The shortage of physicians in rural areas is one of the most persistent problems in the U.S. health care system, with serious implications for access to care.1–4 This shortage is especially critical regarding generalist physicians, with rural areas having only 63% of the per capita primary care physician supply that urban areas have5—despite the similar need for locally available primary care. Family physicians account for the majority of rural generalist physicians and are twice as likely as general internists and general pediatricians to practice in rural areas.6,7 In many smaller communities, family physicians are the only specialists who are able to sustain a medical practice because they care for patients of all ages. Although the shortage of physicians in rural areas has existed for decades,8 the recent decline in the number of medical school graduates entering family medicine and primary care threatens to worsen this problem.7 There is also concern that the rural physician shortage will be exacerbated with the upcoming expansion in health insurance, as has occurred in Massachusetts.9
Over the past few decades, the impact on the rural physician workforce of a number of policies and programs has been studied,10–13 and comprehensive medical school rural programs (RPs) are one of the most successful of these.3,14 Medical school RPs consist of a cohort of students who either are preferentially admitted because of their background and career plans which make them likely to practice in a rural area, and also take a required rural curriculum; or who take an extended (six months or longer) clinical rural curriculum. According to the results from six RPs with published outcomes, which included more than 1,600 graduates across 30 years, more than half of RP graduates practice in rural areas, and their long-term retention is approximately 80%.14 Although successful, the size of these RPs is relatively small, with most having 10 to 45 students per class, and their overall impact on the rural physician workforce is uncertain.
International medical graduates (IMGs), who represent approximately one-fourth of all U.S. physicians, have also traditionally been seen as a solution to the rural physician shortage.9,15,16 Overall, IMGs have been less widely distributed in their practice locations than U.S. medical school graduates (USMGs), heavily concentrating in those areas which already have the greatest supply of U.S. graduates. The percentage of IMGs practicing in rural areas has been similar to that of USMGs, but because of their large overall numbers, they make a sizeable contribution to the rural workforce.17,18
To provide information regarding the relative impact of medical school RPs on rural physician supply, and also to help inform future policy options, this study compared the contribution of RPs to the rural primary care workforce with that of the much larger cohort of IMGs. Because the impact of RPs is primarily within their own state, and because the contribution of IMGs varies among states,15,17 we chose to focus on state-level outcomes. We also differentiated family medicine from primary care as an outcome measure because of the essential role of family physicians in rural health care. We focused our study on the three long-standing and successful RPs that include preferential admission of students likely to practice in rural areas as well as having a required rural curriculum: the Physician Shortage Area Program (PSAP) of Jefferson Medical College of Thomas Jefferson University; the University of Minnesota Medical School Duluth (UMD, a two-year program where students take their final two years at the University of Minnesota Minneapolis); and the Rural Medical Education Program (RMED) at the University of Illinois College of Medicine at Rockford.19–21 We compared the number and proportion of rural family physicians and all rural primary care physicians graduating from these RPs with those of all IMGs practicing in the respective states of Pennsylvania, Minnesota, and Illinois.
We identified all graduates of the three programs through their respective medical schools, beginning with their initial RP class and through the graduating class of 2005. We then matched graduates with data on their practice type, self-reported specialty, and office address from the American Medical Association (AMA) Physician Masterfile (2010). We also obtained identical information from the Physician Masterfile for IMGs practicing in the states of Pennsylvania, Minnesota, and Illinois who graduated from medical school in the same years. We included in the study only those physicians whose practice type was in direct patient care. We defined addresses as rural according to the Rural–Urban Density Typology (RUDT).22,23 Because no standard definition of the term “rural” exists, we selected an alternate definition of rural as well, namely, practicing in a nonmetropolitan county according to Rural–Urban Continuum Code (RUCC).24
We then compared the number and percentage of graduates from each of the three RPs who were practicing rural family medicine and rural primary care (i.e., family medicine, general internal medicine, and general pediatrics) in their RP home state with the same outcomes for all IMGs in the respective state. Relative risk (RR) and 95% confidence interval (CI) were calculated, comparing outcomes for RPs versus IMGs. In all analyses, we considered P values of less than .05 to indicate statistical significance. All statistical testing was two sided. This study complied with the applicable standards for the protection of human subjects, as determined by the institutional review boards of Thomas Jefferson University, the University of Minnesota, the University of Illinois College of Medicine at Rockford, and the American Academy of Family Physicians.
