Northern Exposure

The old guy wearing blue jeans and a ball cap leans in at the little arched window, his hips out to one side, to absorb a story that his friend is telling about a mutual acquaintance."Well, I told him I don't know if we can do it then. We've got company coming for dinner that night," the seated woman is saying. She is middle-aged, with glasses and a quiet, unhurried manner. "But you know how he is," she adds.

Just then, another younger woman carrying a clipboard passes by behind the first. "Hello, neighbor," says the man at the window, catching her eye. She looks up and flashes him a smile."Haven't seen you lately," the young woman shoots back.

Remarkably, all of this geniality is occurring in the waiting room of a doctor's office at a hospital in Houlton, Maine, two thirds of the way up the state on the right-hand side. The easygoing woman expecting company for dinner is the receptionist;the man in loose-fitting jeans is the patient, and the woman gliding by in the background is a nurse. We are a far cry from the studied detachment and the-doctor-will-see-you-now coolness of an urban milieu.

The fun doesn't end in the waiting room. Once the man in jeans is called to his appointment, he can be heard laughing in the near hallway, where someone new is telling him, "My grandmother loves that place. The soups are good, too. So how you been?" "Oh, pretty good," he says, moving gradually toward the doctor's exam as though this were a poker game with pals that he'd been looking forward to all week.

It's a different pace up here, but the friendliness and winsome good cheer on display in Houlton are misleading in a way. This afternoon's sunny mood masks a crisis for rural Maine. Few young doctors are electing to practice medicine in small-town Maine, and the consequences of this long-term trend are dire for the people who live in far-flung locations such as this.

There are really two Maines. The first,consisting roughly of the coastal band that arcs from the New Hampshire border up to Acadia National Park, is well-known and beloved by calendar makers, who can't resist the look of snug harbors filled with sailing craft and lobster buoys heaped in the side yards of the cottages. Once you go 30 or 40 miles inland, or push much farther up the coast, however, all bets are off. You enter an area of small towns, immense fields and deep woods. The state turns poor and bedraggled-looking fast. "As you move away from the southern coast and get north of the I-95 corridor around Bangor, that's where the challenge is," confirms Charles Dwyer, director of the state's Office of Rural Health and Primary Care.

Doctors tend to be more concentrated in cities than in rural areas.While this is a national demographic truth, Maine is harder hit than most places. According to a comprehensive report released by Dwyer's office in 2008, only five other states in the U.S. have a higher percentage of people living in non-metropolitan areas - an index known as a state's degree of rurality."The report found that Maine's rural residents are older, poorer, sicker and less educated than its more-urban dwellers. They are more likely to be unemployed. They suffer disproportionately from chronic illness and substance abuse. In medical terms, rural residents are hanging by a thread. And just39 percent of them have a personal doctor.

In Maine, as elsewhere, doctors are getting older and retiring. The trouble is that their numbers are not being replenished. As director of the Maine Hospital Association, which tracks physician openings around the state, Jane Ham knows this better than anyone. (Few doctors in Maine are not affiliated with a hospital.) "It's a worsening situation," she states. "When we started our recruitment center a decade ago, we had 91 openings. A year or so ago, we had 206. Now we've got 272 physician openings, of which 121 are in primary care"the backbone of health-care delivery in Maine."

To narrow the gap, Maine began importing foreign doctors to complete their residencies in rural areas under a federal J-1 visa program, which requires that the visa recipients practice for three years in an underserved area. According to Dwyer, 116 foreign-trained doctors unpacked their bags at sites around the state between 1997 and 2004.

Charles Macomber, '59, saw this firsthand. Following retirement from a stressful obstetrics practice in Concord, N.H., Macomber spent a gratifying spell treating grateful patients at a hospital in Caribou, Maine, 50 miles north of Houlton. "Those were the two best years of my professional life," he is quick to say. The bulk of doctors he worked with were not born in the United States, Macomber reports, citing Canadian, Sri Lankan, Indian, Filipino and Chinese physicians on staff.

