Brave Little State is Vermont Public’s listener-powered journalism show. In each episode, we answer a question about Vermont that’s been asked — and voted on — by you, our audience. Today, a question from Jen Kaufman, in Vergennes:
“What is the state of primary care in Vermont and where is it anticipated to go? Why is it so hard to get a primary care provider?”
Reporter Lexi Krupp sizes things up and talks to a father-son doctor duo about how times have changed. Plus, how some are working to fill in the gaps.
Note: Our show is made for the ear. We highly recommend listening to the audio. We’ve also provided a transcript. Transcripts are generated using a combination of robots and human transcribers, and they may contain errors.
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The search for primary care
Bobbie Groves: Well, we had a doctor we liked very much and she switched from being a primary doctor to being a hospitalist and so we lost her.
Jon Holmer: Probably a couple times a week, I would just spend a couple hours making calls.
Alex Spieler: And that’s, that’s where I heard the phrase, “Not accepting patients,” and I was like, “Oh, okay.”
Paul Capcara: And It wasn’t until the first several calls when I was being told things like, “The wait list is so long we’re not even going to put you on it,” that I started to have a sinking feeling of my odds of finding success.
Jon Holmer: I started calling just anybody, anywhere — St. Johnsbury, Rutland, everywhere.
Alex Spieler: And I put in my zip code — I put in South Burlington zip code. It says, “Oh we have six doctors in your area.” It turned out, though, they were all in Randolph. And I looked them up and they all worked in an OB-GYN, and I do not need those services.
Bobbie Groves: No it's not optional, we’re 78 and we have many accumulating physical challenges.
Alex Spieler: I ended up calling – 1, 2, 3, 4, 5, 6, 7 – I called seven different places. And all but one of them were not accepting patients.
Jon Holmer: And, you know, everybody that I called tried to be helpful by saying, “Well, why don’t you try so and so.” And I had already tried them. So it was just one dead end after another. I think, I think I called over 50 providers.
Alex Spieler: And in fact one of them was just a name, and I googled his name and the first thing now that pops up is just obituary.
Jen Kaufman: I mean I get requests almost daily when I’m at work. And it’s just a really tough conversation because … it’s not that I want to say no, it’s just that we sort of have to say no because we’re already so overburdened.
Lexi Krupp: Jen Kaufman is a primary care doctor in Vergennes, in Addison County. That means she’s the entry point for patients into the health care system. Jen’s an MD, but your primary care provider could also be a nurse practitioner or a physician assistant.
She got into this type of medicine because of the relationships — getting to know patients over the years, from routine visits to end of life care.
Jen Kaufman: And that’s what you get in primary care is sort of a little bit of everything. Jack of all trades, master of none, but a continued patient connection.
Lexi Krupp: And she recently wrote into Brave Little State with a question about this line of work — her line of work. Because in Vermont, it seems like things are not great.
Jen Kaufman: Like yes, I'm aware that there's a bit of a crisis. And I guess I was really hopeful during the pandemic that I was like, “Oh, now's the reckoning. Here we go.” And that came and went, and things are not better. If anything, they're worse.
Lexi Krupp: Jen’s calling this a “crisis” because, well, if you’ve been trying to get an appointment recently, you might know how backed up things are for patients.
But according to Jen, it’s also untenable for many on the other side of the equation.
Like, she’s cut back on the number of patients she sees to manage her workload. And a lot of primary care providers have left the field altogether.
Jen Kaufman: I guess I've just been thinking about it a lot. And I guess I’m like, being a little selfish and like, “Can we all talk about this?” Because this is a big problem for me. And a big curiosity for me.
Family practice
Patient: Good morning.
Staff: Hi, how are you?
Patient: Not too bad, how are you?
Lexi Krupp: Green Mountain Family Practice has been operating for almost 80 years in Northfield, a town in central Vermont of around 6,000 people. For much of its existence, the office has been across the street from Norwich University, at the base of what was once a ski hill.
Craig Sullivan: I’d go up at lunch time and do three or four runs at the old Norwich skiway, you know, go up in the little chair lift, go up and come down. The toboggans would come down off there with broken legs and stuff — they would ski the toboggans down there into the back door of my office, up the ramp, right into the X-ray room.
