ABSTRACT

Background

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.

Objective

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.

Methods

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.

Results

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.

Conclusions

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.

What was known and gap

Graduates from rural and RTT residency programs are more likely to practice in rural communities when compared to non-rural programs, but comparative retention rates and workforce contributions in rural practice were unknown for rural and non-rural programs in geographic proximity.

What is new

In order to replace the rural workforce years produced by 1 graduate from a rural or RTT residency program, it would take nearly 3 graduates from a non-rural program.

Limitations

The AMA Masterfile is limited by incomplete osteopathic residency program data and a time lag that may impact the practice address of physicians included in the study.

Bottom line

We challenge existing state and federal programs designed to address the maldistribution of physicians in the United States to consider using the rural workforce year to quantify their contribution to the rural workforce.

Introduction

The graduate medical education (GME) system in the United States effectively controls the overall size and makeup of the physician workforce.1  Yet despite a more than $15 billion public investment in GME, we lack accountability measures and mechanisms to align GME training outcomes with community health needs.2  This problem is particularly evident in rural areas, where 19% of the US population is served by less than 5% of all physicians.36  Deficiencies in rural workforce and access to care were well-known prior to the COVID-19 pandemic, which has only heightened awareness of each as already-challenged rural hospitals and primary care practices now struggle for their survival just as they are most needed.7,8 

Several interventions have been proposed to address the geographic maldistribution of the US physician workforce.916  Policymakers and workforce planners increasingly view community-based education and training in medical school and residency, including rural training tracks or integrated rural training track residencies (RTTs or IRTTs, which are synonymous), as a solution, citing clear but limited evidence that graduates tend to practice in close proximity to their training locations.1723  These programs located in rural areas have been successfully sending graduates to practice in rural communities at higher rates than graduates from other residency programs without meaningful rural training exposure.24  For these reasons, some have argued that training programs like RTTs represent a better investment of public dollars than non-rural residency programs for developing a physician workforce that addresses the geographic inequities of access to medical care throughout the United States.25,26  However, to our knowledge, the workforce contributions of RTT programs have never been compared to a matched cohort of non-rural programs in nearby geographic areas. This analysis adds to our understanding of the comparative workforce contributions while controlling for differences in residents' training experiences within the rural-urban continuum.

Federal investment in rural residency programs from the Health Resources and Services Administration (HRSA) through the Rural Residency Planning and Development Program in 2019–2020 necessitates further evidence of their overall success in developing a primary care physician workforce that serves rural needs. In this article, we describe GME impact on rural access to primary care physicians and present a new measure, the “rural workforce year,” as a means of quantifying the contributions of graduates of various GME program types to the rural workforce. We then apply these methods to compare outcomes of rural programs (including RTTs) to a geographically matched cohort of non-rural and non-RTT programs.

Our “rural workforce year” is an extension of Bowman's proposed “primary care year,” but focuses its application in a rural workforce context.27  Bowman proposed the “primary care year” as a standardized measurement tool to compare the primary care workforce contributions between family physicians and all other health professionals (eg, nurse practitioners, physician assistants, general internists, and pediatricians). Bowman does not apply this measure to assess the workforce contributions of GME training programs. In contrast, our rural workforce year is specific to the contributions of family medicine physicians (while avoiding a comparison between other specialties and/or health professions) and provides further rationale for targeting educational investment in rural/RTT programs to support and sustain the rural physician workforce.

Methods

In this retrospective cohort study, we used a 2013 directory from the Accreditation Council for Graduate Medical Education to obtain residency program locations and characteristics. We cross-referenced this list with a directory of rural programs created by The RTT Collaborative and identified each of the rural programs, including RTTs, active in 2013.28  We adopted The RTT Collaborative definition of a rural program in family medicine, which is a residency program where residents spend more than 50% of their time training in a rural place by at least 2 federal definitions. This includes separately accredited programs that are both rurally focused and rurally located and are integrated and affiliated with another program (typically larger, urban) as a deliberate rural track.29  We then selected a corresponding geographically matched cohort of non-rural programs from the same state (table 1). If no non-rural/RTT residency programs were located within the same state as the rural/RTT program(s), we found a program from a neighboring state that was geographically closest to a rural/RTT program.

