On paper, Hoke County is the portrait of a medically underserved rural community, with a ratio of just one primary care doctor per 16,000 residents, compared with a state average of about 1 to 1,500, according to a 2015 county health care assessment.
Almost a fifth of the county’s more than 50,000 residents live in poverty, according to 2015 census estimates, and about the same percentage are uninsured.
But Hoke also has a secret weapon as it fights common health woes such as diabetes and heart disease – Dr. Karen Smith, a family doctor over the past 24 years whose Raeford-based practice has earned national accolades for its innovative approach to patient health.
Smith was recently named the national Family Physician of the Year for 2017, thanks in large part to her innovative use of technology and preventive care to maintain the health of her large patient base.
But Smith also practices the mainstays of the rural family doctor, calling her practice “high touch and high tech.” She makes house visits in her pickup truck to those who can’t travel and sits by the bedside of the dying. She knows her patients by name.
She’s active in promoting her community’s health in other ways, working with hospitals, encouraging students to enter family medicine and coaching her community on health habits.
Greg Griggs, vice president of the N.C. Academy of Family Physicians, calls Smith a “superstar” among family doctors who works toward the health of her community both in and out of her office.
He recalls a radio show on healthy eating where she counseled residents to try grilling fish instead of frying it, as well as computer training her office has held to be sure patients can access their medical records.
“She looks at her patient care beyond the walls of her practice, and she is so embedded in her community,” says Griggs. “It’s still an underserved community, but if you pulled that practice out of there, they would be in real trouble.”
Drawn to Duke
Smith grew up in Maryland, in a small and diverse community she says was quite similar to Hoke County. She was drawn south for college largely by the area’s reputation for college basketball. At the time, Duke University’s star was Vince Taylor, and once she visited, she fell in love with the Sarah P. Duke Gardens.
She graduated from Duke with a biology degree in 1984. Itching to move back north, she went to medical school at Hahnemann University in Philadelphia.
But she missed North Carolina and ended up doing her residency in Fayetteville, where she served a community of military families based at Fort Bragg. She jokes that being single at the time, she thought the male-to-female ratio was ideal; in fact, she met her husband of more than 20 years there.
She was among a small team of doctors, with the scant six residents at the Cape Fear Valley Medical Center shouldering a heavy workload.
“It was a tremendous experience,” she says. “We all fell in love with that hospital.”
At the time she finished her residency, nearby Hoke County had been identified as in critical need of family doctors, and Smith was recruited through the Southern Regional Area Health Education Center to fill that need.
When she first came to Hoke County in 1992, she joined a practice of two older doctors that served much of the county.
“Their only doctors were older, and if anything happened to them the community would have no doctor,” she says. “There was a very extreme shortage.”
In the years since, the population of the county has exploded, due largely to an influx of migrant workers and military families, making that shortage even more acute. While turnover among rural doctors is common, Smith has resisted the temptation to leave.
Smith says her forward-thinking use of electronic records started as soon as she got to Hoke. The practice she entered had 18,000 paper charts – a massive patient load made possible only because the doctors knew their patients so well after years of serving them.
But Smith knew she’d have to make changes, so she turned to the emerging field of electronic medical records.
“I knew no one,” she says. “So we got the paper charts, and we organized them electronically. We became one of the early adopters.”
When she started her own practice, in 2003, she continued to explore the use of electronic records, at one point even working to get high-speed internet access to her office so she could handle the data.
The results are impressive, enabling her practice to better serve patients while saving time and resources. For example, she can pull up the test results of all of her patients whose diabetes is going untreated, along with their contact information.
Then, she can set a date for all of them to come in at once to get information on how to improve their condition, as well as one-on-one consultation, and send notices via email and text message.
We’ve always taken care of everyone who comes through the door.
Her patient base extends beyond Hoke into Scotland, Moore and other nearby counties.
“Some of these communities don’t have primary care doctors who take Medicaid,” she says. “We’ve always taken care of everyone who comes through the door.”
She’s also helped expand access to health care in other ways, working with FirstHealth Moore Regional Hospital to create a new Hoke County campus. She’s medical director and supervising physician for the county’s primary health clinic, which serves many of the county’s older and low-income patients whose care is covered by Medicaid and Medicare.
The area experienced a lot of turnover among doctors, and Smith admits she’s considered leaving, as well. Smith says she’s stayed “despite challenges and opportunities to move on.”
“This is so important, as many rural doctors are leaving due to several factors, but to stay is encouraging,” she says.
The financial implications of that decision have been difficult at times, particularly in recent years due to both the Affordable Care Act and a move by the state legislature to reject some federal Medicaid funding.
But her large practice helps. The electronic records allow her to be efficient, and the small community where she works helps her know her patients well. Both factors allow her to take on more patients.
She can see upward of 50 patients a day and has more than 7,000 patients of record.
“The mere fact of being in practice so many years helps,” she says. “I know the patients, and that can reduce the cost of care.”
But Smith is also aware that she can’t make up for the lack of rural health care providers alone. She’s developed a program to help train providers to work at the health department, and she regularly hosts students from area universities such as East Carolina, UNC-Greensboro and N.C. Central with an eye toward interesting them in primary care careers.
“We want them to see what it’s like to practice rural medicine,” she says. “I don’t have a rheumatologist or a pulmonary specialist nearby. I need to be able to manage, recognize and diagnose a lot of problems. In a lot of cases, I’ll continue to treat patients even after they’ve seen a specialist.
“Around here, a lot of people want to stay close to home.”
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Dr. Karen L. Smith
Born: October 1962, Washington D.C.
Career: Family doctor in private practice
Education: B.S. biology, Duke University; M.D., Hahnemann University
Family: Husband Michael, children Marcus, Michaela, Marquise and Mikara
Fun Fact: Smith is a big sports fan and notes that her husband played football at Clemson University. Before they met, she saw him play in a game against Duke in 1982. Duke won.