Residents in a Room
Episode Number: 72
Episode Title: Rural Anesthesia
Recorded: January 2024
(SOUNDBITE OF MUSIC)
VOICE OVER:
This is Residents in a
Room, an official podcast of the American Society of Anesthesiologists where we
go behind the scenes to explore the world from the point of view of anesthesia
residents.
Your anesthesiologist
in these rural places is your next-door neighbor or your kids play soccer
together.
We're on the
frontier. I want to see how far we can push it. How much can we advance
anesthesia so that people don't have to travel so far.
They're making the
best of the resources that they have and are able to provide really impressive
care.
DR. AUDRA PARRETT:
Welcome to Residents in
a Room, the podcast for residents by residents. I'm Dr. Audra Parrett. I am a
CA3 at West Virginia University. Your host for today's episode, we're going to
dive into a subject my fellow residents and I are passionate about, which is
rural medicine. So before we dig in, let's meet my fellow residents.
DR. ALEXANDRA RICE:
Hi, my name's is Alex
Rice. I'm a CA two at West Virginia University.
DR. BENTON NANNERS:
And I'm Benton Nanners.
I'm also a CA two at West Virginia University.
DR. PARRETT:
All right, so let's
start with why this topic matters. I know why it's important to me. And I'm
interested in hearing your stories as well. Can you tell me where your passion
for rural medicine stems from?
DR. NANNERS:
Yeah, I think for me,
you know, it's kind of my life. I grew up in a rural community in West
Virginia. I've kind of stayed in rural medicine. So, you know, developing rural
medicine here where I'm at is kind of the way I can provide better care to my
family, my community and my friends.
DR. RICE:
Yeah. For me, I grew up
in rural Ohio, a town of like 2000 people, where healthcare was pretty limited.
You had to travel a while to, to get to any kind of real, like tertiary care
and did medical school in eastern Kentucky. So in the kind of the heart of
Appalachia. And so it's kind of had a special place in my heart.
DR. PARRETT:
Yeah. Um, so fairly
similar for myself. Um, grew up in a small town in Indiana, um, in southern
Indiana, with a population of about 10 to 12,000, and then did my medical
school in Lewisburg, West Virginia, which has a population of about 4000. And
they also have a dedication towards rural primary care as well at the medical
school. So did a lot of rural care throughout medical school. And then now just
serving the population of West Virginia. Um, and then I currently have a job
secured going back home, um, and will be serving a bit more of a rural
population as well when I go back.
So moving on to the
second question, what rural anesthesia actually is. There can be some
misunderstanding about that for like what is rural? I guess not all small towns
are, and not all rural communities are small. Um, like for instance, where
we're at right now, I think, you know, WVU is in a fairly big town of
Morgantown, but we serve a very rural population. And to me, I guess what that
means is we serve a population that doesn't have a ton of access to care. So we
get people from so many different avenues of life, you know, from truly the
haulers where they have to come sometimes for hours to the hospital just for a
primary care visit. Um, limited resources or medical knowledge. But sometimes
it can be just rural practice, meaning like separated from a lot of places. So
some of those primary care places that I worked with in medical school, um,
there was just a primary care, like family medicine doctor for the whole, you
know, 20 mile radius. And so sometimes that is what it means for rural as well.
So I don't know if you guys kind of have a different outlook on what you would
think of as rural practice.
DR. NANNERS:
I think you kind of
touched on it. I mean, I think for me, like when people say rural
anesthesiology. Uh, you know, we're not practicing anesthesia in a barn. We
still have the ASA basic monitors. But in reality, it's the population we
serve. So whether it's here or at a different center, you know, we have
patients who do have a lot of different challenges than in a big city when it
comes to travel, access to care, primary care providers. So, um, kind of
meeting our patients where they are is a big focus for us.
DR. PARRETT:
Yeah, I agree.
DR. RICE:
Yeah. I think also, um,
in medical school, I was in a smaller place than this, um, that served a lot of
rural communities and was in some community hospitals there and got to do some
anesthesia with those providers. And a lot of it, too, is you don't have the
same resources that we have at this academic center. Um, and a lot of these
small rural community hospitals that, you know, we're doing anesthesia, we're
doing sick patients, um, in rural parts of West Virginia and Kentucky. And it's
not something that people expect to be in a small little town hospital, you
know, but you end up getting some higher level cases in places that otherwise
wouldn't. But it's mainly because they're the closest thing, and sometimes
bigger places like this are too far out of the way. And patients need care at
the moment.
DR. PARRETT:
Yeah.
DR. NANNERS:
So anesthesiologists
everywhere are dealing with some of the same challenges: workforce shortages,
complex patients, payment issues, to name a few. How do you think rural
anesthesiology is unique? Do you see challenges that are specific or perhaps
more acute in the rural communities?
DR. PARRETT:
Yeah, I think part of it
is that we're not fully in practice yet, so we don't necessarily see some of
the behind the scenes that I think a lot of people like higher administration
deals with as far as insurance and that kind of stuff. But, you know, we have a
lot of patients at our current facility that come four hours away the morning
of surgery, but they had, you know, an electrolyte abnormality, or they ate
something and or they misunderstood instructions or something that would delay
their surgery. And you have to really, really consider sending that patient
away because they might not turn around and come back because it's too far
away. They already spent, you know, this month's savings to come to drive all
that way and get a hotel and stay in Morgantown. And that's things that we
don't always think about as physicians. But I think in rural communities, you
actually, you really have to get to know your patients and do what's best for
them. And sometimes that means getting creative with what you do, whether that
means getting an admission or getting like a quick pre optimization prior to
rolling back, um, or, you know, doing a gastric ultrasound, uh, to expedite,
making sure that even though they didn't follow the MPO guidelines or something
that you still have an empty stomach or no solids or something like that. I
think those are some of the challenges that we see, is just making sure that
they actually get the care, and they don't just turn around and never come
back, and they're lost to follow up, because we didn't take that into account.
DR. RICE:
Yeah, I think that, uh,
kind of coming off of that with like the periop evals, it's not really
something that you're going to get, um, you know, in these rural settings. I
remember in medical school, we, uh, you know, 200 bed hospital where I did my
rotation. Decent size, but still in the middle of Appalachia where, you know,
people weren't really going to be able to make it in for, like, pre-op clinic
to be seen. So the pre-op clinic was kind of very small and almost
non-existent. And so patients would come in, you know, that may or may not
follow up with their doctors regularly, you know, because of access and issues
like with rides and things like that, which is something we definitely see here
in Morgantown. Um, but I remember, you know, patients would show up with
congestive heart failure and AF of like 30. Um, hadn't been seen by a
cardiologist in over a year. You know, things like that. And we definitely see
that here. But I feel like we're able to get to those people now a little bit
more so than some of the smaller places where, you know, people walk in kind of
off the street like that and have not really had a lot of medical care because
they just don't have good access. And I think that, uh, it kind of, you know,
makes these patients almost more acute in a way. And sometimes they end up in
these small hospitals that, you know, may not have the resources that that our
big academic institutions do. Yeah.
DR. PARRETT:
You know, I think, too,
a lot of that goes with like, medical literacy. Uh, because, like, we've had a
number of times that a patient with that pre-op evaluation, sometimes it has to
be kind of virtual. Um, and we're giving them instructions over the phone, and
they don't necessarily really understand what you've given them, but they don't
want to say that they don't understand. Um, and, you know, it's part of our job
to take away that bias and so that they feel comfortable asking those
questions, but they will go a week without taking any of their medications
because they heard you say not to take one of them for one week or so, like
your GLP ones, for instance, you say, don't don't take your Ozempic for a week.
And then they held their beta blockers, their statins, they held everything
their Plavix and whatnot. And then you're in kind of a rough situation there.
