IU trains physicians to practice in rural and urban areas of critical need
Jan 18, 2024
The United States is facing a daunting physician shortage. According to a recent national address from American Medical Association President Jesse M. Ehrenfeld, more than 83 million people in the United States live in areas without sufficient access to a primary-care physician. The American Association of Medical Colleges projects a national physician shortfall of at least 37,000 — and possibly well over 100,000 — in the next decade.
Indiana University is tackling the challenge with two unique School of Medicine programs designed to train and retain physicians where they are needed most: in medically underserved rural and urban areas.
Rural Medical Education Program at IU School of Medicine-Terre Haute
Wearing their white coats, Indiana University School of Medicine students Maddie Wright and Andrew Gauger enter the room at Valley Professionals Community Health Center for a postpartum visit with a young mother and her 13-day-old baby. They ask her questions about her healing and her newborn’s feedings, and they listen to her concerns. Although they are not yet M.D.s, Wright and Gauger are the medical professionals in the room.
It’s an intentional approach employed by their preceptor, Dr. Angela Hatfield, a family physician in rural Clinton, Indiana.
“The process that I use for teaching is very hands-on for the students,” said Hatfield, an adjunct clinical assistant professor and the family medicine clerkship site leader at IU School of Medicine-Terre Haute. “I’ve had some students tell me that they’ve never been alone in a room with a patient before, so I make it a very purposeful decision to allow the students one-on-one time with patients. The way you learn to build rapport and create that relationship with the patient is by practicing how to talk to a stranger until they’re not a stranger anymore.”
Hatfield is certainly no stranger when she makes her rounds as a hospitalist at Clinton’s Union Hospital. Not only does she live in Clinton (population 4,782), but she has been practicing in the area since her graduation from IU School of Medicine in 2015. She rarely needs to take a patient history because she knows nearly everyone in town.
“I joke that I subspecialized in the Wabash Valley,” said Hatfield, who completed every rotation in medical school and her subsequent family residency in the region.
She embodies the vision for the Rural Medical Education Program created by the School of Medicine in 2008. In fact, Hatfield started down that track a year earlier, in 2007, when she entered the Rural Health Program at Indiana State University. The unique partnership with IU School of Medicine is a pipeline program for rural Indiana high school students to earn a bachelor’s degree and then matriculate into medical school if they meet certain academic and Medical College Admission Test requirements.
Across the nation, most physicians train in urban centers and tend to stay there, where pay and access to resources are better. That leaves many rural counties with only a handful of primary-care physicians and even fewer specialists. Studies show the best hope for keeping doctors in rural America is to recruit physicians who come from rural areas themselves.
Take Hatfield, who grew up in Trafalgar, Indiana — population 1,500 — and wanted no part of big-city life.
“The Rural Medical Education Program recruits people who are familiar with what rural life looks like and are committed to working in rural areas, in part, because that’s who they are,” she said. “Someone who grew up in a farming community is going to understand that there are certain things that just wait until after harvest. Understanding those differences in community and personal priorities makes a big difference in developing that rapport with patients.”
In the same week, Hatfield often welcomes newborn babies into the world and eases the suffering of people in the local nursing home as they near their final breaths. This is the life of a rural family physician.
“As the primary care providers, we have to learn how to do more things,” Hatfield said. “You have to be more self-sufficient because (specialty care) is just not available. That doesn’t mean that I don’t want or need specialists; I absolutely do. There are lots of procedures I can never and will never learn to do. But I certainly have learned how to manage some conditions to a higher level than I would have if I had practiced in an urban area.”
Nearly a third of Indiana residents live in rural areas designated as medically underserved by the Indiana State Department of Health and national Health Resources and Services Administration. Nationally, 80% of rural America is medically underserved.
Since its inception, the Rural Medical Education Program has produced 143 medical school graduates, and most have gone into primary-care residency training. Today, 21 Rural Medical Education graduates practice as primary-care physicians in rural counties, 61 practice in medically underserved areas, and 58 practice in counties designated as health professional shortage areas.
As associate dean and director of IU School of Medicine-Terre Haute, Taihung “Peter” Duong leads the program he was recruited to develop in 2008. It was Duong’s job to convince rural physicians working in busy clinics and critical access hospitals throughout the state to take on the additional duty of training medical students. He found overwhelming support.
“The physicians said, ‘We need the next generation to take over for us,’” Duong said.
He calls Hatfield an exemplar of the goals of the Rural Medical Education Program. She started down the rural health track at age 18 and spent all four years of medical school and her subsequent residency training in the rural environment. She now practices primary care in a rural county while strongly supporting the School of Medicine’s educational mission as an outstanding physician preceptor and mentor.
“Her career trajectory typifies what was hoped for when the Rural Medical Education Program was established,” Duong said.
Starting with just eight students in 2008, the IU School of Medicine program currently has 63 medical students and operates from Holmstedt Hall on the Indiana State campus and from the Landsbaum Center for Health Education in Terre Haute. The Landsbaum Center also houses Union Hospital’s Richard G. Lugar Center for Rural Health, the West Central Indiana Area Health Education Center and Indiana State University nursing programs, all of which use the high-tech Rural Health Innovation Collaborative Simulation Center to train future health professionals. This collaborative arrangement creates a hub focused on innovation in rural health care.
