State Policy Environment and Geographic Practice Preference Among Sexual and Gender Minority Medical Students

Importance: Medical school graduates have nonrandom geographical preferences for their location of practice, which affects patient access. The association of state policies regarding specific health care issues with medical school graduates' preferred location of practice is not well understood. Objective: To characterize the association between state-level policies specific to sexual and gender minority (SGM) people and health care services (eg, gender-affirming care) and medical students' preferred state to practice. Design, Setting, and Participants: This cross-sectional study was a secondary analysis of questionnaire responses from students graduating at Association of American Medical Colleges (AAMC) accredited US allopathic medical schools from 2020 to 2024. Eligible participants were US medical students graduating from AAMC-accredited allopathic medical schools who responded to the AAMC Matriculating Student Questionnaire in 2020 to 2024. Main Measures and Outcomes: The primary outcome was medical students' self-reported preferred state to practice. State policy environment was categorized based on a year-by-year tally of existing laws and policies specific to SGM people and health care services. Medical students' demographic characteristics (eg, SGM status) were self-reported. Proportional odds ordinal logistic regression estimates were performed adjusting for medical student demographic characteristics as well as additional medical student factors affecting anticipated future practice setting (ie, rurality, importance of social change in career decision-making). Results: From 2020 to 2024, there were 79 615 unique respondents (70.0% response rate), with 34 224 meeting inclusion criteria included in the analysis (18 587 aged 23 to 25 years [54.3%]; 19 549 female [57.1%]; 9755 Asian [28.5%], 2990 Black [8.7%], 4100 Hispanic [12.0%], and 19 642 White [57.4%]). A total of 4567 respondents (13.3%) reported an SGM identity. In adjusted proportional odds models, SGM status was associated with preference for higher-equality states (adjusted odds ratio [aOR], 1.56; 95% CI, 1.47-1.66; P < .001). Increasing rural practice preference was associated with lower preference for higher-equality states (aOR per category increase, 0.76 ; 95% CI, 0.75-0.77; P < .001). A greater emphasis on social change was associated with higher-equality state preference (aOR, 1.16; 95% CI, 1.13-1.19; P < .001). Conclusions and Relevance: In this cross-sectional study, state-level policy environment was significantly associated with anticipated future practice setting preference of medical students, particularly SGM medical students; this association persisted after adjustment for demographic, professional, and temporal factors, and was resistant to extreme missing-data assumptions. Policy environment may be meaningfully associated with the anticipated distribution of the physician workforce.