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THE GRAYING OF RURAL MEDICINE

Brody School of Medicine targets pending physician shortage

By Steve Tuttle and Doug Boyd
ECU News Services


Pediatrician Beverly Edwards ’88 shakes her head when she thinks about retiring. “I don’t want to, which is good because I can’t afford to,” she says with a smile.

She loves caring for her patients but says it’s often a struggle to run Ahoskie Pediatrics, a solo practice she has owned for 24 years. She often worries about paying bills and making payroll for herself and her nine employees. In the middle of a Medicaid reimbursement crisis 18 months ago, she had to withdraw her life savings – $400,000 – and lend it to her practice to keep the doors open.
Pictured above, Brody School of Medicine alumna Dr. Beverly Edwards '88, who runs Ahoskie Pediatrics, chats with patients at her solo practice. Edwards is among a number of physicians practicing in rural areas who are nearing retirement age.

Photos by Jay Clark

At 57, Edwards is on the younger end of a Baby Boomer bulge health policy leaders are watching anxiously. They are concerned that a statistically significant number of primary care doctors in the East are nearing retirement age at a time when most of them must work harder to get paid less under Medicaid and most private insurance policies.

Fortunately, East Carolina University’s formula for recruiting students likely to stay in their home state to practice is ideal for taking on this challenge of replacing physicians who retire. According to 2014 data from the Association of American Medical Colleges, the school ranks at or above the 90th percentile among U.S. medical schools in the percentage of graduates practicing in rural areas (19.5), underserved areas (40.6), practicing in the same state as the school (55), practicing in primary care (41.8) and practicing in family medicine (20).
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Physicians Charles Sawyer and Colin Jones are shown at the Ahoskie Comprehensive Care Center. Research indicates that the average age of physicians east of Interstate 95 is 51.2, with about 25 percent aged 60 or over.



And recent developments such as a $1 million American Medical Association grant to remake medical education are adding to the ECU’s toolbox for populating the East with physicians.

What’s the matter?

Increasing the number of primary care doctors in North Carolina is a key component of the mission of the Brody School of Medicine, along with improving the health of eastern North Carolina's residents and improving access to a medical education for minorities.

Addressing the issue of retiring doctors is one Brody is eager to take on, but it won’t be fast or easy for a number of reasons.

“If we started today it would take a decade-and-a-half to get to where we might need to be,” says Dr. Paul Cunningham, dean of the medical school.

Data compiled by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill highlights this graying of rural medicine in the East:
  • Primary care doctors here are older than doctors in the rest of the state. Statewide, 18 percent are 60 or older, and the average age is 48. East of Interstate 95, about 25 percent are 60 or older, and the average age is 51.2.

  • Of the 15 counties in the state with the highest average age of primary care physicians, eight are east of Interstate 95.

Officials say the situation is especially worrisome in northeastern counties. That region contains six of the 10 North Carolina counties that suffer from persistent physician shortages, according to the federal Health Resources and Services Administration.

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Brody School of Medicine graduates Drs. Darlene Keene and Jamande Jones are pediatricians at the Ahoskie Comprehensive Care Center. More than half of Brody's 2,200 graduates practice in North Carolina; nearly one in five serves in eastern North Carolina.

So, there aren’t nearly enough doctors to begin with in northeastern North Carolina, and half or more of them are aging out.

Cunningham practiced in rural Bertie County before joining the Brody faculty in the 1980s. He says he knows many of these older doctors still practicing in small towns across the region.

“Many of us who have served in rural areas … are facing imminent retirement, and we need to consider the need for replacing them in these rural communities,” Cunningham says. “Very soon, it will become more acute.”

ECU’s history shows it’s ready to tackle the problem. More than half of the school’s 2,200 graduates practice in the state, and nearly one in five does so in eastern North Carolina. Among all Brody graduates who enter primary care, statistics show three-fifths of them are still doing primary care five years after graduation. No other medical school in the state comes close to that record.

But indications are more is needed to offset the numbers of older physicians leaving their practices.

