How local, state programs are helping fill retiring doctors’ ranks | Health Reporting Lab
On the day he retired in May, Dr. Don Caruso — a primary care physician who was also president and CEO of Cheshire Medical Center — saw his final patient.
“It was really emotional. Many of these people I took care of I had taken care of for 30 years,” said Caruso, 65.
Although other doctors at the Keene hospital would step in to serve his patients, Caruso knew that a new physician would be an adjustment for many of them.
“Many of [these patients] had learned how I practiced medicine and were incredibly comfortable,” he said. “All physicians have styles, so we were really attached to each other.”
It’s a scene that’s likely not uncommon in the area, as more doctors reach retirement age. More than one in three practicing physicians in New Hampshire, including more than 40 percent of primary care physicians, were 60 or older, per 2019-20 data from the Association of American Medical Colleges (AAMC), the most recent statistics this organization has available.
The aging workforce isn’t unique to the Monadnock Region or the Granite State: National estimates project a primary care physician shortage of up to 48,000 doctors by 2034, according to the American Medical Association (AMA).
This is due in part to retiring doctors, while younger doctors choose higher-paying specialties, rather than primary care, the AMA notes. Yet New Hampshire’s mostly rural setting makes it more difficult to draw physicians to the state, compounding the problem and potentially leaving rural Granite Staters without adequate access to health care, experts say.
“The impact of losing a small number of physicians in a community because they retire could be much greater in a rural area,” said Michael Dill, director of workforce studies at the AAMC.
Efforts are underway to ensure that as New Hampshire residents continue to age — putting more strain on the medical system — they’ll have access to the providers they need.
A new residency program in Keene, grants to bolster the number of nurse practitioners in the state and visa waiver programs that allow immigrant doctors to practice in New Hampshire aim to address the shortage. And yet, experts say systemic changes — like investing in affordable housing — are critical to attract doctors to a rural area and retain them once they’re here.
“We have to do something, to keep [highly trained doctors] in the state,” said Dr. Daniel Perli, chief medical officer at Monadnock Community Hospital in Peterborough.
“We have to do something, to keep [highly trained doctors] in the state,” said Dr. Daniel Perli, chief medical officer of Monadnock Community Hospital in Peterborough.
Residency will bring doctors; retention could be tough
One way to increase the number of doctors in New Hampshire is by bringing more medical residents to the state, experts say. These are doctors who have graduated medical school and are completing additional on-the-job training.
Often, physicians continue to practice near where they completed their residency. In fact, more than 55 percent of doctors who’d completed their residency from 2012-2021 were practicing in the state where they did this training, according to a 2022 report from the AAMC.
“We know that residents tend to stay close to where they’re trained,” Caruso said. He was somewhat of an exception, moving to New Hampshire to practice rural medicine after completing his residency in Massachusetts.
Currently, there are only two residency programs in New Hampshire: one in Concord and one in Portsmouth. But next year, that will change when Cheshire Medical Center’s family medicine residency program welcomes its first cohort of six medical residents. Plans call for the three-year program to bring in six new doctors each year, for a total of 18 residents working in the community at a time.
Dr. Karl Dietrich, director of the family medicine residency program, said that while these newly minted doctors are practicing in Keene, the community — both within the hospital system and at large — has a chance to show them the merits of living and working in a rural area.
“If we can create a positive learning environment and welcome people into the community, it’s easier to get them to stay,” he said.
Dr. Karl Dietrich, director of Cheshire Medical Center’s new family medicine residency program, is shown in February at what will be the patient registration area at a new clinic on Maple Avenue. Dietrich said that while the residents are practicing in the Elm City, the community — both within the hospital system and at large — has a chance to show them the merits of living and working in a rural area.
However, retaining physicians has traditionally been difficult for the state. New Hampshire ranks 45th nationally when it comes to doing so. Only 34.4 percent of doctors who had completed their residency in New Hampshire were still practicing in the state, according to 2020 data from the AAMC.
“The state could do a better job of keeping highly trained and very talented physicians from training programs,” Perli said.
Dietrich said he hopes that up to 60 percent of residents at Cheshire Medical will continue to practice in the region. That’s about on par with the national median for statewide resident retention, according to the AAMC, although the association has no data on the likelihood of residents staying in a specific area, like the Monadnock Region.
In part, Dietrich is optimistic because Cheshire Medical’s program will target doctors who are specifically interested in rural health.
“We’re recruiting people who want to stay and practice in rural environments,” he said.
