County faces shortage of healthcare providers

Ginny Pond, a licensed clinical social worker, moved to Washington County in 2004 to practice. Her decision, based on a combination of practice conditions, competitive compensation and the strong connection to place and people, exemplifies what happens when all the right factors come into play when recruiting and retaining a healthcare provider to a rural area.

Healthcare workers in primary and family practice care -- physicians, nurses, dentists, social workers and more -- play a central role in community health. They work with community members over their lifetimes to ensure good health, treatment and continuing care of chronic health issues and are often the first place where a significant health issue is identified. But national shortages of primary care providers contribute to challenges of recruitment and retention in rural areas. Washington County is not alone in identifying and facing this shortage.

Pond spent much of her adult life in the Boston area and went back to school as a mid-life career change. After graduating, she thought she would settle in South Dakota, but in 2002 she and a friend stopped in Calais on their way to Nova Scotia for a camping trip. The friendly advice they received at their lunch stop about how to beat the long line of traffic waiting to cross the border combined with the beauty of their previous night of camping at Cobscook Bay State Park "created an aura about the place," she says. This early connection to the county and its people drove her decision to look at position openings in the area. She found a position in the county that met her compensation and practice needs. There may not be opera, but "we have lovely people, miles and miles of natural beauty, neighbors who take you under their wing. Life feels well balanced." She considers the county her permanent home. "I can't imagine anything that would entice me away."

In 2009, Fitzhugh Mullan, M.D., Murdock Head Professor of Medicine and Health Policy at George Washington University, presented testimony to the United States Senate Committee on Health, Education, Labor and Pensions, stating that health centers around the country "currently have a shortage of over 1,800 primary care providers." While there are over 800,000 practicing physicians in the country, "current density of physicians is 272 per 100,000." However, he notes, "Less than 10% of physicians practice in rural areas while 20% of the country's population resides in these areas."

While Pond is not a physician, her decision to practice in the county is one that can bring light to the problem of rural retention. According to Maine Department of Health and Human Services' (DHHS) numbers, Washington County has seen a decline from 67 practicing physicians in 2004 to 45 in 2010, and the state has seen a decline from 3,674 to 3,261. Mullan's figures on density would suggest that 81 primary care physicians would be the more adequate match to Washington County's population of 30,000.

"It's not a unique problem," says Andrew Coburn, research professor and chair, Health Policy and Management at the Muskie School of Public Service in Maine. "We're not producing enough primary care physicians and it's a very competitive environment to recruit J-1 visa physicians."

International medical graduates can utilize J-1 visa waivers to practice in underserved areas of the United States. In exchange for this service of work for a set period of time -- in Maine it is a three-year requirement -- the practitioner receives a green card to remain in the country to pursue his or her career. Jim Dowling, workforce development manager with Maine Primary Care Association and the Maine contact for a national rural medical provider recruiting organization, 3RNET, says of the many J-1 visa practitioners he has helped to place, "They tend to be wonderful citizens... a little bit older, and they are marvelous clinicians. Maine has had a good retention record, but there are fewer and fewer of them."

Mullan notes in his testimony that international medical graduates in the U.S. comprise 25% of practicing physicians and 29% of physicians in residency training. "This has been an enormous gift to the United States." This body of medical practitioners has been "available to fill the gaps in residency programs and in specialties that are out of favor with American graduates," resulting in a lack of planning and funding strategies targeted to graduating primary care providers from this country. Public policies and medical education systems will need to "work towards self-sufficiency," a road that has been started, Mullan says, with positive developments occurring with the formation of new medical schools and class size expansion at existing schools.

From 1990 to 1992, Dr. Cathleen Morrow's first position out of residency was as a physician with the Eastport Health Center and the Pleasant Point Health Center. Now the predoctoral director and associate professor with Dartmouth Medical School's Department of Community and Family Medicine, Morrow says, "The medical system in this country is highly skewed. Many factors discourage students from going into primary care." She notes that the educational system in Canada is structured so that primary care physicians do not graduate with $250,000 in debt, a figure that is becoming increasingly common in the United States. In England and Canada 60% of the medical school population concentrates on primary care. In the U.S., the primary care concentration rate is around 40%.

"There is study after study, think tank after think tank, all asking how do we find the person who will go into rural family practice medicine and specialties in primary care," Morrow says. A number of strategies are being looked at, she explains, including the educational framework, starting as early as elementary school, but focusing heavily on what she terms the "pipeline." These are support programs that "create interest early, such as in high school and particularly with kids in rural areas that lack models where they can imagine themselves as a doctor." Programs include summer camps with a medical emphasis and job shadowing.

Both the Regional Medical Center at Lubec and the Calais Regional Hospital work to educate high school students about the possibility of healthcare careers, and both facilities work with medical schools to place students for rotations and residencies. Marilyn Hughes, CEO of the Lubec medical center, says, "We're working with medical schools. Students can see how a rural community practice is so that preconceived ideas can be dispelled." She notes that around the country the problem is being tackled by different university and community coalitions who are working to seek out local candidates to send to medical school and who will then return to practice in their own communities. "That is certainly an exciting way to go. Invest in your community, your youth, in a long-term commitment to serve."

Scarcity of other primary care practitioners

The scarcity of physicians in rural areas is not the only area of concern for recruiters, patients and policy makers. Nurses, physician assistants, dentists and social workers are a part of the primary care network. Recruitment sites, such as 3RNET and the National Health Service Corps, list anywhere from eight to 19 vacancies in the county. Increasingly, nurse practitioners and physician assistants are taking on many of the duties previously associated with family practice physicians. A number of states are considering policy changes to allow for increased authority for those practitioners to act without the presence of a physician for sign-off on a number of functions.

