Bulls and Hippos: Listening to Rural Voices in Healthcare

We had lived in Baraboo for about a year when we were invited out to lunch with a few older members of our church. They began speaking of a man who had cancer years before.

"In the end, the bull got him." Thinking that he was speaking metaphorically, we nodded solemnly at this statement. Then another man spoke up.

"Yeah, bulls are mean animals. My cousin was killed by one as well."

It was at that moment that it really hit home. We certainly were not living in the city anymore.

My husband and I went to school in Chicago, but I ended up doing my residency training in rural Wisconsin.  Being originally from a suburb of Minneapolis, I had not seen myself going into rural medicine.  I liked the idea of serving an underserved community, but had pictured myself in an inner-city community, like I had seen in Chicago.  However, I had always been drawn to the idea of being the doctor who could do everything, including obstetrics, and so I went to a rural training program in Baraboo, Wisconsin, where I could get the training that I desired. To say that this changed the direction of my career is an understatement. I was stunned and impressed by how much family medicine doctors took on in their practice, primarily because there was no one else to do it. Many people would not or could not go to Madison to see specialists. So, we became the ones to manage many conditions that otherwise would have gone to specialists.  Because if we did not, no one would.  And indeed, in many cases, no one had. There were many people who came to us with illnesses so advanced that I had only ever read about them in textbooks.  We did what we could, but there was always the feeling that we needed more help, and more people to serve the community.

Going from urban training to rural practice is a stark transition, but one that many professionals who work in rural communities go through, simply because there are few large learning institutions outside major metropolitan areas. Medical education in urban settings creates an unfortunate myopia where trainees are not exposed to the unique challenges of rural healthcare until they are in practice. Or, for those who never work in a rural area, a complete disconnect from and avoidance of these communities entirely. And while logically, many can comprehend that there might be some differences between rural and urban environments, in practice, it can be easy to gloss over the differences when you are unaware of the nature of the bull.  

But though I was not raised on a farm, it did not take long to see how blatantly wrongly the urban healthcare community spoke about rural medicine. I once heard a speaker discussing telehealth as the key to bringing better healthcare to rural communities. As I racked my brain trying to remember where the speaker practices medicine, she answered it for me: She is at a tertiary care center in a large city.  Since I had started residency training in the pandemic, many of my Madison colleagues had whole days dedicated to telehealth. I, on the other hand, had a total of five telehealth appointments in three years; three of them had turned into phone calls due to technical problems.  The truth was that many people in our area did not have the technology to have successful telehealth encounters. Including many of the providers! One doctor could not even do documentation at home due to inconsistent internet.  It is a common fallacy to think that other people have the same wants and needs as yourself, and that if you would benefit from something, others would as well. And while this can create a sense of connectedness between people, it causes a great deal of judgment, frustration, and anger when you perceive other people as acting irrationally based on what you see as right. 

There is an allegory I was told when I first started working in global health about some relief workers who came to an area to help out a starving farming village. They looked around and saw a lush patch of land that had never been cultivated.  “How could the locals not make use of this perfect land,” they wondered, and set about planting the area. A few weeks later the relief workers woke up to find that their farm was trampled by hippopotamuses. Someone from the local village told them that the hippos regularly travel through that area, and that is why it was never farmed. 

The allegory is meant to illustrate why it is important for an outsider to not impose their ideas on a community without first listening. Because while it seemed obvious to the relief workers to use all available farm land to help the starving community, it was obvious to the community that it would fail.  The importance of listening is prominent in global health, and is picking up speed in some nonprofit circles working with marginalized populations. But it is absent from the conversations surrounding rural healthcare and rural needs in general.  That is because it can only exist after those with power – in this case urban medical education – see that there is, in fact, a difference between the communities.

The disconnect between rural and urban communities is hardly a new phenomenon.  Nor is it necessarily an inevitable “us vs them” situation. But this disconnect led to a road to hell paved with good intentions, especially when it came to the COVID pandemic and the post COVID world.  Early in the pandemic, when states started instating lockdown rules, one concern from rural communities was that they were being held to the same standards as large cities, despite small towns not yet having any cases of COVID. While the argument could be made that this was not necessarily the wrong policy, it led to many rural communities feeling as though their needs were not being taken seriously, and laid further groundwork for distrust of medical recommendations for masks and vaccines. Obviously, these issues had other instigating factors, including political and media pressure, however, this ongoing narrative that urban individuals simply do not know or care about what is happening in rural communities continues to be a powerful force that no one seems to be attempting to mitigate. 

So, what will actually bring change?

While I do not think that I have the answers to end the divide between rural and urban communities, I can speak for myself and say that my views of rural medicine have changed dramatically by being part of a rural community. It has come from listening to both the healthcare providers around me and my patients to understand what their needs are. But that is not enough.

Right now, one of the biggest galvanizing causes for providers in the state of Wisconsin, and in the country as a whole, is how much autonomy mid-level providers should have. A bill to reduce the amount of physician oversight for nurse practitioners was proposed in WI by a rural nurse practitioner, who said that she was struggling to find physicians in the area to support her so that she could continue to practice. As expected, there has been a great deal of physician push back against this proposal, mostly from urban physicians who see mid-level providers as encroaching on the care they provide. While that may be true in urban centers, in Baraboo we would not have running clinics, or certain specialty care, or any anesthesia for surgery, if it were not for our midlevel providers. I am willing to bet that we are not the only area in this situation.

In order for rural healthcare to improve and thrive we need to encourage rural voices to be heard, both in personal, educational and political spheres. That means actively creating space for it to be heard like we do in other areas of diversity interactions, and taking seriously the differing beliefs and needs of these communities. We also need to do a better job of exposing trainees to rural medicine, to help pave the way for the next generation of rural health care. Even for those who do not end up practicing rural medicine, to allow them to develop a healthy respect for some of the similarities and differences of working in a rural community.  Even with the best intentions, I know that there might still be the occasional hippo that catches us off guard. But my hope is that through humility and a stubborn dedication, we all can work together to take on the metaphorical bull of the division between urban and rural healthcare, and improve patient care and health outcomes for everyone.