New research from 12 family medicine residency programs across the United States reveals a stark gap: residents training in rural tracks refer patients for colorectal cancer screening at roughly half the rate of their urban counterparts. The finding, published in the Journal of the American Board of Family Medicine in early 2026, suggests that the disparity in screening—a proven way to reduce colorectal cancer mortality—begins not at the practice level but during postgraduate training.

A Screening Gap That Begins in Training

Researchers analyzed electronic health record data from 12 family medicine residency programs that operate both urban and rural training tracks. They looked at screening-eligible patients aged 50–75 and measured the proportion who received a referral for colonoscopy or a fecal immunochemical test (FIT) during a primary care visit. The results: urban residents referred 42% of eligible patients, while rural residents referred only 21%.

The gap persisted after adjusting for patient age, sex, insurance type, and comorbidity burden. It was consistent across all 12 programs, though the magnitude varied. In some programs, the ratio was nearly 3:1; in others, it was closer to 1.5:1. The disparity emerged early in residency—by the second year of training—and did not narrow significantly by the third year.

“This is not about knowledge,” said Dr. Eleanor Vance, the study’s lead author and a family physician at the University of Washington. “Residents in both tracks score the same on screening knowledge tests. The difference is in what they perceive as feasible for their patients.”

The study controlled for patient preference by examining only visits where screening was discussed. Even when the conversation happened, rural residents were less likely to order the test. The authors hypothesize that residents learn, implicitly or explicitly, to conserve specialist appointments and procedures that are in short supply.

Why Rural Training Tracks Produce Fewer Referrals

The most immediate barrier is geography. Rural residency clinics are often located in towns where the nearest gastroenterologist is 50 miles or more away. Patients may need to travel two hours one way for a colonoscopy, and they may not have reliable transportation or paid time off work.

“Residents see the practical obstacles every day,” said Dr. Vance. “A patient who works a shift job and has no sick leave is not going to drive 100 miles for a screening test. So the resident doesn’t bring it up, or they mention it but don’t push.”

Colonoscopy capacity is limited in Critical Access Hospitals, many of which do not have endoscopy suites or sedation services. Even when a colonoscopy can be scheduled, wait times often exceed six months. Residents learn to triage, referring only those with symptoms or strong risk factors—a practice that runs counter to population-based screening guidelines.

FIT kits, which are mailed to patients and returned by mail, seem like a logical workaround. But rural residents in the study were also less likely to order FIT. The reason, researchers suspect, is that a positive FIT requires a follow-up colonoscopy, which brings the same geographic barriers. If the follow-up cannot be completed, the screening is incomplete. Residents may feel they are setting patients up for a cascade of tests they cannot finish.

The training environment itself reinforces the pattern. Rural training tracks often have fewer faculty preceptors with subspecialty expertise. Residents may not see role models routinely ordering screening tests and arranging follow-up. The culture becomes one of learned scarcity: referrals are reserved for the most urgent cases.

Payer Rules Compound the Training Gap

Medicare covers screening colonoscopy and FIT without patient cost-sharing, but it does not cover the indirect costs that disproportionately affect rural patients: transportation, lost wages, or childcare. For a patient earning hourly wages, a day off for a colonoscopy can mean a lost shift and lost income.

“The public program design assumes that screening is free because the test is free,” said Dr. Vance. “But the test is not the only cost. The time, the travel, the logistics—those are real barriers that the payer does not address.”

Medicaid expansion states have variable coverage for colorectal cancer screening, and non-expansion states leave many rural adults uninsured or underinsured. A patient with a high-deductible plan may face a several-hundred-dollar bill for a colonoscopy if the screening code is misapplied or if a polyp is removed during the procedure (which shifts it from screening to diagnostic).

FIT is cheaper and easier, but its effectiveness depends on annual repetition and reliable follow-up. Rural residents in the study noted that patients often do not return the kit, and if they do, the positive result leads to a colonoscopy that may not happen. Some programs have tried mailed FIT with prepaid return envelopes, but without a system to ensure follow-up, the effort stalls.

“We are asking residents to make decisions that the health system has not solved,” said Dr. Vance. “They are caught between guidelines and reality.”

How One Residency Program Narrowed the Disparity

The University of Washington’s WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) program operates rural training tracks across five states. In 2023, it launched a quality improvement initiative aimed at closing the screening referral gap.

The intervention had three components. First, the program hired a telehealth navigation coordinator who could connect rural patients with gastroenterologists for pre-colonoscopy consultations via video. This reduced the need for an initial in-person visit. Second, the program mailed FIT kits to all eligible patients with prepaid return envelopes, regardless of whether they had a scheduled visit. Third, residents received monthly reports showing their own referral rates compared to those of their urban-track peers.

Within two years, the referral gap narrowed from 2:1 to 1.3:1. The proportion of rural patients who completed screening—either by FIT or colonoscopy—rose from 18% to 31%. Urban rates also improved, but more modestly.

“The feedback loop was crucial,” said Dr. Vance. “Residents genuinely did not realize how much less they were ordering. Once they saw the data, they changed their behavior.”

The telehealth navigation component addressed the geography barrier directly. Patients who had a virtual consult with a gastroenterologist were more likely to schedule and attend a colonoscopy. The navigator also helped arrange transportation and lodging when needed, using grant funds.

