The United States has a long-standing and well-documented shortage of rural physicians.1,2 Rural populations also face considerable health-related challenges, including rural–urban disparities in health status,3,4 increased poverty rates,3 and a widening rural–urban disparity in life expectancy over the past 40 years.5 Improving rural residents’ access to rural physicians is crucial for improving population health.
Bolstering the rural physician workforce is inextricably linked to the development and recruitment of primary care physicians. Rural physicians tend to be generalists; the more specialized a physician, the less likely he or she is to practice in a rural area.6 The challenge of meeting the need for rural physicians in America is linked to the challenge of increasing student selection of primary care careers.
Selective medical school admissions and focused rural/generalist curricula may be the best way to increase the number of graduates who intend to practice in rural areas.7–10 In response, several medical colleges and residencies have developed rural training programs, which increase the percentage of graduates choosing primary care specialties or initial rural practice,7,11–14 while maintaining high educational standards.12,15,16 Less has been published about the regional impact of such distributive education models, but a few studies highlighting graduates’ early-career practices have shown a positive trend toward their choosing regional practice.17,18
In 1971, Michigan State University College of Human Medicine (MSU-CHM) developed one of the nation’s first rural training programs, the Upper Peninsula (UP) Rural Physician Program (RPP).19 A campus designed to train rural physicians fit MSU-CHM’s mission to educate primary care physicians who would serve the needs of the state and was a natural extension of MSU-CHM’s model of community-based medical education.20 We present the history of MSU-CHM’s UP RPP and describe the practice patterns of the program’s graduates. Specifically, we aim to illustrate the impact of the rural clinical training model on graduates’ specialty choices and practice locations, and on the physician workforce of the program’s rural region.
MSU-CHM’s UP campus began as an idea in 1971. The program’s founders theorized that medical education could exist outside the walls of large teaching hospitals and become an integral part of the health care system in a region experiencing a physician shortage.21 This idea was controversial. There was concern that a medical education received in the rural UP—400 miles from MSU-CHM’s main campus—would be inferior. Nonetheless, there simply were not enough rural physicians, and the remote campus offered potential relief. In 1972, MSU-CHM received a Federal Bureau of Health Manpower Grant and Michigan legislative funds to develop a rural medical education program targeting the UP. A shared goal between the main and UP campuses was a curriculum that would embody community-based, humanistic, and self-directed learning principles.22
An early decision, likely influencing the program’s success, was to design a UP-wide program rather than one affiliated with a single city. Although the city of Marquette has evolved into the educational hub of the program, RPP students have always been trained in various communities throughout the UP. Over time, this engagement with multiple communities has given the program adaptability to respond to the changing needs of students and the region.
In 1990, practice location and specialty choice patterns for early graduates of the UP program were published, showing a tendency for rural practice and primary care specialties.19 We present the current RPP curriculum and expand on this earlier publication with outcome data describing the first 30 years of program graduates.
The RPP shares many features with other successful rural predoctoral training programs, including rural clinical experiences, a commitment to primary care, and an admission policy targeting students of rural origin.23 The RPP’s most unique feature is that since inception, every class of RPP students has received all of its required clinical training in a nonmetropolitan area.24
Twelve RPP students are selected each year. Interested students interview for the program after acceptance to medical school and before matriculation. They are chosen on the basis of interest in rural health, rural life experience, and program fit. This early selection is important to attract students interested in rural medicine and help them identify with the rural campus early in their education.
RPP students receive basic science and preclinical training with their classmates on MSU-CHM’s main campuses. During this two-year period, they meet together with UP campus administrative faculty twice yearly. These meetings allow students to form relationships and provide opportunities for mentoring.
Once students begin their third year in the UP, they rotate through clerkships in internal medicine, surgery, and psychiatry at Marquette General Hospital. Early in year three, they spend four weeks learning family medicine in Marquette. They spend a portion of their pediatrics and obstetrics–gynecology clerkships in Escanaba and Iron Mountain, respectively. The cornerstone of the program is an eight-week family medicine rotation, spent in a rural UP community at the end of the third year. The students live in their assigned community and experience a range of care settings, including office, hospital, nursing home, and home visits. Thus, RPP students have a total of 12 weeks of family medicine training, including both exposure to a family medicine residency program and practice experience in a remote community.