table 1

List of Sample Programs

List of Sample Programs
List of Sample Programs

We used 2013 American Board of Family Medicine (ABFM) residency program identifiers to include family medicine graduates from each of the rural/RTT and matched control family medicine residency programs from 2007 to 2013. We then matched the ABFM sample to the American Medical Association (AMA) Physician Masterfile for each year from 2008 to 2018 to track those graduates through their primary practice location from 2008 to 2018. We geocoded the practice locations from 2008 to 2018. Rural was defined as a county with a 2013 Rural-Urban Continuum Code (RUCC) of 4 or greater.30  The RUCC is a classification system that distinguishes metropolitan counties by the population size of their metro area and nonmetropolitan counties by degree of urbanization and adjacency to a metro area. We selected the RUCC classification system because it is suited for binary rural/non-rural distinction at the county level. We restricted the sample to residency graduates from 2007 to 2013 with a self-reported specialty in family medicine (to remove those who had further specialized). We considered a physician to be practicing if their status was classified as direct patient care in the AMA Masterfile for a given year.

We measured the total years that graduates participated in the rural workforce (rural workforce years) and the percentage of their total practice years spent in rural areas. We calculated average rural workforce years per graduate for the rural/RTT and the matched cohort by multiplying average practice years by the average share of total workforce years in a rural location. Then, we divided average rural workforce years per graduate by the rural/RTT cohort average rural workforce years per graduate to calculate how many matched graduates were needed to match the rural workforce year contribution of the rural/RTT graduates. To further explore their contributions to the rural workforce, we grouped each of the rural/RTT and matched cohorts by graduation year (2007–2013) and tracked them longitudinally from 2008 to 2018, beginning 1 year after the year of residency graduation. We assessed contribution of rural workforce years at 3 cross-sections: 5, 8, and 10 years in practice. We conducted t tests to compare the rural workforce years between rural/RTT graduates and the matched cohort. Next, we conducted a multivariate linear regression testing the association between the dependent variable, percent of total practice years that were rural workforce years, and the independent variable of interest, rural/RTT residency program graduation status, accounting for clustering at the program level. Covariates included total years in practice, gender, US medical graduate (USMG) or international medical graduate (IMG), degree type (MD/DO), region, and age at residency start.

Statistical analysis was conducted using STATA 14.2 (StataCorp LLC, College Station, TX). The study was approved by the Institutional Review Board of the American Academy of Family Physicians.

Results

The final sample consisted of 1791 physicians, 682 in the rural/RTT cohort and 1109 in the control cohort, from 29 rural/RTT programs and 29 matched programs (table 1, online supplemental table 1). We found that the rural/RTT cohort contributed a greater number of rural workforce years both in aggregate and per physician compared to the non-rural/RTT cohort (table 2). 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 (table 2). In our sample, this is an additional 865 non-rural/RTT physicians. Collectively, graduates from the rural/RTT cohort spent over 50% of their professional time in rural locations during our study period, while graduates from non-rural programs only spent 18% of their time in rural locations (figure 1).

table 2

Total and Standardized Rural Workforce Years

Total and Standardized Rural Workforce Years
Total and Standardized Rural Workforce Years
figure 1

Average Percent of Total Practice Years That are Rural Workforce Years

figure 1

Average Percent of Total Practice Years That are Rural Workforce Years

For graduates in practice for 10 years, the cohort of rurally trained physicians contributed an average of 5.24 rural workforce years, while the average rural workforce year contribution for non-rural/RTT physicians was 2.03 years (P < .001; table 2). For graduates in practice for 8 years, rural/RTT graduates had an average of 4.46 rural workforce years compared to the matched cohort's 1.43 (P < .001). Of those in practice for 5 years, rural/RTT graduates contributed 2.77 years in practice and non-rural/RTT graduates contributed 0.89 (P < .001). Of all rural/RTT program graduates, 44% contributed at least 5 rural workforce years, while 31% contributed none (table 3).

table 3

Average Rural Workforce Years by Cohort Type and Years in Practice

Average Rural Workforce Years by Cohort Type and Years in Practice
Average Rural Workforce Years by Cohort Type and Years in Practice

The effect of program type (rural/RTT versus geographic match) was statistically significant in the adjusted model with all covariates included (figure 1). Significant predictors of higher rural workforce years also include DO degree compared to MD degree, USMG status compared to IMG status, and age less than 30 at residency start compared to 30 and above (figure 1). We found no statistically significant differences in rural workforce contribution between regions of training or between men and women in either cohort (figure 1).

