- Rural healthcare access, a challenge for communities across the region.

Patients often traveling hours for care, with providers stretched thin.

How medical professionals are adapting, and what solutions might close the healthcare gap.

That's next on Health Matters.

(upbeat music) Accessing healthcare continues to be a struggle in rural areas.

Transportation, and provider shortages, creating barriers that can delay critical care.

What does this mean for our communities, and how can we address these needs?

Good evening.

I'm Aaron Luna.

Joining us tonight to explore these questions, Dr. Melanie Barnes, primary care physician, serving patients from across the region at Providence Family Medicine in Chewelah.

And Dr. Jamie Bowman, Vice Chair of Family Medicine at Washington State University's Elson S. Floyd College of Medicine.

And Dr. Francisco Velazquez, health Officer for Spokane County, who works closely with surrounding rural counties.

Thank you all for joining us.

And Dr. Barnes, we'll start with you, your clinic in Stevens County serve patients traveling from as far as Republic to see you, what are the biggest barriers your patients face in accessing care?

- Well, it always comes down to two different categories.

One, having the insurance, and having the financial ability to get care.

And the other one is actually just physically getting to the doctor's office.

We don't really think about the number of people in a rural area that don't have reliable transportation, they may not have cars at all, or cars that might not make it as far as the doctor's office, and then gas is expensive also.

So, our patients really have to be tactical about how often they come to the doctor, and how often they come into town in general.

- And Dr.

Bowman, the Elson S. Floyd College of Medicine was established, in part, to help meet the need of rural healthcare in our region.

Going as far to relay, or really try to attract students from rural backgrounds themselves, and how does the program specifically work to train providers to fill that gap?

- Absolutely.

So we were founded in order to serve all of the communities across Washington, especially those that are underserved, which includes our rural communities.

What we found in the evidence is that, communities, when they have a shared identity with their provider, have an increased amount of trust.

So we have prioritized admitting students who come from rural communities, or who have a significant amount of rural experience in their background.

- How do you measure the success in that area?

- So we're really excited that consistently about 25% of each of our MD classes, are students who identify as having a background in rural Washington.

When we look at our outcome data, we look to see, where are our students going for the next phase of their training, where are they going to residency?

And we're really happy that over the years, we have more than half of our class picking primary care, which is by far the best group of specialties to serve rural areas.

- Great.

And Dr. Velazquez, from your perspective as Spokane County Health Officer, how does the healthcare situation in rural communities affect the entire region, not that specific area?

- Sure, well, if you think about it statistically, we see a higher prevalence of like chronic illness, and that's accentuated by sometimes the lack of access to providers.

So thank you to our medical schools who are trying to address that.

And I think information in general, plus sometimes, longevity can be an issue in some of those areas, because we don't have access to the appropriate care for what is an aging population all over the state.

So I think we work very closely to try to bridge that gap by sharing the resources that we have, sharing the information that we have, sharing technological issues such as Dashboards, so they can do the same thing to inform the community, 'cause sometimes awareness could be an issue if patients don't have the access.

- And Dr. Barnes, you are a doctor that specifically wanted to work in a rural community.

Your arrival at Providence Clinic cut the wait list from new patients in half.

And what does that tell us about the demand for primary care, especially in your area?

- Well, you know, the demand will never end.

The population does grow a little bit at a time, maybe not as rapidly as in some cities, but, every small turnover that we have, because we are not so deep in our provider pool, even losing one person if they retire, or move somewhere else, or stop doing a particular function, 'cause a lot of us do a lot of different things, that's a really big loss in the community.

And so to even add one new provider is a huge, that's a huge change in the percentage.

So, and I did my training in the rural area, so, I knew what I was getting into, and I'm very committed to it.

- A lot of people when they think about growth, especially in rural areas, they think maybe more connectivity, but that doesn't seem to be always the case.

- No, definitely not.

And especially in a rural area where, the reason people go to a rural area and want to live in a rural area is because they want to be a little bit disconnected, and they want to have space, and peace, and that also can sometimes lose to...

It can lead to quite a bit of disconnection.

- And Dr.

Bowman, there's a clearly a shortage of general care providers, but that's also true for specialized care.

Why is specialized care critical for rural communities?

- Primary care physicians can take care of a vast number of problems for our rural communities.

But there's always gonna be a need for a specialized level of care, especially surgery.

