Supporting Community-Based Family Medicine Residency Training Programs in North Carolina and their Potential Impact on Healthy NC 2030
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POLICIES & PROGRAMS – INVITED COMMENTARY
Supporting Community-Based Family Medicine
Residency Training Programs in North Carolina
and their Potential Impact on Healthy NC 2030
Audy G. Whitman, Geniene Jones, Danny Pate, Herb G. Garrison III, Alyson Riddick, Kim Schwartz, Greg Bounds
North Carolina is a leader in family medicine, but a growing the region in PCPs on a per capita basis, with 62 PCPs per
health care chasm exists between the state’s urban centers 100,000 persons in North Carolina as compared to 74 per
and rural areas. Training family medicine residents in rural 100,000 in the Southeast and 76 per 100,000 nationally [5].
communities can address disparities in health care access A more appropriate PCP-to-patient ratio would be 83 PCPs
and improve rural population health metrics for all subsets per 100,000 persons, indicating there are current and ongo-
of the population, goals that align well with renewed state ing state, regional, and national PCP shortages [6].
and national strategies. North Carolina is home to 20 family medicine residency
training programs that offer a wide variety of training envi-
Introduction ronments [7]. Of these, four are community based, nine
N
are community based with a university affiliation, five are
orth Carolina is a national leader in family medicine university based, and two are military programs. These pro-
residency training and provides fertile ground for new grams are distributed across the state, with two in north-
rural family medicine residency programs. Peer-reviewed eastern North Carolina, four in southeastern North Carolina,
evidence indicates that family medicine residents are likely three in the Sandhills region, three in the Research Triangle
to remain in or near the communities in which they com- region, two in the Triad region, three in the Metrolina region,
pleted their residency training [1, 2]. Rural and underserved and three in Western North Carolina.
communities throughout the state face health care dispari- North Carolina is one of the fastest-growing states in the
ties secondary to access problems, an aging physician work- nation in terms of natural births and net migration, indicat-
force, and socioeconomic attrition to larger, more affluent ing the state is a desirable place to work, live, and start a
urban centers throughout the state. Healthy North Carolina family [8, 9].
2030, a public health initiative with multiple stakeholders, Our current primary care workforce shortage coupled
seeks to bridge these chasms over the next decade and with a fast-expanding population demonstrates the need
improve the health and well-being of all North Carolinians for further investment in training and retaining primary care
[3]. Rural, community-based family medicine residency physicians to meet the current and future needs and to pro-
training programs can be agents for positive immediate, and mote the growth and resiliency of a healthy and productive
long-term change toward that goal, and as such, resources citizenry.
should be invested to that end. This view is shared by the
National Academy of Science, Engineering, and Medicine
Philosophy of Family Medicine
(NASEM). Family medicine is a medical specialty that focuses
on providing comprehensive primary care for all stages of
Family Medicine in North Carolina an individual’s life. Family physicians believe in building a
The North Carolina Academy of Family Physicians is the strong interpersonal relationship with the patient and pro-
largest medical specialty organization in North Carolina, and viding them with continuity of care throughout the spectrum
is one of the largest of the 55 constituent family medicine of their life, with mindful orientation toward the environ-
academies comprising the American Academy of Family ment, family, and community to which the patient belongs.
Physicians (AAFP) [4].
Recent physician workforce analyses have shown that Electronically published May 2, 2022.
family physicians comprise the largest component (44%) Address correspondence to: Audy G. Whitman, Department of Family
of primary care physicians (PCPs) in North Carolina, higher Medicine, Brody School of Medicine, 101 Heart Dr, Mail Stop 654,
Greenville, NC 27834-4354 (whitmana14@ecu.edu).
than comparable Southeastern state and national trends
N C Med J. 2022;83(3):173-177. ©2022 by the North Carolina
(38% for both) [5]. However, this same analysis also Institute of Medicine and The Duke Endowment. All rights reserved.