But even with that emphasis, retention can be complicated, Dill said. To attract physicians, rural communities need to “think about what a highly educated workforce is looking for,” he said.
Dr. Michael Lindberg, a primary care physician who retired as chief medical officer of Monadnock Community Hospital in 2021, often had doctors he was recruiting express concern about the availability of cultural activities, quality jobs for their significant others, good schools for their children and a nearby airport.
“These are the negatives that I’ve heard from people I’ve tried to hire,” he said. “We can’t always offer what is needed to support [physicians and their families]. Sometimes we just can’t.”
In addition, the same challenges that impact other demographics can also drive physicians from the state.
“One of the greatest challenges that we’re facing in rural New Hampshire is workforce housing,” said Shawn Jackson, head of the Rural Health and Primary Care Section of the N.H. Department of Health and Human Services. Jackson pointed out that he had recently spoken with a doctor who lived in the Upper Valley and drove 90 minutes each way to work.
UNH program graduates local NPs
People with a community connection to the Monadnock Region or an interest in rural living are more likely to navigate challenges like finding housing and needing to drive farther to an airport, said Cynthia McGuire, president and CEO of Monadnock Community Hospital.
Physician recruitment is the hospital’s most critical challenge, she said, and it can sometimes take years to find the right candidate for an open physician position. Those who are interested in working in the region are often willing to overcome its challenges because, to them, it has many benefits, McGuire said.
“Often, people who come for interviews here have family connections, or want to be in a rural area with access to small communities and outdoor living,” she said. “We attract a cadre of people who want to be in our location.”
Cynthia McGuire, president and CEO of Monadnock Community Hospital in Peterborough, said physician recruitment is the hospital’s most critical challenge.
That’s also the idea behind a University of New Hampshire program that educates advanced practice registered nurses (APRNs), providers with at least a master’s degree.
ANEW — which launched in 2019 and is funded by federal grants — covers the cost of higher education for existing community nurses to become APRNs. Many of these graduates then work as primary care nurse practitioners (NPs), a type of APRN, meeting some of the need for rural primary care providers.
“NPs in New Hampshire are actually addressing the issue, especially in primary care,” Doyle said.
In the Granite State, NPs have full practice authority, meaning they can write prescriptions and serve as primary care providers. While they work as part of a health care team that includes doctors, they do not need a physician’s oversight.
Ultimately, “having more prescribing providers work with a team means better patient experiences,” she added.
Research from the journal Healthcare shows that NPs can bolster the number of primary care providers, increase health care access and utilization, and improve quality of care in rural settings.
Yet, graduating APRNs leads to another concern: the shortage of registered nurses and other health care workers who leave their current positions to pursue higher education and ultimately practice in NP roles, Doyle said. The health care system is complex, she said, and any efforts to address a specific workforce population — like physicians — must also consider bolstering the health care workforce overall.
Graduates from ANEW work either in family practice or mental health, and commit to working for two years in a rural or underserved setting in New Hampshire. Many will stay beyond that, Doyle said, since they’re already living and working in the communities they serve.
So far, 68 percent of ANEW grant recipients are from rural communities in the state, Doyle said. She said she would like to see the program work with more health centers in Cheshire County in order to have more NPs serving this area.
Britney Waldrip, a family practice NP at Concord Hospital Primary Care in Meredith, graduated from UNH as part of the ANEW program in December 2022, and started working as an NP earlier this year.
Before getting her APRN, she was working as a registered nurse in the Lakes Region, where she lives, and she plans to continue to practice in the area well beyond the commitment required by the ANEW grant.
“This is where I see myself longterm,” she said.
About 40 APRNs have graduated under the ANEW program. Over the next four years, Doyle hopes to have 20 APRNs graduate annually.
“Although it seems like a lot, it’s really not,” she said. “There’s a really large need.”
Dill, of the AAMC, said that fortifying the existing health care workforce helps keep providers in their community and is a salve for New Hampshire’s retention problem.
“That’s a great example of taking the resources you’ve got and figuring out how you can make the most of those,” he said of ANEW.
Other states utilize similar programs for recruiting doctors from their local communities. For example, the Doctors for Maine’s Future program provides scholarships of up to $25,000 per year to Maine residents who attend medical school in the state.
“Those are real incentives for people from [that state] to go to medical school,” Caruso said.
Dr. Don Caruso, shown at Cheshire Medical Center in May, practiced primary care and retired as president and CEO of the Keene hospital that month. “It was really emotional,” Caruso, 65, said. “Many of these [patients] I took care of I had taken care of for 30 years.”
