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Amazon Pharmacy chief: Patients demand more convenient care

“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. Vin Gupta, Chief Medical Officer of Amazon Pharmacy and keynote speaker at the 2024 Sanford Health Annual Meeting on the topic of leading through change and uncertainty to create the next breakthrough.

Courtney Collen:

Dr. Vin Gupta, thank you so much for joining us this morning, and welcome to Sioux Falls.

Dr. Vin Gupta:

Thanks for having me. Great to be here.

Courtney Collen:

What are the top three opportunities you see when it comes to finding solutions to the most complex challenges in health care and society now and into the future?

Dr. Vin Gupta:

You know, Courtney, it is the essential question we have to ask the entire U.S. health care system, and everybody involved: In the care of patients, how can we do better? Especially coming out from the wake of, or the very peak of the pandemic.

What we’ve ignored is that there has been a baseline chronic epidemic of chronic disease undergirding all of American society. It’s a challenge that has its roots in a lot of issues, but I think number one, the biggest opportunity is people often don’t know they have illness when it first sets in. And so how do we empower patients with better diagnostics so that they know when they have early-stage hypertension that they can get treated soon?

And that leads me into the second opportunity, which is we’ve seen such an emergence of telemedicine at home health care efforts. If you can compare better diagnostics that if you can let somebody know that there’s a problem early on in their illness, whether it’s a chronic disease like hypertension, better diagnostics for cancer. Courtney, I’m a pulmonologist. 5% of people that are eligible for a lung cancer screening test, like a CT scan, actually take advantage of it. People don’t get, utilize the diagnostics that they have available to them right now, but better diagnostics coupled with these at-home health care services, hopefully will allow us to really intervene earlier when somebody has disease, to keep them out of the hospital, to keep them out of the four walls of an inpatient facility like exist at Sanford and maybe within the outpatient environment.

And then lastly, I’ll just say generative AI. We were all talking about how artificial intelligence can help augment the clinician experience. I think it’s going to help us with burnout. I think it’s going to help us with documentation of notes and also reduce misdiagnosis. So there’s a lot of opportunity there.

Courtney Collen:

Thank you for the insight. That’s really eye-opening.

Dr. Vin Gupta:

Yes. It’s pretty extraordinary.

Courtney Collen:

Where have we made progress, Dr. Gupta, when it comes to innovation and success in health care technology? Where does work remain? How will this shape policy and strategy moving forward?

Dr. Vin Gupta:

You know, what we’ve seen already is that now 30% of primary care visits are virtual. People are now normed to experience health care with the doc that they may love within the comfort of their home. And so now our behaviors for health care have changed dramatically in just five years. I’m Chief Medical Officer of Amazon Pharmacy. 10% of pharmacy scrips are delivered direct to home. 90% people still go into the retail environment, which is difficult, especially if you’re sick and pick up their medications.

A survey was recently done showing that a third of people waste on average 13 hours every single year waiting in line at the pharmacy. So when we think about what’s taking root, how we can make it more convenient, how we can make the health care experience more engaging for patients, and maybe reduce risks for medication on adherence, what we’re seeing take root here is, is real traction in virtual telemedicine and services that are direct to doorstep that like getting your medications direct to doorstep. This is not just convenience. This is not just consumerism and health care. This can improve health care outcomes. Yeah.

Courtney Collen:

That’s great to hear. Change is hard, Dr. Gupta, for most people, let alone large organizations like Sanford Health or Amazon. What does it take to get everyone on the bus moving forward in the same direction? How can we motivate our teams to embrace change and innovation?

Dr. Vin Gupta:

You know, I often think that. I’ll say this, at Amazon, one of the criticisms I would have of my own company is that we often build products and services, especially in health care, with the best of intentions but without an understanding of what problem we’re trying to solve. And often in traditional health care, I see patients 30% of my time and in the four walls of an ICU. And we’re rooted to think that we know better because we’ve gone to school more than say somebody else that’s trying to do the right thing but might be an engineer or might have a different skill set but is really focused on the customer or the patient experience.

That’s why I’m so glad to be here today at Sanford because, as somebody that has feet and roles in both sides of health care, I think we need humility more than anything else. If we’re really talking about meaningful, durable change. We’re not just talking about disruption for disruption’s sake. If we’re talking about change that’s going to have traction and scale, both sides need humility. We both have to be open to conversation. But no one knows better.

And that’s the problem I’ve seen too often, especially in traditional health care, that we think we know better. We’re patriarchal in that there’s only one way to do things. And at a place like Amazon, they often build products and services with the best of intentions without clarity on if they’re actually solving a real pain point or a problem for a patient or provider. That’s why we need to come together.

Courtney Collen:

What excites you most about the evolving health care landscape and the potential for the next great breakthrough?

Dr. Vin Gupta:

You know, I think people are talking about health care. The average American is talking about health care in a way that maybe we were not four years ago, Courtney. That the pandemic, if there’s a silver lining to the last four years of crisis, is that now we are much more aware of our own health. What it means to be medically higher risk and what it means to receive care in different types of environments. Like, like again, your home. And oh by the way, different tools to, and different ways to reduce cost of care.

It’s a lot cheaper sometimes just to buy a medication through say, cost-plus drugs that Mark Cuban is innovating on than using your insurance co-pay. People are understanding now that health care innovation means something for the bottom line, their pocket, and also for convenience, ultimately for their own health care outcomes.

That is what’s given me a lot of hope here, that we’re not having to convince corporate administrators of what the right thing is to do. We’ve gone directly to the people. The people have seen the change that’s happening before their eyes. They’ve seen the ways in which the health care system has struggled that the last four years of the pandemic and they want change. And that is now going to cause a demand for a different way to do things. That’s what’s giving me hope.

Courtney Collen:

What is one thing you want us to take away from your conversation on the stage and your visit here in Sioux Falls?

Dr. Vin Gupta:

I think everybody likes to talk about the future of health care buzzwords. Like AI, it’s sexy to talk about. And what I’m going to focus on today are actual true innovations that are scaling as we speak, that represent real opportunity for Sanford, for Amazon, for all of us to come together to do what’s right for patients. But we’re not going to talk about the abstract today.

We’re going to talk about ways in which we can help the Sanford health care system grow, grow in a way that’s fiscally sustainable, that’s going to be able to reach your patients in a scalable way. By 2030, we expect that there’s going to be less health care workers for the demand that’s going to exist in a place like Sioux Falls.

So how can Sanford grow and meet that challenge by 2030? It’s going to be through technology, but it’s not going to be through abstract ethereal conversations on technology. It’s going to be about what I’m going to talk about today, the movement towards at-home health care, meaningful integration of generative AI in the electronic medical record and better diagnostics.

Courtney Collen:

Dr. Vin Gupta, thank you so much for your time, your insight, your leadership, and all that you do in the medical industry. 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.

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Doctors, nurses sound the alarm as vaccination rates drop

Alan Helgeson (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about childhood immunizations and vaccines. Our host is Dr. Joseph Segeleon, vice president medical officer, Sanford Children’s Hospital.

Dr. Jospeh Segeleon (host):

Good afternoon. This is Joe Segeleon, and welcome to a Sanford podcast on childhood immunizations or vaccines. I’m very excited today to talk about this subject that I know has caused some controversy and has been in the news quite a bit in the last couple of years. Vaccines have generated a lot of attention in the past few years, so let’s tackle this important issue so we can shed guidance and clarification and really give our recommendations on science-based guidance. So today, I’m excited I’ve got two great, great experts that are going to add quite a bit to this conversation, and I’ll have them introduce themselves first. So, Andrea, why don’t you go first?

Andrea Polkinghorn:

Yeah, thanks for having me. My name is Andrea Polkinghorn. My background is I’m a nurse and I’m currently the lead immunization strategist for Sanford Health.

Dr. Jospeh Segeleon:

Great. And welcome. It’s good to have you here. And then we also have Dr. Dani Thurtle as well. Dr. Thurtle, why don’t you introduce yourself as well?

Dr. Dani Thurtle:

So, I am a pediatrician. I am boarded in general pediatric medicine as well as pediatric hospital medicine. I also have a special interest in vaccines and immunization, and I co-chair the (Sanford Health) Enterprise Immunization Committee with Andrea.

Dr. Jospeh Segeleon:

So as our audience can tell, we have two experts that have significant experience in childhood vaccines. And so we’ll go ahead and dive in.

I think what we’ll start with is, I know the entire subject of vaccines as a whole is fairly daunting. But for our listeners, maybe if either one of you would like to offer a brief history of vaccines, why are they important both in the United States and in the world for everyone? What is their place in preventive health medicine, and perhaps what have been some of the success stories, or what have we learned and what have we gained from having childhood vaccines?

Dr. Dani Thurtle:

So I guess I can kick it off. Vaccines have been around for a really long time. Actually, the first that we think of is a smallpox vaccine, which was developed in the late 1700s. Our vaccine science has come a really long way. Modern vaccines really started around the 1950s with the polio vaccine. And since then, our technology and our knowledge of viruses and bacteria has really taken off in a way that’s allowed us to create safe and effective vaccines against a wide range of diseases that we see every day.

I think the most impressive worldwide impact is when we can eradicate a disease. So like we did with smallpox in 1980, the CDC and the World Health Organization declared smallpox eradicated, which means you can’t really catch it anymore. It only exists in labs and we’re able to prevent death and hospitalizations in all kinds of settings from that.

Andrea Polkinghorn:

Yeah, so I think Dr. Thurtle outlined it really well. I think the other thing that I’d like to highlight or help people understand is, you know, when we’re vaccinating, we’re not always working to prevent a hundred percent of disease. And there are some side effects, very mild, that are associated or you can get from vaccines. But we see the same thing, and that’s why we developed the vaccine.

So if you think about the complications that came from polio, so people having to be in iron lungs or not being able to walk any longer. I know an adult polio survivor who lives in Brookings and he’s wheelchair bound. Thankfully those are his only complications and that he didn’t have a more severe reaction from that disease. And so everything is a risk versus benefits, but they’re safe and effective, and that’s why we have more vaccines now today than we have in the past.

Dr. Jospeh Segeleon:

Well, thank you. I appreciate that. So I saw Dr. Thurtle brought up smallpox and we certainly, I haven’t seen a case of smallpox in my career and we attribute that success to vaccines. And of course, a vaccine does not work unless it goes into an arm (laugh).

So let’s talk a little bit about other success stories in measles, diphtheria, pertussis. Other things come to mind. So maybe Andrea, maybe you’d be best to talk about that from the standpoint of, are vaccines effective in eradicating organisms from people or from the population in general?

Andrea Polkinghorn:

Yeah, so really it goes down to public health and we need so many people to get vaccinated so that we can prevent the spread of that disease or having like a large outbreak. We have seen great success. So if you go back and look at the data of the incidence of pertussis before the vaccine came out, it was very high. And it’s much, much lower today when you look at the data. So while we still see some cases, we’re not seeing the outbreaks because a sufficient number of people have been vaccinated to help prevent that from happening. And so when you look at the historical data compared to where we are today, the incidence that these diseases are happening is much less.

The flip side to that is that what they say is vaccines are a victim of their own success. And so people aren’t seeing the diseases as frequently, which leads them potentially to have a feeling that they’re not needed anymore. And that’s just simply not true. These diseases, you know, they occur more frequently or at a higher rate in other parts of the world. And so with international travel, if we loosen up on our immunization right here and people are traveling, if they’re not vaccinated, not only are they susceptible to those diseases, but potentially bring them back and cause an outbreak here.

Dr. Jospeh Segeleon:

Great, thank you. And I think we’ll expand upon that point maybe in a couple minutes here because we acknowledge that vaccine rate is in fact declining and we have concerns about decline of that uptake. So we’ll tackle that in just a couple of minutes.

What I’d like to do now for our listeners is I’ll go to Dr. Thurtle. Dr. Thurtle is a pediatrician. So Dr. Thurtle, if you will, for the individuals who may be on the listening end, let’s pretend that you are talking to new parents as they get ready to start their journey in parenthood, recognizing there’s no manual that I know of yet. And so they’re going to their pediatrician. And how would you discuss what does childhood immunizations look like and also influence their decision on how important the immunizations are for the health of their child?

Dr. Dani Thurtle:

Thank you for this opportunity. It’s definitely a really big topic. Anytime you’re letting someone affect the health of your child, it’s a really big decision. So I love that parents are curious about this. Childhood vaccination really starts at birth. We now have two different viruses that we can immunize against in the hospital, including RSV, which you may get in the hospital or shortly afterwards, or the hepatitis B vaccine, which we know is most effective the closer it’s given to birth.

So we try to give within the first few hours of life, childhood vaccinations go through the entirety of childhood up to 17 and 18 years old. And there’s over 17 different viruses or bacteria, depending on how you count, that are recommended for all children to be vaccinated against. The real bulk of those immunizations start at the 2-month visit. And then at the 2-, 4- and 6-month visit, we’ll see quite a few different vaccines. Those are mostly bacteria that cause brain and lung infections and even polio and tetanus and whooping cough are in that batch.

Then kind of scattered throughout the 15-, 18-month and 1-year visit, there’s a few more. And then at 4 years old we do the kindergarten shots. That’s the point at which most people think your traditional childhood vaccines are kind of wrapping up. Then we get into the group of older kid vaccines, which include more whooping cough and things that older children are more susceptible to, such as brain infections, like meningococcal disease.

So I think the important points here are that vaccines are really targeted to the population that is most at risk. So we know young babies are more at risk for some things, and that’s when we vaccinate. And older kids are specifically at risk for different things, so that’s when we vaccinate for those. It’s really targeted at the time and then you have to get quite a few doses of many of those to get a response. So that’s why there’s numerous booster doses.

Dr. Jospeh Segeleon:

Great. And so for those young children that are so vulnerable, what would be the risk if they did not get vaccinated?

Dr. Dani Thurtle:

So the risk really does go up and include death. And I don’t mean to be really morbid and the bearer of such bad news, but we really vaccinate against very serious diseases. Things like pneumococcus you might have heard of, or haemophilus influenza type B. Those are well known to cause very serious blood, brain and lung infections that can kill children in a short period of time.

We’ve seen a significant decrease in death in this age group because of those. Some of them like rotavirus you might know and have more experience with. Children do get diagnosed with rotavirus or vaccinated against rotavirus in the 2-, 4- and 6-month vaccines. That’s been more useful in preventing hospitalizations and like very severe dehydration. So it really runs the gamut of mild to severe. But I don’t want people to discount the importance of these vaccinations. They’re very important and very devastating illnesses.

Andrea Polkinghorn:

Dr. Thurtle, me, myself, I had chickenpox and I think that’s a really good example of a lot of people or a lot of adults today had chickenpox and probably thought, oh, I was uncomfortable for a period of time, but I did just fine. And so can you talk about some of the complications that we saw there, which is why we actually recommend vaccination now, even if somebody was lucky enough just to have that itchy rash when they had the disease in the past?

Dr. Dani Thurtle:

Yeah, so many common childhood illnesses actually have a small percentage of very severe complications. Chickenpox is going to be one of those where you can actually have a devastating brain infection that can cause scarring and seizure disorders later in life. Additionally, if you have a very severe chickenpox infection, it can put you at risk for bacterial infections.

The same thing with measles. Measles has a long-term complication that can cause devastating brain effects and neurological outcomes later in life. So things that people think are really simple illnesses, a small percentage of those do have devastating and severe complications that we can’t prevent, we can’t predict and we can’t reverse. So the safest and best way to prevent those is through vaccination.

Dr. Jospeh Segeleon:

I want to thank both of you for those great comments. As a physician and as a pediatric critical care physician, I was in my training and in my early practice years prior to some of those bacterial vaccines that Dr. Thurtle spoke about had come out. And so I did want to make sure that we pointed out that we don’t want to take it for granted that we don’t see as much of those illnesses because we don’t see it because, in fact, children are vaccinated against those. And so with our rates declining, I wanted to make sure we pointed that out.

I also wanted to comment on something that Andrea said earlier. We now have an RSV vaccine. RSV is the number one cause of hospitalization in children. We have a flu vaccine, which we’ve had for many, many years, and though you may still get the infection, if you are vaccinated, the likelihood that you will get very sick or hospitalized or die is significantly reduced if you’re vaccinated. So I thank you both for pointing out those extremely important points.

Andrea Polkinghorn:

Dr. Segeleon, I like that you touched on flu because I was going to lift that up relative to Dr. Thurtle’s comments. Every year there are on average probably about 150 to 200 children who die from influenza every year. A majority of those are unvaccinated. I think people also tend to think, oh, they’re probably kids with chronic conditions, but the data does not show that. These are completely healthy children who are dying from this disease. And so people who, you know, say that, well, the flu vaccine doesn’t work that well, I don’t want it, kind of what I’ve told them is like, it’s the best defense that we have. And yes, even if it’s only 30 to 60% effective in preventing you from getting sick, that’s still better than zero and it will prevent you from those severe complications like hospitalization and death.

Dr. Jospeh Segeleon:

Yeah, I appreciate that. As an intensive care doc, we’ve all taken care of children who have had severe flu, just like also you reminded me in asking about chickenpox. Prior to the chickenpox vaccine, the secondary pneumonia that kids can get is also extremely virulent. So thank you.

We said at the beginning of the conversation that vaccines have really been in the media quite a bit, and there’s been some, perhaps some unnecessary controversy surrounding vaccines. The unfortunate result of that is that the rates have been declining. So I would like to ask both of our guests perhaps what their opinions might be on why are these rates declining? And then for either of you, what are the consequences of vaccines declining for both an individual and also for the general population?

Dr. Dani Thurtle:

Yeah, I think that what we’ve seen is, especially through the pandemic, we saw a lot of this. That fear is an incredibly powerful motivator for people and how they act and how they protect themselves. Since vaccines are, as you’ve already heard Andrea say, a victim of their own success, fear is no longer on the side of these illnesses to motivate for vaccination. They do cause severe complications and death, and they are things that I think parents should be afraid of. Instead, fear’s on the side of what we see more often, everyday things in our social media feeds, right?

So there are complications to vaccines, just like with any medical treatment that we do. There’s always a risk-benefit analysis. As a pediatrician, for the majority of patients, the risk-benefit analysis is going to come out on the side of the vaccine. But people are going to see more about complications, particularly when you’re surfing social media. So people see more about different conspiracy theories and other considerations. There have been waves of these kinds of things such as in autism and other things going through the news.

These are always debunked with really, really good evidence and studies that again and again have affirmed that vaccines are safe, they’re constantly monitored, they’re constantly reviewed, they are constantly scrutinized. The CDC does a great job with this. So I fully endorse the safety of vaccines. But I think that there is serious fear out there and we know people respond to fear as a motivator.

Dr. Jospeh Segeleon:

I hear the passion in your voice. Andrea, go ahead please.

Andrea Polkinghorn:

So I think it’s important for people to know that vaccine hesitancy isn’t new. There’s a infographic or it was really a cartoon back from when the smallpox vaccine was coming out that essentially tried to tell people that if you accepted the vaccine it would turn you into a cow. I think what has changed since that’s not new is the ability to quickly, effectively, and broadly disseminate misinformation.

So you talk about things like Facebook, that’s absolutely true. But even some of these news articles, like if you saw something, there’s usually buttons below it that you could share it quickly with like 15 other websites. And so that’s something unfortunately that we have to work to overcome. I think the questions are OK. I totally agree with Dr. Thurtle. You know, when you see that information, it can be really alarming. So I think the important thing is that people are following up with their provider to have discussions about what they saw and to get their questions and concerns really addressed or seek credible websites. Some of the opposition groups actually have robust websites that really look credible, but they’re not.

Dr. Jospeh Segeleon:

Great. OK. Well thank you. I heard Dr. Thurtle use the word “fear” a number of times. And I think of fear, and then when it comes to information or misinformation, I naturally go to the word trust. So if I want to get a trusted information source – and Andrea, you appropriately pointed out the myriad of social media that is available to all of us when it comes to childhood vaccines – what should be my trusted source? Where is that information out there that we can advise and guide our listeners so that they can get credible science-backed information that they can trust?

Dr. Dani Thurtle:

I always say that the best source of information is going to be your child’s doctor. And the big reason for this is because they know you and they can respond to specific concerns in the context of your family and your child’s health. So for example, when I was seeing family in clinics, if I had a family who had a history of seizure disorders, then I could focus on the adverse reactions that I thought were most likely for that family. And then we can talk to those very specific concerns that pertain to you in a really methodical and thorough way to answer specific questions. But that’s why the pediatrician is going to be the best source of information.

Outside of that, the CDC has a wealth of websites and information that are really great to look at. They’re really easy to read, full of excellent information and infographics. You hardly have to read anything. It’s all in pictures, but it does address a lot of the concerns and controversies in a really evidence-based way that’s easy to digest. So I also enjoy the CDC. The American Academy of Pediatrics has good information as well, targeted towards families. But where else do you point families to Andrea?

Andrea Polkinghorn:

Probably not as well known, but Vaccinate Your Family has a pretty good website as well. I think the readability of the CDC is probably a little bit better there. That’s honestly my go-to, especially if you don’t have a clinical background. It’s put in into very good layman’s terms for people without that background.

Dr. Jospeh Segeleon:

Well, I appreciate that. I heard primary care physician, I heard some great sites on the CDC and other sites. We discussed some of the misinformation and the fear, and the importance of trust.

Before we go to access to vaccines, I think I did want to just for a moment talk about, as we’ve seen some decline in vaccines, well, every year in the United States we hear about measles outbreak. We look globally, we have seen some resurgence of diseases that we really haven’t seen in quite a while. So I guess I would like one of you to talk about with this misinformation which has resulted in a decreased (immunization) rate. Maybe we can use measles to talk about what’s the danger to both to our population. We hear about schools that have measles outbreaks, et cetera. Andrea, are you willing to tackle this one?

Andrea Polkinghorn:

I absolutely can. So I would say there is a lot of concern for those of us who work in health care or public health about potential measles outbreak due to the decline in childhood immunization rates.

Measles is a very contagious disease and we need about 95% of people to be immunized to prevent the broad spread of that disease. So even if you look at the data and see that we’ve dropped two, that’s like 2%, that’s still a lot because we can’t keep ourselves protected.

We kind of talked about the other parts of the world too, and measles occurs more often there. And so the concern that we have is that if we lessen, if we loosen up and drop our immunization rates, that our communities are going to be vulnerable to a measles outbreak, which we absolutely do not want.

Dr. Thurtle, I don’t know if you want to talk about some of the complications of measles?

Dr. Dani Thurtle:

Yeah. So I already kind of mentioned it earlier, but you can definitely get secondary bacterial infections, pneumonias, things like that. But the one that we really worry about is something called subacute sclerosing panencephalitis, which I like to say out loud because it sounds really scary, but it’s essentially a brain deterioration that happens years and years after your original measles infection.

So even if you think you get through the original infection and bounce back OK, there’s always that lifelong risk that you could have a reactivation and deterioration in your brain function later. It’s not uncommon to see rebounds of these. I think there were over 6,000 cases of mumps last year, and that’s over 50 cases of measles in the United States last year. These are things where we used to have zero cases every year. So they are around, you’re exposed to them and like Andrea said, we have to have a large percentage population to be vaccinated in order for everyone to be protected.

Dr. Jospeh Segeleon:

Well, thank you. I appreciate those comments. I think what I would add as well is with respect to whooping cough or pertussis, when you are a young child, until you complete your first three series of pertussis (immunizations), you remain vulnerable. And often when a young infant gets pertussis, it is life-threatening. Pertussis is the same as whooping cough, and they frequently may get it from a grandparent or a parent or an older sibling if they haven’t been immunized.

So we do continue to see pertussis. It is a very, very serious illness in our young children. And so that’s another circumstance where immunizing a general population protects our most vulnerable children. So really in recapping our conversation we had a great conversation about the history of vaccines. The phenomenal success of vaccines have been for our children both globally in the United States.