Surgery can be very difficult in rural areas, because it's often emergent, so you need that care right now.

One of our priorities is working to assure that our students get in a rural surgical experience when they are in their clerkships, so they can better understand what rural surgery looks like.

It's very different in rural communities compared to urban areas.

- Can you give us an example?

- Absolutely.

So in our fourth year of the MD program, our students get to choose between doing a month long immersion rotation, in either an urban underserved, or a rural underserved community.

And 70% of our students, so three quarters, end up choosing a rural community.

In those communities, far from places like in the Tonasket region, or way out on the Olympic Peninsula, they're working side by side with a general surgeon who serves a catchment area, that could be eight hours from one side of that catchment area to another.

So they get to see firsthand, what are the challenges that are coming into that community, and importantly, what's the creative solution in order to meet the patient when they have a need.

- Excellent.

I had the opportunity to sit down with Dr. Deirdre Mooney, a doctor with the Center for Advanced Heart Disease, and Transplantation Cardiologist at the Providence Heart Institute here in Spokane, to really dive into how lack of access impacts patients when they need a specialist, like a cardiologist, and the different ways they're trying to get creative, and meet the need.

(upbeat music) - [Aaron] By the time patients see Dr. Mooney, their conditions are pretty advanced.

- I'm a general cardiologist who also has additional training in advanced heart failure, meaning that I get to take care of people who have reached a very aggressive, or advanced stage of their heart disease.

- [Aaron] People in the United States are living longer.

An unintended effect of that, an increase in heart disease.

According to the CDC, it's one of the leading causes of death in rural areas.

And access to care for heart disease is not keeping up.

- This is people who have to drive a great distance to see a cardiologist.

So the red area is where people have to drive over 60 miles to see a cardiologist.

All the little areas where they're driving 20 miles or less are usually urban centers.

Heart failure is one of the hardest doctors to see.

Interventional cardiologists are the people who open up the heart arteries in the middle of the night, they are more spread out, but heart failure tends to be at research centers or major centers like Sacred Heart Medical Center, because we want to collaborate, offer research trials.

- [Aaron] In urban areas, 50% of people live within 12 miles of cardiac care.

For people living in rural areas, that number drops to just 5%.

The distance isn't the only barrier for people who need to travel to urban areas for care.

As people age, driving into bigger cities can be intimidating.

Then there's parking, and navigating a medical campus, before even sitting down with their doctor.

- And now they're short of breath, tired.

And now we're supposed to have a meaningful conversation about what are their goals, what are we gonna do, what is the right diagnostic testing for them?

That's hard.

And they may or may not have their significant others or caregivers with them.

- Add in things like blood work, testing, imaging, reviewing the results, and an appointment that might take a few hours locally, can end up being a three day trip for patients.

There is technology that is helping eliminate unessential travel; video appointments.

- Most of our virtual health usually is some sort of audio visual, so we're hearing them and we're seeing them.

With like our Stevens County virtual clinic, we were able to bring an electronic stethoscope into the room, and so we would have a medical assistant put it on the patient's chest, and I could hear them breathe, I can hear their heart sounds.

We have that technician who can do EKGs from a check oxygens and vital signs.

- [Aaron] Allowing patients to visit the closest clinic and get connected with a specialist who is hours away.

- And so that's been excellent to keep care local, we can get their labs local and have their labs sent.

We can get the echoes pushed electronically, and be reviewed ahead of time.

I think that has been amazing.

I had another patient I just saw recently who, we can call him Jim.

Jim was having profound shortness of breath.

- [Aaron] And Jim lived hours away.

Weather and travel over mountain passes a huge barrier to the care he needed.

But with technology bridging that gap, he was able to keep his appointments, and find targeted solutions for his heart condition.

- We are simplifying meds.

And we have a protocol where, he was seeing a cardiologist every one to two months.

We are now doing virtual visits, we're getting echoes closer to home, and having the images uploaded.

So he's barely gonna have to come down here, and getting one of the newest FDA approved medicines specifically designed for this disease.

- [Aaron] This solution doesn't work all the time.

There are some things that just don't translate over a computer screen.

Labs and studies might get uploaded in a different way.

- If you had your lab drawn at a local lab, it might get scanned as a PDF, it might get entered on a separate line, maybe the echo tech in a rural community doesn't have the same level of cutting edge echo machines that we've got the latest and the greatest.

