[UPDATED April 6, 2019: We reached out to filmmakers Laura Green and Anna Moot-Levin to gather their thoughts on why they titled their film The Providers.]
The filmmaking team behind the Independent Lens documentary The Providers live on opposite coasts from each other — Laura Green in San Francisco, Anna Moot-Levin in Brooklyn — but they came together for a project set in an entirely different place: rural New Mexico. Their film gives a very human face to the physician shortage and opioid epidemic in rural America, following three healthcare professionals who are doing everything they can to make a difference in northern New Mexico through a safety-net health clinic that aims to help marginalized patients.
“The Providers delivers a deeply moving portrait of selflessness and dedication that feels particularly timely in this era of division between the red and blue states,” wrote Frank Scheck in the Hollywood Reporter. “The warm, caring interactions between the medical practitioners and their patients form the heart of the film.”
Both Anna and Laura are experienced documentary editors and have made several award-winning short films, and as both of them are the children of healthcare providers themselves, the subject of The Providers seemed a perfect fit for their feature film debuts. We talked to them about that lifelong connection to health care, how they got such intimate access to not only the providers but their patients, and how this film can make a difference.
Why did you make The Providers? What drew you to tell a story about health care?
We are both children of doctors and share a lifelong fascination with medicine. We grew up with lunches stored in the “Biohazard” fridge and dinner table discussions about the unequal and often unreasonable American healthcare system. When we began this project in 2014 Laura was a freelancer and an Affordable Care Act recipient (like many filmmakers). We were intrigued when we heard a radio story about how even after the ACA, many Americans remained unable to access care in rural communities where doctors are often few and far between.
Over the course of making this film, we grappled with the uncomfortable reality that as Americans we are ourselves complicit in a healthcare system where those who have been dealt the harshest hand in life typically receive the worst care. The film follows rural providers enacting a healthcare model that seeks to serve those routinely left out of healthcare, helping to heal the traumas many on the margins of society have experienced, rather than compound them. As these healthcare providers work with underserved rural Americans to take control of their health, the film posits that healthcare is a human right.
While healthcare is familiar territory for us, we have often joked that it’s hard to find more “city” people than us, coming as we do from San Francisco and New York. However, we formed an immediate connection with the providers in the film. In a sense, we are all healthcare nerds (although we don’t know if the providers would appreciate the moniker!) As we spent more than a hundred days filming in New Mexico over the course of three years, we saw the ways the healthcare problems in these small towns are entwined with the broader challenges facing rural American communities and witnessed firsthand the insidious connections between poverty, hopelessness, illness, and addiction.
Particularly in a political moment where our national narrative is of a deeply splintered America, it was very hopeful for us that the process of making this film felt like a coming together across divisions over a shared vision for healthcare.
While the film addresses many aspects of the crisis in rural healthcare, the core of the film speaks to the profoundly positive impact of human connection within healthcare, particularly for people who have been marginalized.
In different ways, each of the providers in the film connects deeply with their patients and the communities they serve. While nobody disputes that clinicians must excel at the “science” of medicine — diagnosis and prescription — the film illuminates the ways that the “art” of patient interaction can itself be healing.
As is articulated in the film, it is sometimes feeling cared about that makes the greatest difference for the most vulnerable patients. We hope to leave audiences thinking about the ways that healthcare centering on human connection can heal both medical and social ills.
Our documentary follows a doctor, a nurse practitioner, and a physician assistant, all of whom practice primary care and “provide” for their patients in both a medical and holistic sense. Naming a film is often a long and convoluted process and, like our film, many documentaries go through several titles before landing on a final one. While it may seem a simple enough thing on the surface, it requires boiling a film down to its essence to find a title that conveys what a film is truly about in just a few words.
We originally thought of The Providers as a working title, but after two months of brainstorming, and considering 10-12 different titles, we realized that The Providers had a resonance. At its core, our film focuses on the intimate and deeply healing moments of interaction between patients and their primary care providers. The Providers not only speaks to what the film is about on a surface level, but in a more poetic way gets at the deeply respectful and humanizing ways that Leslie, Chris, and Matt “provide” for the emotional and psychological needs of patients as well.
