Rural training in medical education
Rural training tracks and programs focus medical school training and learning experiences on the skills necessary to practice medicine in rural communities. These initiatives often recruit students from rural backgrounds and students who have expressed an interest in practicing medicine in small towns and rural locations1. Recruitment often starts in high school and continues through medical school2, 3.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased availability of physicians in underserved areas
Increased access to care
What does the research say about effectiveness?
There is strong evidence that rural training programs increase the number of physicians who choose to practice in rural areas, increasing access to care for rural patients2, 4, 5, 6, 7, 8, 9.
Rural medical school curricula, rural practice learning experiences, and rural residency programs increase the likelihood that participating students will choose to practice in a rural area2, 4, 5, 9, 10. Programs that recruit students with rural backgrounds and have a rural-focused curriculum increase the number of students who choose rural practice locations2, 4, 10 and remain there over the long-term4, 5, 7, often as primary care or family medicine physicians5, 8, 10, 11, 12. Having obstetrical (OB) providers train rural family medicine physicians in this specialty may increase access to rural maternity care. Experts suggest that rural medicine residency programs foster positive relationships between family medicine clinicians and OB providers, develop efforts to retain family medicine faculty and mentors, and advance a shared vision of improved access to local maternity care among hospital and community partners13. Surgical residencies with rural training tracks are more likely to produce additional general surgeons that enter practice immediately following graduation, but these graduates may not stay in rural practice14. Other studies suggest surgeons who practice in rural areas during residency are also more likely to remain in rural practice than their peers1, 9, 15. When establishing a rural surgery training program, experts recommend that program planners conduct a needs assessment and review perspective local residency training locations and partnerships, secure sufficient funding, offer surgical and clinical/operative education, and receive program approval from a surgical residency review committee16.
Additional efforts are needed to retain rural physicians and to train other health care providers, such as nurse practitioners and physician assistants, to be part of rural health care practices and pipelines17. A study of a statewide, county-based rural pipeline program in Alabama suggests that supporting prospective medical students beginning in high school and continuing through medical residency may increase the number of family medicine physicians and other health care providers that will practice in their home counties18.
Models indicate that expanding rural training programs to all medical schools would substantially increase the supply of rural physicians19. However, federal funding allocations are a barrier to increasing the number of residency slots available for rural physicians. Most funded slots are in urban areas, especially the northeastern U.S., and are designated for non-primary care (or specialist) training20. Rural hospitals have fewer resources and less infrastructure to accommodate separately accredited programs, which are required to qualify for additional funded slots. The Consolidated Appropriations Act of 2021 (CAA Section 126), is designed to reduce geographic disparities in medical training and includes 1,000 new funded slots, with 200 available per year beginning in 202321.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: supported by strong evidence.
There is strong evidence that rural training in medical education has the potential to reduce disparities in access to care for rural patients by increasing the number of physicians who choose to practice in rural areas2, 4, 5, 6, 7, 8, 9.
Clinical training in both rural and urban underserved areas significantly increases the likelihood that medical students will practice in underserved areas and makes it even more likely they will choose to practice primary care there5. Primary care physicians have increased in both rural and urban counties, though increases have been greater in urban areas; further efforts are needed to recruit additional providers to care for rural communities35.
Whether medical students have a rural background is a key predictor of if they will choose to practice in rural communities as physicians4. Medical training in rural areas triples the likelihood of choosing rural practice5. However, relative to the nation’s population overall, rural students are underrepresented in medical schools. Efforts to increase diversity of medical school classes should consider how to recruit and retain underrepresented minorities (URMs) and non-URM rural students36, 37. Minority physicians appear to be more likely to practice in underserved, high-need areas than their non-minority peers7.
A small, Washington-based study suggests that medical students who identify as Black, Indigenous, and People of Color (BIPOC) may experience more anxiety when training in majority white rural communities than during urban placements38. Experts recommend that rural training locations and medical schools support BIPOC students through efforts such as cultural competency training for faculty, rural preceptors, and all medical students39; this training should continue throughout professional practice, allowing providers to better understand and care for the communities they serve39, 40.
