By Liora Engel-Smith
Camden County’s health care workforce is as lean as it comes. There are no psychologists or nurse practitioners in the rural bedroom community in the far northeastern corner of the state. No podiatrists or nurse-midwives. No physician assistants either.
The county of roughly 10,000 has one dentist, one hygienist, one pharmacist and one primary care physician as of 2019, according to data from UNC Chapel Hill’s Sheps Center for Health Services Research. The county also boasts 16 registered nurses and six licensed practical nurses.
It isn’t that there are no health needs there. Residents say substance abuse is among the top concerns in the county, according to a health assessment Sentara Albemarle Medical Center in Elizabeth City conducted last year. The county’s rates of heart disease, diabetes, breast cancer and obesity are also higher than the state average. Access to health care, the assessment found, is among the top concerns of residents in the county.
Camden’s provider shortage is chronic. Since 2000, the number of providers in the Eastern North Carolina County fluctuated somewhat, Sheps data shows. The county gained a pharmacist but lost three physicians and six registered nurses. The number of dental professionals and licensed practical nurses remained roughly the same.
It’s a problem that many rural counties in North Carolina face, despite decades of federal and state efforts to bolster the health care workforce in some of the state’s most remote areas.
“I am a hopeful person, but when I look at the data I become cynical because we have been trying to address this for 40 years,” said Erin Fraher, who studies the state’s health care workforce at Sheps.
Among the state and federal government’s oldest tools to combat the shortage is loan repayment. Both the North Carolina and federal programs began forgiving a portion of school loans of health professionals in the 1980s in exchange for service in areas of high need for a few years.
But assessing the success of this financial incentive approach in addressing North Carolina’s rural provider shortage can be difficult.
The geography of choice
In theory, North Carolina’s rural areas should have gained more than 250 new providers — doctors, nurses, dentists and nurse practitioners — in the last fiscal year. But the actual number is far lower in practice.
The federal government invested just under $10 million in loan repayments and scholarships for almost 200 providers in North Carolina in FY2019. Of these, 168 providers signed up for loan repayment. Exactly how many of them actually serve in rural areas is hard to ascertain. Cities such as Durham, Charlotte and Raleigh also have pockets of high need and providers can choose a placement there and still receive loan repayment; the federal database does not list service locations for loan repayments on its site.
That same year, the state of North Carolina invested roughly $2 million for 106 placements in underserved areas — both rural and urban. According to the Office of Rural Health, Pitt and Buncombe counties, both urban, attracted 25 placements between them. By comparison, many rural counties — including Camden — had no placements. Other remote locales, such as mountainous Clay and Macon counties, got one placement apiece.
Michelle Skipper has been thinking about that problem for much of her career. Skipper, who recruits nurses to East Carolina University’s doctoral nursing program, said that loan repayment programs can encourage students from rural areas to attend school. She also noted that the more experience with a rural area a provider has, the more likely they are to practice there throughout their career. Yet clinics across eastern North Carolina continue to struggle with chronic shortages.
“If we’ve been doing this work for a long time, we’ve ought to be able to fill up those clinics,” Skipper said. “And we’re not. Certainly, you’re getting some attrition there with age and retirement,” but, she added, it’s likely most who received loan forgiveness hit the road once their loans are paid.
These disparities in placements — and the potential turnover in more remote clinics — are in part a function of choice, Skipper said. Graduates themselves select the area they’d like to serve from a menu of clinics in need, and many providers prefer to live in a city or near one. The reasons for these preferences are complex, but Skipper said spouses of practitioners are more likely to find a job in a city.
Even if they place in rural areas first, some providers later choose to move closer to cities with better education options once they have children, she added.
The Office of Rural Health does not have accurate data on turnover as of yet, according to Stephanie Nantz, who works with the state’s placement program. A data-gathering collaboration with the Sheps Center about turnover is underway, she added.
Though loan repayment can be a powerful incentive to serve in a rural area, it is just one piece of a much more complicated puzzle, said Office of Rural Health leader Maggie Sauer.
“If providers feel that they are accepted in the community, if they feel like their children can get a good education … those kinds of things, that in combination with loan repayment [can attract providers to rural areas].”
