Maintaining healthy rural communities depends on proper preparation and supply of a rural health workforce,
includes professionals living and working in rural communities and distant providers who provide services or
support through telehealth and referral services. This involves ensuring that physicians, nurses, dentists, and
other healthcare professionals are well-educated, well-trained, and have had experiences that expose them to and
prepare them for rural practice and supporting healthcare services in a rural context.
Strategies, programs, and activities used to educate and train the rural health workforce may include:
Grow-Your-Own and Career Ladder Programs
Programs like job shadowing, career fairs, and scrubs camps, that introduce rural students to health
Healthcare facility programs that help employees advance their education and careers, including
Education and Training Provided in Rural Areas
Nursing and allied health education at rural community colleges
Rural rotations or curricula, including rural interprofessional education experiences
Residency programs and fellowships specifically designed to train physicians and nurse practitioners for
Continuing and professional educational opportunities for rural health professionals
Technology to Educate the Rural Health Workforce
- Distance learning
- Telehealth applications for learning
Investing in rural healthcare education can facilitate recruitment and retention efforts in rural areas,
reducing workforce shortages and increasing diversity.
Frequently Asked Questions:
How can grow-your-own programs improve the future health workforce available in rural
Grow-your-own programs help to address the shortage of healthcare workers in rural areas. They focus on
encouraging individuals to consider choosing healthcare careers, cultivating their interest, and helping them
develop skills that they can use professionally in their home communities. This approach recognizes and builds
on the idea that health professionals are more likely to consider serving in the community in which they were
raised. It does not provide healthcare workers who will enter the labor force immediately.
Instead, it is a
long-term strategy that moves people into the health workforce pipeline and enables rural communities to more
effectively address their future healthcare workforce needs.
Parental involvement can be key in sparking young people’s interest in healthcare careers. Regionally, targeted
admissions processes into healthcare professions training can also be a key factor in recruiting and training
graduates more likely to return to their home communities or similar rural areas.
Career awareness and exploration programs provide an effective way for community organizations
to work together, partner with healthcare facilities and schools, and expose students to careers in rural
healthcare. For example, scrubs camps provide students the opportunity to meet and interact with a variety of
healthcare professionals and engage in healthcare-related activities. These camps increase interest, awareness,
and understanding of health careers available in rural areas among elementary through high school students.
Other career awareness and exploration activities that healthcare facilities or schools might undertake include:
- Hosting healthcare career fairs
- Inviting healthcare workers to schools, to speak about their careers
- Providing opportunities for students to shadow healthcare professionals
- Ensuring that teachers and school counselors are aware of requirements for entering health professions
schools, so that they can make informed suggestions about which courses and activities will make students
strong candidates for admission
How do career ladder programs benefit rural healthcare workers and healthcare facilities?
Career ladder programs are sponsored by healthcare facilities to help employees advance their
education by developing higher-level skills. These programs tend to increase
employee satisfaction, which leads to higher retention rates. Programs may include:
One-on-one career counseling and mentorship
Tuition reimbursement or assistance with other educational expenses
Paid time off to pursue training
Onsite training and education opportunities, including apprenticeships
Healthcare workers employed by facilities offering career ladder programs can grow professionally and prepare
for jobs with a higher level of responsibility while retaining their current positions. By providing a reward
system for employees who have shown potential to learn new skills and develop new competencies, healthcare
systems reduce employee turnover, increase productivity, improve worker satisfaction, and promote staff
Where can I find information on Medical School Rural Tracks and Rural Training Track Residency Programs?
Medical School Rural Track (RT) Programs
Many medical schools offer programs that provide rural training experiences to students who are considering
practice in rural areas. Rural tracks (also called programs, pathways, concentrations, or other terms) give
students exposure to the broad scope of practice rural physicians experience. This can fuel students’ interest
in residency and a career in a rural area. For other students, it helps them realize that they are better suited
to an urban environment, which is important to know before committing to rural practice.