And they come in with uncontrolled blood pressure, all that kind of stuff. And
so sometimes that's a challenge as well. Just making sure that they have the
right instructions and they follow them, or dealing with the consequences of if
they don't follow those instructions too.
DR. RICE:
Yeah, I actually had
that exact scenario yesterday. Um, yeah. A patient said that, you know, it was
too many different instructions for his many medications. And he's like, so I
just stopped all of them a few days ago. Um, and a lot of times, you know, patients
may not even be able to recognize medications by name if you say them to them.
And so, you know, it definitely goes back to the health literacy thing. It kind
of becomes a Becomes a challenge to figure out, you know, what people took and
when they took it, and if they even even take it anymore.
DR. PARRETT:
And I want to reiterate
that the population, I'm not referring to anybody as being uneducated. I mean,
that medicine is hard for people to understand. And so medical literacy is a
completely different language. And so for some of these people, when they're,
you know, these blue collar, hard working people, they're not familiar with,
propranolol like, that can be a hard word to say and understand or amiodarone
and all those kinds of things that it just doesn't click for some other people.
But they're very talented in so many other things. So I don't want to put down
anyone for medical literacy, just meaning it's a completely different kind of
language sometimes.
DR. RICE:
Yeah, I agree
completely. I think that, you know, that's a thing that can kind of be conveyed
in a way that may not always, you know, it may seem that we're talking down
upon people, but it's really more of just like a knowledge base. And I think
Appalachia in In particular, but rural communities in general have some of the
kindest, warmest people you'll ever meet. Um, most of these patients are some
of the nicest people you'll ever meet that are the kind of people that would
just, you know, they want to know about you and they want to talk to you. And I
think that's like a big thing that is important with a lot of our patients,
especially here in West Virginia, where if you can establish a relationship
with your patient kind of quickly and kind of get to know them, they'll trust
you a lot more. But it's definitely something that's a little bit more
welcoming and just a general community. Some of the nicest people there are the
kind of people that if you're a flat tire on the side of the road, they're going
to stop and try to help you.
DR. PARRETT:
Yeah, I agree. Um,
access to care is a real problem in many rural communities, and this impacts
anesthesiologists’ day to day work. So some listeners who aren't as familiar
with rural care might be surprised by some of the hoops we have to jump through
to find care for our patients. Do you have experience with this, and can you
shed light on the problem for some of these listeners?
DR. NANNERS:
I think this is a kind
of a common problem that we see on an everyday basis, and I think it kind of
highlights the current model that we're living in, where a lot of patients do
get triaged by outside facilities and then kind of end up where we are at WVU,
um, kind of kind of a big deal. You know, you see the community based approach.
So sometimes it's about finding family members, you know, housing or, um, you
know, hotels because it's not a day journey, you know, or other times it can
be, uh, you know, finding that responsible adult who's going to take
responsibility for the patient after the anesthesia. And a lot of that stuff
could be easier in a rural setting. But when you add in a four hour drive or,
you know, family members who have a tough time getting off work, um, you know,
it can just exemplify the issue. And it really highlights too trying to
maximize the time we do have with our patients. And I think you guys talked
about, uh, you know, access to care with the last question. And so these patients,
you know, may not have the ability to come in 3 or 4 different times to get a
pre-op evaluation and subsequent testing, and then finally come in on the day
of their procedure. So for us, it's kind of, you know, working with what's safe
and also maximizing the time we have with them.
DR. RICE:
Yeah.
DR. PARRETT:
Yeah for sure.
DR. RICE:
Yeah. Like a lot of
times we see patients in the PAC and you know, there's things that we want
done, whether it's a virtual visit or if it's in person. And there's things
that we want to get done, but they live 3 or 4 hours away and they don't have
anyone near them that has any openings for, say, like a TTE if they like
someone with a heart history that needs follow up with that, and it may not be
able to be something that they can get done in a reasonable time prior to their
surgery. And so I know one thing that we've kind of been been doing to try to
help help with that issue is just some POCUS bedside stuff. And it's something
that I think we are moving towards being able to do in our preop clinic and
things like that, and just bedside preoperatively. And I think that's helping a
lot where we're able to do a little bit more point of care things for patients
that may not be able to get this stuff done ahead of time before surgery.
DR. PARRETT:
Yeah. It also reminds me
of another case that we had a couple of months ago where a young guy, he had a,
some kind of motor vehicle accident, and he was in the SICU. And we as
residents at De view, we cover the SICU for two months in our CA1 and once in our
CA two year. And, um, he was in a lot of pain and he had a lot of orthopedic
injuries and including significant rib fractures, like his whole right side was
pretty much fractured everywhere. And we wanted to offer him some nerve blocks
to try to help with that and get him moving and get him out of the ICU. And
even just us walking in the room, he was like, please don't talk to me. I don't
want to be billed for this. I don't even want the nerve block because I don't
want to pay for it. I don't have insurance. And please, I don't even want to be
billed for you talking to me, so please don't even talk to me. And it was just
it was just kind of sad that, you know, those are some of the patients that we
deal with, uh, in rural communities that they're not always insured. And when
you think about an ICU stay, those are big dollars that they're stressed about,
and they work really hard for a living and they don't expect those offsetting
things. So really, the real superheroes are are care management, uh, who try to
help with the financial end. We rarely ever really do this side that is finding
those hotels for patients or finding transportation or figuring out insurance
or how to get them insurance and get them into rehab facilities and stuff like
that. But, you know, in rural settings, I think we do more of recommending and,
um, working with care management to do that more than like some bigger
facilities where you're you're just anesthesia. You only do anesthesia. Um, but
when you have to actually be part of that patient centered care, you work a
little bit more with some of some of those other people too, and realize how
important their jobs are.
DR. RICE:
Yeah, I actually had a
patient when I was on the regional pain service. Um, you know, we offered her
this nerve block pre-op and, um, I believe it was for an orthopedic procedure.
And she asked me the question, you know, will my insurance cover it? Um, and,
you know, I didn't have a good answer for her. And a lot of people that I asked
that have been involved with their regional service for a while said that, you
know, it's kind of hard to figure out, you know, obviously, like they'd have to
talk to their, their insurer and things like that. And we all know how
difficult that can be. And so, you know, ultimately she ended up not getting
it. It's kind of similar to the to the guy you were talking about, Audra. Um,
it was sad because, you know, it's something that is great for pain control,
but there's no way to quickly for us in that kind of short time period pre-op
to, to figure that kind of stuff out for patients. Um, so kind of sad, you
know, not being able to, to offer those kind of things to some people.
DR. NANNERS:
I think sometimes, as
much as it is about like resources or like access to care or health literacy, I
feel like in these rural communities it's a trust-based thing. And so, you
know, we're talking to patients who in their communities, you know, they get all
their information from, you know, people they know at the store, you know, so
in their day-to-day life, it's all revolved around trust. And so when they come
into the hospital, it's, you know, difficult for them to sometimes, you know,
when they come in and they see 100 different people that they've never met
before, they're all telling them so many different things, like with the
patient Audra mentioned, you know, establishing that trust because maybe the
nerve block that we're offering actually might decrease the length of stay or
the medical management in the ICU. And if you're offsetting ICU length of stay
versus nerve blocks and that kind of stuff, um, you know, the finances make
sense a little bit a different way. And the same thing with the pre-op evaluations,
you know, my family kind of coming from the state, you know, my grandfather was
a health care provider. And it wasn't that he didn't have medical literacy. But
it was that, you know, he comes in every few months and sees his health care
provider, and they give him a new long list of things that he has to do. But he
trusts his family care provider a little bit more. And then it just kind of
puts the system at such a stress, because you have such a small group of people
trying to do so many different jobs that when we come in in anesthesia, right
where it's a perioperative setting, it becomes ever so more important to
establish that trust, to kind of bridge all these different gaps in so many
different areas, because they might have a perfect understanding of our, you
know, health care literacy. And it may not be an insurance thing, but it still
is something that can be bridged at the end of the day by just a little bit of
a more in-depth conversation.
