I was 68 miles along 33E, driving away from the sunset and my medical school in Columbus towards Hocking Hills for the 2022 Rural Health Scholars retreat. Moving along, as judged by the wind hissing through the window cracks and the increasing number of pothole jolts as I branched off urban roads, I wondered silently to myself, “I know rural medicine is practiced outside of a city, but what does rural medicine look like exactly?” Over the next three days I learned through experiences: camping near Old Man’s Cave, a morning run along those foreign bumps that the non-city folk of Ohio call “hills” and the testimony of numerous lifelong servants of rural healthcare who painted a picture of what rural medicine looks like in practice.
During the 2022 Ohio Rural Health Scholars Retreat, students from every medical school in Ohio traveled to Hocking Hills and sat down with several rural family doctors. We listened to their experiences serving rural communities and sympathized with their challenges advocating for policy changes to support their communities in an — at times — biased and broken system.
On Friday evening, we heard from Dr. Scott Anzalone, a rural family doctor of over 20 years, who has served the Hocking county and surrounding area and provided much more than flu shots and blood pressure checks in his years of rural practice. Dr. Anzalone shared that rural primary care physicians are just as talented as traditional specialist doctors since they are well-versed in a wide variety of skills and procedures that arise on a weekly basis.
“Rural physicians not only understand pediatrics, internal medicine and geriatrics, but even act as partial general surgeons – delivering babies, draining skin abscesses and removing decayed teeth when necessary,” he shared.
Like many non-rural doctors, Dr. Anzalone prefers to keep his professional and personal lives distinct, although this proves quite the challenge – he must be cautious in an area where everybody knows everybody, lest the grocery store or church foyer becomes an area for exchange of personal medical inquiries without the protection of clinic privacy and resources. Finally, he advised us as medical students to always practice humility (from the Latin word humus, meaning “earth, soil;” often used to truthfully admit one’s lowliness, but also one’s talents) in interacting with patients and their families. As a physician, he can distinguish prostate cancer from benign prostatic hyperplasia and pneumonia from the common cold, but as a homeowner, car driver and provider for his family Dr. Anzalone collaborates with local laborers in many industries who are experts in their own fields. He knows to defer to the professionals in other areas of his life, as he as a family doctor knows to refer patients out when their problems present out of his scope of practice.
Later in the weekend, we shared time with Dr. Steve Ulrich who served in the military as a medic (despite a later revelation that his right leg is two inches shorter than the left)! He earned his medical degree from Southern Illinois University School of Medicine and has served in the Ohio National Guard and as a rural family doctor for 42 years.
When he first began independent practice at a primary care office in New Lexington, Ohio, Dr. Ulrich recalled reviewing patient histories “loosely recorded on index cards – with a height, weight and perhaps a blood pressure reading or two noted if I was lucky.”
The previous physician had not been negligent in the least – rather, he had impressively committed to memory most of his patients’ medical histories. Dr. Ulrich implemented a new medical record system and data collection technology in his office, but he also left a footprint beyond basic record-keeping: He brought essential values of personalization, autonomy and humble service to the forefront of his work and used these values to ground his daily work caring for patients.
One example of his individualized, patient-centered medical practice is illustrated through an emergency call to his office from a local farm. A patient family of Dr. Ulrich had been scorched badly in a fire and a doctor was needed to help rescue the victims in a timely manner. Many of us have heard of the mobile clinics “Medicine on Wheels” sponsored by churches and other small groups that offer charitable services to the medically underserved in urban areas, but have you ever heard of “Medicine on Skids?” In this emergency medical situation, these helicopter skids were the tool that Dr. Ulrich used to reach patients in need miles away from his rural practice.
With there existing a significant distance between rural families’ homes and the nearest major hospital (sometimes hours by ambulance and not much quicker by air), rural communities depend on primary care physicians to direct their care and manage their health. In a similar way, physicians also rely on their spouses, social workers, local politicians and blue-collar workers to connect those in need with the necessary aid to achieve stable housing, income, food and safety. This ensures that, for instance, the insulin doses prescribed by a rural family physician receive proper refrigeration despite the reality that some families lack reliable electricity supply to their homes. Ultimately, it is this communal interdependence that stood out to me as a hallmark of rural medicine.
In conclusion, rural medicine is a vital but often overlooked specialization within the medical field. According to 2021 state-specific governmental statistics, most of the 19 counties in Ohio marked as “rural” are also medically underserved in some areas. Nationally, the Census Bureau defines rural as “any population, housing, or territory NOT in an urban area.” In legislation and zoning, any community under 50,000 people qualifies by most standards to be “rural.” Yet, a redefinition of terms may be in place: in the same way that my sister prefers to be called by her own name, “Sienna,” not “the other Caridi daughter,” and just as my medical school prefers to be identified as “Ohio University Heritage College of Osteopathic Medicine” in lieu of “the OTHER large public university in central Ohio” or “non-OSU school,” so too the US healthcare system should honor rural communities by defining them in light of the via positiva (the characteristics that uniquely define it) and not only the via negativa (the definitive things that it is not). Only when we see “rural” as an entity in and of itself will we achieve true health equity by providing rural Americans the healthcare they need with resources allocated specifically to their wellbeing.
Image credit: Custom artwork by the author for this Mosaic in Medicine piece.