Welcome to Season Four of This Rural Mission. We're excited to connect with you again and talk more about the wonderful things that rural communities have to offer and the impact our leadership and rural medicine students and graduates are making for these communities. I'm your host, Julia Terhune and let's get started.

Last season, we highlighted how COVID-19 affected residency, and I thought it might be time to talk about residency and what we as a college have been doing to impact the rural workforce.

Now residency, well medical education as a whole, was a totally foreign concept to me before I started with this job. In fact, that foreign understanding is actually something we're going to talk about again this season. Why am I spending so much time talking about this? Well, I think that if we all understood the complexity of training that our doctors undergo, we might better understand the necessity and the resource that they are, especially for our rural communities. So here it goes, here is my brief recap of how doctors are trained. Four years of undergraduate work, specifically in the sciences, test number one, the Medical College Admission Test, four years of medical school, two board tests, residency with board exams throughout their entire training, three years to seven years of residency, depending on what field they go into, plus possibly fellowships. No, they don't make a whole lot of money during this residency. No, they aren't done with their training. No, they haven't learned everything. Yes. They still are under the jurisdiction of other doctors. Yep. They're still learning. And yeah, it's a lot of work.

And all of this getting into undergrad, getting into medical school, and getting into residency is earned. It's not a given. You have to have the grades, the volunteering, the research, the personality, the drive, and then be accepted by the programs that you are applying to. It's a big deal. Now it's also a big deal to have a residency in a rural hospital. That's because residencies are sponsored by universities and housed in hospitals that can provide the number of faculty, aka other doctors, and clinical patients to help students finish their training, which means they need to have a lot of both of those things.

In Michigan, we have some rural residencies in family medicine. They are located in Marquette and Traverse City primarily. Midland also has a residency program, which at its start was rural, but the county's population has increased to turn Midland county urban. But that limitation of rural residency is changing, both in geography and in specialty. This is all thanks to the fantastic work of our legislators, medical schools, and hospital partners throughout the state. Thanks to a program called MIDOCs, M-I-D-O-C-S, more primary care doctors are being trained in rural and underserved urban areas than ever before. So let's hear about how this program came to be from Jerry Kooiman, our Dean of External Relations at MSU College of Human Medicine.

Yeah, so it goes back probably eight years ago, a number of medical school, government affairs folks got together and started talking about graduate medical education and the need for residency's really to be in parts of the state that we weren't training residents now, at that time. And in areas of residency focus that are lacking in the state of Michigan, in particular primary care. And so we began meeting, we met with legislators and began saying what if, and so the legislature gave us some planning money in one of the budget years. And we began to put together, out of research, our research in terms of what are the needs out there, just to make sure that we were data-driven, where are the parts of the state rural, urban, across the state and what are those disciplines that really are shortage areas for health professions. In the UP, psychiatry was their number one issue. In Traverse City in Northern Michigan psychiatry was their number one issue.

And then with Alpena it was a matter of, they had been wanting to start family medicine in Alpena for some time from Mid-Michigan health and so that became their focus area. So it's evolved the four medical schools are Central Michigan University, Western Michigan University, Wayne State University, and Michigan State University College of Human Medicine. And so, we presented that back to the legislature and to the budget office at the state and asked for $5 million from the state. $5 million would be contributed by the medical schools. And then we would apply for a two to one match from the Centers for Medicaid and Medicare and from the federal government. And so the idea is we would have $20 million, and that would be enough to fund residents from each of the colleges and medical schools for their entire cohort. So if someone's going into psychiatry, that $20 million would cover psychiatry for all four years for that cohort. Because we didn't want to leave it up to the legislature each year with the possibility that they didn't provide the funding we'd need, be liable for the full cost of that training.

Well, the CMS came in with a one to one match, and so we had to downsize the program. And so we're at five residents per medical school per year. We're actually asking the legislature for $6.4 million in this current budget process to get us up to six residents per institution. So total of 24 residents two of our residents are going into psychiatry in the UP. Two of our residents are going into psychiatry in Northern Michigan, and then one resident that's paid for by MIDOCs is going to Alpena through Mid-Michigan Health and Family Medicine. If the legislature gets us to $6.4 million in this coming budget year, we will be paying for two residents in Alpena. So that's the goal. We want to be to a point where it's sort of level funding and not ups and downs, which we've been at for the last four years.

If we can recruit medical school students from these areas of the state where there's a shortage, get them to go to our medical school and have them train in, say Midland or Marquette or Alpena, and then our own residency program, which is going to train them as residents in those areas. You're just adding up all of the reasons for a resident to eventually practice in that area. We're just trying to add reasons for them to stay in. And I think this is, it's building our own. It's much cheaper to invest in this at the front end than to have to pay huge signing bonuses, to get them to go to Alpena or to Marquette or to Traverse City, even. So that's why we're in it. I'm really excited that Michigan State, a number of our own students have chosen this program as a way to do their residency program, because that's really the intent.

So you heard it, this program is really in line with what our college is doing as a whole and what our college is all about. Not to mention it's meeting the mission of our leadership and rural medicine programs. And our leadership in rural medicine programs have influenced some of the direction of this program. We are all working together to make the MIDOCs program a success. In fact, our first psychiatric rural MIDOC students in Marquette started an LRM graduate. And this year we have a student piloting the family medicine MIDOCs program at Mid-Michigan Health Alpena through the Midland Family Medicine residency. Not only that, but that student piloting the program is a Leadership in Rural Medicine graduate and tipped into the Midland program, a program I'll explain, just a little bit. David Westfall is his name, Dr. David Westfall. And he is a pretty remarkable person. So let's get a bit of his mission and why he's doing what he's doing.

But you stayed true to your goals and your mission throughout medical school, now in residency, you are a tenacious human David, good job.

That may be even more so than you realize. I have wanted to go to med school since I was in middle school. So the idea that I didn't necessarily get accepted into medical school my first time around wasn't something that was going to deter me. A lot of my family, friends are all sort of in awe that I have gotten to this point where I'm graduating from med school now, because I never gave up on any of that. I applied for medical school five times and during med school, I struggled with my prep for step one, a little bit. So I ended up taking an extra year there as well, but none of that has... It's been a struggle, but it's nothing that I've seen as insurmountable. And I've just taken the challenge and found the best way to address it.

What's kept you motivated?

So my original aspirations for going to med school, were when I was growing up, I lived in a rural area where there weren't enough physicians. And when your parents are filling out documents for school, they usually ask who your primary care provider is and most of my friends just put closest in that spot because they didn't have an actual primary care provider. A couple of them did, but the number of physicians was nowhere near enough to meet the needs of the community, so that was really something that I always wanted to address. And it was a big part of why I chose primary care to go into as well as my background in public health. But seeing that need was something that I always wanted to help with. And I thought that when I didn't get into med school, okay, I'm going to continue to do that.

But maybe this public health thing might be another avenue that I can help address those things. And I found that when I graduated from my Master's in Public Health. It's a lot harder to get into the realm where you would be helpful in those sorts of situations. Getting into administrative positions, you need so much experience that you can't get without experience. So it just makes it a lot more challenging. And I started doing the sanitarian thing as a way of gaining some of that experience, but it wasn't as fulfilling as I wanted it to be. And it wasn't a bad job, but it wasn't what I wanted to do with my life. So that additionally just spurred me to continue reapplying for med school and get the goal that I had set out for initially.

And what drew you to the MIDOCs program in Alpena?

That was actually you, Julia. You told me about it at some point, and I didn't know anything about it at that point. So I started looking into it and it was like, well, this is what I want to do anyways. Always been interested in working in rural northern Michigan. And when I found out about the program is everything just sort of fell into place. So after I met with Dr. Hill, it just sort of felt like the right fit. Since then, I've gotten to know the residents a lot, and it's a very cooperative feel to it, working on their inpatient service over my fourth year, which is one of the requirements of TIP. I got to interact with a lot of the residents, the current residents, and they all worked very well together. There was a very sort of relaxed, open environment between them and things just went very smoothly. So that just sort of solidified my decision that this is where I wanted to be. So, I mean, there's incentives for the program that were enticing, but like I said, they all are just kind of the cherry on top. It's what I wanted to do anyway, working in a rural area, moving further north has always been my goal. The fact that there's a loan reimbursement associated with it is just sort of a bonus.

For more than six years. I have had the pleasure of getting to know and work with the Midland Residency Program and the staff. They have been a tremendous partner in our clinical medical education goals at the Midland Regional Campus. And in the past six years have matched seven of our Midland Rural Community Health graduates into their program. Six of those students have entered the residency through the TIP program. The TIP program stands for The integrated Program. It's something that students apply for in their third year of medical school. It's a partnership between our rural residencies and our medical schools. Students apply knowing that they want to be a family medicine doctor and that they want to work with that specific residency. If accepted to the program, students get a chance to work with faculty at the residency and do rotations there throughout their last year of medical school.

They then agree to rank that residency first during match match. Match is how you get a residency, going back to that discussion about applying and being accepted. Plus there is a financial incentive, which is always nice. Now the MIDOCs program is great, but like David said, it's not just these incentives that bring students to the residency. It's the people. People like Dr. Hill, Dr. Hill is the director of the Midland Residency Program and her colleague, Denise Sheldon is the coordinator. They work really hard to make the residency the place it is today, Dr. Hill is also a graduate of this residency. And like many students, she wasn't necessarily going to stay in this small town, but I think we won her over.

Yeah. I say this to applicants, I feel and I recognize that I am biased about this place. I think that Family Medicine is such an incredible opportunity and having gone to medical school on the east coast and come out here, the training in general in the Midwest is so good. And there are so many good opportunities, but I really do think it's, a lot of times it's where do you fit in? Where do you feel like these continue my people? And so we just would like the opportunity for people to take a look and say, wow, what we do during interviewing is no different than what we do any other time of year. We all look the same. I think we all act the same. And so I think when people feel just that genuineness within the group.

People ask me sometimes what's the story? How did you get here? Why are you still here? I saw in the pamphlet or the booklet that you've been here a long time. And it's so funny, I still remember Bob Lashant, he was a Program Director at the time, kind of making me eat crow after that for so many years and say, tell the applicants how you weren't going to stay and then you stayed. And all he meant by that, he wanted, it was a positive thing, but I came here and was at my last interview and was like, yeah, okay. My husband had a job opportunity. I'll just tell him I don't like it. And Bob, again, the world is such a small place, but Bill Wadland, who'd been the Department Chair for a long time, was my advisor at the University of Vermont when I was in medical school and I had gone to him and I said, "So, hey my husband has a job offer in this town. What do you know about this place?" And he goes, "You need to go look at that place." Okay. And I came in here and I remember thinking, this is where I'm supposed to be. These people are learning a ton. They are smart. They've got a ton of good opportunities. They treat each other well. And that's what it was like for me that whole time.

I mean, did we work hard? We did. We worked really hard, but to be able to get that training and do it with people that cared for you and you cared for them, it matters because this is kind of your second family. And it frankly is your first family, because you work a lot. So you get to see your other family some, but to have that kind of support, I think is critical.

That is really cool. And Dr. Wadland now has an endowment that he put in the name of our program and-

Isn't that crazy.

Come full circle. That's so cool.

I know, it's so fun when that... You're like, "Hey, I know you, how did this happen that I ended up here." So yeah. I think he got a big kick out of that when I showed up at one of the first MSU meetings. Like, "Oh, there's a student that I had when I was at Vermont." It's like us seeing our residents places or them coming back and finding their picture on the wall with all the photos of the graduates. And that part is so much fun. And to have them come in and smile about the experience that they had here. That's been a newer idea of mine in the last few years when I've interviewed, I've said to people, "I think sometimes we look at residency, you're kind of towards the end of your training, you've been in school for a really long time. And you're like, okay, I need to, I need to survive this three years, but you really don't. You need to thrive in those years." You get to do this one time and it needs to be one of these life experiences that is challenging, but so good. And when you have people around you and it's a happy place, even though it's a challenging place and you work hard, it makes all the difference in your ability to thrive and not just survive.

I think I've had residents say to me over the years, "I had no idea. I thought I was going to come here and see kind of regular stuff. I'd see some pneumonias and some heart failure and broken legs. I can't believe all the variety, all the pathology and strange things." And so I said, "Really wherever there's patients, there are all those things." There are a lot of patients who come a long way to see us. And I think when they get out of town or have a day off and drive, realize how far it is to go to Gladwin or how far it is... And some people have been patients here and then moved and then still come back to see us. But it's challenging to say, "Hey, I want you to come back," Well I don't have a car or I live 30 miles away and we don't have a working car or can't they take dial-a-ride, not there, because it's not within the city limits or you can't take County Connection because it's not in the county.

So there's a lot of eye opening experiences for residents about that, for sure. I think some of them have had different experiences, poverty at a different level, in an inner city that we don't see necessarily those things, but we see different things. I know that residents don't realize how invested we are in them and this job. For those of us who do it, I mean, you care about the residents, you care about their learning, you care about their experience here.

So what's the goal of all of this. Well, Jerry has put it pretty simply-

You know, it's not one dimensional. It provides I think, significant value. And then of course the value to the community, you're building a physician base that would not have developed otherwise. Training residents in the UP, and [inaudible 00:24:19], in Traverse City for training family medicine residents, in Alpena where they've never trained before. And so now you're also building a faculty in those communities who can be utilized for undergraduate medical education. And it's a win, win, win. I think from the standpoint of the medical school, the standpoint of the resident, they benefit in terms of their training, being a rural site, or a underserved site, which is what they were interested in, they get a stipend or a loan forgiveness. And in quite frankly, if they do well in their residency, they've got a job coming out of the residency.

Thank you, Dr. Westfall, Dr. Hill, Jerry Kooiman, and Denise Sheldon for speaking with all of us today. I'm so grateful that you provided all of your stories, but more importantly, I'm grateful for all of the hard work that you've put in over these last few years. Thank you so much for making the rural workforce a priority and not just talking the talk, but working every day to make a difference. Thank you to Dr. [inaudible 00:25:40] for devoting all of her time and energy and talents to this and for empowering students to go into rural primary care. We are so grateful to you. Thank you for listening to this episode. We can't wait to send more your way and help you learn how you can make rural your mission.

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine, the Herbert H. and Grace A. Dow Foundation, and the Michigan State University College of Human Medicine, Family Medicine Department. We are so excited to bring you season three. I'm your host, Julia Terhune, and I hope you enjoy this episode.

In season one, I was so proud of the witty title for the episode Women Rural, R-U-R-A-L, but I was more proud of the content. Because in 2016 when I was recording the interviews for that episode, we were in the middle of an uneasy presidential campaign where for the first time in our history, one of the major presidential contenders was a woman. Now, four years later, we've made history. For the first time we have a female vice president of the United States.

Thanks to social media and memes I think we are all acutely aware of how the "other side" feels about Vice President Harris's appointment. From my vantage point, her appointment was described as either one of the greatest feats in gender equality and female leadership, or as a political ploy aimed at winning minority votes.

And that's where it starts to suck. Because on either side of the argument, that is a heavy lift for Vice President Harris. That's a heavy lift to be a pawn and it's a heavy lift to be the first. And so no matter how you slice it, being a female leader of her capacity is huge. Being the first one to do anything is huge. You have to move so much rubble and take so much heat so that you can clear a path for everyone else.

Tony Morrison is one of the most famous black female authors of our time. She has a very famous quote from a 2003 O Magazine interview. Perhaps you've seen it. It said, "I tell my students when you get these jobs that you have been so brilliantly trained for, just remember that your real job is that if you are free, you need to free somebody else. If you have some power, then your job is to empower somebody else. This is not just a grab bag candy game."

If you've read the whole article, you know that she's speaking generally about how marginalized groups who make a way to do something first need to do the heavy lifting so that those firsts don't continue. She says this because she was a first. In the 1960s she wrote her novels without any consideration for a white audience or white acceptance of her work. She went on to receive a Nobel Peace Prize and write some of the greatest novels of our time. Her achievements were not without a lot of heavy lifting that cleared a path for some amazing modern black authors like Kylie Reed or one of my favorites, Jesmyn Ward. She writes from a black impoverished rural perspective. And if you haven't read Salvage the Bones, you need to.

So in order to make the heavy lifting a little easier task today, we're celebrating. Celebrating four outstanding female hospital CEOs who are serving rural communities all around the state, from the upper peninsula all the way to the thumb. While not all of them are the first female CEOs to be with their hospitals, they are still doing the hard work that is changing and caring for rural communities in a real way and making an empowered path for young women to come right alongside them.

We're about to get into the heart of the interviews today. But before I do, I want to share some statistics compiled by the Harvard Business Review. That is to say, in 2018 women made up over 80% of the healthcare workforce, but only 6% of all healthcare CEOs were women nationwide. Women provide a unique and different worldview, challenge, and set of skills to the workforce in general, a difference that is vital to the vitality and completeness of any organization, effort, or mission. Women deserve equal and equitable representation in all areas of the economy. And therefore when discrepancies like the distribution of leadership roles in healthcare is askew, I believe it's the job of all of us to find a way to remedy that situation.

So how do we do that? Well, we're going to find out. We're going to learn about how to really empower and make a difference in the workforce and in the lives of others through these four fabulous interviews. One of the things I often take for granted when doing these interviews is the consistencies that emerge among my participants. But in this episode, the commonalities between these remarkable women was too positive and too interesting not to take note of.

The things I noticed about all four of these stories was this: mentorship is the best way to make impactful leaders. Leadership is not about you, but everyone around you. And to reach your potential, you have to take risks. And sometimes that risk is being the first.

Our stories today come from Marita Hattem-Schiffman, who is the CEO of MidMichigan Health System in Gratiot, Isabella, and Clair counties. Yes, that many counties and that many hospitals. Karen Cheeseman from the Mackinac Straits Health System in St. Ignace; Jean Anthony, the President and CEO of Hills and Dales Hospital in Cass City; and Lyn Jenks, who is now retired, but was the CEO of the Munson Health System in Charlevoix, Michigan. A little secret about Lyn? She hired our director, Dr. Andrea Wendling, for her practice in Charlevoix and is very well-loved and respected in Northern Michigan.

So let's start with some origin stories. We'll start with Marita and Jean and then move on to Karen and Lyn. One thing I think you'll find with these stories is that not one of these women started their career with the plan to become a CEO. But with mentorship from trusted guides, they learned their own potential, took risks, and found a way to empower others to take the reins too.

While Marita is a Michigan native and a graduate of Central Michigan University, Marita began her time in hospital leadership in a hospital system in Wisconsin. She took on a major strategic leadership role with a bank before realizing what she really wanted to do with her career and where she wanted to go back. Here's Marita.

