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Your perimenopause questions, answered

Dr. Breanne Mueller:

Number one, find someone that you trust and that cares about you. And if you don’t feel like you have a connection or someone who’s motivated to help you, change. There’s a hundred doctors out there. Find someone that you jive with and who’s treating you appropriately. If someone is saying, you know, it’s just menopause, we’ll see you later. That’s not appropriate anymore in 2024. I think there’s more investigation to be done. And so definitely don’t get dismissed and stand up for yourself and know that there are plenty of healthy, well researched, safe, affordable options to treat problems that arise.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We are starting new conversations about age-old topics from pregnancy to postpartum, managing stress, healthy living, and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

In this episode, we are talking about perimenopause. I have Dr. Breanne Mueller joining me for this conversation. She specializes in obstetrics and gynecology at the Sanford Aberdeen Clinic in Aberdeen, South Dakota. She is a National American Menopause Society certified practitioner, one of the only practicing providers in this space in the state of South Dakota. So I’m so happy to have her here with me. Dr. Mueller, thank you so much for your time and welcome.

Dr. Breanne Mueller (guest):

Thank you so much for having me. I really enjoy being able to talk about this topic.

Courtney Collen:

Yeah, we’re so excited to have you for this. It wasn’t until recently, I’ll be honest, that I learned menopause can be grouped into three phases or stages. They are perimenopause, menopause, and postmenopause. And while we’re focusing specifically on perimenopause during this conversation, Dr. Mueller, I’d love to have you start with an overview of menopause in general to help us level-set.

Dr. Breanne Mueller:

Totally. So I think menopause is, I mean, first of all, to understand menopause, I think you can compare it to adolescents and puberty. So most people understand what puberty is and what puberty isn’t, because we get classes on it in high school, or not high school, elementary school. They start at elementary school letting you know your body is going to change. This is normal; this is abnormal. And most parents and most people are like, oh, my kid is a little grumpy, or my kid is getting acne or something like that. And they have like a halfway decent expectation of what’s going to happen. So they aren’t spooked. Most people make it through.

Some people need help going through puberty, like they have some problems, but most people make it through and they’re fine. And I think that menopause is puberty in reverse. So the only difference is that we don’t get classes on it. Nobody’s educated on it. And so it can be really scary. It can be really unsettling for people because it’s as life-changing as puberty. But we just have no really societal standard for educating women on “this is normal” and “this is abnormal.” So it can be really upsetting.

Courtney Collen:

That is so fascinating. Puberty in reverse.

Dr. Breanne Mueller:

So the term perimenopause just means around menopause. So what the clinical definition of perimenopause is: it begins with the onset of cycle problems or differences. So if your menstrual cycle is irregular, plus or minus like seven days from your normal and other menopause related symptoms, so like we can go over the symptoms later.

But basically any change from your normal, it starts at that and an extends past through the menopause transition more than a year. So what is the clinical definition of menopause? It is 12 months without a period. It’s, like that simple, but also there’s a lot more to it than that because you know, you can have symptoms before, you can have symptoms after. But perimenopause encompasses the beginning stages, the actual transition, and one year after that menopause, one year without a period. I know. Clinical, huh? So kind of dry.

Courtney Collen:

As far as symptoms, and you said simply put that it’s 12 months without a period. Are there other symptoms or things that we can be looking for that are associated with perimenopause?

Dr. Breanne Mueller:

Totally, and I think it’s nice to distill it down to like what it is. What it is: 12 months without a period. I mean, so it’s not this nebulous thing. It’s this. I mean, I think to just have nail it down and say this is what it is. However, that’s a retrospective diagnosis, right? I can’t tell you are through menopause yet if you haven’t had a period for nine months. Right? Technically, but it’s a little bit irrelevant.

What’s relevant is people’s symptoms. And I think that’s really important. Also, we can talk about hormone testing later, but what’s most relevant about perimenopause is how you are feeling and what your symptoms are. And I think that when people realize that, I think it’s really hard in our society today to not think about it like a thyroid test or hemoglobin A1C, right? My thyroid is two, when it should be four, that means I need medicine to regulate it.

And it’s important to understand that hormones aren’t like that, especially female hormones. There’s no range that’s perfect for everybody. They’re supposed to fluctuate. And in those fluctuations, are you doing well or are you not doing well? And that’s where someone like me can come in and say, OK, is this what we’re talking about? Is this perimenopause? Is this something I can help with? Or is this something else? So it’s nice to have someone who has the context and kind of knows you to go through it and figure it out.

Courtney Collen:

What is the general age range for when this starts?

Dr. Breanne Mueller:

Totally. So the average age of menopause is 51.6 (laugh), which again, it differs on ethnicity. It differs on health status. It differs on genetics. But if you have all comers in America, it’s 51.6. So and then if people go through a menopause way early, for us that is 40, sometimes 45, that’s called premature ovarian insufficiency. So that’s not menopause. That’s something else completely. And later menopause is also a different animal. But you know, that’s the average age of women, all comers. Of people who go through, like I said, that 12 month months without a period.

Courtney Collen:

What does a woman’s care journey look like? Like at what point do they need to come see you for care? Or are there specific questions they should be asking their providers, say, at a yearly wellness checkup?

Dr. Breanne Mueller:

To be a hundred percent honest, by the time they see me, by the time most women see me for “menopause,” the wheels have completely come off the bus and they’re struggling with life and they’re like, I don’t know what’s happening, but I feel like everything’s wrong. You know, like it’s not something that people usually preemptively come to me for, but sometimes, but not usually.

And honestly, like being a hundred percent transparent, usually by the time they come to me, it’s like, this is happening, and this is happening, and I feel crazy. and what’s going on? And I’m like, whoa, whoa, whoa. We’re going to be OK. We’re going to get through this.

But you know, I think what a different approach could be is, you know, at your yearly visits kind of prep things and be like, Hey, you may find that your period, there’s more time between your periods. You may find that your periods are strange, maybe they’re heavier, maybe they’re lighter and maybe they’re more painful. Maybe they’re not. Here are reasons to call me. If you start having this, this, this, and this, please call me. You don’t have to put up with that.

And I think it’s because of that lack of education on the front end that it’s anxiety provoking. You know, I feel off, I feel like I’m waking up all the time and I’m hot, or I’m not, and I’m trying to Google if this is good or not. And you could just get lost in the weeds a little bit. And I wish we had like a uniform, not a class everyone had to take right? (laughs) But something just to give people some ground to stand on.

Courtney Collen:

Can a woman get pregnant during perimenopause?

Dr. Breanne Mueller:

So it’s possible. And so that is actually a matter of debate. How long do we need to put people on contraception before we can safely say you’re good to go, right? And there’s no agreement on that. And it really boils down to each individual person. How strongly do you feel about not getting pregnant? That’s kind of my question to people.

And if you feel very strongly that you absolutely do not want to get pregnant, then let’s continue contraception kind of above and beyond maybe. There’s no harm in continuing contraception into your mid-50s if you wish. But if you’re like, you know, it’d be fine. I’m OK either way, whatever. Then maybe we start earlier and maybe you go off your reliable contraceptive earlier if that doesn’t matter to you. So, I really think it depends on each individual person and how much of a negative outcome they view that as. That’s kind of clinical, but you know what I’m trying to say.

Courtney Collen:

Yes. Are there medications or therapies that can treat perimenopause symptoms? Let’s talk through some of those either hormonal or non-hormonal options for women.

Dr. Breanne Mueller:

And there is plenty of medication. So if you go through a doctor who knows, who’s trained in this and knows what they’re doing, there’s pills, patches, vaginal rings, tablets, creams – all kinds of things that are through a pharmacy that are FDA-approved that go through your insurance, and they’re pretty affordable.

Honestly, most hormone treatment is extremely affordable. Treatment for menopausal symptoms is based entirely on symptoms. So the National American Menopause Society and ACOG, which is the American College of Obstetrics and Gynecology, they don’t necessarily recommend basing it on hormone blood tests or any other hormone tests. They really recommend doing it based on your symptoms because that’s way more meaningful in a medical way.

So as an aside, but also an interesting aside, the hallmark of menopause is hormonal variability. Meaning it’s not that your hormones are doing like this, like it’s steady downward decline that’s very predictable. It’s very much not like that. It’s actually very erratic. So have you ever run your car out of gas?

Courtney Collen:

Yes.

Dr. Breanne Mueller:

So I have too, and it’s really crappy. But here’s the thing is you know how you turn it over and like, you kind of get a little juice and you’re able to like lurch forward a little bit and then it dies, and then you turn it over again and you’re like, maybe I can get through this intersection. Ah, you know, you try to like give it a little gas and you’re like, oh yeah, I can go a little further (laugh), and then you stop again.

So I think of the ovaries doing that in the end here. So, the brain is telling the ovaries, “Hey, produce estrogen, produce these hormones that are going to make people ovulate, the woman ovulate.” So when the brain is like, “ovaries go, ovaries go, ovaries go,” and the ovaries don’t got anything left, they’re like, your gas tank that’s out of gas, they can kind of do some last minute spurts. Like, OK, let’s try our best. And you get like a little lurch out of it and sometimes you don’t. But the hallmark is just this crazy inconsistency in it, right?

And so you could have a normal cycle and then you could have three cycles that are not normal. You could have actually a very high cycle where you actually have more hormones than a teenage girl in your 50s, but then the next cycle is like dead, like nothing. So that is the hallmark of menopause. So that’s why hormone testing isn’t especially helpful because it could be anything. It doesn’t mean that you don’t deserve treatment or don’t need treatment or aren’t in perimenopause. So just as a caveat of that.

Another way to say that is like, OK, the other way I think about menopause or women’s cycles – do you play music or piano or anything like that?

Courtney Collen:

Yeah. Piano growing up, violin. Yeah.

Dr. Breanne Mueller:

So think of a song. So like each person, like think of like “Für Elise,” like, don’t judge me on my singing, but everybody can recognize that tune. And they kind of understand what it is. So when I meet a woman, I’m like, OK, this is her tune. May be in a different key. It may be in a different tempo, but it’s a tune and it’s recognizable, right? So when we’re doing hormone testing and come, like, think about trying to evaluate “Für Elise,” that classical music song by just saying, OK, the notes are on the piano. Well, yeah, they are (laugh), but that doesn’t mean that the song is playing correctly, right? And so what I do, how I think of hormone testing is like if I test you today and we get like an F sharp, maybe it’s an F sharp that belongs in the song, maybe it’s not, but it’s not really relevant.

What we need to evaluate is the whole song. Is it playing correctly for you? Does it sound good? Is it working? Yeah. Then that’s what matters. It doesn’t matter that on this Tuesday in December, your hormone level was this. What matters is your body, how it’s functioning, what the cycle of it is, and what that means for you.

So anyway, maybe that’s off topic or whatever, but anyway, when we’re looking for hormone treatment, what I’m looking for is what’s going to make sense for you? What are your symptoms, what are your goals? And oftentimes I just ask people, what is your goal here? And honestly, it’s been the best question I’ve ever asked people because my goal is not always congruent with their goals. And then we just cut to the chase and say, OK, my goal is actually my mood. Cool, let’s tackle it. And then after that we can tackle a different thing.

But as far as hormones, treatments, so basically when you’re thinking about menopause, every cell in the human body, and again, I’m talking about women now, I only deal with women, I don’t deal with men sorry, (laugh), but every cell almost in a woman’s body has an estrogen receptor on it. So that means that in menopause, potentially any system can have changes to it. Yeah. So people can have hot flashes, night sweats, you know, and that is actually a function of you withdrawing, same as you would withdraw from a drug, you are withdrawing from estrogen. And that’s what that feels like which I think is kind of interesting. So how do we fix that problem? It is very acceptable and very, very safe and effective for many, many women to be put on a dose of estrogen. And it literally fixes that problem.

Courtney Collen:

So fascinating that any part of the body could feel the effects or show the effects, present symptoms during this phase. OK. I’m learning so much.

You mentioned mood a couple minutes ago. What are some mood changes or mental health concerns that we could be on alert for during perimenopause? And if a patient is struggling during that time, what are some of the signs and where or how or when should they seek help?

Dr. Breanne Mueller:

Being an obstetrician/gynecologist, basically I specialize in assisting women through major phases of their life. Like that’s kind of how I see myself. I’m walking alongside, but also easing the transitions of life. Transitions of adolescence, transitions of pregnancy, of motherhood, of contraception and then the menopause, right? And any transition in life, you have a risk of having mental health changes, right?

So pregnancy people, some people struggle. It’s just a huge change. Your whole identity is changing. And I think menopause is the same. And it’s complicated by the fact that there is very little education. So it’s anxiety provoking for a lot of people, not everybody, but you feel different than you have for 40 years, right? And so I think that there’s been debate, there’s been randomized control trials, there’s been a lot of research on is menopause itself a risk factor or a cause of anxiety, depression and other mental health disorders? And there’s mixed data on that, quite honestly. And is it truly menopause or is it the transition or whatever?

I don’t know that anyone has a solid, solid answer on that. But I will tell you: anyone who’s had an episode of depression earlier in their life is at increased risk of having a recurrence of that major depression in menopause. I can say that for sure. So what that means is, so this is actually one of the things that I screen for all the time. I see a ton of people sometimes who come in and they’re like, I think my hormones are off. That’s always the complaint, right? I think my hormones are off. And I always love delving into that more because I just saw someone the other day. Love her to death. I think she’s outstanding.

And she goes, my hormones are off, my hormones are off. And then we ended up talking more and she lists off literally the clinical criteria for major depression. I have loss of interest in the things that I usually had interest in. I can’t get out of bed. I want to go to sleep and not wake up. And I’m like, oh, for Pete’s sake, we can fix this. But it is a depression issue more than it is a menopause potentially issue. You know what I mean? And so I think it’s a super important to get someone who is able to have, first of all, get to know you as a person. Because you matter as a person. “Für Elise” isn’t two notes. It’s a whole, you know, melody, and you’re a melody too. You’re not a one-note wonder. And I want to know all of that before I say, you know, piano’s a little out of tune, lady.

Courtney Collen:

1. Love the music analogy.

Dr. Breanne Mueller:

So I think if I had like a really bottom line message for people as far as menopause and medicine, I would say number one, find someone that you trust and that cares about you. And if you don’t feel like you have a connection or someone who’s motivated to help you change, there’s a hundred doctors out there. Find someone that you jive with and who’s treating you appropriately. If someone is saying, you know, it’s just menopause, we’ll see you later. That’s not appropriate anymore in 2024.

I think there’s more investigation to be done. And so definitely don’t get dismissed and stand up for yourself and know that there are plenty of healthy, well-researched, safe, affordable options to treat problems that arise.

But the other underlining message I have is be careful who you trust. So in this environment, it’s a money maker, right? You have people who are suffering and it’s oftentimes hard to discern who’s selling you something versus who’s treating a medical condition. And so I follow this lady on TikTok, Molly McPherson, and she’s a PR fixer, and she said, I always know who’s telling the truth because I follow the money. So if she’s talking about a PR nightmare or who’s in trouble and who’s not, she goes, I always know the truth because I follow the money. And I tell patients that all the time. If I say, you know, I could prescribe you this cheap testosterone or cheap estrogen, but if you buy my potion, lotion, pellet, whatever you just be aware of that, you know, if there’s money involved that is going directly to the person, I always just kind of like, I don’t know, maybe you view that as you would.

Courtney Collen:

That is such good advice, especially for this is a new transition of life. Like you said, you care for the women as they go through different transitions, and it can be scary and overwhelming and mentally taxing. And so that’s why we are so grateful for the advice that you just gave us as we go through that care journey, but also being mindful and aware of what we’re getting into and pay attention to our bodies of course, too.

Dr. Breanne Mueller:

I think one phrase that I think needs to be said is, what you’re going to see in this space when you educate yourself, which I always ask people like, how is it that you get information? How do you intake information? Do you go to TikTok? Do you go to Instagram? Do you read a book? Do you listen to a podcast? Do you listen to an audiobook? Do you talk to your friends? Like, how is it that you get information?

And then I try to provide people reliable resources in that space, whatever space that is comfortable for them. And I would say, you know, one term you’re going to see a lot is bioidentical. So there’s all this talk about bioidentical hormone therapy and how it’s safer or better, and you have to understand what that term is. It’s a marketing term.

So basically there was a time period where women weren’t really given hormones and they could kind of get a bad rap maybe a generation ahead of me, right? Where hormone therapy will give you breast cancer and kill you, right? That was the prevailing thinking. And so out of that space, unfortunately women were still suffering, but doctors weren’t prescribing medicine.

And so what you had was a space where people could sell products and not have it go through the FDA and not seem as scary, but accomplish a similar kind of symptom relief. It’s a product that hasn’t been studied, approved, researched, or has reliable dosing. And so because it’s not FDA approved, they don’t have to provide a warning label to it. And to some people, because they don’t have a warning label, they think it’s safer. But understand that there are safe prescription medicines that are better arguably for women.

Courtney Collen:

If a woman comes to you and is just overwhelmed and anxious … and she just needs some reassurance that it is going to be OK, and this is part of life and transitioning as a woman into midlife, what do you tell her?

Dr. Breanne Mueller:

I try to approach people where they’re at, and what is it that you want your life to look like and how can I help get you there? You know, if people want reassurance, again, it goes back to me asking what people’s goals are. And a lot of people’s goals are, tell me I’m normal. Tell me I’m not going to die. Tell me I don’t have cancer. Tell me that I’m not falling apart. Tell me this isn’t going to last forever. And I’m happy to do that. I’m happy to do that.

And I’ll be like, you know, let’s talk about it again in three or six months. Let’s digest a little bit. Let’s get some information and let’s talk again. I’m not abandoning you, I’m not dismissing you, but I’m telling you like, you aren’t going to die. Your life is just beginning. The rest of your life is just beginning, just like when you were 13 or 12 or 11. It’s not better or worse. It’s just different.

And then on the flip side, if she is like, no, really, my quality of life is actually circling the toilet bowl. I need some help. Then that’s totally different too. If they say that I want help medically, then we go that route. But it really boils down to who you are as a person and how I can understand you, but also help you and meet you where you’re at. I’m not pushing anything. I’m not selling anything. I want to help you wherever, whatever that means for you.

Courtney Collen:

And that’s why we’re so grateful for you at Sanford for your expertise and of course for this conversation. Like you are truly an expert in this space and we are so grateful for that and for your insight. Is there anything else that I didn’t ask you that you wanted to add on this topic?

Dr. Breanne Mueller:

I just want to reiterate that there’s so many good providers around the state, and I think the people that I love associating with are not people who are trying to isolate or keep information from anybody, but just supporting everyone in the space and being like women, doctors, providers, physical therapists, sex therapists, actual counselors.

Let’s all be on the same page to help women. Let’s work together to get women the best health care possible, and let’s help educate and get everybody care they need. And that’s the sort of people that I want to be around, and that’s the sort of people I want to be associated with.

And to be clear, I’m not the only perfect person out there for everybody, but I want you to find your perfect person for you. And I want you to understand that you’re not alone, that there are people out there who can help you. And whatever you are feeling or whatever we can help you with, understand that there’s options that are safe and good.

Courtney Collen:

Well, I love to hear it and I could not have said that better myself. Dr. Mueller, thank you so much for your time. Sanford Health, OB/GYN in Aberdeen, South Dakota, and a National American Menopause Society certified practitioner. We so appreciate you and all that you do for women, for patients all across the community. Thanks so much.

Dr. Breanne Mueller:

Thank you so much for having me. I super appreciate it.

Courtney Collen:

I sure hope you learned as much as I did from our conversation today. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.

Get more episodes in this series

We ask a lactation specialist all your breastfeeding questions

Samantha Zeeb:

Find the people that support you no matter what. Breastfeeding is great. It has great benefits, but ultimately, Mom and Baby need to be healthy. You know, Baby needs a healthy, stable mom. And so you have to do what works best for your family. You have to do what works best for you, and everybody is human and everybody needs a break.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News.

These are new conversations about age-old topics from pregnancy to postpartum, managing stress, healthy living and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

This is a topic near and dear to my heart and one I’m delighted to share as a newer mom. We are talking all about breastfeeding in this episode from frequently asked questions to tips and tricks and beyond. If you’re a new mom or an expecting mother, the breastfeeding journey looks different for everyone. No matter where you are in yours, know that you are not alone and there are so many resources available and people to help you feel confident in your journey.

Sanford Health has a team of full-time lactation consultants, and Samantha Zeeb, RN, IBCLC, is one of them. She is a registered nurse and Sanford breastfeeding specialist in Bismarck, North Dakota, and I am so happy to have her here for this conversation. Samantha, welcome.

Samantha Zeeb (guest):

Thank you. I’m excited to be here.

Courtney Collen:

What does a typical day or week look like as a Sanford breastfeeding specialist?

Samantha Zeeb:

You know, we are in different locations, whether it be in the clinic or in the hospital setting, but all the way around, obviously our focus is helping moms with lactation or anybody who may be lactating. So, in the hospital, our typical day, we get to the floor and we will go ahead and look at the bed board and see who is all delivered and what those moms’ wishes are. So that’s a perfect example of why having a birth plan or an idea going into labor and delivery of what your feeding wishes are, because we do look at that and make sure that you’re on our radar so that way we can make you a priority to go in and visit.

And we will go in – we try not to bombard you after delivery right away unless you’re wanting the help or needing the help. But we will go in and check with every breastfeeding mom and just see how things are going and assist with those first latches. I think a lot of times people equate breastfeeding to natural, but natural does not mean easy. So just teaching moms those tips and tricks for proper positioning and latching and encouragement.

And we often will see moms multiple times. And so the nice thing is I do work both in the hospital and the clinic setting. So I do get to develop a rapport with my patients. And so some of the ones that I helped right after delivery, I will then help the first few weeks after in the clinic just seeing how things are going because the biggest thing about breastfeeding is it is a journey.

Courtney Collen:

And for that, I am so grateful as a new mom because having that support during those first hours postpartum and even more so in the days and weeks that followed. Talk about some of the benefits of breastfeeding or why someone would choose to breastfeed.

Samantha Zeeb:

I could kind of nerd out and talk about this for days on end. But I will, for the sake of our listeners, we’ll limit it to the big ones.

So for Mom, there’s a lot of benefits. So there’s the decreased risk of ovarian and breast cancer. There’s the decreased risk of osteoporosis. It helps decrease the chances of cardiovascular disease. It might help you lose weight. You do burn more calories when you are breastfeeding. And then it also helps you produce a hormone called oxytocin, which is going to help you feel calm.

So while moms might have stresses with breastfeeding, overall, studies do show that breastfeeding and bonding with your baby can help with postpartum depression and help with some of those anxiety-like feelings that you have post-delivery.

And for Baby, it helps promote bonding. There’s studies that show that babies who have been breastfed have higher IQs. There’s decreased chance of allergies, decreased chance of diabetes, asthma, GI bugs.

The biggest thing for moms is knowing that the breast milk that they’re providing their baby with is giving them antibodies to help protect against any viruses or illnesses that they are around. And we’re getting right into that fall season. So that’s a huge one, especially with COVID. When we didn’t know what COVID was doing for babies, in the beginning there, everybody’s like, “oh, separate the babies from the moms.” But the studies are showing that the breast milk and breastfeeding that baby is the best thing that mom can do and provide those baby those antibodies.

Decreased chance of obesity, ear infections, protective for SIDS (sudden infant death syndrome), helps decrease the chances of SIDS. And not to mention it’s easier to digest. It’s free. Kids are sick less often, so moms don’t have to take off as much work. And it’s convenient. I mean, you don’t need a bottle and a milk warmer. You just bring yourself and the milk’s the perfect temperature and it’s available whenever they need it.

Courtney Collen:

You mentioned antibodies a moment ago. I would love to learn more about the benefits of breast milk.

Samantha Zeeb:

Breast milk is amazing and there is still more to be learned about it and the fact that it changes constantly. There are live components in it that cannot be replicated no matter how much time people spend in a lab to try to replicate breast milk. The truth of the matter is, you’re never going to be able to replicate it because it has live components that are constantly changing day by day, minute by minute, feed by feed.

So as that baby ages, that breast milk is going to change, it’s going to have more melatonin at night, so that’s going to help the baby fall asleep. It’s going to increase, if baby’s needing more fat content, it’s going to increase the fat content. If you were recently around a bunch of people that had a certain cold, your body is going to get those antibodies and it’s going to put that in your baby’s breast milk.

So the more that you can have that baby at the breast and stimulating and having that saliva contact with the areola, the more you’re going to have that communication. One thing that I do get a lot of, let’s not forget our pumping moms. So sometimes people are concerned, they’re like, well, if I’m pumping, is my baby still going to get those benefits? And your baby still does because you guys are still in the same environment, you’re still exposed to the same things and you can still do skin on skin contact. In fact, I encourage it because it’s going to help with the hormones.

Courtney Collen:

Yes. And those skin-to-skin moments during that newborn phase are just the best. No matter if we are breastfeeding or not. Sam, how does our body physically produce breast milk?

Samantha Zeeb:

The breast doesn’t completely finish developing until you are pregnant. So those tender breasts that you get in pregnancy are for a reason that is your breast revving up to be able to produce that breast milk. In fact, that’s one of the red flags. If you don’t notice a change during pregnancy, that would be something we would want to know.

But what happens is around 16 weeks in pregnancy, you are actually already starting to produce what we call colostrum, which is extremely high-impact, high nutrient-dense sticky-like milk, and it’s the first milk that you produce for your baby. And before I go down a rabbit hole but to answer your question, what happens is the infant starts to suckle on the nipple. And what that does is that stimulates nerve endings. And/or if you’re pumping, same concept, stretching of those nerve endings, that is going to signal the pituitary gland in your brain to release two different hormones. It’s going to release prolactin and oxytocin. The prolactin is what’s going to tell the alveoli to take nutrients from your blood and turn it into breast milk.

So that’s a really huge kind of a wow factor for people’s learning that breast milk is made from blood. So that’s why I’m making sure what you’re taking in is very important because you, your body turns that into breast milk.

Courtney Collen:

Are you speaking specifically to like medication or supplements or food in general?

Samantha Zeeb:

Yes, absolutely. Medications and then even just like pathogens. So if you are exposing yourself to risky behaviors or if you are getting a tattoo or Botox, stuff like that, there is a risk of if there is a transfer of any like HIV or Hepatitis C, you want to be leery of those things. And then same with like your nutrients, just making sure that you’re eating a well healthy rounded diet, healthy foods, because those nutrients are what’s needed to make that breast milk.

Courtney Collen:

Yes. So important. Thank you for that. I remember being super conscious during those early months. It was winter, we were sick a lot or so it seemed, so making sure the medication that I was taking was safe for baby also.

You mentioned colostrum. And if we start to see that before baby arrives, should we save it? What’s the difference between colostrum and regular breast milk?

Samantha Zeeb:

Colostrum is beginning to be produced by our bodies about 16 weeks into our pregnancy. You know, some people will leak during pregnancy and some people will not. And that is not a marker of how much breast milk you are going to have. So when moms come to me and they’re like, “I didn’t leak during pregnancy,” that to us is it, it’s null and void. We don’t worry about that because everybody is so different.

But if you are leaking, collect it, collect it, collect it, collect it. It is liquid gold. It does have that higher nutrient density to it. It’s more proteins, more antibodies. They call it the baby’s first immunization because it is providing all those beneficial protective factors to the baby.

But the one thing about the colostrum is it is more easily digested because it is designed for infants, so they do digest it quicker. So that’s where that frequent feeding comes into play. So that’s why in the beginning days we say, frequent feeding on demand because that colostrum is readily digested and easily digested. And it also helps line the digestion tract so that it helps create a healthy microbiome of the infant and might help decrease with like chances of any allergies or just the good gut flora.

But colostrum, you can start to collect that, we would say, no earlier than 36 weeks in pregnancy and I would absolutely not recommend it if there’s any risk factors in your pregnancy. So I would say if you are considering collecting your colostrum or stimulating, I should say, it’s one thing if it’s just leaking out and you’re collecting it. But if you’re going to actually be stimulating with a pump or hand expression, I would recommend reaching out to your OB/GYN so that way they can give you the go ahead just to make sure that there are no risk factors.

Courtney Collen:

How long does it take for milk to come in, and is it different for everyone?

Samantha Zeeb:

Everybody is different. Depending on what risk factors they have, depending on what their delivery was like, depending on how much stimulation and time they spent with their baby. But typically, the average is three to five days. You know, if you were a C-section, if you were on magnesium because you were pre-eclamptic, certain medications during delivery, rough labor, you lost a lot of blood. Things like that can kind of delay that milk coming in but the best thing that a mother can do is if you are with your infant and plan to feed at the breast, is to get that skin-on-skin contact going ASAP after delivery.

Put that in your birth plan that you want that skin-on-skin contact with the awareness that if Baby is needing immediate assistance, they will have to do that, but otherwise just encourage them to put that baby skin-to-skin. You can do that in the, or if you had a C-section, just make sure you communicate that with your team.

And then that’s going to help with the hormone production and then that frequent nursing on demand. So one thing that I sometimes hear is I’ll have moms say that they just want to offer bottles while they’re in the hospital and they’ll breastfeed when they get home. And I hate to be the party pooper on it, but unfortunately that does not theoretically work out the greatest for the mothers in the long run because scientific studies have shown that the sooner that a mother stimulates that breast milk production, either via a pump or baby, the better her chances are of having a really good milk supply in the long run. And we have studies that show the data for that. In fact, the recommendation is within the first hour after delivery.

Now, is that realistic for everybody? Absolutely not. But I think if we can do our best to get that baby or pump, get to that mom as soon as possible and educate her, the better off she’ll be.

Courtney Collen:

Certainly it is a journey, and worth repeating: Everyone’s will look different. You said that first hour is so important after baby arrives, Sam, that leads to my next question. OK, baby is here. How do we get a good latch and start that process as soon as possible?

Samantha Zeeb:

So the very first breastfeed, when that baby comes out and gets placed skin to skin, I would really just encourage moms to take in the moment. So babies actually will go through a series of movements that can take one to two hours. But they do what we call a breast crawl. And so if you leave an infant undisturbed on a mother’s chest, they have reflexes where they will actually start to kind of scoot themselves up towards the breast. And the amazing thing is, is your areola emits smells that are similar to the amniotic fluid that the baby was surrounded in, in utero.

So with that scent, and then your areola is darker that helps guide the infant towards the breast, and then they will actually take their little arms and start to kind of scoot the breast inwards and try to mouth around. So they’ll kind of start crawling up. They might take a break, they might nap for a little bit, they’ll wake up, they’ll start to lick, explore taste. We do that with our hands. Babies do it with their mouths so that baby’s going to start sucking on their hand.

They’re going to start licking around at the breast and before you know it, majority of babies, if they’re not implicated by certain medications during labor that might make them sleepy or just a rough delivery, but a baby can find the breast on their own. So we do like to give them the chance to do that because studies have shown that a baby-led latch in the beginning has been shown to be beneficial and babies tend to do better, but sometimes they just need help. And so that is when you can always request either most labor nurses are trained, but also you can request a lactation specialist to come in at that moment and we can help you kind of navigate that timeframe.

