ThePracticeOfMedicine By Scott A. Shipman, Andrea Wendling, Karen C. Jones, Iris Kovar-Gough, Janis M. Orlowski, and Julie Phillips doi: 10.1377/hlthaff.2019.00924 HEALTH AFFAIRS 38, NO. 12 (2019): 2011–2018 ©2019 Project HOPE— The Decline In Rural Medical The People-to-People Health Foundation, Inc. Students: A Growing Gap In Geographic Diversity Threatens The Rural Physician Workforce Scott A. Shipman (sshipman@ ABSTRACT Growing up in a rural setting is a strong predictor of future aamc.org) is director of rural practice for physicians. This study reports on the fifteen-year primary care initiatives and clinical innovations at the decline in the number of rural medical students, culminating in rural Association of American ’ Medical Colleges (AAMC), students representing less than 5 percent of all incoming medical in Washington, D.C. students in 2017. Furthermore, students from underrepresented racial/ ethnic minority groups in medicine (URM) with rural backgrounds made Andrea Wendling is director of rural health in the up less than 0.5 percent of new medical students in 2017. Both URM and Department of Family Medicine, Michigan State non-URM students with rural backgrounds are substantially and University, in Boyne City. increasingly underrepresented in medical school. If the number of rural students entering medical school were to become proportional to the Karen C. Jones,nowretired, was a research analyst in share of rural residents in the US population, the number would have to the Workforce Studies unit, ’ AAMC, when this work was quadruple. To date, medical schools efforts to recognize and value a performed. rural background have been insufficient to stem the decline in the number of rural medical students. Policy makers and other stakeholders Iris Kovar-Gough is a research librarian at the Michigan State should recognize the exacerbated risk to rural access created by this University College of Human trend. Efforts to reinforce the rural pipeline into medicine warrant Medicine, in East Lansing. further investment and ongoing evaluation. Janis M. Orlowski is chief healthcareofficeratthe AAMC. Julie Phillips is assistant dean s of the 2010 census nearly sixty morbidity5 and infant mortality.6 Recent losses for student career and million people lived in rural com- of obstetric services have also disproportionately professional development in the Office of Student Affairs munities in the US, and almost one affected rural counties that have high percen- and Services, Michigan State 7 in five people in the US were rural tages of minority women of reproductive age. University; and an associate residents.1 Although popular me- More than 15 percent of rural residents are professor at the Sparrow- Adia often highlight compelling narratives of a members of racial/ethnic minority groups, and Michigan State University 8,9 Family Medicine Residency specific region or rural community in decline this percentage is increasing. Research has Program, in Lansing. and seek to make broad generalizations about demonstrated that members of rural minority rural depopulation, the overall size of the US groups—particularly black, Hispanic, and Amer- rural population has been stable for several ican Indian/Alaska Native populations—face decades. higher chronic disease burdens and worse access Rural populations have higher rates of many to care than non-Hispanic white rural residents.10 chronic illnesses and have not enjoyed the same Physician shortages in rural settings, which gains in life expectancy that urban populations are magnified by the disproportionate health have in recent decades.2,3 People living in rural care needs of rural communities, have been a communities are less likely to receive recom- widespread and perennial challenge. Only 11 per- mended preventive services than their urban cent of the physician workforce practices in rural counterparts are.4 Compared to urban hospitals, communities,11 and as of 2019 over 62 percent of rural hospitals have higher rates of maternal all federally designated primary care Health Pro- December 2019 38:12 Health Affairs 2011 Downloaded from HealthAffairs.org on January 15, 2020. