THE EFFECTS OF RURAL TRAINING DURING RESIDENCY ON PHYSICIANS’ RURAL PRACTICE AND RURAL PHYSICIAN SUPPLY

Rural populations in the United States persistently experience lower physician supply than urban counterparts. Despite increased investments in rural graduate medical education (GME), there is limited causal evidence on whether rural training during residency increases physicians’ likelihood for rural practice or affects community-level physician supply. This dissertation provides the first national-level causal effects of rural training during residency on physicians’ subsequent rural practice and evaluates the effects of establishing rural residency training sites on community-level primary care physician (PCP) supply. Using physician data from American Medical Association (AMA) Physician Masterfile, residency training data from the Accreditation Council for Graduate Medical Education (ACGME), and county-level national data from the Area Health Resource File (AHRF), this dissertation examines three aims. Aim 1 uses an instrumental variable approach to estimate the causal effects of rural training on physicians’ subsequent rural practice, leveraging plausibly exogenous variation in local rural residency slot availability and medical school rural pathways to predict rural training. We find that each percentage-point increase in rural training raises the probability of rural practice by 1.1 percentage points, with effects consistent across gender, primary care or non-primary care specialty, rural origin, and years since residency completion. Aim 2 evaluates the causal dose-response relationships between rural training and rural practice using the same instrumental variables. We find that moving from no rural training to low dose rural training (1-50% exposure) increases rural practice by 41 percentage points, while intensifying rural training from low dose to high dose (>50%) yields smaller positive and statistically insignificant effects. Aim 3 evaluates community-level spillover effects using a staggered difference-in-difference. We find that establishing a residency training site in nonmetropolitan counties increases county-level PCP density by 8% on average, with effects emerging in four years of post-establishment. These findings provide actionable guidance for policymakers, including lowering the 50% rural training threshold for rural program designation, expanding rural rotations within urban residencies, and strategically launching training sites in rural counties with supportive infrastructure. In summary, this dissertation demonstrates that rural GME is an effective intervention to boost rural physician workforce that can reduce rural-urban health disparities.