By Shana F. Sandberg, PhD, Research Writer, Association of American Medical Colleges Center for Workforce Studies
Comparison of Academic and Practice Outcomes of Rural and Traditional Track Graduates of a Family Medicine Residency Program
Stephen M. Petrany, MD, and Todd Gress, MD, MPH
Rural Track Training Based at a Small Regional Campus: Equivalency of Training, Residency Choice, and Practice Location of Graduates
William J. Crump, MD, R. Steve Fricker, MPA, Craig Ziegler, MA, David L. Wiegman, PhD, and Michael L. Rowland, PhD
Summer in the Country: Changes in Medical Students’ Perceptions Following an Innovative Rural Community Experience
Kevin Y. Kane, MD, MSPH, Kathleen J. Quinn, PhD, James J. Stevermer, MD, MSPH, Jana L. Porter, MS, Weldon D. Webb, MA, Harold A. Williamson, Jr., MD, MSPH, and Julie Burdin, MD
About Rural Training and Practice
Rural areas of the United States face difficulties recruiting and retaining physicians, compromising access to health care. Only about 10% of U.S. physicians currently practice in rural areas, and AAMC data show that less than 3% of students entering medical school today indicate plans to practice in a small town or rural area after graduating. Over the past two decades, medical schools have addressed rural physician shortages by establishing rural training tracks designed to encourage student interest and opening regional campuses where students may undergo some or all of their training in a rural setting, learning first-hand what it means to practice rural medicine. However, questions have been raised about whether these programs have been successful in producing students who will practice in rural areas and about whether students in rural training tracks are academically on par with their counterparts in more traditional medical training programs.
The Marshall University Family Medicine Residency implemented a rural track (RT) in 1994 in which residents spend part of their training at a community health center in rural Lincoln County, WV. Petrany and Gress compared practice outcomes of graduates of the RT with those of the traditional track (TT) and found that RT graduates were more than twice as likely as TT graduates to practice in a rural location upon graduation (83.3% versus 40.4%; P < .01). They also found that academic outcomes (including median PGY 1 and PGY 3 ITE scores and percentage of ABFM certification) were similar between the two groups, indicating that RT graduates do as well academically as TT graduates.
Crump and colleagues compared University of Louisville School of Medicine students who are enrolled in a program to complete their third and fourth years of medical school at the rural Trover Campus (ULTC)—which is 150 miles from Louisville in Madisonville, KY—with students who spend all four years at the main campus. They found that ULTC graduates were 6 times more likely than main campus graduates to choose a non-metropolitan area as a practice site (55% versus 9%; P = .001). While ULTC students did score lower on the MCAT, USMLE Step 1, and USMLE Clinical Knowledge (CK) scores, the mean differences between the two campuses actually decreased between Step 1 and Step 2 CK, indicating that the ULTC students tended to close some of the gap after their clinical training. In addition, after controlling for USMLE Step 1 scores, a non-inferiority analysis demonstrated that shelf exam scores in obstetrics, surgery, and pediatrics and USMLE Step 2 scores, ULTC scores achieved equivalence with those at the main campus.
Kane and colleagues compared students at the University of Missouri School of Medicine who completed the Summer Community Program—in which medical students spend 4-8 weeks during the summer after their first year working alongside rural, community-based physicians—with students who did not participate in the summer program. Students who participated in the rural summer program were more likely than students who did not to enter a primary care residency after completing medical school (RR=1.31; 95% CI: 1.12-1.50), and twice as likely to choose family medicine specifically (RR=2.21; 95% CI: 1.68-2.88). Overall, 72% of the students who participated in the summer program indicated increased interest in rural practice, and 46% did go on to choose a rural location for their first practice site.
- What kinds of barriers do you think exist to encouraging more students to practice in rural locations after medical school and residency?
- Each of the programs described focuses on a different stage in medical training and requires a different time commitment from students. What difference, if any, do you think it makes when in their education students are exposed to rural training and how long their rural training lasts?
- Special programs designed to increase training in rural medicine—such as the ones reported in these articles—while achieving impressive results, are often small programs (for example, the University of Louisville program provides the opportunity to train at the Trover campus to 6-10 students per year, the University of Missouri School of Medicine summer program trains 10-20 students per year, and 12 residents graduated from the Marshall University Family Medicine Residency rural track between 1994-2006). How might these programs be increased in scale or spread to other schools? What do you think it would take to achieve results on a larger scale?
- One critique that has been raised about this type of study is that it is not always possible to determine whether it was the curriculum itself or the types of students selected into these programs (who may have already been predisposed to rural practice) that account for the outcomes. What additional information would you want to know to better understand the reasons for the outcomes? If you were able to design a study, what factors would you take into account?
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