Rural patients who identify as non-white can also benefit from a diverse health care workforce. Increasing diversity among health professionals and expanding opportunities for patients to be cared for by health professionals of the same race or who speak the same language may reduce disparities in the quality and use of care, along with improving patient satisfaction and communication between patients and providers41, 42, 43. In some circumstances, patients visiting providers of the same race has been associated with improved appointment attendance, adherence to care plans, and better health outcomes; however, additional evidence is needed to confirm these effects. Generally, how well and how long providers have known their patients appears to have a stronger influence on positive patient health outcomes than race concordance44.
As rural health care facilities consolidate, relocate, or close, the distances patients must travel to clinics can become even greater, further reducing access to care, particularly from specialists45. As of 2022, 19% of Americans live in rural areas and rural communities are aging rapidly: models indicate that by 2040, rural communities will be made up of 25% of households that are 65 years old or older, compared to only 20% in urban communities45. Rural and urban mortality in the U.S. also differ significantly, with higher rural mortality associated with income, race, ethnicity, education, insurance status, primary care physician supply, and health behaviors; rural populations generally have higher rates of chronic health conditions and experience more poverty46. Pregnancy-related mortality is also higher in rural areas, and some reports estimate more than half of rural U.S. counties do not have a hospital offering prenatal or labor and delivery care39.
What is the relevant historical background?
Rural training tracks and programs in the U.S. attempt to address the shortage of rural physicians and health care providers. Early medical schools in the U.S. originally had high enrollment, low costs for attendance, minimal laboratory facilities, and few entrance standards. In the late 1800s, European-trained physicians returning to the U.S. advocated for more rigorous entrance requirements and curricula47, though in contrast to Germany, for example, the U.S. remained without a national social health insurance system. In 1907, the American Medical Association (AMA) began publishing medical school ratings47. Shortly after, medical system reformer Abraham Flexner’s 1910 report evaluating the quality of American and Canadian medical schools asserted that there were too many inadequate medical schools producing poorly trained physicians48. The Flexner Report contributed to decisions to virtually end women’s admission to medical schools until the 1970s and to close five out of seven historically Black medical colleges and severely restrict Black students’ admittance to other schools49, 50. Medical school programs standardized49 and began charging higher tuition and fees, which further limited who could attend. At the same time, graduates may have been drawn to urban areas post-graduation due to higher salaries, larger patient bases and networks of health professionals, and more modern technology and facilities, such as laboratories47. By the 1920s, public health officials warned that fewer providers were practicing in rural areas47.
For most of American history, access to higher education and health professional schools was reserved for white males, typically from wealthier backgrounds. In the 1960s and 1970s, there were efforts to increase access to college and health professional schools for students identifying as minorities, from low income backgrounds, and for women. Recruitment efforts, pipeline programs, and affirmative action policies were designed to address the long history of structural barriers that prevented underrepresented minority students from enrolling in higher education, including medical schools51, 52, 53, 54, 55. However, available evidence suggests that substantial racial disparities persist in college and medical school enrollment, as well as in health professional employment51, 52, 55.
Historically, rural training in medical education was not considered a priority by large teaching hospitals or the Centers for Medicare and Medicaid Services (CMS); the few programs that existed in rural areas received substantially less federal funding and support than programs in urban or suburban areas21, 46. However, family medicine has a history of training rural providers and continues to have a much better provider-to-population ratio in rural areas, compared with internal medicine46.
The number of medical students with rural backgrounds has been declining since the early 2000s and underrepresented minority students with rural backgrounds remain a small percentage of medical students; for example, less than 0.5 percent of new students in 201737. Half of rural physicians are over 55 and a third are scheduled to retire by 203322, so there continues to be a substantial need to train and retain rural providers.
Equity Considerations
- How can medical school program administrators connect with rural practices to establish rural training opportunities? How can programs support faculty and rural preceptors in connecting with interested students?
- Who else can support medical schools and rural medical practices in maintaining strong training pipelines? How might rural students benefit from formal or informal networks of support throughout their medical training?
- When do rural pipeline programs for students interested in pursuing medicine begin in your community (e.g., middle school, high school, college)? How could programs be added or expanded to provide steady support for participants, including for underrepresented minorities, throughout their academic and medical careers?
- What additional strategies can be implemented to retain providers in rural areas? How might scholarships, loans, and debt forgiveness programs offset the costs of medical education and potential lower salaries?
Implementation Examples
In 2023, the Health Resources and Services Administration estimated that 65% of rural areas are experiencing a primary care physician shortage. While approximately 46 million Americans live in rural communities, they are cared for by only 10% of the nation’s physicians22.
