The persistent shortage of physicians in

Medical School Programs to Increase the Rural Physician Supply: A Systematic Review and Projected Impact of Widespread Replication Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W. Markham, MD, and Jeremy R. Wortman Abstract Purpose To systematically review the outcomes of comprehensive medical school designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication. Method Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed. Results Ten studies met all inclusion criteria. Outcomes were available for more than 1,600 graduates across three decades from six. The weighted average of graduates practicing in rural areas ranged from 53% to 64%, depending on the definition of rural. If 125 medical schools developed similar for 10 students per class, this would result in approximately 11,390 rural physicians during the next decade, more than double the current estimation of rural doctors produced during that time frame (5,130). Conclusions All identified comprehensive medical school rural have produced a multifold increase in the rural physician supply, and widespread replication of these models could have a major impact on access to health care in thousands of rural communities. The current recommendation to expand U.S. medical school class size represents a unique and timely opportunity to replicate these. Acad Med. 2008; 83:235 243. The persistent shortage of physicians in rural areas continues to have a major impact on access to care for those living in small communities. 1 Although one of every five Americans (20%) lives in a rural area, only 9% of physicians practice there. 2 The scope of this problem is Dr. Rabinowitz is Ellen M. and Dale W. Garber Professor, Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Dr. Diamond is research professor, Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Dr. Markham is professor, Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Mr. Wortman was a research assistant, Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Correspondence should be addressed to Dr. Rabinowitz, Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Suite 401, 1015 Walnut Street, Philadelphia, PA 19107; telephone: (215) 955-7416; fax: (215) 955-0640; e-mail: (Howard.Rabinowitz@jefferson.edu). substantial, because more than 20 million of the 60 million people residing in rural areas live in federally designated Health Professional Shortage Areas (HSPAs). 3 This rural physician shortage has existed for more than 80 years, 4 despite the fact that, in general, people living in rural areas have a greater need for medical care, being older, sicker, and poorer than their nonrural peers. 5 Of greater concern, the future rural physician workforce is likely to decline even further, with only 3% of recent medical students planning to practice in small towns and rural areas. 6 Factors associated with this decline include the decreasing number of physicians entering family medicine and primary care, 1,7 the increasing number of women in medicine, 8 the changing lifestyle preferences of younger physicians, 1 and the increasing level of medical student debt. 9 A number of have attempted to address the rural physician shortage over the past century. Among the most successful have been the small number of comprehensive medical school that have increased the supply and retention of rural physicians. 10 However, the success of these medical school in addressing the rural physician shortage is not widely acknowledged. In addition, concerns have been raised regarding their generalizability, and the overall impact of these on the rural physician workforce has been questioned for decades. 11 13 Perhaps as a result, these have not been widely replicated. To address these issues, we decided first to systematically review the literature to identify the outcomes of comprehensive medical school whose primary goal is to increase the rural physician supply, and then to develop an evidencebased model of the projected impact if every U.S. medical school replicated this type of program. Method In 2006, to identify all publications that were about comprehensive U.S. allopathic medical school designed to increase the rural physician supply and that included recruitment and Academic Medicine, Vol. 83, No. 3 / March 2008 235

retention outcomes, we systematically searched the following databases: Ovid MEDLINE (1966 to September 2006); Ovid CINAHL (1982 to September 2006); Ovid EBM Reviews: ACP Journal Club (1991 to September /October 2006), Cochrane Database of Systemic Reviews, Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials (third quarter 2006); Ovid ERIC (1965 to August 2006); Ovid PsycINFO (1806 to September 2006); The Campbell Collaboration: C2-SPECTR, and C2-PROT (September 2006); and Scopus (1996 to September 2006). Search terms were medical education; medical education, undergraduate; medical schools; medical students; medical specialties, education; medical specialties, manpower; rural; rural health services; rural population; medically underserved area; professional practice location; rural health; rural health personnel; rural areas; rural physicians; rural physician supply; small towns; rural urban differences; nonmetropolitan areas; geographic isolation; and rural environments. Only English-language studies published in the U.S. literature were chosen, because this study focused on outcomes of only U.S. medical school. We searched for additional publications