Getting patients in to see primary care practitioners is key to the Affordable Care Act. Image courtesy DIBP Images, flickr creative commons.
Getting patients in to see primary care practitioners is key to the Affordable Care Act. Image courtesy DIBP Images, flickr creative commons.

By Taylor Sisk

Geoffrey Jones understands why a young doctor would be drawn to the idea of traveling to eastern Africa or southern Asia to heal suffering and promote wellness. It suggests a potentially rewarding experience under challenging circumstances.

But you can have a very similar experience right here in North Carolina, Jones tells them.

Rural Rx: NC Health News coverage of rural health issues. This week: Henderson county.
Rural Rx: NC Health News coverage of rural health issues. This week: Henderson county.

Jones is director of the Family Medicine Residency Program in Hendersonville. His job is to train and otherwise prepare young primary care doctors to live and work in rural North Carolina.

The need for these doctors is considerable. According to a 2013 report from the Program on Health Workforce Research and Policy at UNC-Chapel Hill’s Sheps Center, the gap continues to grow between areas of the state reasonably well served by primary care doctors and those that aren’t.

Ten North Carolina counties are considered to be what the federal Health Resources and Services Administration identifies as health professional shortage areas. Seven of those counties – Clay, Gates, Graham, Northampton, Tyrrell, Warren and Washington – are rural counties. Thirty-one other counties were found to be partially comprised of shortage areas; 21 of those are rural.

The administration defines a primary care HPSA as an area that has no more than one primary care physician for every 3,500 residents, or no more than one for every 3,000 if 20 percent or more of the population lives in poverty.

Similar shortages are found in rural areas in the number of registered nurses and dental and behavioral health professionals. According to the North Carolina Institute of Medicine’s “North Carolina Rural Health Action Plan,” released last August, Tyrrell County has no physicians whatsoever. Neither does it have a dentist or psychiatrist.

Tyrrell’s poverty rate is 27.2 percent ($23,850 for a family of four); the state average is 17.8 percent.

A sense of community

The inability to attract enough young doctors into primary care in general is an issue nationwide. In 2008, the Association of American Medical Colleges projected a shortage of 45,000 primary care physicians in the subsequent decade.

Dr. Steve Crane runs the Bridges to Care Program.
Dr. Steve Crane launched the family medicine residence program in 1994.  Photo by Judith Long, courtesy Bridges to Care

Attracting those docs into rural areas is an even bigger challenge – one that Steve Crane chose to tackle in 1994 when he launched the Mountain Area Health Education Center’s  Family Medicine Residency Program.

Crane recognized that, as Jones put it, “If we want to keep docs here, we need to grow our own.”

The three-year residency is now one of four such administered by the Area Health Education Centers program, known as AHEC, located in community health centers serving rural and underserved areas. The other AHEC programs are in Greensboro, Prospect Hill and Wilmington.

The Hendersonville residency brings in four residents each year. Crane said recruits tend to be older than the average medical school student, with more life experience. They’re more likely to be married with kids. Many of them have rural or small-town backgrounds.

“We’re looking for people who have a strong sense of community service,” he said. Often that sense of service comes from a student’s faith.

They also want students who are independent minded and entrepreneurial. The curriculum is designed to nurture self-reliance and offer exposure to a wide range of issues a rural doctor is likely to encounter.

Residents practice inpatient medicine, including rotations in pediatrics, cardiology and critical care. They’re trained in labor and delivery. They spend time with surgeons and in an emergency room.

The program partners with Blue Ridge Community Health Services, which Jones said is the oldest migrant health center in the country, having just celebrated its 50th anniversary. Residents also put in hours at rural practices in neighboring communities.

Goeffrey Jones is now director of the Family Medicine Residency Program. Photo credit: Taylor Sisk
Goeffrey Jones is now director of the Family Medicine Residency Program. Photo credit: Taylor Sisk

And they go out on house calls. Jones said those can be anxiety inducing when it means visiting people who “live in conditions that most of them have never seen growing up.”

