Rural medical students at urban medical schools: Too few and far between?

BACKGROUND: Rural regions of industrialized nations are experiencing a crisis in health care access, reflecting a high disease burden and a low physician supply. The maldistribution of physicians stems partly from the low rate of entry into medical school of applicants from rural backgrounds. METHODS: We analyzed applicants to the University of Toronto medical school in 2005 (n = 2052) to test for possible institutional bias against rural applicants and possible applicant bias against the institution. The designation of rurality was assigned using the Statistics Canada classification of residential postal codes to detect residence in communities with a population of fewer than 10,000 people. RESULTS: Consistent with past reports, rural applicants were under-represented (n = 93, 4.5% of applicants relative to 20% of baseline population). Rural applicants, on average, were equally competitive with urban applicants as measured by grades, test scores, and interviews. Rural applicants were just as likely as urban applicants to be offered admission (17% vs 14%, p = 0.43), indicating no large bias from the institution. Rural applicants, however, were more than twice as likely to decline the admission offer (69% vs 24%, p < 0.001), indicating a large bias against the institution. This discrepancy was not explained by financial disparity and was not confined to those applicants most likely to receive invitations to other schools. CONCLUSIONS: Programs to increase physician supply in rural areas need to address students' concealed preferences that are established before enrolment. Medical schools, in particular, need to encourage more rural students to apply and to persuade those offered admission to accept.