Which Medical Schools Produce Rural
Physicians? A 15-Year Update
Frederick Chen, MD, MPH, Meredith Fordyce, PhD, Steve Andes, PhD, and L. Gary Hart, PhD
Abstract
PurposeDespite continued federal and state efforts to increase the number of physicians in rural areas, disparities between the supply of rural and urban physicians persist. The authors examined the training of the rural physician workforce in the United States. Method
Using a national cross-sectional analysis of the 2005 American Medical
Association and American Osteopathic Association Masterfile physician data, the authors examined a 10-year cohort of
clinically active MD and DO physicians who graduated from medical school between 1988 and 1997.
Results
Eleven percent (20,037) of the physician cohort were currently practicing in a rural location in 2005. Eighteen percent (2,045) of osteopathic medical school graduates were currently practicing in a rural location. Twenty-three percent (6,282) of family physician graduates practiced in rural areas. Women continue to be less likely than men to practice in rural areas, although the gap is
narrowing. Rural residency trainees were over three times more likely to practice in rural areas (RR⫽ 3.4, P ⬍ .001).
Conclusions
The proportion and number of physicians entering rural practice has remained stable compared with earlier analyses. However, recent trends such as declining primary care interest are not yet reflected in these data and may portend
worsening shortages of rural physicians. Acad Med. 2010; 85:594–598.
Editor’s Note: A commentary on this article appears on pages 572–574.
A
mong the most enduring problems in rural America is the shortage and maldistribution of physicians.1–3Despitecontinued federal and state efforts to increase the number of physicians in rural areas, disparities between the supply of rural and urban physicians persist.3–5
The recent Institute of Medicine (IOM) report on rural health quality highlights the critical need for well-trained physicians to deliver high-quality care to
rural areas.1Although the report
emphasizes that rural physicians must be trained in quality improvement, information technology, and evidence-based medicine, the availability of high-quality care in rural areas depends primarily on an adequate supply of physicians practicing in these areas. It has been more than 15 years since Rosenblatt et al6,7described the
MD-granting schools that train rural physicians. In addition, recent literature has not adequately described the contributing role of DO physicians and international medical graduates (IMGs) in the rural physician workforce. This report describes the training of the rural MD and DO physician workforce in the United States and examines the variations in the ways medical schools and residency programs produce rural physicians. In the original study, Rosenblatt et al6found
that a small subset of the nation’s medical schools produce the majority of rural physicians in the United States. We sought to update that finding and expand the analysis to residency training
programs, with a specific focus on training programs located in rural areas. Method
In 2006, we performed a national cross-sectional analysis of the 2005 American
Medical Association (AMA) and American Osteopathic Association (AOA) Masterfile physician data. We examined a 10-year cohort of clinically active MD and DO physicians who graduated from medical school in the years 1988 through 1997 and had completed residency training. This cohort allowed for a reasonable
comparison with the 10-year cohort from Rosenblatt and colleagues’6previous
work. In addition, this cohort allows for the most recent graduates (from 1997) to have completed residency training (typically three to five years) and then to have established practice to be captured in the AMA Masterfile. We excluded resident physicians and osteopathic physicians with an unknown professional employment status from the analyses. We determined physicians’ locations by the reported ZIP code of each physician’s primary practice location. When the primary practice location was not available, we used the physician’s home address. We mapped the ZIP codes to Rural–Urban Commuting Area (RUCA) and county designations. RUCA codes use census tracts rather than counties as a means of identifying degree of rurality or urbanicity.8,9A ZIP code approximation
version of the census tract-based RUCA codes has been developed (http://depts. washington.edu/uwruca/ruca-data.php)
Dr. Chen is lecturer, Department of Family
Medicine, University of Washington School of Medicine, Seattle, Washington.
Dr. Fordyce is investigator, WWAMI Rural Health
Research Center, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington.
Dr. Andes was a research scientist, American
Osteopathic Association, Chicago, Illinois, at the time of this study.
Dr. Hart was director, WWAMI Rural Health
Research Center, and professor, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington, at the time of this study.