‘A broader skill set’

This past year, 190 U.S. and 1,000 foreign students applied for the four available slots. They all expressed an interest in working in underserved communities. But unless they’re enrolled in a scholarship or loan-repayment program (see box), there’s no guarantee they’ll go on to practice in a rural area.

Not everyone is cut out for it. Running a rural practice is a lot about figuring out how to manage scarce resources and being a jack-of-all-trades.

Further incentive

A recent report from the North Carolina Institute of Medicine’s Task Force on Rural Health titled the North Carolina Rural Health Action Plan”  laid out six priority measures to improve health outcomes in rural communities. Among them is to ensure “adequate incentives and other support to cultivate, recruit, and retain health professionals to rural and underserved areas of the state.”

The state offers loan repayment through the Office of Rural Health and Community Care to health professionals who commit to practicing two to four years in a health professional shortage area. ORHCC also offers assistance in applying for state and federal loans.

But the report points out that the General Assembly has reduced these incentives from more than $3 million annually a few years ago to $1,499,977.
The federal government provides scholarships and loan repayments through the National Health Service Corps to primary care doctors and behavioral health and dental professionals who agree to practice in a HPSA.

The task force recommended that community colleges expand strategies to recruit students into two- and four-year degree programs on or near their campuses, “as people who are trained in rural communities are more likely to practice there.”

It also recommended that health care programs supported by state funding place a priority on admitting students who grew up in or have a desire to practice in a HPSA.

“It tends to be a broader skill set, and that’s where that maturity and self-confidence is really important,” Crane said. If seeing a specialist requires that a patient travel 50 miles, often over secondary roads, odds are strong the follow-up will never happen. Treatment then falls back on the rural doctor. “You’re going to end up seeing more people with a higher level of acuity.”

These doctors, Crane said, are “the full-scope family-medicine doc.”

“When I interview people, I say that you need to be very aware that being a doc in a rural area means that you’re doing it all,” Jones said, which includes running an office and, ideally, being active in the community.

Louisa Conroy, a current resident, welcomes that role. “In a rural area, you’re expected to be the old-school kind of doctor,” she said, “taking a leadership role in the community. That’s encouraged here and is part of your training.”

But, Conroy added, to be good at this, “You have to be self-driven.”

Without that drive, and the desire, Jones said, “you’re going to go into a rural area and totally flame out, and you’re going to be uncomfortable, and you’re going to leave.

“It’s hard for communities to recruit people, but it’s devastating when they recruit them and they can’t keep them.”

Forming networks

Training doctors to practice in rural areas is for naught if there’s no place for them to then go out and make a living doing it.

Asheville-based Mission Health has been buying a number of small practices in Western North Carolina. Jones said that “the hope is that by being part of a network, you can create places for your doctors to go” where they’re linked to other practices and can share resources.

Even that jack-of-all-trades, he said, can’t, after all, be “everything to everybody.”

The Mountain Area Health Education Center is also offering opportunities.

Grey Tilden, who completed the residency in 2013, recently joined Kate Sloss, who’s been doctoring in the mountains for 30 years, to launch Lake Lure Medical Center, a MAHEC-administered clinic.

Tilden, the father of two small children, values playing a key role in the “economic and social aspirations of a community,” recognizing “how much health care and access to health care means to that.”

He said he intends to practice in Lake Lure for the duration of his career.

Doing it differently

As of two years ago, Crane said, the Family Medicine Residency Program had placed nearly 80 percent of its graduates into HPSAs. His prognosis for the future of attracting young doctors into rural areas is that it’s not going to happen naturally.

“We have to do things differently,” he said, meaning “pushing more training of not only physicians but dentists and other practitioners out into rural areas.”

MAHEC now operates a dental clinic for an underserved population in McDowell County and has proposed a fellowship program to train nurse practitioners in rural primary care.

“A lot of the people who grow up in suburban communities and urban areas, which is where most of our medical schools are, have no idea that places exist in this country where people don’t have electricity or running water,” Jones said.

“You just have to look.”

Coming soon: Grey Tilden sets up shop in Lake Lure.

This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.

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