There are a growing number of medical schools with programs that provide rural-specific training. Examples include the state university systems of Illinois, Missouri, and Wisconsin23, 24, 25, 26, 27; the State University of New York (SUNY) Upstate Medical University’s Rural Medical Scholars Program28; Thomas Jefferson University’s Sidney Kimmel Medical College Physician Shortage Area Program (PSAP)29; the University of New Mexico’s School of Medicine Rural and Urban Underserved Program30; and the University of Kentucky’s Rural Physician Leadership Program (RPLP)31.
The University of Washington School of Medicine’s Targeted Rural Underserved Track (TRUST) provides rural-specific training through a network of residency programs which care for underserved communities in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI)32. The University of Alabama’s Rural Health Leaders Pipeline to Engage Community Leaders program supports rural students interested in pursuing medicine from high school through medical school, with the goal that students will return to care for their home communities as physicians18, 33.
The University of Kansas School of Medicine’s Scholars in Rural Health program offers early medical school acceptance to Kansas undergraduate sophomores intending to become rural physicians. The program provides juniors and seniors with a rural physician mentor and strongly considers students that are first generation college attendees and/or from health professional underserved areas34.
Implementation Resources
‡ Resources with a focus on equity.
RHIhub-Rural health disparities‡ - Rural Health Information Hub (RHIhub). Rural health disparities: Frequently asked questions.
RTT Collaborative - RTT Collaborative. Rural education & training: Resources on rural residencies, training tracks, program locations, and financial resources.
UWSOM-TRUST - University of Washington School of Medicine (UWSOM). Targeted Rural Underserved Track (TRUST), caring for underserved communities in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI).
STAT-Empinado 2023‡ - Empinado H. Treating rural America: The last doctor in town. STAT: Reporting from the frontiers of health and medicine. 2023.
Footnotes
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1 Wendling 2016 - Wendling AL, Phillips J, Short W, Fahey C, Mavis B. Thirty years training rural physicians: Outcomes from the Michigan State University College of Human Medicine Rural Physician Program. Academic Medicine. 2016;91(1):113-119.
2 Wheat 2017 - Wheat JR, Leeper JD, Murphy S, Brandon JE, Jackson JR. Educating physicians for rural America: Validating successes and identifying remaining challenges with the Rural Medical Scholars Program. Journal of Rural Health. 2017:1-10.
3 Wheeler 2017 - Wheeler DL, Hackler JB. Preparing physicians for rural-based primary care practice: A preliminary evaluation of rural training initiatives at OSU-COM. The Journal of the American Osteopathic Association. 2017;117(5):315-324.
4 Johnson 2018 - Johnson GE, Wright FC, Foster K. The impact of rural outreach programs on medical students’ future rural intentions and working locations: A systematic review. BMC Medical Education. 2018;18.
5 Guilbault 2017 - Guilbault RWR, Vinson JA. Clinical medical education in rural and underserved areas and eventual practice outcomes: A systematic review and meta-analysis. Education for Health. 2017;30(2):146-155.
6 Cochrane-Grobler 2015 - Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database of Systematic Reviews. 2015;(6):CD005314.
7 Goodfellow 2016 - Goodfellow A, Ulloa JG, Dowling PT, et al. Predictors of primary care physician practice location in underserved urban and rural areas in the United States: A systematic literature review. Academic Medicine. 2016;91(9):1313-1321.
8 Nelson 2017 - Nelson GC, Gruca TS. Determinants of the 5-year retention and rural location of family physicians: Results from the Iowa Family Medicine Training Network. Family Medicine. 2017;49(6):473-476.
9 McCarthy 2015 - McCarthy MC, Bowers HE, Campbell DM, Parikh PP, Woods RJ. Meeting increasing demands for rural general surgeons. The American Surgeon. 2015;81(12):1195-1200.
10 Patterson 2023 - Patterson DG, Shipman SA, Pollack SW, et al. Growing a rural family physician workforce: The contributions of rural background and rural place of residency training. Health Services Research. 2023:1-7.
11 Petrany 2013 - Petrany SM, Gress T. Comparison of academic and practice outcomes of rural and traditional track graduates of a family medicine residency program. Academic Medicine. 2013;88(6):819-823.
12 Rabinowitz 2012 - Rabinowitz HK, Petterson S, Boulger JG, et al. Medical school rural programs: A comparison with international medical graduates in addressing state-level rural family physician and primary care supply. Academic Medicine. 2012;87(4):488-492.
