Rural Scholars are offered acceptance into the MUSOM, conditional on their achievement of certain academic standards, their ongoing demonstration of professional conduct, and their participation in required activities. Rural Scholars must maintain a cumulative overall grade point average (GPA) of 3.3 and a cumulative math/science GPA of 3.3, and they must earn As or Bs in required courses specific to each participating institution. Rural Scholars are not currently required to take the Medical College Admissions Test (MCAT) for matriculation to the MUSOM, but these students must attend biannual retreats designed to assist with the transition to our problem-based learning curriculum and to promote discussion of topics relevant to rural medicine. Students are provided housing and a travel stipend to attend the retreats.
We require Rural Scholars to enter a mentoring relationship with a rural physician during their sophomore year in college. Students spend at least 20 hours a year with their mentor, most of which is in shadowing, but they also devote time to career guidance, professional development, etc., and the students write two reflection papers annually about their shadowing experiences. Additionally, we require Rural Scholars to log 20 hours of other health-related experiences and 8 hours of community service per year because service experiences in underserved rural areas prior to medical training further increase the likelihood of eventual rural practice.16
Students who experience repeated exposure to and training in rural areas have increased interest in rural practice and remain in rural practice longer.12 Therefore, upon matriculation into the MUSOM, Rural Scholars volunteer at our retreats, participate in the Summer Community Program for six to eight weeks, complete three of their seven required third-year clinical clerkships as part of the RTC Program, and—beginning with the graduating class of 2013—complete at least one fourth-year elective as part of the Rural Track Elective Program. Students who successfully complete all four of these medical school requirements receive a $2,000 scholarship during their fourth year in medical school. We have allowed exceptions for students facing academic, health, and/or family issues that preclude successful completion of a particular component.
Summer Community Program
The Summer Community Program is an opportunity for the MUSOM's rising second-year medical students to participate in a clinical program in a rural community setting. A participating hospital or clinic sponsors students. Each student receives a stipend ($1,000–$2,000 based on the length of the experience) as well as room and board.
The program is open to all first-year medical students in good academic standing; those with an expressed interest in rural practice are given preference. For traditional medical students (i.e., students who are not Rural Scholars), this program is the first opportunity to participate in the MU-RTPP. During the program, students work closely with physicians practicing in smaller Missouri communities for four to eight weeks (Rural Scholars are required to complete a minimum of six weeks). Students may work with one or more community-based physicians in a variety of specialties. Students experience the benefits and rewards of rural practice and perform appropriately focused medical histories and physical exams under the supervision of the physician (they may perform other clinical care tasks with supervision as appropriate). See Table 1 for a complete listing of program goals and content. During the experience, physicians provide students with frequent feedback incorporating personal observations and comments from patients, office staff, and hospital personnel. At the end of the summer, the physician completes a brief evaluation which is kept in the student's permanent files in the Office of Medical Education. Students do not receive a grade because the Summer Community Program is not part of the MUSOM's formal, required curriculum.
The Rural Track Clerkship Program
Rural programs with greater intensity that include the opportunity for students to live and work in a rural community, which exposes them to the challenges of rural medicine and the joys of a rural lifestyle, result in a higher number of graduates entering rural practice.16–18 Therefore, the RTC Program offers all third-year medical students the choice of completing one to three of their seven required core clinical clerkships in community-based rural training sites across Missouri (Table 1). For traditional students, this program may be their first exposure to the MU-RTPP.
We selected our 10 clerkship training sites (which may differ from Summer Community Program sites) based on the commitment of the community-based faculty, hospital support, funding, and geographic proximity to underserved rural areas. Students live in the community while completing their clinical rotations (of eight weeks each). The regional AHECs provide housing, in cooperation with local hospitals. We encourage students to remain in one location to more fully integrate into the community; however, some students request rotations at more than one site to experience a variety of rural settings. Another reason students may complete rotations at more than one training site is the availability of housing or community-based faculty.
All 150 community-based clerkship faculty have adjunct appointments with the MUSOM and voluntarily serve as primary teaching faculty. Additionally, local medical directors at each site facilitate the delivery of the curriculum, assist in community-based faculty recruitment, and help with local and regional faculty development seminars. The MUSOM supports a small portion of their time. Regional AHEC staff facilitate the scheduling, housing, didactics, and orientation of each student. In these busy rural settings, students have opportunities to care for a large number of patients and to develop continuity relationships with community-based faculty and patients.
