By Taylor Knopf
A year ago, Greg Wood had a problem when his golfing buddy wanted to move away.
But Wood, who runs the Scotland Health Care System, in Laurinburg, would be losing more than a member of his regular foursome. He’d be losing the only ear, nose and throat doctor in the area, along with his friend’s wife, a pediatrician.
“He’s been pushing us for three years, to help him run his practice, he keeps losing more money. We’ve helped him as much as we can legally,” Wood told a group of legislators at a meeting in March 2018. “He finally showed up and said I have two offers to leave town, here are the offers, my wife will come with me.”
So Wood went to his board of directors to ask their permission to hire him as a hospital employee, a move that would mean spending of hundreds of thousands of dollars to improve his friend’s offices, update his computers, hire him another staff person and pay him the salary he could have gotten elsewhere.
“He’s the only ENT in town, do you want to employ him or see your ENT service leave?” Wood recalled asking his board.
Wood said the board easily made the decision to spend extra to “employ this ENT physician, something that we used to get for free.”
These are the types of decisions being made by hospital boards in rural areas all over the U.S. and North Carolina. It’s often what it takes to recruit physicians to rural parts of the state and keep them there.
Now, the latest issue of the North Carolina Medical Journal dives into a number of issues surrounding rural health, including just this problem.
In his article, “The Sufficiency of Health Care Professional Supply in Rural North Carolina,” Mark Holmes, a health economist who runs the Sheps Center for Health Services Research, lays out a few economic theories behind the rural physician shortage.
Holmes argues the businesses and services that exist in any given area are often the result of America’s free market society.
“We recognize that the economics of the area—the ability and willingness to pay, the market size, the degree of competition, the elasticity of demand—all determine whether an organization—be it a fast food restaurant, professional sports team, or health care provider—can generate enough revenue to cover its costs and survive in the area in the long run,” Holmes wrote.
He asks the question: “should we think of health care as a different kind of business—something that we can’t leave the free market to settle?”
There are many policies and laws in place — such as EMTALA, which requires that emergency rooms treat and stabilize patients who walk through the door — that enhance access to health care. At the same time, those policies and laws can skew market forces.
And in order to ensure rural areas have health provider to meet their needs, Holmes argues that many entities need to get involved. Simply adding more and more physicians to the overall workforce and hoping some will overflow into the rural areas is not enough.
“If we are serious about increasing access to health care in rural North Carolina, it will take a concerted effort from multiple stakeholders over a long period all pulling in the same direction with a common vision,” Holmes wrote.
In Wood’s case, market forces were pulling his ENT doctor to leave town, so the hospital intervened. But the choice made by Scotland Health Care’s board is one that, increasingly, cannot be made by rural hospitals under increasing financial pressure.
Rural recruitment strategies
Many rural counties in North Carolina lack a sufficient number of physicians for the people living there. And then there are counties that do not have any providers in a specific field. For instance, in 2017, three N.C. counties did not have a primary care provider, 17 had no general pediatrician, and 27 had no obstetrician/gynecologist.
One strategy for recruiting physicians to work in rural areas is to train them there. Residents “who develop an affinity for the area” and who gain “relevant experience in rural areas” are more likely to practice in similar communities, Holmes wrote.
And there are already residency programs like this starting in North Carolina, such as the new program at Southeastern Health in Lumberton. Of the recent graduating class, four residents chose to live and work there, while several others are relocating to other rural North Carolina locations.
Another strategy Holmes highlighted is to recruit middle and high school students from rural areas in need of health care providers into programs that feed medical and other health professions.
“In an era of heightened accountability and transparency, a program with such a long payoff may find it difficult to make its case for continued funding,” he wrote.
“It will require leaders—policymakers, to be sure, but also training programs, health systems, and others working in this space—to balance accountability and vigilance with the patience to wait for the investments to bear fruit.”
In the short-term, Holmes said that loan repayment and telehealth systems can be effective.
Rural workforce retention
Once physicians are successfully recruited to rural areas of North Carolina, how do we keep them there?
“Clinicians who provide health care services—physicians, advanced nurses and physician assistants, nurses, and allied health care professionals—who are recruited to rural areas via loan repayment or other short-lived incentives often leave after only a few years,” wrote Herbert Garrison, associate dean for Graduate Medical Education at East Carolina University, in an article for the NCMJ.
He argued that the one-third of North Carolinians who live in rural areas “deserve the same optimal health care that’s easier to find in urban areas.”
In order to recruit and retain rural physicians, Garrison said that it will require commitments from the federal and state government, local communities, medical schools, hospital-based mega systems and insurers along with more funding.
[sponsor]Few studies have focused specifically on interventions to improve rural retention rates, and it’s not fully understood why some health care providers stay in rural communities long-term, Garrison said.
He agrees with Holmes that targeting students from rural communities for health care training should be a priority.
Garrison said there are some elements shown to help with retention, such as community support of the provider in the form of schools, salary, loan support and spousal employment. He lists a few programs with the North Carolina Medical Society and the N.C. Office of Rural Health that can help local leaders in making their communities more attractive for physicians.
A healthy practice environment — such as favorable call schedules — also improve retention rates, he said.
“The inability to unplug from work, professional isolation, lack of resources to support patient health in the community, and challenges of an evolving health care system … can push providers to leave tenuous rural settings,” Garrison wrote.
He suggested that consolidating health systems should “use their resources to improve the practice environment and meet the special needs of rural communities as they struggle to retain clinicians.”
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I was in a frontier medicine practice for 16 years and burnout from the inability to unplug and get away from the practice/hospital as well as the constant banter that we were not making any money from the board all the time and we were close to closing despite my working all the time covering in patient, OB, ER and clinic drove me away.
Unfortunately in rural it seems you work harder than your urban counterpart for not.
Also rural community boards lack understanding of the market of healthcare and the practice of medicine with its stresses and problems. The community board of my previous job did not appreciate what I did which added to it. Power trips from them and the feeling I was easily replaceable so I should just work harder and do what they said drove me away as well. I took a job elsewhere for less pay for better life balance to help my increasing depression and burnout despite financial loss.
Rural areas and their all powerful hospital boards need to assure balance and respect the physicians who practice there or why should they stay?
They have an unfortunate belief “why would someone not come to our amazing small town we all grew up in and never left. We are offering them the most amazing place and they should feel blessed to be here.” There are a lot of jobs out there and treating your physicians like slaves and gaslighting them when they don’t do what you want by making as much as possible while they miss sleep, concerts, family time and can’t leave town is not the way to keep them.
Trust me. They need comparable pay, respect and life balance or they will leave. I did.