Petrany, Stephen M. MD; Gress, Todd MD, MPH
Since its inception in 1977, the Marshall University Family Medicine Residency (MUFMR) program has maintained a special focus on preparing primary care physicians for rural and small town practice. As the program is located in West Virginia, a state that continues to count a majority of its rural counties as medically underserved,1 the training of highly qualified family physicians to serve the health care needs of rural West Virginia and the surrounding Appalachian region has always been a major tenet of its overall mission. In an attempt to fulfill that mission and increase the number of its graduates practicing in West Virginia, the MUFMR developed the state’s first “rural residency program” in cooperation with Lincoln Primary Care Center (LPCC), a rural community health center (CHC) with which the Marshall University Joan C. Edwards School of Medicine (MUSOM) Department of Family and Community Health has had a long-standing, mutually supportive relationship. The MUFMR received initial approval from the Accreditation Council for Graduate Medical Education in 1994 to establish a second model family medical center at the LPCC for rural track (RT) residency training.
Concerns have been raised regarding the future viability of rural-focused residency training and the attractiveness of such programs to graduating medical students.2 Geographic and community characteristics seem to influence Match rates the most for RT residencies.3 The MUFMR is located in the university community of Huntington, West Virginia, with easy accessibility to the rural CHC training site in neighboring Lincoln County (30 miles away). This unique structure has helped us consistently recruit trainees to our RT.
The proximity of the rural and main (Huntington) family medical center sites enables RT and traditional track (TT) residents to share all necessary educational experiences that occur outside the model family medical centers (e.g., conferences, required rotations). A T1 line between the two sites makes it possible to provide RT and TT residents with shared didactic sessions, including journal clubs, via educational video conferencing. This greatly simplifies curriculum development for the RT. Thus, only one major variable distinguishes resident learning experiences in the two tracks: the location of the ambulatory continuity practice site.
Specifically, each week RT residents provide longitudinal continuity care under faculty supervision at the LPCC for 1 half-day during their first year, 3 half-days during their second year, and 4.5 half-days during their third year. Their home visit and extended care facility experiences also occur in Lincoln County. Longitudinal care, home visit, and extended care facility experiences for TT residents follow the same structure but take place in Huntington. All other curricular elements are the same for every resident in the program. Although the RT is approved for up to six total residents, we have generally had two to three total residents participating across all levels of training in any particular year.
Our RT was initiated without outside funding. Required resources were provided by the MUSOM’s Department of Family and Community Health and the LPCC, which expanded into a new facility to provide clinical and educational space to accommodate residency training requirements. The LPCC supplied clinical staff support and provided some attending physician supervision for the program. The MUFMR provided qualified residents with an interest in rural primary care and the major portion of the requisite physician faculty supervision. In 2000, however, resource-related issues necessitated a one-year suspension of the RT. Subsequently, we were able to secure grant funding, which presently supports the majority of the RT cost.
Several approaches to graduate medical education have been developed that emphasize rural and small town primary care.4–8 Outcome studies of different educational models have shown positive but somewhat variable results.9–12 In almost all cases, these studies have focused on graduates’ practice location and practice type. Less easily assessed—and, therefore, less examined—has been the issue of the academic equivalence of residency programs’ RT and TT curricula.
In this study, we assessed the impact of the RT curriculum on training outcomes of the MUFMR. We compared outcomes of RT and TT graduates, as well as outcomes of graduates who entered the program before and after RT implementation. The outcomes we studied included practice location and practice type, which relate to the goals of the residency program. In addition, we evaluated measures of academic performance to gauge the academic equivalence of the RT and TT curricula.
We included in this study the 174 MUFMR graduates who entered the residency program from 1984 through 2006. This sample comprised the cohort of residents for the decade prior to implementation of the RT as well as the cohort of residents in the post-implementation period who had graduated and been in practice for at least one year at the time of data collection.
Data on graduate characteristics and outcome measures were collected retrospectively from resident records maintained on a prospective basis by the residency program as a requirement for accreditation. These data are obtained at residency enrollment, during residency training, through exit interviews at the time of graduation, and via surveys and telephone contacts following graduation. Complete study data were available for most graduates; however, in some instances we obtained updated data, via telephone or e-mail, to ensure a comprehensive evaluation. This study was approved by the Marshall University institutional review board.
