UNC medical programs encourage graduates to serve in state’s rural areas

Imagine driving nearly an hour or 60 to 70 miles along backroads just for a simple checkup at the doctor. For many North Carolinians, basic healthcare is a major issue – and even more dire in an emergency situation.

State lawmakers and healthcare officials face significant challenges in providing healthcare to residents of underserved and rural areas. With new initiatives from medical programs in the University of North Carolina system, relief might be on the way.

The UNC School of Medicine in Chapel Hill and Asheville and the Brody School of Medicine at East Carolina University are among the medical training programs in the state encouraging graduates – through special training, scholarships, and fellowships – to practice medicine in rural areas.

Maggie Sauer, director of the Office of North Carolina Rural Health for the state Department of Health and Human Services, said, of the 100 counties in the state, between 70 and 80 counties are rated Tier 1 or Tier 2 and are considered to be underserved. She noted the Centers for Disease Control recently issued a report that people in rural areas have greater health risks because of a lack of preventative care.

In the 1970s as national concerns about rural healthcare came to the forefront, the state, in partnership with UNC School of Medicine, established Area Health Education Centers, or AHECs, in different regions to try to meet the needs of the rural population. At the same time, the state also created Brody to serve the eastern half of the state, particularly regions that were medically understaffed.

Now, the partnership is moving to the next level with programs designed to train medical students to work permanently in rural areas.

UNC School of Medicine

Dr. Robert Bashford jokingly said his favorite new word is “synergy.”

As associate dean of the UNC School of Medicine and director of the Office of Rural Initiatives, Bashford is helping to spearhead several initiatives promoting careers in rural healthcare. Bashford wants to coordinate his efforts with other medical school programs and state and county health services. Hence, the need for synergy.

“There are a lot of players, and I’m trying to get my arms around it to attain synergy,” he said. “It’s become an important word. The North Carolina Medical Society, the Office of Rural Health, and the Legislature – there are so many important players.”

Complementing the Brody School of Medicine’s efforts is an important part of Bashford’s goals.

“East Carolina has done what they said they were going to do better than anybody, which is training doctors for the eastern part of this state. So, they are integral to what we do,” he said.

The UNC School of Medicine rural medicine initiatives include:

  • Kenan Primary Care Scholars: Funded by the Kenan Charitable Trust, the program was launched in 2013. Kenan scholarships support the second, third and fourth years of medical school and reduce student debt by a total of $30,000 per student. Students spend their third year working at the UNC School of Medicine’s Asheville campus working in clinics in the western part of the state. Scholars also take part in a six-week summer program which includes housing and a stipend. The scholarship also has recently expanded into underserved urban communities, with some students working in Charlotte, and the program will soon expand to a Wilmington campus.
  • Kenan Scholars Fellowship: This new program is a one-year fellowship following medical school but before residency. Students are supported with housing and a stipend to work in a rural area to become engrained in a community. Bashford hopes many of the students will eventually want to serve in local government and contribute to the community beyond healthcare.
  • Fully Integrated Readiness for Service Training (FIRST): This is a fast-track program that allows students to complete their medical degree in three years and guarantees them admission into the UNC Family Medicine Residency Program, currently ranked No. 2 in the nation by US News & World Report. After the residency, FIRST scholars commit to three years serving in a rural or underserved part of the state.
  • North Carolina Rural Health Scholars: Launched last year, this state-funded program is a $40,000 scholarship paid upon medical school graduation. Scholars commit to serving in one of the state’s 80 rural counties after residency.
  • Primary Care and Population Health Scholars: A voluntary program for elective credit, it serves medical students who are interested in practicing cost-effective, high-quality primary care with the larger vision of improving the health of populations. Students also develop skills in research, writing and leadership.
  • Family Medicine Rural Track Residency: The Department of Family Medicine offers an Underserved Track for residents seeking more experience caring for that population. The program gives residents the opportunity to work with a high volume of Spanish-speaking patients. This program was the first of its kind in the state, launched in 2012.

UNC officials studied programs in other states, such as Alabama and Wisconsin, which have launched similar rural health initiatives. While it’s too early to measure the impact of the programs in North Carolina, Bashford said other states have shown encouraging results.

“You look at their data, and it’s pretty damn good,” he said. “We’ve got our fingers crossed. We’re trying to pick the right people who want to work in rural areas.”