in the bibliographies of those we had already retrieved, as well as in literature reviews that included descriptions or outcomes of these. Finally, we searched the Internet sites of medical school that were identified, to seek more recent rural outcomes. Studies that included recruitment and retention outcomes of U.S. allopathic medical school were included only if the program met all of the following criteria: The primary goal of the program was to increase the supply of rural physicians. The program focused on a defined cohort of medical students. The program had either (1) a focused rural admissions process (i.e., based on student background and/or commitment) and a required rural curriculum, or (2) an extended (six months or longer), full-time required rural clinical curriculum during the last two years of medical school. Educational interventions are often difficult to assess because of the large number of uncontrolled variables, so we chose these relatively selective inclusion criteria to best evaluate the effect of the rural program itself. Studies were thus excluded if they identified medical school with multiple goals (e.g., both decentralizing medical education and addressing physician maldistribution, or increasing the supply of physicians practicing in either rural or urban underserved areas). Studies were also excluded if they identified that included only one programmatic component (e.g., a single rotation or course), or if they described changes in either a medical school s overall curriculum (e.g., adding required or elective courses) or overall admissions process (e.g., giving additional priority to students reared in a rural community), rather than focusing on a specific group of students. Finally, only published studies and evaluations on program Internet sites that contained the most recent available rural outcomes (i.e., the percentage of program graduates practicing in a rural area) were included. Two of us (H.K.R. and J.R.W.) independently reviewed the citations, as well as appropriate abstracts and full-text reports, for possible inclusion. We specifically excluded publications that (1) were not related to U.S., (2) addressed rural issues, studies, or that were not medical school, (3) reported on individual medical school courses or overall curriculum changes, (4) focused on osteopathic medical schools, (5) were literature reviews, or (6) described allopathic medical school that were not comprehensive, did not focus on a defined group of students, or had a primary goal other than to increase the rural physician supply. In the small number of cases where disagreements occurred, these were resolved by consensus. The following information was extracted from each study: medical school and program name; year that the program started; source of outcome data; study population; sample size; and outcome measures, including rural supply and rural retention and their definitions (see Table 1). None of the data extraction was done in a blinded fashion. We (H.K.R., J.J.D., and J.R.W.) evaluated the methodologic quality of each study by determining whether there was sufficient description of the methodology, definitions, and outcomes. Because differing definitions of rural were used in these studies, as in most of the rural literature, we summarized the outcomes of these by using a weighted average based on the number of graduates calculated for each of three different categories of rural definitions used. Using the evidence-based outcomes from this systematic review, we then developed a model of the projected impact of replicating this type of program at all 125 U.S. allopathic medical schools.* For this model, we assumed that every medical school without such a program would initiate a new program with 10 students in each class. For schools that already had such a program, the model proposed that these would be expanded by 10 additional students per class. Projected outcomes were compared with the current baseline of expected rural outcomes from all medical schools, based on the 2004 2005 entering class size for all U.S. allopathic medical schools (17,109 matriculants), 14 and the 3% of recent medical students who indicated that they plan to practice in rural areas or small towns. 6 A second set of similar models was also developed considering a projected 30% expansion of class size, as recently recommended by the Association of American Medical Colleges. 15 Results Rural that met the criteria The initial search of electronic databases resulted in a total of 1,796 publications. The search strategies yielded 143 after we removed duplicates and irrelevant citations (Figure 1). After applying the inclusion criteria to the abstracts and full-text articles and studies, there were 33 publications that identified seven medical school. After review of these publications and the seven Internet sites of these, another 26 publications and four of the Internet sites were excluded on the basis of not having any quantitative rural outcomes data, or not including the most recent outcomes available for that program for any rural definition. Overall, 10 sources (seven * At the time of the study, 2006, there were 125 U.S. allopathic medical schools; now, there are 126. 236 Academic Medicine, Vol. 83, No. 3 / March 2008

