Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Cynthia McNamara


This study is a needs assessment for rural health education at United States medical schools. Health disparities between rural and urban populations are significant and worsening. Rural areas are home to 20% of Americans but just 11% of physicians, contributing to health inequity. Medical schools must produce more future rural physicians to meet the needs of the population. To understand the need for rural health education in medical schools, medical students were surveyed on attitudes toward living and working in rural areas and comfort with clinical competencies important in rural areas. The hypothesis was that medical students at schools focusing on rural health would have more favorable attitudes toward rural areas and feel more comfortable with competencies important in rural areas, underscoring the importance of rural health education in medical schools.A novel online survey was developed to measure trainee attitudes toward rural areas and comfort and experience with skills important in rural practice. The instrument was distributed at six medical schools, three of which had a mission statement including a focus on rural health. Institutional representatives and research partners emailed students with an invitation to complete the survey with a gift card lottery incentive. Survey data was analyzed by chi-square, linear correlation, and student’s t-test to assess attitudes and competencies versus student hometown rurality, identity as rural or urban, institutional mission statement, and time spent in rural areas. The average institutional response rate was 13.4%; a total of 287 students completed the survey. Of these, 131 indicated that they were in their first or second year (“pre-clerkship”) and 146 were in their third year or above (“clerkship”); the proportion was not statistically different between schools with and those without a rural focus, nor by student identity or time spent in a rural area. Student hometown rurality, rural identity, attendance at a school with a rural mission statement, or time spent in rural areas (collectively “rural learning”) were all positively associated with positive attitudes and negatively associated with negative attitudes toward rural areas; the inverse was true for students who self-identified as urban. Pre-clerkship status was negatively correlated with comfort with all groups of competencies. Among all students, rural learning was positively associated with comfort formulating a plan for initial care in urgent patient presentations in non-tertiary care settings, diagnosis and management of regionally endemic illnesses, and opportunity to develop comfort with an aggregate of elements of professional flexibility. Each element of rural learning was associated with greater exposure to several components of professional flexibility, a category including skills like improvisation, community engagement, and task-shifting, or taking on the role of other health professionals when necessary. Hometown rurality was associated with greater comfort with an aggregate of diagnosis and management categories and specifically with diagnosis and management of chronic diseases and acute infectious diseases. It was also associated with greater exposure to procedures in aggregate and specifically to skills in dermatology and imaging interpretation. Rural identity was positively associated with exposure to dermatologic procedures. Time spent in a rural setting was associated with greater exposure to gynecologic examination and procedures in aggregate, specifically dermatologic and musculoskeletal procedures. Attending a school with a rural mission statement was associated with greater comfort with musculoskeletal examination and exposure to reproductive health and dermatology procedures and with less exposure to point-of-care ultrasound. Of students at schools with no rural mission statement, 95.8% felt that rural health was not adequately incorporated into their curriculum, while 98.1% of those at schools with a rural mission felt it was adequately incorporated. Interest in dedicated rural health curricula was not significantly different between students at schools with and without rural mission statements. Overall, as hypothesized, rural learning was associated with more favorable attitudes and self-reported comfort with competencies important in rural medical practice. In contrast to students at schools with rural mission statements, those with rural identities and past rural exposure had increased comfort with more skills important in rural settings. This underscores the importance of recruiting students with rural backgrounds. However, the current supply of rural students is inadequate to meet the workforce need; therefore, these results also reinforce the importance of incorporating rural health education in order to promote positive attitudes about and comfort with skills important in rural areas. These findings also suggest that medical schools without rural mission statements are not meeting student interest in rural health curricula. Finally, this work provides possible targets for educational development in the urban setting, including training in or increasing exposure to endemic illnesses, musculoskeletal examination and procedures, dermatologic procedures, reproductive health procedures, and professional flexibility.


This is an Open Access Thesis.

Open Access

This Article is Open Access