A 2013 study of the 35 existing and planned medical school rural tracks showed that the number of students
participating in a given program ranges from 4-60, typically 5-10% of a medical school class. Medical
School Rural Tracks in the US, a policy brief on the study findings, also identified the following key
points about rural tracks:
Selection criteria for the programs often include rural background, a commitment to serve rural areas, and a
desire to enter a primary care discipline
Many programs offer scholarships for rural track participants
Most rural tracks rely on funding from sources other than their medical school
The annual cost of running a rural track for 15-25 students is $350,000-$600,000
Approximately 44% of rural track graduates reported entering rural practice
According to the 2021 Journal of Rural Health article Pipelines to Pathways: Medical School
Commitment to Producing a Rural Workforce, 64.8% of U.S. medical schools provided students with rural
clinical experiences, but only 21.4% of these schools did so as part of a formal rural program.
Rural training tracks (RTTs) and other residency program models involving time spent in rural areas provide
graduate medical education to prepare resident physicians for careers in rural family medicine. Programs also
exist for critically relevant rural specialties, such as general surgery, internal medicine, pediatrics, and
obstetrics. Shortages in the rural primary care workforce are a serious concern that residencies with a rural
focus attempt to address.
The Health Resources and Services Administration (HRSA) funds formation of rurally-located
residency programs under the Rural
Residency Planning and Development Program, with a supporting website, RuralGME.org, offering technical assistance to forming new programs.
Medicine Rural Training Track Residencies: 2008-2015 Graduate Outcomes reports that over 35% of
graduates of RTT residency programs were practicing in rural areas during the 7 years after graduation, which is
about twice the percentage of former family medicine residents overall.
Models of rural residency training include:
- Rural Training Track programs, which provide a hybrid of training in urban and rural areas
- Rurally-located residency programs
- Urban-located programs with a rurally-located continuity clinical site
- Urban-located programs with rural focus
Some rural residency programs offer opportunities for students to complete residencies in community clinics and
community hospitals. The Teaching Health Centers model, begun in 2011, allows residents to receive clinical
training in health centers that provide community-based ambulatory care. In this way, they can learn to provide
care for patients in underserved areas.
In addition to family medicine residencies, there are some rurally-oriented general surgery and OB/GYN residency
programs. The American College of Surgeons maintains a list of rural
surgery programs. The University of Wisconsin-Madison's Department of Obstetrics and Gynecology was
the first OB/GYN program in the country to offer a separate rural residency track.
For recommended curriculum guidelines, see the National Rural Health Association Policy Brief, Graduate
Medical Education for Rural Practice.
For more information about Rural Training Tracks, visit:
RTT Collaborative – A national cooperative of rural
education and residency programs.
RuralGME.org – An organization bringing together experts in
all aspects of rural graduate medical education.
Do rural health rotations and curricula increase the likelihood that students will practice in rural
Comprehensive Medical School Rural Programs
Produce Rural Family Physicians, an article in American Family Physician, examined three
comprehensive medical school rural tracks, which produced six times the national average for graduates
practicing in rural areas. The
Impact of Rural Training Experiences on Medical Students: A Critical Review, published in Academic
Medicine, reports on a review study of 72 studies related to rural training experiences. The
authors found that:
“…most studies revealed that student experiences in a rural setting predicted future employment. In
general, medical students completing rural rotations were three times more likely to practice in a rural
community compared with the national average…Students in self-report studies felt that their skills
significantly increased in areas such as chronic disease management and ability to handle acute problems,
the largest gain in understanding health systems and the community during their rotation in a rural primary
Authors of Recruiting Rural Health
Providers Today: A Systematic Review of Training Program Success and Determinants of Geographic Choices
examined 55 studies exploring the impact of medical training programs and found that “Growing up in a
community is a key determinant and is consistently associated with choosing rural practice.” A Social
Science & Medicine article, Why Doctors
Choose Small Towns: A Developmental Model of Rural Physician Recruitment and Retention, notes that rural
upbringing and residence in a rural area for more than ten years are strong predictors of rural practice choice
for physicians. The same article says that other predictors of future rural practice include rural residency
tracks, rural medical school track participation, experience in community service, and an inclination toward
early in their medical school coursework.
