Just north of Greenville, farmers in rural Henderson County grow 65 percent of all the apples in North Carolina — the seventh largest aggregate crop in the country.
The Ginger Golds and Pink Ladies, the Honey Crisps and more than a dozen other varieties peak on their own schedules from August through October, which is just to say that a lot of migrant apple pickers walk into the low-income clinic where Dr. Kari Koch works each fall.
“A lot of these migrants, they come back year after year,” she said.
Koch’s training makes her a good fit for the job. She attended Cuba’s Latin American Medical School in Havana — a program that offers free tuition and an extra year of Spanish language immersion to international students in exchange for a non-binding commitment to practice medicine in a rural or under-served community when they return to their own country after graduation.
Koch said free tuition was too good to pass up. She wanted to practice medicine in a small town, but balked at the student loan debt some of her friends already enrolled in American medical schools were facing.
“The amount of debt that they were managing was really incredible,” she said. “That debt can be really crippling.”
Medical school students typically borrow more than $150,000 in loans over four years — one reason why fewer of them apply to lower-paying, primary care positions in rural parts of the country after graduation. With such substantial debt, even some doctors who might prefer practicing medicine in a rural area feel they have little choice but to pursue careers in higher-paying sub-specialties. All this contributes to a doctor drain in South Carolina, where specialists abound in big cities, but primary care physicians are hard to find in rural counties.
Data published by the Office for Healthcare Workforce Analysis and Planning paints a stark picture. There are nine rural South Carolina counties without a single full-time pediatrician; 12 counties without an OB-GYN; and eight counties without either. Pediatrics, obstetrics and gynecology are considered primary care medical fields. Meanwhile, 1,800 specialists work in Charleston alone.
While some stateside experts doubt that the Cuban medical school model would work in South Carolina, Congresswoman Barbara Lee, a California Democrat, said at a Medical University of South Carolina forum last month that the American system needs to fix this student debt crisis.
“When you look at medical schools, they cost a heck of a lot of money,” said Lee, who visited the Cuban school last month. Doctors there don’t have to worry about that debt, she said. “They’re not saddled with thousands of dollars of debt and they receive a quality education.”
Nearly 100 American students are currently enrolled in the Latin American Medical School, Lee said.
A spokeswoman for the school said none of them are South Carolinians.
Dr. Chris Pelic is the associate chief of staff for education at the Charleston VA Medical Center and an MUSC professor. He agreed that free tuition is attractive, but he said student loan debt isn’t the only reason American medical school graduates tend to pass over rural jobs.
“A lot of students don’t want to live in a rural area,” he said. “You become accustomed to living in a certain-size city.”
Pelic said international medical school graduates are increasingly taking jobs that U.S. medical school graduates don’t want, especially in rural parts of the country. This happens, he said, partly because new U.S. doctors are considered more competitive candidates for residency slots at top urban hospitals. Medical schools in this country, which are accredited by the Liaison Committee on Medical Education, set a more stringent criteria for admission.
Koch, for example, didn’t have to take the MCAT to apply to the Latin American Medical School. “That’s not part of their requirements at all,” she said.
The test is considered an important component of medical school applications in this country.
The Latin American Medical School has been “evaluated and fully accredited” by the Medical Board of California, but not the Liaison Committee on Medical Education. Graduates of the Cuban program must pass the same exams to practice medicine in the United States as American medical school students.
Dr. David Garr is the executive director of the South Carolina Area Health Education Consortium. He agreed with Pelic that free tuition won’t solve the problem here.
In fact, one rural South Carolina county used to offer prospective medical school students free tuition in exchange for a commitment to practice medicine there after graduation. It didn’t work, Garr said.
Students too often changed their mind in the middle of medical school and had to repay the money.
“People start with good intentions and then, for whatever reason, they made decisions that were different than what they thought they were going to be,” Garr said.
Loan re-payment programs are more effective, he argued.
South Carolina now offers medical school graduates up to $25,000 a year for four years to practice medicine in an under-served or rural area. It may not cover their total debt, but Garr said the program is very popular.
“We have more people who want to participate in that program than we have funds,” he said.
Garr wants state lawmakers to invest more money in the loan repayment program. He also thinks medical schools should accept more students from rural parts of the state because they’re more likely to return to a small town after graduation.
Dr. Koch, who grew up in small towns in New Hampshire and eastern North Carolina, said rural western North Carolina seems like a natural fit.
“I like the rural aspect of it,” Koch said. “Both my husband and I are interested in living rural. We both grew up rural.”
Reach Lauren Sausser at 937-5598.