For each MUFMR graduate, we gathered data on year of and age at entry to the program, hometown, gender, track (curriculum) participation, in-training examination (ITE) scores at postgraduate years (PGYs) 1 and 3, practice location (West Virginia or not) and practice type (rural or not) following graduation, primary care practice (excluding hospitalist and occupational medicine specialties), and American Board of Family Medicine (ABFM) certification. Our main study outcomes were practice location, practice type, ITE scores, and ABFM certification rates.
To assess the impact of the RT curriculum and its equivalence with the TT curriculum, we compared outcomes of RT and TT graduates who entered the program from 1994 through 2006 (i.e., after the RT had been implemented). To further evaluate the impact of the RT curriculum, we compared outcomes for all graduates who entered the program from 1994 through 2006 (the post-implementation cohort) with those who entered from 1984 through 1993 before the RT was implemented (the pre-implementation cohort).
Continuous variables were summarized using the median because of their nonnormal distribution. Comparisons of study variables for RT and TT graduates and for pre- and post-implementation cohorts were carried out with the chi-square test (or Fisher’s exact test when appropriate) for categorical variables and the Wilcoxon rank-sum test for continuous variables. Because of the small sample of RT graduates, power was limited to approximately 75% in order to detect an absolute difference of 40% between the RT and TT groups for a dichotomous variable. However, power was greater than 80% to detect an absolute difference of 25% between the pre- and post-implementation cohorts. We used multiple logistic regression to examine practice type while simultaneously adjusting for age at entry, gender, West Virginia hometown, and PGY 1 ITE score. All analyses were performed using Stata version 10.0 (StataCorp, College Station, Texas).
Of the 174 MUFMR graduates in our sample, 106 entered the residency program from 1994 through 2006, after the RT had been implemented. Twelve (11.3%) of the 106 were RT graduates, and 94 (88.7%) were TT graduates (Table 1). One of the RT graduates lived within Lincoln County during training; another was raised in Lincoln County but did not live there during residency. Graduates of the two tracks were similar in terms of median age at entry and having a West Virginia hometown. A greater proportion of RT than TT graduates was male, but the difference was not significant. Primary care practice on graduation was similarly high for both tracks.
After completing their residencies, 83.3% (n = 10) of the RT graduates practiced in a rural area compared with 40.4% (n = 38) of the TT graduates (P < .01). This difference remained significant in a multivariate model (OR 7.54; 95% CI, 1.5–37.9) simultaneously adjusted for age at entry, gender, West Virginia hometown, and PGY 1 ITE score (Table 2). More than 80% of RT graduates (83.3%; n = 10) practiced in West Virginia compared with 68.1% (n = 64) of the TT graduates, although this difference did not reach statistical significance (P = .34).
Table 1 also presents academic outcomes for RT and TT graduates. The groups’ median PGY 1 ITE scores on entry to the program were similar (RT: 455 versus TT: 460), as were their median PGY 3 ITE scores (RT: 525 versus TT: 530). However, the average increase in ITE score during training was slightly higher for those in the RT (89) than in the TT (79), although this was not statistically significant. ABFM certification rates were high for both groups, at or near 100%.
Table 3 compares the characteristics and outcomes of the 106 graduates in the post-implementation cohort with the 68 graduates in the pre-implementation cohort. The pre-implementation cohort had a higher median age at entry, and its graduates were less likely to be from West Virginia. Median PGY 3 ITE scores were similar for both cohorts. Whereas the cohorts’ rural practice rates were similar (RT: 48.5% versus TT: 45.3%; P = .68), the rate of practice in West Virginia was significantly higher for the post-implementation cohort (69.8%) compared with the pre-implementation cohort (51.5%; P = .02). However, practice in West Virginia was no longer significant in a multivariate model (OR 1.51; 95% CI, 0.62–3.34) that simultaneously adjusted for age, gender, West Virginia hometown, and PGY 1 ITE score (Table 4). The two cohorts’ ABFM certification rates were similarly high, at or close to 100%. Primary care practice rates were also high for both groups.
When we conducted additional analyses to examine baseline characteristics of the entire study sample (N = 174) to see whether there were any significant predictors of choosing a West Virginia practice location on graduation, we found that graduates with a West Virginia hometown were 12 times more likely than those without (OR 12.3; 95% CI, 4.3–35.3) to choose to practice in the state, in a multivariate model that simultaneously adjusted for age, gender, and being an MUSOM graduate. In the same multivariate model, being an MUSOM graduate was not associated with choosing a West Virginia practice location (OR 1.4; 95% CI, 0.52–3.7). Because of the potential interaction between being both an MUSOM graduate and from West Virginia, we tested the interaction term and found no significant interaction (OR, 0.52; 95% CI, 0.04–6.1).