The 2011 Academic Emergency Medicine article Availability
and Potential Effect of Rural Rotations in Emergency Medicine Residency Programs describes the types of
rural rotations in emergency medicine residency programs and the correlation with rural practice after
graduation. Emergency medicine residency graduates were more likely to select a rural job if rural rotations
The WWAMI Rural Health Research Center publication Graduates
of Rural-centric Family Medicine Residencies: Determinants of Rural and Urban Practice examines the
reasons physicians trained in residencies that required at least eight weeks of rural training selected rural or
urban practices. Reasons for choosing rural practice include:
Positive perceptions of their rural residency training experiences
Rural experience prior to medical school
Being prepared for rural living
Partner/spouse from a rural area
Obligations or incentives to work in underserved communities
Rural rotations are also available for other health professions, such as pharmacy, dentistry, advanced practice
nursing, and the physician assistant profession. For example, students in West Virginia University's School of
Pharmacy must complete a 5-week-long
Pharmacy Practice Experiences (APPE) rotation in a rural areas of West Virginia, and dentistry students
must provide several weeks of
supervised patient care through the West
Virginia Institute for Community and Rural Health.
Other examples of successful rural rotations that prepare students for rural practice include:
The RTT Collaborative offers a free tool for determining community capacity for physician residency education.
See TREES (Training and
Rural health professions Education that is community Engaged and Sustainable).
What are Area Health Education Centers (AHECs)? How do they help to prepare the rural healthcare workforce?
Area Health Education Centers strengthen the supply and distribution of healthcare professionals in rural and
underserved areas, focusing on primary and preventive care. AHECs act as liaisons between communities and
institutions and assist in arranging training opportunities for health professions students, tailoring their
programs and activities to the needs of their region.
AHECs help prepare students for rural healthcare through activities such as:
Recruiting and training minority students and those from disadvantaged backgrounds
Placing students in community-based clinical practices settings, focusing on primary care
Improving quality of care by promoting interprofessional education and collaboration
Facilitating programs and continuing education resources for health professionals in rural and underserved
Conducting pipeline activities to expose pre-college students to health careers
The National AHEC Organization provides a directory of AHECs. According to
its website as of 2019, there are at least 46 AHEC programs with more than 261 centers operating throughout the
United States, working collaboratively with approximately 600 nursing and allied health schools and 120 medical
The AHEC Scholars program is open to students
enrolled in a wide range of healthcare and pre-healthcare certificate or degree programs. The instruction
supplements students’ existing training programs, and must take place in rural or underserved areas. Each cohort
lasts two years and ends in completion of a certificate or a degree.
AHECs are funded through the HRSA Bureau of Health Workforce. They also use other funding streams to match their
federal funds and operate additional programs. Successful programs include:
Rural Experiences for Health
Professions Students (REHPS), based in the Yankton Rural Area Health Education Center, raises
awareness for healthcare needs in underserved areas of South Dakota through placement of health professions
students in rural or frontier areas of the state.
The Naloxone Education
Empowerment Distribution Program, organized by the San Luis Valley Area Health Education Center,
worked to train and certify healthcare workers and community members to administer naloxone. This was a
one-year program that ended in September 2016.
(Providing Rural Opportunities in Medicine through Inspiring Service and Education), is an educational and
experiential pipeline program based in Spruce Pine, North Carolina. This program provides high school
seniors with medical academic training, mentor relationships, and experience in rural North Carolina medical
The FORWARD NM (Frontier and Rural Workforce Development New Mexico)
Health Careers program has initiated grow-your-own activities to support comprehensive workforce
pipeline programs for middle and high school students, undergraduates, medical students, graduate students,
The MU AHEC (University of Missouri Area Health Education
Center) Summer Community Program provides opportunities for second-year medical students to work
under the direction of rural community-based physicians for 4 to 8 weeks.
