Welcome to Mile Markers, a bimonthly newsletter about rural higher education. I’m Nick Fouriezos, an Open Campus national reporter who grew up at the crossroads of suburban Atlanta and the foothills of Appalachia.

Today’s Roadmap

01: Postcards: Medical training in Clinton, Indiana

01: Postcards

Dr. Angela Hatfield's workday doesn't follow the neat boundaries of urban medicine.

At her health center in rural Clinton, Indiana, she might deliver a baby in the morning, round on hospital patients at lunch, and end her day checking on nursing home residents.

Between what are essentially four different employers — she also works as an adjunct professor at the University of Indiana — she's become the kind of comprehensive family doctor that rural communities desperately need.

"There's nothing that's not my job," as Hatfield puts it.

Her path to Clinton began at 18, when she enrolled in Indiana State University's Rural Health Program. From there, she moved straight into Indiana University’s Rural Medical Education Program in Terre Haute, completing all four years without ever rotating outside the region.

“I subspecialized in the Wabash Valley,” she likes to joke.

Such programs exist to keep doctors in rural communities that desperately need them, and in this case, it worked: Hatfield signed her first contract during her intern year and has been serving the same community ever since.

More than one-fifth of Hoosiers live in rural areas, according to the Indiana Business Research Center. That population is growing for the second year in a row, defying years of rural losses, yet rural areas have just 10.3 physicians per 10,000 residents, half the rate of urban areas.

Those numbers underscore the value of rural-focused exposure programs like the one Hatfield graduated from.

Medical residents who train in rural settings are much more likely to practice in similar environments, according to a report from the Indiana Rural Health Association.

The discrepancy is significant: Only 3-5% of urban-trained physicians ever move to rural practice, compared to 53% of those who spent most of their residency in rural areas.

Will they stay or will they go?

Today, Hatfield plays a major role in exposing the next generation of students to rural service — so much so that her office has become part hospital, part teaching laboratory.

Medical students shadow her often moving between her outpatient clinic, hospital rounds, and nursing home visits.

Her patients have grown so accustomed to seeing students that they ask where her trainee is during the rare weeks she works alone.

"Medicine in general is an apprenticeship," she explains. "The students just come and live my life with me for a month."

The immersive approach serves a dual purpose: Students get genuine exposure to rural practice's full scope, while Hatfield evaluates whether they can handle the independence and breadth required.

Some thrive; others find the responsibility intimidating, especially those already leaning toward mastering a subspecialty rather than doing the all-encompassing work a rural area often needs.

Hatfield has also noticed a major difference in the retention of those who come from a rural background already, compared to those who don’t.

The gap comes down to comfort level, Hatfield believes. Rural doctors must work with limited specialist backup, keeping patients local when possible to avoid overwhelming regional medical centers.

Real barriers, creative solutions

Transportation emerges as Clinton's most persistent healthcare barrier.

With no ride share drivers or public transit, patients depend on expensive taxis from one town over or group medical transport that can cancel with 15 minutes' notice if too few people need rides.

The hospital, local churches, and others have tried organizing shuttle services, but it was too cost-inefficient to employ drivers and they couldn’t find enough volunteer drivers to make it work.

Childcare presents another obstacle. Clinton has exactly one certified daycare, limited to children over three and requiring full enrollment rather than drop-in care.

For counseling appointments or lengthy visits, parents often can't arrange adequate supervision, forcing them to skip care or bring children who disrupt treatment.

These challenges require the kind of community-embedded problem-solving that defines rural medicine.

Union Hospital, Clinton's 25-bed critical access facility, typically houses 10-11 patients daily while managing everything from diabetic ketoacidosis to a "Swing Bed" program—short-term rehabilitation that helps patients avoid further-away nursing homes.

Telehealth has emerged as a crucial tool for overcoming some of her region’s geographic challenges.

With improved reimbursement making virtual visits financially viable, Hatfield can conduct follow-ups for medication adjustments and mental health care without requiring patients to navigate transportation challenges.

Teleconsultations with otherwise inaccessible specialists expand her treatment capabilities while keeping patients close to home.

“If we just need to follow up on a new medicine for headache or medicine for depression or something like that I don't need your physical body in front of me, then that telehealth visit can be super helpful,” Hatfield says.

The ripple effects

For Julie Wineinger, Hatfield's presence transformed her access to health care.

Before the doctor arrived, Wineinger faced hour-long drives to Rockville or extended waits at walk-in clinics.

When she fell ill without insurance, Hatfield not only provided hospital care but established an ongoing primary care relationship.

"When you're feeling sick, the last thing you want to do is get in the car and drive a long distance," Wineinger told IU News. "Dr. Hatfield was really a lifeline for us."

The economic impact extends beyond individual patient care.

Rural physicians create nursing jobs, support staff positions, and economic activity that helps sustain communities.

As Wineinger said: "The community dissipates when they don't have care."

Continuing the work

Indiana University School of Medicine's Rural Medical Education Program has produced 177 graduates since its creation, with most entering primary care fields and many remaining in rural Indiana counties.

The model emphasizes early clinical exposure, integrates rural relevance into basic science courses, and embeds residents in rural communities near Terre Haute.

For Hatfield, the work represents more than filling physician shortages.

It's about sustaining the kind of communities where neighbors know each other's children, where local festivals mark the seasons, and where comprehensive care comes from doctors who understand that healing happens within the fabric of community life.

"I chose to practice in a rural community because I want a deeper, multifaceted relationship with my patients," she says. "It helps me understand the stressors going on in their life, if they're not just a chart."

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