The number of students enrolled in medical school from rural areas of the U.S. dropped by 28% over a 15-year period, with students from those communities representing less than 5% of total incoming medical students in 2017, according to a new study in Health Affairs.
The findings, published Tuesday from staff at the Association of American Medical Colleges, come as the nation faces a physician shortage in rural communities. A frequently cited 2010 study from the University of Washington School of Medicine found only 11.4% of physicians practice in rural settings although 19.2% of the population lives in those areas.
The new Health Affairs study is the first to explore over a long period how many students from rural backgrounds are accepted into medical school, said Scott Shipman, lead author of the study and director of clinical innovations at the Association of American Medical Colleges.
Shipman and his co-authors were interested in looking at this trend because there is a strong body of research that shows physicians from rural backgrounds are more likely to practice in rural communities after medical school compared with students from urban areas.
"If you have never seen the practice of medicine in a rural area, the likelihood that you are going to practice there is considerably less," he said. "If you have never lived in a rural area, and you don't know what it's like, the likelihood that you are going to take a chance is also less."
In addition to finding that the number of students from rural areas enrolled in medical school has declined, the study also found the number of applicants from a rural background dropped during the same period. Just 2,032 people from rural areas applied to medical school in 2017, down by 18% from 2002, when 2,479 applied.
The study used Rural-Urban Continuum Codes, a classification from the federal government that relies on ZIP codes, to determine if applicants were from rural backgrounds or not.
Although the study's methodology doesn't explore why the number of students applying and enrolling in medical school has declined despite stable population rates, Shipman said there may be several reasons.
Students may not apply to medical school because they aren't exposed to careers in medicine; don't feel prepared academically; can't or don't want to travel far from home, which is likely required given that there aren't many medical schools in rural areas; and are unwilling or nervous to take on the financial debt often necessary to attend medical school, according to Shipman.
As for the decline in enrolled medical students from rural areas, it may be because the students aren't as competitive during the application process as candidates from urban areas, Shipman said. The study found that while applicants from rural areas had higher GPAs on average compared to their urban peers, they had lower MCAT scores on average, which is the test required to apply to U.S. medical schools.
At the same time, when factors were controlled to isolate admission to medical school based on if a student was from a rural or urban setting, the study found rural students were more likely to be accepted to medical school than non-rural students.
Shipman said that shows "ruralness by itself, as a characteristic of an applicant, seems to work in the favor of students, it's just that they have other things working against them that are overcoming that attribute."
In addition to lower MCAT scores on average, rural students may have fewer extracurricular activities that improve their competitiveness such as having research experience or a physician mentor to recommend them.
Shipman and his co-authors recommend several changes to increase the number of rural applicants and enrollees to medical school such as pipeline programs for high school students in rural areas to expose them to medicine as a profession early. The Health Resources and Services Administration currently offers grants for such programs but they are usually targeted for racial and ethnic minority students, Shipman said.
The Area Health Education Centers Program, which operates under HRSA, is intended to offer networking and academic opportunities in rural and medically underserved areas but its funding is frequently in jeopardy.
"Providing secure and robust funding for the centers—along with requirements for evidence-based programming that both meaningfully exposes rural youth to relatable mentors and provides longitudinal support to promote confidence and competitiveness for the pursuit of a career in medicine—could be an effective way to build on existing infrastructure," the authors said.
The study has several limitations including that it's unlikely all students who live in rural settings were captured because rural identity can be identified in different ways. Additionally, the study only focused on students receiving a medical degree. Osteopathy students, students at international medical schools and other clinicians like nurse practitioners weren't included in the study. These other groups "contribute meaningfully to the rural workforce," according to the authors.
