Abstract
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.
Keywords: health equity, health policy/politics/law/regulation, health workforce, primary care, rural health
What is known on this topic
Geographic maldistribution of the health care workforce in favor of urban areas threatens access to care in rural communities, where low supply is associated with poor health outcomes.
Factors associated with choosing rural practice include having a rural background and participating in clinical training in a rural place.
Past research on rural practice choice has not adequately distinguished the discrete and interactive effects of rural background and rural training experiences.
What this study adds
Using data from a recent national, longitudinal cohort, we found that both rural background and rural residency training are strong, independent predictors of rural practice among family physicians.
Rural residency training is more strongly associated with rural practice than rural background. Individuals from a rural background who trained in a rural residency were the most likely to choose rural practice.
In addition to recruiting more rural students to undertake medical education, increasing opportunities for training residents from both rural and urban backgrounds in rural programs could greatly increase the number of family physicians entering rural practice.
1. INTRODUCTION
The geographic maldistribution of the health workforce is associated with negative rural population health outcomes, including excess mortality. 1 , 2 Rural communities frequently struggle to attract and retain a sufficient supply of health professionals. Primary health care services are the foundation of a robust health care system 3 ; ensuring access to primary care, especially for under‐resourced populations, is a paramount health policy goal. Rural primary care clinician density has increased over time, 4 but rural gains lag behind urban, and federally designated primary care Health Professional Shortage Areas persist in rural areas, particularly poorer communities. 5 Family physicians are more plentiful in the rural United States than all other primary care clinicians except nurse practitioners, have a broader scope of practice, and are the only type of primary care clinician whose supply is more concentrated with increasing rurality. 6 Understanding how to promote rural practice among family physicians is therefore essential for rural health care access.
Research studies over decades have identified personal and environmental predictors of intended or actual rural clinical practice. Individual studies and systematic reviews provide strong evidence that a rural background—growing up or attending high school in a rural area—is associated with the intent to choose rural practice and subsequent rural practice, including among rural primary care physicians. 7 , 8 , 9 , 10 However, the number of rural students pursuing medical careers has been declining. 11 Women were historically less likely than men to practice in rural areas, 9 , 12 , 13 but women's proportion of the rural workforce is growing, and evidence on the impact of gender on rural practice is lacking for more recent cohorts. Medical school experiences matter: while evidence on the effects of attending US or Canadian medical schools versus international schools is mixed, numerous studies find that students participating in rural rotations, particularly within comprehensive rural medical education programs, were more likely to choose rural practice. 8 , 9 , 10 Osteopathic medical school graduates also comprise a disproportionate share of the rural physician workforce generally and in primary care. 13 , 14 Residency location is an important determinant of eventual practice location. 15 Compared with graduates of urban residency programs, rural program graduates are about two to three times as likely to locate in rural areas, and they devote more total workforce years during their careers to rural practice. 13 , 16 , 17
While laying important groundwork, past studies have important limitations, including small samples (frequently from a single institution, such as one medical school) and insufficient data to account for selection effects 8 , 9 , 10 or to examine simultaneously the effects of background and training experiences. 17 Past research on rural residency programs focused on subsets of programs 17 or did not specify a clear definition of what constitutes a rural program. 13
Family physicians complete 3 years of residency training (also known as graduate medical education [GME]) after graduation from medical school, and therefore residency is the educational experience most proximal to the time when physicians choose where to practice. Knowing whether self‐selection or exposure to rural residency training leads to rural practice has important implications for designing and implementing effective policy and practices to ameliorate primary care workforce shortages. This study expands on past work by comparing the rural physician yields of all rural and all urban family medicine residency programs (accredited by the Accreditation Council on Graduate Medical Education as of 2018) as well as incorporating a measure of rural background to investigate the discrete and combined impacts of background and residency training experiences on practice choice. We also use an explicit definition of residency program rurality that aligns with definitions in residency accreditation and GME financing. 18 , 19
2. METHODS
2.1. Data and study sample
We used two de‐identified data sources for the main analysis in this observational, longitudinal cohort study of board‐certified graduates of family medicine residencies. The main study sample consisted of family physicians certified by the American Board of Family Medicine (ABFM) who completed the ABFM's National Graduate Survey (NGS). The NGS is a validated instrument administered to all ABFM‐certified physicians 3 years after residency training. Our three‐year pooled sample of NGS participants completed residency in years 2013 through 2015 and responded to the survey from 2016 to 2018. NGS survey methods have been described in detail elsewhere 20 ; response rates for the 2016–2018 cohorts ranged from 66.7% to 67.8%. An analysis of nonresponse showed that international medical graduates, those completing medical school outside the United States or Canada, were less likely to respond in the 2018 cohort only. No other significant differences in response by age, gender, or type of medical degree (allopathic or osteopathic) were detected. 21 We matched NGS respondents using a common identifier to American Medical College Application Service (AMCAS) records from the Association of American Medical Colleges (AAMC). The AMCAS questionnaire is completed by all prospective medical students as part of applying to US allopathic medical schools.
