The shortage of physicians in rural areas represents one of the most enduring and serious barriers to health care access in the United States.1–4 Although this shortage is most critical for family physicians, who form the core of rural health care,5 a number of other specialties are also needed in rural areas, for instance, general surgery.2,6–8
Although much is known regarding the specialty distribution of physicians currently practicing in rural areas, less is known regarding the relationship of the specialty plans of entering medical students and subsequent rural practice. Prior research has provided strong evidence that freshman plans for entering family medicine are one of the two most powerful predictors of eventual rural practice (in addition to rural background) as well as of rural primary care and rural family medicine.2,9,10 Little is known, however, regarding the rural outcomes of entering students with other planned specialties, including how these compare with the outcomes of those initially planning family medicine. This information is especially important in designing comprehensive medical school rural programs (RPs), which have been successful in producing rural physicians,1,11 given the recent federal Rural Physician Training Grant program supporting the expansion of RPs that was part of the Affordable Care Act of 2010.12
The Jefferson Longitudinal Study (JLS) of Medical Education, one of the oldest and most comprehensive medical trainee databases that includes entering medical student specialty plans, is one of the few long-standing datasets available to inform this issue.13 The JLS includes approximately six million pieces of data on all medical students and graduates of Jefferson Medical College (JMC) of Thomas Jefferson University since the entering class of 1968. Jefferson also has had a three-decade-long commitment to addressing the rural physician shortage, including its successful rural Physician Shortage Area Program (PSAP).14,15 Using the JLS, we examined the relationship between the planned specialty choices of matriculating medical students and their eventual practice in rural areas.
As part of our ongoing longitudinal study of JMC graduates,14–18 we obtained data from the JLS regarding the entering freshman medical students’ planned specialty choice (collected by questionnaire during orientation) from the 25 graduating classes of 1978–2002. Data were also obtained on the 2007 practice location for these graduates from the Jefferson Foundation, which maintains an address dataset of JMC alumni that is updated every three months and has been found to be highly accurate.16 As in previous studies, we used physicians’ office address (county),14,16–18 and, when unavailable, we used home address county, assuming it was of similar rurality. As in our prior study,18 we considered graduates to be practicing in a rural county if their 2007 county was designated as rural, based on its rural–urban density typology.19
We then grouped matriculating student individual specialty plans into 12 categories: family medicine; general internal medicine; internal medicine subspecialties; general pediatrics; pediatric subspecialties; general surgery; surgery subspecialties; emergency medicine; obstetrics–gynecology and their subspecialties; psychiatry and their subspecialties; the hospital specialties of anesthesiology, radiology, and pathology; and all other specialties. Similar to our prior studies, those planning general practice were included with family medicine, and those planning geriatrics, sports medicine, and adolescent medicine were included with their planned primary care specialty (i.e., family medicine, general internal medicine, or general pediatrics). For each of the planned specialty groups, we determined the number and percentage of graduates practicing in rural areas in 2007. Similar analyses were performed on a subgroup of 1978–1982 graduates who grew up in rural areas, for whom these data were available.
We conducted chi-square tests comparing freshman career plans and rural practice location using SPSS version 16 (SPSS Inc., Chicago, Illinois), and two-sided P values less than .05 were considered to indicate statistical significance. This study was approved by the institutional review board of Thomas Jefferson University.
Of the 5,419 JMC graduates from the classes of 1978–2002, 5,362 (98.9%) were alive in 2007. Of these, 3,006 graduates (56.1%) had data available for both their planned specialty choice at matriculation and their 2007 practice location, and these graduates were included in this study. Compared with those who lacked complete data and were thus not included in the study, their mean age at entrance to medical school was similar (23.2 versus 23.1 years). They included a slightly lower proportion of women (28.8% [865/3,006] versus 31.7% [748/2,356]), and their rural outcomes were similar (20.4% [613/3,006] versus 19.8% [374/1,893]).
At matriculation, the 3,006 JMC graduates selected 70 different individual specialties as their future planned career choice, although most of these specialties (65.7%, or 46) were selected by fewer than 10 graduates. When grouped into the 12 specialty categories, planned specialty was strongly related to rural outcomes (P < .001).
