BACKGROUND AND OBJECTIVES:Place-based clinical education is vital for promoting the growth of the rural clinician workforce; where learners receive their education strongly influences where they practice. Yet students may struggle to find rural placements. In this study, we sought to understand trends in teaching by family physicians for varied health professions and the associated physician, practice, and community factors. METHODS:We analyzed data from 14,789 early career family physicians surveyed from 2016 to 2023. We compared the teaching status of rural and urban physicians overall and by year. We conducted trend analyses and multivariate regression to investigate the relationship between physician and practice characteristics, practice activities, community characteristics, and teaching status. RESULTS:More rural than urban physicians taught premedical students (30.8% vs 18.7%), medical students (62.2% vs 54.4%), and advanced practice professional students (51.2% vs 33.7%), while more urban than rural physicians taught residents (41.9% vs 37.8%) and fellows (8.7% vs 2.3%). Trend analyses showed an 8.4% increase in rural physicians teaching residents from 2016 to 2023, and a decline in teaching advanced practice professional students over the same time period. In adjusted analyses, family physicians who were younger, male, and White non-Hispanic were more likely to teach, as were osteopathic physicians, those with a broad scope of practice, and those who provided obstetric services. CONCLUSIONS:A larger share of rural than urban early career family physicians teach health professions students, but the rate who are teaching advanced practice professional students has declined significantly. Understanding and arresting the decline will be essential to addressing rural workforce capacity.

Background In 2019, the U.S. Federal Office of Rural Health Policy (FORHP) began funding the Rural Residency Planning and Development (RRPD) awards, intended to help rural communities develop residency programs. The Accreditation Council for Graduate Medical Education requires faculty development for all programs. Rural programs, especially those starting out, often struggle to incorporate faculty development. Objective To characterize types of faculty development that new rural residency programs with RRPD awards are using, describe typical structures of these programs, and assess differences by specialty, region, size, or program structure. Methods We used descriptive and bivariate analysis of FORHP performance report data from fiscal year 2023 of 43 RRPD grant recipients who were starting new residency programs to determine types and structure of faculty development programs. Results Sixteen of 43 grant recipients (37.2%) indicated their faculty participated in structured, mostly longitudinal faculty development programs; 22 (51.2%) participated in a faculty development activity such as a conference or class; and 12 (27.9%) reported no faculty-related activities in that year. Those further along in development were more likely to report engagement in faculty development. There were no differences in faculty development quantity or type based on specialty, region, size, or rural track structure. Conclusions New and developing residencies in the RRPD program engage in faculty development through a myriad of activities, including structured, longitudinal programs as well as conferences, workshops, and trainings.

Context: Rural America has fewer physicians leading to poorer health outcomes. In an attempt to bolster the rural physician workforce, the Health Resources and Services Administration (HRSA) funded a series of Rural Residency Planning and Development (RRPD) awards to develop rural residency programs in needed specialties. These 3-year program start-up grants were awarded to the initial cohort of RRPD grantees in 2019. Objective: Explore early workforce outcomes of the RRPD grants program, using resident recruitment data Study Design & Analysis: cross-sectional, descriptive analysis of qualitative and quantitative evaluation data Setting: new rural residency training programs across the U.S. Intervention/instrument: grantee exit survey, administered at the conclusion of their RRPD award Population studied: Cohort 1 RRPD grantees: 25 newly developing residency programs in Family Medicine (n=20), Psychiatry (n=4) and Internal Medicine (n=1) across the US Outcome measures: Median total and eligible applications per available position; median interviews offered and completed per position; positions filled in the main residency Match vs the Supplemental Offer and Acceptance Program (SOAP); residents from the state where program is located Results: The 25 Cohort 1 RRPD programs range in size from 2 to 8 residents per year. Most programs (16 or 64%) were considered rural training tracks and anticipate that residents will spend on average 73% of their time at rural training sites (50% min to 100% max). Of the 25 sites, 17 (68%) were far enough along in development to participate in the 2022 Match. These programs received a median of 152 (range 25-349) total applications per position, 22 (range 5-122) of which were considered eligible. They offered a median of 15 (range 5-45) interviews per position and completed 15 (range 5-33) of these. Most of the 68 total positions were filled in the main NRMP Match (79% average) though some (19% average) were filled in the SOAP. Approximately 1 in 3 (34%) of residents currently enrolled in Cohort 1 RRPD programs are from the state in which the program is located, though this ranged from 0 to 79% by program. Conclusions: Early resident recruitment outcomes suggest the RRPD model is successful in creating and supporting new physician workforce training in rural communities. A strong main Match fill rate (79%) may indicate student interest in rural training, including those who are local to the area.