Lexi Krupp: Dr. Craig Sullivan started there in 1983. In the early days, he worked at the practice with one other doctor. His wife was the office manager. And they did just about everything — going back and forth from the hospital, making house calls and taking X-rays. His son, Matt, remembers watching all this as a kid.
Matt Sullivan: You’d take the X-ray into a dark room and put it into the different — I still remember you developing X-rays.
Craig Sullivan: Put in the fixer, put in the developer, then hang it up on clothespins on a clothesline in there to dry them. (laughter) That's what we were doing. It was pretty unique. It was pretty unique.
Lexi Krupp: Craig is semi-retired now. He volunteers at a free clinic in Barre, and helps treat football and hockey players at the university. And he still fills in at the office when it’s needed.
These days, Matt is the Dr. Sullivan who’s in charge. And he gets why things aren’t quite like they used to be.
Matt Sullivan: I can see how the health care system may not look at some of those things as “efficient” now. (laughter)
Craig Sullivan: (laughter)
Matt Sullivan: You’re doing a job of a tech or somebody else and you’re not working to the highest level of your licensure.
Lexi Krupp: Today, the office is a lot nicer than when Craig was starting out. It’s in a new building. There’s a lab with all sorts of fancy tech and noisy fans.
Matt Sullivan: Testing all sorts of things. Pee, blood, spit. Swabs — swabs of just about anything you could swab.
Lexi Krupp: There’s a lot more staff — a social worker, a team of nurses.
Craig Sullivan: These are the people that make him look good. Some days.
Matt Sullivan: Exactly right.
Lexi Krupp: But even with all this staff, Matt is actually seeing fewer patients than his dad did in the ’80s. Here’s the elder Dr. Sullivan, again.
Craig Sullivan: I could see far more patients than Matthew ever sees. I could see double the number and spend more time with them, because my charting was very minimal — it was minimal, but I thought it was adequate for what I needed to know for next visit and everything else.
Lexi Krupp: That charting that’s he talking about — or writing notes — it’s documentation required in part by insurance companies to bill for a visit. These days, it’s a big time suck.
Another is this constant negotiating with insurance companies, trying to convince them to greenlight the drugs or tests or other treatments clinicians like Matt say their patients need. Before 8 o'clock in the morning, he had already been dealing with this.
Matt Sullivan: Yeah, we were, I had to sign forms and look in somebody's chart and legitimize why I'm ordering something — like, of course, “It's in my note. Yes! There's a reason I wanted this asthmatic to have this type of steroid inhaler. Come on!” Anyway.
Lexi Krupp: This is actually supposed to get a little better next year — thanks to a new state law allowing doctors to bypass this haggling process in certain instances.
But this only applies to some insurances that the state regulates — so not things like Medicaid or Medicare — and only some treatments. It doesn’t get rid of this process for most prescriptions, which Matt says actually takes up most of his time.
All this behind the scenes stuff has really ramped up in the last couple decades — the negotiating, the billing, plus reviewing notes from other doctors, answering messages and following up on lab results — it takes hours every day and cuts into time seeing patients.
In many ways, it makes this really important job sort of suck.
Craig Sullivan: I watch Matthew now, and I just go, “Wow, a different level of stress.” My stress was way different. I had a lot of stress. But it was time, and it managing different things — he has a way different level. Harder. In so many ways.
Lexi Krupp: More than half of residents who train in primary care end up going into specialties or working in hospitals instead, according to a recent report on the status of primary care in the U.S. This is something Matt witnessed first-hand.
Matt Sullivan: So many people in my residency, some of the most wonderful, brilliant people that I’ve met in my life — there was 12 of us in my class, and only four of them are still providing primary care.
Lexi Krupp: A big reason why comes down to money.
In medicine, the money is in the specialties — those providers get paid more andthose visits are worth more according to insurance companies. It’s been that way for a while.
Matt Sullivan: And that led to a pattern where primary care could barely make money despite being kind of the linchpin in the healthcare system. It could barely stay afloat and really couldn't, which is why a lot of practices had to be bought by larger health systems.
