We are pleased to introduce a new series on the ACGME Blog: Pathways to Practice: Stories from Underserved in Medicine. The series will feature interviews with current residents and fellows, as well as recent graduates sharing their personal journeys – from formative experiences before medical school to the realities of being in their graduate medical education (GME) programs. Each post highlights the moments, mentors, and motivations that led them to choose GME programs focused on medically underserved areas (MUAs). Through these reflections, interviewees explore how their backgrounds and clinical education and training shaped their commitment to providing high-quality health care for all and influenced the paths they plan to pursue in practice.
This first post in the series features Rachel Heuer, MD, a graduate of the Maine Medical Center Rural Internal Medicine Maine (RIMM) program who is currently a practicing internist at Barrett Hospital and Healthcare in Dillon, Montana.
Upon graduating in June 2024, Dr. Heuer sought positions that would allow her to practice true full-spectrum internal medicine, including primary care, hospitalist work, geriatrics, home visits, and advanced procedures. She also sought an independent health system where she could be actively involved in day-to-day operations and have agency in how she practices. That led her to Dillon, Montana, a ranching community of about 4,200, serving a broader area of around 8,000. Located in the largest geographic county in Montana, the region is classified as “frontier” by the US Department of Health and Human Services, with fewer than six people per square mile.
ACGME: Tell us about your journey and how it led you to where you are today—including about your medical school and residency or fellowship.
Dr. Heuer: My interest in rural health began very early in life. Like many who ultimately choose this path, I grew up in a rural community—on a dairy farm in a small agricultural town in Minnesota with a population of about 1,500. I also had the unique opportunity to watch my mother, the sole dentist in our town, experience the intimacy of practicing small-town health care.
This foundation naturally influenced my medical education. At the University of Minnesota Duluth, I was introduced early on to rural and Native American health. In my first and second years, I worked alongside rural preceptors, and I spent my third year completing core rotations in rural Minnesota. These experiences were pivotal: they confirmed for me that rural medicine was not just meaningful, but the career I wanted to pursue. I loved the closeness of rural practice—making home visits, being part of the community, and running into patients at the grocery store. I also valued the broad scope of care I witnessed. The rural physicians I worked with did it all—from obstetrics to nursing home care, from home visits to inpatient medicine. The variety and depth of their practice stood in stark contrast to my urban rotations, where medicine often felt siloed and limited.
When it came time to choose a residency, I knew I needed a program that would prepare me to be a full-spectrum internist in a resource-limited rural community. After extensive research, I discovered the Maine Medical Center RIMM program, the most comprehensive rural internal medicine program I could find nationwide. It not only offered advanced procedural training, such as in cardiac stress tests and colonoscopies, but also the chance to learn directly from internists who had spent their careers practicing at a critical access hospital in Norway, Maine. By the end of residency, I had honed a wide range of skills and felt fully prepared for the challenges and rewards of a rural internal medicine career.
Background and Early Influences
ACGME: How did your background and early experiences help shape your interest in medicine and your understanding of health care disparities, especially in underserved areas?
Heuer: I studied public health as an undergraduate, which deepened my interest in understanding health disparities and the ways in which patients’ life circumstances shape their overall well-being. During medical school, I witnessed these disparities firsthand across multiple settings—Native American health, rural health, and urban health—each presenting its own unique challenges. In rural health care specifically, I saw the impact of geographic isolation, limited access to specialists, lower insurance coverage, health literacy barriers, and socioeconomic constraints. Having grown up in a rural community myself, I not only understood these challenges academically but had also lived them. This personal connection made it natural for me to be drawn toward addressing health disparities in rural populations.
Choosing a GME Program
ACGME: When it came time to choose a residency or fellowship program, what inspired you to select a program focused on underserved areas, and which aspects of the program aligned with your goals or values?
Heuer: Despite having no prior connections to Maine or New England, I chose the RIMM program as my top residency choice. The program’s vision—to train internists for a rural practice—aligned perfectly with my goals. With a nationwide shortage of internists entering primary care, and an even more pronounced gap in rural areas, the RIMM program stood out as uniquely designed to address this need. It was the only residency offering comprehensive rural education and training, splitting my time between Stephens Memorial Hospital, a critical access hospital in Norway, Maine, and Maine Medical Center, a tertiary care center in Portland. Just as importantly, it provided advanced procedural training essential for rural practice, including in colonoscopies, electrical cardioversions, and cardiac stress tests. I knew this program would give me the skills and confidence to thrive as a rural internist. What I also deeply value about my time in the RIMM program were the lifelong bonds I formed with mentors who had dedicated their careers to rural medicine and generously shared both their expertise and their passion with me.
