It’s a fact that doesn’t bode well for rural healthcare: Over a 15-year period, the number of medical students from rural backgrounds declined 28%.
Because growing up in a rural setting is a strong predictor of a future decision to practice in a rural community, the decline could mean a worsening in the shortage of physicians in rural areas of the country down the road.
While overall medical school positions increased by more than 30% from 2002 to 2017, the number of medical students from rural backgrounds decreased by 28%, so they made up only 4.3% of the incoming medical student body in 2017, according to the study published in Health Affairs.
“In that context, I think it is pretty striking,” the study’s lead author, Scott Shipman, director of primary care initiatives and clinical innovations at the Association of American Medical Colleges (AAMC), said in an interview with FierceHealthcare.
Those students from rural backgrounds are seen as a key to meeting physician workforce needs for rural communities, he said.
“It makes sense that individuals who come from a rural background understand what life is like and what the culture of rural life is like. They are more familiar with it and more likely to consider that as a place to set up their lives and their careers in practice,” he said.
Given the 30% growth in new slots for medical students from both the creation of new medical schools and expansion of existing schools, “it’s been a period where there arguably should be opportunity for more rural students to get into medical school but we’ve seen just the opposite,” he said.
The AAMC predicts a shortage of up to 122,000 physicians by 2032, with rural and historically underserved areas experiencing those shortages most acutely. Many rural areas are already experiencing shortages of primary care and specialty physicians.
Only 11% of doctors practice in rural communities, and as of 2019 over 62% of all federally designated primary care Health Professional Shortage Areas were in rural areas, the study noted.
“From a workforce pipeline perspective, this study has made it clear that students from a rural background are an increasingly underrepresented group in medical school,” the study authors said. If the number of rural students entering medical school were to become proportional to the share of rural residents in the U.S. population, the number would have to quadruple, the researchers said.
The study authors recommend stronger programs to support the pipeline of rural students and urge medical schools to consider rural background as an important component of diversity.
While the overall number of students from rural backgrounds dropped, it was also true for students in underrepresented racial/ethnic minority groups in medicine who are from rural backgrounds, who accounted for just one out of 200 incoming students (less than 0.5%) in 2017.
“This study highlighted the deeper disparities that exist at the intersection of rural and underrepresented racial/ethnic groups in medicine,” the study said. So while gains have been made in the number of racial and ethnic minority students entering medical school and medicine, those gains have not been been experienced by rural minority students, Shipman said.
“To date, medical schools’ efforts to recognize and value a rural background have been insufficient to stem the decline in the number of rural medical students,” the researchers wrote. “Policy makers and other stakeholders should recognize the exacerbated risk to rural access created by this trend.”
The December issue of Health Affairs focused on rural healthcare given the relatively poor health outcomes and heightened rate of socioeconomic disadvantage of rural America, where 1 in 5 Americans live.
While the number of medical students from a rural background declined from 1,186 in 2002 to 852 in 2017, at the same time the number of students from urban areas increased by 35% from 13,871 to 18,745, based on data from the American Medical College Application Service.
Although it wasn’t the focus of the study, asking why there’s less students from rural backgrounds going into medicine is a natural question raised by the research, Shipman said.
The study found that the number of students from rural backgrounds applying to medical school dropped, along with the numbers getting into programs. Complicating the fact that a smaller number are trying to get into medical school, those who do apply may be less competitive than their urban peers when it comes to all the characteristics that admission committees seem to favor in deciding who to admit, he said. For instance, the study said, rural applicants may have less research experience.
“So it’s at least a two-fold factor,” he said.
Treating rural background as a diversity factor
It’s time for medical schools to consider students’ rural backgrounds as they do factors such as race and ethnic background in creating a diverse student body and in the future a diverse physician workforce, Shipman said.
As research has shown when it comes to diversity, having a physician workforce that understands the population they serve is important for patients. “Having people who grow up in rural communities and understand those communities and the people in them—the lifestyles and the priorities—are an important part of a diverse workforce. So, just as other forms of diversity are critically important to serving our diverse patient population across the country, rural background is one factor we need to increasingly focus on,” he said.
Some medical schools already do this, but the study shows it has not been sufficient, he said. Thinking about students’ rural background as they do other diversities is an opportunity to help turn around the trends the study uncovered, he said.
Some possible solutions
So, how can healthcare find ways to increase the number of students who are more likely to practice in those rural communities?
“It’s a multi-factorial problem and it’s going to take multi-factorial solutions to overcome it,” Shipman said. Strengthening the pipeline to get well-qualified students from rural backgrounds into careers in medicine is the obligation of medical schools, the rural communities themselves and the health systems in those rural areas to expose young people to role models and experiences in medical settings, he said.
It’s important to grow the pool of interested young people from rural communities and then help them be as strong as possible when they apply, he said.
Colleges can offer preparation courses for students who want to take the test for entrance to medical school, application assistance, financial aid education and opportunities to shadow physicians, the study said.
Medical schools can provide more experience during training to expose students to the rural practice of medicine. There’s also an opportunity for the several medical schools located in rural communities, as well as those located in states with large rural populations, to recognize the role they can play as an important part of pipeline development for the future workforce to meet those rural population needs, he said.
“Our hope is that by calling out the national trend that has emerged in terms of a dearth of rural students entering medical school more schools will reconsider what they could do and identify the opportunity to expand the pool of rural students who can become capable, caring doctors in the future,” Shipman said.
It’s important to support the resources in place to increase the healthcare workforce, he said. For instance, in many states, Area Health Education Centers have been an important source of programming for the entire healthcare pipeline, the study noted. However, the centers receive highly variable support at the state level, and federal funding is continually in jeopardy, it noted.