Teaching Hospital-Based Rural Physician Fellowships Advance Health Equity


The rural United States is a rich landscape of diverse communities and health systems. Yet, the nation has failed these communities and health systems, which experience increased mortality across racial/ethnic groups. These outcomes owe to factors including historical neglect, structural racism, workforce gaps, and structural urbanism—that is, health system design favoring urban locations. Many rural counties are considered highly socially vulnerable according to the Centers for Disease Control and Prevention’s Social Vulnerability Index and nearly 80 percent are health professional shortage areas.

While academic medical centers (AMCs) have a broad mandate, caring for the underserved is key to their collective mission. As directors of the nation’s four teaching hospital-based rural physician fellowships, we believe that the time has come to organize stakeholders and define a pathway to more fully engage AMCs in equitable rural health. That effort should be inclusive, forward-looking, and directly address the racist and urbanist structures that burden rural communities. Rural fellowships have a small but important place in that effort.

Treating the rural US as a monolith—for example, using the term “rural” as a noun instead of an adjective—has been a successful strategy of lobbying groups and others during the Trump administration. In the past four years, important progress was made for programs to treat substance use disorders, promote rural training track residencies, and make reimbursement adjustments for rural health systems. However, implementing a monolithic approach to the rural US is a form of structural racism: It obfuscates the unique needs of rural populations that are, for instance, Black, Indigenous, undocumented, or migratory. Examples of gaps during the last administration include pernicious policies around border health and, compared to the Biden Campaign, lack of a structured commitment to the Indian Health Service.

Our fellowships at University of California, San Francisco, University of Washington, Massachusetts General Hospital, and University of Utah train physician and community leaders across the US, with a focus on partnership with Indigenous communities that lack support from teaching hospitals. We have developed the programs because we believe that bilateral engagement between resource-denied rural communities and high-resource teaching hospitals will prove to be valuable in addressing structural urbanism and structural racism. Fellows matriculate in our programs because they share that belief, because they seek to steward the rural health system toward a more equitable future, and because many intend to serve in underserved, rural communities after their fellowships end. We now seek to expand this movement both to increase the number of health professionals who join rural fellowships as well as to lower the barriers for teaching hospitals to build rural partnerships. The fellowships, fellows, and their community partners will benefit from:

  • A structured public program that creates reciprocity between teaching hospitals and rural communities by
    • Supporting costs at low-resource rural health systems that provide clinical placements for teaching hospital-based rural fellowships and
    • Supporting fellowship costs at teaching hospitals that longitudinally invest in rural communities and health systems;
  • A loan forgiveness option for fellows in positions that bridge teaching hospitals and low-resource rural health systems;
  • Public or subsidized course offerings in public health and related disciplines that develop skills to fellows and rural partners to help them guide our nation toward rural health equity; and
  • Ongoing teaching hospital support, facilitation of a community of peers, and loan forgiveness incentives for fellows who assume permanent positions in rural health systems.

We are optimistic that teaching hospital-based rural physician fellowship programs will grow in number and impact. The start of the Biden administration offers an opportunity to map a smooth pathway to that future and, in so doing, strengthen ties between teaching hospitals and governmental organizations, non-governmental organizations, and rural communities. While we work toward that bright future, let us also abandon the monolithic noun “rural” and instead use the word as it naturally arose, as an adjective that describes a vast landscape of rich and diverse communities.

Authors’ Note

Several of the authors have clinical positions at Indian Health Service hospitals. The opinions expressed in this blog post are the authors’ own and do not reflect the view of the Indian Health Service, the Department of Health and Human Services, or the United States government.


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