MedicineMainStreet_20181031_Transcript

- The following program is a co-production of The University of Wisconsin- Madison and Wisconsin Public Television with additional financial support from Greg and Carol Griffin.

§ §

[water flowing]
[wind blowing lightly]

- Rural Wisconsin. It calls to mind images of friendly small towns, lush farm fields, and beautiful rolling landscapes.

For many across the state, making a life in a smaller community is a choice made for the health and well-being of their families. But living in a rural community can have its challenges. Smaller towns means fewer options for shopping and dining. It may mean limited employment opportunities. And it can also mean less access to health care providers. Throughout Wisconsin are doctors, nurses, and pharmacists... providers meeting the healthcare needs of rural residents by choosing to practice medicine on Main Street.

 Dr. Amy Kind is a researcher at the University of Wisconsin- Madison whose work focuses on health disparities on a state and national level.

- Dr. Amy Kind: When we look at the location of disadvantage across the United States, not only are highly disadvantaged neighborhoods found in inner city cores, but they're very often found in rural areas, as well.

- When Dr. Kind started to look at the problem, there wasn't a solid tool to analyze the scope of the issue. So, she created one. Dr. Kind and her research team created an accessible online program called the Neighborhood Atlas. The atlas not only shows where health disparities are in a state, it also helps clinicians get a better understanding about the environments their patients live in.

- Amy Kind: In our work, we spend a lot of time mapping out the precise locations of neighborhoods that have more of these challenges than others. So that we can inform policy, inform next steps in health care program development- When Dr. Kind looked at Wisconsin, she noted a stark difference between the well-served areas on the map in blue and the underrepresented sections in red.

- Amy Kind: There are many types of health care challenges that often are linked to resource and access that they have to face every day.- Access to health care in rural communities is an issue not just in Wisconsin, but across the country. Health care professionals here are joining forces to find equitable solutions.

§ §

Black River Falls is a cozy town of 3,600 people in west-central Wisconsin. It's an energetic city surrounded by a lush state forest and a strong agricultural and tourism industry.

It may seem small to some, but it's exactly the type of community and lifestyle that Michelle Forsting was looking for.

- Michelle Forsting: Black River Falls is, I think, known as being just a nice kind of a quaint small community. It's tightknit and it's committed to health and supporting people to advance. My family is and our extended families are all here. We're just family people. We like to spend our weekend with family. So, that's what really was important to us.- She's been eating good, likes to stay active.

- Also important to Michelle-- providing high-quality care to her community as a doctor practicing family medicine.

- Michelle Forsting: Good girl. I deliver babies all the way until end of life.

[speaking baby talk] You are such a beast, look at you! One of my kind of special areas of interest is OB, and I do C-sections and obstetrical surgeries. And there aren't very many places where you can practice medicine like that if you're a family medicine doctor. And so, for two reasons: it was both the type of medicine I wanted to practice and both the life I wanted to live.

- Byron Crouse: When you practice irregardless of what specialty you're in if you are in a rural community, you'll practice the full continuum of that specialty.

- As the Associate Dean for Rural and Community Health at the University of Wisconsin School of Medicine and Public Health, Dr. Byron Crouse believes a rural physician needs a comprehensive skillset and vast knowledge to practice in smaller communities.

- Byron Crouse: As a family physician here in Madison, I could focus on doing just geriatrics. I could focus on just sports medicine. My practice in Spooner: I was doing emergency medicine. I was doing assisting in surgery, I was doing obstetrics and I loved it. But you had to have that full scope of practice and be comfortable with that full scope. And that's a challenge that's daunting to some people.

- Living in a community she loves and practicing the type of medicine she's most interested in, for Michelle and many physicians across Wisconsin is ideal. But in many rural areas across the state, finding and keeping local 'hometown' doctors is a challenge.

Over a decade ago, the Rural Wisconsin Health Cooperative surveyed its member hospitals to determine what they viewed as the biggest threats to their long-term survival.

- Byron Crouse: Finances were a concern but number two on the list was physician workforce. that led to a really statewide workforce assessment, particularly looking at our needs in rural Wisconsin.

- Amy Kind: There are certain things that are just more difficult to come by. Different types of specialty care are hard to find. So how do we deliver services up there? How do we develop new ways to try to improve recruitments of physicians up into northern Wisconsin and other health care personnel-- not just physicians, but nurses and pharmacists and others?

- Recognizing the issue of recruiting and retaining physicians in underserved areas, the UW School of Medicine and Public Health developed a program specifically designed to address this need.

- Byron Crouse: We looked at developing the Wisconsin Academy for Rural Medicine, or WARM, to really address that physician need in rural Wisconsin.

- WARM is a rural education program within the Doctor of Medicine curriculum at UW-Madison.

