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Podcasts Archive - Page 8 of 13 - Sanford Health News

What is joint pain and what can you do about it?

Simon Floss (host):

Hello, and welcome to the latest “Health and Wellness” podcast, brought to you by the experts at Sanford Health. I’m your host, Simon Floss, with Sanford Health News.

Our conversation today is about joint pain. Helping answer questions that we may have all had at some point is Dr. Cody Sessions, who’s an orthopedic surgeon with Sanford Orthopedics and Sports Medicine.

Thank you so much for being here today, Dr. Sessions.

Dr. Cody Sessions (guest):

Yeah, Simon, thanks so much for having me. Real privilege to be on the ortho podcast. So like you were saying, I’m an orthopedic surgeon with Sanford Bemidji. It’s myself and two other general orthopedists, and we really do kind of do a full spectrum ortho practice, whether or not it’s sports injuries or arthroplasty or fracture care. So joint pain’s a pretty common complaint that we see in clinic, and we’ll be using this time this afternoon to talk about what it is and what we can do about it.

Simon Floss (host):

Awesome. Thanks again for joining us. So as we get started here, tell us just a little bit about Sanford Orthopedics and the types of patients that you see in your clinics. I would imagine it’s pretty much everybody.

Dr. Cody Sessions:

Yeah, I mean it really is. We see kids with elbow fractures all the way up through you know, your grandma with a hip fracture. And in between we see all kinds of derivations of joint pain, whether or not it’s sports injuries or some chronic lingering pain from osteoarthritis or some sort of tendonitis or rotator cuff injury.

Simon Floss (host):

Hmm. So what causes joint pain? Like why does it happen?

Dr. Cody Sessions:

When a joint is not working smoothly, the body compensates by increasing synovial fluid production, thinking that perhaps maybe more oil can solve the grinding problem within the joint. This leads to an increase in pressure in the joint, which will lead to an effusion. And if the pressure gets high enough for long enough, it can create additional spaces of fluids such as a ganglion cyst or a baker cyst. Finally, the irritated state of the knee can cause inflammation to the synovia, which can further increase pain within the joint.

The process can begin from multiple different directions. Sometimes the pain around a joint is not actually coming from inside the joint. For instance, the gluteal tendon, which provides critical hip function, can get irritated and inflamed. This inflammation over the lateral hip is different pathology and can be treated much differently than pain from inside of the joint. Or take for another instance, an autoimmune disease such as rheumatoid arthritis. The problem often starts within the synovium, which is the barrier that keeps the synovial fluid from the joint and ends up damaging the cartilage from a different direction.

Simon Floss (host):

I just find it fascinating that one part of your body might be hurting a lot. Like for instance, I just turned 30 by the way, but I have the back of, like, a 70-year-old and deal with, like, sciatica and all these things. But really the culprit might be tight hips or things like that. So how unique is it that, I guess it’s kind of a funny question, but how unique is it that everything’s connected within your body? Imagine that you know? (Laugh)

Dr. Cody Sessions:

Yeah, no, I would say it definitely is a common occurrence where, you know, a previous injury can cause somebody to change their gait, which then can precipitate some tendonitis in a knee when really the initial injury, like you said, was in the back.

Simon Floss (host):

So are there ways to manage joint pain for patients by themselves?

Dr. Cody Sessions:

Yeah, absolutely. I would say depending on the source of the joint pain, there can be a variety of things that someone can do to manage their pain on their own. For instance, for osteoarthritis of the knee, the American Academy of Orthopedic Surgeons states that there is strong evidence that anti-inflammatories, medications like ibuprofen or Aleve, low-impact aerobic cardiac exercise, and weight management can be quite effective in initially managing your discomfort.

With regards to hip osteoarthritis, there’s also evidence that a cane or a walking stick can decrease the joint forces, which will cause less pain. However, if the source of pain is coming from something else, these treatment modalities may not be so effective. So it’s often wise to come in and be evaluated for persistent pain to ensure that you have the correct diagnosis.

Simon Floss (host):

So you mentioned, like, low impact exercises or low weight-bearing exercises. What would be some examples of that? I would assume maybe swimming or biking or yoga? What would you tell people? What are some examples of that?

Dr. Cody Sessions:

Yeah, I think you got a pretty good idea of what it looks like. So all three of those would be very acceptable. Other things that I encourage people to consider are like an elliptical or an arc trainer at the gym. I would say anything that gets the joint moving without the pounding is probably what’s going to be most beneficial for you.

Simon Floss (host):

Sure, yeah. I’m just curious and picking your brain here a little bit. Everybody’s talking about cryo chambers. They’re all the rage. Or, that cold exposure can help. That one guy Wim Hoff talks about it all the time and I mean, he basically lives in a frozen lake, but does cold therapy or maybe time in the sauna on the opposite side of that, does that have any impact or could that help people out?

Dr. Cody Sessions:

Yeah, I think that’s a good question. And that actually comes up pretty routinely. I would say that a patient comes into my office with a previous recommendation from one of their friends or an experience that they’ve had. And the things that I had previously talked about are the ones that the American Academy of Orthopedic Surgery says that there is multiple studies that say that they do make a difference. A lot of those other things I think people experience a positive effect from, but maybe there’s not the level of evidence to support them or not. So, I don’t think that it hurts to try some of those.

There are some supplements that people like to try and interestingly enough, those aren’t regulated as well by the Food and Drug Administration. So I’d say if you’re going to be, like, taking something, maybe you should talk to somebody before you start trying that. But if you find that ice makes your knee feel good, or heat makes your knee feel good, I think that there’s minimal harm in trying some of those things.

But I guess it would just generally be good practice to run it by your primary care or your sports medicine or orthopedic surgeon before you implemented it for too long or ended up wasting a lot of money on something that maybe has no evidence at all.

Simon Floss (host):

Yeah, sure. I just going to say, I’m sure there’s a lot of like snake oil salesmen out there who would say, “take this turmeric and you’ll never feel knee pain again.” And you know turmeric is fine, I’ve used it and it’s great from time to time. So, what happens if a patient would need professional medical help? What are their options?

Dr. Cody Sessions:

Once non-operative treatments have been exhausted, surgical intervention for joint pain may become necessary. The principle for osteoarthritis is the same for all joints. The goal is to remove the painful arthritic surface and replace it with a new metal and polyethylene joint that will be able to move less painfully. In recent years, advances in surgical practice and anesthesia have changed the surgical experience.

Many patients are now candidates for a same-day total joint, where the patient comes to the hospital for a joint replacement and literally leaves that afternoon to sleep in their own bed. If a patient is a good fit for having surgery, the perioperative team will meet with the patient that day, getting them all the preoperative appointments and labs necessary prior to their surgery routine.

Total joint classes are offered, giving the patient a comprehensive overview of what to expect leading up to their surgery and after. While the initial surgical intervention is not inconsequential, with regards to pain and recovery, Sanford has every resource necessary to guide the patient from start to finish, allowing them to get a surgery that will be necessary to return them to meaningful activities that would’ve otherwise been prevented by their joint pain.

Simon Floss (host):

Great stuff. Dr. Sessions, before we let you go here today, is there anything else you wanted to add or, you know, what would maybe be, like, a take-home message that you would want the listeners to know?

Dr. Cody Sessions:

Yeah, I would say that take-home message, at least from the Bemidji community, is you don’t have to wait for forever. There are definitely things, and just because you come in doesn’t mean that you’re going to get scheduled for surgery or something else, but if you’re out there and your joint is bothering you, come in and see what’s available for you.

Simon Floss (host):

Yeah. Awesome. Well Dr. Sessions, again, thank you so much for joining this conversation today and enjoy that sunny weather in Florida. We’re all, you know, very happy for you, but also equally as jealous. So thanks again for coming in.

Dr. Cody Sessions:

Absolutely. Thank you for having me.

Simon Floss (host):

You bet. This episode is part of the “Health and Wellness” series by Sanford Health. As I mentioned at the top of the show, hear more episodes in this series or some of the other Sanford Health series that we have. You can find those on Apple, Spotify, or Sanford Health News and that link is news.sanfordhealth.org. For Sanford Health News, I’m Simon Floss, and thank you again for listening. Take care.

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NDSU’s advances in nursing school keep human touch

Alan Helgeson (announcer):

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. Carla Gross, associate dean for the School of Nursing at North Dakota State University. Our host is Erica DeBoer, Sanford Health chief nursing officer.

Erica DeBoer (host):

I’m so excited to have you here to really kick off our reimagining health care and what does it really mean for nursing. So we’re gonna pull a couple episodes together to really talk about what an incredible gift our colleges are in our states that help to support our nursing practice and the workforce needs that we have.

Carla Gross (guest):

And we are so fortunate to have practice partners like Sanford. I mean, we could not educate our nurses without a really strong relationship like that. So we appreciate you too.

Erica DeBoer (host):

Well, appreciate that. Now, Carla, do you mind just introducing yourself and the roles that you play, please?

Carla Gross (guest):

Yes, I am Carla Gross. I am the associate dean for the School of Nursing here at NDSU. I could probably tell you a little bit about it. We have two sites, as you know. We have our campus here at NDSU in Fargo, and then we have a site in Bismarck that we call NDSU Nursing at Sanford Health. That was a very careful title that we agreed upon. And so at those sites we have the pre-licensure BSN program in Fargo, we admit 64 each semester. And in Bismarck, we can admit up to 56 each semester.

And then we also have a family nurse practitioner program that is a doctor of nursing practice degree. And we have that on both sites as well. So we admit like about 12 every year in Fargo and six in Bismarck. And that’s face-to-face. Just, you know, a traditional taught course or program. And it’s – we put out really excellent graduates on that course.

Erica DeBoer (host):

Absolutely. Yeah. We appreciate that a lot. Again there’s also pharmacy here. I had the privilege of walking through your beautiful building and just really saw not only pharmacy, but also other allied health services, as well as public health. So, so amazing programs and people that you’re helping to contribute to the workforce. And we so need them. So, yes. Fantastic.

Well, obviously, so excited to be here with you today. I love that you’re willing to just take a little bit of time to spend time with me and really talk about what and how NDSU is contributing to our workforce challenges, but also getting super creative and using technology to help us address some of the needs that we have as well. So, really appreciate that. The hope is really to highlight some of the innovations that we’re using to help prepare our nurses of the future, as well as how do we partner as an institution, as well as our colleges of nursing to try to just prepare in this rural space that we live as much as you’re in Fargo?

Really, when we look at South Dakota and North Dakota and really where Sanford Health sits, it’s really rural. And so we have a unique set of challenges that we’re really trying to address. So, I wonder if you wouldn’t mind just telling me a little bit about what your thoughts are on what today’s nursing students need to be prepared that’s different from in the past. I know you’ve been part of the NDSU team for a really long time. And you’ve seen a lot of changes in health care. So I would love to hear your insights on that.

Carla Gross (guest):

Patients and families are more complex than they’ve ever been. At the same time, the health care system is so complex, so helping new graduates learn how to navigate that is, to me, it seems overwhelming what they walk into. But they’re able to do that, and they need to be able to analyze and interpret data and then appraise evidence so that they can give the best care possible and hopefully come with better patient outcomes.

And another thing that is so important is that they’re able to very quickly assess and adapt to these ever-changing environment – that is so important. And at the same time, health care has gotten more and more specialized. So they need unique sets of skills and knowledge more so than ever before, I believe. And health care has gotten more interdisciplinary, and nurses are often the leaders on those teams. So they need those leadership skills.

And they, I think our scope of practice has expanded so much, and nurses are more independent than they’ve ever been. And our students are excited about that. They feel like that’s a big challenge. Never before have they needed such high level critical thinking and clinical decision making skills. And think about it, now they have to be ready to take care of patients during disasters. I mean, it could have been the pandemic, but it could be a mass shooting or all these environmental disasters that are going on.

So there’s a lot of challenges in trying to help them develop the skills that they need. And I think we’re really realizing how important self-care is. It’s not just a luxury; it’s an absolute necessity. And we have really embraced that. And we start with self-care in our first introductory course. And we also start with learning what professionalism means and what they need to start developing their professional identity the minute they start in the program.

So we’re really trying to lift them up in that respect. And, you know, I also have to say that never before have we had the mental health issues that we have, not only in their patients and families, but in their colleagues. You know, so helping people through burnout or caregiver fatigue, that is like at the forefront of their practice. They also have to be prepared for the violence that we’re seeing in health care and how to keep themselves safe. I, so when I think about all the things that they need to learn, it seems overwhelming.

Erica DeBoer (host):

It’s not just about mamm-phys. It’s not just about assessment skills. It’s really a lot that has to do with mental health. It’s the things that, even social determinants of health and how that impacts not only well-being, but their physical health as well.

Carla Gross (guest):

That’s another thing that we’re introducing the first course. The only other course they’re taking is health promotion, and then they’re taking this introductory course. And so they had them design a community that would be cognizant of the social determinants of health. And it was really cool to see what they included, you know – health care, but schools and homeless shelters and, you know, starting to think like that right from the beginning is, it’s so important.

Erica DeBoer (host):

Well, I think that’s the key. And the huge, like, glimmer of hope that I have in our new nursing workforce is they do think about things differently. They do. They don’t have some of that traditional thought that some of us are steeped in. So I say that I’m steeped in it just like everyone else. Yeah. But they can see through a different set of eyes and they can help us get super innovative. So I love that activity. Yeah. And that is one of those things that just helps us actually. Just advance and understand through the lens of that patient.

Carla Gross (guest):

They come to us with – they embrace diversity, and they can teach us a lot about that. So I really admire that about this age group as well.

Erica DeBoer (host):

That’s awesome. So tell me a little bit more about how you use technology and digital tools to allow nursing students to be better caregivers.

Carla Gross (guest):

We do a lot in the simulation lab. That is becoming such an important part of nursing education. Well, really any health care field. And so we really try to make sure that every one of our students gets an opportunity to take care of patients in common situations. So everyone gets to take care of a mother giving birth. So the high fidelity simulators are cool you know, someone in shock. They do a code simulation with the pharmacy students. So we’re really trying to do like a lot of interdisciplinary things. But, you know, what is more powerful than these $150,000 high fidelity simulators is we hire actors to play the role of, for example, one scenario is a patient that has schizophrenia and is hospitalized and is hearing voices and having hallucinations. And so having the students learn how to interact with and communicate. It’s really powerful.

And another one, another thing that we learn from our graduates is how difficult it is to take care of a patient the first time a patient dies. So we have a simulation where they take care of a family during an expected death, and then we do it in an unexpected death cuz they’re such different situations. And so some of those are so powerful. And I think one of the other ones that’s really powerful is it’s an infant simulator and a shaken baby syndrome. And so that comes in with head trauma, but also the parents are there and learning how to interact with parents during that very stressful situation.

So we find that if we can help them practice those skills with our guidance, they’re gonna be better prepared for some of those situations when they get out. Yeah. And, you know, lots of stuff that they learn, even some of those simple communications transfer to other situations. It’s just like learning how to just meet the patients where they’re at and talk at their level and respond in with compassion.

Erica DeBoer (host):

It’s really amazing. I think what I’m hearing you say is, although technology is an important part of it, it really is the relationships and the scenarios that really build that expertise and build that comfort level so that they can manage in that real life scenario.

So I really appreciate the interdisciplinary approach, too. It’s super important for all of us to understand the important role that each one of our teammates play. It doesn’t matter if we’re talking about that hospital scenario in a rural setting, in a clinic setting, or in even our skilled facilities. So yeah, those relationship skills, the learning how to manage and be that leader for the team is really incredibly important. So I appreciate you calling out how much nurses are really looked to as leaders in that patient care.

Carla Gross (guest):

We’re there 24/7 and we’re the ones that are interacting with the patient and the family and all the rest of the health care team, and making sure that there’s that continuity and that high quality. And so that’s really important.

I think another really creative thing that we do is we have a poverty simulation. Faculty are involved, staff are involved, they play different roles. Someone might be the social worker, someone might be the police officer, someone, and they put the students through these. These are homeless, there is a – and so they’re having to figure out some really hard decisions. Like, I only have this much money. What am I gonna spend it on? Alcohol or groceries or … they can kind of see how people get desperate and do illegal things because it’s survival.

Erica DeBoer (host):

Well, and if you really start to think about it, those are those real life scenarios that they’re gonna have to work on navigating. When you think about motivational interviewing and really getting to the bottom of what’s forcing that patient to not necessarily contribute to their health in a way that’s most meaningful. And in some cases, it’s survival.

Carla Gross (guest):

Yeah. And to understand where they’re coming from, you know, what kind of life they’ve led and the shoes they’ve walked in. You know, it’s like they need to really develop that compassion and empathy.

Erica DeBoer (host):

Yes. And I think in the technologic world, it’s building those relationships, which takes time to develop over time if it’s not something that naturally comes for them. So I appreciate your emphasis on that.

What do you find, or why do you find students today decide to pursue a career in nursing compared to maybe what you had had in the past? Maybe it’s the same, but I’d love to understand if you’ve seen any changes or differences in their why.

Carla Gross (guest):

Our most outstanding students still feel a calling to nursing. They wanna help people and they wanna make a difference in their lives. And that we see that over and over again in their essays. But, you know, we also see some pragmatic reasons. OK. I mean, because nursing, you’ll always have a job no matter where you go. It’s so flexible, and the salaries are becoming much more attractive. And I think even the hours are becoming, you know, I think that it’s more attractive that way than it used to be.

But I think also students realize how many opportunities there are. If you have a BSN in nursing, you can do anything, you know? Yeah. So that’s what they see and they see that you can work with any age group, you can work in any setting, almost any setting. Absolutely. And if you want, you can go on and advance your education and be, you know, an advanced practice provider or a manager or leader or come into education. We need and welcome education, you know, and we have actually a mentor program in our lab skills. So we – once the students have taken the two, we have a beginning skills and an advanced skills course, and they can apply to be a lab mentor. And so they then spend time in the lab with more junior students.

Erica DeBoer (host):

That’s amazing.

Carla Gross (guest):

It’s powerful because they actually are harder on their peers than the faculty are. That’s great. The students are more receptive to their feedback, you know. So but a serendipitous finding that we had is they realized they love to teach. So then it’s like, oh, well we get more students that are interested in nursing education.

Erica DeBoer (host):

Nursing education, being a clinical instructor. To your point, the flexibility and the options are endless, but I think people don’t really understand that. They don’t. They make assumptions that in all actuality, I have to work here or I have to work there. Yeah. But obviously I think you’ve had a journey as have I. That I’ve done a host of different things across my entire career, and in some cases it wasn’t part of the plan.

Carla Gross (guest):

No.

Erica DeBoer (host):

And those doors open.

Carla Gross (guest):

Yeah. What other, what other discipline can you do that in? I mean, nursing is really unique in that way, and I think that’s what’s so attractive about it. We’re seeing more men in nursing too, so.

Erica DeBoer (host):

Absolutely. And I appreciate the way that they think about things and they problem solve differently, so, oh, they do. I think to your point about diversity and really leveraging some of the different schools of thought, it’s really incredibly important as we look to the future and reimagine how we take care of patients across the board. Do you feel like COVID had any changes or motivated people in a different way?

Carla Gross (guest):

Yes. I don’t think it was healthy for them to be isolated, and learning online was not ideal. So and our students were the first ones to say that they did not like – we saw a lot of mental health issues too. We were only out for half of a semester, thank goodness.

Erica DeBoer (host):

Good for you.

Carla Gross (guest):

Yeah. But we did see like a decline in motivation and, and we’re still recovering from that. And, you know, nursing education is cohort based, so that’s what I think makes it so strong because they get so close and they motivate each other and they, not being close to your cohort during that time was hard.

But I do know that when they came back, they were more anxious to get out and practice and help than ever. And especially at the beginning of the pandemic, you know, nurses were seen as heroes and respected, but as the pandemic became more and more prolonged, and we saw this vaccine, you know, vaccine hesitancy, and I think that that’s been a little bit hard too, because all of a sudden some of our patients are skeptical and as the most trusted and respected profession (laugh) that’s hard for us to understand. So I’m hoping that that’s just a phase and, you know, we’ll be able to reestablish that.

Erica DeBoer (host):

It’s so important. I can, I’ll never forget that when we started to have some solutions that came onto the market to help us and just how incredibly relieved people were that we had something that we could do instead of just supportive care: the vaccine, monoclonal antibodies. It really, everybody just wants to help. And that calling. That care. As well as really the silver lining of COVID for me was how incredibly connected everyone was as we navigated it and what problem solves – problem solving, excuse me – we could do.

Carla Gross (guest):

They were just so, I mean, so many innovative things, and I honestly think that nurses should partner with engineers and be entrepreneurial.

Erica DeBoer (host):

I love to hear you say that. So I do believe that we can be data scientists as nurses. Yeah. I do believe that we have an engineering mindset. Yeah. And if we partner and help people understand the why behind what we do, as well as the important role that engineers actually play at Sanford, we actually have some engineers that actually help watch some of our workflows.

So again, we talked about how important tradition is to nursing, but how breaking some of those traditions are really what it’s gonna be necessary.

Carla Gross (guest):

Yeah. We gotta do things smarter.

Erica DeBoer (host):

Yes, exactly.

Carla Gross (guest):

Yeah. And exactly. It’s interesting because, you know, we have engineers big on NDSU campus. Love it. You wouldn’t believe how many nurses and engineers get married.

Erica DeBoer (host):

That’s so interesting. That’s so interesting. Now also, I do have to call out since you brought up engineering that Sanford partnered with some of your engineering students. Solutions with different robots that could actually help transport supplies. Again, that efficiency and that effectiveness and that innovative spirit is just so exciting. It’s so exciting.

Carla Gross (guest):

It is. We had one time, we had a group of nursing working with a group of engineer students because they were going to create some kind of a device to detect seizure activity in infants, but they thought it would be no problem to just insert it in the brain (laugh).

Erica DeBoer (host):

Oh!

Carla Gross (guest):

Well that would just be fine. So our nursing students had to walk ’em through this, what this really means. So they do think differently.

Erica DeBoer (host):

Hundred percent (laugh). Hundred percent. It’s safer if we’re working at it together. Yeah. Fair, fair. So I really appreciate that partnership. Curious from your perspective, Carla, what can we do as an institution that’s bringing in and using students for our clinical experience? What can we do to help support that experience more effectively?

Carla Gross (guest):

Well, honestly, just welcoming the student. And make ’em feel like they’re valued. And for us, we kind of coach our students that we don’t want them just observing or sitting around. I mean, if you have extra time, you could see if someone needs help, you know, so getting that team spirit right away, you know, ingrained in them.

But yeah, I think it’s all about creating an environment where they feel welcome, where they feel valued, and they can contribute to, you know, what we all want: quality patient care, good outcomes, and a team, you know, a team that enjoys coming to work. And that’s what I think we really hope for is that we work so hard to make sure that our students are practice ready when they graduate.

And we just want them to be able to find an environment where they can practice, you know, at the highest level of their scope and feel like they’re valued and feel like they’re an important part of the team, because that’s what they want. They’re looking for that.

Erica DeBoer (host):

Yeah. When you think about some of our traditional nursing students, that’s a very important part of it, is making sure that you have colleagues that you can trust. And that I think all of us know, we spend a lot more time working than we do away from working. Yeah. And so it’s important. Yeah. And I appreciate how that’s elevated for them.

Carla Gross (guest):

I mean, that becomes your second family, really.

Erica DeBoer (host):

Absolutely. Absolutely. I’m curious if you have any questions for me, Carla?

Carla Gross (guest):

Oh, I think I do. So what is the biggest challenge that you see for nurses in the earliest part of their career?

Erica DeBoer (host):

The biggest challenge, and if I were to name one, I’d say that it’s prioritization. Yeah. So when we think about the complexity of health care and expecting our nurses to really be that leader, there’s a lot of stimulation that’s coming to them as it relates to especially that inpatient setting. But even in an ambulatory setting, those visits are really quick and there’s a huge set of expectations on the table. So I would say prioritizing that care and making sure that we’re constantly looking at the patient as the patient and at the center of everything. Yes. It’s difficult not to become a task master.

But they come to us at their most dire times. Doesn’t matter if we’re talking about an inpatient setting or the clinic, or even in our skilled facilities. That care, that compassion, that empathy is so essential to really making sure that they have a good experience and that they understand everything that’s happening. Again, it takes a lot to manage all the tasks, one, but then how do you prioritize that relationship that you have with your patient in that 12-hour day?

Carla Gross (guest):

Yep. And it’s gonna take ’em a while to get there developmentally. You know, because they’re so focused, like we learn, like our nursing students, they’re so focused on tasks right away. And so once we can just get ’em over that level, then they can see this higher level tasks that they, the, well, not even task responsibilities …

Erica DeBoer (host):

It’s the responsibility. It’s that critical thinking. I have the privilege to mentor a couple other senior nursing students. And my favorite calls are when they start asking me questions and they’re critically thinking through, if I had this super complex patient help me understand how I would manage. And so sometimes it’s really about just giving ’em that reassurance that it’s gonna take you some time.

Use your resources. Use those details and start asking all the questions that you can. Because there are resources available around them you can just talk through things. So it’s so exciting to see how the wheels start turning. And how they’re starting to try to process through how to do things. So I think our clinical experiences are extremely important. I think our internships are also super intentional. And essential for them being well prepared just to give them that extra experience that they need to be successful.

Carla Gross (guest):

Yeah. We highly encourage them to do one or two internships if they can. Right. So, I agree they can have all the technology at their hands that are, you know, available, but they have to trust their own assessment skills and their own gut. Don’t ever underestimate how important those are.

Erica DeBoer (host):

I’m not wearing my bracelet today, but it says, trust your intuition. Right? Yeah. So trust your gut.Makes all the difference in the world. And that gift that a patient, those words that they use, the things that they share with you, what a gift that is to your assessment.

Carla Gross (guest):

Absolutely. Because you can’t rely on that. Right. I mean, you’ve still gotta know, you know. Never underestimate your own assessment skills.

Erica DeBoer (host):

Agreed. Agreed. I think it’s super essential. I think all of us love technology, but I always say we have all these things in place for a reason. If you don’t use them or you skip those steps, if it’s, again, I think it’s up to us as an institution to make sure that we make their work as frictionless as possible.

So how do we reduce that documentation burden? How do we make sure that there’s value in the work that they’re doing? I have a, a word that, or a phrase that I always use, it’s called GROSS: get rid of stupid stuff. So it doesn’t matter if I’m talking to the nurses on the floor, if I’m talking to our patient access teams, but what are those things that actually don’t add value to your work? And so I think what I would love to hear from our front-line teams and especially people that come into our institution with fresh eyes is, what are those things that don’t make sense? And if people can’t tell you their real why, then, gosh, I think we should maybe just look at that and reevaluate. Is that adding value to your work and the care that you provide? And if it’s not, sometimes we just maintain some traditions because we think we have to, one, in all actuality, challenging the norm is what we need to do.

Carla Gross (guest):

And that’s, that was a gift of COVID.

Erica DeBoer (host):

Yes.

Carla Gross (guest):

You know, there, that was a bright lining we learned to do things differently. Anything we can do so that nurses can be present in the moment with patients and families will make a difference.

Erica DeBoer (host):

Absolutely. Absolutely.

Carla Gross (guest):

So another question I have is nursing has changed since you entered the field (laugh). So what do you tell nurses who are interested in a leadership role like yours?

Erica DeBoer (host):

Oh, that’s a really great question. So it has changed a lot. And I came up through the rankings, started as a nurse aide in the Good Samaritan Society near my hometown. So in that long-term care space was a nurse aide on the pulmonary unit. And at that time – this is what else has changed – there was only one position open and six of us that were graduating. Can you imagine?

Carla Gross (guest):

That was how it was when I graduated.

Erica DeBoer (host):

So I think times were different. When I think about the advice that I give to our front-line teams is you’re a leader every day. You’re the lead of that patient care. And so you need to do, and you need to learn as much as you possibly can every time you enter the walls and every time you take care of a patient, there’s so many things to learn.

The other thing that I share with people is don’t rush. Right. I know that there’s always maybe that next best thing that you feel like is gonna make a big difference, or it’s what you’re seeking. Follow your heart, follow your gut, and give yourself time to just learn and grow in the space where you’re at. I think, as we mentioned already, nursing is such an incredible field.

You can do anything. And so if you think about the opportunities that we have really to be in our shared governance, so as a senator to be part of performance improvement and quality improvement, we need the innovative spirit. We need that scientific brain that nurses have to help us solve the health care issues of the future. Yeah.

And to that point, we talked a little bit about internships during some of our other conversation. There’s actually a lot of other opportunities to actually shadow and spend time with our executive leaders to really understand really what is it? And how would I contribute in a positive way to that type? But again, giving yourself time to be in the moment and learn as much as you possibly can, seems to be a really important thing for me to share. That if it’s OK not to have a goal in the, in the next year, give yourself time to learn.

Carla Gross (guest):

They’re all so quick to get to the next step. And it’s like, you know, what we try to tell our students is you can do so much with a BSN degree. Oh, yes. And you can make such a difference at the bedside. And there’s probably not a more rewarding role than at the bedside with the patients and families. So for some reason or another, this generation thinks they’ll have to go on and get an advanced degree. And it’s like, no.

Erica DeBoer (host):

(Laugh) You really don’t. You don’t. There’s so many things that you can do within the scope of practice of what you have. Like you talked about being a clinical instructor, going back and helping teach courses, it’s a, there’s so much relevancy to the BSN degree. Yeah. Awesome.

Carla Gross (guest):

So why would, why did you tell nursing students, graduates, why they should choose Sanford Health as their place of employment?

Erica DeBoer (host):

Oh my goodness. That’s a great question. Thanks for that. I think, Carla, the most important thing that we try to do is differentiate ourselves from other organizations. And I think the two ways that we do that is, one, we’re on our high reliability journey. And so our culture of safety is at the best that we possibly could. We’re constantly looking, we’re constantly searching for those ways that we can continue to deliver high quality care without error.

So we engage all parts of our organization in quality and safe patient care. Not that everyone doesn’t, but I feel like our SAFE journey, Sanford Accountability For Excellence, has really taken us to that next level. So that’s one thing that we’re paying attention to at the highest part of our organization. Quality patient care, our patient experience, serious safety events, not only for our patients, but how are we actually making sure that our employees feel really safe within our walls.

I think the other thing that I am super proud of that Sanford has is our World Clinic program. And so we try really hard to build our mentorships around some of those unique experiences that they’ll have the privilege to be a part of. Obviously we can’t have everyone be a part of every program, but I think the opportunity not only to grow as a nurse in different parts of our organization, but also to have some of those other unique experiences.

Carla Gross (guest): 

Have they been traveling?

Erica DeBoer (host):

I’m so excited to share. We actually had several – we had six actually last year that were part of the World Clinic mentorship program. Several went to Ghana. We have someone who’s just coming back from New Zealand to finish up her experience. So Kelsey is one of our mentors from Brookings. She’s actually an ambulatory nurse there and helped with a host of different things around immunization and some of those workflows. Tiffany Johnson was in Ghana and did a lot with education in those teams. Costa Rica is the other location that we’ve had some teams actually go and spend some time specifically around education, setting up skills labs in Costa Rica. So, and I had the privilege for the first time to travel to Ghana just last month. And it was a life-changing experience.

Carla Gross (guest):

Oh. Yes.

Erica DeBoer (host):

The commitment, the love that they have for the communities that they serve is just unbelievable.

Carla Gross (guest):

At NDSU, nursing, before the pandemic, was like the second largest study abroad, had the second largest study abroad program. We’d gone to Kenya, Malawi, Haiti; we went to India once. Amazing. Yeah. Amazing. We’re just finally getting back. We’re sending a group, a large group of students to Malawi in about less than a month.

Erica DeBoer (host):

That’s amazing. I really do think that it’s a differentiator that we learn how fortunate we are in the United States. I think the other piece that to your point about technology, technology is incredibly important, but the basic back to basic skills are really even more important than ever. As we look at some of the supply shortages, some of the other challenges that we’re having to navigate in health care today, and we’re gonna have to get creative in Ghana, they call it improvision. And I said, I call it innovation.

Carla Gross (guest):

Improvision?

Erica DeBoer (host):

Yes. Yeah. Yeah. Improvise. We improvise. I said, well, I like to call it innovation. Right. So let’s discover what works. Yeah. Do a lot with a little and make a difference for patients.

Carla Gross (guest):

Yeah. So it’s amazing you know, the things that they get to do and see when they go on those study abroad.

Erica DeBoer (host):

Yeah. Yeah. It’s an eye-opening experience. Well, Carla, it’s been an absolute pleasure to get to know you a little bit and have some time to have conversation with you. Thank you so much for joining us today.

Carla Gross (guest):

Thank you.

Alan Helgeson (announcer):

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

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USD collaborates for the next generation of nurses

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 nursing education and collaborative partnerships in developing the next generation of nurses. Our guest is Dr. Anne Pithan, department of nursing chair at the University of South Dakota. Our host is Erica DeBoer, Sanford Health chief nursing officer.

Erica DeBoer (host):

Anne, welcome. I’m so excited to have the opportunity to chat with you today about how USD and our partnership is helping to address some of the nursing workforce issues. So maybe to start, do you mind introducing yourself?

Anne Pithan (guest):

Thank you. Erica. My pleasure. My name is Anne Pithan and I am the chair of nursing at USD. I have been in the nursing profession for 36 years. And have really had a blend of nursing practice, academics and leadership. So it is really my pleasure to always let you know what USD is doing and how we can support your work.

Erica DeBoer (host):

Amazing. A long profession. And we are so privileged to be able to partner with you, and I appreciate all you do. I think to start off December of 2022, USD celebrated and welcomed to the USD’s newest home for health careers in education. I’m here today with you at the Center of Health Education in this amazing state-of-the-art building. Tell me how this is a differentiator for your nursing students who attend USD.

Anne Pithan:

Thank you, Erica. And we are so pleased that you’re here to be able to see our facilities. So what we love about our USD nursing facilities is we really feel that this is an opportunity where students can learn in state-of-the-art facilities and really learn in an environment that is safe for them. It really allows them to make mistakes. And it allows faculty to really mentor and talk them through how they can really perfect their nursing skills.

So we love our facilities in the fact that it really supports practice readiness. We have, again, state-of-the-art facilities in our simulation and in our lab where students can gain confidence, they can develop their nursing skills, their communication skills under the mentorship of our excellent faculty.

Erica DeBoer (host):

Yeah, I agree. I had the chance to meet a couple of your faculty as well as take a tour of the facility. And it makes me really excited cuz I think as you well know, I’m an ICU nurse by background, so to go in your simulation labs to see the high tech, the same beds that we see in our hospital setting, the pumps that we have, as well as just that environment and the attention to detail that the team has put into it. I’m really impressed.

I think the other thing that I have to compliment the team on is your commitment to interdisciplinary teams. So you mentioned how important the state-of-the-art facilities are, not only to our nursing professions, but what’s magical about this building, what I experienced, what I heard, and I can see how the interdisciplinary teams can come together to really create that experience that’s gonna prepare our nurses for the future. So, really incredible. So nice work.