To ensure that RTC participants have access to the same educational resources as their peers at the MUSOM, we record individual clerkship lectures on DVD or as podcasts available via the Internet. RTC participants also connect via video conference on a biweekly basis for seminars presented by community-based or MUSOM faculty. These seminars focus on essential topics for all third-year students (e.g., anxiety, amenorrhea, back pain, chest pain) as agreed on by the clerkship directors.
Clerkship directors monitor clinical experience, both off-site and on-site, using required electronic patient logs. Summative faculty assessments of students are online, and the assignment of grades and credit resides with the MUSOM and the clerkship departments. Grades and shelf examination results are indistinguishable between RTC and non-RTC students (unpublished data).
Good rural clinical experiences and learning opportunities are probably not enough to influence students' career decisions. Students should also have time and opportunity to acculturate into the rural lifestyle.19 To provide this opportunity, we encourage students to participate in our Community Integration Program (CIP) as part of their RTC experience. CIP students complete health-related community service projects in an effort to learn more about and understand regional and local factors that affect rural health and rural health care systems. The CIP is a voluntary program; its goal is integrating students into rural communities so that they can develop an understanding of rural culture and quality of life and practice the ethic of service as an integral part of professional practice. Student projects have included organizing bone marrow donor drives; providing primary, middle, and high school health education programs; and completing a health needs assessment for a rural homeless population. Regional AHEC staff assist students in finding projects that not only interest them but also meet a community need. Students voluntarily work with various community agency partners and later reflect on their CIP project by writing and presenting a paper to their fellow RTC classmates and the MUSOM leadership. These types of experiences, designed to occur during a formative time in students' academic careers, are important for fostering students' interest in rural medicine, for improving their understanding of rural practice, and for nurturing in them a community perspective.20
Rural Track Elective Program
In their fourth year, medical students may choose to complete a variety of required monthlong primary care or specialty electives developed and approved by the MUSOM's clinical departments at 1 of our 10 community-based rural clerkship sites. The Rural Track Elective Program provides students with an additional rural clinical experience at the end of their undergraduate medical training, which will help them explore and solidify their commitment to practicing rural medicine (Table 1). Community faculty provide summative assessments, but the assignment of grades and credit resides with the MUSOM and the clinical departments. Beginning with the graduating class of 2013, Rural Scholars will be required to take at least one rural fourth-year elective. The addition of this requirement aligns with studies demonstrating that longitudinal rural training experiences increase the likelihood of eventual rural practice.3,9–11
Pipeline programs like the MU-RTPP require a substantial investment by the medical school and other local institutions—in particular, the community-based faculty. Balancing that investment with results is important. We have tracked outcomes of our program and have enough data to compare outcomes of cohorts of students who have experienced different levels of exposure to the MU-RTPP with a control group of students who have not participated in any component of the MU-RTPP. The primary outcomes are graduates' specialty choice and first practice location, and a secondary outcome is the number of graduates staying in Missouri for residency.
We created three mutually exclusive cohorts of MU-RTPP students to help identify any potential dose–response associations. We defined Rural Scholars as students who were preadmitted to the MUSOM through the Dr. Lester R. Bryant Pre-Admissions Program. The first group of Rural Scholars was preadmitted in 1995 and graduated in 2002; we present data for graduation years 2002 through 2009. We defined RTC participants as any third-year medical student, excluding Rural Scholars, who completed one, two, or three core clinical clerkships at one of our rural training sites but took part in no other MU-RTPP components. Lastly, we defined Rural Track Clerkship Plus (RTC+) participants as any medical students, excluding Rural Scholars, who completed one, two, or three core clinical clerkships at one of our rural training sites through the RTC program, plus at least one additional component of the MU-RTPP (i.e., the Summer Community Program or the Rural Track Elective Program). The first group of students to participate in the RTC program completed their clerkships in 1995 and graduated in 1997; we present data for graduation years 1997 through 2009.
We tracked all participants of the MU-RTPP, maintaining a database of their postgraduate specialty training and their first, as well as subsequent, practice locations. We used information from the MUSOM Alumni Association database, the National Residency Match Program, and the American Board of Medical Specialties, as well as information gleaned from Internet searches and from personal correspondence with program participants, to populate our database. For graduates who certified in geriatrics, sports medicine, or adolescent medicine, we used their primary specialty. If we could not verify board certification using the American Board of Medical Specialties, we reported the participant's specialty as stated on the National Residency Match Program list. If a student had both a transitional year and another residency specialty listed on the match list, we used the residency specialty.