Courtney Collen:

That is so amazing. I had no idea about the areola emitting smells similar to the amniotic fluid. Again, learning something new every day. But our bodies are truly incredible. The baby’s natural instinct is incredible too. Here I was thinking, baby comes out, you do skin to skin, baby’s hungry, let’s try to latch, say a prayer, cross your fingers, let’s go …

Samantha Zeeb:

(Laugh). And sometimes they need that. Sometimes they need a little bit more extra assistance, but sometimes they don’t. Sometimes they do just fine on their own. So I do like to assess when I go in and help a mom with breastfeeding. I will assess what that baby’s doing. I will assess what that mother is doing and really try to only do that if I need to. But then some babies do need a little more assistance.

So when you latch on, my biggest encouragement for moms is to take a breastfeeding class. Sanford offers breastfeeding classes online, and we go over the nitty gritty of latching. You know, there is a technique to it. There is a way, and I’ll bring out my little toy boob and show you how to do that. And a baby doll – steal my 3-year-old’s baby doll. And we do like to go over and explain like how to position that baby to latch for optimal positioning to prevent both nipple pain and promote adequate transfer.

Courtney Collen:

Do some women have a harder time producing breast milk? Are there things like during pregnancy or preexisting conditions perhaps that could lead to the inability for a woman to make as much milk?

Samantha Zeeb:

Absolutely. So one of the things about being a lactation consultant is we are trained on red flags to look for on things that could put a mother at a risk of having a decreased breast milk supply. Along with certain assessment skills that when we are helping you breastfeed, we’re not only assessing your latch, but we are looking at the baby, we’re looking at the baby’s mouth, we’re looking at mom, we’re looking at mom’s breast, the shape of the breast, the shape of the nipples. And the rationale behind that is because there are things that we can see that sometimes will give us a red flag or help us predict potential problems that may arise.

Now the biggest thing is, I want to preface this by saying that these risk factors and red flags do not automatically mean that you are going to be unsuccessful with breastfeeding.

But some risk factors to watch out for is a history of low milk supply. That won’t always necessarily be a risk factor though, because every single pregnancy and delivery, a mother will make more glandular tissue. So with subsequent pregnancies, she has a better chance of being able to produce more breast milk. PCOS (Polycystic Ovary Syndrome), that’s a risk factor. Any breast surgeries or radiation, especially if they cut around four, eight o’clock on the nipple because that could cause potential damages to the ducts and the nerves. Thyroid problems, obesity, wide spaced breasts with no change during pregnancy and just because that could be a sign of glandular tissue or insufficient milk-making tissue. I like to tread with caution because this does not automatically do me, I think I’m very cautious when I talk to moms about this because the best approach for breastfeeding is wait and see because nobody knows the answers until we start doing it.

Courtney Collen:

Yes, such good advice. Thank you.

Samantha Zeeb:

And I think it’s also important too, that I just want to add in that any amount of breast milk is beneficial. It does not have to be black and white. I think a lot of moms come in and they have the mindset that they’re like, well, I’m only making a fourth of my baby’s intake as breast milk. And that fourth of breast milk, that fourth of the intake of the baby being breast milk is important. And it’s beneficial because that baby’s still getting protective factors.

Now of course, a mother has to kind of decide what’s best for her and her family because a baby also needs a healthy mom. And if it’s just not realistic for her and her family, that’s OK. That is OK. And I think sometimes too, moms need to be able to be told that.

Courtney Collen:

The most important thing is that baby is fed.

Samantha Zeeb:

Absolutely.

Courtney Collen:

Sam, why is breastfeeding painful for some and how can we alleviate that?

Samantha Zeeb:

Absolutely. So ultimately breastfeeding should not be painful. If breastfeeding is painful, we recommend working with a lactation consultant, whether it’s you’re still in the hospital, then I would encourage you that second I want to call for lactation support. So we can come in. Sometimes it’s a simple positioning or sometimes it’s a reminder that we need to move the baby’s body a certain way, so that way that latch

Often when we’re latching and there’s pain, typically it’s due to an inappropriate latch or a shallow latch. And so what that baby is doing is essentially that baby, instead of rubbing on the breast tissue, they’re chomping on the nipple. You know, we can examine the nipples and see what’s happening. So if there’s certain creases or marks, a lot of times that will give me markers for what might be happening when they’re latching and give them tips to try to remediate the pain.

Now once damage is done to the nipple, often the latches thereafter are going to be sensitive because that damage is already there on the nipple. So until that heals that can be a little bit sensitive. I have had some moms who just in general have a little bit more sensitive nipples and immediately postpartum, the latch may be good and there’s no signs of a tight frenulum. But that mom just has sensitive nipples and some of them work through it. Some it’s too much, some can’t, and that’s OK.

So really it just comes down to getting professional lactation support so that we can help troubleshoot what is causing this pain, how can we remediate it, what might this be. Another reason that might cause nipple pain is if you are an extended breast feeder and you get pregnant again, those hormonal changes during the pregnancy can cause your breast to be more sensitive.

Courtney Collen:

All the creams, all the creams at the beginning for me, I’ll raise my hand and say, it was painful to start because not so much the latch. I mean, it was a poor latch in the beginning, and we worked through that, thankfully with breastfeeding specialists on your team. But we were continuing to breastfeed through some of the pain and trying to work through healing creams and things like that. So it was just this ongoing cycle of, oh, this is painful because they’re sensitive, but I’m trying to feed my baby as well to get my milk to come in. So, absolutely. And solidarity for any moms who are listening who potentially could experience this too, but it does get better.

Samantha Zeeb:

And there are, like you said, there are creams, so the Lanolin, there’s hydrogel pads. But the best thing is like express breast milk, rubbing that in and letting it air dry. And then, there are routes sometimes there is so much nipple damage that that Mom has to take a break on that nipple from the breastfeeding, and pumping might work better for her until that nipple heals. So there’s options and, I’m going to say again, just reach out to your lactation professional because we can kind of help walk you through those.

Courtney Collen:

As a lactation professional, Sam, I’d love to hear the questions that you get most often, either in the clinic or out in the hospital setting.

Samantha Zeeb:

One of the most frequently asked questions or one of the things that I see quite commonly, outpatient-wise at least, is I will have moms come in the first few weeks postpartum and they are questioning their baby’s breastfeeding behaviors.

So, we do usually educate mothers that cluster feeding behavior can be expected and is normal, especially at night because your hormones are higher. But I don’t think we emphasize; we say those words, but there’s so much more going on behind the scenes that I think when moms experience, they’re like, oh my goodness, this must be cluster feeding. But it seems so extreme that they think it’s abnormal.

Historically with bottle fed babies, they get every three hours, they get so many ounces. Formula sits in the tummy longer. It’s harder to digest. So they’re fuller for longer, so they might sleep longer. Well, breastfed babies need to feed more frequently. That is biologically normal because that is more readily digested. And they also do that cluster feeding behavior because the more they’re at the breast and the longer they’re breastfeeding, the fattier the milk you will actually produce. It gives your body the message that there is a newborn. And so this is just a little bit of solidarity to all the moms. Like, you’re not alone at night feeding that baby all night. Unfortunately, it’s a rough patch.

I tell moms, they’re in the trenches of it. It gets better. Babies do have cluster feeding behaviors in certain periods. They might go through it. But babies breastfeed for a lot of reasons other than just for nutrients. You know, it’s comforting if you think about it. They were surrounded in your amniotic fluid and could hear your heartbeat and smell you and hear your voice and feel your breathing. So it makes sense that a bassinet that’s flat and hard and they can’t smell you, they can’t see you, they don’t hear your heartbeat, that it makes sense why they’re a little distressed. And so that’s where that cluster feeding and that contact behavior comes from.

So I always tell moms, you can expect that you’re going to have those frequent night wakings and prepare for it. So during the day, and this is the age old “sleep when the baby sleeps.” I used to hate it when I had my newborn, but truly sleep when the baby sleeps. I mean if you have somebody that can take your baby for a feed, breastfeed the baby or pump and feed the baby and then go lay down for three hours, that three hours of uninterrupted sleep is sometimes the difference between a mental breakdown. So having a support system in place, knowing that you’re not alone and knowing that it will come to an end. It’s not forever but it is normal.

Courtney Collen:

Teamwork is so important. And even in my own experience, having a partner, whether it’s a husband, a loved one, or a friend, helping you on this journey is so critical. Talk about the role of a partner or how they can help support someone who is breastfeeding.

Samantha Zeeb:

I think my husband would like to chime in on this part. (Laugh) I luckily had a very a very supportive husband who wanted to take part. And there are a lot of dads that want to help. And sometimes when moms are choosing to breastfeed, they don’t know how to help. And so there are plenty of ways for a father to help, especially with the breastfeeding baby. So if you’re breastfeeding, Dad can change the baby’s diaper and bring Baby to you. He can put pillows and blankets around you. He can refill your ice water, get you snacks. He can swaddle and sway and rock the baby when Baby gets done eating. He can burp.

At night you can develop a system where when baby first initially wakes up and needs to be changed, Dad can do the diaper changing and then bring Baby to you. You breastfeed. And then when you’re done, give the baby to Dad for him to settle. Or if you’re pumping, Dad can clean the pump parts and he can bottle feed the baby. And dads in these newer generations are a lot more involved, I think, and they want to actively take part. There’s actually studies that show that the more a dad is interacting and taking part in these cares, the more his brain will actually change like a mother’s brain will. And he will have more of those bonding behaviors.

Courtney Collen:

My husband was my milk manager, I joke. He would make sure pump parts and bottle parts were always clean, milk was getting stored properly. But even more so making sure that I was eating and staying hydrated because it was so easy to forget to eat, to drink things. Can you speak to that for a moment? How important is it to stay nourished when you are deep into the newborn trenches and breastfeeding as well?

Samantha Zeeb:

A little life hack is to get yourself a little rolling cart that you can put in wherever you mainly breastfeed. So say you breastfeed often on the couch. Have a little cart and have it stacked with protein bars and good snacks, healthy snacks, fruits, vegetables, crackers, water. And the other thing about water is it’s important to stay hydrated, but also, I’ve had some moms that come in and they’re like, I’m drinking three gallons of water a day. (Laugh) Drink to hydrate. Drink to your thirst. You don’t need to go overboard. The rule of thumb: eat to hunger, drink to thirst.

Courtney Collen:

Yes, do it. Self-care is so important. Healthy mama, healthy baby.

If there are new moms listening who might be in the thick of the newborn phase, trying to get into a groove with breastfeeding, maybe there’s a poor latch and some pain associated with that. Maybe she’s feeling overwhelmed with engorgement making too much milk or feeling like she’s not making enough because baby seems hungry all the time. And she’s unsure if she can continue. Sam, what would you tell that woman to help feel supported and encouraged and certainly not alone?

Samantha Zeeb:

So, I would absolutely tell her to find her village. And so what I mean by that, when I say find your village, is find the people that support you no matter what.

Find the people that support you no matter what. Breastfeeding is great. It has great benefits, but ultimately, Mom and Baby need to be healthy. You know, Baby needs a healthy, stable mom. And so you have to do what works best for your family. You have to do what works best for you, and everybody is human and everybody needs a break.

I usually will say, well, what would make you feel better? Would getting sleep help? Do you have someone to take the baby so you can sleep? Do you need to go and have a couple hours alone? Do you need to give a bottle so that way you can just have a weight lifted off your shoulder? I think that sometimes as lactation consultants, people think we’re kind of breast or nothing. And while we emphasize the importance of breastfeeding, we also are there to support you and recognize that sometimes you need a break and sometimes it doesn’t work. And so we’re here to help you feel supported and we will evaluate what your goals are and we’re there to meet you at your goals.

Courtney Collen:

What do you love most about what you do?

Samantha Zeeb:

I have the best job in the world. I have moms all the time and grandmas all the time that are like, oh, I bet you just love your job. And truly I do. I kind of fell into it. So I when I was in nursing school and I was picking my internship, I got matched with our public health department and lo and behold, I was matched with an IBCLC. So an IBCLC is an international board certified lactation consultant, and that is the highest education you can receive in the field of breastfeeding.

I had my two children and I breastfed them both. And there is something about feeding an infant from your body all alone and just feeling like you two are the only ones on this earth. Just watching that sweet little baby nuzzle in and hearing the little sounds and just the bond that it gives. And I wanted to be able to give that gift to other people, and I wanted to be able to help other people.

I think women, it’s hard for us out there. Sometimes we’re providers and we’re mothers and we’re cleaners and we’re errand runners and all the things. And I think that in solidarity with that, just trying to be supportive of each other and help each other through where we can.

Courtney Collen:

Yes. Beautiful way to wrap this up. The lactation professionals at Sanford Health are angels on earth. (Laugh) Samantha Zeeb, thank you so much for your time and for all that you do.

Samantha Zeeb:

Thank you. It was a pleasure.

Courtney Collen:

I sure hope you learned as much as I did from our conversation today. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.

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Sober curiosity can inspire better relationship with alcohol

Mindy Broden (guest):

Overall though consumption still remains up, binge drinking is also higher, much higher than what it was I would say 10 years ago. And the most notable change in that is that women actually are drinking more frequently, consuming more alcohol than in previous times.

Cassie Alvine (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about sober curiosity and the rise of a sober generation. Our guests are Mindy Broden and Ashlea McMartin with Sanford Health Bemidji. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Welcome Mindy and Ashlea. Why don’t you guys introduce yourselves and your roles. Mindy, let’s start with you. What is your title and what is your role?

Mindy Broden:

My name is Mindy Broden, and I am a licensed alcohol and drug counselor. I have been for the last 15 years and I’m also a licensed professional clinical counselor, which is the last two years. I am the clinical lead over our substance use disorder services, including our medication for opioid use disorder clinic.

I’ve been with Sanford for seven years. I’ve got the great opportunity to work residential prior to coming to Sanford and then now do a lot of outpatient education, working on prevention, all of those fun things. So this is kind of the vein of what I do is substance use.

Alan Helgeson:

The stuff you talk about every day, right, Mindy?

Mindy Broden:

That is correct.

Alan Helgeson:

All right, Ashlea, go ahead and talk about yourself and your role with Sanford.

Ashlea McMartin (guest):

Absolutely. So Ashlea McMartin, I am one of the directors of behavioral health for the Bemidji region. Similar to Mindy, I’m a licensed professional clinical counselor. Been with Sanford since we merged back in 2017, but really technically been with them since 2013. Then when we were Upper Mississippi Mental Health Center. I am not a licensed alcohol and drug counselor, as Mindy had mentioned that she is.

But really in mental health we see in our region a huge crossover, co-occurring disorders, which means both mental health needs and substance use disorder needs are present at the same time. And so my service lines, I work closely with those that are experiencing urgent or emergent mental health needs, and drugs or alcohol are often included in those experiences when someone’s having a mental health crisis. And so see the work ancillary through the work we do through our crisis services, but then also our long-term ongoing services as well.

Alan Helgeson:

Well, Mindy and Ashlea, again, glad to have you as part of this program today. And we’re talking about “sober curious.” It’s one of those terms that it seems like you didn’t hear anything really about. It’s one of those newer things, kind of a phrase that has come about here the last few years in regards to alcohol and alcohol addiction.

So Mindy, let’s start with you. Can you maybe share a few of those current trends in regard to alcohol consumption?

Mindy Broden:

Absolutely. Current trends per capita really are actually down compared to 2022, which is kind of the last statistics that we have. And the most notable ages of that are actually that 18 to 34. And part of that is some of that sober curiosity. And I would also say the incredible increase during COVID overall though consumption still remains up. Binge drinking is also higher, much higher than what it was I would say 10 years ago.

And the most notable change in that is that women actually are drinking more frequently, consuming more alcohol than in previous times. There’s been an increase of persons that are totally abstinent from alcohol overall as well in more recent time here.

But just in terms of what people are drinking, there’s a lot of craft drinks, health drinks, organic drinks. There is some mixing now currently, especially I would say in the state of Minnesota with the legalized cannabis. So there’s THC and alcohol drinks that are being produced. And so there are some trends I would say, just in terms of what people are consuming. But overall in the last couple years we have decreased, especially since COVID.

Alan Helgeson:

So Mindy, you talked about as it’s kind of gone down, which is good news, but those rates increased during the pandemic. Let’s talk a little bit about that and why that was and what was going on there?

Mindy Broden:

We talk about addiction being a disease of isolation and when the pandemic came, isolation was a huge factor in the increase of alcohol consumption as well as the decrease in activities, which I think Ashlea, I’ll reference after a little while here.

But the other part too was liquor stores were essential businesses. They remained open and increasing the amount of people that were drinking at home. So when people drink at home, sometimes they might not be as cognizant of how much they’re consuming or how often they’re consuming as they would be in a social setting like say a bar or a lounge or something, even out to dinner or something. So when working from home, having isolation, possibly boredom, lack of activity, the increase of consumption was the outcome.

Unfortunately for those who have a propensity for drinking, it moved the progress forward much quicker than if they were not isolated. For many, with the lifting of the restrictions and the return to normal life, their drinking did decrease to pre-COVID rates. But for others it began to become a problem, which we’re seeing now, and I suspect that we will still see an uptick in alcohol use disorder diagnosis based on the trends that we’ve been seeing in the treatment setting, kind of as the fallout from the pandemic.

Alan Helgeson:

And then the good news that we’re starting to see things trend downwards, which is again, great news. Ashlea, let’s switch to you now. It’s reported that binge drinking rates are highest in the Midwest, which is in Sanford Health’s footprint. Can you speak to that a little bit?

Ashlea McMartin:

We find that in the Midwest we’re very rural, right? So we have smaller communities very far apart. I think about, you know, the community of Bemidji that’s just shy of 15,000 is probably one of the bigger cities within a two-and-a-half-hour radius.

And so we have to Mindy’s point about her piece of isolation, we have communities that don’t have a lot going on. So I think sometimes drinking comes as a result of boredom and then it becomes part of the culture. And so we have this combination where alcohol is present at many different events and it just becomes part of what we do and who we are.

We also have in the last couple decades seen this increase in the craft beer and the brewery and the pub idea. And so again, it’s become this trendy, enjoyable social activity. And so it is something that brings people together. And so there’s that delicate balance between engagement and connection, but ensuring that it’s in a healthy venue, and alcohol is typically present at many of the different social activities that we see.

Alan Helgeson:

We do see that as kind of a foundational thing for getting together with the social thing. You go out with friends and you have that – it’s much like food, right? We always have that around and we have it present.

So let’s pop back to you Mindy. Let’s talk about binge drinking for men. What does that look like for men?

Mindy Broden:

Binge drinking for men is actually defined as having more than five drinks on one occasion. And then heavy drinking would be defined as having 15 drinks or more per week. And for women it’s more than four drinks per occasion or eight drinks per week.

The only thing that I would add to that is that back to that cultural context of the Midwest or we talk about with young people, binge drinking is a really common thing. I don’t think if we went out and did a kind of a poll of our college campuses, most people would not think that five drinks was anywhere near a binge. But nationally that is what we identify as binge drinking is five for men and four for women.

Ashlea McMartin:

I think it’s important to note, and Mindy correct me if I’m wrong, but like there’s binge drinking and then there’s also what maybe the medical field would suggest as excess. And women shouldn’t drink more than one drink a night and men shouldn’t drink more than two for the health components of things. So she’s mentioning binge drinking and how people would be like, what? Five? No, that’s not binge drinking, but if we talk about just overall health impact, like more than one a day is more than likely having a negative impact on her health.

Mindy Broden:

And our sleep and our emotional wellness and all of those things too. I agree with you Ashlea. Like I said, when we talk about this, there’s different kind of schools of thought with it. From a substance use kind of context or perspective, it’s not necessarily how much a person’s drinking. It is how it’s impacting their life.

So we can’t give a substance use diagnosis on how much a person drinks by itself. There has to be other components. It has to be negatively impacting their life in some way. And so a lot of times while we do binge drinking is part of kind of the way that we assess, it also includes is it impacting you emotionally, physically, relationally, socially, employment wise? Because that’s really what determines whether a person’s having a problem.

Alan Helgeson:

Alcohol is a depressant. So then what does that mean for those who might not know? Let’s take that a step further then.

Mindy Broden:

There’s three different drug categories. We have depressants, we have stimulants, and we have hallucinogenics. And alcohol falls into the depressant category and it acts just as the name implies, it slows the central nervous system down, slows breathing, slows heart rate. The challenge is that a lot of people experience what might be called a buzz or euphoria that they feel when they start to drink, but that isn’t because the alcohol isn’t still depressing the central nervous system. It’s because alcohol also impacts the brain, primarily the prefrontal cortex that has to do with judgment and reasoning.

So when that judgment and reasoning is skewed for a person, it gives people the feeling of feeling relaxed, of not caring what other people think. And that is a lot of times the feeling that people look for when they, especially when they’re in social settings.

Alan Helgeson:

So as you talked about that then, how does alcohol affect us emotionally?

Mindy Broden:

When a person usually starts to drink, it enhances positive emotions, decreases anxiety when they’re drinking, but when alcohol begins to wear off, there’s a boomerang effect. So people often will experience heightened anxiety when they are sobering up or when the alcohol’s coming out of their system. Sometimes they might be unable to sleep, have an increase of heart rate, breathing, racing thoughts, worry, et cetera.

As a person’s drinking often continues down the road, they will maybe have more, when I say like heightened emotions, so they might have a little bit of sadness, but then when they drink they might get uncontrollably sad. Or like what Ashlea talked about, a lot of the people that we see presenting in crisis situations have maybe alcohol or drugs on board is that will take maybe a little bit of a thought and it just blows it up.

And so somebody might be sad, once they drink, now they’re experiencing suicidal thoughts and because the prefrontal cortex is impacted by this, they now don’t have the reasoning or judgment not to do it. And so that’s a lot of times where Ashlea’s service lines will get involved with our patients as well.

Alan Helgeson:

So then let’s switch over to the physical side then Mindy.

Mindy Broden:

Sure. One of the reasons why men can drink more than women is because men have an enzyme in the stomach that starts breaking down alcohol prior to it reaching the large and small intestines. Women don’t have that same enzyme and so women are more greatly impacted because of that, plus usually the weight difference between men and women, muscle mass, all of those things.

But alcohol is broken down through all those various internal mechanisms. But namely the liver’s impacted by alcohol use, especially over time. Long-term effects have resulted in liver failure, kidney problems, stomach, digestive problems, and we often do see that in the medical field as well. The negative impacts of how alcohol is affecting a person physically.

Alan Helgeson:

Mindy, let’s talk next about those warning signs that someone might have a problem with alcohol.

Mindy Broden:

Absolutely. I think some of the of the greatest warning signs are increased use, needing to have drinks more frequently, more often maybe you started with having one to two drinks and now you’re having two to four drinks. That’s usually the first indicator.

Obviously some of the concerns would be use in which it’s physically dangerous. So if you do have a medical condition or driving under the influence, being unable to control drinking blackouts is something we see, especially with binge drinking. Some of the younger crowds possibly would be experiencing blackouts. That’d be a pretty good indicator there could be a problem.

But more than anything we talk about is it impacting your relationships? Are you not being able to fulfill obligations? Change in friend group is a pretty good indicator or you’re not hanging out with friends that used to be really important to you and now your friend group’s changing to people who maybe drink more. Relationship problems due to drinking. Legal problems. Those are some of the first signs that we see that somebody might be having a problem with alcohol.

Alan Helgeson:

So knowing about these warning signs when someone might have a problem with alcohol, we’re hearing a lot these days about sober curious, Dry January and awarenesses about paying attention to maybe overuse of alcohol. Let’s talk about sober curious and what is it Ashlea?

Ashlea McMartin:

Ironically, Alan, you mentioned at the kickoff that it’s a relatively new term, right? Just in the last couple years and there’s accuracy in that. Sober curious has its roots going back to the late 2010s. That sounds so strange to say, right? The 2010s (laugh).

In 2018, Ruby Warrington wrote a book called “Sober Curious,” sober curiosity. She started a podcast around it, really a millennial push around this content or context of mindful approach to alcohol use. And so what that looks like is being curious or questioning what our alcohol use is having an increased awareness of what our drinking habits look like, maybe taking a break from drinking during certain times, and then doing more sober activities, engaging with others that are taking maybe that sober curious approach.

Mindy Broden:

I would just add one thing too, Ashlea, and I absolutely love that answer. The additional piece I think is that there used to be a pretty harsh judgment on people who were maybe practicing sobriety or practicing abstinence, and it was very kind of almost shameful.

And so this shift of the sober curious movement I think has just brought in just a non-judgmental stance of you don’t have to be an alcoholic to go to a meeting or you don’t have to be an alcoholic to practice sobriety. It brought in just a totally different feeling to the idea of choosing not to drink.

Alan Helgeson:

Give us your expert opinion on putting some labels on different things like this in raising these awarenesses.

Mindy Broden:

I think that just these different campaigns that have came out have really done a lot to exactly what you said, raise awareness that these are issues, these are things people are doing, in some ways almost make it popular to maybe practice a month of the year that you’re going to not consume alcohol or use any substances.

But I think that the normalization of it has actually decreased the stigma as well because when you see these different campaigns for different months, I think we have a suicide awareness month, we have, like you said, Dry January, we have a sobriety month, we have all these different things and it just brings more normalcy to it and it gets people talking about it and puts out resources into the communities, which I think are just fantastic to be able to kind of all come around and reduce that stigma and judgment.

Ashlea McMartin:

I think it gives permission to, right, like when we talk about the Midwest having higher rates of binge drinking and why that might be, and with it being boredom and part of our culture, sometimes we need permission to be anti-culture.

And so picking maybe a month to say, can we collectively do this or try this, gives people the OK and a reason that if someone’s going to ask, oh, why aren’t you drinking at this event? Someone can say, I’m, well, it’s Dry January and I’m trying my hand at this. It can almost create a ripple effect where it creates greater curiosity around that. Right now we have the chance for someone, our acquaintance to say, tell me more about Dry January and why you would be committed to doing that.

Alan Helgeson:

Well let’s talk more about those specific tips for living a sober or sober curious lifestyle. Ashlea, can you share some of those?

Ashlea McMartin:

Yes, Alan, great question because as people are listening, maybe they are thinking, how can this even look? What would this even be? And so I oftentimes tell people, find your people, right? If the folks that you’re hanging around aren’t welcoming to the idea of you choosing to be sober curious, maybe it’s an opportunity to branch outside that initial circle that you have and create a wider net or a greater support system that would be willing to say, “Hey, that’s cool. That’s all right. Yeah, like, you know, maybe we’ll keep drinking. But you don’t have to.”

If you are running into people that are tearing you down or continuing to reinforce that you should be, it might be time to look a different direction to find support.

Coping forward is another strategy where maybe you’re working on. I really want to commit to Dry January, but I’m also going to this work event, or I’m going this family birthday party, sports event that I know there will be alcohol at.

And coping forward means that we just plan for that. So how do I want to approach that? Maybe I even practice what I’m going to say to people in the mirror to gain confidence in explaining why I’m not going to be participating in drinking or drinking to the same extent that others might be.

And then the last piece is don’t give up. When we start to change culture, it takes time. And I just recently read that there is a section yellow at the Green Bay Packer stadium and the section yellow is a sober curious or sober section where people go to celebrate the Packers. How incredible, right? Green Bay Packers are an NFL football team, very well decorated. And there are fans that have come together that have said, we want to support a community that doesn’t want alcohol to be part of football. And we can still come and be present around other people that are doing that. We’re also going to support each other. And they have a section, they have a color, they actually hand out pins. That’s one game at a time.

And if you’re familiar with AA, NA, they talk about one day at a time, one hour at a time, one minute at a time, and have laid that over top of football to say one game at a time. And I just think that’s fantastic. And it goes to show how this movement is growing and how it’s impacting people in positive ways.

Mindy Broden:

You know, we look back 40 years even, there was never a non-smoking section in a restaurant and then we started almost like the non-smoking movement. You know, you can’t smoke in any restaurants anymore. And I think about that and how when we look at the kind of trends of people who smoke, that has decreased exponentially because it normalized that not everybody smoked. So that is so cool to kind of usher in the sober curious generation.

Ashlea McMartin:

And I don’t remember if you guys recall when smoking was banned from restaurants and bars, there was a huge uproar, right? There was like, people were like, what are we going to do? People aren’t going to go out to eat, they’re not going to do these things.

And then we adjusted, right? And people, some people stepped away from smoking, others made adjustments so that it wasn’t as negatively impacting other people, children, people that didn’t have a choice whether they wanted to inhale secondhand smoke.

And so our culture evolved and I’m hoping with this sober curious movement, we’ll see this continued growth exponentially of people being curious about their use habits.

Alan Helgeson:

Mindy, let’s turn now to younger people like those middle school, high school and college students that maybe try new things. What are a few things to look for in someone that might be going through some of these changes and experiencing those changes with alcohol, and in a harmful way that they may not have previously? And how can we help a person?

Mindy Broden:

That’s a great question and I think something that every parent has struggled with and maybe a lot of different friends have struggled with. If they see some things, I’d say some of the number one things to look for if a person’s having some difficulty is you’re going to see a change in behavior. Might be a lack of interest in the things that they had before. A significant change in friends, sudden drop in grades, sudden drop in friends, all of those things. Kind of that idea of isolation over time, that’s what will happen is that isolation will kind of step in there.

I think one of the hardest things with youth is it’s much more difficult for youth to recognize that there might be a problem, even if someone that is watching them can see that it is. A lot of times youth have kind of that 10 foot tall and bulletproof mentality, not me, I can handle this, this isn’t a problem, this is normal.

And so I always just think communication is the starting point to connection with them, being cautious, not to accuse or shame and so on. Instead, using phrases like, “I’m really concerned for you because this is what I see,” or “Help me understand what this is doing for you.”

One of the greatest challenges with youth is that they’re not likely to experience the significant consequences that maybe somebody that’s further into their use disorder would, and then they also compare themselves to others. And so maybe somebody else was able to drink the same amount but didn’t have the same outcome. Like I said earlier, if a young person is blacking out from using alcohol, that’s always a pretty significant sign that they might need some help.

Alan Helgeson:

Well, as we switch now talking to both of you, which we know are great resources, what other resources does Sanford Health have?

Ashlea McMartin:

I think there’s many different starting spots for patients that are receiving care at Sanford or maybe they haven’t ever received care at Sanford. First and foremost, reaching out to your primary care provider and just asking questions and seeing what referrals that they can make for specialized care if you’re concerned about your drinking or really any substance use habits. And that can include things like binge eating, gambling, different addiction habits.

I know oftentimes we think of addiction as just alcohol or drug related, but really we have a wide spectrum of what addiction can look like. Many of our regions have specialty care in the form of behavioral health services, and that can include mental health services, but also substance use disorder services. It might be outpatient, it could be residential, it could be inpatient. And so really kind of getting a good lay of the land of what is close to you or what services are offered virtually.

