Growing a rural family physician workforce: The contributions of rural background and rural place of residency training.

OBJECTIVE: To determine the distinct influences of rural background and rural residency training on rural practice choice among family physicians. DATA SOURCES AND STUDY SETTING: We used a subset of The RTT Collaborative rural residency list and longitudinal data on family physicians from the American Board of Family Medicine National Graduate Survey (NGS; three cohorts, 2016-2018) and American Medical College Application Service (AMCAS). STUDY DESIGN: We conducted a logistic regression, computing predictive marginals to assess associations of background and residency location with physician practice location 3 years post-residency. DATA COLLECTION/EXTRACTION METHODS: We merged NGS data with residency type-rural or urban-and practice location with AMCAS data on rural background. PRINCIPAL FINDINGS: Family physicians from a rural background were more likely to choose rural practice (39.2%, 95% CI = 35.8, 42.5) than those from an urban background (13.8%, 95% CI = 12.5, 15.0); 50.9% (95% CI = 43.0, 58.8) of trainees in rural residencies chose rural practice, compared with 18.0% (95% CI = 16.8, 19.2) of urban trainees. CONCLUSIONS: Increasing rural programs for training residents from both rural and urban backgrounds, as well as recruiting more rural students to medical education, could increase the number of rural family physicians.

A Match Made in Rural: Interpreting Match Rates and Exploring Best Practices.

BACKGROUND AND OBJECTIVES: Although rural family medicine residency programs are effective in placing trainees into rural practice, many struggle to recruit students. Lacking other public measures, students may use residency match rates as a proxy for program quality and value. This study documents match rate trends and explores the relationship between match rates and program characteristics, including quality measures and recruitment strategies. METHODS: Using a published listing of rural programs, 25 years of National Resident Matching Program data, and 11 years of American Osteopathic Association match data, this study (1) documents patterns in initial match rates for rural versus urban residency programs, (2) compares rural residency match rates with program characteristics for match years 2009-2013, (3) examines the association of match rates with program outcomes for graduates in years 2013-2015, and (4) explores recruitment strategies using residency coordinator interviews. RESULTS: Despite increases in positions offered over 25 years, the fill rates for rural programs have improved relative to urban programs. Small rural programs had lower match rates relative to urban programs, but no other program or community characteristics were predictors of match rate. Match rates were not indicative of any of five measures of program quality nor of any single recruiting strategy. CONCLUSIONS: Understanding the intricacies of rural residency inputs and outcomes is key to addressing rural workforce gaps. Match rates likely reflect challenges of rural workforce recruitment generally and should not be conflated with program quality.

Academic Achievement and Competency in Rural and Urban Family Medicine Residents.

BACKGROUND AND OBJECTIVES: The quality of training in rural family medicine (FM) residencies has been questioned. Our objective was to assess differences in academic performance between rural and urban FM residencies. METHODS: We used American Board of Family Medicine (ABFM) data from 2016-2018 residency graduates. Medical knowledge was measured by the ABFM in-training examination (ITE) and Family Medicine Certification Examination (FMCE). The milestones included 22 items across six core competencies. We measured whether residents met expectations on each milestone at each assessment. Multilevel regression models determined associations between resident and residency characteristics milestones met at graduation, FMCE score, and failure. RESULTS: Our final sample was 11,790 graduates. First-year ITE scores were similar between rural and urban residents. Rural residents passed their initial FMCE at a lower rate than urban residents (96.2% vs 98.9%) with the gap closing upon later attempts (98.8% vs 99.8%). Being in a rural program was not associated with a difference in FMCE score but was associated with higher odds of failure. Interactions between program type and year were not significant, indicating equal growth in knowledge. The proportions of rural vs urban residents who met all milestones and each of six core competencies were similar early in residency but diverged over time with fewer rural residents meeting all expectations. CONCLUSIONS: We found small, but persistent differences in measures of academic performance between rural- and urban-trained FM residents. The implications of these findings in judging the quality of rural programs are much less clear and warrant further study, including their impact on rural patient outcomes and community health.

Rural Versus Urban Family Medicine Residency Scope of Training and Practice.