For a comparison group, we identified the cohort of students who did not participate in any part of the MU-RTPP (called nonparticipants). We were unable to obtain accurate first practice locations and fellowship training locations of nonparticipants.
We used first practice location (office address and county) to determine if a graduate was practicing in a rural county, based on the Rural–Urban Density Typology (RUDT).21,22 The RUDT classification system uses the population density thresholds of the U.S. Census Bureau's classification system, the U.S. Office of Management and Budget's urban population nucleus requirements, and other criteria to classify counties as “rural,” “mixed rural,” “mixed urban,” and “urban.” We used the RUDT classification because it most accurately classifies rural counties for the purpose of our study and because it provides a standardized method of separating rural and urban counties. Because there is no single, universally accepted definition of rural, we also evaluated outcomes based on our previously used classification system, in which we defined rural as a town (a population of less than 50,000) at least 20 miles outside of a city (a population of 50,000 or more).
For all graduating classes since 1997, we calculated the percent of students matching into a primary care residency (family medicine, general internal medicine, general pediatrics, and internal medicine/pediatrics) or into other specialties. We also noted the location (in Missouri, out of state) of each graduate's residency program. We calculated relative risks (RRs) and 95% confidence intervals (95% CIs) comparing outcomes of Rural Scholars, RTC participants, and RTC+ participants with nonparticipants for matching in a primary care specialty, family medicine, and a residency program in Missouri. We calculated RRs and 95% CIs with the online calculator at StatPages.org.23 The University of Missouri–Columbia health sciences institutional review board reviewed and approved this study.
Since 1995, 344 (23%) of all MUSOM medical students, excluding Rural Scholars, have taken advantage of some component of the MU-RTPP. Since 1995, 109 Rural Scholars have participated in the MU-RTPP. Table 2 shows program participation numbers by component. Currently, 48 Rural Scholars are in the pipeline as medical students.
Table 3 shows match results for residency specialty choice and residency location of Rural Scholars since 2002. Rural Scholars, compared with nonparticipants, are as likely to match into a primary care specialty and more than twice as likely to match into family medicine. Table 4 shows the match results for residency specialty choice and residency location of RTC and RTC+ participants since 1997. Of note, RTC+ participants (who had at least one additional clinical experience with the MU-RTPP) chose family medicine at a rate substantially higher than the RTC participants (who participated only in the RTC program; RR = 1.63; 95% CI: 1.04, 2.58).
As of 2009, 20 Rural Scholars, 36 RTC participants, and 52 RTC+ participants had completed postgraduate training and started practice. As shown in Table 5, over half (57.4%) of the graduates from all three cohorts chose to practice in a rural or mixed rural county. Of the 20 Rural Scholars, 18 (90.0%) are practicing in Missouri. (When using our program's other accepted rural classification [town population of less than 50,000], the percentage of graduates practicing in rural areas is 43.5%.) We are not able to make practice comparisons with nonparticipants because their data are incomplete. A total of 13 MU-RTPP graduates are active, community-based faculty in one or more of the program components.
Discussion and Conclusion
The MU-RTPP delivers, over the course of several years, a well-targeted sequence of interventions that are unique both for their duration and their position as an integral part of the medical curriculum at the MUSOM. In 2008, the Liaison Committee on Medical Education described the MU-RTPP in an unpublished report as follows:
The Rural Track program provides students with excellent opportunities for education in rural communities. It is a highly sought after experience for students that has enhanced the collaboration between the school and rural communities, AHEC, and local health care providers. In addition to offering unique learning experiences, it is designed to help address the state's physician workforce needs in rural areas.
Several other medical schools across the country have rural track training programs.9,24,25 Our program differs from many in the length of our pipeline, which stretches from preadmitting qualified college students into MUSOM, to exposing them early to rural practice, and culminating in providing clinical training experiences in rural, underserved communities. Our “self-renewing pipeline” loop is completed when our graduates then serve as rural, community-based faculty for subsequent medical students participating in MU-RTPP components.
Rural Scholars are more likely to stay in Missouri for residency compared with nonparticipants. Missouri has Accreditation Council of Graduate Medical Education–approved residencies in only two non-major-metropolitan areas, one being at the MUSOM. Because graduates tend to select practices near their residency,26,27 we believe that retaining graduates for residency in Missouri will help us produce more Missouri rural physicians.