We’re talking about rural health care, right, where we know that it might be a long drive in and a lot of resources for someone to receive inpatient or in-person care for a substance use disorder. And so also recognizing that we have virtual options that can help support people living anywhere to receive services that might be vitally important to their well-being.

And then the last resource I want to call out that isn’t Sanford specific, but that has been a huge push in the last two years since its rollout in 2022, is the phone number 988. 988 mimics 911 in the sense of when someone is in need of emergency services, whether it be an ambulance or law enforcement, you can call 911 and they will respond. 988 is linked to the national suicide hotline, so someone calling 988 can receive support as it relates to mental health services, mental health crisis, and that includes substance use disorder services as well. This is a national number, so you can call it from any state at any time. It’s answered 24 hours a day. And when people are like, where do I even just start? 988 is a great starting spot.

Alan Helgeson:

Someone listening today that might be struggling with alcohol, those final thoughts to share with them?

Ashlea McMartin:

I think we can mirror the one game at a time concept and say, let’s take it a minute at a time. And that’s relative to maybe sobriety, but also trying to figure out what your next steps are. When we have difficulty or a problem present, we don’t have to solve the whole thing today. And so breaking it down into bites that we feel like we can digest is very important. And so what is in the next minute or hour, something that you can do to support yourself?

And then along that same line, don’t hesitate to reach out for services, whether that’s formal or informal. There are many people that want to support you in this process. And hopefully as this sober curious culture shift takes hold, people will find more and more places to connect with others to say, I think I want to change my alcohol use habits.

Mindy Broden:

I was just going to add in addition to that too, and what Ashlea said is absolutely accurate, and we do have a lot of resources. But I think sometimes a person might be scared. “Well, maybe I’m not ready to quit. Maybe I just want to cut down,” or whatever. And most places – I can speak specifically for our teams – we really meet patients wherever they’re at.

And so if somebody’s having a problem, they just want to have a conversation about it, or maybe they just want to identify, am I having a problem or what am I getting from it? Or what is it giving to me? Alcohol isn’t prejudiced. It impacts any person, any color, any age, any culture. Some people’s bodies are more primed to have issues of substances than others. That’s a fact.

Like I said before, addiction thrives in isolation. So we have a saying in SUD (Sanford substance use disorder team) that says, you’re only as sick as your secrets. So the number one thing is to talk about it with someone. So just like Ashlea says, 988, talk to your primary care provider, case manager if you need to, but just talk to somebody about it. That is the number one thing.

Alan Helgeson:

Well, let’s move on to somebody that may have a loved one, a family member, friend, coworker that is struggling. What would you say to someone that’s listening that might be going through that?

Ashlea McMartin:

I think reiterating what Mindy said, that addiction doesn’t discriminate. When we look at supporting people that are experiencing addiction, some of the best ways to do that are to set really healthy boundaries for ourselves as those that aren’t experiencing addiction, to keep ourselves healthy for that other person oftentimes.

And Alcoholics Anonymous even has a parallel group for children of alcoholics because it’s not uncommon for a loved one colleague to feel responsible or like they did something or should have done more to help someone through addiction.

And addiction is just, it’s beast. And it takes many different people, a lot of different connections. And so keeping yourself healthy through self-care and also setting boundaries with that loved one or that colleague is very important. And even though it might feel at times like those boundaries are harsh or that person with that addiction is responding with words that are hurtful, knowing that maintaining those boundaries are extremely important for our own well-being because we can’t help those when we’re ourselves are unwell or struggling.

Alan Helgeson:

Wonderful information that you’ve both shared today. Mindy and Ashlea, we so appreciate your time and being part of this podcast and talking about sober curious and living a sober curious lifestyle.

Cassie Alvine:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.

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Medical & tech leader predicts health care’s potential

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, host Courtney Collen with Sanford Health News talks with Dr. Nworah Ayogu, head of Healthcare Impact at Thrive Capital. Dr. Ayogu is a speaker at the 2024 Summit on the Future of Rural Health Care.

Courtney Collen (host):

We’re so happy to have Dr. Ayogu in Sioux Falls. Welcome.

Dr. Nworah Ayogu (guest):

Thanks for having me. My first time in Sioux Falls and I’m loving it. I’ll be back.

Courtney Collen:

Love to hear it. So glad to have you. You’ll be speaking on a panel about expectation to experience, really rethinking health care to serve today’s consumer. What is one message or a couple of messages, golden nuggets as I like to call them, that you want to drive home with our audience here today?

Watch the Sanford Health News vodcast of this episode

Dr. Nworah Ayogu:

So, I spend a lot of time thinking about innovation. You know, I spent a bunch of time in startups, spent time in big tech at Amazon, and now I’m at Thrive. So we hear pitched startups all the time thinking about innovative ways to solve problems.

And to me, I think one of my biggest pieces and one of my biggest takeaways is going to be we used to say a lot, necessity is the mother of innovation. And when I think of where’s innovation going to take hold and where do I think innovation is going to come from for this next sector of health care innovation, I think we’re going to see it in densely urban areas and very rural areas.

So people think a lot about, you know, Silicon Valley and, you know, the Upper East side of New York. And there are two kinds of innovation people talk about. There’s sustaining innovation and there’s disruptive innovation.

Sustaining innovation is doing the same things we’ve always done. Doing it, you know, faster, doing it cheaper. Disruptive innovation is really thinking outside the box to say, how do we do things in a completely different way? And we need a more disruptive innovation in health care. But the way that we’re going to get that is through the communities that truly have needs, the communities where the current health care system is not serving them appropriately. And to me, that’s part of why I’m so excited about this summit because one of the big things I’m pushing, one of the big things I’m anchored on is that that’s where real disruptive innovation comes from, are people who understand the needs and necessity is the mother of innovation.

So it’s going to be our rural communities, and it’s going to be our densely populated urban communities that are going to drive that innovation because that’s where the need is. And honestly, there’s so much talent in these communities to drive that innovation as well.

Courtney Collen:

Is there anything that has surprised you, something that you’re taking away personally from the events so far today?

Dr. Nworah Ayogu:

So, honestly, one of my favorite parts has been talking with the Sanford Health leaders throughout. I think there are probably three pieces:

One is that they’re really leaning into virtual care as a modality, but also as a way to redesign how they connect and support patients. And not because, you know, it’s fun, not because it’s a shiny tool, because they’re saying, look, we know we have communities where the nearest doctor is literally miles away, tens, hundreds (of miles) away, depending on specialists. And they’re saying, this is what we need to actually serve the customer and serve the patient that we have. So the way that they’re embracing virtual care is one that’s been really amazing.

I think there’s a deep cultural aspect, and we talk a lot about reimbursement mechanisms in health care. We talk a lot about the technology. But culture is actually what ties together whether or not an organization can be successful.

And there’s a deep focus within Sanford and the leadership, the clinicians on the culture and the community. They care about the people around them because that’s their family, those are their pastors, those are their teachers. And that culture is actually very key for making sure that you’re innovating but also you’re innovating compassionately and with the patient in mind. And I’m, I really love that.

Courtney Collen:

I’m glad that you’re part of this and you’re part of the dialogue as well. Dr. Ayogu, what do you think is the biggest misperception about rural America right now?

Dr. Nworah Ayogu:

To me, it comes back to the fact that people who haven’t spent a lot of time in rural America can think that it’s stagnant and people don’t want to innovate and people don’t want to adopt new technology. And that’s, I’ve not seen that to be the case at all.

So I think the biggest misconception to dispel is that this is a community and these are areas that want to innovate, but they want to innovate on things that are truly going to solve their problems. So if you’re willing to engage the community and work back from their problems, you will find that these are communities and health systems that are eager and excited to really not just innovate, but actually to drive the innovation.

Courtney Collen:

And I’d love to know what innovation or action in your mind will it take to move the needle forward say in the next one to two years?

Dr. Nworah Ayogu:

I’m a big fan of AI. I spend a lot of time leaning in to understand and see sort of what that tooling is. And I think of three categories of AI.

There’s what we call Fortune 500 use cases, so things that are as useful to a Sanford Health system as they are to a Walmart. So that’s things like, making sure that your data and your engineers can move more rapidly, making sure that your call center when you call in, we can actually have that be automated such that you can get to your problem quickly without having actually having to talk to a person. You can solve your problems yourself. Whether that’s Sanford to use that the same way that American Airlines can use that.

Then we have clinical health care specific administrative use cases. So that’s things like scheduling and revenue cycle management and sort of prior auth and then we have clinical use cases. And it’s been interesting. I think there are less of those that people are deploying.

But one of the things I do is, every week, there are case studies in the New England Journal of Medicine. These are kind of the “House MD” level cases, the super sort of complex medical mysteries. And I put them in every single week and you know, chat GPT’s newest model just to see how does it perform. And we’re going on six weeks straight of me doing this.

And you know, me and my colleagues, the cases that we often can’t get, it does a thorough differential diagnosis. That with super complex esoteric, it gives us the treatment guidelines to the same level that the New England Journal of Medicine’s experts are giving. So it just shows that this technology is here and the clinical applications can really do a lot to improve access, but also make sure that no matter what your zip code, you’re getting that kind of same level of expert care.

Courtney Collen:

Isn’t it fascinating?

Dr. Nworah Ayogu:

It’s amazing.

Courtney Collen:

Yeah. Incredible. How do we strengthen trust in health care during a time of rapid disruption?

Dr. Nworah Ayogu:

So in my mind, trust comes down to two things. Say what you’re going to do and then do what you say. And that’s it. If we continue to do that, we will earn people’s trust.

But it’s remembering that trust is a thing that is earned. And if you go in with that mentality and you do those two things, you tell people what you’re going to do to set those expectations, and then you do it to earn the trust. And then you do that repeatedly over time, you’ll earn trust.

Courtney Collen:

Fantastic. OK, and lastly here, what book are you reading right now? And if not right now, what book potentially has been really key or influential in your career thus far?

Dr. Nworah Ayogu:

I’ll answer both. So the book I’m reading right now and is called – well actually, let me start with the one that’s been influential. So it’s called “Pathologies of Power.” It’s by Paul Farmer, who was a doctor and mentor of mine, did a lot of amazing global health work. But it’s really, it’s very much a values driven book. And one of the things he talks about is he was a great person and I think mentor of mine who I learned about a lot from, and one of the principles in it is the preferential option for the poor. It comes from a Catholic teaching, but it’s all about you should focus your time on the areas and people who need you most, about how do you triage? What do you focus on?

There’s some people will say, focus on the lowest hanging fruit. His was always focused on the most need and that’s how you order and prioritize your time. He did that in his global health work. He did that honestly in his personal time as well. And I, the more and more I think about it now is you’ll learn a lot of knowledge as you go through your career. You’ll learn to work with new tools, but you know, we’ll have AI that’ll make it easier for us to do all of our jobs.

But the one thing it won’t do is set our values. And I think to me, I think more and more that the things I learned early on, the people who taught me those values and the books that help me think about what are the values I want to exist in those, this world, I find that to be more and more important. I think it’s only going to get more and more important that we’re not afraid to talk about our values and live our values and make sure that our organizations and the systems we’re a part of our values aligned.

Courtney Collen:

What do you love most about what you do?

Dr. Nworah Ayogu:

I think it’s being able to work with amazing, talented people who are following their passion. So every day we hear from entrepreneurs, and we get to work with entrepreneurs who are spending all of their time focused on a problem that is near and dear to their heart and soul. That is kind of their passion, their meaning, their reason for being. And when you’re around that passion, it’s infectious.

And the fact that every day we get to, in some way, shape or form, assist them in that journey, that’s awesome. I think that’s my one wish is that everyone gets the chance to fully pursue their passion and hopefully has, you know, sherpas around them to support them.

Courtney Collen:

I love that. Well, we are so grateful to have you here in Sioux Falls for the third Rural Health Summit and for this podcast as a guest. Thank you for being here and for all that you do.

Dr. Nworah Ayogu:

Thank you for having me, and I will definitely be back.

Courtney Collen:

Looking forward to it.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and news.sanfordhealth.org.

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Inducing labor: What to expect if you need an induction

Dr. Lacey Krebsbach:

Even though it’s sometimes a surprise that an induction is coming it doesn’t necessarily mean that, you know, it’s a bad experience. It certainly can be a very positive, healthy experience.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We are starting new conversations about age old topics from pregnancy to postpartum, managing stress, healthy living, and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

In this episode, we are talking about labor induction and some of our most common questions when it comes to inducing labor, either planned or unplanned. And I have two guests joining me for this conversation. Dr. Lacey Krebsbach is an OB/GYN, and Paige Neameyer is a labor nurse who spends a lot of her days now educating nurses for labor and postpartum – both at Sanford Health in Fargo, North Dakota. Dr. Krebsbach, Paige, thank you so much for taking the time to join me.

Both:

Thank you. Yes, thanks for having us.

Courtney Collen:

So we’re going to start with this question for you, Dr. Krebsbach. What does it mean when we talk about inducing labor? And please feel free to chime in, Paige. I’d love to know why a woman would be induced and when is it recommended?

Dr. Lacey Krebsbach:

So, the process of an induction of labor is essentially getting the uterus to start contracting before the spontaneous onset of labor. And there are different methods to do that. And there are different indications with which we do that as well.

They’re often medical indications, which is the most common cause that we induce labor. And those can fall under the category of maternal issues. If mom has underlying medical concerns such as hypertension or diabetes those could be baby issues. If there’s a concern for growth restriction or other issues as to why baby would maybe need to have a timed delivery instead of waiting for the onset of labor.

And then there are more elective type of inductions where medically the pregnancy is healthy and mom and baby are fine, but for other reasons between the provider and the patient, it’s decided upon to move towards delivery sooner than waiting for labor.

Courtney Collen:

What methods are used to induce labor?

Dr. Lacey Krebsbach:

The labor induction process can be just that. It can be a process. It can be a few days of a process. And the determination of what we use to induce labor all depends on the starting point for the patient. So there is a process that kind of kickstarts labor when the cervix maybe hasn’t quite started to soften or dilate, and that’s called cervical ripening. And then there’s the more active labor process where we’re using medications through the IV or potentially breaking the bag of water around baby to help kickstart those contractions.

Courtney Collen:

Paige, why would a patient need an induction, or why would they opt for one by planning ahead?

Paige Neameyer:

Yeah, so we do have what’s called an elective induction will call list. So these are people that do not medically need an induction, but they want one. And in order to get on this list, their cervix has to be ready. So that will be determined by what’s called a bishop score that the provider will do in the clinic.

They have to be at least 39 weeks, and once they meet this criteria, they can get their name put on a list. So this doesn’t give them a specific day that they will be induced, but it does put them on a list so that the birth center knows, hey, these people would like to come in to be induced and their cervix is ready.

I think the difference with this is that for one, they don’t medically need to get in, but if there’s enough staff or the birth center is looking good, and we would like some patients, we can bring them in. And so that’s really nice because we know that their cervix is ready.

So that induction process does look a lot different than somebody who’s starting at a closed cervix or a not ready cervix. And so the process for induction, just like Dr. Krebsbach said, there are so many different ways to induce, and it really depends on the patient and the start of their cervix.

Courtney Collen:

Yeah, I certainly think that is one overarching theme when it comes to these conversations – that every patient’s journey is going to look a little bit different. Every labor and delivery is going to look a little bit different.

So obviously if you have specific questions about your journey, your care journey, then you know, ask your provider, ask your physician, ask your nurse. These are all such wonderful conversations to have and we’re so grateful for your insight and your expertise to help just us learn a little bit more about what this is all about.

Paige Neameyer:

Yeah. And I do feel like a lot of people like to share their birth story, so it’s easy to compare yourself to somebody else. And I think that can be hard too, because you may be talking to a friend who was induced and her cervix maybe started at five centimeters. So her induction only took a couple hours where maybe you are being induced for a medical reason, or your water broke early and your cervix is starting at closed or one centimeter.

It’s important to know and not compare yourself to others because that induction process could take days. And if you think about it, we are doing what your body would naturally be doing over maybe a week, two weeks, and we’re doing that in one to two days. So really just letting patients know they’re not behind.

I think that expectation if they go into it knowing like, OK, we’re going to take this step by step. I’m not behind because my labor is taking longer. That’s OK. And the end goal is a healthy mom, healthy baby, and we can absolutely take our time if that’s what is necessary to do. And I think with cervical ripening, just knowing that, hey, it might take one to two days to even get my cervix to open and then another day to get it to dilate.

And just knowing that really sets the mom up for success knowing, OK, like, this might take some time, and that’s OK. That doesn’t mean they’re going to be in pain that whole time either. I think that’s important to know too. You’re not going to be in excruciating pain for three days. The actual labor part comes later.

Courtney Collen:

Yeah. That’s, that’s such good information and insight, Paige. Thank you so much. Dr. Krebsbach, are there any risks associated with an induction?

Dr. Lacey Krebsbach:

Sure. In medicine, anytime we use medications, there are potential risks or side effects or adverse events that can happen. The goal of induction is ultimately to get the uterus to contract. And so the process of that can be slow. And for some women it can be fast.

Some women respond very quickly to those medications where the uterus starts to contract and can contract very rapidly. That rapid uterine contraction is a condition called tachysystole. And with that, we can sometimes see that babies don’t necessarily like to have those contractions so close together. Moms don’t necessarily tolerate that very well. And so there are some medications that allow us to have very rapid movement or titration of that medication to turn it off or turn it on where we can resolve those contractions.

In rare cases, if baby doesn’t tolerate that, we can see changes in baby’s heart rate. And that can sometimes lead to the need for more interventions that could lead to the need for monitoring, more internal monitoring that could lead to the need for a cesarean section as well. But ultimately, the goal of an induction is a vaginal delivery.

Courtney Collen:

We talked about the risks or possible risks. What about the benefits? What are the benefits of an induction for a mom looking ahead to her own labor and delivery?

Dr. Lacey Krebsbach:

So many of the benefits, especially in the setting of medical inductions, are that there’s some process going on where it may no longer be safe for baby to be inside, and it might be safer for baby to be delivered. Whether that is a worsening of a maternal health condition such as hypertension or preeclampsia. Whether that is a concern over the placentals, placenta’s behavior, growth issues for baby, or if there’s signs of infection for mom.

Also in the setting of where the water does break early there really is a higher risk of infection developing if we allow women to process because that process can sometimes be hours, but it can also be days. And in that timeframe, any of the normal bacteria that lives on our skin can go up into the uterus and cause infections for both mom and baby.

There are also social benefits for some women. We talked about the elective induction list where you don’t medically need to be induced. But there are instances where women may have had very fast labors in the past or they live a distance away from the hospital or perhaps just socially if their partner is going to be deployed, if they’re going to have other instances where timing their labor and delivery, if they are healthy and favorable with the cervix, is beneficial from that matter too.

Courtney Collen:

My water broke after my 38-week appointment. I remember I was hardly dilated at that time and hoping to wait it out in labor some at home. But I was encouraged to come in by the Sanford triage nurses. An infection was a concern, I should say, in that scenario. But I then opted for an epidural because my body responded really quickly to induction by use of Pitocin. The contractions became so strong.

So my question for you, Dr. Krebsbach or Paige, do you tend to see women requesting an epidural during induced labor more often than those whose labor begins on its own to manage some of that pain?

Dr. Lacey Krebsbach:

I don’t know that we see the request for an epidural more often. I think that the biggest difference in what I discussed with my patients in the office is that in spontaneous labor and natural labor this could be weeks or even days of kind of slow progression where your body is getting used to these contractions they’re farther apart. They’re maybe not as intense.

And so it’s almost like a warming up to the idea of labor versus when you come in to be induced you could go from, you know, zero to labor in a few hours and so the abrupt onset of those contractions, I think it’s more of the abruptness of the contractions where many women feel that inductions are more painful than in the setting of a more slow kind of rolling onset of natural labor.

Paige Neameyer:

Yeah, I would agree with Dr. Krebsbach. I think that if you have your mind set on an epidural, whether or not you go into natural labor on your own or are induced, I think your plans on getting that epidural is about the same. When you do, like Dr. Krebsbach said, come in for that induction, yes, you probably feel a lot more, a lot quicker. But then it’s also done a lot quicker as well. So some people like knowing that as well.

But I think if you’re going to get an epidural, you would get it either regardless. And if your plan was not to get an epidural, people who are induced, if their plan is not to get an epidural, they do that all the time. Just because you’re induced doesn’t mean you have to get an epidural or that you won’t be able to tolerate it. We don’t want your contractions to be every minute like Dr. Krebsbach said earlier with the tachysystole, we have to allow that two to three minute between contractions is actually like perfect. Two to three minutes apart is ideal. It gives the baby and the mom a chance to recover before the next one. And so that’s what our goal is, either way, whether the mom is doing it on their own or being induced, two to three minutes is incredible. Like, that’s amazing.

Courtney Collen:

Yeah. That’s such good insight. Thank you for that. If a woman is trying to say, avoid a cesarean birth, for example, is labor induction something that could reduce the likelihood of that outcome?

Dr. Lacey Krebsbach:

So there was a trial that came out called the Arrive Trial and that was published in 2018 where they looked at low-risk populations with a singleton or a single baby. And they compared groups. One group was being induced at 39 weeks, and the other group was allowed to progress to natural labor.

Now, this is a clinical trial, very controlled setting, but what they found was that women who were induced at 39 weeks actually had a decreased chance of cesarean section and outcomes as far as concerns with maternal hypertension, complications with delivery, neonatal results were equal if not better in the induction group. Now, we can’t extrapolate that to all pregnant women. There’s many high-risk features where being induced at 39 weeks is not appropriate. But you don’t necessarily increase your risk for cesarean section by choosing or needing an induction.

Paige Neameyer:

I think that there’s a lot of factors that are out of our control, out of the patient’s control, out of the care team’s control, how the baby’s going to respond. And that could be either whether you’re induced or not induced.

Sometimes babies just don’t tolerate labor, or something happens where the patient needs to progress to a C-section. And that just happens. I don’t really think that one way or another that I have personally seen whether being induced or not induced puts someone at higher risk for a C-section. But I mean, I understand the question, like it’s a very important question.

Courtney Collen:

Let me jump to this. Things that the internet tells you might help induce labor naturally. Things like dates, pineapple, certain types of tea, maybe some certain oils, having intercourse, stimulation of the nipple. Dr. Krebsbach, is there any truth to any of this, and what would you tell women who might be looking for some answers and they are wanting to induce labor ASAP?

Dr. Lacey Krebsbach:

So one thing I talk with my patients a lot about is if there was anything that was medically proven to work in all pregnant patients, nobody would ever get to their due date or go beyond. So there are certainly things that aren’t harmful but aren’t necessarily medically accurate in getting labor started.

One of the medications that we use when we do cervical ripening is a medication called prostaglandin. And that’s one we use for early labor inductions.

Now, there are a few natural things that will stimulate the release of prostaglandins. Nipple stimulation and intercourse are both possibilities that could potentially kind of kickstart the uterus. Not proven that it, you will go into labor, but again, not necessarily harmful.

Some of the foods and drinks and those questions that I see the pineapple, there’s no evidence of that but again, you know, not necessarily harmful.

The red raspberry leaf teas, there’s just not a lot of great safety data on that. So if you’re drinking that just as in normal consumption, it’s unlikely to be harmful, but there’s also no evidence that it works.

There actually are studies on the dates. However, the date issue is that usually you need to consume three to 10 dates a day for multiple weeks in advance. So usually starting at, you know, 35 to 36 weeks, you’re eating potentially up to 10 dates a day every single day. And in those scenarios, there might be a slight increased chance of delivering before your due date. But again, very controlled studies that it wasn’t sure necessarily significantly statistical significance.

One that I do get questions on a lot is use of castor oil. Castor oil is something that’s been around for a very long time as a very potent laxative. And so one of the things that can happen when you consume castor oil is you can develop a lot of GI cramping even a lot of very frequent and loose stools, which to any pregnant woman, it does not sound appealing.

Courtney Collen:

Sounds awful to a non-pregnant woman.

Dr. Lacey Krebsbach:

<Laugh>. Exactly. Also with that, you can become a little dehydrated and any woman who’s been pregnant knows that if you’re behind in your fluids, you’re dehydrated. For whatever reason, the uterus starts to cramp and contract. So not necessarily scientifically validated or safe, really, for most people.

Courtney Collen:

Well, thank you for clearing the air a little bit on that. When we talk about trying to induce labor naturally at home, is there a timeframe that would be considered unsafe to start doing some of these things if we think that that’s going to work for us? When you say something like 35 weeks, that seems early to me. But talk through like what would be a safer time, if any, to start some of these experimental labor induction methods?

Dr. Lacey Krebsbach:

Sure. Really, we consider a term pregnancy at 37 weeks. However, there is still a lot of development that happens up until 39 weeks. So doing things like nipple stimulation after 37 weeks, it can release your natural oxytocin, which is Pitocin in its natural form, can lead to some uterine contractions, but hasn’t been shown to be effective unless you’re already favorable, meaning that cervix is already starting to soften, starting to dilate a little bit. So doing anything like that preterm wouldn’t necessarily be suggested.

With respect to things like intercourse, again, at term, at 37 weeks and beyond, if you want to attempt that, but in the setting of knowing for sure that your water hasn’t been broken or there aren’t leaking fluids, because that can increase the risk of course for infection as well.

And then there are certainly pregnancies where none of these options should be considered. There are instances where there are placental abnormalities or there are previous surgeries that have happened on the uterus that put you at very high risk for inducing where we wouldn’t recommend even these home mechanisms to try to get labor started.

Courtney Collen:

Paige, if a woman has – on her birth plan – hopes for an unmedicated, natural labor and delivery, is there a way for her to lower her chance of having an induction if that’s not something that she truly desires for her labor and delivery?

Paige Neameyer:

That is such a great question. I guess medically there are always things that come up medically, but if her goal is to have an unmedicated, natural birth, I think that we do an amazing job with this. We do have something called an empower tower that we recently created where it has all different things that help with distraction, relaxation and pain control once you are in the hospital.

I do think if your goal is unmedicated and your water is still intact and you’re laboring at home, it’s OK to labor at home for as long as you want, as long as you feel safe, your contractions aren’t too close together. If they’re still like five to 10 minutes apart, 10 minutes apart, that’s OK. Once you get closer to that five minutes apart, and like I said, your water’s still intact, that’s when we would want you to come in more. But as far as whether or not being induced if they can prevent being induced … nobody has to sign up for the will call. No one has to get induced unless it’s medically indicated.

Courtney Collen:

Sure, sure.

Paige Neameyer:

But even if you are induced, I do feel like there are so many ways we can help to help that birth plan so that you don’t have to get an epidural. We have amazing large whirlpool jet tubs that we can dim the lights, we can do little candles in there, we can put your playlist on. I think anybody who comes prepared knowing they want to do an unmedicated birth can be successful.

Dr. Lacey Krebsbach:

I think one thing to keep in mind for all patients, especially those patients that perhaps an induction wasn’t something on the radar when they come into the office and perhaps there’s a new finding, like a new onset, high blood pressure or something that urgently the recommendation turns from we’re waiting for labor to now we need to send you to the hospital. That can be a very scary moment for patients. That can be very abrupt, change and shift in the plan that they had made.

I just hope that patients realize that an induction is not, you know, a failure of your body or a failure of your pregnancy by any means. There are so many things that are out of your control when it comes to your health in pregnancy, and complications that can arise at the drop of a hat.

And so, ultimately, and Paige mentioned this before, but ultimately our birth plan for everybody is a healthy mom and a healthy baby. And we want you to achieve that regardless of how it has to be started.

But we don’t take inductions lightly, especially medical inductions. There’s very strict guidelines as to when and the timing of inducing pregnancies for each specific type of complication that could arise. And we adhere to those guidelines very closely here at Sanford with the goal again is we want this to be a good experience for you, but also a safe experience, and we want to give you a safe baby at the end of it.

Courtney Collen:

Thank you so much. That is such a good reminder. And we are so grateful for all that you both do at Sanford Health to care for an expectant mom before and during and after the labor and delivery.

Paige and Dr. Krebsbach, for that mom or and or her spouse or partner, what advice helps maybe calm fears or eases anxieties? Maybe she’s coming in and labor is going a different way than she had hoped, like a blood pressure concern. You know, the way baby is facing in utero. What do you say in the moment and how do you help ease anxieties that they have?

Paige Neameyer:

For me, and I think a lot of our nurses, just letting the patient know, we are there for them. We are going to keep them updated on everything that we’re seeing. If we are concerned about something, we will let them know when it’s time for them to be concerned. But ultimately, we’ve got them, we are going to watch mom, we’re going to watch baby very closely. And we want to hear those fears.

We want to know what the patient’s feeling and what they’re anxious about, so that, I mean, maybe they’re anxious about something and we don’t know about it, and we could easily address it. We want to be there for them.

And I think just having good communication and letting them know, we are here for you. And I think it’s important to know, like, things aren’t always going to work out the way that you have planned, but the way that we can do our best to make sure that mom and baby are healthy and OK, we’re going to do everything we can to make sure that that is the end goal.

Dr. Lacey Krebsbach:

I often will joke with my patients that labor process and sometimes the last couple weeks of pregnancy are a crash course into parenting where you no longer have control over anything that goes on anymore. This baby is the boss and they’re making the decisions most of the time. And yeah, you just kind of have to go along for the ride.

But seriously … we’ve dedicated our lives and our careers to women’s health care for a reason. We want the best for our patients. We want the best for their babies. We’re privileged enough to be present for these moments, these life-changing days and moments, and we would never want anything bad to happen to our moms or our babies.

So even though it’s sometimes a surprise that an induction is coming, it doesn’t necessarily mean that you know, it’s a bad experience. It certainly can be a very positive, healthy experience.

Courtney Collen:

I had one of those very positive, healthy experiences myself, and I am so grateful for the care team at Sanford, for your teams, for that experience before and after labor and delivery. If you’re listening and you’re planning ahead for labor and delivery, have these conversations with your care team to make sure that you’re getting the best care for you and for baby.

Paige Neameyer, Dr. Lacey Krebsbach, thank you so much for your time and for all that you do for women and families all over the region.

Both:

Thank you. Yeah, thanks for having us.

Courtney Collen:

I hope you learned as much as I did from our conversation today. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.

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Health care needs creative solutions to ‘caregiving crunch’

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, host Courtney Collen with Sanford Health News talks with Ceci Connolly, president and CEO of Alliance of Community Health Plans (ACHP). Ceci is a speaker at the 2024 Summit on the Future of Rural Health Care.

Courtney Collen (host):

Ceci, welcome to Sioux Falls. It’s so nice to have you here.

Ceci Connolly:

Courtney, thank you. It is nice to be back in Sioux Falls and at the Summit.

Courtney Collen:

You were joining us this morning for “Shaping the Future: Policy, Politics, Advocacy in a Dynamic Environment.” That was the topic. I’d love to hear your takeaway or a couple of takeaways that you want to drive home with our audience here.

Ceci Connolly:

I had a couple. One was especially listening to my colleagues from the AMA (American Medical Association) and then the Pennsylvania association focused really on nursing home assisted living, et cetera, is that the workforce shortages in health care continue and will likely get worse if there are not more creative solutions brought to bear.