BACKGROUND AND OBJECTIVES: Little is known about how rural and urban family medicine residencies compare in preparing physicians for practice. This study compared the perceptions of preparation for practice and actual postgraduation scope of practice (SOP) between rural and urban residency program graduates. METHODS: We analyzed data on 6,483 early-career, board-certified physicians surveyed 2016-2018, 3 years after residency graduation, and 44,325 later-career board-certified physicians surveyed 2014-2018, every 7 to 10 years after initial certification. Bivariate comparisons and multivariate regressions of rural and urban residency graduates examined perceived preparedness and current practice in 30 areas and overall SOP using a validated scale, with separate models for early-career and later-career physicians. RESULTS: In bivariate analyses, rural program graduates were more likely than urban program graduates to report being prepared for hospital-based care, casting, cardiac stress tests, and other skills, but less likely to be prepared in some gynecologic care and pharmacologic HIV/AIDS management. Both early- and later-career rural program graduates reported broader overall SOPs than their urban-program counterparts in bivariate analyses; in adjusted analyses this difference remained significant only for later-career physicians. CONCLUSIONS: Compared with urban program graduates, rural graduates more often rated themselves prepared in several hospital care measures and less often in certain women's health measures. Controlling for multiple characteristics, only rurally trained, later-career physicians reported a broader SOP than their urban program counterparts. This study demonstrates the value of rural training and provides a baseline for research exploring longitudinal benefits of this training to rural communities and population health.

Building Rural Primary Care Research by Connecting Rural Programs.

Both research and medical education make substantial contributions to rural primary care and health. An inaugural Scholarly Intensive for Rural Programs was conducted in January 2022 to connect rural programs within a community of practice focused on promoting scholarly activity and research in rural primary health care, education, and training. Participant evaluations confirmed that key learning objectives were met, including stimulating scholarly activity in rural health professions education programs, providing a forum for faculty and student professional development, and growing a community of practice that supports education and training in rural communities. This novel strategy brings enduring scholarly resources to rural programs and the communities they serve, teaches skills to health profession trainees and rurally located faculty, empowers clinical practices and educational programs, and supports the discovery of evidence that can improve the health of rural people.

An Integrated Rural and Urban Underserved Pathway in Medical School.

Problem: The need to increase the number of culturally responsive physicians, particularly primary care physicians, serving in rural and urban underserved communities is well documented. To address this need, an increasing number of medical schools are implementing separate rural or urban underserved training programs or tracks. Intervention: The Rural and Urban Scholars Pathways program is designed as an integrated program, not as separated tracks, and includes critical reflection groups, professional development workshops, individual coaching, a scholarly project, and immersion experiences. The program does not separate students by initial interest in either rural or urban underserved practice settings, but rather promotes their interactions across all four years. Students can join (or leave) RUSP in any year of medical school and, although strongly encouraged toward eventual practice in an underserved community, students are not committed to a specific specialty or practice location. Context: The RUSP program was developed and implemented at the Heritage College of Osteopathic Medicine at Ohio University in 2013 with a grant from the Osteopathic Heritage Foundations. The program resides within the Office of Rural and Underserved Programs at the Heritage College and is one of many medical school programs across the country aimed at producing more physicians for rural and urban underserved communities. RUSP is now funded by the College. Impact: Overall, based on a 60% return rate in 2019-2020, students in all four years report that the RUSP program enhances their professional, personal, social, and academic development. Cumulatively, 67% have matched into specialties with primary care potential, including family medicine, pediatrics, general internal medicine and internal medicine-pediatrics. Of the 14 RUSP graduates in practice, six are practicing primary care in rural locations and five are practicing primary care in urban locations. Five of the fourteen are practicing in communities officially designated as underserved. Lessons Learned: Offering flexibility via a pathways model promotes continuing individual and program growth and expansion. A co-curricular strategy allows for nimble program refinement but requires significant volunteer time commitment from faculty and staff. Having clear program goals, a logic model, and mechanisms for gathering and analyzing student experiences help to maintain program focus and allow for ongoing formative and periodic summative evaluation of short-term and long-term objectives.

Exploration of Remote Didactics at Rural Family Medicine Training Programs.

BACKGROUND AND OBJECTIVES: Distance learning is a feasible and effective method of delivering education, especially in rural settings. Few studies focus on remote learning in graduate medical education. This study explores remote didactic practices of rural family medicine programs in the United States. METHODS: We conducted an electronic survey of rural family medicine residency site directors across the United States. We completed sample analyses through descriptive statistics with an emphasis on descriptions of current didactic practices, facilitators, and challenges to implementation. RESULTS: The overall response rate was 38% (47/124) for all participants from rural residency programs, representing 28 states. About 24% of rural training track (RTT) participants reported no shared remote didactics between urban and rural sites. More than half of RTT participants (52%) reported remote virtual didactics were either not shared between urban and rural site or were shared less than 50% of the time. Top challenges to implementing remote shared didactics were lack of appropriate technology (31%) and lack of training for faculty and residents in delivery of remote didactics (31%). Top facilitators included having technology for the remote connection (54%), a faculty champion (42%), and designated time to develop the curriculum (38%). CONCLUSIONS: There is potential for improving shared remote didactic sessions between rural and urban sites for family medicine RTTs, which may enhance efficiency of curriculum development across sites and maximize opportunities for bidirectional learning between urban and rural sites.

Pipelines to Pathways: Medical School Commitment to Producing a Rural Workforce.

