Chen, Frederick MD, MPH; Fordyce, Meredith PhD; Andes, Steve PhD; Hart, L. Gary PhD
Among the most enduring problems in rural America is the shortage and maldistribution of physicians.1–3 Despite continued federal and state efforts to increase the number of physicians in rural areas, disparities between the supply of rural and urban physicians persist.3–5 The recent Institute of Medicine (IOM) report on rural health quality highlights the critical need for well-trained physicians to deliver high-quality care to rural areas.1 Although the report emphasizes that rural physicians must be trained in quality improvement, information technology, and evidence-based medicine, the availability of high-quality care in rural areas depends primarily on an adequate supply of physicians practicing in these areas.
It has been more than 15 years since Rosenblatt et al6,7 described the MD-granting schools that train rural physicians. In addition, recent literature has not adequately described the contributing role of DO physicians and international medical graduates (IMGs) in the rural physician workforce. This report describes the training of the rural MD and DO physician workforce in the United States and examines the variations in the ways medical schools and residency programs produce rural physicians. In the original study, Rosenblatt et al6 found that a small subset of the nation's medical schools produce the majority of rural physicians in the United States. We sought to update that finding and expand the analysis to residency training programs, with a specific focus on training programs located in rural areas.
In 2006, we performed a national cross-sectional analysis of the 2005 American Medical Association (AMA) and American Osteopathic Association (AOA) Masterfile physician data. We examined a 10-year cohort of clinically active MD and DO physicians who graduated from medical school in the years 1988 through 1997 and had completed residency training. This cohort allowed for a reasonable comparison with the 10-year cohort from Rosenblatt and colleagues'6 previous work. In addition, this cohort allows for the most recent graduates (from 1997) to have completed residency training (typically three to five years) and then to have established practice to be captured in the AMA Masterfile. We excluded resident physicians and osteopathic physicians with an unknown professional employment status from the analyses.
We determined physicians' locations by the reported ZIP code of each physician's primary practice location. When the primary practice location was not available, we used the physician's home address. We mapped the ZIP codes to Rural–Urban Commuting Area (RUCA) and county designations. RUCA codes use census tracts rather than counties as a means of identifying degree of rurality or urbanicity.8,9 A ZIP code approximation version of the census tract-based RUCA codes has been developed (http://depts.washington.edu/uwruca/ruca-data.php) and was used in this study. Use of these smaller basic building blocks allows for much more precision in defining rural and urban locations than do the larger-scale county-level taxonomies. RUCA codes identify areas as metropolitan (urbanized), micropolitan (large rural), small town (small rural town), or rural (isolated small rural) and are based on both core population size and “work commuting flow” relationships. Core populations are categorized as metropolitan (continuously built-up areas of 50,000 or more), micropolitan (10,000–49,999), or small town (2,500–9,999). Work commuting flow accounts for the direction and the extent to which a core population commutes to a city or town of similar or larger size. RUCA version 2.0, used in this study, consists of 10 general settlement types that are themselves further broken down into the 33 subcategories based on work commuting patterns. These 33 subcategories were aggregated to create a four-category classification, which identifies areas as urban, large rural, small rural, or isolated small rural. We identified the medical school of graduation for each physician. IMGs were defined as physicians who graduated from a non-U.S. or Canadian medical school; graduates from Puerto Rican schools were counted as IMGs. The AMA Masterfile receives these data directly from medical schools. As a result, some but not all medical school campuses are reported separately from their parent institutions. For example, the University of Minnesota–Duluth has separate data from the University of Minnesota, whereas University of Illinois–Rockford data are included with the University of Illinois data set. We identified the most recent residency program for each physician and identified the location of that residency program as rural or urban on the basis of its ZIP code. Rural residency programs were those located in large rural, small rural, or isolated small rural RUCA categories. The residency analyses focused on family physicians (FPs) because family medicine is the predominant specialty in rural areas.
We aggregated rural physicians to each medical school, and medical schools were compared to show the percentage of the rural physicians produced by each school. A similar analysis was performed for residency training programs. Standard bivariate statistical testing was performed using SPSS (v. 11.0.4, Chicago, Illinois). This study was approved for an exemption by the University of Washington institutional review board.
