Enticing Rural Residents to Practice Where They Train

Andrew Fry, MD, grew up in a small rural Pennsylvania community about 40 miles southwest of Harrisburg. He completed medical school and residency in the state and, after graduating last year, is now a family medicine doctor in a nearby rural area within an hour from his hometown.

Fry is an example of the recent renewed national effort by public and private health organizations to entice new physicians to train and practice in rural communities after graduation. A recent boost in incentives for new doctors and funding for the medical education programs that train them aims to help offset physician shortages in those areas and meet the growing needs of rural healthcare, particularly for specialty services.

Summit Health, now part of WellSpan Health, agreed to pay Fry’s medical school tuition at Thomas Jefferson University’s Sidney Kimmel Medical College in Philadelphia if he agreed to practice in a rural community near his hometown for 4 years after residency. WellSpan honored that commitment, encouraging him to work for them. The program is funded through WellSpan’s foundations and donor gifts.

“I probably would have been back here,” practicing in rural Pennsylvania, said Fry, who works at a WellSpan Family Medicine outpatient clinic in Chambersburg after training at WellSpan York Hospital about 60 miles away. “They made the decision easier.”

Physician Shortages Plague Rural Communities

Nearly 70% of the nation’s Health Professional Shortage Areas for primary care are in rural communities, according to the US Health Resources and Services Administration (HRSA).

The Association of American Medical Colleges (AAMC) estimates the nation will face a shortage of up to 86,000 physicians by 2036, including primary care doctors and specialists.

Physician shortages are compounded by the closing of rural hospitals. Since 2010, 138 rural hospitals have closed, with 19 closing in 2020 alone, according to the Centers for Medicare & Medicaid Services (CMS).

Worsening the problem, only 2% of residency training occurs in rural areas, according to the US Government Accountability Office.

Several federal health organizations recently bumped up funding for rural residency training programs. They offered loan repayment incentives to residents who agreed to stay in the communities in which they train.

For example, the HRSA announced that it would award nearly $11 million to establish new residency programs in rural communities, particularly to meet a growing need for obstetrics and gynecology training in those areas.

More than half of rural US counties lack hospital obstetric services, so the new residency programs being developed include the nation’s first obstetrics and gynecology rural track and six other new family medicine residency programs with obstetrical training in rural communities.

The HRSA also increased student loan repayment amounts by 50%, forgiving up to $75,000 of debt if a primary healthcare provider commits to practicing in rural areas for 2 years.

Training physicians in rural areas has increased the likelihood that doctors will practice in those rural communities. “How and where you train impacts how and where you practice,” said Emily Hawes, deputy director of the HRSA’s Rural Residency and Teaching Health Center Planning and Development programs.

HRSA Makes a Difference

Since 2019, the HRSA awarded nearly $64 million to the Rural Residency Planning and Development (RRPD) program. Past recipients have created 47 accredited rural residency programs approved to train 587 residents. The residency programs primarily offer family medicine, internal medicine, psychiatry, and general surgery training. In the 2024 residency match, residency programs created through RRPD matched 163 new residents who began training in the summer.

The HRSA also reported that its Teaching Health Center Graduate Medical Education (GME) received $175 million in fiscal 2024 for 81 community-based residency programs, some of which are in rural areas. And the HRSA’s Teaching Health Center Planning and Development Program provided nearly $45 million to plan and establish an additional 90 new residency training programs in community settings, with nearly 50 training sites in rural areas, according to the program’s Technical Assistance Center.

Meanwhile, the HRSA’s Primary Care Training and Enhancement: Residency Training in Primary Care supports 21 grantees who received nearly $9.4 million. Of those, 19 provide rural rotations for their trainees, and 14 have rural training tracks within their residency programs.

Barriers to Progress

Despite increased public funding for GME training, most funding is still not reaching rural communities and healthcare settings where underserved populations lack care, according to a 2023 report about the Teaching Health Center GME program. Congress created the program in 2010 as part of the Affordable Care Act to support residency programs in community-based health centers.

More than 75% of primary care residency training still occurs in hospitals instead of community-based outpatient care, according to the report Hawes co-authored through her work with the Teaching Health Center GME program.

