Rural Residency Training as a Strategy to Address Rural Health Disparities: Barriers to Expansion and Possible Solutions

Abstract

ompared to individuals living in urban locations, those in rural areas experience worse health outcomes. 1,2 A key contributor to rural-urban disparities is the geographic maldistribution of physicians. With fewer health care professionals available, clinical practice in rural communities demands physicians with skills to care for patients with a wide range of complex health needs. 3 While many factors affect the supply and distribution of physicians, graduate medical education (GME) funding is a major determining factor. [4][5][6] According to the Congressional Research Service, ''the size of the federal investment in GMEestimated at $16 billion in 2015-makes it a policy lever often considered to alter the health care workforce and impact health care access.'' 7 Unfortunately, the current distribution of GME funds do not align with rural workforce needs. Estimates suggest that almost all (99%) of Medicare spending for GME training goes to programs in urban areas. 5 Studies have also shown that physicians often practice within 100 miles of where they completed residency and that training residents where they are needed in practice is one promising strategy to increase the supply of rural physicians. 5,8,9 Recognizing the rural health crisis and the role that GME investments play in building workforce capacity, Congress appropriated funding for a new Rural Residency Planning and Development Program (RRPD) under the Health Resources and Services Administration (HRSA). 2,7 In 2019 and 2020, HRSA awarded approximately $28 million in grants to 38 organizations across 25 states to start rural residency programs in needed specialties, including family medicine, general internal medicine, and general psychiatry. 10,11 Despite these investments, rural communities still face significant barriers in developing and sustaining residency programs. This article identifies these barriers and proposes potential solutions. These solutions require action by multiple stakeholderssome are regulatory fixes, while others require Congressional action. Given the complexity of GME organization and financing, we have included definitions of key concepts and terminology used in this article in the online supplementary data. 4,[12][13][14][15][16][17]

Rural Versus Urban Family Medicine Residency Scope of Training and Practice

“…Rurally-trained physicians, who are more likely to practice in rural areas over the course of their careers, 16 can be uniquely valuable to rural communities due to their broad scope of training and preparation to care for rural populations. 29 More can be done to increase rural training opportunities. The Accreditation Council for Graduate Medical Education is making efforts to support programs in rural and underserved settings, where constraints and contextual factors differ from those faced by large urban programs.…”

“…30 A more equitable distribution of funding and other resources across rural and urban academic settings would also help support rural residency programs. 12,29 Study limitations include biases associated with selfreported information collected via survey. We do not know if this would cause people to over-or underreport the content of their practice or their sense of preparedness.…”

System- and Individual-Level Barriers to Accessing Medical Care Services Across the Rural-Urban Spectrum, Washington State

“…Policy changes for graduate medical education funding are also needed to better support rural residency programs, which are important for building the local healthcare workforce in which they are located. 50 For example, evidence suggests that 56% of family medicine residents practice within 100 miles of their program and 39% practice within 25 miles. 51 Ensuring that rural residency programs receive the financial support needed to grow the rural healthcare workforce is therefore one long-term strategy to increase healthcare access in rural areas.…”

Rural Internal Medicine Residencies: Models, Facilitators, Barriers, and Equity Considerations

“…Historic practices at large teaching hospitals and the Centers for Medicare and Medicaid Services (CMS) have not prioritized rural training. 14 In response, new federal initiatives fund and facilitate rural training programs (RTPs), defined as new residency programs that provide 50% or more training in a rural setting.…”