Why is interprofessional education important for future rural healthcare professionals?
The goal of interprofessional education (IPE) is to prepare students to practice team-based care after
graduation, which is important to ensure patient-centered, coordinated care in rural areas, particularly if all
members of the care team are not in the same location.
Rural student IPE experiences often involve a rotation in a rural underserved area to learn how different
professions work together. Students interact with healthcare professionals, learning about building
relationships and teamwork.
For further information on the impact of rural IPE programs, see:
How are online and telehealth training being used to prepare the rural healthcare workforce?
Rural healthcare workers are often reluctant to leave their homes or place of employment for training and
education due to travel challenges, coverage in staffing, family commitments, and costs. Online and telehealth
training programs can
accessible training for current and future healthcare professionals. These programs may provide degree programs,
continuing education classes, training in cultural competency skills, and leadership training.
The Rural Monitor article Education at a Distance:
Virtual Classrooms Bring Healthcare Classes to Rural Areas highlights distance and hybrid programs for
occupational therapy, physician assistant programs, and nursing. These allow rural students to earn their
degrees while living and working in their home communities.
RHIhub's Rural Health Models and Innovations feature the following successful online training
EMS Live @ Nite
Provides monthly training to rural EMS providers throughout the northwestern United States.
Project ECHO® (Extension for
Community Healthcare Outcomes)
Developed to provide increased capacity for chronic disease management. The model uses videoconferencing to
connect primary care providers with specialists who can assist with patient treatment and increase the
knowledge base of participants.
How is simulation technology used to educate rural healthcare providers?
Various forms of simulation have been a part of healthcare education for many years, including volunteers
role-playing patients, practice suture pads, and anatomical replicas. However, improvements in technology have
advanced the capabilities of the simulation tools available to students.
Simulation Technologies in
Higher Education: Uses, Trends, and Implications, a 2010 publication from EDUCAUSE, reports that
simulation technology is most often used to practice low-frequency events that require high acuity, such as
emergency procedures and irreversible procedures such as surgery. Since rural healthcare professionals
typically see fewer high acuity events, simulation is especially useful in rural areas.
The 2013 article Integrating
QSEN and Technology to Address Rural Health Care: Initial Outcomes presents results
of a project intended to promote six core competencies in the Quality and Safety
Education for Nurses initiative, through technology-focused simulation exercises.
Two methods of simulation technology are discussed in Medical
Simulation Education: Results of an AAMC Survey, a 2011 study by the Association of American Medical
Colleges (AAMC). These are:
Mannequin Simulation – The AAMC study indicates that the most common type of
equipment is the full-scale computerized mannequin, described as a life-sized robot that mimics
various functions of the human body, including respiration, cardiac rhythms, and pulsation.
Screen-based Virtual Reality – The AAMC study defines screen-based simulation as a
program, exclusively computer-based, that allows learners to interview, examine, diagnose, and treat
patients in realistic clinical scenarios. Examples include virtual patients, virtual environments, or
Examples of simulation technology used in rural areas include:
Community colleges play an important role in educating students who plan to work in healthcare,
particularly people in nursing and allied health fields. These schools offer degrees and certifications in a
variety of healthcare occupations, including programs for:
- Medical assistants
- Respiratory therapists
- Health information/medical records technicians
- Dental assistants and hygienists
- Surgical technologists
- Physical therapist assistants
Career counselors at community colleges should keep abreast of employment trends, including the needs of local
healthcare employers, and certification requirements for healthcare professions, so that they can guide students
toward courses and activities that will be most beneficial.
Community colleges strive to provide educational opportunities close to rural communities. In the 2012 policy
brief The Contributions of
Community Colleges to the Education of Allied Health Professionals in Rural Areas of the United States,
the WWAMI Rural Health Research Center studied the geographic relationships between community college programs
for 18 allied health occupations, rural populations, and healthcare facilities that hire these professionals.
The researchers found that:
- 99% of urban residents lived within a one-hour drive to a community college offering allied health
coursework, compared with 73% of the rural population.
