My father was a small-town family doctor. He spent his entire career in one community, Howland, serving his neighbors from an office in the basement of our home. Despite his colorful rants at inopportune phone calls, he loved his life and the role he played in providing around-the-clock medical care, personal guidance, emotional support, and leadership for the people and families of our region.
When I first considered following in his footsteps he commented to me, “When you’re a doctor, you’re a doctor first, before everything else.” Were my father alive today, I think he would be concerned about a system that increasingly fails to uphold the standard of care to which he dedicated his life.
Over the 33 years of my own career as a family doctor, much has changed. Physicians now graduate with six-figure student loan debt, and primary care specialties are among the lowest-paid career options for doctors.
Unlike my father, health care professionals now focus on a reasonable work/life balance. Unfortunately, primary care offers a highly unpredictable day-to-day workload. The advent of electronic health records, with all of their benefits for managing complex information, have changed the nature of a doctor’s work and interfere with the profound human interaction that is so critical to the provider-patient relationship. Meanwhile, the consolidation of health care delivery systems and shift to employed positions limit physician autonomy, which is fundamental to professional satisfaction.
These changes in medical practice, along with dwindling local resources, have harmed rural communities in Maine by producing an exodus of health care professionals and services. Across the country, more than 100 rural hospitals have closed since 2010, and 430 more are at risk of closing. Two hospitals in Maine have filed for bankruptcy, and others are forced to eliminate key services, such as obstetrics. This puts our rural communities at risk, as demonstrated by a recent study showing an increase in mortality associated with the closure of rural hospitals. A companion study showed that adding 10 additional primary care physicians per 100,000 population is associated with a 51.5-day increase in life expectancy.
Between 2005 and 2015, the U.S. has seen a decline in the number of primary care physicians (from 46.6 to 41.4 per 100,000 population). That decline is even steeper in rural areas, and it has been widely publicized that for the first time since World War I, life expectancy in the U.S. is decreasing. That decrease is most dramatic in rural areas affected by primary care shortages.
These alarming trends can still be reversed. Targeted investment in primary care has been shown to improve outcomes and reduce costs. Medicaid expansion is associated with lower rates of hospital closure. Physician training that focuses on the skills and values needed to provide care to the underserved can help to build the workforce necessary to sustaining services, and telemedicine can play a key role in filling in gaps in services for those who live in rural Maine.
Maine’s 2nd Congressional District is one of the most rural in the country and has been deeply affected by these negative trends. Legislation has been introduced in Congress that would allow people ages 50 to 64 to buy into Medicare, which would improve access to care and increase funding for local health care institutions. There are additional congressional efforts to ensure that Maine and other states which were late in expanding Medicaid receive the same levels of federal funding as states which expanded earlier, to improve access to rural broadband and to increase Medicare payment for telehealth (which would help to bring telemedicine to rural Maine), and to support the training of physicians and dentists for rural care. We are fortunate that U.S.Rep. Jared Golden has worked to support all of these efforts.
Rural Americans deserve quality health care delivered close to home. Policymakers, hospital administrators and primary care leaders must collaborate in new models of partnership with the people we serve to create sustainable health care services focused on reducing competition, eliminating waste, improving access to care and fully meeting the health care needs of our rural communities.
Dr. Noah Nesin is the chief medical officer at Penobscot Community Health Care. He has practiced as a family physician for more than 30 years.