Late this summer, in partnership with Maine Medical Center, the medical school launched an innovative program aimed at alleviating the physician shortage in ruraland small-town Maine. Called the Maine Track, the program enrolled 36 students who have shown promise for establishing practices in the state. Of these, 20 slots were reserved for Maine natives or applicants with close ties to the state. Half-tuition scholarships were offered to these students as and added enticement.

"Tufts has a strong track record of training Maine physicians, and there are more than 300 Tufts-educated doctors now living in Maine, with perhaps half this number engaged in active practice," says Michael Rosenblatt, dean of the medical school. From the 1930s through the early 1980s, federal funding provided opportunities for Tufts studentsto work in Maine hospitals, including Maine Medical. "Although this is a new agreement," Rosenblatt notes, "our affiliation with Maine Medical Center began in the 1930s. We are excited to re-establish and revitalize this important relationship." Peter Bates, chief of medicine at Maine Medical, calls the joint enterprise "the perfect match of needs and philosophy" between the two institutions.

Maine Track students will spend their first two years in Boston before shifting to the 600-bed Portland hospital for their third year clerkships and part of their fourth-year rotations. Extended, multi-month clerkships will ultimately be offered at a half-dozen sites around the state so that students can immerse themselves in community-based medicine on an intimate scale.

Give the kids a whiff of pine and hope they like it and decide to stay - that's the gist of the idea. "It's all about quality of life," Jane Ham points out. "We always tell doctors they can have a good clinical practice here, plus be able to spend time with their family." And what if the prospective docs enrolled in the Maine Track sample the country life and decide they don't like it? "Well, at least they've had some exposure," Ham responds,laughing. "Rural life is not for everybody. But right now they're not getting any exposure at all." Maine has no allopathic medical school of its own, exacerbating the doctor-supply problem.

Let's do some math. The Maine Track will enroll 36 students per year. The program's goal is to retain 75 percent of the class as physicians practicing in rural Maine. Even if the ambitious goal is reached 27 doctors annually that's not a huge number. A skeptic might wonder how much difference this few can make when distributed across a state as large and needy as Maine.

Don't let Tim Churchill hear it. He's president and CEO of Western Maine Health, which operates Stephens Memorial Hospital in Norway, Maine, a blue-collar town of 5,000 residents a short hop north of Portland. The 50-bed hospital will provide four Maine Track students with clerkship rotations. "We believe every physician we get coming to this state is a difference-maker," Churchill insists. And he should know - his hospital has been trying to fill a physician vacancy for more than a year now.

What is it like to practice medicine in rural Maine? In late June, Tufts Medicine set out to answer the question. We visited three Tufts graduates who have served three distinctly different geographic regions of the state - woods, northern coast and potato field - for a collective total of 85 years. We figured if these people didn't know, no one would.

BINGHAM: NOTHING ELSE FOR MILES

The town of Bingham, Maine, has seen better days. From its weather-beaten mainstreet, with its handful of boarded-up storefronts beside the surging Kennebec River, to its lone, mostly vacant motel, this town of fewer than a thousand people looks like it's been whacked hard and is still reeling from the blow. Lumber trucks hurtle along the main drag, sometimes empty, sometimes full. Ten miles north of here, you are in to some serious woods. Bingham residents have few employment options, either working in the woods, or seasonally for one of the river-rafting companies, or over at the nursing home.

"It's a town in decline," says resident Myron Morris, 82, bluntly. "The mill went away, and the logging industry has gone down hill." Morris moved to town in 1950 and formerly owned a trucking company. Now he's seated in the lobby of the Bingham Area Health Center, a modern one-story building in the middle of town, waiting for his regular check-up.

Cynthia Robertson, '80, sweeps into the waiting room. Petite and dynamic, with frosted hair and a quick smile, she is perfectly cast for the role of the briskly efficient, small-town doc. Robertson signed up with the National Health Service Corps, which gives financial incentives for service in rural America, after graduation. In a way she was echoing her father, who had been a small-town physician in upstate New York. "The main thing I saw in him was a contentment in his life," she says. Robertson did her residency in Augusta and has been Bingham's chief physician for the past 26 years.

