Solving rural health disparities starts with listening to rural doctors

By Kimberly Becher, MD, FAAFP
Rural Health Advisory Committee Chair

We know clear, long-standing health disparities exist in rural America. We also know that adding 10 primary care physicians per 100,000 people reduces mortality rates, including in rural areas.

But not enough people remember that your ZIP code influences an estimated 60% of your health outcomes.

It’s actually not that complicated to understand why geography has a bigger impact on health than what we do in the exam room. Just go to a rural town and observe behaviors, buy food or try to find childcare as a new parent.

Face to face with rural health disparities

The barriers to improved health you’ll notice are one of the reasons we have to incentivize physicians to work in rural settings. Rural physicians, like me, often have fewer resources than our urban peers even though we care for a higher proportion of high-risk patients.

We have more heart disease without the cath lab. More diabetes without grocery stores.

And increasingly, value-based arrangements with payers put rural practices in a precarious position because these communities need more funding, not less, to change the trajectory.

As the family doctor in a rural town, you might also face professional isolation that can increase burnout.

Why I love rural family medicine

So why do so many of us still love rural medicine? It’s simple. We buckle down and grow roots in the rural communities we serve because we know we are making an impact despite the challenges.

We also know we could reduce rural health disparities even more if we just had the right resources and access for our patients. The wins feel bigger out here because we work harder to get them.

Every single patient, no matter who or where, deserves the best health education, diagnostic workup and treatment that modern medicine has to offer. We don’t accept poor health because it’s harder to survive in some parts of the country. Family physicians are trained to pivot based on our community’s needs.

This is why I will always preach that rural health care needs to be a priority in medical education, health policy and all levels of medical system development. Because it doesn’t matter if something improves health in one hospital system, for one payer. You have to be able to replicate it wherever you practice, period.

Rural voices and patient perspectives are often missing from insurance company decisions and medical research. However, having access to clinical trials can improve a community’s health metrics. The trials elevate and educate the rural workforce while also improving access to new or investigational therapies. Increasingly, researchers are attempting to include patients in these ZIP codes with a higher rate of poor health outcomes.

The American Heart Association’s Road to Rural Health initiative included rural listening sessions that will guide the next steps to reduce preventable deaths in rural America through science, education and advocacy.

In my own practice, which is in a county of approximately 7,500 people, we are hoping to participate in an NIH clinical trial targeting secondary stroke prevention.

I find that people working outside rural settings tend to assume rural communities won’t embrace opportunities. Or they don’t engage community members and end up recommending things that simply aren’t feasible, like remote patient monitoring in areas that have unreliable cell service or internet access.

When I joined a CDC rural immunization task force soon after COVID vaccines became available, health professionals who didn’t understand my rural community suggested I obtain a mobile clinic. I laughed and told them we’d already driven our own cars to administer thousands of COVID vaccinations in people’s homes, community centers and churches. We were a well-oiled machine that finished giving vaccines to everyone who wanted one before the rest of the world could figure out how to start.

The same keep-it-simple approach works in many aspects of rural health care. Someone asked me how I share information with my community health worker. Somewhat dumbfounded I said, “I call her and she calls me, or we find each other in the clinic.”

Sometimes I think rural medicine is my passion because it’s rewarding, and I love seeing generations of families and hearing stories about the amazing people I have the honor of seeing as patients. But it’s also that a single email, or handful of phone calls or texts, lets everyone in the county know when we have a disease outbreak, and that we know who to ask for help getting a patient signed up for benefits or driving a family member to the hospital to visit a loved one. That’s how we sleep at night—well, that and the chorus of spring peepers in April, crickets in summer and fall, and ice cracking in the winter, all without traffic, sirens, music or voices outside our windows.

There are abundant examples across the globe where rural health outcomes have been prioritized and improved, like Costa Rica, for one.

So I’m excited that the AAFP and other U.S. organizations, including the American Heart Association and the Health Resources and Services Administration, are recognizing that we need to improve rural health, and that starts with including rural communities in the strategy. We live here, we work here and we die here, often at much younger ages than we should.

One of my favorite quotes attributed to Winston Churchill quotes is, “You can always count on Americans to do the right thing, after they have exhausted all other possibilities.”

Maybe that is where we are, finally, on the cusp of doing the right thing.

We don’t yet know exactly what will move the needle, but rural family physicians definitely know what could help our communities and what simply won’t work.

Kimberly Becher, MD, FAAFP, is chair of the new AAFP Rural Health Advisory Committee. She is chief medical officer at Community Care of West Virginia and president-elect of the West Virginia AFP. She previously served the AAFP as a member of the Commission on Governmental Advocacy, new physician delegate to the AAFP Congress of Delegates and resident member of the Board of Directors.