By Liora Engel-Smith
Later on this month, more than 550 newly graduated physicians will hang their stethoscopes around their necks, don their scrubs and begin residency training at medical centers across North Carolina.
Despite a crushing need for primary care practitioners, few of those residents — roughly 1 in 4 — will train in family medicine.
Fewer still will train in rural areas, despite a decades-long legacy of physician shortages in some of the state’s most remote areas. As Bryan Hodge, director of rural initiatives at the Asheville-based Mountain Area Health Education Center sees it, rural communities often lack the staff and financial resources to establish and sustain residency programs.
“It’s harder to train in those environments and there’s less workforce in those environments,” he said.
A modest but growing number of primary care physicians, however, will train in smaller facilities at least part of the time. Residents in these “rural track” programs typically spend a year in a large medical center, followed by two years in a rural hospital, clinic or community center.
This year, Duke University has created two such slots in collaboration with Duke Primary Care Oxford and Henderson-based Maria Parham Health. Watauga Medical Center has a partnership between MAHEC and the medical center at UNC Health in Chapel Hill, yielding four additional rural health slots in Boone.
Molly Benedum, a MAHEC physician who oversees the residency in Boone, knows the need for primary care in rural areas is bigger than her program alone can fill. Four primary care residents, however, are enough to make a huge difference in her town, she said.
“While the residents are here, they’re also helping to meet the primary care needs of the community,” she said. “ … We have a clinic here, and since they got here, they’ve been taking care of patients in the clinic and in the hospital. It immediately creates access where there wasn’t access.”
Recruiting physicians, for a price
The price of that access can be quite steep, often more than cash-strapped rural facilities can afford.
Residencies are a partnership between medical schools and hospitals. Medical schools offer a pipeline of recent graduates as well as access to research opportunities for newly minted MDs. Hospitals cover resident salaries, staff training time and the cost of materials. The cost per resident can average roughly $150,000 annually, said Matthew Huff, director of postgraduate affairs at Campbell University’s Jerry M. Wallace School of Osteopathic Medicine, a Harnett County institution that has placed 134 graduates in family practice residencies from 2017 to 2020.
While some funding for residencies can come from Medicare, in most cases, hospitals seek grants to absorb at least a portion of the costs. Other hospitals elect to absorb the losses on their own, a prospect that may be beyond some of the more financially unstable programs.
Campbell’s collaboration with UNC Health Southeastern in Robeson County has eight family medicine slots of which five have been filled for 2021, data from Residency Match shows. Hospital officials told NC Health News in 2018 that these 8 slots, along with several specialty slots cost them roughly $11 million. The hospital recoups roughly a third of that cost from Medicare, said Campbell medical school’s associate dean for postgraduate affairs, Robin King-Thiele.
Hospitals that can afford this kind of hefty price tag will often set up residencies as a way to eventually recruit at least some of these physicians-in-training to stick around.
“Having the chance of recruiting one to two, maybe three primary care physicians a year once the program matures, that’s a wonderful opportunity,” Huff said.
Patient volume is another issue.
For instance, primary care physicians in training are required to care for children and deliver babies. In most rural communities, pediatrics and obstetrics are difficult to practice not only because maternity units have shut down but because there aren’t nearly enough pediatric patients for residents to see. The hospital in Boone, for example, only admits roughly four to six children a month, Benedum said.
The Accreditation Council for Graduate Medical Education, the body that accredits residencies in the United States, requires at least two months and 250 pediatric encounters with children in the hospital, a benchmark the hospital in Boone cannot fulfill on its own. By comparison, Watauga Medical Center’s more than 600 births per year on average are more than enough to satisfy the ACGME’s gynecology and obstetrics training.
Benedum, the MAHEC physician overseeing the Boone residency, helps residents in her program get the training they need by sending them to a larger hospital to fulfill their pediatrics training.
That arrangement or “rural track” appears to be gaining momentum, in part thanks to a Health Resources & Services Administration program that recently awarded a collective $20 million over three years to 27 organizations nationwide focused on rural health. MAHEC and Duke’s rural primary care residencies were among the recipients. HRSA signaled that it is planning to allocate roughly $23 million to the expansion of the rural track grant program in FY 23 and 24.
Funding alone likely won’t address all of the hurdles for rural residency programs, Hodge said, especially because of the long lead time it takes to set up new programs.
“There has to be some balance here,” he added. “Because if you try to set up a residency in a place that really doesn’t have enough capacity to train them there, then there’s a risk of having poorly trained physicians and that’s not going to solve our problem.”
One very obvious way to address the tremendous shortage of rural health providers would be to utilize the many Advanced Practice Nurses in our state. Research has shown that using Nurse- Midwives and Nurse Practitioners (Family Nurse Practitioners, Womens Health Care Nurse Practitioners, Psychiatric Nurse Practitioners, or Neonatal Nurse Practitioners, for ex) results in improved health care outcomes and would save North Carolina a tremendous amount of money.
There is plenty of data to support this- why then are we looking to solve the rural health care crisis by focusing on physician care? It is time to consider supporting health care teams that bring together MDs, NPs and PAs to address the healthcare provider shortage. Let’s start by passing the SAVE Act that would modernize the state’s Nurse Practice Act.
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