Primary health care is crucial: It saves lives and reduces health disparities, especially in rural areas. But nearly a third of Americans don’t have access to a primary care provider — and that number is growing, according to a recent report by the National Association of Community Health Centers.
In the Northeast Kingdom town of Island Pond, one primary care doctor has been taking care of the community for more than 30 years. We’re going to join him for the day as he sees his patients and reflects on his career.
This story is a collaborative documentary, told from the point of view of its main subject, in his own words. The narration is the result of many hours of conversation and work between Dr. Primeau and Anna Van Dine, written based on transcripts and emails.
Some interviews did not make it into the final story; we are deeply grateful to everyone who participated.
This story is made for the ear. We highly recommend listening to the audio. We’ve also provided a transcript.
Dr. Bob Primeau: [Reading patient list] OK, so I have a patient starting right now. The nurses are just putting her in. Next guy, just kind of routine, diabetes, anxiety. Next one, interestingly, I have two patients with the same name, and I, [laughs] I think this is the one who's a nurse who's got high blood pressure. We'll see.
Dr. Bob Primeau: I'm Dr. Bob Primeau. This is my list of patients for the day. I'm the primary care physician in a small town in the most rural part of Vermont. I'm one of the only primary care providers — and the only MD — for miles around, and I treat people of all ages, from all different walks of life with all different kinds of problems.
Dr. Primeau: Next guy's an 83-year-old tough as nails old farmer, still helping his son on the farm. Next one's a middle-aged woman with diabetes who struggles to control her weight. I'm hoping to get a house call in to a woman that's sort of semi-palliative with heart failure —
Dr. Bob Primeau: I've been working here for 34 years, and I've gotten to know most of my patients well. Lately, though, my job has been changing and not for the better. I waste more and more time on the computer that I could be spending with my patients, and I'm getting ready to leave.
Before I do, I'd be happy to let you tag along with me for a day at the clinic as I see my patients, to give you a window into what I do here.
[Baby cooing in an exam room]
Patient: He's big!
Dr. Bob Primeau: He’s a pretty good size for four months, isn't he?
Patient: He's, he's the biggest boy of them all, by far. Not weight at birth but weight right now. Like looking at the baby books and stuff, what he weighs is a lot more.
Dr. Bob Primeau: He's gonna catch up to some of the other guys before they know it. OK.
Dr. Bob Primeau: On a given day, I often see a patient or two at the hospital, then at the clinic, I'll usually see about 15 patients, maybe a dozen adults and three kids.
Dr. Bob Primeau: Yeah, 80th percentile on his height, 60th on his weight, so he’s big but he’s not huge. Good, healthy size, let me get the numbers down for you. So that means his Tylenol dose is to the halfway mark, the 2.5 now.
Patient: OK. Yeah, I've been sticking with what you told me for now while he's been teething.
Dr. Bob Primeau: Island Pond is in the region of Vermont known as the Northeast Kingdom, which has the Canadian border to the north and New Hampshire to the east. Most things that people think of that make Vermont unique compared to the rest of the country are amplified in the Northeast Kingdom: the winter and the terrain, and their isolating effects.
Bobbi-Jo Letourneau: There's huge socioeconomic disparities in this area. You know, we're one of the poorest in the country, let alone the state.
Dr. Bob Primeau: Bobbi-Jo Letourneau is our community health worker. She helps patients navigate different aspects of the health care system, and often other parts of their lives, as well.
Bobbi-Jo Letourneau: You know, we have a lot of people that are probably on assistance just because the jobs are few and far between. They don't always necessarily pay as good as other places. Because we are so rural, we're not a city.
Dr. Bob Primeau: Island Pond is in the center of Essex County, which has less than one person per square mile. The Island Pond Health Center, where we work, is embedded solidly in the middle of a town of about 1,000 people. It's relatively isolated; we're about 25 miles from the nearest hospital and other available medical care.
Bobbi-Jo Letourneau: So you know, you're locked into an area where you have very limited options.
Dr. Bob Primeau: The Island Pond Health Center has seven exam rooms, half a dozen nurses, and an in-house pharmacy. We share the building with a dental office, so it's pretty much a one stop shop. We have roughly 2,000 patients total, split between myself, a nurse practitioner and a physician's assistant. I'm certified in both internal medicine and pediatrics, which means I'm able to treat pretty much anyone who walks in the door.
