Recruitment to retention – Addressing the needs and driving improvement within the rural physician pipeline

Dear Editor-in-Chief:

Rural Americans, like many with lower socioeconomic status and marginalized identities, face stark healthcare disparities, with rural environments experiencing a 20% higher death rate for the top ten causes of death compared to urban areas.¹ Telehealth coverage and increasing the scope of practice of non-physician providers have historically been the primary responses to these disparities by increasing access to primary care clinicians, but these solutions fail to address in any systemic way the fact that rural residents face higher rates of chronic illness, lower vaccination rates, and greater medical mistrust.^2,3,4

For race, gender, and sexuality, the importance of personal identities in shaping the healthcare experience has been widely discussed and, in response, the medical community has begun deliberate efforts to construct a provider workforce that mirrors the patients it serves.⁵ The challenges of a rural upbringing are similarly unique, and experiences and values like self-reliance, religion, and family-centered practice cannot always be taught. In this essay, we argue for the need to recruit and retain students from rural identities into the primary care physician pipeline.

There are obvious hurdles associated with this task. Less than 30% of rural high school students enroll in college, compared to 48% for urban students, and fewer than 5% of incoming medical students are from rural backgrounds, despite 15% of the U.S. population residing in rural areas.⁶ This proportion of medical students with rural backgrounds has only continued to decline over the last 15 years.⁷ For physicians who begin their attending careers in rural communities, they may not choose to stay, exacerbating physician shortages in these areas.

Medical programs targeting rural students and alleviating barriers can thus be instructive for addressing rural physician workforce challenges. For example, the Maine Track at Tufts University, the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) program at the University of Washington School of Medicine, and the Rural Medicine Program (RMP) at the University of Alabama School of Medicine all provide successful templates for rural-focused initiatives. For Maine Track medical students at Tufts, MS1s complete their first year in Boston and then spend their remaining three years of medical school in Maine. Unlike the Tufts program, WWAMI program students must be born, lived, or attended school in one of the WWAMI states. WWAMI students then receive in-state tuition and medical training from both local universities and the University of Washington during their first two years and can complete clinical rotations at community-based sites in the WWAMI region during their third and fourth years. Thus, the WWAMI program not only focuses on recruitment of those with interest in rural practice but also lived experience in rural communities, a key factor for rural retention.

For RMP students, they must be a legal resident of Alabama, lived or attended school in rural Alabama for eight years or more, and be committed to practicing family or primary care medicine in rural Alabama. The RMP is five-years long with the first year involving tailored classes at Auburn University, addressing each students’ academic needs, and remaining years consisting of traditional pre-clinical years followed by clinical rotations with a rural focus. As such, the RMP not only provides rural students with continued rural exposure during medical school but also has built-in support to address any previous lack of academic resources.

Beyond more widespread implementation of recruitment programs, retention of these students is similarly critical. Rural students face significant financial hurdles, lack of community support, and academic success barriers in their journeys to becoming physicians. Here, collaborations between colleges with large rural student populations and medical schools may offer guidance. More broadly, models utilized for retention of underrepresented minority (URM) populations in medicine could be cross applied for rural students. Establishment of diversity deans, early intervention and support services, and structured mentorship programs are just a few ways institutions have addressed the “leaky pipeline” for URM populations, and similar programs – either newly created or through increased scope of existing ones – could help improve rural retention throughout medical school and residency.⁸

Continuing along the physician pipeline, rural training tracks for resident physicians are vital to providing new medical school graduates rural experience within their medical specialty. Examples include the Family Medicine Residency - Rural Training Track at Duke University, the Family Medicine Residency - Rural Training Program at the University of Arkansas, and the Shiprock University of New Mexico (UNM) Family Medicine Residency which integrate rural rotations and exposure for physician residents. Duke’s Rural Training Track combines training primarily in Oxford, NC with the main campus in Durham, NC, while the Rural Training Program residents spend the majority of PGY-2 and PGY-3 in rural Carroll County. In contrast to both programs, Shiprock UNM residency’s training focuses on Native American patients and communities, serving as the first federal Indian Health Service residency program in the country and providing resident physicians experience in both rural settings and with indigenous populations.⁹ This is particularly important as indigenous communities suffer from poorer health, reduced quality of life, and have life expectancies up to 20-years lower compared to their non-indigenous counterparts.¹⁰

Programs should also address challenges rural attending physicians face as well. Initiatives such as the Community Apgar Project, the Rural Telementoring Training Center, and the University of New Mexico’s Project ECHO focus on retention and connecting rural areas with outside resources. These programs recognize the challenges rural attendings face and offer resources to address these issues through improved infrastructure and support. The ultimate goal of all these efforts is to create a virtuous, self-perpetuating cycle where rural faculty mentor undergraduates, medical students, and residents to help them enter rural practice and mentor the next generation of rural physicians.

Recruitment of rural students to medical school and a continued focus on retention are actionable solutions to improve representation and physician-patient concordance in rural America. With the continued growth of rural-urban mortality disparities, now more than ever, we need to focus on the cause rather than symptoms of the rural medical experience, addressing these issues before disparities worsen.