- Michelle Forsting: And I thought, "Well, that's me. This is exactly what I want to do." It was a program built for people from Wisconsin's smaller communities looking to go back and practice medicine in smaller communities. And in the interim then, you get hands-on experience in smaller communities rather than just spending all of your time in Madison.

- Professor: There are two parts...

- Byron Crouse: I think really one of the keys to success has been really identifying the right person to come into the WARM program. We want something that obviously is going to be a good physician. that's going to have an empathetic reaction with patients, good communication skills, knowledgeable, and understand the science, but, more importantly, we also want something that has that with that passion that love and commitment to rural Wisconsin. We can teach people communication skills, but they have to have that love, that passion, that drive themselves to want to go rural.

- But being a physician in rural Wisconsin means dealing with some misconceptions about the level of care in smaller communities.

- Mona Baker: I was a medical snob because I lived in a big city and had access to everything.

- Mona Baker moved to Black River Falls from Dallas, Texas. She was anxious about the kind of medical treatment she'd be able to access in a small Wisconsin community.
- Well, Mona, how are you today?
- I'm well, thank you.

- Any concerns she had were alleviated after meeting Dr. Forsting.

- What’s bringing you in? How can I help you today?

- Mona Baker: Well, my foot is still bothering me.

She's warm and inviting. She looks you in the eye. She's not walking out the door telling you something. She's waiting until you're completely through talking to her. I had to have a knee replacement treatment three months after I moved here and it was just wonderful. It was so easy. And instead of driving 30 minutes to physical therapy, I went six minutes from home to the hospital physical therapy department.

- We actually are really lucky to have outreach at our clinic, as well, which means specialists come and they see patients at our clinic rather than our patients having to travel.

- Byron Crouse: There are myths about rural health that we are constantly facing. You know, one of those is there are not adequate facilities, there are not good hospitals, there's not good support. There is support there.

- Michelle Forsting: Access can be a big challenge. There's a large number of patients who want to be seen. And a small number of doctors.

- It's just your INR today?

- Patient: Yep, just my INR today.

- But we have new physicians. And the hope is that we're picking people and that they are picking us for the same reasons that I wanted to come here. And that the patients will then flourish under their care, as well. 
[students talking in background]

- Now in its 10th year, the impacts of the WARM program can be measured. Since the program has started, 91% of WARM graduates still practice in Wisconsin. And over half of WARM graduates are practicing in rural communities.

- Byron Crouse: So, I'm very pleased with that outcome. They're in the state. They're going to rural areas. They're meeting our mission and goal of helping address the needs in rural Wisconsin.

- When it comes to health care needs in these areas, the challenges are many, but for Michelle, so are the rewards. 
[knocks on, opens door]

- Hi, guys!

- Michelle Forsting: So, I'm not just a doctor to patients. I'm a doctor to my family, my friends, my neighbors, and I think that's really important to somebody who's planning to practice rural medicine because that's just the way it works. You know, you're part of the community. That's a big part of what medicine is in a rural community. So, usually, at the end of the day, I get the feeling that I've helped people. And that's usually enough to keep me going. I just have to remember that, yes, I am making a difference in people's lives.

[birds chirping]

- While many health care professionals live in the communities they serve, that's not always the case. Long commutes are part of the daily routine for many doctors and nurses who practice at clinics and hospitals spread across several counties.

- Aeron Adams: So, to come here to Lancaster, it takes me about an hour and 20 minutes one-way. Two other days a week, I'm in our Dodgeville office.

- Aeron Adams is a nurse practitioner specializing in mental health care at Unified Community Services clinics in Lancaster and Dodgeville, an area of southwestern Wisconsin defined by rolling farm fields, dotted with bustling small towns.

Aeron's not the only person spending a lot of time behind the wheel.

- Aeron Adams: I've had patients routinely drive a half hour, 45 minutes to get to an appointment with me. There's a shortage in mental health providers, specifically psychiatrists. There are other places to go but many have long waiting lists.

- Long waiting lists and a shortage of mental health providers are issues across Wisconsin.

- Gina Bryan: We saw a huge need in our state and nationally for more psychiatric providers. So, the University of Wisconsin decided that we would have the ability to put a program in place for people that were already advanced practice registered nurses to come back and do graduate education so they could sit for board certification in mental health nursing. The program was designed because there were a lot of providers in the community that were working in primary care that are doing the heavy lifting of psychiatric services. And where does nursing play into that? When we arranged the program, we had a really big response. There were a lot of people identifying this as an area that they wanted more education and were passionate about.

- Students earning a postgraduate certificate in the mental health nursing program are placed in rural clinics, giving them a feel for the scope of a practice in a smaller community. It's an experience that can't be taught in any classroom.