Overall, there were 1,757 RP graduates: 338 PSAP graduates from the classes of 1978–2005, average 12.1 per year; 1,287 UMD graduates (1976–2005), average 42.9 per year; and 132 RMED graduates (1997–2005), average 14.7 per year (see Table 1). Of the 1,551 (88.3%) matched in the AMA Physician Masterfile with an office address, specialty, and in direct patient care, 979 (63.1%) were practicing in a rural area of the United States, 956 (61.6%) were practicing in their state of graduation, and 610 (63.8% of in-state) practiced in rural areas of their state. Regarding IMGs, 6,474 were in direct patient care in the three states (4,319 IMGs from the classes of 1978–2005 in Pennsylvania, 1,281 IMGs [1976–2005] in Minnesota, and 874 IMGs [1997–2005] in Illinois). Of these, 1,716 (26.5%) were in rural areas.
As seen in Table 2, 39.3% (376/956) of RP graduates were practicing rural family medicine within their state, 10 times the percentage of IMGs from the same graduating years practicing rural family medicine in the same states (3.9%, 254/6,474; P < .001). RP graduates were almost four times as likely as IMGs to be practicing any of the primary care specialties in a rural area (45.3% [433/956] versus 11.9% [768/6,474]; P < .001). This pattern was seen within each of the three states for both family medicine (RR range 5.3–12.7) and primary care (RR range 2.5–5.0; see Figure 1).
Although there were almost 7 times as many IMGs as RP graduates within these three states, the absolute number of RP graduates practicing rural family medicine was 1.5 times greater than IMGs (376 versus 254). RPs produced more than half as many rural primary care physicians as did IMGs (56.4%, 433/768).
When the alternate definition of rural (RUCC) was used, the pattern of results was similar (i.e., the absolute percentage of physicians practicing rural was lower for both RP graduates and IMGs, but the ratios were similar). For rural family medicine, the RR comparing RP graduates with IMGs was 11.3 (CI 9.2–13.9, P < .001) (compared with the RR of 10.0 using the RUDT), and for rural primary care the RR was 4.2 (CI 3.7–4.9, P < .001) (compared with RR = 3.8).
Our findings show that medical school RPs have a substantial impact on their state rural family physician and primary care physician supply. Although RP class size is relatively small, the proportion of their graduates practicing rural family medicine and primary care was many times greater than that of the much larger cohort of IMGs, with the absolute number of graduates being 1.5 times greater for rural family physicians and half as large for all rural primary care physicians. These findings suggest that an RP graduating 16 students annually could produce as many rural family physicians in a state as the current IMG cohort. For rural primary care, graduating 41 RP students per year (within one or more medical schools in a state) could produce similar state-level outcomes as all IMGs.
This overall pattern occurred not only in the aggregate but also was seen with individual RPs of different size and structure, in different states, and using different definitions of rural, thus supporting the generalizability of these findings. All three RPs that we studied preferentially admit students with background and career plans that make them likely to practice in rural settings. Each has a required rural curriculum and a 9- to 30-year track record of success. However, the RPs varied in size from 12 to 41 graduates per class and differed in medical school and programmatic structure: The PSAP takes place in a private medical school and includes a requirement that students take their six-week third-year family medicine clerkship in a rural community19; UMD students attend this public medical school for two years before completing their medical education at the University of Minnesota Minneapolis, where approximately one-third participate in the Rural Physician Associate Program, an extended nine-month multispecialty third-year rural curriculum20,25; and the RMED program also takes place in a public medical school and includes a required 16-week fourth-year rural preceptorship.21 These RPs also take place in different areas of the country. Two of the RP states, Pennsylvania and Illinois, have relatively large overall populations and larger numbers of practicing IMGs, whereas Minnesota has a smaller general population with fewer IMGs. Combined, the proportion of the population that is rural within these states (19.4%) is similar to that of the entire United States (21.0%), though variation exists among the states (Pennsylvania, 22.9% rural; Minnesota, 29.1% rural; Illinois, 12.2% rural).26 And, although we used the RUDT classification of rural for this study because it accurately measures local rural outcomes such as primary care physician supply,22,23 our findings were similar when an alternate rural definition (RUCC) was used.
