Every problem in rural healthcare eventually comes back to the same question: who is going to do the work?
There are not enough doctors, nurses, dental hygienists, or medical assistants in the mountains of western North Carolina — and recruiting people from outside the region has not closed the gap. The answer the region keeps coming back to is simpler, and harder: grow your own.
In the finale of WNCW's "More to the Story" series on rural healthcare access, host Dylan Henson sits down with Dr. Bryan Hodge, chief academic officer at MAHEC — the Mountain Area Health Education Center — along with Dr. Susan Mims, CEO of Dogwood Health Trust, and Maggie Sauer, director of the state's Office of Rural Health, to talk about a shrinking workforce and a region trying to build its own way out.
Dr. Bryan Hodge has been a family physician for 22 years. He runs the academic programs at MAHEC in Asheville, but he has never stopped seeing patients in Hendersonville. Staying in practice, he says, keeps him grounded in the real problems his programs are trying to solve.
"I stay in practice so I can not only get a better sense of what the real issues are in our communities, but hear from the sources directly," Hodge said. "To make good decisions, you really have to be proximal to the real issues."
Some of his patients have been with him for more than 15 years. Research backs up what that continuity is worth. "There are statistics that will show that if you've had a primary care provider for more than ten years, you have better health outcomes," he said.
Sometimes that relationship shows up in dramatic ways. Hodge described walking into his waiting room to find a patient who had collapsed — someone who waited rather than go to the emergency room, because they wanted to see him first. He has put oxygen on patients in his own waiting room and called EMS himself.
The absence of that kind of trust, he says, is part of what is killing rural communities. People in rural areas live one to two years less than their urban counterparts, and Hodge traces much of that gap to the scarcity of accessible primary care. The problem is not simply a provider shortage — it is a distribution problem. "Many times we actually probably have enough healthcare professionals that we could better take care of our total population," he said. "We're just putting them in the wrong places. When we put them more than 15 minutes away from people, then it becomes an inconvenience."
For people without insurance — or with deductibles they cannot afford to meet — even a nearby provider can feel out of reach. "Our systems are fundamentally letting them down," Hodge said. "Somehow we've agreed it's acceptable for people to question whether or not they should seek help when they're worried about their health."
Sauer, who leads North Carolina's Office of Rural Health — the first such office in the nation — says the workforce shortage does not start with a lack of interested people. It starts with barriers that look nothing like healthcare problems. "When people are trying to get trained, if they don't have childcare, that restricts their ability to actually go in and fill some of those positions," she said. "And if you don't have the right supports around mental health and substance use, then you're narrowing your workforce."
Mims and Dogwood Health Trust have made the grow-your-own strategy the center of their workforce investment — starting with teenagers. "Working with Polk County Schools, we have funded a project to increase health science career and technical education," Mims said. "They have increased credentials nearly 60 percent in the last year."
When students train in the region, they are more likely to stay. Mims pointed to Blue Ridge Community College's Licensed Practical Nurse program as a proof point: 20 students a year, a 100 percent licensure rate, and graduates likely to remain in western North Carolina. Dental care is another critical gap. Dogwood is investing in students at three community colleges in the region, building the pipeline of future dental assistants and hygienists.
For physicians, the pipeline runs through residency — the years of clinical training after medical school. MAHEC has been building that pipeline since 1974, when it launched the region's first family medicine residency on a single premise: train people where there is need, and they will stay.
The numbers are striking. MAHEC represents just two percent of residency programs across North Carolina, but accounts for 17 percent of the state's rural healthcare workforce. "We represent only 2 percent of the residency programs — but we account for 17 percent of the rural North Carolina workforce by what we produce," Hodge said.
For this series, WNCW requested interviews with the region's major hospital systems. Spartanburg Regional, Prisma Health, and Atrium Health did not respond. Mission Health — the region's largest system, owned by HCA Healthcare — did not make anyone available for an interview, but a spokesperson provided a written statement. In it, Mission says the hospital recently invested more than $10 million in additional pay increases and exceeded its goal of hiring 90 medical-surgical nurses in 90 days. Mission also points to a paid-to-learn pipeline — medical assistant and nursing assistant programs where students earn a paycheck while they train — and says it remains a major clinical training site for MAHEC, helping prepare more than 230 residents and fellows. The system recently opened a $5 million simulation and training center and has received state approval to add 95 inpatient beds at its Asheville campus.
A federal initiative called the Rural Health Transformation Program is now adding resources to the region's efforts. Sauer said workforce development is at the center of North Carolina's plan. "It's going to take people sort of holding hands from high school, to community college, to other kinds of training opportunities, so that people feel like they can participate, be supported — and then stay in the community," she said.
Hodge said the program has given him more optimism than he has felt in years. "We have all sorts of data that shows if we have more primary care providers in rural areas, we're going to have better health outcomes," he said. "We really just haven't had the will, the strength, the courage to invest in these things. We've got to have the will to work together and make it happen."
Mims has watched western North Carolina up close — through the storm, and through everything since. Asked what gives her hope, she did not hesitate.
"What gives me hope is what I see every day in our communities — the connection and creativity that happens when people who really know their place, and understand the needs of their communities, come together," she said.
This is part three of More to the Story's series on rural healthcare access in western North Carolina. Part one examined emergency response and hospital finances. Part two looked at transportation, social determinants of health, and the cost of care.
