How Liora Engel-Smith covered efforts to address the resident shortage in Western N.C.

About Melba Newsome

Melba Newsome is AHCJ's core topic leader for health equity and a veteran freelance journalist with more than 20 years’ experience. Her health and science features have appeared in Health Affairs, Oprah, Prevention, Scientific American, Chemical & Engineering News and North Carolina Health News.

Liora Engel-Smith

Liora Engel-Smith

Rural health care facilities must employ enough professionals to meet the needs of their communities. But maintaining the health care workforce is a problem that goes back a long way. Their professionals need adequate education and training, cultural competency skills, and hold appropriate licensure or certification.

Medical residents who train in cities tend to stay in cities. Some rural providers say that closing the rural-urban physician gap is a matter of luring some residents away from these population centers.

In “Tackling NC’s rural provider shortage, one residency slot at a time,” Liora Engel-Smith looks at the way Mountain Area Health and Education Center (MAHEC) in Western North Carolina recruits and trains rural family medicine residents to provide full-scope primary care services. It might be a model for other rural communities.

What prompted you to report on this story? 

The lack of providers — particularly primary care doctors — is almost synonymous with rural areas, but a lot of stories about the challenges don’t go deep enough. Often they focus on one program or initiative but ignore the systems that created the issue. My goal was to help readers see how seemingly unrelated factors, such as Medicare funds or the economic well-being of an area, exacerbate the rural physician shortage.

How did you find the information about the cost to train residents to practice in rural areas?  

Residencies are a partnership between schools, hospitals and communities. I talked to a medical school that was looking to create rural residencies. I wanted to understand the cost of a residency, and one of the medical school sources happened to have a rough estimate that helped put the sheer cost of training new doctors in context.

What were the biggest reporting challenges? 

Writing about societal and systemic forces that contribute to a problem means talking to experts,  and the answers may be too technical or complex. You may find yourself drowning in jargon or lacking a tangible way to explain why your story matters.

It helps to remind the experts what the readers need. I’ll often ask things like, “What’s a simple, non-technical way to explain this system?” or “How would you explain this cost to readers?” If the answers aren’t simple enough, I’d repeat what they said in simpler terms.

Is the shortage contributing to the lack of health equity in rural areas?  

The rural provider gap is one of the biggest issues remote communities face. The time and cost of traveling deter many people from getting seen by a provider. Some people don’t have reliable transportation; others can’t afford to take a full day off work for an annual physical. By some estimates, roughly 3,500 North Carolinians died of potentially preventable deaths, including heart disease, cancer and lung disease in 2015. The same trend exists in rural areas all over the country. That’s a lot of lives potentially cut short.

What can communities do to attract more providers? 

There’s a lot of funding out there now for collaborations where residents get part of their training in an urban area and the other part at a smaller, rural facility. This funding and collaboration could make the task of starting a rural residency cheaper and more feasible.

It isn’t the whole solution, however. Residents tend to gravitate to cities, mainly because they perceive these areas as having more opportunities for spouses, partners and children. So factors like the job market or the rigorousness of the school district in the area also play a role in attracting new doctors to a community.

Do you believe expanding Medicaid has any impact on physician recruitment? 

Medicaid expansion can contribute indirectly. Most rural hospitals care for a large segment of uninsured patients. Before the Affordable Care Act was enacted, hospitals got a lump sum to offset the losses associated with uninsured patients, but that payment has been phased out in lieu of financial incentives to expand Medicaid.

In a way, that puts rural hospitals at a serious disadvantage because they still have patients who could have been insured by Medicaid, but they aren’t getting any money to offset the losses. And when a hospital is in the red, it’s much harder for executives to bring on new initiatives, especially ones as costly and time-consuming as a rural residency.

What is your advice for journalists who report on rural health care? 

If you are from the community you report on, use your experiences to guide your coverage. Think about the challenges you and your neighbors face. Often, story ideas born of personal experience yield fascinating and impactful reporting. If you aren’t from the community, talk to long-time residents, ask the chamber of commerce or the library about life in town. Be open and curious. You won’t be disappointed.

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