Anne Pithan:

Thank you Erica, for saying that we really pride ourselves on our interprofessional education, and we know that as we move our graduates into practice, that is so essential to be able to work within that team to promote excellent patient outcomes. So thank you for recognizing that. We see that value as well. Our students see that value and when they graduate, they understand the importance of working within that interprofessional team. So it supports all of our programs here and it really allows that teamwork and that collaboration that is so important as our nurses get into practice.

Erica DeBoer (host):

Yeah, I do agree it’s likely a differentiator when you think about the rural footprint that we serve and the people that we have the opportunity to serve. Building those communities inside the walls of a university as well as what they might experience in building those relationships are so key.

I know that USD nursing had the opportunity to apply and they received a $1 million HRSA grant to grow South Dakota Nursing Workforce. I’m excited to hear a little bit more about your involvement in that and what we can see in the future.

Anne Pithan:

Oh, thank you Erica. We are thrilled about this. This is really exceptional for our nursing program, for our nursing faculty and our nursing students. So this grant is really focusing on that exposure to rural health. And as we both know, that is so important in the state of South Dakota. And it’s really giving our students an opportunity of awareness and just knowledge of how rural health works.

So what this grant will do, Erica, is it will provide the funding for 24 students per year to immerse themselves in rural health. And that is an opportunity that we haven’t really had before based on just the ability to get those students to these rural areas.

So we’re really excited about infusing that passion, that energy, and that love of rural nursing. So, and again, we’re so pleased with our partners, all of our partners, including Sanford, that has just stepped up to partner with us to really engage our rural health that is so needed in the state.

Erica DeBoer (host):

It is really important. And obviously what really brought us to our colleges of nursing and really brought this series together is how do we reimagine health care? How do we reimagine how we’re going to care for the rural nature in which all of us serve? Because there’s a different magic that comes with this population. There’s different challenges that come along with it too. And getting creative and really dedicating time and energy to that longitudinal plan of care for our patients is so important. Obviously my background is acute care nursing and critical care, but when we think about how much value nurses bring at all parts of our patients’ journey, a lot of that care can happen outside the walls of the hospital and those clinics. And so the importance of that rural experience is so important. So appreciate your commitment to that.

Anne Pithan:

Thank you Erica. And as you stated, you know, with South Dakota being so rural and, and our goal is really to serve the state of South Dakota. So we feel that this grant will really offer students that exposure that they might not have had before. And as you stated, it’s its own specialty. It has its own gifts and blessings and challenges. (Laugh) And, and we really are going to immerse these students in 135 clinical hours. And really give them that comprehensive view of rural health.

Erica DeBoer (host):

I love it. I can’t wait to see what we’re gonna learn from them. Cuz I think that’s the other privilege that we have as we reimagine health care and we reimagine how we work through what nursing looks like in the future. Our workforce needs are gonna be different. Our community needs are gonna be different. And so I appreciate the innovative thought that the team is taking to that.

So in having said that, from your perspective, what do today’s nursing students need to be prepared that’s different from the past? Obviously you’ve been in health care for a little while, so I’m curious what feedback you have.

Anne Pithan:

Yes, thank you. That is such a great question. And I think as we work with our students and they’re so innovative and they’re so passionate and creative. But I do believe that their needs are a little different perhaps than when you and I were in school. And I think one thing that has, that our students need is that ability to manage those complex patients.

They have really their complex patients and that ability to really look at social determinants of health and look from a really holistic view for our patients. So I think that’s one thing that’s a little bit different. And, and as you know, even our national licensure exam has really changed to capture that – that is a need that students have.

I think another need that I think our hospitals and our universities are doing a great job of, Erica, is really that mentoring. I think there has never been a time when new nurses and even our seasoned nurses, all of us need mentors. So I think that is a need that has really risen to the top. And we’ve seen that.

Another need that I have really seen is, again, that relationship management, using those communication skills to work with, you know, diverse populations, populations that have a lot of needs that perhaps we’re not as, maybe we weren’t as aware of. So I think conflict management, I think as you mentioned before, working within interprofessional teams is just essential as well as collaboration and teamwork.

And why I’m so excited to have this interview today with you, Erica, is it really puts a microscope on really the need for our partnerships that, you know, with regulatory, with universities and with practice partners, is really how we’re gonna really solve complex problems and really help students get what they need today.

Erica DeBoer (host):

Agreed. I think our nursing students, there’s a lot of pressure on our nurses. It doesn’t matter if we’re talking about our profession inside the walls, but as a nurse, I think you well know that we’re looked to as the most trusted profession. And so in many cases, maybe it’s not even our expertise, but really making those personal connections and building that trust.

Anne Pithan:

Absolutely.

Erica DeBoer (host):

So incredibly important. So tell me a little bit more about how technology and digital tools allow nursing students to be better prepared to be caregivers of the future.

Anne Pithan:

Yes, thank you. That is something that’s a great question. And I think we’ve all learned so much through the COVID pandemic. I think it’s really spurred our innovation and our creativity. And I think, Erica, what I love right now in this time is that technology has really allowed us to connect in ways that we have never been able to before.

And so, for example, what I’m excited about is here at USD, we are part of a global rural nursing exchange network. And that has allowed our nursing students to connect with students from Tanzania, Africa. And technology has just changed things in ways that we really didn’t anticipate. And it’s allowed our students and the students in Africa to develop that cultural sensitivity, that awareness, that ability to work with people that may be different than yourselves. And I think that’s one way that this will also transition into really making better caregivers, is they have more exposure. And it’s made a kind of a big world a little bit smaller for us, so that we can connect.

The other thing that I’m excited about is I think technology has allowed us to connect with nurses in a different way. So, for example, you, we talked about the importance of mentoring, and I think telementoring allows that, where we don’t have to be physically sitting next to each other, but we can still use technology in a way to mentor, to educate our patients, to use telehealth, to connect with our patients in ways that we haven’t been able to before.

Erica DeBoer (host):

I love that, Anne. I do believe that to your point, nursing is not ever going away. It’s always gonna be a hands-on field. It’s always gonna be a relationship-based field of practice, but we do use technology to connect with each other in different ways. I think some of what we’re hoping as we reimagine the rural health care footprint is how do we help our patients navigate the complexity in our health care system, as well as use technology as it makes sense to save the many miles that so many people have to drive in some cases, to receive specialty care.

Anne Pithan:

What I think we’re bringing to the workforce, and I’m sure you see it every day, is we are bringing technology savvy students that really can forge the way for us. And so, I, I love the students of today because I think they’re really gonna make a difference for us.

Erica DeBoer (host):

I agree. I think they are innovative spirits and their fresh eyes are gonna only help us continue to really forge different paths.

One other thing I wanted to chat with you a little bit about, Anne, is I love the commitment that you have to Tanzania and those experiences for our student. As you maybe know or don’t know, Sanford has world clinics across the world, and I just had the privilege to spend some time with our Sanford staff in Ghana. And when you stop to think about what that experience just gave me, it does make the world a little bit smaller. It also reminds us how fortunate we are and how innovative we can get with so little. So I’m curious what your students say about those experiences.

Anne Pithan:

Thank you, Erica. Last year, this is our, our second, we have a second grant with our global rural nursing exchange network. And last year we had six students. This year we have expanded to 16 students. And I agree with you, it was a very life-changing event for me as well. And I think what it did, Erica, is it really created a bond where I think what tied us together was that love of service, that love of making a difference and really caring for patients. And that’s universal.

And I think both are Tanzania and our USD students saw that. And it also opened eyes to, gosh, how we may be different, but how we’re so similar. And so I’m excited for you for, for the experience you had. And I, again, I think it makes our big world small where we’re able to connect with that love and passion for the profession.

Erica DeBoer (host):

I Agree. And of course, when we look at some of the solving for our workforce issues, there’s just not enough human beings in the United States to fill the need for our aging population and the nursing needs that we have. And so as we explore internationally educated nurses and how that could help us actually address some of the workforce issues, your commitment to having some of those experience only helps us actually guide some of those experiences. So again, I just wanna thank you Anne and the USD team for partnering and being innovative around those things.

Anne Pithan:

Oh, thank you. I agree with you, Erica. I think the more that we can expose our students to differences, I think it’s just gonna create a really strong diverse workforce.

Erica DeBoer (host):

I agree. I agree. Well, Anne, I’m curious if you had any questions for me. I know that I’ve spent a ton of time asking you questions, so I’m curious if there’s anything that you’d like to ask.

Anne Pithan:

Yes, Erica. I would love to. And, and one thing that I love to watch and learn from is the nursing leadership that I’m exposed to at Sanford. I have, am always so impressed by the relationship skills, the leadership abilities. So I do have a few questions that I would love to ask you.

Erica, as you are in your role right now, what are the biggest challenges that you see?

Erica DeBoer (host):

I’d say the biggest challenges from a nursing workforce standpoint is making sure that we listen and pay attention to what it is that they need. Not only are nurses that are coming out of school, how can they help us learn and see the world from a little bit different perspective, but also how do we support that incredible wisdom that we have in our nursing profession? And so, when I think about the biggest challenges, I worry about the burnout and I worry about our profession as a whole. How we can actually support them in loving the profession and knowing the gift that it is to be called to care. And the gift that we have the opportunity to, to give to not only our colleagues that we work side by side with, but also just to manage the message and the continued trust that our communities have in our nursing workforce.

So, preparing our brand new nurses, how do we support them in their journey and make sure that they can get over that hump? Cause nursing and the health care profession is so challenging, but so exciting at the same token. So as we reimagine health care, as we think about different ways to do the work, how do we listen to our new technology savvy students? But then how do we mimic that? And how do we partner that with the incredible wisdom that we have?

We are so blessed at Sanford with such longevity in our nursing staff. It’s really incredible. We have people that have been with us from anywhere from 35 to 47 years, and the privilege to just learn from them and gain that wisdom and insight about what they’ve seen, how things have changed, and how things in some cases need to continue to change to address really the health care needs of our society today.

Anne Pithan:

Thank you, Erica. That is such a great answer. And, I think that is our challenge, whether we are in academics or we’re in nursing practice, is we know that it’s a challenging profession, but we also know the gifts that this profession brings and the blessings it brings. So I love that on both sides here, our vision is to really make our nurses excited about this profession.

How is Sanford Health working to support your nurses?

Erica DeBoer (host):

Great question. I think as we reimagine how we’re going to have to manage the population of patient that needs us, we’re actually investing a lot in reimagining our workflows. I know it seems probably fairly simple and back to basics, but so complex. When we think about all the technology that we have the privilege to use to take care of our patients, how do we simplify that?

I always use the phrase, get rid of stupid stuff or gross. What are those things that nurses don’t need to do? How do we put the right people beside our frontline teams so that they can do their work and care for that patient and build those relationships? So we’ve actually invested in technology to help actually reduce that burden our, on our frontline team so that we can focus on that patient relationship.

I think the other piece is we’re asking ourselves really clear and concise questions about, is this something that nurses should be doing to allow them to work at the top of their license in the top of their scope? Or is there other teammates that could actually be supporting that work?

I think the other really important culture change that we’ve been working on for the last three to five years is our high reliability journey. So SAFE is what we coin it: so Sanford Accountability For Excellence. And it’s really truly how we’ve actually built those relationship skills built that culture of safety that everyone can speak up for safety. And we use patient safety stories to help us do that. But it’s not just about our medical teams.

All of our teams at Sanford Health are there to take care of our people and our patients as well as our communities of which USD is a part of. How do we continue to build really that culture of everyone’s contribution to making things better, to learning and to constantly looking for ways to make it safer for our patients, but also more reliable.

Anne Pithan:

I love that, Erica and I, I love – the two things that really stood out to me is really examining that workflow to really make that as with as much ease for our nurses as possible. And then I just love what you’re doing to continue to make this nursing such a trusted profession by really focusing on that safety, and allowing nurses to really be in that arena where they perform best. So that’s, it sounds like Sanford has, is doing, I know that Sanford is doing such great work.

Erica DeBoer (host):

Yeah. Maybe the other thing I might add, Anne, is our shared governance model, I think is also really important to make sure that that voice of the nurse is heard. So our shared governance, or we call it senate, is the opportunity for our teams not only inpatient, but ambulatory, and even our post-acute teams can come together, ask questions, problem solve those things that are those pebbles in their shoes every day. So how do we make sure that we’re lifting up that voice of the nurse to make sure that they’re contributing to the solutions, but also then that follow-through and what are those things that they can contribute? So shared governance is another really important initiative that it’s been part of the culture that I’ve grown up in, but it’s even more important now to make sure that they have that voice.

Anne Pithan:

I see that, Erica, so vividly when I have been on Sanford meetings, and often it’s exactly that, you know, we’ll have to take this back to our shared governance for their perspective. So I see that in your nurses. I see it in your leadership. So I think you’ve just done a great job of infusing that throughout your culture.

Erica DeBoer (host):

It takes, it’s a team effort and it’s a history, right? There’s a lot of really amazing people that have come before me at, in the Sanford team.

Anne Pithan:

Well, you guys are doing great work on that.

Erica DeBoer (host):

Thank you.

Anne Pithan:

Erica, how has nursing changed since you entered the field?

Erica DeBoer (host):

Wow. That’s a great question, Anne. So probably the first thing that’s changed is when I actually graduated, there was only one open position on the floor that I wanted to work. So when I look at the great number of open positions that we have in all types of nursing across the nation today, that’s one thing that’s probably the most different is that there was more competitive then.

I’d say the other thing that’s changed is our access to different pieces of technology. And I think sometimes that automation and that technology has created, in some cases a different way about thinking about how we do things. I love technology, I love data cuz it helps me make decisions. It helps me think through and process things in a different way.

I think the third thing that’s really changed about nursing is really the continued emphasis on them as the most trusted profession. They always have been, but I’d say the variety and the enhanced ways that nurses can contribute to health care is different than it was before too, which is really exciting. When I think about our, not only our nurses, but our family nurse practitioners and how they contribute in all parts of health care, it’s really quite incredible to see how the profession continues to grow and change.

I’d say the fourth thing specifically because of COVID is I think that our nurses are really scientists. They actually are innovative. They can figure out things in the moment and they get it done no matter what without a lot of fanfare. We’re just always the ones that are gonna get it done. And I think we’ve always been that way, but COVID really helped lift that, but it also created a dynamic in which there is a fatigue factor with our nursing practice today. So we certainly have to address that. But on the same token, incredible profession, the ability and the resources that we have are absolutely incredible.

Anne Pithan:

You know, Erica, I love what you said about really using data and also being scientists. That is something that I agree – we have students leaving, graduating and then entering the workforce and they know how to tackle problems, and they go to the evidence and they go to the data to do that. And, and I think nursing has done a great job of getting us to this point.

The other thing that I love that Sanford does is that, which is a little bit different, I think, than perhaps when you and I first started. And that’s the ability to present, to disseminate that information, to share that with your peers. And I think in academics we do a really nice job of getting them ready to do that, where they’re comfortable. But I think that our hospital organizations have just taken that to the next step where you’re really showcasing your nurses and I think that has just been a tremendous move, what our profession has done.

Erica DeBoer (host):

Our quality and safety scores show it, right? We’re the hands and feet that make that magic happen. And without the nursing profession and that commitment to high quality care, it makes it tough for it to happen. So it is amazing to use that data to continue to drive that competitive nature of how can we even be better.

Anne Pithan:

Absolutely.

Erica DeBoer (host):

And of course, we all wanna prepare so that we have amazing nurses to take care of us someday, right?

Anne Pithan:

Thank you, Erica. As I stated earlier, I love to watch your leadership team. I just think they’re very skilled leaders, and every time I learn something new from them at every meeting that I attend. What would you tell someone who is interested in a position like yours?

Erica DeBoer (host):

Oh, interesting. Now, my journey was a little bit unique compared to most and I actually obviously have just been in this chief nursing officer role for just two years. So if I were to tell, and I have an opportunity to mentor a lot of nursing students as well as others is my biggest piece of advice is give yourself time. There’s so many things that you can learn in every step of that journey. It’s not always about maybe going back for that master’s degree right now. Sometimes it’s just that one magazine or that one podcast. What can you do to contribute and learn every day so that you can continue to grow and change?

The other thing that I share with my nursing colleagues, especially if there’s a fatigue that they’re actually talking about is taking care of yourself is incredibly important. And having that balance. So what does that look like for you? Because it’s different for everyone.

Additionally, take every opportunity to get involved outside the walls of your facility. Getting and getting to know other people outside in different realms is so important. As we think about growing as a professional, as well as growing with others, relationships are so incredibly important. And building that trust, no matter if it’s in the health care field or outside, there’s always something to learn.

Anne Pithan:

I love that, Erica. And I think as I was listening to you, the other thing that really popped into my mind is what we had talked about earlier. And no matter at what level you need those mentors, you need those people to really seek guidance from and kind of that lived experience. So I love that you have and take the opportunity to mentor students because wow, what a great opportunity for them.

Erica DeBoer (host):

Well, and I learned from them in some cases more than I learned, than they learned from me. I had the privilege to actually mentor a student who’s has her preceptorship or her internship in ICU, and she just happened to send me a quick text and said, do you happen to know what an impella is? And I’m like, oh my goodness. Yes. I took care of the first patient who had an impella at the med center. I can tell you what room it was in. And then she sent me this two and a half minute long voice text about all the different questions she had about this particular situation. So again, once a nurse, always a nurse, we spent a good 45 minutes talking about pathophysiology and just, it’s amazing the questions and the insights that they bring to the table and how they won’t quit until they have their answer.

And so she was just astounding to talk to and actually work through this process. And then of course, I did even some follow up back with our front-line teams to say, gosh, what else do we need to do? If we couldn’t answer this question, do we need to have more clarity? So again, that voice, that brilliance at the bedside from our nursing students, from our frontline teams, you can learn so much by just listening to the magic in what they see and what they experience. So it’s fun once a nurse, always a nurse. And of course, I love talking about critical care (laugh).

Anne Pithan:

That is such a great story. And what I love about that is just that, that opportunity to, to be lifelong learners, right? And how much wisdom you gain, not only at the bedside, but that wisdom comes back to you, that you absolutely can share in this role now, and you can share that now with nurses. So I love, Erica, that you’re just such a great role model for our nurses, for those, for those nurses that really want to get to that next level of leadership. So I think that’s just great insight and, and great advice for those seeking that.

That kind of leads to my next question for you, Erica. And we so appreciate the support that we get from Sanford. They do a great job of coming to visit our students and really talking about all the great things that that Sanford has to offer. Why do you think, Erica, that Sanford is a great place to work for nursing students?

Erica DeBoer (host):

I love that question. I think that Sanford is a great place for our nursing students to come for clinicals as well as to start their profession because of our culture of high reliability, because of our SAFE culture, as well as the differentiators that we have in our nursing practice.

We have a couple different experiences, the Becky Nelson Fellowship, which is an opportunity for a individual high performer to spend a whole year with our nurse exec team and actually experience what it’s like to be in that executive role. So in some of those meetings, attending the annual meetings so that they can explore what that’s like. Part of the Becky Nelson Fellowship is an opportunity to do a project as part of that process too. Something that resonates with them and something that needs to happen. It’s about 20% of their work. So I think that’s another way that we help to continue to build our leaders of the future.

I think the other really important differentiator, and I mentioned this a little bit already, is our World Clinics. We actually have a world clinic mentorship program in which we select four to six nurses from our facility that get to partner with our World Clinic. So Ghana, Costa Rica, New Zealand, they have virtual calls with teammates from those other clinics. They get to partner on different projects, learn from one another, and then they do have the opportunity to travel there and experience their culture for at least a week as part of that experience.

So when I think about what differentiates us, one, we’ve got incredible nursing leaders, we’ve got our shared governance structure that helps us, but I do believe we have some other experiences that help people grow as a human being, but also in the profession of nursing. And of course, our SAFE culture is what’s fundamental to a lot of that.

Anne Pithan:

I just wanna kind of touch on a few things that you said there. I think what Sanford offers just from listening to you, Erica, is, is where your interest lies. Like they will find a way to support that. Whether it’s leadership, whether it’s leading shared governance, whether it is inpatient care, the opportunities are just endless as far as getting people where they want to go in their career.

And I think as you and I speak, that is one thing that I so love about this profession is there is so many avenues to go, and really, again, as you spoke about, just, you know, opportunities for humans. It’s really finding those strengths, working from those strengths to really give back to others. So again, I love that about Sanford. It’s just all the opportunities that they give their nurses.

Erica DeBoer (host):

Yeah. We know that nurses are the very backbone of how patient care happens. And so the partnership that we have with our interdisciplinary teams are incredibly important. And nurses are leaders at the bedside, no matter if it’s in that clinic setting, inpatient setting, or even in the post-acute space. Nurses help to lead and problem solve every day. So it’s a pretty amazing profession.

Anne Pithan:

Absolutely. And I have one last question for you, Erica. And here at USD, we really pride ourselves in our nursing department on our values. And so, we live those values, and again, we hang our hat on this, and our values are relationship centered, excellence, professionalism, and service. And I think you and I have talked a lot about those values and how we live those every day in the profession of nursing. How does nursing excellence at Sanford Health align to USD’s values of excellence, professionalism, service, and relationship centered?

Erica DeBoer (host):

I love that. So nursing actually has their own vision statement as it relates to really how we connect to not only health and healing, but also to innovation and discovery, as well as development as professional nurses. So I would say, when you think about the vision statement as well as the values that we live at Sanford, we connect really well to the commitment that we make to deliver high quality care, but also to share that through discovery, through innovation, as well as service to not only our communities, but to our, the patients that we serve.

Anne Pithan:

Thank you, Erica. I think that – I love what we share here, and that is really that commitment to a lifelong professional and how we can serve others and how we can make our communities and our organizations even stronger. And I, as we started this podcast, it’s really that partnership. And I think our partnerships and our excellent relationships that we have with each other are really how we’re gonna solve some challenging times that we will and always have experienced in this profession. So I, I so appreciate the alignment that we both share.

Erica DeBoer (host):

Yeah, I appreciate your time today, Anne. Thank you so much for sharing so much of your time as well as your expertise and the innovation that you continue to bring to our workforce.

Anne Pithan:

Oh thank you, Erica. It was my pleasure.

Alan Helgeson:

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

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The evolving customer experience in health care

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 evolving consumer experience. Our guest is Ken Hughes, leading consumer and cyber behaviorist. Our co-hosts are Dr. Jeremy Cauwels, Sanford Health chief physician, and Jared Antczak, Sanford Health chief digital officer.

Dr. Jeremy Cauwels (co-host): Hello everyone. My name is Jeremy Cauwels. I’m the chief physician for Sanford Health. I’m here with Jared Antczak, our chief digital officer. And as we are here today, we are just after a wonderful presentation by Ken Hughes who came to talk to our annual meeting. We are asking him just a little bit about the way he sees the world evolving from a digital and customer service standpoint, and would just like to take this time to have an excellent discussion on where things are and where we see things going in the future.

I think the one thing that I would say, Ken, that you talked about fairly early in your talk was that change is the only constant. And I would wonder, as you see change being the only constant moving forward, what does that mean sometimes in health care, and probably more importantly in customers, in general?

Ken Hughes (guest): Thank you, Jeremy, for having me. First of all I think, yeah, I’m fascinated by disruption in general, by societal disruption, anthropological disruption, digital disruption. And we live in such a decade of disruption at the moment. We have all these forces pressing down in every business. And you’re right, it doesn’t matter whether it’s health care, financial services, retail – everything is up for grabs.

Business models of old certainly aren’t fit for purpose in 2030. We’ll look back at this decade and we’ll think, wow, you know how innocent we all were in 2020? So even, you know, post-pandemic, the things that matter to consumers now are different to what they were three years ago. And that will change again the next three years. We have a pace of change that we haven’t probably had before.

Most leaders in organizations led teams and things didn’t change that much, maybe in their career. Whereas today, every six months you have a new 10-year plan.

You know, the idea, I remember at university starting strategic management, we were taught the idea of a short term, a medium term, and long term plan. And you wrote a short term plan for one or two years, a medium term, five years, and no one writes a medium or long term plan anymore in any industry because how could you? How could you know what’s gonna happen in the next five years from a customer expectation point of view, from a technology point of view?

So with metaverse breathing down our necks with the customer wanting things faster, better, more seamless, more frictionless, more transparent every day gen alpha, gen Z all coming up underneath us in terms of their expectations, huge pressure on talent and recruitment. And I mean, the issues are huge. And so what we need to build is teams that, leadership teams that can deal with that kind of disruption, agile teams and that are hungry for it.

Dr. Jeremy Cauwels (co-host): Thank you. Appreciate it. Jared?

Jared Antczak (co-host): So, thoughts, building off of that, you know, concept of disruption, right? I think it’s fairly easy to recognize other industries that have been disrupted or other organizations that have been disrupted. You look at what Netflix did to Blockbuster or what Amazon did to Sears, right? But many in the health care industry would say, but health care is different, right? Health care is about that relationship between patient and provider.

How worried should we be about disruption, and what should we do as a large, complex, multifaceted health care organization to future-proof ourselves to withstand the winds of disruption that might be facing us?

Ken Hughes (guest): Yeah, it’s, it’s a great question and it’s one that is, is asked many times where many industries was asked by Kodak at the time of digital, you know, it’ll never kill film. It was asked of Nokia, you know, we’re the biggest mobile phone brand of the world. No one will ever touch us. That there is a wonderful expression that Einstein had that the only thing more dangerous than ignorance is arrogance.

And arrogance – that arrogance of any industry to say that we’re fine, we’re protected, we have physical assets, we have first mover advantage, we have all the clinical experience, therefore no one’s ever gonna touch us – is the very industry that would be disrupted very quickly. Rug pulled under from you. And there, there’s players who will look particularly in health care at the most profitable sector, maybe at the wellness end, and take the profitable younger consumer from you around the health care wellness piece and leave you with the less profitable, harder work.

So, I know I don’t agree with that at all. I think health care, financial services, these are industries that have this kind of sometimes little arrogance and ego to them around the skills they have. And this idea that outside influence can take those away. They will. Absolutely they will. And we see that again and again. So many examples. So many industries being disruptive from and usually disruption, the point about disruption as a word, is that it is unpredictable. Otherwise we’d call it predictive change and we’d know what was coming.

Disruption will always come from a place you don’t expect from a player you don’t expect, and from technology you didn’t even know existed. And so all we can do in the industry then is to prepare our industry. And we do have first mover advantage, by the way, in health care. And we do have all the clinical experience. So we are way ahead and we have all the data, we have all the patients. And so, but resting on our laurels and thinking, oh, you know, it’ll all come good for us. We’ll be fine doing the same thing that we’ve always been doing will be a very – it’s like seeing the iceberg on the Titanic, and saying, actually, we’ll go through it. Our ship is quite indestructible. We’ll just go through that iceberg, won’t we? Yeah. Dangerous.

Dr. Jeremy Cauwels (co-host): I wonder, you talked a little bit about the etymology of the word patient how it literally comes from the root to suffer or to bear. And slightly later in the talk you talked about predictive health care, where we would be moving with those that I would call the walking well or the more healthy. How do you think we change from the one who has to bear their illness to the digital consumer who’s predicting their illness along with us before it happens and hopefully turning the corner the right direction before they ever land in that hospital?

Ken Hughes (guest): Yeah, I think that is the future of health care, I’ll be honest. OK, so the two-part question. The first one about the, the origin of the word patient. I hate the word patient. I really do. I think it’s the really wrong word for us to use at all times. If we start to use the word customer, I think we’ll automatically create processes and operations that are more consumer, customer friendly, but calling them patients, they become a part of a cog in a machine, someone wearing a plastic bracelet. I think we need to get away from that word. And it is a very passive role we expect them to play and it’s no longer suitable in our, in our current society. Cuz customers expect collaboration, they expect kind of brand partnerships to community. They want brand tribal belonging.

One story I always love is that, you know, Harley Davidson talks about the hundreds and thousands of sales reps they have on their road every day. Cuz everybody riding a Harley is a sales rep, you know, they believe in their brand, they tattoo the logo on their skin. Do you have a Sanford Health logo on your body somewhere?

Jeremy Cauwels: (Laugh) I do not.

Ken Hughes (guest): But you should. And so the idea is how can we form and foster belonging? And so I don’t think patients today feel a belonging to their health care necessarily. They feel appreciative that’ll happen to them. And so we do need to move away from the word patient, I think, and see it as customer. You know, who is the customer? Who is the consumer? How can we build everything around them?

The second part of the question is, the future of health care, I definitely agree is the walking well, absolutely. We already see it today. People wear trackers and fitness. And so the future is data. The future is keeping me well. And that’s everything from mental health, nutritional health. It’s not just my physical health and my emotional health, even my spiritual health. You know, how, how far you wanna take us up to you. But the idea of having a partner in my life, a brand partner in health care who has my back at all times and doesn’t wait till I get sick, who actually intervenes along the way.

The best example I can give from another industry is the financial services industry where you take out a mortgage and you only hear from them, you know, once a year or maybe once every five years. It’s the most profitable product they have of you. But once they have your money, they don’t really care. So that’s the danger. But let’s not communicate to our customers only when they get sick or only when they need us. Let’s, let’s be there for them at all times in their lives. And they’re gonna go through all their different life stages in their twenties. They’re gonna maybe have family in their thirties, they’re gonna grow older in their forties, fifties, sixties. Now. How, how can we be there for ’em at all times? How can they feel supported by us in a way that, you know, has emotional and resonance with them? You know, that to me is the future of health care.

Jared Antczak (co-host): I’ve heard often that health care is a little bit of a misnomer for what we actually do as an organization and as an industry. We’re really in the business of sick care, we take care of people when they’re sick, not necessarily when they’re healthy. And so that shift from sick care to health care, I think is a little bit of what you’re alluding to with that more customer-centric perspective. Right? Thinking about people or having people think about us too in moments in between visits rather than just when they’re sick or just when they need care as a patient.

Ken Hughes (guest): Yeah, absolutely. I mean, I think that the focus has to be on the person themselves and their journey and what they’re going through. If we wait till they’re sick to make contact with them, then we’re always fixing, it’s like a mechanic fixing the car when it breaks down, as opposed to maybe the car talking all the time as to diagnostically how I’m doing. And so I think, yeah, if we’re looking for customer lifetime value, then we need to step into that space. And even from a profitable point of view, actually for an industry point of view, there’s more people healthy every moment than there are sick, you know, in life. And so why shouldn’t we be talking to them every day about what they need and how our brand can help them and support them?

And that’s the space I think it is – it is a bit of a jump from traditionally health care has been hospitals and clinical care as opposed to wellness. And there is a shift, I know in the, in the wellness industry and the physical wellness industry, like gym membership is around 20% globally, which they love. Cuz that means 80% of people currently don’t have a gym membership. So it allows huge potential and growth for the industry. Same in health care. I think, you know, we’re working with the maybe clinically sick today, but that leaves that are 80, 90% of people every day who are clinically well but, you know, want some kind of health care partner in their life and that should be us.

Jared Antczak (co-host): So I, I’d love to pull on that thread just a little bit and then I’m gonna ask a little bit of a, a challenging question cuz you just said that the very nature of disruption is that it’s unpredictable, right? (Mm-Hmm <affirmative>) But if you had an opportunity to predict and just envision for a moment what the health care consumer customer experience could look like in five years or 10 years, what would you see? How would you see it being different than it is today?

Ken Hughes (guest): If I knew the answer to that, I’d be on a yacht in The Bahamas (laugh) right now doing this podcast. Yeah, I think seeing the future’s really difficult, but I think it would be technologically driven. It’s definitely a guarantee as AI, I mean, I think everyone watching AI this year, particularly with ChatGPT and all the visual stuff, we’re all getting to use it individually for the first time in our lives when think like, ooh, this is kind of cool. And so this year will be the a the step change for AI. Over the next five years we’ll see that play out more and more and more – robotics, the same automation, the same technology. So the loads of converging. So it definitely would be technologically driven. I think people will become more responsible for their own health care themselves. They’ll have access to their own data, which they haven’t had before.

And so we already, we all have friends like this who will track everything about their lives already. And from a health care point of view, they’ve got seven wearables on at all times. You know these people. I think that will become more normal for us all. I think we will and we will happily hand our data over to people to watch that data on our behalf.

And so I think wellness will become technologically driven, but there’s yet for a brand to step into that space with a bit of fun and play. And I think that brand will be quite successful, the brand that kind of makes it a little bit more playful to be healthy. And so I think that there’s space there for, for a first mover to come in and make things different. But I think it will be more personal. I think it will be less clinical and procedure driven. I think health care needs to move in that way. Maybe smaller.

I mean we’ve had, you know, the large hospital kind of model for a long time. I think we probably will start to see maybe a little bit of a fragmentation and, and more customer service aspects in that, and that deliverable in a smaller way. That’s again, it’s a guess.

Dr. Jeremy Cauwels (co-host):

I think one of the things you talked about was also the experiential portion of health care. As we start thinking more about people as customers than patients. You told a couple of stories. I’d love you to go back to the one about the patient checking in for surgery and the details that were brought out during that initial encounter with the nurse that actually made all the difference for him.

Ken Hughes (guest): Yeah, I think I’m fascinated by people. I mean, ultimately I’m a social scientist, right? So I’m fascinated by people, of the human mind, and I’m fascinated by brands who fail to capitalize on the emotional experience and the ability to bond emotionally with someone in health care. We have a really unique proposition where the person presenting to us is in a quite a vulnerable state. They’re usually sick. They’re usually scared. And so we actually have a potential, unlike a retail transaction, which is kind of low in their caring to really make a difference in their lives. So anything we do will be kind of magnified both in a good way or in a bad way. So if they feel unseen, if they feel unheard, they feel invisible, those things are magnified by their vulnerability. Similarly, if we do something positive in experience, that’s also magnified.

So the story you’re referring to is about an older gentleman who checks in, is scared, is heading for surgery. The nurse is helping him settle into the bedroom. And he’s understandably scared. And, so as an intelligent human nurse, she uses the time to get to know him a little bit, to relax him and to start to ask him what his hobbies and what his interests are. And he mentions that he’s big into fishing and she knows nothing about fishing, but she has a short conversation with him about fishing. And the day goes on and the next day as she’s passing, she takes the fishing magazine from the cart going up and down the corridor and drops it into him and says, you know, you might like this. In his patient satisfaction survey that came back, that was the one moment that made a huge difference to him, his entire stay.

And it doesn’t, wasn’t really matter whether the surgery was successful or not, the care he got, it all came down to this one moment that he felt seen, heard and valued. Someone had listened to him. And not only that, but they had been compassionate and acted on that. So compassion is a verb. You have to do something like love is a verb. You dunno what you can say, I love you to your wife and husband, but unless you show it, it’s kind of pointless.

The same thing is true in health care and as we show the compassion. Otherwise, it’s just sympathy. Sympathy is when you care about someone’s suffering. Compassion is when you relieve the suffering. When you action something, that compassionate moment, we need to have that every moment. And so the question you need to ask yourself in health care is, have I created a fishing magazine story for myself today?

