Filling a Prescription for more Physicians
Water drips at his feet on black-and-white mosaic tile the size of checkers. The smell of fresh paint hangs in the dampness from the downpour outside, and Jim Roberts’ voice echoes in the empty lobby. He gestures at the art deco floor. “When we ripped out the old carpet, this is what we found.” A large, affable man, he could pass as the football coach of the Fighting Camels as easily as what he is, Campbell University’s vice president for business. Renovators wanted to rip out the floor. “I said, ‘Wait a minute. This is one of our oldest buildings, built in the ’20s. No sir, we’re going to leave it.’”
In August, 32 students will begin filing into this 85-year-old building for daily lectures and to pore over bodies in anatomy classes. The inaugural class of physician assistants, a milestone in itself at this school in the state’s rural heartland, is a warm-up for a bigger act. In 2013, Campbell will open North Carolina’s fifth medical school. It’s a bold, $60 million move for a Baptist school that boasts that a larger percentage of its 9,400 students are from North Carolina than any other university in the state. Some 3,900 are on its main campus in Buies Creek, a Harnett County hamlet that relinquished its status as a town in 1967. The medical school will be there. “Buies Creek is Campbell University,” says Britt Davis, vice president for institutional development.
Administrators say the medical school is another example of the university’s focus on professional education that began in 1976 with its law school, now housed in a renovated, $30 million complex in downtown Raleigh. In 1983, Campbell opened its Lundy-Fetterman School of Business. Its pharmacy school, opened in 1985, moved it into the main channel of North Carolina health-sciences education. Its beginning class of 150 would put the medical school on track to become the second largest in North Carolina, eclipsing those at Duke University, Wake Forest University and East Carolina University and behind only UNC Chapel Hill. The university is considering dental, rehabilitation and nursing schools, too.
Aside from swelling medical academia, the med school could become a crucial bridge in a state where patients have access to some of the best medical care in the world — or die struggling to reach it from isolated counties that have few or no doctors. The N.C. Medical Board lists three with none: Hyde, Camden and Tyrrell. Five others have fewer than six. Campbell will recruit students from medically underserved regions, train them with emphasis on primary-care and family medicine, then steer them back home. “When you look at the increase in population, the aging of the physician population in general and the fact that so many physicians go into specialties rather than primary care, it was obvious there was a need for another school,” Campbell President Jerry Wallace says.
If the need for more frontline practitioners is a sure thing, Campbell’s medical school is nevertheless a multimillion-dollar gamble. It assumes that more than a century of internecine rivalry within medicine has abated — and that the medical teachings of a frontier physician who vowed reform after three of his children died from meningitis will become as widely accepted as those descended from traditional doctors, whose failings he blamed for their deaths.
Campbell’s physicians will be trained in osteopathic medicine and have D.O., doctor of osteopathy, after their names rather than M.D., doctor of medicine. Like M.D.s, they will get four years of medical school, followed by three or more years of residency training. Their credentials will be accepted in all states, and they’ll be licensed by the N.C. Medical Board and become side-by-side members with M.D.s in the North Carolina Medical Society and North Carolina Academy of Family Physicians. Osteopaths are common in the military. In some states, including Michigan and Oklahoma, one doctor in four is a D.O.
However, they’re rare in North Carolina, where only about 3.5% of Tar Heel physicians — 811 of the 22,881 practicing in the state last Dec. 31 — are doctors of osteopathic medicine. They have struggled for decades to achieve equal standing with M.D.s in a profession in which turf is protected and title is coveted. Though most of their practices and procedures are identical, D.O.s emphasize primary care and holistic medicine. “I treat the patient, not the disease,” says Anthony Elkins, one who practices family medicine in Charlotte. But D.O.s also train in manipulation of the muscles and skeleton, which often results in their being confused with chiropractors.
Drive 3½ hours westward from Buies Creek, mostly through rolling farmland and forests, to a Main Street family-medicine clinic in the small Gaston County town of Cherryville. Here, for 33 years, Dr. George Bradley has helped lead osteopathic physicians’ fight for equal status in North Carolina. “I came at a time when there were 66 D.O.s in the state, and the medical board was just waiting for us to die off,” Bradley, 69, says. “I was 13 years out of medical school — I’ve been practicing 43 years now — but I had to take a special exam just to get my license.”
