Down East 2013 ©
Matchmaking can be stressful work. Will the two parties find each other attractive? How will financial expectations compare? Will the extended family get along?
No one understands these stresses better than Jane Ham, director of the Maine Recruitment Center. For the past ten years, Ham’s office, a service of the Maine Hospital Association, has been matching physicians with openings in cities and towns across Maine, and she’s seen everything from the storybook romance to The War of the Roses play out in hospitals and small-town doctors’ offices.
“We look at recruitment as you’re recruiting the family,” Ham explains. “We had one physician who was interviewing for an orthopedic position, and her husband was an avid fly fisherman. So we made sure he got out fishing, and that went a long way toward making that situation work.”
Across the country, small towns are facing a shortage of physicians, especially in primary care, as medical school graduates are increasingly turning to specialties that allow them to quickly repay huge student loan debts. In Maine, the situation is especially dire: the ninety-one physician openings Ham faced in 1999 have skyrocketed to 272 today. “We’re in a full-blown shortage, and it’s only going to get worse,” she says, as the health-care industry expands to handle the state’s graying population. Since 1980, total employment in Maine has increased 52 percent. That sounds impressive until you contrast it with the 200 percent increase in the state’s health-care industry. So Maine definitely needs doctors. “But the good news is that Maine is still an attractive place for physicians who want four-season recreation and quality of life,” says Ham.
Indeed, over the past few years Maine has taken several steps to increase its appeal to both young doctors looking for pleasant, safe communities in which to raise their families and older physicians seeking to finish out their careers. “Maine is sort of out here at the end of the world,” Ham explains. “We have a national reach, but we’re reaching out to docs that we hope have some connection to Maine. Maybe they grew up here and are thinking of returning, or maybe they just have vacation experience in Maine. Then there’s that group of physicians who are on the back side of their career and who think they’re not quite ready to retire and want to work a few more years.”
“I called it my midlife crisis. In 2004, I was in my mid-forties living in northeast Maryland, and I just wanted to do something different,” Benner says. Having been to Boothbay and Bar Harbor on vacation and to Portland for a conference, she decided to take the plunge and contacted the Maine Recruitment Center. “And we’ve had nothing but wonderful experiences ever since. In Maryland I had to become a recluse all summer, since the ninety-degree weather hits in May and June and the windows close up, the air-conditioning goes on. I have a new lease on life here — I’m always outside.”
She admits her teenage daughters sometimes complain about the lack of shopping opportunities in Maine compared to elsewhere, a craving that is quickly cured by a weekend in Boston or New York.
While Maine’s small towns and outdoor opportunities are often most attractive to physicians’ fly-fishing spouses, the growing trend of doctors becoming employees of hospitals often appeals to the physicians themselves.
“We employ close to 80 percent of all the physicians in Lincoln County, and that will go to 100 percent in the not-too-distant future,” says James Donovan, president and CEO of Lincoln County Healthcare, which operates Miles Memorial Hospital in Damariscotta and St. Andrews Hospital and Healthcare Center in Boothbay Harbor.
“[The trend] has been evolutionary across the state, but it has rapidly increased in momentum over the last five years or so.” Donovan says doctors, especially in small towns, have discovered that working for the local hospital allows them to pass off bookkeeping and administrative work and instead focus on treating patients. “It’s very difficult to run a physician practice these days,” he says. “It’s a small business, with all the complexities of that, but most physicians want to practice medicine.”
Charles Dwyer, director of the Maine Office of Rural Health, agrees that the administrative headaches of running a private practice, including how to deal with low reimbursement rates through MaineCare, can often outweigh the benefits of staying independent.
“If I’m struggling to keep the overhead of my back office, and I have one case where I need to rebill something, I’ve basically lost any kind of margin,” he says.
Statewide, Maine hospitals now employ 45 percent of the 5,400 licensed doctors, and a whopping 78 percent of all licensed primary care physicians. “For physicians tired of the hassle of paperwork, Maine is very attractive,” Ham says. “We’re so much further along in all of this — we started employing doctors in hospitals in the early nineties, and what I hear from colleagues nationally is that they’ve just started looking at doing this.”
But the ability to focus on patient care isn’t always enough when it comes to attracting good doctors to Maine small towns. Pay scales for physicians in Portland are comparable to the national median, but Donovan says rural areas are always hard-pressed to offer the high salaries that doctors need to repay student loans. As the physician shortage in Maine has worsened, hospitals like Donovan’s in Damariscotta and Boothbay Harbor have seen a rapid escalation in salaries required to secure quality doctors.
The other compensation that doesn’t make it onto a spreadsheet, she says, is the camaraderie that exists among doctors in Maine. “The physician camaraderie is great here — everyone knows each other, as opposed to Maryland, where you came in, worked, and went home, and nobody really knew you.”
One program through which Maine has been most successful in attracting new doctors is the J-1 visa waiver program, whereby foreign doctors are allowed to practice in rural areas, including Maine, in exchange for a two-year commitment. Dwyer’s Office of Rural Health surveys these international physicians when their commitment is complete and has found that a surprising majority of them continue practicing in Maine. Of the last group of 116 foreign physicians surveyed, in 2004, 71 percent intended to stay in the state, up from 69 percent the previous year.
“I’d be surprised if you did a random sampling of non-foreign physicians if you’d find a higher percentage,” Dwyer declares. “Especially in this labor market, which is fairly fluid.”
He says the local community usually deserves as much credit for retaining these doctors as the hospitals that they end up working for. “One of the things that makes a huge difference for whether these physicians stay or go is how well they were integrated into the community. Is there more than a small group of people in your area that has your same religious preference? Are there other people that your family can relate to?”
Ham says retaining doctors once they arrive in Maine is especially critical today, when competition for primary care physicians is at an all-time high. “It used to take three to six months to recruit a family practitioner; now it takes a year,” she says.
Even if the state is able to entice a doctor from another state to join a Maine practice or hospital, often the sagging real estate situation nationwide will put a cross-country move on hold. “Physicians who are practicing in other parts of the country who might want to move to Maine are hung up in the real estate bust. They have homes, usually expensive homes, that they just can’t sell.”
One factor working against Maine’s ability to attract new doctors over the years has been its lack of an additional medical school to supplement the University of New England's College of Osteopathic Medicine, which has operated since 1978. Since building a bricks-and-mortar medical school would be exceptionally expensive, this fall the state will launch a new agreement with Tufts University and the University of Vermont to allow medical students to do some of their clinical rotations in Maine.
“We need to grow our own, to let kids see what it’s like to work in Maine,” Ham says. “The more we can expose people in training to physicians in Maine, and to the health-care system in Maine, the more likely they are to stay here.” This period in a medical student’s training is especially critical for states like Maine, Ham says, as this is when young doctors typically marry and choose where they’d like to raise a family.
Without doubt, though, the biggest asset Maine can offer its doctors is a quality of life that is the envy of much of the nation.
“In my view, spouse and family issues are 51 percent of the decision,” remarks Lincoln County Healthcare’s James Donovan, “Maine is such a great place to practice.”
In the end, Maine’s ability to attract new doctors to its small towns will rest not on a single strategy, but rather the multi-faceted approach that has evolved over the past few years: allow doctors to practice more and administrate less by joining hospitals’ payrolls; foster communities that welcome doctors and integrate them into their small town; and create partnerships with out-of-state medical schools to bring physicians in training to Maine and expose them to the quality of life, and of patient care, that the state offers.