We know that, for instance, the typical physician needs seven to 10 years of schooling and training. We don’t necessarily have a decade to solve some of the crunch that is out there when it comes to caregiving, so I love when government gets out of the way a little bit and enables the creative entrepreneurial spirit to take over.

My colleague Zach from Pennsylvania, my home state, was talking about the way in which they trained up certain nursing technicians, and by starting with a very lower level, take an online course, then go into a nursing home, get a little bit of training experience, and kind of work their way up, the way that they’ve started easing some of those demands because we know that we don’t always need an M.D. for everything. But we need many more people on our health care teams. And so I loved hearing about some of the really nice experiments that are going on out there in the country.

At the same time I was listening, thinking to myself, I really hope that government – state or federal – doesn’t start kind of mucking around with this.

Courtney Collen:

Well, thank you so much for the insight and for sharing that with us. Do you have a hot take that you’re going to take home?

Ceci Connolly:

Well so I don’t know if this is so much a take, but you know, I got fairly riled up hearing from my good friend Dr. Scott Gottlieb on some of the pharmaceutical industry perspective, because I think that that is still really the piece of our American health care system that is operating in a black box, especially when it comes to pricing. And yes, they go through FDA approval for safety and efficacy.

But his comment that the price is what the market will bear is troubling when you think about the pricing, and again, this black box of how the heck did they come up with a thousand dollars a month for a GLP-1, for instance? It’s just not sustainable. So that’s one that really continues to alarm me, and I wish that the pharmaceutical industry would begin to give some thought to how we as a country are going to afford their very exciting innovations.

The other thing I just love is hearing Bill Gassen talk about the integrated approach, because that’s really our whole philosophy at ACHP.

Watch the Sanford Health News vodcast of this episode

Courtney Collen:

Thank you so much for that. What innovation or action, Ceci, do you think will move the needle in the next one to two years?

Ceci Connolly:

I’m probably going to say, you know, I’m going to say virtual care for mental health. And so that’s not so much one innovation, but it’s really taking two elements and starting to bring them together in a very powerful way that has the potential to address one of the biggest unmet needs in our country in a way that patients are very enthusiastic about.

I think in the early days, we didn’t know how patients were going to feel about virtual care of any kind. And some of it varies by age or circumstances, but what is fascinating to me is that for so many people struggling with some sort of behavioral or mental health issue, they’re very, very comfortable. I think they feel it’s a very private setting. It’s convenient. They might be interacting from their own home. They’re not going out to some facility somewhere in downtown that says, “mental health clinic” or something like that kind of screaming out loud. And so I’m extremely excited about the potential there.

Courtney Collen:

Wonderful. What is the biggest misperception in rural health care would you say?

Ceci Connolly:

You know, in rural health care, it is probably just sort of this notion of behind the times and stalled and stuck, you know, kind of stuck in your ways. You’ve been doing it that way forever. And it’s really, honestly, because not many people, especially on the coasts and places like Washington, D.C., are getting to rural communities to see it for themselves. But I certainly know from my travels here and many other states I’m thinking about, we have Presbyterian in New Mexico is another wonderful member of ours. We have members in the Pacific Northwest.

And you and I get to travel around and what you see is the old cliché: necessity is the mother of invention. And I love the ingenuity that we have seen in places such as Sanford. I mean, you certainly know this Courtney, but Sanford has been pursuing the virtual care, care at home options for such a long time, made such big early investments. And I really think and hope now it’s going to pay off.

Courtney Collen:

Yeah. We’ve got our virtual care center opening in just a few weeks.

Ceci Connolly:

I was here when they were shoveling the dirt.

Courtney Collen:

Yes. I was too. And we’re so grateful and thankful of Sanford’s continued commitment to virtual care.

Ceci Connolly:

Yes.

Courtney Collen:

And you mentioned, mental health, that’s going to be huge. AI in health care, Ceci – how do you feel about how it’s impacting health care? Is it overhyped? Where do you see the impact most?

Ceci Connolly:

So, absolutely early days, and I’m going to suggest that with so many other things in health care, there’s kind of this early, oh, it’s all going to happen super fast. And it won’t because health care moves slowly.

I think that the obvious places where we will see benefit is first of all, around streamlining any kind of administrative tasks, chores. It has the potential to help consumers. For instance, when you go to your health plan or hopefully it’s an integrated system and you’re logging on, AI can help you get to the right place to answer your questions and take care of your services. It can kind of direct and move and navigate you through these mazes much more quickly. You need to refill a prescription, boom, you’re over here. You need to see a specialist. Oh, you’re going into this place. That’s terrific.

And then I do think for clinicians, there will be the ability to bring information to the bedside quickly. That said, I don’t see AI getting in the middle of the very sacred, trusting doctor-patient relationship. Yeah. That’s not going to happen too quickly. And as a former journalist, I can be pretty obsessed with accuracy. And so I do have some concern about how we all as consumers are really going to know which sources to trust along the way.

Courtney Collen:

Well, we are grateful for that insight. Thank you. I did not know you were a former journalist. That’s fantastic.

Ceci Connolly:

25 years!

Courtney Collen:

Well, the industry is lucky to have you, that’s for sure. I’d love to hear about a book you’re reading right now, or maybe what’s in your queue. And also is there a book that is influential in your career, thus far?

Ceci Connolly:

So I’m going to say with respect, I’m a voracious reader. I have been since I was a kid. But my reading habits have probably shifted a little bit. So I’m still a major news consumer every single morning. It’s typically three newspapers, lots of the health care newsletters, you know, all of that good stuff. I am still old-fashioned enough that I sit with a newspaper and I turn the pages.

Courtney Collen:

I love it. I’m the same way.

Ceci Connolly:

Because that’s how you come across the interesting stories that would never be in your health care feed. Absolutely. Right?

Courtney Collen:

Is there a go-to publication you love most?

Ceci Connolly:

Well, I mean, my former and my husband’s employer, the Washington Post has to be right there on the list. But we also get the New York Times and the Wall Street Journal, so we’re pretty equal opportunity on our newspapers.

But when it comes to books, the first thing that I’m looking for now is good writing. And I guess it’s because of my background as a journalist, I have less and less patience for mediocre writing. So one that I read recently that I loved, and it was purely because of the writing, was a book by Anne Patchett called “Tom Lake.” It is set in Michigan during the pandemic. It is cherry-picking season, and it is just incredibly well-written. The other one, which, I had COVID once, I was down for a few days and I plowed through “The Covenant of Water” by Abraham Verghese and that is an absolutely dazzling, brilliant book. You need some time, sure. It’s a tome, but wow, what a marvel it is.

Courtney Collen:

And coming from you, it’s probably two great ones to add to my list, journalist to journalist. Ceci Connolly, president and CEO of Alliance of Community Health Plans, thank you so much for your time and for again, being here at the third Rural Health Summit in Sioux Falls.

Ceci Connolly:

Thank you for having me, Courtney.

Courtney Collen:

Thank you.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health Series on Apple, Spotify, and news.sanfordhealth.org.

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What does preterm labor feel like?

Dr. Rebekah Tompkins:

We have so many new moms that are out there, and it is such a scary and exciting time, but it is stepping into the unknown, and it’s probably the biggest or one of the biggest things that they’ll ever do in their life.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. We are starting new conversations about age-old topics from pregnancy to postpartum, managing stress, healthy living, and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts. In this episode, we are talking about preterm labor.

I have Dr. Rebekah Tompkins joining me. She specializes in obstetrics and gynecology at Sanford’s Southpointe Clinic in Fargo, North Dakota. Dr. Tompkins, welcome. Thanks so much for being here.

Dr. Rebekah Tompkins (guest):

Thanks so much for having me.

Courtney Collen:

So happy to have you. OK, let’s jump right in. If a normal pregnancy lasts around 40 weeks, what is considered preterm?

Dr. Rebekah Tompkins:

Yeah, you’re exactly right. A normal pregnancy is considered about 40 weeks, and term is considered 37 to 41 weeks. And so preterm would be anything prior to 37 weeks.

Courtney Collen:

What are signs or symptoms that a woman might be experiencing preterm labor?

Dr. Rebekah Tompkins:

Sure, great question. And it can be so tricky because sometimes some of the things that we’re feeling are completely normal and those can bleed over into preterm labor:

• So some of the symptoms could be cramping, and that can happen at normal or with preterm labor, but it often is associated with vaginal discharge.
• There can be some bleeding that’s associated.
• And there can be a lot of pressure or even pain in the pelvis, a dull lower back ache that’s constantly there.
• And you can feel that sometimes women really feel their belly getting very, very, very tight and uncomfortable.
• And then of course what makes it obvious is if the water breaks along with that.

But so those are some of the things, some of the symptoms that occur with preterm labor.

Courtney Collen:

Thank you. Can preterm labor be stopped if any of those signs or symptoms have started?

Dr. Rebekah Tompkins:

It can, and sometimes it even just stops on its own. About 3 in 10 women with preterm labor, it will stop on its own. And for those other 7 out of 10 women, there often are things that we can do to help. A lot of it depends on how far along they are in the pregnancy and a lot of what is actually happening at that exact time.

So there are some medications that we can give. Some IV fluid hydrations can sometimes help, but there are some things that we can do to help out preterm labor to make it stop in a majority of the cases.

Courtney Collen:

Moving on to regular contractions versus Braxton Hicks. What is the difference, Dr. Tompkins, and how do we know?

Dr. Rebekah Tompkins:

Something I tell a lot of my patients when they’re asking about it is, I have women that worry that they aren’t having Braxton Hicks contractions, and then I have women that worry that they’re having too many Braxton Hicks contractions. And what if they turn into regular contractions and how do I know?

So with Braxton Hicks contractions, they’re usually irregular and they don’t really have a specific pattern. You might get, you know, one and then your belly gets really tight and then there’s another one five minutes later, but then it’s 15 minutes until the next one. And so, they don’t have a pattern. They don’t get closer over time. And then the big thing is they’re not changing the cervix, which is obviously hard to know unless you come in to get examined.

If you are having Braxton Hicks contractions, a lot of times if someone drinks water, lays down, empties their bladder, that can really help to make them stop. If someone’s having regular contractions, doing those things isn’t going to make them stop. If someone’s actually in labor, none of those things will make the contractions go away as opposed to other things with contractions.

If they’re real contractions, they’re usually increasing over time, getting closer together. And that’s why you may have heard during your pregnancy, or a lot of women that have been pregnant have heard the 5-1-1 rule where contractions are happening every five minutes, they’re lasting for a minute and that pattern is going on for an hour or more. That’s definitely a time that we want somebody to come in and get checked out. It doesn’t mean that they are for certain in labor, but it certainly is one of the things that we worry about.

Courtney Collen:

If a woman is experiencing any of these things, specifically symptoms of preterm labor like we talked about earlier, what should she do?

Dr. Rebekah Tompkins:

Well, if they have concerns, I always tell someone that they should come in and get checked out.

And so that’s the really truly the only way we can really know what’s going on is to have someone come up and get the baby on the monitor, make sure the baby’s doing well, look for a contraction pattern and see what that’s doing, and also check the cervix often and we can sometimes check the cervix and then an hour or two later check the cervix again and see if there’s been any change that’s happened.

And then obviously we also have the medications that are there that can sometimes help stop the labor as well, if that is deemed to be necessary.

Courtney Collen:

Do you find that there are any lifestyle factors or health factors that might lead to a preterm labor more so in some women than others?

Dr. Rebekah Tompkins:

There are. If someone has had a procedure done to their cervix so that it is shortened or weakened, that can increase the risk for preterm labor. Certain chronic conditions also can increase the risk for labor diabetes, high blood pressure, some autoimmune diseases can also increase that risk. And then there can be infections that are present that can increase the risk for preterm labor. So there certainly are things that can lead to preterm labor that when we do the new OB visit that we’re discussing and throughout the pregnancy we’re checking for to see if anything develops.

Courtney Collen:

And are there any risks associated with preterm labor?

Dr. Rebekah Tompkins:

If someone has had a previous preterm birth, that would certainly increase their risk for having that happen again. It’s certainly not guaranteed, but it can increase that risk if they have a very shortened cervix for whatever reason.

It’s one of the things that we’re looking for when we do the ultrasound at around 20 weeks. When we do – we call it the anatomy scan – we’re also looking at that cervical length and if there’s any concern that can certainly be followed up or looked into more. If the cervix is starting to dilate or looks abnormal even on that first visit, that’s why we usually are looking and checking the cervix at that point.

And then if they’ve had injury during a previous delivery to the cervix, that could increase that risk as well. And bleeding during pregnancy can increase the risk, having more than one baby in there, the more room that they’re taking up, the more chance and pressure that there is that that could cause issues in the future with preterm labor. Smoking, as well. There’s many, many reasons not to smoke. But that’s one of them. And then also being younger than 17 or older than 35.

Courtney Collen:

Are there any risks to baby as a result of preterm labor?

Dr. Rebekah Tompkins:

If they are just in preterm labor, but don’t deliver the actual just contracting of the uterus doesn’t necessarily that doesn’t increase the risk to the baby at all.

But preterm delivery, if the baby were to, if the woman were to go into actual labor and deliver the baby early? Yes, absolutely. I actually had a preterm baby myself. And so, knowing the medical side of things with that, but also knowing the other side of things with that there are definite risks that come along and it depends a lot on how early the baby is born and how developed the baby is and what medications they were able to get beforehand.

We do have some things that can help baby with lung development and some things to help with helping the brain a little bit. So there definitely are things that can be done to help those preterm babies thrive a little bit more right after delivery. And that’s why we encourage women to come in if they have concerns of preterm labor.

Courtney Collen:

Are there things a woman can do during pregnancy whether she is more at risk for preterm labor to prevent those symptoms and maybe reduce the risk of preterm labor?

Dr. Rebekah Tompkins:

Oh, that’s such a great question. There are, especially if someone has had preterm labor before, sometimes there are medications that we would give with progesterone that can help to decrease that risk a bit.

There used to be, if someone had had preterm delivery in the past, there used to be a shot that we would give people, but that actually had, the research has shown that that is not helpful any longer. And so that is not something that we do any longer, but there are things that we can do to help support the cervix and if we find it to be decreased in length, we can do things to try to help keep it at that length and not get shorter.

In general, at home, stop smoking. There are no positive effects to smoking at all, but especially during pregnancy that can increase to preterm labor risk.  Drinking lots of water, keeping well hydrated, eating a healthy diet is really, really important, and getting rest. So those are all things that can help to decrease that risk a bit.

Courtney Collen:

Placenta previa is a medical risk factor for preterm labor. Can you explain what that is and why it would be a concern?

Dr. Rebekah Tompkins:

So placenta previa is when the placenta grows over the cervix. And so that can be a very dangerous situation. Thankfully it doesn’t happen very often. It can happen more often at the beginning of pregnancy, but the uterus often as it’s growing, just kind of takes that right out of the way and it becomes a non-issue.

But for those few women that it does stay over the cervix, then we can’t have them go into labor because we don’t want the cervix to dilate be because of the bleeding concern for baby and for mom. And so it, we actually deliver those women early because we don’t want them to go into labor.

And so we usually deliver them around that 36- to 37-week mark. Having that over the cervix can irritate that a bit, and so it does increase that risk some for preterm labor, but it isn’t something that we can really, we can’t move the placenta unfortunately and it doesn’t happen very often. So it isn’t one of those things that come to mind as much for a risk factor for preterm labor, but it certainly is.

Courtney Collen:

Thank you. What do you say to women to ease their anxieties and ease any fears that they have, especially when this is all new to them?

Dr. Rebekah Tompkins:

Yeah, absolutely. It’s something that we see and talk about almost daily because we have so many new moms that are out there and it is such a scary and exciting time. It is stepping into the unknown and it’s probably the biggest or one of the biggest things that they’ll ever do in their life and a big change.

So what I typically tell women is that if you’re taking care of yourself, it means you’re taking care of baby. Doing all those things that we’d already talked about, there is a low likelihood that anything bad is going to happen and that Sanford Health does have just such wonderful obstetrical care. We’re very, very fortunate. If there is something that is happening, we can often pick up on it quickly because we have such an advanced unit up at the hospital.

We have our maternal-fetal medicine, our high-risk pregnancy experts, and they are able to come in and consult and help out with the pregnancy if needed. And if that little one just decides that they want their birthday to be early and they’re going to come no matter what, which does sometimes happen, our NICU is just amazing.

I’m from North Dakota originally. I did residency in Phoenix. Both of my kids needed to be in the NICU. And so when I was coming back to the Midwest, I wanted to pick some place with an excellent NICU as well, just because sometimes no matter what we do, those little ones need some extra help. And so the NICU at Sanford are also spectacular.

And so I really feel like a woman can feel comfortable that most likely what they’re doing is great, and if they’re taking care of themselves, they’re going to do just fine for the pregnancy. If they don’t, we’re always there to help them out and we’ve got just a wonderful amount of resources to help with the pregnancy and with the baby if the little one decides to come a little bit early.

Courtney Collen:

Well, we are so grateful for your insights and your expertise, Dr. Tompkins. Is there anything else on this topic of preterm labor that you wanted to add to this conversation today?

Dr. Rebekah Tompkins:

Boy, I don’t think so. Your questions were wonderful. I just hope that women feel comfortable going into the pregnancy and if they have any questions at all about preterm labor or concerns with it because, boy, even as an OB/GYN myself, my first pregnancy, when I started feeling those Braxton Hicks contractions, I was like, “oh, what is this?” and really had to think about it and kind of sit down and time them out a bit and figure out what was going on. And then once you get used to it, it was more like, “oh, OK, this is a Braxton Hicks contraction.”

I always tell women to never feel embarrassed or that, oh, this is going to be a silly question. There are none. And when you’re going into such a new – even if it’s your sixth pregnancy, you know – never hesitate to reach out and ask. That’s why we’re there.

Courtney Collen:

Yeah, certainly. I know a lot of people take a, “well, let’s just see what happens” approach, but there’s certain things you just don’t want to mess with. Exactly. Preterm labor is one of them.

Dr. Rebekah Tompkins:

Exactly that. And Dr. Google isn’t always the best source. But certainly, if you are really concerned and worried and considering whether you should go into the hospital and be checked out, you probably should be calling. We have 24-hour access throughout Sanford land. And so probably go to an expert, not Dr. Google.

Courtney Collen:

That’s why we’re so grateful for all your information and all that you do to care for patients in and around the Sanford community. Dr. Tompkins, thank you.

Dr. Rebekah Tompkins:

Thanks for this platform to be able to get that information out to people.

Courtney Collen:

Thank you so much for your time.

Dr. Rebekah Tompkins:

Absolutely.

Courtney Collen:

I sure hope you learned as much as I did from our conversation today. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.

Get more episodes in this series

‘While the kids are with you, they’re safe’

Taunya:

Elena I knew had been born, but I really wanted her birth mom to have some time before she was taken, before we picked her up. So I didn’t go to the hospital right away. I just let her mom have that space. And when she was about three days old, my mom and I went to the hospital to meet her and we found out then that the birth mom had not been up since she was born and she’d been alone. However, the nursing staff in the NICU, because Elena was in the NICU for five days, the nursing staff said they made sure someone was holding her all the time. So they took turns. They took turns taking care of her, holding her, rocking her, loving her.

Cassie Alvine (announcer):

This is “Family Portraits,” a podcast series by Sanford Health. And now, Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

We don’t often hear clocks that tick anymore. Come to think of it really only happens these days if you’re strolling down the aisle of an antique store or maybe watching an old movie with popcorn of course, or listening to an amazing podcast. Seriously, why is time so special? It’s because it’s the same for you and for me. I get the same amount that you do, 24 hours today for a total of 8,760 hours this year.

Now what I do with it, that’s where it can go so many ways. Now today’s episode is about kids. And while getting things ready for this show, I thought about my two kids and when they were younger and how time just seemed to rush by so fast.

Today you get to meet Taunya and learn about her and her husband Todd, and using the same amount of time we all get, hear about how they followed their heart and their calling. (Editor’s note: We are only referring to them and their family members by first name for their privacy.) Today, you get to hear a special story about what it means to be in the corner for someone and to fight for them when they can’t do it on their own. For this story, let’s revisit that time thing again and let’s go back in time. Now I hope you brought some rice to throw because we’re going to a wedding.

(romantic music with man singing)

“Wrapped up in the moonlight. We’re dancing with the stars in the sky and the stars in your eyes. I got a feeling this is a moment.”

Taunya:

Todd and I had childhood best friends that married each other. So we met as I was the maid of honor and he was the best man in 1998. At the time he was married, and I was moving to Texas and in school. It was just a nice guy that I met in this wonderful little event of their marriage.

So three years later, his marriage ended and he asked if I was around and if they would set us up, and they did. And less than seven months after that, we were married.

Alan Helgeson:

When Todd and Taunya got married, they had a family day one.

Taunya:

Todd had primary custody of his 12-year-old daughter at the time. So she has always been with us. So I became a mom immediately. She was sad about her mom leaving and she needed somebody to fill the void. So it was me and we were close right away.

Alan Helgeson:

Life moves quickly and it wasn’t long before their family of three grew.

Taunya:

After we got married, less than one year after we met, we were married with a baby. So Parker came along pretty quickly.

Alan Helgeson:

Two, now four. And then one more makes a full house. For the record, any similarities here and with that TV show are purely coincidental.

Taunya:

Parker is now 22 and Nicholas is almost 20. So that is how they came about. Ashley moved out once she graduated from high school and then it was time for us to start fostering. We decided to foster.

Alan Helgeson:

Becoming foster parents and with young kids still at home.

Taunya:

Oh no, the boys were little. Parker was probably 6 and Nick was 4.

Alan Helgeson:

It’s not a decision that you make quickly, but one that you might know that is meant to be. As was the case for Taunya.

Taunya:

I had always felt a calling to foster. I have always felt like we needed to do something more. It took Todd a little bit longer to feel my calling, but he finally agreed to at least take the classes and see what he thought. So we did. And then he was hooked.

We never wanted to adopt. That was never our goal. We just wanted our children to know in life we take care of others. So we wanted our boys to know that. And we kept the birth order intact. So the boys were always a little older than the children that we brought in. And we usually had babies, and we had 20 different kids within that four years we fostered.

Alan Helgeson:

According to the organization, the American Society for the Positive Care of Children, right now over 430,000 children are in foster care. A child can spend on average between 12 and 20 months in foster care, and children in foster care can wait three to four years to be adopted. With Taunya and Todd, they fostered their children over a few years.

Taunya:

Just four years. There were some that were with us just a week. A lot of them were with us just a week, but we had quite a few that were with us almost a year.

Alan Helgeson:

Quite a whirlwind around the house with kids, school, activities. And then you add on both parents managing to work outside the home, too.

Taunya:

(Laugh). Yes, so (laugh), in fact, when we got our youngest daughter, she came to us at 5 days old. I was back to work the next day with a newborn.

Alan Helgeson:

Now I don’t know about you, but maybe I need to take a break and go get one of those fancy coffees or something because I’m tired just thinking about how Taunya and Todd managed everything. Whew.

Taunya:

You have to be very organized, but I always say once you get to three kids, it’s all easy after that because you have to be organized with three kids. So if you add a couple more, it doesn’t really matter because you’re already organized, so.

Alan Helgeson:

Over a handful of years, Todd and Taunya welcome many children to their home to care for them, contributing pages and chapters to each story of their new beginnings. You know, it’s funny, life can just be moving along comfortably. We’re doing our thing. And then as it happens, oftentimes there’s a phone call.

Taunya:

We received Desi at 5 months old. I received a phone call that there was a baby at the Sanford ER that had been shaken and dropped and used as a human shield.

She was having some testing done to make sure brain function was all good. At that time, we still had another little foster boy at home who needed a lot of attention, but we knew he would be leaving soon. So I went to the hospital, I went to Sanford to the ER, and I picked up Desi and she was healthy and pretty blank-expressioned. But after having her home for a month, she started just perking right up and was smiling for the first time and all of that. That’s when we picked up Destiny.

Alan Helgeson:

Destiny, or Desi. A beautiful little girl needed the care and love of Taunya and Todd’s home. Desi was 5 months old when she came into foster care with them. For the next year, Desi grew in a home around a family with love, but something had changed for Taunya and Todd. They wanted to adopt Desi. What happened, and why now?

Taunya:

Well, Elena was born.

Alan Helgeson:

Elena is Desi’s sister.

Taunya:

So Desi was 5 months old when she came to us. And then her sister was born about a year later. And so that’s when we picked her up, at 5 days old. The girls are 16 months apart in age.

Alan Helgeson:

Elena – or Ley – joined the family. At this point, it’s been about a year since Desi came into foster care and the family was cruising right along with their version of normal, right? Remember when I mentioned how life can get comfortable and then we get that call? Also, sometimes you just need to take a moment and smile knowing there are people that are doing good things when we can’t always be there to do it. Carry that with you today and tomorrow as you hear Taunya and how she meets Elena.

Taunya:

Elena I knew had been born, but I really wanted her birth mom to have some time before she was taken, before we picked her up. So I didn’t go to the hospital right away. I just let her mom have that space. And when she was about 3 days old, my mom and I went to the hospital to meet her and we found out then that the birth mom had not been up since she was born and she’d been alone. However, the nursing staff in the NICU, because Elena was in the NICU for five days, the nursing staff said they made sure someone was holding her all the time. So they took turns. They took turns taking care of her, holding her, rocking her, loving her.

Alan Helgeson:

Baby Elena, Destiny’s little sister, joins the family, a beautiful little girl. But as her life was beginning, there were medical challenges.

Taunya:

She spent five days in the NICU. They were concerned about her heart. They thought they heard a murmur, so they were watching her closely. They knew that her birth father had a chromosome deletion, a very rare one, and that she more than likely had that. She was tested immediately as soon as she was born. She had enlarged ventricles in her brain during ultrasounds. So they were really just keeping her and making sure that all was well before we took her home.

At this point, we still did not think that adoption was even on the table. The girls are both half Native. And so we knew that that would be a long, complicated process where we probably wouldn’t get them in the end anyway. So it wasn’t even an option for us until about a year later when we were asked, “So you want to adopt the girls, right?”

Alan Helgeson:

Starting the adoption process. It takes time and lots of patience.

Taunya:

By the time the adoption happened, Destiny was 4 and a half and Elena was not quite 3.

Alan Helgeson:

Over these days, months and years, the girls were growing. But for Elena, medical challenges grew, too.

Taunya:

Well, while in foster care we have to keep the doctors that the parents had started with, which was fine. We had a pediatrician through Sanford who was amazing, and when Ley was only 18 months old, she was still not making baby noises. She wasn’t crawling, she wasn’t attempting to crawl, she wasn’t eating food, she wasn’t interested in food, she only wanted milk.

And I knew as a mom, I had quite a few children, (laugh), these were not normal and that milestones were not being met. And so she then underwent testing through Birth to Three where they thought, no, everything’s fine. She doesn’t need any extra services.

So we went to her pediatrician appointment and he was amazing, Dr. Duck. And he said, what did they say? When I told him the story that she didn’t need speech therapy or physical therapy or anything. And he excused himself and stayed in the room, picked up the phone and started making phone calls. And he said to me, you’ll be receiving a phone call today. And then she was retested and she received all the services because he took the time to pick up the phone and make a call.

Alan Helgeson:

Here we go again. Another phone call. This one would change things so much for Ley, a world of services began to open up and this little girl began to bloom.

Taunya:

She started speaking. She started crawling. She had a special education teacher that came to the house. She had occupational therapy, she had all the therapies, and she started making noises, baby noises, and moving. It was amazing. It didn’t take long.

Alan Helgeson:

When you have a child that has special needs, it’s hard to truly understand some of what the child goes through and also what parents and caregivers need to do to support and help that child. What can we do? We can learn by listening to their stories. In this case of what it might be like for a young child with a brain disorder.

Taunya:

So Elena has sensory processing disorder, and she was a runner when she was little. So we couldn’t go to a park without her running away, or we’d have to put a backpack on her with a little bit of weight in it to help her feel grounded. I started learning tricks through occupational therapy on what to do to help her. But we couldn’t go to a park. We couldn’t go on a vacation as a family. We tried and found out quickly that that was not, it was not going to work for her. She needed stability, she’s needed structure, she needed normalcy in her life.

So not being able to take Destiny then to a park or the boys to a park, because I couldn’t take, Elena was hard unless I put her in a swing. And then once she was in a swing, that little girl was fine. She loved the swing movement, the movement of the swing. It was something that she needed for her senses.

Alan Helgeson:

As Elena grew, having the right people to help with her growth made all the difference.

Taunya:

She was in early childhood with the school district, and she had an amazing special ed teacher who gave me literature on things. I didn’t know anything about sensory processing disorder. And she gave me information and told me what I could do to help regulate her. And that was when things started making sense. And when I started digging into, we just didn’t know what her syndrome was going to be because her chromosome deletion is very rare. She has a microdeletion on her sixth chromosome. It doesn’t even have a name. Her birth father has the same deletion. So we knew there would be things with Elena that would pop up and we just learned as we went.

Alan Helgeson:

Elena, having a rare genetic condition, Todd and Taunya learned that she may have bursts of aggression that could pop up anytime.

Taunya:

Well, she only made it through two months of kindergarten before she needed to be moved to Horace Mann to the Bridges program. It’s through Boys Town. It helps kids that have behavior issues and learning how to deal with those in the public, that kind of thing. So she went to Horace Mann in kindergarten and she was there through fifth grade.

Alan Helgeson:

There were also behavioral struggles.

Taunya:

In kindergarten, she would go into the bathroom and tear apart everything. All the toilet paper, all the paper towels would be all over the floor. So even just going to the bathroom, she would lose it, let’s say. And things would go flying.

She would run. You couldn’t get her to stay with you. She needed somebody next to her all the time just to watch her because she was a fast little thing too. So that was part of her behavior.

(upbeat music with male singer)

“That the sun would push through the rain and you’ll feel like yourself again one day, so go ahead, feel what you need to feel ‘cause it’s OK.”

Alan Helgeson:

Elena is 12 now. Several months ago, a new diagnosis.

Taunya:

Elena had been going to a psychiatrist since she was little. She’s been on medication since she was 4. And we would go into the psychiatrist every like every six months. He would hang out with us for five minutes, help us with med changes, was great with helping us whenever we thought we needed something to change. And he left. So we needed a new doctor.

It’s very hard to get it into a child psychiatrist. Someone told us about Sanford Behavioral Development, the team there, and we were able to get in and meet with Erin Schroeder. And she sat down with us the first day for an hour and a half and she asked Ley questions and she asked us questions and she just observed Elena in the room. And after about an hour, she looked at Todd and I and said, have you ever thought autism?

And Todd and I had always both known there was something else going on for Elena. We just didn’t know what it was. And because of her genetic deletion, the microdeletion on her sixth chromosome, there are a lot of unknowns, and all the children present differently. So we knew there was something, but we didn’t know what.

