Rural training in medical education

There is strong evidence that rural training programs increase the number of physicians who choose to practice in rural areas, increasing access to care for rural patients (Johnson 2018, Guilbault 2017, Cochrane-Grobler 2015, Goodfellow 2016, Wheat 2017, Nelson 2017, McCarthy 2015).

Rural medical school curricula, rural practice learning experiences, and rural residency programs increase the likelihood that participating students will choose to practice in a rural area (Johnson 2018, Guilbault 2017, Patterson 2023, Wheat 2017, McCarthy 2015). Programs that recruit students with rural backgrounds and have a rural-focused curriculum increase the number of students who choose rural practice locations (Johnson 2018, Patterson 2023, Wheat 2017) and remain there over the long-term (Johnson 2018, Guilbault 2017, Goodfellow 2016), often as primary care or family medicine physicians (Guilbault 2017, Patterson 2023, Nelson 2017, Petrany 2013, Rabinowitz 2012). Having obstetrical (OB) providers train rural family medicine physicians in this specialty may increase access to rural maternity care. Experts suggest that rural medicine residency programs foster positive relationships between family medicine clinicians and OB providers, develop efforts to retain family medicine faculty and mentors, and advance a shared vision of improved access to local maternity care among hospital and community partners (Fredrickson 2023). Surgical residencies with rural training tracks are more likely to produce additional general surgeons that enter practice immediately following graduation, but these graduates may not stay in rural practice (Halline 2022). Other studies suggest surgeons who practice in rural areas during residency are also more likely to remain in rural practice than their peers (Wendling 2016, McCarthy 2015, Deveney 2013). When establishing a rural surgery training program, experts recommend that program planners conduct a needs assessment and review perspective local residency training locations and partnerships, secure sufficient funding, offer surgical and clinical/operative education, and receive program approval from a surgical residency review committee (Mercier 2019).

Additional efforts are needed to retain rural physicians and to train other health care providers, such as nurse practitioners and physician assistants, to be part of rural health care practices and pipelines (MacQueen 2018). A study of a statewide, county-based rural pipeline program in Alabama suggests that supporting prospective medical students beginning in high school and continuing through medical residency may increase the number of family medicine physicians and other health care providers that will practice in their home counties (Wheat 2021).

Models indicate that expanding rural training programs to all medical schools would substantially increase the supply of rural physicians (Rabinowitz 2008). However, federal funding allocations are a barrier to increasing the number of residency slots available for rural physicians. Most funded slots are in urban areas, especially the northeastern U.S., and are designated for non-primary care (or specialist) training (Nielsen 2017). Rural hospitals have fewer resources and less infrastructure to accommodate separately accredited programs, which are required to qualify for additional funded slots. The Consolidated Appropriations Act of 2021 (CAA Section 126), is designed to reduce geographic disparities in medical training and includes 1,000 new funded slots, with 200 available per year beginning in 2023 (Hawes 2022).

There is strong evidence that rural training in medical education has the potential to reduce disparities in access to care for rural patients by increasing the number of physicians who choose to practice in rural areas (Johnson 2018, Guilbault 2017, Cochrane-Grobler 2015, Goodfellow 2016, Wheat 2017, Nelson 2017, McCarthy 2015).

Clinical training in both rural and urban underserved areas significantly increases the likelihood that medical students will practice in underserved areas and makes it even more likely they will choose to practice primary care there (Guilbault 2017). Primary care physicians have increased in both rural and urban counties, though increases have been greater in urban areas; further efforts are needed to recruit additional providers to care for rural communities (Zhang 2020d).

Whether medical students have a rural background is a key predictor of if they will choose to practice in rural communities as physicians (Johnson 2018). Medical training in rural areas triples the likelihood of choosing rural practice (Guilbault 2017). However, relative to the nation’s population overall, rural students are underrepresented in medical schools. Efforts to increase diversity of medical school classes should consider how to recruit and retain underrepresented minorities (URMs) and non-URM rural students (Wheat 2023, Shipman 2019). Minority physicians appear to be more likely to practice in underserved, high-need areas than their non-minority peers (Goodfellow 2016).