- [Aaron] And in some cases, experience with those tests can be a hurdle, which means there's still a need to meet people where they live.

- So we in our advanced heart failure group, recognizing that barrier, have historically gone to major centers, so that patients don't have to travel as far, even though they still have to travel, we have gone to Swedish to help some of our patients on the western side of the state to Tri-Cities, and to Missoula.

We've also gone to our more rural patients in Stephens County.

And so those are often need-based clinics.

- And Dr. Mooney talked about the role of telehealth as helping in quite a significant way.

Dr. Barnes, given your experience, can you talk about some of the limitations that we're seeing as well, 'cause the one size doesn't fit all, right?

- Right, yeah, it's great to have it as a possibility.

There are a lot of conditions that are just, they don't lend themselves to telehealth.

If I need to look in your ears, I can't do that on telehealth.

And there's just, there's a lot that's missed when you're not in the room with the person, a lot of nuance that we do use in the physical exam.

- Talking with Dr. Mooney, she says, one of the benefits unintended maybe, is that when you're also videoing is with someone, you are able to see them in their own environments, and you might see factors in the background.

Does that happen in your case very often?

- It does, sometimes.

I haven't done a lot of telemedicine, I'm still fairly new, but yeah, it is kind of nice to see, like what kind of a place do you live in?

What is your home like?

Especially in the rural area, you have a lot of people who live off grid, which could mean anything from a broken down trailer to a famous YouTube, you know, with a full solar array, and really everything in between, and you just really don't know, people live however they want.

- And so that could be also a limitation in technology as well.

- Exactly, yeah.

Not everybody has a good internet connection, and not everybody has cell phone service at their house.

- Which is kind of surprising.

- It's kind of radical.

- Yeah.

Dr. Velazquez, beyond telemedicine, what other technological or innovative approaches are being explored to address rural healthcare challenges?

- So actually, I wanna address something that was mentioned, which is sometimes we think about technology, and technology is as useful as the technology is available to you.

And one of the conversations we have with a lot of our partners that are in rural healthcare, is you may have this technology, but we don't have the ability to implement it, and or service it, and or provide it.

So I think we, we need to think about that, and that's why providers in rural medicine is kind of a different experience.

I have a good friend who's a health officer, emergency room physician, and when needed, he's the paramedic in the ambulance, because there's no one else to do it.

Sometimes when you transplant someone from an urban area to a rural area, that's a culture shock.

And it's one of the issues that is being addressed through the medical education process, so they live with that as opposed to move into that, and don't know where they came from.

So let's go to technology.

So I think if you look at the technologies advancing, everything from wearable sensors, there's carpeting that can sense your gate for example.

But again, you need to have access to that.

And I think being able to use biometrics is very helpful for cognitive issues, or other disorders that we will see more of as we are all aging.

Many of us are at the age of 28, and we do know by, in the next five years or so, the population over 65 is going to outnumber the population over 18, and that has its own set of issues.

So, and that is true also of our rural areas, where we have an aging population, and with that comes, not only the chronic illnesses that we talk about, cardiovascular disease, et cetera, but structural issues with bones and ligaments, and also cognitive issues.

So I think technology is gonna be extremely helpful.

You cannot take away that touch of the provider.

And when I say provider, one of the things I wanna mention, one of the applications of technologies as a company in Spokane that is working on what I call an Uber model for nursing, because it's not just about physicians, it's about having nurses, about having providers.

So there's a local scientist that is affiliated with WSU, that has several pilot projects looking at how to deploy nurses when there is a need, almost on an on demand, it's like an Uber, called Uber model.

And I think that would be helpful, not only in urban areas like Spokane, but it would be helpful in areas in which traveling nurses may not be available, for example.

So I think that's one of the applications that we don't think about, but addresses one of the gaps.

- And how has, you know, we talk about the advancement of technology, you know, a lot of people are talking about AI, it's very forefront of people's mind, and I would imagine it's the same in the medical field.

If you want to give some examples of how you think that might play into it, or you know, where we are in an actual timeline, where that makes a huge difference, I'd love to hear some of your thoughts, we'll start with you Dr.

Bowman.

- Yeah, the students are definitely interested in how artificial intelligent can augment the work that they're doing with their patients.