Of the 29 rural/RTT programs, 19 were rural programs located in geographies with a RUCC score of 4 or greater (online supplemental table 2); 10 had primary sites located in geographies with RUCC scores less than 4, but each of those programs were RTTs where residents generally spend the first year in a metro location and the final 2 years of residency in non-metro or metro-adjacent locations (and the metro site was listed as the primary site in the program database used to collect this information). Four non-rural/RTT programs were in large metropolitan areas with a population of 1 million or more (RUCC score of 1), 12 in areas with 250 000 to 1 million people (RUCC score of 2), and 12 in areas with a population of fewer than 250 000 people (RUCC score of 3). There was also 1 non-rural/RTT program located in a small urban area of 2500 to 19 999 people with a RUCC score of 5.

For each class of rural/RTT graduates from 2007 through 2013, the proportion entering the rural workforce peaked in the first 3 to 5 years of their career while the trend lines for non-rural/RTT graduates remained relatively flat (figure 2).

figure 2

Percent of Graduates Practicing in Rural Areas per Year by Residency Graduation Year

figure 2

Percent of Graduates Practicing in Rural Areas per Year by Residency Graduation Year

Discussion

Taken together, these findings suggest that compared with a matched cohort of non-rural/RTT graduates, rural/RTT graduates devote more service to rural communities, both in the proportion entering rural communities and number of rural workforce years contributed per graduate. These findings were consistent across each of the cross-sections of time in practice and across the 10-year study time frame. This also corroborates earlier research using a similar time period suggesting that rural and RTT residency programs are a major contributor for training physicians to work in rural communities.25,26 

While the total number of residents included in our sample is approximately 14% of all US family medicine residents and the number of included residency programs is 9% of all US family medicine residency programs, we feel that our sample is representative of training sites across the United States.31  We therefore believe that these findings show that rural/RTT programs make the best investment to strengthen and support the rural physician workforce.

We also found that 31% of rural/RTT graduates do not contribute to the rural workforce at all. This is consistent with previous literature that found rural/RTT programs place approximately 70% of graduates in rural regions.22,32 

We noted several other important findings that would benefit from further exploration, including differences in the contributions of rural workforce years between osteopathic and allopathic physicians, USMG and IMG physicians, and age at the start of residency. Across all covariates, the percentage of residents from rural/RTT programs working in rural areas appears to decrease over time. This is a well-known phenomenon but would benefit from further study as well.

While there is likely some selection bias within our sample, we do not believe this is the central reason for the success of rural/RTT programs. Many studies have assumed this, but it is an area of research that needs further exploration. While rural upbringing has been associated with a 2.35-fold increase in the relative likelihood of practicing in a rural area as compared to those who grow up in non-rural areas, it is also true that only 5% of medical students and approximately 25% of practicing rural physicians claim a rural upbringing.3237  This suggests that a majority of physicians with rural upbringing actually choose to work in non-rural environments. Similarly, if 75% of rural physicians have a non-rural upbringing, other factors must contribute to their career choice (eg, exposure to rural practice environments in clinical training).

Several limitations of this study should be considered. The American Medical Association (AMA) Masterfile may not capture all osteopathic physicians who graduated from solely American Osteopathic Association (AOA)–accredited residency programs. Therefore, the structure of the AMA Masterfile and the ABFM survey databases necessitated the exclusion of the solely AOA-accredited residency programs from our analysis. The AMA Masterfile has a time lag in updating the practice location of new graduates and may occasionally misidentify practice address. The AMA Masterfile only includes one office location per physician, so we cannot account for physicians who practice in rural areas on a secondary basis. We were also unable to account for other variables that have been shown to influence rural practice including marital status or rural birthplace of physicians.23,24,3847 

Additionally, our matched cohort was generated by reviewing the ABFM list of residency programs active in 2013 and finding the closest geographic match to programs in our rural/RTT sample. We may have overlooked residency programs that could be considered more precise matches for one of the rural/RTT programs. There also may be distinct cultural, socioeconomic, or demographic differences between the matched programs in each of the cohorts, which could limit their utility as a matched pairing.