According to Bashford, many of the students who opt to practice rural medicine come from smaller, underserved areas themselves. Between seven and 10 students from a class of 180 opt to enter one of the rural medicine programs.

Bashford is hoping to address more than access to physicians. Similar recruiting efforts are underway with students studying psychiatry, dentistry and pharmacy.

Training doctors to work in rural healthcare is different, Bashford said. Family doctors in underserved areas are expected to cover a wider range of skills because of a lack of specialists in these regions. For example, a diabetic patient in an underserved area will likely be treated only by a primary physician because there’s no endocrinologist in the county. Family doctors are trained to provide patients with preventative measures and more education in their care, so that the diabetic patient might have better control of his condition.

In continuing efforts, Leah Devlin, a professor in the Gillings School of Health, was appointed by UNC-Chapel Hill Chancellor Carol Folt to create a task force that would identify ways the university could contribute to rural public health.

“We’re going to recommend options to the chancellor by the end of the summer,” Devlin said. “We could focus on specific issues – opioids, mental health, aging – or, focus on broader strategies, such as evaluating rural hospitals.”

Despite the number of strategies to improve rural healthcare, Bashford said it’s still a learning curve.

“What we’re learning is you can’t just plop a doctor down in a community,” Bashford said. “You learn that the community has to want that doctor there.”

Brody School of Medicine

Unlike the UNC School of Medicine, the Brody School of Medicine was created with the idea for its graduates to work in underserved communities in the eastern half of the state.

Dr. Elizabeth Baxley, senior associate dean of academic affairs at Brody, said the process starts with recruiting the right students. Students who come from rural areas, have experiences in rural communities, and who are racial and ethnic minorities are more likely to practice medicine in underserved areas after they graduate. ECU also looks at history of community service and whether prospective students want to concentrate on family medicine. Currently, 40 students from Tier 1 counties are enrolled at Brody.

“In our admissions process, we pay just as much attention to academics as any other school, but our holistic approach also focuses on known predictors for students entering rural practice,” she said. “We also have students working in primary care physicians’ offices right at the beginning in their first year of medical school. In their third year, they have four weeks of their required clerkships in family medicine and two weeks in pediatrics, and these are preferably in rural areas and smaller communities. As such, students have a chance to witness what practices in those environments are like and see the benefits and rewards.”

In addition, students take part in numerous extracurricular service programs that are student-driven. ECU’s clinical practice serves a 29-county region, much of which is rural, so students can experience rural medicine first-hand.

“It’s not a likely place to put a medical school,” Baxley said with a chuckle. “The state of North Carolina was involved at the very beginning when it legislatively defined the mission of the school: to train and produce primary care physicians; to improve the health of people in eastern North Carolina; and to make access to medical education available to under-represented and other disadvantaged students.”

ECU maintains relatively low tuition compared with other medical schools across the country, which allows graduates to select their specialty choice and practice location without as much concern for their ability to retire high loan debt. This can mean more primary care in rural practices.

“The average debt for a Brody graduate is $108,000,” said Baxley, noting that the median household income of Brody students is lower than the national average, and many are non-traditional with prior careers before med school, or have military backgrounds. “The national average for medical school debt is $156,000.  The number of our graduates who practice in rural areas is 15.5 percent, compared with the national average of 5 percent. In primary care, we’re 44.2 percent who practice in rural areas, while nationally, it’s 24.4 percent. We are meeting our mission.”

Baxley reiterated Bashford’s view of disparity between the health of urban and rural populations.

“One of the most significant predictors of a person’s health status is their zip code,” she said. “In many cases, your ability to access health services depends on where you live. The other location impact is related to ‘social determinants of health’ – what access do people have to quality food choices, affordable and secure housing, a safe place to exercise. Additionally, in locations where educational quality is lower, people generally make choices that can result in poorer health outcomes.”

Factors such as public transportation and government services, also play a factor in health outcomes.

Ultimately, a healthier population in underserved areas is better for the state overall.

“Anytime a primary care physician moves into a community, there are consistently documented improvements in health in that community,” she said. “That results in better quality of life, less absenteeism at work and school and generally lowers total costs for the state. There’s also an economic case to be made for preparing the right physician workforce for the locations of greatest need.”