Besides family medicine, there are no other residencies in the UP. This is an important feature of the rural program, as students maintain a prominent role on the care team. Students work directly with faculty, often serving as first contact for clinic patients or first assist in surgery. The UP campus also offers more than 20 elective clerkships, which offer students hands-on experience within a wide variety of specialties.
Because of the remote northern location, RPP students may also participate in an optional northern wilderness emergency and sports medicine program. The program includes an outdoor emergency care course through the National Ski Patrol, lectures on wilderness and sports medicine, community presentations, service projects, and advanced cardiac, pediatric, or trauma life support courses. All of this takes place longitudinally during the third and fourth years.
To determine graduates’ specialties and practice locations, we obtained American Medical Association (AMA) Masterfile data from 2011 for all MSU-CHM graduates from 1978 to 2006. More recent graduates were excluded because data for these graduates may represent residency or fellowship placement rather than true practice location or final specialty. MSU-CHM is a community-based medical school with multiple clinical campuses located throughout Michigan. We built two cohorts: UP Region Campus RPP graduates and MSU-CHM graduates from all other clinical campuses. Any physician listed as retired, deceased, or inactive was removed from analysis. We cross-checked practice locations of 2004, 2005, and 2006 graduates with Internet searches (using Google) to ensure that Masterfile data had captured a practice, rather than a residency training, site. AMA Masterfile data were also supplemented with MSU-CHM matriculation and alumni databases. We obtained student demographic information from the American Medical College Application Service database.
We defined primary care as a primary specialty of family medicine, pediatrics, internal medicine, internal medicine/pediatrics, or general practice. If these graduates listed a secondary specialty in the AMA Masterfile database, we then excluded them from the primary care group, with the exception of physicians who specialized in age-specific specialties (such as geriatrics) and self-identified as practicing primary care. Primary care specialties,25,26 general surgery,25–27 psychiatry,26 and obstetrics–gynecology26,28 have been identified in the literature as high-demand shortage specialties in rural areas in the United States. Graduates who listed one of these specialties without subspecialization were identified as practicing in rural high-need specialties.
Using ArcGIS Desktop Geographic Information Systems Software Version 10.1 (Esri, Redlands, California), we geocoded graduates’ practice locations to the ZIP code level and joined to Rural–Urban Commuting Area Code (RUCA) 2006 data to determine rurality.29 Rural was defined as RUCA values greater than or equal to 4.0 as per RUCA Categorization C. Graduates were considered to be practicing within a Health Professional Shortage Area (HPSA) if at least a portion of their practice ZIP Code contained a Primary Care HPSA (from the Health Resources and Services Administration 2011 HPSA shapefile).30 We also categorized practice location by whether each graduate was practicing within the state of Michigan and whether he or she was practicing in 1 of the 15 UP counties. The entire UP is categorized as rural.24,29
We performed logistic regression to assess the impact on rural practice of UP campus training compared with factors shown to have an effect on eventual rural practice. The model included four independent variables entered a priori (UP campus,7,19 rural origin,7 primary care specialty,31,32 and gender7,33).
To assess the RPP’s state and regional impact we compared practice location and specialty choice of RPP graduates practicing in the UP region, in the Lower Peninsula of Michigan, and outside Michigan. To provide context for our findings, we obtained national data approximate to 2011 from publicly available records34–37 and reported the national percentages of primary care physicians, rural physicians, physicians practicing in HPSAs, and in-state retention from medical education. We obtained numbers of graduates from other allopathic medical schools in Michigan currently practicing in Michigan’s UP counties from Med School Mapper38 and compared these data with RPP grads to demonstrate the degree of program impact on the physician workforce of this rural region. We also compared graduate outcomes (primary care specialty, rural practice, Michigan and UP practice, UP origin) by decade beginning with 1978, to determine how impact changed as the program matured.