Like what have I done today to make a difference in someone’s customer journey that makes them feel special, makes them feel heard, makes them feel that’s about them and not about us, not about profit, not about clinical care, not about procedure, but about actually them. And it can be so simple and sometimes people push back on regulation and they can say, oh, well that’s easy for you to say, we’re so heavily regulated. We’ve got the insurance companies to deal with as well. Yeah. But there is excuses. Nothing is stopping anyone on an individual basis, having a moment of humanity with a patient.

I think the main challenge is pressure of time in that one. So I’m yet to meet a doctor, surgeon, nurse who doesn’t agree with what I’ve just said, but I meet all them all the time who says, yeah, I’d love to do that, but you know, I don’t have two minutes to spend extra with every patient. Cause if I did that, I’d need to spend another hour or two at the hospital today. And already I’m already not seeing my family. So it’s a challenge. It really is.

Dr. Jeremy Cauwels (co-host):

Can I push you directly into another story though? You then told a story about somebody who did have that kind of information at their fingertips where it didn’t take long for people to know what your recent history was and how much difference that made in your personal life as you travel a good bit of your time.

Ken Hughes (guest):

Yeah. So that, that what you’re referring to there is again, building systems that hold data that allow a front-line operator to delve into that system, dip in, it only takes 30 seconds, pull some data and then make someone’s experience a little bit more personal. So I have many, I traveled for full-time for a job. So a lot of time on planes, a lot of time in hotels. And often on a plane, a host will come down to me or host us and we will say, Hey Mr. Hughes, nice to have you back on board. Did you enjoy your trip to Atlanta last week? And why are you heading to Chicago for this weekend? They know all the data on me now. It’s very simple. That’s the system. I mean, I buy the tickets that my name is linked to the tickets.

It’s very simple. They know that Mr. Hughes is in 4A cuz their system shall, they don’t know me personally, but that moment that they take to kneel down, meet you eye to eye and have that little conversation, you feel heard the same as the hotel I stayed at once.

I walked into the hotel and didn’t know the hotel, never stayed there before. But they put my name on the water, they put my name on the local beer in the room, they put my logo into the cheese. You know, everything is just about me and I feel special again. They just stripped all out from my social media. The guest relations manager just spends 10 minutes per guest on a day and he finds the, and it’s only the guest in the suites, you know, he’s not doing it for the hundred, 200 rooms.

He’s, he is cherry picking. But we need to do that. We need to think about how can we build a system that holds very simple data about the customer. Maybe something, stuff that’s personal to them that makes us seem a little bit more clued into their lives as opposed to just talking about the procedure or talking about, I mean, I’ve had my time in hospital myself and I kept a note pad by my desk at all times. Cause it was just fascinating as to be on the other side and to see the pressure of time to see that just being treated like a number, treated like literally a piece of meat in a process of, OK, I’ll fix you, I’ll fix your ankle, I’ll fix your back and I’m moving on. And you never really felt valued to the system. In fact you kind of felt in the way, you were in the way of this doctor or this nurse to get onto the next thing they needed to do. And we need to really dissolve that.

Jared Antczak (co-host):

So building on that concept of, you know, experience and creating a good experience that’s personalized and relevant, you also talked about the need to blend physical and digital, I think you called it ‘phigital,’ right? And the need to consider offline and online, you know, components of what you’re bringing to people. And also how do you make people the center of the universe rather than your services or your procedures or your products as a health system?

You’ve worked with a lot of organizations that have undergone these kinds of transformations in this consumer-centric kind of approach. What are some lessons learned that you’ve seen companies who have been successful at that, and what are some potential pitfalls that you’ve also seen that we should be looking to avoid?

Ken Hughes (guest): That’s a huge question. Yeah. (Laugh) so much in that to unpack (laugh). OK, well the first thing, let’s take two examples. Let’s take a positive and a negative one. Let’s take the negative one first. McDonald’s currently have huge labor shortages. Massive problem. And so they were forced into doing this. So they had to run digital kiosks. So digital kiosks you see to order at the front of all the restaurants now aren’t there because they think digital is the way to go. Even though digital transformation’s important, it takes you about at least two minutes to place your order via a digital kiosk. It took you about 30 seconds, not 10 seconds to say I have a big mac and fries, please. Large coke done, you know, four seconds. Whereas it takes two minutes. So it’s actually frustrating from a customer experience point of view.

That’s an example of digital not actually adding to the customer experience. Digital actually takes away, it’s slowing it down. It’s more frustrating. It’s, it’s clunkier. Now, do they have a choice? No, unfortunately they didn’t have a choice. Cause they don’t, they don’t have the labor. But it’s, it’s, it’s a good example of not, not doing, not using digital as the answer just because it’s digital doesn’t necessarily make it good.

A positive example of of a company that we’re going through this and it’s less about the digital part, it’s going back to really just humanity. I worked with an insurance company, a global player I won’t mention, but their, their, you, you’ll know, everyone will know them. And the motor claim is quite a charged, going back to the vulnerable part of health care, it’s quite a charged moment, you know, of this. So you, you’ve crashed, you crashed your car, you’re worried, you’re scared, you know, you’re thinking, oh, was it my fault? Was it their fault? Am I gonna get enough money for my car? You know, there’s a lot of stuff going on in that first 30 seconds minute. And so the first thing you do at the roadside is generally you either call the police and the emergency services, but you also call the insurance. So it’s the thing we’re all told to do. Take out your phone, call your insurance company, give them the policy details.

So the old script they used to have from a customer service point of view was they would say, Hey Jeremy, hey Jared, gimme your policy number. And they’d type in the policy number and they’d say, oh yeah, I see you’re insured for this or your cover doesn’t cover that. And they go into a process led conversation. So we changed the script to having done all the research and looked at the thing to make it more human and more, again, built around the customer.

And the net PS, the NPS score, dissatisfaction scores went from what kind of mid-50s, 60s to 85, 90 immediately for this particular customer experience and literally overnight was amazing. So now instead of asking for the policy number, they say, Hey Jared, are you okay? Is there anything we can do to help? Do you want me to call your wife, your daughter, your uncle? Do you want me to call the emergency services? Is there anyone with you? Will we order a taxi? And you keep saying, I’ll give you my policy number and I keep stopping you saying, Don’t worry about the policy number Jared, we’ll get to that in a moment. We’re here to help you for that, but is there anything you need right now? And that first 30 seconds of the call changed everything. Cause you’ve gone from being a transaction, a policy holder, a number to being a person.

And generally people would actually cry. I’ve heard some calls like on the call back, that because they’re so charged and so vulnerable at that moment, the moment humanity was reflected back at them, they would let it all out. And it’s, and so then, then there was all therapy part in the training. And, but you know, so that move when that NPS score just shot straight up, because basically if you treat people like people, like humans, and you reach into and you start using emotion and leverage emotion, you create customer bonds that last forever. And that insurance company, I think it was talking about two years ago, they shared some data with me about retention for those customers. And now if you’ve gone through a claim, the retention potential for you as a customer stretches out 10, 15 years.

Which is really interesting. Cause previously to that, a claim often broke the customer loyalty cuz you didn’t get enough of your car. You didn’t, wasn’t that fast enough. And you were grumpy. So you treat people like people and you make them feel special. And actually you lay down the customer lifetime foundation for life. You know, do I feel special ordering at McDonald’s now? No, I don’t actually. And interestingly, my son who’s 16 no longer shops at McDonald’s because of that. He’s the, that instant Gen Z generation. I want now one click, one swipe. I want things fast. And the idea of having to spend two minutes typing stuff, it’s not his gig. You know? And so, you know, are they damaging their very core proposition of fast food? Yes. They’ve actually stripped out the fast part.

Dr. Jeremy Cauwels (co-host): One of the comments you made while you were giving the talk was the new never normal instead of the new normal. And you’ve just described McDonald’s breaking their own model of fast food, you know, also described treating people from an insurance company like a human being. And so even the insurance company is changing their game to adjust it. As you think about health care, where do you think the biggest interventions or possibly the biggest changes could come from? Just like you said, you walk into the building, you get a plastic band, you walk through the process, you hopefully walk out the other side after a major surgery and the entire thing is a transaction. What is the new never normal for that transaction?

Ken Hughes (guest): Yeah, that’s great. And again, the question itself already is loaded because if we answer it, it’s gonna be different in six months. That’s the point about never normal. That keeps changing, that what people want keeps changing. So we have to understand that the next generation of consumers we’ve built to generate a health care proposition mainly for kind of traditionalist Baby Boomers, maybe Gen X, anyone over 40, you know, the system needs to be always been the same. So we all understand it. Millennials, Gen Z, Gen Alpha underneath us don’t understand it. They don’t see the same thing at all. They want it much faster, much better. And so what is the future? I think the future is definitely a place of collaboration. It’s a collaborative feeling that I get, that I, that together, my clinician team and me are gonna be with me on my health care journey.

Cause after all, it’s my health care journey. It’s my health. It’s not your health. And so I think most patients today, and again I’ll steer away from the word news customer feel that it’s not their health care journey. That they are a transaction, a process like an assembly line. You come in, you pop out the other end, hopefully (laugh). And so I think our challenge is to make that yeah, less clinical, less cold, less, you know, even the architecture of hospitals. And we have to challenge everything. Andwe, you know, yes, we have to operate in regulatory state and we have to be hygienic and stuff, but there’s no need for us to be dreary and drab. There’s no fun, there’s no play, there’s no mischief. And these are things the next generation of consumers are looking for authenticity. They’re looking for genuine.

And it’s really interesting. So just go back to fast food, Burger King, McDonald’s, KFC, all these brands, do they offer anything real or genuine? To me, not really. They’re just commodity. Whereas look at street food, street food is booming all over the world because people love the idea that some guy gave up his job in Deloitte Touche, grew a beard and is selling falafels out of a van. You know, they love the realness of that. You know, and people, that’s what people like, they like realness. And so I think sometimes again, doctors, nurses, clinicians are so under pressure. They themselves stop being human. They become machines. So we can lean now into an employee experience conversation because everything I’m saying is also true of the employees who also want to be seen, heard, valued, treated well. They want to be you know, they want to very instantly.

It’s really frustrating for clinicians when the samples that they send away don’t come back the next day. You know, they want instant as well. They want to help people quickly. And so we need to challenge if we’re going to retain the talent and recruit the talent, how do we build a culture around experience for everybody? And it’s what we call total experience, employee experience and customer experience together. Cause if you don’t have happy employees, you won’t have happy customers. And so you kind start there. Richard Branson always said, treat your employees well. They’ll treat the customers well; profits will follow. So he started with the employee, make happy employees who will then make happy customers and then profits will follow after all that. And so, yeah, just, and that’s a fair question. I often get asked, all this stuff sounds great, but it all costs money – where is it coming from? You know, profits are already low. How do we do this?

It’s a challenge. You have to build systems. You have to put, you know, data in place. But that’s the game. The game is preparing for the future. And I think predictive health care is the future. You know, having all the data and knowing how well you are and helping you before you get sick. That’s the future of health care. And that to me, I feel then I feel like I have a partner in my health care as opposed to someone who only wakes up when I have a problem. And when I contact.

Jared Antczak (co-host): So many great stories, concepts, thought provoking ideas. If you had to distill it down to just one major takeaway that you’d like our listeners to walk away from this podcast with, what would be the thing that you want us to anchor on?

Ken Hughes (guest): I’ll tell you a story to finish about a goldfish. So there was this family immigrating from the U.K. to the U.S., mom, dad, kid. They present at the check-in desk. She’s checking them in, looks up and sees a problem. Cause the little boy, the 8 year old boy is holding his bag containing a goldfish, a liquid bag. And the lady’s checking in and thinking, well that’s not gonna work. There’s a hundred more, hundred milliliters of liquid in that bag and fish don’t get to go to America. So she starts to explaining to the family, she said, I’m sorry, I can’t, you can’t go on board with the fish. And the little boy starts roaring crying. Of course he does cuz he’s immigrating. He’s leaving all his friends, his family’s school, his hobbies, and he wants to go. He’s roaring crying in front of her. So she immediately stops and says, oh, I’m sorry.

You don’t understand. What I mean is that you can’t bring the fish on board. You’ve got to give it to me cuz that fish has gotta travel with all the other VIP goldfish that are traveling on the plane today to America. So little boy dries his eyes, hands over his fish, all excited. She gives the lady, gives the parents the boarding cards. They wink and think, thank you so much. They think she’s diffused this really awkward pain point. And they rush the kid through security. What they don’t know is that the lady left there with the fish, takes her phone out, takes some pictures of the fish, sends those pictures to her colleague in Atlanta on WhatsApp, and asks her colleague to leave her workstation, go to the local pet shop where she bought identical looking fish. And 10 hours later, when that little boy lands in Atlanta, she’s standing there at the top of the ramp as he exits the plane and gives him his fish, who he takes proudly to live in America.

It’s a wonderful story that brings the Virgin brand to life in a way that Richard Branson meant. You know, if you see a pain point in any customer experience, if you can help a customer at any point and make them feel special, make them feel seen, heard and valued, do it because they will tell the story for you. That happened 15 years ago. That story’s been told millions of times all over the internet. I tell it all over the world and it’s a story that brings the Virgin brand to life. Neither of the people involved, neither of the two women had to call to Richard Branson and say, do you mind if I take an hour off to buy a fish (laugh)? Because they live inside an organization that says, if you see something that makes a difference, then take it. And that would be my final takeaway to anyone listening.

No matter who you work, no matter what organization you’re in, you can make a difference to people. You can be the person that brings that guy the fishing magazine. You can have the goldfish moment. It’s your job, in fact to, to live a goldfish moment every day. Cause if we don’t, what story does the person have to tell when they go home? Whereas when they do have a story, when they say, you know what happened to me? Yes, I’m better. Yes, they fixed me. But the best part was the goldfish moment or the fishing moment or you know. So we have to look for moments that matter that connect emotionally. Once you connect emotionally, customer lifetime value follows very quickly.

Dr. Jeremy Cauwels (co-host): First of all, Ken, thank you on behalf of Jared and I, on behalf of Sanford Health and on behalf of the idea that if you see something, say something, take an action to help whoever you’re working with and whoever you’re working for that day. It’s been a wonderful time having you here at Sanford, and we very much appreciate your time and obviously all of your contributions.

Ken Hughes (guest): It’s been a pleasure. 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.

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Protecting our mental health postpartum

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, your overall well-being with our Sanford Health experts.

Listen: “Her Kind of Healthy” podcast series

This episode, we are focusing on the topic of postpartum depression.

I am fortunate to have Karla Salem for another great conversation. She is a certified social worker here at Sanford who specializes in women’s health. With over 22 years at Sanford Health, Karla has cared for more than 25,000 women pregnant or postpartum. Her expertise in this space has answered many of my frequently asked questions. Karla, welcome.

Karla Salem: Oh, thank you so much. It’s an honor to be here, and I really feel like the women that have taught me over the years how they feel and what that looks like, I feel like this is dedicated to them.

Courtney Collen (Host):

Love it. And full transparency, as we’re recording this, I am beginning my third trimester of pregnancy. So on a personal note, I know I’m about to learn a lot from this conversation, and I hope you, our listeners, find value as well.

Karla, we’re so glad you’re here. I read a lot about new moms experiencing the baby blues after childbirth. That rush of hormones, emotions. I want to start off talking about this idea of baby blues and distinguishing between what often comes in early postpartum and when that takes a turn to become something that needs more care and support like postpartum depression.

Learn more: Postpartum depression is different from the baby blues.

Karla Salem: Well, that’s a great question because distinguishing me between the two is sometimes hard for women to understand as you’re verbally explaining it before delivery. But after delivery, they go, ‘Oh my gosh, yes, I do understand that difference’.

So blues happens to about 80% of all women, and it happens about two to three weeks postpartum, after delivery. It’s kind of a combination of hormonal activity, kind of playing around, going back where it belongs, and then sleep deprivation. Sleep deprivation is a huge, huge component. And folks who have never gotten more than two to three hours of consecutive sleep for three weeks, we’ll notice that, that they’re greatly impacted by that.

Courtney Collen (Host):

What is physiologically happening in the brain that would lead to a diagnosis of, say, postpartum depression?

Karla Salem:

Well, almost all anxiety and depression has three components: a biological component, a psychological component, and a social component. So understanding the biology becomes very, very important because things have happened to women’s brains during this time.

So, we have serotonin, which manages our mood. And when it’s most effective, it’s very buoyant or bouncy between our neurotransmitters. When you have a baby, it flattens like a pancake. Its primary job is to offer energy. It offers mood control. And it also holds down norepinephrine, which is our anxiety neurotransmitters.

So when serotonin flattens out after having a baby, we have nothing really to hold down the norepinephrine. So you have both a combination of kind of moodiness off and on, irritability for no reason, crying for no reason, plus just this kind of intense anxiety or overthinking, or busy-brainness that also occurs.

And the deal with anxiety is when all new moms start to have, you know, safety thoughts, safety thoughts they’ve never had before, all of a sudden, they enter a room, they look at where the outlets are, they look at, you know, what could be a problem. And so that’s very, very normal.

But norepinephrine, anxiety, overabundance of norepinephrine will take that little startle or that little thought, that little safety thought, and all of a sudden, they can see the whole big picture, a gruesome ending, and somehow they’re inserted in the whole process. So very scary. Like, I’m going down there, or I’m passing the stairs with my baby. Oh, I hope I don’t fall down. What if I fall down? Suddenly, you see yourself at the bottom of the stairs with your baby and all of that, even though cognitively folks know it’s irrational, the anxiety, the chemical change, the biological portion makes it so they’re unable to let go of the thought.

And then they go on to another thought. And it’s so interesting because there’s such common safety thoughts that go this direction. The stairs, bathing the baby, putting children in cars, and what could happen, being alone for the first time, and who might come into your home. Those are all so common as safety thoughts that when I mention them to women, they’ll go, ‘Oh my gosh, how do you know?’ And because many other people have had those same situations, it just is a little bit of a comfort to know they’re normal in the thinking that they’re having.

Courtney Collen (Host): And how long would these feelings last? Whether it is the, like we said at the beginning, the baby blues, the anxiety, or the depression … What kind of a timeline are we looking at?

Karla Salem: Blues occurs for just that two to three weeks. And it’s like crying for absolutely no reason. Like you see a leaf blow and oh my gosh, you start crying. And it mostly becomes an issue for both the patient because they don’t know why they’re crying and their partner or their support people who will say, ‘what are you crying for?’ And they don’t know what they’re crying for and there’s no way to fix it. But it has a pretty short life, especially if people get some sleep in the first two to three weeks. And what people will find, what women will report is, ‘I slept a little bit, I feel so much better’ and that was probably it.

The chemical change that happens with serotonin and norepinephrine after having a baby actually takes two years to restore. So it takes about a two-year period of time, which is always just a phenomenal, interesting idea for people because they think everything should be very immediate and should go back to normal.

Women can notice increased anxiety you know, right after having a baby, they can notice it gets more intense when they’re starting to go back to work or their support people are no longer there. They can even notice it – if they’re breastfeeding – when they stop breastfeeding. So they’ll say, you know, 12 months later, ‘I don’t even know what’s wrong. I don’t know why I’m so anxious,’ but their brain is still trying to restore from having a child.

Courtney Collen (Host): So knowing that a lot of this has to do with that chemical balance in the brain or imbalance postpartum, can postpartum anxiety or depression be prevented beforehand? Is that even possible?

Karla Salem: Well, most folks don’t want to do that. I mean unless they have been through it before. If it’s your, if it’s a second or third baby and people have a history, they know what’s going to happen. They will go oftentimes go on an antidepressant to start restoring those chemicals before they have a baby. Or they start right at the time of having a baby. New moms really want to experience, they want to know what’s going to happen. And so they kind of have to experience it.

But it’s something that’s so easy to educate women on. This is what you’re going to be looking for when you don’t feel like yourself anymore. When you feel like you are, you know, your mouth is yelling at somebody and your brain is going, why are you doing that? When there’s a disconnect, when you know something is irrational, but you can’t stop thinking about it. Those are the kind of the signs and symptoms after about two weeks that you want to address.

And so oftentimes women will come on their own because they don’t feel like themselves. Support people, either a partner or a family member says, ‘I think maybe you need to go talk to somebody.’ And usually once folks find out about this chemical piece, they really are so relieved and anxious to look for solutions, whether they be behavioral, cognitive, or medication.

Courtney Collen (Host): When might a woman first experience that first sign of anxiety or postpartum depression? And when is it time to see a provider?

Karla Salem: The first signs can build up, like, you can have an episode, but it goes away. And so, ‘well, that was probably because I’m overwhelmed or that was probably because of this and that’. I mean, we as humans are good at explaining away things. And so, it’s usually a little bit of a more of a cumulative kind of experience. Like over a period of time they notice that they’re just not themselves. They’re more worried than they’ve ever been before. And coping mechanisms that they’ve always used are just no longer as effective as they used to be.

The thing about anxiety is very odd because a lot of people experience anxiety throughout their life. We are born with our brain chemistry. So, if our brain was busy at one point in time, it’s busy now, but we learn so many coping mechanisms on how to deal with that busy brain, how to distract ourself, how to replace thoughts, that it doesn’t really become an issue. But after having a baby and having an actual chemistry change, all of a sudden, it’s more intense than it ever has been. The solutions, the distractions, all of that, none of them are working the way they used to. And it becomes just confounding for women. I have more women that say, ‘well, I probably have always had a little bit of anxiety. I’m kind of a type A person’ which is usually pretty much code for managed anxiety. ‘But now this is ridiculous. This is, you know, I used to work out and that doesn’t help me anymore. I used to go see friends and now I don’t want to go anywhere.’ And so, all of those things that used to be normal are no longer normalized because of that biological connection.

It is interesting though, when we’re looking at depression and anxiety postpartum, there’s three kinds of variables that people look at as precursors. And one is a history of depression or anxiety. The first is a personal history. The second is a family history of depression or anxiety. And the third, which it just always just knocks me out, is a woman’s perception of how much support and assistance that they have postpartum. So, and it’s perceptual. It’s not what is or isn’t, it’s perceptual.

So if a woman feels like they must do everything themselves, they don’t allow anybody else to do anything, they restrict visitors, their partners are limited as to what they’re allowed to do. That can be an important and controllable factor in whether or not someone develops anxiety or depression postpartum. So, it’s always fun to talk to women about sharing their baby – not pawning their baby off, not accepting responsibility – but sharing, allowing people that they trust and love to start having a relationship with their baby. And at the same time, giving them some downtime from being overly stimulated by that child and all the responsibilities that it brings.

Courtney Collen (Host): This is so interesting when we talk about those first signs or maybe precursors to potential diagnosis or needing care. Let’s talk about finding support at Sanford Health. What does that look like? When does an expert like you step in or that, when is that connection made postpartum?

Karla Salem: There are a lot of points that people get to kind of have a baseline during pregnancy. There are some screenings done regarding depression levels or anxiety levels and also about past trauma. Oftentimes having a baby is such an invasive kind of procedure. You know, privacy isn’t there very much. I mean, it’s just a physical exposure. Oftentimes women who have been assaulted in their past, this starts to bring back memories that some didn’t even know they had. And so that becomes an important question during pregnancy and postpartum, just because you want to make people as comfortable as they can be postpartum and enjoy their baby.

And so, understanding that concept that that could come back, you know, because trauma stores and when it’s triggered, it comes back bigger and more ferocious. So, we try to make sure that we’re doing screenings throughout the pregnancy.

Then postpartum our midwives have always done a two-week visit, but there’s a well-baby visit and they do a postpartum check on mom’s emotional check well-being. And then – those patients that want to go back to their OB/GYN, they’re offered also a two-week visit. So, that two-week time is when you know if things are not getting better. That’s when you can kind of figure that out, and then if the patient wants to speak to somebody, we get them into somebody not for therapy so much, but just for explanations and then not only what just happened to your brain, but also what you can do to help yourself and then what you can kind of monitor to make sure that the symptoms don’t get worse and then what that next step would be.

Courtney Collen (Host): OK. Great information. And what might treatment look like for anxiety, depression, postpartum?

Karla Salem: Well and there’s a whole continuum, you know, for a lot of folks, it kind of depends on what time of year you have your child, April through August in South Dakota are our sunniest, longest daylight days. So, serotonin reacts to that. Our retina exposure to sunlight increases our serotonin. So usually April through August. And honestly, there are exceptions. There’ll be people who will always tell me, ‘But I love the winter. That’s when I feel the best. I get uneasy during the summer’. But mostly we tend to have more energy, be more hopeful, get outdoors, have more exercise in those months.

If you have a baby in September, October, November, we’re coming into a season where the days are very short and become even shorter, which also does affect how fast your serotonin restores. I talk to a lot of folks who’ve had differences even in themselves having children in April or May versus having them in the fall or winter. So, I mean, that’s kind of one thing that you kind of want to look at. So, it’s just one another factor.

Some women just want to talk to somebody and they’ll go into some kind of a solution-based therapist where you look at what’s going on right now, what can we do, what plan can we put together? You stick together a treatment plan and then monitor that periodically.

Other women have some real like family of origin issues. They have some real issues that have been now exacerbated by having a baby. And they’ll go into more prolonged therapy, they’ll go to a therapist, meet with them weekly, every other week. And that’s the treatment they have decided. Some women will decide on more of a pharmaceutical solution. And with that they will get education regarding SSRI antidepressants or selective serotonin reuptake inhibitors. And they will work with their doctor as far as starting that and then monitoring the medication to see what it’s doing and how it’s helping.

A lot of women will go into more behavioral plans, especially folks who don’t really want to go on medication. They will lower their guard and let more people into their life. So they will have people that they trust, you know, come in three times, planned three times a week, just so that they have time to do something else and or they have more exposure to other people. They’ll make a plan with their partners as far as sleep, how to increase their sleep. They’ll make a plan to, especially at their home every day when their partners get home, to be able to leave their home and see something else just to experience something other than their home. And those are all behavioral plans that can be part of treatment to deal with it.

Courtney Collen (Host): You brought up partner or spouse, significant other, whatever it may be at home. We focus a lot on the new mom in this conversation. But can dad or partner, significant other, also experience effects of postpartum depression?

Karla Salem: You know, I’ve read information that says, they can experience it, but I don’t know why other than, you know, more on a psychological versus biological. A lot of males will tend to start questioning their ability to be a father. They’ll look at their own past and that will create some issues for them. Also, the area of fixing things in male brains tends to be more developed than in women just overall. I know there’s some women who do just a dandy job of always wanting to fix things, but male brains tend to be more onto that. And so, they want to fix the situation, especially if they see

there’s a lot of other kinds of things I think that enter into male emotions at becoming a dad. Sometimes I will do education with both, you know and then I’ll put the partner in charge, you’re in charge of watching this, this mood issue and you have got to do it nicely because if you make bad statements, I can’t guarantee your safety, but this is how we’ll use you to be sure to help us in monitoring. And that gives people, that gives the partners a function, it gives them a job, it gives them a way to help.

Courtney Collen (Host): Yes. I was going to ask you about the support that they can provide at home. You brought up earlier creating a sleep schedule. How can we help around the house if new mom is struggling?

Karla Salem: Well, and that is one proactive thing that families can do. And we used to offer a class that kind of talked to couples about this. So in South Dakota, where males do the outside work. Females do the inside work, which is, you know, manageable for many couples. Until you have a baby, then all of a sudden there’s way too much indoor work.

So, trying to divvy up chores and have things a little bit more equitable indoors, knowing that a mom’s time is going to be, especially if she breastfeeds is going to be very much overwhelming. And that can be very helpful before the baby’s even born. Because what can happen is both, both people, I mean just they’re humans. They just fight for sleep. They fight for, you know, who’s going to get to leave the house? Who gets to go to have a job, or now I have to work, can you get to stay home?

Courtney Collen (Host): Who gets to go to Target or make a coffee run?

Karla Salem: Yes, yes. So, getting things a little bit more evened up, at least for them, there’s no one formula that says this is the way it should be. But if there’s a meaningful conversation about it, the couple determines what’s fair for them and what’s better before the baby even comes, that’s a nice precedence to put into play.

Courtney Collen (Host): Sure. And what about a mother circle of friends or loved ones who can provide support? How can they step in and, and offer that support?

Karla Salem: So, I have had many, many women that had their first child and living at their home with their parents and they had mom’s help. Their second child was with a partner living somewhere else. And almost every one of them have told me, ‘Oh, it was so much easier when my mom was there’, because, you know, those are people that they trust mostly. And been through it and genetically are linked, you know, I mean, our brain chemistry is as genetic as our eye color. So, someone else in the family, if you’ve got anxiety, probably has anxiety so they know how to help you out.

So, family members, I find the best way is to just be there and to keep offering. I really try to encourage women to have planned schedules where people are coming in because if you have to call somebody when you’re at the end of your rope, it’s humiliating for women. It’s not fun because now ‘I’m not strong enough, I haven’t dealt well enough with it.’ And it’s better if they know, you know what, ‘I just need to get through till three o’clock’. So-And-So is coming. They’re going to help me with more labor intensive time of dinner and all of that. And it’s just really nice when help can come that way.

Courtney Collen (Host): So don’t say no to help.

Karla Salem: No, don’t say no. Just think of it as being incredibly generous. Absolutely. And sharing the experience. Yes.

Courtney Collen (Host): Yes. So you brought up visitors In those first weeks when you’re back home, maybe mom is nursing, you know, dad’s figuring out or partner’s figuring out the lay of the land here with mom at home with a new baby. How do we establish those boundaries? Family wants to come see baby and you’re just trying to catch up on sleep. How do you balance it all in those first weeks?

Karla Salem: Well, I had so many women tell me that’s the one thing they enjoyed about COVID because they couldn’t have any visitors. And they got to have a lot of time in the hospital with just their partner and them, and then once they got home, they also got to very nicely limit visitors. And so I always laugh because COVID for many people was very much, especially in the 2020 time, was very inconvenient and very much, you know a stressor. But for many women it was like, oh, so happy. I didn’t have to have anybody come over. I just got to get to know my baby by myself. Right.

And that’s possible to do whether there’s COVID threat or not. So it is the families, if they could just offer, let us know when it’s time for us to come, let us know when it’s best for you. That’s the absolute best invitation from a family who loves you that can happen because then you get to decide on your own without guilt or pressure. But if you can’t do that, then it really does become a couple’s effort to sit down and decide who, who in the family is helpful, who is toxic, so who the helpful people you start inviting in at your own leisure, you know, and people that will come and actually do something, not that you have to entertain while they’re there.

And then the other people you plan for a little bit later after the postpartum so that you have a little bit more endurance. But people coming in and just holding the baby so that women can, you know, clean up the mud room or put the dishes away or do something that makes them feel especially, busy-brained women tend to feel better if things are a little bit more neat and organized. And so having somebody to come in and play with your baby while you’re doing that becomes very helpful. Also, a lot of women will try to sleep during that time and some women are able to and some women aren’t, but I always tell women, don’t feel pressured to sleep during the day because if you’re lying there thinking about all the things that you would rather be doing then get up and go do them. Because sleep is better at night.

Courtney Collen (Host): One thing I’m learning so much is establishing those boundaries, but understanding that there is a kind way to say no, politely.

Karla Salem: Yes. You can have boundaries without anger. That is – and usually because it’s thought out and honestly, I have a lot of folks, a lot of women who have never been able to be confrontational or assertive their whole life, but now that they are, you know, representing their child, it’s a whole new skillset that’s coming out and they need a little bit of help with the confidence to do that.

Courtney Collen (Host): Go mama, go. What are some of the things that we can be doing during the end of pregnancy those last few weeks before baby arrives? Because we know that those emotions and those hormones, feelings of anxiety might be heightened once baby comes. What are some things that you would suggest we do as partners, as we prepare, making plans, things like that?

Karla Salem: People spend a lot of time organizing in that last month. They make sure there’s a place for the baby. They talk about their plan for feeding, whether they’re going to breastfeed, formula. They’ve done a lot of research on all kinds of things. So, it’s a lot of researching time as far as what they want to do after the baby comes. And a lot of people feel way more prepared.

They organize who’s going to be in the delivery room and that varies according to comfort level of the mom. I mean, there’s all sorts of configurations in the delivery room. Usually, they have somebody who is going to represent them and somebody who’s going to just constantly focus on them or they just have one person that does both.

And then usually there’s some discussion about who can visit and what that’s going to look like. Like many couples will tell their family, we want you to respect our first 24 hours in the hospital as just being us because we want to have time to, you know, to get to know our baby. There’ll be plenty of time for you to see us later, but the hospital is usually not the time because both men and women, partners and women are receiving so much information during that time. It’s just a bevy of videos and, you know, lactation and is so much to have visitors come in and exhausting is, is exhausting.

And so really considerate family will ask, but couples can make those kinds of decisions ahead of time and let people know what’s going on and then for when they get home. You can tell people, this is what our plan is for when we get home, we’re going to spend a couple of weeks, you know especially if the partner has time off too. A couple of weeks just getting used to routines and getting to know our baby, what the cries mean, how to get stuff done. And then a lot of people schedule out, you know, one family comes one week, the next family comes the next week so that there’s someone in the home, some kind of companionship even after the partner goes back to work, but it’s very methodical. I always admire people who are able to do all of that and then have cooperative family to do that with them.

Courtney Collen (Host): Karla looking ahead to the end of pregnancy, looking ahead to childbirth and the postpartum phase, are there any things that we can do to support our own mental health through each of these life-changing stages?

Karla Salem: I think women kind of go through a constant redefinition of themselves. You know, things that were important in one stage of life are no longer important. So, I think just a kind of a continual inventory of ‘how am I doing? Do I feel like, you know, I’m happy 80% of the time, if I’m content 80% of the time with 20% of the time being a little annoyed or a little bit emotional.’ And then from that inventory you go to, well, what’s causing, it’s always fun to find out what’s causing your joy and what’s causing your distress because the things that are causing joy, you can amplify and the things causing distress, you can start taking efforts and measures to try to address.

I always think the four basic things, sleep, water, eating, and exercise are always like the fundamental foundation of both health – mental health and physical health. So, it’s always good to take a look at that. How much am I sleeping? Our brain requires or would really enjoy five-and-a-half to six hours consecutive sleep so that it can clear out our memories. And it either puts them into long-term memory or deletes them. And since the human brain developed emails, they’re very similar. If you never clean out your emails, it’s going to be slowed, erratic, not predictable. And that’s what happens to our brain if we never get that amount of sleep.

Now you don’t have to get it every night, but at least try to catch up to what is recommended. And that’s always a good thing to kind of look at in that inventory. Am I getting enough sleep? Am I doing OK? If in your inventory you’re dissatisfied with something to the point where, you know what? I’ve been dissatisfied with this before and before and before now maybe it’s time to address it. I always think it’s a good thing if you have a primary care doctor to share that with them. Because they usually know all of the physiological kinds of things. They know about the mental things and they’re going to get you to someone who’s going to be able to help you. And maybe you’re not going to be ready right away but when you’re ready, at least you have the resources to do that.