DR. PARRETT:
And Benton I think you
bring up a good point with the community, too. Um, and you probably might even
have a better idea of it coming from a family that's been in rural anesthesia,
specifically in West Virginia. But you're anesthesiologists in these rural
places--I mean West Morgantown doesn't necessarily fit this bill--but some of
the other places that will end up where I'm going to be next year and where
your dad currently is and everything and where you're from. Your
anesthesiologist is your next door neighbor, or your kids play soccer together
or you know, you're on the PTO together. Like, those are people that you build
relationships with. And you do kind of get that trust, too, from some of that
community aspect. Um, and so you kind of develop a stronger relationship with
your patients based on that too, I think.
DR. NANNERS:
Yeah, I think so. I
think that's one cool thing that, you know, I cherish every day is that I'm
third generation anesthesia provider in the state of West Virginia, and largely
that's done at rural settings and rural hospitals. And so, you know, again, I'm
here at Ruby. So my experience is a little bit different at a tertiary care
center. But growing up, I watched, uh, you know, my grandfather and my father
kind of field questions that the typical anesthesia provider probably isn't
getting asked. But you're right. You know, people want to know from, you know,
people around them or the family members or their friends, someone that they
trust going to help interpret their medications, you know, whether it's chronic
stuff than a primary care physician would be doing or things a little more
pertinent to, you know, our field.
DR. RICE:
All right. So what are
your hopes for your career? Do you believe you can have an impact on your
community? And if so, what does that look like? Trying to think through how we
can all envision the future and our role in making it better.
DR. PARRETT:
I guess I can start
because I'm closest to getting to my career. I just have about six months left,
thank goodness. But I'll be in kind of a rural facility a little bit south of
Indianapolis. And I'm really looking forward to it. But, um, one thing that I
really liked about this place is that they are still a kind of standalone
hospital, meaning they're not bought out by, um, any big kind of overseeing
delegation yet. Like, for instance, WVU medicine has multiple access points to
WVU medicine. This is its own hospital. It's not connected to anything like
that. Um, and their purpose for that was very intentional in wanting to be able
to serve their community in that area outside of Indianapolis, because
Indianapolis has such great access to care. However, for some of those rural
people, it's really overwhelming to drive into the city and go to one of the
five state of the art hospitals that are in Indianapolis. And so they wanted to
be able to provide the care that they could. You know, it's not a trauma center.
You're not going to go there for your big robotic heart surgeries or anything
like that, but you're going there to get the care that you need without having
the mental and physical stress of getting somewhere else. And you can just
trust the people that are in your community, and you get to give back to your
community and just build this nice relationship with your whole town, really,
and just do a little bit of good for everybody while you're there. Your job
doesn't just have to be what makes you money. You get to make relationships and
build upon those and kind of establish yourself. So I'm really looking forward
to actually getting to start that and be able to provide just very patient
centered, community centered care to everybody.
DR. NANNERS:
Yeah, I think, I think
for me, like this is a really exciting question. You know, like, I think we've
spent so much time in school that the concept, I have such a strong sense of
home. So being able to get back home to the communities that raised me, educated
me, kind of helped me grow and start to give back, um, you know, is really cool
and exciting and I think maybe where my career, you know, hopes differ from
somebody who's going to be practicing in a big city kind of centers around the
idea that I would love to, you know, it's kind of like we're on the frontier. I
want to see how far we can push it. How much care can we bring to my community?
How much can we advance anesthesia so that people don't have to travel so far,
and that we can kind of give them what they need? You know, the highest quality
of care, gold, standard of care, you know, far closer to home.
DR. PARRETT:
Yeah. That's great. What
about you, Alex?
DR. RICE:
Um, I'm kind of one of
the outliers in the group. Um, where I came from small places have been in
small places. Um, and in my future, I actually plan to move to probably a
bigger city. Not because I dislike rural health care. Mainly more for, you
know, personal reasons, just for for some change. But, you know, I think in
general, just being in small communities, um, and having seen it and done it as
a med student and resident, it's very rewarding, uh, getting to know your
patients. And, you know, a lot of times we work with someone and we end up with
a patient, and, you know, they know that person personally. You know, it's a
friend of a friend. And I think that's kind of one of the the beautiful things
about being in a small area where you get to know your patients or, you know,
your patients kind of know of you because of a friend of theirs, and you're
able to kind of build relationships that you typically wouldn't as an
anesthesiologist. You know, we are usually relatively, you know, quick
procedures, you know, maybe the patient, they probably don't remember her name
or who we are unless they've seen us a couple times. But but here I feel like
we get to make more of that connection. You know, I was doing a labor epidural
for a patient, and they were like, wait, so don't you play soccer? So and so,
blah blah, blah. Um, and, uh, like, turns out I, they knew a friend of mine
that I played soccer with and they played soccer with, and it was just kind of
a small town things.
DR. PARRETT:
Yeah, I think, Alex, I
have a story, too. It's, um, I had shown up for on my peds rotation. Um, and I
was it was first start of the day. Still hadn't had all my coffee, so I just
wasn't really paying much attention, really, during my, uh, consent process.
And the dad stopped me, and he's like, hey, wait, we know you. And I was like,
you do? He's like, yeah, you did the C-section for this baby. And so it turns
out I actually did the C-section with the mom. And then a year later, I was
doing the little kiddo’s anesthetic just for it was like a very simple case. I
don't know what it was now. But it was just such a full circle thing. And so
you I mean, even though Morgantown is a little bit bigger, it still has its
small town vibes. But that's kind of the the feeling that you'll, you'll get a
lot with those other rural places, which is kind of cool.
DR. RICE:
Yeah. That reminds me of
when I, uh, when I was in Pikeville as a med student in Pikeville, Kentucky, I
was on an internal medicine rotation and ended up coaching one of the
attendings. Like U8 soccer teams? Um, because they had just been having to talk
about how, like, oh, we don't have a team coach anymore. You know, I don't know
what we're going to do. Like, none of the parents have time or want to.
Whatever. And I kind of ended up stepping into the role and meeting a lot of
people in the community that way. And it was just kind of funny because I'm now
working with all these different, like, family and kids, and it was all because
of small town and just, you know, happened to to be somebody who was interested
in soccer, which in eastern Kentucky is kind of still small, small little
sport. So, yeah.
DR. NANNERS:
All right. Kind of the
next topic here is on a larger level, uh, do you have any ideas about what can
be done to improve healthcare in rural communities? And are there any policies
you advocate for, perhaps changes, uh, you think healthcare organizations
should be looking at beyond what we can do with individual doctors? What
systemic solutions do you see on the horizon?
DR. PARRETT:
Dr. Nanners, I feel like
you are much more in tune with some of the policies and advocacy of anesthesia.
Do you have any ideas off the top of your head first?
DR. NANNERS:
Yeah, I do think it's
kind of a challenging question because all of us, at least I think we all wish,
right? There was a solution to happen overnight. And so sometimes it's laying
the groundwork and realizing that we need to do things in a safe, controlled,
uh, manner because I wish we could we could provide everybody, you know, the
highest level of care tomorrow. But it needs to be reproducible. It needs to be
consistent. It needs to be, you know, something that can last years. And so it
takes an infrastructure. And when you're looking about, you know, establishing
an infrastructure, I think it does kind of help to, you know, advocate for
policy. And we need to focus on physician first medicine so that we can kind of
expand the access to care that everybody gets in a slow process. And I think at
the end of the day, you just want to be in an institution that is going to help
you work towards that goal.
