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A reason to care: How students choose rural health

In rural DeKalb County, Tenn., the need for health care is great. The predominantly agricultural area has a population of about 20,000 spread out over 329 square miles of rolling hills and winding rivers, with one ambulance serving the entire area. The county has only five doctors, and several are nearing retirement. The local hospital is not allowed to provide live births. For Ashli Chew, these stark disparities only motivated her to pursue a career in rural medicine.

“I feel a calling to work in my hometown,” she said. “I feel like they are my people, so it’s important to me to give back to that area. I’ve seen the significant need and lack of resources.”

A second-year medical student at East Tennessee State University’s (ETSU) Quillen College of Medicine, Chew grew up in Smithville, Tenn., and has always known she wanted to return home to practice. An emergency room rotation at her hometown hospital made the decision even more personal. The understaffed facility contracts with out-of-town physicians to cover ER shifts, and one night Chew was paired with a distracted doctor who was dismissive of the three patients who came in. For Chew, though, they weren’t just patients – one was a member of her graduating class, one attended her church, and one was a former student of her grandmother.
Ashli Chew
“I knew all of them,” she recalls. “But he was very cavalier and flippant with them. One thing he said was, ‘This seems like a big deal to them, but I’ve seen a lot, and they really don’t need to come to the ER for this.’ It was striking to me because I know these people and I love these people, and maybe it’s not an emergency to him, but it is to them. It was really hard for me to take. But then I decided it isn’t his job to care about these people – it’s mine.”

For Chew and three other rural medical and public health students who recently spoke with NRHA about their career choice, finding their “reason to care” was a huge deciding factor in pursuing smalltown practice – but they also believe exposure can help more students become interested in rural medicine, and rural living has a lot to offer the younger generation.

Choosing a rural career

Like Chew, Sophie Hathaway grew up in an agricultural area in western Massachusetts. Currently studying global health and population studies at Harvard University T.H. Chan School of Public Health, Hathaway hopes to find solutions to rural public health problems by forging partnerships and connecting rural people and communities to resources. She also cites her rural upbringing as a major factor in her career choice, along with the realization that small-town perspectives are lacking in academia. “In contrast with the often-negative portrayals of rural life in media, academia, and other spaces, a lot of people in rural areas focus on the positive – what they do have and are able to cultivate in their community,” Hathaway says. “Underneath that there’s an understanding that people do things in certain ways because they lack access to certain resources and have to work around challenges. Hearing other people’s opinions of rural was a huge shock – a lot of them don’t understand it at all. I knew we needed more rural people in public health and academia – we need more representation. My first months of college were incredibly transformative in that sense.”
Sophie Hathaway
From Rogersville, Tenn., in the Appalachian Mountains, Jennifer Davis is currently enrolled in the Texas A&M University Family Medicine Residency Program. Her rural roots inspired her career choice, along with mentorship from a local family medicine physician and registered nurse, who both encouraged her to pursue medicine as a high school student. While still a teenager she attended a rural high school medical camp with the Rural Primary Care Track at ETSU Quillen College of Medicine, where she completed her first years of medical training.

“My lived experiences growing up in rural area have not only shaped my personal identity, but the way I see opportunities to use my career in medicine and public health to serve rural communities,” Davis says. “It was through my rural experiences with the Rural Primary Care Track, in combination with pursuing an MPH concentrated in community health, that my desire to practice rural was solidified.”
Jennifer Davis
For Bingyue “October” Zhang, the journey to rural America was a little less straightforward. Zhang moved to the United States from China at 17 and finished her last two years of high school in Lawson, Mo. She is currently a medical student at the University of Missouri School of Medicine in Columbia, where she is completing a family medicine residency. Zhang found meaning and connection in her small town, and she hopes to stay in a rural area after graduation.

“I really like being able to do a little bit of everything, which is why I chose family medicine,” Zhang says. “I want to practice in a rural area because rural residents are not getting the same quality of care as people in cities, where resources are more available. I feel like being a provider there offers me greater power to help others. Personally, I really like the lifestyle. I like the slow pace and getting to know everyone and getting involved in the community.”

Increasing rural exposure

It makes sense that having a personal connection with rural areas sparks a desire to serve there, but to create a broader interest in rural careers, all four students had one primary suggestion: Medical students from various backgrounds need more exposure to rural health care. Chew feels many people have misconceptions about rural practice that can be dispelled by firsthand experience and finding reasons to become invested in the community.

“As a doctor in a rural community, you’re getting a full scope of practice,” she says. “Showing people what rural medicine is makes a big difference – sure, some days you’re just doing follow-ups in your office, but other days you’re out in the field doing wilderness medicine and postpartum checkups. People are so desperate for care without having to drive far away that they’re willing to give you more trust.”

Having opportunities not only to practice in a small town but to get involved with the community made a huge difference for Zhang. She did her last year of clinical rotations in Sedalia, Mo., where she also worked with local high school students on mental health awareness. This made her feel connected to the people who lived there, which she says is vital for a rural physician.
Bingyue “October” Zhang
“A lot of physicians in Sedalia are highly involved in the community and people really look up to them,” Zhang says. “I think having that exposure and knowledge of what rural medicine is about is a great start to having more students get interested in rural medicine.”