A small, Washington-based study suggests that medical students who identify as Black, Indigenous, and People of Color (BIPOC) may experience more anxiety when training in majority white rural communities than during urban placements (Cedeno 2023). Experts recommend that rural training locations and medical schools support BIPOC students through efforts such as cultural competency training for faculty, rural preceptors, and all medical students (COGME-Rural health workforce); this training should continue throughout professional practice, allowing providers to better understand and care for the communities they serve (Young 2016a, COGME-Rural health workforce).

Rural patients who identify as non-white can also benefit from a diverse health care workforce. Increasing diversity among health professionals and expanding opportunities for patients to be cared for by health professionals of the same race or who speak the same language may reduce disparities in the quality and use of care, along with improving patient satisfaction and communication between patients and providers (AHRQ-Kronick 2014, Gilliss 2010, CWF-Cooper 2004). In some circumstances, patients visiting providers of the same race has been associated with improved appointment attendance, adherence to care plans, and better health outcomes; however, additional evidence is needed to confirm these effects. Generally, how well and how long providers have known their patients appears to have a stronger influence on positive patient health outcomes than race concordance (Meghani 2009).

As rural health care facilities consolidate, relocate, or close, the distances patients must travel to clinics can become even greater, further reducing access to care, particularly from specialists (SGA-Thakkar 2023). As of 2022, 19% of Americans live in rural areas and rural communities are aging rapidly: models indicate that by 2040, rural communities will be made up of 25% of households that are 65 years old or older, compared to only 20% in urban communities (SGA-Thakkar 2023). Rural and urban mortality in the U.S. also differ significantly, with higher rural mortality associated with income, race, ethnicity, education, insurance status, primary care physician supply, and health behaviors; rural populations generally have higher rates of chronic health conditions and experience more poverty (Zabel 2023). Pregnancy-related mortality is also higher in rural areas, and some reports estimate more than half of rural U.S. counties do not have a hospital offering prenatal or labor and delivery care (COGME-Rural health workforce).

Rural training tracks and programs in the U.S. attempt to address the shortage of rural physicians and health care providers. Early medical schools in the U.S. originally had high enrollment, low costs for attendance, minimal laboratory facilities, and few entrance standards. In the late 1800s, European-trained physicians returning to the U.S. advocated for more rigorous entrance requirements and curricula (Moehling 2020), though in contrast to Germany, for example, the U.S. remained without a national social health insurance system. In 1907, the American Medical Association (AMA) began publishing medical school ratings (Moehling 2020). Shortly after, medical system reformer Abraham Flexner’s 1910 report evaluating the quality of American and Canadian medical schools asserted that there were too many inadequate medical schools producing poorly trained physicians (Duffy 2011). The Flexner Report contributed to decisions to virtually end women’s admission to medical schools until the 1970s and to close five out of seven historically Black medical colleges and severely restrict Black students' admittance to other schools (Barkin 2010, Laws 2021). Medical school programs standardized (Barkin 2010) and began charging higher tuition and fees, which further limited who could attend. At the same time, graduates may have been drawn to urban areas post-graduation due to higher salaries, larger patient bases and networks of health professionals, and more modern technology and facilities, such as laboratories (Moehling 2020). By the 1920s, public health officials warned that fewer providers were practicing in rural areas (Moehling 2020).

For most of American history, access to higher education and health professional schools was reserved for white males, typically from wealthier backgrounds. In the 1960s and 1970s, there were efforts to increase access to college and health professional schools for students identifying as minorities, from low income backgrounds, and for women. Recruitment efforts, pipeline programs, and affirmative action policies were designed to address the long history of structural barriers that prevented underrepresented minority students from enrolling in higher education, including medical schools (Toretsky 2018, Figueroa 2014, Thelin 2022, US ED-Harvill 2012, NCES-Gandara 2001). However, available evidence suggests that substantial racial disparities persist in college and medical school enrollment, as well as in health professional employment (Toretsky 2018, Figueroa 2014, NCES-Gandara 2001).

