Beyond the City Limits: The Critical Value of Rural and Remote Medical Education Experiences

Abstract

The rapidly urbanizing USA and the world risk distorting medical education and shaping perceptions of medical needs toward urban health challenges, since most schools of medicine are based in large cities. The value of hands-on rural and remote experiences for medical students is increasingly recognized, though their underlying principles and competencies may remain underappreciated. Rural training experiences not only enhance medical knowledge but also increase students’ appreciation of the challenges and opportunities in these areas. Domestic rural and international experiences also offer complementary opportunities for competency development. Allowing medical students to engage in research supporting rural and remote communities not only addresses the needs of these populations but also provides the foundation for groundbreaking discovery and offers opportunities to teach students how to think. An urban-centric training approach risks producing physicians unprepared for rural and resource-limited environments, both domestically and internationally. Providing a robust “classroom” helps ensure that future physicians are prepared for the challenges of healthcare, regardless of where they practice, and that they will be capable of engaging in shared decision-making and thoughtful solutions.

As medical educators, we aim to build well-rounded physicians who can serve both rural and urban populations. The rapidly urbanizing USA and the world risk distorting medical education and shaping perceptions of medical needs toward urban health challenges, since most schools of medicine are based in large cities. However, it is increasingly recognized that the value of providing medical students with broader, evidence-based, hands-on rural and remote experiences matters, but the underlying educational principles, health needs, and transferable competencies risk being underappreciated.

This matters for competency development. As authors, we are educators at one of only three medical schools in the Commonwealth of Kentucky and have a longstanding interest in the development not only of competent physicians but also of compassionate, dedicated doctors who appreciate all aspects of practicing in challenging environments. Kentucky is a largely rural and impoverished state, with 90% of counties designated as Health Provider Shortage Areas for primary care and more than one-third of hospitals designated as critical access facilities. ¹ An increasing body of data shows that experiential learning in rural communities increases the chance that a student will return to practice in a similar community.^2–4 Rural training experiences not only teach students the “nuts and bolts” of providing care in resource-limited environments but also introduce them (many for the first time) to the culture and community of small towns far from the bustling metropolitan medical school region. ⁵ These positive experiences not only enhance their medical knowledge but also give students a better understanding of individual and community priorities around health-related issues, allowing for a greater opportunity to build trust and develop needed skills in empathy.

Domestic rural and international experiences also offer complementary opportunities for competency development. Medical students may have been former Peace Corps Volunteers or may have been born in the USA to parents born outside the USA, and offering low- or middle-income country experiences in clinical observation or desk-based research can allow a personal connection to their education. Resource-limited settings strongly emphasize the need for preventive rather than curative healthcare to save the greatest number of lives. Rural domestic and low- or middle-income country rotations challenge physicians not to think about using the newest and greatest technology, but rather to focus on saving a life by repurposing what is available locally (since specialized care and equipment may be many hours away or across international borders). Educational experiences in these environments also enhance students’ education about communicating with people from diverse backgrounds, as well as about listening to and learning from colleagues, patients, and families. These experiences require students to stretch not only their communication skills but also their knowledge and skills in trust-building and shared decision-making, which may be considerably different from those needed in well-resourced and densely populated urban centers. These are professional skills we seek to impart to our students in all training settings—urban or rural, resourced or not.

A well-rounded clinician must not become solely disease-focused. Many challenges faced in rural communities have equivalent counterparts in urban areas. Transportation, healthcare costs, access to insurance, navigating healthcare systems, food deserts, and other social determinants of health are often remarkably similar, and rural rotations highlight these universal needs. Exposure to global health practice also reveals parallels of limited technology, improvisation, and community engagement. Many learners are surprised to find that the “urban–rural divide” is relatively narrow. Moreover, clinical rotations with rural physicians often provide students with more hands-on experience than might be available in busy urban teaching hospitals. Surgery clerks may first assist rural general surgeons, and obstetrics students may actively participate in deliveries. Students return from these experiences with a new appreciation not only for rural primary care but also for specialty care in rural communities.

Finally, biomedical research and innovation are defining elements of the academic mission of a medical school and health sciences center. It is a commonly held belief that research is limited to urban campuses and tertiary care hospitals. However, research in rural and remote communities not only addresses the needs of these populations but can also provide the foundation for groundbreaking discoveries and contribute to improving trust in medical providers and scientific inquiry in general. Environmental exposures and toxins, for example, are of critical concern not only in the urban core but also in rural communities. Successful research in rural and global lower-resourced communities is increasingly “community-engaged research,” which requires students to develop research questions in partnership with community stakeholders to refine and prioritize solutions around pressing health and disease challenges. Also, medical students are increasingly researching in the global field of wastewater-based epidemiology, expanding what they are taught to do with data from clinical sources. ⁶ Research in rural and remote global environments can provide students with additional and unique opportunities to understand the importance of compassion, fully acknowledge the social determinants of health and their relationship to health outcomes, and explore novel exposome aspects, which influence disease development and health diminishment across all patient populations, not just underserved communities. For medical students, research experiences teach them how to ask the right questions, review literature (including identifying potential bias), analyze data, and communicate conclusions; in short, they teach students how to think with a widened lens of community-informed medical and population health priorities rather than solely investigator-driven hypotheses.

An urban-centric training approach risks depriving physicians of the opportunity to be prepared to serve rural and resource-limited environments, both domestically and internationally. Implementation strategies need to be intentional across the educational continuum and may include a longitudinal rural track,^2,3 rural domestic and international experiences and research available to all students, ⁶ and specialized models such as a third-year surgery clerkship. ⁵ Training across diverse contexts outside the urban classroom is essential for the resilience of the health system and to avoid (or delay) physician burnout. Providing a robust “classroom” helps ensure that future physicians are prepared for the challenges of healthcare, regardless of where they practice and the inherent, and often dynamic, challenges of those practice environments.