1796 Articles identified and screened for retrieval 1244 MEDLINE 49 CINAHL 47 EBM Reviews 139 ERIC 32 PsycINFO 1 Campbell Collaboration Databases 284 Scopus 143 Potentially relevant articles screened 102 Retrieved for full-text review 33 Articles identified 7 Internet sites of these 7 also searched 10 (7 articles and 3 Internet sites) included in systematic review (6 medical school ) studies 16 22 and three Internet sites 23 25 ) with rural outcomes from six medical school met all of the inclusion criteria and were, therefore, included in the systematic review. Eight of these studies addressed overall rural program outcomes, and two focused on rural retention outcomes. The six medical school that were identified in the studies were (see Tables 1 and 2): The Rural Physician Associate Program (RPAP) at the Minnesota Medical School; 1653 Duplicate and irrelevant articles removed by citation search 41 Excluded by abstract review* 1 Not U.S. program 12 Study of other rural issues 8 Programs, not medical school 9 Medical school courses, not program 1 Osteopathic 11 Medical school program, not primarily rural 69 Excluded* 28 Study of other rural issues 5 Programs, not medical school 21 Medical school courses, not program 2 Osteopathic 7 Review article 18 Medical school program, not primarily rural 30 (26 articles and 4 Internet sites) excluded 22 no data included 8 did not include most recent data *Some articles excluded for multiple reasons Figure 1 The search and selection of publications of comprehensive rural medical school in U.S. allopathic medical schools, 2006. The Minnesota Medical School, Duluth; The Upper Peninsula Program (UPP) at Michigan State University College of Human Medicine; The Physician Shortage Area Program (PSAP) at Jefferson Medical College of Thomas Jefferson University; The Rural Medical Education Program (RMED) at the State New York (SUNY) Upstate Medical University; and The Rural Medical Education Program (RMED) at the Illinois College of Medicine at Rockford. The most recent rural outcomes for RPAP graduates were available from both an article and the Internet, related to two different rural definitions 16,23 ; for the Minnesota, Duluth, the most updated outcomes were available on the Internet 24 (for both the RPAP and Duluth, Internet outcomes were similar to previously published outcomes 16,26 ). The most recent rural outcomes for the UPP, PSAP, and RMED (SUNY) were obtained from published articles. 17 20 Although published studies of RMED (Illinois) failed to include rural practice outcomes, 27 information was provided on the program s Internet site. 25 Regarding rural retention, only two published studies with outcomes were identified: Duluth and the PSAP. 21 22 Most of the studies had methodologic limitations, and in five instances the methodology was not clearly described. All 10 were specifically noted to be, or seemed to be, retrospective cohort studies. Data sources used by the studies authors for practice location included the American Medical Association Masterfile, individual medical school alumni data, and a graduate questionnaire, although in five instances the source was not specified. Years of graduation were clearly stated in five studies and could be inferred in the others. For studies addressing overall program outcomes, three different definitions of rural were used: (1) rural (i.e., either a non- Standard Metropolitan Statistical Area [non-smsa] county, or in three studies simply the word rural without further explanation), (2) communities of 50,000 or fewer people, and (3) communities of 25,000 (20,000 in the Duluth study) or fewer people. For two of the (RPAP and PSAP), two studies were available for each, providing outcomes for different definitions of rural. For the retention studies, rural was defined as (1) communities of 30,000 or fewer people and (2) non-smsa counties, and for both of these retention studies, outcomes about only family physicians were provided. The number of graduates with reported practice outcomes from the six individual ranged from as few as 28 graduates from the UPP to as many as 1,264 graduates from Duluth. For two Academic Medicine, Vol. 83, No. 3 / March 2008 237

Table 1 Studies Examining the Rural Outcomes of Medical School Programs Addressing the Rural Physician Supply* Program Medical school Year started Reference Data source Population Sample size Study outcomes: no. (%) of program graduates working in rural communities Rural <50,000 Population <25,000 Population Methodologic limitations Rural Physician Associate Program (RPAP) Minnesota (UM) Medical School 1971 Verby et al, NA NA; practicing in 1991 16 Minnesota 284 167 (59) 223 (79) 192 (68) Number of classes not given, 1972 1987 inferred; rural not defined; methodology not described; includes some UMD students... UM Internet, Outcomes, 2007 23 NA 29 classes (1972 2000); practicing in the United States 869 521 (60) Rural not defined; methodology not described; 64% of grads in Minnesota, 62% of Minnesota graduates were rural; includes some UMD students Minnesota Medical School, Duluth (UMD) Minnesota Medical School, Duluth 1972 UMD Internet, NA NA; practicing in Alumni, 2007 24 the United States 1264 NA (62) NA (47) (population 20,000) Number classes not given; sample size identified as all grads; methodology not described; some also part of RPAP 28 NA (50) Upper Peninsula Program (UPP) Michigan State University College of Human Medicine 1974 Brazeau et al, Grad questionnaire 1990 17 (100% response) 3 classes (1978, 1980, 1982) ; practicing in the United States Physician Shortage Area Program (PSAP) Jefferson Medical College, Thomas Jefferson University 1974 Rabinowitz et