And throughout the whole time I talked to the CEO about, "I still love healthcare and odds are I'm going right back again." And he kept going, "No, no, no, no, no. We're not for profit. We're helping people too. You're going to love this. You're going to want to stay." And I got to that two year mark and had already decided like six months earlier that when I hit two years, it was going to be time to go back to healthcare. And in the middle of all that I had come back to Michigan for a college reunion. Had not been back in I won't tell you how many decades. Really long time.

And driving back to the airport I called my husband back in Wisconsin and I said, "I don't know what's happening to me, but I want to come home." So he said, "Well, sure, why not? I'll support you in that." And that was July of 2016. February of 2017 was that two year commitment to the credit union. And at that point before I did anything, all these doors and windows started to open and some of them had Michigan on them. So I remember sitting down with my husband and saying, "Okay, here's all these crazy things that are coming up. Clearly the message God's giving me is you were right to make a two year commitment. Now it's time to go back to healthcare. Here are all these different places you could explore or people who are calling you." And we both agreed Michigan would be our first priority. And it all turned out, which is fantastic.

I am Jean Anthony, President and CEO of Hills and Dales. And my current role as CEO came to fruition probably almost four years ago, but I have a long, long history in healthcare. I started as an LPN and I tell the employees here during orientation, "I came with the building," and they love it. They all love it and they laugh about it. But I started as an LPN. I learned the organization, went back and received my associates. And then from there had that desire to do more in management and continued my education through bachelor's and master's and continued in the organization to pick up more and more management administrative duties until I became the COO approximately 17 years ago. And took on services with physicians, physician practices. And it was all exciting to me. It was a wonderful experience.

And so I worked in human resources for a number of years, really had the opportunity to really [inaudible 00:10:48] the program and develop it. At that time, the hospital was starting to expand. Big physician recruitment initiative underway and we were adding a number of services. So I was really fortunate to be a part of that. In about 2005, we started planning for the new hospital. And I was really fortunate to be a part of that in a number of different ways. And that led me to really be involved in a lot of different operational aspects throughout the years and throughout that process. And so I began just becoming involved and taking on other roles and responsibilities. Ultimately then became the COO and then had the opportunity to apply for the CEO job.

[inaudible 00:11:55] been in that position for a year. That's such a [inaudible 00:11:59]. Also in between I went back and I did my master's degree in organizational management in 2012. So just really tried to take every opportunity I could to advance and grow as the health system would allow.

You are now retired?

Yes, I am.

Are you excited? Is it good?

It's getting there. Let me just say that. It's getting there. When you've been going a hundred miles an hour for your entire adult life, going to zero miles an hour is hard. It's very hard. And I think what it is is when so much of who you are is wrapped up in what you do then it's not only a question of having something to do, but who you are. So I'm still dealing with that and I'm reinventing myself. And so I'm getting used to it.

I don't miss getting up at the crack of dawn. I don't miss going in on a midnight shift. I don't miss taking 400 people to bed with me every night and not being able to sleep for worrying. That's the stuff I don't miss, but yeah, I'm getting used to it.

Yeah, absolutely. So where did you start? How did you get to become the CEO of Charlevoix Hospital?

Well, I can tell you it wasn't intentional. Everybody I know who is successful says, "You set goals and you work toward those goals," and this wasn't it. It just wasn't it. I was at Wright State University and mass communication arts. It wasn't a field that would normally lead you to being a CEO of a hospital, but Marilyn Turner was the weather lady. She wasn't going anywhere. So I couldn't get a job there. So I started out in a hospital and public relations and I liked it. I liked the nonprofit world. I liked the sense that even though you were earning a living and doing well, you could do good as well in the nonprofit world. And I liked that about the industry.

I look back now on the time and energy and care that Dr. Wendling has put in my life and I still feel undeserving and so very, very grateful. Now, I don't think that I want or will ever be a CEO of a hospital, but Dr. Wendling has allowed me to grow in other ways that have made a huge difference in my life and the lives of rural medical students. The mentors of Lyn and Jean did the same thing.

Very fortunate. I had good leader, bosses, mentors during my career. And so I was able to really just grow to the fullest during that time. So it was great. I had really good mentors. I was in an industry that had a lot of women in it. Now, not a lot of women in the C-suite when I first started. Women were nurses and a growing population were doctors. Okay, so that continued to grow. So not being in either one of those categories, that part was a learning for me and it was a stretch. And even when you're a big fish in a little pond, as you always are in a rural area, you're still competing with mostly guys. That's just the way it was. Not so much anymore. We've really come a long way in healthcare in terms of more women in the C-suite and at the VP and up levels.

But even that I think was a good learning, because again I was surrounded with people who were not misogynistic, who encouraged me for the most part. I ran across a couple of that... Well, no, I didn't want to get physical, but I was tempted. There were times when I just wanted to punch them, but for the most part, again, I was very fortunate. Even those that I wanted to punch I found that in many ways because I was a woman, I was equipped with capabilities that quite honestly they weren't.

Wow. When you started day one, did you picture yourself as one day being the CEO?

Absolutely not. My husband and I laugh because when we first got married I was an LPN and that was good and we'd have some children and I'd work part-time and oh my goodness, that went right out the window and different things as you get involved in the work... And this has been such a good community. It's been a good place to work. The whole community is good. The school systems are good. It just was such a natural fit that I just kept growing with it.

And that good mentorship leads to some really good ideas.

I see our culture just in general, not even really getting to generations, moving in a different direction to more of what's considered an authoritarian style, which the tagline for that is, "Come with me," where you're engaging people in a vision and you're figuratively taking them by the hand or putting your arm around them and bringing them forward and eventually being able to let them run out in front of you. And then there's affiliative, which is very much about building consensus. And that tends to be where I spend most of my life. And I've been having to learn and really work on being more of that authoritarian style. And the bigger your job gets, the more people you need to be able to put your arms around and bring forward and trust that they're doing the same thing with their people. And I just love that image of taking people by the hands and marching forward together.

So those studies wouldn't be showing us that those are the right leadership styles if it wasn't for the way society is changing what people need from us. And who knows where we'll be another 10 years from now? It may have shifted to a different type of style again. But if you think back to the Jack Welchs of GE... And I'm trying to think of some of the other big names. They were very much that coercive or pace-setting style, which is, "I'm the smart one." Captain Kirk. "I have all the ideas. We're doing this." And all these intelligent people just, "Okay, whatever you say," instead of being able to contribute to the conversation and to the decision-making.

So what I'm hearing you say though is that really that mark of leadership is almost a lifelong learner and being willing to say that, "My ideas are not the best. I need to go and find out information from others so that I can best lead," and not staying in your own silo.

Oh, yeah. The higher you go in a position, the less you know about how to get anything done. We all start at some point doing a job and becoming an expert of that job. And then somebody says, "You do that really well. Let's have you lead others who do that job." And sometimes it's a disaster because just because you could do it doesn't mean you can lead it or teach it. And sometimes it works out great. And then that's the person that gets to carry on in management.

But at some point you get to the point... I'm running a hospital. I'm not a nurse. I'm not a doctor. I'm not a pharmacist. I'm not the subject matter of any of those things. My job, like I was saying earlier, is to get the best people we can, get them in the right seat, get them the resources that they need, let them know that they're empowered, that they're trusted, and we're going to support them. And then just get out of their way. They have the answers for a lot of the things that we need to solve. My job now... And I joke sometimes I got the easy job. I don't have to do anything. I just have to get people to do all this stuff. Obviously a lot harder than that sounds. But my job is to try to stay as far above the fray as I can so I can see the big picture.

What I'm most proud of is that I instilled a philosophy of the customer is important but the employee has to come first. Because if the employee comes first... Employee slash physician. They're going to take care of the customers. They're going to take care of the patients.

The way I tend to look at things is I'm really proud of our employees. It's really about their success and the contributions that they make each and every day to the hospital. And so for me it's really about creating and sustaining a culture where we really contribute to our community, providing the best patient care that we can, the best healthcare that's available to our community. And so for me, it's really about the success of our employees. We're doing all those things well in terms of providing quality care and delivering great customer service. Those are the things I'm most proud of at the end of the day.

I like to see my staff make decisions. It means we're doing something right. It means that we've mentored them to a point where they have ownership maybe of their department, of their area. It's nice. They'll come and they'll talk to you and you can talk it through. But you know in your heart they've grown a little bit because they've come to you with the answer. So I like to see my staff make decisions and I like interaction. Some of my favorite things are interactions with the physicians, to see what we're going to do next, what areas we can improve on.

And finally, here's some advice for all of you budding female leaders.

The importance of stepping outside your comfort zone. You tend to gravitate towards things where your strengths lie and the things that are most comfortable. In looking back for me I certainly would have taken a few more risks a little earlier in my career.

Oh, that's interesting. Like what?

Could be a number of different things, really. Could be anything from getting out and joining a committee either internally or externally in the hospital, having a few opportunities to do that. And thinking, "I don't have enough knowledge yet," or, "I know I don't have enough expertise." That type of thing. Just putting yourself out there, learning some new skills that maybe you thought somebody else was better at, where you didn't give yourself enough credit to go out and really grasp that and [inaudible 00:24:09].

So being confident.

Yes. Gaining a little more confidence early on. Absolutely.

I could have easily said, "No, I don't have the degree to be a CEO of a hospital. I don't have the background that you need." It would have been relatively easy to say that. I made more money consulting, quite honestly. But I'm glad I did it.

So do you hear that ladies? Take risks. Go outside of your comfort zone. Try something new and trust the people around you who are encouraging you. If you're that person who is near one of these budding young female leaders, consider how you can empower them to do the things that they are going to benefit from and how those talents and skills could benefit the world. I am so grateful for the women who have done that for me.

Thank you for listening to this episode. I want to thank all of the mentors that make a difference in our lives and in the lives of our students. I want to thank all of the brave individuals who became firsts. We couldn't do any of the things that we're doing without you. Thank you for your leadership.

As always, we are grateful for our podcast audience and our supporters and all of the people who make this possible. Thank you to Marita, Lyn, Jean, and Karen for being interviewed for this episode. And thank you Dr. Wendling for all of the women and men that you encourage and mentor through the College of Human Medicine. I'm your host, Julia Terhune. And as always, we want you to make rural your mission.

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine, the Herbert H. and Grace A. Dow Foundation, and the Michigan State University College of Human Medicine, Family Medicine Department. We are so excited to bring you season three. I'm your host, Julia Terhune, and I hope you enjoy this episode.

So, I remember it being the week of March 9th, that we got the news about us needing to pretty much convert our lives in the office, working directly with our students and I remember that being the last time that I walked into the office until I went back in late July.

That's Susan Tincknell. She's the director of student programs at our Marquette Campus in the Upper Peninsula. In November, I asked her to recount what's gone on since that early March date last year. It felt like we were talking about a time long, long ago, but I also hear from Susan in just a bit the impacts of COVID on our health care systems and our medical education at MSU, all of those impacts are happening still and right now. To explain a few of these ongoings, I want to walk you through a very rough timeline of everything that happened to our students from that March 9th date, going onwards to today. COVID landed in the United States, but seemed to relegate itself to major cities. That was until it didn't anymore. When it hit Michigan, it felt inevitable and unbelievable at the same time. Maybe you can resonate with that feeling as well.

Once it hit Michigan, our students were pulled first from the Traverse City Campus, and then from all of our other six campuses. The reason really was that there just wasn't enough personal protective equipment to keep our students safe. And the more people gathered in one space, the more likely they were to contract and spread the virus, so they were pulled. Since our curriculum at MSU put students in clinical settings starting year one, all 800 of our students at the college were not in clinical settings for several months. Now, doctors, medical students, residents, all of these individuals who go into a medical career are smart and resilient people. It seems like an understatement, they obviously are smart and resilient, but you'll never really know how smart and how resilient you can be until those skills are put to the test.

And the physician faculty at MSU and our medical students are some of the most resilient and smartest people I know. Within days of things going into lockdown, our college had online learning that was keeping students on track with their education and helping give them the skills they needed to tackle COVID-19 when they return to the clinic. The online education that was implemented was revolutionary. But as we know from other forms of online experiences, it's not ideal and can't last forever, especially when you're talking about clinical learning. Nevertheless, it was the best thing we could do with what we had, but learning wasn't the only thing that moved online.

Match Day 2020, and Match Day was Friday, March 20th. And that was supposed to be a grand celebration, in-person to celebrate some really hard work and accomplishment in finding out where everybody goes to residency. And that was converted last minute to virtual. It's not the same. That was really an eye-opener that this is actually happening and we're not able to gather with people. And moving forward, that same thing happened with commencement.

We are going to share the perspectives of students on this episode. Something that I think many people are interested in, but there was a whole group of non-clinical people who have been affected by this pandemic and their story is important to hear too. There's something we at the leadership in rural medicine programs share about our campuses. And that's the real personal connection you have with our staff and faculty and preceptors. But we don't just say that to promote our program, we say it because it's true. Not only that, but we have staff members in these communities that want to have connection with students, that have gotten into this work because they like and desire to work and impact student lives. COVID-19 has taken away a lot of human connection for a lot of people. And that has extended to our medical school administrators as well.

Very, very strange and somewhat difficult to change my life working with medical students to remote work. Zoom, although it's nice that we have it, isn't the same as meeting in person. And I'll just give you a little view of what the days were like if I were in my office. I would be sitting in my office and doing whatever it is I'm doing and a student would pop in and they'd say, "Hey, can I talk to you for a minute? I'm really wondering about finding a mentor in the specialty of surgery." And that would turn into a 30-minute conversation about their goals for their life, why they love surgery, who would be great mentors, okay? And then they'd leave and I'd have a smile on my face. And I'd think, "Wow, that was just a really great connection with that student."

And then maybe an hour later, a student would come in and say, "Hey, do you have a minute?" And they're struggling with something personally and we talk about that, or they've decided that they no longer want to be an anesthesia. They don't want to do that anymore, they want to go into pathology. And so we just have this great conversation that happened on the fly, in-person. I could give them a hug if they needed a hug and Kleenex if they needed to dry their tears. And because now we have to schedule, schedule, schedule, schedule.

We're going to now fast forward to the fall. The campus and the Upper Peninsula was able to send their students back to in-person learning first. At the time, there were limited cases of the virus in the Upper Peninsula region. It was a wonderful thing for these students and for the staff at the campus, but it didn't last long. After the summer months were over, Marquette County and parts of the Upper Peninsula and Wisconsin showed the highest rates of COVID-19 in the country. And all of a sudden, the situations that the UP campus had thought were in the past were blazing a new trail for their students.

I am now finding myself having to tell students, I'm sorry, you can't do this elective because COVID has affected that physician's office. I'm sorry, they're shutting down whatever office it is due to COVID. And to be honest, that the UP was immune from all of that. I thought, "What? Can this be happening?" And it is, and our students are being affected by it. And our community is definitely affected. Our hospital is affected and I'm scared. I'm scared for the remainder of the year. I am not so much scared that it's going to be harder work for me, but I do worry about our students' safety first and foremost. They'll become physicians, okay? I truly believe that that is going to happen, but for them to have the potential of not being safe, scares me.

When I reflect on what's gone on in our college, within our hospitals, within our personal lives and the lives of our students and faculty, preceptors, and doctors, I just feel heavy. I don't know if there will ever be enough words or interviews to tell you all what it's been like to be in medical education, let alone rural medical education during a pandemic. But like I said before, you just don't know how resilient or smart you are until it's been put to the test. And if the pandemic was a test for our medical students, I would say that they would graduate with the highest honors.

I would say that since our world was turned upside down, I think the students' resilience has been absolutely amazing. They amaze me every day. I could actually tear up talking about it because they're the heroes in this, they made it through. I'm here no matter what. I get paid to do this job, right? These students, yes were scared about their future, right? They were asking a lot of questions. Their rotations were all affected by this virus. We had students that really had some big plans to go and do some pretty amazing away rotations and to check out residency programs and cities and towns that they'd never seen before. And they were so excited and we've been prepping them for the whole year. And then I know isn't going to happen. And these students took it with class. They just amazed me and still do. And they still do.

I just think, "Wow, you'd never know that you guys have gone through medical school in the craziest time of this life." It's insane and they are rolling with the punches and they will do great things. We graduated students during a pandemic, okay? But then we kept the next group going and we started another group and all of these students have smiles on their faces. I am proud of our students. I am proud of our students. And what, if we didn't have great people helping the students and our staff has been amazing, it's just everybody's pulling together. Everybody's just wanting the same thing and that success for our students.

So there it is in a nutshell, the timeline of COVID-19. Students were pulled in March, by May, June, we had students back in learning situations in hospital systems with fantastic PPE and lots of precautions and yet with surges, ebbs and flow, changes in vaccination availability and the like, our students are still always being tossed back and forth. But that's what this story is about today. It's about our students, our residents, our faculty, it's telling the true tale of the type of people that we recruit to the leadership in rural medicine programs, the people who are going to serve your rural communities as leaders in the future, and the people who are currently leaders in your hospital systems, rural communities and larger urban centers. Shelby, who you'll hear in our podcast about 20 Years of Medical Education in the Thumb was in the Thumb when she found out that she wouldn't be returning. Here's her story of leaving and coming back.

Yeah. So I was actually working with Dr. Ramsey in Elkton, and we had been discussing the possibility that things could shut down from the MSU standpoint. The day beforehand and most of that day, I had heard other people had gotten pulled, another student that was in the clinic with nurse Burr in the system with the nurse and her sisters. She was pulled the weekend before and she had been my roommate leading up to that at the system. So we kind of knew that something might be coming down the pipe. So everything was pretty normal. We were seeing patients. This was before all of the mandated masks and everything, I believe. Things still seemed normal. So I went to see my patient and I came back and I could tell he was going to be a couple more minutes in the room he was seeing and so I checked my email. I don't know why I chose to check my email right then. And it said that we were being pulled from clinic at 5:00 PM that day and did not know when we were going to be coming back.

So it was around, I think probably late afternoon, the day was already pretty much over. It was our last couple of patients of the day. We came back and asked about the patient and I told him what was going on. And then I said, "And also, I will be leaving at five o'clock today." And that was kind of it. It happened, he quick threw a bunch of lectures together because we had wanted to talk about it. I had another half of a week or so with him. We'd wanted to talk about these subjects, he threw them together really quickly. We said goodbye at the end of the day, hoped everything would be okay in the end and I went back to the house that she was providing and packed up my stuff and left.

So I went back with Dr. Ramsey in Elkton. It kind of seemed like no time had passed when really a decent amount of time had passed. I had left his clinic that day to go home for an unknown amount of time. And just the same, I pulled up on that Monday and parked in my parking spot that I had been in the other weeks and walked in. And it was like nothing changed except now you have to check your temperature and wear a mask. And the whole office staff is just very like, "Oh, your back. We're so excited. Welcome back. What did you do in your time off? How did that work?" Dr. Ramsey went right back to our normal schedule of, "Well, you know how we did things. So here you go, go see this person." And it was like no time passed at all really, which was kind of an odd feeling like so much had changed, but also so little had changed.