showed that North Carolina lags behind its neighbors and 0029-2559/2022/83309
NCMJ vol. 83, no. 3 173
ncmedicaljournal.comA central tenet of family medicine is a holistic approach of pediatric and geriatric patients, a decrease in employed
to disease that utilizes a biopsychosocial model, seeking to workers with health insurance, and a stagnant economy with
understand the interrelation of biological, psychological, a dwindling tax base to fund schools and other public inter-
and social factors influencing the patient that affect overall ests that attract migrants looking to establish a home [14].
health. All of these factors compound, making physician recruit-
All aspects of health care (medical, dental, behavioral) ment and retention to these areas a more daunting task.
and environment (spiritual, social determinants of health) This exacerbates access problems, enticing more citizens to
interact to create a patient’s quality of life and their respec- migrate to a wider array of opportunities in urban centers,
tive disease burden and disease outcomes. Family medi- thus making this a cyclical issue.
cine is an adaptable generalist specialty with broad scope, Family medicine residents look for programs in which
a broad spectrum, and a holistic and community-oriented they can obtain high-quality and up-to-date training that
mindset. allows them to practice at the top of their license and
Family physicians serve as competent generalists with a as physician leaders of interdisciplinary teams [16, 17].
broad scope of practice; effective gatekeepers to the health Allocation of health care resources to train resident physi-
care system who coordinate patient care with other special- cians in these rural communities is prudent stewardship, as
ists and assist patients in navigating an increasingly com- it invests money and resources into rural communities that
plex and labyrinthine health care system; physician leaders are hemorrhaging human and fiscal capital and immediately
of interdisciplinary health care teams; and physicians who improves medical access. If done well, these efforts improve
engage patients as equal partners in their own health care quality of health care, and if done with persistent commit-
outcomes within the context of family and community. ment they will improve the health metrics of the rural com-
munity in which this residency training occurs. Given the
Rural/Underserved Challenges and Opportunities access needs across the life spectrum and dearth of primary
Access to care is critical to health outcomes, an area in care physicians in these underserved regions, rural commu-
which the entire state has room for improvement. Of North nities provide an excellent opportunity for family medicine
Carolina’s 100 counties, all contain a geographic area or residents to reach these training goals whilst simultaneously
population designated as a health professional shortage providing for the common good of the state and its people.
area (HPSA) in primary care, mental health, oral health, or Work is already underway in North Carolina to provide
any combination thereof [10]. family medicine residents with longitudinal and immersive
This problem is amplified as one looks to rural areas rural training that not only exposes them to the unique chal-
throughout the state, and a major contributory factor is lenges and opportunities of practicing in resource-scarce
physician access [11–13]. Even though North Carolina is rap- rural environments—in which the residents can practice at
idly urbanizing, a significant percentage of people still live the top of their license—but also integrates them into the
in rural areas of the state; when compared to other states, fabric of the rural community in which the training occurs,
North Carolina has one of the largest rural populations [14]. making them part of and accountable to the rural commu-
Physician workforce analyses show that while 22% of North nity they serve. It should also be noted that as a whole, these
Carolina’s population lives in rural counties and 27% lives programs are few in number, small in class size, and rela-
in underserved counties with more than 2000 persons per tively new. Examples include community-based programs
PCP; only 18% of the family physicians in the state work in such as the MAHEC program in Boone or the Harnett Health
these counties [5]. As the largest component of the state’s program in Lillington, as well as community-based programs
primary care workforce, family medicine needs to improve with university affiliation such as the MAHEC program
upon current rural physician recruitment and retention in Hendersonville, the Duke Rural program in Oxford, the
efforts if we wish to remedy the urban-rural chasm in health Sampson Regional program in Clinton, the Campbell pro-
care access and subsequent outcomes. gram in Lumberton, or the ECU Health Rural Program with
Physician shortages and subsequent access issues in multiple sites in Ahoskie and Beulaville/Kenansville.
