The path for students from rural areas to become physicians, especially orthopaedic surgeons, is challenging. Physicians are more likely to practice in rural areas if they are originally from those areas.

This was the case for Isaiah Roepe, MD, a fourth-year orthopaedic surgery resident at the University of Kansas in Kansas City. “Growing up in a small town, I quickly recognized the significant impact a physician can have by returning to practice here,” Dr. Roepe recalled. “In contrast to larger city practices, rural physicians may become the sole healthcare provider for hundreds, if not thousands, of patients. In a world where physicians are incentivized to spend less time with patients, a physician in a rural practice will ultimately learn about and connect with their patients as they encounter them in their small community.”

However, students from rural areas are more likely than those in urban areas to come from households with lower parental educational attainment and are less likely to graduate from college. This trend is reflected in the continuing decrease in the number of students from rural areas applying to medical school. Students from rural areas tend to have lower MCAT scores, resulting in even lower percentages of matriculating medical students who come from rural backgrounds. As of 2019, only 4 percent of medical students were from rural areas. This lack of a strong education background from the beginning can make it challenging for students to eventually be accepted into orthopaedic residency training, although it is unknown how many orthopaedic residents and practicing surgeons come from rural backgrounds.

Pipeline programs have successfully increased the number of women and underrepresented minority medical students entering orthopaedic residency programs. A similar approach can be used to increase the number of students from rural America attending medical school and matriculating into orthopaedic programs. Advocacy efforts could include appealing to orthopaedic residency program leadership to include commitment to eventually practicing orthopaedic surgery in rural communities as a positive applicant consideration.

Once medical students are accepted into orthopaedic residency training, regardless whether they are from rural backgrounds, there is an opportunity to interest them in rural care. Experiences during residency can have a significant impact on encouraging students to practice in rural areas. As long as training sites and faculty meet Accreditation Council for Graduate Medical Education (ACGME) requirements, rural electives are a way to allow residents to experience orthopaedic surgery in a non-academic and non-tertiary care environment, see the breadth and depth of procedures performed, and recognize the ability to practice to the limit of their training. These electives also allow residents (and their families) to experience the lifestyle in a rural community. Formal rural-track programs, however, are more challenging to develop in orthopaedic surgery, as meeting the ACGME and Centers for Medicare & Medicaid Services definition of a rural-track program requires that more than 50 percent of training be completed in a rural facility. Achieving this program structure would be difficult given the faculty development and scholarly activity requirements for training programs and the case-log numbers needed for resident graduation.

Issues with interest in rural orthopaedic care extend beyond residency training. More than 90 percent of residents are currently pursuing subspecialty residency training, which has been identified as a factor leading orthopaedic surgeons to not practice in rural communities.

Although rural training experiences can be developed, the impact of such programs is unclear. General surgery has several programs that include rural experiences, and graduates from those programs are less likely to pursue fellowships but not more likely to enter rural practice. This trend indicates that the issue is not just about allowing residents to experience rural areas or encouraging them to enter practice without pursuing fellowship training.

As Dr. Roepe noted, when considering returning to practice in rural America, “I am mindful of the roadblocks that exist to returning to or going to rural America to practice medicine. The lack of routine access to healthcare [and] a struggling economy and education system make it challenging to recruit physicians and their families, such as my own, to rural communities.”

There is a need for rural healthcare facilities to provide the infrastructure necessary for successful practice and for rural communities to have opportunities to accommodate the needs of surgeons’ families.

Laney McDougal, MS-HSM, contributed to the creation of this article.

Kim Templeton, MD, FAAOS, FAOA, is professor, vice chair, and former residency program director in the Department of Orthopaedic Surgery at the University of Kansas Medical Center in Kansas City; codirector of the University of Kansas Rural Health Council; and a member of the ACGME orthopaedic residency review committee.

References

1. Shipman SA, Wendling A, Jones KC, et al: The Decline in rural medical students: a growing gap in geographic diversity threatens the rural physician workforce. Health Aff (Millwood) 2019;38(12):2011-8.
2. Halline CG, Mokhashi N, De Bie FR, et al: An examination of general surgery residency programs with a rural track. J Surg Educ 2022;79(2):315-21.