The rural doctor is in
“How do you define rural?”
In Ohio, the word conjures cattle and cornfields, horse-drawn buggies and barn-dotted landscapes. But when Dr. J. Alex Heintzelman asks his medical students at NEOMED this question, he wants more than the postcard definition.
He wants to know what “rural” means to them.
“More animals than people,” one student says.
“There’s really no right answer here,” he says. “Sometimes it’s a feeling.”
Rural means no public transit or sidewalks. It means being able to take out your guns on your property or have a big event without worrying about neighbors or the police. When a student says rural means “self-sufficiency,” Heintzelman agrees there are cultural components. “It's not just how things look.”
Also, rural is relative. Columbiana County, where Heintzelman practices, meets the federal definition of rural, even though the city of Columbiana has a population of around 6,000. One student is from a town of 400. And rural places exist in Alaska and Mississippi, India and Russia.
The postcard versions differ, but across rural America, the public health pictures are similar—and troubling. During Heintzelman’s seminar, the first and second-year students will learn why rural populations tend to be sicker than many urban ones.
For decades, rural economies have suffered from the loss of industry, and now the pandemic has created even more unemployment. Fewer jobs mean more poverty, less opportunity, less education, worse housing. Many people have left. Rural hospitals have closed, creating medical deserts. There simply aren’t enough doctors in rural America and that’s one reason rural people are sicker than they should be.
While this may be news to many students, medical schools have known about the rural doctor shortage for decades. To increase supply, authors of an influential study published in 2008 recommended that all medical schools develop rural programs.
Heintzelman’s students are in one of them at NEOMED, the Rural Medical Education Pathway.
Being on the pathway to rural practice is not required. They’ve all chosen to be here.
Rural doctors like Heintzelman are trying to help them stay.
Doctors, patients and rural communities
The definitions of “rural” vary, from a focus on population size to the character of a place. Ohio’s Office of Rural Health’s definition is the same one used by the federal office of rural health within the U.S. Department of Health and Human Services. A county is “rural” if it lacks an urbanized area or cluster, and it is not adjacent to a metropolitan area.
It’s helpful to think of rurality as existing on a population continuum, as some researchers do, with a large city at one end and a remote frontier at the other.
You can think of physicians who care for rural people as also occupying a continuum. The doctor practicing out of his pickup truck in Amish Country would be at one end and Heintzelman closer to the other.
Columbiana County shares its border with Pennsylvania to the east and West Virginia to the south. Soon after drivers cross into Ohio from Pennsylvania on Rt. 14, a sign warns them to watch out for horses and buggies. The highway is rimmed with single-family homes, crops and car dealerships. Heintzelman sees patients in a one-story, beige brick building sandwiched between a soybean field and a new housing development. His patients come from nearby small towns and the Youngstown suburbs, as well as from Mennonite and Amish communities, for whom he makes house calls. Technically Appalachia, Columbiana is considered rural, but it is not as medically underserved as other rural areas in Ohio.
Heintzelman grew up here. One of his patients, 88-year-old Marjorie Rudibaugh, remembers his mother and four aunts. They grew up less than two blocks from where she lives in the small town of Elkton.
“I was really surprised when I found out my doctor turns out to be somebody that I knew his mother,” she said on a recent visit.
Heintzelman is used to these personal and professional intersections. He still lives in Columbiana County with his wife, on a farm where he grows hops for a local brewery.
“In a rural setting you live alongside your patients,” he says. “When I go to the grocery store, I'm going to see someone there. When I go to the brewery uptown. I'm going to see someone there. When I am on the sidelines on Friday night as a team physician, I'm going to see some of my patients there. And I'm going to see the community's children there.”
His patients are lucky most of them don’t have to come far to see him or the specialists who practice here, including cardiologists and surgeons. One of his patient’s daughters, Beth Ann Mine, tells me things are worse over the border in Beaver Falls, Pa. She had a hard time finding an ear, nose, and throat specialist within driving distance. Now she’s wondering what will happen when her primary care doctor retires.
“A few years ago, they took his picture and put him in the paper,” she said. “He was saying, ‘Who’s going to take care of me when I’m older?’ because the new doctors are not coming to our area, they’re going to the big cities.”
Most of Heintzelman’s patients are white. Many are lower income. According to county health research funded by the Robert Wood Johnson Foundation, nearly one in five children live in poverty in Columbiana County. Close to a third of adults smoke. More than a third are obese. There’s only one primary care doctor for every 2,500 people. The Ohio average is one in 1,300.