Background and Objectives: Institutional racism causes worse health outcomes for patients of racial/ethnic minority groups via limited access to health care, disparities in quality of care delivered, and lack of physician diversity. Increased attention to racism in 2020 led many medical institutions to examine their diversity, equity, and inclusion (DEI) efforts. In the context of increased national attention to health equity, this study sought to investigate the current status of DEI infrastructure by evaluating leadership and support related to DEI in family medicine departments in 2020 and 2021. Methods: We analyzed department and chair characteristics as well as departmental DEI infrastructure (ie, leadership and actions) from Association of Departments of Family Medicine survey data in 2020 (data collected from June to September 2020) and 2021 (data collected from September to December 2021). We performed multiple regression analyses to evaluate whether department characteristics or specific DEI activities were associated with increased DEI infrastructure in 2021 compared to 2020. Results: Of the 165 department chairs sent the survey in both 2020 and 2021, 56 (33.9%) responded both years. Departments with a designated DEI leader increased from 42.9% in 2020 to 60.7% in 2021, but about 40% of departments lacked key supports for this position (ie, funding, staff support, and a pathway for advancement). Regression analysis did not demonstrate associations between independent variables and three measures of departmental DEI activities. Conclusions: This study demonstrates that designated leadership for DEI work increased in family medicine departments between 2020 and 2021.

BACKGROUND AND OBJECTIVES:The Medicare Primary Care Exception (PCE) permits indirect supervision of residents performing lower-complexity visits in primary care settings. During the COVID-19 pandemic, Medicare expanded the PCE to all patient visits regardless of complexity. This study investigates how PCE expansion changed resident billing practices at a family medicine residency during calendar year 2020. We hypothesized that residents not constrained by the PCE would bill more high-level visits.METHODS:We queried billing codes from attendings' and residents' established evaluation and management visits associated with the University of Washington Family Medicine Residency (UWFMR) from January to December 2020. We used χ2 tests to compare resident and attending physicians' use of low/moderate and high-level codes by quarter.RESULTS:Resident high-complexity code use increased after PCE expansion in Q4 (odds ratio [OR] 3.50 [2.34-5.23]) compared to Q1. No change was observed among attending physicians (OR 1.05 [0.86-1.28]). Resident and attending billing patterns became more similar following PCE expansion.CONCLUSIONS:With the PCE expansion, senior family medicine resident physicians at UWFMR used higher-complexity billing codes at a rate approximating that of attending physicians. The findings of this study have implications regarding the financial well-being and sustainability of primary care residency training and raise a relevant policy question about whether the PCE expansion should persist. More research is needed to determine whether these findings were replicated in other primary care residency practices, the impact on resident education, and the impact on patient outcomes.

