Abstract
Background:
Those who live in rural areas generally exhibit higher prevalence of musculoskeletal conditions than urban populations. Already limited access to local orthopaedic care is becoming more challenging, as orthopaedic surgeons in these areas tend to be older and nearing retirement, while few graduating residents are selecting rural practice. However, little data exist on why orthopaedic residents are not choosing rural practice despite the clear need.
Methods:
A 22-question survey was created in REDCap. A letter of invitation to participate was sent to interested program directors through the AOA Collaborative Orthopaedic Education Research Group (COERG). Questions included those related to community of origin, level of interest in rural practice, and areas in which more information is needed.
Results:
One hundred seven orthopaedic surgery residents from 16 programs completed the survey. Only 6 respondents plan to practice in rural areas. Thirty-two reported no interest in rural practice. Sixty-nine respondents were unsure about rural practice. No significant differences in rural interest were found based on gender or parental status. The only demographic factor impacting interest in rural practice was coming from a rural background. Factors leading to interest or disinterest in rural practice were similar. Those indicating that they were unsure wanted more information regarding impact on families, call, compensation, and case volume and complexity.
Conclusion:
Addressing the gap in rural orthopaedic care is complex, but there are opportunities such as outreach to rural students to encourage them to consider medicine and then orthopaedic surgery as a career, as well as education sessions and rotations during residency training to expand rural interest.
Clinical Relevance:
Understanding the factors that lead to orthopaedic residents pursuing (or not) practice in rural areas is important in addressing access to musculoskeletal care in these areas.
Introduction
According to the CDC, 15% of all Americans live in rural areas1. Those living in rural areas have higher rates of musculoskeletal injuries and chronic conditions, including soft tissue injuries2, low impact hip fractures3, and osteoarthritis.
Despite the need for musculoskeletal care in rural communities, there is a relative dearth of orthopaedic surgeons. From 2013 to 2018, the total number of orthopaedic surgeons in the United States grew by 1.9%, but the proportion practicing in rural areas declined by 0.9%, the latter a decline from 4.55 to 4.47 per 100,000 population4. A survey of hospital administrators5 found that 25% of rural hospitals had no orthopaedic surgeon available for their communities, and 40% relied on locum tenens surgeons. For those communities without orthopaedic surgeons, patients traveled 20 to 250 miles (mean 50 miles) for emergent care and 20 to 135 miles (mean 45 miles) for elective care. Lack of access to local orthopaedic surgeons has consequences: older adults in rural areas have noted issues with access to care in treating osteoarthritis, often seeking treatment in local emergency departments6, and mortality rates after hip fracture have been found to be higher than for those living in urban areas, attributed, in part, to lack of sufficient resources, often resulting in delays in care7.
The relative dearth of orthopaedic surgeons in rural areas is due to both local economic factors8 and the changing demographics of the orthopaedic workforce. Orthopaedic surgeons practicing in rural areas tend to be older9 and thus likely to be aging out of practice, while younger orthopaedic surgeons are more likely to join practices in urban communities.4,10. There are no data that address the latter point to identify interest in future rural practice among those currently in training. Understanding the views of orthopaedic trainees on future practice in rural areas and the major influences on these decisions will allow interventions to help address the gap in rural orthopaedic care.
Methods
A survey was developed through review of the literature, as well as input from orthopaedic surgeons in rural practice, and administered through REDCap (Appendix A) to current orthopaedic surgery residents. Per protocol of COERG, an electronic invitation to participate was distributed to all 103 COERG programs. Eighteen programs indicated interest, and another 11 who are members of CORD but not COERG were contacted to increase geographic representation. Sixteen of the 29 programs indicated that they had distributed the survey link to their trainees.
Demographic data collected included age, year in training, gender, race/ethnicity, and geographic region. Participants were asked about their interest in rural practice, with response options of yes, no, or maybe-have/have not considered. Residents who indicated that they were interested in rural practice were asked to check all that applied from a list of attributes of this practice; those who indicated no interest were asked to check from a list of potential barriers. Those who answered “maybe” were provided a free-text option to address “what additional information about rural practice would be helpful in making the decision?” The answers from the free-text question were assessed independently by 2 of the authors to identify themes, with differences in interpretations resolved and comments tabulated.
Data were stored in a secure REDCap database accessible only to study investigators. The study was approved by the Institutional Review Board of the University of Kansas Medical Center.
