Exposure to rural medicine during residency training is associated with a significant increase in the likelihood a physician will practice in a rural setting upon entering practice, a recently published study found.

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The study—published in the Journal of Graduate Medical Education—found that family medicine residents who spent 50% or more of their training time in rural settings were at least five times more likely than residents with no rural training to practice in a rural setting. The findings, gathered from a sample of more than 12,000 family medicine physicians who completed residency training between 2008 and 2012, also indicate that even a small amount of rural training time—between 1%-9%—significantly increases the odds of a trainee subsequently opting for rural practice.

One in five Americans lives in a rural community. Yet, those areas face physician shortages across medical specialties. Residency training institutions are moving to address the need with programs like Fully Integrated Readiness for Service Training (FIRST), a project aiming to expand the reach of graduate medical training across the state of North Carolina. The program, which received an AMA Reimagining Residency grant, is an expansion of the University of North Carolina School of Medicine’s (UNC) residency readiness program.

FIRST provides a dedicated pathway to practice in rural areas consisting of three years in medical school, three to five years in residency training, and three years of early career mentorship once established in practice in a community in North Carolina.

Catherine Coe, MD, is an assistant professor at UNC and primary investigator on the FIRST project. “One thing that this program facilitates is residents building longitudinal relationships with the community,” Dr. Coe said. “Students get exposure to some chronic illnesses that may be less well controlled due to resources that are available and have to think outside the box to get patients the care they need. In some ways it is the kind of exposure that allows them to understand those communities.”

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Most residents in the study—more than 90%—had no rural training. The study found that 14% of all family medicine residents were pursuing rural practice opportunities in 2018. The vast majority of family physicians practicing in a rural setting had little to no training on the unique aspects of delivering care to that patient population, which can create a tough transition to practice.

“Any physician is equipped to go to the rural setting from a medical training standpoint,” Dr. Coe said. “Part of the challenges that we don’t necessarily train folks for are systemic, such as patient access to care. Some of it you can certainly learn on the job, but that’s the element you get when you do residency training in that area.”

Deterrents related to attracting residents to post-training rural opportunities, particularly those in smaller rural communities, may be related to the limitations in practice those positions present.

“For family medicine, many rural communities have closed labor-and-delivery practices and are shifting that to bigger academic medical centers,” Dr. Coe said. “That not only impacts patient care but also impacts our ability to train our residents and the available job opportunities for physicians who want to practice full scope family medicine.”

The FIRST project is in its infancy, and its roots start in medical school. Still the first few cycles have yielded three graduates, all of whom went to practice in rural or underserved areas after exposure to them during residency.

“The hope is that this continues,” Dr. Coe said. “We want to create a program where graduates will feel a connection to the community and either stay there or pursue a rural track position elsewhere.”

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The AMA has developed policy to address and eradicate the rural physician shortage. Many of the interventions the Association is calling for start in medical training.

Among the policy’s aims is to work with stakeholder in medical education “to consider adding exposure to rural medicine as appropriate, to encourage the development of rural program tracks in training programs and increase physician awareness of the conditions that pose challenges and lack of resources in rural areas.”

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