Randall Longenecker

Background and Objectives: Although rural family medicine residency programs are effective in placing trainees into rural practice, many struggle to recruit students. Lacking other public measures, students may use residency match rates as a proxy for program quality and value. This study documents match rate trends and explores the relationship between match rates and program characteristics, including quality measures and recruitment strategies. Methods: Using a published listing of rural programs, 25 years of National Resident Matching Program data, and 11 years of American Osteopathic Association match data, this study (1) documents patterns in initial match rates for rural versus urban residency programs, (2) compares rural residency match rates with program characteristics for match years 2009-2013, (3) examines the association of match rates with program outcomes for graduates in years 2013-2015, and (4) explores recruitment strategies using residency coordinator interviews. Results: Despite increases in positions offered over 25 years, the fill rates for rural programs have improved relative to urban programs. Small rural programs had lower match rates relative to urban programs, but no other program or community characteristics were predictors of match rate. Match rates were not indicative of any of five measures of program quality nor of any single recruiting strategy. Conclusions: Understanding the intricacies of rural residency inputs and outcomes is key to addressing rural workforce gaps. Match rates likely reflect challenges of rural workforce recruitment generally and should not be conflated with program quality.

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.

Problem: The need to increase the number of culturally responsive physicians, particularly primary care physicians, serving in rural and urban underserved communities is well documented. To address this need, an increasing number of medical schools are implementing separate rural or urban underserved training programs or tracks. Intervention: The Rural and Urban Scholars Pathways program is designed as an integrated program, not as separated tracks, and includes critical reflection groups, professional development workshops, individual coaching, a scholarly project, and immersion experiences. The program does not separate students by initial interest in either rural or urban underserved practice settings, but rather promotes their interactions across all four years. Students can join (or leave) RUSP in any year of medical school and, although strongly encouraged toward eventual practice in an underserved community, students are not committed to a specific specialty or practice location. Context: The RUSP program was developed and implemented at the Heritage College of Osteopathic Medicine at Ohio University in 2013 with a grant from the Osteopathic Heritage Foundations. The program resides within the Office of Rural and Underserved Programs at the Heritage College and is one of many medical school programs across the country aimed at producing more physicians for rural and urban underserved communities. RUSP is now funded by the College. Impact: Overall, based on a 60% return rate in 2019–2020, students in all four years report that the RUSP program enhances their professional, personal, social, and academic development. Cumulatively, 67% have matched into specialties with primary care potential, including family medicine, pediatrics, general internal medicine and internal medicine-pediatrics. Of the 14 RUSP graduates in practice, six are practicing primary care in rural locations and five are practicing primary care in urban locations. Five of the fourteen are practicing in communities officially designated as underserved. Lessons Learned: Offering flexibility via a pathways model promotes continuing individual and program growth and expansion. A co-curricular strategy allows for nimble program refinement but requires significant volunteer time commitment from faculty and staff. Having clear program goals, a logic model, and mechanisms for gathering and analyzing student experiences help to maintain program focus and allow for ongoing formative and periodic summative evaluation of short-term and long-term objectives.