DR. PARRETT:
Yeah, yeah, I totally
agree. The, you know, physician care team model, I think is the safest model
and that it allows a much more kind of like wide range of people to be taken
care of at all kinds of facilities with the safest amount of care. Um, to where
you have a physician overseeing multiple, uh, other anesthesia providers. Um,
and you're providing care consistently. Having that team model, I think, is one
of the biggest policies out there right now that's kind of being discussed. Um,
but I think that that's definitely something that needs to be solidified
everywhere.
DR. NANNERS:
I think I think everyone
just does such a great job at, you know, working in the hospital system.
Everyone's job is so important that we don't want to forget any step along the
way. We just want to make sure that we're kind of expanding access, working in
different communities, bringing, you know, that gold standard of care with us
everywhere we go, and making sure that everyone kind of comes along with us.
DR. PARRETT:
Exactly. Yeah.
DR. RICE:
And I think, like some
of the things that we've kind of been seeing, at least, you know, at our own
institution and I'm sure everyone is kind of working with this. And I think
Covid kind of brought a lot of this upon us. But the telemedicine stuff, you know,
obviously we're not doing a physical exam, but I think the telemedicine visits
for pre-op optimization are huge. Um, you know, I think since we started doing
this, we've probably got people in better places, or at least, you know, had a
better ability to kind of work them up before they show up on the day of. And
it's a lot better for access for our patients. So they're not having to travel.
And typically these visits I feel like are usually well covered in terms of
like insurance and things. And I think that that really gives them the ability
to, to be seen when maybe otherwise wouldn't be be seen ahead of a surgery. I
think, you know, also in general, just preoperative evaluation, whether it be
via zoom or, you know, a clinic that is partnered with the institution can be
very helpful and, and kind of just bedside POCUS and things like that, things
that we've kind of already discussed. But I think those kind of things that
we've started working towards, allowing us to kind of get better ideas of our
patients and just kind of have more knowledge and more information to help us
create better anesthetic plans for these patients.
DR. PARRETT:
Yeah.
DR. NANNERS:
Yeah, I think it's
exciting. I think it's a there's a certain degree of creativity in making sure,
you know, whether it's the rural visits or the, you know, it's kind of fun to
help bring all this stuff and all our goodie bags from the tertiary care center
out at this, you know, as far as we can stretch it.
DR. PARRETT:
I do think that POCUS is
becoming a much more emphasized skill set for anesthesiologists. POCUS being
point of care, ultrasound for anyone who might not know that abbreviation. It
basically you can get a focused cardiac exam. You can look at their gastric
contents. You can do a abdominal exam, um, and kind of get just general overall
pictures. It's not going to be necessarily diagnostic, but it gives you a
general picture of your patient. Um, and so for those people that you have a
lot of unknowns about, they're the person that doesn't go to the doctor. So
they have no health issues type person. You can throw an ultrasound probe on
there in a skilled way and kind of assess their heart and their function and
their valves with that kind of certification as well. And I think that that's
kind of an up and coming thing that, you know, us as residents at our program,
we've kind of been introduced to and have been encouraged to go forward. But I
think that even some of our attendings are now starting to go back and get that
certification as well. So I do think that that's something that will be on the
horizon for a lot of other people in the future. Um, so before we wrap up, I'm
wondering if there are any myths and misperceptions that persist about rural
medicine. Um, anything you'd like to clear up for our listeners?
DR. NANNERS:
Yeah, I think this is an
easy one for me. I just think that sometimes we, you know, as a system or
maybe, you know, people who aren't exposed to this on a daily basis don't
understand that. You know, these people are just like us. They you know, they
are they come from communities, you know, just like ours, even if in different
sizes. And they just want to provide and have the best access to care for them
and their family members. And so when they kind of come in, sometimes it is a
big deal, you know, and it does take a lot of travel and a lot of work, and it
is a big investment for them. So, uh, you know, I just want everyone to realize
that, uh, you know, no one is any different than us providing this world care
is kind of, you know, an exciting way to address maybe some disadvantaged
individuals that don't have such ready access to care. And so it's pretty fun.
DR. PARRETT:
Yeah, I agree, I think
it's so important. And just remember that these are all humans that we're
treating, um, humans with so many different backgrounds. And whether that
background includes medical education or a health class, or maybe they needed
to drop out of high school to be able to get a job to provide for their family.
Um, everybody has different walks of life. And just because they have different
access to healthcare and health literacy, uh, does not mean that they are not
serving a greater purpose. And, um, you know, doing amazing things in this
world as well. Um, and so they deserve the best treatment. And it's up to us to
be able to provide that for them.
DR. RICE:
I think another kind of
misperception that maybe exists is that rural medicine or rural anesthesia,
either one, um, can't provide certain levels of care. But there are a lot of
small places that handle a lot of really sick patients. Um, I've seen this quite
a bit in smaller community hospitals where, you know, patients who are very,
very sick and, you know, aren't going to be able to get to one of these bigger
places because they were in an accident or what have you. They are getting
very, very good care at some of these small places that with limited resources,
but they're making the best of the resources that they have and are able to
provide really kind of impressive care with what they have.
DR. PARRETT:
Yeah. Um, so there is an
ASA, uh, rural scholarship program out there, and I was wondering, do either of
you know much about that, uh, to share with our listeners?
DR. RICE:
Yeah. Actually, uh, when
I was a fourth year med student, I actually applied for this scholarship and
received it. The first thing I'm going to say was, you know, a relatively easy
process. And basically what it what it's here for is to help get medical
students to be able to kind of experience anesthesia in a more rural
environment. Um, and basically it's it's an online thing. It's pretty, pretty
easy. And then there's a list of um, areas as well as the mentors that are in
the area. Um, it's basically for you to get to do a rotation as a third or
fourth year in one of these kind of rural areas. And I'll put a plug in for for
one of the mentors in Pikeville, Kentucky. He's still a mentor there. He's who
I work with quite closely as a medical student and a he’s Dr. Tyce Latin. And,
um, he's actually the one that told me about the program. So I think kind of
urge people to to look and to see if they've got anything that's that's close
to them as they, you know, do fourth year rotations and have more time to kind
of choose what they get to do. And I think it's a great opportunity. And the
scholarship mainly is just to help you, you know, with lodging and travel and
things like that to these, to these to these places. Um, I think it's something
that if you have the ability to do, uh, it's can be a great adjunct to your
learning in fourth year and get to see a different type of anesthesia,
especially because a lot of times, you know, you you get to residency and
you're in these, you know, bigger hospitals and with a lot more access. And
then, you know, you get out into private practice and it's going to be a lot
different than what you saw as a resident. So having that experience as a
medical student, I thought was really valuable because they kind of saw what
that looked like in a small, you know, community hospital and what a seizure
looked like versus, you know, what we have now, um, where some people start in
places like like WVU, which is phenomenal for med school, but they just, you
know, it's one thing that it's a little bit harder for you to get the real feel
for. Um, so kind of a plug for that. I think it's a great opportunity and
something people should take advantage of. And it's, I'm guessing is probably
underutilized because it wasn't something that I was aware of. It just happened
to know one of the attendings and he kind of, you know, was like, you need to
apply for this. You should be doing this. So definitely urge people to look at
that. It's on the ASA website.
DR. PARRETT:
Yeah. Sounds awesome.
Good job Alex. Well, this has been a really interesting conversation. Um, so
I've enjoyed it and hopefully our listeners have too. I know Dr. Nanners and
Dr. Rice have as well, but thanks for joining me today. And to our listeners, please
come back soon for more Residents in a Room, the podcast for residents by
residents.