al, Alumni database 14 classes (1978 1999 18 1991); practicing in the United States 200 68 (34) (non-smsa counties)... Rabinowitz et al, NA NA NA NA (76) NA (68) Data source, population, sample 2000 19 size, and methodology not described, but assumed the same as for 1999 study Rural Medical Education Program (RMED) State New York (SUNY), Upstate Medical University 1989 Smucny, et al., American Medical 2005 20 Association Masterfile 11 classes (1990 2000); practicing in the United States 86 22 (26) Classes not clearly identified Rural Medical Illinois 1993 UIC Internet, NA 6 classes 61 56 (92) Illinois grads only (74% all Education Program College of Medicine Outcomes/ (1997 2002); grads); rural not defined; (RMED) at Rockford Statistics, 2007 25 practicing in Illinois methodology not described Weighted Average (57) (64) (53) * These data are from a 2006 review of literature that included practice outcomes of graduates from comprehensive rural medical school. These six met three criteria: (1) the primary goal of each was to increase the supply of rural physicians, (2) each focused on a defined cohort of students, and (3) each included either a focused rural admissions process and required rural curriculum, or an extended, full-time rural clinical curriculum during the last two years. Rural is defined as non-smsa (standard metropolitan statistical area) county, or the authors use simply the word rural without further explanation. NA signifies not available. Data not included in weighted average, because of more recent outcomes. Students admitted in alternate years only. 238 Academic Medicine, Vol. 83, No. 3 / March 2008

Table 2 Studies Examining the Rural Retention Outcomes of Medical School Programs Addressing the Rural Physician Supply * Program Minnesota Medical School, Duluth (UMD) Medical school Year started Reference Data source Population Sample size Study outcomes: rural retention Methodologic limitations Minnesota Medical School, Duluth 1971 Boulger, 2000 21 Alumni database 21 classes (1976 1996); continuing to practice rural family medicine in Minnesota after 1 20 years NA 87% remain in communities of 30,000 or fewer Sample size not given; family physicians in Minnesota only; some also participated in Rural Physician Associate Program at Minnesota... Physician Shortage Area Program (PSAP) Jefferson Medical College, Thomas Jefferson University 1974 Rabinowitz et al, 2005 22 Alumni database 9 classes (1978 1986); continuing to practice rural family medicine in the United States 11 16 years after first located in practice * These data are from a 2006 review of literature that included practice outcomes of graduates from comprehensive rural medical school. These six met three criteria: (1) the primary goal of each was to increase the supply of rural physicians, (2) each focused on a defined cohort of students, and (3) each included either a focused rural admissions process and required rural curriculum, or an extended, full-time rural clinical curriculum during the last two years. NA signifies not available. 38 79% (30) still in rural area (non-smsa county); 68% still in same rural area (26) Family physicians only, RPAP and RMED (Illinois), some outcomes were limited to only those graduates practicing in their state. In the case of RPAP graduates, we assumed that those state outcomes in communities of 50,000 people or fewer, and those of 25,000 people or fewer, were similar to all RPAP graduates, because recent Internet data for all rural graduates were similar to prior outcomes for in-state graduates. 16,23 For RMED graduates, even the assumption that no additional out-of-state graduates were practicing in rural areas would have minimal effect on the overall weighted average. As seen in Table 1, the studies showed a range of 26% to 92% of physicians working in rural communities, which is multiple times greater than both the 3% rate of current students planning to go rural and the 9% of current physicians practicing rurally. Overall program outcomes were available for between 1,639 and 2,508 physicians who graduated from medical school between 1972 and 2002 (this range of physicians includes an unspecified number of graduates of the two-year Duluth program who also participated in the RPAP program). The overall weighted average of graduates practicing in rural areas (i.e., non-smsa counties, or not further defined) was 57%. Similarly, 64% of graduates were practicing in areas of 50,000 or fewer people, and 53% were in practice in areas of 20,000 to 25,000 or fewer people. As seen in Table 2, retention outcomes from Duluth showed that 87% of graduates practicing family medicine in Minnesota communities of 30,000 or fewer people remained for a 1- to 20-year duration. PSAP outcomes showed that 79% of graduates practicing rural family medicine were continuing to do so 11 to 16 years after they were first located in practice (which occurred five to nine years after graduation). Replication model Given the 53% to 64% range of rural practice outcomes from these studies, depending on the definition of rural used, we used the lower number (53%) as the conservative estimate, and we developed a model of the projected impact if 125 U.S. allopathic medical schools developed a similar small program (i.e., 10 students per year). As seen in Figure 2, initiating new in every medical school would be expected to result in 1,139 rural physicians yearly, more than twice the number produced if there were no such (513). During