As a family doctor practicing in the small Kansas town of Fredonia, Jennifer McKenney juggles a far wider range of duties than her urban counterparts typically do. She provides colonoscopies to her patients, for example, since the nearest gastroenterologist is 90 miles away in Wichita. She directs hospice and home health care for the town. And in emergency situations she has delivered babies.

“We do a lot,” said McKenney, referring to rural practitioners. “We’re not just in the exam room, we’re also the ER doctors, we’re also the hospitalist doctors, we’re the nursing home doctors … We are resilient, we’re resourceful, we’re creative.”

But even the most resourceful doctor can’t provide some types of specialty care and diagnostic tests, and rural residents often lack easy access to that care. McKenney noted that her patients often face a six-month wait to see a neurologist, for example. “We have trouble getting that expert care that we need for our patients, and it becomes a barrier for us,” she said.

McKenney spoke at a recent webinar hosted by the National Academies’ Forum on Advancing Diagnostic Excellence that explored the obstacles to diagnostic care in rural areas, as well as initiatives that are working to overcome them.

Unique barriers and strengths

One in every five Americans live in rural areas, and they are more likely than urban residents to die early from conditions like heart disease, cancer, and stroke, according to the Centers for Disease Control and Prevention — in part because of less access to health care.

“Rural is not a smaller version of urban,” said Meggan Grant-Nierman, a primary care physician in rural Colorado who spoke about the health care context in rural communities. “Every rural community is unique in terms of its cultural demographics and primary industries. What is common, though, is that we see fewer clinicians in rural communities, and a more limited base of health and human service infrastructures.”

Rural hospitals are struggling financially, Grant-Nierman said, and rural residents travel greater distances for care, especially specialty care and mental health care. There is also a greater reliance on Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP) to pay for patients’ care.

Attracting and retaining a health care workforce has long been a challenge in rural areas, said Grant-Nierman, and the rural radiology workforce — a field important to diagnosis — is small and steeply declining. Rural communities depend heavily on nurse practitioners and physician associates.

Like McKenney, Grant-Nierman noted the broad range of services that rural clinicians are called upon to provide. “It’s not uncommon that as a rural physician you may be doing a C-section in the morning, coordinating a transfer of a neonate over lunch, maybe admitting a [patient] with new-onset atrial fibrillation through your emergency room into your ICU in the evening, and squeezing in about 15 to 20 clinic patients throughout the day,” she said.

While challenging, this broad range of roles is also an advantage, said physician Mark Deutchman, who practiced for years in rural Washington state. When rural primary care is provided by clinicians with a broad scope of care, it can be less fragmented, he said. This enables better continuity and communication across transitions of care, such as from inpatient care to outpatient rehabilitation. Any efforts to improve diagnosis should aim to preserve this defragmented approach, he said.

Another strength of rural health care and diagnosis is clinicians’ deep familiarity with patients and their circumstances, said Deutchman. “I had a very intimate knowledge of environmental health and other constraints that my patients [faced],” he said. “In fact, I shared those.”

It was a point echoed by other speakers. “We know our patients really well,” said Kevin Stansbury of Lincoln Health, who heads a hospital in the small town of Hugo, Colorado. “They’re your loved ones, they’re your neighbors, you sit next to them at the basketball game, your kids babysit their kids.”

‘Diagnostic excellence starts with access’

Multiple speakers stressed that a key step toward improving diagnosis in rural areas is expanding access to care.

“Supporting rural health care professionals in diagnostic excellence starts with access to primary care,” said Matthew Probst, a physician associate and primary care provider for the University of New Mexico Office for Community Health. He explained a hub-and-spoke model that is expanding such access in rural New Mexico.

The model uses brick-and-mortar school-based health centers as hubs, with spoke sites at frontier schools that use available space — such as nurses’ offices or converted classrooms — to deliver care. The model delivers care on a three-part platform through community health workers, virtual exam technology that can improve diagnostic access, and connections to medical and mental health care clinicians, including Probst.

Each day that school is open, health care is available — in most cases not only to students and staff but also to family and community members. “In many of those towns, there are no other health care services available,” said Probst. The program currently delivers care through three hubs and 24 spoke sites.

“Success — as measured by clinical quality, patient access, and patient satisfaction data — has been phenomenal,” he said. A grant is enabling the team to expand beyond schools to senior centers, and they are exploring opportunities to build specialty-care delivery onto their hub-and-spoke platform.

Another project being developed to expand access to primary and specialty care was described by Emily D’Agostino of Duke University School of Medicine and Mission Mobile Medical, who is working on an ARPA-H project that aims to deliver advanced, hospital-level care to rural counties.

D’Agostino and her colleagues are developing mobile medical units called MARCUS — electric vehicles built to traverse rugged terrain that carry modules designed to deliver various types of specialty care. One module is built to deliver wound care, for example, while others are designed to deliver chemotherapy or maternal health care. Still others are planned to enable mammography and cancer screening. The modules carried by the MARCUS vehicles can be easily exchanged depending on the type of care that needs to be delivered to a particular area on a given day.

The plan is to create a home base or “mission station” in regions where there is significant need, and the MARCUS units could travel to different areas within the region, D’Agostino explained. Communities or health organizations could rent out a vehicle along with the module they need. “You can provide, through specialty units, much more timely diagnosis [and] access to care,” she said.

The benefits and limits of technology

Telehealth has expanded rural access to diagnostic care, particularly specialty care, and its benefits were highlighted by several speakers. Vida Passero from the U.S. Department of Veterans Affairs, for example, described how telehealth has enabled the VA to provide oncology care to nearly 28,000 veterans around the country, many of them in rural areas.

Telehealth can also offer support to clinicians in rural areas, which can help stabilize the workforce, said Deutchman. “When people feel confident in the care they can provide, they will stay where they’re working much longer.”

Still, challenges to wider use of telehealth remain, including insurance coverage for telehealth and ensuring rural communities have the necessary broadband capacity, said Grant-Nierman.

Sue Sheridan, a patient advocate with Patients for Patient Safety US who lives in rural Idaho, pointed to the potential of a more recent technology, artificial intelligence. Sheridan described how an AI chatbot suggested Bell’s palsy as a potential explanation for her symptoms after a clinician at a large regional hospital said her symptoms were “probably stress.” Armed with information from ChatGPT about the short window of time to treat her symptoms, she sought a second opinion from a clinician at a small rural hospital — who accurately diagnosed her and provided treatment right away.

Other speakers noted the continuing importance of physical assessment in diagnosis. Nurse practitioner Lyn Behnke held up her hands and said, “Your best diagnostic tools are these … You need to touch people. You need to touch their limbs. You need to touch their heart. You need to touch their lungs. You need to be able to do a good diagnostic physical exam.”

Investing in rural communities

Multiple speakers urged a broad approach to strengthening rural health, working beyond diagnostic approaches and technologies to support healthy communities. “We need resources for the people providing the care and for the patients — and what that means to me is not just the machines but also just investing in small towns,” said McKenney. 

In a later session, obstetrician Johnna Nynas of Sanford Health, who leads a program to improve maternal diagnosis in rural Minnesota, agreed. “We can bring all of the [health care] providers and technology in the world to tiny communities, but until we have built the infrastructure for healthier communities — access to food, access to water, improving the health literacy of our communities, understanding access to primary care and how to navigate the health care system — we can only do so much in terms of the diagnostic realm.”

Watch the workshop sessions