Episode Transcript
Interviewer: You're listening to Pathways in Academic Medicine from The Scope Radio. We're live at the AAMC's Learn Serve Lead. And we're going to learn more about the innovative pathways, academic medical centers or building to impact education, research, and inpatient care. And today we've got Dr. Sam Finlayson, he's the interim dean of the University of Utah's Spencer Fox Eccles School of Medicine, and Atul Grover, the leader of the AAMC Research and Action Institute. When we talk about pathways, we usually are talking about problems that need to be solved and how are we going to do that.
Sam Finlayson: So today we'd like to talk about the problem of access to care, particularly in rural areas. We live in a rural state in Utah. We have a population center up and down the Wasatch range. But then once you get out a little bit further, there's a lot of difficulty with access to care, something that the University of Utah cares a lot about. As a public institution, we feel a tremendous amount of responsibility for providing providers for the state. You and I have talked about rural health before, specifically about how we make sure that we have enough physicians to cover the needs of the population. So we'll start off with the question of why is it important to you and what is the AAMC's role in addressing this?
Atul Grover: So I think one of the most important things in terms of trying to find policy solutions, and that's mostly what I focus on, is what can we do in public policy to solve people's problems? They don't want politicians and policymakers to just define the problem. They want to find solutions. And I tend to think about the problems in rural health as needing to be better defined. What's the problem we're trying to solve? So clearly I know that if you talk to the average American, particularly one that lives in a state that is heavily rural, they will say, "We have a crisis in rural health care." And so my interest is in understanding what is that crisis as defined by the people who are living in those areas. What do they think the problems are that they would like you as an academic center, as the only academic center in the entire state of Utah, which I have a lot of respect for, but it brings you a lot of responsibility.
So what do they want from you? What do they want from policymakers? What do they want from society in general? Because to me, when I look at the problems of rural health and rural health care, there are access to clinical care issues, which quite frankly, if you look at utilization of primary care services, it's pretty equal between rural and urban populations. So we're finding a way to get them some care, but there are a lot of problems that people in rural areas have that aren't necessarily going to be fixed by a physician or a nurse or a hospital alone. It needs a lot of investment really from kind of cradle to grave or from womb to grave to think about how do we actually improve people's education? How do we reduce their levels of economic hardship and poverty?
How do we help them with some of the harder issues to solve like substance use disorders, a lot of which are tied to education and a lack of financial resources. So I think you kind of have to figure out which pieces of this you really want to tackle before you come up with, "Hey, this is the answer." And so I would kind of turn it back to you to say, as you look at those rural populations that are just intimately connected with you and Salt Lake across the state and really across the region, what do they want from you versus what do they want from say, the governor or the state legislature or their local mayors or city councils in terms of the things that they need to be healthier?
Sam Finlayson: So at the University of Utah, I think historically we've focused a lot on producing more physicians and doing it in a way that encourages them to stay in Utah and particularly in areas that are underserved. We have a couple of programs that are federally funded and state funded that give the students more experiences in rural areas to really help them better understand the kinds of issues that go beyond simply the delivery of care. The social determinants of health have a clear understanding of how those things in the rural areas are impacting health and how to address them. I think historically, as I said, we've been focused on producing more physicians. I thought the point that you made that the people's actual encounters with primary care are not that much different from a frequency perspective than urban areas, which really suggests that the model that we have for delivering care in urban areas is perhaps not a great fit in rural areas. Then maybe it's not the number of physicians, but something about the way that we structure and deliver care.
Atul Grover: And I think you've managed to do that as again, you're not only a leader in your state, you are a leader in the region of the country where you provide a number of services that are high-tech, high investment. So when I look at where patients come for both inpatient care and come to Huntsman for complex cancer care, they're not just coming from all over Utah. They're coming from Wyoming, they are coming from Idaho, they are coming from the Dakotas. And I see a similar situation when I look at University of Colorado in Denver. I think you guys kind of split stuff up depending on which side of the mountain you're on. And I've had to explain this to congressional members from say, the state of Wyoming where they say, "Why are we investing in these programs that are based out of cities in Salt Lake or Denver?"
And the first thing I say is, "Sir or ma'am, you ever been somewhere when the helicopter comes and picks up a patient or the fixed wing, you know they land somewhere?" A lot of times that's going to be Salt Lake or it's going to be Denver, or it's going to be Seattle, or it's going to be someplace else where it doesn't make sense to move that entire apparatus out into every state and every neighborhood. And so I think we have to begin to think about how we regionalize and deliver good care to people regardless of where they live. Part of that, I think, can be done by technology, but even with technology, my sense is number one, we don't have... We saw this during COVID. I live in the suburbs of Washington DC. I have no issue with broadband. If there's a major catastrophe, the cell service goes down, but otherwise I've got 5G, LTE, 4G, whatever I can get on the broadband superhighway. In rural states, we have an infrastructure bill that hasn't been completely appropriated from a couple of years ago.