We are also aware that the term “provider” is not without its critiques, particularly in that it engenders a view of medicine as a product (the idea that “providers” sell a service to “medicine consumers.”)
We found this New York Times blog post particularly interesting because it addresses the term “providers” in a way that both gets at why we chose it as a title and also why people feel negatively about the term. The author writes:
[Dr. Pamela Hartzband and Dr. Jerome Groopman in The New England Journal of Medicine] put their finger on what is so grating about these terms. They note that the term “provider” has a deliberate sterility to it that wrings out any sense of humanity, and connotes a widget-like framework for that which is being “provided.” It makes us feel like a vending machine pushing out hermetically sealed bags of “health care” after the “consumer’s” dollar bill is slurped eerily in.
At the same time, particularly because physician assistants and nurse practitioners are so important in rural medicine and primary care, we wanted to use a title that acknowledges the tremendous work of primary care providers, regardless of whether they have an MD after their name or not. While the author of the NYT blog post writes eloquently about the negative connotations of “provider,” we really appreciate her analysis of why the term came to be used, and the upsides it has as well – that it is an inclusive and “leveling” term that de-emphasizes hierarchy in medicine. She continues:
I can’t quite remember when the term “provider” slipped into the hospital lexicon. It was perhaps 10 years ago, when our hospital started hiring physician assistants and nurse practitioners to share the clinical load. In contrast to the regular staff nurses, who cared for the patients in conjunction with the doctors, physician assistants and nurse practitioners would see patients independently, the way the rest of the doctors did. So there needed to be a term that would include all three groups – physician assistants, nurse practitioners and doctors — who could have primary responsibility for patients.
“Health care provider” came into vogue as the catchall phrase and was quickly truncated to just “provider.” The term does have its upside, helping to minimize hierarchy. History has shown us that medical hierarchy usually serves more to stomp on underlings than to provide leadership. In fact, physician assistants, nurse practitioners and doctors have more similarities than differences in their day-to-day interactions with patients, even as they come from unique backgrounds and bring different strengths to the table.”
Who do you hope the film will impact the most?
Given the political and discursive tension of the last decade over how to shape the American health care system, we think it’s a particularly important time to have conversations as a country, and in all parts of the country, about what we want our healthcare system to look like in the future. One of our favorite parts of making the film was meeting the Semillas de Salud (Seeds of Health) students from rural areas who are interested in pursuing healthcare careers. We hope the film will inspire more young people to go into rural healthcare, and we are developing an outreach campaign that will target both rural high schools and medical education institutions, including medical schools, nurse practitioner programs, and physician assistant programs.
“Do you have any updates on the main characters in your film you can share with our audience? Do you know what the latest situation is at El Centro?
Tiffany Encinias has been following her passion for healthcare through classes at Luna Community College in Las Vegas, New Mexico. In the fall she will transfer to a local four-year university, New Mexico Highlands University, where she will pursue a degree in biology, which she hopes will ultimately facilitate her following in Matt’s footsteps to become a Physician Assistant.
El Centro Family Health has started a scholarship fund to support students like Tiffany from underserved communities when they encounter financial hardship on their paths to pursue careers in medicine.
Matt Probst is working with the local, state, and federal government to open the first comprehensive treatment center for substance use disorder in northeastern New Mexico.
Chris Ruge’s program, now called El Centro Care, is under threat yet again as it lost one of its primary sources of funding in early 2019. The El Centro administration is scrambling to identify other funding sources.
21 medical providers at El Centro now offer medication-assisted treatment for opioid use disorder, representing 13.5 % of the practitioners in New Mexico certified to prescribe Buprenorphine in 2018. As a result, Dr. Leslie Hayes can no longer say she will have no one to take over her patients should she retire.
What were some of the biggest challenges in tackling a story as complex as this one?
The Providers is our first feature-length documentary, and as one mentor has said to us, “a director’s first film is often multiple films jammed into one.” While we planned to structure the film around three healthcare providers from the outset, during production we were drawn in many unexpected directions — from the stories of the many phenomenal patients we met, to the funding crisis Chris Ruge’s program faced.