PURPOSE: Despite the efforts of numerous medical schools to produce rural physicians, many rural communities in the United States still experience physician shortages. This study describes the current landscape of rural efforts in US undergraduate medical education and catalogs medical school characteristics and activities that evidence has suggested, and that many experts in rural medical education believe, may result in more graduates choosing rural practice. METHODS: This is a descriptive study of publicly available and rurally relevant characteristics of all 182 allopathic and osteopathic medical schools operating in the 50 states and the District of Columbia in 2016, with rural program information for these schools updated in 2019. The authors constructed a "rural program" definition in order to systematically catalog coordinated and strategic medical school efforts to produce a rural physician workforce. FINDINGS: Few (8.2%) medical schools expressed an explicit commitment to producing rural physicians in public mission statements. However, most (64.8%) provided rural clinical experiences and many demonstrated their commitment in other ways. Only 39 (21.4%) did so through a formal rural program. CONCLUSIONS: In establishing an explicit rural program definition and documenting other markers of rural commitment, this paper provides a baseline for future studies of rural workforce production and medical school investment in these programs, activities, and personnel. Demonstrating the effectiveness of schools' rural physician education efforts will require collaboration across institutions and more intensive evaluations of programs involving students who, though relatively few in number, have great potential for contributing to the health of rural communities across the nation.

Targeted Medical School Admissions: A Strategic Process for Meeting Our Social Mission.

BACKGROUND AND OBJECTIVES: Increased medical school class sizes and new medical schools have not addressed the workforce inadequacies in primary care or underserved settings. While there is substantial evidence that student attributes predict practice specialty and location, little is known about how schools use these factors in admissions processes. We sought to describe admissions strategies to recruit students likely to practice in primary care or underserved settings. METHODS: We surveyed admissions personnel at US allopathic and osteopathic medical schools in 2018 about targeted admissions strategies aimed at recruitment and selection of students likely to practice rurally, in urban underserved areas, or in primary care Results: One hundred thirty-three of 185 (71.8%) US medical schools responded. Respondents reported targeted admissions strategies as follows: rural, 69.2%; urban underserved, 67.4%; and primary care, 45.3%. Nearly 90% reported some type of recruitment outreach to 4-year universities, but much less to community colleges. Student characteristics used to identify those likely to practice in targeted areas were largely evidence-based. Strategies to select students varied widely. CONCLUSIONS: Most responding US medical schools reported a targeted process to recruit and select students likely to practice in rural, urban underserved, or primary care settings, indicating widespread awareness of workforce challenges. This study also demonstrates varying approaches to and allocation of resources toward admissions targeting, especially the application and interviewing processes. Understanding how schools identify and admit students likely to practice in these fields is a first step in identifying best practices for selective admissions focused on addressing workforce gaps.

Rural Workforce Years: Quantifying the Rural Workforce Contribution of Family Medicine Residency Graduates.

BACKGROUND: Rural regions of the United States continue to experience a disproportionate shortage of physicians compared to urban regions despite decades of state and federal investments in workforce initiatives. The graduate medical education system effectively controls the size of the physician workforce but lacks effective mechanisms to equitably distribute those physicians. OBJECTIVE: We created a measurement tool called a "rural workforce year" to better understand the rural primary care workforce. It quantifies the rural workforce contributions of rurally trained family medicine residency program graduates and compares them to contributions of a geographically matched cohort of non-rurally trained graduates. METHODS: We identified graduates in both cohorts and tracked their practice locations from 2008-2018. We compared the average number of rural workforce years in 3 cross sections: 5, 8, and 10 years in practice after residency graduation. RESULTS: Rurally trained graduates practicing for contributed a higher number of rural workforce years in total and on average per graduate compared to a matched cohort of non-rural/rural training tack (RTT) graduates in the same practice intervals (P < .001 in all 3 comparison groups). In order to replace the rural workforce years produced by 1 graduate from the rural/RTT cohort, it would take 2.89 graduates from non-rural/RTT programs. CONCLUSIONS: These findings suggest that rural/RTT-trained physicians devote substantially more service to rural communities than a matched cohort of non-rural/RTT graduates and highlight the importance of rural/RTT programs as a major contributor to the rural primary care workforce in the United States.

Microresearch: Promoting Scholarly Activity That Addresses Health Disparities in Rural Health Professional Education Programs.

Microresearch is an innovative, mentored research experience, originally developed in Africa and adapted for U.S. health professional trainees preparing for rural primary care practice. This report describes program elements (funding, mentorship, and peer support) that others may replicate to develop research and leadership skills through community engagement to address health disparities.

A Design and Dissemination Studio: Building a Scholarly Community of Practice in Rural Health Professions Education and Training.