Spending to keep practicing

Due to expenses Edwards incurred just keeping her practice open as it shifted to a new electronic medical records system and online reimbursements – and the fact she had to withdraw her life savings to do that – she won’t be retiring anytime soon.

With the evolving economics in the medical marketplace, her type of solo practice isn’t alone in facing obstacles.

“Small practices are a dying breed,” says Tom Bacon of Chapel Hill, the longtime executive director of the N.C. Area Health Education Center program. “Used to, when a small-town physician retired, he could sell his practice to a young doc just out of medical school. That just simply isn’t happening any more.”

Debt from medical school and lifestyle options force many young doctors into different choices, Bacon says. That creates a dilemma for many older doctors in rural communities; they can’t sell their practice, and it’s too expensive to hold on to it.

That’s one area where Brody has an advantage. According to the Association of American Medical Colleges, ECU medical graduates on average leave school with $85,877 in debt. That number seems staggering, but is lower than the average of 90 percent of the nation’s other medical schools.

Dr. James Peden, associate dean for admissions at the medical school, says he’s heard graduates say the low cost of their medical education allowed them to enter the specialty of their choice rather than feeling pressured to pursue a more lucrative medical career path that wasn’t as appealing to them.

Peden oversees an admissions committee made up of faculty physicians, basic scientists and medical school upperclassmen that populates the Brody rolls with students who believe in the school’s mission.

“Have they shadowed doctors, volunteered in clinics, seen what physicians do on a day-to-day basis,” Peden says of what committee members look for in applicants. Rural roots point to the likelihood of returning to the small towns and country crossroads that lack adequate services.

“Our goal is to accomplish just that, provide care to the woefully underserved eastern region of the state,” Peden says.

The new face of rural health care?


While Beverly Edwards and other small-town family doctors struggle, a new model of delivering rural health care seems to be succeeding just a mile away at Roanoke-Chowan Community Health Center.

RCCHC is a full-service medical center with four locations and a staff of about 120 delivering primary care, pediatrics and behavioral care.

The center was founded in 2005 and moved into its current facility in 2012, paid for with a $6.2 million federal grant. With a pharmacy in the lobby, the building’s beside the ECU dental community service learning center.

A not-for-profit led by a volunteer board, RCCHC serves Hertford and surrounding counties and accepts patients regardless of their ability to pay.

In addition to its Ahoskie campus, RCCHC has clinics in Murfreesboro and in Colerain in Bertie County. It also operates a student health center at Hertford County Middle School. All the clinics usually are open evening hours, and some see patients on Saturdays.

RCCHC is one of 34 federally qualified health centers in North Carolina. These centers receive funding under Section 330 of the Public Health Service Act and qualify for higher reimbursement from Medicare and Medicaid, as well as other benefits.

The center recently received a $250,000 grant from the Health Resources and Services Administration to expand its mental health services.

FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality-assurance program and have a governing board of directors.

North Carolina’s 34 FQHCs operate nearly 180 rural health clinics that treated about 470,000 patients in 2013. A dozen of these community health care centers are based east of Interstate 95 and operate about 80 clinics.

CEO Kim Schwartz says a key to RCCHCs success is a financial and organizational structure that allows providers to avoid back-office hassles and earn a decent income while caring for people in one of the poorest counties in the nation.

That’s what attracted Chief Medical Officer Colin Jones and the three other older doctors now on the RCCHC staff. They were in private practice together in Ahoskie and got fed up with the problems of owning and managing a rural practice. They became the founding staff of RCCHC when it opened.

“Now, I don’t have to think at all about running a business. I can concentrate everything on my patients,” he says.

Officials say the positive aspects of practicing at a center such as RCCHC eliminate a big negative that young doctors often perceive about rural medicine – being isolated and unsupported.

This structure recently helped attract three Brody pediatricians to the RCCHC staff. Drs. Darlene Keene ’83 ’89 and Jamande Jones ’10 practice mainly at the Ahoskie facility. Dr. Geniene Jones ’10 practices at the Murfreesboro clinic, where she’s helping take some of the caseload of the clinic’s senior physician, Dr. Mike Alston ’75. Jamande and Geniene Jones are married.

