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Study: Medical students from rural backgrounds declining

  • Dr. Scott Shipman, an assistant professor of pediatrics and community and family medicine at Dartmouth’s Geisel School of Medicine, is the lead author of a study published in Health Affairs that found a decline in numbers of medical students from rural backgrounds as the overall number of medical students has been on the rise.

Valley News Staff Writer
Published: 12/9/2019 9:55:15 PM
Modified: 12/9/2019 9:55:10 PM

LEBANON — As a student at Hanover High School in the late 1990s, Sam McWilliams worked as an orderly and in the mailroom at Dartmouth-Hitchcock Medical Center.

Though the South Strafford native didn’t know what his future held at the time, now, a couple of decades later, the 38-year-old is a pediatrician at the Lebanon hospital.

“Without that sort of exposure (and) access, I don’t think I ever would have thought of it,” he said.

McWilliams, who graduated from Albany Medical College in 2012 before completing his residency at the Children’s Hospital at Dartmouth-Hitchcock in 2015, is among a shrinking minority of physicians who come to the field from a rural background.

A study led by Dr. Scott Shipman, an assistant professor at Geisel School of Medicine at Dartmouth, published this month in Health Affairs found that even though positions in medical schools grew by more than 30% from 2002 to 2017, enrollment in medical school by students from rural backgrounds declined by 28% over the same period.

“Four times the number of rural medical students would be required for these students to be proportional to rural representation in the overall U.S. population,” the study found. “Given that trends over time have been in the opposite direction, we believe that efforts to enhance the rural pipeline warrant consideration.”

This is important, Shipman and his fellow researchers said, because rural populations have higher rates of chronic illnesses and have not seen the same increases in life expectancy that urban populations have in recent decades.

Previous studies have shown that providers who grew up in rural areas or trained in them are more likely to end up practicing there, something that recruiters in the region know well.

Dr. Joshua White, chief medical officer at Gifford Medical Center in Randolph, grew up and attended medical school in Iowa, before training in Springfield, Mass., and spending the early part of his career in Minnesota.

“The return back (to rural New England) was actually very comfortable based on the fact that I had grown up in an area like this,” White said.

Comfort with rural living is something White now looks for as he recruits providers to Gifford, he said. That ranges from “understanding what mud season is,” to being willing to tolerate living in an area where it’s difficult to find three different restaurants to eat at each week, he said.

It can take years for medical practices to find the right fit. The Bradford-based Little Rivers Health Care has been recruiting for a primary care physician for its East Corinth location for six years, said Dr. Fay Homan, who works at Little Rivers’ Wells River practice.

Though the federally qualified health center staffs the East Corinth clinic with two nurse practitioners, Homan said they’d like to have the support of a doctor to help manage cases they haven’t seen before or that require procedures they haven’t performed.

Homan, who is part of a primary care advisory group for the Green Mountain Care Board, said this matters because the success of health reform hinges on being able to better prevent illness and manage chronic conditions through primary care.

“If we can’t get the workforce figured out, it’s not going to happen,” Homan said.

In an effort to describe the problem through the study, Shipman, who also directs primary care initiatives and clinical innovations at the Washington, D.C.-based Association of American Medical Colleges, and his co-authors used information on medical school applicants and current students for the school years 2002-03 through 2017-18, which included 618,856 applicants and 281,845 students.

They found that the number of medical school applicants from rural backgrounds — those from communities with populations of fewer than 20,000 people — declined 18% from 2,479 in 2002 to 2,032 in 2017. At the same time, the number of urban applicants increased 59% from 27,023 to 42,894.

Rural applicants were more likely to be men and were slightly older than their urban peers, the researchers found. Rural applicants had higher GPAs going into medical school,, but lower scores on the Medical College Admission Test, and they tended to come from households with lower parental educational attainment.

The study also found that rural students of racial and ethnic minorities are especially underrepresented in medical school.

While the study did not examine the reasons for the decline in medical students from rural backgrounds, Shipman said the results point to poor pre-medical school preparation for rural students; a lack of exposure to role models in the field; and the cost.

“On the whole, rural Americans have lower socioeconomic status than their urban and suburban counterparts,” Shipman said. “Anyone from a family of lower economic means may balk at the high cost of medical education, and the large debt burden required to pay for medical school. Even the cost of applying to medical school can be a barrier.”

The tuition at Geisel this year is $65,566 and rent, utilities and food add at least another $11,250, according to the school’s website.

Some medical schools have eliminated tuition, but Shipman said, “it is too soon to know if this will have an effect of bringing more rural applicants from lower socioeconomic levels to the table.”

Nora Doyle-Burr can be reached at or 603-727-3213.

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