Our analytic sample consisted of 3694 NGS respondents who could be matched to rural background information from AMCAS. Rural background information was not available for an additional 2053 NGS respondents, most of whom were osteopathic physicians or international medical graduates, who either may not have applied to a US allopathic medical school or did not attend a US high school. We also conducted a sensitivity analysis, described below, incorporating those missing rural background data.
To examine longer term rural versus urban practice patterns of physicians later in their careers than those completing the NGS, we used data from the ABFM Continuing Certification Questionnaire (CCQ), a mandatory (100% response) component of the registration process for physicians to continue their certification, administered every 7 to 10 years after initial board certification. The pooled sample consisted of 44,325 later career physicians completing the questionnaire from 2014 to 2018.
The RTT Collaborative is a nonprofit cooperative of programs and individuals committed to the mission of sustaining health professions education in rural places, and we obtained residency location data from its curated list of rural programs, 22 which includes the location for the rural community, rural hospital, and rural family medicine practice where residents acquire more than 50% of their training.
3. MEASURES
3.1. Rural background
Based on prior research showing that self‐reported rural background and high school rurality are strongly linked to rural interest in practice, 7 we counted physicians as having a rural (as opposed to urban) background if either of two conditions was met, according to responses on the AMCAS questionnaire: (1) they attended high school in a US rural county (as classified by the 2013 Rural–Urban Continuum Codes; codes 4–9 were considered rural); or (2) they responded “yes” to the question, “Do you wish to be considered a disadvantaged applicant by any of your designated medical schools which may consider such factors (social, economic or educational)?” and they also responded “rural” to the question, “In what area did you spend the majority of your life from birth to age 18?” (only those considering themselves disadvantaged were asked the second question).
3.2. Rural residency training
Family medicine residencies on The RTT Collaborative list 22 are considered rural if their family medicine practice is in a rural location by two federal definitions and their residents spend more than half their training time in a rural location by the same definition. We limited our sample to programs whose family medicine practice had a Rural–Urban Commuting Area (RUCA) code of 4 or greater, indicating location in a nonmetropolitan area. 23 RUCA codes, developed by the U.S. Department of Agriculture Economic Research Service, are based on population density, urbanization, and daily commuting. Rurally trained physicians are those who completed residency in 1 of the 97 rural programs by this definition in operation in 2018. We considered all other residency graduates to be urban trained.
3.3. Rurality of practice location
We classified practice location ZIP codes reported on the NGS and CCQ surveys as rural if their RUCA codes were 4 or greater, all others were urban.
3.4. Other covariates
Other covariates included age (categorized as 28–34, 35–39, and 40 years or older), gender (reported as a binary variable, male or female), medical school degree type (osteopathic or allopathic), medical school location (United States/Canada vs. international medical school), and residency program Census Region (Northeast, Midwest, South, and West). Race and ethnicity data were unavailable for the entire study cohort and therefore not included.
3.5. Statistical analysis
Separate multivariable logistic regression models examining the effects of rural background and residency training on rural or urban practice location adjusted for the covariates described above. We calculated predictive marginals and 95% confidence intervals using the Delta method. We also conducted a sensitivity analysis testing the robustness of our results by rerunning our model adding the 2053 cases missing rural background information (for a total of 5747 physicians), specifying rural background as a three‐level categorical variable (no, yes, and missing) and incorporating an interaction term between this variable and rural residency training.
We used Stata 16 (StataCorp; 2019) for all analyses. The American Academy of Family Physicians Institutional Review Board approved this study. The University of Washington Human Subjects Division determined that this study was not human subjects research because individuals were not identifiable in the analytic dataset provided by ABFM and AAMC.
