For at least five years, there was no doctor in Summerton.
Dale Barwick, a nurse practitioner who was considering moving to the area, stopped by the small town's pharmacy to ask where the physicians went. One lost his license. Another worked at a clinic that moved locations. The last went out of business.
The pharmacy owner offered her a lease at the building he owned next door, and Barwick set out to set up her own primary care practice there.
But first, she needed to find a way to adhere to a South Carolina law that requires her to contract with supervising physician within 45 miles of her Clarendon County practice. The law also states each doctor can be a "preceptor" for only three nurses.
Critics say the law is outdated and bars the nurse practitioners, who might provide primary care in rural areas that lack providers, from setting up practices. Nursing groups have tried time and again to change the law, which has already been done in many other states.
But with Gov. Henry McMaster's support this year, they hope this legislative session will be different.
Sen. Tom Davis, a Beaufort Republican, is the sponsor of a bill that would lift some of those restrictions. He said nurse practitioners' education level has increased since the laws were written.
"There’s no reason why nurses shouldn’t be allowed to provide health care services they are qualified to provide," Davis said.
Brian Symmes, spokesman for the governor's office, said McMaster would sign Davis' bill into law out of concern for the health of South Carolinians living in rural parts of the state.
"The governor is committed to removing obstacles that prevent health care professionals from providing services," Symmes said in a statement.
Barwick said she asked about 20 doctors to serve as a preceptor for her Summerton practice before one, in nearby Sumter, finally agreed. She opened her office in January 2017.
The existing law requires her to meet her preceptor at his office once a week as he opens his doors, and he signs the needed paperwork. Barwick said both she and the physician find the arrangement ridiculous. For Barwick, the threat lies in the possibility of the doctor moving or deciding he doesn't want to take on her liability anymore.
"I would be in an untenable situation," she said.
Barwick has 533 patients. She treats them for the difficult chronic issues they developed, in part, because they had no primary care provider.
Joseph Ellison is one of her patients. Ellison said he struggles with paranoia. He also lost both of his legs from frostbite during a blizzard in New York in 1993. He stopped by Barwick's office Wednesday to ask for two Tylenol and some paperwork. He sees Barwick regularly for checkups, and said he likes her even better than many of the doctors who have treated him.
"She's different," Ellison said. "She seems to be more intelligent."
Some patients told Barwick before she came to town, they would go to the emergency room just to refill their blood pressure medication.
The low-income Medicaid program covered more than 25,000 visits to emergency rooms for varying kinds of upper respiratory infections in 2016. The agency paid about $4.6 million for those claims in a single year. Some of those cases likely warranted a trip to the hospital, but many of these patients probably could have been treated in a primary care setting. Nurse practitioners argue they can do this for a fraction of the cost.
There were 1,920 family practice doctors in South Carolina in 2016, according to the state's Office for Healthcare Workforce. There were about 2,036 nurse practitioners.
But 19 of South Carolina's 46 counties have 10 or fewer family doctors. Seven counties have less than five. Calhoun County lacks any type of doctor at all.
Nurse practitioners often point to this shortage when they argue that the state law should be changed.
But there are groups that disagree with them.
The South Carolina Hospital Association offered restrained support for the nurses. A spokesman said the group supports expanding the number of nurses a physician can supervise, but qualified the statement by saying the physician should remain "head of the team."
Meanwhile, some physicians argue that medical professionals with a nursing degree are ill-equipped to practice health care on their own. The South Carolina Medical Association's position has long been that doctors, with their more advanced degrees, are the only people who can deliver the quality of care patients should expect.
"The SCMA remains committed to protecting the patients of South Carolina from those who seek clinical privileges through legislation instead of education," a position statement on their website states.
Barwick said she felt nurses should work in a doctor's office before striking out on their own. At this point, she said there is very little she hasn't seen before. And she said she would refer a patient to a doctor if she needed to.
There is also the issue of money. Nurse practitioners who operate their own practice are sometimes charged $1,000 or more by doctors serving as preceptors. On top of this, nurse practitioner Gaye Douglas said she also paid thousands annually in malpractice insurance for her doctor.
Douglas had to close her health center in Johnsonville for six weeks at one point because her preceptor was suspended by the state's medical licensing board. She had 3,000 patients during the seven years the center was open, she said. Douglas scrambled, and eventually found another physician to take her on.
She said the clinic in rural Florence County became financially unsustainable. She was forced to close in 2013.
"We never seemed to get back up and going again," Douglas said.