“I wanted to serve the children and families of this underserved area of North Carolina,” says Jamande Jones. “The demographics of this area add additional barriers to receiving adequate health care services.”

Keene is a native of Ahoskie, so RCCHC is allowing her to live her dream and pay the rent. “This place is home to me, and I am so pleased to be back and providing pediatric care to the area,” she says.

“I don’t think bigger is necessarily better when it comes to delivering good health care in a rural community,” Schwartz says. “But having a deeper talent pool, more modern facilities and easier access to funding, that does make a difference.”

Schwartz says RCCHC is not in competition with small-town doctors such as Edwards. She says it makes her sad when she hears about any medical practice closing.

“But this is such a different day, such a different time,” she says, “and we must move into a new future.”

– Steve Tuttle


The new face of rural health care?


While Beverly Edwards and other small-town family doctors struggle, a new model of delivering rural health care seems to be succeeding just a mile away at Roanoke-Chowan Community Health Center.

RCCHC is a full-service medical center with four locations and a staff of about 120 delivering primary care, pediatrics and behavioral care.

The center was founded in 2005 and moved into its current facility in 2012, paid for with a $6.2 million federal grant. With a pharmacy in the lobby, the building’s beside the ECU dental community service learning center.

A not-for-profit led by a volunteer board, RCCHC serves Hertford and surrounding counties and accepts patients regardless of their ability to pay.

In addition to its Ahoskie campus, RCCHC has clinics in Murfreesboro and in Colerain in Bertie County. It also operates a student health center at Hertford County Middle School. All the clinics usually are open evening hours, and some see patients on Saturdays.

RCCHC is one of 34 federally qualified health centers in North Carolina. These centers receive funding under Section 330 of the Public Health Service Act and qualify for higher reimbursement from Medicare and Medicaid, as well as other benefits.

The center recently received a $250,000 grant from the Health Resources and Services Administration to expand its mental health services.

FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality-assurance program and have a governing board of directors.

North Carolina’s 34 FQHCs operate nearly 180 rural health clinics that treated about 470,000 patients in 2013. A dozen of these community health care centers are based east of Interstate 95 and operate about 80 clinics.

CEO Kim Schwartz says a key to RCCHCs success is a financial and organizational structure that allows providers to avoid back-office hassles and earn a decent income while caring for people in one of the poorest counties in the nation.

That’s what attracted Chief Medical Officer Colin Jones and the three other older doctors now on the RCCHC staff. They were in private practice together in Ahoskie and got fed up with the problems of owning and managing a rural practice. They became the founding staff of RCCHC when it opened.

“Now, I don’t have to think at all about running a business. I can concentrate everything on my patients,” he says.

Officials say the positive aspects of practicing at a center such as RCCHC eliminate a big negative that young doctors often perceive about rural medicine – being isolated and unsupported.

This structure recently helped attract three Brody pediatricians to the RCCHC staff. Drs. Darlene Keene ’83 ’89 and Jamande Jones ’10 practice mainly at the Ahoskie facility. Dr. Geniene Jones ’10 practices at the Murfreesboro clinic, where she’s helping take some of the caseload of the clinic’s senior physician, Dr. Mike Alston ’75. Jamande and Geniene Jones are married.

“I wanted to serve the children and families of this underserved area of North Carolina,” said Jamande Jones. “The demographics of this area add additional barriers to receiving adequate health care services.”

Keene is a native of Ahoskie, so RCCHC is allowing her to live her dream and pay the rent. “This place is home to me, and I am so pleased to be back and providing pediatric care to the area,” she says.

“I don’t think bigger is necessarily better when it comes to delivering good health care in a rural community,” Schwartz says. “But having a deeper talent pool, more modern facilities and easier access to funding, that does make a difference.”

Schwartz says RCCHC is not in competition with small-town doctors such as Edwards. She says it makes her sad when she hears about any medical practice closing.

“But this is such a different day, such a different time,” she says, “and we must move into a new future.”

