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Reasons you may not be enjoying sex

Dr. Laurie Landeen: I’m going to give you the number. I’m going to throw it out there. 42% of women at some time in their life have some issues with sexual functioning, whether it’s decreased libido, whether it’s inability to orgasm, whether it’s painful intercourse, you know, so you are not alone. That’s my message to women. You are not alone. You should not be ashamed. And please, if you come see us, we’re going to validate your concerns and, and let you realize that you know what? We just want you to have a life that is as full as you want it to be.

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.

In this episode, we are having a sex talk specifically about why you might not be enjoying your sex life. Well, if you’re someone who just doesn’t like sex or intimacy, I’m here to say that’s OK. But we’re going to take a deep dive into some of the reasons why you might not be enjoying it and how to overcome that.

If there is any physician at Sanford Health whose mission it is to ensure you have a healthy sex life, it’s OB/GYN Laurie Landeen, MD. Joining her for this conversation is Molly Kuehl, DNP, APRN, CNP. Both of them specialize in sexual health at Sanford Women’s, and we are so grateful to have you both for this conversation. Welcome.

Dr. Laurie Landeen:

Thank you.

Courtney Collen (Host):

Now, Dr. Landeen, I know you’re so passionate about this topic. Both of you are, really, and you’ve said before intimacy and sex are part of our natural well-being. And as women, we go through so many stages of life in our marriage, partnerships through parenting beyond. Is it normal to experience sort of an ebb and flow of intimacy and desire?

Dr. Laurie Landeen:

Absolutely. And you use the exact words I was going to use, ebb and flow. I mean, there’s no doubt that, you know, sexual well-being has a lot of things that help it and hinder it. You know, we have what we call the things that enhance and give us our acceleration. And we also have the things that put on the brakes. And actually that’s a great way, it’s out of a book that we actually recommend patients read.

And so I think that what women need to realize is, number one, our testosterone levels are one-tenth that of a man, even if we have normal testosterone levels. So, of course our drives are different. We can’t expect to be the same.

Number two, what causes us to have sexual desire? Certainly hormones. There is no doubt it is natural for a woman to feel more amorous with her partner during ovulation because her estrogen levels peak. It is very natural for a woman to have no sex drive after having a baby because her estrogen levels plummet. Stress plays a major role. Medications can play a major role.

And then on the other side of life, you know, having a cancer diagnosis, you know, just for instance, a breast cancer diagnosis, we remove your breasts. We take away your, you know, what I would call your self-esteem about your own sexual well-being. And then on top of that, we take away your estrogen. And, you know, it’s a surgical menopause. You know, when we stop your estrogen levels, it’s not like the, you know, you’re rolling down a hill, going through menopause. You’re jumping off of a cliff. So that can also do that.

And then just natural menopause. Again, you’re going to have changes that cause painful intercourse. A lot of the reasons why women say they have decreased libido is because they’re not enjoying sex and they’re not enjoying sex because they have some medical reason why it hurts to have sex.

Courtney Collen (Host):

Why are we having painful intercourse? Let’s talk through that, Molly.

Molly Kuehl:

There are a lot of reasons that women may have painful intercourse. Some of them are self-limiting, many are not. And anytime a woman is having painful intercourse, it’s really, it’s not normal, and they should seek medical care for that. And evaluation.

Some of the reasons, as Dr. Landeen already mentioned, could be hormonal. And that can happen again after having a baby. For instance, with low estrogen levels, there can be pain at the opening of the vagina and within the vagina after certain medical treatments like radiation to the pelvis. Even with colon cancer, some women receive kind of radiation to that area that may, you know, leak into the vagina, so to speak. And that can affect those tissues causing stiffening of the vaginal membranes, scarring of the vaginal tissue that causes loss of elasticity.

There can be, you know, lacerations with birthing that can cause scarring and pain. Some women who are, you know, elite athletes in high school, who are elite athletes in college, women who are marathon runners, things like that, they can have injuries in their pelvis, their lower extremities that alter their gait. And even those types of things can cause high tone in the pelvic floor. And women don’t realize it, but that is the, the base of our entire body. It holds all of our organs. And any alteration in that musculature can actually cause painful sex.

And things as simple as contact irritants can cause almost an allergic dermatitis type reaction at the opening of the vagina, recurrent yeast infections, recurrent bladder infections, something as simple as constipation can cause painful intercourse. So there is a whole, you know, gamut of reasons and they range from very simple to very, very complex.

And that’s our job as specialized clinicians, is to do a detailed evaluation, a detailed history, and to kind of tease those things out. You know, when did this first start occurring? Does it happen all the time? Is it a limited thing? Is it just with this partner or did its precede this partner, et cetera?

Courtney Collen (Host):

Dr. Landeen, do you see a lot of patients come in and may be embarrassed to express?

Dr. Laurie Landeen:

Absolutely. So I’m just, just before I came here, I had a sexual health consult. I usually save that as my last appointment in the morning. And then I have a special clinic that we will do just exclusively with sexual health patients, because number one, we want to give you time. You know, in general, you do a pap smear yearly exam, you know, 15 minutes, boom.

But with the patients that have these issues, half of it is just making them feel comfortable with us to even talk about these issues because we have shamed people. You know, society has made it a taboo.

I’m going to throw it out there: 42% of women at some time in their life have some issues with sexual functioning, whether it’s decreased libido, whether it’s inability to orgasm, whether it’s painful intercourse, you know, so you are not alone.

That’s my message to women: You are not alone. You should not be ashamed. And please, if you come see us, we’re going to validate your concerns and, and let you realize that you know what? We just want you to have a life that is as full as you want it to be.

Studies have shown that women who have a very fulfilling intimate life, they live longer, you know? Women who have painful intercourse may also have some urinary symptoms. This weekend I read an article and it was stated, “genitourinary syndrome of menopause is killing women.” I thought, what a great article. I was actually going to show it to Molly here, because people don’t realize that if you have vaginal irritation and you’re having recurrent urinary tract infections because the estrogen levels are low, it can also, people will maybe have painful intercourse. But you can also have some urinary symptoms that can lead to what’s called sepsis.

And that’s like a majority of women who are menopausal. It can lead to death. I mean, so there’s a lot of things that, you know, we dismiss because we don’t want to talk about it because we’re embarrassed.

Courtney Collen (Host):

And Molly, we know that having a healthy sexual relationship in our marriage or in our partnership is important. And, and having intimacy is important. If something is painful and maybe we’re seeking care or we’re going to seek care, hopefully after listening to this, it would encourage someone to seek care as to not continue having painful intercourse. But Molly, how do you keep your partner satisfied in the meantime? How can we be intimate when sex is painful?

Molly Kuehl:

So there are a lot of ways to be intimate without having penetrative intercourse. And I think number one, we want to encourage women to be open with their partner and to not continue to have penetrative intercourse if it is painful for them.

One of the worst things that women can do is to just grin and bear it, so to speak, because that’s just going to reinforce that cycle in their mind, the sexual response cycle, that pain, painful sex equals bad, you know, and their libido is going to continue to decline. They may actually build up some resentment against their partner. And if their partner doesn’t know that this is causing them pain, number one, how are they to understand this? But number two, if they do not openly and honestly communicate with them what they’re experiencing, they really have no fair chance at helping their partner solve this problem.

There are many other ways to satisfy a physically intimate relationship, and we can kind of help you come up with some of that. But you can, you know, use oral stimulation. We actually prescribe vibrators there, you know, digital stimulation, penetration, things like that. But ultimately there’s many ways.

Intimacy is about physical and emotional intimacy and being emotionally vulnerable with your partner. And one of those things is to openly and honestly communicate about when you are feeling pain. And we want to encourage women that it’s not embarrassing to be vulnerable with your partner. And this will only further expand, you know, the depths of your relationship.

We also encourage you to bring them to your appointments because a lot of the appointments are education-based, and the partners really seem to get a lot out of that by understanding that what we’re able to provide informationally at the appointments.

Courtney Collen (Host):

Where do we begin to seek care when it comes to painful intercourse or otherwise?

Dr. Laurie Landeen:

Well, one of the first things is, you know, certainly any of your primary physicians can refer you to our clinic, to our intimacy clinic that we have.

The other thing is we do telemedicine. You know, we can have the first visit. I don’t have to physically examine a patient at the first visit, and sometimes I don’t do that because I feel like I need to build that relationship with them because they’re vulnerable with us as well because of what they’ve gone through.

The other thing is, there is always an emotional and psychological component that we always want to make sure is OK. And, you know, some patients have had a history of sexual abuse, a history of rape. And although they love their current partner, they’re having a hard time disassociating lovemaking with the one they love, with a past experience where it was non-consensual and painful and caused trauma.

So you know, again, you don’t have to physically come in if you cannot and you’re far away, we would prefer it because I always feel like one-on-one close up. I like to see my patients. And, you know, we all know in this day and age of Zoom and everything, it’s taken away a little bit of the relationship piece, you know?

Courtney Collen (Host):

Let’s talk about sex after pregnancy. What can we expect during postpartum and how can we resume intimacy after baby?

Dr. Laurie Landeen:

There’s two main things that occur when you’re postpartum, your estrogen levels plummet and you have significant sleep deprivation. And this is even worse with breastfeeding moms and bottle-feeding moms. OK? But it can happen with both.

But two-thirds of relationships postpartum take a dive. Two out of three relationships. I don’t care how good they are, they take a dive during that first 12 months because you are forgetting to help each other with your own love language.

You know, so you are resentful that he even wants sex. He’s resentful because you’re watching the baby. And he hasn’t become the number one player on the team anymore. You know, and it’s not that he doesn’t love the baby, but the bottom line is, first of all, acknowledging it. That’s the biggest thing, is acknowledging that piece. And number two, doing what you can.

I say go on a date night. If you hopefully have, you know, grandparents are willing to watch the kid, maybe even overnight, you know, go to a hotel room where there is no interruption. You don’t hear a baby crying, you know? Get out the good old lubricant. And we’re a fan of natural products. Bring your olive oil, your coconut oil that you have at home. They are not harmful. They are natural.

Anytime that you, you know, use anything that’s over the counter, look at the label, it usually has a whole bunch of ingredients. And you don’t need that. If you look at olive oil, look at the label, it says olive oil. Right.

So again, there’s a lot of things you can do to maintain an adequate and maybe even enhanced intimate life, even in those situations where, you know, you just don’t feel it, feel it as much, and it’s understandable.

Molly Kuehl:

And I’ll say too, Courtney, you know, I am a little over two years out. My daughter still doesn’t sleep. She’s up multiple times a night. I do this for a living. And, you know, our sex life is not back to where it was pre-kids. And we work hard at it, you know, we really try. Mama’s touched out, at the end of the day. Mama’s tired. Baby only wants Mom in the middle of the night. She doesn’t want Dad. And again, the best thing you can do is just be open and honest.

And, you know, he still comes to me, you know, horny as ever asking for it, you know, five times a week. And he might only get it two times a week, and that’s how it is. But he understands that I am tired. I’m touched out. I still deeply love him. And, you know, it’s just not at the top of my priority list right now to be physically intimate when the kids need so much attention.

There’s great books out there. There’s great relationship resources out there that can help with a woman’s or a partner’s ability to communicate these types of things to their significant other.

Dr. Laurie Landeen:

I’m also going to say that even if you don’t have the desire, most women, once they get into the actual intimate time, they actually enjoy it and they get aroused. Yeah. So I basically tell women whether you have the urge or not in your mind, make an appointment.

Because studies show that if you can have intercourse twice a week with your partner, it’s also going to make the relationship better. You know, most women are going to still enjoy it while they’re in the moment.

Molly Kuehl:

That is true. Mama usually enjoys it once she’s in it.

Dr. Laurie Landeen:

(Laugh) Right. And so, you know, so again, realizing that this is the biggest thing, you know, you get a lot of conflict resolution when you become intimate. And that’s the biggest thing is, if there’s conflict in relationship, intimacy can really help it. And it may not be the end-all. You have to have, communication is the key, but intimacy is such an important part of relationships.

Courtney Collen (Host):

How often should we be intimate with our partners?

Dr. Laurie Landeen:

Studies have shown that having intercourse two to three times a week is what keeps us healthier. And we live longer. And I’m not telling you that you have to. I’m not talking penis in vagina either. You know, there’s other ways to be intimate.

We have what we call the five love languages. I encourage all women and men to read that, because for a lot of women, it’s not the physical touch. For men, it’s more physical touch than for women. For a lot of women, it’s affirmation, you know? I mean, there’s other things that you know, but if it sets you off, that’s going to make you want to have intercourse more. And if it’s physical touch, well, we as women, we need to understand if our significant other, that’s what’s important to them, then we need to answer to their love language also.

Courtney Collen (Host):

Thank you so much. And just to wrap things up here, both of you, how would you encourage women listening, no matter what stage of life they’re in at this point, that it doesn’t have to be painful. It doesn’t have to be not enjoyable for one person, that it can get better and there is help. What would you say to those listening?

Molly Kuehl:

I would say that, in this day and age, there are so many resources available. And they’re good research evidence-based, scientifically sound resources that we can help you with, we can direct you to.

If you feel hopeless, please do not. Please reach out and allow us to help you. If we can’t solve it for you, if we can’t answer your questions, we have a vast network of great clinicians that we can refer you to. But the amount of women that we have been able to help, the amount of partnerships that we’ve been able to help in just the couple years we’ve dedicated to this is amazing. And it’s been really rewarding work that Dr. Landeen and I have been able to do together.

Dr. Laurie Landeen:

This is a multidisciplinary thing that we do here. We have physical therapists involved. We have you know, our mental health therapists and triage specialists involved. We have couples therapists involved. We have, you know, primary care physicians because lots of times it’s not just a girl thing or a boy thing, it’s a we thing, you know? And so, you know, it may be, people don’t realize this, but a little bit of erectile dysfunction in a dry vagina that sets the stage. It’s like a synergism. So it might be that we need to help, you know, the male partner as well.

And although Molly and I don’t take care of the male partner, we have great resources to get them to be taken care of. Come see us. We want you to have the best fullest life that you can have. And there really is not a taboo. And, you know, we are open to hearing what you have to say and not feeling ashamed, not feeling judged.

Molly Kuehl:

We have fun together. We take it seriously, but we have fun and we try to make things as comfortable as possible. We always ask for consent before we do an exam. You know, we’ll never do anything that you are not personally comfortable with. We encourage you to bring your partner with. And we would love to meet you.

Courtney Collen (Host):

This is a topic that I just feel like isn’t discussed enough, and we are so grateful for your time and all that you do for Sanford patients. Your expertise. Dr. Landeen, Molly Kuehl, thank you so much for your time today.

Molly Kuehl:

Thanks, Courtney.

Courtney Collen (Host):

To learn more about Sanford Women’s or to make an appointment and find solutions to improve your sexual health, visit sanfordhealth.org. This was another episode of “Her Kind of Healthy,” a podcast series by Sanford Health. For Sanford Health News, I’m Courtney Collen.

Thanks for being here.

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Choosing the right birth control

Courtney Collen:

There’s a lot of options. (Laugh)

Dr. Amy Kelley:

Yeah, totally. There’s tons of options. And I didn’t even talk about condoms. I didn’t even talk about barrier methods, which is kind of the other group.

Courtney Collen (Host):

Hello and welcome to “Her kind of Healthy,” a health podcast series brought to you by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. We want start new conversations about age-old topics from fertility to managing stress, healthy living and so much more. “Her Kind of Healthy” is designed to bring you honest conversations about self-care, happiness, your overall well-being with our Sanford Health experts.

On this episode, we are talking about birth control, or contraception, the use of medication devices or procedures to prevent pregnancy. And there are so many different types. For a lot of us, it can be very overwhelming. Let’s bring in Dr. Amy Kelley, who is an OB/GYN at Sanford Health, and a specialist in pediatric and adolescent gynecology. If you ask me, she is the perfect person to have this conversation with. Dr. Kelly, welcome. Thanks for your time today.

Dr. Amy Kelley (Guest):

Thank you.

Courtney Collen:

So let’s start with the basics. We have a lot to get to. What exactly does birth control do physiologically in the body to prevent a pregnancy?

Dr. Amy Kelley:

It depends a little bit on what method you’re talking about, on how it prevents pregnancy. Things that are fairly common and have been around for a while, like birth control pills or the birth control patch, they work by kind of taking the job of the ovary away. So they basically give you a little bit of estrogen and a little bit of progesterone every day. And that makes you not ovulate. So it kind of takes the ovaries’ job and says you don’t have to do anything right now. And he kind of keeps your hormones basically very similar from day to day.

Courtney Collen:

So how would a young woman or women of any age know what birth control is right for them and where do they even begin?

Dr. Amy Kelley:

Well, there’s actually a few really good online resources to kind of do a little bit of looking around on your own. The one I like the most is called bedsider.org, and it’s an app as well. And I like that one because it’s not from a company. It’s actually run by a nonprofit. So you know, they’re not trying to sell you anything; they’re just trying to give you information.

But otherwise I would say going to your physician is a great place to start as well. What you do for contraception I think varies a lot depending on what stage you are in your life and what you need. Some people you know, are using contraception more because their periods are bothering them, especially in the teen years. And they may want something different than what they want maybe when they go to college and their life is busy and they have to worry more about the contraception or the pregnancy prevention part, maybe then and they also, maybe their life’s a little crazy because they’re in college and they can’t remember their pill anymore.

So I think that what you do varies a lot based on your personality and also what stage of your life you’re in.

Courtney Collen:

Now let’s talk through some of the options. Yeah, like explain some of the various types of contraceptives that are available.

Dr. Amy Kelley:

Yeah, so I kind of put things into different categories. So I put things into high maintenance and low maintenance categories because that’s kind of how I roll. I like low maintenance things.

The things in the low maintenance category are also a little bit more effective to prevent pregnancy. So that’s kind of a good category for people who are most concerned about that. It’s also a great category for people who need low maintenance options where you don’t have to think about them very often.

So the two big ones in that category are the implant that goes in your arm. And I actually have one right here. You’re probably going to be kind of hard to see it since I have just such a little screen, but it’s very small. It’s really, really tiny and it goes under the skin in your arm. And that works for about four years. And it is the most effective thing for contraception. It has a failure rate of a half a person in a thousand. So it’s like right up there with getting your tubes tied or doing something permanent.

The other one that’s very similar in effectiveness is IUDs. There’s a couple of different kinds of IUDs, but IUDs stand for intrauterine device and it’s a T-shaped device that goes in the uterus. They’re also quite small, so this is an example of one right here. They’re not very big.

Courtney Collen:

Wow. That is small.

Dr. Amy Kelley:

Yeah, they’re pretty small. And intrauterine devices come in a couple different flavors. There’s one that doesn’t have any hormones at all and that has copper in it. That works by causing some inflammation in the uterus. But it also works because copper makes sperm unable to penetrate eggs. So it actually prevents the process of fertilization. The copper IUD is good for 12 years. It’s good for a very long time. That one doesn’t really change your periods. It can make them a little heavier and more painful sometimes because it causes inflammation, but otherwise you have regular periods with it.

The two hormonal IUDs that are used the most often there’s one called Kyleena and there’s the Mirena. The generic of the Mirena is called the Liletta. And those work for five years and eight years. And hormonal IUDs have just a little bit of progesterone in them, so they make the lining of the uterus really, really thin. And some people actually don’t have periods with them because they just don’t have a lining to shed very often because it’s so thin.

So Kyleena is smaller. They’re the five year one and they’re made specifically and FDA-approved for people who haven’t had children. The Mirena and Liletta are just a tiny, tiny bit bigger and it’s good for eight years. And it’s specifically FDA-approved for people who have had children.

Now we have lots of studies that show that people, whether or not you’ve had a child, can use either one of these. But the company just hasn’t gotten FDA approval for both of them, for both kinds of people. But those are all very low maintenance options and they work really well for contraception.

The downside to the hormonal ones is that they can make your period kind of wacky. And that’s a little bit different for every person. For IUDs, a lot of people don’t have periods at all and if they do, they’re pretty light, maybe a little sporadic. For the one in your arm about one in three women don’t have any periods and then everyone else has periods and they can be kind of crazy and long, but not usually heavy or painful. But they can also just be spotting every couple of months. So it varies a lot. And that’s, those are probably the main side effects that we talk about when we talk about using those for people. But those are, those are our low maintenance options where you don’t even have to think about them. We put them in, you’re done.

Our kind of medium range options that I think are pretty low maintenance, but you have to remember more often, is Depo-Provera, a shot and you, every three months you have a little wiggle room. It’s every 10 to 13 weeks. And most people it stops their period actually. Because it’s also a bunch of progesterone. So that lining gets really thin. Depo is kind of in that medium range because you only have to remember it every three months. For some people that’s great and they remember, it’s good. Other people it’s easier to remember things every day than every three months. Everybody’s a little different. So that’s kind of a medium range option.

The most high maintenance options are the birth control pill, which you take every day. The patch which you change once a week and something called the birth control ring. There’s a couple of different kinds of the ring. And you change that once a month. So those are a little bit higher maintenance because you have to remember them more and you have to go to the pharmacy and you have to get refills on them and if you move or if you’re in college, you have to figure out how you’re going to get those refills. So those are just a little bit more like time consuming and you have to think about them a little more. Those are the only ones that keep your period really regular, too. And a lot of times they have really nice side effects. Most of them help with acne. A lot of them help with, if we feel kind of moody around our period, a lot of them help with that.

So those are pretty popular ones and they’ve been around for a long time too. Those have a much higher failure rate though. The failure rate for those is about 70 in 1,000 versus like two for IUDs and a thousand or a half a person for the one in your arm.

Courtney Collen:

There’s a lot of options.

Dr. Amy Kelley:

Totally. There’s tons of options. And I didn’t even talk about condoms. I didn’t even talk about barrier methods, which is kind of the other group. Condoms are also definitely contraception because they prevent sperm from getting to eggs. But they’re kind of the most high maintenance option really. Because they don’t work in your drawer or in your purse or in your truck. They only work if you use them every single time. But they are also the only method that helps protect you from things like gonorrhea and chlamydia. And so they’re a super important option, particularly in our state that’s really having a surge of different STI infections right now.

Courtney Collen:

And a great way to get the partner involved too. I mean it, you know.

Dr. Amy Kelley:

Absolutely.

Courtney Collen:

They’ve got to do their part.

Dr. Amy Kelley:

Yeah, I mean it is unfortunate that there aren’t very many options for males, right? At least not reversible options for males. There’s always been talk of getting reversible options for males but they just never seem to let come to fruition.

Courtney Collen:

What are some factors, Dr. Kelly, that might determine what is right for each patient? I mean does age come into play? Health history, sexual activity, maybe having had previous children? Talk through some of that.

Dr. Amy Kelley:

Yeah, absolutely. I think there’s a lot of factors that go into it. Certainly what you want after children sometimes is different than what you want before you have children, but I tend to – and everybody’s a little bit different so of course there’s lots of different factors – but I tend to try to talk to people about two big ones to try to pick what they want to do. And those two big ones would be what do you want your period to be like or what can you handle as far as your period goes and how important contraception is to you. And I try to stick with those two things because there’s just so many other factors too.

But the reason why I think those two play a big role is because these kinds of options vary a lot on how effective they are, and getting pregnant is a huge thing. Changes your whole life. And so you know how worried you are about that is a very big determining factor on what option you choose. And most of these affect your period.

Now, they usually affect your period in good ways with our high maintenance options like the pill, the patch, the ring – most people’s periods get shorter, they’re less crampy less and sometimes they’re a lot lighter as well. But you still have them every month.

There are ways to kind of skip and manipulate your period with them, but you have very regular periods and for some people that’s super important and that’s what they’re looking for. With our low maintenance options, you’re getting much better contraception, but you may have periods that are irregular and not as predictable. You might also not have a period at all. And sometimes that’s people’s goal is to not have a period maybe because they don’t like it. Like a lot of our autistic teenagers have – it’s a sensory thing that they don’t like or sometimes it’s because they’re super busy with a sport and they don’t want to deal with that period. Sometimes it’s because they miss school because it’s so painful or so heavy every time. And so we’re trying to have them have less periods.

There’s really good reasons to consider not having a period for some people. But if that’s their goal then I’m going to recommend different things than if they want regular periods or if they can handle a little bit of irregular bleeding. Sometimes that drives some people crazy. So I think knowing a little bit about how you’re going to feel is a good way to kind of figure out what might be a good option for you.

Courtney Collen:

Are there any risks that a patient should consider before choosing a birth control or any specific risks behind any of those types of birth controls?

Dr. Amy Kelley:

Yeah, so the ones that are high maintenance pills, the patch, the NuvaRing, and actually there’s more than just Nuva so I should just say the ring. But those three have estrogen in them. Estrogen does have the potential risk of blood clots. Which is, you know, a serious risk. It’s not a very common one. But there are some people who have medical conditions or who have certain genetic issues that make them too high risk to use estrogen. So there are some women who are not good candidates for those three options because they shouldn’t use estrogen.

The other ones have other risks. You know, certainly any medication has some risks. People can have things like stomach upset, headaches, nausea, but most of the time any of those types of side effects, you always have to compare them to what the alternative is too. So if the alternative is the potential to get pregnant, pregnancy has a lot of complications and side effects too. And so most birth control, if you’re comparing it to pregnancy, is much safer than pregnancy.

But there are some people who have some mood changes because with hormonal options or Depo is associated with weight gain in some people. And so those kind of side effects vary from person to person. But we always discuss that with people so that they know if they have them what to do and you know, if we think that they’re likely to have them or not.

Courtney Collen:

If an individual is planning to get pregnant but they’ve been on birth control for a period of time, be it the more high maintenance options, the pill or something more low maintenance like the ring or IUD. Is there a period of time that they would need to be off the birth control before successfully conceiving? And is it different based on the type of birth control? Can we talk through that for a moment?

Dr. Amy Kelley:

Yeah, you actually don’t have to wait at all. It’s a little bit of an urban myth that you have to wait a couple months when you go off of the pill or go off of really any birth control. I’ve had plenty of people who we pulled their IUD and they never even got a period they got pregnant instead. So it can happen rather rapidly. Almost all of our methods of birth control are once you take them out or once you stop taking them, your fertility comes back very quickly.

The exception to that is Depo-Provera, the shot. That can take six months to a year to wear off. So that isn’t a great option for people who think they’re wanting to have children soon because it can take a while to wear off. Now I’ve also had people who have gotten pregnant on it because Depo has a failure rate, so that’s not a universal truth, but it can take a while to wear off. The Nexplanon also can take a few months to wear off. But I’ve had people also get immediately pregnant with that. So it does vary a little from person to person. But yeah, that’s an urban myth that you have to wait. You can definitely start trying right away.

Courtney Collen:

Well thanks for clearing the air on that. I appreciate it. Now speaking of myths or misconceptions, are there any that you hear of about different birth controls? Either the types or things you’re seeing on social media? Any fear that you hear of? Talk about that.

Dr. Amy Kelley:

All the time. When you think about birth control is something that 90% of women take or use in their lifetime. Women make up more than 50%, you know, 50-52% of the population. It’s no wonder there’s all these myths because when so many people are using something like contraception, it’s very easy to blame contraception for lots of common things, whether it causes that or not.

One of the biggest concerns I get from parents a lot of times is: will this affect fertility in the future? There’s this myth that like you take the pill for 10 to 15 years and then when you go off of it, you can’t get pregnant anymore, or Depo or whatever it is that you’re on. And that really is very much an urban myth.

The biggest issue with fertility nowadays is actually age. So if you’re on the pill for 15 or 20 years, you’re trying to get pregnant in your thirties, maybe even your late thirties and it’s much harder to get pregnant as you get older. So I think that’s a common misperception and it really is just, it’s based on some other things. It’s not a crazy thing to think by any means. But I hear that a lot.

The other thing I hear a lot is that contraception, especially hormonal contraception, makes you gain weight or it makes you crazy. And there’s a kernel of truth to that as well because some people do gain weight with hormonal birth control and some people do think it affects their mood. But lots of other things in life do that to us too. You go to college, a lot of people gain the freshman 15. College is super stressful. People have a lot of anxiety when they’re at college, especially that first year. And so sometimes those things aren’t just from birth control, but it can be really hard to tell.

Regardless if you think your birth control is causing some of that, it’s not something that we hear very often. I would put it in the under 5% category. So if you look at all kinds of birth control, a small number of people might have those side effects. But really if that’s the case, switching to a different method usually will fix that. So it doesn’t mean you can’t have any kind of birth control if you have one that you don’t like or doesn’t work well for you. The one birth control that consistently is associated with weight gain in studies is Depo. And the average weight gain with Depo is five pounds. And about 10 to 20% of people gain weight with Depo. So, you know, if you think about that being the only one that consistently shows that, that’s kind of worst-case scenario. So really all the other ones are probably much better for most people.

Courtney Collen:

Yeah. Good to know the risks or side effects I guess before you go in.

Dr. Amy Kelley:

Yeah, absolutely. And we talk to people about those. I think that we’re very open with what people might potentially experience. On TikTok lately there’s been a lot of stuff about IUDs and how horrible they are. And so there’s quite a bit of fear around getting IUDs for some people too. And the interesting thing about IUDs is how much the experience varies from person to person. I do think that they can be uncomfortable and crampy. I myself have three IUDs and this is my third one. And I really don’t like getting them because they are kind of yucky to get, but it’s also like less than a minute. And you know, there are things we can do to make it better. There’s medicine we can give you beforehand if you’re anxious, there’s medicine we can give you that kind of helps the cervix be a little bit more open to putting an IUD in. And we even sometimes put people to sleep for IUD placements if they’re really anxious or if they have a history of trauma or for kiddos who maybe can’t cooperate with an exam like children or teens who have developmental delays and things like that.

But there are definitely things we can do to make it make it better. I had a teenager just the other day, 16, who did way better than I did with my last IUD insertion. So it does vary a lot from person to person. But most people can get through it.

Courtney Collen:

Yeah, good to know. Now how young is too young to start on a birth control and what to consider there because – and then you know, how old is too old to continue birth control? Can you talk to that?

Dr. Amy Kelley:

So really once you have your period, you could be on something for birth control.

Courtney Collen:

So as early as 11, 12 …

Dr. Amy Kelley:

You know, even nine, 10 because some young ladies do get their period as early as nine or 10, especially African American teens and Hispanic teens sometimes get theirs a little early. But there are some special considerations in young people. There’s the potential for a little bit of loss of height in that first year after you get your period. You can still grow a little bit. We don’t have great studies to prove that if you take estrogen that it makes you not grow as much. But there’s that concern. So sometimes we start out with things that don’t have estrogen in young ladies who just started their period.

But, if you’re having problems with your period or if contraception is needed, then it’s really as soon as you get your period, we can be helping you with that if it’s an issue. As far as how old you can be, it’s unlikely, but you can get pregnant all the way up until menopause. So I think it’s important for our perimenopausal women to understand that, you know, once you hit 40, it doesn’t mean you can’t get pregnant anymore. And so it’s important to still use contraception if you need it and it depends on what method you’re using.

As you get older, things with estrogen do start having a little bit more risk. But if you are someone who can still take estrogen, you can take it until menopause. You can take birth control pills until menopause. If you have a reason why we think estrogen’s not a good idea, you develop hypertension or you know you’ve had a blood clot or something, then there are other methods. There are those methods that don’t have estrogen that you can use.

Courtney Collen:

Different factors. Let’s talk through some of those that might affect the success or effectiveness of any method of birth control.

Dr. Amy Kelley:

Yeah, so there are some medications that do affect birth control and how effective it is for contraception. So it’s really mostly our estrogen containing birth control methods. So the pill, the patch, the ring that are affected by other medications. So some of those medications can include seizure medications and antibiotics.

But there’s actually only a couple of antibiotics that really affect contraception. And they’re actually antibiotics for tuberculosis. So one of them is called Rifampin. So most of your antibiotics you’re going to get for like an ear infection or strep throat or sinusitis or a yeast infection is not going to impact your contraception method, even if it is a pill, a patch or a ring. But again, there are some medications and those would be the two big ones that are common would be a couple, a handful of antibiotics and anti-seizure medications.

Courtney Collen:

How long should a patient be on any specific birth control before they might be able to switch or something’s not working out? Or are there some that are riskier to be on for a long period of time?