4. RESULTS
Table 1 presents sample descriptive characteristics. Over half of ABFM‐certified family physicians were women (57.3%) and aged 28–34 years (57.2%) at 3 years post‐residency. About one fifth (21.0%) had a rural background. Most physicians had attended allopathic medical schools (86.4%) in the United States or Canada (86.8%).
TABLE 1.
Descriptive characteristics of the study sample.
| Characteristic | Overall |
|---|---|
| Age (years) | |
| Mean (SD) [Range] | 35.0 (3.5) [28–62] |
| 28–34 | 2112 (57.2%) |
| 35–39 | 1263 (34.2%) |
| 40+ | 319 (8.6%) |
| Gender | |
| Female | 2117 (57.3%) |
| Male | 1577 (42.7%) |
| Background a | |
| Urban | 2917 (79.0%) |
| Rural | 777 (21.0%) |
| Degree type | |
| Allopathic | 3192 (86.4%) |
| Osteopathic | 502 (13.6%) |
| Medical school location | |
| United States/Canada | 3206 (86.8%) |
| International | 488 (13.2%) |
| Residency program rurality b | |
| Urban | 3546 (96.0%) |
| Rural | 148 (4.0%) |
| Residency program Census Region | |
| Northeast | 569 (15.4%) |
| Midwest | 1006 (27.2%) |
| South | 1106 (29.9%) |
| West | 1013 (27.4%) |
| Practice location rurality c | |
| Urban | 2976 (80.6%) |
| Rural | 718 (19.4%) |
| Survey year | |
| 2016 | 1161 (31.4%) |
| 2017 | 1238 (33.5%) |
| 2018 | 1295 (35.1%) |
| Observations | 3694 |
Note: Data sources include the American Board of Family Medicine National Graduate Survey, 2016–2018, and the American Medical College Application Service (AMCAS) of the Association of American Medical Colleges.
A rural (as opposed to urban) background is defined as meeting any of two conditions: (1) attending high school in a US rural county, as classified by the 2013 Rural–Urban Continuum Codes (rural codes: 4–9), or (2) self‐reporting a rural background on the AMCAS questionnaire by responding “rural” to the question, “In what area did you spend the majority of your life from birth to age 18?”
Rural residency programs have a family medicine practice in a rural location (defined as having Rural–Urban Commuting Area [RUCA] code of 4 or greater) and their residents spend more than half their training time in a rural location by the same definition.
We defined practice locations with a RUCA code of 4 or greater as rural.
Just 4.0% of family physicians had completed a rural residency program, but nearly one in five of all graduates (19.4%) were practicing in a rural area 3 years after residency. In unadjusted analyses, family physicians trained in rural programs chose rural practice over three times as often as urban program graduates, 56.8% versus 17.9% (not tabled; p < 0.001). Similarly, those from rural backgrounds chose rural practice over three times as often as physicians from an urban background, 42.6% versus 13.3% (not tabled; p < 0.001).
Table 2 presents predictive marginals calculated from the logistic regression predicting rural practice choice. In our adjusted model, the effect of rural residency training was the strongest predictor of rural practice: 50.9% of family physicians training in rural residencies chose rural practice, compared with 18.0% of those from urban residencies (p < 0.001). Family physicians from rural (vs. urban) backgrounds were more likely to choose rural practice (39.2% vs. 13.8%, p < 0.001). The interaction of background with residency program location was significant (p = 0.045): physicians from rural backgrounds training in rural residences were the most likely to choose rural practice (82.7%), followed by those from urban backgrounds training in rural residencies (42.7%), and finally those from rural backgrounds who graduated from urban residencies (37.3%). Physicians from an urban background who had completed urban training were least likely to choose rural practice (12.5%). Significant covariates included gender, medical school location, and residency program Census Region; age and degree type were not significant. Women (18.0%, p = 0.007) and international medical graduates (15.8%, p = 0.019) were less likely than men (21.3%) and US/Canadian medical graduates (20.0%) to choose rural practice. Family physicians attending residency programs in the Midwest (25.3%, p < 0.001), South (17.8%, p = 0.009), and West (18.2%, p = 0.006) regions were more likely to choose rural practice than those from the Northeast.
TABLE 2.