The RT at MUFMR is meeting its goals of producing family medicine physicians who go on to practice in rural areas and in the state of West Virginia: More than 80% of our RT graduates have opted for rural practice, and more than 80% have chosen to practice in our state. Importantly, our findings demonstrate that the MUFMR has been able to accomplish these goals while maintaining the quality of the educational experience for RT residents.
Although we found that a greater percentage of RT than TT graduates decided to practice in the state, the difference did not achieve statistical significance. The most striking difference we observed was in the choice of a rural practice location: 83.3% of RT graduates practiced at rural locations compared with 40.4% of TT graduates (P < .01). This finding suggests that we have been successful in recruiting appropriate trainees to the RT and in maintaining their interest in rural primary care after graduation. We believe that the unique structure of the MUFMR and the geographic location of the rural CHC site—within a reasonable driving distance of the main family medicine training site and teaching hospital—provide our RT with a recruiting advantage.3
Little has been published regarding the academic equivalence of special RT residency curricula developed over the last two decades. In this study, we compared our RT and TT graduates’ ITE scores and ABFM certification rates as measures of their academic progress. Given that all elements of the RT and TT curricula are identical except for the location of the residents’ continuity practice (rural or city), any differences in academic outcomes should reflect the impact of that variable. Our results, which show no statistically significant difference in ITE scores or ABFM certification rates, support the academic equivalence of the RT curriculum.
By comparing outcomes for cohorts of graduates who entered the MUFMR before and after RT implementation, we hoped to assess the overall impact of the program within the larger family medicine residency. Our results show that the development of the RT has been associated with a substantial and statistically significant increase in the proportion of MUFMR graduates practicing in West Virginia: Whereas 51.5% of graduates in the pre-implementation cohort went on to practice in our state, 69.8% of graduates in the post-implementation cohort did so (P = .02). This increase may be related to the higher number of graduates with a West Virginia hometown in the post-implementation cohort, particularly given the strong association between being from and choosing to practice in West Virginia. In our examination of predictors of a West Virginia practice location, we found that graduates with a hometown in the state were 12 times more likely than other graduates to choose to practice here. (We did not find a significant association with age at entry, gender, or even attending MUSOM.)
Although a significantly higher proportion of post-implementation cohort graduates were from West Virginia, it is unclear whether that increase is related to the development of the RT. Our findings suggest, however, that our recruitment efforts should be directed toward medical students with West Virginia hometowns. They also support the development of pipeline efforts to encourage the state’s secondary students to consider careers as physicians.
We were somewhat surprised by our finding that the percentage of MUFMR graduates entering rural practice was similar for the pre- and post-implementation cohorts. We did not see an increase in relative numbers of graduates deciding for rural practice. The consistent, substantial percentage of our graduates opting to practice in rural areas may be explained by the residency program’s rural mission and focus since its first days in 1977 and its long-standing efforts to recruit qualified medical school graduates with an interest in rural primary care.
Our study is limited by several factors. The sample size of the RT graduates is small, limiting the statistical power for all assessed outcomes. There may be unaccounted-for temporal factors influencing our comparison of the pre- and post-implementation cohorts. Our results may not be generalizable; they represent findings from only one residency program and would benefit from the addition of information from other similarly designed RTs in family medicine residencies. There is likely some selection bias—RT graduates chose to participate in that special track because of their interest in rural practice—which may influence our study outcomes. In addition, the MUFMR’s emphasis on rural primary care did not begin with the implementation of the RT but, rather, has been a major focus for recruiting and curriculum design since the first days of the residency program.
In conclusion, this comparison of MUFMR RT graduates with their TT counterparts suggests success in achieving the residency program’s goals of graduating primary care physicians who go on to practice in rural areas generally and in West Virginia specifically. The development of the RT was associated with an increase in the number of residents from West Virginia hometowns, which we found to be highly related to remaining in the state to practice after graduation. As expected, RT graduates were more likely than TT graduates to practice in a rural location. ITE scores and ABFM certification rates indicate that RT residents advance academically at least as well as their TT counterparts. Our results are encouraging for continuing efforts to expand RTs to help meet the ongoing need for primary care physicians in rural areas. Moving forward, continued follow-up and assessment of our program outcomes are planned. Collaboration with other residency programs with similar tracks is needed to determine whether a special RT is effective at other training sites based on program infrastructure and features and the characteristics of the individuals who pursue such training.
Other disclosures: None.
Ethical approval: This study was approved by the Marshall University institutional review board.