these rural areas are also exacerbated by attrition trends Thoughtful program implementation, engagement of
secondary to an aging physician workforce [11]. There are community partners and stakeholders, and community-
fewer and fewer young physicians moving into these rural focused curriculum design are crucial for the success of
areas to take the primary care helm left vacant by aging phy- these rural programs. In the ECU Health Rural program,
sicians exiting the rural workforce as they reach retirement residents have a MATCH number specific to their rural
age [14]. site, providing buy-in and affiliation to the rural clinical site
Further exacerbating this issue is the net out-migration and the rural community prior to the resident starting their
of rural county populations for more affluent urban centers training. The resident may do some rotations at the affili-
in the state in search of better socioeconomic opportunities ated tertiary academic center, but they belong to the rural
[15]. This decrease in overall rural county population tends site. In-depth analyses of the rural communities’ health care
to result in a population schism with bimodal distribution infrastructure and stakeholders were performed prior to the
174 NCMJ vol. 83, no. 3
ncmedicaljournal.comcreation of each program, allowing all parties involved to be directly or indirectly moved toward 2030 target goals by
have an impact on the design and implementation in order to investing in rural family medicine residency training in North
meet the unique needs of the rural community. Additionally, Carolina. Undoubtedly, other primary care specialties and
these analyses allowed us to be good stewards of health care medical subspecialties are important to a properly function-
resources and tax dollars through augmentation of existing ing health care system, but given that these other groups
infrastructure, rather than direct competition with existing each only provide care for specific subsets of a community’s
practices diligently working to meet the health care needs of population, they are less likely to be recruited to or retained
these underserved communities. within rural communities long term, and it is difficult for
The continuity clinics are based in rural federally quali- them to have the same impact, dollar for outcome, as a fam-
fied health centers (FQHCs), providing a robust volume of ily physician on the overall health of the entire community
patients across the life spectrum and, due to the nature of [18].
the population demographics served by these FQHCs, excel-
lent complex teaching cases and training opportunities while
NASEM Rationale for Implementing High-Quality
performing a public service. These FQHCs include Roanoke-
Primary Care
Chowan Community Health Center in Ahoskie and Goshen Over half of North Carolinians live in urban settings, with
Medical Center in Beulaville. Residents participate in con- the majority of the state’s 10.5 million people living in the
tinuity clinic weekly for all three years of training, with an greater metropolitan areas of Metrolina, the Triad, and the
increase in clinical days and clinical volume as they advance Triangle [19]. The majority of North Carolina’s family medi-
through the rigorous program. A concerted effort is made cine residency training programs (13 of 20) are also located
to have residents complete as many rotations in the rural in these urban areas (Figure 1) [20]. More importantly, these
environment as existing infrastructure and patient volumes urban programs tend to be larger and constitute the major-
will allow; and for teaching opportunities that cannot be ity of the family medicine residency positions available in
obtained in the rural environment, residents are brought to the state [20]. In fact, these urban training sites account for
Vidant Medical Center, the affiliated tertiary academic cen- 360 of the 447 family medicine residency positions in North
ter, to supplement their learning opportunities. Residents Carolina (almost 81% of the total available family medicine
then take these lessons learned in the tertiary setting and training positions) [20]. With this statistic in mind, atten-
bring them back to practice in the rural community they tion should be drawn to the fact that nearly a third of North
serve. Carolinians live in rural areas of the state, but only 19% of
family medicine residents are trained in these same rural
Healthy NC 2030 areas (Figure 2) [20]. Undoubtedly, this uneven distribution
Healthy NC 2030 is a public health initiative that seeks to of family medicine residents and the resources brought to
bridge health care disparities in North Carolina. This initia- bear to adequately train them contributes to health dispari-
tive brings together experts and leaders from multiple fields ties between urban and rural North Carolina and limits the
to inform the development of a common set of public health opportunities that rural communities have to meaningfully
indicators and targets for the state over next decade. There engage residents in hopes of recruiting and retaining them
are 21 health indicators in Healthy NC 2030, all of which can for their physician workforce.
figure 1.