The Collaborative for Rural Primary Care Research, Education, and Practice (Rural PREP) has adapted a process, originally developed for cancer research, to engage community members in a research Design and Dissemination Studio in rural health professions education, enlarging a scholarly community of practice in preparing a future rural health workforce.

An Organic Approach to Health Professions Education and Health Equity: Learning In and With Underserved Communities.

Since the Flexner Report in 1910, medical education has taken a primarily technical approach to preparing students for science-based medical practice. Adequately addressing the complex problems leading to population health disparities and achieving health equity is not possible through a technical approach to education alone. Inspired by Frank Lloyd Wright, who brought organic architecture to the world of building design, the author suggests an organic approach to health equity through education and training of a workforce in and with rural and underserved urban communities. An organic approach can claim many roots-in philosophy, education for social justice, the pedagogy of place, relationship-centered care, patient-centered and community-oriented primary care, community engagement, and complexity science. Though framed in theory, such an approach has a growing evidence base in professional education generally and has practical implications for the location of education and training, emergent curriculum design, and a community-responsive approach to program implementation.

Challenges and Best Practices for Implementing Rurally Targeted Admissions in U.S. Medical Schools.

Student attributes can predict future rural practice, but little is known about how medical schools use these factors in admissions. This mixed-methods study examined admissions strategies to recruit and select students likely to practice rurally. Admissions personnel at U.S. allopathic and osteopathic medical schools were surveyed about rurally targeted admissions. Personnel from selected schools were interviewed to understand further targeted admissions practices. Among 185 medical schools, 133 (71.8%) responded. Schools engaged with students from four-year universities through career exploration (89.9%), admissions preparation (57.7%), academic enhancement (47.7%), and articulation agreements (42.9%). Applicant selection practices included preferential scoring in screening (38.2%) and admissions decisions (30.0%), modified MCAT (21.4%) and GPA cutoffs (18.8%), and reserved class slots (20.2%). Personnel from 10 schools identified key themes of motivations, resources, challenges, and recommendations. Understanding how schools identify and admit rurally inclined students is a first step in identifying best practices for addressing rural workforce gaps.

Family Medicine Rural Training Track Residencies: Risks and Resilience.

BACKGROUND AND OBJECTIVES: Family medicine rural training track (RTT) residency programs produce a higher proportion of graduates who choose rural practice than other programs, yet RTTs face continuing threats to their existence. This study sought to understand threats to RTT sustainability and resilience factors that enable RTTs to thrive. METHODS: In 2014 and 2015, the authors conducted semistructured interviews of 21 RTT leaders representing two closed programs and 22 functioning programs. Interview topics included program strengths providing resilience and sustainability, risk factors for closure or vulnerabilities threatening sustainability, and advice for other RTTs. The authors performed a content analysis, coding pertinent themes in all interview data. RESULTS: From the top three assets, risks, and advice that respondents offered, the following nine themes emerged, in order from most to least mentioned: leadership, faculty and teaching resources, program support, finances, resident recruitment, program attributes, program mission, political and environmental context, and patient-related clinical experiences. Interviewees frequently reported multifactorial causes for RTT sustainability or closure. CONCLUSIONS: Numerous factors identified, such as distance, can operate as positive or negative influences for program resilience, depending on place and context. Resilience depends on multiple forms of social capital, including robust networks among individuals and various communities: the local population and patients, local health care providers, residency faculty, and RTTs in general. The small size and remoteness of RTTs make them vulnerable to multiple challenges in finances, regulations, and accreditation, requiring program adaptability and suggesting the need for flexibility in the policies that govern them.

Competence Revisited in a Rural Context.

BACKGROUND AND OBJECTIVES: General competencies developed in undergraduate and graduate medical education are sometimes promoted as applicable in any practice context. However, rural practice presents challenges and opportunities that may require unique training. The objectives of this national survey of both undergraduate and graduate medical educators and practicing physicians were to further develop a previously published list of competency domains for working in rural communities and to assess their relative importance in education and practice. METHODS: Using six rural competency domains first refined with a national group at the Society of Teachers of Family Medicine Annual Meeting in Baltimore in 2008, the authors employed a snowball strategy to survey medical educators and physicians regarding the importance and relevance of this list and to solicit additional domains and competencies. RESULTS: All six domains were considered important, with average responses for each domain ranging from 4.16 to 4.78 on a 5-point Likert scale (1-not important; 5-extremely important). Unique relevance to rural practice was more varied, with average responses for domains ranging from 2.36 to 3.6 (1-not at all unique; 5-extremely unique). Analysis of free text responses identified two important new domains-Comprehensiveness and Agency/Courage-and provided clarification of some competencies within existing domains. CONCLUSIONS: This study validates and further elaborates dimensions of competence believed to be important in rural practice. The authors propose these domains as a common language and framework for addressing the unique challenges and opportunities that training and practicing in a rural setting present.