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. ThePracticeOfMedicine fessional Shortage Areas were in rural areas.12 school in a county in one of the fifty states or This gap in access to physician care is likely to in the District of Columbia. be an important contributor to increased rural This study was approved by the American In- morbidity and mortality. stitute of Research Institutional Review Board. The recent significant growth in the number of We used the 2013 Rural-Urban Continuum new US medical schools and the increase in size Codes26 of each applicant’s birth and high school of existing ones presents an opportunity to train graduation counties to identify rural back- a workforce better suited to meeting the needs of ground. Applicants were considered to be from rural communities. Unfortunately, that growth a rural background if either their birth or high has been accompanied by a decrease in the per- school graduation county had a code of 6 (mean- centage of students who report an interest in ing that the county had an urban population of practicing in small towns and rural communi- 2,500–19,999 and was adjacent to a metropoli- ties.13 This decline in interest in rural practice tan area) through 9 (meaning that the county may be because medical education, most of was completely rural or had an urban population which is based in metropolitan areas, dispropor- of fewer than 2,500 people and was not adjacent tionately exposes future physicians to medical to a metropolitan area). All others were consid- practice in urban and suburban settings. It ered to be from an urban background. Applicants may also be driven by a paucity of incoming who applied in multiple years were counted in students who have experienced a rural lifestyle, each year, and the data include the outcome for including being familiar with the distinct cultur- each year (accepted or not accepted)—with the al aspects of small-town life. This is important exception that only one accepted record was in- because multiple studies have demonstrated that cluded for those who deferred admission. students from rural backgrounds are much more We examined the trend in numbers of appli- likely to decide to practice in rural settings.14–20 cants and matriculants from rural and urban Research has similarly shown that physicians backgrounds and compared rural and urban from racial/ethnic minority groups that are tra- counterparts on key demographic and academic ditionally underrepresented in medicine (URM) factors, including age, sex, URM status, Medical are more likely to practice in underserved com- College Admission Test (MCAT) score quintile, munities and provide care to minority popula- grade point average (GPA), and highest parental tions.21,22 Important research and coordinated education. efforts have focused attention on strengthening We used the MCAT score quintile rather than the pipeline of URM students and on the impor- the actual score because of changes in MCAT tance of racial/ethnic diversity in medical school scoring over the study period. The Association and the physician workforce.23–25 of American Medical Colleges administers the Despite widespread recognition of the need for MCAT. The version used from 1991 to January more rural physicians, we are aware of no longi- 2015 (MCAT91) was revised, and a new version tudinal national studies that have examined the was implemented after January 2015 (MCAT15). proportion of rural students who apply, are ad- These versions are scored differently and on dif- mitted, and matriculate to medical school. Given ferent scales. Thus, for all applicants who took the importance of ensuring equitable access to the MCAT91, we calculated score quintiles and care for rural populations, we sought to better assigned them to a quintile group, and we ap- understand these trends over time for MD-grant- plied the same method to assign applicants who ing schools in the US. took the MCAT15 to a quintile group. This ap- proach allowed us to combine data from individ- uals throughout the study period. For each per- Study Data And Methods son in a given year, we assigned a quintile based Data Sources And Analytic Approach We ob- on the most recent MCAT score. tained data on applicants and matriculants from We then used a logistic regression model to the American Medical College Application Ser- examine the likelihood of acceptance to any med- vice for the period 2002–03 through 2017–18 ical school for rural and urban applicants, con- (hereafter, academic years are referenced by trolling for age, sex, MCAT quintile, GPA, URM the first year, so the two year ranges above are status, highest parental education, and applica- presented as 2002 and 2017). Only people who tion year (additional information on the details were born in the US or were permanent residents of the regression model is available from the who graduated from high school in the US were authors on request). For applicants who were included in our sample. Because of data limita- accepted, we also employed a logistic regression tions, people from any of the US territories could model to evaluate the likelihood of matriculating not have a rural status assigned to them, except for rural and urban students, controlling for the those who were born or graduated from high same demographic and academic characteris- 2012 Health Affairs December 2019 38:12 Downloaded from HealthAffairs.org on January 15, 2020. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. tics. Poisson regression was used to obtain the available to medical school admission commit- relative risk estimates for each of these models.