Intentional Rural GME: A Study of Competency Needs for Rural Family Medicine

Family physicians in rural communities must provide a broad scope of services, adapt to resource limitations, and sustain continuity across geographically dispersed patients. Preparing residents for rural practice requires competency domains not fully encompassed by general assessments such as the Accreditation Council for Graduate Medical Education (ACGME) Milestones,¹ and most residencies are inconsistent in their incorporation of rural-specific modalities in the preparation of their graduates for practice.²

Competency-based medical education was designed agnostic of place and remains a dominant paradigm in graduate medical education (GME). While universal frameworks provide consistency across training sites, they may inadvertently obscure the contextual demands of different practice types. In rural communities, where physicians often practice in geographic isolation and with limited resources, the most appropriate care paradigms may distinctly differ.³ Moreover, the consequences of competency gaps and their impacts to patient and physician well-being are likely amplified in settings with less peer support and fewer resources.⁴

Prior conceptual work has argued that competence in rural practice is multidimensional, dynamic, and contextual.^5,6,7 Other work has emphasized actual rural exposures as crucial to the development of competence and downstream rural practice.^8,9 Rural physicians are called not only to demonstrate breadth of skill, but also to exercise judgment, resilience, and adaptability in settings where no immediate safety net may exist.¹⁰ Existing literature has mapped themes such as adaptability and courage, but relatively few empirical studies have systematically identified which competencies matter most for rural practice from both educator and practicing physician perspectives.⁵ Furthermore, evidence integrating perspectives of program directors, residents, and practicing rural physicians remains limited. This study addressed that gap by examining how rural educators and early-career rural physicians describe the domains, curricular features, and educational modalities most important in preparing physicians for rural practice. Rather than proposing a new competency framework, this study focused on how training environments, curricular flexibility, experiential learning, and rural immersion may support preparation for sustainable rural practice.

This study was approved by the American Academy of Family Physicians Institutional Review Board.

We used qualitative methods to explore rural physicians’ experiences. Two focus groups were conducted at the Rural Training Track (RTT) Collaborative annual meeting in April 2023 in Missoula, Montana. Focus group participants (N = 11) were identified by the RTT Collaborative as rural program directors and invited to participate via email by the second author (A.K.; PhD, anthropology). To maintain anonymity and confidentiality, A.K. did not inform the first author (D.S.) about final participant recruitment or participation. Each focus group had one resident present (two out of 11 focus group participants were residents). Focus groups were comprised of two components: discussion and written. The focus group guide was informed by a scoping review conducted previously by the authors¹¹ and piloted with two practicing physicians prior to implementation. Focus groups were recorded and a notetaker (A.B.) was present.

Following verbal consent of the participants, the focus group moderator (A.K.) prompted them to discuss what is unique about rural practice, what a new physician should know about rural practice, and what was learned in rural practice that was not taught in residency. The moderator took notes on a large easel to reduce repetition and encourage diverse ideas. Next, participants received one of five papers with a different question at the top of each sheet. Questions asked for key competency domains for rural practice, how programs prepare graduates, learning experiences, and curriculum adjustments. Each participant had 1 minute to brainstorm as many answers as they could. After 1 minute, the paper was handed to the right, and each participant responded to a new question. Once all pages were circulated, the moderator prompted a verbal discussion of each question by asking participants to highlight key ideas and what was missed.

Interviews were conducted in June through August 2023 with 11 early-career American Board of Family Medicine diplomates, randomly recruited from the 2023 National Graduate Survey. We specifically chose to interview early-career physicians because of their proximity to residency and their new perspective on rural practice. Verbal consent was obtained at the start of each interview. Interview questions were the same as the focus group questions, but followed a semistructured format, with the interviewer (A.K.) able to ask more follow-up questions and elicit a deeper level of nuance. Interviews lasted an average of 45 minutes. Interviewees received $ 150 in remuneration for their time and effort.

Interviews were recorded and transcribed verbatim. Data were iteratively analyzed by two authors (A.K., D.S.) via inductive content analysis. The initial codebook was created by A.K., then tested by D.S. using the first focus group transcript. Through iterative discussions, a final codebook was developed and applied to the remaining focus group and all interviews. Additional codes were added as needed, then reapplied to previously coded transcripts. Coding disagreements were reconciled via discussion. The qualitative software NVivo version 14 (Lumivero) was utilized for data analysis and a coding comparison query; all codes achieved greater than 90% agreement. Representative quotations have been edited for readability.