Experiences During Residency/Fellowship
ACGME: Can you share some of the most meaningful challenges and lessons from your residency/fellowship program working in underserved communities, as well as how they have influenced the kind of physician you are becoming?
Heuer: As I progressed through residency and mastered the science of medicine, I also began to appreciate the art of medicine. In a small community, the physician-patient relationship extends far beyond the walls of the clinic or hospital. One experience that has stayed with me was the poor outcome of a young woman I cared for during my first year in residency—an event that weighed on me for months. I came to understand that in rural practice, being so closely connected to your community means sharing in both the triumphs and the heartbreaks of your patients.
Another challenge I faced was navigating access to specialty care. Because of the long distances to specialists, many patients were hesitant or resistant to seeking outside care. I had to learn how to approach these conversations with humility—recognizing my own limitations—while also developing the skills to manage conditions independently, often with the guidance of my mentors.
I also learned that caring for patients extends into everyday life: at the grocery store, at community gatherings, or in passing on the street. These interactions require a careful balance of professionalism and genuine connection, but they also allow for a depth of relationship rarely possible in larger, urban settings. In this way, the rural physician is not just a clinician but also a neighbor and friend.
ACGME: What unique skills or insights have you developed through your residency program that you might not have gained elsewhere?
Heuer: Internal medicine education and training are often characterized by a strong focus on inpatient care, with most residency programs preparing graduates primarily for careers in hospital medicine or subspecialties. In contrast, my residency experience provided comprehensive preparation across multiple settings—primary care, inpatient medicine, nursing home care, home visits, and procedures. I completed a leadership curriculum, recognizing that rural physicians are frequently called upon to take on diverse roles both within their organizations and in their communities. I saw this modeled by my mentors, who skillfully balanced their clinical work with leadership responsibilities. Taken together, the RIMM residency equipped me with the breadth of skills and experience necessary to thrive in a full-spectrum rural practice.
Looking Ahead
ACGME: What does your future in medicine look like? Can you share the kind of difference you hope to make in underserved communities and any advice you have for physician learners considering similar paths?
Heuer: As I complete my first year as an attending and grow more confident in my role, I am energized by the opportunities ahead. I have already taken on leadership responsibilities within our organization and will serve as Medical Staff President in the coming year—a role that will allow me to gain a better understanding of our organization and its challenges, as well as influence decision-making at a higher level. I will be welcoming medical students from the WWAMI [Washington, Wyoming, Alaska, Montana, and Idaho] program and hope to share with them the same passion for rural medicine that I had the pleasure of experiencing in my residency education. Looking forward, I hope to expand my involvement in rural health care at the state level through the Montana Medical Association, advocating for policies that improve access and advance the health of all rural Montanans.
For learners considering a path in rural medicine, I encourage you to seek out as much exposure as possible during your residency. Spend time in rural medical communities—both within larger health systems and in independent practices—and ask questions about the community’s strengths, challenges, and access to care. Find mentors you trust and learn not only from their clinical experience but also from their lives outside of medicine. Engage fully with rural communities, pursue opportunities that immerse you in these settings, and train broadly so you are prepared for the wide scope of practice rural medicine requires.
ACGME: What are important considerations for graduate medical education programs to help prepare residents and fellows for practice in underserved communities?
Heuer: First and foremost, GME is still largely concentrated in urban academic centers. I would urge programs to place residents and fellows in the areas most in need—whether rural communities, Native American health systems, or urban underserved settings. Without meaningful exposure during residency, physicians are unlikely to develop the skills necessary to practice in these environments, and even less likely to choose careers there. Too often, programs offer only brief rotations—two weeks in a rural clinic or tribal health setting, often late in residency. Instead, these experiences should be longitudinal and immersive, as modeled by the RIMM program, allowing residents to develop not only the clinical skills but also the relationships with staff members, mentors, and patients that are essential for long-term success in these communities.
Lastly, with regard to rural education and training specifically, it is important to expose learners not only to rural medicine but also to the rural lifestyle early on in their experiences. Residents should be paired with mentors who can introduce them to the full scope of rural living—whether through outdoor activities, volunteering, or participating in community events. Mentors should also be transparent about practical considerations, including compensation and loan repayment opportunities, which are often more favorable in rural areas than in urban settings. Equally important is being honest about the challenges, such as the potential for isolation or the longer distances to airports, restaurants, and other amenities. By providing a realistic and well-rounded view, we can better prepare learners to make informed choices about pursuing a career in rural medicine.
If you are in your last year of residency/fellowship or a recent graduate serving in a medically underserved area, and would like to be featured in a future post in this series, email muap@acgme.org to share what you’re doing. Visit the MUA/P web page to learn more about the ACGME’s efforts.