Residency Training Options

There are four primary types of rural training programs. Of these, “1-2” Rural Training Track programs are considered to be the most effective. They’re generally characterized by one year of medical residency training in an urban environment, followed by two years of residency in a rural environment with support from the urban facility. Including the RTT approach, here are the four program types.

Rural Residency Program Comparisons

  Rural location and rurality (Rural defined as a RUCA code of 4 or greater) Capacity/year Outcomes
RTT 21 to 31 months; often RUCA codes of 5 or higher 1 to 3 75% to rural practice
Rurally located 31 or more months; generally RUCA 4 (micropolitan) 4 or more [Has not been measured]
Hub-and-spoke (IRTT) Longitudinal; variable rurality for the rural component 1 or more [Has not been measured]
Rurally focused Variable, usually urban with targeted rural experiences 4 or more Greater than 50% to rural practice

“1-2” Rural Training Tracks (RTTs)
These programs represent variations from the original “Spokane model” prototype, with as few as four and as many as 15 months spent at the urban site, and generally with fewer than four residents per year. They are not all located in strictly rural areas, but are truly rurally focused, with program outcomes measured on that basis. Because of their smaller size, training tends to be more individualized and more like an apprenticeship. Although not yet formally recognized as such, a number of osteopathic programs share features of this model.

Rurally located residency programs (i.e. not tracks)
These programs have at least 4 residents per year of training, at least in allopathic (MD) family medicine programs. Block urban months are generally limited by the ACGME¹ RRC² for Family Medicine to five or less over three years of training because of the rules for electives, “away months,” and continuity. Osteopathic residency programs are permitted by the AOA’s accrediting body³ to have fewer residents per year but are only open to graduates of osteopathic medical schools in the US.

Urban-located programs with a rurally located continuity clinical site(s)
Called “hub-and-spoke” or “integrated rural training tracks” (IRTTs), these programs have a variety of configurations. Many programs that are not accredited “1-2” RTTs use the phrase “rural training track” loosely. In 2003, the National Rural Health Association adopted the following definition for integrated rural training tracks:

  • 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.
  • 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 so that the resident will be fully prepared to handle rural emergency situations.

Rurally focused urban programs
Those urban programs that graduate more than 50% of physicians to rural practice are simply defined by their outcomes.

¹Accreditation Council for Graduate Medical Education, the body that accredits allopathic residency programs
²Residency Review Committee, a specialty division of the ACGME responsible for actual program standards, accreditation and review
³American Osteopathic Association, Council on Post-Graduate Training