Statistical Methods
Study outcomes were summarized with counts, means, and standard deviations. Psychometric properties of the attraction and repulsion (“never”) sections of the survey were assessed using Cronbach's alpha. A level of alpha = 0.70 or higher was used to determine good reliability11. Comparisons of categorical outcomes were made using Chi-squared tests or Fisher exact tests as appropriate. Normality of continuous outcomes was assessed using Shapiro-Wilk tests. Comparisons of continuous outcomes were made using either independent sample t-tests or Wilcoxon ranked sum tests as appropriate. All statistical analyses were performed using R 2026.01.2 (R Foundation for Statistical Computing), with significance set at α = 0.05.
Results
One hundred seven residents out of 404 from 16 programs completed the survey (26.7% response rate). Twelve of the programs were in Rural-Urban Continuum Code (RUCC) 1, and 4 were in RUCC 2. Respondents were predominantly men (77%), with a mean age of 29.6 years (SD 2.5). 86% did not have children. (Table 1) Most respondents trained in academic programs (64%), and trainees represented all US regions. A plurality of residents was from communities of <50,000 population. (Table 2)
Table 1.
Participant Characteristics and Training Context
| Characteristic | Category | N (%) or Mean (SD) |
|---|---|---|
| Age (years) | 29.6 (2.5) | |
| Gender | Man | 82 (77) |
| Woman | 25 (23) | |
| Race/ethnicity | American/Alaskan Native | 5 (5) |
| Asian | 14 (13) | |
| Latino | 4 (4) | |
| Non-Hispanic Black | 1 (1) | |
| Non-Hispanic White | 80 (75) | |
| Not reported | 3 (3) | |
| Relationship status | Married | 60 (56) |
| In relationship | 35 (33) | |
| Not married | 12 (11) | |
| Children | No | 92 (86) |
| Yes | 15 (14) | |
| Program type | Academic | 69 (64) |
| Community-academic | 33 (31) | |
| Community | 5 (5) | |
| Training region | Great Lakes/Midwest | 32 (30) |
| Southeast | 26 (24) | |
| Mid-Atlantic | 19 (18) | |
| Northeast | 17 (16) | |
| Southwest | 8 (7) | |
| West | 5 (5) |
Table 2.
Background and Exposure Variables
| Variable | Category | N (%) or Mean (SD) |
|---|---|---|
| Childhood community size | <50 k | 37 (35) |
| 50 k-100 k | 20 (19) | |
| 100 k-500 k | 20 (19) | |
| 500 k-1 M | 20 (19) | |
| >1 M | 10 (9) | |
| Distance from urban/suburban area | <50 mi | 27 (25) |
| 50-99 mi | 6 (6) | |
| 100-199 mi | 4 (4) | |
| Not reported | 70 (65) | |
| Longitudinal rural training | No | 85 (79) |
| Yes | 22 (21) | |
| Rural rotation length (weeks) | 19.5 (33.5) | |
| Episodic rural outreach | No | 86 (80) |
| Yes | 21 (20) | |
| Overseas underserved experience | No | 82 (77) |
| Yes | 25 (23) |
Interest in rural practice was limited. Six respondents (6%) reported definite plans to pursue rural practice, while 32 (30%) reported they would never consider rural practice. The largest group (69) were those who indicated “maybe”: 42 (39%) had considered it, and 27 (25%) had not considered it. (Table 3). Residency program type was not associated with interest in rural practice.
Table 3.
Associations Between Trainee Characteristics and Rural Practice Interest
| Characteristic | Yes (n = 6) | Maybe-considered (n = 42) | Maybe-not considered (n = 27) | Never (n = 32) | p |
|---|---|---|---|---|---|
| Gender: man | 4 | 33 | 22 | 23 | 0.731 |
| Gender: woman | 2 | 9 | 5 | 9 | |
| Age, mean (yrs) | 28.5 | 29.69 | 29.89 | 29.31 | |
| Childhood community <50 k | 4 | 20 | 8 | 5 | 0.011 |
| 50 k-100 k | 1 | 8 | 7 | 4 | |
| 100 k-500 k | 0 | 4 | 8 | 8 | |
| 500 k-1 M | 0 | 3 | 2 | 5 | |
| >1 M | 1 | 7 | 2 | 10 | |
| Longitudinal rural rotation (yes) | 3 | 9 | 7 | 3 | |
| Episodic rural experience (yes) | 5 | 7 | 5 | 4 | |
| Overseas experience (yes) | 3 | 13 | 7 | 2 |
Most of the demographic variables (age, gender, relationship and parental statuses) were not associated with interest in rural practice. The only variable significantly associated with rural practice interest was childhood community size (p = 0.011). Respondents from smaller communities (<50,000 population) were more likely to report definite or possible (“maybe”) interest in rural practice compared with those from larger communities (Table 3).
