruit physicians who come from rural areas themselves.  

Take Hatfield, who grew up in Trafalgar, Indiana, population 1,500, and wanted no part of big-city life. 

“The Rural Medical Education Program recruits people who are familiar with what rural life looks like and are committed to working in rural areas, in part, because that’s who they are,” she said. “Someone who grew up in a farming community is going to understand that there are certain things that just wait until after harvest. Understanding those differences in community and personal priorities makes a big difference in developing that rapport with patients.” 

Throughout the week, Hatfield welcomes newborn babies into the world and eases the suffering of people in the local nursing home as they near death. This is the life of a rural family physician. 

“As the primary care providers, we have to learn how to do more things,” Hatfield said. “You have to be more self-sufficient because (specialty care) is just not available. That doesn’t mean that I don’t want or need specialists; I absolutely do. There are lots of procedures I can never and will never learn to do. But I certainly have learned how to manage some conditions to a higher level than I would have if I had practiced in an urban area.” 

NEARLY A THIRD of Indiana residents live in rural areas designated by the Indiana State Department of Health and federal Health Resources and Services Administration as medically underserved. Nationally, 80% of rural America falls into that category. 

Since its inception, the Rural Medical Education Program has produced 143 medical school graduates, with most going into primary-care residency training. Today, 21 Rural Medical Education graduates practice as primary-care physicians in rural counties, 61 practice in medically underserved areas, and 58 practice in counties designated as health professional shortage areas. 

Taihung “Peter” Duong, PhD, associate dean and director of IU School of Medicine-Terre Haute, leads the program he was recruited to develop in 2008. It was Duong’s job to convince rural physicians working in busy clinics and critical access hospitals throughout the state to take on the additional duty of training medical students. He found overwhelming support.

“The physicians said, ‘We need the next generation to take over for us,’” Duong said.

He calls Hatfield an exemplar of the goals of the Rural Medical Education Program. She started down the rural health track at age 18 and spent all four years of medical school and her subsequent residency training in the rural environment. She now practices primary care in a rural county while strongly supporting the School of Medicine’s educational mission as an outstanding physician preceptor and mentor.

“Her career trajectory typifies what was hoped for when the Rural Medical Education Program was established,” Duong said.

Starting with just eight students in 2008, the IU School of Medicine program currently has 63 medical students. It operates from Holmstedt Hall on the Indiana State campus and from the Landsbaum Center for Health Education in Terre Haute.

The Landsbaum Center also houses Union Hospital’s Richard G. Lugar Center for Rural Health, the West Central Indiana Area Health Education Center and Indiana State University nursing programs, all of which use the high-tech Rural Health Innovation Collaborative Simulation Center to train future health professionals. 

This collaborative creates a hub focused on innovation in rural health care.

Wright, a fourth-year medical student, grew up in Monrovia, Indiana, population 1,643, where she volunteered with a free health care clinic during high school. She now helps lead the student-run free clinic in Terre Haute, where Hatfield and other local physicians volunteer to care for uninsured and low-income patients.

Her appreciation for the full spectrum of care that rural doctors provide has only grown after working alongside these physicians.

“Dr. Hatfield does so much for her patients; it’s personal,” Wright said. “It’s rare you have a family medicine doctor who sees patients in the hospital, has a full clinical day, delivers babies and goes to visit patients in a nursing home. She embodies that cradle-to-grave health care approach.”

Wright plans to specialize in pediatrics, addressing the dearth of primary-care providers in rural Indiana. Gauger, an Indianapolis medical student aspiring to specialize in dermatology, will likely practice in an urban setting. He landed in Clinton with Hatfield for his family medicine rotation because IU School of Medicine wants all students to get first-hand experience in the diversity of care provided by family physicians across America’s rural landscape.

“IU’s focus on immersing students in these rural areas for training is very helpful because if you don’t understand how life is different in a rural community, then it makes it difficult to tailor your treatment approach—to see where you, as a provider, can help (rural patients) achieve better health,” Hatfield said. “IU is helping students develop a mindset that is more collaborative and that will lead to better patient outcomes.”