(Soundbite of music)
VOICE OVER:
Your anesthesiologist
in these rural places is your next-door neighbor or your kids play soccer
together.
We're on the
frontier. I want to see how far we can push it. How much can we advance
anesthesia so that people don't have to travel so far.
They're making the
best of the resources that they have and are able to provide really impressive
care.
DR. AUDRA PARRETT:
Welcome to Residents in
a Room, the podcast for residents by residents. I'm Dr. Audra Parrett. I am a
CA3 at West Virginia University. Your host for today's episode, we're going to
dive into a subject my fellow residents and I are passionate about, which is
rural medicine. So before we dig in, let's meet my fellow residents.
DR. ALEXANDRA RICE:
Hi, my name's is Alex
Rice. I'm a CA two at West Virginia University.
DR. BENTON NANNERS:
And I'm Benton Nanners.
I'm also a CA two at West Virginia University.
DR. PARRETT:
All right, so let's
start with why this topic matters. I know why it's important to me. And I'm
interested in hearing your stories as well. Can you tell me where your passion
for rural medicine stems from?
DR. NANNERS:
Yeah, I think for me,
you know, it's kind of my life. I grew up in a rural community in West
Virginia. I've kind of stayed in rural medicine. So, you know, developing rural
medicine here where I'm at is kind of the way I can provide better care to my
family, my community and my friends.
DR. RICE:
Yeah. For me, I grew up
in rural Ohio, a town of like 2000 people, where healthcare was pretty limited.
You had to travel a while to, to get to any kind of real, like tertiary care
and did medical school in eastern Kentucky. So in the kind of the heart of
Appalachia. And so it's kind of had a special place in my heart.
DR. PARRETT:
Yeah. Um, so fairly
similar for myself. Um, grew up in a small town in Indiana, um, in southern
Indiana, with a population of about 10 to 12,000, and then did my medical
school in Lewisburg, West Virginia, which has a population of about 4000. And
they also have a dedication towards rural primary care as well at the medical
school. So did a lot of rural care throughout medical school. And then now just
serving the population of West Virginia. Um, and then I currently have a job
secured going back home, um, and will be serving a bit more of a rural
population as well when I go back.
So moving on to the
second question, what rural anesthesia actually is. There can be some
misunderstanding about that for like what is rural? I guess not all small towns
are, and not all rural communities are small. Um, like for instance, where
we're at right now, I think, you know, WVU is in a fairly big town of
Morgantown, but we serve a very rural population. And to me, I guess what that
means is we serve a population that doesn't have a ton of access to care. So we
get people from so many different avenues of life, you know, from truly the
haulers where they have to come sometimes for hours to the hospital just for a
primary care visit. Um, limited resources or medical knowledge. But sometimes
it can be just rural practice, meaning like separated from a lot of places. So
some of those primary care places that I worked with in medical school, um,
there was just a primary care, like family medicine doctor for the whole, you
know, 20 mile radius. And so sometimes that is what it means for rural as well.
So I don't know if you guys kind of have a different outlook on what you would
think of as rural practice.
DR. NANNERS:
I think you kind of
touched on it. I mean, I think for me, like when people say rural
anesthesiology. Uh, you know, we're not practicing anesthesia in a barn. We
still have the ASA basic monitors. But in reality, it's the population we
serve. So whether it's here or at a different center, you know, we have
patients who do have a lot of different challenges than in a big city when it
comes to travel, access to care, primary care providers. So, um, kind of
meeting our patients where they are is a big focus for us.
DR. PARRETT:
Yeah, I agree.
DR. RICE:
Yeah. I think also, um,
in medical school, I was in a smaller place than this, um, that served a lot of
rural communities and was in some community hospitals there and got to do some
anesthesia with those providers. And a lot of it, too, is you don't have the
same resources that we have at this academic center. Um, and a lot of these
small rural community hospitals that, you know, we're doing anesthesia, we're
doing sick patients, um, in rural parts of West Virginia and Kentucky. And it's
not something that people expect to be in a small little town hospital, you
know, but you end up getting some higher level cases in places that otherwise
wouldn't. But it's mainly because they're the closest thing, and sometimes
bigger places like this are too far out of the way. And patients need care at
the moment.
DR. PARRETT:
Yeah.
DR. NANNERS:
So anesthesiologists
everywhere are dealing with some of the same challenges: workforce shortages,
complex patients, payment issues, to name a few. How do you think rural
anesthesiology is unique? Do you see challenges that are specific or perhaps
more acute in the rural communities?
DR. PARRETT:
Yeah, I think part of it
is that we're not fully in practice yet, so we don't necessarily see some of
the behind the scenes that I think a lot of people like higher administration
deals with as far as insurance and that kind of stuff. But, you know, we have a
lot of patients at our current facility that come four hours away the morning
of surgery, but they had, you know, an electrolyte abnormality, or they ate
something and or they misunderstood instructions or something that would delay
their surgery. And you have to really, really consider sending that patient
away because they might not turn around and come back because it's too far
away. They already spent, you know, this month's savings to come to drive all
that way and get a hotel and stay in Morgantown. And that's things that we
don't always think about as physicians. But I think in rural communities, you
actually, you really have to get to know your patients and do what's best for
them. And sometimes that means getting creative with what you do, whether that
means getting an admission or getting like a quick pre optimization prior to
rolling back, um, or, you know, doing a gastric ultrasound, uh, to expedite,
making sure that even though they didn't follow the MPO guidelines or something
that you still have an empty stomach or no solids or something like that. I
think those are some of the challenges that we see, is just making sure that
they actually get the care, and they don't just turn around and never come
back, and they're lost to follow up, because we didn't take that into account.
DR. RICE:
Yeah, I think that, uh,
kind of coming off of that with like the periop evals, it's not really
something that you're going to get, um, you know, in these rural settings. I
remember in medical school, we, uh, you know, 200 bed hospital where I did my
rotation. Decent size, but still in the middle of Appalachia where, you know,
people weren't really going to be able to make it in for, like, pre-op clinic
to be seen. So the pre-op clinic was kind of very small and almost
non-existent. And so patients would come in, you know, that may or may not
follow up with their doctors regularly, you know, because of access and issues
like with rides and things like that, which is something we definitely see here
in Morgantown. Um, but I remember, you know, patients would show up with
congestive heart failure and AF of like 30. Um, hadn't been seen by a
cardiologist in over a year. You know, things like that. And we definitely see
that here. But I feel like we're able to get to those people now a little bit
more so than some of the smaller places where, you know, people walk in kind of
off the street like that and have not really had a lot of medical care because
they just don't have good access. And I think that, uh, it kind of, you know,
makes these patients almost more acute in a way. And sometimes they end up in
these small hospitals that, you know, may not have the resources that that our
big academic institutions do. Yeah.
DR. PARRETT:
You know, I think, too,
a lot of that goes with like, medical literacy. Uh, because, like, we've had a
number of times that a patient with that pre-op evaluation, sometimes it has to
be kind of virtual. Um, and we're giving them instructions over the phone, and
they don't necessarily really understand what you've given them, but they don't
want to say that they don't understand. Um, and, you know, it's part of our job
to take away that bias and so that they feel comfortable asking those
questions, but they will go a week without taking any of their medications
because they heard you say not to take one of them for one week or so, like
your GLP ones, for instance, you say, don't don't take your Ozempic for a week.
And then they held their beta blockers, their statins, they held everything
their Plavix and whatnot. And then you're in kind of a rough situation there.
And they come in with uncontrolled blood pressure, all that kind of stuff. And
so sometimes that's a challenge as well. Just making sure that they have the
right instructions and they follow them, or dealing with the consequences of if
they don't follow those instructions too.