The clinic serves as an all-purpose health center for the town since there's nothing else for miles around. A dentist stops by several days a week to examine Bingham's teeth and there are ambitious plans to expand the service. Two therapists are available part-time for mental health counseling. During the summer months, there's even a high school guidance counselor who's ready to advise kids one day a week in an office down the hall. The clinic has made itself a trusted neighbor. "When you're a country doc, you're sort of responsible for the health of that community," says Robertson, who has served as medical director of the town nursing home and worked in a nearby hospice. She still makes house calls two or three times a month.

Forging a close relationship with patientsis a key concern in rural areas, and absolutely essential to cultivating good health, the doctors interviewed for this story agree. Your life is transparent. There's no place to hide. You live or die by what people think of you. Robertson says the Bingham clinic's central location and its staffing with town residents reflects that focus. "All the people who work here are familiar faces," she points out."People trust us, and therefore they bring their problems a little sooner, and they don't get so sick. We keep them out of the ER, out of the hospital, and in that way we're really cost-effective."

A general wariness of the wider world underlies much of the need for treatment facilities near at hand, Robertson explains. Many country people aren't comfortable venturing even short distances beyond their front porches and backyards. "This clinic is close to home for them. People who don't like to come out of the woods - what do they call it, "woods queer"? - and those who would be afraid to drive around a big town like Waterville, an hour away, are willing to come in here and be looked at."

The medical issues are about what you might expect in a county where the poverty rate runs about 50 percent higher than the state average. Depression and lots of addiction ("pills of all kinds") are rife among Robertson's patients. And although she has managed to develop a network of peer contacts around the state, medical support services near at hand are virtually nonexistent. So how would she describe the rewards of her demanding practice? At this, Robertson shakes her head side to side as though dazed, but grinning from ear to ear. "Beyondwords," she says.

MACHIAS: LAUGHTER IN THE HOUSE

If you drive up the maine coast about 50 or 60 miles farther than tourists usually do, into Washington County, the people start to be outnumbered by lobster boats. The land is windswept and rocky, and the towns are scattered and few. Nobody makes much money; this is about as close to the bone as life in Maine gets. With slightly more than 1,000 residents, Machias is something like the capital of this northern stretch of coast. Christopher Mace, '68,grew up in this community, where his dad ran a lumber mill.

After graduation from medical school,residency in Washington, D.C., and the beginning of military service in Vietnam, Mace was recruited back home by U.S. Sen.Margaret Chase Smith to provide desperately needed medical care to the region. He ended up being one of the rare doctors in the vicinity, first working for three years at a clinic in Gouldsboro and then carrying on his practice back in Machias for a longer stretch. Mace retired in 2005. When things were good in the practice, he says, they were very good, and when they were bad, "they could be exhausting."

In Gouldsboro in the early days, "the demand was non-stop," he recounts. "People would come to the house. Then I'd have to walk into my closet since I'd see them coming into the driveway and knew they would look in the windows."

From a business perspective, being a doctor was simplicity itself. Seated on a couch in his comfortable retirement home an hour's drive south of Machias, now white-haired, wearing a sweater and looking altogether relaxed, Mace laughs at the memory. "You didn't have to document everything" for reimbursement, he comments in his light,soft voice that bears a salty trace of Maine."It was much easier in that respect." Mace took his own X-rays and read them, handled basic lab work, even provided veterinary care as needed. "I remember I treated a rabbit with an abscess one time and also a dog with porcupine quills," he muses.

Once back home in Machias, where he was one of a few doctors in solo practice, Mace found that everything was personal.The handshake, the smile, the nod to a neighbor was another brand of cure. The sense of responsibility also felt intensely personal. "As a doctor, you're part of a community where you have a certain standing,"he says. "The major rewards of that involved dealing with patients who were grateful."Every holiday season, townspeople would show up at the doctor's door bearing homemade cakes and cookies in tribute to his devotion.

Often the doctor's healing came down toan old-fashioned laying-on of hands or the deft application of a soothing voice. Macehad a home office in those days. His wife,Suzanne, recalls how she would often see apatient trudging into the house with some unknown complaint or other. "And then I'd hear this laughter," she marvels. "The patient would come out saying, "I don't know whathe does, but I feel so much better."