There were 175,649 clinically active physicians in the cohort of physicians who graduated from medical school in the years 1988 to 1997. Of these, 93.6% (164,385) were MD physicians and 6.4% (11,264) were DO physicians. Eleven percent (20,037) of this cohort of physicians were practicing in a rural location in 2005. Eighteen percent (2,045) of DO-granting medical school graduates were practicing in a rural location, but only 11% (17,992) of MD-granting medical school graduates were in a rural location (Table 1). Thirteen percent (3,513) of IMGs were practicing in a rural location.
The proportion of medical school graduates entering rural practice varied by specialty. Among the specialties, 23% (6,282) of FP graduates practiced in rural areas. In comparison, 16% (916) of general surgeons, 11% (3,075) of internists, and 9% (1,236) of pediatricians practiced in a rural area (Table 2). During the 10-year study period, there was a stable number and proportion of MD physicians practicing in rural areas, with a small increase with the most recent graduating cohort in 1997 (10.3% of 1988 graduates versus 11.6% of 1997 graduates). There was a more consistently increasing trend among DO physicians entering rural practice over the decade (18.1% of 1988 graduates versus 19.6% of 1997 graduates) (Figure 1).
Rural physician gender
Among all the MD physicians in the cohort (rural and urban), 37% (60,912) were female. In the cohort of DO physicians, 31% (3,467) were women. Over the course of the 10-year study period, the percentage of MD and DO female physician graduates increased from 32% in 1988 to 44% in 1997.
Thirty-one percent (6,211) of rural physicians are women. Women continue to be less likely than men to practice in rural areas, although the gap is narrowing. There was, however, an increasing proportion of female physicians entering rural practice over the study period (7.8% to 9.8% female MDs, 12.2% to 17.7% female DOs) (Figure 2). This finding represents a significant change from previous analyses of women entering rural practice.5
Medical schools and residency programs
The medical schools that produced the highest percentage of rural physicians placed between 21% and 36% of their graduates in rural areas (Table 3). There was no substantial change in the list of MD-granting medical schools graduating rural physicians when compared with the earlier study by Rosenblatt et al.6 However, several DO-granting schools were identified that contributed relatively high percentages of rural physicians.
Only 1.4% (2,247) of MD physicians in the cohort trained in a rural residency location. Among these physicians who trained in rural residencies, 36% (814) were in rural practice at the time of our study. In comparison, 3.6% (343) of DO physicians in the cohort trained in a rural program. Fifty percent of DO graduates (170) who trained in a rural residency were in rural practice according to the 2005 Masterfile. Although we found that rural residency trainees are over three times more likely to practice in rural areas (RR = 3.4, P < .001), rural residencies account for only 5% of MD physicians practicing in rural areas and 10% of DO physicians in rural areas.
Rural family medicine training programs are an important contributor to the rural physician workforce.10 Sixty percent of rural family medicine residency graduates were in rural practice at the time of this study, and they were three times more likely than graduates of nonrural residency programs to practice in a rural location (RR = 2.8, P < .001). However, only 9% of all rural FPs in our study cohort trained in a rural residency.
This analysis of national data shows that the proportion and number of physicians entering rural practice has remained stable, compared with Rosenblatt and colleagues'6 1991 results. DO physicians and primary care physicians are more likely to practice in rural areas. Although the number and percentage of rural physicians produced by medical schools was widely distributed, a small number of medical schools produced high proportions of rural physicians. As seen in Table 3, only 10 medical schools had over 25% of their graduates in rural practice. The study by Rosenblatt et al6 identified a slight decline in the percentage of physicians entering rural practice over time. The data we studied show that the decline has stabilized, although the overall percentage of graduates practicing in rural areas has decreased. In 1991, 12.6% of recent medical school graduates entered rural practice. In 2005, that number had slipped to 11% of recent medical school graduates. We believe this difference is primarily due to different definitions of rural practice between the two studies. More important, on the basis of our own anecdotal observations, we suspect that this downward trend has accelerated in recent years, although it is not yet captured in the data.