Historically, rural training in medical education was not considered a priority by large teaching hospitals or the Centers for Medicare and Medicaid Services (CMS); the few programs that existed in rural areas received substantially less federal funding and support than programs in urban or suburban areas (Zabel 2023, Hawes 2022). However, family medicine has a history of training rural providers and continues to have a much better provider-to-population ratio in rural areas, compared with internal medicine (Zabel 2023).

The number of medical students with rural backgrounds has been declining since the early 2000s and underrepresented minority students with rural backgrounds remain a small percentage of medical students; for example, less than 0.5 percent of new students in 2017 (Shipman 2019). Half of rural physicians are over 55 and a third are scheduled to retire by 2033 (STAT-Empinado 2023), so there continues to be a substantial need to train and retain rural providers.

• How can medical school program administrators connect with rural practices to establish rural training opportunities? How can programs support faculty and rural preceptors in connecting with interested students?
• Who else can support medical schools and rural medical practices in maintaining strong training pipelines? How might rural students benefit from formal or informal networks of support throughout their medical training?
• When do rural pipeline programs for students interested in pursuing medicine begin in your community (e.g., middle school, high school, college)? How could programs be added or expanded to provide steady support for participants, including for underrepresented minorities, throughout their academic and medical careers?
• What additional strategies can be implemented to retain providers in rural areas? How might scholarships, loans, and debt forgiveness programs offset the costs of medical education and potential lower salaries?

In 2023, the Health Resources and Services Administration estimated that 65% of rural areas are experiencing a primary care physician shortage. While approximately 46 million Americans live in rural communities, they are cared for by only 10% of the nation’s physicians (STAT-Empinado 2023).

There are a growing number of medical schools with programs that provide rural-specific training. Examples include the state university systems of Illinois, Missouri, and Wisconsin (Zink 2010, Glasser 2008, UICOMR-RMED, MU-Rural Scholars, UWSMPH-WARM); the State University of New York (SUNY) Upstate Medical University’s Rural Medical Scholars Program (SUNY Upstate-RMSP); Thomas Jefferson University’s Sidney Kimmel Medical College Physician Shortage Area Program (PSAP) (Jefferson-PSAP); the University of New Mexico’s School of Medicine Rural and Urban Underserved Program (UNM-RUUP); and the University of Kentucky’s Rural Physician Leadership Program (RPLP) (UK-RPLP).

The University of Washington School of Medicine’s Targeted Rural Underserved Track (TRUST) provides rural-specific training through a network of residency programs which care for underserved communities in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) (UWSOM-TRUST). The University of Alabama’s Rural Health Leaders Pipeline to Engage Community Leaders program supports rural students interested in pursuing medicine from high school through medical school, with the goal that students will return to care for their home communities as physicians (UA-Rural programs, Wheat 2021).

The University of Kansas School of Medicine’s Scholars in Rural Health program offers early medical school acceptance to Kansas undergraduate sophomores intending to become rural physicians. The program provides juniors and seniors with a rural physician mentor and strongly considers students that are first generation college attendees and/or from health professional underserved areas (KU-Scholars in Rural Health).

‡ Resources with a focus on equity.

RHIhub-Rural health disparities^‡ - Rural Health Information Hub (RHIhub). Rural health disparities: Frequently asked questions.

RMTC - Rural Medical Training Collaborative (RMTC). (n.d.). Growing the next generation of rural medical professionals. Retrieved July 22, 2025.

STAT-Empinado 2023^‡ - Empinado H. Treating rural America: The last doctor in town. STAT: Reporting from the frontiers of health and medicine. 2023.

UWSOM-TRUST - University of Washington School of Medicine (UWSOM). Targeted Rural Underserved Track (TRUST), caring for underserved communities in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI).

* Journal subscription may be required for access.

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UWSMPH-WARM - University of Wisconsin School of Medicine and Public Health (UWSMPH). Wisconsin Academy for Rural Medicine (WARM).

UWSOM-TRUST - University of Washington School of Medicine (UWSOM). Targeted Rural Underserved Track (TRUST), caring for underserved communities in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI).

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