Recruitment of Residents to Rural Programs: Early Outcomes From Cohort 1 of the Rural Residency Planning and Development Grants Program

To bolster the rural physician workforce, the US Health Resources and Services Administration (HRSA) funded multiple Rural Residency Planning and Development (RRPD) awards to develop rural residency programs, in which residents spend greater than half of training time in a rural area in needed specialties, including family medicine, internal medicine, preventive medicine, psychiatry, general surgery, and obstetrics and gynecology.¹  These 3-year start-up grants were awarded to the initial cohort of RRPD grantees in 2019.²  With guidance from the RRPD Technical Assistance Center (TAC), including the team on this study, grantees worked through the program development “roadmap,” from the first stage of exploration through the final stage of program maintenance.³  Existing studies of rural residency programs predominantly focused on established rural programs^4-6  or general workforce outcomes,^7,8  leaving a substantial gap in knowledge concerning the short-term outcomes and formative stages of developing rural residency programs, including how to attract and retain applicants. The objective of this study is to explore early resident recruitment outcomes of the RRPD grants program.

Specifically, this study highlights the early recruitment outcomes of the 25 Cohort 1 RRPD grantees establishing rural residency programs, offering insight into recruitment strategies, application trends, and initial grantee successes. Understanding these emerging programs’ experiences is crucial for educators and leaders striving to enhance equity and access to health care in rural communities.

This study used cross-sectional data gathered through a grantee exit survey administered to the program directors and/or program administrators (eg, coordinators or managers) of the 25 Cohort 1 RRPD grantees at the end of the RRPD award period in 2022. The survey was emailed as a document to the program director indicated in the HRSA grant documentation by the study team. Programs are required to engage with the RRPD-TAC as part of their grant award. The survey was developed using the study team’s experience in gathering similar data for a regional network of residency programs⁹  and included questions about applications to the residency and the Match process (see online supplementary data for survey). Depending on timing of the survey and the Match, as well as no-cost extension requests for the RRPD grants, an update in the year following their application and Match process may have also been requested.

Once accredited, programs participate in the National Residency Matching Program Match and prepare to onboard residents the following academic year. Outcome measures gathered in this study for each Match included total number of applications to the program, applications considered “eligible” after excluding any categories the program will not consider (eg, some programs exclude applications of individuals who have been out of medical school for more than 2 years), number of interviews offered and completed, positions filled in the main residency Match and the Supplemental Offer and Acceptance Program (SOAP), and residents from the same state where the program is located. Programs also reported their marketing and recruitment strategies from a predefined list.

We conducted descriptive analyses and report trends in early outcomes of the RRPD program. We excluded incomplete program responses and those in which data for another program, such as the urban program of the rural track, were combined in reporting. The study received an exemption determination from the University of North Carolina Institutional Review Board (22-0425).

Cohort 1 RRPD grantees included 25 rural residency programs in family medicine (20 of 25, 80.0%), psychiatry (4 of 25, 16.0%) and internal medicine (1 of 25, 4.0%), with most programs (16 of 25, 64.0%) starting as a rural expansion of an urban program. Program characteristics have been described previously.²  Programs enrolled 2 to 8 residents per year, collectively contributing 98 new residency training positions per year to rural communities: 85 in family medicine, 10 in psychiatry, and 3 in internal medicine. Of the 25 programs, 17 participated in the 2022 Match and 20 participated in the 2023 Match; 4 of the remaining 5 programs aimed to participate in 2024. Additionally, one program recruited in 2021 and then closed and did not recruit in 2022 or 2023.

Our final sample included responses on the 2022 Match season from 15 of 17 participating programs (88.2%) and on the 2023 Match season for 16 of 20 participating programs (80.0%). After exclusions, we report on data on 13 of the 17 (76.5%) programs (11 family medicine and 2 psychiatry programs) for 2022 and 14 of the 20 (70%) programs (12 family medicine and 2 psychiatry) for 2023; this includes 16 unique programs in the study, 11 of whom reported in both 2022 and 2023.

Outcomes of the 2022 and 2023 interview and Match seasons are shown in Table 1. Overall, 2023 Match season numbers were similar to those in 2022. Of the 16 programs, most reported on all of the possible marketing and recruitment strategies; these results are shown in Table 2.

Programs in Cohort 1 filled at a rate comparable to that of more established rural programs in family medicine over the last decade.⁴  This fill rate, even in the face of a substantial 2-decade increase in the number of rural residency positions available,⁴  suggests an appetite for rural training. This interest in rural training is further substantiated by the median number of applicants per available position (151.8 in 2022, 127.5 in 2023). Our findings on interviews completed per position (14.8 in 2022, 15.7 in 2023), are consistent with previously reported data.⁹ 

Much has been written about the importance of place-based education to the rural workforce.^5,6,10,11  In rural residency programs, learners capitalize on their rural medicine experiences and cultural immersion in a unique rural environment. Other studies in the United States and internationally have found that rural residency training is an important predictor of eventual rural practice,^7,8,12-15  even more than rural upbringing.¹⁶  Our findings on the early markers of success of these new programs demonstrate the RRPD grant program’s potential for enhancing the rural physician workforce and may provide a model for those in other countries looking to develop their rural physician training opportunities as well.

Study limitations included lack of access to complete and consistent data, suggesting the need to improve the process by which applicant and interview data are gathered and tracked. Additionally, success in resident recruitment does not automatically translate to creating a local workforce and is not the only factor required for a healthy and sustainable program. The question about which residents “came from the same state” was not defined further, and so could be interpreted by respondents how they chose; this question also asked about “current residents” and not just residents matching in that particular year.

Future research is necessary to determine if development of these new programs results in eventual practice and retention of physicians in needed specialties to rural communities. Research about how applicant and program characteristics contribute to other important workforce outcomes, such as providing critically needed rural services (eg, obstetrics, opioid treatment), is also needed. Future cohorts of RRPD are developing programs in other needed specialties such as general surgery and obstetrics and gynecology and may provide needed data on the success of other specialty programs.

Early resident recruitment outcomes of the RRPD model, including number of applicants, interviews per position, and Match fill rate, represented sufficient success to support program continuation.

The authors would like to acknowledge the RRPD Technical Assistance Center team, program advisors, and all others who have been involved in supporting the RRPD grantees as they start up new residency programs in rural places around the United States.

The online supplementary data contains the survey used in the study.

Funding: All authors have some of their time funded by the Rural Residency Planning and Development Technical Assistance Center (RRPD-TAC), which provides technical assistance support to the RRPD grantees described in this manuscript. The RRPD-TAC is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under cooperative agreement #UK6RH32513.

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

Disclaimer: The contents of this article are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the US Government.

Portions of this manuscript were presented at the North American Primary Care Research Group Annual Conference, October 31, 2023, San Francisco, California, USA. The abstract for this presentation is included in the conference proceedings in the Annals of Family Medicine.