BACKGROUND AND OBJECTIVES:The quality of training in rural family medicine (FM) residencies has been questioned. Our objective was to assess differences in academic performance between rural and urban FM residencies.METHODS:We used American Board of Family Medicine (ABFM) data from 2016-2018 residency graduates. Medical knowledge was measured by the ABFM in-training examination (ITE) and Family Medicine Certification Examination (FMCE). The milestones included 22 items across six core competencies. We measured whether residents met expectations on each milestone at each assessment. Multilevel regression models determined associations between resident and residency characteristics milestones met at graduation, FMCE score, and failure.RESULTS:Our final sample was 11,790 graduates. First-year ITE scores were similar between rural and urban residents. Rural residents passed their initial FMCE at a lower rate than urban residents (96.2% vs 98.9%) with the gap closing upon later attempts (98.8% vs 99.8%). Being in a rural program was not associated with a difference in FMCE score but was associated with higher odds of failure. Interactions between program type and year were not significant, indicating equal growth in knowledge. The proportions of rural vs urban residents who met all milestones and each of six core competencies were similar early in residency but diverged over time with fewer rural residents meeting all expectations.CONCLUSIONS:We found small, but persistent differences in measures of academic performance between rural- and urban-trained FM residents. The implications of these findings in judging the quality of rural programs are much less clear and warrant further study, including their impact on rural patient outcomes and community health.

Background and Objectives: Although rural family medicine residency programs are effective in placing trainees into rural practice, many struggle to recruit students. Lacking other public measures, students may use residency match rates as a proxy for program quality and value. This study documents match rate trends and explores the relationship between match rates and program characteristics, including quality measures and recruitment strategies. Methods: Using a published listing of rural programs, 25 years of National Resident Matching Program data, and 11 years of American Osteopathic Association match data, this study (1) documents patterns in initial match rates for rural versus urban residency programs, (2) compares rural residency match rates with program characteristics for match years 2009-2013, (3) examines the association of match rates with program outcomes for graduates in years 2013-2015, and (4) explores recruitment strategies using residency coordinator interviews. Results: Despite increases in positions offered over 25 years, the fill rates for rural programs have improved relative to urban programs. Small rural programs had lower match rates relative to urban programs, but no other program or community characteristics were predictors of match rate. Match rates were not indicative of any of five measures of program quality nor of any single recruiting strategy. Conclusions: Understanding the intricacies of rural residency inputs and outcomes is key to addressing rural workforce gaps. Match rates likely reflect challenges of rural workforce recruitment generally and should not be conflated with program quality.

Background and Objectives: Family physicians are the most common health professional providing rural obstetric (OB) care, but the number of family physicians practicing OB is declining. To address rural/urban disparities in parental and child health, family medicine must provide robust OB training to prepare family physicians to care for parent-newborn dyads in rural communities. This mixed-methods study aimed to inform policy and practice solutions. Methods: We surveyed 115 rural family medicine residency programs (program directors, coordinators, or faculty) and conducted semistructured interviews with personnel from 10 rural family medicine residencies. We calculated descriptive statistics and frequencies for survey responses. Two authors conducted a directed content analysis of qualitative survey and interview responses. Results: The survey yielded 59 responses (51.3%); responders and nonresponders were not significantly different by geography or program type. Most programs (85.5%) trained residents to provide comprehensive prenatal and postpartum care. Continuity clinic sites were predominantly rural across all years and OB training was largely rural in postgraduate year 2 (PGY2) and PGY3. Almost half of programs listed “competition with other OB providers” (49.1%) and “shortage of family medicine faculty providing OB care” (47.3%) as major challenges. Individual programs tended to report either few challenges or multiple challenges. In qualitative responses, common themes included the importance of faculty interest and skill, community and hospital support, volume, and relationships. Conclusions: To improve rural OB training, our findings support prioritizing relationships between family medicine and other OB clinicians, sustaining family medicine OB faculty, and developing creative solutions to interrupt cascading and interrelated challenges.