Courtney Collen (Host): Well, this has been so valuable and I learned so much as I always do. Karla Salem, thank you so much for your time, for the conversation and all that you do to support so many women and mental health here at Sanford. Thank you.

Karla Salem: Well, thank you for the opportunity.

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Research screenings give rare disease families hope

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 medical research and a potential breakthrough in screening for a rare disease. Our guest is Dr. Jill Weimer with Sanford Research. Our host is Simon Floss with Sanford Health News.

Simon Floss (host): We’re talking to Dr. Jill Weimer, who heads up the Weimer Lab at Sanford Research in Sioux Falls, South Dakota, about a potential breakthrough in screening for a rare disease. Dr. Weimer, thanks for being here.

Dr. Jill Weimer (guest): Thanks for having me.

Host: So, you are one busy person. Can you explain a little bit about, you head up a lab and then you’re also in Philadelphia quite often?

Dr. Jill Weimer: Yes. So I’ve been at Sanford Research for 13 years. I started my research program here right as Dave Pearce was launching the Children’s Health Research Center, which has kind of evolved over time to really have a heavy focus on rare diseases. Initially my research team was very basic in our biology. We were understanding how the brain develops and how when you have mutations in specific genes that can lead to rare pediatric diseases.

Over the course of the next five to seven years through some funding from the NIH and from several private foundations, we expanded our work to really focus on drug development. Specifically, early on, we were looking at how we could actually correct those defective genes using technologies like gene therapies.

And so our group helped in collaboration with a team at Nationwide Children’s Hospital to develop gene therapies for two rare lysosomal storage disorders called CLN3 and CLN6 Batten disease. Those programs then were taken on or taken over by a Philly-based pharmaceutical company called Amicus Therapeutics. And at the time, in early 2019, they asked me to come over and head their science division. But I really love my time at Sanford and my research team that I had built here, and I wasn’t willing to leave that. So, I actually negotiated to do both jobs. So, now I split my time between running the lab here at Sanford still, but also heading the science division at Amicus in Philadelphia.

Host: Do you have time for any hobbies?

Dr. Jill Weimer: Oh, well, I think I structure my spare time a lot of times around my passion. So I spend a lot of time, a lot of my free time working with the foundations that we support and that we work with for Batten disease specifically. But I do enjoy gardening and reading and hiking and being outside and scuba diving, so it’s crammed in there. Tightly.

Host: (Laugh) Okay, let’s get to what we’re going to be talking about here today. First, what is Batten disease?

Dr. Jill Weimer: Yep. So, Batten disease is actually a family of rare lysosomal storage disorders. So the lysosome in your cell, think of it as sort of like the recycling center. So it takes proteins that need to be turned over or broken down like a recycling center would, and breaks those down into amino acids so they can be reused by the cell to build new proteins.

In lysosomal storage disorders, the lysosome is dysfunctional. It doesn’t break that material down, so it accumulates and you get storage material that then can impact the cells. In Batten disease, there’s actually 13 different genes or 13 proteins that can lead to different forms of Batten disease. And how those differ really is around the age of onset – so anywhere from infantile to late infantile to juvenile to adult onset of the disease. But also sort of the order of the phenotype, how the disease presents can vary depending on which form of that disease the patient has.

Host: Talk about maybe the severity of Batten disease?

Dr. Jill Weimer: Yep. A lot of the work in our lab has focused on the, in the late infantile form. So just to give you a typical progression of a kid with a late infantile form: They usually are born relatively healthy. Around the age of 2 to 3, they start to have motor problems; they might present with seizures. Over the course of the next few years, their motor ability deteriorates their language ability deteriorates. They’re not meeting those cognitive milestones that a 3-, 4-, 5-year-old would make. When they’re hitting kindergarten, their seizures progress. They become wheelchair bound. In many cases, they will go blind and usually they succumb to their disease around the age of 10 to 12.

And there are no cures for any form of Batten disease right now. For one of the forms of late infantile CLN2, there’s an enzyme replacement on the market that’s approved, and as I mentioned in clinical development, a number of different gene replacement or gene therapies that are being tested.

Host: So, I understand we’re going to be talking a little bit about CLN1 and CLN3. Can you explain what those are and what the differences are?

Dr. Jill Weimer: Yep. So CLN1 is actually the classical infantile form. So that’s the most severe form of the disease. And it’s caused by a mutation in the CLN1 gene. CLN3 is the classical juvenile form. And so, the kids with CLN3 usually don’t have a disease onset until they’re about between 4 and 6. And their symptoms usually start with visual decline. So they could actually have visual deficits that persist for one to two years before they have any of those other symptoms.

We’ve worked on gene therapy programs for CLN3 and actually our lab now works on I would say drug development, non-gene therapy. Our Sanford team really focused on identifying small molecules that would have more of an impact across multiple forms about disease. So we actually work on CLN1, CLN2, CLN3, CLN6, and CLN8, all in parallel.

Host: Oh, wow. So, there’s not one that you’re studying more than the other, or would you say it is CLN3?

Dr. Jill Weimer: Yeah, I would actually say because of the tools that we have in hand, a bulk of our work over the last few years have been centered around CLN3 and CLN6, and maybe a little bit more on CLN8. But we’ve developed a number of tools that really take us all the way from the basic bench work, to the clinical work, and then also building translational tools in between.

Host: So, some terms that are critical for your line of work, and the average listener might not know exactly what these are talking about biomarkers and genetic mutations. So, what are biomarkers and within those, what are you looking for, and what are genetic mutations?

Dr. Jill Weimer: Yeah, so biomarkers are actually something that we originally started looking at as a way to kind of identify or diagnose the disease to track its progression. So, in our lab we work with mouse models. We’ve also developed a number of pig models for Batten disease. And really the way that we track the disease is to collect the brain from that animal, look at the pathology, but we also run what I call like our mouse Olympics. Like we have a battery of behavioral tests that we’ll put those mice through to look and see do they have vision deficits? Do they have behavioral deficits, motor deficits that correspond to disease? So that then when we treat them with the drug, we can see how they actually respond. Do we stop the progression of coordination deficits, right? Are they able to run better with the drug?

But in human patients, you can track those things, but they’re, as I mentioned, with C3 Batten disease, it may be very protracted. And so, as I mentioned, they may start to have visual decline, but they, you may not see motor changes for two or three years. So, imagine now running a clinical trial in patients, you’ve given them a drug and now you have to just sit and wait and see for two to three to four years, is this drug effective because it takes that long for the disease to start to progress.

So, what biomarkers allow you to do is collect information from let’s say a biofluid, like a blood sample, urine sample, even a cheek scraping, central spinal fluids, your CSF. It could also be things like imaging, brain imaging. MRI can be used as biomarkers. And these are things that are more readily available, that you can collect from the patient multiple times over a year, and use them to track disease.

And so historically, none of these biomarkers exist for Batten disease. So, it really, when you enter into a clinical trial and you’re testing a drug, it means it’s going to take years for you to have an answer. Is this working? So, what our lab has done is use those mouse and pig models that we’ve developed to identify novel biomarkers that we can identify in the animal models from blood samples. And so, the approach that I always said is, I think a lot of times when people look for a marker of disease, they’re looking for a needle in a haystack. And sometimes seeing that needle in that haystack is really difficult, but in the age of AI and big data, why not look at the whole haystack? So, our approach has been, let’s take as much information as we can. We’ll build these algorithms that then use that information to condense that, to create a biomarker scoring system.

So, we’ve done this with a number of our mouse models looking at neuroimaging and gait analysis, movement, motor movement to come up with a scoring system. We’ve also used blood samples to then start looking at the biofluids to see if we can mine those to look for changes in the, in different things that are expressed in blood and then use that information to develop better biomarkers that then can be used in the clinic. So we’ve taken that information now and validated some of these in CLN3 patient samples.

So, really the next step be then to develop a qualified assay that can be run in a diagnostic lab, that then the patients in clinical trials or Batten disease patients as they’re diagnosed, would send these samples into that lab. They would read those and give them, here’s where you are in your disease progression, and now if you’ve received a drug in a clinical trial, is it correcting the progression of that disease?

Host: I was literally just about to ask, what comes next for this process? So, you already answered my question.

Dr. Jill Weimer: And the other, the cool thing is too, that some of the biomarkers that we’ve discovered after a drug is approved, now you need to actually find a way to identify these patients. So, many of us are familiar with newborn screening of disease. In order, in most states to be added to the newborn screening panel, there has to be a drug that patients could receive to treat that disease, right? So they don’t want to necessarily do newborn screening and tell you, your kid is going to develop X disease, but there’s nothing we can do at this point. And so, really like the newborn screening panel is for diseases that we have treatments that we could get patients on right away. So the next step, usually after a drug is developed for one of these rare diseases is to then start working on a newborn screening panel. That can take years.

So, in the instance of CLN2, when I said there was an enzyme replacement therapy, that hit the market about seven years ago, and most states still do not have a newborn screening panel for CLN2, right? So, it takes usually about a decade behind when a drug is approved to get it on the newborn screening panel. And part of that is developing an assay that could be used to detect that. So, the nice thing about these biomarkers that we’ve discovered, we think that they actually could also be used for newborn screening. So, we’re kind of ahead of the game before we even have a treatment. We would actually have some of those tools lined up that would actually expedite getting these drugs to patients as quickly as possible.

Host: Yeah. Man, this is fascinating. Why is this so important?

Dr. Jill Weimer: I think for me it is giving these families hope. Rare diseases are so infrequent. And some of these diseases, for instance, CLN8, there’s probably less than 10 patients in the United States that have this disease. CLN1, two and three are a little bit more prevalent. And so, those are about one in 12,000 to one in 20,000 patients in the United States.

But the other forms of Batten disease we work on are one in 200 to 300,000 patients. Right? So when you think about Alzheimer’s, there are many people in the United States, scientists, clinicians, working on treatments for Alzheimer’s, understanding like how this is impacting the brain. But for some of these rare diseases, there are, like for CLN6, for many years I was the only person in the United States working on this disease, right?

So, it gives these families hope that there is somebody that cares about them, that there’s somebody fighting for them, that there’s potential, maybe not in their child’s lifetime, but in like, if we keep working, that we will get to cures, we will get to treatments that will help these kids.

Host: Yeah. And just to put it into context even though it’s a rare disease, there are, it’s, I assume many, many people affected by the Batten disease or variations of it. Yes. How, off the top of your head, do you have any numbers of how many people that might be?

Dr. Jill Weimer: Yeah, there’s probably 500-plus patients living in the United States with all the forms collectively of Batten disease. Like I mentioned, CLN1, two and three are the more prevalent forms. And so those are the ones that people would be more familiar with. But it doesn’t make those other forms any less important.

Host: Lastly like I just said, it’s a rare disease and Sanford Health, whether people know this or not, is a huge player in studying rare diseases in this realm. Can you talk about the CoRDs registry and how involved we are in researching rare diseases?

Dr. Jill Weimer: Absolutely. So, the CoRDs registry is really a way to help us identify those rare disease patients. So essentially, initially it was set up as a registry where different foundations, or even it’s disease agnostic, but they have foundation partners where a patient can go in and enter their information on the back end. Scientists, researchers, clinicians can access that registry to be able to identify patients, do research, ask questions, connect with those patients. Say a clinical trial becomes available. It’s a way to reach out to reach out to those patients.

But I would point out that CoRDs is instrumental to what we do in rare diseases at Sanford, but it’s only a small fraction of the rare disease work that we do. So, when we really started recruiting scientists into that original children’s health research center 13 years ago, we were fortunate that we started recruiting a number of scientists that actually work on rare diseases.

So, I would say about 15 of the 30-plus labs that we have at Sanford Research work on some different rare disease. So, we really have become this like hub. CoRDs is sort of the part of the infrastructure that we’ve built to be able to do that.

But we built other things too, in place. So, we have like a drug screening facility and a translational sciences facility. So, say a scientist here is working on Friedreich’s ataxia and they want to be able to get skin samples to make a cell line from a patient with particular mutations. CoRDs can help them identify those patients, consent them under an IRB to collect that, that skin biopsy, to then bring it into our translational science core to build those cell lines that they can then study for basic biology or drug screening, or a number of different things that they might need to do with their work.

Host: Wow. This is just so fascinating and it’s no surprise we ran out of time. We’ve got to go (laugh). So, Dr. Weimer, thanks again so much for being here, but more importantly, everything that you do.

Dr. Jill Weimer: Absolutely. Thanks for having me.

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

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Flexible work and well-being in rural health care

Matt Holsen (host):

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 around workforce challenges and solutions. Our guest is Ashley Wenger-Slaba, vice president of employee experience at Sanford Health. Our moderator is Ann Nachtigal, director of Sanford Health News.

Ann Nachtigal (moderator):

Hello everyone and welcome to the “Reimagining Rural Health” podcast. We are talking today about workforce challenges and solutions. And joining me today, our guest is Ashley Wenger-Slaba. She is vice president of employee experience here at Sanford Health. Ashley, welcome. Thanks for joining us today.

Ashley Wenger-Slaba (guest):

Thank you, Ann. It’s great to be here.

Ann Nachtigal (moderator):

So vice president of employee experience, that sounds like a big job. Can you explain a little bit about what that role entails?

Ashley Wenger-Slaba (guest):

It’s a really great job ‘cause we get to focus on one of our most important things here at Sanford, which is our people, one of our greatest resources. And I get to lead our employee experience team as well as our DE&I team, and employee and labor relations as part of that.

Ann Nachtigal (moderator):

Wow, that’s great. And as you say, really the people are at the crux of every organization and I think when we talk employee experience that really has changed. Work has changed for so many people across the country. Right. And really what led that was the COVID-19 pandemic and specifically we saw in health care how those challenges really were heightened, which led to some staffing shortages, increased health care worker burnout and other hurdles that really still persist. So, but really similarly that gave us some opportunities to really innovate and think differently about the way we do our work. Can you talk about that?

Ashley Wenger-Slaba (guest):

Yes. One of the main ways it provided an opportunity for us was when Covid came, we sent people home, right. In droves as quickly as we could ‘cause safety was the number one priority. And I think it thrust us into this idea of working flexibly that we maybe had not adopted as much as an organization. It’s also just not as common in the health care industry.

Seeing the success of that and our ability to work differently led us to adopt a working flexibly policy and toolkit that we formalized this past year. And as a result of that, have been able to really expand our flexible work arrangements, not just for our nonclinical staff, but for our clinical staff as well, which has been a real opportunity for us to recruit and retain a different, different populations of employees.

Ann Nachtigal (moderator):

Sure, absolutely. And that is really unique that it’s in the clinical space, right. I would think that’s a huge draw for attraction and retention. Do you see this as really the wave of the future of HR?

Ashley Wenger-Slaba (guest):

I do think we’re gonna have to think differently about talent and meeting employees where they’re at. You know, I think the job market has changed significantly. People have options and with remote work, especially being in the Midwest, we are competing against a whole nationwide of employers. And so being able to provide opportunities for employees to work in a way that works with the rest of their life is really important.

Ann Nachtigal (moderator):

What do you think are the greatest opportunities in attracting and retaining that top talent?

Ashley Wenger-Slaba (guest):

Two of the main areas where we’ve seen populations that this has really appealed to. One has been our employees that are not just caregivers at work but caregivers at home. So whether that be for young children or an aging parent, having that flexibility to play those other important roles out of work.

And then I think the other big group has been with our more senior nursing staff, really looking at ways and areas outside of nursing ways that we can maybe have phased retirement and kind of offboarding ramps for people that want to slow down but don’t want to stop working altogether.

Ann Nachtigal (moderator):

Yeah, that’s great. What do you think similarly, what are some of the biggest challenges? And you mentioned this a little earlier, but do you think that the rural footprint that we are in here, does that help or hinder?

Ashley Wenger-Slaba (guest):

It depends on the role, whether it helps or hinders, you know, I think it’s a distinguishing factor and creates a different mission and vision for us, which can be an attraction factor for people. We also, our base largely in the Midwest and so sometimes people wanna stay there if they’ve got family and friends and this is home.

But I do think it is sometimes there’s a stigma that goes along with that that maybe does not attract folks from outside the Midwest until they come and visit or meet people from the Midwest.

Ann Nachtigal (moderator):

We’re seeing that too, right? (Laugh) Yes, yes. People are like, oh it’s nice here in South Dakota. Yes. Would you say that kind of that ultimate goal is to be the employer of choice in all of our markets? And if so, I would imagine that would really take a concerted effort to be that employer of choice.

Ashley Wenger-Slaba (guest):

That absolutely is our goal. We can’t do any of the work we do to serve patients and residents without having, you know, top-notch employees who feel like their job is incredibly important and feel like they’re valued for what they do. But what’s tricky about that and it is definitely challenging is that what each employee wants and needs is slightly different as well as what each different market within Sanford needs. So we have to make sure we provide tailored options for everybody.

Ann Nachtigal (moderator):

Let’s talk about some specific examples of really some innovative ways that Sanford Health is engaging its workforce to be that employer of choice. We’ve talked about the work flexible policy, anything else? Can you give us kind of some examples? And I know that you have them ‘cause I’ve heard you talk a little bit about those in the past.

Ashley Wenger-Slaba (guest):

A few different changes that we’ve made this past year in response to our employee engagement survey is that we’ve revamped our benefits offerings. So in this new year in 2023, we are offering for the first time a paid caregiver leave and fertility treatment benefits for employees, which when you look at Sanford’s demographics from an employee perspective, we have a largely female childbearing year population. And so that’s been an incredibly loud that we’ve heard and that we’re answering.

One other area that comes to mind is just a focus we’ve been putting on psychological safety. We hear on our survey results again that there is a power dynamic that exists in health care and all industries, whether it’s physician to nurse or leader to employee and really trying to make sure that everybody feels like they are empowered to speak up, whether it’s about co-worker concern, a safety concern with the patient, whatever the issue is.

Ann Nachtigal (moderator):

You bet. And we see that in Sanford Health marketing. I know the SAFE initiative is system-wide, but we have a weekly huddle and people talk about those stories and lift them up so that they know that they’re able to speak up. And I think that’s wonderful and we’ve really seen some success specifically in marketing, but obviously that would be system-wide as well.

So you talk a little bit about, you know, listening to what our employees need, but I would assume that data helps inform our decisions too. And you mentioned the employee engage engagement survey that was last done in December of ‘22 and we did ask employees a number of questions about how they feel about their work, you know, how engaged they are, et cetera. And those responses really did tell a success story, didn’t they? Can you tell us a little bit about that?

Ashley Wenger-Slaba (guest):

Yes, we were very happy with our results from the survey this year. Again, I think because employees are starting to see that we are listening and then not just listening but responding with actions and initiatives to respond to their, that we’re seeing some positive survey results, we’ve been able to increase our ENPS score, which is kind of your overall satisfaction. Are you likely to recommend Sanford as a place to work?

And then we are also seeing increases in our inclusiveness score as well as employees meaningful work score, which is wonderful. We want people to feel like there’s purpose in their work and they believe in the mission and vision of Sanford.

Ann Nachtigal (moderator):

I have a couple of numbers that came out of that. So in, in relation to those, the net promoter score for mental well-being, we ranked 13 points above the industry benchmark in that latest survey, which is amazing. Also, Sanford Health ranks in the top 25% among peers in the health care industry for that meaningful work, and inclusiveness is a strength.

Ashley Wenger-Slaba (guest):

There is a huge component of health equity and just the impact on health outcomes for our patients that come to see us and just how much better their outcomes are if they are asked questions in a welcoming way. If doctors are trained on unique differences of differing identities that may influence how they show up in the doctor’s office and that they can respond to what they might need differently.

Ann Nachtigal (moderator):

And I know we’re doing a lot in terms of employee well-being. Can you talk a little bit about that?

Ashley Wenger-Slaba (guest):

Certainly. Our focus on employee well-being has really been about, I think first destigmatizing the need to ask for help. But we know that especially within health care, employees have been through a lot through COVID and we see a lot of burnout. So really equipping leaders and co-workers to have the resources and skills to be able to identify employees in need and connect them with resources, whether it be through our Employee Assistance Program where we have both in the moment support for employees that’s unlimited or free sessions to go visit a private counselor in person, as well as just weaving well-being tips into everyday activities that employees do.

So we’ve been weaving well-being into weekly emails, into huddle topics that we do as part of our SAFE initiative, into questions that leaders can ask as part of their regular employee rounding, just because we think it’s that important. And we know, I was reading something this morning that next to your spouse, your immediate leader has the greatest impact of anything else in your life on your well-being. And so when you think about that as a leader, that is very convicting in terms of how important it is, how you engage with your staff. And so having a leader that you know cares about you is incredibly important.

Ann Nachtigal (moderator):

Oh, absolutely. I can speak from both sides of that, right? Being a leader of people, I think bring the humanity to work, right? Everybody has their lives outside of work and that’s important. And so just bring that humanity and also just understanding how important it is to have that supportive boss, which is wonderful. Another couple of examples you gave earlier: Can you talk about the IT team and what has happened in terms of success with them and it really was kind of born out of that COVID pandemic and the craziness there?

Ashley Wenger-Slaba (guest):

Yes. Our IT team was great enough to be one of our pilot groups when we were working on our working flexibly policy in rollout. And that team had a great success rate. They were able to have a 29% adoption of flexible work arrangements within their department. And it’s one of our larger corp service departments here at Sanford.

And I, what I think is the silver lining, not only have they received really positive feedback from their employees who feel like this is an added benefit, a reason they’re gonna stay with Sanford, promote it to others, but they’ve actually felt that from a business continuity perspective, because Sanford is a 24/7 operation as a health system, they can provide a better continuum of care to their clinical partners because they’re here and they have people that are working in early and a late shift because it works for their personal lives.

Ann Nachtigal (moderator):

That’s a wonderful story. I think it’s great that, you know, despite what went on with COVID, right, that we persevered and we found these solutions that we might not have looked at earlier. And so it’s just a wonderful success story for Sanford Health.

Wrapping it up here, and I know we have lots more we can talk about, and we’ll continue this conversation ‘cause it’s very important. Can we just end with talking about what have we learned about what works and what doesn’t in terms of employee engagement and how does that shape the strategy moving forward?

Ashley Wenger-Slaba (guest):

I would say the thing we’ve learned most importantly that doesn’t work is just, you know, me and my team sitting in a room and trying to decide what the next best strategy or initiative is. What really works is listening to our employees periodically, and right now we’re doing that twice a year to get their feedback.

Taking that to heart and watching trends and reading comments and themeing those comments so that we can have our initiatives and programming respond to what our employees are telling us they need. That’s a bit of a moving target, but we wanna be responsive to employees and we want them to know that what they’re telling us matters.

Ann Nachtigal (moderator):

Seems so simple, but I don’t think it’s, it isn’t always that simple. Right. Well, really appreciate you joining us today, Ashley. It was a great conversation and we will do more in the future.

Ashley Wenger-Slaba (guest):

Sounds great. Thank you.

Matt Holsen (host):

Thanks again. 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 Matt Holsen, and thank you for listening.

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Seasonal affective disorder intensifies mood

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 and postpartum depression 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.

Listen now: “Her Kind of Healthy” podcast series

In this episode, we are focusing on seasonal affective disorder (SAD): what it is, how it affects us women, and what we need to know. I have the privilege of welcoming two guests for this conversation. I have Wendy Vetter, D.O., who is an internal medicine physician in Sioux Falls working to help patients understand how nutrition, mental and spiritual factors impact physical health. And I also have Karla Salem, a certified social worker who specializes in women’s mental health. Thank you both for joining me.

Karla Salem (guest): Thank you.

Dr. Wendy Vetter (guest): Thank you.

Courtney Collen: Dr. Vetter, I’ll start with you. Can you define seasonal affective disorder and explain how common it really is?

Dr. Wendy Vetter: Seasonal affective disorder is a variation on depression and it’s unique in that it seems to coincide with the fall and winter months and its onset and it also resolves typically with the coming of spring and summer.

Courtney Collen: How common is seasonal affective disorder around here?

Dr. Wendy Vetter: So, because we are in the Midwest and we have shorter daytime hours in the winter we have a large amount of seasonal affective disorder, probably way underdiagnosed.

Karla Salem: And then the other part of it is there’s kind of a continuum for some people. They don’t have specifically seasonal affective disorder, but they’re very affected by the shorter days because of the brain chemistry issues that sunlight impacts serotonin levels and so when the days are shorter, serotonin levels decrease, which is kind of like serotonin is like the volume of your mood. So moods that would be just kind of stable and normal normally where are all of a sudden a little louder, like anger is a little more intense, sadness is a little bit more intense. So people can kind of feel that impact even without the official diagnosis of seasonal affective disorder.

Courtney Collen: So what is physiologically happening in the brain, you talk about serotonin levels, when someone might be showing signs or symptoms potentially leading to a diagnosis of seasonal affective disorder?

Karla Salem: Well, serotonin is your, like I said, your control over your mood. It’s next to norepinephrine in your brain, which controls your thinking. So that’s your anxiety neurotransmitter. And the two really work very closely, hand in hand. So serotonin is, should be more buoyant and it becomes less buoyant when it’s not exposed to sunlight. But it is a genetically predisposed. So you’re born with your brain chemistry. So that’s kind of the underlying or the initial kind of indication that if you have a history of depression, then you might be more impacted by the winter the seasonal affective disorder, the extra symptoms that come with it. But our brains and our guts are also interconnected and then it’s interconnected with sleep. Because serotonin creates melatonin which makes our sustained. And then, so in the shorter days, sleep can either be more or less so you also have that sleep deprivation.

Dr. Wendy Vetter: Yeah. I was going mention the melatonin component as well in relation to circadian rhythms. Yeah. And I think that’s part of what we understand about seasonal affective disorder.

Courtney Collen: We talk about what’s happening on the inside of our brain but let’s speak to the signs and symptoms. You talk about someone might be predisposed to seasonal affective disorder if they’re potentially struggling with mental health or have history of depression. What are the signs and symptoms that we should be looking for?

Karla Salem: People will have the typical signs of depression, which would be, you know, more lethargy, lack of energy maybe more hopeless thoughts. With seasonal affective disorder, there’s some additional, like you tend to want to hibernate, not get out of bed. There’s the carbohydrates or the diet issue. Have you seen that with your patients?

Dr. Wendy Vetter: Yeah. There’s a craving for carbohydrates.

Karla Salem: It’s maybe more intense symptoms or it’s just people just will report, “I just don’t feel like myself. I’m screaming at my kids and I don’t normally do that and I don’t want to exercise. I normally exercise, but I don’t feel like it.” So, it’s like you take some of the things that they use for normal coping and don’t have them anymore because they don’t have the energy to do it.

Dr. Wendy Vetter: And that seasonal affective disorder is a little bit more slanted in symptoms. They’re consistent with that fatigue, low energy, but sleeping more, weight gain and increased appetite. Whereas depression can sometimes go either way where there are problems with insomnia or sleeping too much. There can be problems with loss of appetite or increased appetite, but we see more of the hibernation, I think is a good word to describe the phenotype.

Karla Salem: So with every mood or anxiety, you always have three issues: you have the biological, you have the social, and then you have the psychological. So oftentimes people are coming off of Christmas, they might have seen family, not seen family, they’re still going through kind of sadness about maybe losses and, and they have no winter trip planned. So that also will impact people’s mood beyond just seasonal affective disorder.

Dr. Wendy Vetter: The key with making it a true diagnosis is that all of those impact symptoms impact your functioning like Karla was saying. So your social functioning, your biologic function and then of course memory and your work.

Karla Salem: So every part of you gets kind of impacted. It kind of feels like a mess sometimes, people report.

Courtney Collen: So at what point is it time to seek help and, and at Sanford Health, where do you start?

Dr. Wendy Vetter: I would be biased to say you can start with your primary care doctor.

Karla Salem: I was going to say the same thing!

Courtney Collen: Well, good thing we have both of you here.

Dr. Wendy Vetter: Yeah, absolutely. And then we’re very fortunate to have lots of options available to treat. I think sometimes just identifying it, naming it and getting it out in the open is a relief for people. So just simply having somebody to talk to about it and empathize. And then we have medications that can help with treatment and again, we have embedded our therapists and IHT (integrated health therapists) in our clinics to help with talking through what they can do for themselves.

Courtney Collen: Let’s expand on the treatment and what that patient journey might look like and what, you know, as a therapist, as a social worker, Karla, and an expert in your field, what you bring to the table and how collaboration works to benefit the patient.

Karla Salem: Oftentimes people will want to go the route of medication. So, one of the things that can happen in therapy is kind of monitor how that’s going and kind of explain what it does for folks. The other, another really good behavioral technique is light therapy. It’s often used that it can restore what you’re losing because of the wintertime to your serotonin. And it’s real affordable. Used to be like light boxes you had to rent because they were so expensive. Now you can jump on Amazon and get one for $60. And so that used throughout the wintertime or when the days start getting shorter can also help in restoration. And then people just like, like Dr. Vetter said, normalizing the situation. Just making sure people understand because they’ll be thinking, thinking, thinking. And they’ll come in and say, ‘I think I’m crazy’ and no, this is a very normal way that, that people get during the wintertime and explanation and then ideas on how to get out of bed and go take a walk or go outside even though it’s really cold out to get some of those behavioral kinds of techniques to help.

Courtney Collen: How might we support friends or loved ones who may be impacted by seasonal affective disorder?

Karla Salem: Well, one of the ways is just to understand and to listen. A lot of times people don’t want to talk about that with friends and loved one because they think that brings them down or, or they’re a burden. And so just to be open, if you notice something different, somebody’s kind of off. It doesn’t hurt to just ask, you know, ‘what’s going on? Is there something I can do to help?’ And just to be a listening ear oftentimes is very supportive.

Dr. Wendy Vetter: I would say if you are concerned about someone or if someone comes to you saying, ‘I’ve been feeling down or blue’ entering a conversation with curiosity, and I use that same phrasing with my staff in-clinic too. Just don’t make judgment. Just be open, patient curious and they’ll come to you with what they need in their time.

Karla Salem: You really encourage people to go to your medical doctor because those are usually people that patient trusts and so that’s something, you know, they tell them all sorts of things. And then can help guide them in a way. So that can also be a place where friends and family can guide a patient to go to talk to their doctor.

Learn more: How to support someone struggling with their mental health

Courtney Collen: Yeah, wonderful to have that support. Relative to that, we know winter can be a tough time of year, and if we don’t like the cold, we tend to spend a lot of time indoors. So what tips or advice do you have to combat any additional stress this time of year?

Dr. Wendy Vetter: There are lots of things I could say about that. I think like Karla was mentioning winter vacation or just even thinking about and planning forward to something in the future, whether or not it’s a trip. So setting a goal making sure we’re focusing on getting adequate sleep and in particular with seasonal affective disorder, having a very routine going to bedtime and getting out of bedtime can be helpful for maintaining, I guess, normal mood and energy and focusing on diet and, and physical activity or exercise definitely increases our endorphins and that improves our mood.

Karla Salem: And beyond, you want make sure, just like Dr. Vetter was saying, that your foundation is as solid as can be. The main eating and drinking water and sleeping and such and other ideas you can have is just to again, have some focus, have some directions, maybe some personal challenges during January: see how many books you can read or you can see how many steps you can walk like walking up your steps at your building or somewhere else. And just challenge yourself to those kinds of things. Those personal challenges. Also, you know, the planning, that’s such a great idea. I mean, even starting to plan your garden, starting to plant some seeds and have a little greenhouse ready to go. Any of those things that distract you from, from any kind of doldrums and charges you into the future just a little bit. Things that you can look forward to.

Courtney Collen: Always good to plan ahead, especially thinking about those warmer months and those sunnier days. Is there anything else that I might not have asked you that you wanted to discuss on this topic of seasonal affective disorder and what women need to know about this?

Dr. Wendy Vetter: My high points would be it’s really common, don’t keep it to yourself and it will get better.

Karla Salem: Excellent notes to end on.

Courtney Collen: Agree. Karla Salem, Dr. Wendy Vetter, thank you so much for your time and your expertise in all that you do here at Sanford Health. Thank you.

Dr. Wendy Vetter: Thanks.

Karla Salem: Thank you.

Courtney Collen: I’m Courtney Collen. Have a great day.

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Servant leaders make a difference in daily practice

Alan Helgeson (Host): 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 around servant leadership and the difference it makes in the daily practice. For clinicians, our guest is Dr. Craig Uthe, family medicine physician, and Sanford Health enterprise director of clinician professionalism. Our moderator is Dr. Luis Garcia, president of Sanford Clinic.

Dr. Luis Garcia (Moderator): Thanks for joining us today, Dr. Craig Uthe, with an exciting topic, which is servant leadership. And I was just prior to starting this recording, I was having a conversation with Craig about how the last couple of years have been interesting to say the least for clinicians and how we just feel beaten down and devalued, and yet we have the most honorable profession, right? Where we get to use our talents and our gifts to help people in their greatest needs. And we need to continue to show up unlike restaurants and malls that they can close shops or cut down tables. You know, we have a commitment to our patients and we need to continue to show up. And I think our clinicians have done that and have excelled at doing that despite the circumstances. And a lot of that during the pandemic and the post-pandemic era has been leadership. Craig, you and I have had conversations numerous times about one thing is to have a title, and another thing is to have is to be a leader, right? Well, and to be a servant leader.

Dr. Craig Uthe (Guest): Yes. Being a medical doctor, MD, DO, nurse practitioner, PA, that is a title, that’s a formal leadership title. We are looked to as leaders whether we want to or not, and there’s responsibility that goes, goes with that. And when I ask people, why did you decide to become a health care professional? Always in that answer somewhere is, well, I want to help people. Seems like a, you know, very simple answer, but it is, gets to the core of why we go into medicine. And sometimes it’s not easy to remember that if you get beat down through a pandemic or if you’re up all night or through the rigors of being a physician, it’s not always easy to be in that job and to have that title.

Dr. Luis Garcia: You ask people a question, why do you become a physician? That’s a great introductory question for a great conversation. Let me ask you the same question. Why do you choose to become a physician?

Dr. Craig Uthe: Thanks for asking me. Again, it’s that proverbial, I really wanted to help people. I grew up in Sioux Falls, South Dakota. I went to Augustana College at the time, now Augustana University. I was a camp counselor in high school, in college. I worked at a YMCA camp in high school. And I remember they had the triangle of the body, mind and spirit. And I loved that analogy of the human. And so I wanted to go into profession that would take care of the body, mind, and the spirit.

I grew up in a Christian background. I’m a faith-based person, so the spirit is important to me in a person’s health. And I got to the last two years of college Augustana, but it’s called a four-one-four curriculum. So you have two semesters, and in the middle of that you take one course.

And so in my junior year of college, I shadowed a second-year family practice resident doing community medicine in Sioux Falls in the area. Went down to Keystone Addiction Treatment Center, saw my first delivery of a baby, worked in the clinic, loved it. Senior year I shadowed the three hospital chaplains at the time, Sioux Valley Hospital, now Sanford. And I loved them both.