Dr. Amy Kelley:

The vast majority of them, it’s fine to be on for a long period of time. There is kind of this myth about Depo that you can only be on it for two years because there is a slight risk of some bone loss with Depo-Provera, however, that bone loss is not associated with broken bones or hip fractures, risk factors, anything like that. And in fact with Depo for two years you lose a little bit of bone and then it stabilizes.

So if you’ve already been on it for two years, there’s actually no really good reason to quit unless you just don’t like it or don’t want to use it anymore. And the amount of bone you lose is about the same as you would if you had a baby and then breastfed for a year because you lose some bone and some calcium from those things as well. So we don’t really consider it to be a risk that would make us not want to do it in most people.

Courtney Collen:

What are some questions that maybe a young woman and her mom or her parents or a woman and her partner should ask their OB/GYN or their provider during the appointment when they’re discussing these different options? And/or any questions that you get that you would suggest listeners consider before beginning a method?

Dr. Amy Kelley:

Yeah, I think it’s really important to be honest with the person that you’re seeing with your provider. And you know, that can be hard in front of parents specifically sometimes, like if you really need contraception, but maybe your parents aren’t aware of the fact that you need contraception. I always think it’s better to have parents involved in these conversations, but you know, it is OK to talk to your provider alone if you feel like that is appropriate and you need to in fact, most providers I think do talk to teenagers alone for at least a little bit.

We do need parental permission in South Dakota to give adolescents any medication. And that does include contraception. There are some ways around that, but in general that is required. So it, it can be a little bit of a little bit of walking a tightrope sometimes in my shoes when you’re trying to like not out a teenager that might be sexually active, but also make sure they’re getting what they need. And I feel like that’s a conversation between the parent and teenager.

My goal as provider is to be a person that can give someone information and make sure they have the information they need to make good choices for themselves. But I think that being honest is important because you want to be honest about are you at risk for sexually transmitted infections so that we can talk to you about condom use if that’s an important piece of this. And do you need contraception or really are we just trying to get your period better? Like what is your main concern and reason for contraception? I think that those are things that are really important is just being honest.

You also want to make sure that we know and are aware of all the other medicines that you’re taking to make sure that we don’t have any interactions. And also to make sure that what we’re giving you is safe and that you don’t have these risk factors that would make us not want to give you estrogen. But I think that really, there are no dumb questions. I think that if you have concerns or you’ve heard rumors about birth control and you are worried about something specifically, just ask us. I mean, that’s what we’re here for.

Courtney Collen:

Yeah. And we’re so thankful to have you and other physicians and providers and a whole care team to be there when we’re considering these big decisions. Dr. Kelley, thank you so much for your insight on this topic and all that you do for patients at Sanford Health. I appreciate you.

Dr. Amy Kelley:

Thanks so much. It was great to be here.

Courtney Collen:

Thank you.

Learn more about this topic

• Endometriosis is common, yet commonly undiagnosed
• What is preventive care and how can it keep me healthy?
• Family planning at Sanford Health

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What does it mean to future-proof our workforce?

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. Tommy Ibrahim, former president and CEO of Bassett Healthcare Network. Dr. Ibrahim joins as a keynote speaker at the 2023 Summit on the Future of Rural Health Care with the topic future-proofing our workforce – what we can learn from each other about preparing for the next generation of care?

Courtney Collen (host):

I am joined by Dr. Tommy Ibrahim. He is here in Sioux Falls from New York. Welcome.

Dr. Tommy Ibrahim:

Thanks for having me.

Courtney Collen (host):

We’re happy to have you. What are the top three opportunities you see when it comes to building a stronger rural health care workforce?

Dr. Tommy Ibrahim:

You know, I think first and foremost, we really need to take a heart-in approach and listen to our people. There’s a lot of change and dynamic sort of paradigm shifts that are happening now in the industry. I would even argue that there are some permanent shifts happening around workforce and our ability to sustain – successful workforce models in the future are going to be contingent on how we could re-engage our workforce and our people.

Our people know exactly what they’re looking for. They know what they want. They know what works, what doesn’t work. And I think as leaders, it really is incumbent on us to be there to listen empathetically and to begin to customize solutions that meet their needs first and foremost.

Courtney Collen (host):

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

Dr. Tommy Ibrahim:

I think we’ve seen a lot of momentum catalyzed throughout and after the pandemic. I just sort of reflect on virtual care, for example. I remember having conversations with my medical staff just prior to the pandemic about how impossible virtual care models were going to be implemented. And, you know, in the height of the pandemic and the initial surges, we saw a 10,000% increase in the number of virtual visits that manifested across the organization.

So that essentially happened all overnight. So the initial impossibilities became truly magnified potential that we now continue to enjoy across the entire spectrum of the health care industry. Obviously those levels have not been sustained, but we’re certainly doing much better today than we were prior to the pandemic.

Courtney Collen (host):

Thank you for the insight.

Dr. Tommy Ibrahim:

Yeah.

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. Tommy Ibrahim:

You know, I think it’s really important and sort of maybe a really obvious thing to say, but the consumer and the patient is going to be absolutely essential. I still believe that we are in a provider-centric health care system, and I think we need to rapidly shift the focus to the consumer to meet the desires, the needs, the wants of our patients to put team-based care around our patients and to support all of their care needs holistically.

Courtney Collen (host):

What excites you the most about the future of rural health care?

Dr. Tommy Ibrahim:

You know, I really love the focus on rural health care right now. I think it’s more than just rhetoric. I think there are true interests and sincere focus points across the entire segment. And our lawmakers are saying all the right things. I think our leaders are certainly mobilized and activated to advance our priorities. And I think we just need to be resilient and diligent. And despite all of the challenges that we view and see as leaders today in health care, I think it’s a really exciting time in general to be in this moment, I think, and to have this great responsibility to be able to shape the future of health care.

Courtney Collen (host):

Well, we appreciate your time and all that you do.

Dr. Tommy Ibrahim:

Thank you so much 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

• Help wanted: Health care workers in rural America
• How SDSU is preparing nurses for rural care
• Solving worker shortages in nursing homes

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Solving worker shortages in nursing homes

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 Mark Parkinson, president and CEO of the American Health Care Association and the National Center for Assisted Living. Mr. Parkinson joins an expert panel at the 2023 Summit on the Future of Rural Health Care with the topic “sync or swim,” aligning workforce solutions to support care across the continuum.

Ann Nachtigal (host):

Mark Parkinson, welcome. Thank you for joining us here at the Summit on the Future of Rural Health care.

Mark Parkinson:

Glad to. Excited for the day.

Ann Nachtigal (host):

Yeah, I think it’s going to be just so fun to have this incredible group of thought leaders here to talk about the future of rural health care. Such an important topic. We are here, of course, to talk about that and I want to know, what is the current environment in the long-term and post-acute care providers? What are they operating in right now?

Mark Parkinson:

Well, long term, I’m optimistic and I want to make sure that comes through, but in the short term, we’ve got some real challenges. The short-term challenges are that we’re still recovering from COVID. I mean, obviously COVID was a once-in-a-hundred year, hopefully once-in-a-thousand year type experience. And even now, three years out from the vaccine we’re still in the recovery phase. And it’s really a twofold issue for operators.

The first is census. Census has come back pretty well, but not completely back. The bigger problem is what we’re talking about most of the day today, which is workforce. We saw a massive decrease in the number of people that were working in nursing homes and long-term care facilities across the country. And it has slowly recovered, but it has got a long way to go.

When we look at the data, you know, we started out with 1.5 million people working in nursing homes at the start of the pandemic. We lost 250,000 of them that left our sector. We’re still 150,000 short. Which, to put that in perspective, that’s about 10 workers a building. So it’s a big deal. And it makes it very hard.

Ann Nachtigal (host):

So the staffing mandate, obviously that’s a huge topic right now. And I know that you’ve published an op-ed in The Hill back in March talking about you know, let’s not leave some really practical solutions on the table. Let’s talk about how we can you know – that’s not the solution, to have a mandate when we can’t even find the workers. So let’s talk a little bit about that. What’s that environment like? What are your expectations for how that comes out?

Mark Parkinson:

Well, the staffing mandate was clearly put together by people that do not understand rural America, do not understand the staffing challenges that we have, particularly in rural buildings. And it is basically a death sentence to nursing homes that are in rural areas.

Because when you look at the data, there are virtually no buildings in the rural part of the country that meet the staffing requirement. We are then mandated to meet a requirement where the workers aren’t available. And if we don’t meet the requirement, it’s not like we just get like a negative notation or a slap on the wrist. They can shut us down.

And so, we’re taking this extremely seriously. We need folks to contact members of Congress and say, “Hey, just don’t let the administration do this.” It’s very, very worrisome. Now, I have faith in our system, you know. I’ve been involved in public policy for almost 50 years now, and I think that we’ll get some improvements in this policy. We’ll eventually get it right. But it is an enormous threat.

Ann Nachtigal (host):

Let’s talk about, we’re here to talk about workforce solutions. What about trying to, like you said, we’re down a lot of people, right? In the long-term care, post-acute care environment, how do we attract, retain those good workers going forward? What are some of those strategies to find that?

Mark Parkinson:

Well, as a Kansan and a person that still has a farm in western Kansas, I’m pretty bullish about just rural life in general. You know, one of the things that happened with the pandemic is that all of a sudden, companies across the country started saying you can live and you can work where you want to. And we’re going to let you make your choice on where you want to live and work.

And what we’ve seen over the last three years is we’ve seen an increasing number of people that said, I don’t want to live in a big city. I’d like to live, you know, where I grew up or out in the country, or where the pace is, there’s no traffic. There’s not the craziness of the big towns.

And so you look at the data and for the last several years, there have been large parts of rural America that have actually had an increase in population. Now, I don’t know if that’s going to continue. We’ll find out in time. But I’m hopeful that it will. And I just think stabilizing the population in rural America will be very, very helpful to all these workforce challenges.

On top of that, what excites me are conferences like this. I mean, we’ve got some of the best thought leaders in the world, you know, with Sanford and with other rural health care organizations that are just super committed, not just to providing great health care, which is extremely important, but to preserving the way of life that people in rural America have. I mean, the listeners that live in the rural parts of the country know what I mean.

There’s a real mantra, sometimes unspoken, that we’re not going to lose this for future generations. We’re going to figure out a way to make this work. And just, you know, the excitement that you can feel already this morning, it’s just a part of that.

Ann Nachtigal (host):

It is really exciting. And, you know, rural America, we could be the leaders, right? I mean, I think that’s what the people that are here today are here to try to find those solutions and lead the way for the rest of America. Right? And it almost seems like in an earlier interview I did, we talked about that we can be more nimble.

Mark Parkinson:

Yeah, absolutely.

Ann Nachtigal (host):

And innovative.

Mark Parkinson:

Yeah. You just don’t have the bureaucracies that these super large organizations have. And the passion and the commitment to the community is not something that you see typically in an urban area. So I think there are a lot of challenges, but there are also a lot of things that rural America has going for it.

But the other thing that we’re going to have to figure out, and this is across the whole health care spectrum, but it’s certainly true in rural parts of the country, we’re going to have to figure out how to take care of people with less workers.

You know, you look at the demographics and for the whole country, we have a tremendous aging of the population going on. We’re going to have a lot more people that need hospitals, that need long-term care facilities. And we have a diminishing number of younger people, that the fertility rate is dropping, the number of young people coming along is less than we’ve had in the past.

So we’re going to have to be very innovative. We’re going to have to use technology. We’re going to have to actually go the opposite of the minimum staffing requirement where we figure out how to take care of people with less folks. And that’s the real challenge of the next 20 or 30 years.

Ann Nachtigal (host):

Innovate, right? Yeah. Forced to innovate. Look outside the box.

So we have a wide range of speakers here today. Why is that kind of broad perspective of continuum care so important when we’re talking about this field?

Mark Parkinson:

Well, I think we really learned in the 1980s, 1990s, before electronic medical records really became the standard in health care, we learned that having operators siloed in their own areas just did not work.

And so we would often see patients come into nursing homes that had several doctors that were getting prescriptions from multiple physicians. The physicians didn’t know what the others were giving and it just wasn’t working for the patient. By integrating care so that everybody is part of the team to improve the health care of one particular patient, it’s really improved care.

It’s also made care less expensive because there’s not the overlap and inefficiency. So Sanford, you know, bringing everybody together is a terrific thing. And I think that this integrated health care is something that we’ll see more and more in the future.

Ann Nachtigal (host):

Last question. Try to keep these fairly short for our listeners and know there’s lots more to talk about. But what excites you the most about the future of rural health care? Is it that we are convening groups like this? What is it?

Mark Parkinson:

You know, I’m getting towards my retirement and one of the things that’s exciting to me is to see really great young leaders coming into the space. I was able to spend some time with the Sanford leadership team and that’s pretty reflective of across the country.

You see younger people that are super smart, you know, really want to do the right thing, mission driven. I think we’re seeing a new generation of leadership and to me that’s very exciting.

Ann Nachtigal (host):

That is exciting. Mark Parkinson, thank you so much for joining us here at the Summit on the Future of Rural Health.

Mark Parkinson:

It’s been great to spend time with you.

Alan Helgeson:

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

Learn more about this topic

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PCOS can affect your fertility and more

Courtney Collen (Host):

Hello and welcome to “Her Kind of Healthy,” a health podcast series brought to you by Sanford Women’s. I’m your host, Courtney Collen, with Sanford Health News. We want to start new conversations about age-old topics from fertility to managing stress, healthy living, and so much more.

“Her Kind of Healthy” is designed to bring you honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

On this episode, we are talking about polycystic ovary syndrome, or more commonly referred to as PCOS. And joining me for this conversation is Dr. Keith Hansen, who is a specialist in fertility and reproductive medicine at the Sanford Fertility and Reproductive Medicine Clinic in Sioux Falls. Dr. Hansen, welcome. Thanks for joining me.

Dr. Keith Hansen:

Thank you, Courtney. I appreciate it.

Courtney Collen (Host):

Well, let’s dive right in. Polycystic ovary syndrome: What is it? Tell me about some of the warning signs symptoms, how it’s diagnosed.

Dr. Keith Hansen:

Well, polycystic ovary syndrome is the most common metabolic endocrine abnormality in women. And it does have a number of different presenting symptoms that can occur. One of them is it can cause infertility because a lot of these gals are either only ovulating once in a while or not ovulating at all. And of course, if you don’t make an egg, then you can’t get pregnant.

Other symptoms that they can have include irregular periods or no periods, primarily because they’re not ovulating or only ovulating once in a while. They can also have very heavy periods because the endometrial lining gets so thick that it can cause heavy bleeding. Then if it goes on long enough, they can even get what’s called the endometrial hyperplasia in the lining of the uterus and that can even develop into endometrial cancer. So we have to be aware of this and treat these patients early so that hopefully that doesn’t present.

They can also come in with symptoms like what we call hirsutism, which is where they have excess hair growth on their face, like a mustache and beard, hair on their chest, hair on their abdomen. And if it gets really severe, they can even have what’s called virializing symptoms, which is like balding in a male pattern and other type, increased muscle mass, lowering of their voice and those kind of things. But that usually is in the more severe cases of polycystic ovary syndrome.

These patients are also at higher risk of other metabolic abnormalities. One thing is diabetes is also very common in these individuals. Increased weight and obesity can be an issue. And also they can have problems like sleep apnea and a number of other later-in-life conditions like heart disease and other cardiovascular abnormalities because of things like lipid abnormalities and glucose intolerance.

So it’s a wide spectrum of abnormalities that these patients can present with and it also depends on what stage of their life is as to what their primary symptom will be.

Courtney Collen (Host):

Let’s talk about how it’s diagnosed. How would you diagnose a woman with PCOS?

Dr. Keith Hansen:

That’s a great question. Polycystic ovary syndrome, PCOS, is diagnosed by a number of different factors. And the way we diagnose the disease has evolved over time. The most, some of the more recent studies are put forward, or the most recent diagnostic criteria are put forth by the Rotterdam criteria, or they had a consensus and came up with criteria. There are other ones, but these are basically that the patient has to have two out of three things and no what are called the endocrine mimics or diseases that can mimic polycystic ovary syndrome.

The two out of the three things is she has to have either irregular or no periods, because of the fact that she’s not ovulating a lot or she’s not ovulating at all; she has to have some evidence of elevated androgens, be that increased blood tests that show elevated testosterone or other androgens, or clinical evidence like a mustache and beard and chest hair and more male pattern increased hair growth; or polycystic appearing ovaries on ultrasound. But she only has to have two out of the three of those things. OK.

And then we have to rule out other endocrine diseases that can mimic that, such as late-onset congenital adrenal hyperplasia, where the adrenal gland is abnormal and it mimics polycystic ovary syndrome, but the treatment for it is totally different. We’ve got to rule out other conditions like hyperprolactinemia thyroid dysfunction and other endocrine and other endocrine type of diseases that can mimic polycystic ovary syndrome.

Courtney Collen (Host):

Are certain women at a higher risk for PCOS?

Dr. Keith Hansen:

Yeah, there are women that are at higher risk. And first, just so you’re aware, there are really two major categories of polycystic ovaries. There’s the obese polycystic ovary syndrome and then there’s the thin polycystic ovary syndrome. So just because a woman is thin doesn’t mean she can’t have polycystic ovary syndrome. And yeah, there are in a family, when there’s a family history of things like diabetes, women where their mothers and their grandmothers had polycystic ovary syndrome it’s thought that the male equivalent may be diabetes and male pattern balding may be a sign of the male kind of polycystic ovary syndrome.

Other things that are known to do it are if a girl has early onset of puberty, that can be a sign that she may later develop polycystic ovary syndrome and such.

Courtney Collen (Host):

As a specialist in fertility and reproductive medicine, let’s talk about pregnancy and PCOS. How does this diagnosis affect a woman’s fertility?

Dr. Keith Hansen:

It definitely can affect her fertility because, you know, before she’ll be able to get pregnant, she has to make an egg. Women who have polycystic ovary syndrome usually will not ovulate or will have a decreased frequency of ovulation, meaning that they have less chances of getting pregnant. So what we try to do in reproductive endocrinology is try to improve their ability to ovulate so that hopefully they’ll ovulate more and be able to get pregnant.

And there are a number of ways we can do that. One of the ways is to try to help through diet and exercise. If the person is overweight, sometimes by losing weight, even 3 to 5% of their body mass, they can actually improve their ability to ovulate, or they may even start ovulating on their own. So that can be very helpful.

One of the other big areas are drugs to try to help them ovulate. Like letrozole, which is an aromatase inhibitor. It basically decreases the amount of estrogen that’s made, or clomiphene citrate, which is what’s called a selective estrogen receptor modulator, which kind of tricks the body into thinking estrogen levels are lower so then they make more hormones to stimulate ovulation. The letrozole is the one that has really been – recently there was a large study showing that it works better than clomiphene citrate in women with polycystic ovary syndrome.

So a lot of times we try to treat them with letrozole to try to get them to ovulate and, and then we watch them closely. The biggest risk with letrozole is there’s about a 1 in 10 risk of having a multiple baby, like a twin or even more, ovarian cysts, which can be very uncomfortable, but it means it’s working because the cyst is, means that she’s developing follicles.

Courtney Collen (Host):

And does that go away eventually?

Dr. Keith Hansen:

Oh yeah. They’ll resolve, but they’re kind of there forever, not temporarily.

Courtney Collen (Host):

But it’s working.

Dr. Keith Hansen:

But it’s working, just doesn’t feel very good. And then it can cause things like hot flashes and they sweats and mood swings and some fool is making their hormones go crazy. Yeah, and then, hopefully once we get them ovulating, that can help them to get pregnant usually.

In the old days, we used to always say in women with polycystic ovaries, we’d say, let’s get you ovulating for six months or six cycles, and then if you’re not pregnant, then we’ll do a sperm count.

Well, in women with polycystic ovaries, we can get like 80-to-90% of them to ovulate with letrozole or with other method, other oral medications. But if the group that doesn’t get pregnant, that group, the most common reason for them not to be pregnant is something wrong with a guy. And so now we’ve pretty much changed where we now just say, look, why don’t you get a sperm count right up front to make sure there’s not something wrong with the male side of this too. It saves some time too. You don’t want to have somebody go on medicine for six months and then find out there’s no sperm.

And then if letrozole or CME don’t work, there are a number of other options. Like there’s shots, we can do human menopausal genotropin shots. The problem with those, though, is they have a very high rate of multiple babies. It’s like 30 to 40% of time, and that’s how you can get like quads and septs. And so we try to avoid that one if we can.

There’s also the option of in vitro fertilization. There’s also, sometimes what we’ll do is if we put the patient on birth control pills and just shut her ovary down for a little bit and let everything, all the hormone levels kind of get back down to normal, then stop it, then many times they’ll start ovulating on their own. Or will respond better to the medications. Probably better to say, respond better to their medications. Then if that doesn’t work, there’s a number of other combinations of medications we can do to try to help them.

And then finally, there’s even surgical options. We can go in and do what’s called an ovarian drilling, which basically the ovary, all the eggs are on the outside and the stroma is on the inside. And the stroma is what makes all the hormones the androgens, which then go out to the eggs, which then make estrogen. Well, one of the problems with polycystic ovaries is they make a lot of androgens. And so theca cells inside the ovary are just cranking out the androgens a lot. So if you can somehow lower those levels, like with a birth control pill or with surgery, get rid of some of those theca cells, then the androgens will drop and then the ovaries will be more responsive to therapy.

In fact, the very first studies that were done in polycystic ovaries back in like 1930 or 1940s by Dr. Stein Leventhal at Rush University, they actually had eight women with classical polycystic ovary syndrome. They wanted to study the ovary. So they went in and did a big incision, took a big chunk out of the ovary, and then went and looked at it under the microscope. Well, they sewed the ovary up and sewed the gal up. And lo and behold, all eight of these women who had never had a period for a long time started to have regular periods and every single one of them got pregnant.

And so it became what’s called an ovarian wedge resection, where we go and take out a big chunk of that internal part. But of course, you have to sacrifice some of the eggs, and then a lot of those gals will start to ovulate.

Then Clomid came along probably in the fifties. Yeah, exactly. In the fifties. And it kind of replaced the ovarian wedge resection. But it still can be very helpful in women who don’t respond to medications. And now we don’t do the big wedge resection anymore. We go in and we have a catheter, a little insulated needle, and we put the needle tip into the ovarian stroma and fulgurate the inside or, you know, burn the inside, fulgurate it, and it destroys part of the stroma. So, it’s kind of like taking it out, but not actually having to take it out. And then a lot of those gals will start to either ovulate on their own or will respond a lot better to medications and such. So there are a lot of different options available.

Courtney Collen (Host):

The options that you have and the advancements in medicine, just hearing some of these things – amazing. Incredible. What is it like to be able to provide this type of care to help of course, women or families grow?

Dr. Keith Hansen:

Oh, it’s wonderful. It’s very helpful. It’s very nice to be able to help people achieve what they want. Their dream, a little baby to keep them awake at night.

(Laugh)

Courtney Collen (Host):

Yes. Once a woman is pregnant, but she is living with PCOS, are there any complications or risks to her or baby moving forward?

Dr. Keith Hansen:

One of the big concerns is does she have diabetes or is she at higher risk of developing gestational diabetes later on in pregnancy? And so they want to monitor her very closely for that. So there are some other data showing possibly earlier deliveries in some of the gals with polycystic ovary syndrome. So we do like them to be very monitored very closely by their OB/GYN during pregnancy and watch and make sure that they hopefully don’t get any of those complications.

Courtney Collen (Host):

Yeah, that was my next question, what the care journey looks like. A woman comes in, you help her hopefully achieve pregnancy or at least get to ovulation and go from there. Do they stay with you in the clinic through pregnancy or can they go back to their OB/GYN, continue that care seeing you when needed? Talk about what that looks like.

Dr. Keith Hansen:

Yeah, we usually, once they’re pregnant, we like to send them on to see their regular obstetrician so they can be observed very closely and watch throughout the pregnancy and get through their prenatal care.

Courtney Collen (Host):

Would that be considered high risk if they were, if they came in with PCOS?

Dr. Keith Hansen:

No, it just makes it just sort of like alerts the OB to watch for things like diabetes and other potential issues.

Courtney Collen (Host):

Any other concerns for women who are diagnosed with PCOS or what it might lead to? Any other issues it might cause?

Dr. Keith Hansen:

Well, just a couple things. It’s really hard to diagnose it during adolescence and actually menopause. And the reason is because a lot of the symptoms of polycystic ovary syndrome are similar to the symptoms of puberty and the symptoms of menopause. And so, like irregular periods, they’re common at both ends of the spectrum. Acne is often a sign of androgens. Well, in teenagehood you know, acne is a real common finding. And so it’s really difficult to make the diagnosis at that point.

Now the nice thing about menopause is usually you have that history before of what their periods were like before they started. Puberty is a lot harder. In fact, they suggest that you don’t make the diagnosis of polycystic ovary syndrome until she’s a little bit older. Some people argue maybe even into the 20s before you say that it’s actually polycystic ovary syndrome.

But did you say she’s at risk for developing it later in life? There are some new guidelines coming out that say, you know, we had talked about making the diagnosis based on irregular periods, elevated androgens or hirsutism, elevated androgens and polycystic appear ovaries on ultrasound. They actually now are also saying that if we, there’s a level called AMH or anti-malarial hormone, which is a blood test that reflects how many eggs are in or how many follicles are in the ovary. And when that’s elevated, that’s often a sign of polycystic ovaries. But they’ve now adapted that for inclusion in the criteria where we can now use that as making the diagnosis of PCOS. We don’t have to rely on the ultrasound so much.

In terms of diagnosis, of course, the hard part is what does this do for women after they go through, had their kids, and they’re starting to approach menopause? Well one of the things we worry about is the hirsutism, getting a mustache and beard and hair growth. So, one of the big questions is, can you suppress the ovaries? And the answer is yes.

One of the ways we can suppress the ovary is the birth control pill. Now, of course, you don’t want to give that to somebody if they’re at high risk, but it does work really nicely at keeping those theca cells not producing a lot of androgens. And there are other options, but there are things we want to do to help out with those cosmetic issues because those are not a lot of fun.

The other one is we worry about developing diabetes. In fact, the new recommendation is that women with polycystic ovaries should probably get a glucose tolerance test every two to three years. And not just the hemoglobin A1C or a fasting sugar, but a full blown glucose tolerance because it can diagnose glucose intolerance a lot easier and better. It’s more sensitive for diagnosing that than a fasting sugar or a hemoglobin A1C. Also lipid panels, because they can, once again, insulin resistance increases the risk of lipid abnormalities.

High blood pressure is something we want to keep a watch on and make sure that they keep that under control. We also worry about developing endometrial hyperplasia and cancer. We don’t want them to get endometrial cancer. And so we want to make sure that they’re either ovulating on their own or getting some form of progesterone to prevent the development of endometrial hyperplasia or cancer. And there’s a number of ways we can give progesterone.

The other thing is, we can’t forget about sleep apnea. There are studies showing that women that have polycystic ovary syndrome see a higher risk of sleep abnormalities, specifically sleep apnea. And new recommendations are that if a woman feels like she is tired during the day, unless she has a baby at home, snores, ever woke up gasping for air or had any issues that might suggest sleep apnea, that you get a sleep study. So, yeah. So there are a lot of things that we want to monitor for sure throughout the life cycle.

Courtney Collen (Host):

Is there a connection, Dr. Hansen, between PCOS and insulin resistance?

Dr. Keith Hansen:

Well, there definitely is a connection between polycystic ovary syndrome and insulin resistance. In fact, it’s hard to know though – is it the chicken or the egg? Is it part of the process that results in the polycystic ovary syndrome or is it a result of the polycystic ovary syndrome? But we do know that they’re both interconnected. In fact, we know that that’s probably why they’re at higher risk of developing glucose intolerance and later in life, getting diabetes mellitus.

In fact, a lot of these gals will come in and will have other signs of insulin resistance. Like they’ll have what’s called acanthosis nigricans, which is darkening of their skin around the base of their neck or under their arms or in their inner thighs and then skin tags. Then elevated androgens are a result of the insulin resistance. So they’re kind of all tied together. And that’s why, you know, weight loss through diet and exercise and such can actually improve the way the ovary works is because it improves insulin sensitivity.

Courtney Collen (Host):

What do you recommend to patients as far as lifestyle, diet? You about diabetes being a concern later, potentially cancer. Are there lifestyle or diet changes that you recommend for women who are in your care?

Dr. Keith Hansen:

Well, you know, the healthy lifestyle is a really good idea. I mean, diet and exercise are very helpful for everybody who’s trying to get pregnant. We do like the gals to make sure they’re taking a vitamin with folic acid because that’s been shown to lower the risk of neural tube defects, which is amazing. And then also, a lot of people will go on their supplements, like myo-inositol is thought to be very helpful at improving insulin resistance and improving how people feel that have polycystic ovary syndrome.

Another one that has some data is cinnamon. People say that cinnamon actually can be very beneficial. And then one of the things that’s kind of hard is whether or not to use metformin. You know, it wasn’t that long ago, like maybe 10 years ago, where if you had polycystic ovaries, we automatically started you on metformin because it improves insulin resistance. And so, we got everybody on it, but it does have some side effects, primarily GI you know, like urgency to have diarrheal stools and nausea and vomiting and those kind of things. At one point we were giving pretty much anybody with PCOS, we’d give them metformin, then it kind of went back to say, well just give it to them if the person has diabetes or glucose intolerance. And that makes sense too.

And then if it also, now it’s kind of swinging back a little more that it might be beneficial for women to help them ovulate because there are some women with polycystic ovaries that if you give them metformin, they’ll actually start ovulating better and they can get pregnant because it improves their insulin resistance and improves their hormonal profile. It’s not as good as Clomid, not as good as Letrozole, but it does have a lower risk of multiple babies.

Courtney Collen (Host):

Does PCOS ever go away?

Dr. Keith Hansen:

Well, that’s a fascinating question, and the answer is no. The PCOS though, you know, is kind of one of those diseases as a woman ages, her ovaries may start actually ovulating on their own. So what’ll happen is she won’t ovulate when she’s in her 20s and maybe 30, 35, and then all of a sudden she’ll start having regular periods and be able to get pregnant because she’s finally ovulating. So as the ovaries start to kind of tune down, they’ll start to work a little better. So that’s one thing that does change.

But one of the hard parts is, you know, even if you go in and like, let’s say if a gal said, I’m tired of this PCOS, I’m going to have my ovaries taken out. She still has all the other problems, though. She still has the insulin resistance, she still has a higher rate of glucose intolerance, lipid abnormalities, high blood pressure and risks going forward. Then on top of it, she has the risk of having her ovaries taken out at a young age, which increases the risk of cardiovascular events. And we really don’t like to take the ovaries out of somebody until they’re, you know, in their 60s because of the risks that are associated with that.

And so, most people do not argue to take the ovaries out in somebody with polycystic ovaries syndrome. So it’s kind of one of those conditions where it’s more of a total body metabolic endocrine imbalance. So you can’t remove it and it doesn’t seem to get totally better over time. Wish it did.

Courtney Collen (Host):

Let’s say, Dr. Hansen, a woman is listening or a loved one of a woman who might be showing symptoms or have concerns that a lot of this sounds very familiar, at least some of those early warning signs we talked about. What might she do? How does that care journey begin and who does she talk to? Who does she reach out to?

Dr. Keith Hansen:

That’s a great question. I think one of the first persons they could talk to is their family medicine physician or their OB/GYN, whoever they’re seeing. And then, they evaluate them and start the journey. And then if they have any issues, of course they can always send them on to us. Or when they’re, you know, want to get pregnant and they want it to us to help them, we can do that. But that’s probably the first person to talk to.

Courtney Collen (Host):

Good start. How can we support a friend or loved one who might be diagnosed with PCOS? And specifically because we are at the fertility and reproductive medicine clinic, you know, if they’re trying to get pregnant we want to be able to support our friends or loved ones who are on that journey, that fertility journey. What would you recommend that we do? Or what can we do for them to show our support?

Dr. Keith Hansen:

Being supportive of the individual and helping them realizing that they have this endocrine condition and have to go through a lot of different types of therapies possibly, I think that can all be very helpful. You know, lending an ear so that they can chat with you and discuss their options and stuff if they want. The biggest thing is polycystic ovary syndrome is a very common endocrine metabolic abnormality, affecting a large number of women. And it can have some very devastating effects upon their reproductive and endocrine and their metabolic condition.

