Characteristics and Distribution of Graduate Medical Education Training Sites: Are We Missing Opportunities to Meet U.S. Health Workforce Needs?

Growing a rural family physician workforce: The contributions of rural background and rural place of residency training

OBJECTIVE

To determine the distinct influences of rural background and rural residency training on rural practice choice among family physicians.

DATA SOURCES AND STUDY SETTING

We used a subset of The RTT Collaborative rural residency list and longitudinal data on family physicians from the American Board of Family Medicine National Graduate Survey (NGS; three cohorts, 2016-2018) and American Medical College Application Service (AMCAS).

STUDY DESIGN

We conducted a logistic regression, computing predictive marginals to assess associations of background and residency location with physician practice location 3 years post-residency.

DATA COLLECTION/EXTRACTION METHODS

We merged NGS data with residency type-rural or urban-and practice location with AMCAS data on rural background.

PRINCIPAL FINDINGS

Family physicians from a rural background were more likely to choose rural practice (39.2%, 95% CI = 35.8, 42.5) than those from an urban background (13.8%, 95% CI = 12.5, 15.0); 50.9% (95% CI = 43.0, 58.8) of trainees in rural residencies chose rural practice, compared with 18.0% (95% CI = 16.8, 19.2) of urban trainees.

CONCLUSIONS

Increasing rural programs for training residents from both rural and urban backgrounds, as well as recruiting more rural students to medical education, could increase the number of rural family physicians.

Possible relationship between rural surgical rotations during a residency period and an increased number of general surgeons in rural areas: a systematic review

Objective: Rural surgical training for residents is expected to increase the number of general surgeons working in rural areas; however, the impact of rural training programs to ensure such surgeons remains to be determined. Therefore, we reviewed the relevance of rural surgical rotation to the increase of general surgeons in rural areas. Materials and Methods: Studies on the outcomes of rural surgical rotations during the residency period in comparison to non-rural surgical rotations were retrieved using electronic databases through April 2022. Results: Among the 514 articles, five were eligible for review. All studies were published in the United States. Four studies reported an increased number of general surgeons in rural areas owing to rural surgical rotations. A meta-analysis of all studies showed a positive impact on the number of general surgeons in rural areas (odds ratio=2.19, 95% confidence interval=1.23-3.91). The programs generally ranged from 2 to 12 months with extensive experience with minor surgery and subspecialties necessary for surgery. Conclusions: Rural surgical rotations during the residency period can increase the number of general surgeons working in rural areas. Further studies are needed to evaluate the placement of general surgeons in rural areas.

Family Medicine Residencies: How Rural Training Exposure in GME Is Associated With Subsequent Rural Practice

BACKGROUND

Rural US populations face a chronic shortage of physicians and an increasing gap in life expectancy compared to urban US populations, creating a need to understand how to increase residency graduates' desire to practice in such areas.

OBJECTIVE

This study quantifies associations between the amount of rural training during family medicine (FM) residencies and subsequent rural work.

METHODS

American Medical Association (AMA) Masterfile, AMA graduate medical education (GME) supplement, American Board of Family Medicine certification, Accreditation Council for Graduate Medical Education (ACGME), and Centers for Medicare and Medicaid Services hospital costs data were merged and analyzed. Multiple logistic regression measured associations between rural training and rural or urban practice in 2018 by all 12 162 clinically active physicians who completed a US FM residency accredited by the ACGME between 2008 and 2012. Analyses adjusted for key potential confounders (age, sex, program size, region, and medical school location and type) and clustering by resident program.

RESULTS

Most (91%, 11 011 of 12 162) residents had no rural training. A minority (14%, 1721 of 12 162) practiced in a rural location in 2018. Residents with no rural training comprised 80% (1373 of 1721) of those in rural practice in 2018. Spending more than half of residency training months in rural areas was associated with substantially increased odds of rural practice (OR 5.3-6.3). Only 4% (424 of 12 162) of residents spent more than half their training in rural locations, and only 5% (26 of 436) of FM training programs had residents training mostly in rural settings or community-based clinics.