Overall, 20.4% of graduates (613/3,006) were practicing in rural areas. As seen in Figure 1, those initially planning various specialty groups were then divided into three clusters depending on their eventual rural outcomes—that is, above, similar to, or below the mean. Those planning family medicine were “highly likely” to practice rural, with 29.4% (238/810) in rural practice. They were 1.5 times as likely to practice rural as a “mid-likely” group, at 19.6% or 229/1,167—that is, those planning general surgery (21.0%, 84/400), psychiatry (21.0%, 13/62), emergency medicine (19.7%, 14/71), general internal medicine (19.1%, 70/366), or one of the medical subspecialties (17.9%, 48/268). Students planning family medicine were also 2.1 times as likely to practice rural as a “lower-likely” group, at 14.0% or 142/1,016—that is, those planning general pediatrics (14.3%, 51/357), one of the surgical subspecialties (14.0%, 61/436), the hospital specialties of anesthesiology, radiology and pathology (13.8%, 12/87), and obstetrics–gynecology (13.3%, 15/113), or other specialties (13.0%, 3/23). In addition, although those planning one of the pediatric subspecialties had the highest likelihood of practicing rural (30.8%, 4/13), very few entering students during these 25 years planned any of these subspecialties (0.4%, 13/3,006).
Data regarding rural background were only available for the subset of graduates from the earliest five classes (1978–1982). Overall rural outcomes for all graduates from these five classes were slightly higher than for the entire 25-year cohort (22.6% [172/762] versus 20.4%). For graduates from these five classes who grew up rural, 36.3% (93/256) were practicing in rural areas in 2007. Among these rural-raised graduates, their planned specialty groups were also related to rural practice outcomes (P = .03). As seen in Figure 2, those growing up rural who planned family medicine and general surgery were “highly likely” to practice rural, with 44.7% (71/159) in rural practice, including 45.8% (54/118) planning family medicine and 41.5% (17/41) planning general surgery. Similar to the entire 25-year cohort, this highly likely group was 1.9 times as likely to practice in rural areas as a “lower-likely” group (23.0%, 17/74; i.e., those planning general internal medicine [26.5%, 9/34]), general pediatrics (21.1%, 4/19), or one of the surgical subspecialties (19.0%, 4/21). Very few rural-raised graduates in these classes initially planned any of the other specialties (i.e., 3/5 planning obstetrics–gynecology went rural; 1/3 planning psychiatry; 1/7 planning one of the medical subspecialties; 0/7 planning one of the hospital specialties; 0/1 planning emergency medicine; and none planned a pediatric subspecialty or other specialty). Overall, the pattern of outcomes for these 1978–1982 graduates who grew up rural was similar to that for the entire 25-year cohort, except that there was no mid-likely group.
This study is the first to show the overall significant relationship between entering medical students’ future specialty plans and eventual practice in rural areas. As our prior studies have also shown, students planning family medicine were most likely to become rural physicians; however, this study also provides new information that quantifies the absolute and relative rural outcomes of those planning other specialties. Specifically, those students planning general pediatrics, the surgical subspecialties, the hospital specialties, and obstetrics–gynecology were only half as likely to enter rural practice compared with those planning family medicine. Those planning to be general surgeons, psychiatrists, emergency room physicians, general internists, and medical subspecialists were in between the two other groups in their likelihood to practice rurally.
For graduates who grew up in rural areas from the earliest five classes (for whom these data were available), the overall pattern of findings was similar, although there were many fewer graduates in this subset than in the entire cohort. The major differences were that rural-raised physicians initially planning general surgery were almost as likely as those planning family medicine to practice rural, whereas those who planned to be general internists were relatively less likely to be in rural practice.
These findings are important for all medical schools, including those that have or plan to develop RPs, because the mix of matriculants with various specialty plans will likely impact their eventual rural outcomes. These outcomes are also critically important for those living in rural areas, who lack access to appropriate medical care because of the ongoing shortage of physicians. Although consideration of the future specialty plans of applicants in the medical school admissions process raises a number of significant questions, it is essential to recognize that specialty plans are important in predicting rural outcomes.
Although many rural areas need a number of different specialists to care for their community, our findings suggest that matriculating a group of students who plan family medicine will likely result in twice the overall number of rural physicians as will having a class of students who plan specialties with a lower likelihood of rural practice. In addition, although medical educators and policy makers often combine all primary care physicians into a single category because they all provide generalist care, our findings show that medical students who plan to become family physicians, general internists, and general pediatricians have very different likelihoods of practicing in rural areas.
Whereas this study focused on only one variable related to an outcome which is known to be multifactorial,2,10 background factors available at the time of admissions have been shown to be independently related to rural outcomes and most important for predicting rural practice.10,20,21 Although other factors that occur after entrance to medical school, including rural curricula and actual future specialty choice, have also been shown to be related to rural outcomes, this study focused on the predictive nature of specialty career plans which are known at matriculation in order to inform medical school admissions policies. We were unable to address the intensity of commitment toward a planned specialty at the time of matriculation, and we identified rural practice outcomes at only one point in time; future research is therefore needed to examine these issues.