So when Erin asked us, I immediately said, no. Todd immediately said yes. And I looked at him and said, “what?” And he said, “We know there’s something.” And as I looked over, Elena was rocking herself in the corner and that’s when I went, oh my gosh, I’ve missed it. And so Elena was just diagnosed at 12 years old – right before she turned 12 – with autism.

Alan Helgeson:

A new diagnosis for this little girl that has already been through so much.

Taunya:

Doesn’t change our family. Everything is still the same. However, I think it gives people an understanding of, oh, that’s why she does what she does. You know, maybe at the school or if Destiny’s friends see her and don’t understand why she acts differently. Well now it has a name.

(soothing music with male singer)

“There’s always room for you here in these arms of mine.”

Taunya:

That chromosome deletion 6q27 doesn’t really tell anyone anything, but autism does.

Alan Helgeson:

So as Taunya says, it doesn’t change anything. It does help to know. So she gets the right care for the things she’s been diagnosed with.

Taunya (to child):

Do you wanna get out the skillet? What’s a skillet? The skillet. Open up the cupboard. OK, the back. This bottom one. Ready? I’m going to lift this one up.

Taunya:

Elena has a chromosome deletion of 6q27, a microdeletion. She was then diagnosed with ADHD, borderline OCD and then autism.

Alan Helgeson:

Getting to the right place doesn’t mean much if you don’t also have the right people you believe in, the people you trust your family with. Taunya and Todd found that for Elena at Sanford Children’s.

Taunya:

Well Erin, now Erin Schroeder, has been great about making sure that we have connections to whatever we need. So after that diagnosis of autism, Elena started occupational therapy at LifeScape. She did that when she was younger and we felt that it had helped a lot and that some of those issues we were really trying to work on, she had figured out, like things had calmed down a bit.

Well now, years later with a diagnosis of autism, now we’re back doing occupational therapy. And it just, it’s helped her learn how to self-regulate. She’s learned some things about her reflexes, kind of tuning back some of those reflexes that we all naturally have overcome as we’ve gotten older. She hasn’t, she’s stuck in. And so those things they’re working on now with occupational therapy. She receives special services at school. She has a special education teacher at school.

Alan Helgeson:

These days, Elena is a busy girl in school.

Taunya:

Elena’s last year was her first year being just mainstream back in her home school. So she’s in a regular middle school. It was a challenge last year, but she figured it out by the end of the year. If things were going well, let’s knock on wood for this year too. But she does have a special education teacher. She’s on an IEP. She has some gen ed classes, but not a lot. A lot of support classes. She’s behind cognitively in reading though she loves to read. In reading and in math, everything’s just a little harder for her. Everything takes just a little longer. Her walking took longer. Her talking took longer. Her education, everything is just going to take longer.

Alan Helgeson:

And as with middle school aged children, there has to be a social life too, right?

Taunya:

She does have friends and a few friends that we have play dates with even – or get together with I guess. Almost teenagers. So we better say get together with.

Alan Helgeson:

Elena, as she’s growing up, and there are challenging moments that come. Through everything in the family there’s one person there that is her calm from the storm.

Taunya:

Todd is her person. As much as I am with the kids more because I’m off in the summer, Todd is her person. And he always has been. He is the one that she walks straight towards. He’s the one that can get her to calm down the best. And when Dad’s around, then life is just a little easier for her.

Todd:

I suppose that I am her safe zone, if you will. Her and I, I guess have some type of a connection where she feels safe with me to like show her true colors. You know when you have kids, you never know which kid’s going to have a better bond with Mom or Dad and it just works out how it works out. It’s nice to have that connection so that I know and she knows that she can come to us or me with anything and we’ll work through it and we’ll move on to the next thing.

Alan Helgeson:

We’ve talked so much about Elena. Now let’s go back and check in on Desi.

Taunya:

She was a shaken baby and she was dropped. We really didn’t know what life was going to look like. And she was given an all clear, but you still don’t know as they get older and having, holding trauma from birth or from that young even, we knew at some point it would probably come out. So we’ve been proactive and she’s had counseling on and off since she was 3. And then now that she’s 13, she’s just decided now that I’m OK for right now. If I need it later, I’ll let you know. But Desi is in all accelerated classes. She’s, ooh, a little emotional. I’m a little emotional again.

She dances in town. She has I think seven dance classes a week. She’s a beautiful dancer and dancing’s her thing. So she’s funny. She’s quite witty and right now she likes me. And I know the teenage years get hard, but right now they’re OK. So I’m just going to cling to that because I know in a couple years we have some hard teenage years coming up and they just are.

Alan Helgeson:

Desi is a bright, beaming young lady with a brilliant smile. She gets to use that smile quite a bit with her brothers and sisters around.

Taunya:

Everything makes her laugh. She loves teasing her siblings, her brothers. She’s just quick-witted so you can say something and she’s going to come right back at you very quickly with something witty. So she’s just, she’s a good kid. She’s a sweet kid.

She loves her culture. She’s had so many people helping us along – we all have – helping us along the way to make sure that she is proud to be Native. And she is. And she knows far more now than I ever thought she would because of people that have been put in place for her. She’s very proud to be Native.

Alan Helgeson:

Elena is getting to an age where she is starting to understand her Native American culture too.

Taunya:

She is, I don’t think that right now it’s as important, but everything takes Ley just a little bit longer. She knows about her Native culture and she’s proud of it, but it’s not the same as it is for Desi. And I think Desi just has it on a deeper level right now that Ley doesn’t have yet. But she will.

Alan Helgeson:

While Taunya can look back now on everything that her family had to learn and go through in getting the right care for their children, the challenges can seem mighty. There is power in the fight for your children and your family.

Taunya:

With the boys, I never even thought about advocating for their health because there was an issue, we’d go to the doctor, and things would be solved. I didn’t know what any of that meant until Elena came.

So I just have to always be pushing for more. At least until we met Erin and the behavior development team, they pushed for us. So it’s nice not having to do that anymore. But I always felt like I was, and maybe not just medically, but even educationally, I just always feel like I have to be ready to fight, you know?

When the girls were little and they were still in foster care, there’s a lot that we as foster parents don’t get to know, are not told or somebody just forgets to tell us. So physically their physical well-being wasn’t always in our hands. It was kind of like whoever at DSS would take care of things.

But once they became ours, that having to always ask for more, always fight or always be on the ready to fight maybe has been something that we’ve always had to do with Ley. I had to research her chromosome deletion and there wasn’t any information. And I had to find out what are the things that could possibly pop up with this deletion and how do we address those? And to make sure that everyone had the same information I did or that I had their information. Just always having to be ready to fight is exhausting.

Alan Helgeson:

If you ask her, Taunya is pretty direct with how to change that.

Taunya:

You find the right people, you find the right doctors, the right place, and doctors that will fight for you. And we have that now. So yeah. (Pause) I’m a crier.

Alan Helgeson:

Taunya and Todd had a calling. They opened their home and their hearts to children, first as foster parents, then to two of those little girls that they later adopted as their own. Todd was pretty clear on why it’s important.

Todd:

It’s not about us. It’s more about the kids. I guess it means that we’re fortunate enough to have a safe place for them. We’re stable enough to be able to provide for them and take care of them. And that’s the reward, just knowing that they’re safe while they’re with you.

Alan Helgeson:

If foster care is something you thought about, there are plenty of emotions to consider and that’s OK.

Todd:

Hesitation and fear is normal. I had both because I just wasn’t sure what it was going to be all about. But as we started the classes, I was more on board and more on board. And by the end of the classes we were definitely ready to foster.

It’s an eye-opener. It definitely makes you more aware of the world around you. Makes you more aware of different situations that people are in, different things they’re going through. And it’s just nice to have the feeling that while the kids are with you, they’re safe. They have nothing to worry about. And hopefully, you know, it does make an impact on their life. Some are too young to realize it at the moment, but you just need to know that while they’re in your care, they were safe. They had nothing to worry about. And hopefully that impacts them in some way.

Alan Helgeson:

Well, we’ve talked about time and how fast it goes, right? We’re already nearing the end of this episode. Now imagine if able to look into the future. What would Taunya want it to hold for Destiny and Elena?

Taunya:

Well, for all my children, because my children are just my children, whether I gave birth to them or not, we don’t say “half” or “step” or “adopted.” We just are. And my hope is that my children are all just happy, that they’re healthy and that they’re happy. And happy means different things to different people. For Elena, she will graduate from high school and from there she will have a job, she will be a productive member of society. She will have a sense of belonging and purpose in her life. And that’s all I care about.

(upbeat music)

And that’s the same for all of my children. I just want them to be happy. They don’t have to be the most successful or make the most money. That doesn’t mean anything to me as long as they’re happy.

Alan Helgeson:

A story about a family welcoming kids who needed to feel loved and over time, two little girls needed them. Foster care, adoption, medical challenges – all are what make Todd and Taunya’s large family special, or I guess I should say normal. After all, what is normal anyway? When looking at where they’ve been and how far things have come for their family, Taunya and Todd are stronger today because of what they’ve been through.

Taunya:

I just think it’s really important that people search until they find the right doctors, the right team – because really it is a team – to search until they find the right people. And you know when you know, like when you know when they’re the right ones, when they’re the ones advocating for your little one, or they’re the ones that will take an hour and a half of their day to make sure that they learn who you are. I mean, those are important pieces. Or people who will hold a baby who isn’t theirs because there isn’t anyone else holding it.

(soothing music with female singer)

“I think I want hold you.”

Taunya:

Those are important people to have in your corner. Whew.

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Cost Plus Drugs founder promotes less expensive medicine

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, Courtney Collen with Sanford Health News talks with Dr. Alex Oshmyansky, founder and CEO of Mark Cuban Cost Plus Drug Company (commonly known as Cost Plus Drugs). Dr. Oshmyansky is a speaker at the 2024 Summit on the Future of Rural Health Care with the topic disrupting health care, prioritizing affordability, trust, and patient-centric solutions.

Courtney Collen (host):

We’re so happy to have you in Sioux Falls. Welcome.

Dr. Alex Oshmyansky (guest):

Thank you for having me.

Courtney Collen:

As the founder and CEO of the Mark Cuban Cost Plus Drug Company, innovation is in your DNA. We know that. Can you tell us what programs or policies you think should be in front and center today and soon to impact affordability, trust, and patient-centric solutions in health care?

Dr. Alex Oshmyansky:

Yeah. You know, with us, it’s all about transparency. It’s probably, certainly not a panacea solution to everything, but it’s certainly a prerequisite before we can get anywhere like before. If you don’t know what the actual cost of the product or services, how can you anticipate being able to negotiate it for it in any way, shape or form?

And I think that goes not just for pharmaceuticals, but health care more broadly. In classic economic theory, if you have an opaque market, the winners are not the buyers. They’re not the sellers. They’re the people that broker information in between. So like when Goldman Sachs sets up a dark pool of equities, the winners are not the people buying or selling equities. The winner is Goldman Sachs.

And you see that happening in health care to an enormous extent. You see struggling health systems in every state. You see generic pharmaceutical companies struggling to keep their lights on, and yet everybody knows health care and pharmaceuticals are unaffordable for everyone.

So really, we’re all about, “Hey, just post the prices for all parties involved in health care.” It’s going to wind up better, not just for the patient, but paradoxically, seemingly paradoxically also for the provider as well.

Courtney Collen:

This past March, you visited the White House, along with your partner Mark Cuban, to speak to a roundtable on the topic of lowering health care costs and bringing transparency to prescription drug intermediaries. Can you tell us, Dr. Oshmyansky, about that experience and what you think is the next crucial step in disrupting health care?

Watch the Sanford Health News vodcast of this episode

Dr. Alex Oshmyansky:

Yeah, just on an anecdotal personal level, I’d never been to the White House before. So that was super neat. Never even did like the school tour or anything, so that was just cool to see. But yeah, absolutely.

Again, we’re very focused at that meeting on PBM reform. And since they control effectively the entirety of the pharmaceutical distribution market, or at least the payment processing market, like the way they’re structured is very convoluted. But this is effectively what happens.

You know, by the time for any given drug, they can at least double or triple the cost. So the easiest way, obviously it’s a complex multifactorial problem, but the sort of low-hanging fruit from our perspective is let’s reform the payment processing piece of it, because surely that’s the least value add component of the health care system, and at the same time seems to have the highest margin. So if we can start there, we can move on to more substantive problems further down the road.

Courtney Collen:

Former FDA commissioner Dr. Scott Gottlieb spoke on the topic of navigating health care’s next chapter, innovation, AI and the future of patient-centered care. I’d love to hear your take on AI and how it’s impacting health care. Where do you stand?

Dr. Alex Oshmyansky:

Oh, sure. So part of my background – I’m a M.D./Ph.D. The Ph.D.’s actually in applied mathematics. And I’m actually a visiting faculty member this semester at University of Southern California studying mathematics of artificial intelligence. I’ve gotten too far down the rabbit hole on this one.

But I think the important part, the people that seem most enthusiastic are technologists who don’t really know much about medicine and people in medicine who don’t know much about technology. I think it’s really having both sides in communication about what the really, what are the low-hanging fruits in terms of what the applications can be, what the technology has to be.

Certainly LLMs (large language models) transformer architectures are, no pun intended, transformative for the industry as a whole. But they have a number of issues associated with them. Hallucinations, you know, inaccurate outputs. Like how do you train the models in order to have really substantive, meaningful impact? And I think we’re reaching a point where the models themselves can almost be commodified, you know, Claude versus Sonnet versus Llama versus Gemini. And the real value is actually in the data for training the models.

And I think the health care systems are beginning to understand the value of the data they have. So it’ll be a really interesting time commercially as all these dynamics sort of interplay.

Courtney Collen:

Yeah. And those California students will have a lot to learn from you.

I would love to hear, what innovation or action do you think it’ll take to move the needle most say in the next few years?

Dr. Alex Oshmyansky:

I think it’s – Mark and I are both on the same page that I think it really does have to be a private sector solution to all these problems. So, we went to Washington, we go periodically to Capitol Hill. But really the mechanisms that are driving these pathologies, these arbitrages in the health care system are so convoluted that any attempt at regulation or legislation sort of nips around the edges.

The PBM reform measures that are currently on Capitol Hill generally revolve around spread pricing, rebate policies. And the big PBMs have already come out in their quarterly earnings calls and said if these reforms are implemented, they don’t anticipate a meaningful commercial impact to their business, meaningful financial impact.

So really, I think the long-term sustainable solution for this is for large employers, including health systems, because generally they tend to be the largest employers in their communities, and particularly rural communities. We should move off of them onto the smaller transparent alternatives because there’s nothing those small PBMs can’t do that the big players can.

If anything, you tend to get better customer service with the small guys because they really want your business. So yeah, I think as the industry, as employers realize, hey, we’re getting really ripped off here and move to more transparent solutions, really the private sector I think is going to be the one driving meaningful reform for the PBMs.

Courtney Collen:

Thank you. While in graduate school, you founded a startup dedicated to reducing the rates of specific diseases in hospitals called Altitude Medical. The company is continuously operating now for over 14 years. What impact, Dr. Oshmyansky, have you seen with this innovative idea?

Dr. Alex Oshmyansky:

That was a real learning exercise. I started a company when I was like 20 or 21 years old. And at the time, getting a startup funded was, in my mind something like becoming an NBA player or something. Or a rockstar, you know, it’s a fantasy that doesn’t really happen and turns out no. If you have a good idea, you can, you can raise money for it and get it off the ground. Went out and actually what wound up happening with that, so we sold it.

The intent was to keep doctors and nurses from forgetting to wash their hands, going between patients. Because I’m a putz and I forget to wash my hands, so I don’t want to accidentally hurt anybody. But actually where it wound up having the most impact, most sales was actually in hospitality and food processing. So we sold them to a lot of fast food restaurants, a lot of hotels that didn’t want to – you know, think cruise ships. They didn’t want to cross contaminate. Prevent the norovirus.

At the time, it was a real education as to the unique dynamics that hospitals have in terms of sales into hospitals. Because oftentimes the providers that want a certain product, their incentives are not aligned with the purchasers, and it was a great learning opportunity for further projects to understand really how the supply chain works for health systems.

Courtney Collen:

Incredible work. And I’ll wrap it up with this. Is there a book you’re reading right now or a book that was influential in your career thus far that you’d like to share with us?

Dr. Alex Oshmyansky:

Oh honestly, I’m just, when I get a little downtime, I just try to read fiction or alternatively like books that are relevant for work. I’m reading a big textbook on how payment processing works at the moment. But yeah, I’m reading also “One Hundred Years of Solitude” at the moment. It’s a lovely book.

Courtney Collen:

Well, we thank you so much for your time and for being here in Sioux Falls at the third Rural Health Summit. And of course, as a guest on our “Reimagining Rural Health” podcast. Thank you so much for your time.

Dr. Alex Oshmyansky:

Thank you so much for having me. Thank you.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and news.sanfordhealth.org.

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STIs can affect your sexual and reproductive health

Dr. Charles Shaffer:

The toughest thing with STIs is a lot of them are completely asymptomatic. And so you might have these symptoms, but if you don’t have those symptoms, that does not mean that you don’t have a sexually transmitted infection that you can potentially give to other people. And so that’s why a lot of this is just going to come back to, hey, you know, if you’re kind of practicing these behaviors, it’s really responsible for you to get tested in a relatively frequent, regular fashion.

Cassie Alvine (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about understanding sexually transmitted infections or STIs. Our guest is Dr. Charles Shaffer with Sanford Health Park Rapids Clinic. Our host is Alan Helgason with Sanford Health News.

Alan Helgeson (host):

Welcome Dr. Shaffer.

Dr. Charles Shaffer (guest):

Absolutely. Thanks for having me.

Alan Helgeson:

So, as a family physician, can you share how you came to this area of medicine?

Dr. Charles Shaffer:

Yeah, good question. I have a long and complicated history. Coming out of medical school, you do these rotations and I really had a great time in trauma surgery and really enjoyed that and really enjoyed obstetrics as well, and kind of looked into both fields and then found family medicine of just this cradle to grave and being able to do procedures and being able to do obstetrics if I wanted to and those sort of things. And so that’s kind of what drew me in and have grown to love it since. So, yeah, true believer in the family medicine, primary care job. Really liking it.

Alan Helgeson:

Okay, so you get to hang out in such a great part of the country as a physician in around the community Park Rapids. Why don’t you tell us a little bit about that area?

Dr. Charles Shaffer:

Yeah, I’m maybe not the greatest ambassador because I’m pretty new to these shores. I’ve worked in the area for a while. We just moved here like Thanksgiving of this last year and had our first just kind of coming out of completing our first summer and yeah, the Park Rapids area, kind of a resort-ish area. We actually get a good number of people from other places in the Sanford family like Sioux Falls that come over to camp and go to resorts and the lake in general, so we got a bunch of lakes over here. And so that part is pretty fantastic. We spend a lot of time outside. We’ve got the Heartland Trail over here that runs for forever. Nice paved trail for bikes and rollerblading and stuff. And so if you are outdoorsy or lake inclined, it’s a really cool place to be.

Enlarge

Alan Helgeson:

Alright, well let’s talk about our topic today, Dr. Schaffer. It’s about STIs – or is it STDs – or the same thing, and what do those letters mean?

Dr. Charles Shaffer:

Yeah, great question and yes, the nice thing <laugh> great when you get an answer and you can just give, do a straight answer, yes, they’re the same. So synonyms, STD is an acronym standing for sexually transmitted disease and STIs, sexually transmitted infections. But yes, synonyms. And so when people are using those terms, they should be able to be used interchangeably.

Alan Helgeson:

Dr. Schaffer, the news and statistics may indicate that post pandemic, some of the STI numbers are rising. So what might be behind that?

Dr. Charles Shaffer:

Your reference to the pandemic is well taken. You know, a lot of the STD/STI testing and screening and even treatment is done by public health departments and things like that. And so when the pandemic came around, obviously those resources got largely diverted to all things pandemic and places shut down. And so that was kind of the only blipper we saw of, oh, maybe, maybe these infections have gone down a bit. And it was basically just because we weren’t counting.

And so <laugh>, we came back online and you know, people had been cooped up for a while and some of some of these things actually had blossomed a bit more. One of the main ones being syphilis. Just kind of seen more of that than we have in a long time. And so that one’s kind of caught the attention of the medical establishment here and something we always kind of try to keep an eye out for. But yeah, they’re fairly common, and numbers like you said are going up. It’s not at a crazy rate, but it’s definitely something that we should be aware of.

Alan Helgeson:

Are there statistics that give an idea of just how many people are affected?

Dr. Charles Shaffer:

Yeah, good question. And most of the stuff that I’ll be citing as far as like numbers and statistics and things come from the CDC and that data is up to date as of like 2022. So this stuff is always kind of changing and those big things that they compile run a couple of years behind.

But the kind of headline of that is about one in five people in the US have a sexually transmitted infection. They’re fairly common and that includes HPV, which is the most common sexually transmitted infection. And I think we’ll get to some of that here in a minute that the number on that is about 26 million new STDs, STIs per year diagnosed. Some that we hear a lot about like 1.6 million cases of chlamydia, 650,000 or so cases of gonorrhea from like those 2018, 2022 numbers. So, pretty common, like maybe more than you’d think.

Alan Helgeson:

Dr. Schaffer, you’ve talked about a few of the types of STIs, but how about sharing some of the others that might not be as common?

Dr. Charles Shaffer:

There’s quite a few. HPV infection is the most common. Gonorrhea and chlamydia kind of behind that. Next to that is like herpes, general herpes virus.

And so those are ones that a lot of us have heard about – gonorrhea, chlamydia, herpes, HPV, maybe, maybe not one that people have heard about quite as much sometimes as far as putting it in that box of sexually transmitted infection. You know sometimes we hear that in context with Pap smears more and we don’t kind of put the two together.

Syphilis, which we mentioned briefly is kind of gaining some more ground and becoming more common than it was. Other ones to be a little more complete include mycoplasma genitalium, and then trichomoniasis. Ones that people are more scared about and should be cognizant of include HIV and hepatitis C technically being sexually transmitted with hepatitis C. So that’s a fairly comprehensive list of the more common ones that we see.

Alan Helgeson:

Are there STIs that are more specific as it might relate to sex and or specific groups of sexually active people?

Dr. Charles Shaffer:

One thing to bear in mind in general is a lot of these things as far as, you know, maybe we’ll get into some of kind of the screening tempos and things like that. The one thing that I would say, kind of common sense, right? But the easiest way to prevent all things sexually transmitted infection is to be abstinent from sexual activity, right? So there’s thing one, but doesn’t fit for a lot of us.

Thing two is really talking with your partner and agreeing that like, you’re only going to have sex with one person and that person agrees that they’re only going to have sex with you. And these are great ways to limit the STIs in general as far as specifically your question on sex and things like that.

Some are more common specifically with relation to HIV and syphilis and those things that they actually kind of run together sometimes much more common in men who have sex with men. And so the new cases of syphilis are seen more often in men, and the predominance of those cases are in men who have sex with men. And so there’s definitely some trends that way. But then, you know, of course if people are contracting it in one form of sexual activity and then also having sex with women, then it can spread to the female population as well.

Alan Helgeson:

So are there specific age groups where those numbers are greater?

Dr. Charles Shaffer:

Yeah, great question. And back to the statistics and things about half of those, you know, we talked about 26 million new infections. About half of those are seen in individuals between 15 and 24. And so the predominance of screening and things, recommendation-wise falls in that timeframe of if you’re sexually active and especially if you’re younger, reasonable to get screened.

Alan Helgeson:

When you were talking about several STIs, what are some of the more common types being treated?

Dr. Charles Shaffer:

Sure. Yeah, so HPV – probably the most common, and we can spend a little time on that one by far and away. And then gonorrhea and chlamydia are kind of behind that with genital herpes sort of being maybe a fourth one to include in pretty common. More than half a million cases a year for all those. And chlamydia being a little above a million and a half cases.

Alan Helgeson:

With all of this information, Dr. Schaffer, awareness of signs and symptoms has got to be pretty important. Can you talk about those?

Dr. Charles Shaffer:

Absolutely. Yeah. I think a lot of it is fairly common sense. You know, if you are someone who is sexually active, and certainly if you’re someone who has more than one partner or the partner that you have is potentially seeing other people, things that you want to watch out for, any kind of changes in anywhere that you are potentially having sex.

So in your genitalia, anal area or a pharyngeal area, if you were having more irritation, bleeding you know, so penile discharge, vaginal discharge, irritation when you pee, you know, is a common one that you hear. So when you urinate, you’re having burning and things like that.

For ladies, one that sometimes gets missed is bleeding between periods. Like if you’ve always been really regular and all of a sudden, you’re having some bleeding kind of between your periods, those are all reasons to get tested.

That said, the toughest thing with STIs is a lot of them are completely asymptomatic. And so you might have these symptoms, but if you don’t have those symptoms, that does not mean that you don’t have a sexually transmitted infection that you can potentially give to other people. And so that’s why a lot of this is just going to come back to, hey, you know, if you’re kind of practicing these behaviors, it’s really responsible for you to get tested in a relatively frequent, regular fashion.

Alan Helgeson:

OK, Dr. Schaffer, what should I do if I think I might have an STI?

Dr. Charles Shaffer:

The big thing is get tested, right? And so there’s a lot of different ways to do that. There are some at-home methods now a lot of times that is going to be taking a sample and then sending it to a laboratory.

Obviously, we’re on this Sanford podcast; hopefully there’s a Sanford Health facility near you where you can get tested for all these, which a lot of times is urine and sometimes blood depending on the STIs that we’re screening for. But oftentimes not these very invasive tests that people might be scared of.

So urine testing and blood testing for a lot of this. And then really good resources as well are your local health departments and Planned Parenthood. There’s a lot of STI testing and treatment and education. So those are always great resources.

Alan Helgeson:

Can STIs go away? And maybe that leads to some fear that, well, I don’t want to go in because I don’t know if it’ll be treatable and it’ll go away.

Dr. Charles Shaffer:

Yeah, absolutely. And they definitely can go away depending on what they are. And so, you know, when we break down these different types, some of them like gonorrhea and chlamydia are from bacterial infections. They can be treated with antibiotics and then go away.

Kind of common-sense stuff, but you can also reacquire them. And so that comes into the thing of when you get tested, talking to your health care providers and to kind of park there for just a second and reel it back in.

One thing that I hope very much for myself here in Park Rapids and for Sanford providers and hopefully health care providers everywhere is the doctor’s office should be a safe space, right? That should be the place that you can come and be honest with your health care provider and tell them all these things and not feel judged or have to be hesitant about that.

And so that’s a very important thing that I always want to get across is this is a safe space for you. And especially when you’re talking about getting a sexual history from a patient, sometimes that’s obviously somewhat embarrassing for people sometimes, or they’re hesitant to tell their provider, yeah, you know, I am, you know, I am a man and I do have sex with men and this is the frequency and this is, you know, the kind of, the kind of sex that I practice.

Those things are difficult conversations sometimes, and this should be the safe place for you to have those conversations. And so I hope that you are getting that in your current health care environment. And if you’re not, I would encourage you to keep looking. I think health care departments, Planned Parenthood and all the Sanford providers that I know are a safe place to have those conversations.

That’s the first thing is being very honest and open with your sexual history and having a provider that can take a good sexual history and then kind of making recommendations based off of that as far as the most common STIs that are possible for you and what to test for. And kind of back to the question, gonorrhea and chlamydia, bacterial infections, they can be treated with antibiotics and cured, but you should be then telling your provider, “Hey, these are my partners.”

If you have a regular partner, you need to get that partner treated as well because otherwise you guys can reinfect each other. And so being honest about who your partners are and being honest with them about getting treated so that you don’t just continue to reinfect each other. And that’s where some of these numbers get kind of high is reinfection rates and infections in smaller communities that get pretty prevalent sometimes.

Alan Helgeson:

So with that then, Dr. Schaffer, are there some that don’t go away?

Dr. Charles Shaffer:

Yeah there are, and that’s why the front end of being responsible with your sexual practices really matters because the kind of fourth most common when we talked there of genital herpes, that is a lifetime infection. It can be treated and reduced, but that is something that is going to be with you for the rest of your life. And some people are quite bothered by outbreaks that they have and things like that that do require treatment with antiviral medications.

HPV infection, human papillomavirus is another one that, hey, once you get it, you have it. There’s a lot of different types of that virus. Some are more serious than others as far as potentially causing cancers in genital areas. But yeah, those, those are two good examples of very, very common ones that don’t go away even with treatment.

Alan Helgeson:

So we talked about can they go away and you went over what you can do and it led to some of those treatments and what they might be. But let’s get into more treatment options for some of those more common STIs.

Dr. Charles Shaffer:

Yeah, and so with gonorrhea and chlamydia specifically, a lot of times when people come in with symptoms and with a history that’s consistent with, yeah, you very well might have an STI. We will test, but we’ll also a lot of times treat empirically and that can oftentimes be done with a single dose of antibiotics. In the case of gonorrhea, in a shot form for chlamydia, it’s a number of days of medication and pill form. Doxycycline is the recommended antibiotic for chlamydia treatment right now. And so fairly common antibiotics and relatively well tolerated, but definitely something that’s worth getting treated if you have it.

Alan Helgeson:

Dr. Schaffer, with any of these STIs, is part of this telling or having to contact sexual partners about things or if they’ve contracted something, sharing that with them?

Dr. Charles Shaffer:

So gonorrhea and chlamydia would be what we call reportable diseases. So we should be contacting, your health care provider should be contacting, look for health departments and reporting. This individual had this infection and the health department then is usually reaching out and asking you about your partners and contacting them. Good question. But those things would be reportable for the sake of trying to limit the spread of some of these diseases if possible.

Alan Helgeson:

So is that a huge barrier to people coming in? Do you think people are afraid or is there some shame? And what do you say to people that are going and saying, Hey, I don’t want to come in?

Dr. Charles Shaffer:

I think it definitely can be. I mean, I think that’s an obvious barrier. You know, people don’t want to come in and talk about their business or potentially put somebody else’s business out there. That’s kind of that lead in of, hey, listen, this ought to be the safe place for you to go.

And part of this is just being responsible – if you don’t treat your partner as well, and if that person’s potentially seeing other people, sometimes this is also pretty emotional, right? You know, if you think that you’re committed to this person and they’re committed to you and from some side you know that your behavior’s been appropriate, but something’s been introduced into your relationship from outside, you know, you might be just angry and not want to talk to that person or have much of anything to do with them.

We see that sometimes, but it is still responsible to like, you know, OK let’s even have the health care providers reach out to this person and get them treated. Some options that way that some people do take advantage of. This is one of the very rare cases in medicine where depending on where you live and some of the laws, you can potentially get treatment for your partner without them having to come see any kind of health care provider. So in the case of chlamydia, it could be like, hey, listen, we’re going to give you a prescription for your partner as well for you to give to them. And so that person isn’t even necessarily identified. So there are options that way.

Alan Helgeson:

Well, this kind of leads me to my next question and I think it’s fairly obvious as we’re talking to you and as a family medicine physician, but how and where do you get care for STIs?