CONCLUSIONS

There is a linear gradient between increasing levels of rural exposure in FM GME and subsequent rural work.

A Mixed-Methods Study of Teaching Health Center Residents' Experiences of Mentorship, Career Planning, and Postresidency Practice Environments

PURPOSE

The Teaching Health Center (THC) Graduate Medical Education program enables primary care physicians to train in community-based, underserved settings by shifting the payment structure and training environment for graduate medical education. To understand how THCs have successfully trained primary care physicians who practice in community-based settings, the authors conducted a mixed-methods exploratory study to examine THC residency graduates' experiences of mentorship and career planning during their residencies, perceptions of preparation for postresidency practice, and how these experiences were related to postresidency practice environments.

METHOD

Surveys were conducted for all 804 graduating THC residents nationally, 2014-2017 (533 respondents, 66% response rate). Three quantitative outcomes were measured: graduates' perceptions of preparation for practice after residency (Likert scale), satisfaction with mentorship and career planning (Likert scale), and characteristics of postresidency practice environment (open-ended). A qualitative analysis of open-text survey answers, using thematic content analysis, was also conducted.

RESULTS

Most THC graduates (68%) were satisfied with their mentorship and career planning experience and generally felt prepared for postresidency practice in multiple settings (78%-93%). Of the 533 THC graduates who provided information about their practice environment, 445 (84%) were practicing in primary care; nationally, 64% of physicians who completed primary care residencies practiced in primary care. Of the 445 THC graduates practicing in primary care, 12% practiced in rural areas, compared with 7% of all physicians. Just over half of THC graduates (51%) practiced in medically underserved areas, compared with 39% of all physicians.

CONCLUSIONS

This study offers early evidence that the THC model produces and retains primary care physicians who are well prepared to practice in underserved areas. Given these promising findings, there appears to be a substantial benefit to growing the THC program. However, the program continues to face uncertainty around ongoing, stable funding.

Factors Associated With Family Medicine and Internal Medicine First-Year Residents' Ambulatory Care Training Time

PURPOSE

Despite the importance of training in ambulatory care settings for residents to acquire important competencies, little is known about the organizational and environmental factors influencing the relative amount of time primary care residents train in ambulatory care during residency. The authors examined factors associated with postgraduate year 1 (PGY-1) residents' ambulatory care training time in Accreditation Council for Graduate Medical Education (ACGME)-accredited primary care programs.

METHOD

U.S.-accredited family medicine (FM) and internal medicine (IM) programs' 2016-2017 National Graduate Medical Education (GME) Census data from 895 programs within 550 sponsoring institutions (representing 13,077 PGY-1s) were linked to the 2016 Centers for Medicare and Medicaid Services Cost Reports and 2015-2016 Area Health Resource File. Multilevel regression models examined the association of GME program characteristics, sponsoring institution characteristics, geography, and environmental factors with PGY-1 residents' percentage of time spent in ambulatory care.

RESULTS

PGY-1 mean (standard deviation, SD) percent time spent in ambulatory care was 25.4% (SD, 0.4) for both FM and IM programs. In adjusted analyses (% increase [standard error, SE]), larger faculty size (0.03% [SE, 0.01], P < .001), sponsoring institution's receipt of Teaching Health Center (THC) funding (6.6% (SE, 2.7), P < .01), and accreditation warnings (4.8% [SE, 2.5], P < .05) were associated with a greater proportion of PGY-1 time spent in ambulatory care. Programs caring for higher proportions of Medicare beneficiaries spent relatively less time in ambulatory care (< 0.5% [SE, 0.2], P < .01).

CONCLUSIONS

Ambulatory care time for PGY-1s varies among ACGME-accredited primary care residency programs due to the complex context and factors primary care GME programs operate under. Larger ACGME-accredited FM and IM programs and those receiving federal THC GME funding had relatively more PGY-1 time spent in ambulatory care settings. These findings inform policies to increase resident exposure in ambulatory care, potentially improving learning, competency achievement, and primary care access.

Movers and Stayers: What Birthplaces Can Teach Us About Rural Practice Choice Among Midwestern General Surgeons

PURPOSE

This study compares practicing rural Midwestern general surgeons born in urban areas to those born in rural areas to describe the association between birthplace and current practice location.