The movement to get more doctors practicing in rural places is an attempt to help stop the health scourges ravaging them: opioid addiction, COVID-19, and diseases like diabetes complicated by poverty and distance from quality health-care providers.
To get more doctors practicing in rural areas, the research suggests two things work: One, recruit more medical students from rural places and, two, train more of them and more residents there. The first strategy doesn’t seem as promising as the second. The proportion of medical students who come from rural areas declined from 2002 to 2018, according to a study published in 2019. In 2017, only 5% of medical students had a rural background, and most medical schools themselves are in urban places.
However, there are more future doctors being trained in rural areas now. No one has worked harder to make that happen than Dr. Randy Longenecker, a professor of family medicine and assistant dean of Rural and Underserved Programs at the Ohio University Heritage College of Osteopathic Medicine. For more than a decade, Longenecker has collaborated with other medical educators, researchers and practicing physicians to create more rural training programs. There are now 42 rural training tracks in medical schools, up from 17 in 2006. And the number of rural track programs in residency training, where new doctors do their required post-graduate work, has more than doubled since 2010.
The actual number of students currently in medical school tracks is hard to determine, but Longenecker estimates there are about 1,000. He’s more certain of the number of family medicine residents in rural programs. As of July 1, 2021, there were 488 per year, or 1,464 over all three years. This April, when the fourth-year medical students were matched with residency programs, just more than 10% of future family medicine residents matched to rural programs.
Longenecker does not believe we need more doctors to fix the rural doctor shortage.
“Our nation has a long history of throwing more doctors at problems and haven't necessarily solved them,” said Longenecker, who also directs the RTT Collaborative, a nonprofit organization devoted to increasing the rural health care workforce. “We have plenty of doctors, just too many in the wrong place and in the wrong specialty. If we could somehow persuade more folks to do family medicine, general surgery, general psychiatry, even general OB-GYN and get them to live and work in rural places, we'd be much better off as a nation.”
For some students from rural areas, no persuasion is necessary. For others, it’s a long, slow process that begins in a class like Heintzelman’s.
Getting students fired up about the social determinants of health
At that first rural health seminar of the year, Heintzelman and his co-instructor, Mike Appleman, NEOMED’s director of primary care education, relay disease death-rate information from the federally funded Rural Health Research Gateway. Then they ask the students, “Is it rural? Or is it urban?”
Among themselves, the students discuss which population has a higher death rate from heart disease.
Some are surprised the answer is rural.
“Why do you think it might be trending higher in rural places for heart disease mortality?” Heintzelman asked.
“Because butter is delicious,” a student said.
“Eating habits,” Appleman said. “Good.”
The students discuss how the death rate could be higher in rural areas. Heintzelman reminds them there’s less access to health care.
“So, if I'm having my heart attack out in the field, how long is it going to take me to get to the door of the emergency room where they can start to intervene?” he asked.
In addition to heart disease, the students learn rural people are also more likely to die from the other six leading causes of death in the United States: cancer, unintentional injuries, suicide, stroke, chronic obstructive pulmonary disease (COPD), and diabetes.
“I think it's important to like acknowledge you’ve certainly picked up on the trends here. It's like, well, if it's bad news, it must be rural,” Heintzelman said. Students laugh, but he doesn’t leave it there.
“Certainly, as you know, people who grew up there, these aren't necessarily horrible places to live,” he said. “These are cultural, these are economic ... and really, the social determinants of health are behind all of these trends.”
The idea is to be aware of these things, to be ready for them. He says it’s up to the doctor to reach the patients where they’re at. Know what forces could be influencing their health care decisions. Know what they as doctors can do to help.
Dr. AuBree LaForce remembers hearing a lecture like this when she was on the rural pathway at NEOMED, and it got her fired up about the social determinants of health. That was when she realized she had already experienced them.
On the pre-med track at the University of Mount Union, LaForce was paired with a rural couple whose poverty and lack of education made them frequent flyers in the emergency room at Aultman Hospital in North Canton. As a health coach, she visited them every other week, made their appointments, refilled their prescriptions and advocated for their care. She also taught them how to read food labels and make healthy fruit smoothies.