Dr. Charles Shaffer:

Certainly, your primary care provider should be able to provide you that. So family medicine doctors, internal medicine doctors and then the Planned Parenthood like we talked about. They’re a great resource for a lot of that stuff and services as well as your local health care department.

Alan Helgeson:

Dr. Schaffer, are there some STIs that may require more testing or repeated testing? So I guess my question would be how often should you get tested for STIs?

Dr. Charles Shaffer:

One thing with that is back to what we talked about of going to see your provider, being honest with your sexual history and having them talk about what STIs are more prevalent for your current sexual practices and how often you ought to get tested. So that’s kind of the first thing to say, right?

Your testing, your mileage may vary a little bit. Your testing might be a little individualized. You might need to get tested a little more frequently depending on your sexual activities.

But in general, yearly testing, because we talked about that predominance of infections being in that 15 to 24 year timeframe, folks that are sexually active and younger than 25, it’s reasonable to get screened for this stuff every year. So once a year with the caveat of certainly if you’re having any symptoms, that’s a good time to go in and get tested, right?

If you’re having any kind of burning with urination, bleeding between periods and vaginal discharge, penile discharge, OK, we’ll get tested. Otherwise, yearly is reasonable like at just a normal yearly health physical visit, which hopefully people are having. And if not, that’s a great idea, even if it’s just to discuss sexual health.

And then after 25 years old, it’s kind of more with risk factors. So multiple sexual partners, any sexual partner that’s had a sexually transmitted infection and then back to men having sex with men, oftentimes that does include some more sexually transmitted infections that we need to screen for and be cautious about.

Alan Helgeson:

Dr. Schaffer, you mentioned this and touched on it briefly earlier regarding the testing options. Can you go into it a little more in depth on the, in-clinic and at-home options?

Dr. Charles Shaffer:

You know, full disclosure, a little less familiar with some of the at-home stuff. I haven’t used that much personally. Like we don’t send testing stuff home with patients that I’m aware of but I think some of the Planned Parenthood clinics do, and a lot of that came out of COVID. At-home options exist, which may include some of the things we already talked about as far as urine or swabs in your general, anal, throat area. Those sort of things that then you package off and send up to a lab, you know, per their instructions in the clinic.

Gonorrhea and chlamydia most commonly is tested with a urine sample. Some of these other things, including syphilis, herpes can be blood tests, but rarely do we need vaginal swabs or anal swabs. Sometimes that’s appropriate, but that’s something to talk about with your provider in case you’re having symptoms in those areas.

Alan Helgeson:

I know we talked about this earlier on in the podcast too, but it bears repeating. How do you go about preventing STIs?

Dr. Charles Shaffer:

Yeah, no, I’m glad we circled back to that. So this is kind of straight from the CDC website, but I like the way that some of this is worded. And so obviously the number one thing that you can do to prevent sexually transmitted infections is be abstinent from sexual activity. So abstinence, if you’re not having sex with other people, you don’t have to worry as much about these sexually transmitted infections.

And there’s some misinformation there as far as like getting things from a toilet seat or a doorknob and these sort of things that doesn’t have any basis in fact as far as we can see, right? And so abstinence from sexual activity, great, you don’t have to worry about this stuff.

The second thing is really just in general, having fewer partners. So being selective with your partners and then potentially getting into this relationship where you are agreeing to only have sex with this person and they’re agreeing to only have sex with you. So that’s kind of the second thing.

And the next thing is really if you have several partners having conversations with them about any history of sexually transmitted infections and potentially coming to some kind of agreement on testing and getting tested together. So going to one of these clinics, getting tested together, sometimes those results take a couple of days to come back. But if this is somebody you’re going to see on a regular basis, really reasonable thing to do.

And then the last one that is really probably the most important is condoms. And so condom use, using condoms the right way every time. The CDC website, if people go there, they do have a tool there for where you can put in your ZIP code and like potentially get free condoms around your area. Really, really reasonable and responsible thing to do as far as using them correctly, the biggest thing is using them every time.

So like spotty use doesn’t do you a whole lot of good. If you feel a condom break or if you notice that a condom is broken, you need to change it out right away. And then even some of the lubricants you use, so like recommended to use water-based lubricants and things with latex condoms whereas, you know, petroleum jelly, like even Vaseline and stuff is potentially a little more damaging to latex and can make it break easier.

So educating yourself on a couple of those things and being responsible with the condom use is the number one thing you can do to prevent sexually transmitted infections behind all these other things that we talked about.

Alan Helgeson:

Probably something we need to share also. And I think we’ve talked about some of the things as STIs and STDs, but even going unchecked or untreated, what are some additional complications of the STIs if they don’t come in and see a medical professional?

Dr. Charles Shaffer:

Yeah, good, good question. And so one thing that we haven’t touched on at all, and I should have worked in here at some point, is a lot of these sexually transmitted infections and especially the sequela of them, like the bad stuff that can happen with them is worse for pregnant people, people who are pregnant, people that are going to have a baby or while they’re delivering.

So I would make that one carve out, that if you are pregnant and you’re not sure of the possibility of having a sexually transmitted infection, or you’ve had some new partners, you definitely need to get tested with regular prenatal testing. That’s part of it.

But if you haven’t seen a provider, and you haven’t gotten health care, you’ve had more than a couple of babies and you just feel like you don’t need to go see the doctor, that’s a really good reason to go is to at least have that sexually transmitted infection testing and make sure you’re not passing something along to your baby. So that’s a huge one, especially with herpes and syphilis. And some of these can really be harmful to the baby or even result in the death of the baby. So that one’s massive.

The other ones that we see pretty commonly in clinic and things – gonorrhea and chlamydia like we talked about – they may or may not have any symptoms. So if you have this infection and you’re not having any symptoms and you are not having that yearly visit or getting screened at all, you might not even know that you have it.

And for young ladies, one of the things that can happen is what’s called pelvic inflammatory disease, and they get inflammation from that bacterial infection in their uterus, fallopian tubes, ovaries, and they can have pelvic pain that lasts for quite some time. They can have damage to their fallopian tubes that makes them infertile or causes more ectopic pregnancies. So like really, really bad health outcomes from this thing that maybe you didn’t even know that you had. And so the greatest thing is trying to not get a sexually transmitted infection in the first place, followed by, boy, if you have one, you probably ought to get it treated.

Alan Helgeson:

Earlier when we were talking about statistics on the variety of different sexually transmitted infections, you talked about HPV being at the top of the list as the biggest one out there. We should devote some time to talking about that. So what are the benefits of the HPV vaccine?

Dr. Charles Shaffer:

Yeah so benefits of the HPV vaccine. The current HPV vaccine offered in the United States is a vaccine called the Gardasil nine, and it does a very good job of preventing a number of HPV subtypes. So HPV stands for human papillomavirus. There’s a bunch of different types of that virus. And the ones that this particular vaccine prevents are 6, 11, 16, 18, 31, 33, 45, 52, and 58. So if you need some lottery numbers to play, there you go. 16 and 18 are the big ones implicated in cancer. And so those are very, very important for us to guard against. And this HPV vaccine prevents up to 90% of cancers from HPV, which is just massive and starting to kind of be born out in the numbers.

And so, as you know, we started with HPV vaccines in the United States in 2006, and so as we’re seeing some of these kids grow up, the numbers of a HPV infections from these cancerous subtypes are down, you know, sometimes 80, 90%, which is great if the numbers are lower, but what you really care about is the cancers. And so the cancers are down over 40% in vaccinated individuals, which is kind of massive. And so it’s this really great thing that’s come along and a very important thing for us as health care providers to kind of be on top of.

Alan Helgeson:

Is this the vaccine, Dr. Schaffer, that is the regimen of three shots over a period of time?

Dr. Charles Shaffer:

It can be. So it’s a little confusing, the dosing regimen for some folks. So if you start between, it’s recommended to start at 11 and 12, you can start as young as nine years of age with offering this vaccine. If you start between 11 and 15, you only need two doses. And if those doses are between six and 12 months apart, if they’re closer than that, you need a third dose. If you’re above 15 or so when you start, you need a third dose. If you are an immunocompromised individual, we recommend a third dose, but yeah, two to three doses depending on when you start.

Alan Helgeson:

Dr. Schaffer, you’ve talked a lot about STDs, STIs, and we’ve learned they’re one and the same. And STI is really what the CDC is saying we call it. A lot of information here. But as we get ready to wind down this episode, any last things as far as takeaways?

Dr. Charles Shaffer:

Yeah, I think, you know, if there’s one thing to take away from it, it is for me again that your medical home should be a safe place for you. I’m going to try to not get emotional. There are issues, you know, around sex and things right now that are so polarizing and political and difficult. I see medicine as this, like this beacon in this lighthouse and this safe place that you can go no matter who you are or who you love or what your sexual practices are. And if you don’t have that in your current medical facility, you should go find it somewhere else. But I hope that you know, Sanford’s a good place for folks to find that.

Cassie Alvine:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen on Apple, Spotify and news.sanfordhealth.org.

Get more episodes in this series

AMA president on improving patient, provider experience

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, host Courtney Collen with Sanford Health News talks with Dr. Bruce Scott, president of the American Medical Association. Dr. Scott is a speaker at the 2024 Summit of the Future of Rural Health Care.

Courtney Collen (host):

I have Dr. Bruce Scott, the president of the American Medical Association, joining us here in Sioux Falls for the third annual Summit on the Future of Rural Health Care and the “Reimagining Rural Health” podcast. Dr. Scott, welcome. Thanks for your time.

Dr. Bruce Scott (guest):

Well, thank you. It’s great to be here with you.

Courtney Collen:

You joined us for a panel talking about policy, politics and advocacy in a dynamic health care environment. I’d love to hear about the AMA’s legislative efforts to improve quality of patient care during this time of rapid disruption.

Dr. Bruce Scott:

Well, you’ve heard all morning the key of access to patient care is the foundation. And unfortunately, there’s a shortage looming of health care physicians in the United States — estimated as high as 86,000 physician shortage in the next 10 years.

But for rural health care, that’s already upon us. And a major reason for that is the broken Medicare payment system.

Right now, believe it or not, in 2024, physicians are paid 29% less when adjusted for inflation by Medicare than they were paid in 2001. And for the last four years, and potentially pending this next year, physicians have actually received a cut in what we’re paid, despite the fact that physicians’ expenses, just like all the other expenses at the grocery store or the gas station, have increased. And at the end of the day, it’s not sustainable.

So, physicians are making difficult choices and in some cases they’re limiting the number of Medicare patients that they’ll see. They have stopped taking new Medicare patients, or in some cases have dropped Medicare altogether, but perhaps most concerning – one in five physicians in a recent poll say they hope to quit medicine, retire, or pursue other interests in the next two years. We can’t afford to lose even one more physician.

Courtney Collen:

What is your most surprising or hottest take from today’s Summit?

Dr. Bruce Scott:

What is so impressive to me is the commitment, the passion of the leaders who are here to try to fix this access problem that exists for rural health care already in the United States, and the innovative ideas that Sanford Health has to try to improve access.

And then finally, the physician heroes that we heard about this morning. Those individuals who are figuring out ways to provide needed care to their patients. And, you know, all across America, there are physician heroes like this that are taking care of patients, and that’s what’s really special about our profession.

Courtney Collen:

And we’re so grateful for all of our caregivers across the country. What innovation or action, Dr. Scott, do you think will move the needle the most in the next one to two years?

Dr. Bruce Scott:

Well, the innovation or action we need right now from Congress is to fix this broken Medicare payment system. And there’s a bill pending, HR-2474, strengthening Medicare for patients and physicians. This is not some radical idea. It simply would link physician payment to the inflation rate, the same inflation rate adjustment that other components of Medicare financing already get. And this would simply put physicians on level ground and potentially adjust for the fact that it’s costing us more money every year to take care of patients.

Courtney Collen:

What do you think is the biggest misperception about rural America?

Dr. Bruce Scott:

You know, we’re in a political season, and I hear the phrase “flyover country.” I practice in Kentucky, a somewhat rural state. And it drives me crazy when you think about the fact that there are 45 million Americans, 20% of our population, live in rural areas. If you put it all together, that’s more Americans than live in the 25 largest cities in the United States. Can you imagine if the politicians, the legislators ignored the 25 biggest cities in the United States and what the population there needed? And yet, rural Americans live sicker and die younger because of things that are correctable, like access to care.

Courtney Collen:

Dr. Scott, how do we strengthen trust in health care during a time of rapid disruption?

Dr. Bruce Scott:

One of the ill effects of the COVID-19 pandemic that no one anticipated was this loss of trust in science. I will say that study after study shows that patients still trust their physician. You know, the AMA was formed back in 1847 to combat charlatans and snake oil salesmen.

But the difference is today’s snake oil salesmen use the social media to spread their message so rapidly. It’s interesting. We were able to trace back most all of the anti-vaccine comments to 12 individuals that spread the information across the internet. And the impact we’re seeing that now is parents are questioning whether their child should get a measles vaccine. Something that’s been around since I was a child and has been proven to be safe and reduce the risk of measles. I think that the key to restoring trust is for individual physicians to talk to their individual patients and provide true medical, scientifically proven information.

Courtney Collen:

AI and health care. Is it overhyped? Is it real? Where do you stand?

Dr. Bruce Scott:

Well, AI is absolutely real. I will tell you that we prefer the phrase augmented intelligence rather than artificial intelligence to emphasize the fact that AI, no matter what you call it, will never replace physicians. It is a tool that physicians will use, and it’s an exciting tool that will potentially be able to extend what a physician’s able to do.

High percentages of physicians, more than 70%, in a survey, believe that it will help them in terms of documentation and administrative challenges, that it will help them in terms of diagnostic accuracy. About 90% are excited about the potential, but concerned about the transparency, the lack of transparency of many of the innovations that are out there.

We believe that the most important thing is that whatever happens with AI, that it remains patient-centered, that health care needs to be focused on the patient.

Courtney Collen:

Yeah. Thank you for that. I’d love to know what book you’re reading right now, or what book has had the biggest impact on your career, or maybe what’s in your queue?

Dr. Bruce Scott:

That’s an interesting question to ask a physician. I mean, the books that have had the impact on my career have been medical books, otolaryngology textbooks. And what I’m reading right now is a lot of political information, a lot of information regarding health care and the challenges of health care. The book that’s probably on the top of my hopefully to read is Dan Sullivan’s book on continual life improvement. But I don’t know if I’m going to get time to read that or not, maybe on an airplane. I tend to take the advantage of the opportunity to sleep.

Courtney Collen:

That’s not the worst choice to make. Dr. Scott, what do you love most about what you do? Are you still practicing medicine?

Dr. Bruce Scott:

I’m still a practicing ear, nose and throat physician or otolaryngologist. And that’s what I love most, is the opportunity to be able to interact with the individual patient. That said, as I travel around the nation and I meet physicians and I talk to physicians, I’d love to hear their stories and the stories of the physician heroes and how they’re responding to all those challenges that we’ve spoken about during this interview.

Courtney Collen:

Thank you so much for all that you do with the AMA for patients around the country and here with us and your time. Appreciate you.

Dr. Bruce Scott:

Thank you so much for having us. Thank you.

Alan Helgeson (announcer):

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health Series on Apple, Spotify, and news.sanfordhealth.org.

Get more episodes in this series

Rural doctor and farmer relates to her patients

Dr. Elizabeth Brown (guest):

Well, I think it helps them be able to realize that I come from a similar situation to them that I know kind of what they’re going through, kind of their sacrifices that they make to get here. As well as just kind of them knowing the personal aspect that I’m a person, too, and that they can open up to me and feel that they can get good care from me. I know yesterday I even had a patient that was a ranch lady from Beach who we were able to kind of talk to her about why some of her problems may be related to her lifting hundred-pound feed bags when she’s almost 80 years old.

Cassie Alvine (announcer):

“Reimagining Rural Health,” a podcast series by Sanford Health. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Dickinson, North Dakota. It’s right along I-94 in western North Dakota. When you’re in town, a stop at local eatery Blue 42 might be for you if you want a bacon flight. Or how about knocking down some pins and a little bowling talk like the recent Dick Mueller memorial tournament? Well, you can find that at Paragon Bowl. And it’s pretty cool that dinosaurs still roam the area too – that’s at the Badlands Dinosaur Museum where they’ve got 14 full-scale dinosaurs on display.

Dickinson is a community of almost 25,000, and they’ve got a lot going on. And when they need medical care at Sanford Health, patients have access to care for many areas of health, including family medicine, orthopedics, cancer care, plastic surgery, and women’s services.

Now if it’s women’s services and you’re a patient, there’s a good chance you’ll hear her voice right after that knock on the exam room door.

Dr. Elizabeth Brown:

I am Dr. Elizabeth Brown, and I am a OB/GYN at Sanford Health in Dickinson.

Alan Helgeson:

Dr. Brown is one of only three OB/GYN physicians at Sanford Dickinson. More about that though in a little bit. First, let’s hear a different story and one that begins about a hundred miles west of Dickinson and not far from the Yellowstone River.

Dr. Elizabeth Brown:

I am Elizabeth Brown, and I live on a farm in Glendive, Montana.

Alan Helgeson:

To Elizabeth Brown, her husband Todd, and three kids, home is 650 acres, a working hay farm with roaring John Deere tractors, miniature donkeys and highland cows.

Wait a minute, highland cows?

On the farm, having to know and do lots of things is important. Elizabeth Brown’s husband, Todd, knows it means a lot, not only in the wide-open spaces, but also when she’s with her patients.

Todd Tibbets (guest):

She’s down to earth. I mean, she gets out here, she’ll drive a cement truck, she’ll drive skid steer. I mean we work cows. If you wanted us to put a cow in the chute and she could give it a shot.

Dr. Elizabeth Brown:

I apologize in advance. It’s kind of bumpy.

Alan Helgeson:

Elizabeth Brown’s busy home life means trading in her stethoscope for a pair of pliers and some leather gloves. She climbs into the cab of something that might be a Transformer, but this one is hiding out on a ranch and today it’s picking up bales of hay.

Dr. Elizabeth Brown:

I think I have a lot of work cut out for me this weekend, so. (Reporter: Why is that?) Oh, because my husband actually, he made – not that he “actually” – he made quite a few hay bales off of this field this year and a very good yield.

Alan Helgeson:

OK, before we go any further, remember when you were in school and you would call your teacher mister, Mrs. or Miss, then you grew up and you met them in the store, you still call them Mr. or whatever? Well, for the rest of this podcast, to avoid any confusion, let’s stick with Dr. Elizabeth Brown in the clinic or on the farm. Sound good? Great.

Now where were we? Oh yes. Well, when you live in eastern Montana and your clinic and your patients are in western North Dakota, days can start pretty early.

Dr. Elizabeth Brown:

So usually I leave around 5:30, sometimes 6. It depends on what time I need to be there, so if I’m on call, I need to leave for sure by 5:30 so that I get there by 7. I think it’s about 92 miles, but with the interstate, we’re able to, I usually get there about hour 20 to hour 30 minutes depending on what the construction is.

Alan Helgeson:

It’s not really a big deal for Dr. Brown. She knows that her patients are doing it every day, too, and they’re coming from a good distance to see her.

Enlarge

Dr. Elizabeth Brown:

So it’s really probably like east, like eastern Montana and western North Dakota. So we have some people, you know, from south, you know, have some people from like Hettinger. I think we’ve had some people from Bowman coming up eastern Montana, had some from Baker, some from Glendive where I’m from as well. And then north, like Watford City I would say, you know, the longest would probably be like an hour and a half, maybe two hours that they would have to drive to get to us. And that would just be, probably like if they came from Baker, that’s probably the longer drive.

Alan Helgeson:

With all of the time behind the wheel each week for Dr. Brown, she sees all of the weather extremes in rural North Dakota and Montana, and it’s a topic that is never far away at home.

Dr. Elizabeth Brown:

So yeah, so I actually, I don’t know, I watch the weather quite a lot and if, to be honest, if I feel like there’s going to be a storm coming in or the weather’s going to be really bad or it’s icy or anything like that, I try to either go up the night before.

Alan Helgeson:

Or in the clinic.

Dr. Elizabeth Brown:

My patients and I oftentimes bond about the weather. It seems like ranchers and farmers, their lives revolve around kind of what the weather is and when you say all they do at the coffee shop is kind of talk about the weather and you know what’s going on, but it really determines a lot of what we do.

And so for me, I talked about earlier about how I look at the weather reports and make sure, like with driving and I’m understanding to a lot of the patients when they’re like, you know, 15, 20 minutes late and I’m like, well, yeah, the roads were horrible. So let’s go ahead and just see them. Because I know how far they’ve come from and we want to make sure that they don’t have to come back.

Alan Helgeson:

After her morning drive to Dickinson, it’s game on and a full day with patients.

Dr. Elizabeth Brown:

A typical day actually starts with me usually rounding on patients in the hospital if I’ve done any deliveries or any postoperative patients. And then I come over to the clinic and start seeing patients around 8 a.m. Before 8 a.m. if I get over here to the clinic, I’ll go through the chart, see if there’s any results to review, see if there’s any patient messages, nurse messages, other staff messages from other physicians.

Alan Helgeson:

When providing care in a rural community, it means that medical professionals like Dr. Brown are relied upon for their depth of expertise.

Dr. Elizabeth Brown:

Actually, it’s very rewarding to see a lot of different things. We kind of take care of women from menarche all the way to postmenopausal. So a typical day will include, you know, some OB patients, some new OB’s, some routine OB’s. It may include people with bleeding issues, contraception management. We manage abnormal Pap smears, so sometimes I’ll have a colposcopy or a LEEP procedure. And so that’s kind of the typical day is just a variety of things. And so you never know what you’re going to get on any given day.

Alan Helgeson:

For Dr. Brown with a busy professional life and home life. There have to be similarities in there somewhere, right?

Dr. Elizabeth Brown:

I guess one of them is just that you’re almost, you know, you’re going, going, going (laugh). So you know, at the farm there’s not much downtime. Here in the clinic, there’s not much downtime. You also, preparing for your day, just like at the farm, if we need to grease your equipment, you need to make sure you’re fueled up. Make sure that the windshield is clean or kind of come up with that plan of the day.

The same thing over here in the clinic. Make sure the rooms are stocked for me for appointments. It’s making sure that I know exactly what the nurses are going to be, what they need, what I need in the rooms, kind of prepping my nurse before we go into those appointments.

Alan Helgeson:

Having this perspective and seeing these similarities makes a difference with the people she sees every day. Not only in the clinic exam rooms or in the hospital rooms, but likely on the sidewalk, the grocery store or in the stands at the high school game this week.

Dr. Elizabeth Brown:

I think in the rural communities, the patients know you and your family and so you kind of have that connection outside of the medicine, you know, physician-patient relationship. Also, they may know you outside of the clinic and so you kind of have that special bond with them as well.

In the rural setting, when people come from longer distances, I want to make sure that they feel like they get as much out of that visit as possible, as well as trying to coordinate their care before they leave. So if we can, they need an ultrasound, trying to get that ultrasound before they leave, trying to get the lab work done that day, knowing that they’re not going to be able to come back in two to three days very easily.

Alan Helgeson:

It’s knowing how these miles can impact your patients’ lives in rural communities and how it can make such a difference when driving so many miles each day herself. It puts things in perspective for the patients that travel great distances to see her.

Dr. Elizabeth Brown:

I know yesterday I even had a patient that was a ranch lady from Beach who we were able to kind of talk to her about why some of her problems may be related to her lifting hundred-pound feed bags when she’s almost 80 years old.

Theresa (Sanford clinic):

Thank you for calling Sanford. This is Theresa.

Alan Helgeson:

In the Sanford Dickinson clinic. Dr. Brown is ready for a full day and there is a lot to do.

Dr. Elizabeth Brown:

We do a lot of messaging like the MyChart, kind of doing that in the computer. Not everyone is OK with that. And so usually when patients leave I’ll ask them, you know, are you signed up for the portal? Are you comfortable with getting messages that way or would you prefer to be called? Abnormal results or results that I feel like there needs to be a management based on it, I’ll directly call or I’ll have my nurse call.

So there’s abnormal Pap smear. We need to set up different things. I usually have prepped the patient in their visit and so when my nurse calls, she’s able to just kind of explain the procedure, get the patient forwarded to our scheduler and that they’re kind of aware if they have additional questions, she’ll send me a message and then I can reach out to them as well.

Alan Helgeson:

Sanford Health is the largest rural health care system in the U.S. And technology is key in helping connect expertise to patients in rural areas. Being able to see patients via technology is a plus.

Dr. Elizabeth Brown:

And we definitely offer virtual visits. It seems like a lot of people like that face to face (laugh) if they can, but we do offer that ability. And then also if the patients, you know, if they have one or two questions, we’ll answer those. But if not, and we feel like we need to dedicate more time to them, we can convert on a telephone call over to a virtual visit just so that they have that time that’s dedicated to them.

Sometimes in these rural settings, especially when they know I’m a Montana person, they may also know some of my friends, some of my relatives. You know that they definitely do their research before they come in and if they have any common people that they know, a lot of them will actually know who I am and kind of be aware of me before I come in. And so, and they’ve had other people who’ve either friends or family who have recommended coming to see because they know, with me giving care and they know that I’m a pretty down to earth person.

Alan Helgeson:

When working in a community the size of Dickinson, knowing and seeing your patients is important, but when you’re doing things like spending 90 minutes on the road to get to work or loading a flatbed full of hay, personal life balance is always a good thing.

Dr. Elizabeth Brown:

In Dickinson, we try to deliver all of our own patients that are established patients. That being said, we also realize that we need to have our personal lives as well. So our weekends are Friday, Saturday, Sundays, and oftentimes it’s whoever’s on call will manage those deliveries, but if we’re here in town, we’re going to be doing our own deliveries.

Alan Helgeson:

As we’ve heard from Dr. Brown, it’s easy to get a sense that she’s definitely in the right place and with the people that need her most, but how does someone choose where they practice medicine? Does the community seem to call them? Deciding to be a physician isn’t a choice that comes easily in certain parts of the country. Access to medical schooling can be limited. As was the case for Dr. Brown.

Dr. Elizabeth Brown:

There’s a certain number from Wyoming that every year we would get selected and then we would do some of our training at our home state and then we would go out to Seattle and did like an underserved pathway when I was there. And then also did a lot of rotations in rural Wyoming and Washington and then also in Montana.

And I grew up in, you know, my town was like 3,200 people and as far as Dickinson with its size, it’s a lot larger than what I grew up with, but it’s still, as far as OB/GYN world, it’s still a rural setting and providing care for a lot of women in the rural area around Dickinson.

Alan Helgeson:

For Dr. Elizabeth Brown, while she’s seeing patients today, it did take a little while to find the place where she belonged: Sanford Health.

Dr. Elizabeth Brown:

The support that Sanford gives to physicians and kind of supportive of the practice as well as the doctors that I work with at Sanford, the OB/GYN doctors are very in line with how I practice. And so all of those things and for like my mental health and ability, I feel like I’m actually a better mom even though I’m working more and might be gone more.

I probably wasn’t the best mom when I was here because it was not, you know, when you’re not in a job that you enjoy working at you tend to be a little more short, not probably your best person that you could be.

Alan Helgeson:

When you provide medical care in a clinic that serves a diverse patient population in a rural community, you’re afforded great opportunities, and it takes a certain openness and flexibility in doing things. So what kind of person thrives in this environment?

Dr. Joshua Crabtree (guest):

The kind of provider that enjoys a challenge, the kind of provider that is comfortable with not necessarily knowing what’s going to walk through their door on any given day or time.

Alan Helgeson:

Now that sounds a lot like what Dr. Brown has been describing in her day-to-day clinic, but how do you replicate that passion for care and carry those special virtues into other communities when you have hospitals and clinics across a 300,000-square-mile area? Who does that?

Dr. Joshua Crabtree:

My name is Dr. Joshua Crabtree, and I am Sanford Health’s chief physician.

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Alan Helgeson:

Dr. Crabtree, in his role, leads a team of nearly 3,000 physicians and advanced practice providers across Sanford Health’s footprint. And like Dr. Brown, Dr. Crabtree experienced rural health as a physician because he was a family medicine physician at Sanford Health in a rural community for over two decades. With that experience, Dr. Crabtree knows firsthand what else you need to be successful in rural health care.

Dr. Joshua Crabtree:

One who’s comfortable with a more general or broad scope of practice, one who likes to develop a little more of a broad or robust relationship with their patients.

Their patients are not just going to be their patients in the exam room. They are going to also be their patients and connections that they have in communities, in the church, in the grocery store, probably at a sporting event or a choir concert. They’re going to see and engage with their patients on multiple levels.

The provider that will thrive in that environment is one who’s comfortable and actually enjoys that. You have to be comfortable with maybe not knowing all the specific answers right now, but you know how to find those answers.

You know where your resources are, you know that you have specialty colleagues, maybe subspecialty colleagues that are either a phone call away or a virtual visit away or an in-basket message through our electronic medical record away to help find those answers, to help provide those patients that come to us in all areas of our footprint with that top-notch world-class care that they should come to expect from Sanford.

Alan Helgeson:

Dr. Crabtree talked about the many different people involved in providing care at Sanford Health and those various ways he talked about in staying connected.

Dr. Joshua Crabtree:

We have made it our mission. In fact, it’s the statement that we put out there that we are going to provide world-class care no matter your geography, no matter your ZIP code. As an organization, we are committed to making sure that whether it’s through our virtual care platform or through outreaching to these communities, we send physicians or clinicians to over 430 different locations throughout our footprint on any given year to make sure that we’re putting specialty care and high quality generalist care in the communities where our patients are from. That’s our commitment.

Alan Helgeson:

That world-class care, while Dr. Crabtree really looks to make sure, this also means how Sanford takes care of their team, too. Dr. Brown is fairly new to Sanford and knows firsthand that new employee feeling.

Dr. Elizabeth Brown:

So Sanford Health, there’s the professional support. So as far as you know, they make sure I have nursing staff available. They make sure that we’re working to get patients on my schedule, working with the call schedule, coordinating things to make my life as stress-free as possible here. And so Sanford Health, with their physician support structure has been very helpful for that.

Also, Dr. (Amy) Oksa is our clinical director. She’s constantly checking in on me, making sure that things are still going well and how things can improve. And I even know when I was interviewed or even initially hired, even the higher ups in Bismarck, were checking to be like, OK, is there anything else? How can we modify your practice so that we can keep you? They know how hard it is to recruit to this area. And so they definitely make sure that things are going that way.

I think prior practice, kind of the frustrations I’d have, I have not ran into that. If I’m having an issue, people quickly address it, but also I feel like Sanford Health seems like a well-oiled machine that I’m able to seamlessly kind of integrated myself into the clinic. And really to me it seems like it’s been a very smooth startup and been able to establish pretty quickly.

Alan Helgeson:

A transition that allows Dr. Brown and her colleagues to care for patients in the way that is important to them and the people that trust them for that care.

Dr. Elizabeth Brown:

And just know that they know that I’m not just someone who’s some city slicker who’s never, doesn’t have any idea what’s going on. So I know my husband reminded me of a time when I had to explain to one of his friends’ wives that she can no longer throw in the net wrap because the net wrap is very heavy. And they’re usually having to put it in odd angles and I’m like, you can’t do that after a hysterectomy. Like your husband’s going to have to come to the field.