BACKGROUND AND OBJECTIVES:Little is known about how rural and urban family medicine residencies compare in preparing physicians for practice. This study compared the perceptions of preparation for practice and actual postgraduation scope of practice (SOP) between rural and urban residency program graduates.METHODS:We analyzed data on 6,483 early-career, board-certified physicians surveyed 2016-2018, 3 years after residency graduation, and 44,325 later-career board-certified physicians surveyed 2014-2018, every 7 to 10 years after initial certification. Bivariate comparisons and multivariate regressions of rural and urban residency graduates examined perceived preparedness and current practice in 30 areas and overall SOP using a validated scale, with separate models for early-career and later-career physicians.RESULTS:In bivariate analyses, rural program graduates were more likely than urban program graduates to report being prepared for hospital-based care, casting, cardiac stress tests, and other skills, but less likely to be prepared in some gynecologic care and pharmacologic HIV/AIDS management. Both early- and later-career rural program graduates reported broader overall SOPs than their urban-program counterparts in bivariate analyses; in adjusted analyses this difference remained significant only for later-career physicians.CONCLUSIONS:Compared with urban program graduates, rural graduates more often rated themselves prepared in several hospital care measures and less often in certain women's health measures. Controlling for multiple characteristics, only rurally trained, later-career physicians reported a broader SOP than their urban program counterparts. This study demonstrates the value of rural training and provides a baseline for research exploring longitudinal benefits of this training to rural communities and population health.

PURPOSE:There is a persistent rural physician shortage in the United States. Policies to scale up the health workforce in response to this shortage must include measures to draw and maintain existing and newly trained health care workers to rural regions. Prior studies have found that experience in community medicine in rural practice settings increases the likelihood of medical graduates practicing in those regions but have not accounted for selection bias. This study examined the impact of a community-based clinical immersion program on medical graduates' decision to work in rural regions, adjusting for covariates to control for selection bias.METHOD:Data on sociodemographic characteristics and career interests and preferences for all 1,172 University of Washington School of Medicine graduates between 2009 and 2014 were collected. A logistic model (model 1) was used to evaluate the impact of Rural Underserved Opportunities Program (RUOP) participation on the probability of physicians working in a rural region. Another model (model 2) included the propensity score as a covariate in the regression to control for possible confounding based on differences among those who did and did not participate in the RUOP.RESULTS:Of the 994 students included in the analysis, 570 (57.3%) participated in RUOP training, and 111 (11.2%) were currently working in rural communities after their training. Regression analysis results showed that the odds of working in a rural region were 1.83 times higher for graduates who participated in RUOP in model 1 ( P = .03) and 1.77 times higher in model 2 ( P = .04).CONCLUSIONS:The findings of this study emphasize that educational programs and policies are crucial public health interventions that can promote health equity through proper distribution of health care workers across rural regions of the United States.

OBJECTIVE To determine the distinct influences of rural background and rural residency training on rural practice choice among family physicians. DATA SOURCES AND STUDY SETTING We used a subset of The RTT Collaborative rural residency list and longitudinal data on family physicians from the American Board of Family Medicine National Graduate Survey (NGS; three cohorts, 2016-2018) and American Medical College Application Service (AMCAS). STUDY DESIGN We conducted a logistic regression, computing predictive marginals to assess associations of background and residency location with physician practice location 3 years post-residency. DATA COLLECTION/EXTRACTION METHODS We merged NGS data with residency type-rural or urban-and practice location with AMCAS data on rural background. PRINCIPAL FINDINGS Family physicians from a rural background were more likely to choose rural practice (39.2%, 95% CI = 35.8, 42.5) than those from an urban background (13.8%, 95% CI = 12.5, 15.0); 50.9% (95% CI = 43.0, 58.8) of trainees in rural residencies chose rural practice, compared with 18.0% (95% CI = 16.8, 19.2) of urban trainees. CONCLUSIONS Increasing rural programs for training residents from both rural and urban backgrounds, as well as recruiting more rural students to medical education, could increase the number of rural family physicians.

BACKGROUND AND OBJECTIVES Distance learning is a feasible and effective method of delivering education, especially in rural settings. Few studies focus on remote learning in graduate medical education. This study explores remote didactic practices of rural family medicine programs in the United States. METHODS We conducted an electronic survey of rural family medicine residency site directors across the United States. We completed sample analyses through descriptive statistics with an emphasis on descriptions of current didactic practices, facilitators, and challenges to implementation. RESULTS The overall response rate was 38% (47/124) for all participants from rural residency programs, representing 28 states. About 24% of rural training track (RTT) participants reported no shared remote didactics between urban and rural sites. More than half of RTT participants (52%) reported remote virtual didactics were either not shared between urban and rural site or were shared less than 50% of the time. Top challenges to implementing remote shared didactics were lack of appropriate technology (31%) and lack of training for faculty and residents in delivery of remote didactics (31%). Top facilitators included having technology for the remote connection (54%), a faculty champion (42%), and designated time to develop the curriculum (38%). CONCLUSIONS There is potential for improving shared remote didactic sessions between rural and urban sites for family medicine RTTs, which may enhance efficiency of curriculum development across sites and maximize opportunities for bidirectional learning between urban and rural sites.