And I said, you know what? I’m gonna apply to med school once, if I get in, I’m meant to be a physician, and if I don’t, I’m probably gonna go into some kind of a ministry. And my father, my uncle both said, well, Craig, and we think you could probably practice, you could probably minister to people as a physician easier than you could practice medicine as a clergyman. I thought, OK, I agree with that. And I got into med school and the rest is history.

Dr. Luis Garcia: Well, the rest is history. But that history is I think, full of successes and full of achievements, and more importantly, Craig, full of influence. I think that if I were to count the many, many people that you have touched and that you have helped get in a better place, I don’t know that I could. There’s so many of them. And in the medical community, you are recognized and respected.

Talk to me a little bit about that transition. You get into medical school, you become a family doctor, but yet you discover that you have other gifts that some of us wish we could have, you know, which is, once again, of leading, influencing, helping people outside of the clinical work.

Dr. Craig Uthe: Well, I like to remind each other as physicians that it’s a privilege to be a physician. Did I earn the right, I achieved things by getting into med school. You’ve achieved something. I talked to first year medical students, they say, congratulations on getting here. You have achieved something. But never forget what a privilege it is to have the opportunity to have the influence. I love that word influence. I’ve heard that term used as the definition of leadership. There’s a leadership guru named John Maxwell, and he says, leadership is measured by influence, nothing more, nothing less. And it’s that influence that’s the key to being a physician, having that influence.

Dr. Luis Garcia: So sometime in your development, your own individual personal development, you figure out that you’re being influential. Talk to me about that. Young Craig Uthe graduating from medical school and discovering, wow, not only can I be a great clinician and take care of however many patients, but I’m actually, I have other skills that I’m discovering and that I really would love to continue executing.

Dr. Craig Uthe: I realized early on in my career, I’m not sure where it was that intellect is not the only thing that’s needed in medicine. I remember for some reason I was probably about, I was a fourth-year med student and a female OB/GYN physician at Sanford, I looked at her and I thought, how does she know all that stuff? She was probably 40 years old at the time. Everything – how does she know that? Am I ever gonna get to that point and go 10, 15 years later? There was a moment I just caught myself speaking to someone. I can’t remember it was a patient, or if it was like the colleague. I thought to myself, oh my goodness, I have this knowledge base now. We all get that just through the learning.

We’re all forever learners. As physicians, we have altruism, we care about people, we all possess that intellectual curiosity. We love science, we love learning. We’re forever learners. And I remember just thinking, oh my goodness, that intellect is so important. It’s not optional, it’s required, but there’s so much more required. I had Dr. Mary Nettleman, dean of the medical school recently, she asked me one time, Craig, we’d love to bring you on board on our team, and we wanna graduate great physicians at the University of South Dakota. And I said, Mary, I love that. I just have one question. What’s your definition of great physician? And her response to me was, why don’t you go out and find out?

And I’m still looking when I ask groups, and I’ve asked people having breakfast that are retired at Hy-Vee, I’ve asked middle school classrooms, I’ve asked medical people, I’ve asked non-medical people what makes a great physician? And there’s some very similar patterns to the answers. And it’s, well, I want somebody that listens. Compassion, caring, have integrity, good listener, honest, forthright, you know, it goes on and on. And then finally somebody says, knowledge, competency, technical skills. Rarely is competency in the top three statements that people respond.

Dr. Luis Garcia: Isn’t that interesting? But yet you ask our medical professionals, how do we define ourselves? And most of the times it’ll be about achievement. Yes, it’ll be about title, it’ll be about letters behind your name. It’ll be about competencies. Right? But yet, regardless of the specialty, regardless of the condition, patients say, what I love about my physician is that he or she listens to me.

Dr. Craig Uthe: Yes.

Dr. Luis Garcia: That he or she looks at me in the eye. It just humanizes our profession doesn’t it?

Dr. Craig Uthe: There’s the saying, nobody cares what you know until they know that you care. And that’s so true. Even to the point of medical litigation. Evidence shows that physicians, that they get sued. No physician’s perfect; there’s always gonna be the chance of making a mistake. People are forgiving. If their physician cares for them and they’re doing the best they can do, it’s unlikely they will be sued by the patient. The physicians that get sued are those that are seen to be uncaring, detached, and not showing interest in the patient.

Dr. Luis Garcia: You know, it’s interesting you say that. When I teach surgical residents, I always tell them, you know, when you have a complication is not the time to look the other way. It is time to get the closest to your patient, not because of fear of getting sued or not, it’s just the right thing to do. Right?

I mean, absolutely it’s our responsibility, but to that point, the clinicians that are sued are the ones that turn their head out their head away. Right? You know, Craig, you’re talking a little bit about influence and about being a leader and about creating a difference for patients and what matters and what doesn’t matter to patient or a member of the community as we define the great physician. But what about a great colleague and a great role model? Do you think you can apply those same concepts?

Dr. Craig Uthe: Oh, absolutely. You know, servant leadership – I, for me, the definition of servant leadership is, first servant is we’re in a service industry, medicine, my job is to serve others. So it’s not about me. I don’t care what job you’re in. I don’t care what line of work a person does. We are self, each people, I mean, we’re very concerned about ourselves and we should be. But when it comes to being a physician, the privilege we have is people put their lives in our hands and we have a responsibility and an obligation in that then to do what’s best for them. My job is not to be liked, although I want patients to like me. My job is to develop the respect, the trust that’s involved in that type of work. And that just takes time and it takes giving. How do you give of yourself in that situation?

And from a very pragmatic standpoint, in the patient room, I developed a very, very simple internal guide that helped me. And I’d say, OK, does this person need an invitation from me? Do they need to be encouraged or do I need to challenge them in their health right now? If I’m telling them what to do, I’m losing. Because nobody likes to be told what to do. They like to discover what they want to do and then own it and do it. And that’s the leadership part of the definition. It’s again, it’s having influence. That’s how you measure it. Well, how do I influence someone? Well, I do it by showing that I care about them and I want them to be successful. I want them to achieve the things that they want in their life. Sounds so simple. Yet, it is so difficult to carry out.

Dr. Luis Garcia: That’s one of the reasons why you were such a respected, or you are such a respected family doctor. Right. But now leadership inside the medical community. Right? We as physicians don’t like to accept that we need help. We don’t like to accept that we can be vulnerable, that we can be human beings. So as a leader, colleague of other younger partners or even older partners that could be struggling, tell me about that. How do you navigate a relationship where there might be egos involved, where inherently we don’t accept weakness as physicians? We don’t like to get help because we’re used to help people not to be helped. So navigate me through those.

Dr. Craig Uthe: Let’s start with our strengths. Again, I’ll meet with medical students, I’ll meet with physicians, and I’ll say, I know a few things about you. Number one is you’re intelligent. Well, be, again, be thankful for that. Be grateful. Not everybody has the mental capacity to be a physician. You do. And, accept that for what that is. OK?

I also know that you’re probably very competitive. Perseverance is probably required as much as intelligence to be able to get to med school and then get through med school. So I love, love your perseverance.

Also, there’s a good chance you’re quite perfectionistic and you’re quite competitive. And the problem with perfectionism and competition is the person who might be the one you’re the hardest on is the person that looks at you in the mirror in the morning. So what makes you really good is also what could make you very vulnerable.

And so that’s where self-care trumps everything. If you can’t take care of yourself, you’re not gonna be able to sustain care for others. And so the irony and the twist of servant leadership is you can only serve others if you take care of yourself first. So some people get into the servant line and end up getting trampled over, become a doormat. That’s very unhealthy. And again, when we deal with individuals, we will find that that does happen. And it’s because of the perfectionistic, it’s the competition. But again, it’s that person that sees them in the mirror in the morning, and I say, that person that’s talking to you in the morning, when you look in them in the mirror, you need to kick them out of the house. You wouldn’t let anybody do that to you or to anybody you love. So why does it happen to yourself?

Why do you let that happen? And I find that is very helpful for people. It’s kind of sometimes I’ll even see somebody relax their shoulders in a sense of, oh my goodness, I never thought of that before. I’m harder on myself than anybody else. And just that realization – I’m not perfect, I don’t need to be perfect – is a huge awareness that can be very helpful for, well, not just for physicians. That’s what patients too would find, that patients would have that same type of experience and trying to help them to understand that, do the best you can. That’s all you can do is to give your best.

Dr. Luis Garcia: Yeah. And, God, did the last couple of years showed us that, right? That we come with a high level of intellect and a high degree of commitment. And yet there’s a day that comes where we don’t know what are we facing, right? And we don’t have all the answers. And I always say that what initially came as a clinical dilemma became very fast a people’s problem. A people’s challenge, yes. Of how you navigate patients, clinicians, nurses, society, politicians, you name it, through a very, very uncertain times. And how that influential servant leadership really, really served its purpose.

Servant leadership, right? Some people might look at it like, well, is the guy that does everything for me? And I can be, I can treat that person as a doormat. You mentioned the word doormat and that’s not what servant leadership is. So clarify that for me.

Dr. Craig Uthe: Well, servant leadership, first and foremost, is being grounded in who you are and knowing what you stand for, why you’re living the life you live. What do you value in your life? What are your non-negotiables? We need to know who we are first to in order to be able to take care of someone else. And so that’s that foundation. That’s the roots that everybody needs to have. And then I call the emotional part of our lives, the mid-brain, that’s kind of the pleasure centers of our brain, the dopaminergic centers of our brain. We tend to behave in ways that are more on that emotional side. And we don’t bring our thought process to the prefrontal cortex, reason it out. We often make decisions just by your emotions. And so it’s so important as physicians to know what you stand for because our job is to give, give, give, give.

And that’s not always easy to do. And so I’ll catch myself with patients at home with my family, and I have to sit down and think, OK, I have this, this knowledge base, I have this awareness of what illness is, what’s important in people’s lives, what’s really truly important. And unfortunately, the world wants to tell us you deserve this, you deserve that. And they tend to be things that are maybe not healthy for us. And so it’s, OK, I gotta bring this back. And what really is important to a person in their life? What really is that? How can I help them see that so they can live their life in a very intentional way? And do it in a way that you’re serving others, that it’s not about me.

Dr. Luis Garcia: You bring a very interesting point and is, as a leader, servant leader, you are here to help people. You’re here to who get the best out of them. You want your best people at your, at their best and, and get the best out of them. That’s a good leader, right?

But you also talk about boundaries and you also talk about moments in which perhaps the answer is not what the other party is expecting to get. Help me understand how Craig, you, with the best experience that you have in leadership, how do you navigate those instances where the other person needs to hear bad news or needs to hear not what they want to hear, but yet you need to empower them to change?

Dr. Craig Uthe: Well, that’s where our professionalism needs to come out. And our experience, I think, needs to play into this. I do a lot of work with addiction. I do a lot of work with pain, and it’s very difficult to eliminate pain and suffering in a person’s life. That’s what we wanna do. But how can I also reach out to them and help them accept that and live with that in that type of setting? That’s a very difficult walk to walk because I may be misinterpreted as the physician in that kind of setting. Yet that news needs to be heard. How can I help you live with pain that is not treatable? How can I help you get through grief when there’s a loss of something in your health, whatever it might be, or a loved one. And I find that to be sometimes a difficult conversation because I don’t want to be disliked and I don’t want to be misinterpreted.

So how do I walk that difficult journey with them? That’s not an easy one to do. I find what I’ve experienced is if you have compassion and you really care about them, the patient senses that and you hope they come to an understanding and to an agreement and will learn about that. Sometimes it’s effective, sometimes it’s not. That’s the difficult journey I find that we have in medicine and some of those uncertainties that we have. And that just happens to be the patient population I see right now working in a chronic pain clinic. And so that’s such a different setting than a family practice clinic where it’s mostly to feel good. People tell you how wonderful you are and it’s easier cuz you’re talking about diabetes, hypertension, things like that. It’s been a great experience to be involved in the addiction world because it contrasts the other practice I had so much. It gives me clarity into that, boy, this isn’t about me feeling good, it’s about the patient understanding. They’re going through a difficult journey and I wanna walk that with them being honest, saying, I don’t necessarily have an answer.

Dr. Luis Garcia: So how do you take that home, Craig? And this is very interesting. How do you take that home? Because based on our definition of success, when you do not, and this is when I saying our definition, it’s our internal definition that we always have to be perfect. That we always have to solve a problem. That we – so as a physician or as a leader, how do you cope with that circumstance where there’s only so much you can do, you cannot solve the problem and not taking it as a personal failure, as a professional failure?

Dr. Craig Uthe: I’ll answer from the personal standpoint is again, my upbringing was very faith-based. And so for me, from the perspective of Christianity, I live in this world, not of this world. I believe that there’s something much greater after we live this life than we have right now. So that’s the perspective I come in. I mean, this life is preparing me for something greater than that. So I just, I have hope. Hope is my number one core value.

Now my job is not necessarily to take my own feelings and my own beliefs and push it on someone else. That’s not what I wanna do. But I take great comfort in the hope that I have in that. And that’s, I always, I think, have had this sense of hope. I call it the Holy Spirit inside of a person, whatever religions call that spirit filled piece that I wanna portray that in the work that I do.

So even though this world is tough, I want that to be lived as full as it can be. Not meaning it’s gonna always be happy, but I want it to be fulfilling. So I want that patient to live that life as full as they can. That’s why walking that journey with patients who have a terminal diagnosis of cancer, I didn’t want to give them this sort of happy optimism that is not real. I wanted to find out where they put all their marbles, you know, what was most important to them in their world? Is it their family? Is it a faith? And then I wanted to take what they feel is most valuable to them and nurture that. And you can find hope.

Two of the great privileges I had in my 25 years of my regular family practice was getting to deliver a thousand babies. I got a chance to do that. I delivered a baby of a baby, you know, Elton John’s Circle of Life song, whatever you wanna say.

But I also had the privilege of being present in the death at the moment of death of about a dozen patients. And that is a real special experience. I will never forget those moments. Those were privileges. And I found them to be not despairing. I found them to be very intimate. And in that very rewarding both for the patient and for me to be able to experience that with families.

Dr. Luis Garcia: I think you brought topics of clinical relevance, topics of spirituality, topics of leadership, and I think that reflects how complex and positively complex your life has been. Talk to me a little bit about the work that you are doing right now inside Sanford for leadership and how are you interacting with the new generations?

And I gotta say Craig has been instrumental for us in Sanford to develop and implement the professional practice support program, which is a program that helps our clinicians at any stage of their career that need any kind of leadership help or if they’re dealing with challenges to bring really people like Craig and a team that he has developed of internal coaches. And then you have also a phenomenal program that – thank you for inviting me to participate – which is medical students that are looking into that aspect of leadership that you can develop. But a lot of that comes inherently with the individual, right? So talk to me about that.

Dr. Craig Uthe: Well, I think it comes back to that question that Mary Nettleman asked me years ago. “As you know, Craig, we wanna make great physicians, well we want great physicians at Sanford.” And when I left my family practice panel five years ago, that was a difficult thing to do. I had my kindergarten teacher, you know, some, you know, cousins, things like that, that we’re no longer gonna be under my care. And I do, I really wanna give that up to do something else.

Well, when somebody sees something in you, I always wanna listen to that. You know, maybe there’s, maybe it’s time for me to do a change again if I’m gonna be a servant leader. It’s not about Craig Uthe feeling good about patients, telling him how great he is. It’s about doing something that’s gonna make people better. And so what a great quote unquote new patient population than having physicians, med students, you know, all these talented, gifted, caring people.

What I love best about medicine, Luis, hands down is we all have that seed of altruism in our profession. There has not been one person I haven’t worked with in Sanford who doesn’t genuinely say I’m in medicine because I care about people, don’t care. And I look for that seed. I just, I look for that and I try to, if physicians are burned out, they may have lost that focus. And I try to help find that first. Cause that’s burnout. To me, the definition of burnout is when you lost your meaning of why you went into medicine. And I get that once in a while, I’ll get a, I’ll get a stare look when we go to do coach, I’m going time out, no coaching. Let’s get you some help. I don’t think you’re well. Let’s get you well. And once you’re well, then we’ll do the coaching.

And once coaching, I think coaching is going to become a very popular thing in the future. It’s already kind of a craze, I guess right now is what I would call it. But there is some definite value that can be had in that. I always think of the professional tennis players, the Williams sisters, Nadal and Federer, those guys, they all have coaches. And they’re the best in the world. So why would I not want a coach to help me along?

And we could call it a mentor, we can call an advisor, we can call it a coach, whoever it is. But to have that collegial support for each other. When you can have that psychological safety that Sanford offered a resource that, hey, this is about you and your well-being, this is confidential between you and your coach. To create that psychologically safe space is incredibly valuable because now you get colleagues one on one being able to, to really, really be authentic, vulnerable. And that’s where real growth begins in being that great physician.

Dr. Luis Garcia: You talk about an internal coaching program that our physicians, that you have developed to the point of becoming coaches. Yes. And now they’re helping other peers. Help me understand. Why does it have to be a clinician? Why not somebody from the car industry that comes in and coach?

Dr. Craig Uthe: Right. Well, there, there’s something that, there’s value in having been in the same shoes as the other person. I’ve had the same experiences. So working with medical students, working with residents, and working with physicians, when you are one of them, you have a bond. There is a bond. We have Luis, because you and I are physicians. It’s something that has value in it and it gives us an insight into that.

Again, it has to do with influence. Well, who’s gonna be, who’s gonna be one that’s gonna influence you? It’s gonna be someone that’s walked through the same doors that you have, has had the same experience as you have had maybe in different ways, but we can relate and then take it to the Sanford organization to be able to go through the same cultural experiences in the same organization. That gives you an additional insight that’s very helpful.

I believe honesty is absolutely imperative there. And I’ll say, you know, if there’s things you don’t like about the organization, let me know. If they’re the things that you like about the organization, let us know. Because we wanna take those themes that we hear from everybody to make the organization better. And so there’s internal coaching. There’s external coaching. I think they both can be valuable.

The internal coaching program we have at Sanford, I like because we have identified people who are interested in becoming coaches, people that have a skill set in being coaches. And then we’ve just found a couple of tools that we have found very valuable. One being the Hogan assessment, which is a personality assessment. It’s a tool that helps us identify our own strengths and our own challenges. And by actually being able to walk through that with a person who is certified in assessment coaching, we’ve found that has been very valuable for those who have participated in that program.

Dr. Luis Garcia: I’ve had the opportunity to talk to a couple of your coaches or the members of your coaching team, and they speak not only about the influence that they’re having on others and helping them find their best, but how that interaction fulfills them and allows them to grow as well. Not only as coaches, but as individuals.

Dr. Craig Uthe: One of the things I love about being a physician is the title of physician. One of the things I abhor about being a physician is the title of physician. At the end of the day, I’m still Craig Uthe. And taking that title off actually provides some freedoms for me. And so when you get into that coaching, you talk person to person as well as physician to physician. I have found that to be extremely valuable. Being able to say, OK, who is that person along with that physician? And that just provides another dimension that leads to building strength and stamina, I find. And so I always talk to my co-coach and say, I just hope that the person I’m coaching learns as much as I do today because I’m learning something every single time I have a coaching session.

Dr. Luis Garcia: So what’s the most difficult person to coach?

Dr. Craig Uthe: That’s a great question. The most difficult person to coach is a person who has a different value system than yours. Because it’s not my job to push my values onto someone. And so I have to be very aware if this person has a value that’s opposite of what I value. My job is not to push my values onto someone. My job is to help somebody be successful in what they’re trying to achieve. And so that’s very important. And so the most difficult person to coach then is that person where I have to be very, very self-conscious to not be bringing my own personal values into that work.

Dr. Luis Garcia: And not necessarily means that the success would be less. Is that just you as a coach need to be aware of that difference? Absolutely. You know, you mentioned a few people that have been influential in your life and in your own journey, but who is the person that has influenced Craig Uthe the most, to get Craig Uthe to be who you are right now?

Dr. Craig Uthe: Oh, I, you know, I, I probably have five, six or seven different individuals I could say. There’s a book written by the title of Soul Survivor, S-O-U-L survivor, Philip Yncey wrote it, Y-N-C-E-Y. And he took 13 people of influence in his life and they included people that he had not met, like Martin Luther King Jr. And Leo Tolstoy I believe. But then there was also people that he had met and walked alongside. So like C. Everett Koop was a surgeon general at one time. He had met him, he hung out with him. Is that book actually as a text for different programs? There is a theologian by the name of Charles Swindoll, he’s on the radio. Chuck Swindoll. I was a third-year med student and I would say I was struggling at that time, probably the nadir of my medical career was as a third-year med student.

I was single. I was out in the Black Hills in the wintertime. And I remember listening to Chuck Swindoll on the radio at night. He was a pastor and just had a radio show. And I just found that to be very comforting and inspiring for me. So I’ve actually met him. He is, he lives down in Texas since I went to service one time.

My father has been a great influence. My mother’s been a great influence. I just lost my high school basketball coach, just passed away last week. And so he, I think, gosh, what a great mentor. High school music teacher was a great influence for me. And, and just, I’m always having people influence me all the time. I’m always just watching people’s characteristics. You know, Dr. Luis Garcia, what do I love about Dr. Luis Garcia?

Dr. Luis Garcia: No, don’t, don’t say that. <Laugh> Make, I’m sure that list is short, so don’t.

Dr. Craig Uthe: But again, there are those traits, you know, again, it’s –

Dr. Luis Garcia: No, I understand.

Dr. Craig Uthe: It’s the core values that I have that I’ve seen in other people. And again, there are a number of people, and I could have named another 5, 7, 8, 10 people that have an influence on my life. Some who I’ve met and some of whom I have not met.

Dr. Luis Garcia: So, so let me flip the question. OK. Who has been a person that you go like, I do not want to be like that person and don’t gimme names. Give me characteristics of – yeah, you know, who is that person? I go like, I will never be like that person.

Dr. Craig Uthe: Yeah. And I wish I could. There were physicians in my residency that I remember thinking when I’d call him at two o’clock in the morning or I needed their assistance or I reached out, or I just would see them demonstrating either narcissistic behaviors that were very self-indulging or were derailing in an anger mode that was very destructive. And I remember finding myself saying, oh, I’m just, if they only knew how disappointed I was in them, they wouldn’t do that. Maybe <laugh>.

And so as this disappointment of somebody who I respected from a quality standpoint, but when it came to them being real people and caring for others, I was just disappointed. I thought, you don’t realize you’re actually influencing me as much as someone does from a positive way on just how not to be. I thank that person for that.

Now I’ve never, I never told them that I would be critical in some ways, in some kind of a specific faculty person. I’d be critical in, in the, in the evaluation form that I had. But seeing that kind of behavior when she was just so destructive and so harmful, I just call it being disappointed, you know, a person of that kind of authority and influence. It’s just so sad to see that have that negative influence on me at least.

Dr. Luis Garcia: So a good person, yeah, could have a bad influence or a positive influence and then develop personality traits based on that influence. So you teach medical students all the time, Craig, and I’m not talking about medicine. You teach them leadership. Yes. You teach them how to be productive citizens in this world. What do you tell young developing leaders about what you should be, what you should not be?

Dr. Craig Uthe: When it comes to medical students, residents, I always still start with what do you believe in? You know, so why did you go into medicine and what are your values? OK, know what they are, know what they are. That’s what you stand firm on. And then name ’em. Is it compassion? Is it humility? Is it kindness? Is it authenticity? Is it accountability? And then actually ask yourself, what does that literally look like? What does that look like? If you were to see it and say, you know what, that person is accountable. I love accountability, I wanna hang out with accountability. And then use that as your model. Now, the intelligence, the knowledge, the technical skills, they will come. Why are you here in med school? Yeah.

Now you’re gonna spend 80, 90% of your, 95% of your focus on the knowledge piece. I get it. It’s a requirement. It’s not an option. But always keep within your eyesight, within your vision, within your peripheral vision, all the emotional intelligence pieces, because that is the piece that will define the quality of your work as a physician. It’s all those other things, and you’ll get a chance to see it. So just know what you believe in.

And if kindness is your top core value of yours and you see kindness, look at it, study it, what does that look like? Cuz then once you see that, you will start doing that yourself. And for me, what is the epitome of well-being is when somebody comes up to you and says, wow, Dr. Garcia, you are the kindest person I know. And if that’s your number one core value, kindness, you’re going, that was just a grand slam home run I just hit. That’s what I live for. I’m not gonna tell people that, but that’s my goals. I wanna live that in a serving fashion to live those values. So I really search for that. You just have to know what your core is. And then, and everybody’s core is different. And I’ll get that, “Well, what do you think?” And I go, well, it’s not what I think. It’s what you think that makes all the difference.

Dr. Luis Garcia: And I think just in the last couple of minutes, you pretty much described what servant leadership is about and why are you so good at that? Craig, any closing thoughts? This has been a phenomenal conversation, Craig, and thank you for, you know, sharing your insight and your values. Well, thank you and your values and your knowledge and, but any closing thoughts?

Dr. Craig Uthe: Self-care is still the most important thing in being a servant leader. You have to take care of yourself in that and in that journey, maybe the most difficult thing to do, and to me define servant leadership, is when you can in your life, get to a point where you can provide forgiveness to others. We didn’t really talk about forgiveness, but it starts with self-care and it ends with being able to forgive others for things that maybe seem unforgivable.

Sometimes coaching gets to that point in a journey. And I do find that in any kind of a leadership course that I kind of evaluate, I always look for a piece on forgiveness because it is one of the more complicated, more difficult things as human beings to really address and to really walk through and in a mature fashion, be able to deal with that. So I’ll end it with that. Start with self-care and with forgiveness.

Dr. Luis Garcia: Well, Craig, once again you know, every time I sit down and have a conversation with you about life and about leadership, I always come out enriched. And it is a privilege for me to spend time with you. And you mentioned about, you mentioned something about people influencing your life that perhaps you have met or you have not met. And I gotta tell you, those that know you and have met you, agree with me, that their life automatically gets enriched. And if you are listening this podcast and you have not met Craig Uthe, I wish that you could because your life would be equally enriched. Craig. It’s a privilege and an honor. Thank you very much.

Dr. Craig Uthe: Well, thank you. You’re very kind, Luis. Thanks.

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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Digital health literacy for patients and providers

Alan Helgeson (Host):

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 around the importance of digital literacy in health care. Our guests are Brad Reimer, Sanford Health Chief Information Officer, and Jared Antczak, Sanford Health Chief Digital Officer.

Brad Reimer: Just to kind of kick off, the question we always get asked is, why does Sanford need both a CIO and a CDO?

You know, and at Sanford, I guess I recognize that, you know, the health care industry is going through a ton of change, and there’s a lot of areas that are just really kind of transforming as a whole. And for the size and scope that Sanford is, it just appears to me that we need a full-time job for like my team that is keeping the train on the tracks, really focused on the operations and services and projects and all those types of things for the people that are in our care stream today. And we definitely don’t want to distract from that.

And that’s where, in my mind, the focus on the transformation, the reimagine, where we’re going, really is another full-time job. Because there’s a lot of stuff that health care is maybe a little behind on that your teams are able to kind of bring to the table and focus on with the level of energy and with the level of attention that it needs. So in my mind, that’s why we both need kind of these dual roles and these separate roles. So one doesn’t kind of over-index more than it should on the other.

So would love to hear your perspective on kind of how you’re, how you’re feeling about it now that you’re in the seat for a while. And I’ve really enjoyed working with you. So I, I’m curious on what your thoughts are.

Jared Antczak: You know, it’s a really great question, and it’s one that I get asked a lot. How does a system work that has a Chief Digital Officer and a Chief Information officer? And, you know, I’ve had an opportunity to work with a number of different health systems, and each one is organized a little bit differently in this regard. And, you know, maybe that’s an OK thing. You know, every system is a little bit different, but I think one of the big challenges that every health system, you know, really has is determining where to focus their time and attention and their resources when everything seems so important.

And one of the things I’ve really appreciated about Sanford Health, having both the CIO and a CDO, is how it allows us to the point that you just made earlier, to have sufficient resources and attention spent on the things that matter across the technology ecosystem.

You know, it really mitigates the risk of over-indexing on one end of the spectrum at the expense of the other. And so the way that we’ve defined digital and it, I think, is really important to that: So digital encompasses the front end of technology, the part of technology that people interact with, and IT really encompasses the backend part of technology, the interfaces, the databases, the things that work behind the scenes. And so our roles as Chief Digital Officer and Chief Information Officer really complement each other. And, you know, it requires us to be very tightly aligned, but at the same time to be able to have a distinct area of focus.

And so, you know, as Chief Digital Officer, you know, I view a lot of the outcomes that I’m focused on as concepts like engagement and usability and experience. And as Chief Information Officer, a lot of the outcomes you’re really focused on is around security and scalability and reliability of our infrastructure. Both are really critical and interdependent for success, but, you know, really allow us to shift from technology being a cost center to really being a value enabler for the organization.

Brad Reimer: Yeah, I’ve heard, you know, when I’m just talking with people at different conferences or whatever they are, they kind of question, so are these competitive roles? And the way that we framed ’em up here, they’re really not. They really are complementary. And it’s really been fun to kind of see how our teams are starting to work together in a new way. And it really is something that, that truly can be synergistic, and really excited about that.

So, as you’ve been, I know you’ve been at a couple of conferences in different speaking engagements here lately. One was Modern Healthcare and you talked a little bit about the future of digital health. And specifically with that rural lens. What were some of the key takeaways you had from that conference and some of those key messages you were hoping that people would hear from you?

Jared Antczak: The Modern Healthcare Leadership Symposium was really a great conference attended by several different executive leaders from various different health care organizations. And at that conference, I had the honor of joining a panel that was entitled Smart Digital Health Investments, Reshaping and Reimagining Healthcare Delivery, along with David Lubarsky, who’s the CEO of UC Davis Health, moderated by Jeff Terry, who is the CEO of GE Clinical Command Centers.

You know, every time I attend a forum like this, I’m reminded that every health care system is on a similar journey. And, you know, some are further along in some areas and further behind in others, but we’re all somewhere on the path and there’s so much that we can learn from each other. One of the concepts that I spoke about at this particular conference was the difference between digitization and digital transformation. Yeah, right. Both are really big buzzwords that you hear a lot about in the industry, but sometimes people get confused and think that they really just mean the same thing, but they use those terms interchangeably. But from my perspective, there are some really significant differences between the two.

Digitization, from my perspective, really takes existing processes and workflows and essentially digitizes them or lifts and shifts those into a new tool. In many respects, I would say the rush to implement EMRs (electronic medical records) over the past 10 to 15 years really was primarily a digitization event. We took the existing workflows and processes that our clinicians did every day, either in a different tool or on paper, and we digitized it into a new tool.

Brad Reimer: Just replicated it.

Jared Antczak: Yep. Yep. Digital transformation, on the other hand, really addresses the people, the process and the technology holistically and really fundamentally transforms the business and care delivery model. It doesn’t just superimpose technology on top of, you know, existing labor-intensive processes, but really transforms the who, the what and the how to create greater efficiencies, you know, improve productivity and enhance health care experience.

I think it’s really interesting, you know, a study from McKenzie a few years ago showed that over a 15-year time span health care delivery accounted for 9% of US economic growth, but a whopping 29% of net new jobs created during that same period. Yeah. So, you know, in other words, as health care demand increased, we as an industry hired more people and threw more bodies at it and deployed more technology when our productivity actually declined. Well, why is that?

And you know, as you look over the last decade or so, the primary technology that we’ve deployed in health care has been the HER (electronic health record). And I think it’s important to note that the EHR isn’t necessarily designed to improve productivity. It’s designed to document ever increasingly complex requirements for regulatory and billing. And it really serves that purpose well. But the result has been that we’ve implemented a lot of technology and we’ve invested a lot of technology, but we haven’t recognized a whole lot of productivity gains.

So again, we did a whole lot of digitization, but not a whole lot of digital transformation. And that isn’t to say that digital transformation is easy. There’s a lot of culture change that comes with it. But we’d really like to hear some of your insights as well.

Brad, you know, I know you attended recently the, the Becker’s Health IT conference where you spoke on three different panels. I’d love to compare notes and better understand what are some of the key themes that you discussed with other experts in our industry? What did you think sets us apart as we think about our approach when it comes to technology?

Brad Reimer: We had some really good discussions at Becker’s and there were a few themes that kind of seemed to always be the undertone of each of those panels. One of ’em is just around the pressures of the health care industry is under.

I think it’s, you know, everybody that’s in the industry or is watching the industry knows that staffing’s a really, really big challenge. And it’s not just for nurses and caregivers, it’s across the IT spectrum. It’s across the data spectrum. HR, you name it, everybody is really under a lot of stress just from being able to have enough trained people in the right places to be able to care for our patients and take our business forward in the way that it needs to.

And then, you know, the financial pressures, and that’s part of it is when you don’t have the staffing in house, you’re having to pay more for contractors and temp staff and those types of things. Yeah. And that, along with supply chain challenges, the inflation, just some of the global unrest. There’s a lot of things that are influencing and impacting kind of the slim margins that health care already has.

And at the same time, we’re trying to figure out how do we invest more in digital? So we’re getting pressure from the expense side, but we also know that we’ve got this transformation that needs to happen. And that’s not free to do. So finding that right balance is tricky. And I think that every health system is trying to figure out right now is how do we make sure that we do pay attention to the financial situation that everybody is in, but not stop investing in what the future is.

We also talked a lot about and what I’m kind of terming is the modern data health care ecosystem. And there’s, I think, a growing acknowledgement that data systems, just like you said, have really been focused around the EMR the last 10, 15 years. And it has been an appropriate center of gravity for a lot of those solutions and the way that we think about things.

But the tide definitely is shifting and we’re seeing so much more data created outside the EMR that we’ve gotta figure out what are we gonna do with it? Cuz not all of it belongs back in the EMR. Some of it does, and some of it is truly patient record type things, especially if they’re, if it’s data that’s used in assessing a patient’s condition or in providing some type of a treatment, we do need to make sure that that’s back in part of the medical record, but not all of it. Not every heartbeat that your watch is monitoring needs to flow back into the EMR.

And when you think about the proliferation of wearables and wellness wearables and the remote patient monitoring devices that we’re gonna provision and send out to patients to take home with them, all of that data, we’ve gotta figure out what the value is and where we should put it, and then how we should leverage it. So there definitely needs to be a new model, and hopefully it is somewhat standardized across the industry of how we do that.

And one of the challenges that everybody kind of acknowledged is we’ve got a lot of investment with venture capital and those types of things in the health care IT right now. And a lot of ’em are focused on this digital transformation and the new patient journey and new patient experience, but they’re all these little siloed applications, right? And they all have their own data model, and they all have their own way of communicating or not communicating with the EMR.

And we’re gonna have to synthesize that. We’re gonna have to figure out how is that gonna work from a real-time transaction standpoint, how is it going to, from an analytics standpoint, how does it eventually feed into AI and those types of things. So I think the advancement of what we need to do with our data systems is paramount as we kind of think about the upcoming years.