This publication also may be useful to support current policy efforts to expand rural training opportunities. As noted above, the HRSA recently committed $28 million toward the development of new rural training opportunities through the Rural Residency Planning and Development Program. This program will help address the geographic disparity in access to medical care in rural communities and represents an opportunity to further study the efficacy of rural training programs.

We challenge existing state and federal programs designed to address the maldistribution of physicians in the United States to consider using the rural workforce year to quantify their contribution to the rural workforce. These include loan forgiveness programs through the National Health Service Corps, J-1 Visa waivers for IMGs, or debt-free medical education programs (eg, New York University Medical School or the Primary Care Scholars Program at Geisinger Commonwealth School of Medicine). Using the rural workforce year as a tool in this context would help improve our understanding of the relative efficacy of these programs to address the maldistribution of our primary care physicians and inform critical workforce funding decisions at the state and federal levels.

Conclusions

Our findings support and build upon previous research on the utility of decentralizing GME outside of non-rural health centers to address the geographic maldistribution of physicians. To meet the rural workforce contributions of one graduate from a rural/RTT program (measured in rural workforce years), nearby non-rural/RTT programs would need to nearly triple their current production of graduates.

References

References
1.
Petterson
SM,
Liaw
WR,
Phillips
RL,
Rabin
DL,
Meyers
S,
Bazemore
AW.
Projecting US primary care physician workforce needs: 2010–2025
.
Ann Fam Med
.
2011
;
10
(6)
:
503
509
.
2.
Congressional Research Service. Federal support for graduate medical education: an overview.
2020
.
3.
Chen
C,
Petterson
S,
Phillips
RL,
Mullan,
F,
Bazemore
AW,
O'Donnell
SD.
Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions
.
Acad Med
.
2013
;
88
(9)
:
1267
1280
.
4.
Rieselbach
RE,
Phillips
RL,
Nasca
TJ,
Crouse
BJ.
Rural primary care physician workforce expansion: an opportunity for bipartisan legislation
.
J Grad Med Educ
.
2013
;
5
(4)
:
556
559
.
5.
Douthit
N,
Kiv
S,
Dwolatzky
T,
Biswas
S.
Exposing some important barriers to health care access in the rural USA
.
Public Health
.
2015
;
12
(6)
:
611
620
.
6.
Frakt
A.
A Sense of Alarm as Rural Hospitals Keep Closing
.
New York Times
.
2020
.
7.
Phillips
RL,
Bazemore
A,
Baum
A.
The COVID-19 tsunami: the tide goes out before it comes in
.
Health Affairs
.
2020
.
8.
Diaz
A,
Chhabra
KR,
Scott
JW.
The COVID-19 pandemic and rural hospitals—adding insult to injury
.
Health Affairs
.
2020
.
9.
MacDowell
M,
Glasser
M,
Hunsaker
M.
A decade of rural physician workforce outcomes for the Rockford Rural Medical Education (RMED) program, University of Illinois
.
Acad Med
.
2013
;
88
(12)
:
1941
1947
.
10.
Verma
P,
Ford
JA,
Stuart
A,
Howe
A,
Everington
S,
Steel
N.
A systematic review of strategies to recruit and retain primary care doctors
.
BMC Health Serv Res
.
2016
;
16
:
126
.
11.
Marchand
C,
Peckham
S.
Addressing the crisis of GP recruitment and retention: a systematic review
.
Br J Gen Pract
.
2017
;
67
(657)
:
227
237
.
12.
Collins
C.
Challenges of recruitment and retention in rural areas
.
NC Med J
.
2016
;
77
(2)
:
99
101
.
13.
Wheeler
M,
Endres
M,
Pauley
K,
Mahone
M,
Melton
N.