METHODS

The 2017 AMA MasterFile was used to study general surgeons in the Midwest Census Division. Surgeons were assigned to categories based on birthplace and current practice locations: urban-urban stayers, urban-rural movers, rural-rural stayers, and rural-urban movers. Urban and rural classifications corresponded to the metropolitan and nonmetropolitan definitions with Rural-Urban Continuum Codes (urban, RUCCs 1-3; rural, RUCCs 4-9). Bivariate tests and logistic regression were used to determine factors associated with rural practice choice.

FINDINGS

There were 3,070 general surgeons in the study population: 70.6% urban-urban stayers, 13.1% urban-rural movers, 10.7% rural-urban movers, and 5.7% rural-rural stayers. Rural areas netted 74 surgeons (327 rural-urban movers versus 401 urban-rural movers). Logistic regression results found different factors predicted rural practice among urban-born versus rural-born surgeons. Older urban-born surgeons were more likely to practice rurally, as were male surgeons, DOs, and those trained in less-urban residency programs. Among rural-born surgeons, more rural birthplaces and having trained at a less-urban residency were associated with practicing rurally.

CONCLUSIONS

Recruiting urban-born surgeons to rural areas has proven successful in the Midwest; our findings show urban-born surgeons outnumber rural-born surgeons in rural communities. Given the ongoing need for surgeons in rural areas, urban-born surgeons should not be overlooked. Findings suggest educators and community leaders should expand less-urban training opportunities given their potential influence on all general surgeons.

Preparing Physicians for Rural Practice: Availability of Rural Training in Rural-Centric Residency Programs

BACKGROUND

Exposing residents to rural training encourages future rural practice, but unified accreditation of allopathic and osteopathic graduate medical education under one system by 2020 has uncertain implications for rural residency programs.

OBJECTIVE

We describe training locations and rural-specific content of rural-centric residency programs (requiring at least 8 weeks of rurally located training) before this transition.

METHODS

In 2015, we surveyed residency programs that were rurally located or had rural tracks in 7 specialties and classified training locations as rural or urban using Rural-Urban Commuting Area (RUCA) codes.

RESULTS

Of 1849 residencies in anesthesiology, emergency medicine, general surgery, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry, 119 (6%) were rurally located or offered a rural track. Ninety-seven programs (82%) responded to the survey. Thirty-six programs required at least 8 weeks of rural training for some or all residents, and 69% of these rural-centric residencies were urban-based and 53% were osteopathic. Locations were rural for 26% of hospital rotations and 28% of continuity clinics. Many rural-centric programs (35%) reported only urban ZIP codes for required rural block rotations; 54% reported only urban ZIP codes for required rural clinic sessions, and 31% listed only urban ZIP codes in reporting rural full-time training locations. Programs varied widely in coverage of rural-specific training in 6 core competencies.

CONCLUSIONS

In multiple specialties important for rural health care systems, little rurally located residency training and rural-specific content was available. Substantial proportions of training locations reported to be rural were actually urban according to a common rural definition.

Making rural health care better: How to attract interns to rural hospital

OBJECTIVE

We examined the factors that influence medical school graduates' choices for the place of internship, so that they can guide policy-makers to attract interns to rural hospitals.

DESIGN

A national survey.

SETTING

Rural and metropoles of Israel.

PARTICIPANTS

Three-hundred-and-thirty-nine interns who did their internships during the years 2016-2018.

MAIN OUTCOME MEASURE

The participants completed a web survey. We used the results of this survey to deduce which factors were influential in helping the interns choose a hospital for their year of internship.

RESULTS

We received 339 questionnaires from medical school graduates of years 2015-2017. We found that the most influential factors in attracting interns to rural hospital internships are the availability of desired residency and exposure to a rural curriculum in medical school. This far outweighed any economic or life quality incentives. In addition, we found that the exposure to rural hospitals during the medical school years increases the likelihood of choosing an internship in a rural hospital.