Even though our program was not designed to focus exclusively on primary care (or, in particular, family medicine), it is a common measure used to gauge success of rural training programs because students raised in rural areas who choose family medicine are more likely to practice in a rural setting.25 Our outcomes demonstrate that MU-RTPP participants are between 2 and 3.3 times as likely to match into a family medicine program compared with nonparticipants. Other programs, such as the Rural Physician Associate Program and the Rural Medical Education Program, have demonstrated higher rates of rural program graduates entering family medicine: 68%9 and 62%,24 respectively. We recognize the need to produce generalist physicians for the rural and underserved areas of the state, regardless of whether they are traditional primary care physicians, general surgeons, general radiologists, or general ophthalmologists. We did not design the MU-RTPP to focus specifically on primary care or family medicine, perhaps accounting for our lower numbers. If we narrowed our focus, we might anticipate that, overall, the number of graduates choosing primary care specialties would increase. Our study does indicate that multiple, rural clinical experiences are associated with higher rates of students entering family medicine. Unfortunately, the lack of practice location data for nonparticipants, and the relatively small number of MU-RTPP graduates (comprising Rural Scholars, RTC participants, and RTC+ participants) to date limit our ability to test for a dose–response relationship with first practice location. However, because family medicine is the most common specialty in rural practice, we believe this finding supports the validity of our design: More episodes of rural-based training, at various stages in medical school, can increase the number of physicians in rural practice.
A recent systematic review demonstrated that the number of graduates from six well-established rural track training programs who practice in rural areas ranged from 53% to 64%.3 These data, compared with the national average of 9% of physicians who practice in rural areas, indicate the success of such programs. Our outcomes (57% of MU-RTPP graduates were practicing in rural areas) were similar to those demonstrated by the systematic review.
Our study has several limitations. We are unable to control for selection bias, as Rural Scholars and other MU-RTPP participants selected our program. Our study is also limited by the small number of Rural Scholar graduates. In addition, the MUSOM does not have complete data on the practice locations of nonparticipants. Knowing whether our MU-RTPP graduates locate in rural communities at a higher rate compared with nonparticipants would help us both gauge the overall success of the program and allow for comparisons with other published outcomes. We hope to work with the MUSOM alumni office to improve tracking of all graduates. We plan future studies on the influence of the MU-RTPP on the practice locations of participants compared with nonparticipants, and on the retention of participants practicing in rural areas.
We are committed to quality improvement and have continued to modify and update our program as new information and resources become available, paying particular attention to incorporating factors that increase physician retention in rural communities. Selecting appropriate students for the Rural Scholars Program is central to the goal that our program graduates select rural practice locations. We have modified our selection criteria, retreats, and support system to improve the selection and success of participants. The rate of attrition of Rural Scholars is higher than that of traditional students, so we will require Rural Scholars to take the MCAT, starting with the entering class of 2014. The MUSOM uses MCAT scores as a baseline measure to predict academic difficulty in the first and second years of medical school. Examining these scores will help us target early interventions as necessary. The Pre-Professional Scholars Program Committee will review students who do not receive the minimum MCAT score (set by the MUSOM) and may recommend that they be dismissed from the program prior to matriculation; however, we assess students holistically before making any such decisions. We have also found that the higher attrition rate for Rural Scholars is not always attributed to academics. Sometimes students decide not to pursue a career in medicine at all, or they face personal or family issues that interfere with completion of the program. Student selection precedes clinical practice by a minimum of a decade, a delay that limits our ability to estimate the benefits of our recent interventions at this time.
We have also tried to increase the students' interaction in rural communities by increasing the minimum number of clerkships from one to two, and by giving priority to those who take three. In addition, we have added CIP as an optional experience for RTC participants to increase community integration. Finally, we have begun to require the fourth-year elective requirement for Rural Scholars.
Although not directly part of the MU-RTPP curriculum, we have supported MAHEC's additional education programs (e.g., AHEC Career Enhancement Scholars, which help high school students learn about health careers). We have also added a noncurricular program called the Missouri Physician Placement Service, which helps place physicians in rural communities.
The Association of American Medical Colleges supports a 30% increase in U.S. medical school enrollment by 2015, but it has emphasized that this increase alone will not necessarily increase the supply of rural physicians because less than 3% of matriculating medical students report plans to work in small towns or rural areas.28 Targeted rural track training programs can increase the supply and retention of rural physicians3 and should be part of any recommendation or policy about physician supply.