As noted by Rosenblatt et al,6 the likelihood of a physician entering rural practice is associated with specialty. In this cohort of medical school graduates from 1988 to 1997, primary care physicians continue to be more likely to enter rural practice than are specialty physicians. Again, compared with the earlier study by Rosenblatt and colleagues, the percentage of FPs, general internists, and pediatricians entering rural practice has declined (see Table 2). An exact comparison is difficult because the article by Rosenblatt et al used nonmetropolitan county areas to define rural practice location, and this study uses RUCA coding to identify rural physicians.
It is worth noting that the total enrollment in medical schools has increased during the time between these two studies. In this context, the stable percentage of physicians entering rural practice represents an increase in the absolute number of physicians in rural locations. To better understand these findings, it may be useful to consider the overall demographic changes in rural America over the same time period. Since 2000, the rural population has experienced modest growth (0.4%), almost one-third that of the U.S. urban population.11
Of note, the previously reported gender gap among rural physicians is disappearing. The increasing proportion of female rural physicians (Figure 2) is more likely attributable to the increasing number of female medical school graduates coupled with a decline in the percentage of male physicians entering rural practice.
As previously reported, DO physicians are significantly more likely to enter rural practice. The percentage of DO graduates entering rural practice remained stable over the decade, approaching 20%. However, recent studies suggest that this percentage has begun to decline as DO graduates increasingly choose MD specialty residency training programs.
These data further support the valuable contribution to the rural physician workforce of rural residency programs. Though few in number, these training programs are successful at producing rural physicians. A previous study showed that these rural residency programs provided 71% of the nation's rural training in family medicine.10 Unfortunately, rural residency programs, especially in family medicine, face serious financial challenges. In a recent study,10,12 10% (3) of 33 rural residencies have closed, with an additional 7% at severe risk of closure.
This study has several important limitations. As we noted above, we used a different rural definition than the previous study by Rosenblatt et al. Although this limits the ability to compare our findings with those of the earlier study, we feel that the RUCA methodology is a much more robust and accurate estimation of rurality. In addition, there are several well-recognized limitations to AMA and AOA Masterfile data. The data are often inconsistently updated, so changes in physicians' locations may take several years to be captured in the data. The AOA data had a portion of missing data for osteopathic physicians whose professional employment status was unknown, and these physicians were excluded from the analysis. It is unknown how many of these missing physicians graduated during the study period, so it is difficult to estimate bias, but we believe it is minimal.
Perhaps the greatest drawback to these data is that they do not capture the most recent decade of physician workforce trends. The mid-1990s were a time when a high number and percentage of U.S. medical students were entering family medicine and, as a result, rural practice. During that time, the prominent role of primary care gatekeepers in the new managed care systems attracted medical students to the primary care specialties. Indeed, the increasing proportion of rural physicians beginning in 1993 that we saw in these data has not continued. The past 10 years have shown a dramatic and precipitous decline in the percentage of U.S. medical school graduates entering family medicine, with over half of current family medicine residency positions being filled by IMGs.12 The declining interest in primary care will have major impacts on rural areas, whose needs are often met by generalist physicians and which often cannot support any physician practice other than primary care.
As the IOM report emphasizes, rural health is critically dependent on both the supply and the quality of its rural workforce. Not only do rural areas require an adequate supply of physicians to ensure access to care, but the training of these physicians in information technology, quality improvement, and new models of care is vital to the future of rural health. Although this study cannot address the adequacy of training in these realms, future research should explore the extent to which rural physicians acquire these skills.
Current calls to expand medical school class sizes may help support the pipeline for rural physician training. However, if medical schools expand class sizes without explicitly emphasizing primary care or rural health, these expansions may result in more physicians choosing to practice in urban centers, worsening the rural–urban maldistribution.13 On the other hand, medical schools may choose to implement programs and curricula that have a demonstrated success in training rural physicians.14
At the same time, there has been little discussion of the role of state legislatures in holding state-supported medical schools accountable for producing a substantial percentage of rural physicians. Federal rural health programs and Title VII-funded programs continue to support primary care and rural health training.15,16 Whereas these data show little significant change in the rural physician workforce, the effects of these policy changes will need to be closely monitored in coming years.
This study was funded by Health Resources and Services Administration, Office of Rural Health Policy, through HRSA Grant #6 UIC RH 00011-04.
This study was approved for an exemption by the University of Washington institutional review board.
An earlier version of this work was presented at the Academy Health annual research meeting, June 2006.
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