I would love to see states like Utah lay that last mile of fiber into every community in that entire state. That's the only way that I'm going to be able to have technology reach the patients there. Once I have the broadband connection to them, then I've got to help them in some way figure out how to use that technology. And I never would've thought that every single American household would understand how to use a pulse oximeter overnight, but we did. But in the meantime, we had to figure out how to teach people how to do this stuff. And I think what we do need in most communities is not necessarily a physician in every neighborhood. We don't have the resources.
They're incredibly expensive, but we've got to be able to figure out how we put technology there and some type of personnel. Now that might be a nurse practitioner, it might be a PA. You guys have a fantastic allied health program, and so I would love to see you think about how you line up your therapists and social workers and your PAs to also serve the underserved communities in your state. And it might be we don't need a full hospital there, but we do need a micro hospital or a clinic with the technology and somebody there who really knows how to work with that technology and the patients
Sam Finlayson: In addition to the programs that put the students out into rural areas, we're also expanding our campus down to St. George. We recently received support from the state legislature to move there and do it in conjunction with Utah Tech University, which is down in St. George. This will allow us to get a broader experience for our students and trainees to have exposure to rural areas. But at the same time, it's not just exposure. I think there needs to be something further done to help students prepare to become doctors and work in settings that are different. What does the AAMC have in its repertoire of areas of focus that might help with curricular changes that would prepare more students to work in systems that are different than the ones they encounter in an urban environment?
Atul Grover: So again, I think you have to think about the levers that you have that can actually influence the outcome that you desire. Now you've said you want an outcome which places a physician in a rural area or at least gets them prepared to care for that population even if they're located miles away. To get practitioners into those areas, there are a couple of things that we know would make a difference demographically. So it turns out that women, minorities, kids from underserved areas, particularly from rural areas, are more likely to go and want to go and work in those areas. You also have the issue, and I think this is certainly true in a state like Utah where people get married at earlier ages, you've got to find somebody whose spouse is from a rural area as well. Because as much as I may want to go there, my spouse says, "No, I'm city-bound. I'm not going to go."
And so I think there are some things that you can do to look at your applicants to say, not only what are you interested in, but what are the characteristics about the people that would lead me to believe that yeah, you are more likely to go and serve those rural areas. And then I think it becomes exposure. So you can either expose people into or out of some of these careers, and mostly what we have at the AAMC, we're not training physicians, we're not doing bench research, but we do have the data to do good health services research and med-ed research to be able to tell you, "Look, here's the kind of characteristics you might look for. Here's the kind of experiences that might help." And so what I think we know is that rural tracks, there is a selection bias in terms of who's going to say, "Yeah, I'm going to go do that rural track as a learner."
But if you can get people who are at least willing to give it a shot and then you give them a good experience, you've got to find the right preceptors out there in those rural communities that will accept them, that will teach them well so that they are excited about going to those places to practice. That is what's going to make the difference in the long run. But I think at the same time, you've got to be thinking about it as a state and regional referral institution. How do you not only help with the trauma patient or the cancer patient, but how do you just help with a complicated patient in general, whether that person is being seen by their local primary care physician or NP or EMT? The other thing I don't know how you really solve is obstetrics. I need a facility.
I need somebody there. I can do a bunch with certified nurse midwives. And I think part of your opportunity is to figure out, because you do have these other health training programs and sometimes in partnerships with tech or other places to say, "Okay, how do I create and model a system in training that is also going to be feasible in practice so that these new professionals come out and they say, 'Yeah, I can do this. I'll be supported.'" And I know that the university is going to be there as a resource when I run into patients who really need more than I can do for them right there at the bedside in a small town.
Sam Finlayson: I think you're right. You've touched on indirectly interprofessional education, which is something that I think is really key as we work as teams to deliver care. Now I'm going to ask the really tough question. So let's say that we are successful in teaching medical students how to become doctors that could be successful in a rural environment, understanding the special situations that are there, and let's say that we're successful in getting broadband all the way to the end of the road and that we're able to address mental health and substance abuse and other major challenges in health care. Let's say we were able to do all that. Nevertheless, we'd have these doctors going out fully prepared to work in a rural environment where economically, it's really, really challenging to carry a practice. I mean, it's hard enough in an urban area for professionals to be able to carry a practice and the hospitals are having a rough time too. I'm sure you've seen the statistics about hospital closures in rural areas. So what's to be done?
Atul Grover: So this is in part an organizational approach, and the other would be a policy approach. Organizationally, I think you have a responsibility to figure out some of this stuff for the state as the state's only academic health center. Now, the state has a responsibility to support you in that effort, which means that they need to figure out how to make the funds work for you to partner with local institutions throughout the state to be able to give them cover and guidance or to potentially operate as the university health system, smaller hospitals within those areas. And you'll have to financially float them. So one would be to say, "Okay, we're going to use the existing structure of the University of Health system and its health professionals to establish a network of providers including small hospitals and clinics throughout the state." But those are going to be funded by the state legislature through support to the university health system.