CONCLUSIONS

The most important factor for choosing a hospital for internship is the availability of lucrative residencies. Thus, we believe the best way to attract good interns would be to make the desired residency positions available for them. Furthermore, it might be more successful to target either students who have studied in a university affiliated with rural hospital rotations or graduates of universities outside of the country.

Rural training pathways: the return rate of doctors to work in the same region as their basic medical training

BACKGROUND

Limited evidence exists about the extent to which doctors are returning to rural region(s) where they had previously trained. This study aims to investigate the rate at which medical students who have trained for 12 months or more in a rural region return to practice in that same region in their early medical career. A secondary aim is to investigate whether there is an independent or additional association with the effect of longer duration of rural exposure in a region (18-24 months) and for those completing both schooling and training in the same rural region.

METHODS

The outcome was rural region of work, based on postcode of work location in 2017 for graduates spanning 1-9 years post-graduation, for one large medical program in Victoria, Australia. Region of rural training, combined with region of secondary schooling and duration of rural training, was explored for its association with region of practice. A multinomial logistic regression model, accounting for other covariates, measured the strength of association with practising in the same rural region as where they had trained.

RESULTS

Overall, 357/2451 (15%) graduates were working rurally, with 90/357 (25%) working in the same rural region as where they did rural training. Similarly, 41/170 (24%) were working in the same region as where they completed schooling. Longer duration (18-24 vs 12 months) of rural training (relative risk ratio, RRR, 3.37, 1.89-5.98) and completing both schooling and training in the same rural region (RRR: 4.47, 2.14-9.36) were associated with returning to practice in the same rural region after training.

CONCLUSIONS

Medical graduates practising rurally in their early career (1-9 years post-graduation) are likely to have previous connections to the region, through either their basic medical training, their secondary schooling, or both. Social accountability of medical schools and rural medical workforce outcomes could be improved by policies that enable preferential selection and training of prospective medical students from rural regions that need more doctors, and further enhanced by longer duration of within-region training.

Health care eligibility and availability and health care reform: Are we addressing rural women's barriers to accessing care?

BACKGROUND

Rural populations in the U.S. face numerous barriers to health care access. The Patient Protection and Affordable Care Act (PPACA) was developed in part to reduce health care access barriers. We report rural women's access barriers and the PPACA elements that address these barriers as well as potential gaps.

METHODS

For this qualitative study, we analyzed two datasets using a common framework. We used content analysis to understand rural, focus group participants' access barriers prior to PPACA implementation. Subsequently, we analyzed the PPACA text.

RESULTS

Participants described health care access barriers in two domains: availability and eligibility. The PPACA proposes solutions within each domain, including health care workforce training, Medicaid expansion, and employer-based health care provisions. However, in rural settings, access barriers likely persist.

DISCUSSION

While elements of the PPACA address some health care access barriers, additional research and policy development are needed to comprehensively and equitably address persistent access barriers for rural women.

Bolstering the pipeline for primary care: a proposal from stakeholders in medical education

The Association of American Medical Colleges reports an impending shortage of over 90,000 primary care physicians by the year 2025. An aging and increasingly insured population demands a larger provider workforce. Unfortunately, the supply of US-trained medical students entering primary care residencies is also dwindling, and without a redesign in this country's undergraduate and graduate medical education structure, there will be significant problems in the coming decades. As an institution producing fewer and fewer trainees in primary care for one of the poorest states in the United States, we propose this curriculum to tackle the issue of the national primary care physician shortage. The aim is to promote more recruitment of medical students into family medicine through an integrated 3-year medical school education and a direct entry into a local or state primary care residency without compromising clinical experience. Using the national primary care deficit figures, we calculated that each state medical school should reserve 20-30 primary care (family medicine) residency spots, allowing students to bypass the traditional match after successfully completing a series of rigorous externships, pre-internships, core clerkships, and board exams. Robust support, advising, and personal mentoring are also incorporated to ensure adequate preparation of students. The nation's health is at risk. With full implementation in allopathic medical schools in 50 states, we propose a long-term solution that will serve to provide more than 1,000-2,700 new primary care providers annually. Ultimately, we will produce happy, experienced, and empathetic doctors to advance our nation's primary care system.