Rural exposure during training was uncommon: 22 residents (21%) reported longitudinal rural rotations, and 21 (20%) reported episodic rural outreach experiences (Table 2). Participation in longitudinal rural experiences had no impact on interest in future rural practice (p = 0.091), while episodic experiences were associated with a greater likelihood of rural interest (p = 0.004). The latter association remained when combining those who answered “yes” to rural practice with those who indicated that they had considered it but were unsure.
All respondents planned on pursuing fellowship training. Future practice intentions were mixed, and there was no difference in interest in rural practice based on future practice models.
“Attraction” questions showed good reliability with a Chronbach's alpha of 0.86 with an average interitem correlation of 0.44. “Never” questions show good reliability with a Chronbach's alpha of 0.88 with an average interitem correlation of 0.35.
Among the 32 respondents not interested in rural practice, the most frequently noted barriers were personal preference against rural living (97%), partner or family preference (66%), and concerns about personal well-being (59%) (Table 4). Professional concerns included limitations in practicing to the extent of subspecialty training (41%) and resource limitations (41%). Call schedule (19%), compensation (19%), and educational debt (6%) were less frequently cited.
Table 4.
Perceived Barriers and Motivators for Rural Practice
| Barrier | Overall N (%) |
|---|---|
| Panel A. Barriers (among those not interested in rural practice, n = 32) | |
| Prefer not to live in rural area | 31 (97) |
| Significant other/family preference | 21 (66) |
| Personal well-being concerns | 19 (59) |
| Ability to practice subspecialty fully | 13 (41) |
| Lack of technical resources | 13 (41) |
| Lack of subspecialty support | 12 (38) |
| Lack of knowledge about rural practice | 10 (31) |
| Academic practice preference | 9 (28) |
| Call schedule | 6 (19) |
| Compensation concerns | 6 (19) |
| Case complexity concerns | 5 (16) |
| Limited rehab access | 4 (13) |
| Education debt | 2 (6) |
| Motivator | Overall N (%) |
|---|---|
| Panel B. Motivators (among trainees interested in rural practice, n = 6) | |
| Recreational activities/hobbies | 6 (100) |
| Grew up in a rural area | 4 (67) |
| Want to live in a smaller community | 4 (67) |
| Practice full-time | 3 (50) |
| Close to family | 3 (50) |
| Practice part-time | 3 (50) |
| Lower cost of living | 2 (33) |
| Future compensation | 2 (33) |
| Breadth of cases | 2 (33) |
Among the subset expressing definite rural interest (n = 6), half were interested in practicing full time in these communities, while the other half planned on part-time rural practice. The common motivators for rural practice included recreational opportunities (100%), rural upbringing (67%), and preference for smaller communities (67%) (Table 4).
Sixty-six residents in the “maybe” groups provided input regarding areas of needed additional information, including compensation (n = 15), family considerations (n = 13), location (n = 11), volume or scope of practice (n = 11), resources (n = 6), and lifestyle (n = 6). (Table 5). Nine residents noted that they had had no exposure to rural care and had “very little understanding of how it differs from ortho practiced …in urban settings”. One resident noted “I want to give back to the community that gave me so much… I just don’t know which area (academic vs. rural practice) I would best serve yet.” (Appendix 2)
Table 5.
“Maybe” Respondents: What Additional Information About Rural Practice Would be Helpful In Making the Decision?
| Practice opportunities* | 29 (42%) |
| Compensation | 15 (22%) |
| Family considerations | 13 (19%) |
| Location | 11 (16%) |
| Hospital/practice resources | 6 (9%) |
| Lifestyle | 6 (9%) |
Practice opportunities included call, case volume, scope of practice, culture of practice, job opportunities, combined rural/urban practice options, and job requirements.
Discussion
To the authors' knowledge, this is the first study to address why orthopaedic surgery trainees are interested (or not) in future practice in rural areas. In designing the survey instrument, psychometric reliability of the attraction (“yes”) and disinclination (“never”) sections of the survey were found to be good with reasonable levels of collinearity11,12. Better understanding of what attracts (or detracts) residents from considering future rural practice, as well as gaps in knowledge, is critical in designing efforts to encourage orthopaedic residency graduates to practice in rural areas. While only a small minority of participants in this study expressed definite plans to pursue rural practice, the majority were unsure, with most of these having at least considered rural practice.
Childhood community size was the only assessed demographic factor that demonstrated a significant positive correlation with interest in rural practice. This result was not unanticipated: Jarman et al.13 found that those in rural general surgery practice were either more likely to have attended a high school or college in a rural community or have a spouse from a rural area. However, less is known about the rural backgrounds of orthopaedic surgeons, as the only study that has addressed background looked at state of birth but did not provide further granularity into rural or nonrural14.