Dr. Who? Providing stability to recruiting and retaining health care professionals in West Virginia
.
W V Med J
.
2013
;
109
(4)
:
62
64
.
14.
Mbemba
GIC,
Gagnon
MP,
Hamelin-Brabant
L.
Factors influencing recruitment and retention of healthcare workers in rural and remote areas in developed and developing countries: an overview
.
J Public Health Afr
.
2016
;
7
(2)
:
565
.
15.
McGrail
M,
Wingrove
P,
Petterson
S,
Humphreys
J,
Russell
D,
Bazemore
AW.
Measuring the attractiveness of rural communities in accounting for differences of rural primary care workforce supply
.
Rural Remote Health
.
2017
;
17
(2)
:
3925
.
16.
Bourke
L,
Waite
C,
Wright
PJ.
Mentoring as a retention strategy to sustain the rural and remote health workforce
.
Aust J Rural Health
.
2014
;
22
(1)
:
2
7
.
17.
Fagan
EB,
Gibbons
C,
Finnegan
SC,
Petterson
S,
Peterson
LE,
Phillips
RL,
et al.
Family medicine graduate proximity to their site of training
.
Fam Med
.
2015
;
47
(2)
:
124
130
.
18.
Bazemore
AW,
Wingrove
P,
Petterson
S,
Peterson
L,
Raffoul
M,
Phillips
RL
Jr.
Graduates of teaching health centers are more likely to enter practice in the primary care safety net
.
Am Fam Physician
.
2015
;
92
(10)
:
868
.
19.
Goodfellow
A,
Ulloa
JG,
Dowling
PT,
Talamantes
E,
Chheda
S,
Bone
C,
et al.
Predictors of primary care physician practice location in underserved urban and rural areas in the United States: a systematic literature review
.
Acad Med
.
2016
;
91
(9)
:
1313
1321
.
20.
Talib
Z,
Jewers
MM,
Strasser
JH,
Popiel
DK,
Goldberg
DG,
Chen
C,
et al.
Primary care residents in teaching health centers: their intentions to practice in underserved settings after residency training
.
Acad Med
.
2018
;
93
(1)
:
98
103
.
21.
Li
J,
Scott
A,
McGrail
M,
Humphreys
J,
Witt
J.
Retaining rural doctors: doctors' preferences for rural medical workforce incentives
.
Soc Sci Med
.
2014
;
121
:
56
64
.
22.
Maudlin
RK,
Newkirk
GR.
Family medicine Spokane rural training track: 24 years of rural-based graduate medical education
.
Fam Med
.
2010
;
42
(10)
:
723
728
.
23.
Staiger
DO,
Marshall
SM,
Goodman
DC,
Auerbach
DI,
Buerhaus
PI.
Association between having a highly educated spouse and physician practice in rural underserved areas
.
JAMA
.
2016
;
315
(9)
:
939
941
.
24.
Parlier
AB,
Galvin
SL,
Thach
S,
Kruidenier
D,
Fagan
EB.
The road to rural primary care: a narrative review of factors that help develop, recruit, and retain rural primary care physicians
.
Acad Med
.
2018
;
93
(1)
:
130
140
.
25.
WWAMI Rural Health Center
.
Policy Brief #158, March 2016. Outcomes of Rural-Centric Residency Training to Prepare Family Medicine Physicians for Rural Practice.
2020
.
26.
Rural Health Research Gateway. Rural Residency Training for Family Medicine Physicians: Graduate Early-Career Outcomes, 2008-2012.
2020
.
27.
Bowman,
RC.
Measuring primary care: the standard primary care year
.
Rural Remote Health
.
2008
;
8
(3)
:
1009
.
28.
The RRT Collaborative
.
2020
.
29.
Longenecker
R.
Rural medical education programs: a proposed nomenclature
.
J Grad Med Educ
.
2017
;
9
(3)
:
283
286
.
30.
United States Department of Agriculture Economic Research Service
.
Rural Urban Continuum Codes
.
2020
.
31.
Accreditation Council for Graduate Medical Education
.
ACGME Data Resource Book. 2018–2019.
2020
.
32.
Pathman
DE,
Steiner
BD,
Jones
BD,
Konrad
TR.
Preparing and retaining rural physicians through medical education
.
Acad Med
.
1999
;
74
(7)
:
810
820
.
33.
Phillips
RL,
Dodoo
MS,
Petterson
SD,
Xierali
I,
Bazemore
AW,
Teevan
B.
Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student & Resident Choices?
