National Rural Health Day is November 17. OHSU celebrates rural communities and rural health care providers everywhere. Meet a few rural Oregon providers – OHSU graduates – in the story below. Find how OHSU faculty and students are joining forces with rural communities to strengthen local care.
By Rachel Shafer and Erin Hoover Barnett
Alumni, faculty and students join forces with rural communities to strengthen local care
The elderly woman arrived at the small emergency room with rib fractures and a collapsed lung. Jessica Carlson, M.D. ’11, inserted a chest tube and stabilized her, while thinking ahead to next steps. Dr. Carlson is one of two general surgeons covering the Level 4 trauma center at Curry General Hospital in Gold Beach, Ore., a community hospital serving the 22,000 residents of Curry County along Oregon’s remote South Coast.
Knowing the patient’s high risk of contracting pneumonia and the hospital’s limited capacity for critical care, Dr. Carlson concluded: LifeFlight to OHSU. She remembers the patient’s response: “I don’t want to go up there because if I die, I’ll be by myself. If I’m going to die, my family is here.”
So Dr. Carlson and the nursing staff sprang into action, pulling a ventilator and telemetry and suction equipment into a room adjacent to the nursing station to create a temporary ICU. With the help of a respiratory therapist and nurse with critical care experience, they cared for the woman over several days and released her, much recovered, to her family.
It’s outcomes like this one that reinforce why Dr. Carlson practices rural surgery in Gold Beach and why she carves out time to teach OHSU medical students on rural rotation. Rural providers matter.
Across Oregon, communities big and small are grappling with systemic changes in health care. But rural medicine faces additional challenges: limited local resources in equipment, staffing and specialty expertise; patient populations with higher mortality and low birthweight rates, according to Oregon Health Authority; a continual thirst for providers; and long travel times – in some cases, a six-hour drive to specialized treatment.
For decades, OHSU School of Medicine has worked in Oregon’s small communities through its volunteer faculty, rotating students, residents, community researchers and, importantly, practicing alumni physicians and physician assistants.
In recent years, though, school leaders took stock of the school’s rural mission, saw room for improved collaboration and are now doubling down on efforts. Why? The aim is not to thrust an academic health center onto local providers, who are the experts for health care in their communities. Rather, it’s to support community-led collaborations and relationships, deploying OHSU resources to fill gaps where needed and partnering with local providers to improve the health of their communities.
“When your mandate is to improve the health of Oregonians, you don’t get there by bringing everyone to Portland,” said Mark O’Hollaren, M.D. ’80, OHSU vice president for strategic outreach. “OHSU’s resources are finite, but we have been able to partner with a number of rural communities to improve access to care closer to home, conduct community-based research reflecting the needs and conditions of all Oregonians and help seed the next generation of rural providers through education and training programs far from the Portland metro area.”
“A little piece of home”
Jane Johnson had at least one bit of good news when she woke up from her colonoscopy. She’d be able to stay in her North Coast community for much of her cancer care.
Driven by need a decade ago, the mayor of Astoria and leaders of the medical community reached out to OHSU, and together they’ve launched a series of collaborations that bring physicians at Columbia Memorial Hospital and OHSU together. The arrangement means that, in many more instances, medical care and procedures can be performed at Columbia Memorial Hospital. For Johnson, it means seeing her oncologist in Astoria as well as getting her chemotherapy port installed at Columbia Memorial Hospital by Rachel Van Dusen, M.D., assistant professor of surgery in the OHSU School of Medicine.
Then, when Johnson needed major surgery to remove her tumor, Dr. Van Dusen met her in the operating room at OHSU. Seeing Dr. Van Dusen before her surgery, Johnson said, “was like having a little piece of home.” Follow-up care has been in Astoria, including a recent visit with Dr. Van Dusen to discuss additional surgical procedures.
Dr. Van Dusen and Columbia Memorial Hospital leaders note that the focus needs to be on the providers – from CMH and OHSU – doing as much as they can at the community hospital; the collaboration should not become a one-way ticket to doing more procedures at OHSU.
The arrangement also benefits the local hospital and economy in other ways. Erik Thorsen, CEO of Columbia Memorial Hospital, says the hospital has grown by more than 15 physicians and estimates the economic ripple at 150 jobs in the community.
“It’s been a rewarding thing to watch the organization – and our community – grow,” said Thorsen, who grew up on the North Coast. “The community also sees value and takes pride that OHSU is here and that CMH is increasingly associated with the quality of OHSU.”