Data were organized into three overarching areas: competency domains, curriculum, and modes of education. The results are presented here in text, tables, and figures. Each table presents identified themes along with definitions (where applicable) and representative quotations. Each figure illustrates how the themes are related and whether they were identified in focus groups, interviews, or both.

Participants consistently emphasized domains extending beyond standard GME Milestones. These domains included confidence, agency, flexibility, adaptability across settings, lifelong learning, emotional resiliency, and continuity. Table 1 presents each competency domain with its definition and exemplary quotations; the domains also are illustrated in Figure 1.

Rural experiences, curricular flexibility, and fundamental practice topics reinforced and informed one another to form the foundations of a rural-based curriculum. Table 2 presents curriculum content and exemplary quotations; the curriculum content and context also are illustrated in Figure 2.

Regarding rural experiences, participants emphasized the need for residents to spend time in rural communities and clinics, across a variety of settings. These experiences were incredibly important and mentioned regularly in both focus groups and interviews.

I think the biggest thing [in residency] is rural experience. . . . The studies show that the [residents] that train in [rural] environment[s] are a lot more likely to be doing that 7 to 10 years after they’re completed in the small towns doing that full scope practice. So, I think that exposure is critical to help with that because some of it, they don’t . . . really understand some of the challenges of just living in that community, let alone practicing medicine in the community.

Fundamental practice topics included providing comprehensive care, understanding and integrating behavioral health services, and developing skills around practice management.

Curricular flexibility was the central, tethering component. Interview participants in particular highlighted the importance of electives to preparing them for eventual rural practice. Others mentioned the ability to create their own rotations based on the training needs of the community they planned to practice in. The flexibility to incorporate these opportunities was invaluable to preparing residents and meeting the needs of communities.

Educating for rural practice can best be achieved through a combination of experiential learning and modeling or mentoring with an emphasis on strong communication. Residents need to both observe and practice good communication, leadership, and procedural care. Table 3 presents each mode of education and exemplary quotations.

This study identified seven core competency domains for rural practice and linked them directly to curriculum content and modalities necessary to develop them. Participants consistently emphasized domains extending beyond what is measured with use of existing ACGME Milestones.¹ These domains build on earlier conceptual models of rural competency⁵ and included confidence, agency, flexibility, adaptability across settings, lifelong learning, emotional resiliency, and continuity. Our study extended this work by linking competency domains to specific curricular strategies and educational modalities.

The similarities between our findings and Longenecker’s competency domains of adaptability and resiliency reinforce the validity and importance of these domains.⁵ Achieving consensus of domain names is challenging because of overlap and interconnectedness. Participants mentioned living with scarcity and limits, and that is related to Longenecker’s competency domain by that title, among others.⁵ In this study, confidence, agency, and flexibility were identified as teachable characteristics that could help a physician navigate a context of scarcity and/or limits. Furthermore, engaging in lifelong learning can reinforce contextually necessary skills¹² and contribute to community-oriented comprehensiveness.¹³ Of note, the domain from Longenecker’s paper on collaboration and community responsiveness⁵ is about the physician’s relationship with the rural community and is perhaps best aligned with the new domain of continuity. The responses from both the focus groups and interviews of recent graduates may reflect a continuing challenge for family medicine residencies in promoting engagement with the community outside health care. While participants of this study were grateful for competent and responsive colleagues, the framing of questions around competency for individual residents planning to enter rural practice limited discussions of collaboration within the clinical setting. Finally, continuity is important to all primary care practices, but program directors and practicing physicians identified building a longitudinal relationship with patients as central to rural practice.

