About Rural Training Tracks

What is a Rural Training Track Residency Program?

Rural Training Track (RTT) residency programs provide graduate medical education to prepare resident physicians broadly for rural family medicine. The most popular model is the “1-2” RTT. In “1-2” programs, the first year of residency takes place in an urban-based program setting while the second and third years occur in a more rural area. This model capitalizes upon the best training opportunities in both contexts.

Definition of a “1-2 RTT”

Although included in legislation (Balanced Budget Refinement Act of 1999), the terminology “1-2 Rural Training Track” is no longer used by accrediting bodies, either the ACGME or the AOA. The Family Medicine Review Committee (FM-RC) now uses the terminology “Alternative Training Tracks” and these can be self-identified as rural, urban, or otherwise. Therefore the RTT program consortium has adopted the following definition, effective November 18, 2013.

Continuing Definition of a “1-2 RTT” (for the purposes of this RTT grant program)

A residency training program that is either:

  1. Traditional 1-2 RTT: An alternative training track integrated with a larger more urban program and separately accredited as such, with a rural* location, a rural mission, or a major rural service area, in which the residents spend approximately two of three years in a place of practice separate and more rural or rurally focused than the larger program.
  2. "1-2 Like" RTT: An identified training track within a larger program, not separately accredited (i.e. without a separate accreditation program number), in which the tracked residents meet their 24-month continuity requirement** in a rurally located continuity clinic or Family Medicine Practice site (FMP).

*Rural by Rural Urban Commuting Area (RUCA) code of 4 or greater, except 4.1, 5.1, 7.1, 8.1, and 10.1, which are urban
**Continuity requirement as defined by the ACGME Family Medicine Review Committee and the American Board of Family Medicine.

RTTs were first popularized by Maudlin and others as the Spokane model in the late 1980’s and have been accredited by the Accreditation Council for Graduate Medical Education (ACGME) since 1990.

Why are RTTs Important?

With 63% of Primary Medical Health Professional Shortage Areas (HPSAs) and a higher proportion of near-retirement physicians in rural areas, building the primary care workforce in rural areas is a critical need. RTT programs are an important tool in addressing those physician shortages in rural areas. While traditional family medicine residencies are a major pipeline for rural physicians, physicians completing RTT family medicine residencies are even more likely to practice in rural areas. It is widely accepted that physicians often choose to practice in settings similar to their residency experience. In fact, “1-2” RTTs have demonstrated at least 75% success at placing graduates in rural practice (Rosenthal).

What Challenges do RTTs Face?

From a peak of 35 programs in 2000, the number of RTTs has fallen as low as 26. Although several new programs have been established in that time and some have converted to independent rurally located programs, other RTTs have failed. The challenges facing RTTs include:

  • Sustainable financing - Most RTTs still do not receive full GME funding for the rural portion of their programs.
  • Recruitment of both residents and faculty - Over the past decade the number of US medical school graduates choosing family medicine has dropped nearly in half, although there have been some recent signs of recovery. A study of rurally located programs conducted in 2002-2004 demonstrated that rural programs have lower resident match rates (60.1%) than urban programs (72.5%) a reality that continues to the present.
  • Academic recognition and support - Geographically dispersed and separated from their sponsoring urban program or academic medical center, RTTs often find themselves low in priority for grant-writing, support of teaching faculty, research, and strategic planning. Often, they are granted an autonomy that is initially welcomed, but this autonomy unfortunately can evolve into neglect.