Alternatively, if you really wanted to foster independent practice and independent providers and clinics and hospitals and communities, I would disagree with that. I think we've tried to do this for well over six decades. My dad was a public health person in the seventies, wrote a book with some colleagues at Hopkins called Doctors for the Villages. He was focused on India, but it really could have been talking about rural United States. So we have tried for at least 60 years to put a doctor in every county, in every neighborhood. We have not been successful. But let's say you decided you really wanted to pursue that strategy. There are payment levers that you could use. Now, we already know that physicians in the middle of the country and in rural areas make more money than people on the coast in general in the same specialties.
Part of that is built into our Medicare reimbursement system where there is a bonus in terms of the base level of payment for physicians who are practicing in health professional shortage areas. Community health centers are paid basically at cost plus. So you have an average follow-up appointment that might be paid $90 in a physician office. Well, it's going to be paid at closer to $260 or $280 at a community health center. So you can create financing systems that basically buy your way into keeping personnel there. I don't know that that's sustainable in the long run, but it is a way that you could get those providers out there locally.
I just think we're not going to do it entirely with physicians. We need to think about every other professional out there that are members of our teams. We need to think about technology and decide that we can regionalize some of this care the way that we do with really, really technical stuff. And the things that I've seen Utah and places like University of New Mexico do with the approach of Project Echo to say, "I can't get a hepatologist in every community, but I have the best hepatologist in the state and some of the best in the country here in Salt Lake City. And we're going to connect them to primary care docs and to GI docs all throughout the state." And I really think that's the way we need to be going.
Sam Finlayson: Great. I have one more question. We just participated in... Every year, it's highly anticipated, this report on workforce. Everybody's concerned about workforce. You and I have just talked about the fact that primary care encounters are similar in rural versus urban areas. One of the big takeaways of today's presentation was that we're actually not doing so bad on primary care. If you throw in the APCs as well, we're getting close to meeting the demand with supply. But the red flag was on specialty care and the real question of whether we're going to have enough specialty care to take care of our population, particularly as the population ages and their medical problems become more complex. So if we're having trouble with that in the urban areas, are there any special solutions for a delivery of specialty care in rural areas where you don't have the volumes to have super specialists for sure? And even an ENT surgeon would have a hard time having enough business to maintain a practice in those kinds of areas.
Atul Grover: And even aside from the business aspects, from a quality perspective, some of your old colleagues in surgery at Dartmouth did some great work about the minimum surgical volume that you need to achieve to stay proficient and have good high quality outcomes independent of the hospital you're working in or surgical center. So I don't think in that aspect, you want to create a sort of substandard approach to care where you say, "This doc's only going to do five of these a year, but good enough for that population." I don't think that's right. I think what we ought to figure out is bidirectional flow of, in some cases, human beings too. So if you're a cardiologist, if you are an oncologist, can we be sending people out to some of those communities? That's still intensive from a labor perspective. It's expensive. That's one option. The other is to figure out how can we amplify the care that's given by, say, a nurse practitioner out in a rural area when... Look, both of my parents had cancer at some point.
Both were seen by NPs or PAs as their primary point of entry into an oncology practice. That could be happening more. So while I certainly can see that there's a set of services and diagnoses and conditions in primary care, we know that upwards of 40% of visits are somehow involving an NP or a PA or others on the team when they are things like upper respiratory infections, urinary tract infections, low back pain. Less so when it comes to something like a cardiac or a neurologic or an ophthalmologic problem, but it kind of makes sense. Now, what we haven't figured out yet is you are a surgeon, I can't get you out of the operating room in my lifetime. And I know we talk about sort of these focus factories and hernia repairs up in Canada or seamstresses being taught to do cabbages and bypass work in India. That's not going to happen here anytime soon. Not in my lifetime, certainly.
But I do think that we can figure out ways to deploy other really skilled professionals that might have more knowledge, say in cardiology or neurology, than I have as a general internist. So they might be the first point of entry either in an urban cardiac or oncology clinic, or they may be the only point of entry for oncology or that first point of entry in the patient's local community. Right now, I've seen your outpatient footprint for Huntsman. People come from all over and they've got to come to Salt Lake. Probably you guys could tell us which things could be safely done under the supervision of Utah physicians and oncology when it comes to solid tumors or blood tumors that at least could sort of initially cared for out where people live, because that's where people want to be when they're sick. They want to be with their families, they want to be close to home, and we've got to figure out how we can do that for people. The one place I cannot figure this out again, is obstetrics. I don't know how to do this without a facility.
Sam Finlayson: That's for sure. So I really appreciate the work that you're doing in the AAMC, helping us understand these issues, addressing them with policy as well as with education. I think this partnership that the various medical schools and our AAMC organization is really fantastic. And then personally, thank you for taking the time to talk with us.
Atul Grover: Yeah. We both evolved over the years, as professionals, and I think part of that lesson is what I hope we teach in part at our academic centers, is how to listen to each other, how to really listen to each other with the intent to be influenced. Because I learned from you, and hopefully you've learned some things from me over the years.