However, there are a lot of things they can do to help keep it under control, both when they’re trying to get pregnant and when they’re not trying to get pregnant. I think one really important issue that I forgot to mention earlier, when a person with PCOS is not trying to get pregnant, they still need to be treated. They should not, you know, say, oh, well I’ll ignore it. All I want to do is get pregnant. And then I don’t mind not have their baby and then say, “oh, I don’t mind having a period once every year.”

Because then if they don’t, they could go on to develop endometrial hyperplasia cancer. Some of these gals can have terribly heavy periods to the point where we have to give them blood transfusions and do emergency surgeries. They want to be treated. Sure. And some of the treatments that are good for, while you’re like, let’s say you’ve had your baby and you want to wait a year or two, which is a good idea to let your body build back up, you know, then the birth control pills are very good. They’ll keep everything kind of suppressed for us, and probably make it easier to get the woman to ovulate afterwards and prevent endometrial hyperplasia, cancer, and then there’s other progesterone agents that can also prevent the endometrial hyperplasia, but they don’t suppress the ovaries as well as the birth control pills do. Don’t ignore it, diet and exercise.

Courtney Collen (Host):

Dr. Keith Hansen, thank you so much for your time and all of your insight and expertise on polycystic ovary syndrome and all that you do here at the Sanford Fertility and Reproductive Medicine Clinic. Thank you.

Dr. Keith Hansen:

Thank you, Courtney.

Learn more about this topic

• Endometriosis is common, yet commonly undiagnosed
• Choosing the right birth control
• Mammography: Answers to common questions

Get more episodes in this series

TikTok nutrition trends: What’s safe versus a scam

Alan Helgeson (host):

Hello and welcome. You’re listening to the “Health and Wellness” podcast, brought to you by Sanford Health. I’m your host, Alan Helgeson, with Sanford Health News.

Our conversation today is about the TikTok and internet nutrition and wellness trends. Are they facts or are they fiction? Our guest today is Dr. Jennifer Schriever with Sanford Weight Management Center. Dr. Schriever, thanks for being with us today.

Dr. Jennifer Schriever (guest):

Oh, thanks for inviting me.

Alan Helgeson (host):

We wanted to go right to the expert and to talk to you today to maybe answer some of those questions, debunk some of that stuff. I’m wondering is there a danger in jumping into some of these nutrition trends online?

Dr. Jennifer Schriever:

Certainly. Because some of them can be harmful, especially if you have some health conditions or on some medications that could affect those treatments. They also tend to not be very well studied. So then how do you know the true safety, and are the ingredients what they say they are? A lot of the supplements and created products like that aren’t well regulated. And so even pill to pill or jar to jar, you don’t know if you’re getting the same ingredients.

Alan Helgeson (host):

Another question we have here too, Dr. Schriever, is how do we identify a fraud or verify if something’s safe for us?

Dr. Jennifer Schriever:

Certainly look for who is giving you that information. Do they have good credentials? So if they’re a dietician, are they a registered dietitian or a licensed dietitian? Do they have a master’s degree in dietetics, nutrition, public health or other related sciences Or are they a doctor, an M.D., a D.O. or a Ph.D.?

And then also look for multiple sources of information. Don’t just trust the first one. Look for other organizations that might support it. Do they have an organization behind them supporting that? Be alarmed or concerned if it is a famous person selling that and telling you it’s great. Is it just an online testimonial that this worked great for me and my friend? Is there any studies behind it and are there multiple studies and can they be reproduced? Those studies, those are things to look for.

And if you aren’t sure, then look for another health system and look at it there to see if they’ve put any information out to confirm is it safe or not.

Alan Helgeson (host):

These are some of the top ones that are showing up and people are wondering about: powdered greens.

Dr. Jennifer Schriever:

Those tend to be supplements that are made from basically ground up and dried fruit and vegetables. So nutritionally they might have a lot of vitamins and things that are helpful. But really you’re best off still eating the fruit and vegetables because you’ve lost out on the fiber content through that processing. And also keep in mind there might be bad ingredients.

So I look for a third party reviewer. If it’s a good company, they’re going to ask an outlying company to review their product for safety and make sure there isn’t any extra contaminants like lead or something else or heavy metals.

The other thing to keep in mind again is if you have any kidney disease or if you are on some medicines such as blood thinners or a blood pressure medicine that might affect your electrolytes, adding some powdered grains could certainly affect levels of certain medications. And so you want to let your pharmacist know or your doctor know.

Alan Helgeson (host):

Here’s a unique one we’re seeing a lot about is tongue scraping.

Dr. Jennifer Schriever:

Yeah, so that’s interesting. As far as weight management, probably not adding much to your health. If you have, in general, good care of your teeth and oral tissues, do you need to add tongue scraping? Not necessarily.

But if we have poor dental health, then we have extra bacteria in our mouth which can cause inflammation. Inflammation can lead to heart disease or stroke. In pregnancy it can cause pregnancy difficulties such as preterm birth and other complications like infection and pneumonias. You’d be at higher risk for pneumonia if you don’t have good dental hygiene. But do you need to add tongue scraping to your typical routine? No.

Alan Helgeson (host):

I know a lot of people like to look at recipes on Pinterest. I like to do that and we’re seeing a common theme here. One of those things that people talk a lot about these days, Dr. Schriever, is drinking bone broth.

Dr. Jennifer Schriever:

You can certainly use it if you want to be sure it’s safe if you’ve made it yourself. You need to be aware of the risk of bacterial and contamination. And make sure you use it up by the expiration date. It’s, I think, touted as a protein source but there’s only nine grams of protein in a cup. Liquid also tends to be very filling. So if you’re using it to help feel full, that’s a good way to do it. So you can certainly use it as a tool to help with fullness and for protein content.

But we look at least needing at least 30 grams at a time to support your muscle health and regrowth. So that’s only nine grams. So you’d need to be aware of what else is in your meal to help balance that out.

Alan Helgeson (host):

What can you tell us about dry scooping?

Dr. Jennifer Schriever:

Gosh, don’t do that. (Laugh). So dry scooping is referring to using pre-workouts I think mainly. And instead of mixing it in water, just throwing it in your mouth and swallowing it, you’re going to certainly place yourself at risk for choking and aspirating, which is not good for your lung health, could lead to infections. And we all know where choking could go, but also consider those tend to have a lot of caffeine in them and if you’re going to swallow it that quickly, you’re going to absorb all that caffeine so quickly it can elevate your heart rate, could certainly cause some heart damage if you’re going to do anything like that to a significant extent. Or frequently you could have chest pain, numbness, tingling, nervous system effects, dizziness, all sorts of just really not feeling well. So as you look at pre-workouts and if you’re going to use them correctly mixed with water and things, try to keep it under 200 milligrams of protein a scoop or a serving.

Alan Helgeson (host):

Dr. Schriever, as you were talking about the dry scooping stuff here and you mentioned pre-workout, well, let’s talk about pre-workout.

Dr. Jennifer Schriever:

A lot of people that work out like to use pre-workouts. They have caffeine as a stimulant and some other herbal things that can be stimulants as well. So try to be really aware of what is in that supplement and if at all possible, be aware of how much caffeine they’re putting in there. Sometimes it can be very difficult to determine and if it’s difficult to determine I choose another product or you can reliably know how much you’re getting.

People find more energy so that they feel like they can do a more intense workout. It might help reduce – depending on the ingredients of your pre-workout – muscle soreness. You might have more energy after. Some of them have B vitamins so then you can improve your energy that way. Some might have nitrous oxide to increase your blood flow for weightlifting or sprinting but you could also just drink some coffee before your workout, and some have a lean protein prior, and get similar benefits.

Alan Helgeson (host):

Alright, let’s talk about internal shower drinks.

Dr. Jennifer Schriever:

(Laugh) Interesting thoughts of what is out there. So that can be using a lot of chia seeds and water to maybe do a colon cleanse or clean you out. Apparently this is actually a replica of a traditional Mexican drink called agua de chia. But if you use chia in moderation and when a tablespoon or two at a time, that can certainly help with regularity of your bowels because it has a lot of fiber in it. But those little seeds absorb a lot of water. So if you’re going to take a lot of chia seeds at once, they’re going to absorb a lot of water and you could actually end up with a bowel obstruction because they absorb so much water and kind of get glue and sticky-like. So, not a great plan.

Alan Helgeson (host):

(Laugh) It doesn’t sound like a lot of fun and I’m running out of room here on my post-it note Dr. Schriever. And the last one I have here is liquid chlorophyll.

Dr. Jennifer Schriever:

From what I could tell, there’s no proven benefit. You could increase your risk of sunburn. Can they truly get enough chlorophyll in that liquid dropper to make a difference? Probably not. There’s no evidence that it’ll improve your health.

You’re better off eating spinach, kale, green beans and peas if you’re interested in getting more chlorophyll naturally. And those have the added benefit of fiber and vitamins.

There are a few other thoughts I had that might be out there online, too, or on the media to bring out one. And a patient did just bring this up the other day, “Well, I heard magnesium could help me lose weight.” There are some studies showing a little bit of benefit but only in certain populations and not significant benefit. So if you do have a magnesium deficiency, if you have insulin resistance, so that means like prediabetes or those sort of conditions or obesity, you might lose weight supplementing magnesium, but it’s only at 0.21 of a BMI.

So I’m 5’4”, that would be two pounds. So not a significant benefit to taking magnesium. There are other benefits for magnesium. It can help with bowel regularity. For some it helps with sleep so you can use it for that, but I wouldn’t rely on it to help with your weight a lot.

There’s also off and on a lot of concern about artificial sweeteners. “Are they safe?” “I should drink regular Coke instead,” and I would disagree with that entirely. Certainly we want to eliminate as much sugar from our diet as we can and really most of the studies that I can find and have evaluated against artificial sweeteners such as cancer causing or other long-term risk really aren’t very valid. So I’d rather see you using an artificial sweetener to meet a sweet craving over picking a sugary beverage that is going to have a lot of calories.

So you can certainly flavor your water if you want to, if that helps you drink more water. There is that benefit. Now for people who kind of feel addicted to sugar, if you can gradually over time use less sweetener, that can help you adjust your taste buds so you don’t want so much or desire so many sugary things.

I think that’s one of the things online as well called WaterTok. A fad of drinking a gallon of water a day and flavoring it in all sorts of ways and (laugh) a large variety of recipes. So certainly that’s a great idea if it does help you drink more water. But as long as you’re keeping a balanced diet, you know, if you drink too much water and you’re using that to stay full and you’re not eating, so that’s your diet plan, that’s not a healthy way to lose weight.

And I think some of that comes across in the social media that people desire that to look thinner. So they’re drinking these drinks that taste good and help them stay full and maybe distract them from their hunger. But really if you’re doing that not eating enough, you could throw your electrolytes off by drinking too much water. It can be difficult to do in the short term because you have to override your kidneys, and adult healthy kidneys are going to be able to metabolize your electrolytes and water just fine. But if you have any kidney disease or are on any medications that affect that, and if you do that for too long, you are going to gradually deplete your electrolytes and that can be very harmful.

Let’s also touch a little bit on CBD. As far as weight management, there isn’t great human studies on how helpful that could be. There is some evidence that initially it can maybe contribute to weight gain but then can contribute to weight loss. But there’s nothing reliable to show any proven benefit. Some people do use CBD for other health conditions and if that’s such as chronic pain, that’s a very stressful condition. Stress interrupts your weight management. So that could indirectly maybe benefit you as far as your weight management journey, helping you adjust your lifestyle to improve, but nothing to support actual benefits for weight loss currently based on studies.

Alan Helgeson (host):

Dr. Schriever, those were some great tips about some of these things and there’s just so many it would take days to get through them all. Let’s jump in on something you touched a little bit on: cleanses and detoxes. Do these things work?

Dr. Jennifer Schriever:

There’s really no benefit to doing a cleanse or a detox. And again it goes back to are you on medications? Do you have health problems that could make that risky and you throw your potassium off based on a medication you’re on? Certainly in the short term, if you’re going to clean out you might lose a few pounds, but in the long term you’re just going to start eating again and gain it back. If you are struggling with your bowels, then I would certainly talk to a doctor about how to correct that and help you through that rather than risk going through one of these cleanses.

And some of them you also aren’t going to know what are the ingredients and why are they working? Could you cause a colon issue or hemorrhoids or heart disease or something else? If you have diabetes, are you going to throw your blood sugar or weight off or get severe diarrhea and make yourself really dehydrated? Just doesn’t sound very fun or pleasant to do anyway.

Alan Helgeson (host):

Not at all. Dr. Schriever, as you meet with patients on a regular basis, sometimes you have to kind of boil things down to what are those golden rules or what are some of those two or three or four or five, sometimes more, things that you want to share or leave people with or questions to ask. So I’m going to kind of throw that out to you. Do you have any golden rules or maybe questions to take away to ask when seeing a new fad or trend?

Dr. Jennifer Schriever:

Sure. Well certainly is it too good to be true? Does it promise short-term weight loss, or is it even sustainable? Is it something you can do long-term? Typically any, most things you do in the short term, and you return to your typical habits, the weight’s going to just likely come right back. So are they claiming it’s the best kept secret or just one person is claiming it worked for them? You know, someone famous is saying it. So it’s back to going, is it legitimate? You know, if it’s on a website, is it a dot-edu or dot-org? Is that the organization presenting it? Because those are more reliable than dot-com or dot-net.

Alan Helgeson (host):

Yeah. And talk a little bit about how this approach is different.

Dr. Jennifer Schriever:

So we have studied the science behind helping people manage their weight, and we take a full health history throughout life. We know we ask you your weight history and what’s contributed so that we can guide you to a lifestyle change that is sustainable to lose weight, feel good, and help you reach your goals.

We use all the tools – they’re called pillars of obesity medicine. So that includes nutrition guidance, physical activity, behavioral – that might be emotional or stress eating – and then medications if needed to help you. Obesity was re-diagnosed as a chronic disease or finally recognized as such in 2012 or so. So you know, we recognized that it isn’t your fault or the patient’s fault that they have got to that point and we’re ready to help you through the ups and downs and through the difficult times and to help you improve your weight in the right way and maintain it.

Alan Helgeson (host):

Why does this approach work?

Dr. Jennifer Schriever:

We do use the most up-to-date information, and we’re constantly adjusting and all of us are listening to what is new, even in nutrition exercise, and of course the medications. We do use a body composition scale and I think that’s helpful for us, but also very helpful for the patient. Because it shows your muscle health, body fat content, water content, and we can explain progress through that. Your muscle mass is very important to your metabolism. So we help patients understand on the inside what is going on so that they can progress through their healthy lifestyle and understand the importance of protein intake and strength training and other just general movement.

We also provide a lot of support. So there are physicians and nurse practitioners to help guide you. We have dietitians, we have a health coach and we have a counselor to help you through all the angles of weight management. We are also helping to guide you through good exercise options that fit your lifestyle, your comfort level, and also finances. But so, and we’re also looking at adding in support from Sanford Wellness and how can we include that to help our patients as well.

Alan Helgeson (host):

Could you share a little bit about your clinical background in treating overweight patients?

Dr. Jennifer Schriever:

I’ve cared about my own health and nutrition for a really long time and certainly had a passion to try and help patients. But until I did the obesity medicine certification, I really didn’t know very well how to educate patients as well. So during COVID, found the online continuing education I could do to get board certified in obesity medicine. So I did that and so did a couple of my partners and really learned a lot that was very helpful in learning how to talk to patients, how to educate them, what is the science behind helping people lose weight and the science behind obesity to understand that, how it happened in the first place so that we can explain what happens physiologically and metabolically to patients. So did that training in 2021.

Sanford was very helpful and let me start a pilot clinic with my two partners. By half a day a week we expanded then to a full-time nurse, a practitioner, and now have two nurse practitioners as well, as well as three of us physicians working here, two of us part-time and I’m full-time.

Alan Helgeson (host):

How can patients be seen within your clinic? Do they need a physician referral? Do they call just to get in? What, what is the right pathway in?

Dr. Jennifer Schriever:

You can certainly have your physician send a referral. You can also call the number yourself and make a self-referral. We will evaluate your weight and height to make sure you qualify. We have certain guidelines that we take, but generally, we understand patients really want to come here, so we’ll work really hard to make sure you’re accepted if you’re within our BMI guidelines. And currently we take ages 16 and above.

(Adults who qualify for services at the clinic must have a BMI of 30 or above, or BMI of 27 to 29.9 with obesity-associated conditions. The BMI definition for children is based on percentiles.)

Alan Helgeson (host):

You’re doing some great things in your clinic, Dr. Schriever, and I probably should have asked this earlier. But in this technology world, we’re never more than a few arms’ lengths away from our phone and having that in our hands. I’m guessing there are probably some apps that you might even recommend for people, depending on where they’re at in their journey. But are there a few apps that you might share that people could trust as they’re looking into their weight journey?

Dr. Jennifer Schriever:

It can be very helpful if you’re ready and willing to do so to do some food tracking. So we will suggest various apps. You can use MyFitnessPal, Lifesum, Lose It!, MyNetDiary’s kind of nice because it grades your food. Bitesnap, you can actually take photos of your food. And then that’ll help you suggest portions. We will guide you though on your calorie goal and your protein goal, so don’t rely on the app for those things.

But otherwise those are great resources to journal your food if you’d like to. Studies will show that people that do some monitoring of their own intake do better, but it doesn’t have to be a hundred percent of the time. Some people benefit from journal apps or self-care apps. A couple of those are Finch and Habit Tracker. You can also benefit sometimes from meditation apps like Insight Timer, Calm, or Headspace are other ideas I collected from our staff too.

Alan Helgeson (host):

Dr. Schreiver, I feel like you know where I’m going and what I’m thinking, which is awesome because the next question I wanted to ask is, for so many people that with a weight loss journey or have experienced being overweight, that there’s so much of a mental piece to it. How can we move through that journey and better our health and fitness without maybe feeling bad about ourself? And I know that’s probably a whole different discussion for another episode, but maybe just a few things or just a few high level thoughts from you.

Dr. Jennifer Schriever:

And I do love the opportunity to talk about that. I think patients have a very difficult time coming to their first appointment here, and that’s pretty evident sometimes. They’ll say so or be in tears because they feel shamed or fear or embarrassment.

And a lot of patients have experienced weight stigma throughout their life or bias. Did people make comments to them about how much they ate or their weight while growing up or even in life? And even in health care, family, friends, health care providers can say the wrong thing that makes them feel bad about themselves. And once you hear something like that, you internalize it. So even though someone might not be saying something to you about your weight, you’re thinking you don’t deserve better or that you’re down on yourself for these things.

So what we need people to know, first of all, just coming here, we’re not going to judge you. We know obesity is a chronic disease. There are a lot of things that have changed on the inside over time that make it very difficult to lose weight and it’s out of your control. So unless you have good guidance, it can be very challenging. And you can’t lose weight based on willpower alone or diet and exercise typically only gets you a small percentage of weight loss. And willpower only lasts so long. So also, if obesity is a chronic disease, it’s relapsing and remitting. So certainly we’re all going to be successful for weight loss for a timeframe depending on what we choose. But then our body is going to start to think we’re starving and it might make us more hungry and then make it more challenging to continue the program we’ve selected to work on our weight loss.

Alan Helgeson (host):

Such great information. Dr. Schriever, any final thoughts to share on our episode today?

Dr. Jennifer Schriever:

I think people are surprised about how good they feel as we adjust them through their nutrition and exercise and those sort of things. Certainly the joint pain improves fairly quickly. For every pound you lose, it’s like taking four pounds off your joints, particularly your knees. People have more energy, they’re less tired. Just by altering nutrition in the right direction, also adding more protein helps them feel full. So at least as you adjust those sorts of feedback occur fairly quickly. So it is also a challenge. We don’t anticipate patients to absorb all our information the first time.

Alan Helgeson (host):

Well, Dr. Schriever, I want to say thank you for taking time to talk to us today. 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. I’m Alan Helgeson, and thank you for listening.

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Innovative solutions keep senior care close to home

Cassie Alvine (Announcer):

Welcome to the Reimagining Rural Health 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, and rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

Today, Nate Schema, Good Samaritan Society president and CEO leads a conversation on the challenges and the opportunities facing the long-term care industry. Joining Nate are Dana Bachmeier and Luke Wanous.

Nate Schema:

Hey all. My name is Nate Schema, and I’m the president and CEO of the Good Samaritan Society. We have the privilege of serving in more than 200 communities across the United States and are one of the largest not-for-profit providers of senior care and services in the nation. In 2019, we merged with Sanford Health, giving us the opportunity to provide care to people at every stage of life.

Today, I’m honored to be joined by Dana Bachmeier and Luke Wanous, who are administrators in two of our nursing homes in Sioux Falls, South Dakota. Luke and Dana are great up and coming leaders, wonderful people, and I’m excited for our conversation today. Dana, I want to start with you. Can you tell us a little bit about what you do and how you got here?

Dana Bachmeier:

Yeah. So, I am Dana Bachmeier, administrator for Good Samaritan Society – Sioux Falls Village. At the Village, we serve about 160 residents. Previously, I served as administrator of Good Samaritan Society -Miller in Miller, South Dakota, where we served 40 residents. I started in long-term care when I became a certified nurse assistant at Sanford Health Vermillion Care Center. I have also worked in the emergency department at Sanford Hospital as a patient care tech. And then my experience goes as far back as to volunteering on the postpartum floor of the hospital and volunteering as a baby rocker in the NICU (laugh). So, lots of long-term care experience.

I got my start with Good Samaritan Society as administrator in training at the Sioux Falls Center. I’ve experienced many areas of health care and I’m really drawn to senior care because of how rewarding it is.

Nate Schema:

Luke, after graduating from Augustana University, how about you?

Luke Wanous:

Love Augie! Love everything about it. So, I started off as administrator here within Good Samaritan Society in 2019 with Dana Bachmeier. We went through the administrator in training cohort together. I’m currently the administrator of Good Samaritan Sioux Falls Center facility, which serves about 75 residents here in Sioux Falls.

But when I started my training, I started off in Waukon, Iowa, which is a town of about 2,000 people. And we served a census or about 68 residents. The reason I really got into long-term care was to give back to the community. Both of my parents had cancer as I was growing up. And so that really impacted me. They’re both fine today. They’re both healthy and happy and I couldn’t be more thankful to God, but I just wanted to give back into the community. And health care really spoke to me as a career choice.

Nate Schema:

I think I remember receiving the list of the ranking order of our administrators from 2019. And, you know, I’m proud to say that your name – it was in the top half. We’ll just leave it at that Luke. (Laugh)

Luke Wanous:

Dana, I from day one, I knew she was number one, so I was very open about that. But I was just happy to be a part of that cohort with Dana, with Justin Jones. And so we continue to serve with Good Samaritan.

Nate Schema:

It’s been an awesome class for us. You know, certainly a few things have changed since my time as an AIT back 17 years ago starting back in Mountain Lake, Minnesota. Still one of our proud and really awesome locations in southwest Minnesota. A lot’s changed in the last 17 years besides the fact that we weren’t wearing as many masks in the pre-pandemic areas. And we certainly went about the care maybe in a little different way.

In the days that I started we were still on paper charts, and it was before the days of PCC and doing all those different things. We had to actually do those rounds and pull out those quality audits and pencil them out ourselves. So, things have changed.

I’m certainly grateful that we’re able to put the pandemic behind us and really looking forward to the future and just so grateful to have that all behind us. And now that we’ve moved past the crisis of the pandemic, Dana, what are you experiencing?

Dana Bachmeier:

I think you just aged yourself. (Laugh)

Nate Schema:

Fair, very fair!

Dana Bachmeier:

I think post-pandemic, we see a lot more joy – a lot more joy in our residents and our families just as we have visitors coming in the building, really enhancing that family-like environment that we aim to create. So that’s something post-pandemic that’s been amazing. There are still workforce challenges we still experience, and I believe health care industry-wide experiences those.

But senior care, we feel it, especially specifically when it comes to hiring registered nurses and licensed practical nurses, those RNs and LPNs. As an example, I have a position posted for an overnight registered nurse, and that’s been open for 299 days. I looked today. So still feeling that. But we do our best with what we have and our residents deserve that best quality of life.

Nate Schema:

I hear from our peers across the industry right now that hiring’s really challenging. You’re certainly not alone. During the pandemic, and this is well documented on the Bureau of Labor Statistics, for anybody that wants to go out there and do a little data geeking out, there was over 200,000 health care workers lost. And the nursing home sector, specifically long-term care, no other part of the health care sector was affected quite like we were. And so, Dana, what would you say to a family member who is concerned about staffing levels in long-term care today?

Dana Bachmeier:

I would probably say quality of care is our number one priority at Good Samaritan Society and Sanford, when we can’t hire on staff, we don’t go without; we go to travel nursing staff to fill the gaps. We are a family, and all our staff, whether traveling staff or our own staff, are held to the same quality of care our residents deserve.

Nate Schema:

You know, the consequences of being short staffed is often the seniors have fewer options. It becomes an access issue. And I think about the upper Midwest where we have the privilege of serving. Sometimes people may have to go upwards of 30, 40 and 50 miles for care. You know, 70% of the residents we serve live in rural communities. So we are laser focused on ways we can protect seniors’ rights to receive care as close to home. But Dana, what are you doing at the Sioux Falls Village to hire the people you need today?

Dana Bachmeier:

Long-term care is an incredibly rewarding career. So we take a variety of approaches to expose people to the opportunities that we have. We did a food truck hiring event earlier this summer where we had a food truck on-site. We did interviews, facility tours, and then offered free meals to applicants. So that was a creative way that we tried to get people in our doors.

We go as far as to recruit international nurses, and I’m happy to say in September we will have an international registered nurse joining our family at the Sioux Falls Village. So very excited about that.

And then another great benefit to both organizations hiring and to nurses applying is the Build Dakota Scholarship, which is kind of like a partnership between health care organizations in the state to pay for schooling for RNs and LPNs. It’s just a really good pathway and it can lead to being debt free after college. So, who wouldn’t want that?

And then Sanford and Good Samaritan Society also have several internal scholarships that we offer employees and then talk about certified nurse assistants for those who are not yet certified. Good Samaritan Society offers on-the-job training to get that certification. And CNA experience is really important to those looking to go into the nursing career, really any health care career. But it’s also just a really good career in that it teaches valuable life lessons. And it’s so rewarding.

Nate Schema:

You know, I often hear, well, if you just paid more, you’d have more workers. What I’ve often had to educate my family, friends, colleagues, it really is a bigger economic challenge than just that. When you have other industries and businesses, whether it’s Jimmy John’s, Qdoba, McDonald’s, they’re going to charge you and I more for a hamburger or a sandwich. We don’t have that same luxury given that 50, 60, 70% of our reimbursement or our funding comes from the federal and/or state governments. So we don’t have that same type of luxury just to pass along those costs to those we serve. Luke, anything you’d like to add about how you invest in your team members?

Luke Wanous:

Yeah, absolutely. Thank you. I think we just want to go above and beyond to just create a culture of care and family within the Sioux Falls Center. We take our team out to the Canaries game and we go on bowling nights – those little things outside of the facility that really draws a family-like environment. We bought T-shirts for the entire team and the slogan on the T-shirt is the nursing home team. We don’t do average, we do awesome. And we really picked that because if you are dropping your family member off or your loved one at our facility, do you want average care or do you want just an awesome environment, awesome care, awesome people that care for your loved one? And that’s what we really strive for here at the Sioux Falls Center. We have the entire organization also behind us.

We recently had a big event at our facility where individuals from the National Campus, I think Nate, you were there for a little bit, that came and served our team for doing such a great job in providing excellent care for our residents. And I couldn’t feel more support from the National Campus and our entire organization. So I really appreciate that. But it really stems from that culture of family that Good Samaritan has.

Nate Schema:

I love that. And I think you feel that the minute you step into your building there, Luke, the culture, the hospitality, it’s first class. You know, that’s a great segue and I want to talk a little bit about resident well-being. I want to talk holistically about how we deliver an exceptional experience to our residents each and every time. And what those loved ones experience when they walk into your community.

Luke Wanous:

Yeah. So, the experience that they have when they walk into our community is a full on environment of servant leadership. The team really goes above and beyond for the residents being number one. I played football at Augustana University here in Sioux Falls and I reached out to my coach.

Nate Schema:

Well, “played” might be an overstretch but –

Luke Wanous:

I practiced a lot (laugh), I watched a lot of film pass ball calls on the sidelines. I was part of the team. And that’s the thing is servant leadership. Although you aren’t a starter, you still do everything that you could do for the success of your team. And so that just led me to go reach out to my coach, Coach Jerry Olszewski and ask for a number two jersey, which he graciously gave us. And so I have that hanging up in our facility. And just a symbolic reminder of the residents come first. We all are second. We’re number two; they’re number one. And it’s going above and beyond for the sake of others before yourself. And that’s what we really want to strive for at the Sioux Falls Center.

Nate Schema:

You Know what, Luke, I know you’re not a dad yet, but I feel like those dad jokes are going to be right in your wheelhouse someday with these T-shirt sayings.

Luke Wanous:

Yeah, you know, I’ve been told that before, (laugh) especially with my college roommates, I was kind of the dad of the group, so I get it. I get it. It’s a term of endearment for me, Nate (laugh).

Nate Schema:

Dana, I want to talk with you a little bit about innovation. What role do you see innovation playing in enhancing the resident experience?

Dana Bachmeier:

We are constantly seeking innovative ways to enhance the quality of life of our residents. I’ve seen firsthand how innovation and new ways of delivering care have impacted the experience of our residents in a very positive way.

A few examples we have at the Sioux Falls Village is our home hemodialysis in partner with Sanford Dialysis. We have a number of residents who are receiving dialysis services right down the hall from where they live. It’s seamless.

We also have a model of care that ensures care is coming to our facility. It isn’t always easy for our residents to go to appointments, therefore we have physicians in our facility almost every day seeing our residents, dental services coming to our facility and podiatry services. Most of these services are made possible by our Great Plains Medicare Advantage Program. So things like physician services are possible for facilities in Sioux Falls, but also those rural facilities like Miller and Tyndall and De Smet. It goes everywhere throughout the state. These services are truly a game changer in both urban and rural communities because our hot, humid summers, which we’re experiencing now, and our cold winters, it makes traveling difficult.

As I think about Sanford and Good Samaritan society, I think we excel in bringing quality care through innovation to not only Sioux Falls, but our rural communities as well.

Nate Schema:

It’s great that you bring up these innovative opportunities made possible by our partnership with Sanford Health. When we came together with Sanford in 2019 for this very purpose, it really was about how do we reimagine care? What does the integrated health care model really look like and how has it lived out? So it’s super exciting to see this vision come to life through your programs at the Sioux Falls Village. And here you describe the many ways that our residents are benefiting from all the ways that you’re serving there, here in Sioux Falls.

Luke, are there any other ways that you’ve seen our partnership simplify the health care experience for the residents and families you serve?

Luke Wanous:

Oh, absolutely. I think our partnership with you on the Sanford Health Network is just so vital for the overall resident experience. We have open communication and dialogue with the Sanford Medical Center weekly to go through what our residents need what their patient experience is like and how we can better improve as an overall structure and organization. And I really appreciate that partnership because it’s, like I said, the open dialogue is just vital for the overall experience for the residents and patients that we serve.

I’m glad that Dana was able to touch on our Great Plains Medicare Advantage plan. I think that the whole point of that is to provide as much care and service to the residents in-house as possible, to keep them in their home, to avoid the hospitalizations, provide additional services such as podiatry. So we have a podiatrist that comes into the facility and works on our residents’ feet monthly. We also have senior dental that comes out to our facility and works on our residents’ teeth cleaning. Those are some of the services that we can provide here in-house.

And really it just shows the overarching goal of Good Samaritan and Sanford is to treat the resident at their home and in the nursing home setting. And that’s what I really appreciate about the whole environment that we serve. And so, Nate, I think Dana and I have talked a lot today. So what excites you the most about the future?

Nate Schema:

It’s a little bit of everything that we’ve been talking about today. In some ways I reflect back on where we’ve been the last four years, and the whole pandemic threw a bit of a wrench in things. And in some ways it felt like we took a bit of a detour because we were on the path, we were doing all the things that we wanted to do as an integrated health system, and then we kind of had to throw that playbook out the window and rebuild the new COVID playbook.

