One out of five people live in rural America. There is a widening gap for all-cause mortality rates in rural areas that is linked in part to physician shortages.1 Moreover, rural counties with majority Black or indigenous populations suffer the highest rates of premature death.2 Evidence is mounting that the current pandemic has exacerbated these conditions. Family physicians need to be prepared to assume the roles and take the actions that have the greatest impact. Graduate medical education (GME) of family physicians must attain educational quality, but must also go beyond this to become a promoter of the partnerships necessary to find community-based solutions. In doing this we will be returning to our roots of formal community-based education and socially-accountable GME.
Rural communities are diverse but at the same time collectively posses unique characteristics. Strong rural communities offer an existing local fabric of resilience to effectively provide maximal care in an isolated or resource-lean environment.3 Investment in rural GME is an investment in rural communities.
Correcting the existing workforce shortages in rural America with intentional family medicine GME will save lives while contributing to the economic basis of local health care, keeping both patients and health care economic investment close to home. Literature exists addressing the rural placement rates as related to admission of students,4 undergraduate medical education,5 recruitment, and retention strategies employed.6 As we take up our role in GME for rural practice,7 the core concept of situational adaptation applies. In residency training, contextual competence yields confidence. This adaptive confidence for practicing in rural places results in recruitment and retention, resiliency, and increased satisfaction in rural practice. Place-based training has demonstrated favorable workforce outcomes for rural practice, for example, as evidenced by the outcomes of 1+2 Rural Training Tracks (RTTs).8,9
Training With and For Rural Communities
Community competence in family medicine is grounded in the effectiveness of primary care. Evidence for this is perhaps best recognized in the work of Barbara Starfield’s four “Cardinal C’s of Primary Care.”10 When applied to rural and remote practice, the delivery of primary care brings both unique challenges and advantages.
As an a priori example, applying the Starfield “C” of first-contact availability in rural settings must include the golden hour of trauma care but should also address golden hours of maternity care. The Improving Access to Maternity Care Act11 calls for designation of maternity care target areas, and family physicians must be prepared to serve to improve maternal and neonatal outcomes. Family physicians will continue to be called to operate at the top of their license and to the extent of their training. Rural comprehensiveness is defined by the immediate needs of the patient, at the first point of contact. We must train family physicians to anticipate and adapt to what telemedicine does not accomplish as well as to how it can be a tool to augment the skills they have otherwise gained in their training.
Likewise, the Starfield “C’s” of continuity and coordination remain central to everyday rural primary care and yet uniquely demand competence for effective transitions between local care and urban-based tertiary care. Decisions involving transport and timing across many miles and the risks of environmental conditions require an educated and informed perspective. The best decisions require the rural competency of integrity, and recognizing your own limits.
These and other examples demonstrate ways in which competence must be considered in rural context.12 The applied skills and aptitudes of the successfully trained rural family physician will be guided by these same principles of primary care, although through a rural lens.
Development of competence as a rural family physician should particularly emphasize training of resident physicians as “master adaptive learners.”13 Being prepared for the infrequent or unanticipated patient care need, potentially combined with a resource-limited setting requires the rural competencies of agency and courage in addition to comprehensiveness.12 When measuring quality in health care and education, we often rely on outcome measures. However, while simply increasing the volume of training may produce reliable outcomes in similar circumstances, we as educators must also design and implement process measures for the quality outcomes of the master adaptive learner that become evident in a dynamic, resource-limited environment. A well-trained family physician must posses both skill sets, with just enough volume-based experience and also the capability to adapt patient care to the circumstances in the moment that best meet the needs of the patient who is actually in front of them. Thus, the well-prepared rural family physician will be able to shift the context of care to have competence for the situation within their own rural community. This is the value of the rural family medicine generalist, providing just the specialized care their community needs.
Program requirements fit for purpose will involve rural track models (including RTTs) and rural 4-4-4 programs associated with critical access (CAH) and sole community hospitals (SCH). The substantial integration of rural tracks and programs in association with larger hospitals and institutions should include time for subspecialty experiences and bidirectional integration of didactic teaching through use of technology. Sponsoring institution and health care system support of faculty development and faculty recruitment will be particularly important. Studies suggest that rurally-located programs, such as rural training tracks, would benefit from both financial and programmatic support, including flexibility in program design and targeted technical support in areas such as scholarly activity.14 These findings align with the recent Council on Graduate Medical Education policy brief related to rural health, recommending the linking of GME funding to programs that yield a high return on investment for rural communities, such as the Rural Residency Planning and Development program funded by Health Resources and Services Administration.15
The Review Committee for Family Medicine standards should be amenable to the innovations and adaptability of rural programs, while graduates of rural programs should be expected to meet the accepted standards of all GME programs.16 See Table 1 for specific recommendations.
Urban-located programs will likewise continue to contribute graduates to the rural family physician workforce. Flexibility allowing for rural rotations promotes not only a concentrated period for learning rural-applicable skills, but also contextual learning, reinforcing the master adaptive learner elements of the curriculum. Innovation in resource-limited environments is a learned skill and develops from reflective practice. As a curricular example, shared didactics and case presentations between rural and urban locations highlight both rural-specific skill sets and shape the culture in the curriculum, recognizing that care occurs in the context of resources and community. This encourages faculty and residents alike to ask the question, “What if this care were happening in a rural place?” Curricular requirements should prepare all family medicine graduates to acutely assess, stabilize, and triage patients for treatment and/or transfer in the context of place and local resources.
