Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to "small rural" communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.

The examination of correlations between perceived quality of education and self-reported proficiency may be a useful gauge of effectiveness of nutrition training in medicine. Prioritization of nutrition information based on proficiency levels, including information on complementary and alternative medicines and nutritional management of disease, merits further investigation.

With major medical organizations predicting a national shortage of physicians in coming years, a number of institutional models are being considered to increase the numbers of medical students. At a time when the cost of building new medical schools is extremely expensive, many medical schools are considering alternative methods for expansion. One method is regional expansion. The University of Washington School of Medicine (UWSOM) has used regional expansion to extend medical education across five states without the need to build new medical schools or campuses. The WWAMI program (the acronym for Washington, Wyoming, Alaska, Montana, Idaho), which was developed in the early 1970s, uses existing state universities in five states for first-year education, the Seattle campus for second-year education, and clinical sites across all five states for clinical education. Advantages of regional expansion include increasing enrollment in a cost-effective fashion, increasing clinical training opportunities, responding to health care needs of surrounding regions and underserved populations, and providing new opportunities for community-based physicians to enhance their practice satisfaction. Challenges include finding basic-science faculty at regional sites with backgrounds appropriate to medical students, achieving educational equivalence across sites, and initiating new research programs. UWSOM's successful long-term regional development, recent expansion to Wyoming in 1997, and current consideration of adding a first-year site in Spokane, Washington, indicate that regional expansion is a viable option for expanding medical education.