I had my own strife when the pandemic hit as we all did. At the time, I was not only working as the assistant director for our rural programs, but I was also filling in as an interim director at one of our campuses. A job that's not easy on a normal day, let alone when you have to keep up on the medical education of students who can't work. But you want to know what I took away from that was how gracious all of our students were, especially when they were lurched into a new reality. Shelby was so gracious. She made our lives easier. She made my life easier.

I guess at the time, there wasn't really any other options. There was nothing that could really be done. So getting upset and being annoyed or frustrated or whatever it wasn't going to change what was going to happen. Obviously, MSU wasn't going to completely stop teaching students, no medical school in the country was going to just shut down. You can't. You can't just have a whole gap in students. So, I guess keeping the perspective that at some point it would be okay, maybe not perfect, maybe not back to what it was, but it would be okay, and we would get there. And in the meantime, I would get to spend some quality time in my apartment that I hadn't seen in a while. So overall, there just wasn't a good response that we would be productive, it was just kind of go with the flow and see what happens in the end.

And that grace has been extended to the communities students are learning in. Emily, a student who is now completing her rural clinical medical education in the UP, chose to take the time she couldn't be in the hospital setting or the classroom to help the community she was living in.

Yeah. So I Joined the MSU COVID volunteer team. And so I have been staffing the call center and also screening patients at some of our health office buildings to make sure that we're keeping our patients and our visitors safe during these scary times, and then also providing reassurance to patients as well. And so, I've been doing that and throughout my time in East Lansing, I've been volunteering at Cristo Rey Community Center, which is over in Lansing. And so they are still serving the community in this time and even may now be playing an even bigger role in helping the community get through this crisis. And so they provide a number of services to the community. They have free breakfast and lunch every day, they do food distribution. They also have a health center amongst another number of other services, many of which I think have been put on hold at this time just to reduce foot traffic inside the building, but they are still serving meals every day and distributing food. So I've been helping in those ways as well.

The thing about working and learning through a pandemic as a medical student is that even the hard stuff is beneficial. I think it either builds you up, helps you grow, or it's something that you can use to say, "Nope, that's not how I'm going to do things when I'm a doctor." Because you'll be a doctor. That's what I learned from talking with Evan. He was also one of our Thumb Rural students and you will hear him again this season. But this is what he had to say about being uprooted from the clinical learning setting just a few short weeks before he started residency.

On the one hand, it's certainly uncomfortable because like I said, I want to be in the clinic and I want to be using my skills and strengthening those skills as best I can and seeing the things I need to see to be prepared to start residency. But at the same time, I recognize that medical students are not necessarily essential team members at this point in time, and they would be using up that PPE that may be other team members would need. So I can totally understand why we might be asked to step out of the clinic for a few weeks. So I think at this point in time, while I may be feel frustrated, I think that's sort of a selfish thing to feel. And I'm trying to sort of understand the broader argument and appeal and looking to make the most out of these couple of weeks where I'll be doing distance learning and trying to make the most of that.

Some of the advice that I got was take notes, everything you're seeing now take notes. What are your thoughts? What are your feelings? What are you seeing done right and what are you seeing done wrong? Take note because the next time this comes around, you're going to be in that leadership position helping to make those decisions. So I think for me, I'm trying to keep my eyes open as wide as I can and try to capture some of that so that maybe the next time this happens, people will be more prepared. So I think having an emphasis on preparedness is maybe one good thing that will come out of this. There may be some bad things that come out of this, but I think there could be some good things that come out of this too.

So since we are on the subject of residency, let's talk a little bit more about it. Residency is the final step in medical education. Four years of undergrad, four years of medical school, which gets you a doctorate in medicine and three to seven years of residency, depending on what kind of doctor you want to be. It's a huge process. It's what you are working for every day of medical school. Without residency, you can't practice clinically. Students spend months applying, months interviewing and Match Day, which Susan mentioned earlier can be the happiest, saddest and most anxiety-riddled day of many students' lives. It's not just that they find out where they are continuing their education, these students will uproot their lives. And the majority of providers practice within 50 miles of where they went to residency. So having a clear picture of where you want to go, where you can go and why you want to go there, is huge, really huge.

This year, everything is online. Students will meet with their residencies and complete interviews online. They can't travel to these facilities and these facilities don't get a chance to show them anything. So I spoke with Dr. Julie Phillips about this. She's also going to show up again this season. Dr. Julie Phillips is a professor at the College of Human Medicine and the assistant dean of student career and professional development, along with being a family medicine doctor who does OB. And she works for the Family Medicine Residency at the Sparrow Hospital in East Lansing. So I think she might be an expert on residency. One of the things that I think we have all experienced during the pandemic is that the outcomes of what we expected to happen have really thrown us for a loop. So when residency went online, we heard often from students that they felt like they wouldn't do well with interviews, turns out that might not be the case.

I heard something about that in the beginning that the students were nervous about the video process itself. And the program was nervous about getting to know people on video, that it wouldn't be as easy. I actually think as we have done a few weeks of interviews now, we're getting a little more comfortable with that. And that doesn't seem to be quite so challenging as it did in the beginning. I think people are just more comfortable with the process. I do think though... Well, I don't know if this will be true, but I'm a little worried that it is harder for applicants to differentiate programs, one from another, and that it might be hard for them to actually put together a rank list. I was actually talking with an applicant the other day about a few different residency programs where she was applying. One of them was actually a rural program.

And I remember saying, "A lot of this really depends on where you want to live and what it's going to feel like to you to live in this place versus this place. These are two very different places." And she was looking at a rural program in Michigan, and then we were talking about what it would be like to live in Grand Rapids. And she'd never really spent time in Grand Rapids. And I actually said to her... The words came out of my mouth, "When you go, you'll figure it out." But of course she's not going to go, so that's going to be harder to figure out.

And I think that every year, applicants struggle a little bit with all the programs blurring together, especially at the end, which is one of the reasons why I really counseled them to take good notes and to really be thoughtful as they're going through the process about what they like about one program, what they like about another. But I am somewhat worried that this year that's going to be harder for them to really choose because they won't have seen many of the places where they will have interviewed.

So residency placement is uprooted, but residency itself has also been changed. While residents weren't asked to leave the clinical setting, their workload has increased, their stress has increased, and the requirements that they need to finish residency have also been interrupted with limitations in clinical learning. But it seems like our affiliated residency programs at MSU do a pretty good job at recruitment, just like our leadership in rural medicine programs.

There are some things that are unexpected and positive. I am incredibly proud of my residents and how much they have really stepped up and engaged and been cheerful and volunteered for things. And I have so much respect for them. I think they're wonderful physicians. And it makes me proud when I see them do great things for patients because the patients need it, even if it's not like the best learning experience. They take care of the patients first and they understand that and they take care of each other really well too. Just this week, our number of... This is such a thing that you wouldn't even think about. Our number of phone calls to inform employees that they had COVID, there was one day this week when it got crazy. Historically had been a couple of phone calls a day, and then all of a sudden there were so many phone calls. They just had to make so many phone calls and they're not easy phone calls because you have to help the person think through things.

And I watched them really help each other out and take care of each other. And that made me very proud. So I think that even though we're in a difficult circumstance and we all recognize there's an added workload, I also feel very strongly that our residency community is coming together in taking care of each other and I'm grateful for that and pleased for that. I still feel close to my colleagues and to my residents, even though I don't see them as much and even though we're not in the same spaces very often.

We're going to end today with words from two students, Logan and Emily. Both weren't born here in rural Michigan, but chose to stay in rural Michigan for the leadership in rural medicine programs and to stay in Michigan during the pandemic to support their friends, families, and communities. I wanted to highlight these two students because I think what they have to say brings hope for all of us. They are the next generation of physicians who will be serving you, your families, and maybe even your children. When were pulled out of clinical learning, their focus wasn't on the what's in this for me, but rather how could I be helping? I know that's what I want in a rural physician. And I hope it's what you want too. Here is Logan.

If anything, I feel a lot of angst that I wish I could do more as a medical student and knowing that I'm years away from being really useful in a hospital and helping patients, but also that's the things that I want to do and that's why I chose to be a doctor and to have that drive and that want to help people but to know that I'm not useful yet, it's pretty hard, especially... I see my wife go and she is useful in a hospital and she also has that drive to take care of people and that's one thing that we both have, and she is at a place in her career where she can use her skills and take care of patients. And as this grows and grows, she's going to be on the front lines and I'm going to be home.

And the only thing I can do is social distance and flatten the curve and I can be a responsible citizen that way, but I think a lot of things that I really feel is just like... I don't know, regret's the wrong word, but I wish I was born three years earlier. I wish I was born in 1993. That way I could be a fourth year medical student, maybe I could help out more than I can right now, because I know how useful I would be. I know I wouldn't be very useful at all. So, I don't think I should be in that situation, especially with the lack of protective equipment that we're having right now. I know that my me being in the hospital, taking up that protective equipment wouldn't be anything useful when there's other doctors and nurses and healthcare members who need it and are useful. So, it's not that I want to be in a hospital, I just wish I could be useful.

I think as medical students, it's hard to feel like you're having an impact because we're not on the front lines. We're not serving in that position role that we foresee ourselves in two to three years. And our goal right now is just to study and be students. And I think that's not always fulfilling because you're like, "There's a greater purpose. Our communities are suffering and studying at home isn't really helping to fight COVID." But realizing that there is the balance between our studies, but also finding those things that you do enjoy to do like volunteering or in whatever capacity and [inaudible 00:32:35] if it's donating blood or it's helping gather PPE supplies or assisting your friends and neighbors if you are healthy, getting groceries for a neighbor or cooking meals for someone. Just finding that way to feel like you are playing your part.

And I think as a community, and as a globe, as the world in general, we got into this together and it's going to take the entire world to get out of it. And so that means every person doing their part and individualism is not going to help us fight COVID, it's communities supporting each other and whatever that may look like for you. And I think that's going to help us in the days to weeks to come.

If I spent my goodbye thanking every single person who has been helpful, kind, gracious and just all in all interested in making a difference in our medical education efforts at MSU and the leadership in rural medicine programs, I don't know when this podcast would end. I am so grateful to our rural hospital partners first and foremost, because so many of them when I put the call out saying, "If you're willing to take a student, please help us," answered saying, "Send them over." When surges were low in these regions, they took it as an opportunity to educate our students. And then when surges have gone up, they have been careful and protective of our students' safety and wellbeing as well. And I can't thank them enough. I am also grateful to all of the students at the Midland Regional Campus who were a part of my life when I was doing the interim work, because they really all were that gracious and completely understood the need to be cautious and protective.

I know that our administration at our other two rural campuses felt the same about their students and I know those students were wonderful as well. I know how hard it has been for our medical students this year with everything being uprooted and unsure and just plain old different than what they expected their medical education to be like. My heart especially goes out to our first year students who entered medical school in the midst of a pandemic. I don't know what the outcome of all of this is going to be, but I have hope for it. I have hope that it's going to show the resiliency of our students, make better doctors and make us more proud of the efforts that medical scientists have made to protect us and to advance medical care.

So thank you. Thank you to Susan, Shelby, Evan, Emily, Logan, and Dr. Phillips. Thank you for speaking with me and helping me tell a little bit of the story of COVID-19 in medical school. There's a lot more to tell and if you have your own stories to share about how the pandemic impacted your life, I encourage you to share those with us online. You can check us out on Facebook and on our website. I hope that learning about how our medical students, our residents, our faculty, and our administrators care and have worked hard even in the most uncertain of times inspires you to make rural your mission.