It wasn't all sunshine. In small communities like Machias, turf battles often erupted between doctors fighting to preserve their practices. Asked if, even with these underlying tensions, he might have enjoyed a certain advantage from being a local boy, Mace readily concedes the point. "I would say so," he says, chuckling. "I guess I knew the culture. In later years, some doctors would come in and be a little arrogant. Well, humility can be helpful up here. I knew I was in fact accepted when one man I had treated told me, 'Next to God and Dr. Larson, your name is pretty good over in Jonesboro.'"

He wore his stethoscope for 30 years. Realizing that he would otherwise be swamped by the ever-increasing paperwork that went with medicine, Mace signed on with a hospital in town for the final lap of his career. But he continued to make house calls right up until the end. "I was never able to let go of trying to take care of patients the best I could," he says quietly.

HOULTON:A RESIDUE OF WIND AND COLD

Angling north of Bangor on I-95, the land peels back and flattens its line, growing stupendous in scale. Welcome to Aroostook County, the largest county east ofthe Mississippi River - it's about the size of Connecticut and Rhode Island combined - and one of the emptiest, with only 11 folks per square mile. This is a part of Maine where a town of 5,000 people manages to be the biggest deal around.

Ted Sussman, '77, has been a doctor in Houlton since 1980. He and his wife have raised three sons here, and although he doesn't hunt or fish, he has a boat on a nearby lake and savors the life available to him. "Rural practice is the best medicine there is," he says. "Unfortunately, we physicians are a dying breed and can't replace ourselves." Sussman loves his mostly elderly patients, many of whom he has known for many years, and if a morning's sample is any indication, they love him right back.

Sussman's office is at Houlton Regional Hospital, a modern 50-bed facility that resembles the anchor store in a suburban shopping mall and draws patients from a 45-mile radius. The doctor's pace as he moves through the halls is not the easy country stroll you might expect. Instead, he stridesbetween the rooms where the patients wait,swinging through each doorway in turn and,once inside, slowing the speed of his delivery to consult with them. Sussman grew up near New York City and you can see it in the hall.

Ed, the first patient, is 75 years old and drives a truck for work. He is wearing jeans and heavy boots. Ed has been coming to Sussman for 20 years now and reports, with typical Maine understatement, "He's a pretty good doctor, I think." Ed has been taking medicine for a heart condition. Sussman tells him that his pulse rate is still too high and that he'd like to adjust his medication to slow it down a bit. "That's what I'm scared of," Ed replies, studying the doctor's face. Sussman gives a careful explanation of the move."Don't give me too many big words - give me truck-driving words," Ed jokes, but it's clear he is reassured by what he's hearing.

Minutes later, back in the doctor's office,the question arises of how an outsider goes about fitting into rural Maine culture. With his blue work shirt and khakis and his thin dark hair trailing back over the collar, Sussman has a semi-raffish, ex-hippie air. He admits that his politics are far to the left. How does a guy like this make it in a place like Houlton? Concerning his appearance, Sussman reports that his hair was a foot longer a year ago. No big deal.

People in rural Maine are surprisingly tolerant, the graduates interviewed for this story agree. All kinds of differences are fine by them. The one thing you cannot be is a deadbeat. If you stay, you must pitch in and contribute to the life of the community.

This Sussman has done. He carries a full patient load here at the hospital, seeing 20 or 25 patients a day, and is perpetually on call.Lynn York, proprietor of York's Bookstore in the compact business district of Houlton, knows Sussman well as the man who tended his father through multiple surgeries during the final stage of his life ("He kept my father alive for 20 years," he says feelingly) and as someone available to his patients around the clock. "I've been with him at movies over there many times," York relates, pointing directly across the street to the movie theater marquee, "and his beeper would always go off. I doubt he ever saw a whole movie."

Roy, today's second patient, is neatly dressed in a cream-colored checked shirt and dark slacks. His combed hair is pure white. Roy tells the doctor, seated in front of him, that he has been feeling cramps in his right leg whenever he walks any distance."Gettin' so you can't be 80 years old without going to hell just like that," he exclaims,looking around the room with a giant smile.Patients in Houlton are a good hearted and cheerful bunch. No matter what hits them, it seems, they've seen worse.