the next decade, this is projected to result in 6,260 additional rural physicians (Figure 3). Considering the multiplicative effect of increased long-term retention of these graduates, the impact of these would likely be even greater. Similarly, if the class size of all U.S. medical schools were expanded by 30%, initiating these as part of this expansion would be expected to result in 12,920 rural physicians per decade, more than 2.5 times the estimated current output (Figure 3). In this scenario, of the 5,133 expanded positions each year, initiating these rural would result in 779 additional rural physicians, more than five times the number produced by this expansion, but without these (154) (Figure 2). Discussion We undertook this study to answer important and long-standing public policy questions regarding medical school rural. 1,7,11 12 These questions focused on the degree to Academic Medicine, Vol. 83, No. 3 / March 2008 239

Current (2004-2005) class size No rural 17,109 current matriculants @ 3%* = 513 rural physicians Rural 17,109 current matriculants 1,250 @ 53% = 15,859 @ 3%* = 663 rural physicians 476 rural physicians = 1,139 rural physicians 30% increase in class size No rural 17,109 current matriculants 5,133 (30% increase) @ 3%* = @ 3%* = 513 rural physicians 154 rural physicians = 667 rural physicians Rural 17,109 current matriculants 5,133 (30% increase) @ 3%* = 1,250 @ 53% = 3,883 @ 3%* = 513 rural physicians 663 rural physicians 116 rural physicians = 1,292 rural physicians * Percentage of all recent medical school students who plan to practice in rural areas. 10 students in rural at 125 US allopathic medical schools. A conservative rate of success of comprehensive medical school focused specifically on graduating doctors who will practice in rural communities. This number came from a review of six such existing. Figure 2 Projected rural physicians per year, with and without the replication of rural medical school, for both the current (2004 2005) class size and the class size after the AAMC-recommended 30% expansion. which these are successful, generalizable, and have the potential to substantially impact the supply and retention of rural physicians if they were widely replicated. The results from this systematic review indicate that all six identified medical school rural have been highly successful in increasing the supply of rural physicians, with an average of 53% to 64% of graduates practicing in rural areas. The 10 studies reviewed had wide variability in methodology, varying degrees of methodologic rigor, and used different definitions of rural. Nevertheless, taken in the aggregate, we believe that the evidence regarding the effects of these is substantial, with the rural outcomes from these individual between 26% and 92% all multiple times greater than both the 3% of recent students who have plans for rural or small-town practice and the 9% of physicians currently practicing in rural areas. Similarly, the rural retention rates of 79% to 87% are substantially higher than the national norm, where the median duration of rural primary care physicians practicing in the same area is seven years. 28 Regarding the issue of generalizability, these six medical school represent both public (five) and private (one) institutions, are located in different regions of the United States (two in the Northeast, and four in the Midwest), and have graduated more than 1,600 physicians in three decades. Using the evidence from these studies, widespread replication of this type of program to other medical schools is projected to substantially increase the current output of rural physicians. Although rural areas do not equate perfectly with underserved areas, most rural areas are relatively underserved, and most physician shortage areas are located here. 2,3 Only one of the in this review also reported the percentage of their graduates practicing in underserved areas (HPSAs), with results very similar to those in rural counties (30% versus 34%). 18 Nonetheless, additional studies of outcomes of these focusing on underserved rural areas are needed. In studying medical school rural, we developed relatively restrictive inclusion criteria to identify only the most focused and comprehensive and, thereby, illustrate what could be expected if this most expansive type of program were replicated. As a result, a small number of other medical school that are widely considered to be rural did not meet our inclusion criteria. Perhaps the best known of these is the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) program at the Washington School of Medicine. WWAMI is a highly successful, multistate program whose main goal is to improve the health of citizens in a region that has a high percentage of rural residents through decentralized medical education, rather than to primarily focus 240 Academic Medicine, Vol. 83, No. 3 / March 2008