Correspondence should be addressed to Dr. Chen, Department of Family Medicine, University of Washington School of Medicine, 4311 11th Avenue NE, Suite 201, Seattle, WA 98195-4982; telephone: (206) 543-7813; fax: (206) 616-4768; e-mail: [email protected].
and was used in this study. Use of these smaller basic building blocks allows for much more precision in defining rural and urban locations than do the larger-scale county-level taxonomies. RUCA codes identify areas as metropolitan (urbanized), micropolitan (large rural), small town (small rural town), or rural (isolated small rural) and are based on both core population size and “work commuting flow” relationships. Core populations are categorized as metropolitan (continuously built-up areas of 50,000 or more), micropolitan (10,000 –49,999), or small town (2,500 – 9,999). Work commuting flow accounts for the direction and the extent to which a core population commutes to a city or town of similar or larger size. RUCA version 2.0, used in this study, consists of 10 general settlement types that are themselves further broken down into the 33 subcategories based on work
commuting patterns. These 33
subcategories were aggregated to create a four-category classification, which identifies areas as urban, large rural, small rural, or isolated small rural. We identified the medical school of graduation for each physician. IMGs were defined as physicians who graduated from a non-U.S. or Canadian medical school; graduates from Puerto Rican schools were counted as IMGs. The AMA Masterfile receives these data directly from medical schools. As a result, some but not all medical school campuses are reported separately from their parent institutions. For example, the University of Minnesota–Duluth has separate data from the University of Minnesota, whereas University of Illinois–Rockford data are included with the University of Illinois data set. We identified the most recent residency program for each physician and identified the location of that residency program as rural or urban on the basis of its ZIP code. Rural
residency programs were those located in large rural, small rural, or isolated small rural RUCA categories. The residency analyses focused on family physicians (FPs) because family medicine is the predominant specialty in rural areas. We aggregated rural physicians to each medical school, and medical schools were compared to show the percentage of the rural physicians produced by each school. A similar analysis was performed for residency training programs. Standard bivariate statistical testing was performed using SPSS (v. 11.0.4, Chicago, Illinois). This study was approved for an exemption by the University of Washington institutional review board. Results
There were 175,649 clinically active physicians in the cohort of physicians who graduated from medical school in the years 1988 to 1997. Of these, 93.6% (164,385) were MD physicians and 6.4% (11,264) were DO physicians. Eleven percent (20,037) of this cohort of physicians were practicing in a rural location in 2005. Eighteen percent (2,045) of DO-granting medical school graduates were practicing in a rural location, but only 11% (17,992) of MD-granting medical school graduates were in a rural location (Table 1). Thirteen percent (3,513) of IMGs were practicing in a rural location.
The proportion of medical school graduates entering rural practice varied by specialty. Among the specialties, 23% (6,282) of FP graduates practiced in rural areas. In comparison, 16% (916) of general surgeons, 11% (3,075) of internists, and 9% (1,236) of pediatricians practiced in a rural area (Table 2). During the 10-year study period, there was a stable number and
proportion of MD physicians practicing in rural areas, with a small increase with the most recent graduating cohort in 1997 (10.3% of 1988 graduates versus 11.6% of 1997 graduates). There was a more consistently increasing trend among DO physicians entering rural practice over the decade (18.1% of 1988 graduates versus 19.6% of 1997 graduates) (Figure 1).
Rural physician gender
Among all the MD physicians in the cohort (rural and urban), 37% (60,912) were female. In the cohort of DO physicians, 31% (3,467) were women. Over the course of the 10-year study period, the percentage of MD and DO female physician graduates increased from 32% in 1988 to 44% in 1997. Thirty-one percent (6,211) of rural physicians are women. Women continue to be less likely than men to practice in rural areas, although the gap is narrowing. There was, however, an increasing proportion of female physicians entering rural practice over the study period (7.8% to 9.8% female MDs, 12.2% to 17.7% female DOs) (Figure 2). This finding represents a significant change from previous analyses of women entering rural practice.5
Medical schools and residency programs
The medical schools that produced the highest percentage of rural physicians placed between 21% and 36% of their graduates in rural areas (Table 3). There was no substantial change in the list of MD-granting medical schools graduating rural physicians when compared with the earlier study by Rosenblatt et al.6
However, several DO-granting schools were identified that contributed relatively high percentages of rural physicians.