I appreciate Dr. Thurtle’s walking through that new parent to understand what lays ahead of them for childhood vaccines and the importance of them. We also unfortunately had to discuss why rates may be declining, predominantly because of fear and misinformation.

And the way for us best to combat that is to provide trusted information, to provide trusted resources and of course to have that valuable relationship between primary care provider and patient and family.

So now I’d like to talk a little bit about the logistics. How do we get access to vaccines? Are these given only in annual physical visits or just clinic visits? And perhaps we talk a little bit at the end about the Vaccines for Children program as well.

Andrea Polkinghorn:

Yeah, I can start us off here. So I think the rural nature of our footprint here in the Midwest does cause some access barriers in certain geographic areas. At Sanford, anybody can walk in a primary care clinic for a vaccine to get updated. I think what Dr. Thurtle kind of talked about earlier though is as children age, you know, they can talk to us and tell us if they aren’t feeling well. We do see those annual wellness exams start to decline at about 15, 18 months. And in particular she talked about kind of those sixth graders around 11 to 12 years. So we’ve been doing a lot of work to incorporate vaccines into things like sports physicals, or even better yet, educating the public that if they’re overdue for annual wellness exam to schedule it that way and the sports physical can be completed as part of that visit.

Along with updating immunizations, I know that our pediatricians really value the annual wellness exams because they’re looking for appropriate growth and development things that might not be caught as easily. I know my daughter’s pediatrician actually caught a small curve in her spine that had we not had that annual wellness exam, I wouldn’t have known at all. So they’re super important.

Dr. Dani Thurtle:

So we always do them at well child visits, we’ll always look at what you’ve had and what you need and what you’re due for. So that’s the best place to do them.

There’s other places to get them though, especially if you live far away from your primary pediatrician, as we know many people do. There are community health clinics or county health clinics. Sometimes the state has some health clinics out there. So there’s usually a very close place to you to get these vaccines.

Dr. Jospeh Segeleon:

Well, Andrea, I wonder if you could talk to us a little bit about the VFC program or Vaccines for Children.

Andrea Polkinghorn:

Yes. So the Vaccines for Children program, there was concerns, I think it was in the 1990s sometime about the risk for children without insurance to potentially, essentially the parents would not vaccinate them because they don’t have insurance. And therefore, again, our communities would be vulnerable to outbreaks of these diseases. And so the government funded a program called the Vaccines for Children program. So essentially the government is providing vaccines for children. This is through 18 years to any VFC-enrolled provider, for example. I think this is done very widespread.

All of our Sanford primary care clinics participate in this program, but it would provide any routinely recommended vaccine for a child at no cost to them. They can charge an administration fee, but if the person is not able to pay the administration fee, it must be waived. So you can always visit the Department of Health website no matter what state you’re in to identify if your local clinic participates in it. But again, it’s really well known, and I would say most health care providers or clinics who are caring for children participate in this program.

Dr. Jospeh Segeleon:

Thank you. I appreciate that. And the bottom line is that finances are not an impediment to vaccinating your child.

Andrea Polkinghorn:

Exactly.

Dr. Jospeh Segeleon:

Great. Well, I think we’ll go ahead and wrap up here. I want to thank my two guests, Dr. Dani Thurtle and Andrea Polkinghorn, for their expertise and their conversation on this very important issue. We continue to try to be a valuable resource and insight for our consumers to give them the most trusted information and to try to, with the goal of the best health care outcomes for our children.

Alan Helgeson (announcer):

Sanford Health has information about immunizations for all ages at sanfordhealth.org. This podcast 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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From IVF to NICU: One couple’s road to starting a family

Polly Gill (guest):

I was super excited. But you know how many times we had negative after negative after negative. It was like, there’s no way we can be pregnant. Like this is just not going to happen. And that line started getting, we started seeing double lines day by day by day, and we just didn’t want to celebrate yet. But when we found out, when those were two solid blue lines and the pregnancy said positive, we just bawled. And we just said, you know, we’ve been working on this for four years, trying to have our family and it was the best moment of my life.

Cassie Alvine (announcer):

This is “Her Kind of Healthy,” a podcast series by Sanford Health. The conversations highlight topics from fertility and pregnancy to postpartum, managing stress, healthy living, and so much more. In this episode, hear one couple’s story about starting a family through in vitro fertilization. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Being able to share stories and inspire hope and joy is important when first meeting Polly and Nikki. Their story has so much to share and like all good stories, it has to have a beginning.

Nikki Gill (guest):

So, Polly was like a really big volleyball star in high school, and when I was in high school, my team actually played against hers. And her senior year, she’s from Pierre, and they were undefeated all season. And she was a senior and I was a junior. And from our high school, in Rapid City at Stevens High School, we ended up beating them in the state championship. So that was like the first encounter and to this day she does not get to live that down. And so yeah, we played volleyball in college together and then like she said, we were roommates and then became more than roommates and fell in love and yeah, got married and had a baby (laugh).

Alan Helgeson:

So when you decided to start having those serious talks about having a family, was it hard to find the resources or figure out how to go about doing that?

Nikki Gill:

So I had always just imagined like a really traditional way of being able to start a family. So when her and I fell in love and when we got together, we really had to sit down and think about like which avenue we would want to take in order to have a family.

We knew that we wanted to, in a perfect world use like a sperm donor. So what we actually did with Theo was we had Polly get her eggs ready, so we kind of like split the IVF process together. So Polly had her eggs retrieved for the IVF process, and then those eggs were created, like the embryos were created with her eggs and the sperm donor. And then those were put into me. So like Theo would not have been able to exist without either of us put together, which is like what we were really hoping for in a perfect world.

Alan Helgeson:

Ok, so at what point did you go to Sanford and say, Hey, here’s what we want to do. We want to start a family?

Polly Gill:

So once me and Nikki decided that that’s what we wanted to do, and we started at Sanford Health, because I believe that they’re the only fertility clinic in the whole state of South Dakota. So we’re very, very blessed that they’re nearby and we couldn’t ask for the better doctors. So we kind of went back and forth, and from the very start we just worked as a team and they said, we’re going to get you guys through this.

Alan Helgeson:

At Sanford Health, Dr. Keith Hansen and his team are part of a larger group of specialists in women’s health.

Dr. Keith Hansen (guest):

I’m a what’s called a reproductive endocrinology and infertility specialist, which means that we take care of hormonal issues and some other issues like to try to help couples to achieve their dream of starting a family and having a baby.

Alan Helgeson:

With your clinic and your expertise, you’re very specialized in what you do. So where do your patients come from and how do they hear about your services in your clinic?

Dr. Keith Hansen:

Our patients usually are referred to us. Sometimes they come as primary, they make an appointment to come in and be seen, but a lot of times they’re referred to us either by their family medicine doctor or by an OB/GYN. And we then evaluate them once they come to see us. And then we do get couples to just hear about it and call and make an appointment so they don’t have to have a referral to be seen in general. Usually when we have couples who are trying to get pregnant, one of the things we really want to do is try to help them conceive with the least invasive process that’s available to us.

Alan Helgeson:

For Nikki and Polly, they had to navigate other changes as well.

Nikki Gill:

I also have PCOS, so I have polycystic ovary syndrome and that means that like my hormones are just like imbalanced in my body, which can make it harder for like my lining to get really good. So when we started IVF, we had Polly’s eggs retrieved, but my lining couldn’t get thick enough to put the embryos in, so we had to actually freeze the embryos that we had until my body could get where it needed to be to hold the embryos.

Hear Dr. Hansen explain the IVF process

Polly Gill:

And that was a long process.

Nikki Gill:

That was a really long, a lot of like failed rounds of trying. Yep. We hadn’t put any embryos in at that point.

Polly Gill:

Yep. And it got to a point where we were very frustrated, so we just had to take like a year off.

Alan Helgeson:

OK, so for Nikki and Polly, having patience is important and working with the right team is key.

Nikki Gill:

So we started with our fertility doctors.

Alan Helgeson:

Dr. Hansen, can you please talk about the IVF process?

Dr. Keith Hansen:

Usually for in vitro fertilization, first we have to do testing so we can figure out the best medications and all that kind of stuff.

Then the first part of the process is ovulation induction, where we’re giving her medications to stimulate the ovary to try to make more follicles to grow. And so what we do is we start the shots and the gals have to take shots a couple times a day, I’m afraid.

Once the follicle gets to a certain point and her estrogen’s at another point we have to start her on even another medication to try to prevent her from ovulating. And once the follicles get up to a mature size, which is about 18 millimeters in diameter, then we give a shot called the HCG, a trigger shot, which completes the maturation of the egg and starts a process of ovulation. Then 36 hours after that we take the eggs out.

And the way we do that is we go back to a little room in the back here that’s attached to our laboratory and anesthesia comes down, puts the person asleep so they don’t feel what we’re doing. Once we’re asleep, we can clean the vagina out with saline, put a vaginal probe ultrasound, and this ultrasound has a little aiming guide on it.

So we put a needle down through there, we go through the top of the vagina and we just kind of pop into the follicle. Then we, it’s attached to a pump, pump the fluid into a test tube. We take the test tube off, hand it back to the guys in the lab. They’re sitting under a big microscope that’s heated. They pour out the fluid, find the egg, and put it in the incubator. And we do off other ones on one side. Then we go over and do off other ones on the other side.

Then we take everything out and then wake her up and then the lab gets the eggs ready, which probably takes them about four hours to do. They get the sperm ready, which takes about four hours to do. And then depending on the sperm, they either put a hundred thousand sperm right on top of the egg or they do what’s called ICSI, where they go in, find a normal sperm, pick it up and inject it into the egg. Then they put it back in the incubator and the next morning we get to see did it fertilize normally or not. And those that fertilize them can develop and we want them to get up to what’s called the blastocyst stage. So what we do is once we have the blastocyst, which usually takes five, six, or seven days, then we can put it back into the uterus.

Alan Helgeson:

With any medical procedure, there are always things to watch for and why Dr. Hansen and his team have many safeguards in place.

Dr. Keith Hansen:

There’s a number of risks associated with the procedure. The biggest one is multiple babies, and we like to follow the American Society of Reproductive Medicine guidelines, which tell us how many to put in to give us the least risky pregnancy and the most likelihood of a live born baby. And for most women under the age of 35, it’s usually one embryo. For those 35 to 40, it’s one or two, but no more than that. And it depends a little bit on a number of other factors, but it’s usually one, sometimes two, between 35 to 40.

Alan Helgeson:

Are there organizations that you work with to help make sure you’re providing the best care possible?

Dr. Keith Hansen:

We’re closely monitored by, you know, a number of different agencies. The FDA, the pathology group follows us closely, the American Society of Reproductive Medicine. And then we maintain certification and board certification so that we can provide the optimal care to our patients to reduce their risk and improve the chances of a healthy baby and a healthy mom.

Nikki Gill:

So typically an IVF process from beginning to end is not as complicated as mine was, but I had a lot of hiccups along the way.

Alan Helgeson:

When Dr. Hansen talked about the IVF process, the steps were a bit different for Nikki and Polly.

Dr. Keith Hansen:

In this situation, what we did was what’s called reciprocal IVF, where we stimulate the one individual’s ovaries through ovulation induction meds. We take the eggs out, then we fertilize them, and then what we do is we prepare the other person’s uterus to accept the embryo. Then we thaw the embryo and put it in, and then hopefully she gets pregnant, which in this case she did.

Alan Helgeson:

Is it common to do it this way, Dr. Hansen?

Dr. Keith Hansen:

It’s more common than it used to be. I’d say that the more common way is a lot of people decide to do the intrauterine insemination just because IVF has so much to go through. But there are a group and it’s becoming a larger group of patients where they want to use like reciprocal IVF where we stimulate the one, fertilize the eggs, then put the embryo in the other person. And it really does, you know, it’s kind of a cool way to expand a family and have a little baby.

Polly Gill:

I was super excited. But you know how many times we had negative after negative after negative. It was like, there’s no way we can be pregnant. Like this is just not going to happen. And that line started getting, we started seeing double lines day by day by day, and we just didn’t want to celebrate yet. But when we found out, when those were two solid blue lines and the pregnancy said positive, we just bawled. And we just said, you know, we’ve been working on this for four years, trying to have our family and it was the best moment of my life.

Nikki Gill:

So we started with our fertility doctors and they helped to get us little baby embryos that that we were able to work with from the beginning. And then as soon as I got pregnant and we graduated from like the fertility doctors.

Then we went to Dr. Kemper. Oh. And man is she, she’s awesome. Ugh. She is just the best. She’s amazing. She’s amazing. She was our OB/GYN. And she, so then really after you graduate with, from the fertility doctors, it’s like a normal pregnancy. Right? So then you just have like a normal baby doctor.

Alan Helgeson:

For Polly and Nikki, their journey to starting a family has been anything but normal. So at what point did you learn that it was a high-risk pregnancy?

Nikki Gill:

Because it was IVF. That’s what labeled us as a high-risk pregnancy. But yeah, we just had like a normal experience from that at that point. And then at my 20-week scan, that’s when they do like the anatomy scan. We found that my cervix was shortening and funneling, which is a sign of labor like you can go into labor soon. And I was only 20 weeks at that point, so they had to put in a cervical stitch. So I remember at that 20 week appointment, they were like, you could have a baby within the next couple of weeks. And we were like that, that can’t happen.

Alan Helgeson:

This is where the expertise of Dr. Rachel Rodel and her team comes in.

Dr. Rachel Rodel (guest):

Sanford Health as a whole has a vast team of experts to help people start families and to help them be successful in their journey. Fortunately with Sanford, we have multiple avenues for patient care, including certified nurse-midwives, family medicine physicians, OB/GYNs, and us as maternal-fetal medicine subspecialists. So we take care of patients really once they’re pregnant or if they’re planning a pregnancy. And then of course for those who might need extra support in starting a family, we’re fortunate to have the reproductive endocrinology and infertility specialists.

Alan Helgeson:

For Nikki and Polly, this level of care was important with their pregnancy.

Dr. Rachel Rodel:

Often what we see here in maternal-fetal medicine is when pregnancies get unique. So for any patient who might conceive by IVF or in vitro fertilization, they are typically referred routinely to a maternal-fetal medicine specialist at the time of their anatomy ultrasound around 20 weeks to have a little bit more in-depth look at the baby due to risks associated with the IVF process. But for them, some unexpected findings on the typical screening ultrasound led our team to stay involved. And if we fast forward a short time after that, our team became even more involved as her pregnancy progressed.

Nikki Gill:

So I remember at that 20-week appointment, they were like, you could have a baby within the next couple of weeks. And we were like that, that can’t happen.

Alan Helgeson:

With the physical challenges during this time, the mental stresses weigh heavy too.

Nikki Gill:

I felt a ton of pressure, like emotional pressure to like be perfect all of the time when I was pregnant. Because it’s like if I do anything wrong, like I’m going to ruin this pregnancy. So, and I think that’s for every pregnant woman. There’s the women, there’s a lot of pressure onto, it’s like they feel like it’s your job to make their family. Everything’s on you. You have to do everything perfectly. And, and when you’ve never been pregnant before, yeah, it’s scary. It’s like, is this normal? Is this not normal? Scary.

Alan Helgeson:

So let’s go a few weeks down the road. OK, 24 weeks, five days emergency delivery.

Nikki Gill:

Ugh. You’d think you would be able to like get through it after telling the story so many times. OK.

So the night before the emergency C-section happened, I had felt pressure in my vagina and they came and did like a pelvic exam and they said, everything looks good. Theo was like reading normal on like the fetal monitor. There was like, I, I had a, the cervical stitch in. So they said if you were dilating at all, there would be blood. Like, everything looked good. So they had just said like, no concerns at this point. So we said, OK.

So I woke up that next morning and I went to the bathroom. It felt like my vagina was falling out with me. I had called Polly into the bathroom and I said, this is not normal. And so we called the nurse in and she’s like, let’s get you into bed.

And I said, what is this? And it was his umbilical cord that was falling out of me. They say, so like when you’re in, like when you’re waiting and you’re in bedrest, they talk to you and they say, I hope that you never have to experience an emergency C-section, but if you do, it’s like a beautiful symphony. It’s like everybody comes in and they all have their roles and it’s just like a flawless, beautiful symphony.

And there’s really no other way to describe it. Like, they pulled the cord, people came in, they took my clothes off, they put me in a gown. So they wheeled me out and I had a nurse and I just grabbed her hand and I said, I said, is he going to live? Is he going to be OK? And she said, she’s like, we’re going to get him out of there. You have to stay calm right now and like, not give yourself anxiety with everything else that’s happening.

And it was really urgent to get him out of me because with his umbilical cord falling through, that’s cutting off oxygen to him. So we go into the emergency room and they put me on the bed and one person’s at my head and she’s saying, do you give consent to be put out? And I said, yes, just save my baby. And there’s a person like down below, like down below, and she’s just like sticking a catheter. And the surgeon comes in and they have to time the procedure perfectly because they’re putting me under general. Like they’re knocking me out completely. Normally with a C-section, they can give you like a, like a, an epidural kind of paralytic. And they couldn’t. They needed to just put me out completely. There was no time. And so they’re like scrubbing my stomach up and the person by my head is saying, are you ready for her to be put out?

And the surgeon’s saying, nope, not quite ready yet. Not quite ready yet. And then I have somebody holding my hand and I, and they’re looking for the heartbeat. And I said, is, is there a heartbeat? Is he alive? And they couldn’t find one. And so they’re getting ready to like put this mask on my face. And I said, stop. Is there a heartbeat? And they said, yes, yes, we have a heartbeat. I said, OK, put me under. And so then they said, are you ready to be put under yet? And the surgeon said, almost. We’re, we’re almost ready. And so then she said, OK, we’re ready. And so then just like that, I was out.

Polly Gill:

Everybody left and I was by myself, dropped to my knees, praying to God. I had a rush of peace over my heart. And then from that moment I knew that everything was going to be okay. And then I went and saw him for the first time and it was the most beautiful thing I’ve ever seen. And he was kicking and he was sassy. And we actually got to have a delayed cord clamping because he was such a fighter. And ever since then he’s been a fighter and just kicking butt in the NICU and dodged so many bullets. And God’s just held us in our hands.

Alan Helgeson:

Baby Theo is born one pound eight ounces. Now begins a new chapter in their story, a 120-day stay in the neonatal intensive care unit at Sanford USD Medical Center in Sioux Falls.

Nikki Gill:

He was going to have to go to the NICU regardless, like if he would’ve been inside of me and stayed until 34 weeks. We knew that that was going to happen. We just didn’t know how sick he was going to be when he was in the NICU. His first week they say that like, the baby is going off of the hormones that I had provided for him when he was inside of me and it’s like a honeymoon stage. So the first week he was great. And then after my hormones like kind of leave his body and it’s up to his little body to be like, whoa, what? Like I got to do this on my own. That’s when reality sets in. And so it’s like, you, you feel like just this sense of like desperation and, and like panic because it’s like, is this, is this like all that you can do?

And I don’t think I’ve ever prayed more in my entire life just like out of just pure desperation of like just I’ll do anything. Just, just like save my baby. You know? So I think that was like really hard is just feeling like hopeless and just feeling like you don’t know what’s going to happen and they can’t promise you that he’s going to live. Right?

Like I kept asking the nurses, I would be like, he’s going to live, right? And they would say, they would say like, we’ve got really good doctors. And they would say like, we’ve got a really good team. And they would say like, he’s just doing what preemie, preemie babies do, but nobody could ever tell me like, yes, he’s going to live. Because you can’t promise that to families and you just so desperately want somebody to just say he’s going to make it. He’s going to be OK, but you, you can’t. So you just have to like, hold onto your faith that everything is going to make it.

Polly Gill:

And just seeing your little guy hooked up to that many things is just the hardest thing to look at.

Nikki Gill:

Those nurses deserve like all of the good in the world. They are not only medically taking care of your child, but then they’re like counselors to you.

Polly Gill:

And they become like your family.

Alan Helgeson:

Four months in the NICU. Can you speak to what this was like for you and Polly?

Nikki Gill:

They say the hardest part about being in there is the beginning and then right at the end because at the end it’s like, he looks like a baby. He’s doing so good, but like you can’t go home yet. And then he’s like big enough where he just wants to be held and he just like, when he’s really little, he’s just on a machine and he’s, he’s sedated. Like when he is big enough, he is crying out and you, you want to see him and you want to love him and you want to hold him. You can’t take him home and you’re at work, right? Like you’re, you can’t just be in the NICU 24/7. So that was also a really challenging part is you still have to live NICU life with that.

Polly Gill:

That was really hard too because we’re at home with him and he, he’s just the best boy and he’s so happy and he is laughing and we finally get him to see he’s actually acting like a baby, which we were waiting for for so long and we just love him so incredibly much.

Nikki Gill:

I would do all of that over a million times if this was like the result of it.

Alan Helgeson:

In your journey, you guys have learned so much. So with your experiences, are there things you could share that might be helpful to others from your time in the NICU?

Polly Gill:

And so I think like finding your community is helpful.

Nikki Gill:

Like our NICU neighbor.

Polly Gill:

Our NICU neighbor. OK. Yes.

Anyways, and then talking to her, she, her kid, her child right next to us has gone through the same thing Theo has been. And so that was really helpful talking to her. And I think just like it’s helpful to find your community and also like, things might be really, really dark at the time and really, really tough, but like, things are going to get better.

It’s going to get better. It just takes time. And you might be in the darkest place of your life, but Sanford’s there to help you. The nurses are, the doctors are, your family is, but it does get better.

Alan Helgeson:

Dr. Hansen, you and your team have had such an important role in helping Nikki and Polly start a family. Why is it important that Sanford Health provides these services, your services and those that your peers provide for LGBTQ+ families seeking care?

Dr. Keith Hansen:

For any couple that wants to have a baby and wants to expand their family? The services at Sanford are here to supply care to patients from all walks of life to meet their dreams, to expand their family, and to stay up all night. (Laugh) I’m just kidding.

Alan Helgeson:

So what does it feel like for you knowing you are helping people become parents?

Dr. Keith Hansen:

It’s incredibly satisfying and rewarding to have a couple bring in their little one. I originally was in the Navy back when I first started, and I learned that one of the first kiddos that I helped her mom get pregnant with, his father was a Navy SEAL. The only thing he wanted to go into was the Navy SEALs. And I, I learned that he actually made it. He’s now been in, I think he’s probably getting ready to retire from it. But he was a Navy SEAL for quite a while, which is kind of cool, you know, to be able to talk to him. And some of the kids are playing baseball and it’s just really fun to see what they do with their lives.

Alan Helgeson:

Dr. Rodel, what’s it like for you?

Dr. Rachel Rodel:

You know, it’s a great feeling to see the successful outcomes such as with sweet baby Theo, given with what we do and sometimes the very unfortunate circumstances that we see, we really know that not all cases have such a happy ending and it’s, it really is a privilege to support families both in their grief and in their celebrations.

And of course it’s an incredible joy when patients can graduate from our care, don’t need us anymore. And, you know, sometimes bring us their sweet baby or babies to show off because some days can be really tricky and this is always a challenging time in people’s lives to support pregnancies. So it’s quite an honor to help families through the process.

Alan Helgeson:

And for their part, Polly and Nikki are grateful for the medical team who helped them along the way as they begin their new chapter in their life together.

Polly Gill:

They are the story. They are our beginning, our middle, and our end, and our family at the end of the day, even when we’re home. So they are our complete story and they saved his life and they helped us have a baby and our family. It’s just been a, been an awesome journey with Sanford and of course couldn’t get through this without God too. So a lot of praying and a lot of good team is what made it made this happen possible.

Alan Helgeson:

Ok, so what’s the best part of this whole experience?

Polly Gill:

Theo. That’s just it. He is like, he’s just our whole world.