Wright, a fourth-year medical student, grew up in Monrovia, Indiana — population 1,643 — where she volunteered with a free health care clinic during high school. She now helps lead the student-run free clinic in Terre Haute, where Hatfield and other local physicians volunteer to care for uninsured and low-income patients.
Her appreciation for the full spectrum of care that rural doctors provide has only grown after working alongside these physicians.
“Dr. Hatfield does so much for her patients; it’s personal,” Wright said. “It’s rare you have a family medicine doctor who sees patients in the hospital, has a full clinical day, delivers babies and goes to visit patients in a nursing home. She embodies that cradle-to-grave health care approach.”
While Wright plans to specialize in pediatrics, addressing the dearth of primary-care providers in rural Indiana, Gauger has different plans for his medical career. An Indianapolis medical student aspiring to specialize in dermatology, Gauger will likely practice in an urban setting. He landed in Clinton with Hatfield for his family medicine rotation because IU School of Medicine wants all students to get first-hand experience in the diversity of care provided by family physicians across America’s rural landscape.
“IU’s focus on immersing students in these rural areas for training is very helpful because if you don’t understand how life is different in a rural community, then it makes it difficult to tailor your treatment approach — to see where you, as a provider, can help (rural patients) achieve better health,” Hatfield said. “IU is helping students develop a mindset that is more collaborative and that will lead to better patient outcomes.”
Urban Medicine Program at IU School of Medicine-Northwest-Gary
On the flipside of rural medicine is another medically underserved population, often hidden in plain view: those living in poverty pockets of metropolitan areas. Gary, Indiana — once a thriving, industrial suburb of Chicago — is now riddled with vacant buildings, high unemployment and a poverty rate nearly three times the state average.
This is where IU is training culturally competent physicians who are passionate about reducing health disparities. Patterned after the Rural Medical Education Program, the Urban Medicine Program was launched at IU School of Medicine-Northwest-Gary in 2022 and is now recruiting its third cohort of medical students.
“The goal is to graduate cohorts of doctors who are well-rounded, can understand the importance of social determinants of health and have cultural competence that is integrated into their practice on a daily basis,” said Amy Han, the campus director for clinical education and co-director of the Urban Medicine and Health Care Disparities Scholarly Concentration.
Students are recruited from urban areas in Indiana and throughout the United States.
“I grew up in an ethnically and racially diverse neighborhood in Brooklyn, New York, where I realized that many of the health challenges my family, friends and neighbors faced were normalized,” said Gabrielle Li, a first-year medical student in the Urban Medicine Program. “At a young age, I started to learn that access to health care looked different to different populations.
“It was difficult for many of my loved ones to access culturally competent care. I want to mend the gap and advocate for these populations.”
Students learn about disparities through community engagement. They go to health fairs, talk to local residents and provide health resource information in partnership with the Gary and East Chicago health departments. They volunteer with local nonprofits on community service projects like cleaning up trash at parks and sorting donated goods at a food bank.
From their first year of medical school, students begin shadowing physicians at the five Federally Qualified Health Centers in Northwest Indiana. During their third year, they work alongside psychiatry residents in IU School of Medicine’s newly established Psychiatry Residency with Regional Care Group, which is filling a critical need for behavioral and mental health care in Northwest Indiana.
John “Quen” Deckbar, a second-year medical student from Nashville, Tennessee, said he is impressed by the “altruistic intentions of my peers.”
“Many are dedicating their free time to act in the interest of those in need of medical services,” he said. “There is a lot to learn from this underserved population that is often not spoken about openly.”
All students in the Urban Medicine Program undertake research projects aimed at reducing health disparities. Li and Satya Sanapati are working with the local Head Start program to analyze the impacts that COVID-19 shutdowns had on child social and emotional development.
“The Urban Medicine Program has taught me about the nuances involved in caring for diverse populations,” Sanapati said. “I’ve learned how to consider the impacts of external social factors, such as one’s environment, education or economic stability, on a patient’s health. I believe these lessons are important for any physician to learn, as they can ensure that no patient falls through the cracks and that a patient is receiving comprehensive and personalized care.”
Fourth-year medical student Daniel Green piloted the Urban Medicine Program before its official launch and has seen its impact grow.
“Dozens of projects have begun that encourage students to contribute their time and talent to causes that benefit the community surrounding the Northwest campus,” he said.
Green is interviewing with residency programs in pediatrics for the next stage of his medical training, but a research project he initiated will be carried forward by a new group of urban medicine students. They will be working with Methodist Hospitals to compile and analyze 22 years of breast cancer screening data; the goal is to eliminate disparities in screening rates and disease outcomes for Black women.
“I’m grateful to the Urban Medicine Program for the opportunity to play a part in starting research with such staying power and impact on our community,” Green said. “I want to continue advocacy and community engagement in my residency and throughout my career, especially relating to maternal and infant health, reducing premature birth incidence, and quality improvement in the NICU (neonatal intensive care unit). I know the skills I developed through the Urban Medicine Program will help me accomplish these goals in my future career.”