Healing Rural N.C., One Doctor At a Time

When Dr. Ahmed Ahmed clocks out after a 12-hour hospital shift in Lumberton, his work isn’t done.

At the grocery store, the gym, any time he’s out in the community, Ahmed fields questions from patients and their loved ones. Are colonoscopies really necessary? What does he think of this or that medication? 

As a third-year internal medicine resident at UNC Health Southeastern, Ahmed faces more challenges than 80-hour work weeks. Robeson is one of the poorest and least healthy counties in North Carolina, and like many rural areas, it does not have enough doctors to treat patients with disproportionate rates of diabetes and heart failure.

Ahmed, 37, attended medical school in Shenyang, China, and has lived all over the world. But he figured he could learn a lot and make a big impact practicing medicine in a rural area like southeastern North Carolina.

“As a rural physician, you definitely have to step up and try to cover some of the gaps,” Ahmed said, “because you can’t just tell the patient, ‘All right, go down the street and see a nutritionist.’ You have to do some of that work yourself.”

North Carolina hospitals and health systems have 402 accredited residency and fellowship programs in which doctors spend three to seven years in clinical training after completing medical school, according to the Accreditation Council for Graduate Medical Education. But only 10 are in rural areas, where nearly 3 million people live.

That’s less than in some states with similar rural populations. Pennsylvania and Ohio have 21 rural programs to train doctors to serve 3 million and 2.8 million people in rural communities, respectively, according to the Rural Residency Planning and Development Program and the U.S. Census Bureau.

North Carolina needs to nearly double its number of programs to obtain and retain enough doctors to adequately treat its rural population, according to the state’s five-year Rural Health Transformation Plan. State health officials want to add eight to 12 rural residency and fellowship programs by 2031. The increase could add 165 physicians in rural areas, said Emily Hawes, director of the North Carolina Graduate Medical Education Technical Assistance Center (NCGME) and a clinical pharmacist in Boone. The center helps health care organizations throughout the state build and expand residency programs, connecting them to funding sources and technical training.

The state program is funded through the federal Centers for Medicare & Medicaid Services’ Rural Health Transformation Program, which was created under the One Big Beautiful Bill Act that President Donald Trump signed into law last summer. Congress added the five-year, $50 billion program to the legislation to appease the bill’s Republican holdouts, including Sen. Thom Tillis from North Carolina, who said the bill’s deep cuts to Medicaid would gut rural health care. 

North Carolina received $213 million from the Rural Health Transformation Program this year, the 10th largest amount in the nation. State officials have yet to specify how much funding will go to creating new rural residency programs. The state also plans to use the money to establish more certified community behavioral health clinics, increase access to virtual health care for rural residents, and build capacity at rural hospitals and clinics.

“The funding will help us think about how we create sustainable change in these communities where oftentimes access is the biggest problem,” N.C. Health and Human Services Secretary Dev Sangvai said at a virtual town hall last month. “This is really a once-in-a-lifetime opportunity to transform health care in North Carolina.”

No Lack of Interest

Ahmed saw how poor access to health care affected his younger sister during part of his childhood spent in rural eastern Africa. His sister couldn’t readily get treatment for her Type 1 diabetes. So he dedicated himself to practicing medicine.

“I thought, ‘I can actually do this myself,’” Ahmed said. “I can become a doctor and help the people I care about, and also people who are in the same circumstances in terms of having poor access to care.’”

After living and traveling in China, Egypt, India, Saudi Arabia, and Illinois, Ahmed began working as a medical scribe at UNC Health Rex in Raleigh. He applied to UNC Health Southeastern’s internal medicine residency program because he wanted to treat a range of conditions and work with patients with limited access to preventative care.

It can be tough to recruit physicians to rural areas because of lower pay and fewer available resources, according to the National Rural Health Association. But plenty of doctors are interested in rural residency programs, Hawes said.

Nearly 100% of the state’s rural residency positions are filled every year, according to Hawes. She said the problem is that there aren’t enough slots; 165 of the state’s 3,700 current residency positions, or about 4%, are in rural areas. 

It can cost up to $1 million to create a new residency program, according to Lori Rodefeld, NCGME’s graduate medical education and policy adviser. The price tag is out of reach for many rural hospitals, which are more likely to have negative operating margins than their urban counterparts, according to an analysis by KFF, a nonprofit health policy research organization. 

“We don’t have as many residencies in this state because there has been limited startup funding given to rural health facilities for that purpose,” Hawes said.