Unfortunately your browser, (Chrome 79), is not supported by the Rev Transcription Editor. In order to edit your transcriptions, please update your browser. Update 20 Years of Rural Medical Education_WAV_Final_01 arrow_backMy Files All changes saved on Rev 2 minutes ago. more_horiz DownloadShare 00:00 00:00 22:50 Play replay_5 Back 5s 1x Speed volume_up Volume NOTES Julia Terhune This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine, the Herbert H. and Grace A. Dow Foundation, and the Michigan State University College of Human Medicine Family Medicine Department. We are so excited to bring you Season Three. I'm your host, Julia Terhune, and I hope you enjoy this episode. Julia Terhune When I first started this job, I was overcome with the needs of rural communities and the wonderful things that doctors get to do in their professions. I was, I guess you could say, fangirling a little about rural doctors. And I told my spouse that this was really what I wanted to do, that I think I wanted to be a doctor. So I had it all figured out. I was going to go to Michigan State University College of Human Medicine. I was going to do the TIP program at the Midland Family Medicine Residency, and then when it was all said and done, I was going to set up a practice with Scheurer Hospital in the Thumb. Julia Terhune Now, I have to tell you two very important things that came out of this conversation with my spouse. One, he instantly reminded me that I can barely handle a paper cut, let alone a surgery rotation, and he also reminded me that I would hysterically cry before every anatomy, biology, physiology and chemistry test that I took in college. He also reminded me that my GRE examination for grad school almost killed me with stress, so medical school is not in my future and I will stick to making rural doctors out of the likes of all of you. Julia Terhune But one subtle thing that also came out of this conversation was how much I love the Thumb community. Prior to starting with the College of Human Medicine I had never even been to the Thumb, but after six years of working with the Scheurer Hospital and the health departments and other agencies in these communities, I am smitten. I love the people from the Thumb. I love the history, I love the coastline, I love these communities. A story, not unlike many of our medical students, including Shelby Walker. Shelby Walker Yeah, so when I found out I would be going to Pigeon, I had never been there before. I don't think I had ever been to the actual Thumb before, maybe close to it but I don't think it was within what they count as the Thumb. And so I had my boyfriend at the time drive me out there just so I could see where I'd be going. So I thought it would make me feel a little bit more comfortable, and we got there and everything was so small. It was such a small town that I almost didn't believe that there was a hospital and a health system there that could especially accommodate students, so it was kind of an odd like, "What am I going to do for two years with a lot of time out in Pigeon?" It was a very odd feeling. Shelby Walker And so when we started, my first rotation of third year actually started in the Scheurer Health system with Dr. Scaddan in Sebewaing, and everyone was so welcoming and nice, and who let me do things, which as a third year medical student I was like, "Wait, am I qualified to do actual things?" And I think I had so many unique experiences out there because of where I was at. With Dr. Scaddan I got to be introduced to the ER, maybe a little bit earlier, and their definition of an ER was not what I had seen in the past but they still had some pretty intense situations and things that really were true emergencies that maybe you wouldn't expect in the middle of nowhere in, I think, a five-bed ER situation. Shelby Walker We went to the prison to do some healthcare with the inmates. That was an interesting experience that I wasn't really expecting when I had first pulled up into Pigeon. And from there I got to meet so many other amazing physicians and EPPs and just everyone there has been so nice [inaudible 00:05:05] Oh gosh, the administrative staff knows who you are when you show up to their meetings in the morning, because the physicians invite you to go with them to all of these meetings that you feel like you have no business really knowing what's going on, but they bring you to these meetings and the administration staff, they know who you are. They ask how you're doing, they asked how you're liking it. It was such an odd thing to, I guess, stumble into kind of on accident. I'm really grateful that I got that chance. Julia Terhune And if that's not enough anecdotal evidence to prove that Pigeon will win you over, well listen to this. Shelby Walker So I was talking to Chad about this, and then with Dr. Wendling actually, how odd this all turned out that I didn't want to go to Pigeon and I wanted to go to [Alma 00:05:57] and then I was like, "Okay, I'll do the nice thing." And Chad and I got engaged in Caseville. We went to Caseville on the beach. Julia Terhune Our rural medical affiliation with the Scheurer Hospital network didn't start just six years ago. We have a much longer history with the hospital and have been training students in Pigeon for more than 20 years. I sat down with the former CEO, Dwight Gascho, and the current CEO, Terry Lerash, who served and serve the Scheurer Health Network and learned just how it all got started. Terry Lerash Well, interesting story. I was working in Saginaw. I had a good position, felt satisfied, but my wife and I were on a Saturday afternoon or morning, we were standing in a field on an Amish farm in Gaylord or near Gaylord attending a wedding of a daughter of my CFO at the time, a guy that worked with me over many, many years. We were good friends so we got invited to the wedding and we're standing in this field and across the field walks Dwight and Theresa. And we had known each other for some time, Dwight and I had, probably over the last 20 years, involvement in hospital council, and health care executives, it's a pretty small circle in the State of Michigan. Most of us know each other. Terry Lerash Anyways, I said hello to Dwight. He says hello to me, and I said to Dwayne, "Well, I hear you are interested in retiring," and Dwight said, "Yes, I am. Would you like my job?" And I was a little bit stunned. Said, "Well, geez, I don't know." My wife was looking at me weird and I said, "Well, are you serious?" And he says, "Absolutely am serious." And he said, "Why don't you do me a favor? Why don't you come to Pigeon and just visit with me for a day? That's all I'm asking. No commitment, no strings attached, just come up and visit with me for a day." Terry Lerash And out of our friendship, I said, "Okay, I can do that. I can spare a day and run up to Pigeon. This is my old stomping ground anyways. I was born and raised in Bad Axe." So I had been away for probably 40 plus years from my hometown of Bad Ax and it was a chance for me to just get reacquainted with Huron County. So I drove up and I think within the first hour I was so enchanted with Scheurer Hospital because of its culture, friendliness, cleanliness, organization, and clearly Dwight's leadership was a big plus. Terry Lerash And as I talked with Dwight through the course of that day and learned more about Scheurer, I understood that the core values of the organization really matched me, kind of fit my dress code, if you will. And so I was intrigued and left and then made a subsequent visit and met with the board and long story short, here I am and I couldn't be happier. This was really a great opportunity for me [inaudible 00:09:29] Dwight Gascho And as I reflect on that side of the story, my story would match it almost exactly. I was born and raised in the Pigeon area. I was on a farm, left for a few years for school and the service, et cetera. Came back in 1972 and in 1987, I was invited to serve on the Scheurer Hospital Board of Trustees. And we were having some issues at the time, and in 1990, the board asked if I would take the leadership position in the hospital as the CEO. And I agreed to do that on an interim basis saying, "I'll give it a shot, but if it doesn't work maybe I could help find the next leader." Well, after just a matter of a few months, the board took the interim assignment away and gave me the full-time assignment and so I worked here from 1990 until July of 2016, 26 years plus. Dwight Gascho Obviously the hospital was struggling early on. The hospital became more profitable as years went by. We became more successful at recruiting young physicians. And there had been a gentlemen that had served on the board by the name of Loren Gettel. Loren Gettel was a farmer in this area and had a very strong interest in seeing students find opportunities to train in some rural community, and he put that bug in my ear. As a matter of fact, Julie, when I was being asked to serve, Loren asked the board chair if he could spend a day with me. And I'm fully aware of what it was. It was part of a program to see once if I passed the exam, so I think I was being vetted by Loren Gettel. Dwight Gascho So we jumped in the car. We drove to MSU and we walked the campus of MSU. He's a very, very strong MSU campaign leader. I mean, he loves that organization. He was grinning away. And he showed me places that were memorable to him and he showed me plaques on walls where he had made contributions to the organization and he said, "Dwight, some how, some way we have got to find ways to introduce medical students to rural communities because I've lived in a rural community all my life." This is Loren speaking, "And candidly, it's a great place to live. It's a great place to raise kids and we've got great schools, great churches. There's all sorts of things that you can do around here and we've got to find ways to do this." Dwight Gascho And that was something he just kept putting into my head. Unfortunately, he passed away from cancer just few years after I became CEO here in 1990 but his daughter, Peggy McCormick, continues to serve on the board of directors and she has a very similar burning desire to see some sort of a relationship with rural communities. Julia Terhune The Loren Gettel scholarship is a scholarship that our rural medical education students are still receiving today. And in fact, since 2010, 11 students have received this scholarship including Dan Drake who you heard just a few seasons ago and is going to be returning to the Thumb for practice in just a few short months. Dwight Gascho Terry was not a hospital CEO, but he was running an organization at the time that was an important part of the whole council and that's was Synergy Medical Educational Alliance. Terry Lerash So I was, quite frankly, offering to the hospital council opportunities for them to perhaps have students in their communities and in their hospitals, if they were able to provide the right types of resources. Well, after that hospital council meeting, I had two calls. One of them was from Dwight, in fact he was the first one that called me. And I think he probably was reflecting on Loren's message to him, and saw this was a great opportunity and so he called me and he asked if we could talk more about becoming a MSU student site. And so we worked through all the details. I can't remember all the details involved, but I remember driving two students up here and one of them was by the name of Kimiko Sugimoto. And she is now a general surgeon who actually completed the MSU rotation, her general surgery rotation in Saginaw, and is practicing in Saginaw as a general surgeon as we speak. Terry Lerash But she was one of the first students to come to Pigeon, and Dwight was so gracious in entertaining them and took them to board meetings and got them involved and connected with all sorts of things here at the hospital and they had a wonderful experience. And I can't even remember what the length of the rotation was but I know your physicians got involved in- Dwight Gascho It was actually a little longer than what it was supposed to be. It just stretched out. That was a first for them and a first for us, and so we were thrilled and enthralled to have these young students. Of course, they're brilliant kids and they're so much fun, they're very respectful. I included them in my leadership meetings and learn from what we were doing. I wanted them to get as much of an experience in a rural setting as they possibly could get. So medical staff meetings, board meetings, leadership meetings, interact with the patients, interact with the staff, it was all part of it. Terry Lerash And I think that we got raving reviews after that about their experience in Pigeon 20 years ago. And so I look at Scheurer Hospital as really a teaching hospital, and so we've built that culture. We, meaning Dwight, for many, many years, and me most recently, built a culture of a teaching organization and I think that started 20 years ago with Dr. Sugimoto, actually, as that first student. Julia Terhune That involvement with the leadership at our rural hospitals is one of the pillars of our rural medical education certificate, one that really lands with students and makes an impact. Pigeon makes a place for aspiring rural medical doctors, a place where people can come back and grow. People like Elizabeth and our recent graduate, Evan. Elizabeth is a native of Cass City who, when I interviewed her, was planning to go back to the Thumb for her medical education and now is halfway through her third year of medical schooling. Evan recently graduated medical school and is completing an internal medicine residency in Detroit. Elizabeth Yeah, I am super excited to go back. I recently had the opportunity to shadow at Scheurer and had some downtime and was able to go back down to the floor and see a lot of the nurses and the nurses aides that I worked with, and it just made me even more excited to go back there and be back with that group of people and in that environment and continue my education there. And I think it's really important if you eventually want to serve in a rural area to see how rural medicine is different. I can tell you, I had my adult wards rotation for second year at Sparrow this morning and it's way different. It's a different environment, there's different types of cases, so I'm excited about that. Elizabeth I'm excited to develop those relationships that you get to develop in rural areas that you don't get so much in bigger hospitals, relationships with patients and relationships with colleagues, other physicians, other employees in the hospital. I'm really excited to be a part of that and just be a part of that group and that kind of close knit community again. Evan I think the thing that's going to stick with me is that the sort of idealized version of a physician or what a doctor could be, sort of that dream, is still alive in a lot of places. I think a lot of times we get down on what medicine is becoming or has become or how it's changing and how the role of the physician is changing, and maybe it's not what we had thought. You know, a country doctor making house visits, knowing all their patients, delivering babies and doing minor surgeries and really being that do-it-all type of doctor who's also involved in their community, who's also a community leader. We don't see that as much anymore, I think, especially in bigger cities. Evan But having that experience in a rural community shows me that it's still possible. I've met plenty of physicians who were that do-it-all type of person. They were in covering shifts in the ED in the night and then in the morning they were in their clinic and after that they were on the board of the hospital and they still made it to their kids' sports games where they were the sports medicine physician there, and they were on the Rotary Club board as well. I mean, they were just in every facet of their community, being that leader and being that physician and everybody knew them. Evan And so I think it gives me inspiration that I can be the type of physician some day that I think I always wanted to be, or I was always really intrigued by. And I think that's a really great image and vision to sort of hold onto as you go through your training and ultimately look at how you want to set up your practice in life and where you want to end up. Julia Terhune I am proud and MSU is proud of our partnership with the Scheurer Hospital system and all of the hospitals, clinics and health departments that we get to work with in the Thumb region. All of these places have significantly contributed to our students' rural medical education, places like Hills & Dales Hospital in Cass City, McKenzie Health System in Sandusky, the Harbor Beach Community Hospital, and the Huron County, Tuscola County and Sanilac County Health Departments have all been taking our students for many years. The leaders of all of these facilities have become our friends and have taken on so much for our students. I can't even begin to thank them. They have provided not only a place for medical education during regular times and pandemic times, but they've been mentors and leaders that have provided students with perspectives they wouldn't have gotten anywhere else. Julia Terhune On top of that, they have constantly supported our program, our Pipeline program, and even things like this podcast. They have gone above and beyond to be so much more than just medical education partners and I think that that's one of the most important things about rural medical education is that you can't walk into a rural educational environment and not leave with family, friends and a brand new community. So we love Scheurer, we love the Thumb, but what do those who receive care from Scheurer think? I spoke to Lynn and Abby who not only receive medical care from Scheurer Health professionals, but are also employees. Speaker 7 The more we grow, it gives the community another option and they're like, "Oh, well, oh, they can do that there. Okay, well, I'm going to go there then or request services there." Speaker 8 It goes back to not being a number. Really, everywhere that you go here, they know you. They know your family, they know something about you, and they built a Meijer in Bad Axe that opened in July [crosstalk 00:21:40] We've got a clinic in there and things that can't get handled there, they can do at the Bad Axe site, and if they can't do it at the Bad Axe site they can send them to Pigeon. So it's all within... What is it? We have something within 12 miles of each other always. Speaker 7 [crosstalk 00:21:57] Julia Terhune Thank you for listening to this podcast. I want to thank Dwight and Terry for taking time to speak with me, along with Shelby, Liz, Evan, Lynn, and Abby for their contributions to this episode. As always, thank you to Dr. Wendling for making this podcast a priority. I love getting the opportunity to hear and tell these stories. Also, Dr. Wendling, herself, is from the Thumb just adding more proof to the theory that some of the best doctors come from the pollex, the scientific term for Thumb. See, I learned something in anatomy. The Thumb is a wonderful place, a place where you can really make rural your mission. How did we do on your transcript? Rev's Quality Team reviews all transcripts rated 3 stars or less.

*PLEASE BE ADVISED: This episode discusses very sensitive and triggering content including suicide and self harm. Please continue reading/listening at your own discretion.

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine, The Herbert H. and Grace A. Dow Foundation, and the Michigan State University College of Human Medicine Family Medicine Department. We are so excited to bring you season three. I'm your host, Julia Terhune, and I hope you enjoy this episode.

On January 24th, 2020, the CDC published the following, "In 2017, nearly 38,000 persons of working age, that is, 16 to 64 years, in the United States died by suicide," which represents a 40% rate increase in less than two decades. 79% of those 38,000 people were male. And the breakdown of those men in different occupations was as follows, fishing and hunting workers, machinists, welders, soldering, and brazing workers, chefs and head cooks, construction managers, farmers, ranchers, and other agricultural managers, and retail sales persons.

In addition to this devastating data, the CDC has shown that suicides are around 30% higher in rural communities in general when compared to urban communities. What do these two things have in common? Farmers. That's the population that I want to pay attention to on this list, though I want to acknowledge the depravity and the sadness that this list holds.

The thing about farmers is that they are a really important population. They take care of our plates, of plates around the world. And in 1900, 40% of the workforce was in agriculture, but by 2002, that number was down to a staggering 1.9% of the workforce. The United States Bureau of Labor Statistics predicts that there will actually be an even greater reduction, a 6% reduction in farming jobs over the next 10 years. And since the 1990s, the rate of suicides by farmers when compared to the general public is 3.5 times higher.

So here we are. In the last six years, more than 450 farmers have killed themselves. The numbers of farms totally has decreased, but the productivity and output of the farms that are left has increased more than 50%, partly because it's had two. And the total amount of debt that farmers owe has increased 5%, which may not sound like a lot, but that number equals $16.4 billion, billion with a B, that farmers owe since 2017, in addition to what the debt already was.

There's a fantastic article that USA Today has published, and we will link to that on our website. This article goes over many of the reasons why this phenomenon of farmer suicide is happening, but I wanted to provide all of you a perspective from the people who are working with this population, live with this population, love this population, and are trying to do something about this problem.

I conducted interviews for this podcast in late 2019 and early 2020, but the stressors and complexities for farmers that my interviewees talk about are not outdated. If anything, they've become more acute than they were before.

The first thing I want to show is that the stressors that the CDC, NIH, USA Today, and so many others have identified as problems were also identified by my interviewees. And I think that these are issues we're all worried about. We all care about the environment, and obviously we all want to have financial stability, but these are all real stressors for farmers because it affects their livelihood, and their livelihood affects our livelihood. Literally. It's actual food. They make our food. Without farmers, we don't eat.

And of course, there's a lot to say about small farms versus big farms and how that business phenomenon and how that transition is affecting our food, but the idea of farm stress and the idea of farmer suicide doesn't hit one sized farm over the other. It's something that is taking a toll on everyone, and something that my first guest, Sarah Zastrow, knows firsthand and professionally.

So I grew up on a farm out kind of in Freeland, south of Midland a little ways, and my dad and his brother farmed sugar beets, corn, soybeans, and wheat. And I swore that I would never shovel manure again after I left for college. And my dad said, "Don't marry a farmer," and so of course I did.

So we just farm a little bit, both with his grandparents, and so that's kind of fun. It's interesting to see the dynamic of several different farms. We've got a lot of farming families, and so it's kind of cool to see that dynamic and the different ways that every farm operates. So that's kind of cool.

And then what I do is I have my own wellness business where I teach people how to manage stress, which has turned into teaching farmers how to manage stress. And so that's been really, really interesting this year and really has just taken off this year with this terrible farming season and all the pressure with these tariffs and different things like that.

So you came across the issue of farm stress organically?

Yes.

Can you tell me that story? How did this come to into your purview?

Yeah. So I think that farm stress has always been really evident in our family, both my mom's brother's farm and my dad and his brother's farm, and everybody sort of has a touch of anxiety and you just notice things that are affected by that stress. And so I think that I have always known that sort of growing up and that people just handle stress very differently, however, it's always been really apparent to me that farmers in particular are stressed out. And especially when the weather doesn't cooperate and when there's so many factors outside of your control, that contributes to a level of stress because everything feels so crazy and so out of control. And so I think that that was kind of the first introduction I had to farm stress.

We had a farmer neighbor who committed suicide a little while ago earlier this fall. And it was just devastating. And I'm going to be honest, I didn't know him at all, however, we heard the gunshot and then heard through the grapevine later that day that he had committed suicide. And I thought, "This is terrible."

And then we went out for breakfast a couple of days later, and the girls in the restaurant at the breakfast joint realized that there was something different about him, but what do you do? What do you say? And when you notice something is off like that, at what point do you say something? At what point do you mind your own business? At what point does another person need to reach in and help?

And so that was another kind of determining factor for me that this and what I'm doing, this talking about stress management, giving people the tools to communicate with their spouse, with a counselor, with different people, whoever you feel comfortable with is really, really important and really, really needed on every single farm.

This issue of farm stress and farmer suicide is so big that people from the community and people outside of the community, people at the state and federal level have taken note.

Eric Karbowski is a community behavioral health extension educator for Michigan State University Extension, and Eric's job was created by Extension to tackle the immense social issue that is plaguing Michigan farms. Eric's job is to help find large-scale solutions and also develop grassroots and educational efforts to help this targeted population.

Well, my name's Eric Karbowski. I'm behavioral health educator working with Michigan State University Extension. My path to becoming here, I really had no intentions of working for Extension. I grew up in a rural area. My grandparents were farmers. I had the opportunity to participate as part of the CMU football team, which is really part of the reason I actually went to college. My parents never attended a university or anything like that. My dad worked for GM and my mom worked in the post office. And so athletics really was my opportunity to go to the university.

And then, so after that, I started my career. I worked in inner city Saginaw in Detroit, working with individuals with mental illness and helping them find jobs, competitive employment.

Eric's job was created by Extension, and Sarah was developing her business at the same time that the CDC and other health entities were shocked at the suicide rates among farmers, a discovery that was being published and made known at the same time that huge tariffs and trade wars with China were being conjured up by the Trump administration, an administration that was largely supported by a rural farming base.

It was a great opportunity for me to give back, because I married into a farming community, and give back and stay connected with really where my roots are, working with the farmers and talking about farm stress, talking about a lot of the hard discussions, suicide, mental health, mental illness, that really aren't comfortable conversations for people to have. And so it's been a really unique and good opportunity for me to connect with the farmers and really try to make a profound difference in their lives.

So with an America first mindset playing out internationally, huge hurdles for selling commodity farm goods were being positioned for farmers in the United States, something that has led to new cultural and social issues that are developing for many farming families, families like Carolyn's.

Carolyn is one of our leadership and rural medicine students and she grew up on a small farm in the center of our state, one that is still running today, and one that has been managed by her parents, partly because they ran it as a second full-time job, having other means of income outside of the farm.

Yeah. So I just spoke with my father about the tariffs and what his perspective of it was. And he thinks that they lost, because of the tariffs, about $40 to $50 an acre money-wise for... I guess we had soybeans for the tariffs [inaudible 00:12:19] how prices went down.

And then a big conversation that's been at I guess Thanksgiving dinner was whether or not they went and got aid packages, whether they got their Trump checks, and my brother did receive aid. So he went and applied to get this emergency aid for his smaller farm, and I think he got around $1,000, $1,500 for the money that he potentially lost because of the tariffs. My father did not collect any aid. And he said, "Why would I want other Americans to pay for my misfortune?"

What are these Trump checks?

So with the tariffs that happened, there was emergency aid that was given out to farmers in the past couple of years. And so they originally, from my understanding, they originally put a cap on how much that you can collect, but larger farms were using multiple names to go collect more. And then so far, smaller farms weren't able to collect as much. But I think overall, the emergency aid that was given out was just seen as a band-aid. There's no way to really collect that money that was truly lost. You can't get all of that power back, that money back?

So here we are. If I can be so bold, I would say we're in a culture war. We have political, environmental and social issues that are trickling, no, rushing down to our food systems and the people who are taking care of our plates and the plates around the world. This is a totally rural issue and there's too much at stake to turn away from this problem, but I do have a hopeful message for all of you today, and it is from people like Eric and Sarah, people who are caring about this population and trying to do something unique and person first to solve this problem of farm stress, not only for the people who are in this work, but for the future of this work and the future of all of our communities, specifically rural communities.

So I think some of the changes in the industry that we've really been observing and trying to create some unique opportunities for are that farmers don't communicate as much as they used to. A lot of it is done via social media now. And so you don't see a lot of the farmers connecting at the local coffee shops or gathering where they may have in the past. And I think that it was a pretty interesting feedback to hear from especially a couple of the farmers themselves, but then even locally, we tried to do just an observation where we worked with the local elevator just to create an opportunity for the farmers to get together.

We made chili and bean soup, and it was awesome to see even though amidst of all of the difficult times and the financial struggles and the delayed planting and the tough growing season that we had this year, that there was a sense of comradery and there was a lot of smiles and laughter and talking. And it was really cool to see and experience that.

I think there is kind of, there's generational differences for sure. I mean, a lot of the things, especially the more I've transitioned into this role and learning that, I think the average average age of a lot of the Michigan farmers are in their early to mid-60s. And then, if they do have a son or a daughter that are going to start working on the farm, Facebook, internet, cell phones, those didn't exist when they were growing up. And so now those are all kind of parts of where they're at or where we're at today, and I think that creates some communication challenges for sure.

And part of your job is now almost trying to get people back to that grassroots community piece. Is that what I understood?

Well, I think that's kind of one of the things that we're looking into is, if we create some of these social outlets for the farmers that they kind of naturally had in the past, will that help? Because you always feel good when you talk to your peers or your coworkers, or somebody that you know has something in common with you, right? It's like you're speaking the same language, and farmers are no different. It's an opportunity for them to vent, to talk about stuff, maybe good, bad, or indifference, or even just a chance to catch up. And it's amazing just to see really the atmosphere and the environment, how it changed, even just over the course of those two hours. And there was no formal programming or no formal lesson that was being taught at that. It was just, it was farmers talking to farmers.

So what I would hang my hat on are community involvement and stronger relationships in your family, with your spouse, with your community in general, and really just working on and focusing on the things that you have control over. Because at the end of the day, we don't have a lot of control over many things. We don't have it over the weather. We don't have it over the grain market or any commodities market. We don't over the tariffs and things like that. Focus on what you can control.

And I always tell people, you need to figure out a way to manage stress now. Create habits for stress, stressing less over the long haul, and then building those relationships. Those are the three things that we can focus on and those are the three things at the end of the day that are going to make the biggest difference in our lives, in our families and in our neighborhoods, and that is what is important. And then at the end of the day, whatever happens to China happens to China because I have a good home life and good community and things are going to be okay.

Sarah's efforts with her business are helping people and giving people creative solution, and Eric's time with the farming community is starting conversations that need to happen. We can also have hope that the work that farmers are doing is not just feeding us. They are shaping and molding people who are coming out of these communities and working to return and make a difference. Maybe they're not going to be behind the wheel of a combine, but their work will directly affect those drivers.