Nikki Gill:

Watching her be a mom is a very close second.

Polly Gill:

You’re making me cry. (Laugh)

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Nighttime routine can help with sleep problems

Simon Floss (Host):

Hello and welcome. You’re listening to the Health and Wellness podcast, brought to you by the experts at Sanford Health. I’m your host Simon Floss with Sanford Health News. Today we are talking about an issue that everybody faces at some point in their lives: sleep, or lack of sleep.

Here to help us drift through dreamland is Dr. Haven Malish, a pulmonologist and sleep medicine specialist at Sanford Health in Bismarck, North Dakota. Thanks for being here today.

Dr. Haven Malish:

My pleasure. Thanks for having me.

Host:

So, first things first, what are a few sleep stats that you can share with us?

Dr. Haven Malish:

Probably the most common sleep issue is insomnia. And I’d say at least half of the population experiences that at some point more common in older age, but it can affect any age of patients. And another common one is obstructive sleep apnea. That’s probably one of the most common organic sleep disorders. About 20% of the population is estimated to have that. So, a lot of patients out there who are still undiagnosed, there’s been quite some headway in terms of getting people diagnosed and treated over the last 20 years. And even 40 years ago, we had hardly ever heard of this condition. So, a lot of progress has been made and a lot more can be done though.

Host:

And what might be some signs of poor sleep?

Dr. Haven Malish:

So, I’d say, sleep deprivation kind of hits on that, and I think it’s kind of rampant that the average person only gets six to seven hours of sleep per night. And what’s recommended is seven to eight. When you have poor sleep or essentially a sleep deprived state, it’s either not enough sleep or the sleep quality is not as good as it should be, even if you’re getting that seven to eight hours of sleep. If you have either of those, you’re going to present with signs of sleep deprivation or of impairment in some way. And so that can be poor cognition difficulty thinking, difficulty even with executive function. It can affect your mood. Your partner might say you’re more irritable, you know, difficulty staying on task. And one of the most common public health issues is like sleepy driving, especially truck drivers not getting enough sleep or with undiagnosed sleep apnea. There’s a safety concern there. And so that all what applies to truck drivers also applies to the general population. You’re going to have difficulty with motor tasks you know, falling asleep during normal daily activities and so forth.

Host:

So, from a health standpoint, and I know you mentioned side effects, people can expect day to day if they’re not getting enough sleep, but what happens health-wise or physically if someone doesn’t get enough sleep? You know, I’ve heard things like weight gain, a lower immune system. So, what are some risk factors physically if someone isn’t getting enough sleep?

Dr. Haven Malish:

And that, that’s a really good question and that’s a really good distinction to make because the, the, the patient’s not going to come present and say, “hi, my immune system’s weak because I’m sleep deprived.” They’re going to come in with the immediate effects of the sleep deprivation type of situation. So, the actual health effects are going to be like you said, poor immune response. They’ve done actually done some basic science studies in rats where they just sleep deprive the rats and they eventually die from overwhelming infection. And so, every time a rat tries to fall asleep, they have them go on a little platform that they end up getting dunked into water <laugh>, which is kind of an interesting experiment.

Host:

Well, that is no fun for the rats by any means <laugh>.

Dr. Haven Malish:

Right. Even when I did my undergraduate at University of Pennsylvania and there were always these studies you could sign up for as a student and it would essentially be staying up for three days or (getting) maybe two or three hours of sleep a night over a three-day period, something like that. And then they would do blood draws and see how robust your immune system was. And I think the results were that you definitely have a weakened immune system with sleep deprivation. You also have a pro-inflammatory response. So, your cytokines go up, your interleukins go up. Things that promote inflammation, the markers that promote inflammation are all elevated. If you’re sleep deprived, you’ve got increased risk of hypertension. So, it’s got cardiovascular effects which can then lead to increased risk of stroke and heart attack.

Dr. Haven Malish:

In regard to the hormone changes you have the hormones that promote weight gain, or the balance of hormones will promote weight gain. So, with sleep deprivation, you have increase in the hormone grail in which makes you more hungry, and then you have a decrease in leptin. Leptins supposed to suppress your appetite. And so, you’ve got the hunger hormone increase in the appetite suppression hormone decrease and so that just makes you want to eat a donut instead of celery <laugh>.  So, you’re craving things that aren’t necessarily good for you. That tends to be what you’re predisposed to eat poorly with sleep deprivation. There are various other health risks as well. So, the bottom line is that sleep deprivation or poor quality sleep effects a broad array of systems within the body that can adversely affect your health.

Host:

So, doctor, what should good sleep look like then? And I know you mentioned it earlier, but how much sleep does a person really need? You know, some people say, “oh, I really only need four to five hours and I feel great,” but as we’ve talked about here today, that’s really not the case.

Dr. Haven Malish:

Essentially this breaches on the topic of good sleep hygiene and the framework is going to bed, trying to go to bed at a certain the same time every night. And even more importantly, getting up at the same time every morning because really getting up the same time every morning, really kind of set your clock for the whole day. And so, for example, if you go to bed too late, you’re going to want to wake up later. But if you’re waking up at the same time, then that kind of sets things in a regular pattern to where your body is used to, you know, a certain circadian rhythm. And so for most people, in terms of the actual sleep amount, seven to eight hours, with some rare exceptions, there was a saying when I was learning about sleep that they say scholars get seven, bankers get eight and gluttons get nine or more <laugh>.

Dr. Haven Malish:

And so that’s kind of a good way to remember it. Even if you’re sleep deprived, two nights, 10 hours (of sleep) should be sufficient to catch up in most cases. So, once you get more than that, it can also have adverse health effects. More sedentary, I think it’s related to being more sedentary. And so seven, eight hours is the target. There are some rare exceptions to that. But those are people with genetic where they are just short sleepers and it actually is true that there are some people rarely that can get four to five hours. They just can’t sleep more than that, they don’t have any other sleep conditions or underlying sleep disturbances. They feel refreshed after that. But that’s the rare exception. And there, it’s usually a genetic, there’s genetic markers, they’re genetically predisposed to that, but that’s rare <laugh>.

Host:

So, what are some ways to improve your sleep then?

Dr. Haven Malish:

It depends on what your starting point is. I’d say that if people are struggling with the quality of sleep, first thing to start with is good sleep hygiene. And so that has to do in part with what we’ve already discussed: trying to go to bed at a certain time, getting up at a certain time, minimizing what we call stimulus control, some minimizing things that can distract you. Making it a quiet place maybe with some white background noise, which sometimes can be helpful for people if the dead silence, some people will just go to sleep a little better if there’s a little bit of white back background noise, what we call white noise in the background, if you tend to stress about not being able to fall asleep, then we say turn the clock away from you so you don’t clock watch. Avoiding blue light in in the evening, which can disrupt kind of your melatonin and circadian rhythm and make you want to stay up later, which might be harder to get up at the time you want to get up if you’re going to bed later.

Host:

Ah, so what you’re saying is no mindlessly scrolling tiktoks in bed at night? Yeah. Okay. <Laugh>.

Dr. Haven Malish:

Yeah, so avoid the technology, the blue light feature on a lot of technology. It’s a good thing in general, but if you’re scrolling even with the blue light filter on, it’s the seeing things and saying, “Ooh, I like that,” or “, I don’t like this post.” Social media tends to activate your brain too, even if there’s no blue light. And so some people more than others, people who tend to get really into their social media, I’d say just forget the devices altogether for a good two, three hours prior to bedtime. But the blue light’s another factor. So, watching TV with blue light, for example, it doesn’t have the social media component, but then the blue light from it can be disruptive as well.

Host:

So, if you’re struggling to get good sleep and you’re noticing things just aren’t improving, could it be a sleep disorder? When does that come into play and when might that be a factor?

Dr. Haven Malish:

One of the most common presentations that I’ve seen is when there’s a change where people are used to getting a certain amount of sleep or being refreshed to a certain amount from their sleep, and then they notice things start to kind of go downhill where the sleep isn’t as refreshing or the sleep is good, but they’re just not able to get as much sleep could be from a medical illness that’s developing like thyroid condition, a new medication, they’re on a change in work schedule. So, it can be for a variety of different reasons, but when that’s the case, when the patient perceives a problem, they can always start by asking their primary care provider to guide them through the initial part of that. And then if they deem necessary, get a referral to a sleep specialist.

Dr. Haven Malish:

And so, if it’s not one of those first issues, then we look for a primary sleep disturbance. One of the most common ones is obstructive sleep apnea. Like I said, 20% of the population has it. It can present even in children, but it’s also associated with older age. Because, as we age, we tend to gain weight and weight gains associated with sleep apnea. It’s not the only risk factor, but it’s one of them. So, if there’s a problem with the sleep, I’d say go to your primary care doctor first, make sure you’re doing all the good sleep hygiene techniques that we’ve talked about. And then if it’s still an issue, then you might need to see a sleep specialist.

Host:

I know melatonin and zzquil are very popular for over-the-counter sleep aids. What are the pros and cons of over the counter sleep aids and are there any long-term use effects with those?

Dr. Haven Malish:

Well, that’s another good question. So, I’d say I’ll start with the most common over the counter sleep aid, and that’s going to be diphenhydramine, which is an antihistamine and its primarily antihistamines are not intended to make people sleepy. It’s one of the side effects <laugh>. And so oftentimes when you see like a PM in a sleep aid like acetaminophen with a PM or ibuprofen with a PM oftentimes the PM is really diphenhydramine or the common name is Benadryl, and Unisom is another antihistamine that’s pretty common. But they all are in these over the counter sleep aids. And so there can be some benefit short term, like if you’re going on a long plane ride and you just need something to help you sleep on the plane, just one time use, there’s not going to be a whole lot of harm in doing that.

Dr. Haven Malish:

In general, when you do use these types of over-the-counter antihistamines in this fashion, you get more light sleep earlier on, but it’s usually at the expense of deeper sleep later. And so, it’s a tradeoff. Everyone’s a little different. So, some people know that as long as they’re able to get to sleep initially, if they tend to be sleepy people in general, then maybe just getting the sleep, getting to sleep initially is their goal. But by and large, most of the people in the population, you have that trade off where you do get more lighter sleep earlier in the night, but then later you’re going to toss and turn a little bit more and not get that deep REM sleep that you’re supposed to be getting later in the night. Now in terms of long-term use, Benadryl or diphenhydramine has been linked to dementia, and initially we thought this was reversible, but studies have shown that it’s not necessarily the case. So, I would not recommend any long-term use of diphenhydramine to help people sleep.

Host:

Specifically for over-the-counter medicines and sleep aids that contain diphenhydramine, what would some name brands be that contain that?

Dr. Haven Malish:

It’d be Tylenol PM, Motrin PM those, those are probably the most common. One Unisom does (contain diphenhydramine). It’s not Benadryl, it’s another antihistamine. And so, those are the most common ones, I would say. There are somewhat, what I’d say reasonable alternatives and you asked about melatonin, that’s something our body kind of creates anyway. And that can be a good aid to help people kind of readjust their clock or as what we call a hypnotic to help them fall asleep at the beginning of the night. What I’ve seen is that for those, in those patients where it works, it usually works for an initial time period, then a lot of times it’ll lose its effect over time. But it can be very helpful, especially if you’ve got jet lag and, but you got to time it appropriately. Melatonin is a tricky one.

Dr. Haven Malish:

It’s one of those where more’s not necessarily better, and if you take it too late, it could have the opposite effect. And so, I’m going to circle back to Benadryl and the antihistamines is that some people, when they take the Benadryl or things like it, they’ll say that it makes them wired. And usually what I’ve seen in that situation is if those are people with restless leg syndrome. And so, it’s that the antihistamine, if you have restless legs, can make the restless legs a lot worse. And so they’re just moving their legs the whole night. And so, it’s not that it makes you wired, it just makes the restless legs worse and that’s why the Benadryl doesn’t work. If anyone’s out there listening, say(ing), “well, when I take Benadryl, I’m, I’m just crawling off the walls,” then you probably have restless legs and there is treatment for that <laugh>. The first one being avoid medicines that make it worse. <Laugh>.

Host:

So, just a couple more questions here before we let you get on your way. What type of care or programs does Sanford offer for sleep challenges or sleep disorders?

Dr. Haven Malish:

We, there are sleep specialists at most of the major locations. We do offer sleep study testing. This usually involves an overnight study where they hook a bunch of electrodes to your head around your nose. There’s an EKG, it’s got some limb leads on there. And so we get a lot of good information from a sleep study. And so that’s usually going to be the, the initial first step. I know here in Bismarck we go down to age three. We are accredited down to age three with the American Academy of Sleep Medicine, we’ve got a fully accredited lab. And then we also do some other, like daytime testing to look for things like narcolepsy and other, what we call conditions of hypersomnolence. And so we do have a pretty comprehensive sleep evaluation service here and clinicians that can follow up on those results.

Dr. Haven Malish:

And I think that holds through for most of the major Sanford locations. One of the new programs that we’ve developed recently is one of the alternative treatments for sleep apnea. Let’s start by just saying with obstructive sleep apnea, the primary treatment of it is something involving positive airway pressure or continuous positive airway pressure, which is CPAP, which a lot of people have heard of. And so about two thirds of the time patients can tolerate it and within that two thirds, a third of them love it initially, and the second third get used to it eventually. And then the final third just can’t do it <laugh>. And so there’s an alternative that kind of moves the tongue forward in your sleep and clears the airway. And so that’s a newer program. It’s called the Inspire device. And so an ear nose throat specialist puts that in.

Dr. Haven Malish:

Here it’s Dr. Sharon. We’ve done over a hundred of these here and really kind of pioneered the way here in Bismarck in terms of that therapy. I don’t think anyone else is offering that within the vicinity. And so patients are struggling with CPAP. That’s one of the newer programs is to get evaluated to see if the inspire device can help. We also treat the whole gamut of sleep disorders though restless legs, narcolepsy, even if you have insomnia, usually your primary care provider can try to help initially, but insomnia may also be indicator of an underlying sleep disturbance. So, if the initial approach with the primary care provider isn’t getting the patient where they need to be, then a sleep specialist referral may be very helpful.

Host:

Well, this really has been so great doctor, and you’ve shared just a plethora of information that I think is really going to help a lot of people, including me. I’m a rather light sleeper, so I was really excited to do this podcast with you because I was like, “well, I’m going to talk to a pro and I’m going to learn.” And you know what, I did learn a lot today. So, before I let you go here, what would be a good take home message or what’s maybe the most important bit of information that you want people to know who are going to listen and read this?

Dr. Haven Malish:

So, I’d say if, if you’re not happy with where your sleep’s at, be proactive. Start with the sleep hygiene. That’s the regularly going to bed at a certain time using the bed for only sleep. Waking up at the same time, but don’t suffer with it if you don’t have to. Talk to your primary care provider, see if they can help. And if needed, sleep specialty referral, we’re here to help and then we can see what else can be done. The other thing I would say is poor sleep. A lot of people chalk it up to old age and it’s not necessarily the case. I mean, we, just because you’re getting older doesn’t mean your sleep has to be poor. So, be proactive and try to try to get things better. If you’re not happy with where your sleep’s at, we’re here to help.

Host:

Thank you so much for your time and knowledge and for joining us today.

Dr. Haven Malish:

My pleasure. Thanks for having me.

Host:

This episode is part of the Health and Wellness series by Sanford Health for additional podcast series by Sanford Health. You can find us on Apple, Spotify, and news.sanfordhealth.org. Thanks again for listening. I’m Simon Floss.

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How to make your colonoscopy prep experience better

Dr. Johnathon Aho:

We know that polyps turn into colon cancer. We can take these polyps out when they’re small before they turn into colon cancer. The same people that are saying, “I don’t want to have a colonoscopy,” almost certainly they weed their garden, or they are doing other preventative things in their life. You take out a small weed from your garden before it becomes a big weed. A big weed in this case means colon cancer. Take it out when it’s small. Get it dealt with before it turns into something sinister that’s a threat to your life.

Cassie Alvine (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about colonoscopy prep. Our guest is Dr. Johnathon Aho. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Today we’re talking about getting ready for your colonoscopy. Our guest today is Dr. John Aho. And Dr. Aho, thank you for joining us.

Dr. Johnathon Aho (guest):

Yeah, thank you for having me, Alan. I’m Dr. John Aho. I practice general surgery in Luverne and endoscopy in particular. Colonoscopy is a large part of our practice preventing colon and rectal cancer within our population out in southwest Minnesota.

Alan Helgeson:

Let’s start right away with the importance of who should get screened for colorectal cancer. This may be done through a screening colonoscopy?

Dr. Johnathon Aho:

Yeah. Basically anybody over the age of 45 that is in this category we call average risk. So somebody who hasn’t had a colon and rectal cancer in a relative at a relatively young age, somebody who doesn’t have a family history of, or personal history of what’s called FAP or familial adenomatous polyposis, also called FAP or Lynch syndrome, which used to be called HNPCC.

But it essentially, people who are regular risk are regular in terms of their, their risk profile. Typically, we start colon and rectal cancer screening at about the age of 45. But there may be certain instances – talk to your family medicine doctor, your primary care physician – because that does get tailored pretty quickly if there are certain types of polyps or other risk profiles within your family or personal risks that you have, such as, you know, if you’re a very frequent lifelong tobacco user, some people would start screening a little bit early. But the guidelines would say age 45 for those at average risk.

Alan Helgeson:

So you’re talking about the age 45 here. Can we dig in a little bit into that, Dr. Aho, and some of the stats about colon cancer?

Dr. Johnathon Aho:

Yeah, sure. So colon and rectal cancer is a leading cause of morbidity and mortality, in particular mortality in the United States. People think it’s a lot of other diseases, but honestly, colon cancer is a leading killer.

And there’s a reason that your insurance company is willing to pay for a colonoscopy. It’s because it’s a good investment. It’s something that you can catch early. The earlier you catch it, the cheaper it is to treat. You can catch it when they’re polyps and when they’re not cancers, because we do know that certain kinds of polyps do turn into cancers, and we know that that happens with a certain frequency, and we know that that starts to happen as you age.

So there’s a reason that that age is being recommended. You start to have polyps around that age, and those polyps eventually turn into cancer in a not-trivial amount of people. I hate to see it where we screen somebody at age 70 and they have a more advanced polyp than they would’ve had at age 50 or 45.

Alan Helgeson:

Dr. Aho, I really appreciate those stats and really starting out with a who and the why for a colorectal cancer screening, but we know what really holds people back is – everybody talks about it, and it’s the big aura around the prep, right?

Dr. Johnathon Aho:

Yeah,

Alan Helgeson:

Now, I’m going to go out of here and talk about maybe a little too much information, but I’ve had a screen, a colonoscopy. I’ve had a couple of those, and you know, the prep isn’t great, I’ll be honest about it. But I would much rather have a colonoscopy. And I’ll tell you, I am thankful for doing it both times and that my Sanford providers have been amazing each time that I’ve done it.

But the purpose of this podcast here today is we want to talk about the prep for a colonoscopy, all the details that go into it, and give people the important information about that prep. So let’s get right into that. Why is it important to follow the prep instructions for a colonoscopy?

Dr. Johnathon Aho:

Well (laugh), without sounding too crass, your colon has stool inside of it. The polyps are on the inner lining or the inside of that pipe. Imagine your colon is a pipe, or just like your water pipes in your house. The polyps are on the inside of that pipe. I cannot see the polyps, or I would miss polyps if there were gunk on the inside of that pipe. All of that gunk has to get cleaned out, and in this case it’s stool so that I can see small polyps, medium polyps, and large polyps, and actually, you know, tell that they’re there. You can’t see them underneath the dirt. The dirt has to come out in order for me to see if there’s a polyp there or not.

Alan Helgeson:

So this might sound a little bit redundant, and these next questions may follow that, but I really want to get to the core of that and really underscore why you’re saying that. So what happens if the prep is not done correctly?

Dr. Johnathon Aho:

I will miss a polyp and/or I won’t be able to get all the way through the colon. The colonoscope that’s going through your colon, you cannot safely see where the lumen or the hole or the center line of that pipe is. So you’re not able to drive that colonoscope all the way to the end of the colon because there’s stool in the way, essentially. And then on the way back out, even if you are able to reach the end, you’re not going to be able to see the small polyps or medium sized polyps. You’ll probably be able to see a large polyp okay.

But it depends on, you know, how severe or how badly the prep was done. But you’re definitely going to miss polyps, and it’s not going to be what I would consider an adequate colonoscopy. And you’re going to need to have it repeated if you want it to count, basically, because I can’t say with any certainty that I saw what I needed to see in order to say that the colonoscope was good. And we didn’t miss any polyps. I couldn’t go to sleep at night and say, yeah, it was a great colonoscope. We didn’t see any polyps. Well, we didn’t see any polyps because there was stool on the inside of the colon.

Alan Helgeson:

So, beyond that, are there any other reasons why people should not try and cheat the prep protocol?

Dr. Johnathon Aho:

The Cliff Notes version is it makes the colonoscopy not only technically challenging in that it’s hard for me to see where the polyps are. I would say it makes it borderline unsafe and it potentially puts you into needing a second procedure, almost always. And then you’re going to have to go through the whole rigamarole again, and then you need to get another prep, or you need to stick around on that same day and drink more prep and clean things out more.

And there are some people who, you know, it’s their first colonoscope, their colon maybe doesn’t move as quickly as others, and they need an additional prep. And we don’t know about that right out of the gate. And so it’s not necessarily everybody who needs to be re-prepped was in that “they’re trying to cheat” basically category. But some people, you need a little bit of additional prep and there’s nothing wrong with that.

But the main thing is you need to see the inside of the colon safely. That’s what I would reiterate. And prep is a component of that. It’s a big major component of that. That’s you guys meeting us halfway.

Alan Helgeson:

I’ve got friends that I know that, you know, getting them to have a colonoscopy in the first place, a challenge. And then if they didn’t follow the prep appropriately and we had to send them home, chances of getting them to come back, probably pretty slim. Even though they know they should.

Dr. Johnathon Aho:

It’s incredibly frustrating to think you did an adequate job and then you go to sleep and you expect to wake up and you, you know, maybe you had a polyp taken out and everything went great and high fives and go home and (laugh) go about your day. Nope, you need to go home, or you need to stick around and prep more and you need to come back for another colonoscopy. That just takes the wind out of your sails completely. And yeah, the likelihood that you would come back after that is not high. And I can see why.

But don’t try to cheat it. Do it. Do it correctly. Do it completely. It needs to be a liquid and liquid without any elements of formed stool in it for that to be adequate. The amount of volume that we give people is a lot of volume. And if you figured out how to get somebody’s colon ready without having them drink that much volume or having them on the toilet all day, you’d be a millionaire. But we just don’t have that technology yet (laugh). And the only way we have to clean people out is we have to clean them out.

Alan Helgeson:

So with that, how Dr. Aho, can we make the prep more bearable or ways to reduce discomfort?

Dr. Johnathon Aho:

Basically follow the instructions is the most straight, is the best way to make sure that you’re doing it correctly. Ask the nurse or whoever’s telling you about the instruction or who is handing you the instructions. You know, in particular, questions: What am I allowed to eat? What should I be doing? Should I be drinking and, and being well hydrated the day before I start the prep? People think about, well, it’s just the day of the prep that I need to be worried about. No, you should go into that well-hydrated, making sure that you’ve had plenty of fluids the day before you have the prep.

There are some surgeons and endoscopists that would recommend that you try simethicone for gas pain on top of the prep. Some people think that that’s extraneous, but figure out what your options are, and share your concerns with the nurse and the care team.

And there are, there are as many ways to prep a colon as there are endoscopists that are doing it. There are home brew over-the-counter type solutions that we use. There are canned or bottled type of solutions that other people use. There’s a lot of different ways to do it, but at the end of the day, the volumes are pretty much equivalent.

