to medical school or residency those students with a rural background or rural life experience. It requires more than training in technical procedures that urban family physicians may not commonly perform (e.g., orthopedic, emergency, and higher order obstetrical skills). It requires more than an attitude sympathetic to public health. Both urban and rural residency programs are important to the preparation of rural doctors, but to be successful, both must include signicant training intentionally situated in rural places [7, 8]. Success requires more than a list of objectives and detailed curricular content. It requires training in the rural context.

This chapter describes the history and trajectory of training in and for rural practice, followed by a review of the requisite personal character domains of competence in rural practice for both faculty and residents; important and unique curricular design concepts pertinent to the context, content, and scope of rural training; and practical strategies in program develop­ment, implementation, and ongoing improvement. The aims of rural training include placing family physicians in rural communities, assuring competence in all domains required for successful rural practice and meeting community needs, and promoting sustained joy in training and practice.

Although rurally located residency training programs in family medicine have existed from the beginning of the specialty in the 1960s, they were few. In the 1980s, in response to anemic production of rural physicians, rural training tracks (RTTs) rst appeared, structured in a proto­typical 1–2 format—an internship year in the city, followed by 2years of residency training in a rural community—with 1–4 residents per year. Although programs in the 1–2 format existed in the late 1970s, they were not necessarily located in rural places or separately accredited and it wasn’t until 1992 that rural training tracks were ofcially described in the lit­erature as “RTTs” [23, 24]. These programs were rst sepa­rately accredited as such by the ACGME beginning in 1994 [25, 26]. By 2000, early news of success resulted in a peak of 35 programs. In 2000, the Center for Medicare and Medicaid Services (CMS) implemented the Balanced Budget Renement Act (BBRA 1999), a corrective to the Balanced Budget Act of 1997 (BBA 1997). It provided an exception to the Medicare GME funding cap established by BBA 1997 for “rural training tracks” (RTTs) or “integrated rural train­ing tracks (IRTTs).” Over the next decade, despite this provi­sion, many RTTs and IRTTs experienced signicant hardship and closed from lack of funding and a general decline in stu­dent interest in family medicine [27, 28].

In a rurally located or rural track program, both the family medicine practice and the community are the curriculum [41]. The rural context denes the most appropriate and best care provided to patients given available resources for deliv­ering that care, the logistics of referral to a larger care center, and the need for continued coordination of care beyond the immediate setting. It denes situational care that is within the local standard. Care provided in rural and urban settings may be different. Care in a rural community may be better in some respects due to the continuity of care provided by the

rural settings also present opportunities. The relationship­rich nature of a rural community (“fewer people, more rela­tionships”) facilitates quality interprofessional and team-based care. Joint clinical teaching and didactics among a variety of learners may be a necessity. Many rural pro­grams have built on the assets, strong relationships, and resources available within their local community and have demonstrated resiliency and innovation in deploying inter­professional teams to address the health care and social needs of a local population [45]. Enablers of interprofes­sional education in a rural place include identifying a cham­pion, allowing for a broader scope of practice among all team members, and fostering effective teamwork, role clar­ity, mutual respect, and regular opportunities for cross­disciplinary communication [46]. As in any other setting, faculty must reect on their own interprofessional experi­ences and how these shape the formation of new interprofes­sional and team-based learning opportunities [47].

Realistically for medical students, many factors impact residency program selection, including life circumstances, a signicant other’s concerns about rural life or employment, proximity to family, geography, or a desire for training in particular skills [48]. Many will, for a variety of reasons, choose to train urban and still practice rural. Physicians edu­cated or trained in an urban environment, however, may need to “unlearn” habits, heuristics, medical practice patterns, and systems-based practices more appropriate to the urban setting.

Preparing family physicians to deliver care in rural settings, in addition to the challenging variety and breadth of services, includes training to greater competence in rst contact care [61]. Procedures that are infrequent or rare at a rural hospital require creative approaches to training, such as simulation or short well-dened immersion experiences in more urban facilities or with nearby urban specialists. Rural physicians must have technical skills that apply to both high frequency (e.g., attending to orthopedic fractures and suturing) and lower frequency, high impact, and critically important proce­dures (e.g., intubation, chest tube placement) to provide what the patient requires to survive intact during transfer to the next level of specialized care. In providing acute care in a rural setting, the family physician is frequently the rst and best qualied clinician for meeting the patient’s immediate clinical needs. Implementing an immediate diagnostic and treatment plan and providing effective and safe disposition for additional care may not always require a referral to sub­specialty care or a remote intensive care setting, but it does require collaboration with a team to provide immediate and local care within the resources available.

The concept of rural generalism, the ability to adapt services and competencies to the needs of the community, is well recognized internationally [69]. This ability to adjust one’s scope of practice to meet community needs and complement the healthcare team is something that should be taught, mod­eled, and reinforced during residency training. This can be just as important as acquiring a set of procedural or technical skills, which may or may not be needed or sustained over time. Notably, resident physicians in training may express a desire to develop certain procedural expertise and experience in training that may or may not be welcomed or needed by the community they subsequently serve. Training should be balanced by consideration of both personal t and eventual adaptation to practicing in a particular rural community, its needs, and its resources.

Exposure to a variety of means for rural practice is also important, whether employment by a hospital, community health center, or health system; conventional solo or group private practice; direct primary care; locum tenens; or itiner­ant practice across multiple sites and practice models. There are rural twists to each of these. Each of these ways of pro­viding care brings risks, direct and indirect costs, and bene­ts and must be weighed in best meeting community needs and achieving individual t.