- Aeron Adams: One of the reasons that I wound up working out in a rural area was that I actually did about a year of clinicals here at Unified Community Services and I really enjoyed the experience. It kind of kind of spoke to me and I really enjoyed the people.

- Gina Bryan: The evidence really clearly shows that when students learn in a community that's when they fall in love with it and want to go back and serve those communities. So, I think what we've really focused on in our graduate program is growing diverse clinical sites, reaching out to the communities across the state.

- Amy Kind: When you find a community that has found a stable and empowered and passionate group of healthcare professionals to help them promote their health, to take an active role in the community, to try to innovate care in these local environments, it can make a world of difference.

- Aeron Adams: I chose to work in this area. I like the people. I enjoy the wide array of diagnoses that I see I get to sort of treat a little bit of everything, which makes me a better provider. Ultimately, give the best care possible.- Giving the best care possible. For Aeron, this includes dealing with the preconceptions that surround mental health issues and a code of silence that kept many of Aeron's patients from appearing on camera.

- Aeron Adams: There is definitely still a tremendous amount of stigma where people don't want to talk about their mental health concerns. You know, it's seen as a weakness. I have clients who come in and tell me that family members tell them, you know, "Just pick yourself up by your bootstraps and snap out of it." They kind of see me as a person to maybe confide in, especially, if they feel that they can't do that with friends or family members.

- Tackling the challenges-- and seeing the rewards-- of practicing in a rural setting comes from a strong commitment to serving local needs.

- Gina Bryan: What's been really exciting to see is that the people we have returning to school come from a wide reach in the state. We're seeing people that are coming from the parts of the state that don't have psychiatric providers in the whole county, that don't have psychiatric providers within a two-to-three hour drive. And the people we have coming back are really committed to filling that need in their community.

- Main Street is the lifeblood of a rural community. That's where you'll find a place to get a cup of coffee, a grocery store, the post office, and drug store. In some small towns, where a doctor or nurse, hospital, clinic may be miles away, the pharmacist is the only health care professional in town.

- Hi, good morning, everyone. Welcome to the morning huddle.

- Bobbi Freitag is a staff pharmacist at Lakeview Medical Center and a relief pharmacist at Marshfield Clinic in Rice Lake, a community of 8,500 in northwest Wisconsin.

- Bobbi Freitag: I grew up in Thorp. My parents are actually from the Rice Lake and Turtle Lake area. And I had an uncle that was a pharmacist up in Duluth, Minnesota and I liked chemistry. I knew I didn't want to be a doctor or a nurse. But to be honest it never really occurred to me to stay in the bigger city. I knew there was lots of opportunities and lots of need.

- Ed Portillo: If you are a rural health pharmacist, you're a jack of all trades, meaning that you're that person that their patients are going to go to and ask any health-related question.

- Any questions for you?

- No, not at this time.

- Bobbi Freitag: We tend to be generalists... a lot of different hats. You're the administrator. So, you're handling the contracts and the purchasing. You're also doing the clinical part. The distribution, and that's physically getting the medication into the pharmacy, and then, from the pharmacy to the nurse to give to the patient. And there's the education piece: whether we're teaching about Warfarin, whether we're teaching about the new generic bio-similar drugs that are coming out. A lot of times it's supporting, again, behind the scenes.

- David Mott: There's been a huge expansion in the role of pharmacists. Pharmacies are not just the places where patients go and have medications dispensed in rural areas, pharmacists are actually providing medication information. They play a big role in providing vaccinations. They're providing medication therapy management to keep patients healthier, keep them out of the hospitals. And they're also very complementary to other health care providers in rural areas.

- The expanded role of a rural pharmacist and the appeal of a small-town lifestyle are the reasons why Mike Laird chose to enter the profession.

- Mike Laird: When I was a student at Madison, I had the opportunity to do some rotations, actually, in Rice Lake. At that time, the hospital was right on the lake and I was sitting in the director's office, staring out over the lake, watching the eagle flying over.

[bicycle gear clicking]
Basically, I'm living where people want to vacation. That's a big part of why I want to be in rural health care. 
[bicycle gear clicking]

You know every doctor here. I know every nurse here. I had the same doctor deliver all three of our children and that sort of relationships where you can't quite get in a big city.

- Have a great weekend!

- All right, we'll see you.

- Mike is an oncology pharmacist with the Hayward Area Memorial Hospital. For Mike, it's all about the people.

- Mike Laird: I like to personally deliver meds to the patient. That gives me an opportunity to talk to the patient, especially on their first cycle of what we call their chemotherapy.

- Did ya have any questions at all with your infusion today?

- Uh, not right now, no.

- They get a lot of information when they go in that doctor's office. And a lot of it, they may have some emotions going. They're getting good news/bad news, that sort of thing. When they come to us, it gives us an opportunity to one ask them what they do understand? what they did take away from what the physician may have told them, identify what they need to know.

