Population Care

Training future physicians for rural medicine


To address the shortage of physicians practicing rural medicine, one regional medical school has developed a four-year curriculum that allows students to train in rural and underserved areas. Learn how the program creates a unique clinical “continuity experience” for students that’s prompted 90 percent of its graduates to enter residencies in specialties needed in the region.

Serving the needs of the country’s most rural areas

“With 27 percent of the U.S. landmass and 3.3 percent of the population, Washington, Wyoming, Alaska, Montana and Idaho are among the most rural areas of the country,” according to a report recently published in Academic Medicine. The report examines the University of Washington School of Medicine’s (UWSOM) rural health curriculum. As the only four-year MD-granting medical school in the five-state region, UWSOM is one of the new members of the AMA Accelerating Change in Medical Education Consortium and admits 240 students per year.

To address the health care needs of these five rural states, UWSOM developed its Target Rural Underserved Track (TRUST) curriculum in 2008, which centers on “a required four-year clinical longitudinal continuity experience with students repeatedly returning to a single site located in a rural community or small city,” the report explains. “TRUST sites range in population from 1,000 to 30,000 people. This longitudinal placement in a single community differs significantly from other rural programs in the United States.”

How TRUST creates a continuous rural health experience for students

Students in the TRUST program are selected through a targeted admissions process during their general admission to UWSOM, in which students can submit a secondary application explaining their interest in rural medicine. The admission committee interviews and selects TRUST applicants with special attention given to those who exhibit behaviors the medical literature has commonly associated with physicians who return to practice rural medicine.

After a pilot year, TRUST officially launched in 2009. From 2009 to 2015, 776 medical students applied to TRUST, 467 were interviewed and 123 were accepted into the program.  

Students in the program receive a “cohesive educational experience” in rural medicine, which includes repeated preclinical visits, clerkships, electives and mentorship from practicing physicians in rural health sites. “Students in the program are strategically linked to a single rural community over four years, known as their Trust Continuity Community,” according to the report.

While working at their respective Trust Continuity Communities, students participate in courses designed to build their knowledge of caring for patients in rural and underserved areas while fostering continuous connections with their assigned rural health community. Some of these curricular elements include:

  • The Underserved Pathway: This comprehensive longitudinal extracurricular program teaches students the fundamental principles of underserved medicine.
  • The First Summer Experience: This one- to two-week clinical and community experience allows students to explore their assigned rural Trust Continuity Community prior to the start of classes.
  • The Rural Underserved Opportunities Program: This “month-long rural underserved experience in a student’s Trust Continuity Community … incorporates clinical learning and principles of community medicine,” according to the report.
  • The WWAMI Rural Integrated Training Experience: This “18- to 23-week rural longitudinal integrated clerkship experience at a student’s Trust Continuity Community … emphasizes the rural physician’s responsibilities and roles in diagnosing, treating and managing the majority of medical, surgical, obstetrical and psychosocial problems on a continuity basis,” the report notes.

These various curricular elements create a sense of connectedness to rural communities for students while strengthening their clinical skills in primary care. As one student participant wrote on the Academic Medicine blog, “For me, the centerpiece of the TRUST curriculum is the longitudinal relationship we develop at our continuity sites with physician role models in rural communities.” He noted that medical education usually requires medical students to “knit together tidbits of career guidance gleaned from different physicians from three years of largely disconnected educational experiences,” while the TRUST program allows students to spend intensive time “living and working” alongside a single physician mentor who practices in rural medicine.

The impact of TRUST on specialty, residency choice

While interest in the TRUST program and applicant numbers continue to grow each year, “it is too early in the TRUST experience to determine whether the program is producing more rural physicians to meet regional needs,” the report notes. However, preliminary measures “show significant entry into needed specialties.”

Since launching the program, roughly 90 percent of graduates have entered residencies in needed specialties, and nearly one-half of graduates have remained in one of the program’s five rural states for their residency training.

Professors at UWSOM plan to secure institutional funding for new TRUST curricular developments and partnerships with rural residency programs.

“While specific outcomes remain undetermined, the program is enjoying growth and is becoming highly visible within the UWSOM and within the … region, showing the feasibility of a coordinated and comprehensive program,” the report states.

Accelerating change in underserved areas

UWSOM’s rural health program is one of several innovative efforts in medical education training future physicians in underserved areas that is part of the AMA’s Accelerating Change in Medical Education Consortium. The consortium consists of 32 medical schools working together to create the medical school of the future and transform the training of future physicians.

Other members addressing physician shortages in rural areas include the Brody School of Medicine at East Carolina University which recently launched new curricula with a special focus on training students in rural and underserved populations. The school has continued its mission to train underrepresented minorities while focusing on team-based care and population health.

The University of California, Davis, School of Medicine, another consortium member, also has developed a program to train diverse, highly skilled physicians to meet the needs of underserved communities and populations. In partnership with Kaiser Permanente, the program follows a collaborative three-year curriculum, which places a special emphasis on addressing workforce and diversity gaps in underserved populations.