All Paths Lead Home

Nicole El-Khoury’s father has served the rural North Carolina towns of Ahoskie and Aulander as a family physician for nearly 20 years. A first-year medical student at Campbell, Nicole is close to achieving her dream of one day working by his side.

 

By Billy Liggett

The windows are tinted with 15 years worth of dirt, grime and abandonment, so Nicole El-Khoury has to cup her hands over her eyes to see inside the small white concrete building where it all started.

“That’s the lobby,” she says, squinting to recognize the now moldy, water-damaged objects in the dark. “It’s crazy to see it … nothing’s been touched since he left.”

The same could be said for the buildings that surround her father’s old family medical clinic in the mostly neglected one-stoplight town of Aulander in northeast North Carolina.

The corner pharmacy where her father would send his patients (and where Nicole would grab strawberry sodas with her best friend Tori, a daughter of one of the nurses) looks more like a storage unit today with plywood covering most of its windows. The once-bustling hardware store across from the clinic sits empty, save for a few birds seeking shelter from the wind on this cold, blustery January day.

More than 1,200 people called Aulander home in 1996, the year a young Lebanese physician, Dr. Semaan El-Khoury, moved his new family to North Carolina by way of Virginia to work for Dr. Fred Saunders, whose father first opened the small clinic in 1958. Today — in a state that has seen considerable population growth just about everywhere else — the population is nearly half that. And it’s falling.

“It makes me sad, in a way,” Nicole says, looking at the buildings that house so many childhood memories. “But it also makes me proud — it makes me want to work hard to continue what my father started.”

A first-year student at Campbell University’s Jerry M. Wallace School of Osteopathic Medicine, Nicole is preparing herself to do just that, because despite the exodus of people and businesses nearby, Aulander Medical Practice remains. Now housed in a newer, larger building three miles to the northeast of where it all started (between Aulander and Ahoskie, another town largely forgotten by progress), the clinic and urgent care sees patients from Hertford, Bertie and their surrounding rural counties near the Virginia border, some driving an hour or more to be treated.

Her path hasn’t been easy — a few years ago, medical school didn’t feel like a reality. But like the region she grew up in, Nicole has shown grit.

“This goal … it’s what got me through really tough times. It’s what inspired me to push through,” she says. “My parents emulate resilience. I think that’s where I get it from.”

 *  *  *

Ahoskie’s nickname — proudly displayed on its water tower visible from the town’s main strip — is “The Only One,” as there are no other cities or towns in the world that share the name, derived from the Wyanoke Indian word for horse, “Ahots.”

The tower is just one of the “sights” that Nicole points out while providing a tour of the town where she grew up. There’s the small private school she attended from kindergarten through her senior year (Ridgecroft, home of the Rams), the Gallery Theater downtown where she performed in a few plays and musicals, the former Limelight Theater where she caught movies with her friends and the recently built Walmart on the southeast end of town where “most of the action is,” economically speaking.

“I feel like I know just about everybody here,” she says, moments later recognizing a couple of men working on farm equipment just off the state highway. “It’s nice, you know? Bumping into people you know … familiar faces and longtime friends. I could probably show up at my old high school tomorrow and go see my old teachers, and nobody would think it’s weird. There’s a restaurant my family goes to every Friday, and I can just walk back into the kitchen and say ‘hi’ to the owner. I can just make myself at home.”

Ahoskie holds a special place in Nicole’s heart, which is why her goal of one day returning to practice medicine and continue her father’s work is so strong. But there’s more to her dream than familiarity.

There’s a dire need for health professionals like her.

Ahoskie may be unique in name, but it’s very much the norm among the rural towns and small cities in the northeast region of North Carolina that are struggling economically and declining population-wise.

In fact, Hertford County (home to Ashokie, Aulander and small towns like Winton and Murfreesboro), saw the largest drop in population (12.9 percent) in North Carolina from 2020 to 2023, more than doubling the decline of its neighbor, Bertie County (6 percent).

Northampton, Halifax, Washington and Martin counties round out the Top 6 in population loss; all either border or are a county away from Hertford.

Not coincidentally, when it comes to health outcomes, these same counties are near the bottom of just about every ranking in the state. Hertford ranks 84th, Bertie 89th and nearby Halifax and Edgecombe counties are 97th and 99th respectively (out of 100) in health lists that take into account life expectancy, infant mortality rates, diabetes, mental stress, smoking, obesity and teenage pregnancies.

And not surprisingly, the region lacks primary care physicians to meet the region’s health care needs. According to 2023 numbers provided by the North Carolina Health Professions Data System, only 62 counties in the state have at least one primary care provider per 1,500 of the population. Between Northampton and Gates counties — Hertford’s neighbors to the east and west with a combined 27,0000 people — the state lists only four primary care physicians.