Table 1
Number (%) of all MD, DO, and International Medical Graduate (IMG) Physicians Who Graduated From Medical School From 1988 to 1997 and Were Practicing in Rural Areas* in 2005
Physician type
No. (%) in urban areas
No. (%) in large rural areas
No (%) in small rural areas
No. (%) in isolated small rural areas
Total no. (%) in rural areas MD (n⫽ 164,375) 146,383 (89.1) 11,953 (7.3) 4,284 (2.6) 1,755 (1.1) 17,992 (11.0) ... DO (n⫽ 11,262) 9,217 (81.8) 1,172 (10.4) 594 (5.3) 279 (2.5) 2,045 (18.2) ... IMG (n⫽ 26,393) 22,880 (86.7) 2,089 (7.9) 984 (3.7) 440 (1.7) 3,513 (13.3)
Rural residencies
Only 1.4% (2,247) of MD physicians in the cohort trained in a rural residency location. Among these physicians who trained in rural residencies, 36% (814) were in rural practice at the time of our study. In comparison, 3.6% (343) of DO physicians in the cohort trained in a rural program. Fifty percent of DO graduates (170) who trained in a rural residency were in rural practice according to the 2005 Masterfile. Although we found that rural residency trainees are over three times more likely to practice in rural areas (RR⫽ 3.4, P ⬍ .001), rural residencies account for only 5% of MD physicians practicing in rural areas and 10% of DO physicians in rural areas. Rural family medicine training programs are an important contributor to the rural
physician workforce.10Sixty percent of
rural family medicine residency graduates were in rural practice at the time of this study, and they were three times more likely than graduates of nonrural residency programs to practice in a rural location (RR⫽ 2.8, P ⬍ .001). However, only 9% of all rural FPs in our study cohort trained in a rural residency. Discussion
This analysis of national data shows that the proportion and number of physicians entering rural practice has remained stable, compared with Rosenblatt and colleagues’61991 results. DO physicians
and primary care physicians are more likely to practice in rural areas. Although the number and percentage of rural physicians produced by medical schools
was widely distributed, a small number of medical schools produced high
proportions of rural physicians. As seen in Table 3, only 10 medical schools had over 25% of their graduates in rural practice. The study by Rosenblatt et al6
identified a slight decline in the percentage of physicians entering rural practice over time. The data we studied show that the decline has stabilized, although the overall percentage of graduates practicing in rural areas has decreased. In 1991, 12.6% of recent medical school graduates entered rural practice. In 2005, that number had slipped to 11% of recent medical school graduates. We believe this difference is primarily due to different definitions of rural practice between the two studies. More important, on the basis of our own anecdotal observations, we suspect that this downward trend has accelerated in recent years, although it is not yet captured in the data.
As noted by Rosenblatt et al,6the
likelihood of a physician entering rural practice is associated with specialty. In this cohort of medical school graduates from 1988 to 1997, primary care physicians continue to be more likely to enter rural practice than are specialty physicians. Again, compared with the earlier study by Rosenblatt and
colleagues, the percentage of FPs, general internists, and pediatricians entering rural practice has declined (see Table 2). An exact comparison is difficult because the article by Rosenblatt et al used nonmetropolitan county areas to define rural practice location, and this study Figure 1 Percentage of MD and DO physicians practicing in a rural area in 2005, by year of
graduation. The percentage of international medical graduate (IMG) physicians practicing in rural areas is also shown.
Table 2
Number (%) of MD and DO Physicians of Each Specialty Who Graduated From Medical School From 1988 to 1997 and Were Practicing in Rural Areas* in 2005
Specialty
No. (%) in large rural areas
No. (%) in small rural areas
No. (%) in isolated small rural areas
Total no. (%) in rural areas Family medicine 3,137 (11.3) 2,108 (7.6) 1,037 (3.7) 6,282 (22.6) ... Internal medicine 1,925 (7.0) 775 (2.8) 375 (1.4) 3,075 (11.2) ... General pediatrics 876 (6.4) 268 (2.0) 92 (0.7) 1,236 (9.1) ... General surgery 614 (11.0) 242 (4.3) 60 (1.1) 916 (16.4) ... Orthopedics 523 (10.4) 132 (2.6) 28 (0.6) 683 (13.5) ... Obstetrics–gynecology 870 (8.2) 219 (2.1) 46 (0.4) 1,135 (10.7) ... Emergency medicine 592 (6.9) 164 (1.9) 66 (0.8) 822 (9.6) ... Psychiatry 520 (6.5) 131 (1.6) 42 (0.5) 693 (8.7) ... Medical specialties 1,365 (6.0) 336 (1.5) 141 (0.6) 1,842 (8.1) ... Surgical specialties 176 (3.4) 13 (0.3) 11 (0.2) 200 (3.9) ... Total 13,124 (7.5) 4,878 (2.8) 2,034 (1.2) 20,036 (11.4)
uses RUCA coding to identify rural physicians.
It is worth noting that the total enrollment in medical schools has increased during the time between these two studies. In this context, the stable percentage of physicians entering rural practice represents an increase in the absolute number of physicians in rural locations. To better understand these findings, it may be useful to consider the overall demographic changes in rural America over the same time period. Since 2000, the rural population has experienced modest growth (0.4%), almost one-third that of the U.S. urban population.11
Of note, the previously reported gender gap among rural physicians is
disappearing. The increasing proportion of female rural physicians (Figure 2) is more likely attributable to the increasing number of female medical school graduates coupled with a decline in the percentage of male physicians entering rural practice.