So I think what’s been really fun and exciting for me to think about is, let’s get back and rebuild that foundation, get back to those innovations that first and foremost are best for our patients, our residents, and think about how we solve the workforce challenges that we talked about earlier, augment that with the virtual care technology, infuse that with new and exciting ways that we can deliver care.

So I think it’s all of it. I don’t know that there’s one single thing that I can say that’s going to be a game changer, but it’s the collective of being an integrated health system, seamlessly transitioning patients across that care continuum and really delivering health care at the right place and at the right time. The other thing that I would call out is, you know, as I sit down and talk to two young dynamic leaders, I can’t help but to be excited about the future of health care looks like. And I think it’s in great hands.

I think the foundation is still being written, and yet I am so confident that the future of our health care system, the future of our integrated health system, is going to be well taken care of with the talents of two leaders that I’m in front of here today. Luke, you might not have played a whole lot on the football field, but I am confident you are going to make an impact in this organization (laugh).

Dana Bachmeier:

I love that. Nate, what advice do you have for someone who’s loved one may need senior care?

Nate Schema:

When I think back to the reason why I got into this business to begin with, I can’t help but to bring up my four grandparents that were a part of my journey almost the entire way. Up until a year ago, I had all four of my grandparents. I remember growing up and going down the dusty gravel road in Grandpa’s blue Ford and him telling me to “get over, you’re going to drive” at 11 years old. I remember going to feed the cows. I remember going to the creek and catching those frogs and toads.

And so I think about what we do in a very personal way and how we do it. And so I think it’s just really important that we always remember why and the generation that we’re serving, and they really laid the foundation by which we’re able to enjoy all that we’ve come to enjoy here in the United States, and certainly here at the Good Samaritan Society for the past a hundred-plus years.

So, I think it goes beyond just meeting their physical needs. And I think that’s the special thing we’re able to do here at Sanford Health and the Good Samaritan Society. We’re able to meet all of their needs, their mind, body, and soul, and bring all of us to work. At Good Samaritan, our work is more than just a job; it’s a calling. So I’m really just excited about how we continue to build upon this integrated health system and imagine and reimagine what future looks like moving forward. Dana, Luke, thank you so much for joining me in this conversation. Thank you for everything you do for your team members and the residents that you serve.

Cassie Alvine (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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Virtual care becomes everyday practice

Alan Helgeson:

Hello, and welcome to the “Reimagining Rural Health” 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 virtual care and how Sanford Health clinicians are connecting with patients and making a difference. Our guests are Dr. Matthew Eggers and Bonnie Petersen, certified nurse practitioner. Our moderator is Dr. Luis Garcia, president of Sanford Clinic.

Dr. Luis Garcia (host):

Well, Matt and Bonnie, welcome. Thank you for agreeing to do this with me. This is an exciting topic. Sanford recently announced that we’re putting a significant investment in virtual care that has certainly elevated the visibility of many of the things that we were already doing in Sanford, and certainly there’s a lot of questions on what are we going to do with this into the future? So thank you for joining me in this conversation.

Matt, I’ll start with you. Virtual care is quote unquote “new” for some patients and perhaps some clinicians. But in Sanford, we have been doing it for a long time. Can you speak to us about what virtual care means?

Dr. Matthew Eggers (guest):

Sure. Thanks for having me. Virtual care, as it pertains to the service I’ve been involved with, reaching out to patients in rural locations using technology to improve access to high quality health care. This could mean seeing a provider over the computer at your local clinic, or visits at home through another device, a phone or a tablet.

As a psychiatrist, I evaluate mental health needs of patients and collaborate with primary care providers at these sites. It involves medication management and follow up, making referrals to outpatient therapy or locating community mental health resources, referrals to other specialties, collaborating with other clinic staff. The nice part about the system we’re using is we have access to several remote sites, and the messaging is instant. You can see who needs what. If a patient has a question about their medication or treatment, it’s instant access to that as well as collaborating with pharmacies.

Dr. Luis Garcia (host):

Thanks for that perspective, Matt. And it just elevates options for the patient in a non-face-to-face fashion so they can get their needs satisfied. And also, I think you mentioned the interaction between clinicians, right? And it’s not only about patient to clinician interaction, but also learning from each other and providing support to other clinicians. I mean, in your case, mental health is such a hot topic right now, and not everybody has the level of expertise that you have. And how do we help other clinicians to treat patients by utilizing this technology? So thank you for sharing those thoughts with us.

And Bonnie, I’ll ask you a question here about how has virtual care impacted your practice? You know, why did you choose to do it? We talked about how this is not new to Sanford. We’ve been doing it for a long time, but how do you take that leap of faith of this is the way I want to interact with my patients and it will be OK?

Bonnie Petersen (guest):

I think that really what interested me most about it was being able to provide another choice for our patients who maybe in a rural area to access the care at Sanford leap of faith for sure, because we didn’t know for sure what we were getting into, I don’t think. And how great of a service it could be for people.

Dr. Luis Garcia (host):

Yeah. So you do primary care, urgent care, correct? Urgent care in the rural setting?

Bonnie Petersen:

We do urgent care, and we cover the enterprise. It’s acute care providers from Sioux Falls that do the visits. Your patient might be someone in northern North Dakota or could also, really, you could be doing a virtual visit with a mom with a little one here in Sioux Falls too. It doesn’t necessarily always have to be rural, but that was really our main goal, is to reach those patients that don’t have that access. They often have a pharmacy in their town, but don’t have a provider so that we can bridge that gap for them.

Dr. Luis Garcia (host):

It’s interesting that you say that because in Sanford, we have said that we are the premier rural health care system in the nation, right? And 90% of the care that we provide is in the true rural setting. And being able to bring that best care possible to the doorstep is certainly one of the ways that we can achieve that. So thanks for everything that you do.

This is intriguing for me because we always think about how we as clinicians will adapt to the use of new technology. But Matt, talk to me a little bit about how patients actually have embraced the technology. You know, we talk a lot about the importance of the face-to-face interaction, and now we’re putting all these tools and gadgets between the clinician and a patient. How are patients embracing this?

Dr. Matthew Eggers:

We’ve had a lot of positive feedback from patients and their families as well as clinic staff. Not every patient is going to prefer seeing a provider over the computer or some other device at home, but for the most part, the feedback has been very positive and they appreciate having this service being available to them locally.

Dr. Luis Garcia (host):

Matt, and this question to you, again. A lot of people say, well, virtual care should not exist because a lot of the patients that we take care of are in their 60s, 70s, 80s, and they don’t have internet, or they don’t know how to use all these virtual modalities. Have you seen that? Or are patients really engaging regardless of their background and age and all that?

Dr. Matthew Eggers:

I think patients are very engaging. I think as long as you’re showing them that you’re listening to them and their needs and they feel that their needs are being met during a visit, they’re very engaging no matter the age. And also response time – if they need something in a timely fashion. The local clinics have been great to work with as far as that goes.

Dr. Luis Garcia (host):

You know, it’s interesting that you mentioned that. I just recently read some data from our own marketing department and in our own internal surveys, 80% of our patients actually prefer to have a virtual option when possible. So I think that data validates what you just said, Matt. But let me ask you, so we put, once again, a lot of emphasis on a productive relationship between a clinician and a patient to be face to face, and perhaps the use of these virtual care modalities would prevent us from having a good rapport or a good relationship with our patients. Can you talk to me about how do you engage your patients? How do you foster that relationship so the technology doesn’t get on the way and is as meaningful as a face-to-face interaction?

Bonnie Petersen:

I think that we engage with that patient through a virtual visit the same way that we do with that urgent care visit. We maybe don’t have that long-term primary provider relationship with them, but we tailor that visit to what are they looking for and how can we help them with that? And to have it be personal, we actually message them back through their MyChart to give them the opportunity to add anything to that. Or the video visits are especially easy to do that. You can still see that patient and they might be bouncing their little one on their knee or the cat might walk by or whatever, but it’s just engaging their whole family, I guess.

Dr. Luis Garcia (host):

So in your case are patients that you perhaps have not seen before and they request a last minute visit because they have something that is an urgent type of need. So I’m going to put you on the spot: as a surgeon, you know abdominal pain and we have to see the patient and we have to put our hands in the patient’s abdomen. How do you navigate those things virtually?

Bonnie Petersen:

Our nurses screen all of the requests that come in e-visit or video visit or Tyto Care for that matter. And if a request comes in for a visit for abdominal pain, our nurses will call that patient, get a little information from them, knowing full well that the final answers will be to them that you’ll need to be seen in person. Virtual care isn’t for everything and there’s no shame in saying, no, you need to be seen in person. You aren’t trying to handle their problem just because they’ve asked to do it this way. Sometimes they just want to know, should I go in for this or can it wait? But definitely it’s a certain group of chief complaints that you would treat virtually.

Dr. Luis Garcia (host):

Yeah, that’s, that’s really a good point, and I love your comment about there’s no shame on still asking the patient to take the next step if necessary. I think that as clinicians, we always want to do the right thing with the best of the knowledge that we have, and sometimes we just need to take the next step. So I appreciate that.

Matt, as clinicians, some have been really forthcoming with this and really want to do it, want to offer it. Our patients want it, and some others are a little bit hesitant for one reason or the other. What would you tell your colleagues as they try to embrace this model? Go for it, or pay attention to this, or what has worked for you or not? Help me a little bit about that.

Dr. Matthew Eggers:

Yeah, I would say go for it. It’s about reaching out and helping people in areas that otherwise wouldn’t normally have access to certain specialties. And I think as far as embracing these models, yeah, there will be some things out of your control. And working with as many sites as we do, not every site has the same capabilities. There are different staff availability, technology advantages or limitations. But I think it helps if you can be laid back and just work with staff and to troubleshoot any areas.

And the other thing I would say, doing what I do, is it’s a little bit different because I don’t have any direct interaction with staff colleagues or face-to-face with patients. When I was in med school in the late ‘90s, they had us complete the Myers-Briggs personality inventory, which I really gives you kind of a nice snapshot of your genetic personality, extroverts versus introverts. And I think if you are somebody who’s probably more extroverted and likes that interaction with staff and colleagues and gets energized by that, I think that’s probably going to be a little more difficult to do something like I am, just where everything is virtual. But all in all, I think it’s a really good service and a great way to reach out to patients in remote sites.

Dr. Luis Garcia (host):

Thank you to both of you. And I think you both highlighted the differences on the provider end, right? Sometimes you need to rely on your team to assess certain things before you even talk to the patient. In your case, Matt, a lot of that, you do it at on your own without need of staff. Some are patients that have a long-standing relationship with you, and the urgent care is quite the opposite. And on the back end, we are providing all that support for the visit, and that’s our responsibility as Sanford, right? But on the patient, we want to make it as simple and as fast as possible so the patient has a good experience.

So Bonnie, talk to me a little about that. I’m a patient, I want to see you, what do I need to do? Do I get on my phone and my computer?

Bonnie Petersen:

From the patient’s standpoint that visit is requested through their MyChart. So first of all, they have to have a MyChart account, but say you don’t, but you really are interested in still doing this visit, our nurses will walk you through that. And if you’re having trouble, they’ll say, see, you know, go down to the bottom there, see, push that, and whatever we can do to help them, because the IT side of it is the most frustrating for patients, being able to figure out how to make that connection.

And then you can only do so much if they’re in rural South Dakota and their internet access isn’t so great to begin with. That’ll be a struggle for both sides. But just to help that patient know that we can troubleshoot that with them. We’re not in a hurry. We can figure that out. Otherwise, it can be very frustrating if they feel like they’re having connection problems. I can hear you, can you hear me? And things like that. It’s not a satisfying experience for the patient at all. So I would think those are the main things really.

Related: Sanford Virtual Care opens first satellite clinic

Dr. Luis Garcia (host):

I tell you, I’ve never done a virtual visit myself, but I can see myself doing it in certain instances. And it’s just really nice that we offer those options for our patients. Speaking a little bit about the complexity, that even though this is advanced technological approaches to a human to human interaction, it does require a whole lot of infrastructure kind of behind the scenes. And Sanford has been committed now to provide that support for our clinicians of and our patients. And we recently announced this virtual care center that is going to coordinate a lot of the activities that are already happening.

But Matt, give me a sense of how many visits, do you know what Sanford has done? How do we transition from the last year into this new virtual center? A little bit of the philosophy behind that.

Dr. Matthew Eggers:

Virtual care is nothing new to Sanford. They’ve been at it since 2011. And I was kind of amazed when I looked at all the stats. We’re talking about 270,000-plus video visits, close to 80,000 verbal visits and 77 originating sites receiving telemed services. And I think they estimate that it’s saved 20 million miles of traveling. And as far as purpose and vision of the virtual care initiative, obviously to make high quality health care accessible through the use of technology and Sanford’s vision is to become known and nationally recognized for the virtual care services.

Dr. Luis Garcia (host):

You know, Matt, you mentioned the amount of miles, that we have saved our patients 20 million miles in the last year just on virtual visits. But I think a little bit more to the story, is that what that means for our patients. And I heard about a story where a lady for her standard routine prenatal care had to travel two, three hundred miles. And what it meant for her, where her husband was working, she needed to take not only days off of work to come to a visit, but find day care for her children, and the cost of having to travel those miles, and between gas and expenses and food and all that.

So what for us might be a simple 15, 20 minute visit for a patient could be a day changing activity. And this type of support certainly facilitates still that productive and quality interaction with our patients and taking a lot of burden off of our patients. So any of you share stories that you have heard where the patients are really appreciative or the clinicians are really appreciative of that interaction with other colleagues virtually?

Bonnie Petersen:

I think the first one that comes to mind for me, the toddler with conjunctivitis, they have pink eye. They can’t go back to day care. Mom’s got to load them up, go to the clinic however far away that is, sit in a waiting room and the child is exposed to germs that he didn’t have when he came in there just to get the eyedrops. We can talk to that patient over that (virtual) visit and handle something simple like that, tell them what to watch for, and screen the symptoms, make sure that is all it is. The patient has that visit done before they even go to work.

Dr. Luis Garcia:

One of the things that is pretty evident and clear for us nowadays is the lack of access to mental health clinicians. And in your case you’re in high demand right now and your patients absolutely need your services. So how has this virtual care facilitated improvement in access? Can you speak to that a little bit?

Dr. Matthew Eggers:

I started in late 2018 under a, I believe it was a HRSA grant. And the goal was obviously to grow the service and make it sustainable. First six months were a little slow and there were, there’s a lot of virtual meetings with providers to kind of let them know that, hey, this is available. Mental health services are here. A lot of the primary care providers, a lot of providers are comfortable in managing mental health medications to a certain degree. And basically just to get the word out there that this is available. It works. The technology is good, and we can meet patient needs. Feedback has been positive.

Dr. Luis Garcia (host):

We’ve been talking about the patient, right, and what it means for them and make it better for them. But one of the topics that continues to serve as for clinicians is the work-life balance and the burnout. Has the virtual strategy supported your work-life balance and your adaptability to work to have a better life? Can you give me some perspective of around that? And maybe I’ll start with you, Matt.

Dr. Matthew Eggers:

For one thing, less road time. I used to travel a lot to remote clinics in South Dakota and Iowa. So less road time means more time with family. And I would say also it’s important to take care of ourselves as providers. The first year I did this, I learned the hard way that you should get up and move around, take breaks, get your heart rate up. I ended up developing piriformis syndrome and was sort of limping around all summer, but I’ve recovered from that and I have a treadmill and an exercise bike at my office now, so I get up and take breaks. And also just nice to take a break from screen time, also give your eyes a rest.

Dr. Luis Garcia (host):

Unquestionably. Often we forget about taking care of ourselves as caregivers, right? Bonnie, what are your thoughts about that?

Bonnie Petersen:

I think early on it was quite a commitment from our providers. We weren’t quite busy enough to have a dedicated virtual care provider, so you were mixing that in with your regular patients going from just daytime hours to 24/7. And now we have enough virtual care appointments that we have an acute care provider, staff 24/7 just for that most days. And what it’s helped for me in my work-life balance is the opportunity to do a different type of patient care. Maybe I could do an overnight shift from home rather than in clinic it’s worked well. We’ve had young mothers who have been able to, I think, work longer through their pregnancy, because they were able to do a more sedentary virtual care than the in-clinic part of it. There’s many ways we can creatively now help give us that work-life balance.

Dr. Luis Garcia (host):

Well, Bonnie and Matt, you guys are pioneers in all this and you have really helped to shape up Sanford’s path into this future of health care and into providing the same quality of care through different methodologies to our patients. I just would like to ask you for any closing thoughts. This has been a phenomenal conversation and I think it highlights the importance of meeting our patients where they need to be met and facilitate in any way possible that interaction with their clinicians, but Bonnie, I’ll ask you first if you have any closing thoughts about this conversation on virtual care.

Bonnie Petersen:

In order to help our Sanford providers embrace the virtual world, we need to get them comfortable with it early on. That was probably one of our biggest frustrations was the technical side of it. It takes too long to do this, it’s just quicker to make them come in or whatever. If that provider’s comfortable with doing that kind of visit technically as well as through their health care, then it will be easier for them to adapt it into their practice. And we don’t see just everybody. That’s I think what providers worry about is that we’re out there telling people how to take their appendix out or something like that. We screen our patients carefully.

Dr. Luis Garcia (host):

Certainly the technological advances have allowed us to overcome some of the initial hesitancies. And of course now we’re dealing with our other things like reimbursement and policy around this. But in Sanford, we’re just committed to do it right. We’ll figure that out later. We need to provide a service to our patients. We’re committed to that. And then on the back end we work on whatever policy influence we might have to facilitate and solve that. But Matt, any closing thoughts?

Dr. Matthew Eggers:

I just want to say thanks to all the remote sites we’ve been working with. Everybody’s been working hard to make this service what it is, and I think it’s a great service and I’m excited to be part of this moving forward. And would also like to thank Casey Westphal, who has continued in a nursing role working with me, but she’s also had a virtual behavioral health strategy. Patients can reach out to her to schedule her if they have questions. And also like to thank Susan Berry for being part of this. She’s the vice president of operations of virtual care.

Dr. Luis Garcia (host):

Sanford, for very valid reasons, continues to be the most trusted health care system in our regions. And we have the commitment that we’re going to provide the best care for every patient that we touch. And it is because of people like you, Matt and Bonnie, that we are the most trusted system. Not only you bring your heart and your talent to work, but you’re always looking at how can you do it in different ways to meet patients where they need us to meet them. So thank you very much for everything you do. This has been a great conversation. I appreciate everything you do every day. Thank you.

Alan Helgeson:

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

Learn more about this topic

• Ep. 19: Start a mindfulness routine for mental health
• Ep. 16: Virtual clinic shortens distance to health care
• Sanford launches virtual behavioral health appointments

Get more episodes in this series

Virtual clinic shortens distance to health care

Kellie Wettstein:

I think that our small communities, sometimes if you don’t know a rural area, you think that we live out here in the sticks and we don’t have anything available. But we have all the things that you could want and need to live in our community without having to drive out of it.

Announcer:

“Reimagining Rural Health,” a podcast series 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.

Alan Helgeson (host):

The sign adorned by American flags reads, “Welcome to Lidgerwood, population 601” in the southeast corner of North Dakota, just 11 miles north of the South Dakota-North Dakota border.

Briana Spellerberg:

I love living and working in the southeast corner of North Dakota because I grew up here. This is my home.

Alan Helgeson (host):

For Briana Spellerberg, small towns are all she has known.

Briana Spellerberg:

I actually grew up in Milner, North Dakota. And so I grew up in this area. I grew up in Sargent County, and then I moved to over by Lidgerwood, and so I’ve always lived in a small community my whole life.

Alan Helgeson (host):

Briana’s work takes her to several communities. She’s the director of nursing for the Sargent County District Health Unit.

Briana Spellerberg:

One of the big programs that I do a lot of hands-on with is our immunization program. I have a team now that we work together to make sure that our whole community is vaccinated or up to date on vaccines and/or has access to vaccines. So we we’re trying to make it as accessible as possible.

Alan Helgeson (host):

Making health care accessible is part of Julie Falk’s everyday life. She owns Julie’s Pharmacy here in Lidgerwood.

Julie Falk:

I came from a big family. I wouldn’t want to spend it anywhere else besides in a small town. It gives them more opportunity to do things in a small high school. Our children doing things in a small high school gives you – you don’t just have to go out for basketball and focus on one sport. I love the volunteerism in a small town. That’s where I volunteer most is with all the community events.

Alan Helgeson (host):

In communities like Lidgerwood, having businesses like Julie Falk’s pharmacy, a grocery store and a clinic, they’re crucial to the town’s survival.

Brittany Jaehning:

Lidgerwood has had the clinic for quite some time.

Alan Helgeson (host):

Brittany Jaehning is the clinic director for several communities, including Lidgerwood.

Brittany Jaehning:

For the last handful of years. We are open Monday through Wednesday all day, so that’s 8 to 4 and then Thursday just until 1:30. So it really left them a gap Thursday afternoon and Friday.

Alan Helgeson (host):

For patients and families like Kellie Wettstein, having access to health care is deeply personal.

Kellie Wettstein:

We lost our son, Jonah, last September. He was three and a half. So Jonah was epileptic and he was later diagnosed with Dravet syndrome. We doctored and tried to figure a lot of things out, but with those pieces of Dravet, our local clinic came in huge.

We could just go into the clinic then, and he could have his blood draws done, urine samples, all that lab work done right in town. So you made my long commute out from home to town. That was huge for me to be able to get him up in the morning. We would just load up, go to the clinic in town, they would draw his blood, we could go back to work, daycare, our day-to-day type thing. And we were in and out of there again, probably in a half hour. I was so impressed through the whole journey of what we were able to do in town. And I know it was only a piece of the broader spectrum of the care that he needed.

It’s a lot less stressful when you just have to go into town versus, you know, we’re homebodies by nature. It comes from farming and working locally. We don’t go out of town often, so if we have to pack up and go to an appointment, I feel like it adds anxiety to our kids just right off the bat versus if we’re going to town, like we’re always in town. Jonah used to refer to the clinic as “tap, tap, poke,” but you know, it was in a loving context. Him and Jess, the lab tech, got along just fine.

There is a lot of peace of mind in walking in the clinic. They greet you by name, ask you how you’re doing, and you sit in the waiting room, probably with three other people that you know already. It eased a lot of anxiety on our end.

Alan Helgeson (host):

Susan Jarvis is the VP of operations for Sanford Health Fargo. For Susan, Kellie and her family are a prime example of why Sanford Health is expanding the ways people access care in rural America.

Susan Jarvis:

Within Sanford, we’ve been doing virtual care for, gosh, over a decade. So we provide services out to our rural emergency departments. We provide this virtual care where maybe a specialist is in Fargo and they see a patient virtually up in International Falls, Minnesota, or Jamestown, North Dakota, anywhere within our footprint.

Alan Helgeson (host):

In August 2022, Sanford Health broke ground on a state-of-the-art virtual care center, a 60,000-square-foot facility that will change the way care is delivered to rural America and to serve as a hub for a network of virtual clinics such as Lidgerwood. The $350 million project was made possible thanks to the support of visionary donor, T. Denny Sanford.

Susan Jarvis:

There’s the virtual care center that’s being constructed in Sioux Falls, but then there’s just virtual care really all over the Sanford footprint from some of our hubs like Fargo or Sioux Falls or Bismarck or Bemidji, out into our networks or from Sioux Falls out to other places. And so Lidgerwood is the very first virtual clinic out of this initiative, out of these dollars from Mr. Sanford. So it’s really exciting.

Alan Helgeson (host):

In Lidgerwood, residents have also relied on local community leaders to step up and offer solutions. For this community of 601 residents, that was the rural health board.

Kellie Wettstein:

So right now we are the Lidgerwood Hankinson Rural Health Clinic Board, and we are a 10-members board with five of the members being from the Hankinson community and five of the members from Lidgerwood. We own a facility in each town.

Brittany Jaehning:

If they were going to go from Lidgerwood to Wahpeton, it’d be about 45 miles. Say you’re going to go to Fargo, which was a lot of our specialty care and that type of thing, you’d be looking at closer to an hour and 15, an hour and 20 minutes for that commute. This might be the difference of seeking health care or not.

Alan Helgeson (host):

Connecting the dots in rural America is like putting together the pieces of a difficult puzzle. That’s where Sharlene Thompson comes into play. She’s part of Sanford’s virtual care team.

Sharlene Thompson:

Every community has a different need and has a different footprint and a different patient population and dynamics. So when we determine what our next satellite site or step forward is, it absolutely will look different than Lidgerwood, which is exciting because we are going to meet the community need versus just really a copy and paste.

Alan Helgeson (host):

Community nurses like Briana Spellerberg point to the future as the key to survival.

Briana Spellerberg:

This is going to change health care, and I think this is really going to be how, I mean, we’re going to see more of it. Medicine is forever changing, and so you have to be open to the new technology and as much as it might be like, “Oh, I don’t know if this is – this is new and I don’t know if I trust it,” but it’s like, “Give it a chance.” Like everything, you have to be ever changing and so nothing’s ever going to evolve if you don’t go with the world.

Alan Helgeson (host):

Pharmacy owner Julie Falk agrees.

Julie Falk:

I was like, “Oh wow, this is finally happening.” I was so excited, and like I said, we’ve done telepharmacy here for years and it’s worked out so well, and I’m excited to spread the word and send patients that way. I want my grandchildren to grow up here and so I can watch them grow up. My families are close. I think that helps and you have to support the whole network of your family working together, living together and having opportunities in a small town.

Alan Helgeson (host):

For both Kellie and Briana, offering telehealth in a small town is a perfect blend of old and new.

Kellie Wettstein:

It is possible to have all these services offered to a community of just a few hundred people with the right combination of people working together. And if you find the right organization that’s willing to work with you, a lot can happen with a little bit of work.

Briana Spellerberg:

I’m proud to call this area home. I have a lot of family here, I have a lot of friends here, and it’s just, everyone’s so friendly. Like today, I think everybody I passed on the highway waved at me. People are friendly. That’s why we stay.

Alan Helgeson (host):

For Sanford Health leaders, the Lidgerwood Virtual Care Clinic offers the perfect opportunity to live out the company’s mission, to provide outstanding care, no matter the ZIP code.

Sharlene Thompson:

We want to meet our community members where they are versus asking them to meet us where we are. That’s what virtual provides.

Susan Jarvis:

If you live in Lidgerwood, North Dakota, success means that the care that you need is available to you when you need it. The one thing I would want for people to take away from this is that Sanford really does care about delivering quality care as close to home as possible. And we invest resources in that, and time and energy, and think innovatively. We really want to serve the rural population that we serve, and we want to be the premier rural health care provider in the United States.

Learn more about this topic

• Virtual clinic expands in-person health care in rural ND
• How Sanford Health is growing the MN health care workforce
• Ep. 19: Start a mindfulness routine for mental health
• Ep. 16: Prep for baby, postpartum, and ‘fourth trimester’

Get more episodes in this series

Start a mindfulness routine for mental health

Alan Helgeson (host):

Hello and welcome. You’re listening to the “Health and Wellness” podcast, brought to you by Sanford Health. I’m your host, Alan Helgeson, with Sanford Health News, and our conversation today is about mindfulness, how to practice, and the importance of self-care.

Our guests today are Kayla Salathe and Amber Mutalipassi. Welcome and thank you for being with us, ladies. Happy to be here. Can you guys share a little bit of your background and your role at Sanford? So Amber, let’s start with you.

Amber Mutalipassi (guest):

I am an integrated health therapist. I work a lot with interns and do direct patient care within primary care.

Alan Helgeson (host):

Kayla, how about you? Tell us a little bit about your background and your time with Sanford.

Kayla Salathe:

I, too, am an integrated health therapist working in the primary care clinic, so I work directly with patients on mental and behavioral health concerns.

Alan Helgeson (host):

Well, we’re so glad that you guys could take time out of your busy day, and I’m guessing you see a lot of patients through the course of your day. But talking about mindfulness, it seems like one of those things that even now more than ever, we hear more and more about it and we all need more than ever. Right? So for someone new to this, explain what is mindfulness? So whoever wants to jump in and tell somebody who doesn’t really know anything about it?

Kayla Salathe:

So I would say my best description of mindfulness is that it is a state of mind. It’s a state of being. It’s not necessarily a particular set of actions or behaviors, but just a mindset that’s focused on the exact present moment. And it incorporates two distinct concepts. So it incorporates awareness and acceptance.

Alan Helgeson (host):

So I think like normal brain mode is that we’re always thinking the next thing. We’re always making plans, we’re always going, “Hey, what’s coming up?” You know, 6, 7, 8, 9 steps down the road. So with the mindfulness, it’s just maybe just stop and saying, “hold on, let’s think about where we’re at right now, and kind of take an inventory of that.” Is that some of what you’re saying, Kayla?

Kayla Salathe:

That’s exactly right. We tend to either live future tense, right? Worrying about everything we have upcoming that we have to do or in past tense, right? Ruminating on what has already happened and, oh, I wish I would’ve done that differently. So mindfulness is just about holding up on that and bringing it to just be in the moment and be aware of what’s going on and kind of just accepting it for what it is.

Alan Helgeson (host):

Is it odd Kayla that we have to, as humans, think about how do we just stop and take inventory of where we’re at right in this moment? Is it, it’s kind of weird that we have to do that, right?

Kayla Salathe:

Yes and no. Yes, in the sense that with humans being part of the animal kingdom, we are the only ones that have to stop and live in the present moment. Any other animal in the animal kingdom just does that naturally. But being humans, that’s one of the things that sets us apart, is we have that ability to think ahead or ruminate on the past.

Alan Helgeson (host):

Let’s talk a little bit about some of the stats regarding mental health and stress, and why this is placing such an importance on mindfulness.

Kayla Salathe:

Looking at the stats on mental health and stress, one of the ones that stands out is that more than one in five U.S. adults lives with a mental illness, likewise over one in five youth, which would be ages 13 to 18, either currently or at some point during their life have had a seriously debilitating mental illness. Stress is also the number one health concern of high school students, and nearly 30% of adults will be affected by anxiety disorders at some point in their life.

Alan Helgeson (host):

You’ve run through all these statistics here and the one thing is we’re seeing here, it’s not a specific demographic here, a specific age. I mean it’s humans and wondering, Amber, if maybe you can jump in and share a little bit more about the importance here of mindfulness and you know, as somebody that is telling people why it’s important, I’m guessing that you can speak to it from probably experience.

Amber Mutalipassi:

There are many times throughout my day when I feel overwhelmed, and you see that in patients and providers and everybody. And it’s good to just take a minute and remember to take that breath, be intentional with your thoughts for even just a few seconds. It’s important on various levels, including reducing your mental anguish and improving your physical health.

Research has shown actually that participating in mindfulness practices can increase gray matter in the brain, creating better results in learning, memory, education, empathy, it can foster compassion. It also increases your ability to focus and increases your relationship satisfaction. There’s just, there’s no downside to mindfulness, and disregarding it can really hinder your life. Stressors hinder your life improving. So it’s important in many aspects of life.

Alan Helgeson (host):

So Kayla and Amber, I’m going to be honest here, and I don’t know if this is too much information. But as human beings, we know often things that we should be doing, but we don’t take the time to do it. Is there maybe special training needed for a person to practice this? Is it something that I need to do differently or anybody needs to do differently to get involved in this?

Amber Mutalipassi:

I’d say that it is not necessary to have specific practice training in it. That being said, there are different activities that people would like to do that could require training. And so seeking out a professional in whatever that activity is would be beneficial to learn how to do it. I look at mindfulness even down to the point of you can be mindful when doing dishes. You can. No one likes to do dishes and if they do, that’s fine, but in my experience, not a lot of people like to do dishes.

But this example where you stand at the sink and thinking about doing dishes, what is the scent of the soap? What is the water temperature? How does it feel to hold that dish in your hand as you’re cleaning it? I wouldn’t recommend tasting the soap, but you know, using all five senses when being mindful is a good thing.

But basically you’re intentionally being present in that moment with that dish. It’s a very simple act and not something everyone thinks about doing. A lot of times when you’re doing dishes, it’s looking out the window (thinking) what do I have do tomorrow? What else do I have to do right now? Give me the list and there’s a kid over there bothering you, or whatever the case is. Taking that minute, even just do the dishes, it goes by real fast. And then you go, oh wait, I feel better. Cause I’ve just thought about nothing for a good 30 seconds except what I was doing.

