Training physicians to serve in rural areas is a vital piece of modern medical education. It’s also frequently overlooked. Most medical education institutions are in cities, because cities allow us to concentrate the learning opportunities: the specialists, the large hospitals, the high patient volumes. This creates an automatic, unintended bias among doctors—the idea that to be a good doctor, they need to practice in a city. After all, don’t you want to be able to refer a patient to a specialist? Don’t you want to have testing and treatment resources at your fingertips?

I grew up in a rural, geographically isolated area. I returned there for part of residency training and will stay on after graduation. I know plenty of people who grew up in smaller towns—my home of 20,000 is technically a city—but there is a marked difference between people who grew up smelling cow manure and people who did not.

One of the differences is race. Metropolitan areas are made up of about 42 percent racial and ethnic minorities, where rural areas are at about 22 percent, according to the 2018 “Rural America at a Glance” report. It’s easy to look at small, rural towns in the U.S. as dominated by white people, but that elides several factors.

First, people of color in rural areas are not spread out evenly. Geography is hugely important. There are rural areas that are much more heavily Black, or Latinx, or Native, and these are areas that tend to struggle to recruit and retain physicians even more than white-dominated rural areas. While rural areas as a whole have great difficulty with physician recruitment and retention, areas with the most people of color see huge challenges. It is particularly important to note that these areas often have physicians who are white, which raises additional problems. We know from research that white physicians provide lower-quality care for patients of color than physicians of color do.

Second, even in predominantly white areas, people of color still make their homes there. There are excellent reasons why a person of color might live in such an area. There might be work there. There might be a strong tribal presence, even in a predominantly white area; my county is almost 90 percent white, but 5 percent Native. While many Native Americans live in metropolitan areas, there tends to be a higher proportion of Native Americans in rural areas than in urban areas. People of color may live in a rural area because they were born there, because it is their home; because they have family there; because of job opportunities; because of relationships—in short, all the reasons why anyone might live somewhere.

Rural areas suffer from a consistent drain of young people to cities. This has a lot to do with work opportunities, and means that rural areas on average are older than metropolitan areas. This also affects equity of care. When you have a higher proportion of the population that is geriatric, who is caring for them? Who is caring for Native elders? Who is caring for Black rural seniors?

Training physicians to work in rural areas is racial justice work. It is not, by itself, enough. It is also critical to train physicians to be actively anti-racist, because the opposite of being actively anti-racist is to be passively racist. Racism is so deeply ingrained in American culture that we will perpetuate it unless we choose to acknowledge and fight it. This is especially true for white providers, who benefit from racial injustice whether we intend to or not, whether we are conscious of it or not.

This is why I have been so grateful to have been lucky enough to train at a program and with mentors who see the importance of anti-racism training for physicians. It is not enough to have sporadic seminars. Anti-racism needs to be a piece of training that we think about constantly and integrate into the program at all levels. We need to ask ourselves how to make recruitment less racist, how to make programs more supportive for physicians of color, how to make white trainees into better colleagues and physicians for people of color.

People of color living in rural America matter. There are LGBTQIA+ people of color in my county; because of my background, many of them see me for their primary care. I can’t imagine the challenges they face on a day-to-day basis, because my only frame of reference for understanding oppression is being a white queer person. It’s my job to work to understand their lives as well as I can. It’s my job to help them wherever I can, whether it’s with depression and anxiety from living in a hostile world, or with heartburn. That’s what I love about primary care—I take responsibility for my patients as whole people.

I am deeply grateful to my specialist colleagues in my area, because they work incredibly hard. Where a city might have dozens of cardiologists, we have two and a half. For seventy thousand people. We have three urologists. We have a tiny, dedicated group of hospitalists who are constantly overloaded, and my family medicine group also cares for our own patients in hospital. We have no inpatient Neurology. We have no Rheumatology. Patients have to get to the city, two hours away.

We have to work together in rural areas. None of the physicians in rural areas are easily replaceable. We serve unique functions; we have niches, even as generalists. It is imperative that we dedicate ourselves to training more physicians who can provide care for people of color in rural areas. Rural medicine is often medicine for marginalized populations, and we need doctors who can do that work, do it well, and do it with love. I love my community. I want to train more physicians who will love other rural communities, and care for the people of color in them with thoughtfulness, understanding, and grace.

Kristin Puhl is a family medicine resident and can be reached on Twitter @kristinpuhl.

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