And then I try to, when I know you do this as well, try to really kind of put that rural lens on just everything that’s happening with health care. And in Sanford, you know, 80% of our patients are really in that rural footprint. For other health systems it’s kind of the 80-20. There may be 80% urban, 20% rural. And if we’re able to find ways to implement best practices and we really understand the patient behaviors and those types of things for rural, we can actually set those and allow those best practices and those ways of doing care differently for health systems that aren’t necessarily focused on that as their primary constituency. So I do think that there’s a lot of opportunity for us to really be, not necessarily trendsetters, but really raise the tide for a lot of the nation that has rural health.

Jared Antczak: I love that. Couldn’t agree more.

Brad Reimer: So as you think about rural health and you think about digitization, what are some of the biggest things that you think are gonna be game changers?

Jared Antczak: Digital in rural, the digital landscape is constantly evolving. You know, new technologies emerge all the time. Consumer or patient preferences and expectations are constantly changing based on, you know, the interactions they have with other, you know, sophisticated digital experiences in their day-to-day lives. Caregivers’ workflow – caregiver workflows evolve the macroeconomic conditions that you just talked about exert pressure in different ways, right? And so, you know, I think for a lot of those reasons, you know, I always try to resist the temptation to propose you know, a big long three or a five year roadmap for our digital strategy.

Instead, we need to embrace, you know, an agile culture that really allows us to be nimble, responsive, and iterate quickly on the things that bring value into people’s lives. So that said, you know, when I consider I think some of the greatest opportunities in, you know, this next wave of digital solutions, I think there are many sources of inspiration all around us that can help us envision what the Sanford Health digital consumer experience could look like.

So, for example, I imagine a health experience that makes finding care just as easy as finding a product on Amazon and making a purchase or preparing for your visit. As simple as, and as intuitive as booking a ride with Uber, you know, managing my care as personalized as my Netflix profile that prompts me with, you know, recommendations for something to watch based on my interests and my viewing history.

So, you know, in order for that to happen though, these solutions, I think to your point earlier, need to be easily integrated into our core platforms and solutions. We can’t just have a bunch of standalone point solutions and expect it to be a good experience. There are way too many point solutions out there in the marketplace today. I’m reminded back in 2009 when Apple coined the phrase, there’s an app for that, right? And, and at the time that was really a good thing, but nowadays, nobody wants to download yet another app, right? Consumers want those frictionless, seamless, personalized digital experiences that meet their needs at every step of the journey. Not a bunch of fragmented point solutions that only solve bits and pieces along the way. So I think integration is really key to making that whole digital front door concept come to life that we’re all striving for.

Brad Reimer: Yeah. I’ve got way too much clutter on my phone. I’m deleting apps <laugh>, it’s like crazier right now. Yeah.

Jared Antczak: So Brad, there’s a lot of discussion in the industry around digital literacy, you know. What areas is Sanford investing in to help the adoption and the effectiveness of different solutions?

Brad Reimer: My view is that society as a whole is fairly literate with digital experiences and tools. It’s really in most parts of people’s lives other than health care. And it just hasn’t permeated health care in the same way. So I really look at the digital literacy piece kind of from two lenses. One is from the perspective of our patients and our communities, so those that we serve. And then we also have the digital adoption and digital literacy for our caregivers and our employees.

And there’s two different ways I think that we really need to kinda look at how we’re approaching that for patients. Data privacy’s always gonna be a concern, and I think it’s something they’re used to dealing with, like in their life around banking and those types of things. Health care brings a little bit different sensitivity to the privacy of my data. And I do think that that is something that may not be quite the barrier it would’ve been five years ago, but it is still something that is top of people’s minds.

We need to make sure that part of that literacy is their trust in the app or the solution that they’re using to make sure that their personal privacy is taken care of.

Aside from that, I think our patients and our communities aren’t only ready. They’re asking for more digital health care, like you said with Amazon. They’re using it in all other parts of their life, and they’re looking for that very similar experience. And I think as an industry, we do still have some settling in to do on are we going to provide too many apps and there’s gonna be clutter and there’s gonna be almost app fatigue, and we could over-index on just providing way too much technology rather than really having that empathy focused. Patient empathy is the center of how we’re designing these things, because not every moment that matters for a patient should be done digitally.

When you start looking at digital literacy from a, from a caregiver standpoint, we need to be able to make sure that we can differentiate those points that matter and approach them differently. So I’ve kind of compared it to, you know, fast food versus a home cooked meal. You know, there’s a lot of times where a very quick light touch routine and transactional experience is what you want. And it’s probably more efficient, it’s probably less expensive, it’s a lot more convenient, and there’s a lot of transactions that probably should be done that way. It’s your sore throat, it’s your skin rashes, those types of things.

But when you’re dealing with something that’s more serious, more personal, more life-changing in, it’s, it’s sensitive, the stakes are a little bit higher, you’re looking for a little bit more of a sit down home cook type meal situation, in my mind. You wanna be able to sit across the table from somebody, put some real meaty conversations on the table, and make sure that you can understand ’em and dive deep into ’em. And those are the situations that as a health care organization, we should be able to leverage digital tools to augment and help that situation. But it still needs to be a personal relationship built encounter with that patient. So part of the literacy is making sure that we’ve got the right focus on that.

Jared Antczak: I’ve always said that digital, the digital experience in health care can’t just be another lane in the highway. It has to complement and interweave. You know, patients need both, and we need to make it as seamless as possible.

Brad Reimer: The other thing that we’re thinking about with digital literacy was around the caregiver, specifically around AI or artificial intelligence. It’s a term that’s overused, and it’s a term that’s a lot of times misunderstood or underappreciated. So we’ve started to put some efforts towards demystifying AI for our caregivers. And what that looks like is helping them understand truly what is AI and what isn’t it.

When we talk about algorithms and models that have been trained within that AI situation, they should know how was the model trained? What data was used to train that model? Were the patients used in training that model representative of the patient sitting in front of me today or not? And so there’s a lot of things that are maybe a little intimidating for those that don’t understand the technical components. We need to get them comfortable asking the questions because it does make a difference in terms of how they’re thinking about incorporating AI into their care experience for their patients and making sure that it’s a good thing.

So we also talk about website manners versus bedside manners. And, you know, you hear a lot about that in the industry. It’s not something that we’ve came up with, but there definitely is, as we do more and more virtual visits, and especially as we’ve seen the adoption of virtual visits for behavioral health and those types of services, again, that patient empathy and being able to read body language and have a different type of experience through a video rather than in person. We do need to raise our game on that and make sure that we’re understanding some of the differences and some of the advantages it brings and some of the disadvantages that it brings and make sure that we’re bridging that gap.

Jared Antczak: I love that. I mean, the way that health care is delivered nowadays is very different. Technology is such a big part of every interaction. And so being able to empower our workforce and our clinicians with that website manner, I think is a really great concept.

Brad Reimer: So as you’ve been thinking about, you know, the opportunities in rural America and how we connect to our patients, what are the things that excite you the most?

Jared Antczak: I go back to a lot of, you know, the question that I just asked you around digital literacy, right? And I think that it’s so important to understand our patients, our consumers, and, you know, the needs that they have in their lives, and what their preferences and expectations are.

You know, building a new digital app or a website does no good for someone who doesn’t have the ability to use it. So, you know, that’s, it is just another example of a solution looking for a problem. So really starting with our patients and taking a very consumer first, patient first kind of approach to understanding the people in our communities and what their needs and their underserved needs are, I think is absolutely critical. So, you know, as the largest rural health system in the United States, we do have some unique challenges and opportunities that we need to address in order to make health care more accessible, equitable and affordable, you know, for everyone that we serve.

And, you know, digital literacy is just one component of a bigger category that we’ll call digital equity. And recent studies have suggested that digital equity is a social determinant of health, but it looks at things like digital literacy or, you know, how comfortable and confident are people downloading, registering, and navigating a digital experience, right?

But it also looks at things like internet access. Do people have access to broadband either through Wi-Fi or through a cellular signal? It looks at things like device availability. Do they have access to smartphones and tablets or laptops with cameras so that they can engage in a virtual care kind of experience? And so as we look at all of those different components, you know, that helps us to kind of hone in on how do we remove some of the physical, social and intellectual obstacles in people’s lives that would limit their ability to receive really equitable access to world-class care that Sanford Health can provide, especially in some of these rural communities.

You know, that said, as we’ve done some of our research and talked to our actual patients, we have learned some things. You know, going back to I think your earlier comment, many of our consumers in rural areas do in fact have similar expectations as our consumers in more urban areas.

You know, as an example, we found that more of our patients would prefer to schedule an appointment for a checkup online than to call and talk to somebody to schedule their appointment. We know that throughout the U.S. over 85% of the population has access to a smartphone. And so your earlier comment about the same people that use Sanford Health, even in our rural communities, are the folks who are ordering products from Amazon and who are engaging in other digital experiences on a regular basis – I think rings very true.

You know, we’re still learning more and more about the consumers in our communities and, you know, we’ll use those learnings to best inform how we might be able to serve them best. I think one of the most exciting prospects to me though, is the ability to leverage digital and virtual care tools to reach our consumers wherever they are, so that they can have access to care when, where, and how they want it.

So for our rural patients, that means, you know, not having to drive for hours in harsh winter weather, taking time off of school or work, or finding reliable child care or transportation just to be able to see their doctor. How might we be able to use some of these tools to make health care easier for them?

Brad Reimer: So can you talk a little bit about, you know, obviously the patient is the center of our focus, but a key component of that is the interactions that the caregivers are gonna have with those patients and their experience. And we all hear about the level of fatigue that there is right now within the industry with those caregivers. Can you talk a little bit about the type of experience changes that we could give to those providers? How do we get their buy-in into changing some of their behavior to leverage those tools and making sure that we can help reduce some of the burnout and the fatigue rather than adding to it?

Jared Antczak: Yeah, I appreciate that because I think it’s important to note that our digital strategy focuses on our caregivers and consumers alike. It’s just as important to serve our caregivers as it is to focus on our patients when we talk about how do we leverage technology in meaningful ways to remove friction in people’s lives and to create a good experience.

You know, throughout my career, I’ve heard sometimes this notion that if we do something that improves the patient experience, it must come at the expense of the clinician or vice versa. And I don’t think that that’s true. I believe that that’s a logical fallacy. I think there’s plenty of opportunities to really leverage technology and digital tools to benefit both the patient and the clinician simultaneously.

When I think of the caregiver or the clinician experience, I think of the ability for digital tools to really assist, augment, and automate tasks. You know, the three A’s that can really support our workforce. Caregivers enjoy their work more when they’re free to operate at the top of their license or at the top of their skillset. So, you know, to your question, getting buy-in from providers and clinicians means bringing them to the table from the very beginning and really understanding their needs and preferences, just like our consumers. And, and that really helps to ensure that we aren’t wasting our limited and valuable resources building the wrong things.

I think it’s important to note too, that, you know, sometimes I’ve seen organizations kind of get caught in the trap of focusing on the number of features that they’re able to develop, and the feature becomes the goal. Our measurement of success shouldn’t be necessarily the number of features we create, but really the outcomes that we achieve. So there’s sometimes a false premise that a good digital experience is all about, you know, the volume or the quantity of features, but they’re just really a means to an end.

You know, the goal is really the results and the outcomes that the features actually enable. We need to challenge the notion sometimes that, you know, we’ve always done it this way, and so we always have to do it that way and really ask ourselves why we sometimes make health care overly complex and complicated. In health care, we’re incredibly risk averse, and I think for good reason, right? If Amazon messes up your order, you might have a delay in receiving your product, or you might have a few extra dollars charged to your account that can ultimately be refunded. But if we make a mistake in health care, the results can be disastrous. Right? Right. Yeah. We’re dealing with people’s lives. Stakes are much different. Stakes are very high, right? So there’s very low tolerance for risk and for mistakes.

But that said, I think what we’ve essentially done is we’ve built a lot of our clinical and operational workflows around the exceptions rather than the rules because we’re so risk averse.

Yeah. And what I mean by that is we design our processes and our policies around those edge cases, but we apply those processes universally. So we might ask every patient at every encounter questions that only apply to a select few. And in some cases we build processes around a hypothetical situation that’s never even been experienced. But then we wonder why we have so much waste, inefficiency and diminished productivity in some of our processes. So I think that there’s a huge opportunity to create, you know, some smart logic and rules that can help us catch those edge cases and we can mitigate them, but at the same time, really design our processes around the majority of people that we serve. And that can help us to become, I think, a lot more productive and really alleviate a lot of the manual lift and burnout that our workforce, unfortunately, experiences at times.

I think of the best digital experiences are the ones that are the most simple. I think some of the best results often come from a removing things that don’t add value. You know, one of my favorite quotes from Steve Jobs, you know, the founder of Apple was when he said, I’m actually as proud of the things we haven’t done as the things that we have done. Innovation is saying no to a thousand things. So again, when I talk about digital transformation, addressing the people process and the technology holistically, you know, this is really what I mean, how do we simplify it and create a good experience.

Brad Reimer: Yeah. And focus on the right stuff.

Jared Antczak: All right, Brad, so this last question is for you. Sanford has provided more than 600,000 virtual consults with patients over the last decade. What have we learned about what works and what doesn’t?

Brad Reimer: So, one of the statistics that our vice president over virtual care gave me a couple months ago that just always sticks my mind, is that those 600,000 virtual consults that we have done has saved our patients over 20 million miles. And that’s just – that’s just astounding. That’s incredible. And you put, you know, like a mileage rate on that, you think about the gas at that cost, you know, even if it’s a, you know, a dollar per mile that’s $20 million back in the pockets of our patients. In my mind, that’s meaningful, especially for some of the areas that we serve that have some of the highest poverty levels, you know, across the U.S., those dollars make a difference. And it really is impacting the cost of health care, and I don’t think we can look away from that.

And that’s not considering, like you said, the time away from work people are having to take, typically it’s not just one person taking, you know, the drive and maybe the car ride’s not gonna be comfortable for ’em, depending on what their condition is. You know, in this neck of the woods we’re talking about winter roads and those types of things.

So there’s a lot of other benefits that we’re realizing that I think we kind of take for granted. And we’re still used to in rural America, you know, not thinking twice about driving an hour or two to get to a store, whatever it is that we want to get to. But if we can minimize that for this population, it really can be impactful. And then you start talking about, I think, more of the future with devices at home, hospital, at home being able to more proactively interact with patients to keep them healthy rather than just dealing with them when they are sick.

The future of virtual care, in my mind, is really, really positive. It has a lot of potential. And I think that the way we treat and the way we care for our patients and our communities over the next five years is gonna look much, much different than we have today. And it should be able to be better and it will be better.

The other part of it is part of those 600,000 visits have been more provider-to-provider. It’s been from maybe an ER that has a particular specialty physician in it to a rural critical access hospital. Maybe it’s for burn or for stroke, or for something that you want a specialist, but that specialist may not be in the most rural parts of the of the area. And we’ve had really, really good success. And I know that that’s a common model across a lot of health systems, but it’s particularly important around keeping health care close to these rural communities. And that’s what’s helped sustain some of these critical access hospitals in being able to financially be stable through COVID and through these other areas. They need that specialty care.

It is much better for the patients to be able to be treated close to their home and not have to jump in an ambulance and go for an hour. And it’s really impactful for the for the care and well-being of our patients. And really excited to see how that continues to expand over the next few years as well.

Jared Antczak: So, a lot of really exciting work. I appreciate the conversation, the dialogue. This has been fun. I’ve learned a lot from you and look forward to continuing to work together to serve our clinicians and our caregivers and our consumers and our communities. I think the future is very bright for Sanford Health.

Alan Helgeson (Host): 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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Well-being at work: What doctors do for self-care

Alan Helgeson (host):

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 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 focuses on caregivers in the medical community and the importance of well-being in order to provide the best care to those in need. Our guests are Dr. Brian Gatheridge, psychologist with Sanford Health Detroit Lakes Clinic, and Dr. Heather Spies, OB/GYN, and physician director of clinician experience and well-being. Our moderator is Dr. Luis Garcia, president of Sanford Clinics.

Dr. Luis Garcia (moderator):

I’m very grateful to be joined today by Dr. Heather Spies and Dr. Brian Gatheridge. Heather, Brian, thank you for being here today. And, you both are champions of this kind of work and you both are leaders in these type of topics. And I have a question to both of you. Tell us a little bit about yourself, your personal background, your journey, and how did you get involved and passionate about clinician well-being?

Dr. Heather Spies (guest):

Well, thank you for having us here, and I have the privilege of working with both of you in this work, and so I know that we all care a lot about it, so I think this will be a fun conversation to have today together. I started in OB/GYN 20 years ago now, actually, if you think about residency, and then have been 16 years at Sanford practicing OB/GYN. And, most recently in the physician director role for the enterprise for clinician experience and well-being.

Just really feel fortunate to have this opportunity to serve in this role. It’s a new role and it’s been identified as a need because, just to really make sure that as clinicians we’re looking out for each other and making sure as an organization that we’re providing resources and that sort of thing, which we’re gonna talk more about today.

Um, but as far as my journey, I think I’ve always had a passion for well-being, although I think part of the reason I love talking about it and focusing on it is because I never practiced what I preached for a very, very long time. Still probably don’t do it as well as I should, but I think that’s where we all kind of fall somewhere on a spectrum of our well-being, our intentions of looking out for ourselves or looking out for well-being, and it needing to be more of a priority for all of us. So I think just continuing on that journey throughout my whole life is fun to be a part of this work.

Dr. Luis Garcia:

Well, thank you, Heather, and we appreciate what you’re doing and your new role. And you’re right. I mean, as clinicians, we often forget about our own well-being, so thank you for sharing that with us. What about you Brian?

Dr. Brian Gatheridge (guest):

Yeah, I would just say thanks again for the opportunity to participate in what is a very important conversation. So myself I guess I could say I’ve always had a bit of an interest in human behavior, you know, as well as emotional and cognitive processes, you know, how people interact in their environment and with others. In school, I was primarily interested in sports and hanging out, but for whatever reason, psychology was always something that was interesting to me. I also grew up in a really rural area, and I saw how you know, people struggled with mental health and how folks didn’t really understand mental health problems people were experiencing. There certainly was not an encouragement to discuss those problems or acknowledge them, and there really was not help available. And so I always felt like there was a bit of a calling for me that I felt to get into that field, to serve in so far as, you know, clinician wellness.

Like many of us who serve, I’m a clinician who cares about the people that I work with. And as I entered into the field of health care, I began to learn more about, you know, the unique pressures that, you know, clinicians face and the impact that our work has on our health. And sadly, again, that stigma that often prevents people from seeking care. And so, I guess over time, you could say I became increasingly motivated to serve in a way that could hopefully improve the health and welfare of my fellow health care providers. And again, really work to reduce that stigma that still keeps people from acknowledging that there is a concern and seeking care. So again, it’s a privilege to be here and to serve.

Dr. Luis Garcia:

Well, Brian, thank you. And I want to thank you personally for answering to that calling because you do phenomenal work and you’re a great asset to our organization. And, you know, you’re talking about the stigma. And Heather, I’d like to ask you a question about that. As a clinician, why do you feel that’s so important to talk about that stigma about well-being? And what’s your perspective on that?

Dr. Heather Spies:

This is really important for us as clinicians to focus on because we’re all working and living in very stressful environments. Medicine’s always been stressful, but even more recently, I think we’re all acknowledging that not only at work, but just everywhere in our communities and our culture and politics, everything is a little bit more intense and stressful lately. So no matter your specialty or your location, many of us are feeling more and more a sense of feeling devalued – maybe the culture, the public perception of health care has had so many changes lately.

I think all clinicians have invested so much time, energy, really sacrificed relationships sometimes just to be clinicians and to be that person that people trust. You know, traditionally we are the people that everyone looked to and trusted and valued, and the way that that’s happening now is being challenged more and more recently.

So as we dedicate ourselves to knowing the latest clinical information and trying to do the best we can for patients. The media sometimes challenges what a clinician says, and that makes it really hard for us to keep going, I think harder lately than it was in the past where we could always just say that we were the experts in things. And so I think it’s important that we talk about this because we’re all feeling fatigued and we’re all feeling burnt out at times, and what can we do to help with that?

Dr. Luis Garcia:

Thank you, Heather. And it’s just one more challenge for clinicians, right? As if medicine was not difficult enough right? Now, deal with all that devalue part that you’re talking about. Brian, you know, Heather touched a little bit into concepts like burnout, compassion fatigue, but maybe folks, maybe do not know exactly what those term terms mean. From your standpoint, can you define for us, the meaning of these terms? And maybe describe how can we recognize signs of burnout and fatigue on either in ourselves or others?

Dr. Brian Gatheridge:

Yeah, that’s a really important question Dr. Garcia. You know, we hear those terms a lot, but I’m always surprised by the folks who really don’t understand what those terms mean and whether or not they may be experiencing those concerns themselves.

So, you know, compassion fatigue and burnout are two types of stresses that can bring about, you know, psychological, physical, and emotional impacts. If we think about burnout, you know, specifically, it’s important to recognize that it’s not necessarily a psychological disorder. You know, I think the World Health Organization designates it as a syndrome which is a measure of chronic distress that we might feel at times if we’re talking about burnout specifically. Christine Maslow, Dr. Christine Maslow is a psychologist, researcher who’s really studied burnout for decades. And her research has concluded that burnout is characterized by three factors.

So one is emotional exhaustion. So these are folks who are just feeling depleted. They may be irritable, they might be down, and they just can’t seem to recharge. You know, a lot of us can feel pretty heavily, heavy or emotionally depleted at the end of the day, but we go home and we engage our family, or we exercise and we come back the next day and we’re ready to do our work again. And we feel like we have the emotional energy to do that. Folks who are burned out have a hard time recharging.

Depersonalization is the second component of the syndrome, and that’s this cynical or detached approach people may feel to caring for patients. This is where folks, you know, we start to see people as, you know, they’re presenting problem as opposed to, you know, the human that they are.

And then the last is a loss of personal accomplishment, and this is often the last symptom to develop where we just don’t feel like our work has any value or meaning anymore. And we know that, you know, burnout is bad for physicians and clinicians.

You know, it’s really proven, by increased rates of anxiety, depression, and chemical use rates, not to mention suicide, which is a significant problem within the field of health care burnout. It’s also bad for patients because we know that it’s associated with lower quality of care, lower patient satisfaction, higher turnover rates for clinicians, and increased chances of medical errors. Some research has shown that between 40 to 61% of physicians are burned out and additional research shows that about up to 60% of psychologists struggle with burnout. So it, it’s a very significant concern.

Those are things that people need to look for. Compassion fatigue is a little bit different in that it’s a bit more acute. Burnout is often caused by a number of work-related stressors, where compassion fatigue is pretty much directly related to exposure to the stressful and traumatic things that we’re exposed to within the field of health care. It has a much more rapid onset. It can also be a lot of the signs that you see are very consistent with what we’d see with post-traumatic stress disorder – you know, psychological distress, muscle tension, nightmares, cognitive shifts. Again, it’s much, there’s much more of a rapid onset and it really is impacted by helping others. There’s much more of a quicker recovery time than for burnout if we manage it early. So, again, there’s a lot of similarities between these two things but also some pretty profound differences as well.

Dr. Luis Garcia:

Brian, thanks for educating us on that. I mean, I’m gonna be honest. I personally didn’t know the difference, so thank you for that and those are striking statistics, right? The ones that you just shared with us. You know, Heather, Brian talked a little bit about the multifactorial etiology of this. So from your perspective, what things in medicine do you think have contributed to burnout or clinicians struggling to achieve that sense of well-being?

Dr. Heather Spies:

I think that we all know, from the very beginning of our training, we go into medicine and we’re really excited about it. You know, studies have shown that medical students actually have really low burnout. They’re energetic. They are ready to go and excited about things.

And then as we progress through training and residency, the number of us that begin to show symptoms of burnout or compassion fatigue really start to increase at an alarming rate actually. And then as we get into practice. And so I think it’s the time that we invest, the money that we invest. A lot of times, we enter our practices in quite a bit of financial debt, and we feel like we don’t have any other choice other than to do the work that we signed up to do 10, 20, 30 years into our practices.

So that’s one big factor I think that’s contributing. I think to organizational factors, I think sometimes the cultures get stuck kind of in that traditional way. And luckily we’re seeing that culture change and evolve across you know, Sanford and the country luckily to just really say, you know, we don’t have to have things the way that they’ve traditionally been.

We need to be looking out for each other as human beings and as people that need rest, and people that need to take turns and maybe not work for 36 hours straight all the time that, you know, we did in our training.

So I think too, it’s really been in our nature as clinicians to always put other people first. We always, I mean, that’s why we went into medicine. That’s just by nature what most of us are like. And so, you know, traditionally that really contributes, you know, over time, especially, you might do fine for a while, but over time, when you always put others first in every scenario, it’s going to take its toll. And so we’re seeing that definitely with our clinicians.

Dr. Luis Garcia:

Yeah. Not to count the expectations that we need to be perfect, right? And you know, a medical error can have significant consequences. Unlike any other job or industry and all that stress contributes to all that. So thank you for that answer, Heather.

You know, Brian, I think that we all are very aware of how all these stressors and all these factors have been heavily pronounced in the last couple of years. And I think the last couple of years can be easily be defined as full adversity. And from your perspective talk to us a little bit about the power of facing adversity and the relationship to personal growth.

Dr. Brian Gatheridge:

I guess what I would challenge all of our listeners to really pause and think about a time where you experienced adversity in your life. Think about an experience that you know, you didn’t enjoy or that was particularly challenging at the time that you faced it. And then I want you to reflect upon how that experience shaped your life in a positive direction.

You know, most of us are at the point in life where we can reflect upon experiences that at the time were quite challenging, or we didn’t appreciate for what it was. But looking back now, we may not change that because it did have a powerful effect on our life in a positive manner. And what we know is that, you know, for all of us adversity is an OK thing to experience in life. In fact, psychological research shows us that folks who have experienced adverse life events report higher overall levels of satisfaction in their life.

They’re more resilient, and people report fewer symptoms of trauma. They report overall levels of impairment and overall lower levels of emotional distress when compared to individuals with very little or no lifetime adversity. So again, lifetime adversity shapes us in a very positive direction. And, you know, hopefully, we’re all going to see that, through the last couple of years, certainly we’ve all experienced adversity. And on some level, even now, you may be able to look back and reflect upon how life has changed for the better as a result of the pandemic.

For some of us, we maybe haven’t seen that yet. And that observation will only materialize down the road. But this idea of, you know, growing from adverse experiences is also related to this concept of post-traumatic growth, which is another area of psychology, which describes the positive psychological changes that take place as a result of struggling with a highly challenging or stressful life circumstance.

Post-traumatic growth involves, you know, these psychological shifts in thinking and relating to the world and the self that contribute to a personal process of change that’s really deeply meaningful. This is when like the old normal is no longer an option.

And there’s five domains of psychological, post-traumatic growth that have been identified. And the first is, you know, people often experience a development of deeper relationships with others. The second domain that we often see is that people are open to new possibilities in life. This is related to identifying one’s overall purpose and meaning in life, what’s most important to them. The third domain is a greater sense of personal strength and ability. We have a greater idea of that. And the fourth is a stronger sense of spirituality, which is important in people’s life. And the fifth domain that we see as a result of post-traumatic growth are improvements in our overall appreciation for life. And so, again, we’ve all been through pretty tough times, you know, particularly over the past couple of years. But with time, hopefully we’ll see positive changes in our life as a result of this adversity that we’ve faced.

Dr. Luis Garcia:

Well, thanks for sharing that with us. That’s really profound Brian, and the appreciation of life and what we have in life, right? And I think that whether it is at home or at work, these last two years have really unified us as a workforce. And the way that we cared for each other in times of real adversity was just fascinating to watch. I’m highly appreciative for that.

Heather, I think that this conversation is showing us that it’s not a matter of if, but when you or I or anybody else could go through a difficult time, and most of the times very likely you could overcome that adversity alone, maybe without even sharing it with somebody, but there are times in which you’re gonna need help, right? And there are times where you need to accept that help. Can you talk to us a little bit about the wellness initiatives that we are putting in place in Sanford and how do we preserve that well-being at work?

Dr. Heather Spies:

Yeah, absolutely. I’d love to share. I think, you know, looking back on my personal journey that we kind of started with, you know, I think there’s always gonna be a gap in your well-being, but it’s whether you recognize it yourself or if you have the good fortune of a colleague or a friend, maybe saying something, you know, “Hey, I’ve noticed that maybe you’re not doing OK.” And so if you look at the – we have a wheel of well-being that we utilize through our Vital WorkLife resources that are available to all our clinicians at Sanford.

And the Vital WorkLife wheel of well-being has six dimensions. So it’s got your relational, your emotional, your physical, professional, spiritual, and financial well-being components. And I think at any given time, no human being can feel like or say that they’re optimally well in all those areas. It’s just not possible.

And it’s normal. I mean, we’re gonna sacrifice a little bit in one area to focus on one at different phases or seasons of our life. Like when I, when I had young kids, I would, I sacrificed some of my physical workouts some days because I would’ve rather, you know, taken the time to read a story to my kids at night because I had been at work longer that day or whatever. And so that’s OK, you know.

But I think overall we have to encourage people to pause and be just periodically checking in on those six different areas and saying, “Where, what area have I really let lag and is that affecting how I am doing overall?” And sometimes we see that. And so some of the resources that we have available to support those things are everything from counseling both internally, with our CAPS program here at Sanford, where we have counselors that we provide free of cost to all of our clinicians, that they can meet with and talk with.

So whether it’s emotional things or, you know, at work or personal relationship stressors, whatever it might be. So just to kind of get that relationship with the counselor started and see what else the needs might be that we can help provide resources for. We also have external counseling, so if somebody would prefer to have it be a little bit more external so that they don’t have, you know, a potential overlap of that colleague they can do it through our Vital WorkLife resource as well.

And just to go back a little bit, if they do want the internal coaching, we can do it across network too. So, say you do want it within Sanford, but maybe not the person that’s down the hall from you. We can connect our colleagues with people in another area of Sanford.

But everything from, you know, back to that wheel of well-being, everything from financial, you know, so say you just really need to meet with someone because you are feeling stuck and you just have this vision of, “I have no choice but to do this for 20 years. I can’t even see two less patients a day or anything because you just feel such a pressure.” We can provide you a meeting with a financial advisor to say, “OK, no, let’s pause and actually look at this.” I just had a colleague recently who, when she actually met with her financial advisor, she had no idea how much she had in her retirement fund, or how much, you know, what her long-term plan was. And it was actually really refreshing and freeing to her to just, you know, have that meeting and take a moment to look at that. So I think just awareness and knowing where you’re at is helpful to a lot of people.

And then physical, I mean, of course we can help with resources for our wellness programs, so all those kind of things.

And then if it’s relationships that we’re looking for I think that we have so many opportunities in Sanford to pair clinicians up with others. So we have a mentor program. We are now automatically pairing every new clinician with a mentor when they start but we’re also able to, if someone mid-career would really like us to help do that through our clinician experience office, we can help pair those people because really it comes down to relationships. And if you know that someone is listening to you and understands what you’re going through, because they’re also a clinician, maybe even in the same specialty or kind of in the same type of situation it just really does well for our well-being.

So those are a few of the things we have. I could probably talk for an hour on all different resources, but bottom line is, if you are looking for anything, all of our clinicians can contact their clinician experience specialist in their region, and we can lead you to hopefully what you need.

Dr. Luis Garcia:

Thank you for that, Heather, and I think that we have been very proactive at expanding those resources across the enterprise. And to your point, any need for our clinicians should be channeled through that Office of Clinician Experience. We have multiple resources available for them. Thank you for sharing some of them.

You know, Heather, you talk about that wheel of well-being and prioritizing some of these aspects of the wheel. Question for both of you, and I’ll start with you, Heather, again, what is one thing that you personally prioritize and why?

Dr. Heather Spies:

One thing that I’ve gotten much better at doing is my schedule. So I don’t know exactly which wheel that would fall into, but probably all of them, because what I do every Sunday is I intentionally, this is kind of, you know, embarrassing to admit, but I still write it out on a calendar. So I have my Outlook calendar, but I write out on paper – what does my week look like? And if I’m looking at my Outlook calendar and I see absolutely no white space on there, I go through and say, OK, can I move a meeting? Can I you know, move a kid’s appointment that isn’t, you know, urgent? Because if I don’t find time to at least go for a walk or do something like that, have 30 minutes to myself, I really can tell the difference, especially if I’m gonna be on call that week or I just have a really busy week.

It’s almost a necessity that I have some fresh air. So I write that in and then I see too, like, where can I delegate things? What can I ask my husband to do? What can I ask, you know, my 15-year-old to do and things like that. And so, that’s changed completely over the seasons in my life.

I look back to being new in practice and having two little kids, and I did this terribly. And if I could go back and maybe just do this one simple thing of spending literally 10 minutes on a Sunday mapping that out, I would realize that on Tuesday I’m going to be drowning, and I need help that day and just reach out to somebody or cross something off or cancel something but I never did that. I just kind of kept my head above water each day until I, you know, fell over. So that’s the one thing that is making me feel more well at this season in my life than I used to be.

Dr. Luis Garcia:

And it’s amazing how, if you’re not on your A game, how that impacts your family and your patience. Right? Let me share with you something. And, one time I asked my son, how do I make you feel when I’m not on my A game? And his answer was, “You make me feel scared.” And I can tell you that was not easy to hear. Right? You know, when you’re making one of your loved ones feel scared because of your actions that strikes your chord. So, thank you for sharing that Heather. What about you, Brian? How do you prioritize wellness in your life?

Dr. Brian Gatheridge:

That was a great statement that you made there Luis and I appreciate you sharing that story. You know, for me, the thing that resonates the most with me when I think about this question is at one point I learned not to confuse selfishness with healthy self-interest. And we know that many of us who work in health care feel like if we’re not there for others all the time, then we’re somehow acting in a selfish manner. And for me I’m constantly, I guess, checking in with myself to be aware of my stress signals and how I am feeling. As a parent, I guarantee you, my children have also, you know, experienced me at my worst. And, you know that’s something that we want to work to prevent as much as we can.

For me, I’m active in making sure that I participate in activities that ultimately promote wellness in my life. I can just tell you that to be healthy, I exercise quite a bit, and when I can, I am outdoors engaged in all kinds of different activities depending upon the season. And if I can do that with family and friends present, I’m all the better for it. I mean, those types of activities that are physical and outdoors are those that ultimately rejuvenate me and help provide me with the energy I need to be the best clinician and leader that I possibly can be.

Dr. Luis Garcia:

Appreciate that, Brian. And that’s so meaningful in impact of relationships, right? At all levels. So thank you for sharing that. I have one last question for both of you, and maybe Brian, I’ll start with you. What is your call to actions for those that are listening right now, our colleagues, our Sanford family members that are taking the time to listen to this podcast? What would you tell them? What’s your call to action?

