Duke Medical Ethics Journal
The Next Frontier
By: Pratamesh Ramasubramanian
1 in every 5 Americans experience challenges in healthcare access and delivery due to geographic barriers.1 As newly minted M.D.’s continue to flock to urban medical centers and deliver their services to urban and suburban residents, rural residents are left on their own and are often forced to travel over 200 miles for access to basic services.1 For many, such a distance is infeasible to travel, leaving them to care for themselves without any medical supervision, which is especially problematic given emergency medical situations. Unfortunately, the problems only get worse.
Racial minority groups are usually the ones who experience the lack of rural care the most, thereby further contributing to health inequalities. Layering the urban-rural differences along with racial health disparities causes minority groups such as African Americans to have higher rates of mortality than their fellow rural residents.2 Unfortunately, the changes in the medical system over time perpetuate these inequalities and inadvertently place the brunt of the consequences on these groups.
These changes started in the 1920’s when the effects of smaller medical school output coupled with increased relocation to cities as a result of urban sprawl diminished the population of physicians practicing in rural areas.3 As larger medical centers in urban areas received the bulk of the attention, many rural health facilities became largely neglected, as did the health of their patients.
To remedy such health disparities, it is time to put the spotlight back on these rural health centers serving vulnerable populations and allow greater physician access to the neglected populations that need it the most. Such a remedy must tackle the problem early on in the form of medical education. First, students from small and underserved communities that lack access to such services must be incentivized and funneled into the medical school pipeline. These students are more likely to return to these areas and practice medicine than their peers.4 More than simply increasing the number of doctors that practice in these areas, this practice secures doctors who understand their surrounding communities and who are naturally better equipped to deal with the unique situations that arise. Second, increasing the presence of programs that train physicians specifically to practice in rural areas such as the Columbia-Basset Track at The Vagelos College of Physicians and Surgeons would also help mitigate the problem. These programs directly funnel medical students into rural areas, which will otherwise never materialize. As Flexner writes, “the question is, then, not merely to define the ideal training of the physician; it is just as much, [to] … distribute as widely as possible the best type of physician so distributable.”5 It is not enough to simply train physicians and leave the distribution process up to a laissez-faire system. Future reform must create avenues where trained physicians are present in all parts of the country to provide equitable care for all patients.
Warshaw, R. (2017, October 31). Health Disparities Affect Millions in Rural U.S. Communities. Retrieved September 20, 2020, from
Tweedy, D. (2016). Black man in a white coat: A doctor's reflections on race and medicine. New York, NY: Picador.
Starr, P. (2017). The Social Transformation of American Medicine. New York: Basic Books.
Rural Practice, Keeping Physicians In (Position Paper). (n.d.). Retrieved September 20, 2020, from
Flexner, A. (1978). Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Washington, DC: Science and Health Publications.