We compared data using SPSS Statistical Software Version 22 (IBM SPSS Inc., Armonk, New York), using Student t tests for continuous numerical data and chi-square (or Fisher exact test where appropriate) for categorical data. Significance was set at P < .05. This study was determined exempt from review by Michigan State University’s institutional review board.
One hundred seventy-nine students graduated from the RPP between 1978 and 2006. Of these graduates, 1 never practiced clinical medicine, 9 had retired, and 1 was deceased; we removed these 11 graduates from further analysis. During the same period, 2,792 students graduated from MSU-CHM’s other clinical campuses. Of these, 141 never practiced medicine or were no longer practicing (retired, inactive, or deceased), and 41 could not be located. These 182 graduates were removed from further analysis. Thus, 168 (94%) of RPP graduates and 2,610 (93%) of all other MSU-CHM graduates were included in analysis.
Demographic characteristics, including gender, age at matriculation, race/ethnicity, and state of legal residence at time of medical school application, are outlined in Table 1. RPP graduates tended to be younger and were more likely to be Michigan residents, of UP origin, of rural origin, and Caucasian than other MSU-CHM matriculants.
A significantly higher percentage of RPP grads were practicing primary care specialties and in rural high-need specialties in 2011, compared with all other MSU-CHM graduates (Table 2). RPP grads were more likely to be practicing in a rural community (RPP 76/168 [45%]; all-other 361/2,610 [14%]; P < .001), in a designated HPSA site (RPP 106/168 [63%]; all-other 1,279/2,610 [49%]; P < .001), in Michigan (RPP 89/168 [53%]; all-other 1,119/2,610 [43%]; P = .01), and in a UP county (RPP 44/168 [26%]; all-other 28/2,610 [1%]; P < .001). Although these factors are different between the UP campus and all other MSU-CHM campuses, it is also important to note that MSU-CHM’s all-other campus cohort compares favorably to national statistics in all measures for which data approximate to 2011 were available (U.S. primary care physicians, 33.5%35; U.S. rural physicians, 11.4%36; in-state physician retention from undergraduate medical education, 39.2%37; Midwest physicians practicing in HPSAs, 25.5%38).
The overall logistic regression model including factors impacting rural practice choice was statistically significant, χ2(4, N = 2,344) = 142.3, P < .001. As seen in Table 3, all included variables made a statistically significant contribution to the model. RPP participation and rural origin were the strongest independent predictors of eventual rural practice.
To assess regional impact, we analyzed RPP graduates by practice location. In 2011, 44 RPP graduates (26%) were practicing in a UP county. To put this number into context, RPP students were only 1.2% of the total number of graduates from Michigan’s three allopathic medical schools from 1978 to 2006 (168/13,546), yet 21.3% (44/207) of Michigan’s allopathic medical school graduates currently practicing in the UP came from this small cohort of RPP students.38 RPP graduates who stayed in Michigan were significantly more likely to practice rurally (58/89 [65%]) than those graduates who left the state (18/79 [23%]; χ2 28.7, 1, P < .001), but this difference was almost entirely accounted for by those graduates who stayed in the program’s region. Among the graduates who stayed in Michigan but practiced outside of the UP, only 31% practiced in rural communities (Table 4).
Finally, we compared program outcomes for graduates over time (Figure 1). The percentage of graduates practicing rurally and in the UP region has increased each decade, with the trend for UP practice approaching statistical significance (χ2 5.5, 2, P = .06). Primary care specialty choice showed an initial increase in the 1990s (similar to an increase seen nationally36) and has remained steady since then. The proportion of RPP graduates of UP origin has also increased significantly over time (1978–1987: 3/25 [12%]; 1988–1997: 23/60 [38%]; 1998–2008: 39/67 [58%]; χ2 16.8, 2, P < .001).