In addition, the arrangement means that physicians drawn to rural health care who also want the professional experiences possible in an urban medical center can have both. For Dr. Van Dusen, the collaboration with OHSU that her stepfather, longtime Mayor Willis Van Dusen helped convene, clinched her decision to practice in the town where she grew up.
“I didn’t think I could find a position I loved and do the surgery I wanted to do,” Dr. Van Dusen said. “This affiliation with OHSU came up, and it worked out perfectly.”
The Astoria clinical collaboration is just one of dozens playing out across the state, including those affiliated with the OHSU Telemedicine Network. Using secure, two-way video and audio communications, the network gives providers in community hospitals throughout the region immediate access to OHSU specialists, improving patient outcomes, avoiding unnecessary transports and helping rural Oregonians get well in their home communities.
Family physician Jon Schott, M.D. ’96, sees patients in the town where he grew up: Baker City, Ore., pop. 9,828, nestled in the mountain and sagebrush country of northeastern Oregon. Dr. Schott first began practicing there in 1999. “I had no business background, and coming out of residency into a frontier area felt – despite great training – completely overwhelming,” he said. “Connecting to OHSU was a survival mechanism.”
That connection was and continues to be L.J. Fagnan, M.D. ’71, professor of family medicine in the OHSU School of Medicine. Dr. Fagnan describes himself as a former country doc-turned community organizer. He logs significant “windshield time” attending meetings with rural, primary care practitioners around the state as director of the Oregon Rural Practice-based Research Network.
ORPRN staff provide technical assistance and quality improvement resources to aid in practice improvement. They disseminate best practices among clinics. They deliver education and skills training to help practices become medical homes. And they conduct research, investigating clinical questions in partnership with rural providers – linking questions from primary care practices to answers from practices.
In Baker City, an early project with ORPRN involved partnering with Baker City’s health department to increase pediatric immunization rates. “That led to not only increased rates in our area, but to a partnership that still exists today, which has grown from immunizations to include women’s health issues and a clinic located in the high school,” explained Dr. Schott.
ORPRN’s approach is not to tell rural providers what to do, but to facilitate and provide resources that enable practices to innovate and improve on their own. “It’s a stressful time in medicine,” said Dr. Fagnan. “We want to ease the stress on practices.” That’s the job of OHSU employee Steven Brantley, M.P.H., who is based in Ashland. A practice enhancement research coordinator, Brantley works full-time on Healthy Hearts Northwest, a federally funded project coordinated through organizations like ORPRN that help small- to medium-sized primary care practices build a quality improvement structure, while also working on improved heart health outcomes.
On a bright, fall morning, Brantley is in Klamath Falls, leading a meeting with providers and clinic managers at Cascades East Family Medicine. The discussion revolves around progress on the clinic’s smoking cessation efforts. Data are reviewed, survey results examined, problems and ideas aired. There is an easy banter in the room, but also an urgency from clinic staff. Patient health is at stake. Cascades East is doing good work, observes Brantley. “I want to take what they’re doing and share it with everybody else because it’s effective,” he said.
The needs of rural providers are as different as the communities they serve. ORPRN’s knack is to find commonalities and nurture solutions. “It’s my firm belief,” said Dr. Schott, “that our clinic in Baker City wouldn’t exist if not for our relationship with ORPRN.”
Skin in the game
The enormous topographical state map hanging on the wall in the office of Paul Gorman, M.D., keeps this assistant dean for rural medical education in the OHSU School of Medicine focused on his goal: place more medical students into more specialties completing more clinical experiences with more rural physicians across Oregon to increase the number of graduates entering rural practice. Currently, 350 alumni out of 2,276 total physicians practice in rural Oregon.
Dr. Gorman is the first leader in the school’s administration dedicated solely to rural medical education. “School leaders recognize the importance of rural medical education as a keystone to the school’s mission to serve all of Oregon, and we’ve redoubled our commitment,” said Dr. Gorman. “We know this is not a short-term effort. We are in it for the long haul.” Moreover, he added, it’s not what communities can do for the school but what the school can do for communities.