Sauer’s observation is borne out in national research. While loan repayment can make practicing in a rural area more financially feasible, particularly for graduates with a high loan burden, other factors, such as having grown up or trained in a rural area play a much larger role.
“It’s critical to devote more resources to that kind of training, that seems to be a more natural way to get people excited about [rural practice],” said Davis Patterson, who studies the healthcare workforce issue at the University of Washington. “Loan repayment [is] like the Band-Aid you put on after [the fact].”
A sense of mission
Anahita Shaya understands the financial calculus of working in a rural area. A dentist in the Pender County Health Department, Shaya said she knew she wanted to work in a public health clinic since she was a student.
“You kind of put a lot of your life on pause in dental school,” she recalled. “So when you graduate, you’ve got everything waiting for you. Within those years, I got married, moved, bought a house and had kids. So it was a lot of cost of living accruing at once for me.”
Balancing school loans and career aspirations, she said, would have been difficult without some kind of assistance, especially at that stage in her life. Loan forgiveness made practicing in the Pender clinic feasible, she said, but it was the sense of mission that first drew her to the work.
When Shaya applied for a job at the health department three or four years ago, the 63,000-person county had more than 20 dentists, Sheps Center data shows. Mission aside, the placement also had to work for Shaya’s spouse. The couple settled in the nearby city of Wilmington, where her husband, a landscape architect, could find work too.
It was only after Shaya applied for and got accepted to her role that she learned that she was eligible for an up to $100,000 payout over four years from the state.
“It definitely helped in terms of making a dent in some of [the loans] so that I could catch up,” she said, though it did not cover the entire amount she borrowed.
Shaya recently got her last payment from the program but has no plans to change jobs anytime soon.
Practicing elsewhere, say in Camden County, where the nearest big city is roughly an hour away, would have been almost impossible, she said, because her husband would have struggled to find a job. These economic barriers make it harder to recruit providers in some of the state’s most remote clinics.
An uphill battle
Hertford County has more than twice the population of Camden County, about an hour west, but it’s no less remote or rural. The biggest town in the county, Ahoskie, has a population of just under 5,000. It is also home to the Roanoke Chowan Community Health Center, a federally funded provider that also has clinics in neighboring counties.
The clinic at Ahoskie is roughly an hour away from Norfolk, VA and Greenville and two hours from Raleigh, and Roanoke Chowan CEO Kim Schwartz knows she has to work extra hard to attract and retain quality medical staff.
Practicing in the middle of nowhere may not be a dream many providers have, but Schwartz has worked diligently to create a pipeline of providers. Having built relationships with medical schools all over the country, Schwartz said she does a fair bit of marketing in the recruitment process, highlighting some of the benefits of practicing in a rural setting, including a wide array of clinical experiences with a complex set of patients that providers in more populated areas often refer to specialists.
“You get to do everything, to try everything,” she tells candidates. “What can you think of that you might want to try, because this is an open lab.”
State and federal loan repayment is a benefit that may make Ahoskie more attractive financially, she said, but it is not the only factor. Schwartz knows, for instance, that strong community ties can help providers feel a sense of belonging, so she’s dreamed up an initiative that would offer housing in the community to residents who choose to come to Roanoke Chowan. Even with perks such as work-life balance and a positive work environment, roughly half of the loan repayment recipients who come to work at the health center move on after a few years.
Contending with a new provider every few years can be difficult for patients, she said. Here too, the center adapted, by making sure patients connect with a team, rather than one provider, so even when a provider leaves, there’s still continuity. It isn’t ideal, Schwartz said, but it’s the reality of rural care.
Fraher, of UNC’s Sheps Center, said loan repayment alone likely won’t resolve some of the interlocking issues that Roanoke Chowan and other rural clinics in the state are up against.
“We have taken too much of a siloed approach,” she said. “We’ve got to be strategic. Yes, let’s invest in loan repayment, but let’s also tweak graduate medical education.
“We could, I would argue, make a much bigger difference with a strategic plan for rural health that involves coordinating those efforts, yes, then you could solve the problem.”