13 Fredrickson 2023 - Fredrickson E, Evans DV, Woolcock S, et al. Understanding and overcoming barriers to rural obstetric training for family physicians. Family Medicine. 2023;55(6):381-388.
14 Halline 2022 - Halline CG, Mokhashi N, De Bie FR, Greenwood-Ericksen MB, Zonfrillo MR. An examination of general surgery residency programs with a rural track. Journal of Surgical Education. 2022;79(2):315-321.
15 Deveney 2013 - Deveney K, Deatherage M, Oehling D, Hunter J. Association between dedicated rural training year and the likelihood of becoming a general surgeon in a small town. JAMA Surgery. 2013;148(9):817-821.
16 Mercier 2019 - Mercier PJ, Skube SJ, Leonard SL, et al. Creating a rural surgery track and a review of rural surgery training programs. Journal of Surgical Education. 2019;76(2):459-468.
17 MacQueen 2018 - MacQueen IT, Maggard-Gibbons M, Capra G, et al. Recruiting rural healthcare providers today: A systematic review of training program success and determinants of geographic choices. Journal of General Internal Medicine. 2018;33:191-199.
18 Wheat 2021 - Wheat JR, Leeper JD. Pipeline programs can support reforms in medical education: A cohort study of Alabama’s rural health leaders pipeline to engage community leaders. Journal of Rural Health. 2021;37(4):745-754.
19 Rabinowitz 2008 - Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physician supply: A systematic review and projected impact of widespread replication. Academic Medicine. 2008;83(3):235-243.
20 Nielsen 2017 - Nielsen M, D’Agostino D, Gregory P. Addressing rural health challenges head on. Missouri Medicine. 2017;114(5):363-366.
21 Hawes 2022 - Hawes EM, Holmes M, Fraher EP, et al. New opportunities for expanding rural graduate medical education to improve rural health outcomes: Implications of the consolidated appropriations act of 2021. Academic Medicine. 2022;97(9):1259-1263.
22 STAT-Empinado 2023 - Empinado H. Treating rural America: The last doctor in town. STAT: Reporting from the frontiers of health and medicine. 2023.
23 Zink 2010 - Zink T, Center B, Finstad D, et al. Efforts to graduate more primary care physicians and physicians who will practice in rural areas: Examining outcomes from the University of Minnesota-Duluth and the rural physician associate program. Academic Medicine. 2010;85(4):599-604.
24 Glasser 2008 - Glasser M, Hunsaker M, Sweet K, MacDowell M, Meurer M. A comprehensive medical education program response to rural primary care needs. Academic Medicine. 2008;83(10):952-961.
25 UICOMR-RMED - University of Illinois College of Medicine Rockford (UICOMR). National Center for Rural Health Professions: Rural Medical Education (RMED) program.
26 MU-Rural Scholars - University of Missouri School of Medicine. Rural Scholars Program.
27 UWSMPH-WARM - University of Wisconsin School of Medicine and Public Health (UWSMPH). Wisconsin Academy for Rural Medicine (WARM).
28 SUNY Upstate-RMSP - SUNY Upstate Medical University. Rural Medical Scholars Program (RMSP).
29 Jefferson-PSAP - Thomas Jefferson University, Sidney Kimmel Medical College. Rural Physician Shortage Area Program (PSAP).
30 UNM-RUUP - University of New Mexico (UNM). School of Medicine Rural and Urban Underserved Program (RUUP).
31 UK-RPLP - University of Kentucky (UK) College of Medicine. Medical Student Education: Rural Physician Leadership Program (RPLP).
32 UWSOM-TRUST - University of Washington School of Medicine (UWSOM). Targeted Rural Underserved Track (TRUST), caring for underserved communities in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI).
33 UA-Rural programs - The University of Alabama, College of Community Health Sciences. Rural programs: Rural Health Leaders Pipeline.
34 KU-Scholars in Rural Health - The University of Kansas School of Medicine. Scholars in Rural Health program.
35 Zhang 2020d - Zhang D, Son H, Shen Y, et al. Assessment of changes in rural and urban primary care workforce in the United States from 2009 to 2017. JAMA Network Open. 2020;3(10):e2022914.
36 Wheat 2023 - Wheat JR, Gardner AJ, Downey LH, et al. Medical education for African American communities in the rural South: A focus group approach to identify fundamental considerations. Journal of Rural Health. 2023;39(3):535-544.