I guess being on a farm where I have to help my father do things that I've never done before or I've only seen done, it's given me a little bit more confidence in the medical setting that, "Hey, I've done things in the past and I can do them in the future."

So in that aspect, it's been helpful. I don't know if farming has influenced me to go into medicine, but I know it's influenced in where I want to practice in the future. I know I want to be in a small community where I can rely on neighbors and friends and they can rely on me.

Thank you to Eric, Carolyn and Sarah, for speaking with me today. There's so much more to say on the issue of farm stress, and we will be revisiting this issue in season four. So if you have ideas for people, you think would be a great interview for that episode, please email us at [email protected], or message us on Facebook or Instagram. Our Facebook and Instagram handle is @MSURuralHealth.

Our last thank you as always goes out to another farm descendant, Dr. Andrea Wendling. We are so grateful that your time growing up on a centennial farm brought you back to rural Michigan, where you have helped serve so many.

We hope you enjoyed this podcast, and I hope that it inspired you to make rural your mission.

Transcript

Julia Terhune:

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine, the Herbert H. And Grace A. Dow Foundation, and the Michigan State University College of Human Medicine, Family Medicine Department.

Julia Terhune:

We are so excited to bring you season three. I'm your host, Julia Terhune, and I hope you enjoy this episode.

Julia Terhune:

A common pastime for rural residents and tourists alike is the local farmer's market. I love them, and it seems to be a hallmark for many rural communities. Not only do farmers attend these events, but often you'll find local craftsmen, artists and even local musicians.

Julia Terhune:

So maybe that's what you were thinking when I said art in rural communities or arts rural for this podcast episode. And you'd be right. After all, there are many artists who are at these events, but my perspective takes a little different turn.

Julia Terhune:

When I say arts rural, I was actually thinking about some of the doctors and future doctors that I know. So that might sound kind of confusing, but it's not when you think about it this way. I describe it like a Venn diagram. There's one circle with art. There's one circle with medicine and in my world, where they seem to overlap is in rural communities.

Julia Terhune:

You see, growing up in a small town, I experienced a place where people used their crafts to survive, but also where many arts and skilled crafts have survived. If you've ever been to one of those markets that I mentioned, you know what I mean. People make their living off of the things they make, but they also make things to serve them on their farm, in their home. Some families I know, and maybe you know too, have simplified their lives, to make more room for art and music. And there doesn't seem to be a community gathering without those things in many small places.

Julia Terhune:

So what does that mean for the doctors that want to serve in these bucolic communities?

Julia Terhune:

We've talked at length on this podcast about the social and economic complexities that make doctoring in rural communities a little harder. Harder problems sometimes cause more creative solutions, which is definitely something our partners today will speak about. But I think that the people who serve in these rural communities as physicians are themselves a little more complex. They seem to not only come at physical issues with a multi-faceted approach, but have several sides to them as people.

Julia Terhune:

We've said on this show that doing rural medicine is a brave thing to do. Now, I would like to propose that serving rural communities is a creative thing to do.

Julia Terhune:

Let's start with some student stories. Right now in the leadership and rural medicine programs, we have two pretty creative women learning to become rural doctors. Kayla, who you'll hear from first, is originally from Minnesota, but is now completing her clinical medical education in Traverse City and preparing to become either an OBGYN or a surgeon. She's not a hundred percent sure quite yet.

Julia Terhune:

Ellie is originally from Illinois, but came to the upper peninsula during her undergrad and has stayed in Michigan ever since. She will also be going to Traverse City this summer. Both students got a fine art degree along with their pre-medical requirements in undergrad, and yet nothing deterred them from medicine.

Kayla:

So I went to undergrad. I had actually already completed 60 college credits before I even got there. So I only had two years left to do.

Kayla:

But I had this four year scholarship that covered a good amount of my tuition. And I was like, "I don't know if I'll be ready to graduate in two years." So I went to undergrad. I knew I was going to do something science, but my whole family is kind of artistic and no one's really been able to go and entertain that or build on their artistic skill. The [inaudible 00:05:00] high school art classes and then my oldest sister just stopped and my mom kind of stopped and I was like, "I would love to do art."

Kayla:

So I went to undergrad and I did a double major. I did biology and then studio art and then a chemistry [inaudible 00:05:14] but no one cares about that.

Julia Terhune:

And Ellie reiterated that point. Here she is.

Ellie:

I kind of have always wanted to go into medicine. From when I was younger, it was like the first thing that I said when I was five. And I feel like it's very cheesy, but then I never really came up with anything else that I liked.

Ellie:

I just kept finding more reasons as I got older to like medicine. Until I got into high school, I didn't really have any other ideas. And I took my first real art class. I took a ceramics class in high school and I was lucky to be in an area where we had lots of different art classes. So I was able to take a couple years of ceramics back then.

Ellie:

And I just really fell in love with it and I love working with my hands. I've taken so many science classes to try to do well and prepare myself for the future, being a doctor, that I wanted. Just being in art was really nice and relaxing. It kind of gave me a creative outlet that I didn't know that I needed and I just really enjoyed it.

Ellie:

After I took those classes and I was a senior in high school, I said, "You know what? I'm just going to be an art major." And I can still take all of my, my science classes. And I had actually met with my future advisor, pre-medical advisor in college. His name's Dr. Lucas. He's at Northern Michigan University. And he told me to just go for it. He was like, "There's so many people that apply as science majors. And a lot of medical schools now are really interested in people that are doing something different. So have other passions. "

Ellie:

So I just decided to go full force with it. And I really have no regrets. It was one of the best decisions that I made.

Kayla:

And it worked out really well. It's been kind of a stress relief. I'd go to these really intensive biochemistry and then biochem lab. And then I would go and I'd worked 15 hours on a sculpture and it would be like the perfect little ratio for me.

Kayla:

It took me a long time to figure out what I was going to do with my senior art show, a big project you put together at the end of your four years of undergrad. And it's a big group show. I was applying to medical school at the time, going through all my interviews. And I started sculpting all of these heads. And I tried to like convey what does it feel to be anxious or to be so stressed out?

Kayla:

And I kind of just went for it. I just started sculpting this giant head. And then of course it fell apart because art just always falls apart on you. It's really good for problem solving though. So I had to rework it a couple of different ways and it turned out better for it, so that was nice.

Kayla:

But I ended up doing these five heads on these giant four-foot pedestals. So you'd walk into the gallery and all these heads are staring at you. And each one was kind of a different representation of anxiety or stress or kind of depression, but more anxiety and stress. And I had interviewed some of my friends and siblings and I was like, "Okay, what does stress feel like to you?" I was trying to capture how we all feel stress so differently.

Kayla:

So the first one I made, it was based off my face and it was screaming. And then half of it was kind of exploded off. Kind of like if you've ever felt so frustrated, your head's going to explode. So I literally made that, but then I did it very realistic on the side and then where it was exploded, it was very artsy and abstract. And I really wanted to highlight clay and what clay can do.

Kayla:

And then the other four, one was really spiky. It had all these spikes, kind of like how you get really defensive and shove everyone away from you when you get stressed out or at least I do. And then there was another one. My mom was like, "How come none of your sculptures are smiling?" And I was like, "Oh, I got this." The last one I made was smiling, but then it was like empty inside. Kind of how you can put on a smile, but sometimes they're not always... It's just like a face, right?iSo it was empty on the eyes. And the head was crumbling down around it. You put on the face, like I'm still smiling, but on the inside, you're kind of empty.

Kayla:

And it was just such a cathartic experience. I don't think I even understood the stress and anxiety that I was carrying and just shoving down until I put it into these art and it's so therapeutic. It was amazing.

Julia Terhune:

I had to ask Kayla at this point, if she ever felt like the two sides of her brain were at war with one another.

Kayla:

I think in undergrad a little bit. When I was going for it, I had been accepted into medical school and then I had completed this big project and I was so proud of all those sculpted heads. And my art teacher's like, "Are you sure? It would be so like..." She was like, "You would love the art community. You can join us still." And it definitely crossed my mind. I was like, "Oh, if I do medicine, will I have time for art?" But I'm trying to. I'm trying to force myself to incorporate it in, and time management so that I get to embrace both.

Julia Terhune:

What is always fun and interesting about doing these podcasts is the similarities that come out of your conversations and the commonalities that people have with each other, even if they aren't related.

Julia Terhune:

This idea of art, not only being a place of relief, but also a way to think about serving patients holistically was something that I found out from Dr. Julie Phillips as well.

Julia Terhune:

Dr. Phillips is a wonderful partner and friend. While she may not be a rural doctor, she serves in one of the state's largest hospitals as a family medicine doctor who also does OBGYN. So she sees many rural patients.

Julia Terhune:

She not only has worked on numerous rural related research projects with our program, but has a vested interest in helping students achieve their residency goals and finding ways to help them return to rural communities. You'll hear her again this season, when we talk about the complexities of getting into residency in the midst of a pandemic.

Julia Terhune:

She is also a talented writer, artist, and textile artist. Her story about her medical work and creativity mirrors that of Kayla and Ellie's, but in a way that shows how necessary art is in general, especially when caring for people.

Dr. Julie Phillips:

I actually think I was artistic before I learned about science and fell in love with science because when I was a very small child, I liked to write stories and poems. And I like to make things even then, even when I was little, like four or five, elementary school. When I was in elementary school, I used to write, of course. Everybody wrote stories in elementary school. It was a thing that you would do because teachers would tell you to, but I always wrote the stories that the teacher would pull out of the pile and read to the class. I was very proud of my writing, my creative writing, when I was small.

Dr. Julie Phillips:

I kept doing that through school and through college. I actually took English classes a lot, as well as my science classes, because I really enjoyed and loved them and liked using that creative side.

Dr. Julie Phillips:

It's something that I've kept with me. I didn't do it as much when I was in medical school because I think I was just working so hard. I kind of let that piece of my brain be dormant, I guess, is the word. But then after that, I started to pick it up again.

Dr. Julie Phillips:

I love narrative writing as a form of expression for medical doctors. I just think it's really valuable for us to have that and to be able to celebrate it and cultivate it and spend time on it. I think it's a pretty unique way to care for ourselves, to be able to write about our experiences and write about the meaning of being a physician and express ourselves that way.

Dr. Julie Phillips:

I really love to write poetry now. That's kind of my favorite form of writing. But I also write a lot of research papers, right? I have these two far apart on the spectrum pieces that I do. I do research writing that's more technical and very descriptive and very exact. And then I have poetry, which has many fewer rules, but it's kind of challenging in a different way. And I really like both of them. I get a lot out of doing both.

Dr. Julie Phillips:

In terms of making things, yeah, I've always made things like since I was a kid. I love to make things. My grandmother taught me to knit and then I didn't knit for a long time. And then I relearned when I was an adult and I just love that. And I like to sew. I don't know. It's just my favorite way to kind of relax and do something fun is to make stuff.

Dr. Julie Phillips:

I think there's something to be said for thinking outside the box in medicine. And I think I'm pretty good at that actually. That's an indirect link, but yeah, I do think that it does help you look at problems in a different way when you are used to sort of breaking the rules. You can break the rules creatively a lot. Sometimes it's fun to have a patient and just do something that is not the usual because sometimes the patient doesn't need the usual thing. Sometimes they need something special just for them.

Julia Terhune:

So what does art mean for rural communities? Why is it important for people, not just patients? Let's start with someone known very well on this podcast, Brian Eggers. You'll recognize his name because so much of his work has been on this podcast.

Julia Terhune:

The cool part about his story is that he's from Northern Lower Michigan. He's been a musician for many years and grew up near Boyne City. Now he's in Nashville, Tennessee, working on his music career and also song writing and producing. His perspective on the contrast of the rural music scene compared to the bustle of Nashville shows just how unifying art and music can be.

Brian Eggers:

To me, I'd say just as a microcosm, Boyne City has completely changed from 15, 20 years ago 'til now. And they do on Friday nights throughout the summer, they do Stroll the Streets where there's literally live music on every corner of the downtown area. As they've done this, the city has flourished and blossomed and businesses came. The tourism has increased immensely. Just as a whole, it really just pumped up the feeling. When you go there, you're like, "Man, this place is different."

Brian Eggers:

It's rich. It's diverse. It's not just a one faceted, "Oh, this is the town that's on the lake," because there's thousands of those. There's all kinds of these tourist towns who don't have much to offer aside from the scenery. And when you do something like Stroll the Streets on a Friday night in Boyne City, yeah, it's a little town with on the water and it's cute and it's pretty, but the people that you meet and the music you're hearing as you walk through the town or the waiter in the restaurant or whatever it might be, those connections are really what translate to people and it gives you more of a sense of what culturally is available here.

Julia Terhune:

And that sense of community is important because it connects and it gives people an identity, something that we're all searching for. Here's Kayla and Ellie again, giving their take on how art can affect rural communities and rural medicine.

Ellie:

I've had to think about this a lot when people ask me how art is going to help me at all. But I think art is really about communication. And that is something that I think, in medicine traditionally has been a little less of a priority. And I think now people are learning that it's important to talk to your patients and try to educate them and treat them as if they do know and they want to know and be involved in their care more.

Kayla:

And so I think my art degree really helped me take all this scientific knowledge I have and try to break it down into more simple terms. I think that's a really good skill to have, especially in a rural area. There are a lot of people that might not be... They might've graduated high school and then they went to work with the family business or things like that.

Ellie:

And I think that's kind of the biggest area and it would help in any other area as well.

Kayla:

I think, Cold Springs, that's the town I'm from. They had recently got this cute coffee shop, adorable. And they painted this giant mural of the town inside on one of the walls. [inaudible 00:19:41] they painted like this road. So highway 23 is what it takes you to Cold Springs. So it's like the big road that'll get you there. They painted it on the big mural and then they write on it with chalk questions like, "What are you most excited about?" Or "What's your new year's resolution?" And you see the whole community comes in and they're writing on the wall and little kids are drawing pictures on the chalk. And it's just a great way to bring the community together. And everyone gets to see like, "Oh, what did they write?" And so it's just art in small ways that kind of brings the community together.

Kayla:

I think art is so important to a small town. We think about art being in these big urban centers, but art is really important rural communities too. It totally shapes how we view our environment and it represents the community values and it creates conversation. So I don't think it could ever be undervalued. And if there's ever a chance to bring art into a rural community, it should definitely be explored because I think it's so beneficial.

Julia Terhune:

I think the more creative minds we get working together on rural issues, the sooner these issues will become a thing of the past. I think if more creative minds can start to consider the opportunities that rural areas provide, instead of just looking at what's common or what's expected, the sooner we can start to make a real difference in the lives of those most underserved.

Julia Terhune:

It might be one of the most creative things to go back to a rural community and find new ways of tackling medical leadership and economic issues. It's why we make this podcast, to help people think about the differences in rural areas, but how those differences are something that can actually be celebrated, and maybe we could get to that celebration sooner if we understood them better, kind of like an art gallery. You walk in and there's all these styles and approaches and ideas coming together to make one place beautiful and interesting. And yeah, sure. Not everything is your taste, but you can really leave with a sense of appreciation and respect.

Julia Terhune:

Perhaps if we considered the aspects of rural communities, the same way we consider the different aspects of different artistic approaches, perhaps then we can start looking for those commonalities and finding creative solutions.

Julia Terhune:

Thank you, Brian Eggers for not only being interviewed, but for letting us use your music for all of these episodes. Thank you to Dr. Phillips for your time and your contribution to this project and so many other projects we've looped you into over the past years. You have been such an asset to our team.

Julia Terhune:

Thank you to Kayla and Ellie. We are so excited that you are a part of our program and can't wait to see all of the creative things you do with your career. Thank you as always to Dr. Andrea Wendling for letting me exercise my creativity through projects like this. And thank you to all of you for listening. We couldn't do this without our listeners, and we are so grateful for your time. We have more coming for you this season, and we hope that this podcast will inspire you to make rural your mission.

To tell you that we are experts in Rural Medical Education is a bit of an understatement! We have been training and retaining rural doctors in our state for more than 40 years! So, let's take it back to where it all began, the U.P., and learn how it all happened from the man that was there!

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine. The podcast is produced with funds from the The Herbert H. and Grace A. Dow Foundation and The Michigan State University College of Human Medicine Family Medicine Department. Welcome to season two. I'm your host, Julia Terhune, and I hope you enjoy this episode.

I don't think there's been a week that has gone by since I started working for the college of human medicine that I haven't talked about how we have been recruiting, training and retaining rural doctors for over 40 years. For those that I work with, I'm pretty sure they were able to dub those words with almost my exact inflection. I talk about it all the time and not just because it's my job, but because I'm really proud of the outcomes of our program. I'm really proud of the work that everyone for decades has put into the success of our medical students and the success of the rural medical systems that take our medical students. Now in 2019, I get to change my script just a little bit because this year we are celebrating 45 years of rural medical education.

In these 45 years, we have been able to show the outstanding and significant outcomes related to developing the rural medical workforce, and we have expanded our rural medical education certificate programs to include two additional rural campuses where students can receive that certificate. Those campuses are now Traverse City and Midland. With that expansion in 2012, we have been able to cover the map of Michigan with rural medical education opportunities. Those opportunities provide students with an understanding of the unique needs found in many of our rural regions across the state.

For those medical students who want to get rural medical training, they can pick from two different programs, the rural physician program based out of Marquette or the rural community health program that's based in either Midland or Traverse City. Both programs are under one big umbrella called the Leadership in Rural Medicine program. But this umbrella wouldn't exist at all if it wasn't for the men and women who worked so hard to establish rural medical education opportunities in the upper peninsula starting back in 1974. To honor this legacy, we wanted to showcase the man who was there when it started and let him tell you the story about how it all began. Dr. Daniel Mazzuchi was an internal medicine doctor who came to the upper peninsula of Michigan in the late 1960s.

He was an integral part of establishing the program first in Escanaba and then in Marquette in later years. His influence on the college was so tremendous that much of what he's established during his medical education career is still in place today. Dr. Mazzuchi sat down with Dr. Andrea Wendling, the current director of our program, and told us the story of how it all began.

To talk about medicine in Marquette, you have to kind of... Medical education in Marquette, you have to kind of break it up because nothing happens in a vacuum. The political factors that went into allowing the UP experiment, which is what it was called, to be started, the people or cast of characters involved in it, and then how it eventually evolved as medicine evolved in the UP.

We owe a great deal of credit to the development of our Marquette campus and our rural medical education heritage to the late Donald Weston who served as Dean of the college of human medicine from 1970 to 1989.

He's the reason why we're here. I mean, that's a simple declarative sentence. He was a fly fisherman and he and his buddies were up fly fishing somewhere in the mountains. They were dreaming. They were iconoclasts. People really have no idea how iconoclastic they were. They thought that they could develop more of an apprenticeship model of medical education. They thought about it for places like they were fishing in, Montana and Idaho and all. Eventually that became the whammy program. They were also very politically aware and connected and hung out with politicians from the state government. They were drinking and talking and talking about this stuff. One of the guys said, "The hell you thinking about Montana for? I mean, we have a problem in the UP. Why don't we do something in UP?"