Students like Nicole — those not only willing to but passionate about serving in rural areas that are medically underserved — are the dream for Campbell’s School of Osteopathic Medicine, which ranks second in the nation for the percentage of graduates practicing in health professional shortage areas.

U.S. News & World Reports’ latest rankings show nearly 47 percent of Campbell doctors are practicing in areas considered underserved, and the school also ranks 11th in the nation for the most graduates practicing in primary care.

“People know this is rural, but then they move here to work or visit, and they realize this is very rural. Greenville is really the closest thing we have to good, quality resources, and that’s an hour away,” Nicole says. “It takes someone growing up in an area like this to fully understand the community and its struggles, because it’s not easy.

“But these people are my family, and I want to be here for them.”

 *  *  *

Leigh Ann Martin remembers a much younger, no-less-determined Nicole running in and out of offices and “helping” her dad run his clinic as a 2-year-old back when the El-Khoury family first moved to Hertford County in 1997. Nicole remembers the scratch-and-sniff stickers Martin gave her on each visit. When she was old enough, Nicole helped out by handling patient charts, back before the office went completely digital.

Back then, Martin was the secretary for the small white-brick clinic in downtown Aulander. Twenty years later, she’s the clinic manager for the larger office just outside of Aulander, built in 2011 and added onto in 2016. And just like in 1997, she loves it when Nicole comes by to help out.

“Family has always been important here,” Martin says. “I see it in how dedicated her father has been. To come to a small town like this and be willing to stay as long as he has — he’s dedicated to this area, and he’s dedicated to his patients. I know Nicole will have that same dedication.”

Just getting to this point — a first-year student in medical school — has required dedication and perseverance for Nicole El-Khoury. She attended East Carolina University — about an hour south from Ridgecroft High School — and earned her Bachelor of Science in Exercise Physiology degree in 2018. The only thing standing between her and her dream of following in her father’s footsteps was the MCAT, test required by all medical schools in North America to be even be considered for admission.

She bombed it.

“It really took a toll on my confidence,” she recalls. “I felt like, going in, this was something I was always supposed to be good at. And I just didn’t understand why I did so poorly, because my grades were great. I had everything ready to go. I felt like the MCAT score didn’t reflect my potential, and it really got into my head. So I took a little break.”

Nicole became an EMT in Hertford County, an experience that she says really broadened her perspective on health care in rural communities. Being an EMT meant being inside people’s homes during emergencies and seeing how their living conditions correlated to their poor health — something a physician doesn’t get to see inside of a clean doctor’s office.

“You’re seeing people in their rawest, most vulnerable way,” she says. “You don’t have your house done up and perfect when you call 911. So you see exactly how people are living, and that tells you much more than saying, ‘I have some back pain’ at a clinic.”

Nicole worked as an EMT for over two years and seriously considered a career in it before the pandemic hit in 2020, and her help was needed back at her father’s clinic. During that first year of social distancing and overall uncertainty, she worked as a triage nurse and helped set up the clinic’s drive-through area so patients could be seen in their vehicles.

That experience reignited her desire to pursue primary care, so she decided to give the MCAT another try. The scores were better, but still not reflective of her potential, she says. Nicole was told she “wasnt’ ready” at a few interviews, but instead of being outright dismissed, she was pointed toward a master’s program that could better prepare her.

She was introduced to Campbell University’s Master of Science in Biomedical Science program, a two-year degree that provides a “rigorous curriculum” for those looking to enhance their educational resume (like Nicole) and become better prepared for medical school. MSBS courses touch on every aspect of a future professional school application, including clinical experience, shadowing opportunities, community service and professional development. For Nicole, the program not only got her over the application hurdle, it reinforced her passion and her goal of becoming a family physician.

“It helped in so many ways,” she says. “Immediately, I could see why I wasn’t being accepted into medical school. [The MSBS program] boosted my confidence in ways I couldn’t have imagined. The courses and the lectures prepared me for med school. The small classes [there are roughly 20-25 students in each cohort] provided the right environment for me, since I went to such a small high school. 

“All my professors knew my name. All my professors were invested in my well being and my future — whether it be medicine or whatever route I decided to choose. And I could feel that. I liked how they sat down with each individual student every semester and talked about goals. I felt very well supported. It just allowed me to shine and showcase what I could do.”

Before she earned her master’s degree in May 2024, Nicole was admitted into the Class of 2028 for Campbell’s School of Osteopathic Medicine. She had other options, but like Ahoskie and Aulander, Campbell felt like home.