Number of rural physicians / decade 14,000 12,000 10,000 8,000 6,000 4,000 relatively small. It is important to realize, however, the critical impact of a small number of physicians in a rural area. Although increasing or losing dozens of physicians in a large metropolitan area is unlikely to result in substantial changes in the number of people actually obtaining care, adding (or losing) just one physician in a small rural area often has a major impact on access to care for those living in these communities. As a result, even relatively small outcomes from rural can have a disproportionately large impact on small towns. In the case of the PSAP, this program averaged only 14 students a year but contributed 12% of rural family physicians in Pennsylvania. 18 2,000 on producing rural physicians. (This latter goal is included more broadly in one of WWAMI s other objectives: to address the maldistribution of physicians in the region. 29 30 ) Although there is obviously significant overlap in these goals, there is no information indicating that WWAMI has an admissions process primarily limited to applicants likely to become rural physicians, nor is there any required rural clinical experience for WWAMI students. Nonetheless, the proportion of WWAMI students from rural areas seems to be higher than that of their non-wwami peers, and outcomes of the program have shown that 23% of graduates practice in rural (non-smsa) areas. 31 32 0 No rural Rural Current (2004-2005) number of matriculants This study also did not consider osteopathic medical school. Although osteopathic schools have historically had a greater percentage of their graduates practice in rural areas, these doctors represent only about 5% of all physicians. 33 In addition, even though we did not specifically include at osteopathic schools in our search strategy, we failed to note any osteopathic medical school program that would have met our inclusion criteria. No rural Rural 30% Increase in matriculants Figure 3 Projected rural physician outcomes per decade with and without replication of rural medical school for both the current (2004 2005) and expanded number (by 30%, as recommended by the AAMC) of matriculating students. Further, this study did not compare the outcomes of comprehensive medical school with other ways to increase the rural physician supply (e.g., the National Health Service Corps, state, high school and college, loan repayment, isolated admissions policies, individual courses or curriculum changes, and rural residency ), although the results of these comprehensive medical school are among the highest reported. 34 And, although this study did not specifically look at the specialty choice of rural physicians, most of the medical school with published outcomes have focused on family physicians (who contribute the greatest proportion of the rural physician workforce) 8 and other primary care physicians. Although rural communities also have critical needs for other specialists (e.g., general surgeons), little information is available regarding program outcomes for these specialties. Although this study has shown that widespread replication of small medical school rural can be expected to substantially increase the output of rural physicians, the absolute number of physicians projected in these models is Although some have raised concerns regarding the ability to predict at the time of admission to medical school which applicants will actually practice in rural areas, the fact that multiple schools have been doing this for decades provides strong evidence that it can be done. Prior multivariable analysis has shown that the two most powerful factors in predicting rural practice are growing up in a rural area and entering medical school with plans to become a family physician (both of which are known about students at the time of medical school admission). 35 In this study, four of the six (Duluth, UPP, PSAP, and RMED [Illinois]) included a focused rural admissions component (and the RPAP included a number of students admitted to the Duluth program). Also, despite common concerns regarding the quality of students in medical school rural, studies have shown their academic performance to be similar to that of their peers. 16,20,36 This study did not address the cost of implementing these medical school rural. Although important, the cost of a focused rural admissions program is relatively modest, and in some instances a portion of rural curricular costs might be lessened by integrating these into the existing curriculum. Nonetheless, more study is needed to identify the costs of these. Although some have raised concerns regarding the adequacy of the pool of qualified medical school applicants likely to become rural physicians, 11 we believe that admitting 10 additional such students per year at each medical school would be relatively easy to achieve. Academic Medicine, Vol. 83, No. 3 / March 2008 241

As with any systematic review, it is always possible that we failed to identify some medical school rural. Considering the scope and size of our search, however, which included review articles and examining bibliographies of reviewed articles, we believe that our process identified all of the comprehensive rural U.S. medical school with practice outcomes. Regarding our model, even using the current 9% of physicians practicing rurally as a baseline, instead of the 3% of students planning rural practice, the overall projection still shows a substantial increase in rural physician output of 5,500 additional rural physicians during the next decade (compared with 6,260 in our model). Similarly, even if not all of the students in these new would represent a net increase in rural physicians, prior data suggest that most would. 