The program doesn’t require scholarship recipients to practice in Maine for a set amount of time. Yet 58 percent of doctors who received the scholarship are practicing in Maine, according to William Norbert, spokesperson for the Finance Authority of Maine, which administers the scholarship.
“Many more would like to, but find there are not sufficient residency positions or jobs here,” Norbert said.
Lindberg said it’s important to “bring people in who are from the area,” not only because they’re more likely to stay, but because they can connect with patients in the state on a personal level.
“They have a familiarity, and [we] want to capitalize on that,” he said.
New Hampshire has no direct scholarship program for local medical school students. The Granite State offers student loan repayment of up to $25,000 per year for three years, and $20,000 a year for two additional years, to physicians who work in underserved areas of the state, including rural areas, said Jackson of the state health department. Many hospitals, including Monadnock Community Hospital, will match that amount, Perli said.
Jackson says the student loan repayment program is a draw for physicians. But Caruso said it does little to distinguish New Hampshire from other states trying to recruit doctors, since most states, including Maine, have similar loan repayment incentives.
“It’s not very helpful,” he said.
Visa waiver brings in foreign physicians
In addition to the challenges of attracting any doctors to the region, Perli is conscientious about the importance of attracting diverse physicians, including women and people of color.
More than 75 percent of practicing physicians in New Hampshire in 2020 were white, according to data from the AAMC, above the national median at that time of 67 percent. The percentages of Asian, Black, Latino and Indigenous physicians in the state were below the national medians, the same data show. Only 37 percent of doctors in the state were female, slightly above the national median of 36 percent.
Unfortunately, those trends are typically reflected in the applicants to open physician positions in the state, McGuire said.
“Often, we’re trying to find the best fit between the few [physicians] who are interested in working in Peterborough,” she said.
However, one program may be able to help attract a more diverse pool of applicants.
Last year, Monadnock Community Hospital welcomed four new physicians, including three primary care providers, under a visa waiver program that incentivizes foreign doctors to work in rural America, according to Perli.
“That has helped us a lot,” he said.
Doctors who are not U.S. citizens and who did their training in other countries are able to complete their medical residency in the United States under the J-1 visa program. Normally, after finishing their residency, the doctors must return to their home country for at least two years before applying to live or work in the U.S.
However, the Conrad 30 visa waiver program, a federal initiative, allows doctors to remain in the U.S. without returning to their home country if they agree to work full-time in an underserved or rural community for at least three years.
“Hopefully by then, they want to stay,” Perli said.
About half of the New Hampshire doctors who received visa waivers between 2019 and 2023 are Asian, according to state health department data. Just over 12 percent are Latino, about 9 percent are Middle Eastern or North African, and just over 28 percent are white, the data show. (The dataset included only 82 percent of grant recipients, and it was possible for recipients to identify with more than one category. Racial categories with fewer than five individuals were excluded from the data the state provided for privacy reasons).
Cheshire Medical Center has hired 17 doctors under the waiver program over the past six years, according to Audra Burns, spokeswoman for Dartmouth Health, which Cheshire Medical Center is an affiliate of. Sixteen of those doctors are still practicing in Keene, she said.
“These numbers are indicative of a high retention rate,” Burns said.
The downside to the waiver program is that each state has only 30 waiver slots to fill each year, according to Jackson of the state health department. In fiscal year 2023, New Hampshire filled 29 of them, and in fiscal year 2022, the state filled 28.
“There’s a lot of competition among the state hospitals for those 30 spots,” Perli said. “They’re filled quickly.”
A need for more local solutions
Lindberg retired at 66 after being diagnosed with Parkinson’s disease, a progressive neurological condition. He said if it weren’t for his illness, he’d likely still be practicing, both because of his love for medicine and out of a sense of obligation to the community, knowing how hard it can be to find new primary care physicians.
“There’s a pressure to stay,” he said. “Can you tough it out for another year?”
Little changes — like hiring medical scribes to alleviate the burden of updating electronic medical records — can help keep doctors working even as they age, he said. Still, New Hampshire will need to find a way to compete with the rest of the country in recruiting younger physicians who can take the place of the state’s retiring doctors.
That may take some trial and error, as well as local ingenuity, Dill said.
“There are some broad things that we can do as a nation, but really it comes down to what will work best for a particular community or state,” he said. “What will work for rural parts of New Hampshire might not work for rural parts of Arizona. And what works for different parts of New Hampshire won’t be the same.”
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