Abstract

Family physicians are key members of the rural health care workforce, which is inadequate for current needs. From the American Medical Association Physician Masterfile, we identified actively practicing US family physicians during 2017-2023 and their region of practice. We 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. We observed the greatest percentage loss of rural family physicians in the Northeast and the least percentage loss in the West. Ensuring an adequate rural family physician workforce likely requires a tailored regional approach such as medical school pathway programs from rural communities.

INTRODUCTION

Despite research demonstrating health disparities in rural communities and studies of interventions to mitigate them, there has been little progress in reducing these disparities.¹ Family physicians (FPs) working in rural communities can address health disparities, provide necessary preventive care, and reduce mortality. In addition to providing adult medical care, FPs provide emergency care and maternity care including cesarean deliveries.^2-6 They also care for children; in fact, more FPs care for children in rural communities than do pediatricians, although the proportion of each is declining in rural areas.⁷

A 2009-2017 cross-sectional analysis of all US counties found that although the densities of primary care clinicians (including general practitioners, FPs, internists, nurse practitioners [NPs], and physician assistants [PAs]) increased in both rural and urban counties, the increase was greater in urban counties.⁸ During the same period, population growth has exceeded the increase in clinician workforce.

Given the persistent deficit in the rural health care workforce and the key role of FPs, we sought to enumerate and describe actively practicing FPs in US rural communities.

METHODS

Using the American Medical Association Physician Masterfile, for each year from 2017 to 2023, we identified all actively practicing FPs in the 50 states aged 65 years or younger who were not currently in training and were not hospitalists.⁹ We mapped the physicians’ office address to the United States Department of Agriculture’s Rural-Urban Continuum Codes (RUCCs) to identify those in rural areas. When the office address was not available, we used the “preferred” address, which may represent a residential address. (Codes 1 through 3 correspond to communities in metropolitan areas with populations of 250,000 or more, including suburban communities, whereas codes 4 through 9 correspond to nonmetropolitan areas with populations of 20,000 or fewer, which we designated as being rural.) We computed descriptive statistics to characterize the cohorts and used χ² tests to test for statistically significant associations in the data.

RESULTS

We found between 78,070 and 79,464 practicing FPs annually across the United States. From 2017 to 2023, among practicing FPs, we observed significant trends in distributions by age group, sex, and practice location (Table 1). Females represented 44.0% of FPs in 2017, and the percentage steadily increased until 2023, when they represented 49.3% of practicing FPs (P <.001). In rural areas, as in the overall sample, the percentage of female practicing FPs increased from 35.5% in 2017 to 41.8% in 2023, a statistically significant finding (P <.001). There was also a statistically significant increase in the number of urban practicing FPs (from 49.4% to 51.9%, P <.001).

Table 2 shows the overall change in the number of practicing FPs in rural areas, by US region. There were 11,847 rural FPs in 2017 and 10,544 in 2023, a net loss of 1,303 rural FPs (11.0%) for the country as a whole (P <.001). The West lost 67 rural FPs, the fewest on a percentage basis (3.2%); the Northeast lost 193, the most on a percentage basis (15.3%).

Table 3 shows the annual change in the number of practicing FPs in rural areas, by US region. We found year-over-year decreases in FPs in all regions, except for small increases in the South during 2022-2023 and in the West during 2017-2018 and 2020-2021. The mean annual loss of practicing FPs in rural areas was 1.9%, with variation among the regions.

DISCUSSION

Our findings demonstrate an alarming loss of FPs in US rural areas, with the highest percentage loss in the Northeast and the lowest in the West. Internal US population migration trends demonstrate the converse; between 2020 and 2023, rural areas gained residents.¹⁰ This loss of FPs in rural areas has occurred notwithstanding the increased number of US medical schools and family medicine residencies.^11,12 The results of the 2025 National Resident Matching Program identified 148 more family medicine positions compared with 2024 and matched 21 fewer students.¹¹

Although the annual percentages lost may seem small, losing even 0.5% of the FP workforce, as occurred in the West from 2021 to 2022, represents the loss of 11 of these clinicians. Assuming these FPs all work full-time (our analysis is not that granular), based on a panel size of 1,500 per full-time equivalent to 3,500 per full-time equivalent, this represents a potential loss of primary care access for 16,500 to 38,500 persons.^13,14 The implications of the loss go beyond numerical calculations and represent economic, social, and interpersonal losses for communities so affected.¹⁵

The finding of an increased proportion of female practicing FPs overall and in rural areas has further implications. On the one hand, historically, male physicians have proportionally far exceeded the share of female physicians in rural practice.¹⁶ Our study demonstrates a narrowing of this gap; we do not know how many female FPs started in rural areas and could not be retained. Several studies have discussed important considerations in recruiting and retaining female FPs in rural practice, which warrant consideration given the increased proportion of female FPs.¹⁷

It has been suggested that NPs and PAs could fill the gap left by FPs. In the United States, 27 states allow these advanced practice providers full practice authority. The NP and PA scope of practice is narrower than that of FPs, however, often not including maternity, emergency, hospital, and after-hours on-call services.^18,19 Despite the increases in these clinicians in the last decade, projections show decreasing rates of PAs entering nonmetropolitan primary care practice, and 2022 data found the lowest proportion of NPs and PAs in primary care compared with the previous 7 years.^20,21 Although some projections show NPs entering nonmetropolitan practice at increased levels, some training outcomes show NPs pursuing rural primary care practice in decreasing numbers.^21,22 There exist no reliable methods to ascertain whether NPs and PAs practice primary or specialty care.

Our analysis has several limitations. To determine rurality, our analysis used the office address. If rural practicing FPs without a listed office address lived in a more urbanized area, this would result in an undercount of practicing rural FPs in our study. We restricted our sample to FPs aged 65 years or younger, possibly missing older physicians who continued to practice.

Despite decades of programs to develop the rural workforce,²³ our study identifies an ongoing loss of rural practicing FPs. Rural communities bear a disproportionate burden of poor health outcomes; the loss of FPs will exacerbate this disparity.^1,24 State or regional approaches that consider the local needs of communities should emphasize recruitment and admission strategies for applicants from rural backgrounds and continue to support developing and sustaining rural family medicine residencies.^25-27 Additionally, increasing renumeration for FPs in rural settings, including robust educational loan repayment, and recruiting primary care teams to support these vital clinicians in practice may result in a more stable and adequate workforce.

Footnotes

• Conflicts of interest: authors report none.

• Read or post commentaries in response to this article.

• Funding support: This study was supported by the University of Rochester Academic Leave Support Fund.

• Disclaimer: The views expressed are solely those of the authors and do not necessarily represent official views of the authors’ affiliated institutions or the funder.

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