18 And, although it is obviously unlikely that all medicals schools will actually develop comprehensive rural, the more that do, the greater the impact on the rural physician supply. For example, if two thirds of medical schools (e.g., all public medical schools and a few private schools) instituted these, this would still result in more than 4,000 additional rural physicians during the next decade. Although we did not quantitatively include retention outcomes in our model, retention has a critical and multiplicative impact on the rural physician supply. For example, having one rural physician who stays his or her entire career (i.e., 35 years) is equivalent to having five consecutive rural physicians who each stay for seven years (if a community is successful in continuously recruiting successive new physicians immediately after the departure of the previous ones). Finally, we believe that it is critical for more medical schools with rural to rigorously track their graduates practice outcomes, to increase the literature base in this important area. Although substantially increasing the rural physician supply is predicted by our replication model for both the current medical school enrollment and with expanded enrollment, there are important differences in these two scenarios. In fact, the current plan to substantially expand the medical school enrollment represents a unique opportunity to address the rural physician workforce. Because there are many challenges for medical schools in reallocating currently unassigned places for admissions to students likely to become rural physicians, it is usually easier to apportion newly expanded positions to achieve this specific goal. In fact, for the first time in decades, there seems to be a new trend for schools to develop these, and we are aware of five medical schools that have recently begun to plan or develop medical school rural similar to those we examined four of these are linked to plans to expand overall class size. 37 41 This study did not specifically address why medical school rural have not already been replicated more widely. In the past, academic health centers have been ambivalent regarding their role and responsibility in meeting the physician workforce needs of rural communities. 1,12,42 There is strong evidence that medical schools do have significant potential to address this issue, including the results of this study (which show the success of these medical school during the past three decades), the critical nature of both the admissions process and curricular components in these successes, and the wide range in the percentage of graduates from U.S. medical schools practicing in rural areas (2% 42%). 35,42 Despite this evidence, however, medical schools have multiple competing missions and face increasing financial pressures and their missions are increasingly tied to the degree to which they are financially supported, rather than primarily focusing on meeting the needs of the population. It is, therefore, unlikely that the graduation of rural physicians will be a high priority for most medical schools, unless specific regulations require this, or unless adequate financial resources are provided as incentives to support this mission. On the other hand, a unique opportunity thus exists for foundations and state and local governments to provide this financial support and encouragement. In this regard, we believe that the Medical Scientist Training Program (MSTP, which supports MD PhD candidates at a large number of medical schools) represents a potential model for expanding comprehensive medical school rural. Both focus on addressing a critical shortage of health professionals, both select students on the basis of their past experiences and commitments to future careers, and both provide appropriate curricula to achieve their goals. Evaluations of both types of have shown similar outcomes, 43 despite both having study limitations, including variability in methodologies and outcome definitions. The MSTP, which have had strong institutional support, have provided medical schools with substantial external funding and have also stimulated other schools to develop similar without such support. This type of program, together with the imminent expansion in medical school class size the first in decades represents an unprecedented opportunity, during which time the widespread replication of medical school rural could have a major impact. Without such a concerted effort, even the upcoming and substantial increase in class size will do little to address the rural physician shortage. Acknowledgments The authors would like to thank Margy Grasberger, MS, manager, Information Services, Scott Memorial Library, Thomas Jefferson University, for help in developing the search strategy. References 1 Whitcomb ME. The challenge of providing doctors for rural America. Acad Med. 2005; 80:715 716. 2 Gazewood JD, Rollins LK, Galaska SS. Beyond the horizon: The role of academic health centers in improving the health of rural communities. Acad Med. 2006;81: 793 797. 3 Federal Office of Rural Health Policy. Facts about... rural physicians. Available at: (http://www.shepscenter.unc.edu/research_ /rural_program/phy.html). 4 Pusey WA. Medical education and medical service, I: The situation. JAMA. 1925;84: 281 285. 5 Health Resources and Services Administration. One Department Serving Rural America: HHS Rural Task Force Report to the Secretary. Available at: (http:// ruralhealth.hrsa.gov/publicreport.htm). 6 Association of American Medical Colleges. Association of American Medical Colleges Matriculation Questionnaire 2005: All Schools. Available at: (http://www.aamc.org/ data/msq/allschoolsreports/msq2005.pdf). 7 Colwill JM, Cultice JM. 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