A week into her second semester of medical school, Nicole is back home helping out in her dad’s clinic on a busy three-day weekend (MLK Day) in January. For the first time, she’s donning her short white coat with the Campbell University patch and the words “Student Doctor” under her name on the front.

Martin is asked what it’s like to see her today, knowing that not too long ago, she was running the halls, collecting stickers and spilling strawberry soda all over her dad’s white countertop, staining it pink.

“I’m very proud of her,” she says, her eyes welling with tears. “I mean, I saw it coming. She was determined. And her dad is proud of her. It was always his dream for her, too. When he found out she got accepted into medical school, he was just so excited. He was so happy.”

 *  *  *

There’s nothing flashy about Dr. Semaan El-Khoury’s cramped office at Aulander Family Practice. A standing desk. Papers scattered about. Framed photos all around. In one of those photos, there’s a 2-year-old little girl with short hair, wearing a pink jacket and a stethoscope, helping the family business by seeing a “patient” in the old clinic in downtown Aulander.

When Nicole El-Khoury says becoming a doctor and serving in her hometown has been her lifelong dream, she has visual proof.

“It’s all I ever wanted to do,” she says. “Maybe the reasons have changed over the years — when I was young, we would go with my dad to medical conferences and stay in hotels that had swimming pools. Back then, I thought that was what being a doctor meant — a lot of swimming. I wanted to be like him, and we bonded because of the clinic and, eventually, our shared love of health care.”

Seeman El-Khoury was born in Lebanon, and around his seventh birthday, his country fell into a 15-year civil war that would lead to massive destruction, more than 150,000 deaths and the displacement of nearly a million people from the country. He immigrated to the United States in the early 1990s after graduating from the American University of Beirut Faculty of Medicine in Lebanon and performed his residency with the Virginia Commonwealth University Health System in Richmond, Virginia, finishing in 1996.

A year later, he moved his family two hours south to work for a second-generation family physician in Aulander, Dr. J. Fred Saunders, a former wartime MASH unit medic who practiced medicine full time for 40 years before El-Khoury’s arrival (and then part-time for several years afterward in the same clinic).

El-Khoury says he and his family were welcomed immediately. The community needed physicians, he says, and they were grateful to have him — even if he didn’t necessarily “look like” everybody else. And from Saunders, El-Khoury says he learned that it was important to really get to know those patients — beyond their health charts — and respect their struggles that adversely affect their wellbeing.

“I learned to be their advocate and their friend, and I learned to really try to see things from their perspective. These aren’t numbers … these are patients. They’re people,” he says. “Over the years, you get to know their kids and eventually their grandkids. You see them at the store. You see them in the restaurant. We talk about the local football or basketball teams — or whatever important is going on in the community. We share in their celebrations and their sorrows.

“Being here has been very rewarding. We’ve had opportunities to leave and go somewhere else. But we chose to stay.”

Nicole sits next to her father as he says this, smiling and nodding. She adds that there’s no such thing as a quick trip to the grocery store, because someone will always stop them to talk. On Friday nights, the family eats at the same restaurant. They have their table.

“He’s become a pillar in this community,” she says. “He opens his clinic for a half day on Saturday, because he knows there’s many in this community that work all day during the week. He keeps co-pays down, because there’s so many who don’t have insurance. And I think that says a lot about him. He’s had offers to sell the clinic multiple times, and he just doesn’t want it to become a corporate thing. And I think he never gave up on the idea that I would one day want to come back and have this same opportunity for myself.”

Aulander Family Clinic was passed down from father to son, and soon, father to daughter. For 100 years, the area has only known two last names when it comes to family medicine. That means something to El-Khoury.

“Practices are becoming a very rare breed,” he says. “There are big hospitals buying up these clinics all over, and that’s fine, but people need to have a choice. We don’t follow the same regulations, we don’t have the same red tape, and we don’t have to do some things if we don’t feel they’re needed. There comes a flexibility with ownership, and I think the patients appreciate that.”

He looks over at Nicole when he says keeping the clinic all these years has meant keeping a promise to his community. When he talks about how it’s home — a place, like the theme song to “Cheers,” where everybody knows your name.

Having his daughter continue that legacy means the world to him.

“This was her passion all along, ever since she was that little girl in the picture,” he says. “She is wonderful with patients. Some of them have known her her whole life. And they trust her. This business is not for the faint of heart. But you can make a good living out here doing this. You just have to put in the effort and put your heart into it. She’s going to have patients who are easy, and there will be days where it’s very difficult. She’ll need to understand that it’s always a learning process. Everybody makes mistakes. And you have to manage the business side of all of it, in addition to the patient care.

“I think she will be wonderful. She’ll do better than me. She has what it takes to be a very good physician and patient advocate. We know she can do it.”