In recent years, the divide between rural and urban areas of the United States has become more pronounced, with sharply divergent views on both social and economic policies. The results of this latest election show starkly that the divide persists, and indicate that the institutions that shape our nation are not successfully representing all portions of society.
One of those institutions appears to be medicine. A sign of this is how the public has increasingly lost faith in physicians over the past few decades. The New England Journal of Medicine reported that in 2012 only 34 percent of Americans said they had great confidence in the medical profession’s leaders, less than half the reported figure from 1966. Trust has also faded, especially among low-income individuals, fewer than half of whom reported that they trusted doctors at all.
The sharp decrease in public confidence and trust in physicians, especially in low-income individuals, may be closely related to the U.S. health care system’s inability—and doctors in particular—to adequately serve rural communities. Our country desperately lacks rural physicians, forcing many Americans to either forego care or travel hours to their nearest doctor. The National Rural Health Association reports that there are only 39.8 primary care physicians per 100,000 people in rural areas, compared to 53.3 per 100,000 in urban areas. Lack of proper health care infrastructure contributes to worse outcomes compared to metropolitan areas, including higher age-adjusted death rates for all five of the leading causes of death in the U.S., a 45 percent higher rate of opioid overdose death, and even recent struggles against COVID-19. Some medical schools have made efforts to foster interest in rural health care, such as the Physician Shortage Area Program at my own school, and these have certainly helped, but they hardly stop the bleeding.
Very few medical students are familiar with life in rural America, with almost all coming from urban and suburban backgrounds. According to a Health Affairs study, the number of students enrolled in medical schools from U.S. rural areas dropped 28 percent between 2002 and 2017, resulting in rural students making up less than 5 percent of total matriculants. The number of applications has followed a similar trajectory. Medical students also overwhelmingly come from wealthy backgrounds. According to the Association of American Medical Colleges, approximately three-quarters of medical students come from households in the top two income quintiles.
These student population trends have created a rather monolithic culture in medical colleges, with precious few students even vaguely interested in rural health care. The prevailing culture is that successful students should desire a career in a well-compensated subspecialty at a prestigious, urban, academic medical center. Even if, by chance, a student who hails from the city or suburbs, like me, desires to make a career in a rural community, they may not be the best equipped to do so. The patient-physician relationship is tricky, something that requires an almost sacred form of trust and good-will for its full actualization and, if recent patterns tell us anything, it is that trust and good-will are in short supply.
But here’s the thing: Physicians are not tasked with treating a mere portion of the country, and our field should not represent only that social subset. If medicine continues to foster the homogenous culture of elite metropolitans, then we can no longer act shocked when working-class Americans fail to trust us nor when the quality of rural health care continues to suffer. If we could repair broad public trust in physicians by becoming a more diverse field that values all ways of American life, then we might be able to begin healing the wounds of our sick nation.
The means to this end is admittedly complex, and I certainly don’t have all the answers. Innumerable pages have been devoted to studying the broader trends in rural America’s economics, lifestyles, and psychology. However, medical colleges’ administrations and cultures certainly ought to play a more positive role in solving this health care crisis. Whether that role manifests as an honest reevaluation of admissions factors, policies aimed upstream at empowering young rural students to consider medicine as a career, or simply encouraging current medical students and physicians to open their hearts and minds to those who feel like strangers in the world of contemporary medicine. If we want quality health care for all, our only hope is to better engage and welcome our neighbors from those communities most left behind.
Michael McCarthy is a medical student.
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