DR. RICE:
Yeah, I actually had
that exact scenario yesterday. Um, yeah. A patient said that, you know, it was
too many different instructions for his many medications. And he's like, so I
just stopped all of them a few days ago. Um, and a lot of times, you know, patients
may not even be able to recognize medications by name if you say them to them.
And so, you know, it definitely goes back to the health literacy thing. It kind
of becomes a Becomes a challenge to figure out, you know, what people took and
when they took it, and if they even even take it anymore.
DR. PARRETT:
And I want to reiterate
that the population, I'm not referring to anybody as being uneducated. I mean,
that medicine is hard for people to understand. And so medical literacy is a
completely different language. And so for some of these people, when they're,
you know, these blue collar, hard working people, they're not familiar with,
propranolol like, that can be a hard word to say and understand or amiodarone
and all those kinds of things that it just doesn't click for some other people.
But they're very talented in so many other things. So I don't want to put down
anyone for medical literacy, just meaning it's a completely different kind of
language sometimes.
DR. RICE:
Yeah, I agree
completely. I think that, you know, that's a thing that can kind of be conveyed
in a way that may not always, you know, it may seem that we're talking down
upon people, but it's really more of just like a knowledge base. And I think
Appalachia in In particular, but rural communities in general have some of the
kindest, warmest people you'll ever meet. Um, most of these patients are some
of the nicest people you'll ever meet that are the kind of people that would
just, you know, they want to know about you and they want to talk to you. And I
think that's like a big thing that is important with a lot of our patients,
especially here in West Virginia, where if you can establish a relationship
with your patient kind of quickly and kind of get to know them, they'll trust
you a lot more. But it's definitely something that's a little bit more
welcoming and just a general community. Some of the nicest people there are the
kind of people that if you're a flat tire on the side of the road, they're
going to stop and try to help you.
DR. PARRETT:
Yeah, I agree. Um,
access to care is a real problem in many rural communities, and this impacts
anesthesiologists’ day to day work. So some listeners who aren't as familiar
with rural care might be surprised by some of the hoops we have to jump through
to find care for our patients. Do you have experience with this, and can you
shed light on the problem for some of these listeners?
DR. NANNERS:
I think this is a kind
of a common problem that we see on an everyday basis, and I think it kind of
highlights the current model that we're living in, where a lot of patients do
get triaged by outside facilities and then kind of end up where we are at WVU,
um, kind of kind of a big deal. You know, you see the community based approach.
So sometimes it's about finding family members, you know, housing or, um, you
know, hotels because it's not a day journey, you know, or other times it can
be, uh, you know, finding that responsible adult who's going to take
responsibility for the patient after the anesthesia. And a lot of that stuff
could be easier in a rural setting. But when you add in a four hour drive or,
you know, family members who have a tough time getting off work, um, you know,
it can just exemplify the issue. And it really highlights too trying to
maximize the time we do have with our patients. And I think you guys talked
about, uh, you know, access to care with the last question. And so these patients,
you know, may not have the ability to come in 3 or 4 different times to get a
pre-op evaluation and subsequent testing, and then finally come in on the day
of their procedure. So for us, it's kind of, you know, working with what's safe
and also maximizing the time we have with them.
DR. RICE:
Yeah.
DR. PARRETT:
Yeah for sure.
DR. RICE:
Yeah. Like a lot of
times we see patients in the PAC and you know, there's things that we want
done, whether it's a virtual visit or if it's in person. And there's things
that we want to get done, but they live 3 or 4 hours away and they don't have
anyone near them that has any openings for, say, like a TTE if they like
someone with a heart history that needs follow up with that, and it may not be
able to be something that they can get done in a reasonable time prior to their
surgery. And so I know one thing that we've kind of been been doing to try to
help help with that issue is just some POCUS bedside stuff. And it's something
that I think we are moving towards being able to do in our preop clinic and
things like that, and just bedside preoperatively. And I think that's helping a
lot where we're able to do a little bit more point of care things for patients
that may not be able to get this stuff done ahead of time before surgery.
DR. PARRETT:
Yeah. It also reminds me
of another case that we had a couple of months ago where a young guy, he had a,
some kind of motor vehicle accident, and he was in the SICU. And we as
residents at De view, we cover the SICU for two months in our CA1 and once in our
CA two year. And, um, he was in a lot of pain and he had a lot of orthopedic
injuries and including significant rib fractures, like his whole right side was
pretty much fractured everywhere. And we wanted to offer him some nerve blocks
to try to help with that and get him moving and get him out of the ICU. And
even just us walking in the room, he was like, please don't talk to me. I don't
want to be billed for this. I don't even want the nerve block because I don't
want to pay for it. I don't have insurance. And please, I don't even want to be
billed for you talking to me, so please don't even talk to me. And it was just
it was just kind of sad that, you know, those are some of the patients that we
deal with, uh, in rural communities that they're not always insured. And when
you think about an ICU stay, those are big dollars that they're stressed about,
and they work really hard for a living and they don't expect those offsetting
things. So really, the real superheroes are are care management, uh, who try to
help with the financial end. We rarely ever really do this side that is finding
those hotels for patients or finding transportation or figuring out insurance
or how to get them insurance and get them into rehab facilities and stuff like
that. But, you know, in rural settings, I think we do more of recommending and,
um, working with care management to do that more than like some bigger
facilities where you're you're just anesthesia. You only do anesthesia. Um, but
when you have to actually be part of that patient centered care, you work a
little bit more with some of some of those other people too, and realize how
important their jobs are.
DR. RICE:
Yeah, I actually had a
patient when I was on the regional pain service. Um, you know, we offered her
this nerve block pre-op and, um, I believe it was for an orthopedic procedure.
And she asked me the question, you know, will my insurance cover it? Um, and,
you know, I didn't have a good answer for her. And a lot of people that I asked
that have been involved with their regional service for a while said that, you
know, it's kind of hard to figure out, you know, obviously, like they'd have to
talk to their, their insurer and things like that. And we all know how difficult
that can be. And so, you know, ultimately she ended up not getting it. It's
kind of similar to the to the guy you were talking about, Audra. Um, it was sad
because, you know, it's something that is great for pain control, but there's
no way to quickly for us in that kind of short time period pre-op to, to figure
that kind of stuff out for patients. Um, so kind of sad, you know, not being
able to, to offer those kind of things to some people.
DR. NANNERS:
I think sometimes, as
much as it is about like resources or like access to care or health literacy, I
feel like in these rural communities it's a trust-based thing. And so, you
know, we're talking to patients who in their communities, you know, they get all
their information from, you know, people they know at the store, you know, so
in their day-to-day life, it's all revolved around trust. And so when they come
into the hospital, it's, you know, difficult for them to sometimes, you know,
when they come in and they see 100 different people that they've never met
before, they're all telling them so many different things, like with the
patient Audra mentioned, you know, establishing that trust because maybe the
nerve block that we're offering actually might decrease the length of stay or
the medical management in the ICU. And if you're offsetting ICU length of stay
versus nerve blocks and that kind of stuff, um, you know, the finances make
sense a little bit a different way. And the same thing with the pre-op evaluations,
you know, my family kind of coming from the state, you know, my grandfather was
a health care provider. And it wasn't that he didn't have medical literacy. But
it was that, you know, he comes in every few months and sees his health care
provider, and they give him a new long list of things that he has to do. But he
trusts his family care provider a little bit more. And then it just kind of
puts the system at such a stress, because you have such a small group of people
trying to do so many different jobs that when we come in in anesthesia, right
where it's a perioperative setting, it becomes ever so more important to
establish that trust, to kind of bridge all these different gaps in so many
different areas, because they might have a perfect understanding of our, you
know, health care literacy. And it may not be an insurance thing, but it still
is something that can be bridged at the end of the day by just a little bit of
a more in-depth conversation.
