The national shortage of primary care physicians has been a concern for years, and a new study in the Annals of Family Medicine underscores how urgent the problem is and where the biggest pain point lies: in rural parts of the country that are seeing the largest population spikes in nearly a century.
By studying the location of practicing family physicians across the U.S. from 2017 to 2023, authors found a year-over-year decrease in family physicians practicing in rural areas, with a net loss of 11% nationwide over the 7 years studied. The greatest losses were in the Northeast and fewest in the West. There were 11,847 rural family physicians in 2017 and 10,544 in 2023, a net loss of 1,303 (11%) for the country as a whole. The West lost 67 rural family physicians, the fewest on a percentage basis (3.2%); the Northeast lost 193, the most on a percentage basis (15.3%).
The findings were as surprising as they are alarming, according to lead author Colleen T. Fogarty, MD, professor and chair of the department of Family Medicine at the University of Rochester.
"The data reflect what we already experience and know about physician shortages, but the year-over-year numbers for rural areas were astonishing to me. The speed at which this has happened is remarkable and terrible," said Fogarty.
The exodus of rural physicians is happening at a time when young adults in the 25-44 age group are moving to rural areas at the highest rate in nearly a century; two-thirds of the growth took place in smaller cities and rural counties since 2020. Powered by remote work opportunities and attracted to the amenities of country life, they are settling into rural areas but will find it increasingly difficult to access medical care.
Family physicians carry patient panels between 1,000 and 3,500 people, so the loss of even one in a community has a significant impact. When a physician leaves, their patients may turn to an already overburdened colleague still practicing in the community or travel farther to see a physician in another town.
There are several causes for the trend, Fogarty noted.
Family physicians in rural communities serve many roles, making them vulnerable to overwork and burnout that drives them to relocate or retire. In addition to adult medical care, they often provide emergency care and maternity care, including cesarean deliveries, as well as pediatric care.
"Fewer U.S. medical students are choosing family medicine as a specialty, and medical students from rural areas remain underrepresented compared with their non-rural peers. Over the years, international students choosing family medicine have offset the shortage, as they have become valuable and integral members of their rural communities, but current uncertainty around visa requirements for residents and practicing physicians adds another layer of concern about the family medicine workforce," said Fogarty.
One encouraging trend from the study: the proportion of women family physicians has grown to almost equal that of men. Females represented 44% of family physicians in 2017 and the percentage steadily increased until 2023, when they represented 49.3%. In rural areas, as in the overall sample, the percentage of female practicing family physicians increased from 35.5% in 2017 to 41.8% in 2023.
But that trend, too, raises a challenge for recruiting doctors to a rural area.
"Does the rural community have what working mothers need? Healthy boundaries on work life are important; we need to get male and female family physicians the support they need so they are not working around the clock and diagnosing a medical issue while they're at the cash register at the grocery store," Fogarty added.
Reversing the trend will take time and resources. Advanced practice providers can ease the burden on rural physicians, and improved compensation packages may help recruitment and retention.
Medical schools can also play a role, focusing on recruiting candidates from rural areas and developing rural health-specific curricula. Fogarty is leading a team to create a new rural residency training track at the University of Rochester School of Medicine & Dentistry Department of Family Medicine. Based on a national model, residents complete their first year of rotations in a city for the high volume, high acuity care that's foundational, then spend their last two years of residency in a continuity practice in a rural community, and complete rotations working with local specialists.
"It's an important initiative that we hope will make a difference," said Fogarty. The first two candidates at Rochester will match in July 2027 and begin their rural training in July 2028.
Along with study co-authors Hoon Byun, DrPH at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, and Alison N. Huffstetler, MD, at Virginia Commonwealth University's Department of Family Medicine, Fogarty used the American Medical Association Physician Masterfile to identify U.S. family physicians practicing outpatient care during 2017-2023 and where they were located.