As previously reported, DO physicians are significantly more likely to enter rural practice. The percentage of DO graduates entering rural practice remained stable over the decade, approaching 20%. However, recent studies suggest that this percentage has begun to decline as DO
graduates increasingly choose MD specialty residency training programs. These data further support the valuable contribution to the rural physician workforce of rural residency programs. Though few in number, these training programs are successful at producing rural physicians. A previous study showed that these rural residency programs provided 71% of the nation’s rural training in family medicine.10
Unfortunately, rural residency programs, especially in family medicine, face serious financial challenges. In a recent study,10,12
10% (3) of 33 rural residencies have closed, with an additional 7% at severe risk of closure.
This study has several important
limitations. As we noted above, we used a different rural definition than the previous study by Rosenblatt et al. Although this limits the ability to compare our findings with those of the earlier study, we feel that the RUCA methodology is a much more robust and accurate estimation of rurality. In addition, there are several
well-recognized limitations to AMA and AOA Masterfile data. The data are often inconsistently updated, so changes in physicians’ locations may take several years to be captured in the data. The AOA data had a portion of missing data for osteopathic physicians whose professional employment status was unknown, and these physicians were excluded from the analysis. It is unknown how many of these missing physicians graduated during the study period, so it is difficult to estimate bias, but we believe it is minimal.
Perhaps the greatest drawback to these data is that they do not capture the most recent decade of physician workforce trends. The mid-1990s were a time when a high number and percentage of U.S. medical students were entering family medicine and, as a result, rural practice. During that time, the prominent role of primary care gatekeepers in the new managed care systems attracted medical students to the primary care specialties. Indeed, the increasing proportion of rural physicians beginning in 1993 that we saw in these data has not continued. The past 10 years have shown a dramatic and precipitous decline in the percentage of U.S. medical school graduates entering family medicine, with over half of current Figure 2 Percentage of MD and DO rural physicians who are female, by year of graduation. The
percentage of female family physicians (FPs) practicing in rural areas is also shown.
Table 3
MD- and DO-Granting Medical Schools With the Highest Percentages of Graduates (1988 –1997) Practicing in Rural Areas in 2005
Medical school MD/DO
% Graduates practicing in rural areas, 2005
West Virginia University DO 41
...
University of Minnesota–Duluth MD 36
...
University of Mississippi MD 32
...
University of South Dakota MD 31
...
Mercer University MD 31
...
Oklahoma State University DO 30
...
University of North Dakota MD 28
...
A.T. Still University–Kirksville DO 27
...
East Carolina University MD 26
...
University of Kentucky MD 25
...
University of Nebraska MD 23
...
East Tennessee State University MD 23
...
Kansas City University of Medicine and Biosciences DO 21
...
University of Arkansas MD 21
...
Ohio University DO 21
...
family medicine residency positions being filled by IMGs.12The declining
interest in primary care will have major impacts on rural areas, whose needs are often met by generalist physicians and which often cannot support any physician practice other than primary care.
Conclusions
As the IOM report emphasizes, rural health is critically dependent on both the supply and the quality of its rural workforce. Not only do rural areas require an adequate supply of physicians to ensure access to care, but the training of these physicians in information technology, quality improvement, and new models of care is vital to the future of rural health. Although this study cannot address the adequacy of training in these realms, future research should explore the extent to which rural physicians acquire these skills. Current calls to expand medical school class sizes may help support the pipeline for rural physician training. However, if medical schools expand class sizes without explicitly emphasizing primary care or rural health, these expansions may result in more physicians choosing to practice in urban centers, worsening the rural–urban maldistribution.13On
the other hand, medical schools may choose to implement programs and curricula that have a demonstrated success in training rural physicians.14
At the same time, there has been little discussion of the role of state legislatures
in holding state-supported medical schools accountable for producing a substantial percentage of rural physicians. Federal rural health programs and Title VII-funded programs continue to support primary care and rural health training.15,16Whereas these data show
little significant change in the rural physician workforce, the effects of these policy changes will need to be closely monitored in coming years.
Funding/Support: This study was funded by Health Resources and Services Administration, Office of Rural Health Policy, through HRSA Grant #6 UIC RH 00011-04.
Other disclosures: None.
Ethical approval: This study was approved for an exemption by the University of Washington institutional review board.
Previous presentations: An earlier version of this work was presented at the Academy Health annual research meeting, June 2006.
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