By Clarissa Donnelly-DeRoven
In rural areas, family medicine doctors often serve as both the foundation of the local health care system and the gateway to higher levels of specialized care. But not everyone has equal access to these providers.
In North Carolina there’s an average of about 28 doctors for every 10,000 people, according to health workforce data maintained by the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill. But that’s not what the physician landscape looks like in most rural counties. According to that same data set, Anson County, on the South Carolina border, for example, has about nine physicians for every 10,000 people, while far western Graham County has about six and northeastern Currituck County has just four.
In coastal Pender County, for every 10,000 people there are just three physicians.
Filling these gaps will take massive local and statewide efforts. Starting in summer 2024, some physicians in the southeast will start to do their part through the introduction of a new rural family medicine residency program. The new doctors and their mentors will be based primarily out of Burgaw-based Black River Health Services, a local clinic that provides affordable (and free) care to low-income residents.
Janalynn Beste, the director of the family medicine residency program at Novant Health New Hanover Regional Medical Center, will co-lead the new program.
“There’s lots and lots of data that says physicians tend to stay close to where they’re trained,” said the family physician. “They put down roots, their kids go to school there, their spouse finds a job there or finds friends there.”
The hope is that the physicians in this training program will do the same.
Joe Pino is the program’s other co-lead. He’s the associate dean and campus director of UNC’s School of Medicine Wilmington program.
“These residents will grow and develop in the community and learn the skills to become a successful family medicine physician,” he said. “Through this process, we aim to cultivate a love for rural primary care in North Carolina.”
Part of building this program includes hiring a physician who will serve both as the director of the residency program and as the medical director for Black River. They’ll also hire a second doctor who will work closely with the residents.
“We have a hard time recruiting physicians to Burgaw and the surrounding area,” said Lee Ann Amann, the CEO of Black River Health Services. “We are in desperate need of a medical director, so this really helps us.”
A significant need
As in so many places, some areas of Pender County suffer far more than others when it comes to health care accessibility.
Residents in tonier seaside communities tend to be wealthier and able to access care in neighboring Wilmington with more ease than those who live farther inland, or west. The county’s 2018 community health assessment shows that many residents in the largely agricultural western part of the county pay between 32 and 41 percent of their monthly income on housing and that — with the exception of those on the coast — many residents have salaries between 20 and 34 percent below the federal poverty line.
In other words, many Pender County residents suffer from poverty and all of the structural ways poverty harms someone’s health. Increasing the supply of physicians in the area is one way to begin treating the problem.
Still, the scenario repeats across North Carolina. While the state has 20 family medicine residency training programs, just seven are based in rural counties. The 13 urban training programs encompass 360 of the 447 residency positions available, according to staff from East Carolina University’s rural family medicine residency program in a commentary published in the North Carolina Medical Journal this past May.
That means just 19 percent of family medicine residency slots are in rural communities even though about a third of state residents are estimated to live in a rural area.
“This uneven distribution of family medicine residents and the resources brought to bear to adequately train them contributes to health disparities between urban and rural North Carolina,” the authors wrote.
“If the goal is to place physicians practicing high-quality primary care in rural underserved areas and to retain those physicians in that [health professional shortage area] over the long term, then it makes sense logistically and financially to train residents in the areas in which you want them to practice after graduation.”
A funding challenge
Starting a rural training program for physicians is no easy task.
“One of the important policy issues facing this and other rural training programs is financing,” wrote Steven Crane, a family physician in Hendersonville in an email to NC Health News. Crane was instrumental in the creation of the rural family medicine residency program with the Mountain Area Health Education Center, or MAHEC.
“This is a very complicated subject but bottom line is that the most common way graduate medical education programs get funded works against primary care and rural/underserved programs in favor of urban hospital systems,” he wrote.
The U.S. Government Accountability Office estimated in 2021 that 99 percent of Medicare funding for graduate medical education goes to urban programs.
In a 2021 article in the Journal of Graduate Medical Education, a handful of rural health researchers from North Carolina explained how this plays out. Through a series of complicated and technical rules, the graduate medical education funding formula ends up depriving rural training programs of the money they need to pay for the indirect costs of training residents. Rural hospitals also tend to have higher rates of uncompensated care, from treating uninsured patients and patients with higher rates of public programs such as Medicare and Medicaid, so they end up receiving lower reimbursements to cover the cost of paying their residents.
“The funding model actually puts hospital systems such as HCA in the driver’s seat in determining what type of doctors get trained, rather than public health needs,” Crane wrote. “Some states have used the federal match to leverage federal dollars to support [graduate medical education] focused on health needs using the Medicaid program. So far, North Carolina Medicaid has not created such a program, which could go a long way to making rural or primary care training more feasible.”
Grants, networking light the path
Beste and Pino said they’ve wanted to start a training program like this for nearly a decade, but, predictably, money proved to be a major obstacle.
Then, in 2021, they were awarded a half-a-million-dollar grant from the federal Health Resources and Services Administration to support the planning and creation of the new teaching center and residency program at Black River. That same year the federal Centers for Medicare and Medicaid Services announced the creation of 1,000 new residency slots, to be phased in over the next five years. Pino and Beste applied to be funded through that program as well and will hear back in January.
While the funding is a complicated and ongoing process, the close-knit community of family medicine physicians in North Carolina has helped them figure out the best way forward, Beste explained.
“We share secrets — probably to our administrators’ chagrin — we talk about things like how did you get this to happen? How did you get that to happen?” she said.
The program has been approved to host two slots for residents. The tentative plan is for these new physicians to spend all three years of their training primarily in Pender County, at both the Black River clinic and the Pender Medical Center, a 25 bed critical access hospital with 43 skilled nursing home beds. They’ll also go to the nearby hospital in New Hanover for their training in services not offered in-county — namely, pediatrics and obstetrics.
In addition to all the research that shows physicians are likely to practice where they train, Beste has also seen how students from rural backgrounds reliably are pulled to practice in areas similar to where they grew up.
“Students who come from rural backgrounds have a really deep passion to go back to those communities and practice in those communities or similar communities,” she said. ”Maybe they don’t necessarily want to go back and, you know, see their high school teacher for a Pap smear, but they want to go back to a similar type of community.”
For that reason, Beste and Pino look at students’ backgrounds closely during the recruitment process, with the applications of those from southeastern North Carolina getting an extra little bump.