Dr. Brian Gatheridge:

My ultimate call to action, and again, I just, I’m so proud of our organization and proud of the leaders within our organization who have made wellness a priority, who understand the importance of this, who understand that you can’t separate the mind and the body, and we need to take care of each other. And so I think if there’s one call to action, I would say is talk to each other. I mean, the research is pretty clear that within a culture, if we want to change the paradigm, if we want to reduce the stigma associated with acknowledging that we’re struggling and promoting people taking steps to get help, we need to acknowledge and share our struggles. We need to share our mistakes. We need to, you know, oftentimes people feel like, you know, they’re the only one feeling overwhelmed or in doubt or unsure but you’re not alone.

And it’s so empowering when we can speak up. You know, one of the wisest people that I’ve ever met shared three simple words with me, who, which will always stick with me. And it’s “never worry alone.” And so again, it’s just that message that if you’re struggling speak up. Don’t be too, don’t be afraid to acknowledge that you might be struggling. Let others know.

And if you’re not the one that’s necessarily struggling, don’t be afraid to lean in and check in with those colleagues of yours who you might observe to be struggling. Oftentimes we’re reluctant to ask because we don’t want to impose or we’re worried about the response that we may get. But if we don’t ask the question, we miss the opportunity to potentially improve the welfare of one of our close colleagues. And so those would be the things that I would encourage for now.

Dr. Luis Garcia:

Well said, Brian. Thank you. Heather?

Dr. Heather Spies:

Yeah, I think my call to action is simple as well. I love everything Brian said. I think the biggest thing is, you know, making sure we’re giving each other grace. Assume good. You know sometimes we tell ourselves a story that is not reality. You know, we assume someone is, you know, trying to make us work harder than them, this, that, whatever. And I think if we just assume good, that we’re all in this together, we all have the same intentions of caring well for our patients and doing a good job, and if we assume that it just makes the day go better and we end up treating each other so much better.

It’s OK not to be OK. We say that a lot, and I think we need to make sure to keep reminding ourselves that. So if you’re having a day where you’re not OK, like Brian said, reach out to somebody and ask for help who, you know, write down who is your one or two go-to people at work that you trust that you can just say, “Hey, I need you to you know, encourage me a little bit right now.”

And, you know, I’ll tell you, they’ll be happy to. I know if someone reaches out to say that to me, it actually lifts me up then, because I feel happy that they trusted me that they said something, and then I walk away thinking, OK, you know, now next time I need something, I might just ask them too. And I’m sure they’ll return the favor. So doing that for each other.

I think too, just taking one day at a time, be intentional about each day. Sometimes, like I said, when I look at my week, I don’t know how I’m gonna fit it all in. But then you break it down and you do one day at a time, and you just pause and make sure you’re intentional about spending some real time listening to your kids or listening to your spouse. I don’t think we talked about that much on this podcast, but spouses sometimes really get the brunt of things from their physician partner and I think we just need to make sure we are intentional each day. Just take one day at a time and focus on relationships, work, personal, all of those things.

Dr. Luis Garcia:

Well, thank you, Heather. I’ll tell you, Brian, Heather, it has been a pleasure for me to sit down with you today. Thank you very much for your time in this podcast. But more importantly, thank you very much for everything that you’re doing around this topic for our clinicians every day. And to our clinicians that are listening, I mean, what better way to conclude what we just heard? Never worry alone and always assume good. Please remember that we need you. Sanford is the greatest organization because of you. Our patients deserve your talent. And we, and you deserve our support, and we will continue to work on your behalf on this topic of well-being. So thank you for listening.

Alan Helgeson (host):

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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‘Disruptors’ find ways to innovate in health care

Alan Helgeson (Host):

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 on health care disruptors and centered around access for rural and underserved populations. And where does big data fit into this? Our guest is Dr. David Newman, endocrinologist with Sanford Southpointe Clinic in Fargo. Our moderator is Dr. Luis Garcia, president of Sanford Clinics.

Dr. Luis Garcia (Moderator):

Hey, Dave, I have a question for you just to get started. You know, for those of you that don’t know, Dave and I, we actually played soccer together, and one of the things that you should know is that Dave is not only a great soccer player, but he’s actually a great coach. So Dave, what does it mean to have an influence on young children and be able to lead them and to be a role model for them?

Dr. David Newman (Guest):

Oh, it’s phenomenal. You know, I learned so much from the kids every day. It’s been a huge transformation too. So over the past, like seven to eight years I’ve been in coaching, I’ve got to see all these kids grow. I’ve got to see them have fun. I’ve got to see them get better than me. That was like a huge thing. So a couple days ago I was playing with my son in the backyard, and he’s better than I am, and it happened a lot sooner than I thought it was going to. So that probably means that I’m just not as good as I thought I was. Or maybe he’s better than I thought he was.

Dr. Luis Garcia:

Or maybe you’ll have a star in the MLS that you don’t know yet. But, hey, you know, Dave, I think that, the same growth that you have seen in your children and your teams is the same growth that Sanford as an organization has seen on you. I follow your trajectory and it’s nothing but impressive and the way that you have contributed to our organization in so many ways is so meaningful that I would like to just ask you to share some of that trajectory and what has gotten to where you’re at right now.

Dr. David Newman:

Oh, thanks for your kind words, Luis. So I’ve always been kind of a computer nerd. So before I went into to medicine, I thought that, you know, computers are the way, the future. That’s how we get better. Even before I came to Sanford, I was involved in electronic medical records when I was at Hennepin County. And it wasn’t because I liked them, but as I thought it was because I thought they could get better. I don’t think anybody really likes the EMR, to be honest, but there’s some of us that think that it’s such a pain in the butt that there’s gotta be ways to make it better. So when I came to Sanford, I was kind of thrust into a leadership role with the EMR. I’m also a practicing endocrinologist. I specialize in andrology. I do full clinic.

I do full call, so people see me around the weekends all the time. I’m actually on call right now as we’re doing this. Where I’ve really been interested though, is where efficiency and quality intersect. And I really think that comes down to how we use the EMR, how we leverage the EMR. And one of the big pet peeves I have is that technology is trying to drive health care when I really think it needs to be clinician driven, that I want to be asking ourselves every single day, “How can we fix the EMR? How can we make things better?” And it shouldn’t be the other way around that clinicians should be really be driving change at Sanford.

Dr. Luis Garcia:

Yeah, that, those are great thoughts, and I agree with you, Dave – I think that it should be the clinicians that are leading the change and not the other way around. But, you know, I think that one of the constant, or maybe the biggest constant in medicine is change. And as clinicians, we adapt fairly well to change, but then there’s disruption, right? Which, if you think about it is, could be a very positive or a very negative format of change. So in your career, you have experienced both disruption and change, but from your perspective, what is different today?

Dr. David Newman:

Oh, man. So that’s a super good question. So, I like the term innovation better than change, to be honest. So what I think of innovation is doing the same things that we’re doing now. We’re just doing them better. At some point we transition to doing new things. And then what disruption really is, is doing new things that make those old things obsolete. You know, a good example is like the Netflix Blockbuster thing. So, you know, I’m a child of the ‘80s and ‘90s and I used to love going to Blockbuster. So you’d show up and you’re like, you had all these rows of movies and you would just impulse rent something, and it was awesome. You, I mean, I should have invested at that point. I thought it was gonna be great. And then all of a sudden Netflix comes along and people are like, Oh, I mean, you can get DVDs through the mail.

It takes a while. It’s kind of cool, but I don’t know, we’ll see. I’m gonna keep going to Blockbuster. All of a sudden it’s like, Oh man, this is pretty cool. Like, they allow you to stream what’s streaming. I can watch something on-demand at my house, and then at some point, everybody was able to stream. It wasn’t just for the people that had money to do it, it wasn’t for just people that had a high internet broadband access. At some point everybody could stream and it disrupted everything. So now everything is streaming.

And that’s really what I think disruption is gonna be. And in health care it’s the same way. At some point we stopped using prescription pads; at some point, you know, we stopped writing notes on paper. These are things that we’ve gotta be ready for going forward.

Dr. Luis Garcia:

Yeah, those are great examples Dave, and, so, you know, talking about innovation or disruption, however you want to frame it, I think that if we’re totally honest in medicine, we have been slow at adapting to innovation and the pace of change lately. So one of the things that comes to mind is what are the nontraditional disruptors in medicine doing right now? And if you think about it, we always think about reimbursement, about the insurance companies, payers, quality and the traditional things that keep us awake.

But now you need to start thinking about the nontraditional aspects that are coming into our backyard, like Amazon, Microsoft, Apple, even Walgreens. We saw what happened throughout the COVID situation where, you know, the big pharma companies and the Walgreens of the world really got into the distributing and giving vaccines. So are they a true threat or do you think it’s just a factor of this technology development that we have had in the last decade?

Dr. David Newman:

Man, I think it depends on who you think they’re a threat to. Like, are they a threat to the way that we’ve been doing things? Absolutely. And should they be a threat? Yeah. I think the way that we get better is by some of these nontraditional disruptors on their competition because they’ve got good ideas. Like we should be looking at them, watching them to see what works the same way that they should be watching us. You know, some of those companies are amazing. So Amazon, if you haven’t been following Amazon, so like Alexa, Alexa’s HIPAA compliant, so you can say, Hey, Alexa, schedule me a, you know, a appointment with cardiology and Alexa can do that. You know, they’ve got pill pack. They’re kind of redefining how patients get their medications. They’re doing some really cool stuff, man.

Yeah, you brought up Amazon or Google and Apple too. So Google, they’re doing things a little differently. So they are looking at health care algorithms. So we have all this data, we’ve got structured data, which is in, you know, Epic in the fields that we type in. We’ve got unstructured data, we’ve got all these progress notes that, man, nobody probably reads them except for Google. What they’re trying to do is figure out how to leverage all this data to make things better, to develop algorithms to make our lives better and our patients’ lives better.

Dr. Luis Garcia:

Yeah. Those are great perspectives, Dave, and I gotta tell you, I’ve heard people saying, Oh, you know, we don’t have to worry about them because they’ll never have a hospital where they can see patients. So they will never have a clinic where Dave Newman and has to interact with Amazon to see a patient. But from your perspective, what do you think they’re truly, really trying to achieve by knocking on our backyard?

Dr. David Newman:

I, I mean, so the optimist in me wants to think that they’re trying to make things better. They’re trying to, you know, mimic retail. A lot of these companies started in retail to try to make health care access easier to patients, less confusing and less costly. They’re hopefully, hopefully gonna be decreasing costs for their insurance plans. So, like CVS partner with Aetna, one of their big things was to try to decrease patients going to the ER. Cuz we all know that patients go to ER for stupid reasons. Instead of doing that, go to their minute clinics and take care of the things they can there. I think they really wanna stay relevant too, that I think if you look at a lot of the biggest companies over the past 25 years, they’ve seen how big of a deal health care is. They’ve seen how big of a mess it is.

And for them to stay financially relevant and just relevant with the times health care is a big target for them. It’s also super exciting, right? So, you know, medicine has typically been like an altruistic thing to go into, like you’re actually helping people. And for them, some of them think that, you know what? Like, this is us, this can be my legacy that, I can, like, for example, Apple, some of their executives have said they want their legacy to be a health care company. So they’ve developed their apps, they’ve got their Apple Watch that can kind of function like an EKG machine. There’s a lot of things that can be very exciting in health care.

Dr. Luis Garcia:

But to those points, Dave, because I think we touched on a lot of interesting things, but to those points, what do you think is their port of entry? Are they gonna target our patients? Are they going to target our physicians, health care systems? What, what do you think is their strategy?

Dr. David Newman:

Oh, boy. So, I mean, I don’t think that they know their strategy at this point, exactly. So I think that the patient is the easiest thing to target. There are a lot of disruptors out there now that all they wanna do is get to the patients online to do telemedicine, that they feel like that is going to be the next big wave of the future because so much time and money is wasted by clinic space. I don’t see a lot of them directing their efforts towards providers at this point, mainly because it’s so hard because of the geographical limitations for that. I really think their port of entry is gonna be patients for now.

Dr. Luis Garcia:

You know, that’s quite interesting, Dave, because as physicians we’ve always said that the most important and the, and the strongest interaction is between a physician or an APP or a clinician and a patient, right? So are you saying that they’re starting to get the upper hand – if so, how and why?

Dr. David Newman:

Oh man. So I definitely think they have the upper hand with their marketing approach, mainly because they’ve got, you know, years and years of data and they know how to do this. So if you walk into a Target, if you walk into a Walgreens, they know exactly how to market their shelves and their product to you. As health care systems, we’ve mainly focused in on health care, on keeping people healthy, on, you know, operations, on prescribing medications. We haven’t been super great at marketing.

You know, health care is super complicated. Do we need to do everything that we are doing in the office? Does all the health care maintenance need to be done face-to-face? Do patients care about that? Or do they really wanna talk about what’s on their agenda? So a good example of this is, you know, health care maintenance. Would we be able to have a, you know, an army of providers, whether that’s MDs or nurse practitioners or PA’s manage a list of people that need their colonoscopy, and would it be more satisfying for a patient to come in and talk about their congestive heart failure or their fatigue as opposed to talking about when they need their colonoscopy?

Dr. Luis Garcia:

Yeah, no question. Those are great points. Given the thoughts that you just shared, what do you feel should be our position, our approach? Should we ignore these disruptors? Do we, should we engage with them? Should we compete with them? What do you think that as an organization like Sanford, we should be doing in relation to these nontraditional disruptors?

Dr. David Newman:

So I think my thoughts are very much mirrored by lots of the CEOs of health care organizations. I was at some sort of meeting at one point, and the Mayo Clinic CEO, his quote was something like, retreating from innovation is not an option at this point, really, we have to be innovative or we will die as a health care organization, that there’s so many things that are moving towards big data. I think the really interesting point that you brought up is the engage and compete. And those are definitely not exclusive. So the big question that we’ve gotta answer is, when we engage and when we compete, we are big enough at Sanford that there are certain things that we can do ourselves. I think a good example of that is like our quality dashboard. We’ve got a lot of really good work that we’re doing for quality that we don’t need someone else to build for us.

We’ve got this great donation for a virtual hospital, and we’re gonna be able to build our own protocols and really help a lot of people through that, where we’re not gonna need a lot of help from the outside as far as competing. Those are the things that we can do with engaging. There are certain things that we are still not big enough with, so we need to cooperate with the outside.

It’s, you know, health care is a global game, and we are not going to say that we can do everything ourselves. A good example of that is like with Epic. So, we have a good relationship with Epic where we can help make the EMR as dynamic as possible, but we’re not gonna kid ourselves and say that we can do it better than them because that’s all they do, right? So that’s a good example of how we just utilize their software.

We’ve partnered with Livongo, which is like a diabetes technology firm that can do things that we can’t do. So they can contact patients, they can coach patients, and they’ve got a team of, you know, educators that we just don’t have. And we’re being very innovative in that to try to make things better.

Dr. Luis Garcia:

You know, I think those are very strong points and great examples of what engaging could bring, not only just the benefits to us as an organization, but to our patients. So, you know, what would be, what do you think would be the consequences of not taking this route of engagement? What would happen if we choose to isolate ourselves?

Dr. David Newman:

Boy, I don’t think that it’s a really good option. I think it’s actually a super bad option, not keeping up with technology. I think that one of the things that needs to happen is we just need, as providers, we need to realize that we’re not as good as we think we are unless we leverage the available technology. You know, I think of, for me, this was very, very close to my heart as a couple years ago. They started having things like the artificial pancreas, which is a like a box that you wear, an insulin pump on your belt that has a sensor that monitors your glucose levels. And at first I was like, I don’t know about this. Like, is it really better than I’m gonna be changing insulin levels and monitoring glucose levels, and the algorithms are a lot better than I am?

There’s been patients that I’ve been following for like 10 years that I’ve never been able to control, that the computer’s better than I am. And that was really a wake-up call that really for me and my patients to get better. We have to leverage that technology. We have to engage with the companies. We have to say what’s out there and we have to present it to our patients.

One thing that in the Dakotas and in our footprint, we have really, really good relationship with patients and they want to talk to somebody about this technology before they go through with it. They wanna talk to someone trusted about this. It’s like the COVID vaccine. Our rates of vaccination are a lot better after they’ve talked with somebody that they trust. And we can be that intermediary between our patients and technology by, you know, standing behind it to improve our patients’ and our lives.

Dr. Luis Garcia:

I’ll tell you Dave, this is just fascinating. I remember when I was in medical school, it was either type one or type two diabetes, and now I don’t even know, I can memorize the many types of diabetes that you have. And now you’re talking about an artificial pancreas. So talking about evolution and technology, this is just fascinating. Hey, Dave, it’s been an honor to do this. And let me just ask you one last question. I know that you’re busy and you’re on call, but I appreciate your time. What keeps Dave Newman awake at night?

Dr. David Newman:

You know, my kids are old enough, they don’t. But from like a health care standpoint, it is my own ego and like how comfortable I am at this stage of life, standing in the way of improving my patients, or I think the whole health care system in general, like the whole condition. So is there something that I could be doing better than I’m not? I think that there’s gonna be a ton of stuff where us as providers, we get scared.

You know, we like having our jobs. We like being the one in charge. And, for example, like is there a piece of software that can read a chest CT better than the radiologist? Is there a piece of software that can be a better endocrinologist than me? These are things that we need to be aware of and that we need to be partnering with just to improve things. And in the long run, they improve not only our lives, but our patient’s life.

Are these nontraditional health care disruptors doing things better than us? You know, I think that we do things pretty well, but we could do things better. That is, are there people out there that we should be learning from that we’re not learning from?

Dr. Luis Garcia:

You know Dave, I can only think about the years in which you and I were in medical school and in residency and the tremendous amount of progress and the tremendous amount of technology that we’ve been able to witness and change. And it’s just, I can’t imagine how fascinating it is for the new generations to think about what the next 20 and 25 years will bring. And definitely it is an honor to belong to an organization that would allow us to witness that progress. And Dave, I could not have thought of anybody better to talk about this topic than you, a well respected individual and professional. It’s an honor for me to be here. Thank you. And thank you to all the listeners for your time in sharing this podcast with us.

Dr. David Newman:

Yeah, pleasure’s mine, Luis.

Alan Helgeson (Host):

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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Concussions treated quickly can recover quickly

Courtney Collen (Host):

Hello and welcome. You’re listening to the Health and Wellness Podcast by Sanford Health. I’m your host Courtney Collen with Sanford Health News. This series begins new conversations and continues the important ones all designed to keep you well physically and mentally.

In this episode, we are talking all about concussions. We know fall sports are underway, more athletes are taking the field, which can often lead to more injuries. It’s really a good conversation to have year-round because the reality is anyone can suffer a concussion.

Dr. Josefine Combs is a Sanford Health neuropsychologist and expert in concussion care. She specializes in the assessment, the management and treatment of concussions and people of all ages, and athletes at any level of sports participation. Dr. Combs also treats non-athletes who suffer a head injury from work, a home or vehicle accident. And I want to welcome Dr. Combs to the podcast.

Thanks for being here.

Dr. Josefine Combs:

Thanks for having me.

Courtney Collen (Host):

So to start, sort of a two part question. Dr. Combs, how do you define a concussion, and then what physiologically happens in the brain during that time?

Dr. Josefine Combs:

Yeah. Concussions are considered mild traumatic brain injuries. Just because the word mild is in there does not mean they can’t be unpleasant for the individual that suffers one. Typically they’ll result in temporary symptoms and cognition as well as physiological symptoms and even emotional symptoms. So very common symptoms are headaches, feelings of dizziness or unbalance. And often also accompanied by cognitive symptoms that would feel like brain fog or having trouble with memory or concentration. And then the emotional symptoms often encompass kind of like an increased emotionality, feeling a little uneasy, or having emotions switch more rapidly or feeling more intensely overall.

Courtney Collen (Host):

Is there a certain part of the head that feels the impact, that determines what kind of concussion? Is it anywhere on the head?

Dr. Josefine Combs:

Location does not matter as much as one would think because our brain operates as a whole. So it does not matter if I’m getting hit on the left side because it does not mean that that’s where my headache will be.

Actually, concussions do not require a direct blow to the head. If enough force is generated, it could be anywhere to the body. Like for example, in a car accident, if I’m jolted around enough, I don’t actually have to hit my head to experience or to suffer a concussion. And the injury itself is rooted in our anatomy, and that’s also why anybody could get one and it’s not just confined to sports.

Basically what happens is our brain sits in our skull and there’s a little bit of fluid around it, which is a good thing. We all have that. We need that. But when we take a big hit even to the body somewhere, if the force is big enough, the brain can move inside the skull. And when that happens inside the brain, our tiny, tiny cells called neurons, we have lots of those, and that’s a really good thing.

But with that shaking motion, those neurons, those cells can get stretched out and when they become stretched, they can become essentially leaky. And the inside of the cell can get out, and the outside of the cell can get in. And there’s things in places where they normally aren’t and that’s where a lot of those symptoms are coming from. For example, the headaches and stuff like that. And then our brain has to kind of do some extra work to put everything back in place.

The good news is that the stretching is not permanent. It’s a temporary process. Those cells do come back into their original shape and then our brain kind of has to do some extra tidy up or cleanup work, if you will. And that’s why concussion can take some time to heal. Depending on how much stuff is out of place, that will determine how quickly someone can bounce back. The average concussion can range anywhere from two weeks to six months, really. For youth athletes, it’s typically around three weeks.

Courtney Collen (Host):

You talked a little bit earlier about symptoms. Can you expand upon the symptoms that a patient might feel or experience when suffering a concussion?

Dr. Josefine Combs:

Absolutely. So we have essentially three big categories. We have cognitive symptoms, we have physiological symptoms, and we have emotional symptoms.

So physiological symptoms are typically the best known. That’s kind of the signs that people think about when they hear concussion. That’s that headache, feelings of dizziness or being unbalanced. Like sometimes it’s accompanied with nausea or even vomiting. Those are the classic physical symptoms there. Or also people that struggle with vision after concussion, like their eyes aren’t working together as well, which then makes the headaches even worse.

The cognitive symptoms are typically clustered around memory difficulties, trouble with concentration, feeling kind of like the brain is slower than it normally would be, like a brain fog type of sensation.

And then emotional symptoms can range. So it kind of depends on the individual a little bit, but a lot of people feel uneasy or a little bit anxious just because the injury can make us feel less like ourself and that can be a very weird sensation. Some people also feel their emotions more intensely or are just more emotional in general. Like, you’re watching TV, everything’s fine. Now a sappy commercial comes on and all of a sudden I feel like crying when I was fine a second ago. Those are very, very normal sensations that just aren’t that well known.

Courtney Collen (Host):

Let’s talk through the different grades or severities of a concussion.

Dr. Josefine Combs:

Yeah. So in the past, there were several different grading scales, but we have actually moved away from that just because the scientific community could not really agree on a very good scale to use universally. So that has actually gone away. There’s still the Glasgow Coma Scale that gets used in the emergency room, but that’s not just for concussion.

So typically when we now talk about severity or grading scales, a lot of people still classify as mild, moderate, severe, but we have moved away from a number system just because it does not match very well and concussions are a very individual injury, so it’s not a one fits all type of situation. I and my staff in clinic, we always joke if you’ve seen one concussion, you’ve seen one concussion because they can be vastly different. There’s a big spectrum. So, in terms of grades, we kind of think of them as mild, moderate, severe.

We do classify them in a profile model. The most common profiles are vestibular, ocular headache/migraine, anxiety/mood. And then there’s also modifiers, for example, neck and sleep that will significantly impact how the injury presents itself and how the individual feels.

Courtney Collen (Host):

So what are some of the warning signs now that someone may have suffered a concussion? Be it that mild, moderate, severe, maybe break down what those warning signs look like or how you determine which one it is?

Dr. Josefine Combs:

Absolutely. One of the interesting things about concussions is that symptoms don’t have to be present immediately. So the process I described earlier where the brain gets shaken and things kind of get knocked around or out of order, whatever we wanna call it, that is not a floodgate type of process. It is more of like a trickling motion, and therefore it can actually happen that concussion symptoms don’t show themselves until like 24 or 48 hours later.

So we often see that, for example, Friday night football, a kid takes a really big hit and then thinks they’re OK over the weekend. They’re kind of lounging around, not doing a whole lot, feeling pretty good. But then by Monday, when we have to go back to school and use the cognitive skills, really make our brain work, all of a sudden they feel really, really terrible and don’t look so good. So, there is a big spectrum.

Good things to look out for any type of symptom that does not feel normal. So if an athlete or any individual takes a hit, whatever kind, and they don’t feel right, if they have a headache, if they feel off balance – often people also describe light sensitivity, sensitivity to sound. A lot of people get very nauseated. Some people will vomit. That can also be a sign. So anything if we don’t feel right after, and then the physiological symptoms that we had talked about.

Red flags to look out for that would warrant immediate medical attention, like emergency room type of stuff, would be things like altered levels of consciousness. So if they are unconscious for a prolonged period of time, like longer than, you know, I mean people can black out for a couple of seconds, that is not too concerning in the moment. Obviously we still want them to get evaluated, but prolonged loss of consciousness definitely is a reason to seek care, uncontrollable vomiting, any gross neurological changes, and then also rapid deterioration. So if they seem OK at first, but then just get worse and worse and worse and worse, that’s also a sign that we definitely want to seek immediate care.

Courtney Collen (Host):

So really important just to know your body and understand what feels right so when something doesn’t feel right, we can identify that?

Dr. Josefine Combs:

Yeah.

Courtney Collen (Host):

And especially for athletes, young athletes.

Dr. Josefine Combs:

Absolutely. And the culture within the sport is also incredibly important. Like, we have long moved away from that sentiment of like, Oh, you get your bell rung, so just go walk it off. Right? Shake it off. Yeah, it will be fine.

We definitely want to take it seriously, especially because like we talked about, symptoms don’t always present full force right away. Right. So in order to protect the athlete from further damage and even worse injury, we always want to remove them from play immediately. So one of our little memory tricks that we use is the, the saying, “when in doubt, sit out.” So sure we teach that to our athletes. It’s better to get evaluated and checked out by the athletic trainer that is covering the game or maybe the team physician, whoever’s available, a trained medical professional just to make sure it’s better to miss a little bit of the game and be safe than to just try to power through and then pay for it. Very costly.

Research has shown that continued play after an injury can actually prolong recovery. So there’s a study that has shown that athletes that were removed after injury immediately bounce back pretty quickly, kind of that two- to three-week frame that we talked about earlier. And individuals that continue to play five to 10 more minutes actually tagged on several weeks to their recovery. And then individuals that played 10 to 15 minutes more, or more, for whatever reason – I didn’t want to lose my spot – whatever, you know, they tried to justify internally. A lot of them took months and months to recover it.

Courtney Collen (Host):

Wow.

Dr. Josefine Combs:

So it does make a really big difference. And once we kind of provide that education people kind of reconsider, especially coaching staff has been great and got on board because, you know, it matters if I get my athlete back in a week or two or if they’re out for the rest of the season. So education is incredibly important and we place a great value at that in, at Sanford and try to do outreach and have those things available. We also offer baseline testing for youth athletes to help them be better prepared for the seasons in case they do suffer a concussion. Hopefully they do not, but if that helps in the specialty treatment that we can provide here at Sanford.

Courtney Collen (Host):

Let’s say an athlete or any individual suffers a concussion, what do you recommend happens next? Do they seek care? What does that look like? Where do they go?

Dr. Josefine Combs:

Great question. Where here at Sanford are very blessed that we can offer very specialty care with a multidisciplinary approach. A lot of people seek care through their primary care first or go to acute care or the ED, which is appropriate if they, if it makes them feel safer. I do like to point out that it is very OK if the treating provider does not order imaging, a lot of people share their concern that they didn’t get a CT or an MRI. A lot of times that is not necessary and they’re not doing them a disservice by not completing that. We really only want imaging to rule out structural changes because the concussion itself is not going to show up on that. So it is very OK, if you go to the emergency room or acute care for yourself or your athlete and they do not complete imaging, that is not inappropriate and very OK.

Once they seek care, if your primary care provider or your pediatrician feels comfortable managing the concussion, they absolutely can. Typically our recommendation is that if symptoms do not improve by that second week mark, a specialty referral might be appropriate or advisable. I personally like my athletes to come see me within the first week of the injury just because that helps us kind of set the tone, make sure we can speed up their recovery by setting them up for success with the right recommendations. But it’s not that if they see their pediatrician first and don’t see us till like two or three weeks in that they’re losing a ton of time. But that’s kind of the typical timeline. People seek their you know, normal provider first and if that does not improve or get better, then they typically place a referral to specialty care.

Courtney Collen (Host):

So say someone gets a referral to you for their concussion of any severity, walk through what some of the treatment might look like and what happens next once they come to see you for an appointment.

Dr. Josefine Combs:

Yeah. So when they come to see me in clinic, they need to bring a little bit of time because as a specialty clinic, our appointments are longer than the average doctor visit. Typically the way it is set up, we will spend the first hour engaging in neuropsychological testing to get a good understanding of where their functioning is at from an emotional, cognitive and physiological standpoint. So we will do a computerized assessment that kind of screens for the major cognitive domains, reaction time, processing speed memory and visual recognition, stuff like that.

We also do a balance assessment to see how they function there. We also have questionnaires looking for any emotional distress or signs and symptoms. And then after that hour of testing, we spend typically another hour on going over results, talking about recommendations and then discussing the treatment plan together.

So depending on what the individual presents with, we tailor the treatment approach to them because as we talked about earlier, this injury does have quite a big spectrum. A very frequent treatment approach includes vestibular physical therapy. This system is a part of our brain that is basically responsible for like movement motion integration. Like it basically is the part that tells us where we are, where our body is in space. I always joke that it’s our internal GPS, if you will. Sure.

And when we take a big hit that our internal GPS basically gets notched of the rails and then kind of limps along. It doesn’t go offline where we don’t know where we are anymore and fall over often. But does not process at the level it does before. So that’s when people get dizzy or feel very uncomfortable in busy places, those physical things.

And there is physical therapy that we can provide to help retrain that system. And we have a specialty trained physical therapist that I work with very closely. I mentioned vision difficulties earlier. We also have a specialty trained therapist that is an occupational therapist that will then help the individual – whether it’s an athlete or a worker or from a car accident – help retrain the brain to kind of utilize things and put everything back where it came from and use those cells like it did before the injury.

We also collaborate with speech therapy, which can help with memory trouble. And then we also have a wonderful integrated health therapist that can help us for people that struggle with the emotional piece just to kind of provide as much support as we can. We also collaborate with neurology, pain management and rehabilitation services. And so we’re really trying to tailor as much as we can to the individual to set them up for the best success and the quickest recovery we can, because it certainly doesn’t feel good. Sure.

One thing a lot of people always struggle with is that their environment does not understand the injury. They don’t understand what they’re going through because when we suffer a concussion, we certainly look normal, but we don’t feel it and that can create quite a bit of struggle for individuals.

Courtney Collen (Host):

Yeah, I can imagine. Are there any long term effects of a concussion? We talked about earlier, you know, when in doubt sit it out, and the longer that you wait to play again, you know maybe the shorter the timeline of that concussion’s effects. But what about long-term effects?

Dr. Josefine Combs:

Yeah, so generally speaking, concussions are very treatable. So they’re not the boogeyman and if treated appropriately, they are very, I don’t want to say OK to have, but they’re not the end of the world if treated appropriately. We definitely want to take them very seriously because when they are not taken seriously and not healed appropriately, then yes, they can definitely create trouble down the road. But as long as an individual gets back to their pre-injury baseline, whether it is through treatment or the brain kind of takes care of things on its own, if it’s not that severe, it does not predispose us to more concussions.

Obviously contact sports have a much higher risk than non-contact sports, but you know, there’s assumed risk with a lot of activities. It’s definitely not something where we would want to set a record. Like we always tell our athletes, don’t try to get more concussions. But there are also many individuals that had several and they’re very OK. So as long as it is treated appropriately, the chances of long term difficulties or long term trouble are very, very slim.

Courtney Collen (Host):

So get care right away essentially.

Dr. Josefine Combs:

Yeah. Better safe than sorry.

Courtney Collen (Host):

Absolutely. You mentioned earlier part of the treatment process, “IHT” or integrated health therapists. Is depression a concern long term or even short term? You talked about maybe emotional counseling. Talk about what you see.

Dr. Josefine Combs:

So, mental health is always very important because without mental health, physical health is very hard to enjoy and have. They go hand in hand. And the thing with concussion is, it typically does not create something that was not there before. But it certainly can exacerbate things. So especially for individuals, let’s say struggled with anxiety before the injury, they are going to feel their anxiety symptoms a lot more while they’re healing. Similar things for depression.

The thing that I would like to add that to that is that the concussion itself does not cause depression, but the aftermath certainly could. So what I mean by that is, for example, we talked about athletes a lot. So if I have an athlete that has an injury that removes them for several weeks, if not months, whether it’s, you know, they didn’t know to come out right away, or they just were unlucky and ended up with a moderate to severe concussion.

A lot of times what we see is that when they’re removed from daily life, they get taken out of school, they do not see their friends at practice anymore, they basically are just told to rest and wait, that can certainly take a really big toll on their mental health. And we do see depressive symptoms kind of creep in because especially for youth athletes, that is their social environment. School is where they see their friends. Practice is where they get to hang out outside of perhaps meetups or play dates. But generally speaking, that’s a huge part of their social world. Not to mention, a lot of times kids play their sport because they love it, they enjoy it very much. So not only can they not do the thing they love, but now they also don’t get to see their friends, they’re bored, they don’t feel good. So that often takes a really big toll on mental health and especially for individuals that were anxious or struggled with depression prior, that can certainly make things a lot worse.

That is another reason why treatment-wise, we’ve seen a huge shift in the field. Initially, people always thought about, you know, just rest, go lay in a dark room, don’t do anything, it will get better. Well, we’ve learned through a lot of research that rest is not always best. It’s actually a good idea to try to do as much normal stuff as we can. So one of my first priorities if I work with a student athlete is to get them back into school, even if they don’t do all their assignments or, you know, stay the whole day. Anything beats nothing. We want to provide them with as much of their normal as we can.

That being said, obviously we need to protect them and prevent the injury from being worsened. So we’re going to remove them from any kind of contact play. But physical activity, especially cardiovascular in nature, is not a bad idea. So after day one or two, we strongly encourage our patients to actually go for a walk, move around, try to do some normal stuff. A lot of kids are also very ecstatic when they learn that they don’t have to avoid screens completely. So we just kind of teach them how to use it appropriately to manage their symptom better. Yeah. But this whole idea of, you know, isolate, laying in a dark room is actually very detrimental for the injury and we don’t want that.

Courtney Collen (Host):

This has been fascinating, Dr. Combs. Let me wrap it up with this question here. Will you talk about some of the resources and opportunities for patients that set your team of specialists apart when it comes to diagnosing, managing, treating a concussion and providing that efficient and targeted care? Essentially, what sets Sanford apart when it comes to concussion treatment and care?