BACKGROUND AND OBJECTIVESThere is a shortage of physicians in rural communities in the United States. More than other types of primary care physicians, family physicians are the foundation for care in rural areas.1 There are also critical shortages of other specialties such as general surgery, pediatrics, internal medicine, and psychiatry in rural America.2-7 This study assessed student participation in the University of Washington School of Medicine's (UWSOM) Targeted Rural Underserved Track (TRUST) program as a predictor for family medicine (FM) and needed workforce specialty residency match.METHODSThe study group was 156 medical students from 2009-2014; 102 were accepted to the TRUST program compared to a control group of 54 who were not accepted into the TRUST program but did matriculate to UWSOM. Student characteristics for the two groups were compared using t tests. Logistic regression analysis determined whether acceptance in TRUST predicted the outcomes measures of FM residency match or residency match into a needed rural physician workforce specialty; t tests compared match rates to family medicine for TRUST applicants and graduates, UWSOM graduates, and US allopathic seniors.RESULTSTRUST program graduates had the same FM residency match rate and match rate in needed workforce specialties as the control group. The FM match rate for TRUST graduates was 29.1% compared to UWSOM at 16.9% and US seniors at 8.7% (P<.001).CONCLUSIONSAlthough match rates in FM and needed workforce specialties were not different in accepted versus not accepted groups, all TRUST applicants had an FM match rate that approaches 30%, which is higher than the general UWSOM class and the United States. In order to help reach the goal of 25% of medical students matching into FM by 2030, medical schools should consider having a rural program and using rural-focused admissions widely.

W e were pleased to see the recent article ‘‘Mitigating Bias in the Era of Virtual Residency and Fellowship Interviews.’’ It is important for programs to critically examine their application process to eliminate racism and bias. At our program, the University of the Washington Family Medicine Residency, we made several changes noted in the article. We modified our standardized applicant screening rubric to deemphasize metrics such as USMLE scores, clerkship grades, and class rank. We increased emphasis on lived experience, commitment to family medicine, and special interests that aligned with our program strengths. We created a standardized interview format with a scoring rubric where all applicants were asked the same questions. We required that all reviewers complete implicit bias training either by attending a 90-minute webinar or reading an article coupled with an implicit bias training module. All reviewers also received training on how to use our standardized rubric with case examples. We adapted several other existing experiences to support underrepresented in medicine (UiM) students interested in our program. Beyond the formal interview day, we hosted virtual theme town halls that highlighted work from our residency Health Equity and Anti-Racism (HEAR) committee. We also participated in virtual meetups sponsored by the University of Washington Network of Underrepresented Residents & Fellows. Finally, we expanded the capacity of our UiM Sub-Internship. Historically, this was restricted to 2 medical students, but because we translated it to a virtual experience, we were able to support 7 students. This virtual Sub-Internship included virtual shadowing of inpatient and outpatient experiences, residency didactics, resident happy hours, faculty mentoring, and meeting members of the HEAR committee (residents and faculty). Through these efforts, we have seen measurable changes in our interview pool. Compared to last year, we reviewed more UiM applications, increasing from 12% to 21% of our total applicants. We offered more interviews to UiM applicants, increasing from 18% to 31% of our total interview pool. We are encouraged by these changes and will be continually evaluating and improving our processes each year.