DR. PARRETT:
And Benton I think you
bring up a good point with the community, too. Um, and you probably might even
have a better idea of it coming from a family that's been in rural anesthesia,
specifically in West Virginia. But you're anesthesiologists in these rural
places--I mean West Morgantown doesn't necessarily fit this bill--but some of
the other places that will end up where I'm going to be next year and where
your dad currently is and everything and where you're from. Your
anesthesiologist is your next door neighbor, or your kids play soccer together
or you know, you're on the PTO together. Like, those are people that you build
relationships with. And you do kind of get that trust, too, from some of that
community aspect. Um, and so you kind of develop a stronger relationship with
your patients based on that too, I think.
DR. NANNERS:
Yeah, I think so. I
think that's one cool thing that, you know, I cherish every day is that I'm
third generation anesthesia provider in the state of West Virginia, and largely
that's done at rural settings and rural hospitals. And so, you know, again, I'm
here at Ruby. So my experience is a little bit different at a tertiary care
center. But growing up, I watched, uh, you know, my grandfather and my father
kind of field questions that the typical anesthesia provider probably isn't
getting asked. But you're right. You know, people want to know from, you know,
people around them or the family members or their friends, someone that they
trust going to help interpret their medications, you know, whether it's chronic
stuff than a primary care physician would be doing or things a little more
pertinent to, you know, our field.
DR. RICE:
All right. So what are
your hopes for your career? Do you believe you can have an impact on your
community? And if so, what does that look like? Trying to think through how we
can all envision the future and our role in making it better.
DR. PARRETT:
I guess I can start
because I'm closest to getting to my career. I just have about six months left,
thank goodness. But I'll be in kind of a rural facility a little bit south of
Indianapolis. And I'm really looking forward to it. But, um, one thing that I
really liked about this place is that they are still a kind of standalone
hospital, meaning they're not bought out by, um, any big kind of overseeing
delegation yet. Like, for instance, WVU medicine has multiple access points to
WVU medicine. This is its own hospital. It's not connected to anything like
that. Um, and their purpose for that was very intentional in wanting to be able
to serve their community in that area outside of Indianapolis, because
Indianapolis has such great access to care. However, for some of those rural
people, it's really overwhelming to drive into the city and go to one of the
five state of the art hospitals that are in Indianapolis. And so they wanted to
be able to provide the care that they could. You know, it's not a trauma center.
You're not going to go there for your big robotic heart surgeries or anything
like that, but you're going there to get the care that you need without having
the mental and physical stress of getting somewhere else. And you can just
trust the people that are in your community, and you get to give back to your
community and just build this nice relationship with your whole town, really,
and just do a little bit of good for everybody while you're there. Your job
doesn't just have to be what makes you money. You get to make relationships and
build upon those and kind of establish yourself. So I'm really looking forward
to actually getting to start that and be able to provide just very patient
centered, community centered care to everybody.
DR. NANNERS:
Yeah, I think, I think
for me, like this is a really exciting question. You know, like, I think we've
spent so much time in school that the concept, I have such a strong sense of
home. So being able to get back home to the communities that raised me, educated
me, kind of helped me grow and start to give back, um, you know, is really cool
and exciting and I think maybe where my career, you know, hopes differ from
somebody who's going to be practicing in a big city kind of centers around the
idea that I would love to, you know, it's kind of like we're on the frontier. I
want to see how far we can push it. How much care can we bring to my community?
How much can we advance anesthesia so that people don't have to travel so far,
and that we can kind of give them what they need? You know, the highest quality
of care, gold, standard of care, you know, far closer to home.
DR. PARRETT:
Yeah. That's great. What
about you, Alex?
DR. RICE:
Um, I'm kind of one of
the outliers in the group. Um, where I came from small places have been in
small places. Um, and in my future, I actually plan to move to probably a
bigger city. Not because I dislike rural health care. Mainly more for, you
know, personal reasons, just for for some change. But, you know, I think in
general, just being in small communities, um, and having seen it and done it as
a med student and resident, it's very rewarding, uh, getting to know your
patients. And, you know, a lot of times we work with someone and we end up with
a patient, and, you know, they know that person personally. You know, it's a
friend of a friend. And I think that's kind of one of the the beautiful things
about being in a small area where you get to know your patients or, you know,
your patients kind of know of you because of a friend of theirs, and you're
able to kind of build relationships that you typically wouldn't as an
anesthesiologist. You know, we are usually relatively, you know, quick
procedures, you know, maybe the patient, they probably don't remember her name
or who we are unless they've seen us a couple times. But but here I feel like
we get to make more of that connection. You know, I was doing a labor epidural
for a patient, and they were like, wait, so don't you play soccer? So and so,
blah blah, blah. Um, and, uh, like, turns out I, they knew a friend of mine
that I played soccer with and they played soccer with, and it was just kind of
a small town things.
DR. PARRETT:
Yeah, I think, Alex, I
have a story, too. It's, um, I had shown up for on my peds rotation. Um, and I
was it was first start of the day. Still hadn't had all my coffee, so I just
wasn't really paying much attention, really, during my, uh, consent process.
And the dad stopped me, and he's like, hey, wait, we know you. And I was like,
you do? He's like, yeah, you did the C-section for this baby. And so it turns
out I actually did the C-section with the mom. And then a year later, I was
doing the little kiddo’s anesthetic just for it was like a very simple case. I
don't know what it was now. But it was just such a full circle thing. And so
you I mean, even though Morgantown is a little bit bigger, it still has its
small town vibes. But that's kind of the the feeling that you'll, you'll get a
lot with those other rural places, which is kind of cool.
DR. RICE:
Yeah. That reminds me of
when I, uh, when I was in Pikeville as a med student in Pikeville, Kentucky, I
was on an internal medicine rotation and ended up coaching one of the
attendings. Like U8 soccer teams? Um, because they had just been having to talk
about how, like, oh, we don't have a team coach anymore. You know, I don't know
what we're going to do. Like, none of the parents have time or want to.
Whatever. And I kind of ended up stepping into the role and meeting a lot of
people in the community that way. And it was just kind of funny because I'm now
working with all these different, like, family and kids, and it was all because
of small town and just, you know, happened to to be somebody who was interested
in soccer, which in eastern Kentucky is kind of still small, small little
sport. So, yeah.
DR. NANNERS:
All right. Kind of the
next topic here is on a larger level, uh, do you have any ideas about what can
be done to improve healthcare in rural communities? And are there any policies
you advocate for, perhaps changes, uh, you think healthcare organizations
should be looking at beyond what we can do with individual doctors? What
systemic solutions do you see on the horizon?
DR. PARRETT:
Dr. Nanners, I feel like
you are much more in tune with some of the policies and advocacy of anesthesia.
Do you have any ideas off the top of your head first?
DR. NANNERS:
Yeah, I do think it's
kind of a challenging question because all of us, at least I think we all wish,
right? There was a solution to happen overnight. And so sometimes it's laying
the groundwork and realizing that we need to do things in a safe, controlled,
uh, manner because I wish we could we could provide everybody, you know, the
highest level of care tomorrow. But it needs to be reproducible. It needs to be
consistent. It needs to be, you know, something that can last years. And so it
takes an infrastructure. And when you're looking about, you know, establishing
an infrastructure, I think it does kind of help to, you know, advocate for
policy. And we need to focus on physician first medicine so that we can kind of
expand the access to care that everybody gets in a slow process. And I think at
the end of the day, you just want to be in an institution that is going to help
you work towards that goal.