It’s going to end up being about 64 ounces of liquid, sometimes a little bit less, sometimes a little bit more, and it’s going to be a lot of things that make you go to the bathroom. But going into that well-hydrated is very important because you do lose a lot of liquid and some very, very infrequently do we have people get dehydrated or lightheaded from their prep. But that can almost always be prevented by, you know, having a bottle of Gatorade or two the day before you start your prep.

Alan Helgeson:

Let’s get to some of that diet. What does the prep diet consist of?

Dr. Johnathon Aho:

So that, that is variable depending on what your endoscopist wants. Cliff Notes version is: Avoid high residue type of things. Corn. Corn will stick around for a million years in your colon. We have no idea. Like some people say they haven’t eaten corn in a month and there’s still a corn kernel in there. And I tend to believe people because I’ve seen that and heard that plenty of times. There are some foods that for whatever reason will just stick around. Corn is notorious.

String beans is another great example. Celery, other types of, you know, long stringy fibers or short round type of things that are fibrous. And so (laugh) adhere to the diet that your endoscopist is recommending.

Eggs are usually hard-boiled eggs or other cooked eggs. For whatever reason, eggs absorb extremely well and they turn into liquid by the time they hit your colon. So if your colonoscopy is later in the afternoon and they said that you could eat breakfast, they’re probably going to recommend hard-boiled eggs.

Alan Helgeson:

How about some prep drink tips, then, doctor?

Dr. Johnathon Aho:

Don’t guzzle it. Don’t do it all at once. If you have – that’s a lot of liquid to try to get down all at once. And I don’t know if you did this out in your part of the country, but did you ever do the one-gallon milk challenge (laugh), where you tried to drink all one gallon of milk? No. Nobody, nobody in their right mind does that. Do the same thing with the prep. Don’t go hog wild on drinking a gallon of prep and try to get it down in an hour and force it down and think it’s all going to go downstream. It almost certainly will not. And peck at it throughout the day. Set a goal for yourself so that you’re finishing the prep right around the NPO time or that you know, nothing by mouth anymore time. So if they’re saying nothing by mouth at midnight, try to have the prep done by 10 p.m.

Figure out when you’re picking up the prep and then break it up into pieces and be thoughtful about it and put little tick marks on the bottles or “I need to be at this point by 9:00 a.m., I need to be at this point by 2:00 p.m.,” and then work your way through it slowly and consistently. But get it all down and don’t try to rush it.

Alan Helgeson:

Well then let’s talk about, you mentioned times. How long does the prep take?

Dr. Johnathon Aho:

I would say it takes the better part of an afternoon. If you are a reasonable drinker in terms of able to get down volume, I would say you’re looking at probably half a day or, you know, perhaps three-quarters of a working day to get that down.

Alan Helgeson:

So we talked about some foods or maybe a prep diet. Are there things that a person should really look at avoiding eating a few days before their prep or maybe some food patterns or anything like that?

Dr. Johnathon Aho:

Yeah, I, I would say that the vast majority of people doing endoscopy are going to say no high residue string beans, no high residue other types of foods like corn or certain kinds of nuts would be another example. Sunflower seeds I hear once in a while, because some people do eat the hulls. Things of that nature I would say are pretty consistently recommended to avoid by almost everybody who’s advising bowel prep for patients.

Alan Helgeson:

Are there any common side effects of the colonoscopy prep?

Dr. Johnathon Aho:

Dehydration definitely. And nausea, vomiting, especially if they’re trying to go too quickly with the bowel prep. That is pretty common, is people are trying to rush things. They get some cramping, some nausea, vomiting. And if they’ve already gone into the prep being borderline dehydrated, they’re going to be dehydrated after the prep.

Alan Helgeson:

I remember doctor, when I was getting ready for my colonoscopy, you know, you go to the store, you get all the supplies, right? So you gather those things. And then I was thinking about, all right, these are the movies that I’m going to download or I’m going to get ready and watch and what does that list of supplies, maybe someone should have to make the prep go easier?

Dr. Johnathon Aho:

Think about where your bathrooms are going to be. That seems totally obvious, but that in terms of supplies, make sure that you’re being thoughtful about where you’re going and what you’re doing on that day. In terms of supplies, that’s really the only thing I can think of other than getting the prescriptions, maybe laying them out on the table and saying, this is what the sequence of events for the day is going to look like.

There are different recipes. Your prescriber may recommend different preps than what you had before. So lay out the instructions, lay it out as if you’re doing, you know, some type of project or hobby project or something like that. Plan out what the sequence of events are. Plan out your day. Have a plan going into something.

Alan Helgeson:

What about medications? Can these be taken before the procedure?

Dr. Johnathon Aho:

Talk to your prescriber, but on, in, in general, blood pressure, medications, heart rate medications, those are all fine to take, take those as you normally would. Almost always, they’re going to say avoid blood thinners, aspirin, Plavix, Coumadin, aka Warfarin, Clopidogrel, you know, those types of medications. Avoid those or talk to your prescriber about how long they want you to hold the Eliquis as an example for your AFib. Make sure you mention it while you’re talking to the nurse on the phone because they go through that list of medications and somebody has 30 medications, but it’s not in the same place on our end all the time. So make sure that you volunteer to the person who’s talking to you. Hey, my doctor wanted me on, you know, a baby aspirin once a day.

Some endoscopists will say that’s fine. The majority of endoscopists will say it’s not. And so they would want you to hold it for sometimes three days, sometimes five days. Depends on the endoscopist and who’s doing the procedure and what their comfort and what your comfort with having bleeding risks are. Because these polyps are on the inside of your colon. They’re like moles, like on your skin, but they just happen to be on the inside of your colon. Just like if you take a mole off of your skin, it’s going to leave a raw spot there that you can bleed from and that that’s a place that you’re going to bleed from that you might not notice. It might go into your stool, you might digest that blood a bit and you might not notice that you’re losing blood over time.

If it’s brisk, you’re going to have blood in your stool. But balancing out those bleeding risks, I think are the main concerns for what medications are they going to have you hold. There’s other certain kinds of medications and specialized instances that modify how wound healing happens and things like that. But those are much more rare than a blood thinner type medication. But most medications, talk to your prescriber. Most medications go ahead and take normally, but the blood thinners definitely have a conversation with the person scheduling your colonoscopy. They’re going to know what that endoscopist’s preferences are.

Alan Helgeson:

Why do I need a driver on the day of the procedure?

Dr. Johnathon Aho:

(Laugh) Because the anesthesia we give you is pretty stiff stuff and you’re going to wake up and you’re going to feel like a million bucks. There’s a reason that you wake up and you’re in a decent mood on the average and you feel great. It’s because you have essentially, you know, had a few stiff cocktails, you know, medication type that are going to be lingering in your system for the rest of the day. You do not want be pulled over by a state trooper. It’s going to be unsafe for you to drive. And I would not want somebody on the road that is in that condition.

Alan Helgeson:

Well, Dr. Aho, I think these are some great things to talk about. The prep for a colonoscopy and really an important information because people tell their friends and other people go, “ah, I’m never gonna get one of these things.” Now I’ve had a couple of these things and I tell all my friends, it’s something everybody needs to do if they fit the screening guidelines. Absolutely do this.

As we’re doing the “Health and Wellness” podcast, Dr. John Aho is our guest today.

Dr. Johnathon Aho:

Thank you for your time and you know, for hosting me.

Alan Helgeson:

Our discussion today was about prepping for a colonoscopy, but colonoscopies are not the only screening option for colorectal cancer. Another option is stool-based colorectal cancer screening tests, which can also find possible signs of cancer. To learn what screening option is best for you, talk to your primary care provider or visit sanfordhealth.org for more information.

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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Trust science, pros when dealing with orthopedic injuries

Simon Floss (Host): Hello, and welcome to the “Health and Wellness” podcast series, brought to you by Sanford Health. I’m your host today, Simon Floss with Sanford Health News. This series covers a number of topics to lead to a happy and healthy you.

Our conversation today is on preventing orthopedic injuries. Our guest today, and expert, is Dr. Drew Glogoza, a sports medicine physician in Fargo, North Dakota. Thanks for being here today.

Dr. Drew Glogoza (Guest): Hey, thanks for having me on. Happy to be here.

Simon Floss (Host): This is a really good topic. I know a lot of times when people think of like orthopedic injuries and preventing orthopedic injuries, they would maybe think that’s more fitting for older people. But this happens to a lot of people, and I myself am one of them actually. Since October, I’ve been dealing with two herniated discs, two bulging discs and degenerative disc disease in my back. So things are a little slow moving for me right now. And I think this is a topic that’s going to help a lot of people.

So, first of all, we’re going to just talk about exercising and things like that. How important is it to warm up before exercising, doctor?

Dr. Drew Glogoza: I think it’s actually very important, you know it really helps you get ready for whatever exercise you’re going to do. There might not be a lot of physiologic things that happen if you look at the research from it, but it really prepares your body, both mentally and physically to just do whatever you plan to do, whether it’s a workout or run, play a sport, something like that. It does help reduce the chance of injury as well by doing those things. And I think that that’s really where the value of that is.

Simon Floss (Host): And doctor, really quick here, what is sort of your day-to-day life look like in your position? What happens when you clock in and what happens when you clock out?

Dr. Drew Glogoza: We start here with clinic start at eight, and it’s a mostly just like non-operative orthopedics kind of thing. So, lots of arthritis, joint injuries, knee sprains, ankle sprains, stuff like that that we’ll see kind of all day. And then when I check out of the clinic, I go to the training rooms several days of the week at the colleges here in Fargo. So at NDSU, Concordia and MSUM and take care of the athletic injuries that happened there.

Simon Floss (Host): That’s got to be really cool to see some of the best athletes in the Midwest, and I mean really the United States, and work with them directly.

Dr. Drew Glogoza: Absolutely. It’s fun. Working with an athletic population is great. I’m fortunate to see a lot of people who are motivated to get better and want to get better, and I’m happy to be a part of their process and their recovery.

Simon Floss (Host): And speaking of process, we’re talking about obviously warming up before exercising. What might be a good example of an active warmup?

Dr. Drew Glogoza: So, there’s three different ways that we talk about warming up. So, really the best type of warmup is one that’s going to be dynamic. And when we talk about dynamic, if you’re watching sporting events on TV, basically they’re (dynamic) like exaggerated movements. And it really helps with all sports and exercise, and it’s going to be the best way to prevent injury.

Now the other two types of stretches that people will do when they’re warming up are called ballistic. That’s kind of where you bounce. If you see people, you imagine like trying to stretch your hamstrings and people are bouncing, trying to touch their toes that’s when we be ballistic. Now there’s some association with actually injuring yourself doing that. So that’s one type of exercise that we don’t generally recommend that you do for a warmup.

And then you have your static, which is where you just like stretch and hold. So a very common type of thing really enhances your flexibility. It’s not very long lasting for the flexibility. But doesn’t quite help as good as the dynamic warmup, which is really what we want to do.

Simon Floss (Host): Just for some examples of a dynamic warmup, like if there’s like specific moves if you will, what would maybe be some examples of that? Like maybe a lunge with a twist, but obviously don’t twist too hard, you know? (laugh)

Dr. Drew Glogoza: So, I was a soccer player. So, we did a lot of stuff where you’d be kind of exaggerating a kick. So, you’d do a couple steps and then you’d swing your leg like you’re going to kick, and then you’d switch and then kick your other leg. A lot of people we’ll see, we talk about it kind of like “open the gate.” So you’re warming your hips up, where you kind of do a high knee and then you externally rotate your hip to kind of open the gates a little bit to kind of get your hips moving.

Simon Floss (Host): And as Shakira said, the hips don’t lie. It’s very important to open those up and, you know, prevent a lot of injuries that way. I mean, you already alluded to it, but it is possible to overdo a warmup. Is that correct?

Dr. Drew Glogoza: Yeah, a little bit. You know, you don’t want to do too much. It’s kind of one of those things, too much of a good thing can be a bad thing sometimes. So really, it’s just about get(ting) things going a little bit. Get yourself prepared and ready so that you’re not just going from cold to really try to make sure that we’re not getting injured.

Simon Floss (Host): And should a warmup and a cool down almost look the same or similar?

Dr. Drew Glogoza: Yeah, similar. I think that a lot of times you’ll see more dynamic stuff in the warmup. I told you, that’s probably the best way that we’re going to prevent injury. And then you’re going to see a little bit more of that static kind of things that you’re going to do where you’re just holding for a certain amount of time. Usually it’s 10 or 30 seconds, usually we don’t recommend going past 60 seconds, but you’re going to hold. That kind of gives you some back that flexibility that you have. You might feel a little bit stiff after your workout or playing the sport or something like that. So, it’ll kind of help you feel a little bit better when you’re done.

Simon Floss (Host): So, switching gears a little bit here, what are the best types of shoes that one could wear? Or does it kind of depend on whatever the activities someone is doing?

Dr. Drew Glogoza: This is a really interesting question and there’s lots of research and data that’s going into this. Obviously there’s lots of money from shoe companies and things like that. I don’t have any disclosures, I don’t have any relationships with any shoe companies, but really if you look at the, the data on it, the data suggests that if the shoe is comfortable, that’s going to be the best shoe for you to wear while you’re doing exercise. So, that’s really what you want to look for.

So, if a shoe is not comfortable, that’s probably not going to be a good shoe for you. If we’re talking about running, there’s kind of three different ways people run. People run on their toes, and they run on the kind of their midfoot or they run on their heels where they heel strike first. And there’s lots of different shoes and they market it to kind of these different styles of running, but really the evidence hasn’t really shown much of a difference for the different shoes or styles.

More: Orthopedic walk-in clinics offer more convenience, fast care

Simon Floss (Host): Sure. I’ve heard things like, if you’re going to like squat, deadlift (or) hit legs, and you read a million things on the internet, but I’ve heard you should use a flat shoe to keep your weight on your heels. Is there any merit to that? Or is that just kind of a, you know someone said it and it’s like, “oh, I guess I could look cool at the gym wearing Converse,” you know?

Dr. Drew Glogoza: Yeah. I don’t think of that typically for it. Now you’re probably not looking as much for comfort like you are running-wise, but you probably want to make sure that it does have some support to it. A lot of the shoes are, if you try to squish them a little bit when you’re in the store, you can kind of see what their heel is going to look like if you’re putting a lot of pressure on a different part of the shoe. So, you might look for something that maybe has a little bit more support. A lot of that’s actually going to come down to your form and probably not a whole lot to actually your shoes.

Simon Floss (Host): Are there a few, just like off the top of your head, like name brand shoes that you, in your world, have heard good things about?

Dr. Drew Glogoza: Especially for running is, is really where people really talk about shoes. A lot of people like the on clouds wearing them all the time. I don’t know that I see as many people run them, but for running, you’re talking about people are in Hokas, Saucony, Asics, things like that. So, and again, I really think it’s important to try to find one that fits the way you like. I’ve tried out a couple different pairs. There’s some pretty cushiony shoes out there that maybe feel great to take off some of that pounding from the running when you’re on with the ground. But, for me personally, for being a soccer player, I like lighter shoes. My soccer cleats are always very light, so I’m just used to running in something that’s light. So, I’ve migrated towards a lighter shoe when when I exercise.

Simon Floss (Host): Can you stress the importance of progression and easing into something or not overdoing it?

Dr. Drew Glogoza: Yeah, so it’s really important to kind of get used to exercising again. If it’s been a couple months since you did something, or maybe it’s been a couple years and you’re trying to get back into it, you’re not going to want to just jump back into it like you did when you were in high school because you’re just not going to be able to do that at the same level. So you have to modify your expectations and kind of ease into it, you know?

The goal of exercise isn’t really to necessarily cause yourself pain. A lot of times people feel sore and things like that after they’ve done a workout or something like that and they’ll say, “yeah, I can tell I worked out” because you’re feeling a little bit, but that doesn’t necessarily have to be a part of it. You don’t have to push yourself to that point. And that’s where I think kind of working into it can be a really nice thing where you start very simple and easy and just get yourself going a little bit and then slowly progress yourself.

Plus, everybody’s busy these days and it’s not always that enjoyable to be really sore at work. And if you can get yourself active and not really struggle with that pain and things like that where you’re doing your daily stuff, it can be is really nice.

Simon Floss (Host): And personally, this is something that I have had to learn the hard way. With my back, I’ve actually had a couple epidural injections, and after the first one, the problem with epidural injections is that they work, so I was like, “oh baby, I’m back,” and I immediately jumped back into things that I was doing and a few weeks later I was in worse shape than I was beforehand. So, definitely something to stress and a little bit goes a long way.

Dr. Drew Glogoza: Absolutely. Yeah. We do a lot of injections up here in Fargo, so we caution people about that too. Just knowing that you’re going to feel good and try to not overdo it.

Simon Floss (Host): Is it good to work out with an accountability partner, whether it be like a trainer or friend to kind of keep you at the reins if you’re injured, or just make sure you’re doing things correctly, if you’re just trying to exercise more?

Dr. Drew Glogoza: I think it’s very helpful. That might be my personal bias a little bit. I’m a team sport athlete, so I kind of like that team thing. If you look at some of the sports research and things like that, you’ll find that there’s individual sport and then there’s the team sports and people kind of migrate to the way that they kind of like to be.

So, for me personally, I like to have a workout buddy, or somebody to kind of hold you accountable, do the workouts with you, and make sure that you’re staying on top of it.

I talk about this a lot with patients when I’m talking about physical therapy. Actually, some people are motivated to do it on their own. Other times you just need somebody there to kind of help you through it and make sure you’re doing it right, keep you accountable and really help you on your way.

Simon Floss (Host): So, what are some benefits of cross-training or weight-bearing exercises specifically?

Dr. Drew Glogoza: So, it really helps make sure that everything is strong. A lot of times people kind of get focused in on one area, like, “I’m just going to lift weights,” or, “I’m just going to run because I just want to get in shape,” or something like that. And really there’s a lot of benefit (to both) and they both help each other. Weights and cross-training really help running.

Running is not going to make you throw a lot of weight around in the weight room, but it is going to help you with some of your stamina and endurance. But really the weights do help running a lot, and a lot of people who are doing a lot of running, it is very important to do that and it really just helps kind of condition the whole body.

Related: Why running is good for you, according to doctors

Simon Floss (Host): And I want to circle back on that for a second because I’ve personally experienced, if I place a little bit of an emphasis on lifting more than running, I found that when I did start running again, I was slower than I was before. Is that something that’s common for people to experience, or how could one combat that, I guess?

Dr. Drew Glogoza: So, you’re saying you were slower after you started doing weightlifting?

Simon Floss (Host): Yeah. And that certainly might be a product of if there’s a little bit more muscle, then of course you’re just weighing a little bit more.

Dr. Drew Glogoza: So, what the basics of what weightlifting or strength training is going to do if you’re a runner is it’s going to increase your strength of course. That’s what you’re doing. But it’s also going to increase your explosiveness. So, that is really how it can help your running is it’s going to make you stronger so then your muscles are going to work better and you’re going to be able to go a little bit longer, but it’s also going to help you a little bit faster. So, if you’re trying to get faster, if you have a goal in mind for a race or you just have a time in mind just for whatever you want, it’s going to help with those things.

If you’re just strictly running, it’s really just endurance is all that it is. It doesn’t help your muscles a lot. So, I would say that’s probably maybe a little bit of an atypical experience because usually it should help. It really should. Sure. And they usually do work good together.

Simon Floss (Host): Well, maybe I need to make a couple trips up to Fargo and work with you and you can help me get back to my 7:30-mile running days. But anyway, I’m digressing. Can you stress the importance of good form?

Dr. Drew Glogoza: Yeah. This is where it’s going to be really key, and this is going to be hard for everyone to work on, but this is probably where a lot of injuries are even going to come from. So, you’ve really got to have the right form.

Every workplace is always telling you to do all the work stuff right, lift the right way, stand the right way, all those things. So, if it’s important enough that it’s kind of bled into the workplace, we know that it’s definitely going to be important, especially if you’re really shooting to try to lift some serious weights, if you’re not using the right form, you’re definitely going to injure yourself.

Simon Floss (Host): Yeah, that makes sense. Can it be dangerous to lift weights?

Dr. Drew Glogoza: It could be. If you have some underlying health stuff, you hear a lot of stuff about check with your regular doctor before you do an exercise and once you start to get into maybe in middle age that that can be a legitimate thing. You don’t want to cause yourself more problems from exercise when you’re trying to get healthy. Now that maybe is a little bit counterintuitive. You hear us all talk about how important to exercise, but sometimes you got to make sure that you’re doing the right kind of exercise and the right amount of exercise so that it’s safe.

Simon Floss (Host): I’m just curious, in your world, do you see more – and maybe it just depends on the body – but do you see more injuries from weightlifting or running and things like that?

Dr. Drew Glogoza: I feel like I see a lot more from running. You see a lot more just like (over)use. The people that would come in who are hurting themselves with the weightlifting are probably going to be the athletes who are doing CrossFit. Now, that’s a little bit of, it’s like a combination of what they’re doing. They’re doing like max reps, like as hard as they can go, and it’s just a really hard thing on their bodies. But not necessarily like in the weight room, benching 400 pounds kind of hurting yourself kind of a thing. I don’t see a lot of that. Usually, those people have got to the point that they are because they’re probably pretty good at lifting weights and they’ve got good form and they’re really good at taking care of their body.

Now, some of the other stuff, the running and the CrossFit is where you get a lot of people who are your weekend warriors or people who are just trying to be healthy kind of a thing. Trying to get back to being healthy, that kind of stuff. And that’s where we have bad form and do maybe not the best exercises. We’re not following the best running program, things like that. And that’s where we start to get ourselves into trouble.

Simon Floss (Host): Yeah, for sure. So, what are some measures that people could take to speed up recovery for orthopedic specific pain?

Dr. Drew Glogoza: Lots of different stuff that people will try. Obviously, there’s the ice and heat out there. If you’re going to break it down, heat, I generally think of for stiffness. So, if you’re feeling stiff after a workout or before a workout or something like that, I’m probably going to use a little bit of heat to try to warm it up. It’s really a superficial treatment. It’s going to increase some blood flow. Really kind of give you some of that flexibility back if you’re feeling stiff. Maybe help with a little bit of pain too.

Cold’s kind of the opposite, more so for pain. I don’t, I mean I think that’s really what I would use cold things for. It’s going to decrease blood flow, so probably not the best thing to do before a workout, because you want your muscles to be adequately getting everything that they need.

The cryotherapies are a big thing, you know, whole body or certain limbs or stuff like that is kind of a mainstream kind of idea right now. Really the concept behind that when you do it after the workout is that it’s kind of vasoconstrict. So, it’s going to constrict everything go into your body, so it’s going to just kind of shut everything off to your muscles and things like that. And then after you warm back up, everything’s going to kind of open back up and the thought it’s going to kind of wash away a lot of that extra stuff in there that is going to make your muscles feel sore. And I think that’s what people like about those cold tub immersions and things like that, that are pretty popular right now.

Simon Floss (Host): Yeah, I’ve sort of adopted a little bit just taking cold showers and I tell my fiancée that and she’s like, “you are an insane person.” (Laugh)

Dr. Drew Glogoza: There’s a lot of insane people out there with you then I guess (laugh). Yeah.

Simon Floss (Host): Yeah, there’s lots of us. So, this industry that we’re going to tap into is huge: supplements. Are there any supplements that can prevent orthopedic injuries?

Dr. Drew Glogoza: When you’re talking about prevention, it’s probably not (going to help) if you’re like actually going by what research is showing now. There’s lots of research and there’s kind of a lot of stuff that just kind of maybe works, maybe doesn’t work, and that’s sometimes what research shows.