Alan Helgeson (host):

I want to go back here a little bit before we get into maybe some more of the things about how to practice. You know, over the last three years, our world, our country, our communities, and all of us have been touched by the pandemic and with the things that we’ve faced here in work, in our personal lives, in so many ways. So signs and symptoms of stress and burnout that are touching everywhere. Let’s talk about some of those signs, and where we might see some of those things manifest, especially in your roles daily within clinic. Can you share some of those here for us?

Kayla Salathe:

So there is a difference between stress and burnout. I want to make sure that we cover that. First and foremost, stress is that everyday pressure to get things accomplished and to get things done. Burnout is that chronic, prolonged stress where the person experiencing the stress does not have the necessary coping tools to manage it. So just making that distinction right there.

And when talking about burnout, there are three dimensions that will help recognize it. Those are chronic exhaustion, chronic cynicism and inefficacy. So with chronic exhaustion, it’s that feeling of emptiness and being completely depleted. You just don’t have the energy to give to things, even things you know you need to get done. And this can present in different ways. It might be physical, emotional or mental. Sometimes it doesn’t have to present physically either, right? You might feel OK, you’re not tired, you don’t feel depleted, but yet you just don’t have anything to give when that time comes.

Second, we have that chronic cynicism or depersonalization is another word for it. And when your tank is empty, your tolerance for any and everything quickly dwindles, right? You may notice that you’re more easily annoyed or irritable, you start to lack compassion or patience, you tend to be, become more negative, have this negativity around you. You’re not as kind as you used to be. That’s a huge red flag that, “hey, I might be burning out here.”

And then third inefficacy. Now the definition of inefficacy is lack of power, capacity to produce the desired effect. So when you’re burnt out, you don’t perform at your best period. And as that performance starts to decrease, so does your confidence in care. So inefficacy, that’s going to be best marked by that sense of who cares, right? Like what’s the point?

Alan Helgeson (host):

You can engage with mindfulness at any point along that way and it can make a difference like starting now. Is that right?

Kayla Salathe:

Absolutely. So like we said, mindfulness is bringing that awareness to the present moment and what’s going on with you around you. And part of stress, especially stress leading to burnout, is you’re completely unaware, right? You’re just going through the motions of life and you get so wrapped up in trying to get through it. You’re not giving it that active intentional awareness to notice, and we go from being ourselves and being able to function well and having all these good qualities to dipping down into that negative pattern.

Alan Helgeson (host):

So we’ve talked about some of these things to recognize this. Let’s jump right back in again here, Amber. I know it’s not as simple as this, but I’m going to ask you the hard question of how to practice mindfulness.

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Amber Mutalipassi:

Being intentional with your thoughts, behaviors, and actions, all of that can help with bringing mindfulness into your day.

But I usually tell people the goal of mindfulness is to help regulate yourself to a point where you can not react to the situation, but to take it all in and be able to be present in that moment. Identify what it is you need to be doing and then moving forward how to practice it. There are so many different ways to practice mindfulness. It can be as simple as taking that 30 seconds to yourself, taking a breath and refocusing your thoughts on what is it you need to do right now to setting time aside and practicing that daily or every so often as you can, and remembering to engage with self-cares and different things that you can do for yourself to make sure that you can refocus and recenter yourself.

Alan Helgeson (host):

Doing it over and over and over again so that you can maybe build it into your life. Because the things that we do, we make time for what’s important to us, right? And if we want to be better at mindfulness, it’s doing it more often and finding time to work that in. So making it part of a regular routine you’re suggesting as well, correct?

Amber Mutalipassi:

Yes. With the intention of, I’m going to do this so often that it just becomes second nature and my body just falls into doing these mindfulness acts as the day progresses or as my mood progresses. Like if I catch myself heading down that slippery slope into stress and burnout, your body just automatically goes back to being mindful of what do I need to do to keep myself on track and healthy.

Alan Helgeson (host):

So Amber, I want to jump to the next question here. We’ve been talking about how to practice mindfulness. And this might be something that there’s some confusion around this, but is it the same as meditation? Are they one and the same or are they different?

Amber Mutalipassi:

They are completely different and can be similar (laugh). It’s not as cut and dry as we’d like, but you can have mindfulness without meditation. Meditation is a form of mindfulness.

Alan Helgeson (host):

Are there some specific tools or maybe there are some apps that you could recommend that could even be just helping us get started?

Kayla Salathe:

One of my favorite resources to recommend is freemindfulness.org, and they have a selection of free resources, and it has a whole array of guided mindfulness exercises that range from just a couple minutes all the way to an hour.

Alan Helgeson (host):

Kayla, what about some of the apps? We’ve heard about Headspace or we’ve heard about Calm, and there are a number of them out there, probably more than we can count. But what about some of those are, are those of value for people as well?

Kayla Salathe:

Whatever works for you for using that mindfulness, that’s what’s going to be beneficial. Mindfulness is very much a unique individualized experience. The way one person practices mindfulness is not going to be the same as the next. So if you’re finding that your best way of working it into your day and giving it that importance and time it deserves is through an app, wonderful. Do that. Right?

Most of us have our phones on us all day long so if that’s what’s going to make it easy to pull out the phone and pull up Calm or Headspace for a minute, or even just 30 seconds if that’s all I have, something’s better than nothing. There’s no wrong way to engage in mindfulness really, as long as you’re just going with the two concepts: What am I being aware of right now? What am I noticing? And then that acceptance.

And I do want a quick say on the part of acceptance is sometimes that gets confused with being OK with how things are, and that’s not it. Acceptance is simply allowing things to be as they are without judgment and without trying to change it. Now you might not be OK with it, but that part is just trying to let go of that. Is this good or bad? Do I like this or don’t like this? It’s simply what are you noticing and allowing it to be.

Alan Helgeson (host):

This next question, Amber, I’m going to pick on you. Probably the hardest question you’ve had all day. How do I know if this stuff is working for me?

Amber Mutalipassi:

You feel better (laugh) mentally.

Alan Helgeson (host):

Good answer.

Amber Mutalipassi:

Mentally and physically, you just feel more at ease. When challenges come your way, you’re able to lean into resilience. If you feel the world is coming apart around you, you are just able to continue moving forward. It’s not something that is easily measurable to you always. It’s really checking in with yourself and, “Hey, do I feel this is different? Yes, it, I see a lot of people come in or just even like myself. Other people will notice it about me before I notice it, right? So, hey, you’re seeming a lot more calm these days. Oh, thanks, that mindfulness is working. Wonderful.

Alan Helgeson (host):

Let’s shift a little bit here. I want to talk about something else. It seems like one of those in some ways if you don’t know too much about it, you hear it a lot as almost in a buzzword sort of a way. But we hear a lot about the word resilience and I’m wondering, Amber, if you can speak a little bit about it. What does that mean? Why are we hearing so much about it and how does that work into our discussion around mindfulness, meditation and some of the mental well-being?

Amber Mutalipassi:

It really has become more of a buzzword, but it is also very important to know what it is. As you’re looking at mindfulness, resilience, it’s been defined many ways throughout the years, seen as something that you are inherently born with, which is not true. It’s become more seen now as a process that you can learn.

There’s two main components: it’s preventative and corrective work. These concepts work together by warding off negative aspects in life through decreasing adversities and burnout, as well as increasing coping mechanisms to deal with intense or high stressful moments. A person who is able to face tribulation in their life and move forward in a mentally and physically healthy way, they have high resilience. So resiliency and self-care and mindfulness, they all go hand in hand and work together to build that healthy network within yourself moving forward.

Alan Helgeson (host):

We hear a lot about self-care. What is self-care?

Kayla Salathe:

Self-care is the act of attending to your personal needs to maintain your health and well-being. There are multiple different dimensions to self-care ranging from practical self-care such as hygiene, sleep, eating, as well as dimensions of emotional, psychological, spiritual, physical and social self-care. And kind of like the theme with everything else we’ve talked about today, this also has two main components that are necessary in achieving self-care, and those are rest and rejuvenation.

So I like to think of rest and rejuvenation in terms of unplugging and charging. So like we said, technology is all around us now. So think of any device you have, but maybe for now, we’ll just think of our phones. You may notice your battery is dying right on your phone and you need that battery to last a while, so you’re going to put it down, right? You’re not going to drain that battery any further. That’s unplugging, that’s essentially the same as rest.

On the other hand, you may notice that your battery is dying and go, oh man, I need to charge this. Like anybody have a charger, like I need to make this last. And so you plug it in to give it some more juice to be able to last longer and that charging is rejuvenation.

So bringing those ideas back to self-care, consider what activities are useful for you in order for you to get that rest you need. Get that break from your tasks and duties of daily life. And then also, which activities are going to recharge your batteries and energize you and give you that extra juice once you return to those tasks and duties.

There is this cliche out there, right? When you hear self-care, oh, that’s just relaxing in a bubble bath with a glass of wine at the end of the night, right? Like that tends to be the cliche people go to. And that may be the case for some of you out there and some of you’ll be like, that’s not restful to me, that’s not rejuvenating.

Alan Helgeson (host):

Let me just say I’m in for that. I think that’s a good way to do it.

Kayla Salathe:

Doesn’t sound too bad to me either. (Laugh) But yes, Amber and I have very different self-care. I’m sure your self-care is going to look different from ours as well. It’s helpful to get ideas from other people to know what they do in case you’re really stuck and wondering where do I start with self-care?

And then bringing that mindfulness back into it of, does this work for me? Am I noticing that this is taking care of my needs? Am I feeling rejuvenated? Am I feeling restful in this activity? Alright, let’s jot that down as something I can continue to do for self-care.

Alan Helgeson (host):

Can you guys maybe throw out a few ideas or examples of how a person can maybe put a plan in place? Or just how do I get started from zero to maybe putting one step forward to create a plan for mindfulness or self-care?

Amber Mutalipassi:

For mindfulness, if you are very new to it, I encourage learning grounding skills or techniques things to bring you back into that present moment. For self-care, I’d mentioned earlier with the interns and myself and everyone around me, I very much advocate creating a wellness plan, including activities in the areas of your life. So social, physical, emotional, spiritual, and leisure.

Identify what works now and what you want to do in the future for self-care. Address any barriers you have and create a list of emergency strategies for those high stress moments. Include your mindfulness techniques into your self-care as much as you can, and remember to revise it as needed. Our lives change all the time, so your self-care will need to change with you.

Kayla Salathe:

I’m going to jump in quick too and encourage people to start small. Yes, life is busy and when we think about throwing in all these other things that are helpful, right? But still it’s one more thing to add on to our day. Start small. If you’re new to mindfulness, you might only be able to do it a minute, and that’s all right. It’s building a skill. You’re not going to be able to sit down and do it for 45 minutes off the bat. So be kind to yourself and just take it in small steps.

Same with self-care. You’re not going to be able to implement a new routine with 10 different self-care items today. Start small, start with one and build upon that as it becomes part of your routine.

Alan Helgeson (host):

Absolutely. What should people do if there’s some mental health needs that you or a loved one might be experiencing here beyond what we’ve talked today about and how do they get started in addressing some of those wellness needs?

Amber Mutalipassi:

So first and foremost, if you find yourself in an emergent state of need, mentally or physically, call 911 or get yourself to the emergency room because that’s where you’re going to start.

That being said, if you are struggling with mental health, physical health, or both, reach out to your primary care provider. They can help you start the process of addressing your concerns and can help by referring you to trained mental health professionals. Most of our clinics have IHTs or what we are – integrated health therapists – in their clinic. And if they can’t see you for therapy, we can help connect you to places that can see you for therapy, whether that’s within Sanford or without.

We want everyone to feel supported in their mental health and know that there’s nothing wrong with asking for that help. And as we’ve been talking about, if you find that you can’t get the self-care or mindfulness going, that would be a perfect start too with primary care because you come in, you talk to us, we can give you some starters and some skills and touch base, and that way you’re not feeling alone in this because no one needs that.

Alan Helgeson (host):

Any last things? How do we maybe tie the knot on some of the things that we talked about or any things that you wanted to share?

Amber Mutalipassi:

If you can’t be serious in your mindfulness, laugh at yourself because that really cures a lot of things.

Kayla Salathe:

(Laugh) Yes, yes. Along that same note is you don’t have to be perfect at it, right? Like a lot of people don’t try something new because what if I’m not good at it? That’s going to be part of it. And part of mindfulness is I noticed this about myself when I started. Your mind’s going to wander.

You’re going to, you know, sit down for a minute of mindfulness saying, “I’m going to be in the present moment.” And suddenly you’re thinking about all the things you have to do that night and all the things you’ve already done. And that’s OK. That’s going to happen. Just be kind to yourself, bring it back to the present moment and focus on what you need and you’ll be just fine.

Alan Helgeson (host):

Well, Amber and Kayla, I want to thank you guys for taking time to talk to us today about mindfulness and well-being and mental health because we all need more of it in our lives. And it’s such an important thing in what we do as humans. And it’s been just a pleasure chatting with you.

So 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. I’m Alan Helgeson, and thank you for listening.

Learn more about this topic

• Where to start mental health care? Your doctor’s office
• Ep. 15: Protecting our mental health postpartum
• How to support someone struggling with their mental health

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How SDSU is preparing nurses for rural care

Alan Helgeson (moderator):

Hello, and welcome to the “Reimagining Rural Health” 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 education and collaborative partnerships in developing the next generation of nurses. Our guest is Dr. Mary Anne Krogh, dean of the College of Nursing at South Dakota State University. Our host is Erica DeBoer, Sanford Health chief nursing officer.

Erica DeBoer (host):

It’s my honor to welcome you today, Mary Anne. I wonder as we kick off the next session of our podcast about reimagining health care, do you mind just introducing yourself and a little bit about yourself?

Mary Anne Krogh (guest):

My name is Mary Anne Krogh. I’m the dean of the SDSU College of Nursing, and I have been at SDSU since July of 2019. So just finishing up my fourth year. And it is an awesome place to be. It’s really a great time to be educating nurses.

Erica DeBoer (host):

That’s awesome. Thanks for being here with me today. I know that I’ve had an opportunity to chat with several different folks around reimagining health care and really more importantly why we’re here today is that how do we train and prepare our next generation of nurses. So I wonder if I might just ask a couple questions of you. So from your perspective, what do today’s nurses need to be prepared that’s different from in the past?

Mary Anne Krogh:

Well, our health care environment has changed pretty tremendously. I’ve been a nurse since 1985, and it is, could not be more different (laugh) today than it was back then. You know, in the ‘80s, pretty minor surgeries, procedures, patients were hospitalized at least overnight.

Today, most of health care happens in the community. We just do not hospitalize patients the way we used to. And so nurses today have to understand that, be nimble, able to think about what the patient’s needs are when they leave the health care environment, navigate all the complexities of the patient’s home environment, how they might find resources in their community.

And I think about our rural communities and how do we help patients find their health care needs in rural environments? So nurses just really have to navigate the whole spectrum of the health care environment in ways that are completely different than they were 30 years ago.

Erica DeBoer (host):

Agreed. And you well know my passion for SDSU as my alma mater, and I had the opportunity to start my nursing career at Sanford right out of SDSU with my clinicals happening in lots of the spaces where I had the privilege to work after I got my degree. How do you think the process of training future nurses has changed since I was in school? I know when I look at even the college of nursing on the outside, it looks different on the inside. We have a lot more technical components that I see inside the walls, but I think the curriculum has had to probably adjust and change as well.

Mary Anne Krogh:

Yeah. So our curriculum is completely different than when you or I went to school. We right now have a concept based curriculum, which really means that we wrap our whole curriculum around different concepts, acute care, primary care. We no longer have separate coursework for OB or peds or –everything gets threaded around different concepts. So students really learn about nursing care from across the lifespan that way.

We also are really working toward competency-based education, and that will transform how we look at educating nurses and nursing students in a way that I think will transform health care. Because one, you know, one of the challenges about educating nurses is that health care providers expect that a nurse, no matter where they graduated from, will have a certain set of competencies. And so that’s the direction that we’re going with that. So that’s really exciting. So that’s the curricular piece of it.

The other piece that has changed pretty dramatically is that we use a lot of technology today in how we train nurses. When I trained, all of the clinical education happened at clinical environments, some in the community, but primarily at hospitals and health care agencies. Today, much of our nursing training happens in simulation centers, much more in the community. We use virtual reality. We use telepresence robots, lots of different technological ways that we can train nurses in safe environments. They’re not going to harm anybody. And it allows nurses to really practice over and over the same skills so that they can become experts in the skills that nurses need to provide that expert care that we’ve all come to expect.

Erica DeBoer (host):

That’s awesome. Tell me a little bit more about virtual reality and how you use that as part of your curriculum, because I think to your point COVID forced us out of the clinical spaces to the same extent that it did before. But what it has done, if I were to look on the silver lining side of this, is it’s forced us to really explore other ways to do our work, both virtually and in person. So I’m curious, tell me a little bit more about how you use virtual reality in what types of scenarios for your nursing students.

Mary Anne Krogh:

So virtual reality at SDSU College of Nursing is relatively new. We’ve just gotten the technology over the last year or so. So we’re starting it as makeup simulations and clinical experiences for students. The beauty of virtual reality is we can reprogram things so students can have a wide variety of experiences through that virtual reality experience. We can reach students across the state in virtual reality. We have virtual reality experiences no matter where our students train in Aberdeen, Rapid City, Brookings or Sioux Falls. So it provides that.

The other thing is that if we had a student who was perhaps at a rural site, they could put on the virtual reality goggles and get the same experience as a student in Brookings. And so it really provides a lot of flexibility and a nimble educational environment for students as well. I think the opportunities are endless in virtual reality.

Erica DeBoer (host):

I appreciate you sharing your sentiments specifically related to that rural setting. I know that your team has invested a lot based on a grant to really bring nursing students to a separate experience in some of our rural settings. So I really love the idea about virtual reality, how that contributes to some of that flexibility as well as giving our nursing students a glimpse into what is rural care and how do I actually care for patients across their entire longitudinal lifespan.

To your point before around the concepts, how do you feel like the virtual simulators, virtual reality, and some of these practice environments are gonna benefit our patients?

Mary Anne Krogh:

Well, the more variety that students experience when they’re in the educational environment, the better prepared they’ll be for the wide range of experiences they have as nurses. And really, I think that’s true whether a new nurse takes a job in an urban community or a rural community.

So let’s think about Sioux Falls, for example. You know, many of our students take positions at Sanford in the Sioux Falls hospital. In that environment, they’re caring for patients who might be from a rural community. And so they have to understand that rural community, the resources that are available, how do they access those resources all for the benefit of the patient. So we do have programming built right in for students to opt into some rural experiences, both in primary care and in acute care.

So often what happens is that the students select the primary care option and then where they go and they work in a rural clinic, and then they also have the opportunity to use their preceptorship in the acute care environment in that same community. I love that idea because the students see the entire health care system through that lens of both the acute and the primary care experiences. And become enmeshed in that community.

Erica DeBoer (host):

Yeah. It’s so important cuz that is an important part of what our communities need. And when we think about the state of South Dakota, the majority of it is rural and everyone knows everyone, right? So we’re all a big, huge family. So that rural setting is really important.

I think that that technology is also gonna continue to benefit our new nurses as they just gain some of those experiences that maybe in some cases they wouldn’t be able to get during a clinical experience, during a preceptorship or an internship. I’m curious though, when we think about technology, so I think about technology and some of the digital tools. We’ve talked about VR, we’ve talked about simulators and things like that. How do these tools allow our nurses to be better caregivers?

Mary Anne Krogh:

When I think about the use of technology, the first place I go is the amount of data that it gives the nurse and just more information to make decisions, guide treatment and really just take better care of the patient that’s right in front of them, the patient and their family. And so I don’t think of technology and AI as things that replace nurses. It’s more that it gives them more information and better ability to care for that patient at point of care.

Erica DeBoer (host):

Yeah, I like that, Mary Anne. I think the other thing that I think a lot about is in the high tech inpatient setting, but I think the important other component that maybe we haven’t highlighted today is those simulation areas are more than just about a code blue scenario. It’s more than just about medication and administration. What I’ve seen and experienced in those simulation centers is there’s curriculum built around what is it like for that nurse to have that conversation with the patient because these are tough conversations that they’re navigating as new employees in different health care settings.

And so it helps them navigate those palliative care scenarios, those hospice scenarios, and even some of the behavioral health scenarios that don’t require high tech, but at least you have an opportunity to practice. What is that like, what does it feel like? So you understand how to react in those scenarios. Again, not always to an emergent situation, but to those day-to-day social interactions that are so important for the patients that we care for.

Mary Anne Krogh:

Yeah. You know, a couple of the simulation experiences that we have at SDSU that I think really speak to what you just said is we have one simulation that’s all about grief. It helps the nurses to understand, how do you speak to people who are grieving? How do you help them navigate that? And it, that’s really an important thing.

You know, one thing I say all of the time to students and faculty is that every patient care encounter is a behavioral-mental health encounter because people are going through some real crises sometimes and nurses have to help them navigate that.

The other simulation that we have that I think really is transformational for students is a poverty simulation that we have where they really have to look and see what, you know, what are the social resources, the cultural resources, the challenges within the community about poverty. You know, how does a patient or a community member pay rent? How do they find food? You know, all of those hierarchy of needs things that we know people are navigating and then how does that impact their overall health? And how do we think about preventive care when really they’re just trying to get through every day – feed themselves, house themselves, those sorts of things.

Erica DeBoer (host):

I’m so glad that the college is taking some of that on cuz that’s a true reality, not only in our rural settings, but in our metro areas as well. I think we call it social determinants of health and how those things impact our communities. I think we both know that as we look at our communities in which we serve, there’s top five things that really get in the way or that are big priorities for our communities and transportation, finances, housing, are three of those big things. The fourth that comes to mind is really food insecurities.

And so helping our nursing students understand that and have them be prepared for that is incredibly important just because when you think about the communities in which they live and some of those other spaces, there are resources that can help you have to know how to first gain that relationship and trust with that patient.

But then more importantly, how do you connect them with the resources that are gonna be adequately available to them so that they can meet some of those needs so they can take care of their health care issues as well? So love that that’s one of the simulations that help us really bring that reality to the forefront in management of our patients that we’re caring for today.

One last question for you, and then I promise I’ll let you ask me some questions as well. Why do you find that students are deciding to pursue a career in nursing? And maybe a secondary question, how did COVID change these motivators?

Mary Anne Krogh:

So I think what I hear from nursing students often is that they came to nursing because they had an experience with nursing. So either they or a family member had a health care need. And the tremendous impact that nurses made on the outcome for that family member, whether it was an end of life issue or it was, you know, a surgery or some recovery. And that’s what I hear over and over from students is that they’ve seen firsthand the tremendous impact that they’ve had.

Probably the secondary reason I hear from students is that they have a family member who is a nurse. And they just really respect and care about what they do on a day-to-day basis as a nurse. COVID I would say created some challenges initially, and during COVID we really saw an uptick in interest for nursing and I think people really saw the value of nursing and how it’s essential to care for patients in crisis. And COVID certainly was that crisis for our country I think. You know, really trying to make sure that everybody is healthy and recovering from those things.

Erica DeBoer (host):

That call to care, right? (Yes.) So we almost called it the Florence Nightingale effect that really they wanted to be able to make that difference. So we know that you at SDSU have been working hard to really expand some of the seats cuz I think we both know some of the workforce challenges that we have and it’s really basically a compression between the retirement of the baby boomers and just not having enough humans in the United States to necessarily fill all those chairs.

Now I know that enrollment’s been strong, and I know that you’ve got some very engaged nursing students that will be coming. I have the opportunity to connect with many of them on a regular basis. So we appreciate your willingness to partner with us and really look at how do we do our work differently? How do we partner differently so that we can meet the needs of South Dakota and the Midwest? So Mary Anne, I will stop asking questions for a little while and I’ll see if you have any questions that you’d like to pose to me.

Mary Anne Krogh:

So Erica, I know that you work pretty regularly with brand new grads from the various nursing programs across South Dakota and the area since Sanford has a big footprint. So what do you think are the biggest challenges nurses face in the early parts of their career?

Erica DeBoer (host):

That’s a great question. I think I would boil it down to probably two specific things. One in some cases, depending on their clinical experience, and I think that was very true during COVID that really that clinical experience wasn’t exactly what they pictured it to be. So I feel like really the reality of that, if they can get through that first year, year and a half, I want them to love the nursing profession like I do.

But it is a challenging environment. We’ve got a lot of workplace violence. We’ve got a lot of other challenging dynamics with the moral distress that our teams are dealing with. So in all actuality, how do we create that environment for our nursing students and our brand new nurses to make sure that they understand that call to care and how they can contribute? So that’s one.

The other thing that nurses face really early in their career is in some cases they don’t even realize the amazing possibilities that nursing really brings, in some cases, in this instant gratification world that we live in. Sometimes giving themselves a little bit of time to get used to the space that they’re in or find that niche that they love so that they can contribute and really build on that experience that they’ve had makes all the difference in the world. So in all actuality, our responsibility as an organization is to make sure that we create that safe and reliable environment. But more importantly, how do we prepare our teams and that culture to really embrace the brilliance that come from our new eyes that come into our facilities to help us really solve the challenges of the future?

Mary Anne Krogh:

You can do a lot of things with a nursing degree and that I think is really one of the beauties of being a nurse. It can take you a lot of different places that you maybe don’t even imagine when you’re a new nurse. So how is Sanford Health working to support these new nurses and help them grow and stay in nursing and find their passion?

Erica DeBoer (host):

That’s a really great question and it’s something that I think challenges us all the time is how do we maintain that motivation? How do we maintain that interaction? How do we make sure that they understand what a positive contributor they can be to the practice of nursing? There’s several different ways that I feel like Sanford really emulates that is through some of our well-being resources.

We also have a nursing residency program that really helps them guide through that first year, year and a half of their program.

I think the opportunity that nursing students as well as those brand new nurses have is to get involved and get engaged. We’ve got unit-based counsels both in the inpatient and the ambulatory setting so they can contribute and use their voice. And that’s what I ask all of them is sometimes we get blinded by what we think is the right answer cuz we’ve been doing it always that way. So I really appreciate their voice to help support how it is.

I think the other thing that I would say if I were to bring a bubble up, the third point is that we have worked really hard on retaining those wise individuals that have been with the organization for a long time. That wisdom is really important to help our brand new staff understand the best way to care for really complex patients.

As you mentioned before, I think maybe the fourth thing that I would suggest is that it’s really our commitment at Sanford to make sure that we continue to build that safe environment and make sure that they have the resources available, not just through technology, but it’s a hands-on profession. So how do I make sure that our nurses can function at the top of their license and they have the support teams around them so that they can be the best that they possibly can?

Mary Anne Krogh:

So we’ve talked earlier about how education has changed and how we have to think about training nurses differently, but how has nursing itself changed since you entered?

Erica DeBoer (host):

Fantastic question. I think the most important change that I share with people often is if when I graduated from college I was super scared I wasn’t gonna find a job because although there’s a lot of openings now, when I actually started at Sanford on the pulmonary unit, there was six of us that graduated all at the same time and only one position that was open on pulmonary. So fortunately I was the one that was able to be blessed with that position and start my career on the pulmonary unit where I did my residency.

But that’s probably one of the biggest differences is that we had the opportunity to really have a lot of longevity and I’ll commit to you that teamwork that I experienced was really incredible and still to this day my preceptor still works on the pulmonary unit and so when I go to visit, it’s always fun to see Kay on the unit.

I think the other thing that’s changed quite a bit as it relates to what’s different is the amount of technology that we have. And I think many people know this about me, but I love technology and how it contributes to high reliability and how do I help my staff do the right thing? But on the same token, some of that technology has taken away or created a barrier to a certain extent that relationship that you can have with your patient. And so I think that’s the other thing that’s changed a lot. Obviously with my background in ICU, I love technology, I love data cuz it helps to contribute to the problem solving that we can create.

The third maybe that I might suggest is that there is a demand for better work-life balance, which is a little bit different than when I was growing up in the nursing profession. And I respect and really want to lift up the teams that really put that on the forefront for that work-life balance. So it’s really up to us at Sanford and our communities to figure out the best way to support them. So one of the ways that we do that is really making sure that not only we have good retention strategies, but we recruit and are bringing in internationally educated nurses to continue to build really our workforce to help support the patient care we wanna deliver.

Mary Anne Krogh:

So Erica, you’ve been very successful in your profession and you’re a strong leader here at Sanford. How do you support nurses toward leadership within your institution?

Erica DeBoer (host):

Ooh, I like that question too. So I think you well know, Mary Anne, I seek mentorship from a host of different people, you being one of those. But I try to serve as a mentor to many others as well. So if there’s someone that’s seeking advice or insights, I’d commit a lot of time to really mentoring those new leaders and even new nurses in different programs or even informal ways.

I think some of the other ways that Sanford’s invested in really building leadership skills is through a couple different programs. One is the Becky Nelson fellow program. And the Becky Nelson Fellowship Program is really an opportunity for a rising star, a director or above that shows great promise to have a yearlong experience as an executive. So 20% of their time is actually spent attending meetings, going to annual meetings and having unique experiences as an executive within the nursing realm, which is a really fun, really, really fun scenario that we’ve built here.

I’d say the other differentiator at Sanford as it relates to leadership is the opportunity to connect with our World Clinics. Our World Clinic Mentorship Program was a program that we started last year. We just actually announced two of our new World Clinic Mentorship Programs, our new awardees, excuse me, who will be joining and helping with a project in both Ghana and then the other in Costa Rica. So some opportunities to really not only contribute locally, but also how do you contribute around the world?

Again, this isn’t just about nursing. We’ve got clinical teammates and support services teams all across our enterprise and we have a host of different ways that we try to mentor and lead folks through different journeys and pathways to continue to advance their career. We do that through online learning, but we also have a program called Sanford Leader, which basically builds somewhat of an academy around what are those gaps, what are those blind spots so that we can guide you on that journey and what does it look like to be a leader?

And it, again, it doesn’t have to be in title. It means you can be a leader at the bedside, you can be the CEO of your patient care that day no matter what environment you’re in. Cuz I tell you, in the rural care setting, they’re small teams and they really do take care of a lot in those spaces. I’d say even in our post-acute settings, when you think about caring for people in the space where they live, what a valuable asset our teams are and growing and learning from all those folks, no matter where they are on their life’s journey.

Mary Anne Krogh:

Say we had a nursing student who was looking for a job and where they might start their career as they graduate. What would you say Sanford brings to a new graduate that they should consider?

Erica DeBoer (host):

Great question. I’d say that Sanford has the opportunity to really differentiate in the opportunities that they have. Obviously there’s many nursing residency programs, but our lead team has taken our residency program really to the next level to really help them understand how to become a professional nurse, how to really embed themselves in the community of nursing that we have here.

Additionally, I think the amount of different experiences and different opportunities they would have, not only just in Sioux Falls but across our entire footprint, just like we talked about, the possibilities are truly endless as it relates to what are your goals and what do you hope to accomplish. We’ve got awesome teams that really help to create those pathways for our nursing staff to make sure that they can find a space where they can use their talents the way they want to.

Mary Anne Krogh:

You and your family were donors for our virtual simulator at SDSU. Can you just talk about your motivation for helping to fund that project?

Erica DeBoer (host):

Philanthropy is a really important part of how I live. I think my husband and I really are very fortunate in a host of different ways. And so in many ways us being able to donate to the simulation center at SDSU is just another important way for us to give back. I’ve always been really passionate about technology, as I mentioned, and I can recall taking courses about the importance that simulation plays in people learning and being able to respond in those code situations and things like that. So one, it was our, my responsibility to give back.

But more importantly, when you think about when our gift was completed, it was right during COVID, and simulation became a huge part of how our nursing students were prepared. And in all actuality, that’s the way it’s gonna continue to be. So now how do we transform that? I love that we’ve moved to virtual reality and some of those pieces. It’s these pieces of technology that are only gonna help us be able to respond to patients’ needs more effectively. And of course I love SDSU and my Jackrabbits, and so the motivation is really how do you continue to advance the science and the art of nursing? And simulation is an important way that I feel like we can do that.

Mary Anne Krogh:

Well I, for one, I’m grateful that you’re friends of SDSU nursing and I appreciate all you do for us and our partnership with Sanford as a clinical partner. It’s really been a strong partnership and I appreciate that.