Medicare is the largest federal funder of graduate medical education, according to the U.S. Government Accountability Office. The health care program funded 2,343 resident positions in North Carolina as of 2022, according to the American Association of Medical Colleges. Congress sets caps on how much Medicare funding each teaching hospital receives to cover those costs. Health organizations that start their first residency programs have five years before a cap on funded positions is set.

“With the limited federal funding, there has been really no way to grow more programs,” Rodefeld said.

North Carolina already provides money to residency programs through the University of North Carolina System’s Rural Residency Medical Education and Training Fund, which offers $8 million annually to help hospitals start, maintain, and expand programs.

Expanding rural-based residency programs “is a proven strategy to increase rural provider retention,” North Carolina health officials wrote in the state’s Rural Health Transformation Plan. More than 50% of family physicians in rural residency programs choose to continue practicing there, according to a 2023 survey. 

Ahmed is one of them. He’s already accepted a position as a hospitalist at UNC Health Southeastern after he completes his final months of residency.

“I want to have an impact,” Ahmed said, “helping the people who really need my help.”

‘Untapped Opportunities’

Hawes said that NCGME has already identified about 20 rural hospitals to engage in general surgery training and 30 for an obstetrics program. The new programs are critical, she said, given that 25 of the state’s 100 counties have no practicing general surgeon and 27 have no practicing OB-GYN. 

“Our research shows there are untapped opportunities to increase rural physician training,” she said, but added that a local physician is often necessary to champion the effort.

That’s what it took to establish a family residency program in Boone, said Dr. Bryan Hodge, chief academic officer for Mountain Area Health Education Center (MAHEC).

On a Friday evening in 2019, Hodge got a drink with Dr. Charlie Baker, a family physician who has delivered more than 2,000 babies in Avery County. 

Baker asked Hodge what he thought about the prospect of a new residency program, not realizing that Hodge was part of the startup efforts. After Hodge explained how the program could build the local health care workforce, Baker helped get buy-in from the rest of the local medical community.

“He was so known and trusted that he said, ‘Hey, we’re going to build this, and we think we really have something to offer learners that will result in us having a workforce for the future,’” Hodge said.

The state’s plan to develop new residency programs “will be community-driven and regionally tailored,” said Summer Tonizzo, a spokesperson for the N.C. Department of Health and Human Services. She said the state will establish six Rural Organizations Orchestrating Transformation for Sustainability Hubs, or NC ROOTS Hubs.

Boone’s program is adding more specialties, including rural psychiatry and surgery programs at local hospitals. Avery County has only five psychiatrists and one general surgeon to serve more than 17,000 people, according to 2024 data from the North Carolina Health Professions Data System.

“This isn’t an academic exercise, and we’re not looking for academic prestige here,” Hodge said. “We’re actually talking about making North Carolina healthier through education.”

‘Quick Wins’

State health officials are focused on establishing the NC ROOTS Hubs and achieving “some quick wins” in the first year of the Rural Health Transformation Program, state Deputy Secretary for Health Debra Farrington said at the town hall. The Centers for Medicare and Medicaid will determine future funding based on states’ progress toward meeting the goals set out in the transformation plan.

“Year-one successes are vitally important,” Farrington said. “So we want to make sure that we identify and implement initiatives that deliver immediate, visible benefits to our communities.”

Establishing a new residency can take three to five years, Hawes said. The accreditation process with the American College of Graduate Medical Association can take up to two years, according to the association’s website. It takes less time to expand programs or build a program from existing infrastructure, Hawes said.

In its initial transformation plan, the state said it needs $136 million over the next five years to accomplish its workforce development goals, which include creating new rural residency programs. State health officials submitted a budget to the Centers for Medicaid and Medicare for the first-year allocation on January 30. Tonizzo said more information will be provided once the updates are approved by the Centers for Medicaid and Medicare.

Ahmed is eager to see more people enter rural medicine. Practicing in Lumberton has made him a better physician, he said. He’s had to do more with less while learning procedures he would never have a chance to do at a larger hospital with specialized care teams.

“You get to push yourself and try to explore more, not just the baseline of what is expected of you,” Ahmed said. “You have to push further in order to offer more, because you need to offer more in this type of setting.”

Ahmed said he wants to provide the highest quality of care to a community he now calls home.“I think rural physicians—all of us who make an effort to do this—that’s a big driving force.”