And so just trying to relate to them of like, OK. And most of the time, you know, when they’re coming here, like I said, that respect that North Dakotans or the Montanans have for physicians is very great.

Alan Helgeson:

Rural health care. Dr. Brown drives it, lives it, provides it every week to dozens of patients in and around Dickinson, North Dakota. She’s fairly new to Sanford Health and talks about why she does what she does. But let’s hear it from someone that has been in Dickinson and at Sanford Health for longer.

Dr. Erica Hofland (guest):

My name is Dr. Erica Hofland. I’m an OB/GYN out in Dickinson Sanford and I actually grew up in Dickinson.

Alan Helgeson:

Dr. Hofland knows the Dickinson community well. And as a physician with Sanford Dickinson understands that living in a rural community gives an awareness of important things that mean so much for the patients they see every day.

Dr. Erica Hofland:

It makes you a lot more aware of how much time patients put into their appointments and how much time and effort they make to come here. So you really want to do a great job caring for these people. Being cognizant of the fact that we try to do a lot when they do come in because it’s not as easy as like, oh, you know, again, follow up in two weeks. Sometimes we have to adjust schedules, adjust what we’re doing to maximize that time that they’re here in town with us.

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Alan Helgeson:

Sometimes that time might mean looking at their own schedules.

Dr. Erica Hofland:

And this is kind of life that not everyone who lives in more centralized hubs appreciates that how much effort even something as basic as going to work can sometimes be.

Alan Helgeson:

Remember earlier when we were talking about the weather, since it’s kind of a thing in the upper Midwest? It’s important here too. For Dr. Brown and her colleagues and clinic team in Dickinson and communities like this across Sanford Health’s vast footprint, Dr. Hoffman’s words could echo across the windy planes.

Dr. Erica Hofland:

There’s a lot of teamwork. I think there’s a lot of flexibility too, knowing that unexpected things come up. Like again, when she was driving into work, I don’t know if she told you the story, but she definitely hit a deer on her way in here. And so her day changed a little bit.

You know, again, part of living far away from the location you’re working out in rural western North Dakota, eastern Montana. So just, we all have to be supportive, flexible, and able again just to adjust again with what the day brings.

Alan Helgeson:

As the team in the Dickinson clinic stands together for each new day, they’re the front door to the people that are needing health care in western North Dakota.

Dr. Joshua Crabtree:

That those individuals are the way that our patients are going to engage with us as a health system, but also how they’re going to feel safe and how they’re going to trust us to provide that care.

So it’s really, really important that we listen to and we understand what those front-line workers – clinicians, nursing staff, patient access staff – we have to understand what they need and what challenges they’re having on a day-to-day basis. And then try to help and put the resources in place for them to do their job the best they can.

Alan Helgeson:

One of the things that Sanford Health and Dr. Crabtree pay attention to is balance. There’s work and there’s family. They do come together in a way.

Dr. Joshua Crabtree:

For most of us in health care, we spend as much time and sometimes more time with our work families than we do with our families at home. And so if we’re providing and/or able to work in an environment where we’re feeling supported and we’re feeling connected to our employer and our staff, I think what that’s going to do then is it’ll translate into feeling better about going home.

We can leave work at work, and we can go home and do what we need to do at home.

Also, understanding that the organization values that family connection. I mean, we use this terminology, I use this terminology on a regular basis. I call it part of being part of our Sanford family. When I’m talking to new recruits that are coming to the organization or contemplating coming to the organization, I talk about how we want them to be part of the Sanford family and that’s our work family.

But our work families get connected to our at-home families. And I would say that may be amplified in our small or smaller communities because of the connections that I mentioned earlier. It’s not just about going to work and leaving it at work. Your coworkers are probably your friends that you go to a football game on Friday night with, or maybe you’re on a bowling league or a card club or something.

Our teams are connected in many different ways. So I do think that ability to feel supported in the organization at work translate to feeling supported at home.

Dr. Elizabeth Brown:

Here at Sanford Health, I value giving patients good quality care, being able to provide a service where they would otherwise have to go to another community. I think that’s something that Sanford seeks to give care in rural areas. They’ve expanded into rural areas because they see a need: bringing health care to patients versus patients having to travel for health care.

Alan Helgeson:

Bringing health care to patients. It’s not by accident. People like Dr. Crabtree and other physicians and clinicians are leading the way.

Dr. Joshua Crabtree:

Our clinician governance structure, our clinician leadership structure, it’s all put in place very intentionally to make sure that we have physician and clinician input into decisions that are made about how we move our organization forward.

Alan Helgeson:

This matters and helps in growing the team, but also when it comes to recruiting new people to the organization too, like Dr. Elizabeth Brown, OB/GYN in Dickinson, North Dakota.

Dr. Joshua Crabtree:

For our clinicians to be able to see that we have a leadership structure, we have leadership development opportunities for those clinicians that want to progress. I mean, just by definition a clinician in the role that they play in our health care system, they are leaders of teams, the health care teams.

But if they want to expand that leadership, education or opportunities, we have resources. We have internal leadership development programs that will help our clinicians attain those goals. And we’re actively seeking those individuals to make sure that we’re providing that for them or they’re able to find it if they want it. I think that’s an important piece as to how we develop our own and grow our own.

I would also say that Sanford’s investment in graduate medical education and in our own training programs, that’s significant. We know that depending on who you read, 40(%) to 50% of trainees, so we’re talking residents and fellows will stay within a hundred miles of where they train. So by investing in those training programs, we know that we’re going to have a pipeline and a pool of excellent physicians for years to come.

I think that also speaks volumes to how the intentionality of the structure is to make sure that we will have those clinicians who can work in those rural areas.

Alan Helgeson:

This investment into people and growing physicians is important. Even for new people joining like Dr. Brown.

Dr. Elizabeth Brown:

I think having, you know, physicians in those leadership positions and not just administrators that have never practiced, I think it’s useful that they have been on the other end of things. No matter who I reach out to, they’re very supportive and they want me to succeed as a physician as well as a person.

Physician leadership is always checking in, making sure that if there’s any problems or issues, especially they know my living situation. They’re always just checking in and making sure that, asking about how are the kids, how’s the husband, how are things going? Like, that was just something that just never really experienced my last job. And that’s kind of why I chose Sanford.

Alan Helgeson:

Sanford Health is the largest rural health care system in the U.S. So how do you do that?

Dr. Brown has shared her story and why she does what she does. Dr. Hofland has lived in Dickinson for a long time and shared some of her thoughts, and Dr. Crabtree, well his part feels almost like watching over a closely guarded family recipe on just how Sanford Health is focusing on people. But really it’s not that much of a secret, and Dr. Crabtree and the family have just been doing it for quite a while.

Dr. Joshua Crabtree:

We’ve been very intentional about trying to, if distance is a barrier, if resources are a barrier, if finances are a barrier, if transportation’s a barrier, if weather’s a barrier, we’re trying to put the resources in place to make sure that our patients have access to the care they need. Because we know that if we don’t reduce those barriers, people will just not access health care.

We want people to live in the places they want to live. We want them to be able to access the care they need to have access to. And in order to do that, we have to put processes in place and strategies in place. And that is our virtual care. It is our ability to recruit and retain clinicians within those facilities. It’s to partner with communities that our health care facilities are in as to how can we make sure that there are good schools, day care providers, things that help a community be strong and vibrant.

We want to work with those communities too, as a health care provider within those communities, because we know if the community’s strong and the health care is strong, then the people are going to get the care that they need.

Dr. Elizabeth Brown:

It’s very rewarding to work with rural patients. They respect our opinions. They are excited that we’re here. They like the fact that they can get good quality care in rural areas. The other thing is just family wise, the communities of these smaller communities, you have a lot of opportunities for children. You know, it’s a safe, safer communities. You get to form those relationships inside and outside of the clinic and just be able to really care for people in a closer-knit type of situation.

And you get to – the continuity over years of being in the community – eventually, hopefully I’ll be delivering (babies of) some of the people I delivered.

Alan Helgeson:

Health care is about people – people helping people no matter where they live. Elizabeth Brown is a physician and a darn good one. Her Sanford story is a fairly new one. And next time when she walks into the clinic to see her patients, remember Dr. Brown has a story just like you.

Now, Dr. Brown’s story maybe includes a few hundred more bales of Montana hay than yours or mine. And when she’s not in the clinic, you’re likely to find her on that ranch where she’s busy doing all sorts of things, just like a lot of the people she’s going to see tomorrow. And oh, by the way, if you have any leads, Dr. Brown is still looking for that one thing.

Dr. Elizabeth Brown:

When I decided what I wanted in life, I always wanted to have at least a few animals. So I still have not got my horse, but that will come (laugh).

Additional reporting by Jason Anschutz.

Get more episodes in this series

Former FDA commissioner writes health care’s next chapter

Alan Helgeson (announcer):

“Reimagining Rural Health,” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, Courtney Collen with Sanford Health News talks with Dr. Scott Gottlieb, former FDA commissioner. Dr. Gottlieb is a keynote speaker at the 2024 Summit on the Future of Rural Health Care with the topic “Navigating Health Care’s Next Chapter: Innovation, AI, and the Future of Patient-Centered Care.”

Courtney Collen (host):

I have Dr. Scott Gottlieb, former FDA Commissioner here in Sioux Falls, South Dakota, at the third annual Summit on the Future of Rural Health Care. It is a pleasure to have you. Thanks for being here.

Dr. Scott Gottlieb (guest):

Thanks for having me.

Courtney Collen:

We are delighted that you’re delivering the keynote fireside chat at this year’s summit focusing on pioneering innovation in a shifting landscape. Now, as the 23rd commissioner of the U.S. Food and Drug Administration, you were an aggressive advocate for advancing the health of patients, promoting health care access and driving innovation.

During your tenure as the FDA’s Commissioner, we saw a record-setting number of approvals of novel drugs, medical devices, and generic medicines. My question to you is this: How are we doing today? Are we ensuring that the FDA’s consumer protection efforts are put to the most efficient use?

Dr. Scott Gottlieb:

Yeah. Look, the FDA’s continued to have record output. If you measure output in terms of new medical technology, you’re seeing drug approvals in recent years hit near all-time highs. So there’s a lot of novelty in the pipeline. There’s more generic competition entry in the market.

The one place where I think that we’ve seen pullback of investment is around medical devices. And so you’re not seeing the same pace of innovation that I saw when I was there that I think we want from a public health standpoint, in the medical device space. You’ve seen a lot of investment capital exiting that, particularly venture capital.

In terms of consumer protection, I have a lot of confidence in how the agency’s looking at these new technologies, the kinds of safeguards that they’re building in the rigor of the process. I don’t think that there’s an inherent trade-off between trying to foster innovation and make sure regulatory processes are efficient and that they’re adaptable to new kinds of technology and making sure consumers are protected. I think that the agency’s very vigilant and continues to be very vigilant.

So my view was there was never an inherent trade-off. People always used to say when I was there, “well, if you’re going fast or you’re approving all these drugs, there must be some shortcuts you’re taking.” And that’s simply not the case. There isn’t that policy trade-off built in.

Courtney Collen:

Right. Thank you. A regular contributor on CNBC Squawk Box, you recently talked about drug benefits and the disparity between net and list price of drugs on the market. Dr. Gottlieb, you mentioned that consumers deserve less of a disparity. At the same time you noted that venture capital has pulled out of a medical device innovation because the returns are not there and approvals are harder.

My question is, how do we not hurt innovation? Where does the problem lie?

Dr. Scott Gottlieb:

Yeah, so the disparity that you’re talking about is between the net and the list price. So companies will come to market with a very high list price knowing that that’s not the real price in the market that they’re going to have to discount. So they’ll set a high list price knowing that there’ll be mandatory rebidding to government programs like Medicaid, and that they’ll also negotiate concessions with health plans where they’ll give rebates back to the health plans that offer that list price.

The problem is that consumers, some consumers are out-of-pocket for the list cost of the drug. So if you’re underinsured or uninsured for a drug, you’re not paying the rebated price that the health plan’s getting; you’re paying the list price. And also a lot of consumers will pay copays that are based on the list price and not the rebated price.

And so this kind of almost like a fiction that’s grown up in the marketplace between the list price, which isn’t what most people anticipate will be the real price in the marketplace. And then the net price, which is the discounted price of the health plan, creates a real hardship on certain people. And so it’d be much better in the marketplace if you had the price that a drug’s offered at being the real price in the market, being the price that bakes in all the discounts and the concessions that they’re making because of competition.

In terms of just innovation more generally, you know, I think that there’s still a lot of capital flowing into life sciences. New modalities like cell and gene therapy, antibody-based drugs, mRNA technology, antibody drug conjugates, all these new platforms. I think what you’re seeing on the life science side is that the cost of developing a single drug has gone up exorbitantly, could literally be a few million dollars, a few billion dollars direct money out-of-pocket, and maybe more. The cost of putting a single patient into a clinical trial with a cell and gene therapy could be a million dollars.

And so, because the costs have gone up so much, and they’ve gone up, frankly, faster than the price of the drugs, you have more capital, but you don’t have a higher amount of capital to offset the rising costs. And so there’s fewer shots on goal, that companies just can’t put as many drugs into development.

And the other thing that’s happening in the marketplace is that the drugs that they’re putting into development, they’re compelled to do more studies around each drug, not necessarily for regulatory purposes, but for commercial purposes that they have to come to market. If you’re a drug maker, you have to come to market with a very comprehensive drug label because you’re going to have to penetrate the market very quickly.

And so you’re going to need to make the best sales pitch possible to patients and providers and health plans. You don’t have five years to do subsequent studies and slowly get new indications on a drug label, which is what it was like in the old days. And so you’re putting more money into each individual drug, which means fewer drugs will get developed.

On the medical device side, as I said, the concern there is just capital’s come out of it because the returns weren’t there. And the ability to do public offerings in that space has largely eviscerated. So you’ve seen most venture capital firms pull out. I’m a partner at a venture capital firm. We’re still making investments in the medtech space. We’re one of the few, but we’re not making many investments. And we used to be one of the most active medtech investors.

Courtney Collen:

Dr. Alex Oshmyansky, co-founder of Mark Cuban Cost Plus Drug Company, is also speaking here in Sioux Falls at the Summit on the Future of Rural Health Care. What is your take on how this program will further impact innovation in drug price negotiations?

Dr. Scott Gottlieb:

Yeah, Mark’s done a great job kind of eviscerating that model that I talked about earlier, where you had this high list price and this much lower net price by having one price and offering direct-to-consumer access to a range of older drugs, mostly generic drugs where there is no spread. And so there’s much more transparency about what the actual price is.

And for a lot of consumers, it’s a much lower cost-attractive option, especially if you’re out-of-pocket for the cost of the drugs, and you’re not able to benefit from the negotiated prices on a lot of these drugs that is being given to the health plans.

So, I would think what Mark has done more than anything else isn’t necessarily disrupt the manufacturing process … or the development process. What he’s disrupting is the commercial process. He’s disrupting that access point and providing a much different selling model. And that’s really important for a lot of consumers.

And I think you’re going to see it’s already having an impact in the marketplace. You’re already seeing many more instances where health plans say, “you know what? We’re going to make sure that the discounts that we’re negotiating, those rebates get paid back to the consumer at the point of sale.” And so they’ll get those rebates right at the pharmacy counter. And so their copays aren’t going to be based on a much higher list price. I think some of that pressure that they’re feeling is a result of what Mark’s done.

Courtney Collen:

What innovation or action do you think will move the needle the most in the next one to two years?

Dr. Scott Gottlieb:

So certainly, and we talked about a lot here today, certainly artificial intelligence, and you’re going to hear that so many times today.

The other thing that I’m very enthusiastic about: I’m actually writing a book about the history of the development of cell therapy in the oncology space. So the history of the development of CAR-T, and I think that we’re going to see cell therapy applied to a much broader range of human conditions and the sort of holy grail of pluripotent stem cells and other forms of stem cells that we talked about 30 years ago. And this vision that they would one day cure paralysis, which obviously hasn’t happened and is going to be much more complex than we ever potentially anticipated.

But the idea of regenerative medicine, the idea that you’re going to be able to use cells to reconstitute the function of the pancreas or other forms of metabolic disease, that you may be able to reconstitute certain kinds of neurons in neurodegenerative diseases like Parkinson’s disease, that you’ll be able to reconstitute muscle in certain conditions where you have a loss of muscle tone or muscle function that results in a debilitating condition like heart failure. I think those are potentially achievable.

Certainly some applications of this, we’re already seeing in early-stage clinical trials, doctors have success. The idea of recreating a pancreas using cell therapy – I saw a very interesting study that read out recently at Stanford where they’re using stem cells that they’ve been able to reconstitute to replicate the function of smooth muscle to provide tone back to the urethral, the sphincter that controls bladder function for people with urinary incontinence. And so that’s a relatively simple procedure, a relatively low-risk application of stem cells, not like putting them in the heart for a very targeted function that seems to be working.

And so I think we’re going to see a lot more applications like that in the coming years. We seem to have reached a tipping point when it comes to cell therapy in the same way we reached tipping points with other modalities. I would say back in – I’ll just put sort of pause here – but back in like the early 2000s when I was at FDA, monoclonal antibody drugs were just starting to really penetrate medicine. And they were reserved for third-line cancer, certain very unmet medical needs, because there was a lot of theoretical risk, not, there wasn’t really risk, but there was a perception of risk associated with these drugs.

We really didn’t understand exactly how they worked, how to manufacture them. There was a lot of variability or perceived variability, and so they hadn’t penetrated mainstream medicine, but we were right at a tipping point where they were going to start to get more widespread applications.

And today we’re using monoclonal antibodies for lowering cholesterol and treating asthma. If you would’ve said to me back in 2000 when I was a young person at FDA, “oh, one day we’re going to be using monoclonal antibodies to treat high cholesterol,” I would’ve said you’re crazy. It’s just never going to happen. And I think we’re kind of at that tipping point with cell and gene therapy right now, where things that we’ve talked about for 30 or 40 years now seem achievable and we’re going to start to achieve them quickly, I think.

Courtney Collen:

It is so fascinating. Thank you so much for that insight. How do we strengthen trust in health care during a time of rapid disruption?

Dr. Scott Gottlieb:

Yeah, and I think we should, and I think we did, but we should draw a lot of lessons also from COVID around public trust in health care. … I was very aware of this during COVID and talked about this during COVID as well.

I think we didn’t do a good job of talking about uncertainty. And I struggled with this also when I was at FDA where there was this sort of furtive concern in the agency that if you had a concern around a drug, you know, a safety issue, that you were monitoring the post-market and you were too sort of visible, and you talked about it too much, that you might discourage patients from using that drug in a circumstance where it’s otherwise providing benefit and then you’ll just find out six months later that whatever the concern was disproven and it was wrong.

And now what have you done? You’ve kind of influenced a whole bunch of behavior in a very negative way. And so there was this kind of cultural kind of like inhibition against warning about things or informing the public too early. This was back in like the early 2000s. And then we had a whole spate of drug safety issues. A bunch of drugs were withdrawn with … troglitazone. We had issues of concerns around suicidality associated with SSRIs in young people. And what we learned coming out of that was, and the public’s reaction to that was, you knew about this all along FDA, you had been studying this, and you didn’t tell us you were sitting on it.

And that certainly wasn’t the case. The FDA was investigating these things, but didn’t really know about it. They hadn’t drawn conclusions. They weren’t trying to deliberately hide things from the public, but they weren’t at the point where they felt that they could speak intelligently publicly with sort of firm conclusions. And what we learned from that was, you know, it’s OK if we don’t know the answer, but if we’re investigating something, if we have a question, we should tell the public, “you know what, we have some indication there could be this risk. Based on what we know, we don’t think that there’s a causal relationship between the drug and the risk. But to be certain, we’re going to be doing X, Y, and Z and we’re going to have a firm answer by this date.”

And if you’re very clear with the public about what you think, what you’re doing to try to get an answer, what you know, and you don’t know when you’re going to have an answer, most people will say, OK, I’m going to continue using the drug if they should. And when the agency knows about it, they’re going to tell me, and then I’ll be able to make a different decision at that point.

And so, it taught us you have to be much more transparent about what you’re thinking, what you’re doing. And if you’re transparent, you’re not going to influence a whole bunch of behavior in a bad way. People are smart and they do rational things, and they’ll work alongside you if you will. Or they’ll follow your advice as long as they know they’re going to get an answer.

And I think during COVID, there was a lot of hesitation about evidencing too much uncertainty when we, when people had uncertainty. And then talking about public health officials more broadly for fear that it would discourage actions that people wouldn’t get vaccinated, that people wouldn’t wear masks, so they wouldn’t self-distance. And that was wrong. And this isn’t just Monday morning quarterbacking. I was having this debate publicly at the time as well with a lot of public health officials and talking about this on TV that that we needed to talk about our doubts a little bit more with the public. And I think coming out of COVID, we now, we really should have firmly learned that lesson.

I kind of learned that lesson in the early 2000s with these drug withdrawals when we realized, you know what? We need to be communicating with the public more about these things. And if as long as we’re communicating and getting answers and telling people when we’re going to get answers, they’ll follow guidance. And we, I think more broadly, the public health community didn’t do that well during COVID. And I think now we need to think about how to really kind of inculcate these sort of learnings and this culture into medicine.

Courtney Collen:

So much to learn from and thank you for that insight. I have to go back to AI for a second. AI in health care, Dr. Gottlieb, is it overhyped or real? Where do you stand?

Dr. Scott Gottlieb:

Well, I certainly don’t think it’s overhyped. I think it’s going to have a profound impact on drug discovery. Not just on making the process more efficient but opening up opportunities to develop drugs that just wouldn’t have been achievable in conventional systems.

And I work at a venture capital firm. We made a big investment in a company called Cero Therapeutics that is looking at developing novel antibody-based drugs, and AI modeling systems. And we’re looking at developing antibodies that just aren’t, can’t be developed through traditional tools. Typically, we develop antibodies in in vivo systems, in mice models, sometimes in human models, but you can’t develop the full sweep of antibodies that might be achievable against targets, biological targets.

If you can’t develop it in a mouse, you can’t find it in a mouse system. And there’s a lot of things that you can’t do in those kinds of systems. And so on a model, on an AI model, you can generate a much broader sweep of a diversity of human biology that you wouldn’t be able to do in any in vivo system.

But I think probably the most profound application could be on the delivery side, where these tools are really adept. We’ve done a number of studies testing the aptitude of the different AI systems, particularly ChatGPT and ChatGPT IO, the new version of ChatGPT that they have that’s supposed to have an IQ of 120. And its clinical aptitude is mesmerizing. I mean, that’s the best word to describe it.

We have fed it complex clinical vignettes that physicians get wrong 60% of the time. So we’ve gone to banks of questions and it’s not only scoring near perfect on these tests that we’re administering and we’re going to, we publish some of these results. We’re going to be publishing more of them soon. But it annotates why it arrived at certain answers, and its clinical reasoning is very sound. So, you know, will it replace the doctor? I think in the future for certain low-risk encounters, it can and maybe should because it’s going to help improve productivity quite substantially.

But certainly if you have a complex case and you’re not querying one of these systems I think you’re kind of shortchanging. Shortchanging yourself as a provider, but right now they’re not that accessible if you want to do it in a HIPAA-compliant way. Not every system’s deployed an instance of ChatGPT that doctors can use. And so, you know, if they’re using it, they’re using it in a way they’re probably being told not to. So I think systems need to think about how to deploy these tools so doctors can start to query them in clinical practice. Not to, you know, replace their own clinical judgment, but certainly to augment it.

Courtney Collen:

Sure. Thank you. An author yourself of a New York Times bestseller, I’m curious what book you’re reading. What’s at the top of your list right now? And then I also want to know what has had the biggest impact on your career? I know you’re writing a book as well. We look forward to that hitting the market.

Dr. Scott Gottlieb:

Yeah. So the books I’m reading right now are the books that I’m reading for the book I’m writing. So I’m writing a book on the history of the development of cell therapy in the oncology setting, and then how do we extend those achievements into regenerative medicine.

So I’ve read books like Walter Isaacson’s book “The Innovators,” which I think really has been a good model for me because my book, I want my book to be about the story of how innovation happens in the life sciences space. And he does a really good job telling that story in, not necessarily in life sciences, but in the consumer tech world and so it’s been a good model for how to do that well.

So, I’ve looked at his writing and others, and I’m going to be reading his book on Jennifer Doudna next, just a biography of Jennifer who pioneered CRISPR therapeutics.

In terms of just my own career, I think the thing that’s had the most positive impact has been being able to write – hopefully well – I was a writer before I was anything else. I was, I used to work for newspapers. And I think being able to express ideas allowed me to – it opened up a lot of doors for me.

So, it allowed me to certainly get noticed inside Washington and allowed me to parlay that into the policy jobs I’ve had. And then just in terms of strategic communications and policy communications, it was a big part of what I focused on when I was in government jobs, because I think policy communications is a key to getting policy enacted. So, I was always very focused on that and always focused on writing my own statements and speeches to make sure that the messaging was consistent and was being articulated in a way that I thought was going to help us achieve what we were trying to do. So that’s probably been the most important kind of ingredient to what I’ve done.

Courtney Collen:

What an impressive career, Dr. Gottlieb. Thank you so much. And one quick pivot to our final question. What do you love most about what you do? It’s not in the script. What do you love most about what you do?

Dr. Scott Gottlieb:

Yeah, it’s a great question. I mean, the answer to that question is different, at different points in time. I mean, I really loved working in the government and the impact you’re able to have in trying to implement good policy and feeling like I was protecting the prerogatives of FDA, an important public health institution, and representing the agency well. So, that was an energizing job.

I don’t practice medicine anymore. I stopped when my youngest baby was born, shortly after she was born. So it’s been about nine years since I practiced. But I used to love going into the hospital and doing shifts on weekends. … I was a hospitalist. And I love the kind of intensity of in-hospital care.

I think what I love doing most right now, still wading in on policy debates through writing, but I really like the work I’m doing with new ventures and startup companies and new technology. Trying to find the next thing that’s going to be disruptive in health care and help it get financed and help the company through the bumps that you always hit in drug development.

And one of the companies I’ve financed is a company called Comanche Biopharma, which is developing a novel therapeutic for the treatment of preeclampsia, which there are no effective available treatments. We haven’t had new innovation in decades. We’re still using the same things that we used probably when my father was in medical school. And this drug could be potentially disruptive. I mean, it’s a very novel mechanism. The biology of it seems very plausible. You can create a very cogent argument why it should work in this clinical setting.

And if it works, it could be really disruptive because this is an extreme cause of morbidity and mortality in early pregnancy, particularly in developing markets where you don’t have access to intensive care for, you don’t have NICUs and other forms of acute care and intensive care for both the mom and the baby. And so this is a really serious life-threatening condition in those regions where you can’t deliver the pregnancy early and you can’t get NICU care for a baby that’s born premature. And so I think that this is going to have a really profound public health effect if it works.

I think we looked at it, a lot of venture firms looked at it, and I think a lot of people just were nervous about doing anything in this setting. Anytime you’re giving a therapeutic to a pregnant mom, there’s all kinds of other things you worry about in that setting. And so, you know, they struggled a little bit to find the financing and find venture firms that wanted to step up. We did. And Google’s in it, also invested in it. Atlas Ventures and Fidelity … so those are the four investors.

And, you know, I feel like it did take a certain amount of courage to do it. But it was really important. And finding those opportunities, that’s really, that feels rewarding, where you find something that really looks promising have a huge public health impact. And it was the kind of thing that maybe others might’ve been a little reluctant to do. But because I worked at FDA and I know that world, I think I was able to get comfortable with it.

Courtney Collen:

Well, we really look forward to seeing what’s next with you, Dr. Gottlieb. Thank you so much for joining us for an episode of “Reimagining Rural Health,” a podcast series by Sanford Health. A thought-provoking conversation for sure. Thank you so much.

Dr. Scott Gottlieb:

Thanks a lot.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and news.sanfordhealth.org.

Get more episodes in this series

Reduce the risk of falling with strength and mobility

Natalie Fick (guest):

If you’ve known people that have had injuries, you’ve had loved ones that have had a very adverse outcome from a fall, we know that on the positive side that falls are very multifactorial. That it’s a lot of things that you can do to prevent falls and to reduce your risk. And I think it’s something kind of empowering for a lot of people to know that they can kind of take charge of that and they can do a lot to prevent those falls and overall keep them strong and moving well. And that’s, I think, something that once they understand where those resources are, whether it’s with their provider, whether it’s with their therapist or any of like the community exercise programs and things going on too, that they can take those positive steps to keep them moving well and aging in place and maintaining their strength and their mobility too.

Cassie Alvine (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about understanding falls and fall prevention. Our guest is Natalie Fick, Sanford Health physical therapist. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Thank you, Natalie, for taking time to spend with us today to talk about this topic.

Natalie Fick:

Glad to be here.

Alan Helgeson:

Alright, well we’re going to talk about falls prevention and let’s get started here. I guess the big open question we want to start with: why is falls prevention an important topic for older adults?

Natalie Fick:

I think it’s something that any older adult, no matter age, where they live, it’s always a concern at some point. And it’s a really critical topic for them too because it’s such a leading cause of severe injuries and can overall kind of affect their mobility and their independence, which I think is a common concern for people as they age, you know.

Falls, they can increase your risk of hospitalizations, lead to a decline in overall health and function and mobility, which a lot of people, they want to age in place. They don’t want to have to go to a nursing home, feel like they’re more dependent. And unfortunately we know the adverse issues from falls, whether injuries or other things too can usually lead to more of like a dependent type lifestyle if they aren’t able to recover well. So that is a big factor.

And then also we know just by working on preventing falls, we can just help to hopefully maintain people’s physical health and mobility, allow them to age in place like a lot of people want to do, reduce health care costs, which is another huge worry for a lot of people. And support their overall emotional well-being. So kind of reducing rates of depression, anxiety and just kind of helping them feel more confident and safe with their day-to-day activities.

Alan Helgeson:

You talked about that costing, that’s a biggie. Boy, we hadn’t even really thought about that, but you talked about also, you know, all these different things. What really puts them at risks for falls?

Natalie Fick:

So we think of falls as actually a very multifactorial thing. It’s not just one cause causes the falls like, oh, just a trip and they fell and had an injury. There’s a lot of factors that go into it, you know, starting (with) a very common thing with any aging adult is just lower extremity weakness or overall weakness in their body that we know just puts them at a higher risk of falling.

We know that just in general, if they’re having more difficulty with their balance and walking, whether or not they’re using an assisted device or if they need it can put them at a higher risk.

Sometimes even medications that they’re taking can greatly increase their risk of falling because of either side effects or interactions between medications. And people don’t always realize that. So that’s where it’s a great conversation to have with your provider or your pharmacist to see if you are at a higher risk with that too.