“My patients, one was blind, and the other one wasn't mobile and couldn't walk,” she said. “Their insurance only paid for a wheelchair that did not fit out of their apartment door, nor in their tiny car. And they never left their apartment. They couldn't leave their apartment because the wheelchair didn't fit out the door. And nobody knew that. So, nobody knew why they were missing their appointments, or why they were showing up to the emergency room because that’s the only way they could access health care ... And so I'm calling insurance companies. I'm calling the hospitals. I'm making arrangements. We finally got a wheelchair that fit through the door. And now they have their life back. They have their autonomy of being human beings.”
Her experience health coaching in medical school was similar. But as a medical student, she got to attend grand rounds twice a week where she was part of the team managing her two rural patients’ care. One was diagnosed with dementia, and the other had multiple chronic conditions, including COPD.
LaForce became impassioned about improving the social determinants of health, and she focused her final project on the need for more rural doctors in leadership roles. Before graduating in 2021, LaForce had served in multiple national and local positions herself, including on the NEOMED Board of Trustees.
Despite her national accolades and big-city style—she likes to wear classy dresses and pearls with her white coat— LaForce doesn’t want to move too far from her family in Vermilion, her hometown on Lake Erie. This summer, she started her residency at Cleveland Clinic Akron General. When she tells people from home she’s pursuing family medicine, they’re happy for her. They say they need good doctors, and they want her to move back to practice there. But sometimes, when she tells people in the medical field about her career goals, they say, “You're going to get burned out,” and, “Why would you do family medicine? It’s one of the lowest paying specialties?” and, “You're too smart for family medicine in rural areas.”
She says caring for rural patients in medical school solidified her commitment to them.
“I went into medicine because I care about people,” she said. “I care about what makes them who they are and in what contributes to their health. And I'm a firm believer that the social determinants of health are exactly what make someone healthy or unhealthy. There's a quote out there, like your zip code determines how long you live, and that is a fact. I mean, the research is out there. And that, to me, is such a problem. And that's the communities that I want to serve.”
From the classroom to Capitol Hill
After students experience the disparities firsthand, they sometimes join Dr. Longenecker in Washington to lobby for legislation to improve health care access and quality. LaForce and Heintzelman did this, too.
“We would get appointments with our congressmen and senators, and they would listen to us. And they would nod and be very gracious and all of that, but nothing would change,” Longenecker recalled. “And it wasn't until 2016, that all of a sudden, I got noticed ... They wanted to do something for rural. And suddenly, rural had a place that it had not had at the table.”
In 2016, rural Americans and small-town residents voted overwhelmingly for President Donald Trump. Many rural Americans had voted for Republicans in past presidential elections so this was not a new trend. According to Shannon M. Monnat and David L. Brown, the real identifying characteristic of the voters who put Trump in the White House was not rurality but “place-level despair.”
“In many of the rural areas and small cities where Trump performed better than expected (or Clinton performed worse than expected), economic distress has been building, life expectancy has been declining, and social conditions have been breaking down for decades,” they wrote in their 2017 article published in the Journal of Rural Studies.
Perhaps the perception of a “rural revolt” is what made politicians start listening to them, but much of the rural health agenda remains unfulfilled. In 2021, the National Rural Health Association asked Congress for a range of requests, including support for rural hospitals on the brink of closure, help recruiting rural health care providers, funding for new rural residency programs and rural representation on the Centers for Disease Control.
Improving the health care infrastructure in rural areas appears crucial to the effort to attract new doctors there. Students told me they find aspects of rural medicine daunting, especially when it comes to the lack of resources and solitary nature of practicing medicine away from urban centers.
“I think that the biggest concern and thing that I noticed health coaching and that makes me nervous to be out there in the real world is knowing that I know the next best thing to do for this person, and I can't do it because of the resources that are not available in the area,” said Jenna Link, a fourth-year NEOMED Rural Pathway student from Twinsburg.
To help keep students interested in rural medicine and to help them feel supported Heritage College’s Longenecker brings them together with practicing rural physicians to learn, network and relax in rural Ohio for a few days each year. The Rural Health Scholars Retreat is a collaboration between Longenecker’s Heritage College and the Ohio State University Department of Community and Family Medicine. Each retreat has a theme. Last year’s was “Making Population Health for Rural Communities Personal.” The retreat is like a rite of passage for the state’s future rural physicians. LaForce attended them as a med student, and so did Heintzelman.
“And I got there and met these other people that had similar interests,” he said. “And it just felt, right. It was like, 'Oh, these are my people.'”