- One of those patients who appreciates that open and honest communication is Barbara Williamson.

- Barbara Williamson: Mike's a sweetheart here. He brings me my poison every time. He comes in, I say, "Ah, you got my poison." 
[chuckles]

- Feeling better from last week?

- Yes.

- I know we're going to be checking your labs today. He is always warm, always said 'hi.' You know, would take the time to answer a question. He always asks if you have any questions. I think any time you can deepen a relationship with more facets to it it becomes a more meaningful relationship on both sides.- There is an increased need for pharmacists in rural areas because of an aging population and the expanding roles that pharmacists face in clinics and hospitals. Two other factors play a major role, as well.

David Mott: There's a disproportionate number of pharmacists and pharmacy students that are going into rural areas. We have about 14 percent of our graduates end up going into rural areas. The Wisconsin population is about 27 percent rural. We have a lot of older male pharmacists who are owning independent pharmacies in rural areas. And as time goes on and they get closer retirement age, there are not pharmacists that are coming out to those environments to buy the pharmacies from them. And those critical access points, those pharmacies then close and never open again.

- The University of Wisconsin-Madison School of Pharmacy recognizes these challenges and is building a curriculum to face the changing needs of Wisconsin.

- Ed Portillo: Many of the pharmacists practicing in rural and urban settings come from our school. And so, we are uniquely positioned to develop programming using our alums, using the communities that we've formed to help our students currently train as excellent rural health practitioners. We have over 60 clerkship rotations where students spend six weeks as part of a community practicing and being mentored by a rural health pharmacist in rural settings and that is an invaluable experience for students. So, it's taking that combination of community engagement, student engagement, and that actual hands-on experience. That's our recipe for this program to get students out and making a difference.

- We'll see you next week.

- Being a pharmacist in a rural community can offer advantages for the practitioner. For the patients, too. Robert O' Donnell's treatment plan for his rare type of pancreatic cancer requires an imposing medication regiment-- several different medications in different doses.

For Robert, having a knowledgeable and trusted local pharmacist available is essential.

- Hi, Bob, how are you doing?

- Good.

- Bobbi Freitag: Are you here to pick up prescriptions today?

- Robert O'Donnell: Yeah.

- Bobbi Freitag: Okay.

- Robert O'Donnell: What I need from the pharmacies are continuing drugs for the rest of my life. That's a lot of drugs and a lot of communication has to happen between me and the pharmacy. Bobbi helps out a lot. I am really happy that she's here in this system to help me and help many people daily.

- So, we're all okay?

- Yes.

- Okay.

- After a while, you get to be family. you get to know each other really well. It establishes a relationship that you can trust.

- Bobbi Freitag: That's where the trust and the confidence in the advice... When you've known somebody that long, even if it's at the pharmacy counter. But over time, you get to know them well enough that when the subjects do come up… Some new pain medication today you’re going to try? ...It's pretty easy to dive in quickly because you've already established that trust.

- Trust. Community. Responsibility. It's those things that motivate Bobbi and other pharmacists in small towns across this state to go to work every day and develop strong partnerships with their patients.

- Bobbi Freitag: I think for most of us that's why we're in the profession. Those are the days that you go home and say, "This was a great day!" No matter how busy it was, no matter how much the phone was ringing or anything else, those are the days you get home and think, "That one, I really made a difference." Here you go.

- Thank you.

- Thank you.

- See You later.

- You bet.

- Making a difference. That's what doctors, nurses, and pharmacists in smaller communities across Wisconsin are doing. And with the help of researchers and professors at UW-Madison, future health care professionals are seeing the rewards of practicing in rural areas.

- Gina Bryan: Those 92 percent of our students that have gone through that program have gone on to serve under-represented communities in the state of Wisconsin. The commitment that the university has to growing those kinds of opportunities has been impressive. And we're seeing the results of that in our state.

- Amy Kind: There's a lot of opportunities and there's a lot of new innovation, but I would say that much more needs to be done. We need to attract more researchers, more physicians, more clinicians into this field, to think about care for vulnerable populations within rural areas.

- More needs to be done to help to solve the challenges underserved areas are facing in gaining access to quality health care in Wisconsin. And things are improving, thanks in large part to the work and commitment of dedicated health care professionals to their patients and communities.

- Mike Laird: We try to anticipate the needs of people and try to meet them as best we can and we can continue on doing that.

- Michelle Forsting: Hello!

- Hello.

- Perfect. 

I said that I'm working with my patients who are also my neighbors, my family, my friends. I actually want that. I love that. To child: Can you help me with your heart again? Who better would you want to care for somebody than somebody who actually cares?

- The preceding program was a co-production of: The University of Wisconsin- Madison and Wisconsin Public Television, with additional financial support from Greg and Carol Griffin.