Dr. Josefine Combs:

We here at Sanford are very fortunate to have a specialty set up. So we have an actual designated concussion clinic that sees concussion patients of all ages of all types of backgrounds. And like you mentioned earlier, it does not matter if it’s a sport injury or a car accident or a work incident or even, you know, a project at home gone wrong. So we are able to accommodate almost anything. And the fortunate setup here at Sanford is that we can provide that multidisciplinary approach with specialty trained providers.

A lot of times concussions during your medical education did get covered, but often rather briefly, and it can be a very complex injury. So having specialty care where you know you can go if things don’t get better after that initial timeframe, and then being able to receive tailored and targeted care that is really matched with what you are experiencing and what you’re struggling with, not only helps the individuals feel better more quickly, but also helps them to kind of go through this with a little bit more ease. And I definitely consider myself very fortunate that we have such an amazing team here that is very passionate about not only the care of our patients, but also trying to advance the field and continue to work with research and always wanting to learn more about this injury so we can continue to provide the best care for our patients.

Courtney Collen (Host):

Concussions can be a really scary situation. I mean, the head is not something that I want to mess with. So I can understand how important it is to understand the signs, the symptoms, the warning signs, the red flags, and then get into a specialist.

Dr. Josefine Combs:

What I always like to highlight is that it is a very treatable injury. We definitely want to take it seriously because as we’ve seen in recent news, it can go badly. It is a very real thing, like I mentioned earlier. Just because people can’t see it doesn’t mean it’s not happening. It can be a very weird experience because it kind of, sort of tucks the rug out from under you.

If I have an ortho injury, let’s say, you know, my ankle, I’m less mobile, I can’t do that part of my day, but I can still watch a movie and enjoy it. I can have a conversation, I can study, I can learn. Versus with a concussion, it can creep into essentially every aspect of my life. Whether it’s my thoughts, my emotions, my sleep, my daily activities, my social and my recreational things. So it is a very, very different beast.

Clinic wise, with most insurances, we do not require a referral. There are some few exceptions but generally speaking, they don’t need a referral. We can always see self-referred patients as well. It is very OK to come to us directly. You don’t have to stop with your primary care or pediatrician first. Even in cases where we might not be the most appropriate, we always work very hard to get the patient connected to where they need to go.

Courtney Collen (Host):

Dr. Combs, a neuropsychologist and specialist in concussion care here at Sanford Health. Thank you so much for this insight and all that you do here at Sanford.

Dr. Josefine Combs:

Thank you.

Courtney Collen (Host):

And this was another episode of the Health and Wellness Podcast by Sanford Health. I’m Courtney Collen. Thanks for being here.

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The transition from postpartum to parenting

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 and postpartum depression 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 wellbeing with our Sanford Health experts.

In this episode, we are focusing on that special transition from postpartum to parenting. To help guide us along, I have two Sanford Health experts: Dr. Elizabeth Miller, who is a Sanford Women’s specialist in obstetrics and gynecology, as well as Dr. Jennifer Haggar, who specializes in pediatrics. Dr. Miller, Dr. Haggar. Welcome.

Dr. Miller and Dr. Haggar: Thanks for having us.

Courtney Collen (Host): Thanks for being here.

Before we dive into the main topic, I want to level set real quick. When we’re talking about that time period after baby, after delivery, we call that postpartum. What is postpartum?

Dr. Elizabeth Miller: I think that’s a good question because I think postpartum can refer to a few different periods. Postpartum can be immediately after delivery and the care that mom is getting at that time, but it can also be the care that mom needs and the transition her body goes through up to the first year after delivery.

Host: Yeah. Talk about what is happening in the body after you give birth.

Dr. Elizabeth Miller: It is one of the biggest transitions that the body ever goes through. There’s a huge change in hormones, right after delivery. Some of the biggest things that happen is that the uterus has to go from a much larger size, to a much smaller size by contracting down and controlling any extra bleeding after delivery, milk starts to come in. There’s just so much that the body goes through.

Host: And emotionally. This is an important time for mom and baby to really bond beyond just in utero. Talk about how important this time is and how special it is for parents and baby.

Dr. Elizabeth Miller: Yes, this bonding time is so important. I think it’s also important to recognize that some of these emotions can be even more heightened. And mood changes are really, really important to recognize and consider in this transition. It’s not uncommon with these hormonal changes and sleep deprivation, everything else that is going on, that there can be some postpartum blues, depression, anxiety, and we want to make sure that we’re supporting moms through that time. There’s also the really exciting bonding that happens during this time.

Here at Sanford, we really support skin-to-skin after delivery for mom and baby. If baby is doing well, comes out with good color, is crying, we want to get baby to mom as soon as possible, especially for that first golden hour of life. This is so important for temperature regulation for baby, for helping the milk come in. And that is one of the first things that we can do to support mom and baby.

Mom will then be seen by her delivering provider, the OB/GYN team, midwife, or family medicine team in the postpartum suites and make sure that she’s doing well from a bleeding perspective, feeding perspective, that all of her needs are being met. And then we traditionally see patients at a six-week postpartum visit. That being said, if mom has any extra needs, like needs a blood pressure check, needs an incision check, we can see them at one week or two weeks.

And then nationally, we’re really trying to advocate for postpartum care to be covered through the first year of life. And we recognize that it’s not just a six-week visit, you’re done and everything is fine. We can just move on from this whole pregnancy thing. Postpartum care really needs to extend further. The body is not done going through all the changes of pregnancy and postpartum at six weeks. This is especially true for our breastfeeding moms who are going to need continued support during this time but also to be checking on things like mood, making sure that pelvic floor health is being taken seriously. I just think that checking in once can be really hard. So we encourage our patients to come and see us more frequently as needed. So stay tuned as we’re working on that.

Host: Can you walk us through one of those postpartum checkups? What does that care look like for mom?

Dr. Elizabeth Miller: When mom comes in, the first thing that we ask about is how is she doing and how is baby doing. We do a mood assessment to screen for things like depression and anxiety. We ask about bleeding. We ask about feeding plans. And if there’s any difficulty with feeding, whether breastfeeding, pumping or working on bottle feeding, we talk about bleeding and see if that has started to normalize in those first six weeks.

We also review contraception plans. We want moms to feel very comfortable with their family planning and interpregnancy intervals. And so we talk extensively about options for that. And then we also update any routine wellness care that we need. Mom might be due for a Pap smear, for example. And then we set up the expectation for when we’re going to see mom next. We really want to see mom annually, but sooner if needed.

Host: Good to know. What other postpartum services are available for patients?

Dr. Elizabeth Miller: I think that we’re going to talk about lactation services in more detail, but just from a gynecologic perspective, there is a lot that happens to the body during the birth process. And pelvic floor health is really important. We have specially trained pelvic floor physical therapists who can help right after delivery. We usually start that about six weeks or after to help kind of build up and strengthen those muscles and start the repair process. And I think that most women could benefit from that. There is also a really cool service that is a return to running program for moms who have delivered and they use the alter G system to help moms be able to return to their training and running afterwards.

Host: Great to know, let’s switch gears here and talk about baby and bring in Dr. Haggar for this conversation. When baby is born, what happens next?

Dr. Jennifer Haggar: Well, I could hug Dr. Miller for delivering a healthy baby and putting them to mom’s chest because that’s the absolute best way for baby to begin their life. From bonding, from feeding and from connectedness here in the hospital, shortly after birth, baby’s going to be assessed by one of our very skilled nurses and then by their physician after that.

So, a pediatrician or family practice doctor will look baby over from head to toe and also just kind of dig and dive through pregnancy history through ultrasounds. Is there anything that came up during pregnancy that may impact baby’s health? Do we need to do additional screening or evaluation to just make sure baby’s starting out life on a really healthy path and track?

Baby is seen daily here in the hospital. And then we see babies really quickly after they leave the hospital. Typically, we’re seeing babies one, two or three days after hospital discharge, because so much changes in those first few days and it can be so completely overwhelming as a parent. And so we’re there to kind of help and support through all of that.

Host: What do some of those first appointments in the first week look like in the clinic?

Dr. Jennifer Haggar: I really encourage families to come in with a little bit of their own ideas and agenda because if they have anything they’re wondering about or worrying about, we’re going to address that first and foremost, because they usually come with the best questions and know what they need to know better than I do. After that, we’re going to go through how’s feeding, how is sleeping? How is pooping? How is peeing? How’s baby doing at all the things they have to do?

Baby will be looked over, head to toe. There’s a lot of physiologic changes for baby as they go from relying on the placenta to their own lungs and heart. And so we’re going to make sure that transition’s going well. And then we’re also there to assess mom’s mental health at each of those immediate visits. All the way up until six months of age, we’re going to assess moms, any postpartum depression, any postpartum anxiety. And a lot of times then I’m reaching out to her care provider to make sure that she’s getting the care she needs. Because we see them quite frequently in those first few months and can be a resource to help with that transition as well.

Host: So you talked about feeding being one of those things that you really care for new baby and mom of course. Talk about Sanford’s lactation and breastfeeding support for mom and baby.

Dr. Jennifer Haggar: From a lactation and breastfeeding support, one of the first things is just having families set their goals prior to delivery. What are they hoping for with feeding and making sure they have good information and resources on how to get set up for success. And then after delivery, we have fantastic support for them.

Our lactation specialists are here in the hospital and they’re going to meet with every family who hopes to breastfeed and just make sure that those first few days are going as well as possible. We’re going to assess things in the office and then we also have outpatient lactation support. So, they go in, they can have baby weight, they can feed and weigh baby again. And when you’re at awake for the fifth time and not sure if your baby’s getting anything and you can go in and see that they just drank two ounces, it just changes your whole perspective or if it’s not going as well and they’re fantastic at helping troubleshoot what might be the challenge and how we can overcome it.

Courtney Collen: Sure. Wonderful. Now we did talk about postpartum depression. How common is postpartum depression?

Dr. Elizabeth Miller: I think it’s really important to recognize that postpartum depression is much more common than I think people think. And that we talk about and it’s something that I bring up during our prenatal visits, especially to have the patient’s partner on board to also start looking for and screening for any of these changes at home. Some of the signs that we can see are that people are having trouble sleeping, they’re not finding as much joy in things that usually made them happy. They might not be concentrating as well, or they might feel guilty, worthless. You can have changes in your appetite and you can also just have depressed thoughts or thoughts about harming themselves or someone else like the baby.

Dr. Jennifer Haggar: That’s a fantastic description. And postpartum anxiety is probably just as common. And it’s hard not to worry. You get this precious human that you’re now in charge of taking care of and then, oh, don’t worry. But it’s really a question of, is it normal worries? And you, can you kind of think through and process through them or are those worries just running around and around in your head and it’s so hard to shut them off that you can’t sleep or that you can’t concentrate? Are they really the dominant thing that’s in your head? And even when you’re trying, you can’t shut those things off.

Host: Well, thank you for that information. It’s really good insight. And maybe talk about how important that collaboration is between the two of you. I mean, you’re not in the same clinic all the time, but you work together for mom and baby to make sure everyone’s healthy and cared for. Talk about that a little bit.

Dr. Jennifer Haggar: Healthy mom is going to help promote a healthy baby. And so one of the best things I can do, if I’m noticing any concerns, is make sure that I’m encouraging mom to take care of herself. Because you do put so much energy and effort into caring for a baby that you can kind of put yourself on the back burner. But that means sometimes in my clinic we’re taking mom’s blood pressure and sending it over or we’re reaching out and saying, Hey, this depression or anxiety screener looked abnormal. So I think it is important that your care team is a team because the health of mom affects baby and the health of baby affects mom.

Dr. Elizabeth Miller: I just love Dr. Haggar’s point that she’s seeing these patients more frequently, her patients more frequently in clinic. And so if there’s anything that’s picked up about mom and then she lets us know, that just makes our job much easier and we can connect with mom right away. And I just wanted to point out too: a lot of women are concerned about the stigma of mood changes after delivery, about postpartum depression or postpartum anxiety. And I just hope that we can really normalize that conversation and let them know that we have really good resources available. It’s not always about an antidepressant medication. It might be meeting with one of our integrative health therapists. Medication might be needed. It might just be checking in more frequently, but we want to make sure that everyone is getting the help that they need.

Host: Well, thank you for sharing that. When we talk about this transition from postpartum to parenting, do you have any tips for staying well, staying healthy? We, you know, what are some tips that you have?

Dr. Jennifer Haggar: Boundaries.

Just for the family, knowing that this is a time that they will be exhausted, that mom needs to heal. I can’t think of another time where you go through a medical change like delivery and you’re not told to rest. And so moms go through this big change, whether it’s a C-section or vaginal delivery and then they go home and we tell them, you have to wake up every two to three hours and feed baby. That’s exhausting. And so knowing that your primary goal is to care for yourself and care for your baby and eat and shower and maybe go for a walk. The other stuff can wait. And just not putting too much on your plate when really you have this fantastic and joyful, hopefully joyful time. So boundaries, that’s my one word.

Dr. Elizabeth Miller: I think that’s excellent advice.

Host: Dr. Haggar, Dr. Miller, thank you so much for your insight and expertise in this area. I think it’s such a special transition and it’s so great to have both of your insights. Thanks to both of you.

Dr. Miller and Dr. Haggar: Thank you! Thanks for having us.

Host: I’m Courtney Collen. Thanks for being here.

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Virtual care options help reach more rural patients

Alan Helgeson (Host): 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 on virtual care. Our guest is Brad Schipper, Sanford Health President of Virtual Care. Our moderator is Dr. Luis Garcia, President of Sanford Clinics.

Dr. Luis Garcia (Moderator): Well, Brad, how are you doing today? Great to have you here.

Brad Schipper (Guest): Well, thanks for inviting me. I’m doing well.

Dr. Luis Garcia: And thanks for joining us for this podcast. I’m excited to discuss this topic. And I, if it’s OK with you, I’ll just get to the meat of the questions. Brad, Sanford Health recently announced a $350 million virtual care initiative, and that included breaking ground of a virtual care center. So can you tell me a little bit about this virtual initiative and what does it mean for Sanford and, and why a building for a virtual initiative?

Brad Schipper: Yeah, you bet. Well, first of all, we’re so very fortunate for the generosity of Denny Sanford. And $350 million will absolutely help us reimagine how we deliver care for rural and underserved areas. And also areas in inner cities or more on reservations or everywhere. Frankly, the reason for the building is really multifaceted.

We need some sort of flagship command center to help drive all the activities that we do within virtual health care. And that doesn’t imply that all virtual care will only be done from this building. We’re doing it across our entire footprint. We’re doing it across the U.S. We’re doing it across internationally as well, as you’re aware. But the building helps to house a lot of the technological advancements in that backbone and infrastructure for the future of what we’ll be doing.

It also, importantly, houses our educational institute where we’ll train our future caregivers and our innovation center, where we’ll be able to vet out some of the new technologies. So no surprise to you as a practicing provider yourself, some of this still has to be done in person face-to-face. So we’ll have physicians and clinicians going there in person to provide care. Some will do it from their home, but we still do need that building for the backbone and for the education, the infrastructure. And, and frankly, we’ve been very successful in most of our markets that we’re out of space. So we do need additional space for that reason as well.

Dr. Luis Garcia: Yeah, thank you for that. I, I think for that clarification, Brad, and I think you used the word reimagine. How do we do this? And clearly these are not new activities for our clinicians and for our patients. We have been using some of these technologies in Sanford for, for quite a bit of time. But what do you feel are the greatest opportunities with this new reimagining or this new injection of resources to these strategies?

Brad Schipper: Well, there are multiple opportunities, but I do appreciate you pointing out the fact that we’ve been in virtual health care for a long time. We’ve already saved patients 20 million miles of travel, and we’ve had dedicated clinicians and physicians and administration folks, and information technology professionals that have just been extraordinary in doing this work. So first I want to point out that we’ve done incredible work, and it isn’t that we’re just starting.

There’s been people that have been very dedicated to this, the teams of individuals and what we really owe the ability to do this initiative to is those folks who have been doing all this work because they have proven that we have what it takes to be able to really transform health care as it relates to the greatest opportunities.

There are so many – a couple I’d point out is in the inpatient world, for example, if you’re in a small outlying facility and you have a stroke and you need to connect with some additional specialists, you’re able to do that virtually so that if you are a provider in one of those areas, or if you are a patient, going to those ERs distance is still a factor, but it’s a lot less of a factor because you’re connecting virtually with specialists that can help some of your treatment in your care.

If you can stay locally, where 40-some percent of our transfers do stay locally now because of virtual care, which is pretty great for the community and for the person and the care providers and the families. And if you do have to be transferred, then we have a better line of sight to what’s going on and what you need for care when you get to the new facility.

On the outpatient setting, there’s numerous examples, whether it be respiratory therapists out of Aberdeen helping the entire health system, or if it’s Dr. Jim Wallace and his team that’s helping with pediatric asthma around the whole enterprise. Fargo has people that are helping right now with gastroenterology. We have people in Bismarck which are helping with nephrology. So we have providers across our entire footprint that are providing services and allowing a patient to stay at home or to not have to take off work or to travel so many distances.

Or imagine if you’re a nursing home resident and you’re getting bundled up in the cold weather and a nursing home van to go see a physician, you can do that now virtually, and we make sure that it’s the right care at the right place at the right time. So there’s just so many opportunities now and, and it’s endless as it relates to the future. I think we’re just touching on things that can be done as it relates to the technology and the care processes that we have.

Dr. Luis Garcia: Brad, first of all, thank you for giving credit to those that have been pioneers in the use of these technologies. And, and just like the examples that you outlined, I mean, I heard about an example where a lady had to drive three hours for a routine prenatal care, and I think what we don’t take into account is what does it mean for a mother of two or three to have to pay day care and pay for gas and lose a whole day and not go to work just for a prenatal visit. You know, that can be done virtually. So I think those are some of those little things that sometimes we lose sight of.

But you know, to that point, these things have made Sanford the most-trusted health care system in our regions, in all the region regions that we served, said by our populations, by our communities, and a lot of that trust comes from the relationships between patients and physicians or clinicians, nurses, caregivers. Some believe that that relationship cannot be developed unless you are in a face to face or an in-person setting. What will it mean for our patients to have these options and still be able to develop these relationships?

Brad Schipper: Well, that’s the key, right? There’s nothing more sacred than somebody who entrusts their most important asset, which is their health or their life, or the life or the health of a loved one with us. So the key thing that we’re trying to do with virtual health care is making sure that we keep that important bond between the patient and the caregiver.

And that’s through education of how the technology works, through research to make sure that what we’re doing is safe and it’s effective. Because ultimately, as you know, what caregivers want to do is they want to satisfy a need. They want to try to heal and provide comfort and help for an individual. And what an individual wants is they want to be able to trust in that recommended plan of care or an ability to try to get to a state of health of whatever that may be.

So we do work with all of our providers, we work with our patients, and we try to educate on both sides what makes sense. Some things will not make sense for virtual care, but many things will. And there are multiple ways that we can build relationships like we used to do face to face via the use of our technology. But the one thing we’re not gonna take away is the personal nature of that interaction. We need to make sure that that’s still front and center for what we’re trying to accomplish.

Dr. Luis Garcia: Yeah, I appreciate that. And, and I think you highlight the importance that it, that this has for patients, but also for our clinicians, right? And the importance of that relationship. So what do you think this means for our physicians, nurses, and what kind of satisfaction does interacting with patients in this way brings to them?

Brad Schipper: Yeah. What we hope it means, and what we’re hearing that it does mean is it allows our providers of the care the same benefits, frankly, as the consumers of the care. Meaning it’s not overly efficient and it can be cumbersome and challenging for a provider to be on the road for three to four hours to see some patients or to be away from their family or to experience some burnout from the challenges of our geography.

So hopefully through the use of some of our intelligence built into some of our platforms that we have here and our technologies, it allows them to work smarter and not harder. It allows them to maybe stay off the road so that rather than driving in a car three to four to five hours or in a plane, they have an opportunity to do some other work or to see additional patients that are in need.

So we’re really trying to set this up in a way that can benefit our caregivers, just like it benefits those who receive our care. And those are just a couple of the examples of where this can really help for that type of care.

Dr. Luis Garcia: Thank you once again for recognizing that, Brad, because I think that it’s very clear that we’re clinicians continuing to be fully committed to our patients, and at times our own clinicians are also driving or transporting themselves long distances to provide that care. And this would certainly be an accommodating factor for them. So thanks, thanks for recognizing and pointing that out.

Brad Schipper: The other thing I’d point out, like I had done earlier, and like you’ve, so, like you’ve pointed out, is the providers have done so much as well. So I would hate for anybody to misinterpret to think, Wow, now we’re gonna try to be really convenient and patient-centric. We have been convenient, we have been patient-centric, but we’re trying to do it different, right?

We’re reimagining that, but there’s nothing more patient-centric than a provider who works a long day, gets in a plane, works even a longer day, drives in a car, gets back, does their charts, tries to have a professional and a personal life at the same time. So, you know, I would hate for anybody to lose sight of that. We use words like we want to be more patient centric, or resident centric, and by no means would I ever want somebody to misinterpret that people haven’t done what’s right. It’s just a way to do that maybe a little bit differently.

Dr. Luis Garcia: I appreciate that thought, Brad. You know, Brad, if we look at some statistics, national statistics we know that about 20% of Americans live in rural areas and pretty much all our footprint is rural by definition, but yet fewer than 10% of physicians practice in rural communities. So how do you feel that these virtual strategies and this virtual care center will support our own strategy to develop our own? You know, we rely a lot on developing our own workforce and our own physicians to satisfy that shortage and that need. So how do you feel this center will support that educational piece?

Brad Schipper: No different than in our personal lives, right? We want a sense of community, we want a sense of belonging, we want support. What I think the virtual initiative can help do for our caregivers and our physicians and other providers, is they don’t have to feel like they’re on an island of one anymore. They’re connected to a huge network of other caregivers and providers within our footprint in a real time way and in a meaningful way.

It can get very lonely if you’re a subspecialty of one or a family medicine physician, for example, of one or a nurse practitioner of one. This can take away some of that feeling. But, as importantly, it can provide some of that depth and breadth that can help them to feel comfortable and to be able to go to a site where they can have partners maybe a little bit differently, maybe their virtual partners, but it’s different than it was even five, 10 years ago when how that may feel.

So I think that can help us to recruit to some of these areas. I think by investing in the education and training to make people comfortable with the technology and to help our people and allow them to innovate some of this new technology and software and hardware and wearables and everything else, I think it’s super exciting for people to be part of something so different and so special. I know it was for me, that’s why I came back. Really, this is a once in a lifetime, a once in a career opportunity to really do something differently.

And I think that’s why we had such a successful summit, to be honest. We had people that came here that it wasn’t just out of self-interest, our self-promotion, it was truly because they saw that we have the potential to do something very different.

Dr. Luis Garcia: You know, Brad, you talk about moments of loneliness and moments of uncertainty, and I think the pandemic in the last couple of years brought enough of those moments to all of us, and it was just fascinating to see to the point that you’re making how our clinicians market to market or location to location collaborated virtually to really define the treatment of a disease that we had very little knowledge about. And, we all became students and teachers and researchers in a heartbeat. And the use of technology certainly facilitated all of that. So the pandemic accelerated a lot of this and the conversations have been elevated. How is Sanford right now training our existing providers to interact more with our patients virtually?

Brad Schipper: Sure. We’re doing that today as it relates to some of our medical residencies, our fellowships, or working with our medical schools and our universities. So, that’s occurring today as it relates to the things we’re doing in the future. That’s what we’re going to do a lot more of with the virtual care center.

And it can be done virtually as well as in that center, but we will be training the future generations on, on how to utilize our technology and the best practices of that so that people are comfortable, you know, we call it website manner, and it seems intuitive, but it’s not always intuitive.

How you experience that care on the other end of the video is different than face to face. So how you’re talking to somebody, if you’re multitasking, how you’re using the monitors, et cetera, are important to that, that sacred relationship that we can have. So that’s things we continue to work on, and it’s what we learned through the pandemic that, you know, you have some, some lessons learned and, and we did an extraordinarily good job, and most things were, were a great success. The silver lining was, it really pushed forward virtual health care. But one thing we did learn is you can’t just assume everybody’s comfortable using all this technology, whether they’re receiving the care or providing the care.

Dr. Luis Garcia: So to that point, you know, I mean, I talk to my 14 year old about technology and they embrace it like that, right? <Laugh> But you get an old fart like me <laugh>, and … they say, eh, I don’t know if I believe what you’re saying. So, you know, what do you tell those providers, clinicians, nurses who are hesitant about this virtual care?

Brad Schipper: Yeah, so I think the main thing, and it’s not a sell and it’s not a tell, the main thing is we are going to research and make sure that we are driven by outcomes of what’s best for the patient or the resident. And when that happens, people buy in really fast.

This isn’t about a quick return on investment or this isn’t about the new gimmick or the flashy thing. This is truly about impacting the lives of the people that we serve. And when you do that, people get a lot of buy in and they understand. And then when you parlay that with innovation and with education and with data and research it just makes it a lot easier. And, the reality of it is, although like you, my two daughters are much more advanced in the comfort level with all the new technologies, our market research is suggesting that people, regardless of age group, are starting to embrace technology in ways different than they ever did, somewhat facilitated by the pandemic.

And my bad joke I used just today in a meeting frankly, was normally I want to know the confidence intervals and what’s the margin of error. But the reality of it is, I had a sample size one, and it’s my father, he now has a smartphone and he asked about virtual care. So the world has changed.

Dr. Luis Garcia: <Laugh>. That’s, I agree with you. I communicate with my 82-year-old mother through WhatsApp. So that’s really cool. We talk a little bit about the processes and about the strategy, but let’s talk a little bit about the structure of this virtual care initiative and clinics. I heard that that we’re gonna have a concept of satellite clinics in, in very rural areas to provide care using virtual technology. Can you speak a little bit about what’s the purpose of that?

Brad Schipper: Yeah, this is super exciting. We’re trying to figure out is there a way to provide care in a community that otherwise does not have it, or a community that may lose it? We have a lot of interest in that.

So we’re trying to look around our entire footprint to see if there are places without a hospital, without a clinic, without a lab, without a pharmacy that somebody now has to travel for care. And if there is, are we able to provide a clinic staffed with maybe an RN or a nurse practitioner that can do some lab work in the clinic, some imaging work, maybe some pharmacy work, and connect virtually with multiple care providers to try to keep that care as close to home as possible?

So supplementing maybe just off your smartphone, this is yet another way to keep that care close. So we’re actively right now working with certain communities and economic development areas and other things to see where we could pilot these to see what ultimately may make sense.

And, we have right now interest across our entire footprint. I don’t have anything to share today of where the first one may or may not be, but we are excited about this concept to see what that means, what it looks like and what it could ultimately look like down the road.

But just imagine again, if you’re a person in a small community, there’s no health care, you work late, you can’t access anything. Maybe you do it via your smartphone. Maybe now you can go to one of these virtual clinics and you don’t have to take a couple days off work and drive into the city. And I think we underestimate, right, the stress of even just driving into some of our bigger cities if you’re not used to that from some of our rural environments. So that’s what we’re trying to work on and ultimately help the outcomes of the folks in those communities, because sometimes they do at a greater rate, bypass some of the preventative screenings and services because it’s just not convenient for ’em.

So maybe there’s an opportunity to do some of that as well. And, and we’re excited about trying to pilot some of these concepts and we just haven’t quite identified where it’s going to be yet. But, it’s gonna be fun. We got the right system to do it. We’re a provider with physicians. We have bricks and mortar of hospitals, clinics and nursing homes. We have a health plan that provides insurance. We have a research arm that looks at how we’re doing. And I think partnering all that integrated system, the integrated system pieces we have with, with some of these satellite clinics could truly prove to be revolutionary in what happens in some of our underserved areas down the road.

Dr. Luis Garcia: You know, and I appreciate the thoughtful concept of those satellite clinics, but, you know, Brad, I hear that as of 2021, an estimated 135,000 people, it’s equivalent to one in six South Dakotans, for example, and similar, you know, similar ratio in North Dakota, do not have adequate broadband access. So how do you navigate those challenges when you’re trying to bring services, much needed services to very rural communities, but there are external factors that do not depend specifically on Sanford?

Brad Schipper: Yeah, it, it is absolutely a challenge, and that’s why we’re trying to look at some public and private partnerships to be able to bring some of those solutions to those communities. We do believe as we invest in those communities, it will spur other investments in those communities, which can help with broadband. But without a public private partnership and, and working with multiple stakeholders, it will be difficult. At worst case, maybe we can put it in one of these satellite clinics, for example, that has greater connectivity than otherwise people would have within their homes. But ultimately we want to try to deliver it so that they have the, the connectivity that, that we, we all appreciate in more urban areas.

Dr. Luis Garcia: That makes sense. And I think that it’s also a reflection of what Sanford has been historically, right? It’s about relationships, it’s about partnerships and the tide rises for everybody. So I appreciate that comment.

You talk a little bit about your relationship with research, with our health plan, with innovation, and it is my understanding that the virtual care center will also house some research on innovation projects. Can you talk to me a little bit about that?

Brad Schipper: Our vision for the innovation center is really a place where people can think about what needs to be done. They can create what needs to be done, they can pilot and test in a safe environment. Does that ultimately achieve what we are trying to accomplish?

So we have those spaces within this facility that are designed. In addition to that, we will have different vendors or different startups that can have space within the facility to try to come in and try to provide solutions for what we’re struggling to accomplish. And some of these startups, as you know, may be in their garage, so they really don’t have space. Other ones don’t need the space, but, but we’re truly trying to have a space where we can look at software, hardware, and other technological advancements to make sure that we can do absolutely what’s the most convenient and world class for all of our patients.

So that’s part of this. And then it’s partnered with our education center and it’s partnered with our care delivery side. And that’s really the differentiator here. There’s a lot of people getting into this space, but very few are as intentional as we are with combining innovation and research with our education and with our care delivery and doing it as broadly as we are from birth to death. We’re not just gonna pick out one specialty or our one item. We’re trying to do it across all of our service lines and all of our age groups. And it does help that we can do that one because of, we’re an integrated health system and two because of Denny’s generosity, but we’re gonna do it anyway cuz it’s the right thing to do, and we’re gonna be here for life. We’re not gonna jump into this and jump out of this. This is what we do.

Dr. Luis Garcia: Yeah. I appreciate your thoughts very much. Brad and I tell you that, that reflects a lot of the nature of Sanford too. Sanford has been my only employer. And sometimes somebody asks me, How, how would you define Sanford? And I just say, We just hate this status quo, <laugh>, we just don’t like it. Correct. You know, and I think that that defines part of our nature.

And tapping a little bit on that, you know, even though we’re talking about these virtual initiatives, we have done more than 600,000 virtual care consults and visits over the last few years. And as innovators and as leaders in an industry, you know, there’s things that go bad and there’s things that go well. Can you share with us some of those things that have been learning opportunities for us where something just didn’t go as well as we expected, or that we could have done it differently?

Brad Schipper: Sure. I think one of the bigger learnings, and it’s part of having the educational institute in such a laser focus on that is, is we probably at times have underestimated the amount of ramp up or training or education it takes to provide some of these services virtually, whether it be for the patient to try to access these services or whether it be for the care providers to deliver these services. So I can’t say that there’s any one service that we went, Wow, we really shouldn’t have done that. But there were some services where I think if we just spent a little more time on the front end, and had the luxury of that, now the pandemic didn’t afford us all that luxury as we know. But everything we provided, fortunately, we feel was safe and effective, but we think we could even make it a better experience for the consumer of the service or the provider of the service with additional education.

The other thing that gets a little tricky in this, and one of the things that we learned is that, you know, payers and others, insurers treat virtual differently. And it’s really kind of tricky to figure out, well, who’s gonna cover this? Well, only if it’s in your home. Nope. Only if it’s in the clinic. Nope. Only if it’s for this level of service. Only if you’re this age. And those things get really, really kind of complicated to figure out. So we’re doing a lot of advocacy there with data and research to see what makes sense.

And again, we’re really fortunate that we have a health plan, so we sit side by side with a health insurer, us, that we can talk and say what makes sense. And ultimately what we’re going to do is what makes sense. This is, again, not gonna just be driven on all those payer provider discussions that I just said, but we’ll need to be cognizant of them so that we’re aware of how that all works. But if it makes sense at Sanford, we have a history of just doing it.

Dr. Luis Garcia: That speaks loudly about the commitment that we have with our communities, right? And the purpose of our mission where we’re gonna give you or provide care to you, and we’ll just figure out how do we get reimbursed or all those collaterals. So I think that speaks loudly about our commitment.

What does success look like for this center Brad? And this is gonna be my last question, I promise you.

Brad Schipper: <laugh> All right. I think a lot of people would say success is that we open the building on time and we get that built. And a lot of people would say, we maybe have an advancement in a technology that nobody has. And a lot of people may say that, you know, we have great patient or resident satisfaction, or we help some of our recruitment. Those are all incredible measures of success that we would want to celebrate and recognize. For me, it’s more simplistic than that. Did we ultimately improve the health and well-being in the human condition of those that we’re interacting with? We have an amazing privilege and amazing obligation and a challenge to care for those who are in need. So ultimately, if that doesn’t change or we don’t move the needle on that, I will not say that we have been successful in this arena despite the other things.

It’s the ultimate way that we’ll know if we’re successful, but we’re gonna have micro successes along the way. But I think you and I would both agree that those are exciting to celebrate, but if we can really improve the human condition, that’s a game changer.

Dr. Luis Garcia: That’s well said, Brad, and I said it was gonna be my last question, but I lied. This is my last question, <laugh>. OK. You’re a very accomplished professional. You’ve seen a lot of things in your life. What excites you personally about this opportunity?

Brad Schipper: Well, personally, I think it’s rare that you can have an opportunity to have such a global impact on health care that we have. And personally, I believe in it. Professionally, I believe in it. Health care is ripe for change and we need to change. And I just couldn’t be more excited to help be part of a team that has done so much work already and will do so much more work and have the opportunity to, to truly shape health care. And I, I, I just can’t overstate that enough. I mean, that gets me up and gets me excited every single morning that, like I said earlier, I do believe it’s a once in a lifetime and a once in a career opportunity. And I’m just fired up for it. It’s incredible.

Dr. Luis Garcia: I agree with you, Brad, and thank you. It is incredible. And let me just offer, if you allow me my gratitude to the leaders in Sanford that had this vision, and certainly to have the vision to include you in this project because you are the right person for that. So thank you, thank you for joining us on that journey.

My deep gratitude to our benefactors specifically Denny Sanford, who is making this possible, my most sincere gratitude to our clinicians. We have been talking about the tremendous amount of work that they execute every day. And this is just one more way in which they will satisfy that commitment.

And certainly the deepest of the gratitudes to our patients for considering us the most trusted system and continue to come back to us in their times of greatest need. And you’ve said it, you said it, it is a privilege, but at the same time, it’s an obligation and we love the privilege and we embrace that obligation. And this is just one more example in which Sanford will succeed. So thank you very much for joining me today.

Brad Schipper: Thank you so much for your time your kind words and your questions.

Alan Helgeson (Host): 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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