Learning to treat rural patients
Heintzelman says he’s learned a great deal from Longenecker, who is retiring from OU at the end of October but will stay in his position at the RTT Collaborative until next summer. Heintzelman sometimes randomly quotes his mentor. (“Randy says, ‘If you’ve treated one Amishman, you’ve treated one Amishman.’”) In Northeast Ohio, he is building on Longenecker’s work, pitching the Rural Health Scholars Retreat to his students and supporting them and family medicine residents.
On a muggy July day, a 27-year-old, second-year family medicine resident from St. Elizabeth Boardman Hospital is rotating with him in his office. While he finishes with another patient, Samantha Bosak tells me she’s from Parkman, a small town that lies along Rt. 422 between Warren and Cleveland. As a child, she had many Amish friends until they stopped attending school after the eighth grade. Just this week, she visited Amish country on her first-ever house call as a resident.
“They [house calls] are a great resource for folks who have a lot of trouble getting out of the house,” she said. “Like we saw a disabled Amish woman last Friday, who wasn't able to get out of the house, and she has a lot of chronic medical conditions that needed cared for. So we met her where she was, and we helped her out with some of those chronic problems.”
Bosak would love to do more home visits, she said. But today is a clinic day. She follows Heintzelman into a small treatment room. A barefoot 15-month-old with bright red hair is pressing against his mother’s legs, looking warily at us.
“Good morning,” Heintzelman said. “Hello! What's up, bud?”
The child presses closer to his mother. (Later, Heintzelman will tell his mother Dylan is showing an appropriate amount of “stranger danger” for his age.)
“Dr. Bosak is here with us. She’s a second year Family Medicine resident. You may know her from rotating with me this month. I was going to have her ask you how Dylan’s been doing.”
“So how Dylan's been doing?” Bosak asked.
“He's good,” Dylan’s mom said. “He’s everywhere. We had to put a fence up to keep him in the backyard.”
Bosak asks if she has any concerns.
“Well, he's pooping a lot,” she said. “A lot. “
“So more than normal, I'm guessing.”
“Yeah. Like yesterday, it was five times."
Heintzelman tells Dylan’s mother she may want to cut down on the juice. But, overall, the toddler is doing well.
Heintzelman doesn’t wear a white coat. He dresses casually in button-down shirts and comfortable shoes. If not for the stethoscope around his neck and the surgical mask covering his dark red beard, he looks like he could be heading to REI instead of into a treatment room. His patients are relaxed around him. They tell me he’s a good listener.
In two days at his office, I hardly ever see him sitting at a computer. His day is packed with back-to-back, 20-minute visits that he prefers to spend face-to-face with patients, even though this means he’ll spend an extra two hours a night on paperwork.
He walks into patients’ rooms knowing what health issues he will address. But he lets them talk first. East Palestine resident Sandra Smith, 77, wants to know when she can get a knee replacement. Heintzelman says not yet. It’s been too soon since her last heart attack, but he recommends a cream that should help with the pain.
“So I heard you had a question about your second COVID vaccine maybe?” he asked.
“My first one gave me no problem whatsoever. None,” she said. “But I was worried about getting the second one because of my heart.”
She’s heard news reports about the vaccine causing heart problems. Heintzelman explains that heart inflammation has occurred in a very small percentage of people, and most of them have been young men.
“If you were my family member, if you were my mom and my grandma, I would want you to go and finish your COVID vaccine series,” he said. “I worry that getting COVID with some of your health conditions is much more dangerous than anything that the shot’s going to do to you. So, is there a 0% chance that you'll have a problem? No, there's a tiny chance that you might have a problem from the vaccine. But I think that getting sick with COVID will probably be much higher risk to you than anything that could happen from the vaccine.”
At the end of the visit, Smith tells Heintzelman she’ll follow his advice on the knee replacement and the vaccine.
“Okay, I will do what you say,” she said. “You're my family. Doctor, you tell me the truth every time I've been here. So, I ain’t worried.”
Inspiring doctors to go rural
Many things about health care have changed in rural Ohio over the past few decades. According to a 2019 article in the journal Health Affairs, the death rates of rural and urban Americans were similar until the 1980s, when rural rates got worse. The authors say the system for funding health care services favors heavily populated areas. Rural hospitals closed, and they are still closing. There’s less access to doctors and fewer places to deliver babies and get operations.
