As with any complicated relationship in people’s everyday lives, the dynamic that exists between a doctor and their patient is incredibly nuanced, characterized simultaneously by aspects that work and others that could benefit from reform. These nuances are especially evident in rural areas, as other characteristics of rural healthcare interact and shape this partnership into one that looks far different from the physician-patient dynamic typically found in urban settings. Each patient-provider affiliation is shaped by the individuals involved. However, on a general level, the rural doctor-patient dynamic is typically marked by an initial fear or discomfort on behalf of patients, likely stemming from cultural or educational disparities, but has the potential to evolve into a uniquely comfortable and familiar relationship.
Fear at First Sight: Cultural and Educational Disparities
One of the most common issues rural patients have found in the dynamic they share with their physicians is the initial fear or discomfort they hold towards physicians as a demographic. Ana Maria Deaver, a CNA from Dunn, NC, offers a first-hand account of this fear while speaking about visiting with her physician, “My doctor, and when I go to him, my blood pressure goes sky high, and this ain’t nothin’ but a white-coat disease. […] And it’s crazy, because I work here and I go to him and my blood pressure will go real high.”¹ Although Ana is a medical staff member, she is no stranger to this “white-coat disease” that she describes, which is especially prominent in the patient-provider dynamic seen within rural communities and can be largely attributed to the disparity in cultural understanding/experience that exists between each party. According to one study that identified trends in the origins of medical-school matriculations, “the medical school application data confirmed that rural areas have significantly fewer applicants in the pipeline to the future workforce.”² Due to this deficit in physicians originating from rural backgrounds, there exists an innate distance between patients and the physicians transplanted into these communities, who likely lack an experiential understanding of the unique culture of many rural areas, especially when first starting. Additionally, a unique power dynamic is created by the disparity in education levels between doctors and patients found in rural areas. One study on rural education notes that “despite the gains made in educational attainment over time, there is still wide geographic variation in educational attainment within rural areas,” explaining that out of 271 counties in the U.S. where 20% or more of the working-age population lacked a high school diploma, four out of five were rural communities and primarily clustered in the South.³ Such a large gap in educational attainment increases difficulty in both communication and understanding between physician and patient, which can likely make physicians seem far more intimidating.
The Special Bond Between Doctor and Patient
While Ana Maria Deaver discusses her “white-coat disease” or feelings of fear when going to the doctor, she also goes on to express that the experience is “always good. I don’t have nothing negative. I got a good doctor. He always listens, and like I say, I have known him for thirty years.”⁴ Deaver’s example not only illustrates the particular challenges of the rural patient-provider dynamic, but also the potential for amicable and personable relationships that are typically inaccessible to urban patients. Specifically, Deaver’s 30-year affiliation with her doctor portrays a key factor in the familiarity shared between patients and providers in rural settings. As discussed in “Accessing Specialist Services in Rural Healthcare,” the systematic reliance on a single general practitioner in rural healthcare creates a continuity of care that a University of Michigan literature review finds to promote “patient satisfaction, decreased hospitalizations and emergency department visits, and improved receipt of preventive services.”⁵ Time, however, isn’t the only contributing factor in the personal bond shared between rural patients and their physicians. The Dartmouth Medical School curriculum identifies a socio-cultural factor in the observation, “Health care providers may have children in the same class as their patients, or the local grocer or pharmacist may be their patient. […] As a result, providers have increased knowledge of their patients’ lives, behavior, and activities that may potentially influence their perception of those patients.”⁶ The authors identify the potential issues that such an intimate relationship can create, such as doctors assuming a patient’s history. However, this level of familiarity instills a level of comfort that helps to combat the aforementioned challenges of intimidation and miscommunication between patient and physician. One great example of such is Kenneth Cook, another Dunn, NC community member who explains that his doctor had become something closer to a friend, having met his physician’s children and even bringing him eggs as a friendly neighbor would.⁷ A comparative study from the UK recognizes how this distinct sense of “relationship” in rural healthcare shapes the habits of patients through a comparison between urban and rural patients in the lines, “While rural people sought to influence their access through relationships with practice staff, urban people resorted to more consumerist strategies, perhaps based on exerting their rights as a patient.”⁸ Through observing the tendency of patients to use the intimate partnerships they share with their providers to reap medical benefits, the particular value of the rural provider-patient dynamic gains further clarity. Patients in rural areas, typically of a lower economic status, are especially vulnerable to the medical system and pharmaceutical greed, which likely serves as another key component in cultural distrust towards physicians in rural communities. However, these intimate relationships patients share with their providers act as a safeguard to such greed and corruption, acting as a distinct point of power that helps to ensure just and comprehensive care.
Conclusion: Only the Tip of the Iceberg
The rural doctor-patient relationship is defined by both layers of nuance and possibility. While it is initially characterized by a deep-rooted sense of mistrust as a result of cultural and educational disparities, these affiliations each have the potential to grow into lasting personal connections that aid in patient autonomy and improve overall health outcomes. However, the aforementioned aspects of the doctor-patient relationship are only the tip of the metaphorical iceberg, as complexities to this dynamic develop based on a variety of socio-cultural and economic factors that are unique to each rural community. Thus, it is essential to engage in comprehensive, community-specific discussions that address each nuanced layer of the patient-provider dynamic, which will improve health outcomes by fostering a space for compassionate and culturally attuned care.
Footnotes:
¹Interview with Ana Maria Deaver, p.30, 28 June 2018, Y-0020, in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
²Chen et. al. Rurality and Origin-Destination Trajectories of Medical School Application and Matriculation in the United States. ISPRS Int J Geoinf. 2021 Jun;10(6):417. doi: 10.3390/ijgi10060417. Epub 2021 Jun 16. PMID: 35686288; PMCID: PMC9175876.
³Farrigan, Tracey. “Employment & Education – Rural Education.” Employment & Education – Rural Education | Economic Research Service, U.S. Department of Agriculture, www.ers.usda.gov/topics/ruraleconomypopulation/employmenteducation/ruraleducation#:~:text=The%20Geography%20of%20Low%20Educational%20Attainment&text=There%20are%20271%20such%20counties,%2C%20racially%2C%20and%20ethnically%20distinctive. Accessed 21 Apr. 2025.
⁴Interview with Ana Maria Deaver, p.30, 28 June 2018, Y-0020, in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
⁵Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract. 2004 Dec;53(12):974-80. PMID: 15581440.
⁶Davis, Rachel, and Laura Weiss Roberts. “Patient-Provider Relationships.” (2009).
⁷Interview with Kenneth Cook, p.16, 23 June 2019, Y-0093, in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
⁸Campbell et. al., Rural/urban differences in accounts of patients’ initial decisions to consult primary care, Health & Place, Volume 12, Issue 2, 2006, Pages 210-221, ISSN 1353-8292, https://doi.org/10.1016/j.healthplace.2004.11.007.