Things that you can really do, you got to alternate between high intensity and low intensity activity just generally. Now that’s not a supplement, but if you’re alternating, that’s hopefully going to help you recover some. If we’re talking about things that you can do, protein supplement is actually a pretty good idea. When I was in high school and a college athlete, that was not quite that big of an idea yet, that was more like the, you’re built trying to build a lot of muscle if you’re taking protein.

And that’s really not true. Being an athlete and being an athletic person requires more protein. Your body just needs that to recover. So, I think that can be a really good way to help your body out, whether it’s adding it in your diet with the meats and things that you eat or if you want to use whey protein for a protein shake to recover, it really helps with your muscle synthesis. It’s really good post-exercise. So it’s really going to help you just get all that recovery.

Creatine is a pretty popular thing to be the help with short duration, high intensity kind of thing. So definitely if you’re working on trying to improve your weight room performance, you’re going to want to add some creatine in. But then there’s other things like vitamin D or vitamin C and you know, a lot of people are taking a lot of these supplements. Vitamin D is going to help with your bone health.

If you’re an endurance runner or something like that and you can get into trouble with some bone health issues, might not be a bad idea to try to help with that and make sure that you’re keeping yourself recovered. Vitamin C is going to help you retain iron. So sometimes our endurance athletes get into trouble with anemia and low blood counts and stuff like that, so that might help. Things like that. There’s also some thought that maybe it just helps you recover in general. Vitamin C sometimes is kind of this like wonder vitamin that a lot of people try to use for a lot of stuff.

Simon Floss (Host): That’s great information to hear because I’ve heard things like amino acids, magnesium, you know, all these things. And so, it’s nice to hear stuff that can help from an expert and a trusted source such as yourself. So actually, just one more question here before I let you get on your way. It’s well documented that our pros like yourself have worked with some of the greatest athletes. What makes care so special at Sanford or why should someone want to work with us?

Dr. Drew Glogoza: I think we just have a really great team here is probably what it comes down to. So, athletes are used to working with a team and then when you have an unfortunate bump in your road or your path and you need to interact with us, you’re getting the best team that we have. Physical therapists, non-operative orthopedics. We have surgeons. We have everybody. Everybody communicates really well and works really well, and we understand the goals of what the athlete is trying to achieve or what they want to achieve. And we make sure that we work together to try to achieve it.

Simon Floss (Host): Awesome. Well, doctor, thanks again so much for your time and expertise here today.

Dr. Drew Glogoza: No problem. Thanks for having me on.

Simon Floss (Host): 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. Thanks again for listening. I’m Simon Floss.

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Pelvic floor dysfunction explained, and how to fix it

Lindsey Sandbeck:

In physical therapy, we’ve seen just a huge growth in women’s health, pelvic floor physical therapy. And partially I think it’s because social media – people are starting to see some of these things online and they’re realizing like, this isn’t normal for me to experience, or there are things that I can do now to help prevent some of these things in the future.

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

This episode is all about pelvic floor dysfunction, specifically what that is and when you should seek care. I have Lindsey Sandbeck, PT, and Melissa Pytlik Monson, PA-C, joining me for this conversation from Fargo, North Dakota. Lindsey is a physical therapist specializing in both orthopedics and women’s health, and Melissa is a physician assistant specializing in women’s health as well. Both of these providers work with patients at the Sanford Pelvic Floor Clinic in Fargo.

Thank you both, Lindsey and Melissa, for being here.

Both:

Hi. Thank you. Thanks for having us.

Courtney Collen:

To start, let’s talk about defining the pelvic floor. And I know I’m not alone here. I’m actually almost nine months postpartum as we record this. And before I was pregnant, I didn’t know what exactly this was or what it meant to have a healthy pelvic floor.

Lindsey Sandbeck:

Everybody has a pelvic floor, right? But we primarily focus on care for female patients. So the pelvic floor and two, I went through physical therapy school. I felt like I was really well versed in the muscle skeletal system and all the muscles. But even in PT school, we don’t get much education in the area of our pelvic floor. We get basically a lecture or two of, “Hey, this exists, but if you want to treat it, you need to get some more education outside of your graduate program.”

And so it took actually for me, going through my first pregnancy to dive into those muscles. So I was treating everything around the pelvic floor at the time, but it really took my pregnancy to learn more about those actual specific muscles that we consider the pelvic floor. And it was shocking. How did I not know this after I’d been practicing for a period of time?

So when we think about the pelvic floor muscles, the muscles themselves run from the front of our pelvis, so from our pubic bone all the way back to our tailbone. And then kind of from one side to the other, from like those sits bones, so where we sit. And so it forms this hammock. You’ll hear it called a hammock. You’ll hear it called a bowl. But basically it’s a group of muscles that sit in the bottom of our pelvis, but they have to work with a lot of other muscle groups to function well.

And so we can get into some of the different dysfunctions of when those pelvic floor muscles don’t work well. Sometimes it’s because they themselves are not working well. Maybe they’re too tight. Maybe there’s some weakness going on there, but maybe there’s an issue with some of the other surrounding things like the core muscles, the back muscles, how we’re breathing, our rib cage. And so yeah, it’s definitely a group of muscles that is not very well understood until we start to have some sort of dysfunction there.

And it’s always fun to bring out my models for patients and go, OK, so these are the muscles we’re going to be looking at today. And they, you know, they’re always shocked. I have that many muscles down there? I didn’t even know they existed.

Courtney Collen:

It is amazing to learn more about your own body. So it would probably be safe to assume that pelvic floor dysfunction is when things are not working properly.

Melissa Pytlik Monson:

Yeah. So I feel like a lot of times you know, the pelvic floor, again, we’re talking about those muscles and those supportive structures, but oftentimes people will notice symptoms related to a different organ system. And that’s oftentimes what kind of prompts us because that hammock, that basket is supporting reproductive organs. It’s supporting urinary organs and it’s supporting bowel. And so most oftentimes when we really start to think about the pelvic floor is when there’s something wrong.

When you’re noticing urinary urgency, urinary frequency, you’re noticing leaking from your bladder, you’re noticing pain with urination or if you’re noticing constipation or you’re noticing trouble controlling your bowels, people will also notice it when they’re having trouble healing after a delivery or if they’re noticing that the vagina doesn’t feel normal like it used to, or they’re having pain.

And so I feel like oftentimes from kind of the health care provider aspect of it, most people aren’t going to notice anything going on with their muscles. They don’t even realize really that those muscles are there and supposed to be providing support and functionality. Most oftentimes it’s a problem with their sex life or problems with going to the bathroom. And, I feel like because those tend to be a little bit more uncomfortable things for people to talk about or there tends to be some stigma about things, then I feel like oftentimes it’s a conversation that doesn’t happen as early on as it should.

Courtney Collen:

Well, that’s why this conversation is so valuable for women of all ages. Have you seen an increase in questions, curiosity or concerns from women surrounding pelvic floor health in your practice?

Lindsey Sandbeck:

In physical therapy? We’ve seen just a huge growth in women’s health, pelvic floor, physical therapy. And partially I think it’s because social media – people are starting to see some of these things online and they’re realizing like, this isn’t normal for me to experience, or there are things that I can do now to help prevent some of these things in the future.

And so it’s fun to see people coming in that are asking for some of these services or being proactive about these things and taking that control back in terms of their own bodies. And so I work with a lot of pregnant patients that are coming in and they may be coming just for some like low back pain or some hip pain. And so we start having the conversation about some of these other symptoms and then, oh, I can address this now even while I’m pregnant. It’s like, yes, there’s so many things we can do now to help prevent some of these things in the future.

And then things that they can just be aware of that hey, after baby, if you start experiencing some of these things, ask your provider to come on back and see me, and we can work through these things as you can kind of get ahead of it too.

Courtney Collen:

Melissa, you mentioned could be problems with sex life or when using the bathroom. Can we expand on what might be the cause of pelvic floor dysfunction and are there specific age groups where it’s more common?

Melissa Pytlik Monson:

Yeah, absolutely. So really it can be any age that you start to have problems. I would say some of the issues tend to be more common with increasing age, so definitely problems with bladder control or symptoms of pressure. Those tend to be seen more often the older that we get just because aging and gravity definitely work against us.

But things like pain, things like chronic constipation, those things can present from early on that can present from childhood. Sometimes, it is not really addressed until people are older. But yes, definitely can affect all ages. Definitely things that we see more commonly after surgeries, after pregnancies or after deliveries. And you know, it may be that it’s easier to have that conversation once you have had a major event happen and we’re acknowledging that your body has changed. So we’re asking those questions or people are noticing things that are different than they used to be.

Lindsey Sandbeck:

A lot of times too, when people are coming in, one of the first things that we look at are just some of what are our habits around some of our bladder and bowel things. And so being able to start addressing some of those things and kind of figuring out too, like what is normal or typical for somebody to expect? So how often should I be going to the bathroom during the day? Should I be getting up at night?

And so we start by addressing some of those things along with bladder irritants. And those things can make a big difference in terms of somebody’s ability to get more control just from that. So when we think about what’s normal, you know, going to the bathroom every two to four hours during the day is considered normal and then getting up zero to one time at night. And so that oftentimes is something where people can go, “Oh, OK, maybe I do need to change some of those things.”

You know, we grow up with that, like, “oh, we’re leaving the house, you better go just in case.” And then we start to kind of take some of those patterns as we go into the rest of our lives. And so we might be going a lot just in case we might be trying to sit down and we’re busy, we’re in a hurry, and so we might try to rush going to the bathroom and not really give our pelvic floor the time. And so being able to realize like, “Oh, I should just be able to relax these pelvic floor muscles to be able to urinate or have a bowel movement. I shouldn’t have to push either one of those out.”

So we talk a lot about how do you position yourself when you’re using the toilet. And so some of those things can help people that, you know, before they even have some of these dysfunctions, set themselves up for good bladder habits, avoiding some of the irritants.

So, you know, people talk about coffee and carbonation and alcoholic beverages. Some of those things are just more irritating to our bladder. And so realizing that, and that might be contributing to some of the symptoms we’re experiencing.

Courtney Collen:

Yeah. So important. How can we support our pelvic floor or be proactive about our health in this region?

Melissa Pytlik Monson:

Yeah, I think that’s a big part and I think again, it’s just kind of a lack of nobody told you so why would you know?

But I think one of the things that we see, especially over time is I think there’s a lot of what has been normalized as far as constipation, as far as bladder leaking. And so people don’t realize that they could be doing things differently. So I think one thing is just kind of being aware of your body and noticing like, “oh, I guess do I push when I have to go pee? Am I able to have bowel movement without sitting and pushing?”

And so I think a lot of it has to do with paying attention to your body. So if you are not having regular bowel movements or if you feel like you tend toward constipation, looking at almost nobody gets enough fiber in their diet. And so you know, having a goal of getting 25 to 30 grams of fiber in your day, making sure that you are getting adequate hydration.

But there’s also such a thing as too much hydration. So one of the things that I see commonly out on social media is you know, you need to drink half of your body weight, you need to have a gallon a day. And that’s not true for the vast majority of people. You know, you need to listen to your body and drink when you’re thirsty. Ideally your urine should be a pale yellow color. But kind of generally, if you’re getting about a glass with each meal and one to two in between, that’s typically adequate hydration.

And so getting enough that you’re staying hydrated, but not that you’re stressing your bladder out all the time by processing that much. So I think that’s a lot of what we talk about is making sure we’re getting adequate hydration. Of course, we want people to live and enjoy their life, so we’re not going to take away your coffee. We’re not going to say you can never have a beer. But it’s about finding that balance.

And each person will find too what really bothers their body and what doesn’t. And so you know, if you look at your day and you say, “Well, I drink about a pot of coffee and I have maybe a glass of water,” but your bladder’s probably not going to love that. And so of course we don’t want to take your coffee away, but we want to work toward a better balance. And so I think that’s a big part of it.

Like I said, fiber again – almost nobody gets enough fiber. And so getting fiber, getting your fruits and your vegetables you know, getting whole grains, paying attention to foods that bother your body. So common offenders would be things like dairy products. People can have a sensitivity to gluten, artificial sweeteners can be bothersome, red meats can be bothersome. And so kind of trying to pay attention to what you’re taking in as far as what are you eating and what are you drinking.

Another one is activity: Are you moving? So for your bowels to be moving regularly, it helps for your body to be moving regularly. And so not that you need to be running marathons or be a CrossFitter but getting some of that movement in every day.

Courtney Collen:

Yeah. So important.

OK, I have to clarify. So when you’re urinating, you should not be pushing, is that correct? That’s a dysfunctional pelvic floor?

Melissa Pytlik Monson:

Yeah. So I would say kind of like the idea of power peeing or you know, needing to push to start your urine stream or to feel like you fully emptied your bladder is not normal. Yeah.

Lindsey Sandbeck:

So we oftentimes see there’s actually a lot of people that have almost too tight of a pelvic floor and have trouble relaxing their pelvic floor. So oftentimes, especially when it comes to physical therapy, people think, “Well, all I need to do is some Kegels, like, why would I go see a physical therapist? I’ll just do my Kegel at home.” But they are definitely not always the answer and they can definitely make some things worse.

And so one of the areas that we see this in is when people feel like they’re needing to push their urine out and they’ve gotten so used to just doing it, whether they’re just in a hurry, but it’s a sign that those pelvic floor muscles might be a little bit on the tighter side, they’re having trouble relaxing. So when we urinate, our pelvic floor muscles need to just relax to allow that urine stream or that bowel movement to come out. And so we use things to position, you know, if people have heard of the Squatty Potty, any sort of stool that gets those knees kind of up a little bit past their hips to relax those pelvic floor muscles so that they can just sit down and go and not push that urine out.

Courtney Collen:

One vote for the Squatty Potty, by the way. It is amazing.

Lindsey Sandbeck:

Yes, yes. Yeah. Yeah. And I’ll say it like, before I learned about a lot of this stuff, when I saw a Squatty Potty, I thought that was like a white elephant gift. I thought, “Oh my God, that’s so funny.” And now it’s a, you know, important part of my life. And it’s something that I talk about way more than I ever knew I would for sure.

Courtney Collen:

Lindsay, you mentioned Kegels. I have to ask, what is a Kegel and then when is it appropriate to do them?

Lindsey Sandbeck:

So a Kegel is a pelvic floor contraction. And so just like any other muscle in our body, the pelvic floor needs to be able to fully relax and then be able to fully contract. So we want it to relax when we need it to, but then we also need it to contract if we are trying to hold on to get to the bathroom. And we don’t want anything leaving our body before it’s time.

And so a Kegel is actually just working on that strengthening. A lot of times though, there are some different components of that pelvic floor that are going on where we need to learn if it is appropriate. So if somebody does have weakness of their pelvic floor muscles where it’s appropriate to do a Kegel, we need to make sure that we’re doing it correctly. Most of the time in the office when I am doing my assessment, I’ll have people try a Kegel and they’ll say, yep, I’ve been doing my Kegels, I just don’t really feel like they’ve changed anything. And then they go to do their Kegel and they might be bearing down instead of lifting up. And so that makes a difference.

There’s also different types of muscle fibers, and so doing our Kegels a certain way, if we just do ’em one way all the time, we’re working certain ones but not the other ones. So we need those muscles to be able to move through the full range of motion or what we call mobility. And then we also need them to contract quickly. If all of a sudden you need to sneeze or cough and you want those muscles to contract quickly, they need to be able to do that.

And then we need them to have some endurance to be able to hold on when all of a sudden we need to go, but we’re not really close to a bathroom. So being able to use that Kegel. So finding those muscles, being able to isolate those muscles is important of just like, oh, those are those muscles of the pelvic floor.

But then we’re really finding through more research now that it’s great if that is appropriate for someone to do a Kegel, but then doing some of the other surrounding muscles. So really working on a lot of pressure management, working on their core, their diaphragm, their low back, their hip muscles. Those are all fantastic and they all need to work together for that to work in terms of some of the strengthening.

And then they’re not appropriate oftentimes for those patients that are having pelvic floor tension, their pelvic floor is already stuck up a little ways. And so if they start doing Kegels, they’re just playing into that tightness and that’s going to make their symptoms much worse. So with those patients, we don’t do Kegels, we’re working on relaxation exercises. So being able to find that full range of motion so that eventually we can lengthen them to then eventually strengthen them. But sure, we need that full range of motion, just like we wouldn’t work our bicep mid-range, we’re going to work through that full range of motion. Same thing applies to that pelvic floor.

Courtney Collen:

Appreciate you for expanding on that.

Melissa Pytlik Monson:

Yeah. Well, and I think it’s one of those things too you know, understanding pelvis versus buttocks. And so oftentimes what I will see is when I ask a patient to do a Kegel for me to assess some of that, oftentimes I’ll see them contract those butt muscles. And that’s great. Those are, I’m glad that you’ve got some strength there. You can contract those, but it’s not the same. And so sometimes what I’ll see is when patients will tell me, I’ve been doing Kegels, I’ve done them for years, it really hasn’t made any difference. But then when you evaluate and then you can’t fault them. Nobody’s taught you.

And so I think that’s a big part of it, too, is learning what is actually going on, what is involved and how to coordinate all of it. And again, nobody teaches you. So again, I think it’s one of those things where there tends to be a lot of shame or a lot of embarrassment or you know, I don’t know how my own body works. But that’s super common. And so that’s why it’s important that you have people that you can go to, to help you understand.

Courtney Collen:

Yeah. And I think speaking more broadly about this helps to educate because the more you know, the more you know.

Both:

Right. For sure.

Courtney Collen:

When a patient comes in with pelvic floor dysfunction, talk about the care journey briefly.

Lindsey Sandbeck:

We’ll talk through some of those habit type things and just kind of educate them on what is considered more normal in terms of frequency of going to the bathroom and some of the different bladder irritants, their labor and delivery history in terms of did you have an episiotomy? Did you have any tearing? How was your healing after that? And so we’ll talk through their symptoms.

And then I spend quite a bit of time talking to them about their pelvic floor. I have some different models that I use and explain like, these are your pelvic floor muscles. There’s different layers to your pelvic floor muscles. These are these different layers. These are what they do. And then that way they have a better understanding of why do I need to do this exam to find out some of this different information. And so I think that helps in terms of making them more comfortable for that other piece.

Because I hear that’s oftentimes from people, they’re like, “Well, I wanted to do this, but I was a little nervous about having the actual assessment piece done or the evaluation piece done.” But by the time we’re done talking about some of those things, we’re like, “OK, yes, I want to find out what’s happening at those muscles.”

And so I’ll go through a bit of an orthopedic screen in our pelvic floor clinic. It’s a little bit more limited down there compared to what I can do in my regular evaluation. But we’ll go through what is low back, hips, abdomen, what do those things look like, how are they breathing?

One of the first things that I’ll go through with most people is called diaphragmatic breathing. A lot of times people think that they’ve done it before and they’re like, how is it this hard to breathe properly? But the pelvic floor and the diaphragm have a very good relationship when they’re working well. So if we inhale our pelvic floor moves down. As we exhale, our pelvic floor will elevate. So that can really help patients in finding some of that range of motion just by breathing. And so we, we spend some time going through that because that’s oftentimes a little tricky.

And then we’ll go through more of that internal exam if the patient’s comfortable with it. Start by just looking on the outside similar to what Melissa’s doing in terms of just looking at those tissues, which then, especially if I’m seeing them, I can say, “Hey Melissa, what do you think of this?”

And then we’ll do that internal exam. I just use one gloved finger with a little bit of lubrication and I’m just working my way through those different layers of the pelvic floor looking for any areas of tenderness, any areas of tightness. And then we’ll do more of that strength assessment. Can you do that Kegel? Or can you do that pelvic floor contraction? Can you bear down and relax? Can you hold it for any period of time? Can you do some quick ones and have some of that coordination of the pelvic floor?

And then based on that information, then we can go into what’s going to be most appropriate in terms of a home exercise program. So do they need to start more with some relaxation type things first? Are they ready to start some strengthening? And that may include some, you know, I call mobility. Kegels, really moving through that full range of motion and practicing that breathing so that we can then get them up and start working on some of those other exercises so that if they’re in the gym, they’re able to support while they’re doing some of their other exercises.

So how do you get your rib cage over your pelvis so that your pelvic floor can work well for you and not leak while you’re exercising? Because oftentimes people stop exercising because they’re leaking. It’s embarrassing. And they’re like, “I just don’t want to deal with it.” So they just stop exercising.

So that’s one of the things we work towards is finding some exercises they feel comfortable doing, and then how can we progress them so they can get back to picking up their grandkids and, you know, groceries and all those things we have to do throughout the day.

Courtney Collen:

Yeah. Well, quality of life too.

Both:

Absolutely.

Courtney Collen:

That’s what it’s all about.

Lindsey Sandbeck:

Yes. I think that’s the biggest thing with this is I think sometimes it does become so normalized that people just start to think it’s normal. Right? It’s common, but it’s not normal. And so if you’re experiencing any of those symptoms that it’s time to have them checked out because you shouldn’t have to live with any of that at all. So there’s lots of different things that can be done to help those things and get you back to doing the things that you enjoy doing.

Courtney Collen:

Thank you so much.

Melissa Pytlik Monson:

And I think one thing that is important, you know, both of us having graduate level of education, having training, we have actively sought out additional training for these areas. And so I would say don’t be disheartened, don’t be felt brushed aside if/when you first bring something up maybe somebody in family medicine or internal medicine, primary care, this may not be something that is their niche that they have a lot of information about. But never be afraid to ask for the referral to say, I think something’s going on. And if you aren’t able to give me recommendations, there’s somebody who can.

And so you know, I think that happens commonly. That I’ll talk to patients, (and) they’re like, “Oh, I mentioned leaking when I saw somebody a couple years ago, but they didn’t really do anything about it” or, you know, “I guess there’s like medication, but I don’t really want to take a medication.” So just knowing that there are resources out there, and it might not be your primary because they have to know a little bit about everything. But they may be able to get you to a provider who can. And we have the really unique ability to have a collaborative approach from both a medical and a therapy perspective.

But usually no matter where you are, you can find somebody to be your starting point. And oftentimes, before I had the opportunity to be in a pelvic floor clinic in a prior practice I still knew who my PT resources were. So if it was stuff that I felt like I could start with, but you need that PT component. We can refer to PT or patients that have been referred to PT and they think, you know, I think there’s more of a medical perspective that we need on this. So just don’t hesitate to ask for the help and advocate for getting to where you need to be.

Courtney Collen:

Melissa, Lindsay, thank you both so much for your insight, expertise, and all that you do here at Sanford Health. I appreciate you.

Lindsey Sandbeck:

Awesome. Thank you so much for the opportunity. Thank you.

Courtney Collen:

I sure hope you learned as much as I did from our conversation today. For more information or to schedule an appointment and find solutions to improve your pelvic floor health, visit sanfordhealth.org. 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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Eating disorders vs disordered eating: Differences & dangers

Dr. Dorian Dodd (guest):

It’s just incredibly isolating and scary. Somebody with an eating disorder, they’re genuinely feeling afraid much of the time about food, about their appearance, about these things that we can’t escape. We need to live. There is also a very strong denial component, so it’s very, very hard for a person with an eating disorder to actually see the reality of what’s happening for them.

Alan Helgeson (host):

Hi, I’m Alan Helgeson with Sanford Health News. This is the “Health and Wellness” podcast series. Today our guest is Dr. Dorian Dodd, a clinical psychologist with Sanford Eating Disorders and Weight Management Center in Fargo. Welcome, Dr. Dodd.

Dr. Dorian Dodd:

Hi Alan. Thanks so much for having me here today.

Alan Helgeson:

Our topic today is disordered eating versus eating disorders. What causes eating disorders?

Dr. Dorian Dodd:

Eating disorders are a very complex illness and they’re thought of as being multifactorial. So there’s really several different causes that go into it.

So there’s genetic risk and biological risk, and then we know that so people with a family history are at higher risk. And then we know that a lot of sociocultural factors play in as well. So people are at more risk if they have other mental health issues like trauma or anxiety or depression. But the important thing to remember is that it’s both biological and genetic and sociocultural.