Lexi Krupp: That’s exactly what happened here. A while back, Craig sold the business in Northfield to a nearby hospital: Central Vermont Medical Center. Then that hospital became part of a bigger system: the University of Vermont Health Network.
And even with all this consolidation, the practice here is still in the red.
Matt Sullivan: If you look at the monthly budgets, we lose money over time. And that is both known and anticipated. And that's what the budget, the expected budgets look like. And that's usually how it turns out.
The diagnosis
Lexi Krupp: So, from the inside of the primary care system, things do not look good. But Vermont has a lot going for it — at least on paper.
About nine in ten adults in the state have a “personal health care provider” according to a recent survey from the department of health. That’s higher than the national average, and consistent pretty much across the state.
And while the number of doctors in primary care isn’t growing, we have way more nurse practitioners and physician assistants in the field than we used to.
But here’s the rub: Patient needs are higher, mental health issues are more common and, on average, Vermonters are older and sicker than they used to be.
That’s true for patients as well as the doctors treating them. A lot of primary care docs are near retirement —a third are over 60, as of a few years ago.
All these stats mean while a lot of Vermonters do have a primary care provider, those clinicians, like Matt, are overloaded. Many work part-time or switch to working in hospitals or specialties instead — remember, that’s where the money is.
So for the 10% or so of people who don’t have a provider — good luck. If you’re persistent, eventually, you’ll probably get an appointment. It’s just going to be a long wait.
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No magic number
Lexi Krupp: One thing Dr. Jen Kaufman, our winning question asker, wants to know is just how many more primary care providers does Vermont need to meet patient demand?
Jen Kaufman: What does that number look like statewide, and then how does that translate to the actual population? I’m really curious about that. Like, what is this deficit looking like?
Lexi Krupp: When we talked about this, I was a bit presumptuous.
Lexi Krupp: I mean, I think that should be know-able.
Jen Kaufman: Yeah.
Lexi Krupp: So it's great, actually.
Lexi Krupp: The U.S. Department of Health keeps track of “shortage areas” for primary care. For every state, they list how many providers are needed to boost the workforce. It was just updated. Only it says, the number of primary care providers needed in Vermont? Zero. Which doesn’t seem right.
So to figure out what was going on, I started making calls.
Lexi Krupp: Hey, this is Lexi Krupp calling from Vermont Public.
Hey, this is Lexi Krupp calling from Vermont Public.
Lexi Krupp: I talked to several people at the department of health, people working on recruitment for primary care in Vermont, and health care policy experts.
I learned there’s no magic number for how many primary care clinicians you need to keep everyone healthy.
One person I emailed told me that number is such a moving target that no one wants to hazard a guess.
And then I met Dr. Anne Morris.
Anne Morris: And we are currently sitting outside our office. And it's fantastic. It'll be the only sunshine that I get today.
Lexi Krupp: Anne works at UVM’s Family Medicine practice in Milton. She dug up a report from a national research group that tried to estimate how many more doctors we need in the state to meet patient demand.
It doesn’t include nurse practitioners or physician assistants and it’s an old number, but it’s the only real data point we could find.
Anne Morris: This is from — just to be clear, I think it's from 2010.
Lexi Krupp: Okay.
Anne Morris: So it’s old, but it hasn’t been updated.
Lexi Krupp: It says: On top of the 600 or so primary care docs we have, we’ll need 120 additional doctors by 2030. At least, that was the number back when the report was made.
Anne thinks the need is even greater today
Anne Morris: Either we need to hire two times the number of doctors, or we need to figure out the systems changes to allow the docs that we currently have to meet those full-time needs.
Lexi Krupp: She’s thinking about this stuff a lot because she runs the only family medicine residency program in the state, at the University of Vermont — that’s where doctors finish their last few years of training before going into primary care. And by the way, “family medicine” technically falls under the “primary care” umbrella, along with things like pediatrics and internal medicine.
The UVM program graduates six doctors a year — it’s been that way since the program started. And Anne says the reason training doctors in Vermont is so important is that most people end up staying close by.
Anne’s really involved with advocacy at the state level to keep doctors to come here and stay — things like forgiving student loans and spending more money on primary care. Because if not?
Lexi Krupp: It's gonna be bad?
Anne Morris: It will be bleak.