In Wilmington, Barbara Walker, Campbell’s commencement speaker in May and an osteopathic family practitioner, encountered similar skepticism. “The organized medical community, because of its strength of numbers, was able to build on prejudices,” she says, shaking off sleepiness after delivering a baby the night before. M.D.s, for example, often considered osteopathic medicine less sophisticated than theirs and D.O.s intellectually inferior. Walker, now director of Osteopathic Medical Education at New Hanover Regional Medical Center, was the first woman Army doctor deployed in combat with Fort Bragg’s 82nd Airborne Division in the early ’90s. “Osteopathic physicians never had the massive numbers to go out and promote themselves.”
Over the course of his career, Bradley saw acceptance of osteopathic medicine grow. He went on to be appointed to several medical commissions by former Gov. Jim Martin, was elected a Gaston County commissioner and served as physician to the General Assembly. But his early treatment still stings. In the ’80s, an osteopathic-medicine student interning with him was laughed at when she applied for an internship at Carolinas Medical Center in Charlotte. Bradley threatened to refer his patients elsewhere. “I called them up and said, ‘Do you realize that the patient that I sent over there for a heart transplant was the first you ever did from this area?’” Carolinas Medical Center now has 28 D.O.s out of a total of 1,712 physicians on staff. At rival Presbyterian Hospital in Charlotte, about 15 of its approximately 400 doctors are osteopathic physicians.
In the president’s office at Campbell, Wallace relates his first encounter with a doctor of osteopathic medicine, in Rocky Mount. His son injured his shoulder, which required surgery. “I said, ‘Your doctor is a nice young man. I saw D.O. after his name. Is he an orthopedic specialist?’ It’s been a learning curve for me.”
The quiet is striking. On a bright spring afternoon, only scattered hikers wind through holly and pine to reach sheer cliffs overhanging the Cape Fear River, north of Buies Creek at Raven Rock State Park. The river was busier in the 1700s and 1800s, when bateaus carried waterborne commerce inland. If the boatmen or passengers became sick, remedies included arsenic, sugar mixed with kerosene and castor-oil purges. “If a woman had a fever after childbirth, which indicated pelvic infection, it was common for the doctor to bleed several quarts of blood from her,” Walker says. Already weak, the mother often died. The doctors were M.D.s.
In a small conference room at Campbell the next day, John Kaufmann, an osteopathic physician who is the medical school’s founding dean, retraces the period. He describes how Andrew Taylor Still, the founder of osteopathic medicine, was born in a log cabin in western Virginia in 1828. His father was a minister and doctor, and, like him, Still became an M.D. His own dead children, he believed, had been failed by the kind of primitive medicine the Cape Fear’s boatmen would have experienced. He drew the battle lines between osteopathic and allopathic — conventional — medicine.
Still taught that doctors should give equal attention to preventing disease, rather than waiting for patients to become ill and treating them. He taught that medications, when possible, should augment the body’s ability to heal as well as battle its diseases. Muscles and skeletal parts not only facilitate movement, he preached, but can be coaxed to combat disease and promote wellness — a practice called osteopathic manipulation. “We look at the patient’s body, mind and spirit,” Kaufmann says. “Osteopathic medicine is hands-on, caring for the whole person and the whole family.”
Traditionally, M.D.s tried to enforce the small differences between themselves and D.O.s, says Stephen Shannon, an osteopathic physician and president of the Chevy Chase, Md.-based American Association of Osteopathic Medical Schools. “In the late 19th century and early 20th century as medicine became more regulated, D.O.s had to obtain licensing and practice approval state by state. There were political issues. D.O.s had their own colleges, residency systems and own hospitals. There’s been a lot more integration in health care. Most residency programs are now dual, with M.D.s and D.O.s training together. The differences have mostly disappeared.”
Walker says osteopaths organized their own medical association in North Carolina in 1904. In 1916, they were given equal status with M.D.s by the federal government and, in 1966, were accepted as physicians and surgeons by the military as the Vietnam War heated up. As they gained in numbers and popularity with patients, arcane disagreements over medical methodology began to blur with economic issues — turf guarding.