Alan Helgeson:

Can you talk more about some of those risk factors?

Dr. Dorian Dodd:

Absolutely. So eating disorders often start in teen and young adult years, but really anybody can get disordered eating. So being female and being in that younger age group does confer some risk, although again, anyone can get an eating disorder and people who are most at risk generally tend to have a family history of eating disorders or they have other mental health issues going on. Low self-esteem and kind of interpersonal problems are often a risk factor for eating disorders. And then histories of dieting and, and disordered eating. So a history of kind of using food to cope with emotions or things like that.

Alan Helgeson:

Is social media a concern as you look at all those things that come into play for people that may be struggling with an eating disorder?

Dr. Dorian Dodd:

Absolutely. I mean, social comparisons we know that for many young people, social media really leads to feelings of low self-esteem, low self-worth. People are going on these platforms and just comparing how they feel and how they look to all of their peers and really unfavorably tending to do so. So people pay more attention to the ways that they’re not measuring up to their peers as they see it.

And so social media really becomes a platform, especially for people who are already struggling with appearance concerns, body image, low self-esteem. It absolutely can exacerbate those issues and then increase that risk.

Alan Helgeson:

Let’s talk about eating disorders and more about what they are and help give people more of an understanding about them.

Dr. Dorian Dodd:

So the main three eating disorders – anorexia, bulimia and binge eating disorder. We also have, I think one of the lesser known eating disorders is something that we refer to as ARFID, is the abbreviation, and that stands for avoidant restrictive food intake disorder, A-R-F-I-D. And this is an eating disorder where individuals are scared to eat, they’re concerned about eating, but there is no body image component.

So somebody with anorexia, they’re refusing food because they are worried about weight in some way, or at least that’s how it started. People with ARFID are generally presenting with problems eating due to other fears, so fear of choking, fear of allergic reactions, fear that the food is going to harm them in some way. So that’s a presentation that we’re seeing in our clinic.

And then there’s also a disorder called orthorexia nervosa. This is not an official disorder yet. It’s kind of newer in our understanding and research, but this is a kind of obsession with healthy eating. So people become very rigid about, they can only eat certain types of food or food that’s been processed or not processed in a certain way. And that just becomes really problematic, the extent and the rigidity that they develop around that.

And then I would also really like to highlight atypical anorexia nervosa. So people I think might be a little more familiar with anorexia, which involves not eating to the point of being significantly underweight. However we’re seeing more and more and recognizing more and more of this presentation of atypical anorexia. So somebody who has lost a significant amount of weight, they may show up looking at a healthy weight, even looking overweight, but they have lost a significant amount of weight, so they’re not going to have that underweight criteria, but they still have that illness of anorexia.

And so it’s very important for people to understand that eating disorders don’t look any particular way. You can’t tell somebody has an eating disorder just by what they weigh or what they look like.

Alan Helgeson:

Thanks, Dr. Dodd. This really helps in identifying some various disorders. We’ll talk more about signs and symptoms to look for as well as to find help if you or a loved one may be struggling with an eating disorder. Can we shift things a little bit and talk about disordered eating? What is it? And help us to understand how it can impact a person.

Dr. Dorian Dodd:

Yes. That’s a great question, Alan. So when you talk to different people, you’re going to get some different answers on this.

So disordered eating is really any relationship with food, any way of using food other than just kind of meeting those biological needs of managing hunger and getting your nutrition in. And so disordered eating is really along a spectrum. So it’s an unhealthy relationship with food that doesn’t quite rise to the severity level of a diagnosable eating disorder.

For example, if people are kind of restricting and fasting, skipping meals, that could be disordered eating. Many experts consider dieting to be a form of disordered eating if people, especially if they’re crash dieting or yo-yo dieting, doing things that are intended to just take weight off as quickly as possible rather than like a sustainable lifestyle change to manage their health.

Certainly any kind of unhealthy, what we call compensatory behaviors. So if you feel like you have to do something to make up for eating, for example, misusing laxatives or diet pills or making yourself throw up, those would all be examples of disordered eating. Now, if those are consistent and severe enough, then they do kind of rise to that level of an eating disorder. But there are a lot of ways that people can have unhealthy relationships with food that aren’t at that eating disorder severity level.

Alan Helgeson:

So is disordered eating considered an addiction?

Dr. Dorian Dodd:

Yes. Yeah, I would say so. I mean, I think people are absolutely compelled into this behavior. It’s very hard to stop. They do kind of feel like they need to be doing this.

The interesting thing about eating disorders as an addiction or disordered eating as an addiction is that food is what I’m going to refer to as a biological imperative. So many of the other addictions, we think about alcohol or drugs or gambling, we don’t need those things. Somebody can stop those things and walk away entirely. What is very difficult about the addictive behaviors of an eating disorder is there is no abstinence approach. You have to learn how to manage it in moderation. And so that makes it very, very challenging from an addiction standpoint.

Alan Helgeson:

When it comes to eating disorders and disordered eating, can you talk about the things that people may experience as a result?

Dr. Dorian Dodd:

These disorders can cause some very serious health consequences, really impacting a lot of systems of the body. So people with eating disorders can have heart problems and can affect cardiac functioning. It can affect GI functioning, digestion. It affects the neurological system as well. So people with eating disorders tend to have problems sleeping, have a harder time regulating, you know, attention and focus. They can move into this really kind of rigid and distorted way of thinking.

And then there’s also endocrine impacts. So it impacts the endocrine system. Women with eating disorders may go on to struggle with fertility. And then there is a host of psychological and social correlates of eating disorders. So we know that people with eating disorders tend to have more mood problems, difficulty regulating their mood. They tend to isolate a little bit more and really concerningly people with eating disorders engage in self-harm.

So both non-suicidal self-injury and suicide attempts at much higher rates than their peers without eating disorders. So we know that these disorders can affect many areas of life and have really serious consequences up to and including death. And in fact, anorexia nervosa is one of the most fatal mental illnesses.

Disordered eating – you’re going to see some of those similar effects, but to a lesser scale. So it is still going to cause mood dysregulation kind of interruption in kind of healthy adaptive thought patterns. It leads to really shame and guilt and a tendency to isolate, and it can absolutely impact some of those physical health areas that I talked about. So cardiac and gastrointestinal and endocrine functioning as well.

One thing that I would like to add there is that one of the risks of disordered eating is going on to develop a full-blown eating disorder. So we know that that is a major risk factor there.

Alan Helgeson:

Are there any statistics that may show how common eating disorders are?

Dr. Dorian Dodd:

You know, it depends which eating disorder we’re talking about. Overall, there was some recent data that came out of an initiative from Harvard that shows that about 9% of Americans in their lifetime, I think it was maybe 8.5%, but in that neighborhood will develop eating disorders in their lifetime.

At any given time, maybe about 5% of the population or less would be expected to have an eating disorder. And that differs across disorders.

So we know that anorexia nervosa is much less common than binge eating disorder. So when we think of these overall prevalences, that’s across all eating disorders, whereas some of them are a little bit less common.

Alan Helgeson:

What might be signs that a loved one might be struggling with an eating disorder?

Dr. Dorian Dodd:

Yeah, absolutely. That’s a great question, Alan. If you are concerned that you have an eating disorder I think it’s very important to talk to your doctor. There’s also a screening tool online, so the National Eating Disorders Association has a screening tool that is freely available online and it will kind of walk through some of the symptoms, some of the concerns that we look for when diagnosing an eating disorder. And just give an initial sense of, yeah, this does seem like maybe a little bit of risk going on, or no, this seems kind of healthy and appropriate relationship with food.

Alan Helgeson:

Being aware of these changes, but then what should we do once we’ve recognized something, Dr. Dodd?

Dr. Dorian Dodd:

Things that I would be looking for would include not regularly eating throughout the day. So generally we’re thinking people should be eating at least three times throughout the day, at least three meals. And so anybody who is really skipping meals, fasting, going long periods without eating, using food for managing issues other than just hunger and nutrition. So either eating too much or eating too little based on someone’s mood or based on, you know, what else might be going on in their life, being really overly concerned with appearance and body image. So somebody who would become very upset if they were to gain, you know, even a pound or two. I think those are the main ones. And then of course, any significant weight loss within a short amount of time or any of those more overtly unhealthy behaviors like for example, making yourself throw up. That would be a definite risk sign and indicator.

The research is very clear that the earlier you get into an evidence-based treatment, the better your outcome is going to be. And so if you are concerned you have an eating disorder, that’s the very best thing you can do for yourself. If you’re concerned about a loved one with an eating disorder, that can be a little bit trickier. Because one feature of these disorders is often a strong sense of denial.

So somebody with an eating disorder, they might not be receptive to that feedback, they might not be receptive to that concern. So I think it’s important to, you know, consistently just express that you care, express that you’re worried or what you’re seeing that is causing you to be worried, offer support, offer to go with them to an appointment, or do they need help calling their doctor to make an appointment. So really just expressing that concern and encouraging them to get help.

Alan Helgeson:

What type of care does Sanford offer for people with eating disorders?

Dr. Dorian Dodd:

Yeah, so we have a wide range of kind of levels of care here. So we provide care across the continuum.

We have an outpatient clinic up in Fargo and we are able to see people, certainly in North Dakota, but then we are also able to offer some services to neighboring states as well through telehealth. And then we also have higher levels of care for eating disorders.

So we have partial hospital program where people come with us throughout the week, they’re with us Monday through Friday for 11 hours of the day and eating their meals with us, but then they go home at night.

And then we have a traditional inpatient hospital program as well where people are fully hospitalized and they stay with us for a period of time to get medically stable before they then step down to that more outpatient level of care.

Alan Helgeson:

For someone listening to this and looking to make that first step, what do they do, Dr. Dodd? How should they start to seek help for an eating disorder?

Dr. Dorian Dodd:

Very important first step is to see your doctor get an overall health assessment so that you can understand kind of how the eating disorder is affecting your physical health, and then make decisions about a level of care from there. Or you can always just call our clinic and we would walk you through kind of the intake questions that we would be asking to see if it makes sense to come in for in-person intake or assessment.

Cassie Alvine (announcer):

If you would like more information on eating disorders, disordered eating or weight management options, visit sanfordhealth.org. You’ve been listening to the “Health and Wellness” podcast series. For additional podcast series by Sanford Health, find us on Apple, Spotify and news.sanfordhealth.org.

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Get used to diabetes checkups being a call or click away

“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. Dave Newman, medical officer, virtual care and medical director of Informatics, Sanford Health north region. Dr. Newman joins as moderator for the expert panel at the 2023 Summit on the Future of Rural Health Care with the topic: the state of providing rural care from Sanford Fargo.

Courtney Collen (Host):

Dr. David Newman, so glad to have you here with us.

Dr. David Newman:

Thanks for having me.

Courtney Collen (Host):

Thank you for being here. Where is Sanford Health leading in virtual care? What are we doing right today? And on the flip side, as a physician, what are our biggest opportunities?

Dr. David Newman:

Boy, so we have done a lot on the virtual care environment I would say over the last couple years. Our biggest frontier right now is telemedicine and serving our rural patients not just for primary care, but for subspecialists.

We recently opened a satellite clinic in Lidgerwood, North Dakota, and when we talked to the patients in Lidgerwood, they really told us that while they want to have urgent care, they want to have access to primary cares, they want to be able to see their specialists over the winter. They don’t want to have to drive to Fargo. They don’t want to have to drive to even Wahpeton.

And as soon as I told them, you could see their oncologist, you could see their endocrinologist, you could just see their face light up. That is really what we’ve made huge steps in over the last, I would say two years, is access to specialty care for everybody, not just the people in Fargo or Sioux Falls.

Courtney Collen (Host):

Our CEO Bill Gassen recently said we don’t want patients to have to travel very far if they don’t have to, especially during those winter months, which we are very familiar with up here. Serving rural communities as an endocrinologist, Dr. Newman, what do you want patients to know about the progress that Sanford Health is making to improve their access to care?

Dr. David Newman:

So I want them to know it’s way easier than you think it is. If you can turn on your smartphone and open an app, you can most likely do a video visit. And if you’re very uncomfortable with technology, we can set up a visit where you drive to your local clinic and whether you’re in Dickinson or whether you are in Bismarck or Watford City, and then you can see your provider in Fargo or Sioux Falls from that clinic.

So if you’re really uncomfortable with technology, we can make it work. It is kind of like eating brussels sprouts, that if you’re eating brussels sprouts and they don’t taste good, you’re doing it wrong. That we want to make sure that you’re doing things in the appropriate manner and we are here to help for that.

Courtney Collen (Host):

Gotta have the right seasoning. Yes, absolutely. The right way to cook ’em. Absolutely. Yeah. I agree a hundred percent. How are you using technology to provide patient care?

Dr. David Newman:

So I use it in a lot of ways. I do a lot of virtual visits in the wintertime. It’s like 20 to 30% of my practice. For diabetes remote monitoring, I can look at blood sugars, so blood glucose levels from people’s insulin pumps through their sensors. I can look at that remotely and I can take care of things asynchronously. So not at the same time. It’s very, very convenient for a patient to not have to come to my clinic to have their insulin titrated or to have their pump settings changed.

Courtney Collen (Host):

If you could share one piece of advice with a new clinician or physician entering the workforce today, what would that be?

Dr. David Newman:

Integrate virtual care into your practice from day one. Embrace the technology. It’s absolutely going to be a big part of your practice going forward. And the sooner you learn how to do it, the sooner you’ll be happier.

Courtney Collen (Host):

What does the future of Sanford Health look like when it comes to how we best serve those rural communities? And relative to that, what excites you the most about the future of rural health care?

Dr. David Newman:

I think as we get more providers to embrace the technology, the ZIP code won’t matter as much. You won’t have to drive to an urban center to see the subspecialists. The thing that really excites me is decreasing those disparities, making the same subspecialty care available to everybody regardless of the ZIP code is absolutely exciting.

Courtney Collen (Host):

Dr. David Newman, thank you so much for your time and for all you do for Sanford Health.

Dr. David Newman:

Absolutely. Thanks for having me.

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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• Help wanted: Health care workers in rural America
• Virtual care brings specialists to rural, underserved areas

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What shared nursing governance looks like in North Dakota

Alan Helgeson:

“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.

Today’s topic is a conversation on nursing with discussion on shared governance, nursing senate, and Magnet designation. Our guest is Wendy Kopp, Sanford Bismarck vice president of nursing. Our host is Erica DeBoer, Sanford Health chief nursing officer.

Erica DeBoer (host):

As part of this podcast, we’re really trying to highlight the essence of nursing excellence, and what a perfect time to be able to do that as the team has just celebrated their fourth Magnet designation. From your perspective, Wendy, I’m curious, tell me a little bit more about what this achievement for fourth designation means to your teams.

Wendy Kopp (guest):

So the achievement for the fourth designation is pretty incredible. You can look at statistics. So less than 2% of health care organizations in our country have achieved four Magnet designations, and so that’s pretty incredible. It really puts us in with an elite group of health care organizations.

Erica DeBoer:

So shared governance is an important part of our culture across Sanford, but more importantly at Bismarck. Could you explain what shared governance is and how it empowers nurses in shaping practice and policy changes?

Wendy Kopp:

Absolutely, Erica. Shared governance in Bismarck, I’m super proud of. We have a very strong shared governance structure, and when you think about what does shared governance mean in its essence, it’s really like autonomy and shared decision making. And so it’s really a framework and it’s a collaborative approach where our front-line nurses participate in their decision making on practice issues and policies. And so it’s really coming to the table and being present in those conversations that directly impact the work that they do.

Erica DeBoer:

And their energy is amazing. I love spending time with your senators, Wendy. You’ve done a great job leading that team. Tell me a little bit about a couple examples that have impacted nursing practice that have come through that shared governance structure.

Wendy Kopp:

Every year the list just gets bigger and bigger. I think some of the things probably that the senators would say they’re most proud of, that they’ve had a hand in, are probably developing our ICU nurse consult. That has been an incredibly successful initiative, the code blue debriefing. So that also came forward and really we’re implementing now, we’ve had huge success and we’re putting that across even more disciplines and specialty areas looking at in that NICU and OB space. So that really is a perfect example of what coming to the table and voicing your practice needs and concerns.

Charge nurse training and onboarding is another really great example of nurses coming to the table and really kind of sharing what their needs are and where the gaps are and what they feel needs to change.

Another one is point of care glucose testing, again, where we’re doing some pilots based on some things brought forward from senate.

And let’s see, another simple one would be just the need for more lactation spaces for our health care workers. And so we were able to give additional lactation spaces and get creative because they brought forward that need.

Erica DeBoer:

So what’s amazing about the examples that you gave, Wendy, is it highlights not only critical nursing practice pieces, but it also highlights the important health of your environment and making sure that they have that space to pump or really to make sure that there’s a safe space to debrief after a code blue.

I think as we navigate, and I’ve had a chance to talk with some of your ICU team, and they used evidence-based practice to actually support the information that they were gaining from our front-line teams. And to your point, they tested the science of it, they brought a collaborative group together and really met a need of – we don’t have as much experience with code blues or those urgent situations. How do we actually address that? And then how do we support our team? So I think the comprehensive approach that your teams are taking are just really impressive and actually addressing some of the needs of your front-line teams.

Wendy Kopp:

Absolutely. And one more thing, Erica, you reminded me when you talked about wellness, that’s another big initiative and a gap in what we were able to provide for our front-line workers. And they kept bringing the need on work-life integration and balance and needing a place to reset. And so we will be opening up before the new year our Zen Den, and that is an opportunity for our frontline workers to have a place for respite and to reset and rejuvenate. And so we’re really excited about that and that’s a testament to their voices coming to the table.

Erica DeBoer:

And I love the name Zen Den. I can almost smell the lavender. It’s amazing. I think it’s great. Tell me a little bit about the benefits of having your various councils and front-line representatives involved in that decision making.

Wendy Kopp:

Well, that’s quite an easy question. The benefit, it’s the patient. The patient is the one that benefits. When you think about our shared governance structure, and you look at our model, the patient is in the center of every decision that we make. And so when you think about where our shared governance, we call it our nursing senate, is that’s the next layer. And then all of our councils spoke out after that, if you think about it in a wheel fashion. And so it’s bi-directional. And so those councils report into the senate. The senate reports into the councils, and it’s just, I guess you wanna call it a beautiful marriage and how that works.

Erica DeBoer:

And it benefits so many more, not just our colleagues, but also the other people that are part of the collaborative team too. So that’s fantastic.

I wonder if we shift just a little bit to expertise and certification. I know I’m passionate about the role that certification plays in recognizing nursing expertise. How does it contribute to mentorship within the field?

Wendy Kopp:

Certification? Really, I mean, when you advance your knowledge and skills with certification, that mentorship just falls naturally because with certification you demonstrate that you have that advanced knowledge and skills. And so inherently that mentorship role just naturally or organically takes place.

Erica DeBoer:

I think that’s well said. What support does Sanford Health provide to nurses pursuing x certification and how does this support demonstrate a commitment to growth and advancement?

Wendy Kopp:

We definitely have that commitment to growth and advancement, and I think we’re really fortunate. Our learning and development center annually brings in, based on survey results, they bring in typical courses that are very, very popular or will be high users. So they bring those in, and those our nurses can take for free. Exam fees are covered, two attempts for an exam are covered, and then upon successful passing of that certification exam, there is also a bonus that goes along with it.

And so we feel that we do a great job not only initially supporting that, but then sustaining that we recognize our certification, our nurses that are certified annually, and it’s also additional support then for recertification.

Erica DeBoer:

It’s definitely something to be proud of. I know each of us as VPs of nursing and as a chief nursing officer, those are some of the things that I hold very close to heart because it’s really that expertise that’s really core to our commitment, not only to our patients, but to those around us to continue to learn and be that lifelong learner.

Wendy Kopp:

Absolutely.

Erica DeBoer:

Since we’re talking about certification, I wonder if you don’t have your own personal experience or a story of a nurse who benefited from the certification process and went on to become a mentor within the field.

Wendy Kopp:

I think of an example probably with certification process. As you recall, I mentioned the ICU nurse consult in a previous question. And so that particular nurse who brought it forward was certified and so based on advanced knowledge was able to kind of determine best practice. And so that was really a pretty cool moment to see that come to fruition based on that advanced knowledge.

And for myself, I can say for personally becoming certified in executive nursing practice, I want to be able to pay it forward and be able to continue mentoring our emerging leaders as well.

Erica DeBoer:

Yeah, and you do that extremely well, Wendy. When we shift to patient-centered practice, it’s really central to the focus. You’ve highlighted it already very well. How does Sanford Health ensure that all discussions, decisions and change revolve around optimizing patient care?

Wendy Kopp:

I think we could probably look at our differentiated practice model when we think of patient-centered care and the uniqueness that each of these specialties bring to the table. Erica, that was probably the easiest way to kind of summarize that.

Erica DeBoer:

Can you explain the role of evidence-based practice and how that’s important? Being at the forefront of all of our nursing endeavors?

Wendy Kopp:

I think having probably that problem solving approach and that decision making based on the evidence is really sort of ingrained in all of the work that we do. When we look at our professional practice model, research and evidence-based practice is a huge component of that. And so it’s really important to look at what are those influences, both internal and external, that influence our practice and affect our practice to really cause us to critically think about what changes should happen and then going to the evidence and research to help drive that change.

Erica DeBoer:

I think change is definitely a part of what all of us are trying to work on. And how do we do that with evidence-based practice in the forefront? I think you’ve got great examples of a really united and collaborative approach to your evidence-based practice group. It’s been amazing to see how it’s grown, not just in nursing, but also in some of your interdisciplinary teams through physical therapy and some of those last couple questions.

So when we think about the impact that happens through collaboration, how does fostering an open dialogue and knowledge exchange benefit nursing professionals, patients, our teams and the organization as a whole?

Wendy Kopp:

I know I keep going back to our professional practice model, but really interprofessional care and collaboration is another key component. And so when we think about our nursing senate, when we think about professional management, these are all councils and committees specific to Bismarck. Every one of those councils has an interprofessional or interprofessional members on there. We don’t make decisions in a silo. We collaborate and bring all of the entities to the table to really bring up the topics, the initiatives, the ideas, what are the opportunities, you know, how do we move forward again to make decisions that really will benefit not only the front-line workers, but also the patient.

Erica DeBoer:

I’m so excited that the team’s been able to celebrate their fourth Magnet designation. Speaking of collaboration, can you tell me how Magnet embeds that collaboration into that designation and that maturation over time?

Wendy Kopp:

Absolutely. And so I know we talk about Magnet being a nursing excellence award, and I always say, yes, it is. It is the foundation, but there is so much more to it. Not only one Magnet designation, but four designations is really a testament to the culture. We have been able to not only practice but sustain over the course of the years that we’ve been magnet designated. And so it’s the culture that really allows our teams to thrive. It’s all teams, our interdisciplinary teams, that culture again, where teams can have those conversations together, the good, the bad, and the ugly. And so again, just really hats off to all of the teams that allow great care to be given.

Erica DeBoer:

Absolutely. Something to be super proud of. That fourth designation in the MA maturation that you’ve seen, and I’d say even more importantly, you did that maturation, you did a lot of that work throughout the pandemic. And so important to recognize the challenges that came along with that.

Are there any particular innovations or practices that contributed to the remarkable achievement and how that’s influenced your organizational culture? You mentioned how important the culture is, how important the interdisciplinary team is. I’m just curious if there’s specific initiatives that help to drive that.

Wendy Kopp:

I don’t think I could probably list one initiative again, when you think about kind of the things that we focus on, it’s our quality, it’s our nurse, this nurse sensitive indicators. It’s really our patient experience and then it’s our nursing satisfaction. And so everything that we do touches each of those components in a very unique way. And so all of the exemplars have just have had a tremendous impact.

