Editor’s Note: This is the first in an intermittent series of stories that will examine how the Family Practice Center of Eastern Maine Medical Center trains doctors for rural practice. The series will follow a resident through three years of training.

BANGOR – On a shelf in the sparsely decorated office of Dr. Robin Pritham is a book that has been read so many times its pages are loose from wear. The book, “Doc Pritham,” is often lent to aspiring rural doctors who have come to Bangor to prepare for practice in Maine’s hinterlands.

Robin Pritham, director of Eastern Maine Medical Center’s residency program, smiles when he remembers his grandfather Fred, subject of the 1971 book by Dorothy Clarke Wilson.

Fred J. Pritham grew up on a farm in Freeport, earned a degree from the now-defunct medical school at Bowdoin College, and moved to Greenville to practice. Unlike doctors in the big cities, he wore chamois shirts and regularly traveled to see his patients. He hopped trains, piloted boats and drove first-generation snow machines in order to treat patients settled along the shores of 40-mile-long Moosehead Lake.

Despite the distances, he knew the medical and financial history for most of his patients. Consequently, he rarely made extensive notes after treating them.

He might just scribble “sore-throat,” the grandson remembers. Record keeping wasn’t the time-consuming, grinding priority it is today. He had to handle his own billing and office administration. He rarely had any help – not even a receptionist.

There were times, such as after a call to the tiny village of Kokadjo at the northeast corner of Moosehead Lake, that he’d steal a few hours to hunt deer. But Pritham was on-call 24 hours a day and never knew where the next trip would take him – such as the one to a logging camp to help a burly woodsman with an infected tooth.

It was a demanding life that offered slim financial reward but significant social standing within the community.

Fred J. Pritham died in 1972, but his medical legacy lives on. His son Howard became a doctor and practiced for many years in the Panama Canal Zone. Two of Howard’s sons, Robin and Howard G., chose medicine as a career. Howard G. is a surgeon in rural New Hampshire.

Now, almost 100 years after Fred Pritham struck out for Greenville, his grandson is a middle-aged man training the modern equivalents of his grandfather.

His goal is to find medical school graduates who’ll work for three years under the watchful eye of doctors at the Family Practice Center to perfect their skills and then choose to work in rural Maine.

Country doctors today still have less support than their counterparts in regional centers like Bangor. A doctor in a small town has to make crucial decisions about when to transport patients from a local hospital to a more extensive, “tertiary” hospital such as Eastern Maine Medical Center. They also may have less contact with colleagues and state-of-the-art procedures.

With less support staff available, there is also a lot of record keeping to be done in the era of managed care, Dr. Robin Pritham noted.

“I think we lose out in a way because it’s less time with the patient,” he said.

The Maine Medical Association has a task force dedicated to recruiting doctors for hard-to-fill positions in country towns. There are about 20 family practice openings in rural areas today out of a total of about 87 openings throughout the state, said Jim Harnar, a spokesman for the Maine Hospital Association. It commonly takes six months to more than a year to fill these rural openings.

When an isolated community is short a doctor, it’s a major problem. Harnar said that without EMMC’s residency program, the shortage would be even worse.

The shortage of doctors choosing rural care comes from more than just a lack of support staff, Pritham believes. Found even at medical schools is a rooted cultural bias against rural practice, which is viewed as neither profitable nor prestigious, he said.

The same biases, if somewhat weaker, were in play back when he was in medical school at the University of Vermont in what was certainly a rural setting, Pritham said.

“Even in Vermont there was this perception that the brightest people don’t go into rural care, especially on the M.D. side,” he said. Instead they go to the “glamour of the surgical specialties.”

The attitude is fortified by a medical school admissions preference to seek the absolutely brightest people, who “may not be the people who are interested in rural care,” he said.

Another key issue is debt. A medical education can put a prospective doctor $120,000 in debt. Some government programs assist with some or all of the debt burden, if a doctor practices in isolated areas for a certain period of time.

Outside Pritham’s office window at the Eastern Maine Healthcare Mall on Union Street, snow is drifting through the air. He greets Emily Jan June, who comes well recommended from the University of Vermont’s College of Medicine. June had graduated from Vanderbilt University and had been a nurse for nine years before deciding to pursue a career as a doctor.

When she arrives at Pritham’s office, June has already been out to dinner with the program’s current residents and interviewed with several of the doctors who serve as faculty members. This morning she has just a few questions. She wonders what it’s like to have a residency program that has no competing residency programs nearby.

Acknowledging that the program is without “opposition,” Pritham grabs a book of Maine maps whose back cover is faded from use. With his finger, he divides the state from around Waterville northwesterly up to Canada. EMMC’s service area encompasses about two-thirds of the state of Maine and serves 400,000 people, he said.

The small rural hospitals in that geographic region send their sickest patients to EMMC, where even open-heart surgery is offered.

“There’s very little that goes past us,” he said. “That makes for an interesting training environment because we’re a tertiary hospital serving a rural population.”

The residents must do a rotation to rural hospitals elsewhere in the state. Right now, second-year students go to Lincoln and Dover-Foxcroft, he said. Most come back to Bangor amazed at the range of what medical staffs at the smaller hospitals are capable of doing without a lot of technology, he said.

Pritham, who is quick to tell June that both her credentials and a tight application pool should allow her to get a position at her first- or second-choice program, spends most of his time making a pitch for Bangor and the quality of the residency program. He says the hospital is a friendly place where residents will deal directly with specialists and others in devising care for patients.

He talks about the cost of living and the people.

“Most of the people in Bangor are here because they want to be here,” he said. “They’ve recognized that they might make a lot more money somewhere else.”

June said she’s settled on New England and wants to practice in a rural setting. She said UVM officials speak well of the program while there are many others in New England that they criticize.

Pritham smiles. “Our biggest problem is getting people to come look at us,” Pritham admits. “You don’t come here on your way to somewhere else.”

Many graduates of the program have stayed in Maine, Pritham said. A road map mounted in the hallway is dotted with red-headed pins representing residency graduates serving in the state. A cluster is evident on Mount Desert Island. Passers-by have had fun rearranging some of them – one pin sits in the ocean, but the map fairly represents the program’s success, Pritham said.

The program aims to have nine residents a year. Of the more than 160 graduates since 1975, about half are still in Maine today, Pritham said.

Immediately after graduation, an average of 60 to 70 percent stay in Maine. A few, who really take the “rural” in rural health care seriously, have gone to Alaska. Of last year’s nine graduates, seven are in Maine, Pritham said.