Unfortunately, a study by Shipman et al.15 showed a decline in the number of applicants to medical school from rural backgrounds, and in 2017, only 4.3% of incoming medical students were from a rural background15. Understanding the impact of a rural background on future practice could provide motivation for academic orthopaedic surgeons to work with their affiliated medical schools in efforts to increase interest in medicine—especially orthopaedic surgery—among students in rural areas and then mentoring them in their careers into and through medical school and residency.
Several factors such as access to recreational activities and personal or family views of living in rural areas were noted as drivers for both positive and negative views of rural practice and were areas in which those who were unsure about rural practice wanted more information. The importance of rural lifestyle has been described as 1 motivator for family medicine physicians, even those from urban backgrounds, to choose to practice in rural areas16. Exposure to this lifestyle could occur during required or elective rotations and help provide needed information to those who are unsure about rural practice.
While the presumed complexity of cases was not a major deterrent to interest in rural practice, there was concern about the ability to practice to the extent of subspecialty training. This is an important point, as all residents in this study planned on fellowship training, consistent with prior data17. Better understanding of the types of cases available in rural communities could help address this concern, through discussions with residents about the realities of rural practice or having them experience this firsthand through rural training opportunities. An alternative or additional opportunity, as noted by some participants in this study, would be rural-focused webinars. Engaging rural orthopaedic surgeons and facilities in these endeavors would be crucial.
This study identified that some of the factors that have been assumed to affect interest in rural practice, such as compensation and needing to address education debt18, played lesser roles in interest in rural practice than factors such as personal or family concerns, demonstrating the complexity of efforts in recruiting more orthopaedic surgeons to rural areas.
Orthopaedic residents had limited, if any, exposure to rural practice. Such exposure may help to address concerns, such as lifestyle, case complexity, and availability of resources. There are a variety of models of rural surgical training, including formalized tracks and required or elective rotations19. The impact of rural tracks in general surgery has been mixed, with fewer graduates pursuing fellowships but no increase in those going into rural practice20,21. A dedicated rural track, as defined by the Accreditation Council for Graduate Medical Education22, may not provide sufficient breadth and depth of cases for orthopaedic residents to graduate. General surgeons have been found to be more likely to practice in rural communities if they experienced rural rotations21. An option moving forward for orthopaedic surgery could include developing more rural required or elective rotations in which residents train with local surgeons. The impact of these would need to be assessed, especially length of these experiences, given the findings in this study that episodic, rather than longer experiences, seemed to have greater impact. The issues of funding and adequate numbers of cases and teaching faculty would also need to be addressed19.
The primary limitations of this study include the low number of programs and residents who participated. The age, gender composition, and type of training program of respondents were similar to that of orthopaedic surgery in general, but the percentage with children was less than that previously reported23. Racial or ethnic differences in rural practice interest need to be explored further, as the numbers in this study were too small to assess impact. It is unclear whether the rural background reported by participants is similar to that of the larger community of trainees, as there is no available information on background for residents or practicing orthopaedic surgeons. While most participating programs are located in RUCC 1 areas, increased participation by programs or residents with an interest in rural orthopaedic care could have biased the results, as the programs were not assessed for demonstrated focus on rural orthopaedic care. A future larger study would allow disaggregation of results based on program focus, resident background, and year in training, especially any changes in rural interest related to rural training experiences and how these translate into entering rural practice.
Conclusion
This study provides preliminary information regarding why current orthopaedic residents plan to practice in either rural or urban areas, as well as gaps in knowledge about rural practice. Most residents were unsure, providing opportunities for discussion and rural training experiences to help develop this interest. The findings also suggest that current strategies for recruiting orthopaedic physicians to rural communities may not be the most holistic or effective approach to addressing physician shortages in these areas and may need to start earlier in the pipeline.
Appendix
Supporting material provided by the authors is posted with the online version of this article as a data supplement at jbjs.org (https://links.lww.com/JBJSOA/B369, https://links.lww.com/JBJSOA/B370). This content was not copyedited or verified by JBJS.
Acknowledgments
Note: The authors wish to thank Braden Jones, MD, FAAHKS, FAAOS for his contributions to the survey tool.
Footnotes
A. Moore and I. Roepe are co-first authors.
Investigation performed at the University of Kansas Medical Center, Kansas City, KS
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (https://links.lww.com/JBJSOA/B368).
Contributor Information
Andrew Moore, Email: amoore31@kumc.edu.
Isaiah Roepe, Email: iroepe@kumc.edu.
Damon Mar, Email: dmar@kumc.edu.
James Barber, Email: jbarbermd@gmail.com.
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