But they have to first understand how to connect with their patients themselves.

So we focus a lot on the foundational components of building trust, using open-ended questions, connecting with your patient, giving your patient an opportunity to tell you what their barriers might be, rather than you making assumptions based on what you might have read in a textbook.

Then artificial intelligence can come in and help shore up some, and simplify some of the workflows, like taking notes for you while you're working with your patients.

- Dr. Barnes, how many patients do you normally see, just yourself, or providers in your position?

- Just me, I still have a fairly low count, 'cause I'm still a bit new, so probably 18 a day, - Okay.

- 16 to 18.

And I have actually started using a program called DAX.

Providence has really been trying to help the physicians with the paperwork load, 'cause it is pretty extensive.

And so it's a program on the telephone, or an app on the phone that listens to the conversation and then uses AI to generate the medical note.

And I found it to be pretty useful.

If nothing else that I can start it and set it aside, and then I just talk to the patient, and I'm not typing anything, and it just is a far more natural conversation.

And it does a really good job of document, it's not perfect, but I go through and review, and make sure it's correct before I submit the note.

That has been a really helpful thing.

I think AI has a lot of limitations, I think if, if we could create an AI that would stop learning, then it would be good for patients to interact with and learn something.

But I think patients bring a lot of their own home remedies that aren't necessarily as accurate as they could be, or as scientific I guess as maybe we would prefer that term, and that would get introduced then into the AI, and spread around, and so I think there are some challenges, but I think it would be really helpful in the long run.

- And you say you only see about 18 patients a day, to me that seems like a full load.

What are you hoping to breach, or do you have a number where you get cut off?

- Not really, it's how we see patients, I do 30 minute appointments, which is fairly long for primary care, it's usually 20 minutes or 15 minutes.

And part of that is, I'm kind of digging in, I'm gonna hold onto that as long as I can.

But I really feel like my patients need that much time to explain things, and to have a good conversation.

The challenge of it is billing.

We are always, you know, we have to keep the lights on.

So we'll see if I can, if the level of complication of my patients, which it usually is pretty, they have a lot going on.

And so if I can do the appropriate cost benefit, then I'll keep them long.

- Nice.

Dr.

Bowman, WSU takes a unique approach in considering the assets that rural communities bring to healthcare.

How have those communities helped shape the curriculum for rural healthcare?

- One of my proudest moments about WSU's College of Medicine, is how we center community as we think about, not only who we wanna bring in as our medical students, but how we want to train them.

So we have an advisory board that has served WSU'S College of Medicine since before we welcomed our first students.

That advisory board has several folks from rural communities who get to tell us directly, what are the challenges, but also what are the opportunities in a rural community.

We've come to appreciate that rural communities are very gritty, creative people, who are self-sufficient, and will get the job done.

And that has given us a lot of creative ways in which we can adapt that, and incorporate it into our training.

- Can you give a specific example that you might have in mind?

- Yeah, so we recently discovered that our students really wanted to have a sense of belonging and connection to the communities that they have come from.

So we created week long immersion experiences in their first two years, which tend to be the classroom and laboratory learning time, where they get to go out into community and learn.

That came as direct feedback from our advisory board that stated, we wanna see your students right away, we want them to identify with these communities, so they're more likely to come back there as they finish up their training.

- Excellent.

And Dr. Velazquez, your office works closely with surrounding counties on various public health initiatives, how does this regional approach help address rural healthcare challenges?

- That's a great question.

So tomorrow, for example, we have an educational experience for the nine counties around us, where our folks from immunization, epidemiology, and case disease management, are going to provide all of our colleagues from the nine regions all of the tools that we have for measles, which is kind of an issue around the country, and not that is an issue in Spokane, but our goal is to make sure that all of our surrounding counties are as well prepared as we are, and ready to really move forward if indeed they were to have a case, so we're doing two sessions tomorrow, and that's not uncommon, we tend to share all of our resources with our partners.

- How has that changed over the years?

Is that pretty, you know, par for the course, or do you see more and more interconnectivity?

- Yeah, I think we see a lot more interconnectivity, and the part of the issue for that is Spokane is a real referral center, so we do get referrals in healthcare, and we have questions in public health from all over the surrounding counties, so it makes sense for us to actually do that routinely.