37 Shipman 2019 - Shipman SA, Wendling A, Jones KC, et al. The decline in rural medical students: A growing gap in geographic diversity threatens the rural physician workforce. Health Affairs. 2019;38(12):2011-2018.
38 Cedeno 2023 - Cedeño B, Shimkin G, Lawson A, et al. Positive yet problematic: Lived experiences of racial and ethnic minority medical students during rural and urban underserved clinical rotations. The Journal of Rural Health. 2023;39(3):545-550.
39 COGME-Rural health workforce - Council on Graduate Medical Education (COGME). Strengthening the rural health workforce to improve health outcomes in rural communities: Twenty-fourth report to the Secretary of the U.S. Department of Health and Human Services and the U.S. Congress. Health Resources and Services Administration (HRSA). 2022.
40 Young 2016a - Young S, Guo KL. Cultural diversity training: The necessity of cultural competence for health care providers and in nursing practice. Health Care Manager. 2016;35(2):94-102.
41 AHRQ-Kronick 2014 - Kronick R, Clancy C, Munier W, et al. 2013 national healthcare quality report. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2014.
42 Gilliss 2010 - Gilliss CL, Powell DL, Carter B. Recruiting and retaining a diverse workforce in nursing: From evidence to best practices to policy. Policy, Politics & Nursing Practice. 2010;11(4):294-301.
43 CWF-Cooper 2004 - Cooper LA, Powe NR. Disparities in patient experiences, health care processes, and outcomes: The role of patient-provider racial, ethnic, and language concordance. New York: The Commonwealth Fund (CWF); 2004.
44 Meghani 2009 - Meghani S, Brooks J, Gipson-Jones T, et al. Patient-provider race-concordance: Does it matter in improving minority patients' health outcomes? Ethnicity and Health. 2009;14(1):107-130.
45 SGA-Thakkar 2023 - Thakkar A, Smith JR, Bellis R, et al. An active roadmap: Best practices in rural mobility. Smart Growth America (SGA) and National Complete Streets Coalition. 2023.
46 Zabel 2023 - Zabel T, Tobey M. Rural internal medicine residencies: Models, facilitators, barriers, and equity considerations. Journal of General Internal Medicine. 2023;38:2607-2612.
47 Moehling 2020 - Moehling CM, Niemesh GT, Thomasson MA, Treber J. Medical education reforms and the origins of the rural physician shortage. Cliometrica. 2020;14:181-225.
48 Duffy 2011 - Duffy TP. Historical perspectives in medical education: The Flexner Report ― 100 years later. Yale Journal of Biology and Medicine. 2011;84(3):269-276.
49 Barkin 2010 - Barkin SL, Fuentes-Afflick E, Brosco JP, Tuchman AM. Unintended consequences of the Flexner Report: Women in pediatrics. Pediatrics. 2010;126(6):1055-1057.
50 Laws 2021 - Laws T. How should we respond to racist legacies in health professions education originating in the Flexner Report? AMA Journal of Ethics. 2021;23(3):E271-275.
51 Toretsky 2018 - Toretsky C, Mutha S, Coffman J. Breaking barriers for underrepresented minorities in the health professions. San Franscisco: Healthforce Center, University of California at San Francisco (UCSF); 2018.
52 Figueroa 2014 - Figueroa O. The significance of recruiting underrepresented minorities in medicine: An examination of the need for effective approaches used in admissions by higher education institutions. Medical Education Online. 2014;19:24891.
53 Thelin 2022 - Thelin JR, Edwards JR, Moyen E, Berger JB, Calkins MV. Higher education in the United States: Historical development & system. State University Education Encyclopedia. 2022.
54 US ED-Harvill 2012 - Harvill EL, Maynard RA, Nguyen HTH, Robertson-Kraft C, Tognatta N. Effects of college access programs on college readiness and enrollment: A meta-analysis. Washington, D.C.: Institute of Education Sciences (IES), U.S. Department of Education (U.S. ED); 2012.
55 NCES-Gandara 2001 - Gandara P. Paving the way to postsecondary education: K-12 intervention programs for underrepresented youth. Report of the National Postsecondary Education Cooperative Working Group on Access to Postsecondary Education. Washington, D.C.: U.S. Department of Education (U.S. ED), National Center for Education Statistics (NCES); 2001.
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