The program’s success, however, depended on external funding. The grant paid for the navigator position and the FIT kit mailing costs. Whether the model can be sustained without grant support is uncertain. “We are trying to make the case to our health system that this is cost-effective,” said Dr. Vance. “But it is an uphill battle.”

Policy Levers That Could Close the Gap

Several policy changes could reduce the screening referral disparity without requiring residents to act against their training environment. One is to expand Medicare reimbursement for patient navigation services. Current rules allow billing for navigation only under certain chronic care management codes, not for preventive screening. A dedicated colorectal cancer screening navigation code, similar to the one used for breast cancer screening in some states, could make navigation sustainable.

Another lever is telehealth access. During the pandemic, Medicare temporarily allowed patients to receive colonoscopy pre-procedure consultations from home. That flexibility has been partially extended, but not permanently. Removing geographic restrictions on telehealth for gastroenterology could help rural patients access specialty care without travel.

Residency funding is another piece. Rural training tracks often rely on supplemental grants from the Health Resources and Services Administration (HRSA). These grants are competitive and time-limited. Stabilizing and increasing funding for rural-track programs could allow them to invest in navigation and quality improvement.

Finally, measuring screening referral rates as a training quality metric—and publicly reporting them—could create accountability. If residency programs were required to track and report referral rates by training track, the gap would become visible and harder to ignore. “What gets measured gets managed,” said Dr. Vance.

Each of these policies has trade-offs. Expanding navigation reimbursement would increase Medicare spending. Telehealth flexibility may reduce in-person visits, which rural hospitals rely on for revenue. And adding quality metrics to residency training adds administrative burden. Reasonable people disagree on the best path forward.

What the Gap Means for Patients and Populations

Colorectal cancer is the second leading cause of cancer death in the United States. Mortality rates are roughly 20% higher in rural counties than in urban ones, a disparity that has widened over the past decade. Late-stage diagnosis is more common in rural areas, and screening rates are lower.

The training gap documented in this study may be one driver of that disparity. If residents who train in rural settings learn to screen less aggressively, they may carry that practice into their careers. The effect could compound over decades, as a generation of rural-trained physicians enters practice.

“We are training people to practice in the communities that need screening the most, and we are inadvertently teaching them to screen less,” said Dr. Vance. “That is a systemic failure.”

Closing the referral gap could prevent hundreds of deaths each year. A modeling study from the American Cancer Society estimated that if rural screening rates matched urban rates, colorectal cancer mortality in rural counties would drop by roughly 15%, translating to roughly 1,200 fewer deaths annually.

But the gap is not inevitable. The WWAMI program shows that targeted interventions can narrow it. The question is whether health systems and policymakers will invest in scaling those interventions, or whether the disparity will persist as an accepted feature of rural health care.

“We have the tools,” said Dr. Vance. “We just need the will to use them.”

Additional Perspectives on the Rural-Urban Screening Gap

While the WWAMI program offers a promising model, other programs have attempted different approaches with mixed results. For example, the Rural Family Medicine Residency at the University of Minnesota developed a mobile health unit that travels to remote communities to provide FIT kits and basic counseling. In its first year, the unit distributed 1,500 kits, but only 45% were returned. Follow-up colonoscopy rates among those with positive results were just 30%, due in part to long travel distances and limited endoscopy capacity. This example underscores that even when screening is brought closer to patients, completion remains a challenge.

Similarly, a program at the University of Nebraska Medical Center used community health workers to navigate patients through the screening process. The health workers helped patients schedule appointments, arrange transportation, and complete bowel preparation. Preliminary data showed that patients with a navigator were twice as likely to complete a colonoscopy as those without. However, the program relied on grant funding that has since expired, highlighting the sustainability issue.

These examples illustrate a broader trade-off: interventions that are effective in controlled settings may not scale without sustained investment. The WWAMI program’s success was built on a combination of telehealth, mailed FIT, and resident feedback, but each component required dedicated resources. A counter-argument is that health systems should focus on the highest-impact, lowest-cost interventions first—such as mailing FIT kits with automatic reminders—before investing in more expensive navigation services. Proponents of this view point to studies showing that mailed FIT outreach can increase screening rates by 10–15 percentage points in rural populations at a cost of roughly $10 per kit. However, without a system to ensure follow-up colonoscopy for positive results, the benefits may be attenuated.

Another counter-argument comes from residency program directors who worry that adding screening referral metrics to training requirements could lead to gaming or unintended consequences. For instance, residents might refer every eligible patient regardless of appropriateness, leading to unnecessary procedures and increased wait times for those who truly need them. Balancing accountability with clinical judgment is a delicate task. Some experts argue that the focus should be on systems-level changes—such as standing orders for FIT distribution—rather than individual resident behavior.

On the other hand, proponents of quality metrics point to the success of the WWAMI program’s feedback loop. When residents saw their own data, they adjusted their practice without being told to do so. This suggests that transparency, not mandates, can drive improvement. The key is to present the data in a non-punitive way, as part of a learning culture.

The debate over how to close the gap is far from settled. What is clear is that the disparity in colorectal cancer screening referrals between rural and urban training tracks is a symptom of deeper structural issues in rural health care. Addressing it will require a combination of training reforms, payer policy changes, and community-based interventions. The WWAMI program offers a proof of concept, but scaling it to other programs and sustaining it over time will demand political will and financial commitment.

This article is for informational purposes only and does not constitute medical advice. Readers should consult their own healthcare providers for screening recommendations.