In the early ’60s, the M.D.-dominated American Medical Association had spent about $7 million promoting a California ballot referendum to forbid doctors of osteopathic medicine from practicing there, insisting that they were unqualified. The AMA muscled the University of California at Irvine College of Osteopathic Medicine into converting to an M.D. school and forced osteopathic physicians to obtain M.D. degrees, which they could do by paying a nominal fee of less than $100.
After patients protested, the AMA reversed its stance in 1969, welcoming D.O.s as members. North Carolina began issuing licenses to D.O.s in the ’60s, but officials of the North Carolina Osteopathic Medicine Association say it was not until the ’90s that Tar Heel D.O.s seamlessly merged with M.D.s. Bradley, the first osteopath appointed a county medical examiner in the state, pushed for their acceptance in the North Carolina Medical Society. “A lot of D.O.s took the attitude that I was a turncoat, because I got involved with the Medical Society. But they found out we put our pants on the same way they do.”
The remaining major difference is the cornerstone of Campbell’s new medical school, and it could have sweeping implications for Tar Heels hundreds of miles from its quiet midlands campus. Kaufmann holds up a map of North Carolina. Large urban centers — Charlotte, Raleigh, Greensboro and others — are splotches of color and symbols. Vast regions of the state are blank or nearly so. The dots mark doctor distribution. “Doctors of osteopathic medicine largely go into primary care. About 50% do. Others might be brain surgeons, cardiologists, plastic surgeons or whatever, but the emphasis is on family medicine in rural, medically underserved areas.” Harnett County, with a population of about 120,000, has fewer than 60 doctors, about one per 2,000 residents. In Mecklenburg, more than 2,700 doctors tend about 920,000 residents, one per 340.
“Campbell’s medical school,” Kaufmann says, “will be in the middle of all three of those things — rural, medically underserved and a physician-shortage area.”
Magnolia trees have their deep-green spring sheen as students queue to order class rings. Orange-and-black “CU” flags flutter along brick-paved walkways. They teach history here, but they live it, too. In his office, Wallace, a Rockingham native and minister, speaks with the undulating grace of the pulpit and unrelenting zeal of an evangelist about Campbell’s past and future.
In 1887, Baptist preacher James Archibald Campbell founded what was initially Buies Creek Academy for poor students. Wallace, appointed in 2003, is only the fourth president. His more relevant history dates to the 1960s and East Carolina University in Greenville. As an undergraduate there, he knew ECU’s president, an ex-Marine who believed that the lack of medical care in poor, rural eastern North Carolina was a disgrace. Leo Jenkins’ campaign, which led to the creation of the last medical school established in North Carolina, split the state politically and left a legacy of bitterness and envy that simmers today in many medical circles, particularly in Charlotte. Some doctors still refuse to refer patients there for advanced treatment. Are Wallace and Campbell flirting with a similar reception?
Even officials of Campbell’s nearest potential rival — the legislation that created what is now ECU’s Brody School of Medicine mandated that it concentrate on training primary-care doctors — praise the plan. “I worked side-by-side with D.O.s for 20 years in the Army, and they’re a welcome addition,” says Kenneth Steinweg, chairman of ECU’s Department of Family Medicine. “Campbell, being a private school, is not seen as direct competition, particularly in places like Charlotte, and the terrible demographics of eastern North Carolina that Dr. Jenkins worried about still exist.”
“There was resistance when we created our law school, and there was resistance to our pharmacy school,” Wallace says. “But how can anybody say there isn’t a need for more primary-care doctors in the state?” In Raleigh, Gregory Griggs, executive vice president of the 2,900-member North Carolina Academy of Family Physicians, says the gap is widening. “If our growth line for family physicians continues through 2020, we’re going to have about 3,500 in the state, but we’ll need 4,500 to 5,000. That’s about when Campbell’s first graduates would begin coming online. We’re very supportive of them.”
There’s no shortage of students to fill the breach. While schools compete for athletes, potential medical students compete for schools. Davis, Campbell’s development director, says the four medical schools in the state accepted 458 — about 3% — of the 17,000 who applied last fall. And that, Kaufmann says, allays one concern that he and others here have — that Campbell’s school will be viewed as taking students not good enough to make it elsewhere. “We know that’s in people’s minds. But it’s certainly a misperception.”