Family Medicine Residency Training Programs in North Carolina
Source. AMA FREIDA website; Cline M, NC Office of State Budget and Management, Nov. 19, 2020; ResidencyProgramsList.com.
NCMJ vol. 83, no. 3 175
ncmedicaljournal.comfigure 2.
Distribution of Family Medicine Residency Positions in North Carolina
1200
1000
800
600
400
200
0
Urban Training Setting RuralTraining Setting
# of Family Medicine Residency Positions in Area Patient Population Served (in units of 10K people)
Source. Census Bureau; Cline M, NC Office of State Budget and Management, Nov. 19, 2020; ResidencyProgramsList.com.
Inequity in access to high-quality primary care (HQPC) information technology that serves the patient, family, and
disproportionately affects rural communities and results interprofessional care team; and 5) ensure that HQPC is
in unobtainable or uncoordinated care, thereby contribut- implemented in the United States [21].
ing to higher chronic disease burden, decreased preven- Per the NASEM, HQPC is a common good promoted by
tive care, and unsustainably high health care spending [21]. responsible public policy and supported by private-sec-
Additionally, there is evidence that physicians are more tor action. It begins by committing to paying primary care
likely to practice in the geographical area in which they com- more and differently due to its capacity to improve popu-
pleted residency, and this trend is reflected favorably in the lation health and health equity for society. The Centers for
specialty of family medicine [1, 2]. If the goal is to place phy- Medicare & Medicaid Services (CMS), state governments,
sicians practicing high-quality primary care in rural under- and the US Department of Health and Human Services
served areas and to retain those physicians in that HPSA should increase the overall portion of spending going to
over the long term, then it makes sense logistically and primary care, including continued support for COVID-era
financially to train residents in the areas in which you want changes that have facilitated integrated team-based care
them to practice after graduation. and enabled more equitable access to telephone and vir-
High-quality primary care is the foundation of the health tual visits. Sustained investment in new health centers, rural
care system; provides for continuous, person-centered, health clinics, and Indian health service facilities in areas
relationship-based care that considers the needs and pref- designated as HPSAs for primary care is also critical [21].
erences of individuals, families, and communities; and is Primary care practices should move toward a commu-
the only health care component whose increased supply is nity-oriented model. A component of this community ori-
associated with better population health and more equita- entation includes training interprofessional primary care
ble outcomes [21]. These are the aspirational goals of family teams where people live and work, particularly in areas that
medicine. are medically underserved or HPSAs. These teams should
In 2019, NASEM formed the Committee on Implementing reflect the demographic composition of the communities
High-Quality Primary Care. This committee examined the they serve. CMS, Veterans Affairs, the Health Resources
current state of primary care and built upon recommen- and Services Administration (HRSA), and state govern-
dations from the 1996 Institute of Medicine (IOM) report ments should redeploy or augment funding to support this
“Primary Care: America’s Health in a New Era” [21]. The interprofessional training in community-based primary care
committee set about creating an evidence-based plan with practices. HRSA funding for other health professions train-
actionable objectives and recommendations for implement- ing should also be increased and prioritized for interprofes-
ing HQPC in the United States, balancing national needs sional training (via Title VII and VIII) [21].
with scalable solutions that allow for adaptations to local Development of a workforce capable of delivering HQPC
needs. This plan included five implementation objectives will also require reshaping what is expected of training
to make HQPC available to all people living in the United programs and the clinical setting in which training occurs.
States: 1) pay for primary care teams to care for people, not Currently, funding for primary care training is inconsistent
doctors to deliver services; 2) ensure that HQPC is available and insufficient, with most training occurring in a hospital
to every individual and family in every community; 3) train setting rather than the communities in which most primary
primary care teams where people live and work; 4) design care takes place [21].