Increased autonomy does not address the need for increased levels of graduates from nursing, physician assistant, dental and social work programs. Maria Townsend is the director of nursing at the Eastport Memorial Nursing Home and has been working there for 19 years. She is still approached by the lucrative traveling nurses program, a professional choice, she notes, that young nurses just out of school are drawn to because of the high pay and excitement associated with traveling to new places. This kind of competition is difficult to surmount. "There are not enough nursing students and programs," she says. "We have experienced shortages in the past. We have to keep up with other facilities and their pay scale."

The nursing home's administrator, Rod McIntyre, explains that the average age of nurses in the state is about 52 years old, or about 10 years away from retirement. He is concerned that the pending retirement of those nurses will exacerbate the shortage. Nursing schools "are very competitive. Courses are difficult and then because of shortages, they are recruited by everyone. We all need the same resource of talented, caring people." He adds that a "few more doctors would benefit everyone. I think the doctors right now have a large patient load." Shortages of both doctors and nurses have an "impact on the practitioners at the nursing home, hospitals and citizens of the county."

Shortages are caused by a lack of supply, but rural areas do face the additional challenge of the right match of provider to the community. A family nurse practitioner and a physician assistant student on rotation had very different reactions after spending time practicing in the county despite each having high regards for their colleagues, facility, staff and community members.

A recent recruit to the area, family nurse practitioner Tammy Gannaway, MSN, FNP-C, RN, attended the University of Southern Maine MSN options program as a mid-life career change. Her aunt had lived in East Machias and she remembered visiting as a child. "I came to visit and interview. I had other offers, but the beauty of the area, the ocean, the connection with my aunt, it resonated." She notes that her children are raised and out of the home, which gave her much more freedom when choosing a practice area than someone just starting their profession and family. She is delighted to be living and practicing in the county. "Practicing in the field has been so rewarding. People are so nice, so friendly C personally and professionally."

However, Jennifer Hallett, a 24-year-old University of New England student studying to be a physician assistant, spent a rotation at the Eastport Healthcare Center and was not as enamored of the rural lifestyle. While she was impressed with the staff and facility, she frankly admits that the overall environment of the area was not a perfect fit. During her time in the small city she attended church, went to music nights at area restaurants, attended movies and performances at the arts center and utilized the fitness center at Pleasant Point. Despite these efforts she felt isolated, especially on the weekends. After she graduates this spring, Hallett hopes to land a position in Portland where the social scene fits her needs and there are a wider range of job opportunities for her partner.

Recruitment and retention for rural care

Finding the right fit between provider and community takes time. The special identity of a rural community like Washington County can be a draw to healthcare providers if the right recruitment and retention practices are utilized by both healthcare organizations and communities themselves. "All recruiting is local -- start at home," says Jim Dowling of Maine Primary Care Association.

Muskie's Coburn says, "The decision to locate and practice is in part a choice about the community and about a practice environment that is attractive and productive." Connectedness within the medical community of different facilities, practices and practitioners is a growing trend. "To what extent has there been thought given to how all these systems can fit together. Working with others C it is a system that people find appealing."

When CEO Michael Lally came to Calais Regional Hospital (CRH) 15 months ago, he worked with the board, physicians, staff and community members to develop a three-year strategic plan for the hospital. Medical staff recruitment and development was one of the key areas identified as essential to the hospital's ability to help patients attain services without having to go to outlying areas. Lally says recruitment is "a complex subject matter because each staff member and physician has different needs. Each takes a different approach."

CRH has created a variety of successful recruitment and retention strategies. DeeDee Travis, director of community relations, has worked for over 20 years with the hospital, and Kristi Saunders, human resources director and compliance officer, has been with the hospital for 39 years. "Finding the fit takes a while, but it's better to take the time to find that fit. That's what our patients need," says Travis. Saunders adds, "We have to be really honest about what we are." Lally says that new physicians have very different expectations about their work schedules versus the older practicing physician. Life balance is the new catch-word.

That balance between a provider's professional and personal life is increasingly relevant, says Hughes, of the recruitment efforts taking place in Lubec. "More and more I have seen a difference in the providers. We have to be more flexible with the work week we provide, such as a four-day work week, outsourcing on-call service that is triaged." The center offers "competitive salary and benefits." Certainly, she says, the "diverse educational opportunities and peer networking in urban areas is helpful, but for us here, because we have so many clinicians working together, there is a collegial experience to work with." Her facility works with recruitment entities such as Maine Primary Care, but "we also stay in touch with the schools." Hughes tries not to use headhunters. "They are costly, but sometimes we have to resort to that."

Working with a broad range of staff and community members helps with the recruitment process at Calais Regional Hospital. The hospital encourages spouses to come during an interview process. "We want to be a fit for the entire family," says Travis. Usually the interview is for two days and includes visits with the medical staff leadership group, board members, medical specialists and community members who have common interests. Tours of the area are an important part of the visit. Hughes also utilizes local resources to find the right fit. "The one-on-one, personal reaching out is valuable. We're getting more and more people here who have helped expand cultural opportunities -- musicians, artists -- all of these are exciting and we want to point them out to potential candidates."

"It's selling what we have," Travis says. "It just gets back to finding that fit, as long as we wait."