Healthy governance is important to cultivate in any graduate medical education (GME) program. It is especially important to rural programs called integrated rural training tracks (RTTs) that span geographic distances and accommodate significant differences in health system culture and institutional scale.1 Collaboration is both their strength and vulnerability, and addressing authority, decision-making, and accountability in healthy ways is key to their sustainability.2 The sparse literature that exists focuses on centralized urban settings and lacks relevance to distributed rural programs.3,4 For this reason we wish to share our personal expertise in advising rural programs and the wisdom accumulated among a community of rural program directors.Unique challenges exist for the smaller rural entity in an RTT, for whom crafting an affiliation agreement with a large academic medical center can feel like “dancing with elephants.”5 Rural program directors, like their urban colleagues, frequently report to multiple individuals, but in disparate places and cultural settings. Over the past decade there has been a steady trend in rural hospitals affiliating with larger urban health organizations, so that now more than 50% of non-metropolitan hospitals have become part of a larger health care system.6 When a residency program's rural and urban participating institutions are combined under a common central governing body, these institutions must proactively work to ensure a continuing healthy relationship.Affiliations defined by “interdependence” best serve the joint educational venture represented by an RTT, bringing benefits to both urban and rural hospitals (Table). Executing a shared value proposition in designing, developing, and maintaining an RTT requires visionary leadership with an investment mentality and special attention to those benefits that are indirect or delayed.Good governance is participatory, explicit, accountable, effective and efficient, equitable, inclusive, and receptive.3 These general principles, applied in tribal settings, can be specifically adapted to RTTs.7 From our experience in advising developing and existing rural programs, we propose 5 principles of healthy governance particularly key to their sustainability. Urban academic centers and large health systems that strategically share authority and decision-making with rural communities will significantly increase the odds that these GME programs will be sustained, their social mission accomplished, and health improved in rural populations.Engage the rural community in the design, development, and implementation of the program. Frank Lloyd Wright introduced organic architecture more than a century ago, designing houses that perfectly fit the place in which they were built. In the same way, an organic approach to residency design and implementation begins with the assets and capacity of the rural community, then works within the rules of accreditation, finance, and governance to creatively adapt them to local realities rather than imposing a structure that may not fit.8Language is important in reflecting shared ownership and decision-making. The urban program with which an RTT is affiliated is often labeled the “core,” even among its leaders, faculty, and residents. Although almost certainly well-intentioned, this naming structurally defines a relationship that is neither equal nor equitable. Successful residency programs acquire names and identities they can own, establishing community pride and shared responsibility.Intentionally engage the community in governance. Federally Qualified Health Centers set an excellent example of shared governance in the clinical realm, with boards of directors led by patients, empowering the local community.9 A community group advisory to a rural residency can engage local businesses, organizations, schools, even faith-based organizations in addition to health care professionals and patients. In return, the program director can deliberately place faculty and residents on community boards or service clubs.All organizational relationships are fundamentally personal, and fostering these relationships promotes mutual respect and influence.3,10 Generative relationships between rural hospital and rural residency leadership lead to program improvement and innovation and impact program longevity. For example, the authors have witnessed rural hospital executives and board members who have long-cultivated relationships with program leadership choose to bear the costs of the residency during times of financial stress because they were individually convinced of the value of the program to the hospital and community.Purposefully integrate decision-makers from each participating institution's governing body into the fabric of the sponsoring institution (SI). Consider key GME office roles for rural site leaders and look for ways to promote continuity, engaging both faculty and residents from the rural program. Empower rural leadership by implementing a unifying central focal point of organizational decision-making.6 Where there are dual or even greater number of reporting relationships, it is important to establish and regularly revisit clear lines of accountability and closed-loop processes so that decisions are revisited after a predetermined period of time.A transparent and regularly communicated budget process with explicit justification and annual reconciliation is essential not only to planning, but also as a scaffold for critical conversations. GME finance is complicated, and difficult issues are not always immediately apparent. Limited knowledge sharing between rural and urban hospitals and a lack of transparency and shared decision-making have contributed to the demise of some RTTs.2 Simply assuming things are going well until there is clear evidence to the contrary is a formula for failure. When difficulties arise, healthy governance fosters...

Rural regions of the United States continue to experience a disproportionate shortage of physicians compared to urban regions despite decades of state and federal investments in workforce initiatives. The graduate medical education system effectively controls the size of the physician workforce but lacks effective mechanisms to equitably distribute those physicians. We created a measurement tool called a “rural workforce year” to better understand the rural primary care workforce. It quantifies the rural workforce contributions of rurally trained family medicine residency program graduates and compares them to contributions of a geographically matched cohort of non-rurally trained graduates. We identified graduates in both cohorts and tracked their practice locations from 2008–2018. We compared the average number of rural workforce years in 3 cross sections: 5, 8, and 10 years in practice after residency graduation. Rurally trained graduates practicing for contributed a higher number of rural workforce years in total and on average per graduate compared to a matched cohort of non-rural/rural training tack (RTT) graduates in the same practice intervals (P < .001 in all 3 comparison groups). In order to replace the rural workforce years produced by 1 graduate from the rural/RTT cohort, it would take 2.89 graduates from non-rural/RTT programs. These findings suggest that rural/RTT-trained physicians devote substantially more service to rural communities than a matched cohort of non-rural/RTT graduates and highlight the importance of rural/RTT programs as a major contributor to the rural primary care workforce in the United States.