Bobbi-Jo Letourneau: Dr. Primeau has been a provider around here since I was a little girl, and just to be able to have that access to somebody with his knowledge base and experience, it's a big deal. I mean, he literally sees from the day you're born until the day you die, and everything in between. We're never going to see that again. We're never going to be able to replace that in one person in this building, the way he does it.
Dr. Bob Primeau, in the exam room: It's definitely swollen. You can see that, huh, like through there, compared to the other side.
Patient: Yeah, it is tender there.
Dr. Bob Primeau: What about on the side there?
Patient: Aha, yeah.
Dr. Bob Primeau: That's very tender. OK. Right now, the fastest, good knee people, you know, fastest closest, is probably the Alpine Clinic in Littleton. Dr. Korsh, people like him a lot in St. J, but he's like, five months backed up. Our knee guy in Newport recently left, and Dartmouth has a pretty good wait —
Dr. Bob Primeau: Our clinic is part of Northern Counties Health Care, which runs a handful of federally qualified health and dental centers in the region. They operate on a sliding scale that goes deeper than the state's Medicaid rules, so it provides some pretty vital services to a lot of people who need them.
The organization was started by David Reynolds, who's now one of my patients.
David Reynolds: Back when I started the health centers, the community was without any health services at all. I mean, they had solo practicing general practitioners, and then when they retired or moved away, there was nobody there. So the need for local health services was obvious.
Dr. Bob Primeau: The clinic opened in 1977. I started working here in 1991. Despite everything there is to be said about poverty and limited jobs, I found myself surrounded by a really high number of skilled, surprising, eclectic people, both those born and raised in Vermont and transplants.
The community was warm and welcoming, and it was obvious from the beginning that there was limited separation between the office staff and everyone else in town.
David Reynolds: You're part of the community, you know, and you can see, very tangibly, the difference you make. Whereas, if you're in a hospital practice where people may just come in, you don't really know them that well, maybe. And you know, they come in and they go out, and they may come and see you again, or they may not. But it's — the name, I think, says it well: a community health center.
Dr. Bob Primeau: My memories of the early years have gotten fuzzy, but I remember how much I love the fact that we had a facility in the boonies that could do major medical work. I loved that I could make house calls. I loved that I could sometimes go for a swim or a run at lunchtime.
David Reynolds: It doesn't appeal to everybody, but for those that it does, like Dr. Primeau, he's fit here, like, you know, a hand in a glove.
Dr. Bob Primeau, in the exam room: So when is opening day?
Patient: Opening day of fishing season is Saturday.
Dr. Bob Primeau: That's what I thought. Coming right up.
Patient: For trout. Course, you could fish now for perch and other stuff. Catch and release.
Dr. Bob Primeau: No chest pain, chest heaviness, breathing's OK?
Patient: Yeah, up and down stairs, no problem.
Dr. Bob Primeau: Just seeing that thing on your arm, is that new?
Patient: You're supposed to take that one off today. That's why we're here.
Dr. Bob Primeau: Let's get moving. We're gonna go to the other room, OK.
Dr. Bob Primeau: Being a doctor in a place like this isn't like being a doctor in the suburbs. Because of its unusual degree of remoteness, we provide a range of care that's a lot wider than that of the average primary care clinic.
Dr. Bob Primeau, in the exam room: So, T-shirt off and then get yourself comfortable there.
Patient: Do you want me to take off my sneakers?
Dr. Bob Primeau: No, no, fine.
Janet Osborne: Nowadays, most of the doctor's offices around you'll go in, 15 minutes, and whoosh, you’re out the door.
Dr. Bob Primeau: Janet Osborne was the nurse manager at Island Pond Health Center for 38 years before she retired in 2015. She is perhaps the most dominant force that shaped the clinic.
Janet Osborne: When you go to the other places, you basically have to go somewhere else, whatever they're ordering. Like if Dr. Primeau ordered some blood test, nurse comes and draws the blood. If you need some medicine, if you don't have a special coverage for it, and we can do it, you can fill your medicine. If you need a cardiogram, we can do your cardiogram.
Dr. Bob Primeau: I love this aspect of my job. If I was in a typical suburban outpatient practice, I would blow my brains out. Primary care docs like me are supposed to take care of hypertension and diabetes, but as soon as someone says the word “heart,” they're supposed to walk down the hall and see a specialist.