People up here in 1973 had an idea and that was to have this apprenticeship model on an experimental basis built around a practice. He got a lot of communities interested in it. Eventually Escanaba was the site they chose, not Marquette. They hired a guy named Paul Warner and another guy named John Hickner and they developed a family practice down there and he put students in there for all four years. Unheard of. This was an experiment. 10 students every other year. After about three or four years, the LCME called Weston and said, "If you don't stop this, we're going to discredit the school."

Why did they say that?

There was no way... Unless the students decided to take national boards on their own, the LCME could judge the progress of people. The curriculum was let's call it innovative to sprain the meaning of the word. In terms of available data, the students were doing fine, but the available data wasn't sufficient in the minds of the people who were in charge of the LCME at that time. The long and short of it is a compromise was reached to relocate the first two years back to campus and to make this a clinical campus, but with a different mission. That's lasted to this day.

Yeah. What was that mission at the beginning?

The beginning was to try to resolve the problem of rural areas in getting people to come here to practice or even more importantly, to encourage people who lived here, who would ordinarily want to stay here, to get into medical school, to open the doors a little wider for them. We, by the way, had a separate admissions committee. The thing was it was a day when the decision was placed in the hands of a small group of people who had their own ideas about who should be going to medical school and who shouldn't. Although I would say they were very, very well intended people, I was a part of them. It was a very serious matter for them. But they took to what would be viewed today as an extreme, their desire to be sure that people came back here as much as possible.

The bias, if you will, was very heavily towards people from the upper peninsula as was the intention of the founder of this program. That's what he wanted, but also towards women, also towards older people in general. I would say those things have by and large continued as far as I can see in a much different way and under it. But I think this campus has almost always had at least 50 and more percent women students and has always had a handful... Always had people in their late twenties, early thirties coming in, which I think is outstanding. I think it's the way it should be, but no, it was just that they kind of went a little overboard.

Can you talk about how you figured their curriculum out and how you could coordinate that with the main college?

I did not figure out the curriculum. Okay?

Okay.

I worked with department chairs. Department chairs were responsible for the curriculum here from day one just like they were everywhere else. It wasn't a detached program. It was an integrated program. It had people in the department who believed strongly. It was not in a vacuum. It was all integrated and carried out under their distant supervision. Every department had their persons here. They were likely to be local and they made regular trips up here. The students took always the same exams that happened on campus. All that other stuff [inaudible 00:10:25] But anyway, yeah, that part I would describe it as real but imperfect. It wasn't perfect because it wasn't next door. It was far away. I went down there as associate dean in '84, five, six, and I was responsible for all the campuses.

I came back here in '87. I think it was when I came back and took stock of things and I thought to myself, you know what, this place looks like every other campus there is. That's not good. It might've been while still I was... I don't remember exactly, but somewhere in there in the '80s started thinking out loud, we need to do something to make this a special program again. Yes, we were no longer called the UP experiment. They were called the UP campus. Yeah, we had had some graduates and they were practicing all over, but a lot of them are in the UP. I thought, hmm, why not a two month long family practice experience in the little towns of the UP with the people who graduated from this program as their kind of overseers and so forth? Ultimately they gave permission for us to do a two month long...

In addition to the one month, a two month long family practice experience in these little tiny towns.

That extended time in rural family medicine lives on for our rural physician program students in Marquette. I know students are thankful that Dr. Mazzuchi started that model, and I know this because I was able to talk to one of the graduates of the program. Dr. Nicole Zimmer is now a family medicine resident at the MidMichigan Family Medicine Residency in Midland, Michigan. Her longitudinal family medicine experience set her on that path that Dr. Mazzuchi had envisioned. What was a highlight of your time up at the Marquette campus? If you could pick a day that you could relive right now, what would it be?

I really enjoyed... We do 12 weeks of family medicine up there. Four weeks was in Marquette and eight weeks we spend kind of in a rural area. Mine happened to be Ironwood. I loved everything about being up there. It was in the spring, so it was absolutely beautiful. I mean, you could go on the trails. Everything was opening up. I worked with this physician, Dr. Hubbard. He was absolutely an amazing teacher and wonderful and hilarious. I mean, sometimes you get nervous about eight weeks one-on-one with a physician, but it flew by. He was a great teacher. He was amazing. While working with him, I had my very first delivery. It's still just like rocks me to this day. I remember going through the motions with him.

We're kind of talking about, okay, during this stage of labor, this is what you need to do, and this is where your hands need to be, and this is what you're checking for. It was really funny because they didn't find out what they were having, a boy or a girl. I was so excited to deliver this baby because I wanted to tell them this couple if they were having a boy or a girl. When the baby was born, you're supposed to suction and dry off the baby a little bit and then pass it up to mom. Well, I was so excited I kind of forgot about that. I held the baby up like Simba and I was like, "It's a boy." Everyone starts crying and they're all excited. Dr. Hubbard just gently nudge me. He was like, "All right, Nicole, bring him back down."

Then of course, we do the suction and the stimulating and the baby was perfectly fine and crying and everyone was happy, but he always joked with me after that in all of our deliveries. He goes, "Don't do the Simba move this time." It's just kind of stuck, but it was my first delivery. My love of OB as a primary care provider just blossomed on to that and I hope to do that in my future practice. It's one of the reasons I chose this campus too based on the rural medicine and the OB experience you get here. I knew at that moment it had to be part of my life. I had to be delivering babies. It was just such a thrill.

The first team we sent to Haute, two girls, two women. I remember on the front pages of the newspaper, there are pictures there. I remember the little teeny hairs on my head standing up. I go, "Wow. This is exactly what I'm looking for." I mean, they treated them... They had never seen students before. None of these people had ever seen students before. They treated them in a truly heroic fashion, and they had the greatest hands on experience since we went to medical school. You don't want to know about our hands on it. I grew up in the city hospital. I mean, honestly God. But anyway, it was an overnight success and what better people to have as teachers than people who are your own graduate.

I think part of the benefit of a program that's been so well-established is the connections that are made. When we had to set up rotations there, it was office staff who had worked with that physician for the past 20 years. They'd been taking students that whole time. The atmosphere of education and learning and opportunities was already set up. We didn't have to forge the way for that. The previous students and administration, they have been done. We're working with physicians in the community who loved what they were doing, love the UP. They were great teachers. Having that 40 years experience allowed them to realize, "Oh, hey, I know that you guys have this during this rotation. Let me help you out, or I know in the past students have really struggled with this part of the exam.

I think you should read these materials." They were really helpful with resources or kind of identifying weaknesses before you even got there because they had seen students before you who are weak in that area or realizing there was a very human aspect of it too as far as realizing, okay, I know that you have an exam this week. I know that there are surgeries planned for late, but you had seen dozens of appendectomies, why don't you study and we can catch up after this case when the next one comes in? There was definitely opportunities to foster both the educational experience in the classroom still with bookwork and hands on experience. They were really great about realizing kind of what we needed as students before we really knew ourselves what we needed most of the time.

Last year we did a study where we looked at the impact of the undergraduate medical education program and the workforce in the UP and really its impact in rural areas throughout Michigan. We took all of the graduates from the UP campus over a 30 year period, from 1978 up until 2008, and looked at where they were practicing in 2011. What we found was that 27% of all of the graduates of that program were actively practicing in a UP County in 2011.

It's amazing.

Yeah. The impact that that has on the workforce for the UP sustained over time is amazing.

We used to wonder out loud with each other, you know, how much longer we'd be working here.

Yeah, yeah. Now it's 40 years and it's made such a difference over time. The other thing we found in that study is that the mission of the program based on outcomes has actually strengthened over time. We looked at the first decade of graduates, the second decade, the third decade. In the more recent graduates, it's actually a higher percentage of them are from the UP and a higher percentage of them stay in the UP than even early on.

That's wonderful.

It is. Because we worried a little bit would we we saturate what the U P could need even over time, but it doesn't appear to be. It just strengthens over time, which Bill Short at the time we published the article, his theory was that having the graduates of the program become faculty has actually strengthened the program over time both from a mission fit and from a stability fit for the community.

It makes perfect sense to me. It's easy to look at it once it's already happened.

Right.

It was one of our goals for sure.

Yeah.

One of our hopes. I do think that this campus, and perhaps a couple of others, provide students with more clinical hands on experience than most campuses in most medical schools across the country. We used to assess that or try to assess it by asking them after they finished their first year of residency, how they compare to people in their class, and they are always... Many of them had way more physical experience delivering babies hands on in the OR, that kind of thing. They really had a lot of real doctor type experience.

We just did another survey of the last 10 years and that message came through very clearly that they felt like compared to their peers, they had more one-on-one experiences. They had more OR time, more face-to-face patient time, early triage, and then procedures, delivering babies and first assisting in surgery, which many of their peers didn't get.

Our rural medical education programs are a place for rural students to have a home or to return to home. We are also a place for students who want hands on experience in surgery or emergency medicine or even general practice. They can come and learn in a small one-on-one environment. Finally, we're a place for students who want to learn more about health disparity and the needs of those who are most vulnerable and find a way to fix and solve those problems. Some of our students want all three of these things and we provide that too. We leave you today with a short testimony of what this legacy has provided one student, who at the time of this interview was only a medical school hopeful and is now part of our incoming class of 2023. John Berglund is from Bergland, Michigan.

This is what John says about the rural physician program in Marquette and what it means to him to have this opportunity.

Well, to be able to start my training in medicine in the region that I hope to end up one day would be huge for me. I can imagine it being a little tough training in a large city for four years or onwards and then making that huge jump to the rural area like the UP, I think it'll be pretty tough. But it's great to be able to learn and train with the people and the patients that I hope to one day care for before I even progressed. Plus, I would not have to leave my favorite place in the world, the UP. I don't think it could get much better than that. If I can give anything back to my hometown, I hope it's that that I can come and serve the people in my hometown and pretty much my whole county. I guess training there would be would be huge because I would get...

I know the people from Bergland and to be able to train in that area and to train there and to get people to know even more and to build that trust and connection before I even start to be a doctor there I think is huge.

Thank you as always to Dr. Andrea Wendling. Her devotion to rural medicine has paved the way for so many students to make an impact in their communities and has been a mentor and example to so many students. It's an honor and a privilege that I get to work with her. Thanks also to Dr. Mazzuchi, Dr. Nicole Zimmer, and the future Dr. John Berglund. I speak for all of us at the Leadership in Rural Medicine Programs when I say we are happy that our relationship has continued for all of these years. I would like to also thank the community assistant deans who help make our rural certificate programs run in Marquette, Midland, and Traverse City. Those individuals are Dr. Stuart Johnson in Marquette, Dr. Paula Close in Midland, and Dr. Daniel Webster in Traverse City.

Thank you for all of the hard work that you do and all that you pour into the staff and students at your campuses. I hope you've enjoyed this podcast, but more importantly, I hope it has encouraged you to make rural your mission.

We started off this season talking about how limited broadband access can impact student performance and the overall well-being of a community. Today we are going from worry to a celebration and talking about the people who make a positive impact on students in rural communities through the public health system.

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine. The podcast is produced with funds from the Herbert H. and Grace A. Dow Foundation and the Michigan State University College of Human Medicine Family Medicine Department. Welcome to season two, I'm your host, Julia Terhune, and I hope you enjoy this episode.

Education levels in rural communities is something to talk about. While rural communities lead the nation in number of individuals who have a high school diploma, according to the USDA, the number of people living and working with any additional education drops right off. In 2016, only 19% of all rural adults had anything more than an associate's degree as compared to 33% of all urban adults. When we look at county data, rural America leads the way in number of counties where more than 20% of the working population does not have a high school diploma. The prospects for higher education in rural America is bleak and it's low educational attainment seems to perpetuate the issues of rural poverty and the vitality of these communities, but there are success stories.

If we drive North to beautiful Charlevoix County, we will get to a five square mile town called Boyne city. Boyne city is home to around 3,750 people, most of whom are over the age of 40. The average family in this area makes about $31,000 a year, which is more than $20,000 less than the mean income for the state, allowing for the average poverty rate in the county to sit around 12.5%. Like the rest of rural America, the majority of citizens have no more than a few college courses. Meaning that 60% of the population of Boyne City has nothing more than a high school diploma. For all those listening who are interested in medical access in rural Michigan, the health resource and service administration or HERSA has designated Charlevoix County as a health professional shortage area for primary care, dental care, and mental health care.

In 2018, Boyne City High School saw some amazing students graduate. In fact, around 115 stellar graduates came out of points city, if we're going to be straight about it. We are going to talk to three of these amazing students, but I want to quickly set the stage. Boyne City High School graduates are coming from a rural school in a county that has some big social factors to overcome. 38% of all the students at Boyne City High School receive free or reduced lunch, and around 18% of the population that lives on less than $35,000 per year are families with children.

Furthermore, I took the Liberty of plotting how far a student would have to travel to get to the nearest four year university from Boyne and I posted that map on our Facebook page, but I'll give the bag away. The closest four year institution to Boyne City is Lake Superior State University, which is over 90 miles away and across a five mile bridge. Therefore, options for a close to home education don't really exist for young adults looking to get something more than a high school diploma. But I told you there were success stories for this episode and there are. It's just that the students that have found their way to higher ed had more work to do than you would've expected.

So let's introduce our leading ladies, shall we? Katie is going to Northern Michigan University. Katie is the daughter of Joe McCue who you heard earlier this season and is the oldest of a big family. She's staying in the state, but remember NMU is over 150 miles from Boyne. Maddie is going to Brown. Yes, Brown, and is going to tell you a lot about her trail to an Ivy League education and Anna, well, Anna is going to Stanford, you know the number two university in the world.

So what is different for them? Anna, Katie, and Maddie graduated from a class of around a hundred to 115 people and when I asked them about how many were going on to university, they had this to tell me.

University, university? Maybe 40? 50?

Yeah.

Probably 40.

Yeah, because a lot are going to [crosstalk 00:05:04].

Community college.

Yeah.

Okay, and is that pretty standard for your area?

That's pretty good actually. Yeah, our grade I think had-

very ambitious.

Ambitious, very academically inclined grade at least compared to others and the three ahead. Or even the three behind. Just looking forward. Most of our students put academics before a lot of other things, which was kind of uncommon.

So was there a lot of competition then in your grade academically?

Yes.

Yeah.

Yeah.

Everybody was applying for the same scholarships. It's like, "I don't know if I want my friends to read my scholarship letters because they're applying for the same ones." It was hard.

If you look at the top 10% of our grade-

Of level four.

Yeah, it's super impressive the number of people who-

The top 10 had above [inaudible 00:00:05:58].

Yeah.

Okay. So what is different? Why is your class different than the three ahead and the three below?

I have a little bit of theory.

Okay.

So in fifth and sixth grade the math classes were accelerated or there were some accelerated math classes, which was a newer thing in the middle school and they [crosstalk 00:06:21].

They took a whole chunk of us and just pushed us forward.

IT pushed us up and then the chunk right behind us ended up meeting at the same place in eighth grade where we were all in an accelerated class and that was 30 students, and those 30 students continued to be the top 30 in the grade all the way through high school because they've been pushing our grade.

There are lots of educators who care and care a lot about encouraging and promoting student success, but the concentrated effort that these Boyne City graduates experienced is a positive benefit of being part of a rural school. A rural school where they had the ability to identify and focus on those 30 high achievers. This concentration didn't just stop with that top 30. It had an impact on all the other students as well.

Yeah and [crosstalk 00:07:12].

But it grows everybody else up because now the standards-

Yes, now there's more competition.

... Were being good or academically good for lack of a better term is so much higher than everybody else raises. Yeah.

There's something else about the accelerated English classes too with that. The same 30 people are in that.

Because there was so much of a demand.

Then it just kind of ... Everybody had to be working a lot harder to be considered the standard.

So are there any other theories that you guys have [inaudible 00:07:41]?

we were really close and we just so it was all this really positivity. We were are really positive grade and we all had these great outlooks on the future and every chance that we got that we could improve on those AP classes or advanced classes everybody took it, because we'd all just saw this opportunity to do better.

And it almost became a social thing in the sense of if you're in honors English now you get to be with all the fun people in the honors English. So now our honors English class is 30 kids big and it's fun. Or AP World or calculus or physics. You get to be with your friends.

Yes.

So 98 people, that's easy to do, right? If 30 people can easily have an effect on 98 people. So if you guys were at a bigger school, do you think he would have had that same effect or do you think that that would've been the status quo?

I don't think we would've. I think we would have just been that one class full of nerds.

Yeah, because [crosstalk 00:08:44]. You have all the opportunities. It's open everybody normally. And so it's just kind of like, "Oh, it's still part of the thing." You don't as involved because it's just your educational process. There's nothing different. You don't have to fight. For those advanced classes.

For us, we had two AP courses offered taught by teachers and so if there was an AP course everybody's is like, "Oh my gosh, there's something new. We all need to take this." It's really cool where it's like my cousin goes to a bigger school and it's like, "Oh, we have five to 10 AP courses offered and it's no big deal." You take it if you want to take it [inaudible 00:09:24] show your college [inaudible 00:09:26] college SAT scores and all of your grades throughout your previous classes and your grade point average. We didn't even have a [inaudible 00:09:35]. You have to get teacher recommendations to get into these advanced courses because everybody wants to do it.

There's a benefit to that fight that Katie and Anna spoke about. It can prepare you for what comes next. We talk about the plight and vulnerabilities of rural areas on this podcast often, but we also need to highlight the resilience, the tenacity that living with limited resources can provide. Catherine Ellison was from my small town. She is one of those brave souls we speak about who goes away, gets tons of experience in education and comes right back to the community. She is currently the elected school board president for [inaudible 00:10:16] Public Schools and I asked her about the barriers, both perceived and real that rural public school graduates face.

Well, talking about your perceived in reality. I think it's perceived through a disadvantage. It's a smaller school. Maybe they don't have as many offerings as a big school. You have the same teachers for years and you see the same people in the hallways but in a lot of ways, especially with today's these kids where everybody's on their phone, on the computer, you on the tablets, there isn't that social interaction. Small districts can be great. I mean, you're still going to learn how to read and write and do math, all those basic things. But you're also going to learn people skills? You know everybody you're going to school with, you're going to have a conversation with them, not just on the internet. Right? So there is for that focus. I mean, and teachers care about you because they know you. I mean, you might have the same kid two or three years if you're, you know, teach different subjects in high school or something, right? So you get to know those kids.

So I think that's the real advantage is, is the customer service, if you will. Teachers know their kids. Administrators know the kids. It's a small district so a lot of times you'll see a kid ... If you were elementary school teacher you had then so I think you care about those kids as a result because they're not just another random face in the crowd.