This study also added needed detail to curricular content and modes of education necessary to achieving increasing competence. Residency programs should implement a combination of key curricular areas that all future rural physicians receive, incorporating learning in a rural community with curricular flexibility. Curricular flexibility allowed residents to tailor their GME to the needs of their future practice community. Didactics supplemented, but did not substitute for, experiential learning, role modeling, and mentoring. Program faculty must model and communicate, for example, the confidence, agency, and flexibility in treatment plans required when faced with a difficult scenario. Technical breadth alone was deemed insufficient. Participants described a need for adaptive expertise, or the metacognitive capacity to use skills appropriately in unforeseeable, resource-limited contexts.¹⁴

Many identified domains align closely with recently revised ACGME family medicine outcome expectations, including continuity, comprehensiveness, leadership, adaptability across care settings, and lifelong learning. Participants nevertheless described distinctive challenges in developing and sustaining these capacities within rural practice environments. These results could be used to refine areas of further research for those interested in developing supplemental subcompetencies for voluntary use in programs educating residents for rural practice. These internal measures could provide program-level feedback and internal and interprogram collaborative opportunities to adjust curriculum content and modalities. Any future application of these findings should prioritize curricular flexibility and avoid unnecessary administrative burden for rural programs. Gaining a better understanding of the specific curricular and modal basis for program success in training for rural practice would be distinctly valuable and beyond the existing research linking geographic location of rural programs to rural workforce outcomes.

Education in a rural setting was identified as a key component of the curriculum to support competence for rural practice. However, not all states and regions may have equal opportunities for rurally located GME program development. This can be due to resource limitations such as small patient populations or other resource restrictions that would be required for program accreditation.^15,16 Such programs may benefit from additional research and curricular development carried out in a combination of rural and urban locations. For example, sparsely populated rural states may have long or impractical travel challenges from urban centers to training-capable rural communities. They may benefit from a blueprint for implementing a flexible curriculum for rural training through means in addition to periods of rural immersion. Defining rural competency domains and components of educational strategies, such as rural experiential learning as well as modeling and mentoring, allows for intentional program implementation and the measurement of relative effectiveness over time and between program types.

While rural graduate placement outcomes have been noted as an indicator of program success,¹⁷ these analyses may not consider influential factors such as loan-repayment status, personal geographic preferences, or other noneducational factors related to posttraining recruitment and retention.^18,19 By incorporating outcome measures such as the voluntary use of supplemental subcompetencies, programs could measure effectiveness in new ways specifically related to curriculum and teaching modalities. Program success among interprogram variability could support much needed flexibility for rurally located programs. Additionally, establishing best practices for curricular components and modalities specific to rural GME programs may have broader use for both GME planning and related policymaking.

Our findings reflect the experiences of 22 purposively recruited program directors, residents, and early-career rural physicians, and thus may not capture the full breadth of rural training environments or career trajectories. As with all qualitative research, results are context-dependent and intended to provide nuanced insight rather than generalizations.²⁰ A strength of this research was in its methods: collecting and analyzing data from program directors to inform in-depth interviews with early-career physicians. This method ensured a variety of perspectives; however, future research should include mid- and late-career rural physicians or follow residents longitudinally to validate competencies in real time and identify barriers and supports. Future research should validate reported competencies across diverse rural contexts and examine their relationship to physician retention, well-being, and patient outcomes. Further research should validate these competencies across broader samples, refine rural milestones, and evaluate curricular innovations for their impact on rural practice retention and outcomes.

This study identified seven competency domains uniquely important to rural primary care practice: confidence, agency, flexibility, adaptability across settings, lifelong learning, emotional resiliency, and continuity. This study expanded prior work around the domains of competence important to preparation for sustained rural practice and linked each to specific curricular strategies and educational modalities required for learners to achieve foundational competence for rural practice. Our findings also highlighted key curricular components for rural training, including rural immersion, targeted procedural and practice-management skills, and the central role of curricular flexibility. Competency-based education for rural family medicine must extend beyond general educational frameworks and assessment tools. Incorporation of rural-focused subcompetencies and curricular strategies into GME design can strengthen rural workforce readiness and improve alignment between training and the realities of rural practice. This study demonstrated that competency domains for rural practice will be best understood as a dynamic integration of broad clinical scope, adaptive capacities, and community connection.

Limited findings and discussion presented at 2024 Rural Medical Training Collaborative annual meeting and 2025 Accreditation Council for Graduate Medical Education Annual Meeting (poster).

This project was supported by the American Board of Family Medicine Foundation and its Visiting Scholars Program.

We thank the Rural Medical Training Collaborative and American Board of Family Medicine research team for their support, and the physicians and residents who generously shared their insights.