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Am Fam Physician. 2000;62(1):22

Accredited family practice rural training tracks are placing graduates in rural settings at notably high rates: 76 percent overall and 88 percent among programs implemented in the past 10 years. Favorable, immediate results could be expected from their continuation and expansion, permitted by adjustments in the Balanced Budget Act of 1997.

In the early 1960s, concern mounted that a physician shortage was developing. Five comprehensive commission reports published from 1959 through 1970 recommended that the supply of physicians be expanded. Assisted by public funding, 40 additional medical schools were begun and enrollment more than doubled nationally over a period of 20 years. Now, after years of steadily increasing this country's supply of doctors, there is growing consensus that it exceeds need.

Even with this possible surplus of physicians, the mal-distribution with respect to practice specialty and location continues to hinder access to primary medical care for millions of Americans. There is broad agreement that, geographically, rural (non-MSA) regions are the most disadvantaged. In 1997, 787 of the 859 counties that were federally classified as health personnel shortage areas (HPSAs) were nonmetropolitan. Another 641 rural counties had been partially designated as HPSAs. Historically, the residents of remote, sparsely settled communities have relied on family physicians for health care. In many rural settings, family practice is the only generalist specialty that is economically viable.

A variety of programs have been implemented to address this inequity in access to care. Previous research suggests that residents whose training occurs in rural areas and emphasizes services necessary for rural practice are likely to establish practice in these communities. Among the 474 family medicine residency programs in this country, 29 have established separately accredited rural training tracks. Information about the practice location of graduates from these programs was collected by questionnaire in September 1999. Data were not attained for seven programs: one has closed, four are new and have yet to graduate residents and two did not respond to the questionnaire. Remarkably, every graduate (40 residents) of half (11 of 22) of the reporting programs have established practice in a non-MSA county. Overall, 76 percent (136 of 179) of the graduated residents are serving rural communities. Benefit usually accrued to the state in which the training occurred. Of the 136 rural practice sites, 95 are located in the state of residency training.

The effect of the substantial success of the separately accredited rural training track components of family medicine residency programs has been limited by several variables. First, they are small. The largest graduates just six to eight residents annually. Most are new; only three have graduated more than five classes. The tracks are few in number. This is of particular concern because one has closed and another will terminate at the end of this year. However, new starts demonstrated immediate effectiveness. Among programs implemented within the past 10 years, 88 percent (94 of 107) of graduates provided care in a non-MSA county.

This performance for rural placement should be viewed in the context of what has otherwise occurred. Nationally, among all non-federal allopathic family physicians actively providing patient care in 1997, 21.0 percent practiced in non-MSA counties. For the other two primary care specialties, general internal medicine and pediatrics, the proportions were 8.0 percent and 7.4 percent in rural practice, respectively.

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