“The costs of running a hospital in a rural place, I would imagine, are more difficult than running a hospital in an urban place,” Heintzelman said, “because the volume of patients that generate the revenue for the hospital is lower in a rural place.”
Hospitals make money from fixing problems with hearts, joints and other body parts, far more than they make when they prevent problems from happening in the first place. “And so, things like joint replacements and cardiac procedures to save your life while you're having your heart attack are much more revenue generating than treating high blood pressure and managing diabetes over years to prevent that heart attack from happening,” he explained.
Younger doctors and medical students who want to go rural look to Dr. Longenecker for guidance and inspiration. Before he became a national expert at training future rural physicians, he says he had a wonderful practice in Bellefontaine and West Liberty. In 30 years, he delivered 2,000 babies, and he made a good living for his family.
“I had a student tell me, ‘You're a unicorn,’” he said. “And I said, ‘No, I'm not a unicorn, I'm a reindeer, some parts of the world, there are thousands of us.’”
They can become the kind of doctors they want to be, regardless of industry norms, he assures them. They can make house calls. They can take care of people for free. Longenecker knows plenty of doctors, even hospital-employed ones, who do so. As doctors, their services are worth a lot.
“The way you get paid is different than what you can do,” he said. “As physicians become employed, they become helpless. They feel like, well, I can't do it, because my employer won't let me. What do you mean, your employer won't let you? Do it. And if they want to pay you less, so be it. Go work for somebody else.”
While reporting this story, I spoke with three medical students and one resident in rural programs. None of them expressed an interest in a solo practice, but all four say they are committed to being doctors who really know their patients. When LaForce was on the rural track at NEOMED, she was impressed by how Heintzelman talked to his patients. One was the mother of several children. She lived in a remote area and suffered chronic health conditions, including diabetes.
Before LaForce saw this patient, Heintzelman told her what to expect: Every time the patient comes in for a visit, she acts like everything is fine with her health. But the results from her latest blood tests told a different story. LaForce recalls how gently but firmly Heintzelman spoke to this patient. “It was like he was talking to a friend but giving his friend very clear-cut advice,” she says. “And so, he had this way about him that he showed so much empathy, but he also put her in her place at the same time. And I think that he was able to do that because they built that relationship and that trust. And he got to know her.”
The challenge of rural practice appeals to fourth-year student Link. If she becomes a family doctor in a place like rural Pennsylvania, where she was born, she expects she’ll get to treat a wider array of conditions than she would see in an urban practice.
“In medical school, you learn all these like strange, random diseases that they tell you you're never ever going to see in your life,” she said. “And through my rotations, I've seen almost all of them in a rural setting, especially because people will kind of wait on things. They don't want to go to the doctor. They don't want to bother themselves with it. And then weird stuff pops up, and then it walks in your door, and you’ve got to figure out what to do with it.”
Despite all the efforts to get more doctors into rural practice, the doctor shortage persists. According to the National Rural Health Association, 20% of Americans live in rural areas, but only 9% of doctors practice there. Twenty-eight of Ohio’s 50 rural counties have lost doctors since 2018, including Columbiana. There were 105 medical doctors and doctors of osteopathic medicine practicing in the county in 2021, down from 113 in 2018, according to annual reports of the State Medical Board of Ohio. Many of the decreases are in the single digits, but Wayne County lost 50, or 23% of its doctor workforce. Monroe County now has only two doctors, down from 30 in 2018.
The number of doctors increased in the six counties with the state’s most populous cities. Franklin County, where Columbus is located, saw an influx of 546 doctors since 2018.
Longenecker says the rural doctor shortage would be much worse if not for the rural programs that have been created over the past decade, and it could take another 10 years before we know if the medical students and residents from those programs settle into rural family practices.
Since its inception in 2015, 72 students have entered Heintzelman’s program at NEOMED. As of May 2021, 19 have graduated from the medical school. Of the six who already completed their residencies, three are in rural practice.
Even if his students do not end up practicing in rural areas, however, Heintzelman believes their experiences in rural medicine will make them better doctors for all their patients.
“I tell them, hey, if you want to go be some fancy dermatologist or vascular surgeon up at the Cleveland Clinic, or some big urban institution, that's great,” Heintzelman said. “But they're going to take care of people who are from rural places someday ... Whether you're rural or not, working with others who are different, finding our commonalities. That's just being good person.”
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