Erica DeBoer (host):

Yeah, we appreciate all that SDSU does. I actually just had the privilege to be at pinning ceremony this last Friday. One of our senior nursing students, I had the privilege to mentor and she received a multitude of different awards at the pinning ceremony. So it was a great reminder for me about where we start and then where the possibilities could take us. So appreciate SDSU partnership, the advocacy of how we can do our work a little bit differently. How do we prepare our nursing students. So I really appreciate you being here with us today, Mary Anne. And I look forward to seeing you and talking with you again soon.

Mary Anne Krogh:

Thank you very much, Erica.

Alan Helgeson (moderator):

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.

Learn more about this topic

• Ep. 7: Flexible work and well-being in rural health care
• Nurse residency program supports nurses in their first year
• Medical center and clinics achieve 5th Magnet recognition

Get more episodes in this series

Sanford’s journey to zero preventable harm

Alan Helgeson (moderator):

Hello, and welcome to the “Reimagining Rural Health” 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 unique communities they serve.

Today’s topic is a conversation on safety and quality measures – at the core, providing patient care. Our guest is Dr. Jeremy Cauwels, Sanford Health chief physician. Our host is Dr. Luis Garcia, president, Sanford Clinic.

Dr. Luis Garcia (host):

Well, safe and quality as a foundation principle in our everyday activities. Jeremy welcome to this podcast. It’s great to have time to speak to you about such an important topic. How are you doing today?

Dr. Jeremy Cauwels (guest):

I’m wonderful. Thanks for having me.

Dr. Luis Garcia:

Well, thank you, Jeremy. I’m just going to get right into the purpose of this topic. We all talk about quality, and we all talk about being a highly reliable organization, but I got to admit that not everybody gets there and it’s always a work in progress. But tell me a little bit about a physician that just joined the organization, sees everywhere, “safe, safe, safe,” and those that have been here for a long time have seen the transition into this safe thing. What is safe?

Dr. Jeremy Cauwels:

Sure. So SAFE is our acronym. It stands for Sanford’s Accountability For Excellence. If you’re looking for a framework for it outside of Sanford, you would look up words like high reliability organizations. What it really means is that SAFE for us is our individual accountability as people for the things that go on in your work every day that you have direct influence over, and that you can allow or encourage to make better depending on your actions.

And so, as we work on SAFE, the basic principles are as basic as tying your shoes. They’re things like making sure you check your work to make sure you did it right. Making sure you’re engaging people appropriately and making sure that as you’re going through, you’re encouraging the people around you to maintain that same level of culture and ability. The goal really is to say, we’re going to treat other people like we want to be treated.

We’re going to do the things that we promise we’re going to do. And what I mean by that is surgeries and treatments, diseases, and that sort of thing. And we’re not going to do those things which would be unexpected. So our goal is to make sure that every person on the teams are actively engaged in preventing things like negative outcomes or bad experiences. And we can do those things in large part due to the diligence and the intelligence of all of the people that we work with on a day-to-day basis.

And so, using those teams, using a few of those simple skills – one of them we use is called STAR. So we stop, think about what we’re doing, make the action we need to, and then review it. So we actually look back at the things we just did to say, what does it take to check up on this and make sure I did the right thing?

Now the good news is that when we do that, I’m inaccurate probably to the order of 1 out of a thousand times or between 1 out of 1,000, 1 out of a hundred. If you put two of us together and we’re checking each other, we get to 1 out of 10,000 times and our error rate drops down to vanishingly low, which is really our goal every time we work together anyway, is that you and I want to complement each other on a way that makes us better.

Dr. Luis Garcia:

Yeah, and thank you for that last comment, Jeremy. Because I was going to ask you why this work? Because if you think about it, we get into health care and whether you’re a physician or a nurse or a health care provider in any sense, you always want the best outcomes. You always want to be that kind person to the people in need to our patients, to our colleagues. And we always try to work in that environment of collegiality, right?

So what was happening that you felt or Sanford felt that we needed to take a look deeper into it? Because inherently you would assume that everybody’s doing a great job in health care, right? Well, was that not happening?

Dr. Jeremy Cauwels:

I think it’s important to recognize the difference between everybody wanting to do a great job and the systems you can put in place to ensure that everybody is doing a great job.

What I can tell you is that at Sanford, every day we do deliver top-notch medical care. And we do a wonderful job of making sure that the people that we see and that we take care of really appreciate the work that we do.

But that being said, I think we all know the old phrase “two heads are better than one.” And what that means is that if I’m actively engaged in making sure that I deliver for the patient that I’m taking care of, and you’re actively engaged for delivering on the patient that you’re taking care of, we can do the job together and magnify that level of intentionality, that level of thoughtful scrutiny that allows us to do a better job with each patient every day because we’re part of a team.

Because every member of the team knows that not only can they intervene, but they should intervene. And that intervention helps all of us deliver care in a way that is less prone to error and more meaningful to the patient because all of us are actively engaged.

Dr. Luis Garcia:

Yeah, thanks Jeremy. And I agree with you. I think that we all should be very proud here in Sanford of the top-notch work that we do. I mean, we’re leading across the nation and it’s all because of all our physicians, nurses, front-line providers. And so our gratitude to them, particularly in the last couple of years that have been very difficult for them.

But you mentioned a team, right? And I want to ask you this question. You have 50,000 employees in Sanford, you know – 8,000 nurses, 3,000 clinicians. How do you go about engaging that amount of people in this kind of work to obtain better outcomes?

Dr. Jeremy Cauwels:

I think first and foremost, it’s about reminding people that they got into health care to make a difference. Whether you’re the one of our folks that cleans our floors, or whether you’re the person that’s actually going to be doing surgery on somebody’s brain. We all got into health care when we could have went and worked somewhere else because we thought that we could truly make a difference in people’s lives.

And I think the most important part about SAFE is that it reminds people of the possibility that when you go to work today, you’re going to intervene in a way that makes somebody’s life either better or longer, or both. And so as we do that, I think it’s extremely important for us to deliver on that promise. And the most important way to deliver on that promise is to make sure that each member of the Sanford family, all 50,000 of them, are empowered to, if they see something, say something. If they need to reach out and say, I have a concern, that we’ve built the culture all around them to address that concern before we move on.

Dr. Luis Garcia:

Thank you for that thought, Jeremy. So you talk about the importance of anybody, regardless of your ranking, regardless of your title, to speak for safety and to speak for preventing potential errors. And I think we all have seen the last five years and the journey that Sanford has undertaken with this SAFE approach, and it’s ingrained in our hearts and it’s part of our culture and we’re so proud of it.

Can you share of some of those results? Because there’s that example of, there was a neurosurgeon in the operating room that perhaps listened to a nurse that raised the concern, and because of that we had a great patient outcome. But can you share some of those results that you have seen, “Wow, this is truly making a difference.”

Dr. Jeremy Cauwels:

So what we call those in our world is SAFE stories. They are the stories that tell us just a little bit about what making a difference or what intervening really matters and how it really matters. One of my favorite stories was one of our brain and spine surgeons who was getting ready to do a case. And while he was going through the timeout, talked to the rest of the team in the room, and one of the team members actually raised their hand and said, you know, I’m not sure if this was the spot that we were supposed to be doing this surgery, and I’d like to review it before we move further.

What we call that in Sanford is having a concern and raising a concern. I am happy to say that that concern turned into a short deviation in the timeout where the surgeon and that person in the operating room reviewed the case, realized that they had indeed marked the wrong spot for where they were going to go and proceeded to correct that and do it in a very real way.

Obviously it prevented an error with the patient, prevented something potentially devastating if you’re involved in it from a health care standpoint, because like all of us, nobody wants to be engaged or involved in a mistake. And so if you can find it on the front end and raise that concern beforehand, you can turn the story in a completely different direction.

One of my other favorite stories is actually involving our AirMed pilots and mechanic teams. One of our mechanics recently was working on one of our helicopters and in that helicopter, he was inspecting the very back of the of the helicopter in the tail and found a really small crack in the paint. Now normally a crack in the paint is something you go get it painted over and you don’t worry about it. But this person wanted to look a little closer.

And so, using the skill we call attention to detail, managed to take apart that back portion of the plane, realized that that wasn’t just a crack in the paint, but that crack extended all the way from the tail all the way forward through that entire long tail piece of a helicopter. And we actually had to take the helicopter out of commission and drive that part to the repair facility in Texas and drive it all the way back just to repair it. But that crack wouldn’t have been found had it not been for the attention to detail of that airplane and helicopter mechanic in our air ambulance crew.

Dr. Luis Garcia:

Talking about preventing errors and saving lives in a different way. Right?

Dr. Jeremy Cauwels:

Absolutely.

Dr. Luis Garcia:

I mean, whether you’re in the operating suite or in the front-line or you’re flying helicopters, you are creating a safer place to work and saving lives, right? So that’s a great story.

And you know many other stories, Jeremy. I remember that one story where somebody called in to get an appointment to see their physician and the registrar asked some questions and noted something different with the patient, gave him the appointment. The appointment was for the following week. And further inquiring from the registrar she continued to notice something different. This turns out to be a patient that was actually thinking about committing suicide and needed immediate help. Had it not been for her attention to detail and listening with the intent to help, that patient would not be with us today.

So, once again, it just speaks to the fact that no matter what your ranking is in this organization, no matter what your title is, we all are important, right?

From the environmental services people that help us to all the way to whichever direction you want to take it. We are all important. So thank you for that.

So Jeremy, these are safety stories and I’m sure there’s a plethora of them that you can talk and we could spend here hours. But how do these individual safety stories start translating into trends, cultural trends and outcome trends? And once again, we’ve been five, six years in this journey. Can you speak about some of those trends, those bigger picture findings that you can share with us?

Dr. Jeremy Cauwels:

Certainly. I think one of the things that we talk about on a regular basis is what we call power distance. And power distance really is that space that exists in your head between me as a worker and the person that I have to report something or raise that concern to. And one of the things that’s important about telling these stories and about being receptive when people have a concern, is that that distance can get lowered. And whether that’s because, you know, you’re brand new in the operating room and you’re talking to an orthopedic surgeon who’s been around for 40 years, or whether it’s because you are a new nurse and you’re talking to a nurse that’s been around the floors for 30 years, that power distance isn’t necessarily a physical distance. It doesn’t even have to be a difference in career or degree.

It’s just that ability to make sure that everybody is engaged and everybody is encouraged to speak up when they find something that’s concerning. And so for us, as we talk about that, what we get into is we can actually monitor those safety events. We can monitor and put numbers to how many times out of 10,000 patient days we actually have a serious safety event. And I am very happy to say, as we’ve went down through this journey, we have reduced our number of serious safety events so far by over 50%. And that turns out to be a number that ranks up there in the hundreds of people. And our goal, of course, is to reduce it more than 80%.

Dr. Luis Garcia:

And also that’s in the middle of a pandemic where we were dealing with workforce shortages, where we were dealing with supply chain issues, where there was a lot of instability in the clinical field. And yet our teams, despite all those challenges, happened to reduce that number by a significant amount. Isn’t that impressive?

Dr. Jeremy Cauwels:

It is remarkable. If you look around the country in the same set of circumstances that we were in, what you would find is that many, many hospitals unfortunately didn’t have that same encouragement, didn’t have that same timing to be rolling out high reliability during the pandemic. And they did actually see an increase in hospital acquired conditions and infections while we saw a 60% decrease. So for us, it very much was changing the culture at a time when culture would be the most difficult thing to maintain and the most difficult thing to keep going in a good direction.

Because as you all know, the difficulty with keeping our patients safe while the pandemic was going on, while we were having nursing shortages, while we were all trying to figure out how to wear masks and when to wear masks and when to get our vaccine and all of those things, were the exact things that we leaned into and said, this is how we keep our patients safe and this is how we keep our coworkers safe and we want to make sure we continue to do that.

Dr. Luis Garcia:

And of course, Jeremy, you’re too humble. You always are, and you’re not going to be bragging about the tremendous work that you lead. But I really want you to brag in this conversation about the tremendous work that you do. And I hear that one of our markets right now has gone six months without a surgical site infection and another of our markets had over two years without a CLABSI (central line-associated bloodstream infection). And then you see our hospital start rating continuously go up. I want you to talk about that and what it means for the teams in each one of the markets and your team that is leading all these efforts. These are times where just watching these outcomes is just something to celebrate.

Dr. Jeremy Cauwels:

When we started SAFE, we estimated that our error rate would put us at somewhere around an adverse event more often than every single day in Sanford Health. If you looked at us for a system, I am happy to say that so far we’re pushing to towards two days between an event anywhere in the system. And our goal is obviously to push towards zero. I’ve often said somewhat with a smile that I believe that the best day in Sanford Health is when we can deliver on a day where nobody had a medical error occur at any point during their care.

My honest goal is that we can go a month, that we can go a year, that at some point we get good enough at this, reliable enough at this and that we trust each other enough while we do this, that we can prevent all the errors in health care.

Now you may tell me that’s a pipe dream and I’m OK with that, but it has to be the aspiration of every member of Sanford that only in the paint pool that they took care of that day, they did everything they could to be as close to perfect as a human can and that the person that worked on their left and their right was helping them achieve that level of perfection that allows us to walk home and say, you know what? We did the best we could for every patient we had all day today. And that is truly the goal each time we step in.

Dr. Luis Garcia:

Hey, I’ll buy into that aspiration any day, Jeremy, and kudos once again to you and your team for what you’ve been able to achieve in these last five, six years since SAFE started. So, so let me just ask you something. Why does this continue to be important for us? We onboard 150 clinicians every year and we employ many hundreds more nurses every year. Why does this continue to be important? What would you tell a new clinician that is just joining our forces?

Dr. Jeremy Cauwels:

What I would tell a new clinician is something they already know, even on their best day, they’re not quite perfect. And if they’re not quite perfect, what a better way to come to work than to know the person on your left and the person on your right are there to help you be as close to perfect as you can and that you all have the same goal. And when everybody aligns on that goal that we’re going to deliver absolutely exemplary care, then we can honestly say that if somebody stops me from doing something, they were stopping me from doing something because they had a concern. And that concern was not only for the patient in the bed, but it was for me as a doctor as well. Because I think we all know that we beat ourselves up when we find out something didn’t go as well as it could have.

And it helps prevent those days as well. It helps prevent burnout in our health care teams because we have friends around us that are helping us out. It obviously prevents adverse actions and reactions in our patients, which help us feel better about all the people that are able to leave the hospital under their own power and own care. And it helps our patients directly with the fact that they know they are walking into a transparent organization that’s there to treat them as well as they possibly can and to do it as honestly as we possibly can every single day.

Dr. Luis Garcia:

So, so you mentioned the word burnout in your statements and that is something that directly or indirectly we’ve been feeling in the last couple of years more pronounced than before. Do you feel that this work in any way impacts the level of burnout for our employees?

Dr Jeremy Cauwels:

I think this work impacts the level of burnout directly. I think one of the leading causes of burnout is the feeling that you don’t make a difference. That I don’t need to go to work today or I don’t want to go to work today because my opinion doesn’t matter. And I think the more you can engage people in saying, you know what? Your opinion does matter and every action that you have while you’re inside of our walls is going to help us deliver that perfect patient care. Those people keep coming back to work because they have a mission, they have a longing to keep doing that work well. And I think it gives us the opportunity to do a perfect or nearly perfect job of caring for each patient as we go through. But in order to do that, you have to have people that are engaged and you have to have people that are in it for the right reasons. And the good news is that automatically breeds engaged people who aren’t going to burn out because they knew when they went into work that day, they could make a difference.

Dr. Luis Garcia:

Well, Jeremy, you talk about mission. Our mission is to improve the human condition, right? And we have made it your vision to once again elevate quality and safety as a foundation of our culture. And I think that you have been extremely successful at that. And kudos to you and your team. Aristotle said that quality is not an act; it’s a habit. And I think that you have described throughout this podcast how the excellent outcomes that you have achieved with your leadership have been a matter of habit and a matter of creating a new culture for our organization that would allow us to deliver on that promise, which is excellent self-care. So Jeremy, thank you very much for being here today. Thank you very much for what you do every day and the impact that you have not only in our culture, but in our employees and in turn in our patients. Any closing thoughts Jeremy?

Dr. Jeremy Cauwels:

I would just like to thank you for the time today. Thank you for the ability to get in front of this microphone and talk just a little bit about the care that we deliver every day. And I would like to encourage anybody who’s listening to make sure they understand that this is the way we do things here at Sanford. That our goal is to make sure that every single person has the ability to make an impact on our patients, our residents, and our teams every time they walk in the door.

Dr. Luis Garcia:

Thank you Jeremy. My gratitude. Thank you for being here.

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.

Learn more

• Ep. 9: The evolving customer experience in health care
• Sanford USD Medical Center given ‘A’ Leapfrog Safety Grade
• Where to start mental health care? Your doctor’s office
• Ep. 7: Flexible work and well-being in rural health care

Get more episodes in this series

Prep for baby, postpartum, and ‘fourth trimester’

Kayla Quinn, CNM:

For most families in general, it’s just the unexpected, right? You don’t have any idea what to expect if it’s your first baby. And so, it’s the, “I have no idea what this is going to be like. How will I know what a contraction feels like? How will I know if my water breaks what should I bring to the hospital?” There are so many questions, so with our patients, we try to address all that in our prenatal visits.

Courtney Collen (Host):

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

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

In this episode, we are focusing on postpartum and what women can expect those first minutes, hours, days, weeks after pregnancy, labor and delivery, often referred to as the fourth trimester. I have with me Kayla Quinn, who is a certified nurse midwife at Sanford Medical Center in Fargo, North Dakota. Kayla, so glad to have you. Thanks for being here, and welcome.

Kayla Quinn, CNM:

Thank you.

Courtney Collen:

Full transparency, and a note for the audience – I just reached 34 weeks in my pregnancy, so I’m very thankful to have this conversation as I look ahead to my own labor and delivery at Sanford Health in Sioux Falls. But in talking to my provider, reading about this process, trying to get as much education as I can, Kayla, it really is an overwhelming journey. So, I wonder, as a midwife working with women in this same journey what do you hear and how might you be able to ease any anxious feelings or fears during this time as we look ahead?

Kayla Quinn, CNM:

For most families in general, it’s just the unexpected, right? You don’t have any idea what to expect if it’s your first baby. And so, it’s the, “I have no idea what this is going to be like. How will I know what a contraction feels like? How will I know if my water breaks what should I bring to the hospital?” There are so many questions. So, with our patients, we try to address all of that in our prenatal visits.

Courtney Collen:

OK, so let’s move to some of those common side effects or symptoms, post labor and delivery. We know Kayla, there will be blood. Talk about what we can expect and, and how long the bleeding might last. What care products we might need to bring or might Sanford be able to provide. How much bleeding is too much bleeding? Let’s just dive right into that real quick.

Kayla Quinn, CNM:

Absolutely. There’s a lot of blood and it’s always going to look like a lot more to you than it does to us. So, you can expect to see the most bleeding immediately after delivery. That’s when there’s going to be a lot. After that, our goal is for it to not be super heavy, but I do tell people expect it to be like a moderate to heavy period for at least one to two weeks. The first week is usually kind of the worst, where it’s a little bit heavier. You might have some small clots, and that’s OK. Really the ones that we want you to be concerned about is if they’re kind of like a golf ball size or bigger. If you’re having clots that are golf ball size or bigger while you’re in the hospital, definitely let your nurse know.

If you’re having gushes of bleeding that are filling up an entire pad an hour, let your nurse know. And same thing goes for when you go home from the hospital. The good news is we have all the pads you could ever want when you’re in the hospital. We start you out with a diaper pretty much, and hopefully by the time you go home, sometimes we can have you down to more of a normal sized pad. But we’ll start you out with diapers at the hospital. Don’t worry. Every postpartum mom gets to experience the diaper and the mesh underwear.

Courtney Collen:

So, mom and baby both get a diaper?

Kayla Quinn, CNM:

Mom and baby both get a diaper. Yes, absolutely. So, Sanford does have the disposable underwear and pads for you there. So you don’t have to bring any of that with. If you want your own underwear, I do recommend you bring some that are a little bit bigger than normal and usually more high-waisted. Especially in case you do have to have a cesarean section and there is an incision, we want them to sit above where that incision would be just for comfort. But again, you’re sticking a diaper sized pad in there, so you’re going to need a little extra room in your underwear. But otherwise, yes, Sanford provides those.

Once you get home, I recommend that people have kind of a variety of different unscented pads when you get home because it does, it just gradually decreases and you’re going to start with kind of like a moderate period, and then it’ll go down to spotting, and then it might increase again for a day or two and then go back down to that spotting and really light.

So, having everything from some overnight pads all the way down to pantyliners. So, you kind of want a little bit of a variety. You don’t have to have jumbo packs of everything. Your bleeding really should only last about three to five weeks. But the heaviest will be in that first one to two weeks. Once you get home, if you are having a pad on and you saturate that in one hour, if you’re bleeding so much that you’re saturating a pad in an hour, we want you to come in and get checked out because there might be something we need to look further into.

Biggest things when you get home, I tell people:

• Watch for any fevers. So, if you have a fever over a 100.4 especially if it won’t come down after Tylenol, we want to know about it.
• If you’re saturating a pad in an hour or having multiple golf ball-size clots, we want you to come in and get checked out.
• If you’re having any signs of mastitis, which is really hot, red spots on your breast, usually that’s accompanied by a fever, you kind of feel like you have the flu. If you get that, call your provider right away. Usually we can get some antibiotics pretty quick and it’ll heal up. Don’t stop breastfeeding though. Keep breastfeeding and then we’ll kind of clear up that infection.
• If you have severe abdominal or perineal pain or all of a sudden, your swelling that you had after delivery, if that all of a sudden increases a lot, then I want you to come and get checked out also.

Courtney Collen:

Let’s move to tearing and the types of tearing as it relates to a vaginal birth. What types of tearing might we expect or what that care journey, that recovery journey specifically looks like and some of the supplies that could aid in that recovery?

Kayla Quinn, CNM:

Vaginal tearing is pretty variable. You can have everything just from little, little tiny, what we call almost skid marks or little tears by the urethra. Otherwise there’s first- and second-degree tears. Those are a lot more common where the muscle tears a little bit, but it’s not extremely deep. And then there’s third- and fourth-degree tears that really tear really deep into the perineal muscle and down into the rectum, and sometimes even involve the anal sphincter.

Care for each of those is a little different. With those superficial or those periurethral tears, we do recommend using your spray bottle, although you’re probably going to use that for all the tears. But those ones will really sting while you’re going to the bathroom that first few days.

So the hospital will provide you with what’s called a peri bottle, kind of just this little squirt bottle. You put warm water in it and really just squirting it on your perineal area while you’re urinating because it really takes that sting away. Keeps everything nice and clean down there for you. You’ll probably use that for the first one to two weeks when you go home.

So the hospital will give you that, all sorts of ice packs which will be great. We have ones that are pre-made. We can make some up for you. A lot of people have – a lot of kits now come with the gel ice packs. Honestly, I leave those at home. Keep them in your freezer. We’ll take care of all the stuff, especially with the real heavy bleeding the first few days. Let us use ours and the disposable stuff so you don’t have to worry about yours. And then there’s also numbing spray that we can give you afterwards that you use after using the bathroom and that can help.

Back to the tears, all of them are sutured if they’re bleeding especially. But the second, third, fourth degree almost always have some sewing involved. Those stitches do all dissolve, so it’s scary getting the stitches, but you don’t have to come back in and have them removed again, so they’ll just dissolve on their own. And the biggest thing is just especially with those third- and fourth-degree tears is making sure when you’re using the bathroom, you’re not doing any straining. And same with when you go home, not doing any heavy lifting because you don’t want any straining on those stitches, especially those first couple of weeks. As far as healing goes, the little ones, they heal up fast actually within a couple weeks. The second, or first- and second-degree tears take about two to three weeks to heal. Maybe a touch longer for all of the suture to dissolve. But within that first two, two to three weeks, they’re pretty well healed up.

The third and fourth degree, those can take anywhere from more of that four to six weeks before those are fully healed. With any of those, especially the more in-depth ones, you could have a little bit of like urinary or fecal, stool incontinence. Some of that’s just after delivery. Everything’s a little bit looser. Perineal are a little looser. And so if that happens for the first week or two, that’s OK. It’s if we’re getting past that about two weeks, we want to know about it.

Courtney Collen:

Is there any way, Kayla, to prevent even just those third- and fourth-degree tears that we can do ahead of time during the late stages of our pregnancy? Anything we can do to avoid any of that or is it pretty inevitable for most?

Kayla Quinn, CNM:

I don’t want to say inevitable because it just depends on your body tissue and how viable it is. The biggest thing is we don’t recommend a ton of like trying to stretch yourself before. Sometimes that can cause more swelling. A lot of it is going to be listening to your provider at the end when you’re pushing. If you just start pushing, pushing, pushing and don’t take any breaks and you might be a little more likely to have a little deeper tear, whereas it feels awful, there’s a lot of pressure at the end, but letting your pressure stay there and letting that perineum stretch naturally. Listen to your provider during that point, because we can prevent some of it just by not going too fast at the end.

Some of it’s going to be inevitable though. And it just really depends on body type. Hopefully it’s not too bad, but we’ve got all the fun stuff. Medications and ice packs will be your friend. We really recommend using ice packs, especially that first 24 hours just to kind of get the swelling down. Help with some of that, help numb up things up a little bit after that.

Taking warm tub baths or sitz baths, a lot of people have heard of those. Sitz baths specifically are like a basin you can buy, and it sits on the toilet and warm water kind of flushes over the perineal area. But if you have a bath at home, enjoy the full bath experience. You just want to fill your tub up with warm water. Our facilities have tubs also to use after delivery. It’ll be filled with some warm water.

If you’re at home, Epsom salts are great for healing. The recommendation is about half a cup of Epsom salts per gallon of water. So pour those in and really just make sure your whole bottom is soaked. But hey, if you take the whole bath, that’s great. And relax a little bit. And really soaking that bottom though for about 15 to 20 minutes, one to two times a day. I usually say try two, especially with those worst tears. It’s just sometimes hard to do if you’ve got a baby who wants to feed constantly too. But shooting for at least one a day can really help with the healing and help those stitches heal a little easier. Make it less painful for you and just make the whole process a little smoother.

Courtney Collen:

I’m learning so much. Kayla, thank you for all the information. So, the next topic I want to talk about Kayla – C-section birth or cesarean section. For our listeners preparing for a C-section or cesarean birth the recovery process may be a little bit longer. I understand because this is a major surgery. So first, what are your biggest tips to prepare for a C-section birth and then we’ll move to recovery and what to expect after that?

Kayla Quinn, CNM:

Yeah, so preparing is a little bit different, especially if it’s a planned cesarean, right? You’ve got food picked out, there’s usually a time that they’ll schedule you. And so, the biggest thing is they’ll tell you before, “nothing to eat or drink before your surgery.” And I like to tell people like, just remember it is a major abdominal surgery, like you said. So, there is going to be some pain. We don’t expect your pain to be zero afterwards, obviously we want it to be as low as possible and we’re going to help you get there. But to be expecting that there will be some. Abdominal binders are my favorite thing after cesarean section for mamas to use, so if you have one that you really like at home or say you’ve researched or a friend or someone really loved one, bring it with you to the hospital.

The hospital does have them also, but if you have your own and you really like it, awesome, bring it with you and we can help you get it situated on after that first day. But bring that with you.

If preparing for a C-section your hospital bag, loose clothes. You can wear the hospital gown as long as you want, but if you want your own clothes, make sure that they’re high-waisted, loose leggings or sweatpants, something that’s not going to rub against that incision. Same thing, loose underwear that sits higher, high-waisted everything. Because you just don’t want to be rubbing against that incision.

Things kind of to expect, there’s multiple different ways that surgeons cover that incision. Some will have glue and that’s just going to dissolve on its own or kind of flake off on its own after about 10 to 14 days. Some put steri strips or like butterfly strips over the incision and those just fall off on their own after about seven to 10 days. Some use it like a dressing that stays on for about seven days and you keep that on until you go home, and you peel it off about seven days later your own.

And so the biggest thing is people always are worried, can I shower after I have a C-section? Absolutely. We recommend getting you up and into the shower the next day and water can run over your incision. Soap can run over the incision. We just don’t want you scrubbing at it. So don’t rub, don’t scrub at it. And even more importantly, just make sure to pat it dry very well afterwards. Keeping it dry and clean is the best thing you can do for healing with an incision.

Like I said, you’ll have some pain afterwards and so that first 24 hours sometimes isn’t so bad because you’ve got all the great surgical medications on board still. It’s after that. So we have oral medications, we have IV medications. It’s really just being honest and open with your nurse and not trying to be too tough. Because like we said, major abdominal surgery. We want you to not take too much, but also don’t think you don’t have to take anything either. After vaginal birth, we usually expect to discharge home after about 48 hours. And a C-section will be after about 72 hours. So three days, expect about three days in the hospital. The recovery time is a little bit longer. Vaginal delivery we expect you to kind of be up and moving and feeling pretty good within about three to four weeks.

C-section could be closer to those six to eight weeks. Most people though still feel a lot closer to their normal by about two to three weeks. So, I don’t want people thinking, “eight weeks I’m going to feel this much pain and it’s going to be awful.” No, the first week is probably going to be the worst. And where you’re going to be kind of just slow moving and need a lot more help. I recommend having someone at home with you that first one to two weeks, because bending to get diapers or change diapers, all of like those bending motions and even just diaper changes in general can be a little more difficult right away. So having somebody there to help you most of the time, that first one to two weeks, we recommend no driving that first week due to pain and if you’re taking any narcotic medication, obviously.

And so again, making sure you’ve got someone on board to help with catering you around. We recommend no heavy lifting over 20 pounds when you get home. So, a baby in the car seat is usually OK. But I like to tell parents who have other kiddos at home to kind of start preparing for that because that’s a hard, hard thing to come home and then say, “Mama can’t lift you up anymore.” So, teaching your little ones to be monkeys before you go in and really just kind of making, having those conversations with your younger kiddos before you go in that, especially those first few weeks, mama’s got a big owie and we need to limit some of that lifting.

Being a lot more careful too with signs of infections. So we talked about some of those earlier. The fever, the heavy bleeding, but also at the C-section, if there’s any like redness or drainage around your incision, that’ll be an extra thing to watch for after a C-section or really, really severe abdominal pain that won’t go away.

Courtney Collen:

Good information again, Kayla. Thank you. So with regard to a C-section or vaginal birth, let’s talk about some other common symptoms that women can experience in that early postpartum period, that maybe we don’t always hear about or talk about but should be on the lookout for or should expect. I hear about urinary and bowel incontinence, vaginal discharge, constipation – talk about a couple of those things, and maybe when to seek care if something isn’t normal or something that we feel should be cared for.

Kayla Quinn, CNM:

We kind of touched on the urinary and fecal incontinence. If it’s lasting more than one to two weeks, definitely kind of want to check on that. Kegel exercises are great. We don’t do a ton of physical therapy before about six weeks, so kind of knowing that it is normal, all those muscles take some time to strengthen up again. But if it’s constant after about two weeks, we want to make sure nothing is damaged there.

Constipation’s a big one, and everybody’s terrified of that first bowel movement. Your nurses, they think it’s great, right? But everyone else is terrified of that. Usually it’s not as bad as you were worried that it’s going to be. But at the hospital we do have stool softeners that we’ll give you. I do recommend, especially with a second degree or more, second, third or fourth degree (tear) to having a stool softener at least the two to four weeks.

If you have a third- or fourth-degree tear, we’re going to recommend having more than one. Maybe adding MiraLax, adding more of laxative too to help keep things really, really soft. Because the biggest thing is just to not strain. Whether you have a X-section or a vaginal delivery with tears, we just don’t want you straining those muscles. So common things if you want to have on hand at home, Colace is a common stool softener, MiraLax a lot of people like. The other thing we’re really going to recommend is just tons of fluid intake. Eating a high fiber diet, all of that will help.