DR. PARRETT:
Yeah, yeah, I totally
agree. The, you know, physician care team model, I think is the safest model
and that it allows a much more kind of like wide range of people to be taken
care of at all kinds of facilities with the safest amount of care. Um, to where
you have a physician overseeing multiple, uh, other anesthesia providers. Um,
and you're providing care consistently. Having that team model, I think, is one
of the biggest policies out there right now that's kind of being discussed. Um,
but I think that that's definitely something that needs to be solidified
everywhere.
DR. NANNERS:
I think I think everyone
just does such a great job at, you know, working in the hospital system.
Everyone's job is so important that we don't want to forget any step along the
way. We just want to make sure that we're kind of expanding access, working in
different communities, bringing, you know, that gold standard of care with us everywhere
we go, and making sure that everyone kind of comes along with us.
DR. PARRETT:
Exactly. Yeah.
DR. RICE:
And I think, like some
of the things that we've kind of been seeing, at least, you know, at our own
institution and I'm sure everyone is kind of working with this. And I think
Covid kind of brought a lot of this upon us. But the telemedicine stuff, you know,
obviously we're not doing a physical exam, but I think the telemedicine visits
for pre-op optimization are huge. Um, you know, I think since we started doing
this, we've probably got people in better places, or at least, you know, had a
better ability to kind of work them up before they show up on the day of. And
it's a lot better for access for our patients. So they're not having to travel.
And typically these visits I feel like are usually well covered in terms of
like insurance and things. And I think that that really gives them the ability
to, to be seen when maybe otherwise wouldn't be be seen ahead of a surgery. I
think, you know, also in general, just preoperative evaluation, whether it be
via zoom or, you know, a clinic that is partnered with the institution can be
very helpful and, and kind of just bedside POCUS and things like that, things
that we've kind of already discussed. But I think those kind of things that
we've started working towards, allowing us to kind of get better ideas of our
patients and just kind of have more knowledge and more information to help us
create better anesthetic plans for these patients.
DR. PARRETT:
Yeah.
DR. NANNERS:
Yeah, I think it's
exciting. I think it's a there's a certain degree of creativity in making sure,
you know, whether it's the rural visits or the, you know, it's kind of fun to
help bring all this stuff and all our goodie bags from the tertiary care center
out at this, you know, as far as we can stretch it.
DR. PARRETT:
I do think that POCUS is
becoming a much more emphasized skill set for anesthesiologists. POCUS being
point of care, ultrasound for anyone who might not know that abbreviation. It
basically you can get a focused cardiac exam. You can look at their gastric
contents. You can do a abdominal exam, um, and kind of get just general overall
pictures. It's not going to be necessarily diagnostic, but it gives you a
general picture of your patient. Um, and so for those people that you have a
lot of unknowns about, they're the person that doesn't go to the doctor. So
they have no health issues type person. You can throw an ultrasound probe on
there in a skilled way and kind of assess their heart and their function and
their valves with that kind of certification as well. And I think that that's
kind of an up and coming thing that, you know, us as residents at our program,
we've kind of been introduced to and have been encouraged to go forward. But I
think that even some of our attendings are now starting to go back and get that
certification as well. So I do think that that's something that will be on the
horizon for a lot of other people in the future. Um, so before we wrap up, I'm
wondering if there are any myths and misperceptions that persist about rural
medicine. Um, anything you'd like to clear up for our listeners?
DR. NANNERS:
Yeah, I think this is an
easy one for me. I just think that sometimes we, you know, as a system or
maybe, you know, people who aren't exposed to this on a daily basis don't
understand that. You know, these people are just like us. They you know, they
are they come from communities, you know, just like ours, even if in different
sizes. And they just want to provide and have the best access to care for them
and their family members. And so when they kind of come in, sometimes it is a
big deal, you know, and it does take a lot of travel and a lot of work, and it
is a big investment for them. So, uh, you know, I just want everyone to realize
that, uh, you know, no one is any different than us providing this world care
is kind of, you know, an exciting way to address maybe some disadvantaged
individuals that don't have such ready access to care. And so it's pretty fun.
DR. PARRETT:
Yeah, I agree, I think
it's so important. And just remember that these are all humans that we're
treating, um, humans with so many different backgrounds. And whether that
background includes medical education or a health class, or maybe they needed
to drop out of high school to be able to get a job to provide for their family.
Um, everybody has different walks of life. And just because they have different
access to healthcare and health literacy, uh, does not mean that they are not
serving a greater purpose. And, um, you know, doing amazing things in this
world as well. Um, and so they deserve the best treatment. And it's up to us to
be able to provide that for them.
DR. RICE:
I think another kind of
misperception that maybe exists is that rural medicine or rural anesthesia,
either one, um, can't provide certain levels of care. But there are a lot of
small places that handle a lot of really sick patients. Um, I've seen this quite
a bit in smaller community hospitals where, you know, patients who are very,
very sick and, you know, aren't going to be able to get to one of these bigger
places because they were in an accident or what have you. They are getting
very, very good care at some of these small places that with limited resources,
but they're making the best of the resources that they have and are able to
provide really kind of impressive care with what they have.
DR. PARRETT:
Yeah. Um, so there is an
ASA, uh, rural scholarship program out there, and I was wondering, do either of
you know much about that, uh, to share with our listeners?
DR. RICE:
Yeah. Actually, uh, when
I was a fourth year med student, I actually applied for this scholarship and
received it. The first thing I'm going to say was, you know, a relatively easy
process. And basically what it what it's here for is to help get medical students
to be able to kind of experience anesthesia in a more rural environment. Um,
and basically it's it's an online thing. It's pretty, pretty easy. And then
there's a list of um, areas as well as the mentors that are in the area. Um,
it's basically for you to get to do a rotation as a third or fourth year in one
of these kind of rural areas. And I'll put a plug in for for one of the mentors
in Pikeville, Kentucky. He's still a mentor there. He's who I work with quite
closely as a medical student and a he’s Dr. Tyce Latin. And, um, he's actually
the one that told me about the program. So I think kind of urge people to to
look and to see if they've got anything that's that's close to them as they,
you know, do fourth year rotations and have more time to kind of choose what
they get to do. And I think it's a great opportunity. And the scholarship
mainly is just to help you, you know, with lodging and travel and things like
that to these, to these to these places. Um, I think it's something that if you
have the ability to do, uh, it's can be a great adjunct to your learning in
fourth year and get to see a different type of anesthesia, especially because a
lot of times, you know, you you get to residency and you're in these, you know,
bigger hospitals and with a lot more access. And then, you know, you get out
into private practice and it's going to be a lot different than what you saw as
a resident. So having that experience as a medical student, I thought was
really valuable because they kind of saw what that looked like in a small, you
know, community hospital and what a seizure looked like versus, you know, what
we have now, um, where some people start in places like like WVU, which is
phenomenal for med school, but they just, you know, it's one thing that it's a
little bit harder for you to get the real feel for. Um, so kind of a plug for
that. I think it's a great opportunity and something people should take
advantage of. And it's, I'm guessing is probably underutilized because it
wasn't something that I was aware of. It just happened to know one of the
attendings and he kind of, you know, was like, you need to apply for this. You
should be doing this. So definitely urge people to look at that. It's on the
ASA website.
DR. PARRETT:
Yeah. Sounds awesome.
Good job Alex. Well, this has been a really interesting conversation. Um, so
I've enjoyed it and hopefully our listeners have too. I know Dr. Nanners and
Dr. Rice have as well, but thanks for joining me today. And to our listeners, please
come back soon for more Residents in a Room, the podcast for residents by
residents.
(Soundbite of music)
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today at asahq.org/mentorship.
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