It was very important for us to represent all of our characters as multi-dimensional, but having so many storylines to follow, we fought against spreading the film too thin. We ultimately decided to feature five patients, in addition to the three main healthcare providers and it became a process of trial and error in the edit to figure out a structure that could support so many arcs.
The American healthcare system is also incredibly complex, and we struggled with the challenge of deciding how much exposition we needed to include to contextualize our film’s story. We felt it was important to frame the bigger picture of rural healthcare at the beginning of the documentary but ultimately tried to stay as much as possible in the emotional space of our subjects throughout the rest of the film.
Obviously, building trust is a huge part of making a film like this work. How did you establish that with the patients and providers in The Providers?
We spent about 120 days over 2.5 years shooting on location in northern New Mexico, building deep relationships with the subjects in our film. As outsiders to the community, we felt it was important to truly listen to our subjects’ stories and let them guide the direction of the film, rather than impose a preconceived narrative. Before we turned the camera on, we always spoke with people about our central goal for the documentary: to shed light on the challenges of rural healthcare, a subject that is underrepresented in the media.
We also shot the film as a small crew of two directors (with one of us on camera and one on sound), which was critical in allowing us to capture personal, intimate moments. This also created a strong sense of continuity between us and our subjects as we built relationships over time. Above all, we had excellent role models in the healthcare providers themselves, who we witnessed working as nonjudgmental, empathetic listeners in their medical practices. We strove to emulate this in our own documentary practice and throughout the process of making The Providers.
You spent so much time in New Mexico shooting this film; were you in a hotel the whole time or did you stay with locals, too? What was a favorite local discovery (food, culture, otherwise) you made while filming there?
While we spent the night in hotels on occasion (including the historic Plaza Hotel in Las Vegas, NM which served as a set for No Country for Old Men and is said to be haunted), we were so lucky to be able to stay at Chris and Anny Ruge’s home during most of the time we were in New Mexico. As you can probably tell from the film, they are the kind of generous and big-hearted people who are always taking in strays – stray cats, stray horses, and even stray filmmakers!
While our hands-down favorite “discovery” in New Mexico was the incredible people we spent time with and the conversations we got to have, we also became big fans of New Mexican food. We loved eating at Charlie’s Spic-and-Span, a long-time Las Vegas institution with the best handmade tortillas we’ve ever eaten, and we wouldn’t have survived the shoots without our favorite coffee shop, Traveler’s Cafe.
You talked before about both being from urban areas yourselves; in those experiences as outsiders who came to listen, what do you now think are the most common misperceptions Americans have about rural America?
Rural America is an incredibly diverse place with culturally rich communities, a fact which is often under-represented in the depictions urban dwellers see. The history of northern New Mexico where our film is set is fascinating and has resulted in a unique dialect of Spanish still spoken by the descendants of Spanish colonists who arrived in the area from the 16th to 18th centuries. Matt Probst describes his own eclectic lineage as a mix of Hispanic, Colonial Spanish, Native American – and Jewish, hence his surname “Probst.”
Along with the diversity of ethnicities, cultures, political orientations, and life experiences, what we found was that rural America is a place of innovation and the people who we met were amazingly resourceful and solutions-oriented. We saw creativity and problem-solving flourish both in and out of the clinic. Whether it was Matt’s “Semillas de Salud” Grow Your Own Healthcare Professional Program or Ignacio’s uniquely shaped doors on his purple-painted house he built himself, we were in constant awe of the rural Americans we met whose vibrant imaginations were making their community a better place.
What would you have liked to include in your film that didn’t make the cut?
Nurse-midwife Ann Ruge, who is married to nurse practitioner Chris, is an incredible healthcare provider in her own right. She has touched the lives of many women in the Las Vegas, New Mexico area providing women’s health services at El Centro Family Health. She is currently the only practitioner in northeast New Mexico who is certified to perform colposcopies as part of the The National Breast and Cervical Cancer Early Detection Program, which provides access to services for low-income, uninsured, and underserved women.