And we don’t do anything different the year that we go up for Magnet designation. We are that gold standard each and every day because of what we do and who we are. It’s not something we turn off and turn on just because we’re in our year or we’re up for re-designation. It’s really just who we are.

Erica DeBoer:

And it’s a magical culture that you’ve helped to create. Wendy, it’s been an absolute pleasure to speak with you today and share a little bit more about your shared governance structure as well as celebrate the Magnet journey with you. Anything else you’d add?

Wendy Kopp:

We want to reflect on Magnet. I think when patients come to Bismarck to receive care, they should know that they are going to receive some of the highest level of care in the nation. And again, we’re in with an elite group and we’re just extremely proud of who we are and what we’ve been able to accomplish as a rural health care organization.

Erica DeBoer:

I feel like Bismarck certainly emulates this in their daily practice in solving problems in the moment, no matter what might come your way. So congratulations and it’s great to have you.

Wendy Kopp:

Thanks, Erica. Thanks for having me.

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. For Sanford Health News, I’m Alan Helgeson, and thank you for listening.

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• NDSU’s advances in nursing school keep human touch
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Four pillars of weight management, defined

Cassie Alvine (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. Our conversation today is about weight management options, including discussion on recent medications for weight loss. Our guest today is Dr. Jennifer Schriever with the Sanford Weight Management Center. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

We’re talking with Dr. Jennifer Schriever on the “Health and Wellness” podcast. Are there any statistics or things that you can share regarding BMI as we maybe start our podcast today?

Dr. Jennifer Schriever (guest):

Well, the history of BMI is, it’s a really old measurement based out of men in Belgium. So it’s not a perfect measurement, but it’s what the current standard is. So to come to our clinic, we generally require a BMI of 30 and above, or if you have a BMI with weight associated diseases, then we will consider those as well.

We are now starting to accept pediatric patients 12 and above, and they have different ways to qualify their BMI. It’s greater than or equal to the 95th percentile for pediatric or obesity or if overweight and have medical co-morbidities related to weight. Then their BMI is at the 95th, 85th to the 95th percentile for age.

Alan Helgeson (host):

Dr. Schriever, we’re hearing things like weight management versus weight loss management. Are those the same thing?

Dr. Jennifer Schriever:

They are different. Certainly, the goal of most of our patients as they come in is weight loss, but then we want to make sure it’s done in a healthy fashion and appropriately because we want to make sure you’re able to keep your weight off for the long term. And it’s not just about weight, it’s about how is your body composition? And if you have extra skeletal muscle, that’s going to play a factor in how much you weigh. So we want to make sure that you keep that skeletal muscle on board and have the appropriate body composition. So that is more weight management than weight loss.

Alan Helgeson (host):

You know, we hear so much about diets. I mean, we’re just programmed to talk about diets. We see commercials, the ads. Regardless of where you look at it, it’s all about diets. Body image. Do diets work?

Dr. Jennifer Schriever:

No, really because a diet tends to be something short term, and really that you’re not going to be successful unless you find something that can be long-term for you. Short-term weight loss doesn’t necessarily add up to long-term weight loss if you resume old habits. So, and a lot of diets are something that people don’t find sustainable and weight loss may not be in a healthy fashion.

To me it needs to be a lifestyle change that you can develop and continue and adapt to so that you have new habits and understanding that of how you lead your life leads to improved health versus just a short-term program where you can lose weight fairly quickly but then it doesn’t stay off because of maybe your metabolism changed. Or once you resume more routine diets that you’ve done previously, then you can easily gain the weight back.

Alan Helgeson (host):

So if I’ve done a diet in the past, I’ve lost this 20 pounds, you know, a fairly quick fashion, but then I’ll go back to my old ways and it sneaks back on. But not only that 20 pounds but it’s 25 pounds or maybe it’s 30 pounds. Why does that happen?

Dr. Jennifer Schriever:

Yeah. Often what is happening with rapid weight loss or large weight amounts of weight loss fairly quickly is we’re also losing skeletal muscle, and that holds the majority of our metabolism. So if we lose weight through dieting and aren’t aware and understand about how is the best way I can keep my skeletal muscle, then we lose skeletal muscle. Thus our metabolism declines.

And then as we resume old ways, or it can be just become more difficult to maintain that weight loss and easier to gain again because your metabolism has declined.

Alan Helgeson (host):

Dr. Schriever, let’s talk about specifically what weight management options does Sanford offer.

Dr. Jennifer Schriever:

A variety of weight management options. You can start with your primary physician and they can help refer you to a dietician or their health coach in the office to help you with some information on healthy eating and maybe meal planning for your family. Some primary physicians and other specialists are comfortable with weight loss medicines and providing some lifestyle guidance.

Obviously we have the Sanford Weight Management Center and then we have a nice comprehensive team with a dietician and we have connections to behavioral health that can help you with depression and anxiety and binge eating disorder or anything that affects how you feel about eating and the stress related to that or even body dysmorphia. We’ll prescribe medications according to what is safe for you and your health conditions as well as your medication list and physical activity guidance. And as I alluded to earlier, we can help monitor your body composition.

Another option is bariatric surgery. The guidelines are a little bit different than weight management. They now recommend surgery if you want to at a BMI of 35 and above, or above 30 with weight associated medical conditions. And maybe even surgery should be considered lower than that if someone has really made some significant efforts at weight loss.

The first steps: checking on what you should do or consider, you can certainly talk to your primary physician or one of your specialist physicians for recommendations and also check with your insurance and see what is covered. If you are interested in our program, certainly call or have your physician refer you. We will give you some guidance on how to check with your insurance, but you can also be self-referred or have your physician refer you bariatric surgery. You can have your physician refer you to a bariatric surgeon’s office here at Sanford.

You have two surgery options, I believe the sleeve gastrectomy and then gastric bypass. Often they will know, that office will know if your insurance covers it so that they can help save you the time if your insurance doesn’t cover bariatric surgery. And they also often have informational meetings that you can come and get informed in what that process is like.

Alan Helgeson (host):

What are some signs that a person may need weight management care?

Dr. Jennifer Schriever:

First of all, just if they want that in a comprehensive program. Think if you have multiple medical problems, then you might want someone more specialized and focused in with a training to help people with their weight management.

If you feel like you’ve worked on your weight and lifestyle without improvement in your health and are really frustrated and need a new plan, then we can help with that.

If you appreciate and would like ongoing, regular and frequent contact and support, then we’re a good program for you because that’s what we’re here for the duration, for life if you need it or if you’re just confused and not well informed about nutrition and what’s so important in lifestyle because that has been a difficult topic to learn over time. And there hasn’t always been great nutrition information out there. So, and that just keeps getting better. And our group is pretty dedicated to stay up with the latest and greatest.

Alan Helgeson:

I want to go back to something you mentioned when we first talked about this question. One of the things you mentioned is if you have multiple medical problems, could you maybe go into that? It seems like so many things we hear about, one of the things we hear is weight related of just about everything. Weight is tied into so many things. Could you maybe expand a little bit on that Dr. Schriever?

Dr. Jennifer Schriever:

Sure. Sometimes it’s even hard to think of something that is not weight related. You know, certainly diabetes and heart disease are weight related. A variety of cancers are related to weight. So we can reduce risk of cancer by improving one’s health. Mental health is tied to the disease of obesity. So depression or anxiety or eating disorders. High blood pressure, high cholesterol, if you have arthritis and problems with your knees or hips for example or even chronic back pain, it’s going to be related to the disease of obesity.

Alan Helgeson (host):

We were getting ready for the program today and you had mentioned there’s some calculation that losing a certain amount of weight and, and I can’t remember what that number is, but that if you lost such, it equates to another number of taking pressure off your knee.

Dr. Jennifer Schriever:

Yes. So for every pound of weight you lose, it takes four pounds off your knees. So you can see more rapid improvement in your knee pain just with even smaller amounts of weight loss because of the effect of gravity in addition to the weight.

Alan Helgeson (host):

Everybody has knee pain, right?

Dr. Jennifer Schriever:

A lot of people certainly. Or back pain.

Alan Helgeson (host):

Or back pain too. So everything is tied to, I mean so many things are tied to weight related issues. OK. We talked about maybe how to go about getting some help and maybe some of those signs. What does a person need to know about weight management?

Dr. Jennifer Schriever:

So the goal of weight management is to create a lifestyle that leads to improved health and body composition so that you reach a point that you’re comfortable with where you are. Those chronic diseases can improve with just as little as even five to 10% of weight loss. Cancer reduction risk I think is closer to 20% of weight loss. We use a body composition scale to help guide you too so that you understand and appreciate what is going on rather than just trying to watch the scale budge.

Alan Helgeson (host):

Can we talk a little bit about watching that scale? If it’s only about a number, how can you get people off that piece, Dr. Schriever?

Dr. Jennifer Schriever:

I think in our clinic it becomes easier because we do have a scale that helps to measure body composition. So we go over that each visit. It includes obviously the total weight but also what does your lean tissue weigh such as a total number for your bones, muscles and organs. It also has the dry lean mass. So that’s looking at what do your muscles and maybe bones weigh without any water content. So that reflects your muscle health and balance as well as just a number that reflects your skeletal muscle weight.

So we can help you monitor that because as you lose weight, we really only want you to lose less than 20% of your skeletal muscle compared to your total weight loss. There’s also a percent body fat, and we watch visceral fat – that’s the fatty tissue inside our trunk, around all the organs. So that’s different than subcutaneous, which is underneath our skin. The visceral fat causes inflammation and puts us at risk for all the diseases that can occur from organs in our belly like diabetes and heart disease. And then reducing that reduces all of our risk factors or reduces risk for the cancers that occur in those organs.

Alan Helgeson (host):

So we’re talking about what are some of the keys to healthy weight management. Let’s talk about what are some of the do’s and don’ts of weight management?

Dr. Jennifer Schriever:

Find a plan that is sustainable and stick to it. Don’t look at those fad diets or advertisements for supplements that just seem to be amazing because they probably aren’t. And I hate to see patients spend money on something that isn’t well studied for our program. It is most effective or if you follow our guidance then if you feel like you’re stuck and what we’re telling you isn’t working to come back and tell us what you’re doing and give us some details so we can help figure out how we need to adjust that.

Encourage patients never to be embarrassed to come back because life happens and interrupts everything and makes following your plan difficult. And we also strive for consistency, not perfection. So that’s important because we want to participate in different things in life. That might mean we’re eating something that we don’t consider as healthy as others, but that doesn’t mean you can’t enjoy it once in a while.

We focus a lot on tracking nutrition at some point. We don’t want that to be stressful, which it certainly can be for some people, but you’ll find the most success over time tracking to some extent or doing a check-in with yourself. And we at least start with having patients know the right amount of protein to get and working towards getting to that. And then as comfort level improves or understanding of nutrition improves, we can look at other ways to track nutrition.

Exercise is also very important. We do strive to help our patients find a way to do that that is comfortable for them because it can be very uncomfortable at first or they have joint problems that make exercise or knowing how to exercise difficult to understand. So we try to collect as many resources as possible to make that work for them.

And then just don’t give up. We’ll help you figure it out.

Alan Helgeson (host):

Let’s talk about some of those keys that are really core to healthy weight management. Could you cover some of those please?

Dr. Jennifer Schriever:

Sure. So there are, through the Obesity Medicine Association, four pillars that are integral and important to improving lifestyle and they all need to be included.

1. So one of course is nutrition, and the main focus here is getting adequate protein and then creating a calorie deficit for what you need. But we’ll help you adjust to that and figure that out over time.
2. The second pillar, highly important – actually they’re all important – is physical activity. So I always point out it says physical activity, not just exercise. So how much are you moving every day? And for heart health you need at least, or it’s recommended to get 5,000 steps a day or more and sit less than six hours. So that’s really important and that’s called neat non-exercise activity thermogenesis or some people will say time. So how much are you moving every day? And little bit by little bit even extra steps here and there are super helpful in managing your weight.
3. The third pillar is behavior. We often have stress eating or emotional eating or binge eating that we find as we get new patients. I also often talk about how do you get through a social event and feel comfortable about it, go out to eat, go on vacation, and we can help you with some thoughts on how to do those things if you want to keep your health in mind. Now sometimes you might say, this is my time, I’m going to enjoy myself and that’s totally fine, but often it’s as simple as get some protein first, whether it’s there or on your way and then that’ll help fill you up so you don’t feel so hungry there.
4. The final pillar after, so the first three were nutrition, then physical activity and behavior. Then the final pillar is medication. So all of those pillars are important to develop a lifestyle that works for you and medication should be included as long as you need them, as long as they aren’t causing any harm. And even in when you get to a maintenance phase or where you’re comfortable, they’re part of what we’re working on. And so as long as there’s no adverse effects then we continue with those to support you as long as you feel like you need them.

Alan Helgeson (host):

Do you talk to your patients about using the wearable technology and some different apps? Are those important within your clinic?

Dr. Jennifer Schriever:

I think they’re definitely valuable to the right person because it gives you an idea of where you’re at and if you can consider improvement. You know for some patients they don’t or aren’t able to move a lot. So then I say well then can you add an extra 50 to a hundred steps a day, depending on their capability? Or do we look at, can you increase by 250 to 500 steps on average? To make small goals that seem more obtainable. Then we all tend to think that 10,000 steps a day is what we need and if we think we need that, that doesn’t seem reachable. So I do encourage them, if they’re able to get one of those or to at least maybe carry your phone more often for a day. Because it does count your steps and then you at least know where you tend to be at.

Alan Helgeson (host):

Let’s switch topics here because this is really dominating so much of the category of weight management and weight loss. It’s the medications. Could you talk a little bit Dr. Shriver about these medications and how they work and why they’re getting so much attention?

Dr. Jennifer Schriever:

The generic name for Ozempic and Wegovy is semaglutide. And so Ozempic is the brand name used for diabetes and then Wegovy is the brand name used for weight management and the dosing is slightly different. Those are both a GLP-1 it’s called, which is a hormone that your small intestine makes and distributes once you have eaten.

So it triggers some insulin and blocks glucagon secretion, which means that your blood sugar level doesn’t peak as much and you get better blood sugar control. It also slows down your stomach from emptying so you feel full sooner and faster and also sends a signal to your brain to tell you you’re full and satisfied. So it can take away some of those cravings and food noise that people talk about.

Then Mounjaro, it is a GLP-1 medicine but it also has GIP in it and that’s another GI or gut hormone that can increase satiety. So it can help with full feeling but mainly acts by affecting a portion of the brain that makes you feel satisfied, that helps to decrease then your calorie intake. It also is affecting the insulin and the glucagon after you eat and is released into that response. It also can help kind of your fat distribution, encouraging fat deposition into your fatty tissue rather than your organs, which is where you really don’t want it.

Alan Helgeson (host):

Who is a candidate for these medications?

Dr. Jennifer Schriever:

The criteria for medications is the same as the criteria for our program. So anyone with a BMI of 30 and above or the BMI of 27 and higher with a weight associated condition.

Alan Helgeson (host):

But what is an ideal patient journey for these types of medications?

Dr. Jennifer Schriever:

Yeah, it’s kind of funny how a drug gets named. So the drug company goes to the FDA and says we’ve studied this medicine, here’s our evidence and this is a condition we studied and then they pick a brand name.

And then they go back after they’ve studied it and clarified that it can be used for weight management and then they rename it and then it’s called Wegovy and then that’s how the patents are created. But that’s also how insurance determines what they cover those medications for through that process. Which is why your insurance won’t cover Ozempic for weight loss.

So certainly we want to make sure as we screen patients that they qualify based on their BMI and health conditions or and also that they don’t have a contraindication – which sometimes the contraindications are listed but maybe not necessarily an absolute. But generally we don’t start patients on these medicines if they have a history of pancreatitis that we don’t necessarily know why. Although I think some studies show that that’s maybe not as concerning as we initially thought.

There’s a family history of a specific type of thyroid cancer that we wouldn’t recommend those medications for and that’s medullary thyroid cancer, which is not very common. I would also hesitate if a patient has known gastroparesis, which means their stomach already doesn’t empty very quickly and if the patient still wanted to, we’d have a significant discussion about how that’s going to go.

Alan Helgeson (host):

So we talked about the insurance thing. If someone’s insurance doesn’t cover this and they still wanted to pay for it out of pocket, could they do that?

Dr. Jennifer Schriever:

They certainly could. Generally mainly the ones that are FDA approved for obesity but it’s fairly expensive for a while. Maybe you could get it for $500 but I think lately it’s more like $800 a month and we’re still dealing with drug shortages so can be pretty hard to find at the moment.

Alan Helgeson (host):

At what point can we start identifying as something for long-term success with them?

Dr. Jennifer Schriever:

Well by the time a medicine like this has come to market, it’s been well studied and some of the evidence out there is as long as five years. The Ozempic has been out since 2016, not necessarily used and dose adjusted for weight management, for more for just diabetes. So then Saxenda, which is the daily injection liraglutide is also Victoza and that’s been out since 2012 I believe. So then we have some more longer term data in the general population but they’re studied well beyond that for several years prior to coming to market. Probably more like 10 to 20.

Alan Helgeson (host):

So it’s been out there a while.

Dr. Jennifer Schriever:

It has. So far we don’t know of any definite long-term risks of these medicines. I mean certainly there are rare complications which maybe we want to get into.

Alan Helgeson (host):

Yeah, let’s talk about some of those. That’s a good lead into those.

Dr. Jennifer Schriever:

Yeah, so some of the concerns initially and especially based on study is significant or can be significant nausea and constipation. I actually supply the patient with a prescription for something for nausea and caution them to definitely eat slower and drink slower because these are slowing your stomach from emptying and the effect of that can be fairly immediate or it can take several weeks into the dosing.

The latest on that gastric emptying or the stomach emptying slowing, seems to be out there where there are cases reported where they talk about their stomach being paralyzed. That was never necessarily found in the studies as the drug companies did prior to bring it to market. Certainly that condition can happen randomly, so I don’t know if that is a true association and, but it does slow your stomach from emptying. So that is a risk.

And if I have a patient at risk with diabetes for example, which they are at risk, I might ask them a lot of questions about how they feel around eating and if they have any symptoms that make me suspicious. So I have checked a few patients for that prior to prescribing it.

There’s a list of diabetic retinopathy, which is an eye complication that can lead to blindness for patients with diabetes. If their blood sugar is pretty stable, it’s not really a risk if you know these medicines can help their diabetes improve so then that can change their blood sugar levels quickly. But I don’t think that risk is as significant as worried but it certainly doesn’t hurt to contact their eye doctor about what they would recommend as far as maybe dose adjustment or what their blood sugars are doing or what is the status of their diabetic retinopathy.

The medications, you know, can cause pancreatitis. So we might hesitate depending on the cause of the pancreatitis. If it’s due to your gallbladder or some other concern, then the medications are still fine. If we aren’t really sure then we will have extra precaution about continuing those. It can raise heart rate typically only a few points and not an ongoing problem, or can make it feel be significant. But generally that often isn’t a reason that we have to stop it.

They’re the common, just like any medication, since these are injections, you can have a rash at your site or an allergic reaction. Low blood sugars are possible but not very common. Another common one, like in the media or social media is about kidney problems. Often if you’re going to have severe GI problems like nausea or vomiting or sometimes you end up with diarrhea and you aren’t able to stay hydrated, then you know that is a risk for having some stress on your kidneys.

So certainly on these medications especially you don’t think this is just a side effect that I can try to deal with at home, seek care sooner than later.

And then one thing, I don’t know if it’s still such a big deal out there, is that Ozempic face? Ozempic face. Yeah. Really anyone who has weight loss, you know they’re going to lose weight or fatty tissue in particular in a variety of places. So some people will lose more in their face and maybe look a little gaunt or quite a bit different than they used to. So I think that’s what that’s referring to. But that can happen with any weight loss method.

Alan Helgeson (host):

If you are taking these medications, are you on them for a long time or just till you maybe get to a point where you don’t need them anymore?

Dr. Jennifer Schriever:

I think that’s going to vary on the individual. Certainly it’s very important to incorporate all the lifestyle and the pillars that I talked about earlier.

So we have to focus on the nutrition and that certainly helps with satiety feeling. It’s important to focus on the exercise and strength training because we need to maintain that skeletal muscle health, which we also need the protein for.

Have we learned how to address our behaviors or know some techniques or improved with counseling around mental health concerns or binge eating. And how stressful has weight management been for you most of your life?

So for some patients they really do well with those lifestyle changes or a lot of them do, but it depends on, I think, their life experiences and the fear of that hunger returning, how long these medications are needed. Some have done very well having to suddenly stop them based on insurance changes, job changes, et cetera, that they’ve done well and at least maintained stability before they’ve come back to see me. And some certainly have a lot of anxiety of what’s going to happen when they go off. So it really should be a long-term medication that the patient and the doctor can work on a plan if they’re ever ready to go off. But it’s not that way for everyone.

Alan Helgeson (host):

In a quick summary here, a lot of things you would hear the media and some places would say this is the quick miracle drug of the moment. It’s getting its 15 minutes of fame. OK great, whatever, what isn’t this medication?

Dr. Jennifer Schriever:

Yeah, I think the unfortunate part about how it’s advertised, and maybe it’s just what we really hear from that message is how successful these medications are in the studies to help someone with weight loss. But it’s so imperative to do everything together because by themselves they may work to some extent but they’re not going to work for the long term if you aren’t keeping aware of what does my nutrition need to be and how do I support my muscle health and how do I exercise to keep my metabolism?

Because for some it is such a relief to not be hungry anymore and historically they might have lost weight just by eating a lot less or not eating, but that’s not going to work in the long run based on your metabolism and all sorts of things that change internally. So it’s still a comprehensive plan, but that’s a major tool to include. But it doesn’t mean it’s the only thing.

Alan Helgeson (host):

On social media, they’re talking about how these medications may have an unknown added effect that is spilling over into some other addictions. How it is maybe working to curb some other addictions?

Dr. Jennifer Schriever:

Yeah, so the details certainly aren’t fully known yet, but we do know that part of their effectiveness is how they not only send a message to the stomach from the GLP-1 standpoint, but both the GLP-1 and GIP effects are going up to your brain to tell you you’re full and satisfied. That seems to be triggering a portion of the brain that does help with addiction and compulsive behaviors by just taking away that desire to continue to do those sort of things.

And it seems to be having an effect on the dopamine pathway. And our dopamine chemistry is behind a lot of our addiction and cravings behaviors. So people, I even have patients who aren’t necessarily have an alcohol addiction but they just don’t crave that alcohol anymore or it’s helping them quit smoking and then, you know, certainly people do feel addicted to food sometimes and so it helps taking those cravings away. So that’s just such a benefit. Because as you think about those thoughts, they’re very stressful. Because you don’t want those thoughts, you might not want that food or to drink more alcohol, but yet that craving is there.

Alan Helgeson (host):

If you watch the various news reports, they’re making the miracle thing of the moment, but it’s just a thin slice of one of the many options. And there’s so many things that Sanford offers in helping somebody in a journey to finding a healthier way to live. And it’s a lifestyle thing, right?

Dr. Jennifer Schriever:

Certainly. And there are other medication options. Patients are often so disappointed to know that their insurance might not cover these medicines, and they’re so expensive to consider out-of-pocket.

But some of the cheaper medications we have patients very successful on that and they’re also incorporating of course, nutrition and lifestyle changes like exercise and the physical activity as well as any behavior things that need to be addressed. And so they do very good on medications and if weight management isn’t covered by insurance and you don’t have a contraindication to take some of the pills, patients are spending $25 a month out of pocket.

Alan Helgeson (host):

It’s nice to know that there are so many options available and that Sanford Health has really, really gotten behind helping people get healthy in so many ways. And the big takeaway, if you could give people one takeaway from this, what do you want them to do or want them to know?