So we routinely spend time together, we routinely share, and if there's something that we find out about, for example, when the first case of measles in Seattle happened, one of the first things we did, not only notify all of our practitioners in town, but we also make sure all of our partners in the nine regions actually have the same information.

And I think that's going to continue.

And the reason for that, disease doesn't know geographical boundaries, people move, we all have access to going here, going there.

Actually, I understand that Walla Walla, who is not part of the nine regions, is interested in participating in the seminars tomorrow, which will be great, 'cause who doesn't love going to Walla Walla?

I mean, really.

So I think we need to continue doing that, and we do the same with our friends across the border on the Idaho side, because again, these diseases don't know geographical boundaries and patients, people can live there and work there, and Idaho, who can live in Idaho and work here, so we all need to be prepared.

- Does being a regional hub impact our local resources?

- Well, I think it has a...

I'm an optimist, so I see a positive impact.

Because if you, I've lived in a lot of places, I grew up in a small town, by the way, in a farm.

But if you look at Spokane, we actually have quite high levels of care that are not typical of a mid-size city like we are.

But we've developed that, because we serve so many communities around us, or many states around us, that that has allowed us to develop a level of care that is not typical of midsize city, which is a benefit to all of us that live here, and a benefit to all of our neighbors.

- We've talked about many challenges, but what successes have we seen, Dr.

Bowman?

Are the promising signs from your medical school's efforts really shining through here?

- They really are.

You know, we've only graduated two of our classes all the way through our training.

So through medical school, and earned their MD, and then onto residency.

And in those first two cohorts that have graduated, we already see that 5% have come back to small towns and rural communities in Washington.

One of our graduates is out in the Port Angeles area, and we just welcomed a graduate into Cheney, and down to Colfax.

So we're really excited to see that our efforts are making a difference.

It's early, but it's very promising.

- And Dr. Barnes successes that you like to focus on?

- Well, not to toot my own horn, but I graduated from the Colville residency, and I felt like it was excellent training.

That residency itself has about half of the primary care doctors, physicians, working in Stevens County graduated from the Colville residency program.

And so it's been tremendous for training and keeping providers in the local area.

And those that have gone and not stayed, are in other rural areas, so it is teaching people to be rural doctors.

And I thought it was excellent training, and it was an excellent location, so I decided to stay.

- And you haven't looked back since.

- No.

- And finally, Dr. Velazquez, as our region's population ages, what new challenges do you anticipate for rural healthcare, and how do we prepare for that?

- So with an aging population, it's wonderful that we're living longer, but that has its own sets of issues, as I mentioned, the prevalence of chronic illness, as well as the need for other support, whether it's physical therapies, orthopedic surgeons, et cetera, et cetera, and all of the cognitive and mental issues that could come with advancing age, and having access to all of those resources becomes more important.

Isolation in the, I don't like to call them elderly, but people that are a little bit older than others is one of the issues, and we see that in rural areas, because they tend to be more isolated.

So I know one of the organizations in Boston, for example, developed these avatars that you can actually have a conversation with, and they have biometrics, so they can assess by your facial expression, whether you are depressed or whether you're reacting appropriately.

So I think we're gonna have to really leverage all of the knowledge, all of the experience, all the technology.

I agree there's no, you cannot really replace that provider one-on-one relationship, but you can certainly augment it.

And you didn't ask me if I'm gonna answer, one of the successes that I see from us, is, if you think about it, the investment that has been made in higher education, and graduate education at all levels for physicians, for nurses, for therapists.

We did not have this when I moved here 13 years ago.

Now we do, we have two medical schools, we have four nursing schools, we have, I don't even know how many other programs.

And even with that, we still have a little bit of a gap, but we have to remember that Washington, so the US population about five, I don't know one fifth of it lives in rural areas.

Here is between 10% and 16%, depending on how you count it, which is significant.

Similar to other urban areas that are surrounded by rural areas, like we are.

And access to, particularly when you have like two or three major cities, becomes an issue.

And that translates into the surrounding states.

We're seeing the same thing, that rural movement towards Spokane, which is one of the reasons why we have this extraordinary level of care.

- Excellent, thank you so much.

And thank you all for this important conversation.

The challenges facing rural healthcare are complex, but your insights have helped us understand the path forward.

And if you'd like to share this episode with someone you know, you can find it on ksps.org.

I'm Aaron Luna, have a good night.

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