Chew also insists that it’s never too soon to get young people interested in rural medicine – particularly middle and high school students who are already living in small towns, as research has shown they are the most likely to return there to practice. Davis is proof that early mentorship works, and she echoes that learning about rural practice is the best way to encourage people to live and work there.
"Hearing other people’s opinions of rural was a huge shock – a lot of them don’t understand it at all."
– Sophie Hathaway
“I believe rural and community medicine is something all students should have the opportunity to experience,” Davis says. “There’s something special about traveling to a rural community, meeting the people, learning about their resources, and having the opportunity to serve. It’s that connection to the people and the rural communities that I believe will lead students to consider rural practice.”

As an undergraduate, Hathaway had no engagement with other people pursuing similar interests, which illustrates the significant gap in knowledge and resources surrounding rural public health. She says she is lucky to have had supportive faculty who showed her how to pursue what was considered a “niche issue,” and since then she has found many programs that have allowed her to follow her passion, including a trip to the Mississippi Delta region to work on food justice and food insecurity last summer. At Harvard, many city-based employers have more interaction with students, and she believes that needs to change.

“Rural employers need to find more ways to get themselves out there and on platforms where students are looking for jobs,” she says. “There should be outreach to show why students should consider rural and the benefits of being in a smaller area.”

Benefits of rural living and practice

When it comes to putting down roots in the country, all four students cited similar benefits: There’s a lower cost of living, an abundance of natural beauty, wide open spaces, less pollution, and a slower pace of life that many people prefer to the hustle and bustle of the city. Then there’s the biggest boon: the sense of community and connectedness that are hallmarks of small-town living.

“You have a built-in support network of people who are going to check on you and are really glad you’re there,” Hathaway says. “Rural living offers many things, but the big ones are the sense of community, purpose, and place and the ability to make a positive impact on an area just by living there.”

Zhang and Chew both believe rural communities are a great place to raise a family, as the sense of connection and support from neighbors is much stronger than in most cities. To illustrate this point, Chew recalls the time her house burned down at the beginning of her sixth-grade year. Her family lost everything – and Chew suddenly found herself without clothes, school supplies, or a place to live. But her community pooled their resources to help the family, and by the end of the week they had enough money to get back on their feet – and Chew had all of the materials she needed for the entire school year.
"Those sweet moments that you hear about with doctors and patients – that’s something I’m really looking forward to."
– Ashli Chew
“In larger communities you don’t have the support you get in smaller communities,” Chew says. “Every generation – you know everybody, and you take care of each other. It was a great place to grow up. The benefits so far outweigh any grievance.”

Davis points out that employers can also make their practices more appealing to young professionals by giving them a seat at the table and listening to their ideas, thoughts, and concerns, as well as “staying on top of advancements in health care and advocating for resources and funding to support the care team in providing the utmost evidence-based medicine.”

Perhaps more so than previous generations, Zhang adds that younger health care professionals place greater emphasis on flexibility and work-life balance, as well as opportunities to express their values in the workplace and further their training and education. Chew also cites loan repayment as a significant concern for recent med school graduates.
"I think having that exposure and knowledge of what rural medicine is about is a great start to having more students get interested in rural medicine."
– Bingyue “October” Zhang
“With the amount of debt we have, loan repayment is oftentimes a huge factor in choosing a rural location, aside from a personal connection or reason to go to those areas,” Chew says.

As they see their graduation dates on the horizon, these burgeoning rural health care leaders share one final sentiment: They are excited to get to work and put their education into practice where it is needed the most.

“I’m excited about using my knowledge and skills to help others, which is the reason I wanted to get into medicine,” Zhang says. “I’m also excited about the ability to practice in a rural setting. Hopefully that day will come soon, and I will get to do what I truly enjoy, which is providing care to rural populations who may not have as many resources as they need or desire.”
"I look forward to the day that I am able to recall my patients by their name and life story as opposed to a name and an appointment time."
– Jennifer Davis
“I’m so excited to keep working with people, building connections, and placing an empahsis on the humanity and community involved with my work,” Hathaway says. “Also getting the chance to weave connections between people in rural areas so we’re able to have a stronger, more cohesive voice when it comes to issues that impact us and put rural on the agenda.”

“I’m excited to simply establish myself in a rural community, get involved in service and advocacy, and watch the community grow as I practice medicine,” Davis says. “I look forward to opportunities to invest in students the way I was invested in as a high school student. Also, I’m excited for continuity of care with my patients. I look forward to the day that I am able to recall my patients by their name and life story as opposed to a name and an appointment time.”

“After all these years of school – my family and I joke that I’m in the nineteenth grade – actually being able to contribute to society is really exciting,” Chew says. “Having the freedom to start my own family and give back in a way that’s meaningful really excites me. Those sweet moments that you hear about with doctors and patients – that’s something I’m really looking forward to.”

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