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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11 Kusmin L, ed. Rural America at a Glance, 2008 Edition. Economic Information Bulletin No. (EIB-40). Washington, DC: U.S. Department of Agriculture, Economic Research Service; October 2008.
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13 Grumbach K. Fighting hand to hand over physician workforce policy. Health Aff (Millwood). 2002;21:13–27.
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15 Fryer GE Jr, Meyers DS, Krol DM, et al. The association of Title VII funding to departments of family medicine with choice of physician specialty and practice location. Fam Med. 2002;34:436–440.
© 2010 Association of American Medical Colleges
16 Davis AK, Reynolds PP, Kahn NB, et al. Title VII and the development and promotion of national initiatives in training primary care clinicians in the United States. Acad Med. 2008;83:1021–1029.