Further research is needed and a reflective practice is indicated. Even the definition of rurality itself, while important, remains challenging. Rural definitions should be specific to purpose and address a particular audience.17 In as much as rural is diverse, our GME strategy must be unified. Understanding rural GME with a common nomenclature18 and transparency will allow for further study and discussion. Family medicine residency education must be specific to fit and address health outcomes as the priority. Simply put, GME in and with rural communities will yield the best-trained physician workforce for our rural communities.
The evidence of the impact of rural Family Medicine GME should ultimately be better health and life in rural America. Likewise, the satisfaction our graduates experience in rural practice will be well grounded in their residency education.
- Gong G, Phillips SG, Hudson C, Curti D, Philips BU. Higher US rural mortality rates linked to socioeconomic status, physician shortages, and lack of health insurance. Health Aff (Millwood). 2019;38(12):2003-2010. doi:10.1377/hlthaff.2019.00722
- Henning-Smith CE, Hernandez AM, Hardeman RR, Ramirez MR, Kozhimannil KB. Rural counties with majority black or indigenous populations suffer the highest rates of premature death in the US. Health Aff (Millwood). 2019;38(12):2019-2026. doi:10.1377/hlthaff.2019.00847
- Schmitz D, Claiborne N, Rouhana N. Defining the Issues and Principles of Recruitment and Retention. Overland Park, KS:National Rural Health Association; 2012. https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/RecruitmentandRetentionIntrotoRuralHealthCareersPipelineJan-2012.pdf.aspx?lang=en-US. Accessed April 29, 2021.
- Evans DV, Jopson AD, Andrilla CHA, Longenecker RL, Patterson DG. Targeted medical school admissions: a strategic process for meeting our social mission. Fam Med. 2020;52(7):474-482. doi:10.22454/FamMed.2020.470334
- Longenecker RL, Andrilla CHA, Jopson AD, et al. Pipelines to pathways: medical school commitment to producing a rural workforce. J Rural Health. 2020;jrh.12542. doi:10.1111/jrh.12542
- Baker E, Schmitz D, Epperly T, Nukui A, Miller CM. Rural Idaho family physicians’ scope of practice. J Rural Health. 2010;26(1):85-89. doi:10.1111/j.1748-0361.2009.00269.x
- Rural Practice: Graduate Medical Education for (Position Paper). Leawood, KS: American Academy of Family Physicians; 2013. https://www.aafp.org/about/policies/all/rural-practice-gme.html. Accessed April 29, 2021.
- 8. Patterson DG, Schmitz D, Longenecker R, Andrilla CHA. Family medicine Rural Training Track residencies: 2008-2015 graduate outcomes. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; February 2016. https://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/02/RTT_Grad_Outcomes_PB_2016.pdf. Accessed April 29, 2021.
- Meyers P, Wilkinson E, Petterson S, et al. Rural workforce years: quantifying the rural workforce contribution of family medicine residency graduates. J Grad Med Educ. 2020;12(6):717-726. doi:10.4300/JGME-D-20-00122.1
- Stange KC. Barbara Starfield: passage of the pathfinder of primary care. Ann Fam Med. 2011;9(4):292-296. doi:10.1370/afm.1293
- Improving Access to Maternity Care Act. HR 315, 115th Congress (2017-2018). https://www.congress.gov/bill/115th-congress/house-bill/315. Accessed April 29, 2021.
- Longenecker RL, Wendling A, Hollander-Rodriguez J, Bowling J, Schmitz D. Competence revisited in a rural context. Fam Med. 2018;50(1):28-36. doi:10.22454/FamMed.2018.712527
- Cutrer WB, Miller B, Pusic MV, et al. Fostering the development of master adaptive learners: a conceptual model to guide skill acquisition in medical education. Acad Med. 2017;92(1):70-75. doi:10.1097/ACM.0000000000001323
- Patterson DG, Schmitz D, Longenecker RL. Family medicine rural training track residencies: risks and resilience. Fam Med. 2019;51(8):649-656. doi:10.22454/FamMed.2019.769343
- Council on Graduate Medical Education. Special Needs in Rural America: Implications for Healthcare Workforce Education, Training, and Practice. Published 2020. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/graduate-medical-edu/publications/cogme-rural-health-policy-brief.pdf. Accessed April 29, 2021.
- Schmitz D, Crouse B, Epperly T, Longenecker R, Rosenthal T. The Role of Distributed Rural Medical Education in Access to Quality Healthcare. Overland Park, KS: National Rural Health Association; 2013. https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/GraduateMedicalEducationforRuralPracticepolicybriefApril2014.pdf.aspx?lang=en-US. Accessed April 29, 2021.
- Bennett KJ, Borders TF, Holmes GM, Kozhimannil KB, Ziller E. What is rural? Challenges and implications of definitions that inadequately encompass rural people and places. Health Aff (Millwood). 2019;38(12):1985-1992. doi:10.1377/hlthaff.2019.00910
- Longenecker R. Rural medical education programs: a proposed nomenclature. J Grad Med Educ. 2017;9(3):283-286. doi:10.4300/JGME-D-16-00550.1