For one thing, with the flood of applicants, only a fraction of a grade point — often statistically meaningless — determines whether a student is accepted. For another, Campbell will recruit heavily in underserved counties and expects to attract students who make osteopathic and primary-care medicine their first choice. “We’re hoping people will come here because of our holistic philosophy and our focus on strong preventive and family medicine.” Four years ago, the North Carolina Institute of Medicine, created by legislators to conduct nonpartisan studies of state health-care needs, might have unwittingly given Campbell its strongest selling point. In a little-noticed report, it urged the General Assembly to create “a new public allopathic or osteopathic medical school,” giving osteopathic medicine equal billing. If neither materialized, the study recommended the state subsidize students who attended osteopathic or allopathic schools elsewhere if they return to practice in North Carolina. Campbell is responding not only to a social need, but it’s doing it with a market-driven approach that can hoist the school’s status without rupturing its coffers.
Jalapeños appear to be a staple in the Campbell cafeteria, where students bury their faces in pepper-laced subs and class notebooks at midday. Roberts, who also serves as Campbell’s treasurer, picks a table, but instead of food, he talks about creating and running medical schools. Starting this summer, 91,000 square feet sheathed in brick and glass will rise on a 20-acre intramural-sports field across U.S. 421 from the main campus. “It’s on a hill, and it’ll be open, with light streaming out. As they say, ’Light of the earth, salt of the world.’”
The school, designed by Charlotte-based Little Diversified Architectural Consulting Inc., will cost $30 million to build and $30 million to equip and furnish, financed from a small amount of bonds, about $15 million of fundraising and loans from the university to itself from its strong balance sheet. It would cost a minimum of $160 million to start an allopathic-medicine school, and those financial figures reflect some inherent differences between D.O.s and M.D.s. With osteopathic medicine’s focus on primary care and family medicine in rural, underserved counties, Campbell won’t need to build a large teaching hospital for students to gain bedside experience.
Kaufmann and Ronald Maddox, vice president for health programs, say Campbell has tentative agreements and contacts to send students to clinics, hospitals and health systems such as Southeastern Regional Medical Center in Lumberton, a 337-bed hospital in Robeson County, one of the state’s poorest; WakeMed Health & Hospitals Inc., based in Raleigh with numerous clinics in rural and suburban Wake County; Cape Fear Valley Health System Inc. in Fayetteville; Dunn-based Harnett Health System Inc.; and others.
The medical school will be a booster shot not only for Campbell’s prestige but also its enrollment. “When you open a school of medicine, you attract undergraduates in premedical majors,” Roberts says. “Our pharmacy school attracts 400 to 500 undergraduate students a year in biology, chemistry and research studies.” There’s also its impact on the surrounding economy: A study by N.C. State University economist Michael Walden estimates the school will directly and indirectly create 1,100 jobs and pump $300 million into the region in 10 years.
But the school faces challenges. One is attracting students from poor places to the most expensive form of education: medicine. Tuition hasn’t been set, Roberts says, but likely will mirror that at other private medical schools in the state, which charge $150,000 to $200,000 for four years. Students will rely on grants, scholarships, a $5,000 annual state stipend for those who agree to practice in North Carolina and other sources. But future doctors facing such debt might be reluctant to choose primary-care and family medicine.
Primary-care physicians “are on the low end of the medical scale,” says Griggs, who heads the Academy of Family Physicians in Raleigh. Family practitioners in the Southeast earned a median $179,000 in 2009, compared with, for example, invasive cardiologists who earned $465,000, according to a spokeswoman for the Englewood, Colo.-based Medical Group Management Association. “When you have people graduating from medical school with $200,000 in debt,” Griggs says, “that’s a real hindrance.”
In the soft light of his office, Wallace turns on his pulpit voice. “No one,” he says, palms upturned, “can deny the need for more primary care. It’s a critical need, not only in North Carolina but the nation. And no one doubts Campbell can do it. We’ve been successful in professional education, with our law school, our business school, our divinity school and our pharmacy school. People know we’re not blowing smoke.” A third of Campbell freshmen this year are the first from their families to attend college. “When a person from a first-generation family graduates from college, it’s a miracle. This is consistent with our mission as a Christian school. That’s why we exist.” He expects to lure more, from places bypassed by mainstream medical care, and send them back home as doctors. Andrew Taylor Still, he says, would approve.