- Access varied by region, with 58% of the rural population in the West living within a 60-minute drive
compared with 90% in the Northeast.
- Some programs had a higher percentage of rural students within a 60-minute drive, such as Medical/Clinical
Assistants, Emergency Medical Technicians/Paramedics, and Surgical Technologists.
According to a joint statement
issued by the American Association of Community Colleges and the Association of Community College Trustees in
2017, associate degree programs play an important part in the training of nurses who work in rural areas, noting
that 39% of RNs working in rural and urban healthcare facilities earned their degrees through community
Rural Health Information Technology Workforce Curriculum Resources
offers a complete inventory of curriculum resources, including course descriptions and training materials,
developed by the Federal Office of Rural Health Policy's Rural Health IT Workforce Program grantees. Many of the
training programs were created in rural community college settings. Community colleges and vocational or
technical institutions that are developing similar programs are encouraged to use and build on these curriculum
What admissions criteria can health professions programs consider to identify students likely to go on to
practice in a rural community?
The shortage of health professionals in rural America can at least partially be addressed through educational
programs. To produce students who are likely to practice in rural areas, schools must consider factors that are
good indicators of future rural practice. This might be at odds with the traditional tendency of educational
programs to recruit the students deemed most elite by traditional criteria.
For instance, medical school admissions committees in the United States have historically given preference to
the “best of the best” applicants in terms of academics — those with the highest grades and
Medical College Admissions Test (MCAT) scores as well as a
well-rounded background in extracurricular activities, and volunteer or work experience. Applicants meeting
these criteria are likely to be from a background of high socioeconomic status. In 2020, 68.3% of students
entering medical school in the United States had parental incomes of over $100,000, according to the 2020 AAMC Matriculating Student Questionnaire.
Applicants from urban areas typically have more opportunities to pursue
activities that will make them seem “well-rounded” to admissions committee members.
Medical school admissions committees that include faculty members who themselves have rural backgrounds may be
more inclined to look favorably on rural applicants with characteristics such as resilience and work ethic.
By using the traditional admissions criteria, medical schools can produce excellent physicians. However, if
doctors are not inclined to practice in rural communities, maldistribution occurs which ultimately results in
poorer healthcare access for rural Americans.
Characteristics important for rural practice are addressed in Competence Revisited in
a Rural Context and include:
- Living with scarcity and limits
- Reflective practice
In its 2007 Eighteenth
Report: New Paradigms for Physician Training for Improving Access to Health Care, the Council on
Graduate Medical Education (COGME), urged medical schools to admit more students from underserved areas,
“There must be an incentive for medical schools to admit minority students as well as students
from underserved urban and rural areas. This would increase the likelihood that graduates return home to
practice medicine. The admissions practices of many medical schools raise the thorny question of whether
admissions committees cause and perpetuate the physician maldistribution problem.”
The COGME report went on to suggest that states should provide incentives for medical schools to develop special
admissions tracks for rural students, as well as those from other backgrounds that might qualify them as
disadvantaged. A 2016 article,
Rural Doctors? Import a Medical School, notes that this advice may have been followed: As of that
writing, 84 percent of
U.S. medical schools either already had or were planning to implement policies to recruit students who intend to
practice in underserved areas.
The Rural and Remote Health article Medical
Student Characteristics Predictive of Intent for Rural Practice notes that factors associated with
intention to practice medicine in a rural area including being raised in a rural community and having a
significant other who has lived in a rural area.
Intended specialty area is another indicator that can be used to predict future rural practice. Patching the Rural Workforce Pipeline – Why Don't We
Do More? indicates that applicants interested in family medicine are more
likely to enter rural practice, particularly when they have a rural background or interest.