Hemorrhoids are everybody else’s least favorite thing and sometimes we can’t do anything about them. Some people get them during pregnancy. They’re everybody’s least favorite thing. So, if they’re really bad, they’re really irritating after delivery, talk to your provider. We can possibly get you like a kind of a more of a numbing cream for a while. We use witch hazel pads for healing in the hospital also along with that spray in the ice packs. And so those or Tucks pads, those are great for hemorrhoids too. So, we’ll show you how to put those in your pad and keep wearing those for a few weeks. With the hemorrhoids, sometimes we can’t prevent them. They do take time to heal. You’re not going to just go home, and your hemorrhoids will be gone. They can take a couple months even to heal. So don’t stress too much.

The biggest thing is if the constipation is getting so bad, you’re going like three days, and you can’t go, we want to know about it. If you’ve tried all the laxatives and the stool softeners and it’s not working, let your provider know. But the hemorrhoids, if they’re growing and really seeming like they’re blood filled, something like that and getting bigger and bigger and not smaller necessarily, then let your provider know. And try not to let those things go. We schedule you an appointment for six weeks out and everyone figures, “OK, I’m good for six weeks. No one needs to see me.” But if you’re having those things, please call and reach out. We’re more than happy to see you before the six weeks.

Courtney Collen:

Good to know. Thank you. And shifting to mental health for a moment, which I know is just as important as that physical health in recovery and postpartum. I recently recorded an episode with longtime social worker here at Sanford Health, Karla Salem, who specializes in postpartum mental health as part of our podcast series, “Her Kind of Healthy.”

But Kayla, for those who may not be familiar, let’s talk briefly about the difference between the ever-common baby blues and what might lead to a more serious diagnosis, say postpartum depression, for example.

Kayla Quinn, CNM:

Yeah, baby blues are a rollercoaster experience when those come. Crying over commercials, and then laughing, and having no idea why you’re sad. We expect that kind of rollercoaster to happen for about the first two weeks. If it’s those little minor ups and downs that first two weeks, that’s usually more baby blues.

Where we start to get worried about postpartum depression would be if it’s longer than two weeks where you don’t want to take care of yourself, don’t want to take care of your baby, you’re lethargic, don’t want to get out of bed. That’s different than just being exhausted with being up all night with your baby. But just don’t want to get out or take care of yourself. Be more irritable, just snappier and shorter with people. I really recommend that partners pay attention to moms’ mood – she isn’t going to notice first, just figure they’re tired or everything’s normal.

But if you start to notice a decline and where they’re just getting really snappy or just really in this funk and won’t come out of it, if it’s lasting past that first two weeks, I really recommend being seen at about that two-to-three-week mark. Just to even talk about options and talk about counseling or do we need a short-term medication to help with this. Sometimes just talking about their fears is enough where people are like, “OK, I’m feeling a little better.” So, making that appointment with either your OB(GYN) provider, your midwife, or a counselor in that first two to three weeks, is important.

Courtney Collen:

You brought up that support person, whether it’s the father of the child, or it’s a partner, a family member or friend. What are some tips that you have Kayla for that specific person during the transition to postpartum and really into those first days and weeks at home?

Kayla Quinn, CNM:

Really just being present, being there as much as possible. Especially with breastfeeding moms. Sometimes partners feel left out or hopeless because there’s not a lot they can do. But really doing the diaper changes so that mom gets just that, even that three more minutes of rest is kind of nice. Doing the diaper changes. Being prepared to get up with mom too. During breastfeeding, you’re going to be really, really thirsty. And so, as the partner, making sure mom has a full water jug and has some snacks available, just being there with those little things and having them ready because she might not even think about them. She’s so worried about getting baby latched and then all of a sudden you’re stuck and you’re like, I’m really, really thirsty. So, having some of that available.

If mom has fed and has tried everything then, just being there to help rock and hold (the) baby a little bit while she gets some rest and taking those trade-off times. And when you get home, same thing. Having somebody there to help with a little bit more of the housework and easy meals. Don’t shoot for perfection once you get home. That’s your time to huddle in those first two weeks because they’re a little rough. Being helpful, being up at night and helping with the diaper changes. And really paying attention to mom.

That’s the biggest thing I can stress is paying attention to what her mood is, and having the open conversation of what do you want me to do to help you? Feeling able to say, what do you need from me? Because it’s hard. A lot of our partners feel helpless when moms are doing everything and there’s not as much they can do. So just really asking like, what do you need from me? What can I do for you? And moms – be OK with delegating that. That’s a hard thing for us to do. But let them do it for you.

Courtney Collen:

Being present, communicating, having that ability to delegate – all such great reminders. And again, such valuable information. Thank you. Having someone there is so important, whoever it may be. So it’s good to learn more about what they can do to provide the best support possible. So thanks for that.

Kayla, any last bits of insight or things that we can add to our list as we plan for postpartum? In hopes to make that transition as smooth as possible?

Kayla Quinn, CNM:

We talked about the preparing parts. Leave all your stuff at home for the most part. Don’t stress over packing your bag too much. Bring your comfy clothes, but you don’t need a ton, right? We’re going to give you all the pads, we’re going to give you all the medications and the squirt bottles and all the stuff, all that postpartum kit stuff. Leave yours at home because you’ll want it when you get there. So, try not to stress about that too much, but just having comfy clothes or slippers, things that are comforting for you. The open communication between you and your partner, support persons, whoever’s going to be with you, is going to be key to a lot of it: to the labor process, to the postpartum process. And, letting your partner see some of this like, “yep, there’s going to be a lot of blood,” realizing that this is normal.

Maybe I’m not going to want to go and do a whole lot that first week because I don’t know what’s going to be happening down there. And same thing with visitors, just being prepared to say, “we’re not comfortable going to do anything, or I’m not sure how I’m going to be feeling, so let’s play it by ear.” And just remember that you are this new family unit, and you get to make the rules. It should be an exciting time, right? And really just make the most of it and learn from your baby. Open communication’s going to be a huge thing and realize that it’s supposed to be a little bit stressful, and it will be, but it’s also very exciting.

Something we do see a lot, especially in first time moms is we talk about discharge times, right? Being about 48 hours or 72 hours. And those are, they’re kind of imperfect scenarios too, right? We see a lot of mothers whose blood pressure gets elevated, or babies who have jaundice, things like that. And so to really prepare yourself that, yep, the 48 hours or the 72 hours, that’s our normal, right? That’s what we’re shooting for. But if anyone tells you have high blood pressure or baby’s struggling with blood sugars or struggling with jaundice, to really start preparing yourself that 48 hours might not be a thing. Your 48 hours might turn 72 or even more than that. And being prepared. Because that’s really hard. It’s a really hard thing when your provider has to come in and say, “Hey, the safest thing for you to be would be to stay – stay longer.”

And you were so dead set on going home. And so just realizing that might change based on how the postpartum process goes. But high blood pressure is one that a lot starts happening and everyone wants to know why. And it’s a hormonal shift. We don’t have necessarily a huge why. And so, just realizing you’re not doing anything wrong – it’s just your body reaction to the postpartum period. And we want to keep you to watch you a little closer and make sure we get you home and safe with your baby.

Courtney Collen:

Yes. And that speaks so beautifully to our comments at the beginning of this conversation that everyone’s care journey will look a little bit different. No two experiences are the same. But one thing is for certain Kayla, it is so wonderful to have a network of Sanford Health providers who can educate and make us feel comfortable and prepared, which is exactly how I will be leaving this conversation today. So with that, I thank you Kayla Quinn, certified nurse midwife at Sanford Health in Fargo. Thanks so much for your time, your insight, expertise, and all that you do for women in this space. We appreciate you.

Kayla Quinn, CNM:

Thank you. Appreciate it.

Learn more about this topic

• Get the facts about a common post-pregnancy body change
• How to manage stress while pregnant
• Ep. 13: The transition from postpartum to parenting

Get more episodes in this series

A senior nursing student chats about her career path

Alan Helgeson:

Hello and welcome to the “Reimagining Rural Health” 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 the journey to becoming a nurse and insights and highlights along the path. Our guest is Maddie Fitch, at the time of the program, just weeks away from graduating as a new RN from SDSU and beginning a new career at Sanford USD Medical Center. Our host is Erica DeBoer, Sanford Health chief nursing officer.

Erica DeBoer (host):

Good afternoon everyone. This is Erica DeBoer. I’m the Chief nursing Officer for the Sanford Health system and I am so excited to welcome Maddie Fitch, one of our senior nursing students from SDSU and a current Sanford intern with us. And so she’s gonna be working in critical care and as many of you know, it’s my background. I love critical care and so I have the privilege to be mentoring Maddie over the last year. So welcome Maddie.

Maddie Fitch (guest):

Thank you, it’s great to be here. Very excited.

Erica DeBoer (host):

Thanks for coming. So we’re really trying to look at from the perspective of really our nursing students. I think we’ve had the opportunity to meet with a couple of our other colleges of nursing, but really the important part that I always talk about is how do we actually get the feedback and the conversation started with those that I serve? Which is not only our nurses that work at the bedside, but also the students that come and are entering our organization.

So as part of our conversation today, I’d love to talk a little bit about the importance that technology plays, not only for you as a student, but during your experience as an intern at SDSU. So I think for you, you know, how important technology is in that critical care space. I want our nurses to feel super empowered to continue to really use that technology not only to care for patients, but to understand more about the pathophysiology and how they can contribute to the care. Can you share a little bit about how you have used technology during your internship at Sanford?

Maddie Fitch:

I think the biggest piece is the Epic charting. Kind of looking through like different lab values. Like you get a critical from the provider or from the lab and you go and look into the chart and see, OK, is this a trending lab or is this like an acute incidence of it? And then like working with the provider you can kind of address, OK, do we need to order a new medication or whatever it may be. But then also just I feel like the Brain is kind of your guiding force as a nurse and it kind of gives you direction for the day of, OK, this is what I really need to get done and these are the things that are really important. And as a student kind of having I guess a rough outline is very helpful in understanding that things might change based on the different technologies, like if you need to titrate your drips or if you need to adjust your vent settings with respiratory. Just kind of letting the brain guide you but knowing that there are other resources within the patient room that kind of influence how you use the Epic technology.

Erica DeBoer (host):

I love that you mentioned the electronic medical record. I think sometimes for many of us it’s become just a part of what our daily work is. And so I love that you talk about the Brain. Now just for those that are listening online, the Brain is actually an electronic version of really all the different tasks and parameters that guide care for our patients. There’s orders from our docs in there as well as really a key communication strategy that’s constantly up to date when we use it. So thanks for using that. I know I come from old school (laugh) that I had my piece of paper that I had all those things right behind me.

But I think given the current state of where things are at, we have so many teams that spend time taking care of our patients that that the electronic medical record is such an important tool for us to play. So thanks for sharing that. I’m curious, just to step back a little bit, why did you choose to pursue a career in nursing?

Maddie Fitch:

I really wasn’t thinking about it at all. I volunteered in high school at the hospital in my hometown, which was a really great experience, but I was kind of just doing it for the hours I hate to say. And then my junior to senior year of high school, all three of my grandparents got really sick with cancer and kind of encountered a lot of palliative and hospice cares. And so it kind of opened my eyes to what bedside nursing looks like and how it like impacts the patient and family.

And so yeah, I toured SDSU thinking maybe I’ll do a bachelor of science and mathematics with a data science specialization. And then I also toured nursing and I was like, ah, this is an easy decision. (Laugh) Nothing against math, but I’ve really enjoyed getting to learn more about the nursing field and gain a lot more experience through it.

Erica DeBoer (host):

I think the other thing just because I’ve had the opportunity to get to know you over the last year, I think you have a really important philosophy that you’ve taken on the last two years as you’ve started the nursing career and it’s really about saying yes. So don’t be scared; just say yes. Do you mind telling me a little bit more about that? I love that philosophy.

Maddie Fitch:

I think it’s one of those things like as any high schooler, you kind of are in an identity crisis when you’re going to college and I really lacked a lot of self-confidence. And then I got to SDSU and I kind of struggled a bit to figure out what do I want to do? Like what should I get involved in and like how do I pursue nursing to make sure it’s the best experience for myself and my future patients?

And when COVID happened, it kind of shook the world and it was a negative experience for a lot of people. And there were many negative, I think, experiences that I had. But also from COVID I kind of realized, OK I need to get it together just a little bit if I wanna actually pursue nursing. And so it kind of made me realize like life is too short to be afraid and not just jump in and kind of figure things out as you go. And if you’re always nervous about, well, the what ifs or what if I am not good enough, then you’re kind of gonna limit yourself and what you can experience.

Erica DeBoer (host):

Yeah, I love it. You’ve gotten really involved in a lot of different ways, and I’ve been impressed with several different things that you’ve had the opportunity to contribute. Do you mind just sharing a little bit about some of those top three most important things that you’ve engaged in and what impact they’ve had on you?

Maddie Fitch:

I guess the top three, my big research project that I didn’t really intend to be that large, but it kind of got really, really crazy. So I was able to partner with our associate dean of research at SDSU and help with one of her grants focused on kind of transforming a palliative care intervention specific to South Dakota. I’m kind of, you know, using best practices and cultural implications to direct that intervention. So that’s been a really unique opportunity that I never thought I’d have the chance to participate in.

But then also serving on student senate at SDSU has been a really cool opportunity just kind of recognizing the impact that policy within SDSU, but then also across the state of South Dakota has on the student experience. And so it’s been a very challenging and unique environment to kind of voice my opinion in.

And then also just kinda serving on the leadership team in my sorority for the last few years has been a really cool experience to, one, get to know people and what their passions are and how can I help them recognize where their potential might lay. But then also just being challenged in how do I manage this large group of people and having the financial responsibility and time management with all of my classes? So those are kind of the big experiences I would say.

Erica DeBoer (host):

Love it. It’s a good measured approach to not, it’s not just about nursing, but it’s really about how are you actually envisioning yourself contributing in the future. And I think that’s the thing that I love most about your passion for the work. I think the other thing that resonates with me, although we’re talking about technology and the importance that technology plays, I think what resonates with me about you Maddie, is your ability to connect with people instantaneously. So I think some of the leadership skills that you’re gaining in the sorority, in the student senate, but also as a intern at Sanford has really contributed to you being very well-rounded. And I think you’re gonna challenge us (laugh) to be better at Sanford and really making sure that you have things that are gonna challenge you and continue to really promote that growth and learning.

Maddie Fitch:

Yeah, no, the internship at Sanford, I don’t know, I was talking earlier with someone and we kind of were like mentioning how did you get into critical care and how did you become interested? And I was like, well, the first week I was really wanting to not do critical care. I went home and called my mom. I was like, absolutely not. But kind of recognizing I guess just the acuity of the patients and the like aspect of critical thinking that requires a lot of the pathophysiology and pharmacology and using my resources from both school but then also the ones that Sanford offers, like through a lot of the technological resources, it kind of made it not so scary and I was able to get more comfortable after talking with preceptors and things like that. So it’s been really cool experience to yeah, kind of combine everything I’ve done at school into an internship and then kind of how that plays out into my future career at Sanford.

Erica DeBoer (host):

That’s awesome. So I know that simulation is a big part of the curriculum at S D S U and throughout really the nation, it’s really been something that we’ve had to lean on. Obviously there’s technologically advancements that help to support that work, but I’m curious from your perspective at SDSU, what part does simulation play in your training and how has it helped you actually as a student intern and a student nurse?

Maddie Fitch:

I think, well we started simulation like the first semester, which was really nice. We walked into a room and kind of established the basics of OK, this is a patient situation and here’s what you’ve learned in class and here’s how you can apply it, which I found really useful. And the professors and faculty do a great job to make it as real as they can with the resources they have, which thankfully at SDSU and I think across all the schools in the area, they have wonderful resources for their students.

But one of the biggest things I’ve taken away from simulation is when you have those higher acuity, like the code simulation, which we’re not supposed to know that there’s a code, but we do. And that’s OK, but you prepare for it (laugh). And then just our trauma unfolding simulation, it really played out into a lot of the things that I experienced as an intern, which I had the opportunity to experience those real life before I did a simulation. So it was kind of an interesting flip flop in it, but to see how well the actual experience was reflected and what a structured experience was supposed to look like was really unique and it kind of like confirmed, OK, like we’re doing the right things. Like, and I knew that in this situation regardless, but you know, it was a unique opportunity to kind of reflect on both.

Erica DeBoer (host):

Well, and I think simulation contributes in a lot of different ways. But to your point, I love that you had the opportunity during your internship in that safe space to be able to learn what that scenario might look like. I hope that not only did you learn what real life is like but then can contribute back and actually share it with your teams. Because that’s the other really important thing that I’ve highlighted over the last couple interviews is that collaboration and really us learning from one another is incredibly important. So as we look at transforming what health care needs to be, it means we have to make sure that our nurses are prepared well too.

Maddie Fitch:

Yeah. Yeah, I think like debrief after simulation is very beneficial for a lot of my classmates because we’re always asking the “why” questions. And I think my cohort is just really unique and we’ve gotten very close and have had the opportunity to bond a lot through those simulations and talking about personal experiences, but then like looking at, OK, how did the mannequin work and how did the questions that our professors ask us kind of guide us towards these other deeper meaning questions for lack of better terms. So it was really fun to kind of experience that too.

Erica DeBoer (host):

I think I also know you well enough to know that palliative care, and you mentioned it just a little bit already, is something that’s incredibly important to you. It’s something that you’re encouraging not only your preceptors but others to consider in some of these scenarios. Sometimes just because we can doesn’t mean we always should. And so I’m curious, I feel like simulation not only is about the technological components of it, but it also is about that scenario and debriefing to what you’ve mentioned. Is there scenarios that you found to be most beneficial in that palliative care space or in other components?

Maddie Fitch:

I think some of the more appropriate conversations for the palliative care is when we have our simulations with the older adult focus and then also the rural focus, which is one of the kind of big challenges that a lot of nurses face in this state. And so when we are focused on like, OK, the patient for example is driving 40 miles from the clinic to get to the acute setting, how do we, you know, best manage the symptoms at home so they don’t have to keep driving in to receive these intense treatments?

So it’s been kind of a fun opportunity to work with faculty and then also my classmates and saying, well maybe, you know, having them drive every week for this one injection or every three days for this one intervention isn’t necessarily appropriate. And then looking at what we’ve learned in class to apply that to the patient’s situation, it’s been reflected in a lot of the research that I’ve done, like for my research project as well. So that’s been kind of cool.

Erica DeBoer (host):

What an amazing segue. So I wanna just anchor on that just a little bit. Obviously I think you’ve heard, and if you haven’t heard, I’m here to tell you that Sanford is on the pursuit to be the premier rural health care organization in the United States. It’s a huge strategic position statement, but I think what you just said is one of those real life examples of what our rural individuals experience. So how can we reduce the friction for our front-line teams and how do we really look at what’s that scenario? And if it was us, if it was me, is that something that we would wanna do? So I really appreciate your perspective as a senior nursing student. You’re almost done, right? How many weeks left?

Maddie Fitch:

There’s three (laugh). Woo. I know. So exciting.

Erica DeBoer (host):

Three weeks, weeks left. That’s awesome. Yeah. So I’m curious since we’re talking a little bit about your career and as you wrap things up as a student nurse, is there any advice that you would give students early on in their nursing education? Or even somebody who hasn’t maybe considered nursing as a profession yet, what advice would you give?

Maddie Fitch:

I think specifically for nursing students or those considering nursing or maybe haven’t thought about it, just kind of looking at like everything that you’re learning in higher education or after and you enter the work field or whatever it may be, everything you learn has the impact to change a life. And so as a nurse, whatever you’re learning in class as daunting or tedious it might be, it does have the opportunity to change someone else’s life. Whether that’s learning how to say hi in an appropriate manner or you know how to titrate a medication to make sure your patient’s blood pressure is stable.

But then if people are maybe not thinking about nursing, but it has been like an idea that’s been bounced around, kind of looking at how can you like best impact a patient’s life. And I think as a nurse you have the opportunity to share your kindness with others. And so considering a profession that’s focused on sharing kindness to make sure the patient has the best experience possible and their family too is something I would encourage them to do.

Erica DeBoer (host):

That’s awesome. Thanks for that. You know, I’m kind of big on that kindness thing too. It makes a big difference in the chaos of the world today.

Maddie Fitch:

Yeah, no, for sure.

Erica DeBoer (host):

Thanks for bringing that up. I know that nursing wasn’t necessarily the career of choice in the beginning. Help me understand what was that trigger point? Obviously I heard you say when you walked on the campus you have some other talents that you were looking at as well. Tell me what you would’ve done if you would’ve done anything differently. Would you have done something different before you started your nursing career? Tell me a little bit more about that.

Maddie Fitch:

I think I was just really intrigued with the critical thinking of data science and the math behind it and kind of the challenge of solving problems. But I wasn’t necessarily impressed with the opportunity to translate that directly to people. Cause one of my favorite things to do is just talking to people. So this is a really fun opportunity to just chit chat. But I think looking at what I would do in my daily experience as a data scientist wasn’t really what I felt would contribute most to society.

And so kind of looking back to my experiences with my grandparents and seeing the opportunity I had to talk with the nurses and like how complex their situations were, it kind of intrigued me to think about nursing and there’s always a bigger problem with every patient, no matter how simple their diagnosis might seem. And so kind of looking at, OK, well I can one be on my feet every day, which I hate sitting around. It’s not my thing. And how can I also solve complex problems while making a big impact kind of is what changed my mind. It’s awesome.

Erica DeBoer (host):

It’s awesome. And I think all of you can hear in her voice. I get to look at her lovely smile and bright blue eyes that she’s going to be one of our up and coming data scientists. You can be a nurse and a data scientist at the same time. We actually are growing a whole crew of folks that try to look at problems in a different way. So yeah, really appreciate you being here with me today, Maddie. I’m curious, do you have any questions that you’d like to ask me? I know I’ve done a lot of talking so far.

Maddie Fitch:

No, not at all. I think biggest question is would you have done anything differently in your career looking back or where you’re at right now? Like would you have changed anything that’s led to where you’re at right now?

Erica DeBoer (host):

Oh, that’s an interesting question. So I think for many of you that maybe don’t know me, my career path has been a little bit unique. I think that starting as a nurse aide in a long-term care facility, knowing how important it was to take care of my grandpa while I was there was an important start to my career. I think I always, always knew I wanted to be a nurse and my biggest fear is not passing (laugh). And so as you think about getting ready to take your NextGen NCLEX exam, I can remember all the fears that came with that. I do believe I was put on this earth to be a nurse and I do appreciate every single one of the experiences that I’ve had. I have had absolutely some failures, but then what I try to do is take that and grow from it.

Yeah. And share with other people. I think the other important thing that I’ve learned, I don’t know that I would change a ton cuz there’s always tough stuff that you have to go through. But I think the learning that comes from it is probably the most important thing.

I will share with you that I never in a million years would’ve told you that I would be in this position someday. Never in a million years. I absolutely love our nursing practice. I absolutely love taking care of patients and I miss it every day. But I never pictured myself in a position like this (laugh). So I feel incredibly blessed to be in a position like I am.

Maddie Fitch:

Well it’s always nice to have someone leading the charge that cares. So it’s appreciated for sure. Thank you.

Erica DeBoer (host):

Thanks Maddie.

Maddie Fitch:

I guess another question I would have is like kind of the technology piece. How have you as a leader been challenged to implement that? Like with bedside nurses’ input and like with student input, I guess what’s been the biggest learning curve or the biggest opportunity that you’ve seen in conversations with bedside?

Erica DeBoer (host):

Thank you for that. I think people have heard me say often is it really, we do have so much brilliance at the bedside, we just have to ask. They experience it day to day, every day, and they probably have an innovative solution which may not even require technology. I think as we look ahead and as we even look back on what we’ve learned with COVID and our rural setting, technology does have to be part of the solution. And so we’ve constantly tried to look at what’s the biggest problem that we’re trying to solve. And really as I partner with our innovation team, I can bring a whole bunch of pieces and parts in, but if it’s not actually gonna solve the big problem that we have, I really don’t even wanna talk about it, which is a horrible thing to say maybe.

Maddie Fitch:

No, not at all (laugh). But it’s always appreciated. Like those small conversations that don’t contribute much, just like I really appreciate it, but like not the time or the place maybe, maybe in another time.

Erica DeBoer (host):

(Laugh). So I’ll never forget the conversation I had with the innovations team. Gosh it’s been at least two years ago now. But I said, I love that you’re trying to put some of this R and D practice in, but I honestly, it’s not helping me with my workforce. And so when you engage the right people to have the right conversations and look to the market to see what is it that’s out there that’s gonna help us solve this big problem, it’s amazing the magic that comes from it. And so as it relates to technology, we are in the process of putting together a proof of concept on two of our units – one in Sioux Falls and one in Fargo – to use computerized vision technology, to help us really use that to establish a virtual nursing program. Again, it’s technology, but we still have to have the brilliance that’s helping us accomplish that.

But it’s gonna allow our front-line teams to spend more time doing the things that bring joy to their work. So that care, that conversation with the front-line teams, how do we use our virtual nurses to share their expertise and wisdom with us? And bridge some of that gap that we have too? So that’s one technology. It is amazing. And luckily Sanford is willing to invest in some of those pieces, but it does take more time to implement.

I’d say some of the barriers that we have is we like to do things the way we’ve always done it because it’s comfortable. So transformation is super uncomfortable. And so I, my challenge to the front-line teams when I engage them is have we considered, have we thought about changing it this way? If it was our most precious loved one, the person that you care about most, what would you want for them? And so if we look at it from a couple of those different perspectives, it feels like the answer always becomes very clear.

But I think traditions get in our way and I think busyness gets in our way, but I think technology can help us, but it’s not the full answer. It’s really a collaborative effort with all of our teams.

Maddie Fitch:

That’s very cool. You bring those pieces together for sure. And yeah, as a future nurse, it’s always appreciated to know like the bigger picture of things is being looked at, especially on the days where you’re charting and it’s 8:30 and you’re supposed to leave at 7:30 and you’re like, OK, something needs to change. We need to figure this out.

Erica DeBoer (host):

Yes. Exactly. So using technology, using the tools that we have are really important. And then good, bad or indifferent, standardize at every opportunity. We know that we have to be able to have that conversation, but no matter what nurse, no matter what door they walk into, no matter what patient comes to us, if we have a standard process and a standard way that we manage that, it makes it easier for us to scale and actually have more interaction with our patients so that we know what to anticipate.

So I think it’s a journey. We haven’t arrived yet (laugh). But with the brilliance of all of our teams I think we can make a big difference not only in our patient care, but using virtual visits to help support rural access. And really just looking from the perspective of what does this mean for our patients?

I think we have some examples out there with some of our, all of our Sanford Health News stories about some of our specialists that are actually saving hundreds of thousands of miles to our patients. But the patients are still being able to manage their chronic illness, but through virtual visits. So I’m really excited about the opportunity that we have to continue that mindset of innovation and that engagement with our front-line teams.

Learn about the Nurse Residency Program at Sanford Health

Maddie Fitch:

I guess another question I had is how does Sanford support nurses?

Erica DeBoer (host):

Great question. We actually have the opportunity to support in a multitude of different ways. I think first and foremost our culture, which I hope you’ve had the opportunity experience is our SAFE culture. So Sanford Accountability For Excellence, that high reliability journey that we’re on, we support our nurses through that practice, which really has to do with the relationship skills and it also has to do with those high reliability skills.

And we expect and are on the pursuit to continue to get to zero harm. And I think that means nurses cuz we’re the biggest workforce, it’s so important that we continue to lead the way. As it relates to speaking up for safety, that’s our, that’s our safety skill of the month is speak up for safety, but also then help be part of that interdisciplinary team.

If Jeremy Cauwels, our chief physician was here, he would say, we know that there’s a lot of orders that are given. The nurses are the magic that happens in the middle in order to deliver that care. And so I think outside of that high reliability journey and how they contribute and how we support our nurses through being able to speak up for safety, it really is showing the value of our front-line teams.

I think the, the pursuit for Magnet designation, obviously in Sioux Falls, we’ve gotten our fifth designation and that has a lot to do with all of our front-line teams. And really shows that support for the incredible nursing staff that we have. Bismarck is on their way to their fourth designation. And of course we’ve got some other really incredible work that’s happening to really elevate and help people understand the value that nursing brings.

I’d say the third and most important part is how do we engage with our front-line teams? And that’s through our shared governance structure as well as our unit-based councils. And so it’s really there that the voice of the nurse can be heard and then we can work with our interdisciplinary teams to make sure that we can accomplish those things that make the most sense. Because again, I’ll say it over and over again, the brilliance is really at the bedside and you’re the ones that can help us actually solve the big problems that we need to solve.

Maddie Fitch:

That’s great. No, I’ve definitely seen all the things you’ve touched on through my internship, so it’s nice to hear it from way up, but then also to see it every day and yeah. Very, very cool. I guess one other thing, as a senior nursing student, while I have chosen to start at Sanford, why should other students consider starting their career with this organization?

Erica DeBoer (host):

Another really good question. I love that. I’d say from a nursing student’s perspective, we really do try to be ambassadors to not only our patient care, but also to our nursing practice. I think we’ve got a unique nursing practice in the fact that we have a louder voice than maybe in some organizations across the nation that really we contribute. And the reason why our quality scores are where they’re at, our patient experience scores continue to raise is because of the important work of the interdisciplinary team of which our nurses make up the majority. And so, although we can’t do it by ourselves, I think they contribute to the positive nature of the environment. And I want anyone and everyone who is interested in a nursing profession to be able to experience what I did. It’s that team dynamic, it’s that community that you build with your nursing colleagues, day to day working in the trenches, taking care of patients and solving the big problems.

I think the other reason that I would say that there’s a differentiator at Sanford is that we do have a host of other opportunities. So we have a Becky Nelson Fellowship, which is really an opportunity for one of our newer leaders to actually join myself as well as the nurse exec team for a 12-week fellowship to spend time with executives and understand some of those pieces. I think the other thing I’m really, really excited about is our World Clinic mentorship program. Because Sanford has clinics across the world, we have the opportunity to actually engage our front-line teams in helping not only learn from our world clinics but actually us learn from them. I think the other challenge to any nursing student would be, I don’t think that many organizations have the opportunity to have such engagement from our front-line teams.

It’s a huge support system that we’ve built. And so I believe that that certainly makes us a differentiator as well as the opportunities are so grandiose when it comes to nursing. I think from front-line nursing to ambulatory nursing, we’ve got of course our post-acute business that helps us actually take care of individuals in the latter parts of their lives as well. So possibilities are truly endless. And of course I’m a great example. I’ve done so many different roles, had the privilege to develop some of my own roles. I think over the last four or five different roles were really roles that I was able to have the autonomy to develop myself.

So innovative spirit, a willingness to really allow us all to speak up for safety. So again, I’m a huge fan of nursing and so wherever your nursing practice is, we just want you to be a nurse and we want you to feel that fire in your belly cuz our society needs us.

All right. I think Maddie, I can’t tell you how much I appreciate the opportunity to spend some time with you today and really get your vantage point on as a senior nursing student. You are gonna be an incredible Sanford nurse.

Maddie Fitch:

Aw, thank you. I’m excited.

Erica DeBoer (host):

And I can’t wait to have you there. Yes. I like blue too.

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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Caring for patients while making health systems better

Alan Helgeson:

Hello, and welcome to the “Reimagining Rural Health” 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 health care’s digital revolution. Our guest is Dr. Robert Wachter, professor and chair of the Department of Medicine at the University of California, San Francisco. Dr. Wachter has authored 300 articles and six books, including the New York Times Science Bestseller, “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age.” In 2020 through 2022, his tweets on COVID-19 were viewed more than 400 million times by 260,000 followers, and served as a trusted source of information on the clinical, public health and policy issues surrounding the pandemic. Our host is Dr. Luis Garcia, president, Sanford Clinic.

Dr. Luis Garcia (host):

I don’t think that there’s any type of introduction that would really give the proper credit to what you have achieved. I think that we could spend three hours just in the introduction of this podcast to maybe get to what would be proper credit. First of all, our gratitude for being such an influential leader in health care, and what you have done benefits all of us, and your work has been so prolific that it has impacted all of us.

So, to that point, you know, I was watching a video the other day where you were interviewing Andy Slavitt. He used to be the administrator for CMS, and then he also is a senior advisor for COVID-19 for President Biden, and he described you as a health care citizen. And that’s a huge honor to be described that way. What are your thoughts about that, the nomination?