Did you feel you had any advantages?

I mean I think some of the advantages were certainly that, and I was a shy person, but I could talk to people. I wasn't afraid to talk to a teacher because one, I had known everybody in my class since kindergarten, it's the same people. So it was no big deal to get up in front of those people and say something or ask a teacher a question because you knew everyone. So in college, I think that even though I clearly didn't know everybody in my class there I was like, "Well, we got to go talk to the teacher. We've got to ask them the question, we've got to ask the professor a question. This wasn't such a big deal." Which can be the advantage because then once I became a professor I knew if a student makes the effort to come talk to you out of a hundred kids you might get two, I'm probably going to look on them a little bit more favorably when it comes to grading time. Just because they tried, right? They made the effort. A lot of kids don't. I think that is really an advantage, right? To kind of learn that, not be afraid of those people in front of the classroom.

So what barriers do you guys perceive you had to getting higher education being in a rural school?

I didn't know about a lot of things going in freshman year. Just like the courses you can take, all the places that you could apply. It was kind of like a cookie cutter path because it's such a small school they can't offer all of these advanced classes. So when you go to a big school you can just pick between all of these AP courses. For us, even freshman year we knew we were going to take AP world at some point and AP calculus at some point and that just in between you got to pick your electives.

I think also, I mean not to hate on our school. Clearly we had a great academic experience at our school, but in a place that small the measure of success for a school is everybody graduating. That's what they want. They want to push kids through. They want everybody to graduate, which is a good goal. You do want kids to graduate. That's important and for everybody to have a high school diploma, but because of that when it's set up it's set up with the goal of everybody graduating. The goal is not, "We want all of these kids to go to crazy academic institutions." Or anything like that and so when you're setting up your school system for that middle of the road section of your class, then sometimes the top portion has never pushed hard enough. Right from day one it was never, "How are we going to get you into college? How are you going to do this? How are we going to do that?" It was just, "Okay, these are the classes you have to take to graduate."

And I mean, granted, nothing against our school. We had great counselors, academic advisors, but it was hard where we only have two AP courses. I felt that the staff definitely helped me and it was a personalized learning experience, but sometimes I felt like, "Why can't you help me more?" I feel so bad because our counselor's the nicest lady ever.

She's so nice.

She was so sweet to us, but I remember standing in a hallway with her and her saying, "I don't think we're going to have room to put you in this college level government class." And me, because it's saved for the people who are trying to do the early college through the community college and me literally looking at her and being like, "I will bring my own chair and sit in the back every day."

Now how's that for overcoming barriers? Another perceived barrier that we have to deal with in rural communities comes in the form of diversity.

So where it's not diverse culturally, it's very diverse in the sense of living situations or incomes. It's not everybody who lives a life similar to me, it's here. I feel like people live so many different ... If I went to a big school I would find my niche group and I would hang out with probably people who are similar to me and have similar beliefs than me. Here I sit at my lunch table and every person around that table has a different living situation, different to political view and stuff and we just fight it. It's so fun because it's interesting if they can learn from them and stuff. So even though culturally we're all very similar, I think that sometimes you lose that view that's important with income and everything.

I'm sitting here and in my community, I'm a pretty average run of the mill normal living situation, normal everything but from their perspective I'm being recruited by the minority and low income and I'm like, "Huh, that just feels kind of odd that if I go outside of my community I'm in such a different place than they are as compared to all the people I know." And that's just kind of a weird identity thing. I never thought that I will be putting low income as something that my identity as they're trying to recruit me and I'm like, "This feels weird. This feels weird.

And you're comparing yourself to ...

Yeah, and I have to compare myself to a whole different group of people, different groups of students. In Boyne City it's a normal place, but anywhere else where you have to go you're ... The whole environment just makes you reconsider. I've never felt bad about myself in Boyne and I still don't feel bad about myself going up there because it's I love Boyne, I always have this to come back to, but it's just weird.

I mean from the rural standpoint, I feel like the same as you. I'm going out and we're competing against students who have been taking prep classes all four years. I went out last summer for a camp at Brown and all the girls in my dorm, I told them that I worked during the school year and they were just amazed. They're like, "How do you have time with that? Don't you take prep stuff after school?" And I'm like, "No. Then how are you here?" And I'm like, "Ooh, okay. I wonder ..." This is a story I always tell and I'm not like a redneck by any means in any way, but I went out there and I had six girls with me, totally different backgrounds. One was from London, Shanghai, Sudan, all of these places. And we were all just hanging out and talking about TV or something. And I went ... We had a 12 pack of water wrapped in plastic and it took out a Swiss army knife, a little tiny Swiss army knife and cut it open, and they all went silent. They were like, "What is that?" And I'm like, "This isn't a Swiss army knife." And they were like, "Why do you have a knife?" And they were horrified.

And I'm like, "I'm cutting open water. The blade is like-

It's a tool.

It's a tool. It has tweezers. What are you talking about? They were wary of me. They're like, "Why do you have a knife?" And I'm like, "Because I do. Because I have to cut things. Why are you ..." It was just so weird. Just like, "I'm going to go out there and be such a redneck." [crosstalk 00:18:42].

You will always be the girl who had a knife.

That's right. They were so afraid of me.

So what things are you very prepared for from your rural school experience?

Actively seeking out help. That is going to be huge because I mean I was taking these classes and I was the only sophomore high school student in the class full of college students and I'm like, "Oh, this is horrifying and scary. I'm so out of my element." I know the second I go off to school I'm going be like, "This is horrifying and scary. I'm out of my element." Well, I've done it before. So it'll kind of give you the little prep, a little boost like, "Oh, well maybe if to do some extra research. Find the professor who knows what they're talking about and talk to them after hours." Because we can text some of our teachers.

Yeah, that's definitely helped me. Just being able to know how to build a relationship with my teachers and be able to know how to ask for help and get help and stuff because everybody I've talked to is like, "The first year I was just stubborn. Didn't get help from my professors and that caused me to fail classes and I was just going in expecting my professors are going to know my name. I'm going to have their cell phone number, any problems I have they need to help me."

Bake them cookies.

Yeah. I was going to be best friends with my professor because that's just how it's been at Boyne. We'd go camping with some of my teachers at the end of the year and ...

And also the concept of personalized learning. Like getting to know, I know all of my teachers so well at this point. And then yes. So my senior year, I don't really have many options to take advanced courses, but because of that it's like, "Oh, I know for example, like Mr. Pantone really well, he understands my learning process." So I did an independent study with him where I could dive so much deeper into something outside of the normal curriculum bubble, but still advanced me for college in the future and just being able to, I don't know, have a personalized learning schedule and have teachers and staff that were invested in that. If you said, "I wanted to do this." Yeah, there were definitely some hiccups, but they were willing to help you. It wasn't just ... You knew them so much better.

And I remember at graduation I looked at all of my teachers and I started crying because I was so, so grateful for what they had prepared me for and how they'd gotten me to this point. I think I couldn't have imagined anything better.

Being a rural student means that the hill success might not be as tall, but it's very steep. You need people around you to help you along the way. Being a rural teacher means that you don't have quite as many students to work with, but the amount of effort you have to put in because of your limited resources makes up for that lack of numbers. One of those quality over quantity teachers is Mr. Pantone. Anna has already mentioned him, but all three ladies mentioned him over, and over, and over again throughout the course of my interview. Mr. Pantone's job at Boyne was tough and it's only gotten harder as the political and social climate in rural America has changed, but when I asked him why he does what he does, he had this to tell me.

What I love about it is what I consider to be results. I think kids come out of my classroom with an appreciation for the importance of thinking for themselves, for problem solving, for questioning everything. Instead of a long list of classrooms rules I have one rule and number one rule is I'm allowed to ask you to think. But it is an energizing profession and it is different every single day. When you're dealing with over a hundred different students on a daily basis, there's a ton of stories and ton of personalities and all the rest of it. But most importantly, every day you can walk out of here and say you accomplished something and I don't think a lot of jobs are like that. I can look up the numbers, but we're well over 50% free and reduced lunch here and that's shocking in a community that half or more of the families need assistance just to feed their kids. It's, again, sometimes pretty evident and that brings with had all kinds of different issues. Right? Just on a day to day basis.

When I taught in the alternative school, first in Bel Air and then in Charlevoix I brought food to cook every day, because after about a week of being there these kids weren't eating. They didn't have any food. I had three kids in my Bel Air school that lived in a trailer, abandoned trailer on State Park Land that they had left, you know, they were 15, 16 years old and they weren't welcome in their homes or whatever. Didn't have one. So they got together and they found this trailer and they were living in it. So every day for several years, I cooked breakfast. Every morning I'd pick up a dozen eggs and some bacon or whatever, pancakes. We had different things and started our school day just cooking and eating and what was called breakfast table and we'd just sit and talk, but I didn't see how they could get through a day without some food so I always keep food here.

You broke down a huge barrier with that. If you feed people, it means the great unifier.

Yeah. I hadn't thought of it in that way, but in retrospect I'm sure that that was a big part of it. For me, it was a simple matter. These kids aren't going to be able to get through the day, you know?

But what would you talk about at breakfast table?

Oh, lot of stuff that we shouldn't. Stuff that they were doing and I would always just in a mad judgmental way try to get them to talk about how they were living their lives and they would use it as like, "Let's see if we can shock Mr. P." That kind of stuff but for me it was an opportunity for them to listen to themselves and to listen to some of the challenges that their friends brought with them. So there was this common sense that I refused to normalize and in a sense that I would say, "That can't be you. That can't be you. That somehow that can't end up being you." I don't even remember the question you asked me about breakfast table, but you're making me think about things I haven't thought about in a while, you know?

I'm doing my job then.

Okay, good.

I'm allowed to ask you think.

Yeah, no. My wife said, "What are you going to talk about?" I said, "I don't have the least idea." She just wants to say about rural education and this is part of it. The meth, it's part of it. The prison population is part of it. The mixed and multiple families, combinations of five or six blends of kids living under the same roof with sometimes with neither of their biological parents. You know? That a woman and a man had a child and then the husband was taken away or whatever and so the mother remarries and then she takes off and the kid stays with the dad and his new wife because the mom's gone. You have these incredible combinations of families and they're families, but the standard two parents stable two jobs, that's the exception.

Mr. Pantone has had so many things come his way over the course of his teaching career. Many of the hardest parts of his job circulate around an under-resourced, undereducated community that has a hard time accepting outside ideas and innovations. It makes the job of a progressive, empathetic, hardworking, and caring individual like Mr. Pantone harder than you'd expect. So I asked him why, why does he keep doing what he's doing?

So my report card comes the day the seniors graduate and they're all allowed to sit and write a letter to a teacher, and this was this year's letters to me. Making me think and treating all of your students as adults. This is why they want to thank me. Your classes have prepared me for my future and I can't imagine where I'd be without you making me question my thoughts and motives. I know that I didn't participate a lot in class, but I was always interested. You're an awesome teacher. Don't let anyone hold you back. This is my report card. My last thank you had to go to you. You're the first teacher I've ever had to treat us like students ... Treat us less like students and more like people. You will never understand how much I appreciated that.

You showed us real issues, real problems, real things that no other teachers were brave enough to show us. Your classes shaped me into a person I am proud to be. This is my report card and this is why I come back. Because if I don't do this, who's doing it? These kids deserve a chance to do this, to think and to question stuff and I don't mind saying that I am willing to take the heat so that they can have that. This letter this girl wrote me, woman wrote me the other day was like, and she's [inaudible 00:29:41] really strong, strict Christian, very anti-abortion, lots of things that if it would come up to me and her having a discussion, we would disagree about. All she could do is praise me for tolerating opinions, for defending her right to express herself, for not letting kids ridicule her for her Christianity. All this stuff. This is me. I'm the stupid, crazy Liberal, you know? And we could have answered this question a long time ago. Why do I do this? Because it's important to these kids and they matter and they should matter to this community.

There's one last bit of information I need to express to you before we go, and it's logistical in nature. So let's let the school district expert let you in on it.

Well, I mean, I think the biggest issue with schools everywhere, including rural America is funding. And from the political end of things, I mean that's where the money comes from right? From the state and it comes with the kids but when you're a small school, I mean you recruit the hell of it to try to get kids to come to your district, but the dollars follow the kids. So unless you can get kids in, you don't have money. Well, then you end up cutting teacher positions or you cut programs like art music to try to make ends meet, and the state is currently very sort of back and forth. Governor Snyder said, "Hey, I want to give all this money back to schools and increase that per pupil amount for this upcoming school year." Which is great, except it means we're pretty much just back to where we were 15 years ago before things got cut. So it looks like this great increase but in reality it's just back to where it was.

I'm highlighting what Dr. Ellison said because it gets to the heart of helping rural people thrive, other people. To be funded, school districts need students. To keep students, schools need strong, excited teachers to help them learn. People like Mr. Pontoni. People like Mr. Pontoni need people to support him in his work and it then goes back to students. He needs students to have a job. It's the great Mandela. In rural communities there is tremendous need, but there's also tremendous opportunity. There are barriers to overcome, but by overcoming these obstacles, students can create for themselves a skill set that will set them up for life. The takeaway is this, empowered people have to come back to these rural areas and empower the next generation. Set an example for how to hurdle over those barriers and make a difference in the lives of the people that live there. If a few teachers can make big of an impact on 30 high achieving students and those 30 high achieving students can pull the average of 94 students way, way up, and if one teacher can encourage and empower a few students enough to set them on the path towards the top universities in the world, imagine what you can do.

Thank you so much for listening to our podcast. As always, we need to thank Dr. Wendling for empowering medical students to going on and pursue a career in rural medicine. I also want to thank Anna, Katie, Maddie, Dr. Catherine Ellison, and Mr. Pontoni for taking the time this summer to speak to me. I hope that this podcast helped you realize what's needed to help bring up the status quo of all rural communities and that you feel empowered to make rural your mission.

This week we are taking a part-two look at the opioid crisis and talking about who opioid addiction really hurts: children. The foster care system in this state is flooded with children who have had their lives impacted and uprooted by opioid addiction. In this episode we will hear from CPS workers, foster care parents, family service professionals and addiction councilors.

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine. The podcast is produced with funds from the Herbert H. And Grace A. Dow Foundation and the Michigan State University College of Human Medicine family medicine department. Welcome to season two. I'm your host Julia Terhune and I hope you enjoy this episode.

This season I knew I had to address the opioid crisis that is affecting rural communities, but I really didn't want to do it in the traditional way. Truly because there is so much to unpack and in my opinion, I think that when we talk about the issue, we have a tendency to either focus on numbers or start blaming and pointing fingers as to why and who and when and who's not being considered and what the real root cause is. Really what I think is that isn't where any of the conversations should start because it doesn't matter. It doesn't matter how it all started. It's here and it's affecting real people and we have a problem.

We're going to talk about the real consequences and why we should care and why we all should care is because we're talking about children. When it all boils down, the people who are really affected the most and the longest in the midst of this crisis are kids. So in the efforts of impact and to contextualize this real issue, we are going to tell the story of the Brown family. The Browns adopted both of their children from foster care and the origin story for why they are together and a family today is because of opioids.

Back in 2010, Todd and I decided to go for foster care and in 2012 we were gifted with two wonderful children, their ages were nine months and four years at the time. They had been taken out of a home where they received trauma from abuse and neglect and they were placed in our home in a very short amount of time. From the call to the time they arrived in our driveway was about 45 minutes. They came to us, very malnourished. They were very dirty.

We believe they were under the influence of cannabis or second hand of cannabis because they were very dazed and confused. Our foster son at the time was very underdeveloped. We could tell that he had speech issues. He had gross motor skill issues and the little girl, our daughter now, which was nine months at the time, she weighed about 12 pounds and she wasn't able to crawl yet. She was just barely rolling over, so they were very much on the lower end of the scale of development.

Our children's mother had an opioid addiction and actually her mother overdosed on opioids in front of her and died when the mother was about 19 years old. With the opioids, we have all of our children's medical reports and our daughter, especially when she was born she was born at 31 and a half weeks, so she was very premature. She was less than three pounds. She was addicted to meth and cannabis and there was many things in her toxicology when they pulled it. So they had to put her on Suboxone and a bunch of different other medications to help her come off of that addiction along with trying to build her way up because she was so small and she was a premature.

Because of that, now she is a fully developed child. If you saw her, she's very small but she is fully developed mentally and physically and all that, but she does suffer from deteriorated vision in her left eye because of the opioids. So unfortunately she has a patch that's over her right eye right now trying to strengthen her left eye.

That's one thing. People will always say to me, "Those kids are so blessed to have you," and to me it's not that. We are blessed to have these kids. These are awesome kids and once you get to know them and once you see how many great things they can do in their life, it's such a treat. It's just such an awesome, awesome experience.

According to the Center for Disease Control adverse childhood experiences, or ACEs, are referred to as potentially traumatic events that occur in childhood zero to 17 years such as experiencing violence, abuse, or neglect, witnessing violence in the home and having a family member attempt or die by suicide. Also included are aspects of the child's environment that can undermine their sense of safety, stability, and bonding such as growing up in a household with substance misuse, mental health problems or instability due to parental separation or incarceration of a parent, sibling, or other member of the household. Adverse childhood experiences have been linked to risky health behaviors, chronic health conditions, low life potential, and early death.

So if we put some data behind all of this, according to the Institute on Drug abuse, babies being born addicted to opioids has gone from less than one baby per a thousand in 2014 to more than seven babies per thousand being born addicted in Michigan alone. That is an eight fold increase. That means that more than 125,000 children each year are being born either addicted to opioids or living in a situation where they are either removed from their families because of that circumstance or living in a family where there are real consequences of opioid use streaming in almost everything they do in Michigan alone.

So it's time to consider this and start talking about solutions. I spoke to five experts on the topic of children and opioids. We're going to start with Marnie Taylor from the Isabella County Child Advocacy Center. She is going to introduce us to ACEs and then we are going to jump right into talking about foster care with my friend Afton and my friend Doug Lewis.

Afton is now a child protective service worker and Doug Lewis is, well, he's everything. He's a biological foster and adoptive parent and he has been for more than 30 years. He was a child and teen advocate, a foster care worker, an addictions counselor, a community volunteer, a business person, a pride teacher. That's the class you have to take before you become a foster parent and now he takes care of the homeless in rural Michigan. He's also a light in a dark world.

[inaudible 00:08:02] has a high use of opioids and other drugs, but because that is an ACE that is going to increase the number of adverse childhood experiences that a child is going to have if they're exposed to a loved one, an adult who is their main caregiver if they are addicted to heroin or opioid prescription pills. But furthermore, an incarcerated parent causes an adverse childhood experience as well. So if that is happening within families, they have not only a parent who has a substance use disorder, they also more than likely will have a parent who becomes incarcerated at some point in time.

