Doc drop | Primary care physician numbers are declining as salaries fall out of step with med school debt, making recruiting MDs to rural Maine tougher than ever
Doctor Charles Zelnick checked coughs in central Washington, taught medical residents in Cedar Rapids and tended to ailing Aborigines in Australia before deciding he missed being a country doctor. Given the dearth of doctors in rural America, Zelnick, 55, knew he could find work almost anywhere. So for direction he turned to his wife, Vicki, who had long lusted for life in Maine. She had summered in Guilford as a youngster and still had family there and the Zelnicks, who years ago honeymooned in Bar Harbor, had a daughter in the engineering program at the University of Maine in Orono.
And so, last December, in the wake of a two-foot snowstorm, the couple slid into Stonington where Zelnick had taken a job as one of two physicians at Island Family Medicine, a primary care practice run by Blue Hill Community Hospital.
While his wife’s love of rural Maine is what brought Zelnick here, the difficulty rural spouses often face when searching for jobs and amenities in small, remote towns is what prevents many physicians from even considering Maine in their career search, let alone staying here for the long term.
Doctor William Medd, an internist who founded the Oxford Hills Internal Medicine Group, a seven-member private practice in Norway, says he has advertised an internist’s job for three months now with not a single inquiry. The position came up after two half-time doctors left the practice to move to Portland because their spouses wanted that city’s amenities.
“No one wants to be in Norway,” Medd says. “They want to be in Portland. It’s only an hour away, but the lifestyle is so different. If we don’t fill the position, we’ll go back to six [internists], and then someone will retire and we’ll shrink to five.”
Jim Dowling, a recruiter for the Augusta-based Maine Primary Care Association, says a recent survey done by his association revealed the leading reason physicians abandon positions in rural Maine is their spouses want to leave, usually because the small town doesn’t provide enough professional, social or cultural opportunities.
And while piquing primary care physicians’ interest in any place in Maine that isn’t Portland has always been a challenge, recruiters say a nationwide decline in primary care providers entering the workforce and the pricey salaries many docs need to pay back burgeoning medical school loans means Maine is down more doctors than ever.
Love us or leave us
Dowling is currently looking to fill around 20 physician vacancies mostly in Washington, Aroostook and Kennebec counties on behalf of the association’s membership of 22 federally qualified Health Centers and Indian Health Centers. Some positions may be open for a year before they are filled, or simply eliminated, he said. Meanwhile, the Maine Recruitment Center, a non-profit statewide health care recruiting agency based in Augusta, is trying to fill 237.5 full and part-time vacancies, including more than 100 full-time spots for primary care physicians, many of them in rural communities like Presque Isle, Pittsfield and Stockton Springs. The center was founded in 1999 as a service of the Maine Hospital Association and has 32 of Maine’s 39 hospitals and three large group practices as members, all of which pay an annual membership fee to have the MRC recruit on their behalf.
“We started out back in 1999 with 91 openings and gradually that increased,” says MRC Director Jane Ham. “Four years ago, it was around 200, and all of a sudden, earlier this year, it mushroomed to 237.5. It’s a little bit alarming. That’s a lot of openings. It’s a very challenging time.”
With fewer and fewer primary care providers entering the workforce, underserved rural areas like those in Maine now compete with their urban counterparts to attract new med school grads.
“The overriding issue is that we don’t have enough people coming out of medical school wanting to practice primary care medicine, in large part because of the financial penalty they incur,” explains Kevin Lewis, director of the Maine Primary Care Association. “If they know they can’t afford the medical school debt upon leaving residency, then it’s no wonder we don’t have more interest in primary care.” While four in five students going to medical school say they plan to become primary care providers upon graduation, only one in five actually do, explains Dan Hawkins, a policy director for the Washington, D.C.-based National Association of Community Health Centers. He attributes that trend to the appeal of larger, specialist salaries to students who can expect their medical school debt to top $250,000. Specialists also tend to work more traditional hours, he added.
A September Associated Press article citing data from the Journal of the American Medical Association said that just two percent of graduating medical students surveyed planned to work as primary care physicians and with 53% of Maine’s population living in rural areas (compared with 16% nationwide), Hawkins says Maine has been hit especially hard by the primary care recruitment crisis.
“Rural America does not need more dermatologists or cosmetic surgeons, it needs primary care doctors and especially in a places like Maine with its aging population,” says Hawkins.