Dr. Robert Wachter (guest):

I like that. That’s very sweet. Yeah. I’ve always seen my career as being a combination of trying to be a really good physician and taking that part of my life very seriously, but also trying to make the system that we work in work better. And I think that’s the citizens part, citizenship part of it. You know, when I grew up in medicine, probably you too, the idea that the role of physicians, at least at the time, was you were gonna, you need to be a really good doctor. And what being a good doctor meant was being really good one-on-one with patients. If you did a technical thing as you do Luis, that’d be really good at having the skills to do it. And I was very lucky to have mentors who really taught me that. That’s all really important, but it’s also important to figure out how do you make the system work better?

And I, that came a little bit naturally to me because I was a political science major in college. I was someone who always thought about systems and people and organizations and money and structure and all that. And it’s been one of the great joys of my career to find out that even though I always felt I was a little bit of an oddball, having this interest in policy and politics and medicine, that actually there’s this Venn diagram and it’s really important that physicians are good at that. And so it feels – it’s sort of a nice thing to look back on my career and feel like I’ve made a contribution, both as taking care of individual patients, but also trying to make the system work better.

Dr. Luis Garcia (host):

Yeah. That’s very profound. And, and I know you joke often about being a political science (major) in college and then getting into medicine, and of course that surface in your tweets around the pandemic. But I read a statistic that is just so impressive that at the height of the pandemic, your social tweets were viewed over 400 million times.

Dr. Robert Wachter:

Yeah.

Dr. Luis Garcia (host):

How does it feel to have that kind of an audience?

Dr. Robert Wachter:

It feels like a fair amount of responsibility, and particularly during COVID. I mean, it was important to recognize, I’ve been on Twitter for about 10 years, and going into COVID, I had about 15,000 followers. And within a year, year and a half in COVID, I had 300,000. And that wasn’t because I got any smarter, more interesting (laugh) or from, you know, between 2019 and 2020. It was, I was choosing to weigh in on what was the most important issue of the in the world. And people were desperate for trusted sources. So when COVID hit, it struck me that I have this Twitter presence, and I like communicating that way. I also ran grand rounds at my, at UCSF, at my institution, and that was another platform. And I felt like one of my opportunities-slash-obligations is, can I use my voice and my platforms to help people navigate through this pandemic?

And there was a little bit of time where I had some imposter syndrome, as I often do as a generalist, because I’m sometimes weighing into areas where there are specialists who know a lot more about any part of it. But one of the things I’ve learned in my career is that there is a role for generalists and a role for specialists. And the system works best when you have partnerships between the two of them. And so that’s been true for me in patient safety, where I decided to get interested in patient safety, I realized I needed to find people who really understood cognitive psychology or how the aviation industry kept itself safe, or how nuclear power plant designers do their work. Same thing with when COVID hit, it struck me that there are going to be people who know everything you need to know, or you should know about virology or vaccinology or aerosol science.

But what I could do as a generalist is synthesize that to try to pull it together in a way that made sense to me, and then try to communicate it to others. So it was really very gratifying because it’s, it became very clear that there was an audience for that, both personal, regular people and professionals who said, this is the most important issue in the world. It’s confusing as can be. There’s new information coming out every five minutes. Some of it conflicts with what I thought I knew 10 minutes ago. Can I find somebody out there who’s pulling it all together and putting it out there in a way that I find accessible and interesting? So it felt like a lot of responsibility an obligation to get it right. And I guess the other thing I’d say about Twitter and social media in general is it’s an incredible soapbox.

You can reach a lot of people. There are a lot of crazy people out there who will say things that are just incredibly nasty. And you kind of have to decide whether it’s worth it, whether it’s worth it to be, you know, in that arena. I felt like it was. I felt like the value that I had and others who were doing similar things to communicating in communicating to people about what’s going on, what the new research means, in communicating a way that I hope would be trustworthy, where they would say, this is a person who seems to know what he’s talking about, is not too partisan, is not, you know, trafficking in conspiracy theories, is really using the literature, but also feeling comfortable that I would say to people, you know, my son has COVID and I’m really scared. Or, today I, my lunch, I remember I did this in April or May, 2020, I showed people a picture of my lunch. It was SpaghettiOs and double stuffed Oreos. And I said, this is just what I felt like eating today. (Laugh) You know, the world is so scary. So being comfortable not only tweeting out facts and analysis, but a little bit of your personal story, people seem to be looking for trusted sources that way. So it’s an, it’s a responsibility, but it actually was quite a gratifying number of years.

Dr. Luis Garcia (host):

So, you know, Bob, I love the willingness and the courage to be a public trusted source, and at the same time recognizing the responsibility that that meant for you at the time. Oftentimes, I discuss with our clinicians that COVID started as a clinical challenge. We had a new virus that we didn’t know how it was going to behave. We didn’t know the short and long-term impact of it. And we were trying to figure out every day what was the next step.

But very fast, it became a leadership challenge because you mentioned the different reactions that people had, whether it was politically driven or fear driven, it became a people challenge, a leadership challenge. Talk to me a little bit about how you navigated that as a leader in this nation.

Dr. Robert Wachter:

Well, I think somewhat holistically, I mean, one of the things that I’ve recognized in my career is that medicine is always partly political, partly ethical, partly sociological, partly economic. You know, you’re talking about a system that deeply affects people that is intensely personal. There’s probably nothing more, any more personal that is 18 or 19% of the gross domestic product is that is the major employer in many regions that is going to have to traffic in issues that are, have for many people religious overtones or deeply political overtones. And so, I don’t know how you completely can communicate effectively in medicine without at least appreciating all of the kind of sociological and political context.

And obviously in COVID, it became, those became particularly germane, partly because of the nature of COVID and the nature of public health, where there’s an immediate tension between experts saying things where people may be skeptical of the source of their expertise between authorities, whether they are institutional, like from a health system or governmental is telling people what they should be doing, in part because it’s an infectious disease.

So it’s not all about you as an individual, as it might be when we’re trying to figure out how to treat your blood pressure, your diabetes. In an infectious disease, what you do affects other people. And therefore there’s a communal interest in potentially saying to people, you know, I’m gonna restrict your freedom to walk around without a mask or to not get vaccinated, which of course is in the United States going invariably lead to some libertarian backlash, just the nature of our politic. It’s some ways, the core political question in America really, if you think about the parties, is what is the role of government? What is the role of central authorities? And good people on both sides have very passionate feelings about that. And it became very clear to me COVID was going to bring those out. So to me, I guess one of the things that I bring to the table and pretty unapologetically is taking a political lens and being comfortable with taking up having a political lens through which we see this.

One of the reasons I think that’s so important is, you know, I wrote a book about technology in health care six or seven years ago, and I think we’ve all been somewhat disappointed by how bumpy the road to digital Nirvana has been in health care. And the more I looked at that, the more I came to understand that we treated digitization in health care as a technical problem. We’re gonna put in these big things called electronic health records, and we’re gonna turn them on and they’re gonna make everything better. And it turns out everything is more complicated than that. Everything is socio-technical. Everything has an aspect of behavior and people’s willingness to follow guidelines and the relationship between people and their tools. So COVID brought those out to a greater degree than I think we’re used to.

But I think it is a failing in medical education that we often treat medicine as a technical enterprise where if we can just get the facts out and just tell people, take this vaccine or treat your diabetes, or get more exercise or drink more or drink less, or whatever, that we’re done. And I think we’ve come to recognize, no, we’re not, you know, the technical scientific knowledge is only the starting point of a much harder, and to me, actually more interesting challenge of, OK, that sounds, that’s important, but so is people’s attitudes, behaviors, the money, the politics, the policy. And I think COVID just brought that out in an incredibly interesting and obviously very challenging way.

Dr. Luis Garcia (host):

The book that you’re learning to was published in 2015. And I have it here in front of me, “The Digital Doctor.” And, and by the way, it’s a fascinating read. You talk in 2015 about many of the things that we’re dealing with right now as when, as it relates to the relationship of technology and physicians and patients. So, I mean, you are a visionary. You’re not only a leader, but you’re a visionary.

Dr. Robert Wachter:

You know what? Who is a visionary, I think is someone who has their eyes open (laugh) and asks good questions. And the only thing that was that if that book is visionary at all, it was my recognition that electronic health records were going in, health care was experiencing finally its digital moment. And when I looked around, all I saw was unhappiness. All I saw with doctors complaining about their electronic health records in ways that they did not complain about their iPhone or their, or their desktop computer that in many other, or, or complain about Netflix or complain about Amazon in other walks of life. It struck me that digital came in and yeah, there were a few bumpy years. I just noted yesterday, and Netflix just announced that they’ve mailed out their last red envelope after mailing out billions of red.

So, you know, that’s how they started before they became the Netflix we know today. So it’s not like on day one they figured it out. But in other industries, I saw digital come in, and really within a relatively short period of time, people said, this makes things better in this part of my life. And in health care, digital came in, and in many ways it made it worse. And in funny and unanticipated ways. So my epiphany was when I asked people, why is that the answers I got from doctors or tech executives were wildly unsatisfying? They made no sense to me at all. And I just said one day, particularly after we committed a really terrible error at UCSF, that could have only happened because of a digital system and it’s interfaced with people, I just said, I need to understand this better.

So that’s a long way of saying, I think what was visionary was my recognition that I didn’t understand why digital was so hard and why people were so unhappy with their digital tools and that I needed to, and ultimately found the time and energy to go out and just understand it better. And to do that, I had to talk to a hundred different people from every walk of life that I thought was relevant and try to synthesize it into a story. And that’s nice to hear. I haven’t gone back and read that for the last few years, but it’s nice to hear that some of it is held up pretty well. But it was only because I had the privilege of talking to a lot of very smart people who helped me understand why this path was so bumpy.

Dr. Luis Garcia (host):

One of the really smart people that you talked to is Dr. Relman. And Dr. Relman shares in your book, not his perspective as a physician, but his perspective as a patient. Yeah. Of how he fell. He had several fractures and he ended up in a very lengthy recovery. And he speaks about how it feels to be a patient in the era where we perhaps are being too concentrated on paying attention to a computer. So it’s not only about the physician, right? It’s about the patient.

Dr. Robert Wachter:

Yeah, of all of the unanticipated consequences that may be the most interesting and important one. The way I came to know that particular consequence, first of all, I remember reading an article that my friend Abraham Verghese who’s at Stanford wrote in the New England Journal around the time my book came out, maybe a little earlier, where he coined the term the iPatient. And he said, I won’t get the quote exactly right, but he basically said, the patient only exists to keep their digital medical record alive. You know, that they basically are a representative of the physical person. This person with their life and a family and all of the things that make us human is basically sitting in a bed as an avatar for what we are paying all of our attention to, which is the digital representation of the patient.

And of course, that only gets worse over time as we get more and more data and as we’ll talk about tomorrow as AI gets more sophisticated and better. And one of the seminal moments for me was the first article in the popular press about scribes. I don’t know if you use scribes at all here at Sanford, but

Dr. Luis Garcia (host):

We do. Yeah.

Dr. Robert Wachter:

We use a ton at UCSF. The first article that brought scribes to national attention was in the New York Times in about 2015 or ‘16. It was written by my wife who writes for the New York Times. And it happened because I came home one day and I said, Katie, you know how – and she’s covered technology for the Times for a decade before that – I said, Katie, you know how in every industry they computerize and immediately start laying off people? Only in health care could we figure out a way of computerizing, and now we’ve gotta add another person into the room so the doctor and the patient can look each other in the eye.

And she said, wow, that’s interesting. And so she wrote the first big article about scribes in the New York Times. Scribes are an epiphenomenon. Scribes are a manifestation of, OK, you take the patient’s data and you put it in this computer system and you create pretty clunky computer systems where even the process of just doing a regular search is not that easy and you markedly increase the documentation requirements for the doctor. People always blame that on the electronic health record. It’s not really the EHR’s fault. The EHR became an enabler for Medicare to ask you to document these things. For, to, for billing or for someone measuring quality for all I know you are asking people to document certain things because that’s associated with higher quality medicine or demonstrates how sick the patient is. But the consequences of that is the doctor who’s sitting there who you want to have, be making eye contact with the patient is now spending mu much of his or her time looking down at the computer screen.

And the patient notices that very quickly and says, it looks like the doctor’s actually not paying attention to me. What’s happened here? And so what’s the cure for that? Interestingly enough, this cure will probably be better technology. The cure will be digital scribes, will be that you and the systems now are getting good enough that they’re pretty much ready for prime time. That you’ll be having a conversation with the patient. You’ll be able to make eye contact with the patient. That conversation will not only be transcribed, which is easy to do, but that doesn’t help but turned into a doctor’s note. And as the AI gets better, you can actually turn it into a doctor’s note and say, make it in the form of a surgeon’s note, which might be different from an internist’s note. You can even say, make it in the form of Bob Wachter’s notes.

And it can go and look back and look at my last 3,000 notes and put it in that form. Which is, so the technology in some ways creates the problems. And then ultimately, we have to have the technology bail us out. But while we do that, we also have to take a step back and ask some fundamental questions. If the patient is perceiving that I’m not paying attention to them because I’m busy paying attention to this computer screen, that is immediately going to lose trust. And when we lose trust, we’ve lost everything. But the patient doesn’t trust that you’re there because you care about them deeply and you’re listening to them with all of your energy. You, we’re all screwed. I mean, it really is very hard to have the right kind of doctor-patient encounter that we need. So that was just one of many unanticipated consequences that I saw that had nothing to do really with the quality of the digital interface, with the quality of the computer.

They all had to do with what happens when you change the nature of the work, digitize it. None of it’s anticipated.

Another one I went into in the book, which a lot of people have commented on, is in the old days, geezers like me, went down to radiology every day to look at their films. When I talk to the residents now and I tell them that story, they say, what’s a film? (Laugh) They’ve never seen a film. What’s a view box? There was a view box. They have no idea what I’m even talking about. So periodically when I’m on the wards, I’ll say to my team, let’s go down to radiology. And they’ll look at me like I have three heads. Like, why do we need to do that? Don’t you know you can see the image on the computer? I say, yes. Don’t you know you can read the radiologist’s report? I say yes.

And then I take them down and they’re invariably awed because you go down there and the radiologists now welcome us down there, in part cuz they recognize that if they don’t, the younger people will never go down there. And you have this absolutely wonderful, really important conversation, give and take between the front-line doc and the radiologist and the radiologist reports said so and so and so and so. But then you say to them, well let me give you a little bit of clinical context. This is the story. Oh, the radiologist says, well then I would really worry about this and this. So in that exchange, you’re providing better patient care. You’re getting smarter cuz you’re learning from the radiologist. The radiologist is getting smarter cuz they’re learning from you. I’ve gone back and spoken to the people that were at the leading edge of digital radiology and asked them, did they have any clue, any inkling that digital radiology would change the nature of the front-line clinician-radiologist interface?

And none of them said it even crossed their mind. And of course, in retrospect it’s obvious, why did we go to radiology every day? Why did we have radiology rounds? It’s designated time for radiology rounds every day because it was only one place where you could see the film. It lived in only one place and it was in the radiology department. Once it became digital, you no longer had that forcing function. And the same thing is true when I go to the wards. I’ll go to the wards and there are nurses all over the place. There are no doctors cuz the doctors went and see the, saw the patient, and then they went off into their room, their digital room often where they’re hanging out with each other to do their charting. In the old days, you spent your entire day on the floor because there was only one physical copy of the chart. There was only one place where the lab test came to.

So that’s just, those are examples of these unanticipated consequences that happen that are really not about the technology itself. They are the kind of sociological community relationship things that were built around the lack of technology. And we’re just not smart enough and creative enough to understand what’s gonna happen when the technology comes in until we see it. And it’s like, hmm. And then if you don’t have geezers like me around anymore, the young people never knew there was such a thing as radiology rounds. So they don’t miss it.

Dr. Luis Garcia (host):

It’s just amazing to see that despite the tools and technology and what are advancements we have, it really comes down to basic human interactions. Right? You cannot take away the value of that. And whether you call yourself a geezer leader or whatever title you wanna give yourself, I gotta tell you, I’m gonna call you a mentor because that to me is mentorship.

Dr. Robert Wachter:

Thank you.

Dr. Luis Garcia (host):

And I’d like to ask you a question. Nobody gets to the caliber of who you are by randomness or you know, by luck. Had a lot of work, a lot of mentorship. Do you recognize one mentor in your life that you go like, yep, that person changed my life because of whatever?

Dr. Robert Wachter:

Probably the most influential mentor I’ve had is a guy named Lee Goldman who was chair of medicine at UCSF in the mid-‘90s to the early 2000s, ultimately became the dean at the School of Medicine at Columbia. Lee’s this – and so it’s always shocking to me when I’m now the chair of medicine at UCSF. So the fact that I have that job when I think about how incredibly smart and strategic he is, so I have a little bit of imposter syndrome every day. But when Lee came, Lee had been a resident at our institution, went off and spent most of his career at Harvard and then came back to be chair of medicine. And he asked me to take on this new job. I had been residency director at the time.

He said, I want you to be my right-hand person running clinical work. And I said, I love running the residency. And he said, yeah, but basically stick with me. We’re gonna do big things. I want you to be my person and your level of growth in that job will be greater than what you would’ve experienced in the residency. And I, that turned out to be right. The things I learned from Lee, one is he hated the status quo. He just said, and that’s how the hospitalist field happened. So Lee and I wrote the first article that coined the term hospitalist together. And that happened because Lee said to me, you’re in charge of the inpatient medical service. I look at the medical service and it looks exactly the same as it did when I was a resident here 20 years ago. That can’t be right.

So the instinct that he had when a system that had not changed in a decade had to now be wrong because the forces of status quo and inertia are so strong, and I’m lazier than that, it was like, that’s not, would not have been my instinct. It is now when I see a system that hasn’t changed, whether it’s the way we pay people or the way we organize something, my instinct is always that can’t be right. How do we make that better? And that’s where the hospitalist thing came from. We sort of thought about how do you change inpatient medicine? Came up with this concept that actually it probably needs a separate specialist, but not a subspecialist. Someone who’s a generalist who is in charge of this general hospital care but lives there all the time. And the model for that was really what had happened in emergency medicine and what had happened in critical care medicine 30 years earlier.

So that’s kind of how the whole hospitalists field happened. But the one moment that encapsulated Lee to me, and I think I’ve tried very hard to pay this forward, is a very early meeting I had in his office. He invited me in, I’m sitting on his couch, he’s behind the desk, he’s on the phone, he’s editing the Cecil textbook, the big textbook of medicine. He’s the editor, he’s editing it while he is on the phone while having this meeting. He’s one of these remarkable multitasking people. And it was clear he was having a meeting about some leadership thing on the phone. He had the person on speaker so I could hear, and it had something to do with money and space and parking and the usual stuff. And he says to the person, Joe, can I put you on hold for a second?

And he puts the person on hold and he turns to me and he said, this person wants this and this and this. This other person wants this and this and this. Here’s the big picture, like what we’re trying to do as a department. He said, what would you do? And I said, my God, he’s pimping me on leadership the way, you know, in the old days we used to do about clinical medicine presenting a tough case. What would you do? And he is investing in, he believes in me as a potential leader and is going to basically teach me how to do this and is gonna challenge me. So I babbled something about what I would do. And he said, not exactly (laugh). And then he put the person back on speaker and told me what he did. And I said, this is a good decision to work with this guy because he takes one of the things that he wants to do. I now recognize what he was doing was succession planning. Really what he, what he recognized in me, something I didn’t recognize in myself was that I had some leadership potential and that he was going to mentor me and that I was gonna be watching everything he did. And periodically he was going to stop and ask me a question or stop and contextualize what he was doing. So I would learn that. And so a huge amount of what I think I do in leadership, I’ve learned from him.

Dr. Luis Garcia (host):

I agree with you that teachers see on us things that at times, oftentimes, we don’t see on ourselves. And a good teacher mentor is one that allows you to exploit that in a productive way. So, I love that story. I think that you describe also a situation in your life where you found a fork on the road and you had to make a decision of this or that you had a promising career going to the right, but perhaps a promising career going to the left or vice versa. And you chose – so talk to me about risk in your life and other times in which you went like, oh, what would I do? And what helps you make those decisions?

Dr. Robert Wachter:

Yeah, I, the one that comes to mind the most, and I tell young faculty this at our place, there are very few successful, whether it’s faculty members or people who’ve had other career paths, but very few. I find that when you say to them, you know, was it completely linear that from the time you were in diapers to where you are now, you had this view of what you were gonna do and everything just happened at lockstep and you got the right skills and the right qualifications? There’s almost no one who tells that story. The story is always a bump in the road. Something went wrong or an opportunity arose that they couldn’t have anticipated. And a lot of it is, you know, have you positioned yourself to be open to that? Are you asking questions? Are you taking in, are you sort of looking for new knowledge, new people, new relationships?

Because a lot of it is shots on goal. A lot of it is, you know, creating enough opportunities for those things to happen and then recognizing them when they happen. I think my interaction with Lee was one of them. When Lee asked me to take on this different job than the one I had, and I loved the one I had, but he convincing me and ultimately the making the right call that changing jobs to work with him in a larger leadership or a different leadership role was a good call. Probably the biggest one for me was I finished my residency in chief residency. I did a fellowship that was largely focused on research, epidemiology, outcomes policy at Stanford. And then I came and joined the faculty at UCSF and I got the job you’re supposed to want to have in academia, which is quote “protected time,” meaning I had about 70 or 80% of my time was funded by the system for me to do research with an expectation that in two or three years I’m gonna bring in enough grants to pay for that portion of my time.

So I was about 20 or 25% clinician, about 75% researcher. And I had written a number of papers up to that point. And I, people saw me as having a lot of research potential. I put together a big multicenter grant for what I was working on at the time, which was how AIDS patients did when they went to the ICU. Just to show you how long ago that was. You know, there were almost no AIDS patients that go to the ICU anymore. But back then there were. There were a ton. I spent a lot of time on this grant, put it out there, sent it off to the funder and got turned down. You know, it wasn’t even close. And I looked at it and there was a little bit of thumb sucking about, you know, oh, you know, it hurts to get rejected.

But for me it was a moment of introspection, which is, do I want this as a career? Do I want my incentive to be, I’m always trying to publish the next paper? Write the next grant? To me, I recognize that I did. I thought I’d maybe be successful at it, but I didn’t think I’d be that happy. I didn’t think I had the fire in the belly to be that person. And I have hundreds of people like that who now work for me. I admire them deeply. I think it’s an amazing thing that they do. And they’re incredibly impressive. I just think I’d be great at it. And I didn’t. And I thought I was too social. Cuz I think the incentive in that system is you’ve really gotta close the door and write the next grant. And I like talking to people and learning things more than that.

And so decided that that was not gonna be my career path. And I actually did not know what my career path was going to be because I liked being in academia. So it was like, all right, I don’t think I wanna be a full-time a hundred percent clinician. I’m not gonna be a researcher who’s 70 or 80% research and research funded. What do I do? And it was sort of through that period of reflection that I said, I kind of like leadership. I never saw myself as a leader. I wasn’t the president of my high school class. I always thought I was a little bit too goofy. But I was lucky enough to become a leader at an age where people, goofiness became authenticity, (laugh) that the characteristic of someone who’s reasonably accessible is a good listener, became leadership skills that were, became increasingly valued from an, in a prior era where the leader had the most gravitas was really scary, was someone who was very hierarchical.

The idea of a leader being someone who might be accessible, be someone who, you know, people can call by their first name was, became acceptable. And it was like, oh, OK, maybe I can be decent at that. And then it became one leadership role after another and became something that I over time recognized that I liked, was good at and gave me a platform. Even though I didn’t want to be a full-time researcher, I liked writing, I liked thinking, I liked being a thought leader. And through my leadership roles, I recognized that not only could I carve out enough time to do some of that writing and leadership work, but also it gave me an altitude in my health care organization where I would be seeing things that would give me insights into technology or insights into patient safety or insights into how we organize hospital care that I wouldn’t have had if I didn’t have a leadership perch. So it all, you know, I mean, I can describe it now and it sounds like it all was planned and intentional. It mostly was happenstance and just getting into the right place, the right time.

Dr. Luis Garcia (host):

But I love that story, Bob, because I think that by nature we always incentivize our younger generations to look at their strengths, right? But I don’t think we pay attention enough to what, recognizing what your weaknesses are and not engage in a journey where your weaknesses were surfaced, you know. So I, and I think you perfectly describe an instance where you identified, this is not for me, this is not where my strengths are, so I need to pivot and do something different. And, I think that’s the – you talk about the holistic human being and recognizing where you’re good at. What are you not good at? And how do you allow that to drive into your life? So let me ask you a question. Have you ever made a mistake? Have you ever disappointed somebody?

Dr. Robert Wachter:

(Laugh) I had a failed first marriage. So I, I’d say that would be the biggest mistake I’ve made in my life and didn’t seem that way at the time, obviously. But that was hard cuz I’d been successful in most of the things that I had done and professionally successful. And, you know, arguably your marriage becomes, is one of the most important decisions you make in your life. And I remember holding onto the marriage for a number of additional years cuz my kids were in high school, and I kind of had decided that my ex-wife and I almost collaboratively decided we would stay together until they finished high school. I remember talking to an old college friend one day and struggling with this in part because I really felt like it was a failure and I wasn’t used to failing in many things.

And I said, you know, partly we’re staying together for the kids. And he said, the most important lesson you can give your kids is there’s no problem that’s so bad that you can’t figure out a way of making it better. I thought that was really profoundly important. And it turns out that we ended up splitting and it was amicable and been married now for the last 15 years to the most spectacular person in the universe and we’re incredibly happy. And, but that, as I think about mistakes I’ve made, that’s probably the biggest one. But I think it also taught me some incredibly important lessons.

Dr. Luis Garcia (host):

And how do you rebound from, from when you hit bottom right? And I – to the point that you dedicated this last book to your current wife Katie.

Dr. Robert Wachter:

Well, partly because she’s wonderful and partly because I came home the day I decided to write the book was this day, I was chairing our patient safety committee and we gave a kid 40 Septra tablets. Forty. Forty antibiotic pills when the correct dose was one. It was just a breathtaking error. And it only happened because of digital systems interacting with humans, but all the usual stories of alerts firing, but people ignoring them because they got a hundred alerts a day that were all false positives and several other things. I came home at the end of the day and I said, Katie, I think I need to wanna write a book about this. I said, you know, we’re at this incredible moment of digital transformation. I thought it was gonna be so great and it’s not great. And she said she said, I think that’s a great idea.

You should write a book about it, but you need to do it journalistically. As I said, she’s been a journalist for 40 years. She’s quite good. She says, you have to do it journalistically. And I said, what does that mean? And she said, it means you’re gonna have to go out and talk to people. And I said, I hate people. And she said (laugh) she said, you know, I was joking. She said you know, you’re actually gonna love doing this. I’d never done anything like it. And so I took a year partly on sabbatical and interviewed everybody I could think of who had any insights. So everything from the CEO of Epic to cognitive psychologists to interviewing Captain Sullenberger, the pilot who landed on the Hudson, who said, you have to go to Boeing to see, to talk to the cockpit engineers there.

Next thing I know, I’m on a flight to Seattle and I’m flying a triple 77 simulator in Boeing headquarters. So one of the most interesting, rich experiences, but it was really only through Katie sort of seeing that the only way to get this story right was to go out and learn everything I could about it from a lot of different vantage points. So dedicating it to her was partly that, and partly we have, one of the metrics of a marriage is we actually are one of the few couples I know who can edit each other and not kill each other (laugh), which is a hard thing to do, but she’s a wonderful writer and I’ve learned a lot from her.

Dr. Luis Garcia (host):

Well, thanks for sharing that story. I didn’t know that what prompted you to write that book was that medical error with a child.

Dr. Robert Wachter:

Absolutely. When it happened, I went to the head of risk management and I said, this story is so rich, there’s so much in it that are general lessons about digital human interfaces that I think we have to disseminate this. And I said that to the head of risk management and she said, oh, that’s a great idea. Let’s have some, you know, let’s do grand rounds. And I said, well, I’m actually talking about writing a book about it. And I think her hair went on fire (laugh).

It’s like, what? You’re a risk manager. It’s like, this is not a great idea.

Dr. Luis Garcia (host):

You’re gonna make public what? (laugh)

Dr. Robert Wachter:

Ultimately the CEO of our health system, I felt it was important enough for him to, that he needed to greenlight it. And he thought about it for about a week and then then said, you know, one day he said, you know, this story’s so important that I want you to write about it. So I thought that was really a brave and courageous thing to do, but I think the right decision.

Dr. Luis Garcia (host):

I agree. And it was the right decision on, on his behalf as well. And so somebody would argue that you have done so much and you have reached levels that not every human reaches. Do you think you have reached your potential? What’s next for Bob Wachter?

Dr. Robert Wachter:

I’m really proud of the things that I have done, and I’m never good at saying what’s next. Because when I look back at my career, what I see is a thread of leadership roles that have felt important and interesting where I felt like I could make a difference pretty much all at UCSF. So in a big academic institution and one I like very much and respect and like the culture, and like living in San Francisco, but my career has been a succession of every five to seven years. An issue that seems really interesting to me, that fits into my sweet spot, it’s gotta be pretty clinical. It’s got, it can’t be insurance policy, it has to feel very close to the ground. So very clinical often has a training aspect to it, but all has money, policy, politics, ethics, sort of rich sociologically complicated.

And that has led me to studying the politics of AIDS and activism to studying the organization of hospital care, to studying patient safety, to studying the digital transformation of medicine to studying COVID. COVID is drying up now, thankfully. So I suspect I have one or two more of these in me, but I’m never good at predicting them. And it’s not like I say, all right, it’s seven years, it’s time for me to do the next thing. It usually is at seven years or so, the last thing is feeling a tiny bit stale and I’ve kind of done what I can do, and a new thing emerges. And I just say, that is so unbelievably interesting and I think the way I think about the world, maybe I can make a contribution. So it sort of feels like AI is sort of the next step of the technology thing I’ve been paying attention to. It feels like the new advances in AI are that, but what that means in terms of, I don’t know, writing a book or just being an interested observer, I’m not sure. We’ll have to see.

Dr. Luis Garcia (host):

Well, I can’t wait for the next five to seven years cycle. And I definitely wish that for you, it’s not two or three more, but many more seven year cycles because your contributions have been just phenomenal. Bob, this has been a pleasure, an honor for me to sit here and share some thoughts. Any closing thoughts that you want to share with the new generations, with the new leaders?

Dr. Robert Wachter:

I’ll tell you a quick story to end this. At my institution several years ago, we were talking about all the changes in medicine, technology, payment change, regulatory change, everything else. And one of the very senior, highly respected clinical cardiologists got up at the end of this meeting. He usually didn’t speak much at these meetings and he said something I’ll never forget. He said, you know, this could be worse. And I was very surprised cause he was definitely old school. I was very surprised. But then he went on and he said, I could be younger. And I like that story. First of all, I found it very amusing, but I actually think he’s wrong. I actually think that the world we’re entering in health care is one in which the capacity to take care of patients in a way that is better and higher quality and safer and more satisfying, more equitable and less expensive.

I think we haven’t done very well in any of those regards. I think we have the capacity to do that in part through digital systems. But digital systems married with people who never forget about the human aspects to it. So I think it’s gonna be up to great systems and you happen to be in one of the great systems in the United States to think about how we leverage the technology to make care better, safer, cheaper. And I don’t think he’s right. I don’t think medicine has had its golden age. I think we will over the next 10 or 20 years, and I look forward to doing what I can to help. But I think I’m a little bit jealous of, you know, my daughter is an intern in medicine now, so I’m a little jealous of people of that generation cuz I think they’re gonna see some spectacular changes that are gonna be for the better.

Dr. Luis Garcia (host):

Well Bob, thank you for those closing thoughts. And I agree with you. I think that the next two decades in medicine are gonna be positive and energizing. And, and I don’t think we have reached our maximum potential. So thank you, Bob. Whether somebody sees you as a mentor or as a teacher, or as a leader, or as a clinician or as a generalist or as somebody that coined the term hospitalist, it doesn’t matter to me. You are the definition of a great human being, and it is an honor to spend some time with you today. And to our listeners, I wish you could be here to shake Bob’s hands because he’s just a phenomenal leader and influential person in our health care. So Bob, thank you very much for spending time with us.

Dr. Robert Wachter:

Thank you, Luis. It’s really been my honor and it’s just a great pleasure to visit you and get to know your system better.

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

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