Dr. Bob Primeau, in the exam room: So when can you get this wet?
Patient: You said, 48 hours.
Dr. Bob Primeau: Right. When do the stitches come out?
Patient: You said, a week.
Dr. Bob Primeau: A week, yeah, you can do it yourself at home. It's just like taking the hem out of pants. Or you can walk in here, either one.
Patient: OK, Peg’ll do it.
Dr. Bob Primeau: On the one hand, limited access to specialty care can be harmful to patients with significant health issues, and we sometimes have to do a lot of legwork to get patients the appointments that they need. On the other hand, patients benefit when their doctor plays a more active role in managing their complex illnesses than is commonly seen in many practices.
I also do inpatient work, meaning that when my patients are in the hospital, I go in to see them. What does it mean to say you're someone's doctor if you're not there when they're at their sickest?
Janet Osborne: I think it helps greatly in their care. You know, there were kids when I started, well, young folks, that would bring their babies in for their immunizations, and then before I got done, these were people bringing in their kids. So we went through several generations of the same people coming back, but they were the older ones, and then they had their kids. So it gave you that much more knowledge about the family and everybody because you had been seeing them for so many years.
Dr. Bob Primeau: I've known some of my patients for so long that it can feel like seeing an old friend when they come into the clinic. Sometimes they really are old friends. After working together almost 25 years, Janet is also one of my patients now.
Janet Osborne: The place wouldn't have been the same all those years without him there. And to keep somebody that long … nowadays, they just move. I'm on the credentialing committee for the hospital, and we're constantly looking at new applications, because people come and go.
Patient: Let's see. I went to bed last night and my toes were cold.
Dr. Bob Primeau, in the exam room: Yeah?
Patient: And it seemed like I couldn't even get them warm in bed. But when I woke up this morning, they were warm, but then this was hurting.
Dr. Bob Primeau: And you don't feel sick, and you've been able to eat today.
Patient: Yes.
Dr. Bob Primeau: Have you felt more short of breath today at all?
Patient: No.
Dr. Bob Primeau: I think this is probably irritation of one of the veins that's just under the skin. And the good thing is that they're not dangerous, but I always check too to make sure it's not in the deep veins. That means an ultrasound test, and that is something that I have to get scheduled up.
Kenneth Whitehill: When Doc started out, he used to come and see my folks. And he came on his bicycle. And my dad used to say when he saw him coming at noontime, “Here comes that young idiot.” You didn't know what kind of a doctor he was.
Dr. Bob Primeau: This is Kenneth Whitehill. He's 93 and his family's like royalty around these parts. I took care of his father, Lucien, as he got old, and now I take care of Ken.
Kenneth Whitehill: I can remember he and my wife used to argue, and he said, “If you don't like it, go to somebody else.” But she thought she knew more than he did at the time. He was real young then.
Yeah, he's, let's put it, matured. Of course, he still, I guess, rides his bicycle from Newport to Island Pond rather than take his electric car. So, yeah, he's still a healthy boy, and we don't want him to retire. I think he needs to wait till I'm gone.
Dr. Bob Primeau: Why have I stayed so long? I feel such a sense of wonder every day. As a doctor, I have a front row seat on people's lives.
And I love it here. I am deeply in love with the outdoors and this landscape. I can walk out my door and ski or bike in a beautiful place. My wife, Ellie, and I raised our two kids here. And I think there's a lot of ways in which rural areas are better places to live and raise a family. Not always, but a lot of ways. Everyone knows each other, and the lack of anonymity means that the social fabric is more genuine.
Kenneth Whitehill: You know, that makes a difference, if you really get to know the person, or you get to know your own doctor.
And he helped me out when my wife was real bad. She had strokes. And so I kind of listened to him and what he thought was best for her. So I got to know him real well through that. No, I think Bob really knows what he's doing now.
Dr. Bob Primeau, in the exam room: All right. Blood pressure OK, and all that jazz?
Patient: Yes, dear, it was 118 over 66. And I’m down to 141 pounds.
Dr. Bob Primeau: Wow. Were you trying to lose?
Patient: No.
Dr. Bob Primeau: Just being busy.
Patient: Very busy, I told you.
