Training Rural Doctors for Rural People

Start a Rural Training Track

Why We Need Rural Training Tracks

Bowman RC, Penrod JD. Family practice residency programs and the graduation of rural family physicians. Fam Med 1998;30(4):288-92.

Rural training tracks (RTTs) are a critical tool in recruiting and retaining physicians to rural Wisconsin. Since only about 10% of physicians practice in rural communities, despite nearly 25% of the population living there1,2,3, the need for additional rural physicians is substantial. Evidence shows that “…medical residents who train in rural settings are two to three times more likely to practice in a rural area; especially those who participate in rural training tracks.” 4 Also “56% of graduates practice within 100 miles of training after Family Medicine Residency”6 and finally “[Residents trained in rural areas are] better prepared for what awaits them in rural practice5.”

“…medical residents who train in rural settings are two to three times more likely to practice in a rural area; especially those who participate in rural training tracks.” 4

WI needs additional GME slots to support its expanding medical schools. With the investment and success WI has in educating medical students who want to train and practice in rural WI (WI Academy of Rural Medicine [WARM] and the new Medical College of WI campuses in Green Bay and Central WI), expanding GME slots is vital for minimizing the number of students needing to go out of state for their residency training. A Wisconsin educated and Wisconsin trained physician has a 70% chance of practicing in Wisconsin.  Without a Wisconsin residency, that percentage drops to 38%.  If that same student were born in Wisconsin, the likelihood that a Wisconsin-educated, Wisconsin-trained physician will stay in the state is an astounding 86%. (Source: WHA 100 New Physicians Report) 

RTTs attract and retain teaching physicians. Many physicians view teaching as an important part of their practice. The opportunity to teach medical students, residents and new physicians can increase their job satisfaction and fulfill a mission of training the next generation.

“I enjoy teaching the art of medicine, along with the science, during student and resident rotations at Divine Savior Healthcare. I believe that the small community hospital offers an invaluable experience for students and residents that is unobtainable at the academic medical center. I relish the opportunity to share with students and residents the complexities, challenges, and joys of practicing in such an environment.”

– Dr. Michael Walters, MD JD FAAEM, Director of Hospital Based Physicians, Divine Savior Healthcare

To learn more about the first steps to starting a rural training track program click here.

Definition and Types of Rural Training Tracks

A rural training track is a graduate medical education experience where 4 to 24 months of training are completed in a rural community*. It is characterized by an apprenticeship-style training model that encompasses the full spectrum of medicine in the primary care specialties (family medicine, general surgery, internal medicine, pediatrics, obstetrics, and psychiatry) and results in a higher than average graduate placement rate into rural practice (70-80%). 4

*WCRGME uses the same definition as WRPRAP for rural which is a community of fewer than 20,000 people at least 15 miles from any community of 20,000 people or more. Many federal organizations utilize Rural Urban Commuting Area (RUCA) codes of 4 or greater, except 4.1, 5.1, 7.1, 8.1, and 10.1, which are urban.
**Based on Bowman study (see notes) and graduate data from UW Baraboo Rural Training Track Residency Program and UW Eau Claire Residency Program Augusta Track.

Traditional “1-2” RTT

In a Traditional “1-2” Rural Training Track (RTT) program, the resident spends the first year completing mostly high volume, inpatient curricular experiences at the urban-based parent program. During the second and third years of training, the resident relocates to the rural community where they have their own continuity practice and round on hospital and nursing home patients. They also deliver babies and see patients in the ER. These experiences expose the resident to a typical rural physicians practice. The RTT is a separately accredited Alternate Training Track as defined by the Accreditation Council for Graduate Medical Education (ACGME). Class sizes of two per year are common, while some RTTs have as few as one or as many as four residents per year.

Integrated RTT

In general, an Integrated RTT (IRTT) is a rurally focused program or track within a larger program which offers a lesser degree of rural training than a traditional RTT. Its definition is more flexible. Some examples include:

Federal Office of Rural Health (FORH) Policy and the National Rural Health Association (NRHA) define a “1-2 Like” RTT which is an identified training track within a larger program, not separately accredited, in which the tracked residents meet their 24-month continuity requirement** in a rurally located continuity clinic or Family Medicine Practice site (FMP).

**Continuity requirement as defined by the ACGME Family Medicine Review Committee and the American Board of Family Medicine

Federal Legislation and CMS*** define an IRTT as a separately accredited approved medical residency training program that trains residents at least half but less than two-thirds of the time in a rural location.

*** Balanced Budget Refinement Act (BBRA) 1999 and Centers for Medicare and Medicaid Services (CMS) Final Rule 2003

The National Rural Health Association (NRHA) and the American Academy of Family Physicians (AAFP) define an IRTT as a rural focused residency program or track which is not separately accredited by the ACGME in the 1-2 format and that places residents in rural places for less than 50% of their training with the following required components:

  • At least four (4) rural block months to include a rural public and community health experience. During a rural block rotation, the resident is in a rural area for a minimum of 4 weeks, or a  month,
  • A minimum of three (3) months of obstetrical training or an equivalent longitudinal experience,
  • A minimum of four (4) months of pediatric training to include neonatal, ambulatory, inpatient and emergency experiences through rotations or an equivalent longitudinal experience,
  • A minimum of two (2) months of emergency medicine rotations or an equivalent longitudinal experience.
Rural Practice: Graduate Medical Education for (Position Paper)
A joint statement of the National Rural Health Association and the American Academy of Family Physicians, revised and updated November 2013 from July 2008.

See the current Wisconsin Rural Training Tracks here.

First Steps – Starting a Rural Training Track

Contact WCRGME to set up an initial discussion about the possibilities for developing a rural training track at your Wisconsin residency program. These services are grant funded by WRPRAP so there is currently no cost for these services.

Possible Discussion Topics Include:

  • Interest level in developing rural training track
  • Assess current rural rotation options for your residents
  • Examine potential options for a rural training track
  • Discuss how rurally focused residents differ from their urban counterparts

Future Steps – Starting a Rural Training Track

Click here to learn of other technical assistance provided by WCRGME beyond the Initial Discussion.



1Gamm, Larry D., Hutchison, Linnae L., Dabney, Betty J. and Dorsey, Alicia M., eds. (2003). Rural Healthy People 2010: A Comp anion Document to Healthy People 2010. Volume 1. College Station, Texas: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.
2Rosenblatt RA, Chen FM, Lishner DM, et al. The future of family medicine and implications for rural primary care physician supply. Final Report #125. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; August 2010. Available at: http://depts.washington.edu/uwrhrc/uploads/RHRC_FR125_Rosenblatt.pdf   Accessed May 6, 2014.
3Council on Graduate Medical Education. Tenth Report: Physician Distribution and Healthcare Challenges in Rural and Inner-City Areas. Rockville, MD: Health Resources and Service Administration; 1998.
4Patterson DG, Longenecker R, Schmitz D, Skillman SM, Doescher MP. Policy brief: training physicians for rural practice: capitalizing on local expertise to strengthen rural primary care. Collaboration of Rural Training Track Technical Assistance Program and WWAMI Rural Health Research Center; 2011.
5Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas; a review of the literature. Acad Med. 2002;77(8):790-798.
6Training Physicians for Rural Practice: Capitalizing on Local Expertise to Strengthen Rural Primary Care 2011, Available at: http://www.raconline.org/rtt/pdf/policybrief_jan11.pdf   Accessed May 8, 2014