The Robert Graham Center: Policy Studies in Family Medicine and Primary Care. March 2009.
2020
.
34.
Trickett-Shockey
AK,
Wilson
CS,
Lander
LR,
Barretto
GA,
Szklarz
GD,
et al.
A study of rural upbringing and education on the intent of health professional students to work in rural settings
.
Int J Med Educ
.
2013
;
4
:
18
25
.
35.
Hancock
C,
Steinbach
A,
Nesbitt
TS,
Adler
SR,
Auerswald
CL.
Why doctors choose small towns: a developmental model of rural physician recruitment and retention
.
Soc Sci Med
.
2009
;
69
(9)
:
1368
1376
.
36.
Shipman
SA,
Wendling
A,
Jones
KC,
Kovar-Gough
I,
Orlowski
JM,
Phillips
J.
The decline in rural medical students: a growing gap in geographic diversity threatens the rural physician workforce
.
Health Aff
.
2019
;
38
(12)
:
2011
2018
.
37.
Fagan
EB,
Finnegan
SC,
Bazemore
AW,
Gibbons
CB,
Petterson
SM.
Migration after family medicine residency: 56% of graduates practice within 100 miles of training
.
Am Fam Physician
.
2013
;
88
(10)
:
704
.
38.
Hughes
S,
Zweifler
J,
Schafer
S,
Smith
MA,
Athwal
S,
Blossom
HJ.
High school census tract information predicts practice in rural and minority communities
.
J Rural Health
.
2005
;
21
(3)
:
228
232
.
39.
Wade
ME,
Brokaw
JJ,
Zollinger
TW,
Wilson
JS,
Springer
JR,
Deal
DW,
et al.
Influence of hometown on family physicians' choice to practice in rural settings
.
Fam Med
.
2007
;
39
(4)
:
248
254
.
40.
Rabinowitz
HK,
Diamond
JJ,
Markham
FW,
Santana
AJ.
The relationship between entering medical students' backgrounds and career plans and their rural practice outcomes three decades later
.
Acad Med
.
2012
;
87
(4)
:
493
497
.
41.
Duffrin
C,
Diaz
S,
Cashion
M,
Watson
R,
Cummings
D,
Jackson
N.
Factors associated with placement of rural primary care physicians in North Carolina
.
South Med J
.
2014
;
107
(11)
:
728
733
.
42.
Halaas
GW,
Zink
T,
Finstad
D,
Bolin
K,
Center B. Recruitment and retention of rural physicians: outcomes from the rural physician associate program of Minnesota
.
J Rural Health
.
2008
;
24
(4)
:
345
352
.
43.
Zink
T,
Center
B,
Finstad
D,
Boulder
JG,
Repesh
LA,
Westra
R,
et al.
Efforts to graduate more primary care physicians and physicians who will practice in rural areas: examining outcomes from the University of Minnesota-Duluth and the Rural Physician Associate Program
.
Acad Med
.
2010
;
85
(4)
:
599
604
.
44.
McGrail
M.
‘Rurality' and community amenity: How they relate to rural primary care supply and workforce retention
.
Report on 2014 APHCRI/Robert Graham Center Visiting Fellowship, Australian Primary Health Care Research Institute. October 2015.
2020
.
45.
Wendling
AL,
Phillips
J,
Short
W,
Fahey
C,
Mavis
B.
Thirty years training rural physicians: outcomes from the Michigan State University College of Human Medicine Rural Physician Program
.
Acad Med
.
2016
;
91
:
113
119
.
46.
McGrail
M,
Wingrove
PM,
Petterson
SM,
Bazemore
AW.
Mobility of US rural primary care physicians during 2000–2014
.
Ann Fam Med
.
2017
;
15
(4)
:
322
328
.
47.
MacQueen
IT,
Maggard-Gibbons
M,
Capra
G,
Raaen
L,
Ulloa
JG,
Shekelle
PG,
et al.
Recruiting rural healthcare providers today: a systematic review of training program success and determinants of geographic choices
.
J Gen Intern Med
.
2018
;
33
(2)
:
191
199
.

Author notes

Editor's Note: The online version of this article contains 2 tables of (1) sample characteristics and (2) locations of sample residency programs by 2013 Rural-Urban Continuum Code.

Funding: The authors report no external funding source for this study.

Competing Interests

Conflict of interest: The authors declare they have no competing interests.

Supplementary data