Unfortunately, we were unable to find enough patients of hers who were comfortable being on camera due to the sensitive nature of women’s health and the trauma that many in her patient population have experienced. We wish we could have included the life-saving work she is doing and the deep relationships she has with her patients.
Short of cloning people like Matt, Chris, and Leslie in a lab, where are the next generation of rural providers ultimately going to come from? Did the young students seen in the film give you hope?
Research suggests that the best way to increase the number of rural healthcare providers is not to try to increase urban transplants to rural areas, but rather to foster young people from rural communities going into healthcare fields. The young people we met throughout the filming process were not just a source for hope, but a fascinating group of people with varied life experiences, aspirations, and personalities. What they shared was a strong sense of purpose and a dedication to their families and communities.
The challenges facing rural areas in America aren’t easy ones to solve – there are demographic issues that come with an aging population, and financial hardships tied to long-term changes in the US economy. While we know not every young person wants to (or should want to) grow up to be a medical provider, we are inspired by the thought of all the different ways these young people might shape their communities and the evolving nature of rural America as they grow up.
Is there one person in the film or one storyline that stays with you the most?
The scene in which the patient Cheri and her pre-teen son talk about his role as a caregiver in her life is a very emotional one for us. Her alcoholism has become life-threatening at times, and as a result, her son has had to step into the role of “parent.” We hear him describe how he waits by her side all night to make sure she stays alive – a heavy responsibility for a very young person. At the same time, we see the tremendous guilt that Cheri feels, especially as someone whose own mother was also an alcoholic.
For us this scene really epitomizes the intergenerational cycle of trauma, poverty and addiction which we see mirrored in many of the storylines the film follows. Cheri’s son in many ways reflects Matt Probst’s own youth, which we have learned about earlier in the film. To be witness to Cheri’s struggles and the impact of them on her son was a particularly intimate moment to be present for.
How do rural audiences see this film vs. how urban audiences react to it? Given health care is a universal issue and this film isn’t just about New Mexico, what conversations would like you every viewer to have after they see The Providers?
The film has definitely been an eye-opener to urban audiences about the challenges being faced by people living in rural, underserved communities. Healthcare professionals working in underserved urban communities have related deeply to the experiences of the providers featured in the film, while rural audiences have expressed enthusiastic appreciation for the fact that the film depicts a rural community in a fuller, more nuanced way than is typically seen in the media. We have heard from rural audience members that they are so excited to see a documentary that offers hope and healthcare solutions for rural communities, moving beyond a singular focus on crisis and hardship.
Viewers in northern New Mexico have been moved by the beauty of their communities reflected back at them and the duality of pain and strength explored in the film. One audience member who grew up in Las Vegas, New Mexico, but now lives in a different city, was in tears after a screening because the film made her so homesick.
Why is your film company called “Stray Pony”?
As mentioned, during production [on this film], Chris and Ann often graciously hosted us at their home, and one morning when leaving we accidentally let stray horses onto their ranch. They had to hop on their own horses, and spend several hours rounding the strays up, while we watched from the sidelines. It’s just a small anecdote but highlights a deeper question that people often ask as well – which is the nature of our connection to the communities we depict in the film.
But as different as our daily lives can be, we felt an immediate kinship with Matt, Chris, and Leslie, around our shared passion for healthcare, and the belief that healthcare is a human right. One of the most wonderful things about documentary production is that you spend a tremendous amount of time with your subjects and in the communities they are part of. Over our three years of filming, we formed a deep connection and understanding of the world of rural healthcare which had been unfamiliar to us at the beginning of this process.
What are three favorite or most influential documentaries or feature films?
Three documentaries that inspired us tremendously in making this film were Gideon’s Army, The Overnighters, and The Waiting Room.
What film/project(s) are you working on next?
Anna Moot-Levin is producing a documentary in development about neurodegenerative diseases.
Laura Green is currently editing the second season of the Gotham Award-nominated web-series The F Word: A Foster-to-Adopt Story. [Season 1 is on Indie Lens Storycast.]