CMS primarily funds residency training in urban academic medical centers, Hawes told Medscape Medical News.

Congress has also approved 1200 residency training slots in recent years with some allocated for rural and underserved areas.

In addition, Congress recognized the need to provide startup funding and technical assistance to build rural residency programs. Since 2018, through the RRPD program, Congress allocated over $60 million to help healthcare organizations, such as academic medical centers, rural health facilities, Federally Qualified Health Centers, and schools of medicine start rural residency programs in which more than half of the training takes place in rural areas, Hawes said.

She added that it typically takes 3-5 years to launch new rural residency programs.

Rural health facilities must form clinical partnerships, design the curriculum, achieve accreditation, ensure financial feasibility, recruit faculty, and enroll students.

Rural training programs initially provided an opportunity for an urban hospital to establish a medical residency training program in a rural area, generally through a partnership with a rural hospital or at rural nonhospital sites, according to AAMC.

Participation was limited to separately accredited medical residency programs in rural areas. To date, most of the separately accredited programs are in family medicine, AAMC reported.

Hawes said that the Consolidated Appropriations Act of 2021 helped ease some of the process by enabling rural health facilities to partner with academic medical centers to expand their rural outreach and establish new rural residency programs embedded in already accredited programs.

Other barriers to building the rural medical workforce include the need for more faculty to train residents in shortage areas, said Hawes, herself a rural pharmacist and professor at the Department of Family Medicine, University of North Carolina at Chapel Hill.

“I don’t have close proximity to a hospital,” she said. For example, “I’m in a community that does not have an endocrinologist. So primary care physicians have to be trained in a way to provide a broad skill set, such as intensive insulin management.”

Rural communities lack the patients to support specialty providers, said Jonathan Jaffery, MD, AAMC’s chief healthcare officer. “If you are a specialist, you have to have a certain population density to have enough patients to practice. It’s difficult to do in less populated areas. There aren’t enough people to support care for a multispecialty private practice.”

Fry added that practicing family medicine in a rural community with a shortage of healthcare providers, particularly specialists, allows him to stretch his skills across a broad spectrum of health issues. “Yesterday, I saw 20 patients, including a healthy child, a new cancer diagnosis, and an upper respiratory diagnosis…I get to do so much.”

Changes Take Time

AAMC and other healthcare advocacy groups continue to advocate for more grant money to offset some of the costs associated with starting new rural residency programs and for increased funding for workforce programs to help recruit, train, and support healthcare workers.

In the meantime, Hawes believes that new rural residency programs are making an “important or meaningful” dent in the workforce shortage in rural areas.

Half of the 81 graduates of new RRPD programs that began 5 years ago are practicing in rural areas, she said. “Next year, we hope to double the number of graduates.”

While one in two medical graduates staying in rural communities is not a huge number, one more doctor in a practice that accepts new patients makes a difference in a small community, she added.

“There’s a great appetite for training in rural areas.” Nearly all the new residency slots in these new rural programs are filled, she said. “Years down the road, we hope it impacts mortality and health outcomes.”

Residents in the new programs are trained to treat opioid disorders, manage diabetes, provide behavioral health, and address heart disease, some of the biggest health challenges in rural communities. “It’s an effective mechanism to help,” Hawes said. “Is it going to solve everything? No.”

Meanwhile, Fry admitted that practicing in rural areas may not be best for all new doctors. But it was the right decision for him and living near his family factored in. He met his wife Lydia, a new physician assistant, in high school, and she works part-time in a rural family medicine practice where they both grew up.

Fry also believes he is earning more in his current position than he would have staying in Philadelphia, where he attended medical school, with its higher cost of living. Overall, he said that he benefits from practicing in the rural environment. “Some days are hard and challenging, but the patients really appreciate it.”

Roni Robbins is a freelance journalist and former editor for Medscape Business of Medicine. She’s also a freelance health reporter for The Atlanta Journal-Constitution. Her writing has appeared in WebMD, HuffPost, Forbes, New York Daily News, BioPharma Dive, MNN, Adweek, Healthline, and others. She’s also the author of the multi-award–winning Hands of Gold: One Man’s Quest to Find the Silver Lining in Misfortune.