Dr. Jennifer Schriever:

Wow. Big question. But I think what I really want people to know is that there is a healthy and sustainable way to help you with your weight loss. And it’s now available at Sanford and we do our best to meet everyone’s needs and it make an individual plan that works for them. And it is very frightening to come into a clinic and discuss your weight and just know that we are going to treat you kindly and without any bias and really aren’t going to judge because everybody has a different life journey.

Alan Helgeson (host):

Before we go, I want to mention that many of the services and care options mentioned during the conversation with Dr. Schriever are available at the Sanford Weight Management Center in Sioux Falls. If you’d like information on what options are available near you, call your provider, your clinic, or visit sanfordhealth.org.

Cassie Alvine (announcer):

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.

Learn more about this topic

• Weight loss surgery Q&A with an expert
• TikTok nutrition trends: What’s safe versus a scam
• Bemidji woman loses 90 lbs. with help of Sanford nutrition

Get more episodes in this series

Rural health care workforce must ‘skill up, scale up’

Alan Helgeson:

“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 Toni Thomas, chief experience officer and industry advisor, Microsoft. She joins an expert panel at the 2023 Summit on the Future of Rural Health Care with the topic: how can we work smarter, not harder?

Courtney Collen (Host):

I have Toni Thomas here in Sioux Falls from Cleveland, Ohio. Toni, welcome to Sioux Falls and welcome to the podcast.

Toni Thomas:

Thank you. It’s my second trip into Sioux Falls, and as I said at the welcome dinner last night, I have a crush on Sanford ever since coming here the first time and on Sioux Falls.

Courtney Collen (Host):

Well, we are happy to hear that, and we are even happier to have you here and grateful for your time. Toni, what are the top three opportunities you see when it comes to building a stronger rural health care workforce?

Toni Thomas:

Yeah, the first opportunity I think really lives inside the organization and making sure the organization is communicating out to the population that there is a need to address the workforce crisis, that there is one, and how that would impact them or their families in the future. So helping them understand the scope of the problem.

The other opportunity I think that exists with especially a health system like Sanford is the power to be able to help the rural population skill and scale up. So before we can get them into a pipeline where they can be formally educated in the health care professions or the helping professions, we need to take skilling out to the community and also integrate themselves into the public school system, the private school system, and certainly the secondary education system.

Courtney Collen (Host):

Your panel discussion answered the question, how can we work smarter, not harder? I want to throw that question in here as well, Toni. How do we work smarter?

Toni Thomas:

Yeah. So I’m going to take it back to the foundation of what it is I do every day. And that foundation is really around organizing your data and understanding the scope of the problem because we really, truly have to tear down or – my manager likes to say – unlearn what we know about our problems. And that’s a phrase that I’ve adopted. So to do that, we really need to have data that’s accessible and available and then to be able to analyze it, to understand the scope of the problem and how do we work together towards solving that problem?

Courtney Collen (Host):

Where have we made progress when it comes to health care workforce issues? Where does work remain? And how will this shape strategy and policy moving forward?

Toni Thomas:

Right. I really do think that it is a multidisciplinary collaborative effort, and it’s not lost on me that right at this very moment, we’re sitting in a room full of people that have joined together from health care, medicine, nursing, technology, public policy, and government to talk about really hard things and how to fix those things.

And I think the biggest thing that we can do coming out of today, it’s easy to talk, but then we have to take action. So that’s really important. And I’ve been involved in a lot of meetings over the years, summits and panels. But this one is unique. It’s small, but not too small, and it has powerful thought leaders that can lean into the problem.

Courtney Collen (Host):

If you could share one piece of advice with a new clinician or physician entering the workforce today, what would that be?

Toni Thomas:

Wow. That’s a really hard question. I would say that if you’re following your heart and you really want to be in a helping profession, don’t be daunted by the problems that the workforce is facing today. Because there are people, like people in this room, who are really trying to fix that.

There are people that care and that your family, your friends and your neighbors are going to be dependent on people who want to join the health care workforce and take care of the people in the communities where they live. I think that’s so important. It’s like, let’s just get back to the basics and understand that we’re trying to solve these problems and we need people.

Courtney Collen (Host):

That’s great advice. Thank you for that. What excites you most about the future of rural health care?

Toni Thomas:

Yeah. I talked a little bit earlier today about my moonshot and what is my, you know, vision for like health care of the future? And for me it’s really about understanding and knowing the people that are living in your communities and the populations that you’re serving, understanding what their struggles are, understanding how they want to receive health care, where they want to and when they need to receive health care. So just really understanding your populations and being able to increase the access to health care for them in that way.

Courtney Collen (Host):

Toni Thomas, thank you so much for your time and for being here for this event.

Toni Thomas:

Thank you so much for having me. It was a pleasure.

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.

Learn more about this topic

• Help wanted: Health care workers in rural America
• What does it mean to future-proof our workforce?
• Solving worker shortages in nursing homes

Get more episodes in this series

AMA president offers Rx for workforce resilience

Alan Helgeson:

“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. Jesse Ehrenfeld, president of the American Medical Association. Dr. Ehrenfeld joins as a keynote speaker at the 2023 Summit on the Future of Rural Health Care with the topic solving physician burnout – a prescription for a more resilient workforce.

Courtney Collen (host):

Dr. Jesse Ehrenfeld is here with us in Sioux Falls. Thank you for taking the time today. Glad to have you.

Dr. Jesse Ehrenfeld:

Thanks for having me. Appreciate it.

Courtney Collen (host):

What are the top three opportunities you see when it comes to building a stronger rural health care workforce?

Dr. Jesse Ehrenfeld:

Well, you know, we need to address the issue of burnout, and there’s growing awareness of physician burnout and its implication for health care over the long haul, but also the factors driving it. The solution to the workforce crisis, physician burnout, is complex. But there’s bipartisan support to do it. And, you know, we need to apply pressure on lawmakers, on Congress, to make sure that we can shore up the physician workforce, but particularly in rural areas we have the opportunity to make it easier for international medical graduates to practice in rural communities and in the U.S.

And you know, we support the Conrad 30 Physician Access Reauthorization Act, which would make the J-1 visa waiver program easier, make these people who want to come and work in rural areas. There’s also opportunities particularly to rethink medical education. The AMA has made grants to UC Davis in California, Oregon Health and Sciences out in Portland to recruit medical students from rural and Indigenous communities, train them in those communities with the goal that they practice in those communities. And we’ve seen some really wonderful early success. We’re learning more about the power of solving these issues upstream by recruiting students from rural communities to come to medical schools. And I’m optimistic that we can do that.

You know, it’s certainly encouraging to me to see the kinds of things that are also happening to support resilience and physicians who need help. And unfortunately, there are a lot of barriers. There’s a lot of stigma when a physician in burnout needs a confidential place to go to getting that assistance. We’ve supported legislative maneuvers in a variety of states to make sure that there are confidential physician wellness programs that mean that someone, people have a place to turn to. And I will say South Dakota is a leader in this area. A law passed in 2021 that protects physician confidentiality when someone is seeking help for career fatigue or wellness. We need to scale that to other states and certainly we’re seeing some movement.

Courtney Collen (host):

Dr. Ehrenfeld, where have we made progress when it comes to health care workforce issues?

Dr. Jesse Ehrenfeld:

Well, we’ve made a lot of strides in just sort of addressing the fact that we don’t have the people we need and that we need to better support physicians working in the system. The problem is with the system; the problem’s not with the individual physician.

You know, we have our AMA joy medicine recognition program, which recognizes health systems, hospitals, medical groups for their exemplary work in supporting physician well-being. And that program provides a roadmap for leaders to implement policies, to implement programs that can support physician well-being. Seventy-two health systems including 35 first time recipients were recognized in 2023 through our program including Sanford Health, which we’re very excited about, very proud to elevate. Sanford Health was among the systems that got the gold recognition, the program’s highest honor, because you all have demonstrated across a number of distinct areas, a commitment to supporting the practice environment and making it easier for physicians to do their jobs.

Courtney Collen (host):

Where do you think work remains? How will this shape strategy and policy moving forward?

Dr. Jesse Ehrenfeld:

Well, certainly, I think there are a lot of opportunities to make sure that as people are overwhelmed working in the system that we’re in today, that people see that there’s a place that they can turn to that has their back. And certainly as the largest, most influential physician organization, we try to be there. We try to make sure that when we see these challenges, when it’s so easy to be discouraged, that physicians recognize that there is a voice. And you know, I get to travel all over the country as AMA president. I see the heartache. I see the burden.

But I’m optimistic because I’m optimistic when I see physicians stepping up day in and day out, in spite of all of the challenges. I see physicians who step up to counter disinformation. I see young physicians, trainees that I work with who have a bottomless sense of curiosity, a commitment to making a difference. And I’ve seen so much happening in the country that in spite of the political division, the challenges in the world to make sure that patients have access to the care that they need, I know we can get there.

Courtney Collen (host):

If you could share one piece of advice with a new clinician or physician entering the workforce today, what would that be?

Dr. Jesse Ehrenfeld:

You know, it would be to hang in there. In spite of everything that we are facing, I know that we can pull it together. I know when I walk into my hospital and I see patients – I’m an anesthesiologist – I see people putting on their scrubs, putting on their white coat that in spite of what seemed like immense obstacles that there is joy in the profession. And we just need to create those social connections. We need to make sure that people have the tools to do their jobs more efficiently. We need to pull the system inefficiencies out. And I’m optimistic that we can get there.

Courtney Collen (host):

Thank you. And lastly, on that kind of high note, what excites you most about the future of rural health care?

Dr. Jesse Ehrenfeld:

Well, I think technology’s a real game changer when it comes to caring for patients, particularly in rural communities and medically underserved areas. The AMA has been a huge supporter of telemedicine before the pandemic because we saw how vital it can be for patients who have limited mobility, who don’t have direct access to a physician’s care because of geography. And so we have a lot of tools, a lot of resources for practices to integrate these tools and these technologies into what they’re doing.

I’m really excited about what AI can bring. I think we need to make sure that we think about it as augmenting the capability of our clinicians, not replacing it. So that’s why the AMA likes the term augmented intelligence. But I think that there are a lot of opportunities to rely on technologies, re-engineer our workflows, and I’m optimistic about what that’s going to mean for our rural communities.

Courtney Collen (host):

Dr. Jesse Ehrenfeld, thank you so much for your time today.

Dr. Jesse Ehrenfeld:

Thanks for having me.

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.

Learn more about this topic

• Solving worker shortages in nursing homes
• Meaningful work, social links are critical for health care
• What does it mean to future-proof our workforce?

Get more episodes in this series

Cancer patient rep has new title: Breast cancer survivor

Courtney Collen (Host):

Hello. Welcome to “One in Eight,” a new podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We are really looking forward to kicking off this series all about breast cancer awareness because – and we can’t stress this enough – one in eight women will be diagnosed with breast cancer during her lifetime.

Lynn Roemeling is a friendly, familiar face inside the Sanford Oncology Hematology and Infusion Clinic in Sioux Falls.

She is a patient access representative, which is a position she’s held with pride for 13 years.

Lynn Roemeling:

I’ll be checking in patients, checking out patients, making their next appointments. We also send e-referrals to the doctors that are on call when we’re up front.

So it’s a lot of fun. I love my job.

Courtney Collen (Host):

But in June of 2020, that job – and life outside of work – came to a pause.

Lynn Roemeling:

Well, I had a mammogram that showed up a little abnormal and so ended up getting a biopsy and found out I had breast cancer. It was a whirlwind after that.

Courtney Collen (Host):

Suddenly, Roemeling was the patient and started her care at the Edith Sanford Breast Center with a triple-negative diagnosis, a rare type of breast cancer.

Lynn Roemeling:

It’s a scary thing for anybody to get that diagnosis. To be perfectly honest with you, I was waiting for the day for it to come really, because my family is, has been full of cancer.

Courtney Collen (Host):

Her grandmother and sister both had breast cancer so she had a feeling it was a battle she would eventually fight too.

Lynn Roemeling:

It didn’t come as any big surprise to me. But still, when you hear that, it’s like, ‘oh my gosh,’ you know, what’s going to happen now, am I going to make it through this? How am I going to feel it? You know, you’re just, you’re overwhelmed with emotions at that point in time.

It’s scary. It’s very scary.

I had started treatment practically right away. Got done with treatment and had my double mastectomy. I had my nurse navigator, I have my oncologist, I have my surgeon, I have my plastic surgeon. I also went into a trial. They did ask me if I would be willing to go into a trial, which I gladly did, just because if it can help anyone else in the long run figure out, you know, if this is something good or not, I wanted to go ahead and do it.

My worst enemy was fatigue. It just totally drained me. There were a couple times when I finally had to quit working that they would have to take me out in a wheelchair. And that just killed me because I just, yeah. I didn’t want to sit at home and do nothing.

And I missed everybody. I missed my patients. So it was very, very scary. But I knew that I was in the best place to be, to go through this. And man, you can’t have better support than I did.

Courtney Collen (Host):

That support included a comprehensive care team of specialists to personalize her journey through treatment with their advanced training and technology, tailored care to her genetics and rare type of cancer.

Lynn Roemeling:

To know what I had was here just made it so much better. I mean, to have the doctors here with you and helping you through every minute. I can’t say enough about this place.

Courtney Collen (Host):

Beyond breast cancer, as she alluded to, her family knows cancer sadly too well. The disease took both of her parents many years ago. Her mom was diagnosed with ovarian cancer and her dad – pancreatic.

Today – her oldest son was diagnosed with prostate cancer, her youngest son – Hodgkin’s lymphoma – and her daughter passed away after fighting colon and liver cancer.

More than most, Lynn understands the value of life and knows she’s right where she needs to be.

Lynn Roemeling:

When I first interviewed at Sanford, I interviewed at three different places and this was the third place. And I interviewed all three in one day and I got here and it was just like, this is where I want to be. This is my job. So I was so thankful when they offered it to me. And now being on both sides, I mean, I knew kind of what cancer was like and so forth and so on because of my family history.

But until you go through it yourself, it’s not quite the same. You see what they go through. But until you do it, it’s not the same.

And so to come back and know or feel like I’m in the spot that I belong in and just greeting these people, I know everybody comments on my smile. Because I’m always smiling and I think that’s half of your battle is your attitude. You need to keep going. You need to keep fighting. You need to have that. And so I try to bring that to every person that comes here. Anybody that I don’t usually bring up that I’ve had it myself, unless it’s a person that is really down and scared. And then I try to mention just, you know, what I’ve been through what you’re going to be going through and it’s going to be OK.

We have a great team here and if anybody can get you through this, they can. They’re here for you every step of the way. I just can’t say enough that, you know, fight. Just fight.

You’ve got it. You do have this.

Courtney Collen (Host):

An attitude of gratitude – and encouragement – for each new patient facing a similar journey.

Lynn Roemeling:

You get patients who are mad at the world. Why me? Why is this happening? They’re mad and gruff … they’ve been dealt a blow and nobody wants to go through this. Our job is to try to get them through it as good as we can. So, if there’s anything we can do, you know, call, stop you and do what you have to. But we’ll be there. And just to, just to be able to, to do this again and be able to let people know, Hey, you know what, you’re in a good spot. It’s going to be okay. And I just am proud to be part of that.

I am so blessed. I was in the right place at the right time. I think it was meant to be. I, I just can’t thank everybody enough here, and I can’t, definitely can’t thank God enough because evidently he wanted me on this earth a little longer to do what I’m doing too. And I’m glad that I can do it.

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Meaningful work, social links are critical for health care

Alan Helgeson:

“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, Ann Nachtigal with Sanford Health News talks with Dr. Zeke Emanuel, oncologist, vice provost of Global Initiatives, Levy University professor, Perelman School of Medicine and the Wharton School, University of Pennsylvania. Dr. Emanuel joins as a keynote speaker at the 2023 Summit on the Future of Rural Health Care with the topic: Reinventing America’s health care workforce.

Ann Nachtigal (host):

Zeke Emanuel, thank you so much for joining us. We’re really excited to have this room of thought leaders here to talk about rural health care. First question for you is: What do you think are the three top opportunities when it comes to building a stronger workforce?

Dr. Zeke Emanuel:

Well, the most important thing is to make sure the workforce does meaningful work and are invested in their work and the mission that they’re doing.

One of our big problems in health care is that we have too much nonsense and paperwork that has no meaning, right? I mean, doctors go into medicine to take care of patients. Nurses go into medicine to take care of patients. Doing paperwork is not their primary goal. It really makes them sort of upset and depressed because they’re not doing the thing that they care about. And so I think figuring out how to make more high-value activities. The patient care, the patient connection is critical.

I’m an oncologist. The one of the reasons I went into oncology is it’s a critical moment for people in their lives. They’re making big, big life-changing decisions. They’ve just been hit by a truck. They’re exploring their values, what’s really important to them. You get close. That’s what’s meaningful in patient care. That’s why we went in to become doctors. And you know, if what you’re doing is filling out billing forms or filling out quality forms or just filling out forms and updating the EHR, that’s not meaningful. And so we have to figure out how to make it most meaningful for health care providers to actually do the thing that they came into the professions to do.

Ann Nachtigal (host):

You know, I did see that kind of goes to the article that you put in JAMA, co-authoring this article on reassessing the data on whether there actually was a physician shortage. And you talk to you know, what are some of those opportunities that we can look at? So I thought that was really interesting. Where do you think we’ve made progress when it comes to workforce issues?

Dr. Zeke Emanuel:

Well, during COVID, we’ve slipped, right? Unfortunately, we haven’t made a lot of progress because we’ve overworked our doctors. Initially there was a lot of praise for our health care professionals who were really going above and beyond but I think, you know, eventually you can only do that so long. You can sustain a sprint only so long. And then you need support.

And we’re seeing with, you know, strikes at Kaiser and other actions, unionization, that people are upset by the system. And I think one of the important things is: it’s really a system issue. We have to figure out, us leaders have to figure out how we can get back to doing what people care about.

I would say figuring out or thinking about the patient experience has been very, very important. And obviously the labor issues are very important to all leaders. So I’m hoping that as we look forward, we can, you know, how do we reduce our administrative burden? There’s a lot of things we can do. Yes, it’s a complicated situation with payers and providers and all the rest, but there are things we can do to reduce the administrative burden.

How can we actually get patients, you know, have our interactions so that whatever’s easiest for the patient works also for the doctors? Like, you know, we have yet to really fully integrate virtual care and can we make that work? Can we make home care work?

I also, I’m really excited about some possibilities regarding AI and using the phone to actually deliver therapeutic interventions. And I think that’s also going to make a huge difference when we can bring in, again, we have to look, I think, at technology as our friends not as our enemy. A lot of people worry that technology’s going to take over or going to eliminate our jobs. Well, I don’t think so. You know, the history of technology has allowed us to do more and augment what we do best.

Ann Nachtigal (host):

You know, you mentioned COVID-19 and how that was so hard. And I think really what’s come out of that, at least in terms for Sanford Health, and I think a lot of other health care organizations, is really focusing on the well-being of our caregivers. Right? And if, you know, we talk about patient experience, well, the caregiver has to be in a good space in order to deliver great care, right?

Dr. Zeke Emanuel:

Oh, absolutely. And so that’s a huge part of it. We know that if you have burned out doctors and nurses, you have more mistakes. You have people who are disengaged from actually providing care. It’s terrible caregiving. Right?

You know, my father was a pediatrician in Chicago when I was growing up. He used to work maddening hours, 75 a week. He would, you know, every other weekend he was on call, Mondays and Thursdays, he actually was in the office till 9:00 p.m. But he was totally happy, totally fulfilled. Why? Because he was making a difference to patients. And that, I mean, we have to remember the importance of that kind of meaning driving us.

Almost all of us, we’re happy in two, you know, happiness is critical. One is social connections bonding. And I think, again, this is an area that we could do more to think about, and having meaning in your life. Doing what you set out to do to make the world a better place. But I do think this issue of social connection. I didn’t emphasize it, but it’s probably useful to emphasize here.

One of the problems I think is, you know, we used to have doctors’ lounges at hospitals. I remember going in with my father and grabbing doughnuts in the doctor’s lounge and things. You know, talking to his peers and complaining of course about the administrators and the leadership. Swapping sports stories. That kind of bonding is really, really important. We know it’s important, but for a lot of reasons that has actually decreased in health care among the workers and increasing that social bonding, not through artificial things like happy hours, but regular things.

So when I look back at, you know, the time I was working like a dog, internship, in residency … what helped? Well, the midnight meal where all the residents would come together for half hour.

Ann Nachtigal (host):

Shared experiences.

Dr. Zeke Emanuel:

Exactly. Yes. Shared experiences. Yes. Moan about this. Talk about good things that were happening to you. Right. That social relationship, even if it wasn’t deep with all, each of those people is really, really important to your happiness and your sense of, you know, this is a group. You know? We know this from the military, right? I mean, what do people fight for while they fight for their buddies? And that buddy system actually has been used at some medical centers creating buddies.

Ann Nachtigal (host):

Nice.

Dr. Zeke Emanuel:

To actually bolster that social connection. So I think those are some of the things we need to think about as leaders of health care to help our workers.

Ann Nachtigal (host):

Yeah. And you talk a little bit about AI, right? And I know technology, there’s such great opportunity particular in rural America.

Dr. Zeke Emanuel:

Oh, it’s critical to rural health. Critical.

Ann Nachtigal (host):

Right. And we could really lead that way for if rural America can do it, everybody else can. Right. But the balance of using that technology, does that make us more disconnected? You just talked about the importance of social connections.

Dr. Zeke Emanuel:

So technology cannot be a substitute for the social connection. You still need to have the bond. You still need to know the patient and know what’s important to them. But over the course of treating a patient, you know, there are going to be times when it’s better to do it in the house. There are going to be times where, you know, sending someone to the patient is going to be better.

And once you know someone, once you have a relationship with someone, talking to them on the phone or talking to them over Zoom, that’s easy. That’s still bonding. I think that the issue is you do need a base of face-to-face in-person relationships? That is never going away from health care. No.

Ann Nachtigal (host):

Basic human connection. Yes. We are running out of time.

Dr. Zeke Emanuel:

Sorry, I’ve been long-winded. I apologize.

Ann Nachtigal (host):

No, you’ve been great. It’s super. I just want to end with one last question and that is really what excites you the most about the future of rural health care?

Dr. Zeke Emanuel:

What excites me the most? I think that this kind of summit is actually quite important. And what you said about we in rural health should be innovative.

Rural health has, let’s be honest, has always been a sort of afterthought. We’ve been focused on the big high-tech hospitals and major metropolitan areas. And it hasn’t been, well, they’re doing things in rural health or rural health is pioneering this issue. Like, how do we integrate all this technology so we can actually get to our patients who live 120 miles away and can’t come in every day for whatever it is, physical therapy.

I think the fact that rural health is asking the big questions and trying to use all the available tools we have, like technology, to actually address those issues is critical because if rural health can, you know, use the technology and for example, address the mental health crisis in America, that can be adapted in lots of other places.

And I think it’s not, you know, these problems aren’t unique to rural health, as we’ve learned. And so your rural health can be just as pioneering as the big behemoths in center city. And I speak of working at Penn with our behemoth academic health center, we can be innovative, but so can rural health and that I think is a very different place we’ve seen rural health compared to the last hundred years, honestly.

Ann Nachtigal (host):

Embrace being able to be nimble. Right?

Dr. Zeke Emanuel:

Well, nimble and also innovative, right? I mean, there’s no reason that innovation has to live only in New York, Boston, San Francisco.

Ann Nachtigal (host):

Yeah. Absolutely. Zeke Emanuel, thank you so much for joining us today at the Summit on the Future of Rural Health. We appreciate you.

Dr. Zeke Emanuel:

My honor. Thank you for the interview.

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 it mean to future-proof our workforce?
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