We see a lot of people with even just poor footwear. So wearing good supportive shoes so that you’re not tripping over your shoe, just have overall good stability can be a big factor. Vision problems – I don’t know when everybody’s maybe had the last time they’ve had their eyes checked, but other eye conditions too, whether like glaucoma or even just not having an updated prescription can greatly affect your ability just to see your environment and potentially identify or limit your ability to identify trip hazards or things in front of you and around you too.

And then another common one that I actually work with people a lot on is even like low blood pressure so that when they get up from either laying down or from sitting, they might get dizzy or they might feel really woozy and that potentially can cause a fall and an injury too.

Alan Helgeson:

So many different things you don’t even think about.

Natalie Fick:

Right. Exactly. And the nice part in a way about this too is we know there’s so many factors we can potentially control and we can minimize that risk by identifying where am I at risk and knowing that hey, I can get better footwear. I can talk to my doctor about medications. Or I can go get my eyes checked. Doing things like that greatly, greatly reduces your risk so that you’re safer overall.

Alan Helgeson:

So I was just going to tell you here a couple of things while you’re talking about that I’m going through the footwear thing in my mind of the different things I have and I’m going to admit I’ve got some things, they’re not the greatest, you know. I’ve got some junky flip flops. I’ve got some slippers that my wife would say, you need to get rid of those, you know, we all have those.

Natalie Fick:

Exactly.

Alan Helgeson:

I had no idea about certain medications that could put you at risk for things like that. And then what about if you don’t have vision issues strong enough or bad enough where you have prescription glasses but you’ve got readers everywhere and maybe you walk around the house with your readers down? They could be issues for tripping, right?

Natalie Fick:

Correct. So I mean it can potentially skew your vision just enough where you normally used to like a flooring transition or a small step. And you can misjudge that, or I’ve even had people that have had that discussion where they just got bifocals and all of a sudden they’re having issues or trying to figure out the curbs.

So we see it in a lot of places, thankfully, where people are being more aware out in the community where they might highlight those transitions with like yellow paint or some extra grip on certain steps too to try and help minimize that risk. But they’re still there. They can still happen. The sidewalk will heave in certain spots you might catch your toe. So we always have to be able to hopefully see those and be aware of that too.

Alan Helgeson:

Natalie, I want to go back here and the reason we have you here is that you’re kind of special here with some special training in talking about falls. So let’s talk about where do you work, what clinic are you part of and let’s talk about the reason you’re able to talk about this today.

Natalie Fick:

Yeah, so I work at Sanford here in the outpatient physical therapy department at the Madison Veterans Parkway Clinic. And so, I mean that’s just part of my job is we have been trained in being able to help evaluate and assess people in their fall risk, overall strength and mobility concerns, and helping to improve those so that they are safer in the home.

I’ve also had the privilege over the last five years of working with some amazing people here to help implement some evidence-based fall prevention classes in the Sioux Falls area and the region. And so I am a master trainer with the Matter of Balance class. And then I provide kind of the health care professional viewpoint as well with these classes.

And then I’ve been able to work with this group too as they’ve implemented other classes including SAIL (Stay Active & Independent for Life) and Bingocize (combining bingo and exercise) in the community to again help to reduce this large issue that we have not only in the Sioux Falls region, but in the state as a whole too.

Alan Helgeson:

You’ve got some deep training to not only as a physical therapist, but you have a doctorate in physical therapy, correct? What does that mean, having a doctorate in physical therapy? Can you talk a little bit about that?

Natalie Fick:

So in order to get our doctorate, so in order to even just to get into grad school, you have to get your bachelor’s degree. So I’ve had four years for that in kinesiology. And then I had a psychology and coaching BA minor too and then got into grad school. And so additional three years of training extensively, not only on the body mechanics, how the body function and works, but we when you get your doctorate level, they’ve expanded that training and that knowledge too to be able to better understand how all the systems work together. Not only just the musculoskeletal and the getting stronger too, but how the cardiovascular system affects things too. How the pulmonary system, you know, where we can identify some of those yellow, red flags, how can we work with our providers to help keep everybody as safe as we can.

Alan Helgeson:

So good to have expertise like yours and talking about this today. So let’s keep moving on here because there are a lot more questions here to ask you and talking about falls prevention. Next question for you. What are some of those complications for older adults when falling?

Natalie Fick:

So I think one of the, the biggest ones that we hear a lot is, you know, the broken hip. So it’s a very, very common place for people to have those fractures when they sustain the fall. But you know, we also see those broken wrists and shoulders or arms. I’ve even seen some people too that have had like compression fractures in their backs from the falls too.

Obviously broken bones are not good. They take time to heal. And especially as we age, healing takes longer. Mobility is usually greatly limited because of that for a period of time while things heal.

Other things that sometimes we kind of gloss over but actually can be very significant too are even just the head trauma and the head injuries from these falls where you can potentially get even just a concussion or a traumatic brain injury from that too.

Or we touch on a lot in our classes that we teach, especially if you’re on blood thinners, just the risk of a potential stroke or some type of injury like that as well. And unfortunately those take a long time to heal too or potentially have some very adverse outcomes too, where sometimes we see some people that they have that head injury and they end up passing away too from that fall.

The other things that can happen you know, some people, they just all of a sudden whether they have a fall or a close call start to have a great fear of falling too. And that is a huge, huge precursor actually. And a huge risk factor of falls is the fear because we know when people are fearful of falling, they might avoid activity. They might avoid what they’re doing.

I don’t want to move or I don’t want to do this because I’m going to fall. And in turn, because we’re not as active, we see people actually tend to get weaker. And then unfortunately because of that you’re at a higher risk of falling and then you actually might have more of a fall too. So it’s this terrible cycle to get caught into. And so by addressing sometimes even that fear and that concern showing people, you know, how realistic is this? How can we work through this again? We can kind of decrease their risk too.

Other complications people have, and I know this is a big factor or a big thing for a lot of people is just the increased dependency is people don’t want to depend on others. They don’t want to have to have their children help them with things that they can do on their own.

They don’t want to have to even consider leaving their home and going to assisted living or a nursing home or a long stint in rehab to recover. They want to be able to be independent and unfortunately if they have falls and have injuries or limited mobility, sometimes they have to have that assistance and it’s hard to accept it or hard to ask for it too.

And then even again, just like the psychological effects that we see in a lot of people too, a lot of anxiety, a lot of fear and sometimes even that depression and that social isolation that can happen because if people are worried I can’t leave my house, I can’t navigate those stairs, or I want to go to a show at like the pavilion, but I can’t navigate the curbs and stairs, you know, that depression, that isolation of not being able to even just be out with your friends really sinks in too and can be a big struggle.

Alan Helgeson:

Well I’ll tell you, living in this part of the country also, when you have some tough winters and springs that can add even more fear and danger for people that might suffer from that. Right?

Natalie Fick:

Exactly, and we have a lot of discussions with people, not only in the classes I teach, but also in the therapy world. Like we enter unfortunately the winter seasons that are coming too, the ice, the snow, understandably. We don’t like to go out there if it’s icy and snowy no matter the age you are because of the risk of slips and falls. But we know there can be a higher risk of adverse outcomes too as you age, especially if you’re having more issues with your balance and overall mobility too.

Alan Helgeson:

Well let’s switch now. Let’s talk about some ways to maybe get over some of that stuff. There’s such a thing as falls prevention screenings. Let’s talk about that and how these can help older adults and maybe identifying their risk. And this falls prevention education.

Natalie Fick:

So fall prevention screenings are things that we usually incorporate a lot in therapy if that’s a concern for individuals. But also throughout Sanford we do that as a whole too. And we really just sit down and we talk to people too and just assess their risk factors and then, you know, potentially give them some recommendations as to how they can reduce their risk too.

So with the screenings, there’s a lot of standardized tools that we use from a therapist whether we look at maybe their walking general balance assessments too, just to get us an idea of where they’re at, how they’re overall moving and able to maybe even recover their balance.

And then we talk to them too about if they’ve had past falls and injuries. If those individuals, they’re feeling unsteady and when they’re standing or they’re walking, I mean overall again too, if they’re having worries about falling because that’s a huge factor as well with these screenings too, we even just assess modifiable risk factors.

So what are things that we can change to, again, to help make them safer? And that may be in their home environment, whether it’s grab bars things, or rugs if they potentially even need an assistive device, which isn’t always everybody’s favorite thing to talk about, but sometimes depending on how their balance is overall mobility or if they’ve had past injuries or surgeries, sometimes we may need to start considering the use of a cane or a walker or something to help keep them a lot more stable and steady when they’re out and walking.

We talk to them again about the vision side of things. So again, how can they see or have they had their vision checked? Good footwear, you know, we always are encouraging that so that they’re not tripping on their shoes, let alone on the surface as they’re walking over if needed.

You know, we intervene to reduce that fall risk with different strategies. Like sometimes we recommend just chatting with their provider again, especially if there’s concerns of medication of maybe some dizziness or some blood pressure issues. Even if we talk about neuropathy where it can have a decrease in sensation, which can be very common for people, especially if they have diabetes in their feet where they can’t really feel where their feet are, what they’re walking onto, which, you know, greatly increases their risk of a fall because they’re just not sure where their foot is. If they’re stepping on something that could cause a loss of balance.

And then the other awesome thing that we can do too is we can give referrals for different classes that we’re having in the community if we know that that would benefit them based on their current ability level. Or sometimes we recommend having that discussion with their provider too, if some physical or some occupational therapy would be warranted to help overall improve things.

Alan Helgeson:

Natalie, if somebody’s listening to this today and they heard this thing about the screenings and that Sanford offers these, where would they maybe start? Would it be with their local provider in their community and ask about these screenings?

Natalie Fick:

So that would be a great first step too. I know their primary care providers, they can offer you sometimes just a very basic initial screening. Or even just having a chat with their provider too and say, here’s my concerns, whether I’m having maybe some trouble with some balance, or I notice I’m dizzy with some transitions or certain movements so that we can kind of assess and again, then refer appropriately, if there’s again little adjustments and things that their provider can do, or if therapy needs to get involved.

Or we can try to encourage and let a lot of the providers and people in the region know too of what classes might be available for these individuals. Whether it’s like the A Matter of Balance classes, our SAIL classes, our Bingocize, our tai chi, different things like that just to help keep them moving and keep them strong.

Alan Helgeson:

Some really great things and some offerings for people. And again, if you’re listening too, and you may have older parents, family members that might benefit from these, do some research and maybe ask your provider about these, beyond the obvious things, that are great about this stuff. Maybe share a little bit about how or why patients see these classes as beneficial in terms of giving them some of these tools and ways to prevent these falls from happening.

Natalie Fick:

I think a big thing that when I talk to people in these classes too is they feel like they can finally do something to help themselves too. Because sometimes it’s a very helpless feeling when they’re having issues and struggles but they just don’t know where to start or who to turn to. And so whether the classes or utilizing therapy just to get them going and kind of empower them to show that they can help take charge and they can make some improvements.

Just like anything, the more you practice, the better you get at it too. So when we do that it helps to just get them going there and then they can also just have a better idea and they can see for themselves the different risk factors they may have and how they can potentially modify those too.

We hope and encourage them that by doing some exercises or different things too that they can just improve their overall strength and flexibility, which in turn makes them feel better. When you’re active and you’re moving, your body feels better and wants to do that too. And then again decreases their fall risk.

But the other benefit too, sometimes when they go to different classes or they go to the gym or they do some of these things with some friends working together is just that social interaction and aspect too, which is huge. Especially like we talked earlier too, coming into these colder months where it’s hard to really get through these days when they’re dark all the time. You just don’t really feel like you want to be out and about. But when you have that kind of social pull of, I know my friends are going to be there too, you know, we can chat, we maybe have some coffee, we’re going to do the exercises. I think that’s always a huge draw and an extra benefit too.

Alan Helgeson:

Moving on as somebody that may have parents that we may be visiting during a holiday period, you know, as we, we transition to colder months or we might be seeing parents sometime soon. We go into their homes and we see that they might have some of these things, these fall risks. As a child or a caregiver, how can we look and fall-proof our parents’ or older family members’ homes?

Natalie Fick:

So one of the first things that I have people do, whether your own home or in a family member’s home too is looking at just clearing the waste. So are there trip hazards that are around that we can potentially just get rid of? Whether it’s some cords, it could be rugs, just general clutter, whether we have maybe some boxes or things kind of sitting around too just to see. Can we have clear walking paths that we don’t have to worry about tripping over things?

The rugs can be always a hot topic for some people because they don’t always want to get rid of them, which I understand, but can we look at if there’s even some safer alternatives? So some non-slip rugs that maybe have that rubber backing so they’re not sliding. They make some tape or different adhesive type things now too that you can utilize on them just so that they’re not sliding around or they’re keeping the edges down decreases your tripping risk there too.

So things to look at in your environment, but also even then looking at moving furniture if needed. So sometimes our environments, we have a lot of pieces of furniture or how the layout is can make it very tough to navigate. And so can we shift things a little bit so that I don’t have to be kind of scooting sideways to get past this chair or to get in and out of bed? Can I have a better space?

The next thing we always talk about too is how is the lighting in your environment and do you have a good source of light by your stairs, in your bedroom or your bathroom as you’re navigating around so that again, you can see where you’re going? Replacing light bulbs if you need to or looking, is there ways that I can potentially add lighting on these low-light areas so that I can see better and reduce your tripping risk?

When you talk about like your bedrooms too, even just is there a chair? So if you need to be able just to sit down and put your shoes on or to get dressed, depending on where you’re doing that, like your shoes too throughout the house, do I have a surface that I could sit? And it could be as easy as bringing a chair into your bedroom or making sure you have a nice sturdy bench in your porch to put your shoes on too. But just to have that as an option so that you don’t feel like you have to try and just stand on one foot and balance or very precarious with that securing or adding support.

So especially like in your bathrooms, do you have adequate grab bars that you can utilize? And ideally we want them installed well so you know, screwed into a stud, something sturdy that’s not going to pull out of the wall. And I know that another option that we have as an a temporary option if you can’t do the ones that are manually fastened to is sometimes the really strong suction cup ones can be a nice temporary benefit too, that you have something sturdy to grab onto instead of can I just try and grab the shower curtain rod or kind of some of these different things that are around that really weren’t meant to be a grab bar.

Alan Helgeson:

And one of these things too that I would go out to say here too, Natalie, is that working with a trusted and medical equipment facility like Sanford Equip too because they’re skilled at finding the right pieces for the right job that you’re looking for. Because oftentimes you find some of these that are less quality and all it takes is one time for this stuff to bust loose or to break or to not adhere in the right way and that’s when a fall can happen. Correct?

Natalie Fick:

Correct. They have, you know, like toilet risers or shower chairs, things like that too, that if you need it, they have that as something that you can go look at. You can try it out and see if it works in your space and can be a great solution to again, help keep you safe with those areas.

And then the last thing I always like to have people look at too, especially in your kitchens, but just throughout your house too, is just where do you store your most commonly used things too? So are the things that you use a lot, are they really up high in your cabinets or are they down low tucked away where you are either going to have to potentially use a step stool or do some unsafe reaching? Can you potentially shift things so that it’s maybe stored between your waist and your shoulder height so that that’s easily accessible and that you don’t have to constantly be putting it up and down or using the step stool? Especially if that’s not something that’s either safe for you or comfortable for you to use too. And that’s where I know sometimes people prefer like a clutter-free counter, but sometimes we maybe leave that mixing bowl that we use all the time just on the counter so it’s easily accessible instead of lifting in and out of the cabinet all the time too.

Alan Helgeson:

That sure is hard though for people, right?

Natalie Fick:

It is.

Alan Helgeson:

Getting used to it though.

Natalie Fick:

<Laugh>. It is <laugh>.

Alan Helgeson:

Alright, well, let’s move from the physical things. Let’s talk about some of those situational signs though as we may be visiting older adults and see some of those things. We’ve talked about those physical things, but some of those situational things.

Natalie Fick:

Yeah. Sometimes just to keep an eye on your loved ones too and just see, sometimes you can quickly see better than they can if there’s areas that they’re just maybe struggling a little bit more with. So watching like how they navigate stairs into and out of the house, if they’re really having to pull themselves up or really rely on those railings or somebody else to kind of assist them up. Making sure, do they have good railings or is there another option that they could potentially have for added support or safety navigating there?

Looking at just when they’re kind of going around the home too. Do you notice if they’re making quick turns, if they’re losing their balance or kind of stumbling? Or sometimes you’ll see them too where they’re really relying on furniture and the walls to walk and maintain their stability too. That could just be an indication that either, again, they’re not feeling very steady on their feet. Or do we need to potentially entertain the idea of an assistive device just to help to maintain their stability as they’re navigating their home environment or when they’re out in the community too?

Alan Helgeson:

Well, Natalie, let’s switch gears a little bit here. I want to go back to – we mentioned this just briefly as we were talking about fall risk way at the beginning of the episode – but let’s talk about bone health and osteoporosis and the role that that might play in fall risk, like healing broken bones, brittle bones. Is that sex specific? Does it play even more role in certain sexes? But you know, kind of pick and choose where you want to go with that.

Natalie Fick:

Yeah, so when we hear osteoporosis, I think most often you think of women that this is a concern for too because any woman over the age of 50, usually one in two will have issues with osteoporosis in their lifetime. But I never say rule the guys out with that too, because in that same age bracket, so over 50, one in four men potentially have some osteoporosis too, or osteopenia, which is just kind of that precursor. And showing that there’s some weakening of bones as well.

Just even to assess your risk factor of this, again, your providers usually are recommending getting a DEXA scan right around that age 50 just to look and see where that bone health is too.

And from there, if we’re identifying that osteoporosis is something that is of concern for you, they might recommend either some medications or something that is actually very beneficial too is exercise.

So we adding the, the strength training, the resistance, because we know by challenging our bones, by providing some impact safely can actually help to strengthen our bones too. So trying not to shy away from that. And that’s where either therapy or some exercise classes can be very beneficial on finding a way to start with that too and keep you safe and decrease your fracture risk too because we know when osteoporosis is around you are at a higher likelihood of sustaining a fracture. And sometimes then too it may take a lot longer for that fracture to heal.

Alan Helgeson:

Really good information you’ve been talking about here today, Natalie, but let’s go back to your education here as a physical therapist now. Let’s talk about as a physical therapist, discuss how therapy can come in and play a role in helping people preventing falls and in that recovery should a fall have happened in the injury.

Natalie Fick:

With fall prevention and physical therapy, we love to even work with people proactively. So they might have had a fall or they might have had some instances where they’re noticing that they’re a lot more unsteady and this is something that we can gladly jump in and help people out with before we’re even starting with some just general balance and coordination training. So providing them with some exercises and things that they can do at home and in the clinic with us just to improve that overall balance and stability. Just making sure that they feel more confident with their coordination, to be able to react to those different perturbations and challenges out in the community or at home where your balance might be challenged, and knowing that you can hopefully take the steps or adjust to be able to maintain your upright posture so that you’re not ending up on the ground.

We also work with people too and just overall with some strengthening. Because we know that by strengthening those major muscle groups, especially in your legs, that increases your overall stability and reduces your fall risk, and shows that it’s easier to get up out of a chair, do some of those things that also can be very challenging as we age.

And we want to make sure that again, we can age in place, we can maintain that mobility that we want to and not have to struggle with just those daily functions as well. And then we also can work with people too just with assessing their gait, their walking, seeing if there’s that need for an assistive device or if there’s little adjustments and things that we can help recommend just to keep them safer when they’re navigating certain challenges.

Alan Helgeson:

So much good information. Any last thoughts that you want to share today and maybe that takeaway nugget here about falls prevention, Natalie?

Natalie Fick:

We know that falls is a huge concern for the aging population, and it doesn’t necessarily mean that you’ve had to have a major fall in the past. That fear can kind of creep in even if you’ve known people that have had injuries, you’ve had loved ones that have had a very adverse outcome from a fall.

And so we know that on the positive side that falls are very multifactorial, that it’s a lot of things that you can do to prevent falls and to reduce your risk. And I think it’s something kind of empowering for a lot of people to know that they can kind of take charge of that and they can do a lot to prevent those falls and overall keep them strong and moving well.

And that’s I think something that once they understand where those resources are, whether it’s with their provider, whether it’s with their therapist or any of the community exercise programs and things going on too, that they can take those positive steps to keep them moving well and aging in place and maintaining their strength and their mobility too.

Alan Helgeson:

Natalie Fick, thank you for being our guest today. It’s been a pleasure having you here.

Natalie Fick:

Yeah, thanks for having me.

Cassie Alvine:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen on Apple, Spotify and news.sanfordhealth.org.

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Mammography vs. thermography for detecting breast cancer

Dr. Christina Tello-Skjerseth:

I think some people just feel better with getting some kind of exam that is pain-free and doesn’t have radiation. And that’s fine for some people, but you need to know that it’s not actually detecting cancer. And just because you get a negative thermogram does not mean you don’t have cancer. And you really should be using modality like mammography, which has all the data behind it and that’s federally regulated so that things are done consistently and accurately.

Courtney Collen (host):

This is “One in Eight,” a podcast series by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. One in eight women will be diagnosed with breast cancer during her lifetime, so we want these conversations to shed light on awareness, featuring expertise from our Sanford Health providers that could save your life or the life of someone you love. We’re so glad you’re here.

This conversation breaks down the difference between mammograms and thermograms. To help us do that, I want to welcome Dr. Christina Tello-Skjerseth. She is the chief of radiology at Sanford Health in Bismarck, North Dakota, and chief of staff at the medical center, and specializes in diagnostic imaging as a radiologist. Dr. Tello, welcome.

Dr. Christina Tello-Skjerseth (guest):

Thank you so much for having me again. I’m looking forward to this talk.

Courtney Collen:

Me too. So happy to have you here. I’m not familiar with thermography in this space, especially when it comes to screening for breast cancer. Can we start by having you break down the differences between mammography and thermography?

Dr. Christina Tello-Skjerseth:

Sure. So mammography is essentially obtaining a specialized X-ray of the breast where you can see the different kinds of tissues in the breast. And the purpose of that is to find breast cancers when they’re smaller and, you know, earlier and better to treat.

Thermography is a different type of exam. It’s actually like a heat sensing camera that can take the temperature of the skin surface and then make like a different pictorial representation of that. So it doesn’t actually show anything inside the breast. It doesn’t really show you any detailed anatomy, and it’s FDA approved because of its safety profile. It’s a safe technology, but it’s not approved because of its efficacy.

So we actually don’t use thermography to detect breast cancer. It’s really just sensing temperature on your skin. And, you know, the theory behind that is that breast cancers are hypermetabolic, meaning they essentially take up more blood flow because the cancer is making more vessels, and it essentially eats more, if you want to think of it that way. So the thought process is that more vessels, more metabolism, makes that area hotter. It gives off more heat, and then you can see that on your skin surface.

Now, the research behind thermography, most of the data out there is from the ‘70s and ‘80s. There’s really no recent information about it showing that it can actually detect breast cancer. And the FDA actually will put out warnings to facilities that that advertise thermography as a breast cancer detection tool. That’s really not what it’s used for. It’s approved to be used in addition to another type of screening or a diagnostic test, not a stand-alone tool.

Mammography is extremely regulated by the government, by the FDA and MQSA, which is Mammography Quality and Standards Act, since 1992. So there are a lot of guidelines, rules, and certifications we have to stick with and follow every three years to make sure that our equipment is appropriate. Our technologists are up to date, and the radiologists, and how we interpret exams, even the language we use in the reports, it’s all standardized and very regulated. So everyone across the U.S. should be doing it the same if they’re certified in mammography. Thermography really has nothing like that.

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Courtney Collen:

What kind of misinformation are you hearing or reading about specifically when it comes to thermography as some might compare it to mammography? Can you help clear the air there?

Dr. Christina Tello-Skjerseth:

Let me start with the main benefit of mammography. It’s the only tool we have, the only screening tool we have that has shown – from decades and decades and decades of research – to decrease mortality from breast cancer, meaning your chance of dying from breast cancer. And studies have shown that there’s a 40% reduction in breast cancer mortality using screening mammography.

Some of the harms of mammography, and I say “harms” in quotes, the main one is radiation. So yes, we’re taking X-rays of the breast and that makes radiation. So your body is getting radiation from the machine. And most of our data regarding the harms of radiation in general come from atomic bomb survivors in the ‘40s and other different atomic disasters we’ve had. And it’s all extrapolated data showing what the potential risks are for having certain doses of radiation.

Now, mammography has a very, very low dose of radiation. It’s about equivalent to maybe getting three to five chest X-rays. And to us living here on Earth, we get cosmic radiation every day that comes down from the sun, space, everything outside the Earth. And so there’s a certain dosage that we get every year. And getting a mammogram is about equivalent to just living on Earth for two months. It’s about that same dose of radiation. So it’s a very low dose.

Our equipment is very technologically advanced. It’s very modernized. So we’re able to calibrate very well and get the dose as low as reasonably possible. It’s very safe, and there’s been no data out there showing that mammography causes cancer. And that’s really the main I’ll say advertisement that people use for thermography is that there’s no radiation. There’s not an increased chance of getting cancer from that tool.

Thermography is also reported as painless because there’s not any compression of the breast. That’s another one of the, I’ll say, harms or downsides of getting mammography is that you are in a compression paddle. So some people are really sensitive to that and it can hurt for the most part, you know, having them myself, I would just say it’s just uncomfortable, but it’s just for a couple of seconds. There’s no long-term damage for that.

So I guess to kind of summarize that the main issues with mammography are the radiation, the pain.

Another one is the callback rate, meaning if you have a screening mammogram and then we find something and bring you back for more imaging, people get very anxious and concerned about that. But what people need to realize is that there’s really only a 10% callback rate. So for every thousand mammograms that we read, we’re only really calling back 10 people, I’m sorry, a hundred people to get further imaging. And the vast majority of those people will just get sent back to screening or have like a short term follow-up. The biopsy rate is quite small. The actual rate of cancer is quite small. It’s about five to eight people per a thousand mammograms will actually get diagnosed with cancer. So it does cause a lot of anxiety.

Thermography really doesn’t have any of that related to it, so to speak. But one thing I want to highlight is if you do get a thermogram and they find something “abnormal,” the next thing to do is to get a mammogram. So you’re really not preventing getting further imaging. And they’ll actually send you to your doctor and they’ll do a full workup of the breast. So it’s not like you’re completely cutting out mammography or radiation as a whole. But I think the bottom line is that the radiation profile of mammography is very safe and it has not been shown to cause cancer.

Courtney Collen:

And the mammogram is still the recommended tool in prevention and detecting breast cancer early. Correct?

Dr. Christina Tello-Skjerseth:

Absolutely. Yep.

Courtney Collen:

What question should I be asking my provider regarding a mammogram or a thermogram?

Dr. Christina Tello-Skjerseth:

Well, I think now in 2024 we’re really getting more towards a sense of individualized medicine, and having those conversations with your provider as far as your risk profile. There’s a lot of genetics that go into your risk for breast cancer, but there’s a lot of environmental things as well: the age at which you had a child, the age at which you started your menstruation, drinking, smoking, there’s all kinds of different environmental things out there that can increase your risk, if you had biopsies before, if you have certain medical conditions. So it’s important to have those conversations with your doctor early.

We actually recommend having some kind of risk assessment by the age of 25 just to see if you would fall into those average risk guidelines for mammography versus high-risk guidelines. And those do change. If you’re average risk, the recommendation from all of the major societies that we follow in this country are to start annual screening, mammograms at age 40, so you get those every year. If you’re higher risk, we may start you as early as 30. If you’ve had a relative – a first year relative, like your mother or sister had it in their 30s – maybe you’d start 10 years earlier. So even in your 20s. So we are actually screening some women in their 20s.

Additionally, you may add on a breast MRI if you’re high risk. So there’s really a lot of options we have. So again, it’s really important to have that risk conversation with your primary care provider to decide what schedule you should be on.

Courtney Collen:

What role, if any, does thermography play in breast cancer screening?

Dr. Christina Tello-Skjerseth:

You know, to be honest, it really doesn’t play a role in screening. I think some people just feel better with getting some kind of exam that is pain-free and doesn’t have radiation. And that’s fine for some people, but you need to know that it’s not actually detecting cancer. And just because you get a negative thermogram does not mean you don’t have cancer. And you really should be using modality like mammography, which has all the data behind it and that’s federally regulated so that things are done consistently and accurately.

I will also say that the FDA does a really good job at watching some of these facilities that offer thermography, and mostly they’re going to be like medical spas or naturopathic, homeopathic type places, chiropractic care, that offer thermography. The FDA watches these facilities pretty closely. And if they advertise thermography as a screening tool and advertising it as having the ability to detect breast cancer, the FDA will send those facilities a letter, essentially telling them to cease and desist and to not give out that misinformation to the community.

We have one here locally that advertises it, but they advertise it appropriately and saying that this tool does not detect breast cancer. It’s to be used as an adjunct tool. So they’re at least advertising it correctly. But again, thermography really doesn’t have any data behind it showing that it can detect breast cancer and that it’s a good stand-alone tool and it’s not approved to be a breast cancer screening modality on its own.

Courtney Collen:

Sure. And like you said, if they were to detect anything, then a mammogram in most cases is the next step.

Dr. Christina Tello-Skjerseth:

Exactly. And when you really think about it, again, it’s a camera that’s detecting the temperature of your skin. So anything that’s increasing your temperature in that area could cause a positive thermogram. I could touch my breast and just put a little pressure on it. That’ll increase the heat there. Being outside will increase the heat. I mean, there’s lots of things, any type of inflammation will increase that heat. So it’s not specific for cancer.

Courtney Collen:

1. And to recap, schedule your first mammogram starting at age 40 every year. And then if you’re high risk, sometimes as early as 30, and some women are even screened in their 20s in some cases.

Dr. Christina Tello-Skjerseth:

Yep. And then adding on some kind of supplemental screening if you’re high risk such as a breast MRI. That’s really the number one tool that we use in addition to mammography.

Courtney Collen:

Such valuable information. Thank you so much, Dr. Tello. What else do you want us to take away from this conversation?

Dr. Christina Tello-Skjerseth:

I guess I would just say if you do have any questions, please talk to your provider. I’m hoping you know that a lot of people now have good information about thermography so that they can have those conversations with their patients. And if the providers ever have questions, they can always call the radiology department. There’ll be a breast imager there that can answer any of their questions before they talk to those patients.

But I think just as a whole, it’s good to have good information, ask questions out there, whether you’re a medical provider or a patient, just to kind of know what the options are and what’s appropriate. And again, please know that mammograms are completely safe and very federally regulated so that things are being done safely and effectively. And again, it’s the only modality we have that can decrease your chances of dying from breast cancer, and that’s from decades and decades of research.

Courtney Collen:

Dr. Tello, thank you so much for your time and for all that you do.

Dr. Christina Tello-Skjerseth:

Thanks for having me. I appreciate it.

Courtney Collen:

This was “One in Eight,” a podcast series by Sanford Health. Find more of these podcast conversations featuring our Sanford Health medical experts on Apple, Spotify, or news.sanfordhealth.org. For Sanford Health News, I’m Courtney Collen.

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