Associations of demographic characteristics and residency location with rural practice location.
| Covariate | Predictive marginal (%) | Lower CI | Upper CI | p‐Value |
|---|---|---|---|---|
| Age (years) | ||||
| 28–34 | 19.2 | 17.6 | 20.8 | REF |
| 35–39 | 18.8 | 16.7 | 20.8 | 0.737 |
| 40+ | 23.5 | 19.2 | 27.8 | 0.066 |
| Gender | ||||
| Male | 21.3 | 19.5 | 23.2 | REF |
| Female | 18.0** | 16.4 | 19.5 | 0.007 |
| Background a | ||||
| Urban | 13.8 | 12.5 | 15.0 | REF |
| Rural | 39.2*** | 35.8 | 42.5 | <0.001 |
| Degree type | ||||
| Osteopathic | 21.7 | 18.4 | 25.0 | REF |
| Allopathic | 19.1 | 17.8 | 20.3 | 0.143 |
| Medical school location | ||||
| United States/Canada | 20.0 | 18.7 | 21.3 | REF |
| International | 15.8* | 12.7 | 19.0 | 0.019 |
| Residency program Census Region | ||||
| Northeast | 13.0 | 10.1 | 15.9 | REF |
| Midwest | 25.3*** | 22.8 | 27.8 | <0.001 |
| South | 17.8** | 15.7 | 19.9 | 0.009 |
| West | 18.2** | 15.9 | 20.4 | 0.006 |
| Residency program location b | ||||
| Urban | 18.0 | 16.8 | 19.2 | REF |
| Rural | 50.9*** | 43.0 | 58.8 | <0.001 |
| Interaction term (background × residency program location) | ||||
| Urban background × urban residency | 12.5 | 11.3 | 13.8 | REF |
| Rural background × urban residency | 37.3 | 33.9 | 40.8 | <0.001 |
| Urban background × rural residency | 42.7 | 33.0 | 52.4 | <0.001 |
| Rural background × rural residency | 82.7 | 72.1 | 93.4 | <0.001 |
Note: Data sources include the American Board of Family Medicine National Graduate Survey, 2016–2018, and the American Medical College Application Service (AMCAS) of the Association of American Medical Colleges. The outcome variable is rural versus urban practice location as measured by Rural–Urban Commuting Area (RUCA) codes (N = 3694). We defined practice locations with a RUCA code of 4 or greater as rural. CI = confidence interval (95%). Statistical significance is shown at the *0.05; **0.01; and ***0.001 levels.
A rural (as opposed to urban) background is defined as meeting either of two conditions: (1) attending high school in a US rural county, as classified by the 2013 Rural–Urban Continuum Codes (rural codes: 4–9), or (2) self‐reporting a rural background on the AMCAS questionnaire by responding “rural” to the question, “In what area did you spend the majority of your life from birth to age 18?”
Rural residency programs have a family medicine practice in a rural location (defined as having Rural–Urban Commuting Area [RUCA] code of 4 or greater) and their residents spend more than half their training time in a rural location by the same definition.
Data on rural/urban backgrounds are unavailable for the later career sample of physicians, but 1274 (2.8%) graduated from rural programs. The unadjusted yield to rural practice from rural versus urban residency programs was very similar to that of early‐career physicians, 52.7% versus 18.1%.
Our sensitivity analysis incorporating physicians missing rural background information into the sample yielded similar effects of rural background and training locations on rural practice choice (Table S1).
5. DISCUSSION
Using a combination of longitudinal data from student applications to medical school and surveys of ABFM‐certified family physicians 3 years into practice post‐residency, our multivariable model found that both rural residency training and rural background were strong predictors of rural practice. Furthermore, we found a similar pattern of rural practice according to residency location among later career physicians.
The effect of rural training, however, was stronger than rural background. Over half of rural residency program graduates were in rural practice 3 years post‐residency, whereas just over two in five family physicians from a rural background eventually practiced there. Consistent with other studies, these independent rural background and rural training yields to rural practice were two to three times those of their urban counterparts. The joint effect of being from a rural background and completing rural training resulted in the highest likelihood of rural practice. The ability to account simultaneously for both rural background and rural training in a large national pooled sample of recent family medicine residency graduates represents a significant contribution to our understanding of these important influences on rural practice choice.