176 NCMJ vol. 83, no. 3
ncmedicaljournal.comConclusion 6. Raffoul M, Moore M, Kamerow D, Bazemore A. A primary care pan-
el size of 2500 is neither accurate nor reasonable. J Am Board Fam
North Carolina has a robust family medicine presence, Med. 2016;29(4): 496–499. doi: 10.3122/jabfm.2016.04.150317
7. AMA FREIDA. Program Results. AMA FREIDA website. Ac-
but there are identifiable areas in which we can improve cessed February 1, 2022. https://freida.ama-assn.org/search/
upon this rich history and tradition, particularly in service to list?spec=42736&loc=NC&page=1
rural and underserved areas in the state. North Carolina has 8. United States Census Bureau. State-to-State Migration Flows: 2019.
Revised October 8, 2021. February 1, 2022. https://www.census.
fertile ground for offering high-quality primary care train- gov/data/tables/time-series/demo/geographic-mobility/state-to-
ing in the communities in which our people live, and family state-migration.html
medicine promises a cornucopia of prevention, quality care, 9. Centers for Disease Control and Prevention. National Center for
Health Statistics. Fertility Rates by State. Updated January 19, 2022.
and overall well-being for its citizenry that is well aligned Accessed February 1, 2022. https://www.cdc.gov/nchs/pressroom/
with the goals and objectives of Healthy NC 2030 and the sosmap/fertility_rate/fertility_rates.htm
NASEM committee for implementing HQPC [22]. Work is 10. North Carolina Department of Health and Human Resources, Of-
fice of Rural Health. North Carolina Office of Rural Health Counties
already underway to this end, but additional and continued Designated Health Professional Shortage Areas. Data as of January
public and private investment is needed to effect long-term 01, 2021. Accessed February 24, 2022. https://www.ncdhhs.gov/
meaningful change in health care access and equity dispari- media/9374/open
11. Skinner L, Staiger DO, Auerbach DI, Buerhaus PI. Implications of an
ties between rural and urban areas of the state. aging rural physician workforce. N Engl J Med. 2019;381: 299–301.
doi: 10.1056/NEJMp1900808
Audy G. Whitman, MD, MS program director, ECU Health Rural Family 12. Singh GK, Siapush M. Widening rural-urban disparities in life ex-
Medicine Residency Program, Greenville, North Carolina. pectancy, U.S. 1969-2009. Am J Prev Med. 2014;46(2):e19–e29. doi:
Geniene N. Jones, MD site director and chief medical officer, ECU 10.1016/j.amepre.2013.10.017
Health Rural Family Medicine Residency Program and Roanoke Chowan 13. Singh GK, Siapush M. Widening rural-urban disparities in all-cause
Community Health Center, Ahoskie, North Carolina. mortality and mortality from major causes of death in the USA,
Danny Pate, MD site director, ECU Health Rural Family Medicine 1969-2009. J Urban Health. 2014;91(2):272–292. doi: 10.1007/
Residency Program, Beulaville, North Carolina. s11524-013-9847-2
Herb G. Garrison III, MD, MPH designated institutional official and vice 14. Garrison HG, Heck JE, Basnight LL. Optimal care for all: the criti-
president of medical affairs, ECU Health GME programs and ECU Health cal need for clinician retention in rural North Carolina. N C Med J.
Medical Center, Greenville, North Carolina. 2018;79(6):386–389. doi: 10.18043/ncm.79.6.386
Alyson Riddick, MHA director, ECU Health GME programs and Medical 15. Tippett R. One way to think about rural-urban interdependence.
Staff Support, Greenville, North Carolina. Carolina Demography. Published May 2, 2016. Accessed February
Kim Schwartz, MA, BCC chief executive officer, Roanoke Chowan 24, 2022. https://www.ncdemography.org/2016/05/02/one-way-
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Greg Bounds, PhD chief executive officer, Goshen Medical Center, 16. Coutinho AJ, Cochrane A, Stelter K, Phillips RL, Peterson LE. Com-
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Disclosure of interests. No interests were disclosured. 17. Peterson LE, Fang B, Puffer JC, Bazemore AW. Wide gap between
preparation and scope of practice of early career family physi-
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