Dr. Bob Primeau And I know your diet’s pretty healthy. Is Gary keeping his weight down?
Patient: Actually, you'd be proud of him. You've really been working hard.
Dr. Bob Primeau: Is he keeping the beer down?
Patient: Actually he’s down to like, three beers a night, sometimes four. That’s it.
Dr. Bob Primeau: Excellent. So I won't schedule you back just yet Jane, OK, you can call, because — well, let's see. When did you have your last physical? August?
Patient: I was here in August.
Dr. Bob Primeau: I actually will schedule that for August.
Patient: You'll still be here, right?
Dr. Bob Primeau: In August I will, yes.
Dr. Thomas Moseley: The most important thing is that you do your technical job very competently, but to do it in a way that you took care of people that you knew for long periods of time.
Dr. Bob Primeau: This is Dr. Thomas Moseley. Most people know him as Mike. He is a giant among doctors who opened a pediatric clinic here in the '80s. He practiced for almost 40 years. These days, he's retired, and he's also one of my patients.
Dr. Thomas Moseley: You know, that's what primary health care is about, having connections with those people. You know, in a given day you might see a child of a lawyer, or a teacher, or a farmer, or someone with no fixed description of employment, and, you know, in one way or another, they were all doing the best they could.
Dr. Bob Primeau: Any doctor worth their salt will tell you the same thing. But these days, it feels like the health care system has begun to disregard the most essential part of what it means to be a doctor. And things are shifting in ways that, frankly, I find to be in complete opposition to the work I'm here to do.
This takes a few forms, but one of the most infuriating is the amount of time I waste on data entry instead of talking with my patients. I have to check a growing number of boxes and a growing number of poorly designed systems; the systems feel to me like they are designed to deliver data to managers and insurers, rather than designed to help me do my job.
When there are hundreds of items to check off a list, there is little hope of making time for the complexity and surprises of people's lives. Finally, though I could go on for much longer, the systems reflect a great deal of wishful thinking that if we harangue patients enough, they will change their lifestyles.
Dr. Thomas Moseley: So much of the patient-doctor relationship has to do with intimacy, trust, knowledge of the things that aren't on the problem list, in which the lives that they really lead.
And that's the part that is never going to show up in the medical record in a concrete description, and certainly not going to show in the productivity stats that the administrators are interested in. But I think that is the essence of caring for people.
Dr. Bob Primeau: These changes are harmful to the people I've spent the past 34 years taking care of. I'm disappointed that outpatient medical practice is going in this direction, and I don't want to participate in it anymore.
At the end of the summer, I'm leaving the primary care practice. I'll still be working in the area, but only doing inpatient care at the hospital in Newport. I'll have more time to devote to our local trail network, to play music, maybe even do some work overseas or teach at the high school. None of that will be as important as the 34 years I spent as the doctor in Island Pond.
Dr. Thomas Moseley: I think it's going to change things. I mean, he knows, just as I did, he knows people who will not, no matter what their medical problem is, will not leave the community to get care. So he's going to have to take care of it, and he does so with aplomb.
So, yeah, I mean, it's gonna be a huge loss. And a huge loss when this generation of primary care doctors disappears. And I have no idea who I'm going to go to for medical care.
Dr. Bob Primeau: After seeing patients all day at the office, I often end my day by getting in the car to make a house call. These are typically visits to patients who are old or dying and aren't able to come in to see me at the clinic. House calls are a special luxury, when I'm honored to meet people in their own space, even as they are departing it.
It's been hard to tell people that I'm leaving. Every day as I share the news with patients, I realize that I am letting them down. This job is critical. I know that I will never be good enough at it, and it certainly doesn't feel like I should ever finish.
It's been a privilege to do this work, from catching infants to saying goodbye to old friends. Or treating a middle-aged woman, hit with multiple life-threatening issues at once, requiring endless tests, treatments and multiple specialists. Or a child, laid low by a mystery illness — still unsolved, and yet the parents still seem to rely on me. Even a friend, taken down in less than a month by the emperor of maladies. There was nothing pleasant about that one; it was standing shoulder to shoulder with the family in the path of a tidal wave. ■
This story was featured in Vermont Public Docs, our podcast feed for longform audio journalism. Subscribe on Apple Podcasts, Spotify or wherever you listen.