Study limitations include underrepresentation of osteopathic physicians, who may not have applied to allopathic medical schools or obtained ABFM certification, and international medical graduates. The response rates to the NGS were fairly robust, and although only one difference in response rate was detected in the 2018 cohort only, nonresponse bias is always a potential threat to validity in survey research. Another limitation was the large number of cases missing rural background information, but inclusion of these cases in a sensitivity analysis did not change the overall pattern of our results.
Our results draw attention to the need to provide educational opportunities for rural students that will enable them to pursue medical careers. The troubling decline in medical school applicants with a rural background 11 calls for intensified efforts to prepare rural students for and recruit them to medical school. This study's results also show that rural training can yield high proportions of residents from an urban background who choose rural practice, indicating that rural programs with a mission to produce rural physicians can effectively target recruitment efforts toward students from urban as well as rural backgrounds. Our findings thus provide strong evidence for workforce policies that enable rural communities to continue and expand their role in educating a physician workforce that will meet their needs.
Given that roughly one in five persons in the United States resides in a rural area, the fact that only 4.0% of our sample population—about one fifth of rural family physicians in our study—had trained in rural residency programs underscores the disproportionate concentration of residency education in urban areas and the small numbers of rural residency programs and positions by comparison. This lack of alignment between the United States' largely federally funded GME system and societal needs has led to calls for increased social accountability. 24 , 25 , 26 , 27 Family physicians already stand out from other primary care clinicians in their higher propensity to choose rural practice, 6 and rural family medicine residency training can further address primary care workforce imbalances. Meanwhile, nurse practitioners (NPs) and physician assistants (PAs) also constitute significant proportions of rural primary care workforce supply, and the numbers of NP and PA education programs continue to expand, 28 , 29 offering more opportunities to implement and test rural place‐based training strategies in these disciplines.
Many fewer rural residency programs exist in physician specialties other than family medicine that are also important to rural health systems. 22 , 30 , 31 Rural physician training initiatives, such as the federal Rural Training Track Technical Assistance program (2010–2016) 16 and the subsequent Rural Residency Planning and Development grant program (2019–present), 25 , 32 which supports new programs in several specialties important to rural health systems, including family medicine, internal medicine, preventive medicine, psychiatry, general surgery, and obstetrics and gynecology, represent important steps. Given the long time required to develop residency programs, recruit residents, and graduate into practice, a comprehensive evaluation of the impacts of these initiatives is still premature. The potential of incorporating more rural training opportunities into urban programs should also be explored, given the relationship between exposure to rural training and eventual rural practice also found by others. 33 Small studies of residency training in emergency medicine and surgery also indicate rural background and rurally located residency training can lead to rural practice. 34 , 35 Future research should examine the characteristics and outputs of programs outside of family medicine. Larger reforms to rural GME funding in general are also indicated.
In summary, our findings provide evidence for the importance of rural context and the value of current and future initiatives to strengthen and expand the availability of residency training in rural communities, an endeavor that requires support at many levels, including local community health partners, state‐level GME initiatives, and federal support through sustained funding and technical assistance.
Supporting information
Data S1. Supporting information
ACKNOWLEDGMENTS
The authors are grateful for the contributions of Zachary J. Morgan, MS, and Zakia Nouri, MA, in preparing the data for analysis. This research was supported by the Bureau of Health Workforce (BHW), Health Resources & Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement #UH1HP29966. The information, conclusions, and opinions expressed in this article are those of the authors and no endorsement by BHW, HRSA, or HHS is intended or should be inferred.
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 Serv Res. 2024;59(1):e14168. doi: 10.1111/1475-6773.14168
DATA AVAILABILITY STATEMENT
Study data were from the American Board of Family Medicine (ABFM), Association of American Medical Colleges (AAMC), and The RTT Collaborative. AAMC data are not available for public use. ABFM data are available after study protocol review and approval, a data use agreement, and ethical approval. Data from The RTT Collaborative are publicly available: https://rttcollaborative.net/rural-programs/.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1. Supporting information
Data Availability Statement
Study data were from the American Board of Family Medicine (ABFM), Association of American Medical Colleges (AAMC), and The RTT Collaborative. AAMC data are not available for public use. ABFM data are available after study protocol review and approval, a data use agreement, and ethical approval. Data from The RTT Collaborative are publicly available: https://rttcollaborative.net/rural-programs/.