We read with great enthusiasm the article “Point-of-Care Ultrasound and Modernization of the Bedside Assessment” by Maw et al.1 We support and thank the authors for highlighting point-of-care ultrasound (POCUS) as a diagnostic tool and for pointing out the challenges inherent to POCUS curriculum development in graduate medical education.We surveyed attitudes on POCUS from the incoming intern class (2021–2022) of our university-based family medicine residency program. On a scale of 1 to 10, with 10 representing the most excitement and interest in POCUS education and application, the incoming intern class (n = 10) was both “very excited” (9.8, range 8–10) for formal POCUS education and “very interested” in applying POCUS to patient care during (9.1, range 8–10) and following (9.3, range 8–10) residency. Eight of 10 residents reported some degree of POCUS exposure during medical school, including 4 residents who completed a full formal course. One resident reported utilizing ultrasound for patient care during medical school between 21 and 50 times, while the remaining 9 residents used it 10 times or less.These limited data are subject to a number of potential biases and confounders but nonetheless lend themselves to the following conclusions:Maw et al point out that lack of faculty expertise may be a chief barrier to the implementation of POCUS within residency programs. We also agree with the authors that the threat of a gap between resident POCUS enthusiasm and residency faculty expertise is real. Nevertheless, with ultrasound technology rapidly advancing and exposure during medical school ongoing, we suspect that interest in the use of POCUS during family medicine residency training will only continue to grow.At our program, we have implemented a longitudinal POCUS curriculum that includes regular didactics and workshops, POCUS use on inpatient services, and resident rotation in a “POCUS clinic.” We suggest that other family medicine residency programs interested in developing similar curricula invest in identifying and training individual faculty POCUS “champions” via continuing medical education courses or other means. These champions can then capitalize on that training to build a residency POCUS program consistent with American Academy of Family Physicians guidelines.3

Purpose Despite the efforts of numerous medical schools to produce rural physicians, many rural communities in the United States still experience physician shortages. This study describes the current landscape of rural efforts in US undergraduate medical education and catalogs medical school characteristics and activities that evidence has suggested, and that many experts in rural medical education believe, may result in more graduates choosing rural practice. Methods This is a descriptive study of publicly available and rurally relevant characteristics of all 182 allopathic and osteopathic medical schools operating in the 50 states and the District of Columbia in 2016, with rural program information for these schools updated in 2019. The authors constructed a “rural program” definition in order to systematically catalog coordinated and strategic medical school efforts to produce a rural physician workforce. Findings Few (8.2%) medical schools expressed an explicit commitment to producing rural physicians in public mission statements. However, most (64.8%) provided rural clinical experiences and many demonstrated their commitment in other ways. Only 39 (21.4%) did so through a formal rural program. Conclusions In establishing an explicit rural program definition and documenting other markers of rural commitment, this paper provides a baseline for future studies of rural workforce production and medical school investment in these programs, activities, and personnel. Demonstrating the effectiveness of schools’ rural physician education efforts will require collaboration across institutions and more intensive evaluations of programs involving students who, though relatively few in number, have great potential for contributing to the health of rural communities across the nation.

Background and Objectives: Representation of women in medicine is increasing, including in academic family medicine. Despite this, women continue to hold a minority of senior faculty and leadership roles. This study examines the trends of women first and senior authorship between 2002 and 2017 in five family medicine journals: Family Medicine, Journal of Family Practice, Journal of the American Board of Family Medicine, Annals of Family Medicine, and American Family Physician. The study also examines gender congruence between first and senior authors and women’s membership on editorial boards. Methods: We collected and analyzed data on a total of 1,671 original articles published in the five family medicine journals in 2002, 2007, 2012, and 2017. We also examined the gender composition of the journals’ editorial boards. Results: Overall, women first authorship increased significantly from 32.6% in 2002 to 47.7% in 2017. There was no significant difference in women senior authorship or editorial board representation from 2002 to 2017. Both men and women senior authors partnered with women first authors significantly more over the 15 years. Conclusions: While there was a statistically significant increase in women first authors between 2002 and 2017, there is still a gap between women’s authorship and editorial board representation and their representation within academic family medicine. These gaps could help to explain the continued lack of women represented within senior faculty positions.