I did not grow up imagining I would become a plastic and reconstructive surgeon. What I did grow up noticing, first on the outskirts of Charleston, South Carolina, and now much more acutely while living in Darby, Montana, was how profoundly geography shapes the care people receive.
Darby is a town of roughly 750 people in western Montana. It is beautiful, tight-knit, and remote. Here, specialty care is not a matter of convenience or preference. It is a logistical calculation involving hours of driving, time off work, weather conditions, childcare, and whether follow-up is even realistic. For patients who need reconstructive surgery, these barriers are often decisive.
As a medical trainee, living in rural Montana clarified something for me that years of academic training had not: access to reconstructive surgery is not evenly distributed, and its absence quietly reshapes lives.
Plastic and reconstructive surgery is still widely misunderstood. Many people, including policymakers, reduce it to cosmetic procedures. But what drew me to the field was its breadth and its impact. A single reconstructive surgeon in a rural community can provide hand surgery for traumatic injuries, burn and wound care, flap coverage for chronic ulcers, reconstruction after cancer resections, facial fracture repair, and post-mastectomy breast reconstruction. In places like Darby, one surgeon can determine whether a patient returns to work, regains independence, or lives with a permanent disability.
Yet in much of rural America, that surgeon does not exist.
Patients in my hometown confront this reality repeatedly. A woman eligible for autologous breast reconstruction after mastectomy decides against it, not because she does not want reconstruction, but because it would require repeated trips throughout the state. A ranch worker with a complex hand injury is transferred hours away for care, delaying definitive reconstruction and jeopardizing function. A patient with a chronic wound cycles through temporary fixes because the definitive reconstructive option is simply unavailable locally.
These stories are not exceptions. They reflect national patterns. Rural women are significantly less likely to receive breast reconstruction after mastectomy. Trauma and burn patients in rural areas experience delays that worsen outcomes. Children who need cleft or craniofacial care often lack access to comprehensive teams, resulting in fragmented treatment and lost follow-up. For rural Native American and Alaska Native communities, many of whom are located far from tertiary centers, these gaps are even wider, layered on top of longstanding health inequities and chronically underresourced health systems.
The reasons for this crisis are structural and significant. There is no meaningful rural reconstructive surgery pipeline. Training pathways overwhelmingly concentrate surgeons in urban academic centers. Reimbursement models make complex reconstruction difficult to sustain at critical access hospitals. Investment barriers limit access to the equipment and specialized support staff needed for advanced care. And partnerships between academic plastic surgery programs and rural or tribal health systems remain the exception rather than the rule.
Too often, policy responses sidestep these realities. Laws allowing foreign-trained physicians to bypass U.S. residency training are frequently justified as solutions to rural shortages, yet are designed without any incentive structures to direct physicians to rural areas. Similarly, expanding APP autonomy is often framed as an access fix, even though it does little to address the absence of physicians trained to manage complex surgical pathology. These approaches may lower standards of care without meaningfully expanding access to the services rural patients actually need.
What rural communities need instead are solutions grounded in reality and sustained commitment. Telehealth-supported perioperative care can reduce unnecessary travel while preserving quality. Regional outreach clinics can bring reconstructive services closer to patients. Surgical training programs can incorporate dedicated rural and tribal rotations, exposing trainees to the full scope and importance of reconstructive care outside major cities. Long-term academic community partnerships, not one-off missions, can create sustainable access models that respect local needs and constraints. Loan repayment programs can be expanded to include surgical subspecialties to incentivize rural relocation.
These ideas are not abstract to me. They are the reason I chose plastic and reconstructive surgery.
I plan to return to rural Montana to practice. That decision is not rooted in nostalgia, nor in a desire to “bring charity” to underserved areas. It is rooted in a recognition that modern reconstructive surgery has extraordinary potential to restore function, dignity, and independence, and that potential is currently withheld from large portions of the country simply because of where people live.
Innovation loses its meaning when it remains geographically siloed. A field defined by restoring form and function cannot accept a system that denies those benefits to entire regions. Rural Americans, including many Native American communities, are not simply underserved. They are systematically excluded from the reconstructive care that defines modern surgical practice.
Closing this gap will require more than rhetoric. It will require intentional workforce planning, policy aligned with evidence, and training models that recognize rural communities not as afterthoughts, but as places where reconstructive surgery matters deeply.
Forrest is a fourth-year medical student interested in rural medicine and how to best address the physician shortage in these areas, as well as being particularly interested in health policy and the way it is applied to different groups of people in the U.S. Forrest is a 2025-2026 Doximity Op-Med Fellow.
Collage by Jennifer Bogartz