The 63.1% of RP graduates practicing in rural areas of the United States found in this study was similar to the previously reported 53% to 64% range of rural outcomes from graduates of all six RPs.14 And, although this study specifically focused only on those RP graduates practicing family medicine and primary care in their own RP state, these three programs also produced an additional 177 rural non-primary-care physicians within their respective states as well as 369 other rural physicians (all specialties) practicing in other states, further helping to address the national rural physician shortage. In focusing only on rural impact, we did not address other important outcomes such as the supply of physicians in urban underserved areas. Regarding costs, the generally small subsidy for RPs by state government or medical schools pales in comparison to the federal and state resources supporting graduate medical education training for IMGs. In addition to the financial cost, concern exists regarding the global health cost of the current reliance on IMGs to provide care in this country, resulting in the serious reduction in physician supply in many medically needier countries.27,28
Our research relied on the AMA Physician Masterfile, which has well-known limitations, although it remains the most complete source of physician workforce information.17 Because problems with the accuracy of specialty and practice location data in the Physician Masterfile are greatest for more recent graduates, we limited our analysis to graduates prior to 2006. Of these, the most recent graduates studied may still be somewhat less accurately reported in the Physician Masterfile than others, although this is unlikely to have a significant impact on the overall results because they represent a very small proportion of all graduates. On the other hand, because this study ended with the 2005 graduates, it does not include recent changes that have taken place regarding physician specialty choice and location. This includes the recent increase in IMGs entering family medicine residency programs,6,29 although it is unclear whether this will lead to an increase in those practicing in rural areas. Similarly, we did not look at the impact or changes regarding different types of visas on IMG outcomes. Over the past two decades, there has been a substantial decrease in the number of IMGs with J1 visas (where physicians are required to return home but may remain in the United States with a waiver if they work in an underserved area for at least three years).15,18 At the same time, IMGs with H1B visas (temporary work visas of up to six years with no requirement to go home or work in underserved areas) have increased.30 These visa changes will likely result in fewer IMGs practicing in rural areas in the future, thereby further increasing the relative impact of RP graduates over IMGs found in this study.
The policy implications of this study are considerable. As the United States reforms its health system and increases access to health insurance, less attention has focused on addressing the critical maldistribution of physicians, especially with regard to meeting the health needs of rural America. For those living in urban areas, who often live in close proximity to large numbers of physicians, expanding health insurance may effectively increase both access to and use of health care; providing insurance to those in rural areas may have a much more limited impact on access if local primary care physicians are unavailable.
As the United States significantly increases its overall physician workforce, purposeful expansion to solve problems of distribution and shortage would be served well by the medical school RP model (supported in part by the recent Rural Physician Training Grants program in the Affordable Care Act31(pp1000–1001)). Given that IMGs and USMGs practice in rural areas at similar rates,17,18 widespread expansion of RPs would likely result in dramatically different rural family physician and primary care outcomes compared with the untargeted expansion of traditional medical schools or increasing reliance on IMGs—resulting in increased access to care for those living in rural areas.
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5. U.S. General Accounting Office. Physician Workforce: Physician Supply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities Persisted. http://www.gao.gov/new.items/d04124.pdf
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25. Zink T, Center B, Finstad D, et al.. Efforts to graduate more primary care physicians and physicians who will practice in rural areas: Examining outcomes from the University of Minnesota–Duluth and the Rural Physician Associate Program. Acad Med. 2010;85:599–604.
27. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353:1810–1818.
28. Chen LC, Boufford JI. Fatal flows—Doctors on the move. JAMA. 2005;353:1850–1852.
29. Koehn NN, Fryer GE, Phillips RL, Miller JB, Green LA. The increase in international medical graduates in family practice residency programs. Fam Med. 2002;34:429–435.
Dr. Rabinowitz was supported in part for this study by the Eakins Legacy Fund of Jefferson Medical College.
This study complied with the applicable standards for the protection of human subjects, as determined by the institutional review boards of Thomas Jefferson University, the University of Minnesota, the University of Illinois College of Medicine at Rockford, and the American Academy of Family Physicians.© 2012 Association of American Medical Colleges