Lexi Krupp: There are some bright spots here.
There’s a second family medicine residency program in the works. This one will be geared towards serving rural parts of the state — in Morrisville, St. Albans, Randolph and Rutland. If all goes according to plan, they’ll have their first class of new doctors in 2026 — around six to eight a year.
The state also recently allocated millions of dollars to fund over 70 new positions for mental health and addiction specialists at primary care practices across the state. It’s to expand an existing program that’s been a big help at clinics like Anne's.
Anne Morris: And it's cool because we have the social worker and the nurse who are with us. And so we're providing that wraparound support.
Lexi Krupp: Those new positions, though, are only guaranteed funding for the next two years.
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Filling in the gaps
Lexi Krupp: So there’s a lot being done within our current health care system to make it work better. Then there’s what’s already happening totally outside the system. Like, in a dozen towns in Vermont, there’s something called a community nurse.
Sunny Martinson: Knock, knock! Hello.
Richard Starr: Hello.
Sunny Martinson: Hello.
Lexi Krupp: Sunny Martinson is the community nurse for Thetford, a town in Orange County. She’s retired from working as a triage nurse at Dartmouth Hitchcock Medical Center. And she’s been in this part-time role for the past year.
Sunny Martinson: I brought you a present. C’mon.
Lexi Krupp: Every Wednesday, she visits Richard Starr, an 80 year old who used to teach middle school woodshop and lives in the house he built himself. Today, he has issues with his memory and mobility. Sunny comes over to fill his meds — but she ends up doing a lot more.
Sunny Martinson: So, I’ve found that I'm also managing — like, last fall his refrigerator broke, so I helped him get a new refrigerator, or this driveway is impossible, and he didn't even have anyone to plow it until January. He had no snow tires for the car. So I mean, I'm doing more than just filling the pill box, but anyway, anyway.
Lexi Krupp: On this day, she brings Richard the newspaper with a list of community events. They talk about installing a railing on his spiral staircase. And she looks at his blood pressure readings.
Sunny Martinson: We’re supposed to be writing these down, remember?
Richard Starr: Yeah, I was, I haven’t for a few days. But if you press that left hand button it will just tell you what they were.
Lexi Krupp: And what she's doing — it’s not a replacement for a doctor. But she fills a gap in Richard’s life that the traditional health care system just isn’t set up for.
Sunny and I say goodbye to Richard after about an hour.
Sunny Martinson: All right, Richard, be good.
And this is if I'm gone. By the way Richard, I'm gonna be gone for 10 days in June. So I set up the extra pills (laughter)
Lexi Krupp: Sunny works with about 30 clients regularly, mostly older adults. Some she sees every week. For others, it’s less often.
Sunny Martinson: Sometimes there are real medical needs, but more than anything you keep hearing about, you know, people who were isolated in rural Vermont — boy, are they isolated. So I think they just like to have people visit.
Lexi Krupp: What’s sort of radical about this is it’s totally free for people who live in Thetford. Over 250 people in town have called on the nurse over the past few years.
Here, a nonprofit pays for the position, mostly funded by grants with a small portion coming from the town. In other places, like Tunbridge, the position is entirely taxpayer-funded.
And this model is expanding: Hartford and Putney, Vermont, and Lyme, New Hampshire are currently hiring for a community nurse position.
That means more people like Sunny to look out for patients.
Sunny Martinson: I love these people. I just wish I could help them more, you know, because we are a rural community. And they don't get — a lot of them don't have primary care docs. Or family.
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Credits
This episode was reported by Lexi Krupp and produced by Burgess Brown. Editing and additional production from Sabine Poux and Josh Crane. Angela Evancie is Brave Little State’s executive producer. Theme music by Ty Gibbons; other music by Blue Dot Sessions.
Special thanks to Sophie Stephens, Bobbie Groves, Alex Spieler, Jon Holmer, Gary Drown, Paul Capcara, Jessa Bernard, Susan White, Stuart May, Yalda Jabbarpour, Margaret Gadon, Leigh LoPresti, Fay Homan, John Saroyan, Jess Moore, Sheila Keating, Kristin Barnum, John Olson and Stephanie Pagliuca.
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