A few weeks ago, I attended the incoming class reception for the Tufts University School of Medicine/Maine Medical Center Maine Track MD Program and was buoyed by the optimistic young faces about to embark on a grueling training program. My husband, a rural family doctor (who has an opportunistic streak), accompanied me, in part, to corner students about rural practice.

It was a function of my job to attend, as I work for a small foundation that provides partial student scholarships. We met our “scholar,” a slightly older student originally from Greenville who has held interesting jobs in the health care field before she decided to attend medical school. My husband asked what specialty she was considering. She said she’d like to end up in primary care. He smiled.

Primary care clinicians are the first point of contact in the health care system for people presenting with undiagnosed signs or symptoms. In the physician world, this usually means family physicians, general internists and pediatricians. That first contact is also increasingly a nurse practitioner or a physician’s assistant.

Primary care physicians are very difficult to recruit these days — particularly for rural practices — because they have nearly become an endangered species. Just ask my husband. His health center practice in Coopers Mills has been looking for a physician for three years. In the 1960s, about half of physicians were in primary care practices. That number dropped to 32 percent in 2013. Adding the rural factor compounds the problem. While 20 percent of Americans live in rural areas, only 11 percent of physicians practice there.

Medical care researchers predict a shortfall of between 12,500 and 31,000 primary care physicians by 2025. Expanded access to health care through the Affordable Care Act will add another 16,000 or so physicians to that shortfall.

Why has the supply of “generalist” physicians dwindled, even in the face of increasing demand? Economics is a major reason. Medical student debt has skyrocketed in the past few decades to a national average of $176,300 per student, not counting undergraduate college debt. Increasingly, new graduates feel they can’t afford the lower incomes of primary care clinicians if they are to pay off that debt. Primary care also is saddled with low reimbursement rates from insurers, high administrative burdens and a business model that demands high volume to break even.

The medical education system is also to blame. Primary care role models are few in academic settings where specialist superstars abound. Clerkships — clinical training experiences for students — focus more on specialty rotations. Clinical professors often pull students aside and tell them the “don’t really want to go into primary care.” An Annals of Internal Medicine article about medical school labeled that the Too Smart for Primary Care syndrome. Biases in medical school have turned many students away from the primary care career choice.

Fortunately, Maine has two medical schools that are trying to break the mold. The University of New England has operated the College of Osteopathic Medicine for the past 37 years. US News and World Report recently honored the school for being one of the top medical schools in the nation for producing graduates who choose primary care residencies. It also received high marks for promoting rural medicine; its graduates fill many rural practice slots in Maine. But it was not enough.

The Tufts/MMC Maine Track was created in 2008. As a relatively new medical school, it has the flexibility to develop a program specifically for this rural state. The Maine Track is designed to immerse students in both primary care and rural practice experiences. The program intentionally chooses many students from small towns in Maine. Clerkships are scattered all over the state. Significant scholarship support is critical in this program, recognizing that student debt load drives graduates away from primary care. They have stacked the deck as much as possible to encourage primary care and rural practice.

No structural stigma is hard-wired into the culture of either of Maine’s medical schools. The ethic from the top down is that primary care is valued.

That, plus other trends, gives our rural state some hope. Across the country, medical student interest in family medicine is on the rise. After several depressing decades of unfilled family practice residency programs, there is now an upward trend in medical students choosing that training. Family medicine has been the highest recruited medical specialty for the past eight years, followed by general internists.

As I walked out of the Maine Track ceremony with my husband, I wondered how many of those ardent medical students leaning toward primary care would actually choose that field when all is said and done? And then how many of those will choose to practice in a rural area? I learned later that about three-quarters of the Maine Track 2015 grads are going into primary care. My husband smiled.

Lisa Miller, of Somerville, is a former legislator who served on the Health and Human Services and Appropriations and Financial Affairs committees.

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