Our findings also confirm the importance of having a rural background for eventual rural practice. Prior studies have shown that, although their interrelationships are complex, growing up rural and planning for family medicine are both independently related to rural practice and are additive.20 Although we did not specifically study their interaction in this study, even among those 1978–1982 graduates who did not grow up rural, those initially planning family medicine were much more likely to practice rural than their peers planning other specialties.
Although our findings are from a single medical school, this study involves more than 5,000 graduates across 25 years who have taken their residency training in over 480 hospitals in 45 states and who practice in all 50 states. Although the inclusion of PSAP graduates (who all had rural backgrounds and commitments to practice rural family medicine) may have increased the rural outcomes of JMC graduates planning family medicine, they represent fewer than 6% of all graduates and approximately one-quarter of those planning family medicine. Moreover, this did not significantly impact our overall study conclusions because even non-PSAP graduates planning family medicine were more likely to practice rural than those planning all other specialties. On the other hand, JMC is a private medical school in a large metropolitan area in a nonrural northeastern state7 and is, therefore, likely to have a lower proportion of rural graduates among those initially planning family medicine compared with most other medical schools.
At JMC, we have used the information from this study to modify our long-standing rural PSAP, which, since its inception in 1974, had limited its matriculants to those rural-raised applicants who were committed to practicing the specialty of family medicine in rural areas. Recently, and aligning the program with most of the other RPs, JMC expanded the PSAP to also include students planning rural-relevant specialties other than family medicine, although priority continues to be given to those planning family medicine.
Acknowledgments: The authors would like to thank the Jefferson Center for Research in Medical Education and Health Care for access to the Jefferson Longitudinal Study of Medical Education, and the Jefferson Foundation for access to the address files of Jefferson Medical College alumni.
Funding/Support: The project described was supported in part by grant number D56HP08346 from HRSA / HHS. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the HRSA / HHS. Dr. Rabinowitz was also supported in part by the Eakins Legacy Fund of Jefferson Medical College.
Other disclosures: None.
Ethical approval: This study was approved by the institutional review board of Thomas Jefferson University.
1. Rosenblatt RA. Commentary: Do medical schools have a responsibility to train physicians to meet the needs of the public? The case of persistent rural physician shortages. Acad Med. 2010;85:572–574
3. . Health Care Disparities in Rural Areas: Selected Findings From the 2004 National Healthcare Disparities Report. AHRQ Publication No. 05-P022. May 2005 Rockville, Md Agency for Healthcare Research and Quality http://www.ahrq.gov/research/ruraldisp/ruraldispar.htm
Accessed April 18, 2012
4. Pusey WA. Medical education and medical service, I: The situation. JAMA. 1925;84:281–285
5. Colwill JM,, Cultice JM. The future supply of family physicians: Implications for rural America. Health Aff (Millwood). 2003;22:190–198
7. Rosenblatt RA,, Whitcomb ME,, Cullen TJ,, Lishner DM,, Hart LG. Which medical schools produce rural physicians? JAMA. 1992;268:1559–1565
9. Rabinowitz 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
10. Brooks RG,, Walsh M,, Mardon RE,, Lewis M,, Clawson A. . The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: A review of the literature. Acad Med. 2002;77:790–798
11. Rabinowitz HK,, Diamond JJ,, Markham FW,, Wortman JR. Medical school programs to increase the rural physician supply: A systematic review and projected impact of widespread replication. Acad Med. 2008;83:235–243
13. Gonnella JS,, Hojat M,, Veloski J. AM last page. The Jefferson Longitudinal Study of Medical Education. Acad Med. 2011;86:404
14. Rabinowitz 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
15. Rabinowitz HK,, Diamond JJ,, Markham FW,, Rabinowitz C. Long-term retention of graduates from a program to increase the supply of rural family physicians. Acad Med. 2005;80:728–732
16. Rabinowitz 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
17. Rabinowitz HK. . Recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas. N Engl J Med. 1993;328:934–939
18. Rabinowitz HK,, Diamond JJ,, Markham FW,, Santana AJ. Increasing the supply of rural family physicians: Recent outcomes from Jefferson Medical College’s Physician Shortage Area Program (PSAP). Acad Med. 2011;86:264–269
19. Isserman AM. In the national interest: Defining rural and urban correctly in research and public policy. Int Reg Sci Rev. 2005;28:465–499
20. Rabinowitz HK,, Diamond JJ,, Markham FW,, Santana AJ. The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later. Acad Med. 2012;87:493–497
21. Ernst RL,, Yett DE. Physician Location and Specialty Choice. 1985 Ann Arbor, Mich Health Administration Press