According to the 2006 “Healthcare Occupations Report” by the Maine Department of Labor, while physicians and surgeons are among Maine’s highest earners, the average annual salary for a general practitioner in Maine is $125,362 compared with $181,850 for a surgeon, or $191,693 for an anesthesiologist. The report also concluded that “rural physicians, on average, work more and earn less than their urban counterparts.” And recruiters in Maine have additional challenges — since a general practitioner here earns $12,618 less each year than the national average, according to the MDOL. Some recruiters told Mainebiz the salary divide is actually much larger, though Ham at the MRC says “we’re catching up.”
But while increasing salaries will certainly help make Maine more competitive to those who are considering careers in similarly rural states, it won’t sell a city slicker on small-town medicine.
“Raising salaries just to attract people isn’t a long-term solution. If people aren’t happy, they aren’t going to stay,” says Ann Homola, director of physician recruitment at Bangor’s Eastern Maine Medical Center.
So, when Homola talks to potential recruits, she asks about what isn’t on their CV.
“I don’t think it is any more difficult to recruit here than anywhere else. It’s just about connecting with people who want what we have,” Homola explains. “Our focus is on finding the best match because, for the stability of our hospitals, it doesn’t do us any good to bring someone here and have them leave in a year because they realized they don’t like winter. Obviously you don’t make hiring decisions based on hobbies, but your ears perk up when they say they like sea kayaking or skiing.”
For every two candidates who visit the Bangor hospital after the pre-screening process done by phone and email, Homola says one accepts the position. “Sometimes you don’t have the highest salary offer, but it could be the best fit for that doctor. And if that means something to them, those few thousand dollars here or there doesn’t matter,” she says.
Residencies to residents
One proven way of keeping primary care physicians in rural Maine and energizing the state’s aging physician pool — according to the MDOL report, the average physician here is 50 and 21% of docs are over the age of 60 — is to foster rotations and residency programs here. While this is complicated because Maine doesn’t have a state-run medical school, there are several proactive programs that encourage students to get their start here and stay.
Through its Maine Access to Medical Education Program, the Finance Authority of Maine contracts with three New England medical schools to secure preferred access for up to 20 Maine residents to medical programs at Dartmouth College, the University of New England and the University of Vermont. John LaCasse, chair of the Finance Authority of Maine’s Advisory Committee on Medical Education, says FAME pays $5,000 per student per year (for an annual total of $400,000 spread out over 80 students) as part of an arrangement to increase Mainers’ chance of being interviewed by a medical school over a similarly qualified candidate from another state. As part of the arrangement, those schools agree to send Access students back to Maine for rotations at a primary care facility in an underserved and rural area.
Earlier this year, Maine Medical Center announced a partnership with Tufts University School of Medicine called Maine Track that will bring Tufts med students to Maine Med for year-three and part of their year-four rotations. Twenty of the program’s 36 seats will be reserved for Maine students, who will get subsidized tuition. In 2011, the partnership’s first students will arrive in Maine to join the 300 Tufts graduates already working as doctors here, including 60 at Maine Medical Center in Portland.
“A lot of our providers are very mission-oriented. That’s a big driver for a lot of people we hire — they want to work in underserved areas,” explains Connie Coggins, president and CEO of the Waterville-based HealthReach Community Health Centers, which operates 11 health centers in central and western Maine. One of HealthReach’s nurse practitioners in Livermore Falls, for example, cares for four generations, Coggins says. “Some of our providers treat their friends and neighbors and that’s important to them.”
It’s certainly important to 25-year-old Abby Masterman, a fourth-year UNE medical school student and FAME Access scholar. She grew up in Kingfield (population 1,116) and dreams of returning to western Maine as an OB/GYN when she finishes her training in five years. Because there is only one OB/GYN residency in Maine, she may have to leave in the interim, but knows she’ll be back.
“I like the people in rural Maine, I like the lifestyle. And there is a real need,” she says. “I don’t like driving in traffic. I don’t like stoplights. I grew up in a town where you couldn’t get gas after 6 p.m. And I am ok with that.”
This year alone, she’s borrowed $71,000 to fund her tuition and training, and despite receiving several scholarships, she expects to be more than $200,000 in debt by the time she graduates, including owing $100,000 to the FAME Maine Health Professional Loan Program.
“It’s a little scary, but all doctors, even in Maine, make good money,” she says.
Samantha DePoy-Warren, a writer in Farmington, can be reached at editorial@mainebiz.biz.
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