Over the course of seven or eight patients, not one complains or plays the victim - a world apart from the undercurrentof self-pity that can pervade urban settings. Where does the serenity come from? It just might be one residue of the leveling wind and cold of northern Maine. "Nature's taking its course," an elderly woman in a wheelchair tells Sussman matter-of-factly when he inquires how she is doing. It will be a while until you hear anyone say that in a doctor's office in Boston.

Before he leaves, Roy mentions the hunting camp he owns 15 miles back in thewoods. "My friend Billy and I made that road," he says, his face brightening at the memory. Sussman listens appreciatively without saying a word. Then he concludes the visit by saying: "A little Tylenol, some heat, and you'll be all right. Anything comes up, give a holler."

Sussman worries about the prospects for patients like Roy in the days to come. There was a surge of young doctors into rural areas after the National Health Service Corps came along in 1970, a time coincident with the first sizable crop of women to enter the medical profession. "Most docs came up here in the 1970s. There's a generation about to retire,"he points out. "Our ability to replace them is,right now, zero."

Don't get Sussman started on what he believes are the soft, lifestyle-centered priorities of current medical school enrollees. It's a fact that far fewer students are choosing primary-care specialties, compared to when he came through the system. "Folks now, they want to take no calls, have limited hours and make a lot of money," he alleges. Does Sussman really believe that today's students are completely spoiled? "Worse than spoiled," he answers scornfully, his eyes flashing. "I think we have lost what it means to be a physician."

That's a sobering charge. If Sussman is correct, the challenge facing the graduates of the Maine Track is two fold - first to buck stubborn historic trends by setting up shop in isolated places like Bingham, Machias and Houlton, and then to summon from somewhere deep inside the essence of doctoring. With its rugged landscape, its poverty and its charm, rural Maine awaits the resolution.

THE HOME TEAM

An abiding love of neighborhood, town or region is a powerful motivation to hang near home in your professional life, as these Maine natives can attest. All three are members of the inaugural class of the Maine Track program, a partnership between Tufts Medical School and Maine Medical Center in Portland aimed at encouraging more physicians to practice in this doctor-starved state.

Growing up the daughter of a grocer in Steep Falls, near Sebago Lake in western Maine, Amanda Call, '13, didn't run into many doctors. Whenever she visited the nearby medical clinic in Cornish, she says, "It was always overcrowded, with a lot of impoverished people there." That lack of access to medical care is something she hopes to rectify by establishing a practice in Steep Falls - perhaps in obstetrics and gynecology. "There aren't many women physicians in my area. I would love to practice in the community that I grew up in, and maybe someday have my own clinic," says the 22-year-old Call, who completed her pre-med studies at the Maine College of Pharmacy."My goal is not to make a bunch of money," she remarks, "but to have a stable practice back home."

Heather Bradford, '13, concurs. A native of Eddington, Maine, a small town on the Penobscot River 20 miles east of Bangor, she has seen firsthand the twin barriers to quality health care for area residents - first, the general scarcity of docs, and second, the inability of would-be patients to afford treatment. "A lot of times they don't have insurance or the finances even to shell out for a co-pay," Bradford says of her fellow Mainers. Coming from a single-parent household on a lean budget, Bradford is grateful for the half-price tuition deal she has gotten from her enrollment in the Maine Track. With any luck, that generosity will help guide her return home. "I can't imagine going anywhere else," she says.

Chad Szylvian, '13, the son of an electrician, reflects a similar blend of gratitude and commitment. The salutatorian of his high school class, a member of the football team and a jazz pianist, he has spent time volunteering at Eastern Maine Medical Center near his home in Brewer. Four years at Boston College left him $146,000 in the hole. "Before the Maine Track program came along," he says, "I was looking at $50,000-some a year for medical school on top of my other debt, so that half-tuition definitely helps." Because Maine has no allopathic medical school of its own, Szylvian notes that people in his shoes have no shot at an in-state tuition rate for their medical training. But he's all set now. He intends to add a public health degree to his M.D. and return home to practice in a place where "it feels like you can breathe better," he says. TM