Implementation efforts to increase the supply of rural physicians are necessary in most U.S. medical schools. A relatively minor change in the admissions process is probably easy to implement. Simply asking students during admission interviews about their intentions for practice could increase the number of those admitted who eventually practice in rural areas. Students who grow up in a rural area and communicate a desire to return to a rural area at the time of admission are more likely to choose a primary care specialty and eventual rural practice.14,17 Other efforts to increase the rural physician workforce may be more challenging, yet they are necessary to improve access to quality health care. For example, curriculum changes can help students obtain more exposure to rural medicine. This increased exposure will improve preparedness for living and working in a rural area, especially for students with urban backgrounds.29 Finally, medical schools can work to increase students' perceptions of the value of rural primary care medicine.15
In summary, the MUSOM has created a unique, comprehensive, and longitudinal program that successfully identifies and preadmits students with rural backgrounds and an interest in rural medicine. We believe that the specific strengths of the MU-RTPP include a longitudinal focus with multiple opportunities for learning clinical medicine in rural areas, location in the Office of Medical Education (instead of an academic department), and broad support for students to consider a variety of specialties for rural practice. Even without focusing on primary care, participation in the MU-RTPP is associated with more students entering a primary care residency, in particular family medicine. Notably, we found that multiple rural training experiences increase selection of primary care even further. These findings have important implications for the design of rural training programs and access to health care for rural populations.
The authors would like to acknowledge Mary Lou Cole, MAE, instructional design specialist, University of Missouri School of Medicine, Columbia, Missouri, for reviewing years of residency data, and Nancy Franklin, coordinator, Area Health Education Center, Rural Track Pipeline Program, Department of Rural Health Programs, University of Missouri School of Medicine, Columbia, Missouri, for maintaining the data and creating tables. Their efforts, patience, and expertise were integral while conducting this study.
The Health Resources and Services Administration (HRSA) provides a Model State–Supported Area Health Education Centers grant (U77HP01069-07-01) to Curators of University of Missouri–Columbia, Missouri, and the Missouri Foundation for Health provided a Missouri Physicians for Rural Missouri: A Self-Renewing Pipeline grant (03-0435-ADP-04) to Curators of University of Missouri–Columbia, Missouri, 2004–2008.
The University of Missouri–Columbia Health Sciences institutional review board approved this study.
The authors have previously presented some information from this report:
* University of Missouri–School of Medicine Rural Track Pipeline Program: A self-renewing pipeline for rural training, practice placement, and retention. Paper presented at: Central Group on Educational Affairs, Association of American Medical Colleges Spring Conference; April 2010; Chicago, Illinois.
* MU Rural Track Pipeline Program. Poster presented at: 35th Annual Society of Teachers of Family Medicine Predoctoral Education Conference; January 2009; Savannah, Georgia.
* Influencing residency choice and practice location through longitudinal rural clinical experiences. Poster presented at: National Area Health Education Centers Annual Conference; June 2008; Denver, Colorado.
* Influencing residency choice and practice location through longitudinal rural clinical experiences. Paper presented at: Fourth Annual Association of American Medical College Physician Workforce Research Conference; April 2008; Crystal City, Virginia.
* Influencing residency choice through rural clinical experiences. Paper presented at: National Rural Health Association Annual Conference; June 2006; Reno, Nevada.
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12Rabinowitz HK. Estimating the percentage of primary care rural physicians produced by regular and special admissions policies. J Med Educ. 1986;61:598–600.
13Rabinowitz HK. Evaluation of a selective medical school admissions policy to increase the number of family physicians in rural and underserved areas. N Engl J Med. 1988;319:480–486.
14Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;286:1041–1048.
16Tavernier LA, Connor PD, Gates D, Wan JY. Does exposure to medically underserved areas during training influence eventual choice of practice location? Med Educ. 2003;37:299–304.
17Chan BT, Degani N, Crichton T, et al. Factors influencing family physicians to enter rural practice: Does rural or urban background make a difference? Can Fam Physician. 2005;51:1246–1247.
19Denz-Penhey H, Shannon S, Murdoch CJ, Newbury JW. Do benefits accrue from longer rotations for students in rural clinical schools? Rural Remote Health. 2005;5:414.
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21Isserman AM. In the national interest: Defining rural and urban correctly in research and public policy. Int Reg Sci Rev. 2005;28:465–499.
25Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. A program to increase the number of family physicians in rural and underserved areas: Impact after 22 years. JAMA. 1999;281:255–260.
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27Rosenthal TC, McGuigan MH, Anderson G. Rural residency tracks in family practice: Graduate outcomes. Fam Med. 2000;32:174–177.
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30University of Missouri School of Medicine. Key characteristics of MU School of Medicine graduating students and residents. http://som.missouri.edu/2020.shtml
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