Some medical schools with a rural mission or a rural track do use criteria related to rural interest. Medical
School Rural Tracks in the US identifies characteristics sought for rural track applicants:
- Rural interest or background (39 programs cited)
- Rural commitment (23 programs)
- Community involvement (20 programs)
- Primary care commitment (18 programs)
- Character (18 programs)
- Resident of state/area (15 programs)
Targeted Medical School
Admissions: A Strategic Process for Meeting Our Social Mission identifies selection strategies used by
medical schools that target rural students for admissions. Commonly used strategies include using secondary
application questions, offering targeted financial aid, including rural physicians in the entrance interview,
and preferential scoring for rural candidates in interview screening or final admissions determination.
Dental school admissions committees have also come to recognize the significance of rural background as a
predictor of rural practice. A 2012 article noted that dentists who
came from rural areas were about 6 times more likely to practice in rural communities than their urban
counterparts, based on 30 years of data from a Midwestern dental school. The 2016 article Do Dentists from Rural Areas Practice
in Rural Areas? notes that some dental schools, including those at East Carolina University and Virginia Commonwealth University, have put priority on recruiting
students from rural areas in an effort to address shortages in underserved communities.
Some schools of pharmacy also offer concentrations geared toward students who come from rural areas or would
like to practice in a rural community. Examples include the Rural
Pharmacy Education Program (RPHARM) at the University of Illinois-Chicago College of Pharmacy and the Rural
Health Professions Program at the University of Arizona College of Pharmacy.
What cultural competency skills do rural healthcare providers need and what types of training are
As the rural population of the United States becomes more diverse, healthcare providers are serving more
patients with backgrounds, beliefs, and language skills that are different from their own. According to Cultural
Competence Education for Students in Medicine and Public Health, cultural competencies fall into three
Knowledge (Cognitive Competencies) – Understanding cultural diversity and the influence of culture on
health outcomes. Includes recognizing the need to practice cultural humility.
Skills (Practice Competencies) – Integrating cultural perspectives into treatment/interventions,
communicating in a culturally competent manner with patients, and incorporating culture as a key component
of patient history.
Attitudes (Values/Beliefs Competencies) – Appreciating how cultural competence contributes to the
practice of medicine, assessing the impact of one’s own culture on care and service, and realizing
that cultural competence involves lifelong learning.
Several agencies and organizations provide resources and/or training to implement cultural competence within an
Center for Cultural Competence (NCCC)
Located at Georgetown University. Contributes a variety of services for health and mental health programs
wishing to design, implement, and evaluate culturally and linguistically competent service delivery systems.
Services include a resource database, tools for self-assessment, technical assistance, consultation and
CDC's Office of Minority Health & Health Equity
Develops health policies and programs to eliminate health disparities and serves as a national resource and
referral service on minority health issues. Offers student opportunities in public
Cross Cultural Health Care Program (CCHCP)
A nonprofit training and consulting organization dedicated to promoting culturally and linguistically
appropriate healthcare. Features a medical interpreter training program and offers assessment tools,
resource lists, and bilingual medical glossaries in 24 languages.
Think Cultural Health
Provides free online and accredited cultural competence continuing education programs for physicians,
pharmacists, nurses, and social workers. A product of the Office of Minority Health, U.S. Department of
Health & Human Services.
TRAIN.org: Cultural Competence Courses
Provides free online training in cultural competency skills including health literacy and Limited English
Proficiency. This training module can be taken for credit or non-credit and is appropriate for healthcare
What ongoing impacts will COVID-19 have on the education and training of the rural healthcare workforce?
A 2020 Southern Medical Journal article, Responding to COVID-19: Perspectives on
Curricular Changes in a Rural Medical School, notes that the COVID-19 emergency required rapid response
in determining changes in curriculum delivery and assessment. The authors recommend that medical school faculty
create pandemic-related courses, so that future students and practitioners will be better prepared to handle
similar health crises, as well as courses designed to teach clinical skills remotely or virtually.
The Association of American Medical Colleges (AAMC) offers free webinars
that help students, residents, and aspiring physicians as they adapt to changes brought about by the pandemic.
Sample topics include telehealth competencies for training current and future physicians, and ways to lead and
support other members of the academic medicine community as they navigate COVID-related disruptions in education