MSU-CHM’s RPP, now in existence for 40 years, has proven to be a successful rural training model for undergraduate medical education. Our analysis of almost 30 years of graduates supports the previously published work of other rural programs which shows that rural training models, when combined with selective admissions, can successfully foster student interest in rural medicine, preparing—and potentially influencing—graduates toward rural practice.12,39
RPP graduates were more likely to choose a primary care career or rural in-need specialty, practice in a rural location, and practice in an HPSA compared with all other MSU-CHM graduates. We believe several of the key curricular features we have described contribute to the program’s success. Participants are carefully selected soon after their acceptance to medical school. Although students spend their first two years in urban settings in lower Michigan, they receive twice-yearly mentoring by UP faculty. They spend both of their clinical years in the UP, which is entirely rural. The program also works to ensure that clinical education is spent in settings that are as rural as possible, while still meeting educational needs. The additional training in family medicine and opportunity to learn wilderness medicine are particularly important for building students’ confidence and preparedness for rural medicine.
Beyond demonstrating the success of a single program, this study adds to the current literature about rural medical education in several ways. We found that the majority of RPP graduates are currently practicing rural high-need specialties, including general surgery, psychiatry, or obstetrics–gynecology, as well as primary care. This finding supports recent studies which show increased interest in general surgery among medical students on nonmetropolitan surgery clerkships40 and increased likelihood of rural practice among surgeons who experienced rural training as residents.41,42 This contribution of undergraduate rural medical training programs to the high-need rural specialty workforce is an evolving area for further study.
Although many RPP graduates are practicing in rural areas of Michigan and the nation, the biggest impact of the program is clearly seen in the relatively remote UP region, where 44 graduates, or 26%, have returned to practice. This contribution to the regional physician workforce has been sustained over time and has proportionally increased as the program has matured. In fact, over time the RPP has increased the percentage of graduates meeting all of the goals of the program: primary care specialty choice, rural practice, in-state practice, and practice within the region. We believe this positive trend is potentially influenced by graduates of the program who are now local role models for RPP students.
Our analysis suggests that the farther away from the region graduates settle, the less likely they are to practice rurally. All graduates practicing in the UP region are practicing in a rural area. Only 31% of graduates practicing in the Lower Peninsula of Michigan have chosen rural practices, and 23% of RPP graduates who left the state are practicing rurally. Michigan’s natural division between the Upper and Lower Peninsulas created an easily defined region for this initial study, but a similar analysis of regional impact from other rural programs would be interesting. If the regional impact of other rural programs is similar, this would support an educational model of distributed rural training sites to best meet rural physician workforce needs of the nation.
Another important finding is the program’s increasing selection of UP students over time, which may influence its evolving regional impact. Rural students have historically been underrepresented in medical education.36 As one of the biggest predictors of rural practice is rural upbringing, this disparity is considered a significant contributor to the continued maldistribution of physicians to rural areas.6,7 Our data show that the UP RPP has successfully and increasingly attracted and trained graduates from its rural region. What we cannot discern is at what level this impact begins: Are undergraduate premedical students from the UP more interested in a program that allows training in a familiar region, or are students inspired earlier in their educational careers by the proximity of medical learners? More longitudinal studies as other rural programs mature may help illuminate some of these issues, which are integral to physician workforce pipeline development.
Our study has several important limitations. Data are from a single program, which limits generalizability. Our analysis is retrospective, using self-reported data from the AMA Masterfile database, which could raise concerns regarding validity; however, we personally examined all data and uncertainties were validated using multiple sources. We used a more stringent definition of primary care than usually reported, excluding those graduates who finished a primary care residency but then specialized. We felt that this definition best represented workforce practice patterns.43 However, this definition may limit comparability of these numbers with previously published studies.9,11,44–46 Our definition of HPSA practice may be less stringent than previously published studies, also limiting comparability.38 Most important, any interpretation of results is limited by the inherent selection bias of rural training programs, which students self-select on the basis of rural interest.
In conclusion, characteristics of the UP RPP, including targeting rurally interested students, a primary care focus, and a substantial amount of clinical training within a rural region, can successfully foster rural physician careers. The impact of the RPP has been greatest in the rural region where it is based, and this impact has increased as the program has matured. As medical schools expand with the goal of meeting the workforce needs of the state and of the country, similar programs, based in underserved rural communities, may be of greatest benefit.
Acknowledgments: The authors would like to acknowledge the contributions of Daniel Hanba and Meredith Ollila. Daniel participated in the early analysis of portions of the data presented here; Meredith contributed to the discovery and recording of the history of the Rural Physician Program.
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