Dr. Gorman began his career in rural medicine. Over the years, he’s seen it change. “In all but the smallest towns, there is more technology and specialty care available than a generation ago,” he said. Rural medical education must also adapt by diversifying the spectrum of specialties available to students, Dr. Gorman says. Completing a rural clinical experience was and continues to be a requirement of the school’s M.D. curriculum. In fact, the school’s new curriculum, YOUR M.D., expands this by offering students the choice to experience an array of rural careers. Curious about rural cardiology? Rural emergency medicine? Rural surgery? Students can now sample specialties during rural rotations as well as the broad-based practice of primary care.
Dr. Gorman is the first to acknowledge the school needs to do a better job of strengthening relationships with rural communities and providers.
The school is also challenged to promote rural medicine to M.D. students from within the environs of Portland. But that’s where Nick West, Abbie Huddleston and Emily Thompson come in. Second-year medical students hailing from Imbler, Seaside and Heppner, respectively, they’re passionate about returning to rural Oregon. All of them participate in the state’s Scholars for a Healthy Oregon Initiative, in which the state provides funding for student tuition and fees in exchange for a commitment to practice in a rural and/or underserved area for a given period.
During their first year, the trio wondered why there weren’t more rural activities in the new curriculum. So they set out to fix it. With Dr. Gorman’s help, they launched the Rural Medicine Discovery Program. Between course blocks, any M.D. student can sign up to take enrichment trips to rural communities around the state. There, they precept with a physician, eat dinner with local practitioners to get a feel for the provider network, talk to local high school students about health care careers and enjoy activities such as surfing, visiting museums or biking through the countryside. The trips have become popular with M.D. students. Sign-ups feature waiting lists, and the three have heard from fellow classmates who have become “stoked about rural medicine,” as West put it.
The idea is to ground students in real experiences so they can envision all that a rural commitment entails, the three say. “Rural people distrust the health care system when they have transient physicians,” said West. “Small communities want longitudinal health care, whether that’s the cardiologist, surgeon or family physician.”
West, who grew up on a cattle ranch, added, “We need physicians who are riding for the brand, so to speak. They need to have skin in the game. Rural physicians need to be there, regardless.”
Small town life
Dr. Jessica Carlson of Gold Beach is invested. She’s wanted to live and work on the Oregon Coast ever since rotating in Florence, Ore., as an OHSU medical student. She bought a house in Gold Beach and has joined local clubs. She’s planning outreach activities to local K-12 students. She shops at local businesses. And at work, she considers herself more than just a surgeon. Her personal mission these days is preventive care such as mammograms, she says, because she’s performed a lot of breast cancer surgery on Curry County women. Every woman of a certain age who comes to her clinic now gets a mammogram, she says. If they express hesitation or anxiety about it, Dr. Carlson walks them over to the hospital and sits with them to give them support.
During a break between patients in the small, florescent-lit office she shares with a fellow surgeon, this rural doctor reflects on her definition of success.
“What do I need to do to improve health care as a whole for this community? That’s my job. My job is not to take out a bunch of gallbladders and fix some hernias, and say, ‘Thanks, it’s been fun.’ My job is to look at how I can improve people’s health. If I can provide care for them here, it’s better for them and better for our community.”
New OHSU Campus for Rural Health
Last year, OHSU launched a new university-wide initiative to better support the diverse, health needs of rural Oregon. The OHSU Campus for Rural Health, with academic headquarters in Klamath Falls, is comprised of distributed, learning sites around the state where OHSU medical, dental, nursing, pharmacy and physician assistant students live and learn together.
Students gain valuable, interprofessional experiences in rural clinical settings while immersing themselves in local health issues by participating in a longitudinal, community-based project. Current sites are located in Klamath Falls and Coos Bay, and OHSU is exploring possibilities for a new site elsewhere in the state.
The initiative builds on existing concentrations of OHSU resources and programs around the state to formalize and strengthen learning and teaching outside the Portland metro area.
Studies show that exposing more students to rural areas will directly affect how many people go into rural practice, says Joyce Hollander-Rodriguez, M.D. ’00 R ’03, regional associate dean for the Klamath Falls site. “And even if they don’t go into rural practice, they will apply that knowledge when they see rural people in urban settings.”
Another goal of the sites is to provide organized professional development and training for local practitioners who are teaching OHSU students. “In transforming students into strong, interprofessional providers, we are also transforming ourselves into better providers,” said Dr. Hollander-Rodriguez.
To meet facility needs in Klamath Falls, OHSU and Sky Lakes Medical Center are joining together on the construction of a collaborative health care building.