A number of efforts can be attempted in rural medical education initiatives in recruitment, socialization, curricular reform, and community technical assistance. Further work is needed in identifying strategies that are most appropriate and cost effective in different states and regions that may have different situations and needs. Careful consideration needs to be given to reasons why such ideas have not moved beyond the demonstration stage over the past 20 years; it is suggested that without substantial reform of payment systems favoring rural and primary care, educational reform will have marginal effectiveness and remain at the demonstration level.