BACKGROUND AND OBJECTIVES The University of Minnesota Medical School Duluth (MSD) opened in 1972 with a mission to train physicians serving rural Minnesota, emphasizing family medicine and American Indian (AI) communities. Nationwide there are shortages in family medicine and AI physicians, and MSD is a leader in these outcomes. METHODS This is a longitudinal, retrospective cohort analysis of 1972-2009 MSD graduates using descriptive statistics and multivariate regression to determine relationships between gender, race, age, and hometown and outcomes of family medicine specialty, rural practice, and rural family medicine practice. RESULTS MSD graduate outcomes are significantly higher than other US medical schools but declining, 47% chose family medicine and 37% chose a rural first practice location. Selection of rural and family medicine declined more rapidly for men than women, but there was no overall gender difference. AI graduates had rates of rural family medicine similar to their white classmates and older AI students were more likely to select rural family medicine. Graduates from rural hometowns were more likely to select rural practice but not to practice family medicine. CONCLUSIONS MSD culture and curricula produce AI, family medicine, and rural physicians, but the school is experiencing a downward trend. Understanding the relationship between demographics and outcomes over time will assist policy makers and educators in optimizing strategies to develop the rural family medicine workforce.