– Steve Tuttle


Brody’s success in preparing primary care physicians for the state showed in this March’s annual National Residency Match Day. More than half of Brody’s 80-member Class of 2015 will be going into residencies in family medicine, internal medicine, pediatrics or OB/GYN. Of those, 10 will enter residencies at Vidant Medical Center in Greenville. ECU statistics show that graduates who complete a residency in Greenville tend to stay in the region.

“It starts with our admissions process that reveals the students come from backgrounds that predict they are predisposed to practicing in smaller rural communities,” Dr. Elizabeth Baxley, senior associate dean for academic affairs and professor of family medicine at the Brody School of Medicine, told the Greenville Daily Reflector newspaper at Match Day.

“Their curriculum has them out the very first year into practices all around the state, and they get opportunities to work in rural areas and see the joys of working in smaller practices.” In addition to student recruitment, Brody is adding interprofessional educational opportunities where health sciences students learn to work as a team.

“We have a good recipe, and we know it works,” she told the newspaper.

Honoring a promise

Edwards is the younger of only two private-practice pediatricians in a county where 26 percent of the 24,000 residents live in poverty. She knows it’s unlikely that a young doctor will come to Ahoskie, buy her practice and secure her financial future.

What keeps her going is a promise she made back in 1984.

“When I interviewed with the dean (of the Brody School of Medicine), he asked me, ‘If we admit you, will you promise to practice medicine in rural eastern North Carolina?’ And I said, ‘Yes I will.’”

Baxley says the projections on retiring doctors underscores why Brody must continue working to place physicians in the East.

“That’s how most small-town practices are structured these days,” Baxley says. “So if we can do more of that in their training, then I think all of our graduates — doctors, nurses, P.A.s, N.P.s — will feel more positive about considering the option of practicing in a rural area.”

Toward that end, ECU is one of 11 U.S. medical schools developing a new model for medical education as part of the AMA-funded project. The goal is to educate students about patient safety, quality improvement and team-based care along with new ways of teaching that engage students more actively in their own education.
withpatients
Dr. Beverly Edwards of Ahoskie Pediatrics interacts with patients Arcangel Smith, left, and Hiliani Smith, center.

In addition, medical students are joining dental, social work and nurse practitioner students in a College of Nursing grant program to integrate interprofessional education and expand the use of a virtual community clinic similar to what students will experience in the workplace after graduation.

New and upgraded facilities such as the Family Medicine Center, which opened in 2011, are also helping. With the ability to see more patients in a larger building, the diversity of people and their illnesses, injuries and conditions has grown, adding to educational opportunities for medical students and residents – and the appeal of pursuing a career in family medicine.

More is needed

Brody requires significant state support in order to sustain the preparation of primary care doctors, Chancellor Steve Ballard has said in presentations across the region about Brody and its impact. Its funding model, its mission and the population it serves have always demanded that support.

A number of factors place Brody in an unusual fiscal position. Unlike other academic medical centers in in North Carolina, Brody does not own its hospital. Instead, it partners with Vidant Medical Center, a private, not-for-profit hospital, to provide a teaching setting for all health sciences disciplines, including medicine.

Brody also must keep tuition and costs low so graduates can afford to practice in small or underserved communities.

Finally, Brody serves a population that statistically ranks among the sickest and poorest in the nation.

State appropriations made up 53 percent of Brody’s budget in 1990 compared to just 21 percent today. Shifts in Medicaid reimbursement policies also impact the school's budget disproportionately.

Brody has received national acclaim for producing graduates who choose to practice primary care medicine in North Carolina. Continuing to send those graduates into the region is paramount.

One of those is Brad Beamon of the Class of 2015. In July, he will begin a pediatrics residency at Vidant Medical Center.

“My family is originally from Wilson, so I have experienced firsthand the value of care to patients in eastern North Carolina,” he says. “Also, having done my undergraduate and medical school at ECU has deepened my love for the people in this region.”

During a fourth-year medical rotation in Seattle, he found he missed the patients of eastern North Carolina.

“The combination of their need for medical education and care partnered with their gentle humanity as they tell you about their dog makes caring for the people of eastern North Carolina a joy and honor,” he says. “This is my state, my people and, by God's grace, my responsibility.”

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