This project examined issues related to establishment and maintenance of residencies and residency tracks in rural America. The project involved both a literature review and interviews with key informants related to the issues surrounding rural residency programs. While the project emphasized generalist residencies, it was not limited to them. The policy paper discussed issues associated with retaining and starting rural residencies and tracks such as their training cost and clinical implications, credentialing constraints, and staffing problems. Understanding the issues surrounding the establishment of rural residencies is important for federal and state legislators and administrators as they revamp the nation’s graduate medical education system. Funded by HRSA’s ORHP.