So ACEs are comorbid typically because when one adverse childhood experience happens, then it's highly likely that other adverse childhood experiences are going to happen because of the chaos that comes around that experience. Though, if a family is going through divorce for example, that in and of itself is an adverse childhood experience, but then when you start to look at the number of maybe domestic situations might be going out because of the divorce. So that child's being exposed to some kind of maybe abuse or neglect, even if it's emotional abuse or neglect, those kinds of circumstances increase substance use probably increases in terms of coping mechanisms and people dealing with a difficult time in their life. So it's very easy when one adverse childhood experience happens that others are happening along with that.

You can talk about it being the choices that their parents make in order to have the drugs or the choices they're making while on drugs. So in terms of neglect, children aren't removed from their families because of poverty. However, there is a lot of poverty associated with drug use because money isn't being spent on food, it's not being spent to pay bills and those create very unsafe situations for children.

So you get some of those cases being the reasons that children are removed and then the next broad area is of use and abuse of course gets broken down into the types of abuse. But anytime that you are dealing with someone who is trying to I'll say feed a habit, there may be unsavory characters around and then of course there are people who are caring for children while they are high. We know that part of being on drugs, part of being high is that it changes a person's personality, changes their ability to cope with things. So you have a small child in their terrible twos and you have a person who's high and can't handle that and now we have a situation where child abuse is opportune.

Prenatal trauma is that trauma that children will experience in utero while their mother's carrying them. What they're theorizing right now is that we have this genetic makeup, but that our environment can trigger certain genetic things to happen in us. So not only does our genetics determine who we are, but our environment can affect our genetics and in the process change who we are. So if we look at cortisol levels in the brain, those can be genetically triggered by a mother being exposed to domestic violence or having a lot of emotional experiences during her pregnancy that not only is that affect the genetics of the child, but if a woman is carrying a female child in her, it can affect her development of eggs in utero. So not only will it affect her genetically, it could affect her children genetically too, down to the second generation. So it's much more complicated than what we thought. Now, as an adoptive parent, I think we need to understand a little bit what families.

I think we need to understand a little bit what family systems may look like in a dysfunctional family. I go back to some training I had when I was young concerning a thing called Karpman's Triangle, where we talk about different roles that people play in an in a codependent family. One person plays the victim and another plays a rescuer, and then they both alternate between those two roles and the role of being an accuser or persecuted or because like how dare you do this? Why didn't you bail me out? Or why do I have to bail you out again?, People began to feel like victims who are rescuers and victims not the relationships to be a rescuer, or so it is just an unhealthy pattern that develop in these families, and you can take them out of that family and put them under other relationships and they tend to duplicate those types of relationships and other systems that you put them in.

I think it's important for us to begin to understand how family systems often look like in addictive behaviors. We know that there are some roles that people play. There's the role of the addict. There's often somebody in the family who will be an enabler. They will continue to cover for that addict and try to soften the blow on them. There's often the role of the hero in a family. This is the child who is trying to make everything perfect, organizing the chairs on the Titanic. They're constantly trying to make everything perfect in their lives. They become very stressed out people. Oftentimes as adults, they suffer from stress-related illnesses. We have the scapegoat or what we used to call the whipping boy in the family, is the child who gets blamed for everything that goes on because we're not going to blame the addict and we're not going to blame anyone else.

Oftentimes one person in that family will be that scapegoat for the family, and that relationship is really a difficult one because they grow up feeling the sense of guilt and shame for everything that somebody else has done. Oftentimes you will have the mascot in the family. They're the kinds of the clown of the family. They try to make everything smoothed over by being, everything's a joke kind of a thing and they will often self-medicate with alcohol or drugs themselves and does thus perpetrate the whole cycle of addiction. I think one of the sadness when is the lost child in the family, a child who just doesn't know who they are, and they just completely shut down. They'll have problems forming intimate relationships. They'll tend to isolate themselves as adults.

A number of my children have come who were born addicted to heroin. Back at the time I was adopting, they were not doing tests routinely in the hospital. I would, for instance, one of my children came to us was I'm two days old. We noticed right away she was almost impossible to soothe. It was because she was going through withdrawal. No one knew. It wasn't until July, we were doing a garage sale at our house and her grandmother came to the house and asked how she was doing. We said, "Well, she," we're both, my wife and are both dazed because we haven't slept in months. We said, "She's a lot to handle." She said, "Well as soon as she gets done going through withdrawal she'll do better." We both looked at it kind of with our heads tilted and said, "What withdrawal are you talking about?"

She said, "Well, my daughter was using heroin through her whole pregnancy, and so she was born addicted to heroin." That was an eye-opener. There are certain patterns that often exist in homes where addiction is the centerpiece of the family. We talk about codependent relationships that develop in those type of families, which often, those type of codependent relationships create a whole level of ACEs for kids that are raised in those homes. You take all the genetic things that have happened to these kids and then you take the prenatal things that have happened to him and now you include in that whole process, some really adverse childhood experiences, and you've got what we might consider a perfect storm for these kids growing up. Interestingly enough, I was talking to somebody just today. We were talking about a person who I'm working with who is in their twenties, has never had a birth certificate, never had a social security card, didn't know what their social security number was until a couple of weeks ago.

It's been almost an impossible task just to get that identifying information for foster care, adoption that went rough. The worker tells me at age 23, the reason he doesn't have these things is because he's done some things wrong along the way. It was one of those moments when I just, I had to quietly lose it because yeah, he's done some things that he probably shouldn't have done, but there is [inaudible 00:16:34] . He's part of that perfect storm. He's just part of a perfect storm. As adults, we have to take responsibility for our lives, but we also need to be given opportunities to take responsibility. But when you tell somebody you can't get a job where you earn a wage because you don't have even a social security number, so you're going to have to work under the table or do illegal activities, take responsibility? Let's give them the ability to have responsibility.

Dr. Julia Riddle is a family medicine doctor in Northern lower Michigan. She treats vulnerable women who are addicted to opioids and other drugs while pregnant. This is an important and controversial topic when it comes to rural health care because what we know is that medical-assisted therapy for drug addicts does help with cravings, withdrawal and the effects on developing fetuses. But the opinions on best practice regarding MAT or medical assisted therapy are endless. Dr. Riddle is making a difference in women's lives and taking care of rural women, rural babies, and helping to cut the impact of drugs before they stem and spread and continue this cycle of addiction.

Opiate dependence is a disease. Some people are already in treatment and managing their disease. They're already, maybe on Buprenorphine products and they become pregnant. Other people have been using Norcos or Percocets or shooting heroin and then they find out they're pregnant, and they realize that they have to quit and they can't. Then there's some people who aren't necessarily ready to quit. And despite the fact of being pregnant, not ready to move forward with treatment. Very few of those. Once women find out they're pregnant, they really want to get help and they want to do good. They want to be better. They want to not use during the pregnancy. I would say a vast majority of women are like that. So, if they've been using on the street and they find out they're pregnant and it's not a true dependency, a lot of women would quit.

Maybe they only take a few pills occasionally at a party once a month. They quit. They just don't pick it up anymore. I think the vast majority of women though, if they are using opiates, they have a real dependence on them, and they are unable to just stop taking the opiates because they get sick and they go through withdrawals. We don't recommend that women go through those withdrawals during pregnancy. There's all kinds of rehab centers or detox centers where people just go, and they go cold turkey, and they have sweats and vomiting and shakes and chills and they're real sick just to get off of the opiates. We don't recommend doing that during pregnancy because that's harmful to the fetus. I put them on Buprenorphine. That takes away their cravings and it controls their withdrawals. They don't withdraw so that helps them with their physical symptoms.

The next step is helping figure out their basic needs, trying to find them a place to live, potentially work if they need it, and then getting them into counseling to help deal with the reason they're using, whether it be anxiety, a history of trauma, which is really common. Relationships, getting out of bad relationships. All those things are really important to healing them and healing their brain, getting them off the street, hanging out with people that would get them into the situation of using again.

This is a disease and it is a very powerful disease, and it affects the brain in such a way that it can be really, really, really hard to not use drugs. That's why this medication, Buprenorphine is so important because it gets rid of those cravings, it gets rid of those urges to use and it doesn't make anyone high. If Buprenorphine doesn't work because I sometimes I think it isn't strong enough, that's where Methadone comes in. We don't have access to Methadone in Traverse City. This gets down to the whole rural health concern. We don't have access to send people to that higher level of care. That's sad because I have seen people trying. They're coming into extra appointments. They're taking their medication. They're going to counseling, but the urges are still there, and they need a higher level of care that we just don't have here. We see them and support their pregnancy as much as possible. Sometimes they deliver early because of the stress that puts on the infant, depending on what's going on.

It's tough, and it's sad because if we had more options for medications, we could potentially help them do better during their pregnancy. That's one of the reasons I started working in Gaylord, is so that even though it's an hour from Traverse City and two hours from Manistee, we still have that somewhat availability. Well, the greatest rise right now is the opioid epidemic, and a lot of the children are coming in because of the opioids. Not that they're addicted to them, but their parents are so addicted to them, they're being neglected and they're not being cared for in the manner that every child deserves. So we're, yes, physical abuse, sexual abuse, mental abuse, all that is still current as it was for many years. But the drug abuse has completely skyrocketed in our system to the point where we are having trouble as a society here in Northern Michigan to find placement for these foster kids because we don't have enough foster parents anymore. Unfortunately sometimes they have to be sent down state to open foster homes because there the need is so high and they just can't fulfill it.

I'm going to let you all in on my life for a moment. I am a foster parent. In 2018 my husband and I took care of five different children from four different families, all from a few days to more than six months. Our longest and first placement we love. Love like our own biological child. We got really attached and had to do the thing that we and everyone else says that they could never do, and that was to reunite. We dropped our foster child off with his biological parent at an inpatient rehabilitation center when it was time to bring everyone together, and you want to know something? It was the best thing that could've ever happened to that family. While there were adjustments, we saw both people-

While there were adjustments, we saw both people thrive. We saw our foster child's parents get and stay clean and we saw happiness and attachment and a sense of home for our foster child. Opioids cause so many problems, but we as a people are the ones who can fix them. We just have to be willing to have real hard, messy, beautiful relationships with people. And then the second ingredient is empathy.

First two kids, we get into care and at the nine month review hearing, mom and dad are saying, they're going to get the kids back, they're going to go on and pull some rabbit out of a hat and get their kids back. And so we're like freaked out. We're waiting out a lobby in the court system in the town we were in, and mom and dad are just around the corner and they're spewing off their mouth about we're going to get our kids back and you people will never see these girls again, blah, blah blah. And I'm sitting there thinking all the things that you shouldn't think about birth parents, about what rotten horrible people they are and how they don't have a right to have these kids and blah, blah, blah, blah, blah.

They go into the judges chambers to try to work out a deal before we go into court. They're in there about 20, 30 minutes and pretty soon the case worker comes out and says, "You're not going to believe this. They're in there signing off their parental rights right now. Would you be willing to adopt these two kids?" And my wife and I are both sitting there with our mouths hanging open going, huh?

We're at the elevator, at the courthouse sitting in a bench there. And pretty soon out come mom and dad with their backs to us and push the button to take the elevator down. And I'm looking at these two people thinking, what in the world did you just do? How could you possibly do this to your children? The elevator opens, they step on and they turn around. And in that moment I looked in mama's eyes and I saw something I didn't expect to see. This woman was broken. She had just lost her children. I never had seen so much pain in the eyes of somebody in my life. There was something else I saw in her eyes too. The eyes of those two girls that I had.

And in that moment I thought to myself, how can I love these children and hate their parents when the difference between mom and her kids are just time? These kids could very well end up like their mother and I love them dearly. How can I not love their mother just because life has taken her naturally where it was going to take her anyway. Not that she's not to blame for some of the things that happened, but as a Christian, I don't think my job is to judge people and that's difficult. What would I be like if I grew up in the world that she grew up in and I had the few options in life that she had. I mean, I was given lot in life and I made some really bad choices. So how much worse am I as a person than her who had very few options in her life and made some of the same bad decisions I made as a young person.

One of my best friends died because his doctor prescribed oxycodone and assured him that he could live a normal happy life for the rest of his life and be on oxycodone because of a back pain. And he dropped dead of a heart attack. And as he was dying, he didn't even wake him up from his sleep because he didn't feel any pain. Had no idea that when he went to bed that night, he would never wake up again. And the conversation I had with him a week before, so I told him, you are on a synthetic form of heroin, how are you going to get off of it? And he said, "Doug, my doctors assured me that I'll be fine with this and I can live like this the rest of my life." And then he died. That was about 10 years ago. He's still dead.

In a perfect world, I think foster parents would be considered honorary aunts, uncles, big brothers, big sisters, grandfather, grandmother types to a family who is struggling with a substance abuse. So yes, I might've been a stranger the first time you met me, but we're all going to work together. So that your family, that includes the foster child, the foster mother or the foster child, the biological mother, all of the children, we're all working together. So that little foster kiddo, you get to go home to a family that is safe, loving, nurturing, and we'll even stay in touch over the years. So that mom has a support system, so that mom doesn't feel shame, so that mom doesn't feel blame. So that mom is supported, so that you stay supported little foster kiddo. And it becomes a community effort. It becomes a family effort.

If we're going to address the whole idea of opioid addiction, I think there's two things we need to keep in mind. One is the earlier we intervene in people's lives with trauma informed care, whether it be as foster parents, or daycares, or in schools, the better we are. And then the other thing is, is we need to treat addiction as a family system issue rather than just an individual in a family system issue.

And I think that, that's part of what the great thing about ACEs is, is that the more we educate people on what adverse childhood experiences are. And so this really ties back to my love of parenting and that de-stigmatizing thing. Is this is something that's happened to you. Even as an adult, as a parent, and I'm raising my young children, there is a lot of guilt that comes into parenting. There just is. And some of that is by the poor choices that you make as a parent. Like you get upset because they knock over a ... Silly example, but knock over a glass of milk and then you feel guilty because you got upset and it was just spilled milk. But this really gives us a tool that we can talk with parents and say, it's not all about you being a bad parent. These are things that have happened to you that has impacted your ability to make decisions that's impacted your ability to be the best person that you could be.

And there's ways that we can work with you to move forward from that. And just taking away that guilt and that shame piece allows people to blossom and become a better person than what they were because they're not positively shaming themselves inside or [inaudible 00:31:15]. And so that's one thing we want to do is build that resilience and have that self talk be more a positive self-talk as opposed to a negative self talk.

Thank you to Dr. Riddle, the Brown family, Doug, Afton and Marnie. Not just for the interviews, but for everything, everything you do for families and children in rural communities around the state. Your service does not go unnoticed. A special thanks goes out to Ada, one of our mighty and noble leadership in rural medicine students who help to edit and produce this podcast. After two years of producing this on my own, I can tell you the help was immensely appreciated and all of us at Leadership in Rural Medicine programs love working with you, Ada. Thank you for everything. Thanks as always to our director, Dr. Andrea Wendling, and to all of you the listeners. We could not keep doing what we are doing with this project without you. So in return, we hope that this episode inspired you to make rural your mission and we will hear from you. Next time.

To learn more about the Rural Community Health Program, please visit our website at www.msururalhealth.chm.msu.edu. By joining our website, you can connect to us on Facebook, Instagram, and Twitter. You can also find out more about our musician. Music today was provided by Horton Creek and Brian Eggers, a local musician and Michigan native. We hope you tune in next time to hear more from This Rural Mission.

In our effort to cover the issue of opioid use in rural Michigan, we took to the hospitals, providers, and persons who are trying to have an impact on opioid use and overuse in our state.

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine. The podcast is produced with funds from the Herbert H and Grace A Dow Foundation and the Michigan State University College of Human Medicine Family Medicine Department. Welcome to season two. I'm your host, Julia Terhune, and I hope you enjoy this episode.

I'm sure none of you listening are surprised that we did an episode this season on the opioid crisis. The issue of opioid use, overdose and related deaths has been in the news media for several years now and at this point it seems to be synonymous with rural. But that is because this is a tremendous issue concerning rural populations. It affects every facet of life for many rural communities, from the healthcare system to schools to industries. Rural healthcare facilities are dealing with people addicted to opioids and the legislative policies tied to combating drug-seeking behavior every day. School systems are seeing younger and younger students either becoming addicted to opioids, dying from overdose, or living in homes where families have been impacted by drug addiction.

US census data shows that unemployment rates are highest in rural areas and the opioid crisis has done nothing to help. Poverty is a contributor to drug use, and yet if you can't stay clean, you can't get a job. But this episode is not about these distressing realities. Instead, we're talking about the people who are doing something to combat this crisis. I'm going to spoil the theme of this podcast and let you know in a word what we are hoping you get out of this. People.

We hope you understand that people need people, meaning if we are to make an impact in these communities concerning opioid use and overuse, we have to put people first. Today our stories are going to have a tiered effect. We're going to start at the top and talk about community impact, then we're going to take it down to the practice level, talking about what individual doctor's offices are doing. We're then going to get personal.

So starting off our conversations, we're going to talk about system policies that have made an impact on getting access to opioids. I spoke to Steve Barnett, the CEO of the McKenzie Health System in Sandusky, Michigan, a rural hospital in the thumb. In 2012, his hospital started an Oxy-free ED policy that stopped providing opioids for non-acute medical concerns.

You have people that are accessing the emergency department for real, acute reasons, and yet there's also people accessing the ED because they've run out of whatever substance they prefer and this is an easy way to come in and probably get a couple days worth or maybe even a month's worth of prescription to get them in and out of there. Rather than wasting resources in the ED and being part of the problem, we decided we wanted to try and at least provide some solution. It's just one door of multiple doors, you know, but it's at least taking a position that we're not going to be that place that pushes drugs.

Were you concerned about any unintended consequences of making this change in your ER?

Sure, we were. Our primary concern was that once they figured out, those patients that are seeking drugs through the emergency department, that we're not going to support that, then they'll simply move to other emergency departments locally and then we won't be viewed very kindly by those other hospitals who have an uptick in volume, but it's really drug-seeking volume. So we presumed, we assumed that that would happen and we talked to everybody, let them know that we were implementing this Oxy-free ED and they may see an uptick and we'd like to hear about it if that in fact occurs.

The other things that we were concerned about is how the patients would react that are seeking drugs when they come in, realize you have a policy and a process that doesn't provide them with what they're looking for, because they could become combative or unruly. So we want to make sure that we have support locally from police and community mental health. Being a County seat, all those services are right nearby anyway, so it was a good way to inform the community and try to get them on board and be supportive of this process that we're going to start implementing, policy implementation, and the way in which we're going to proceed.

And all of those concerns did not actually come to fruition. In fact, the policy positively impacted drug-seeking behavior and did reduce the number of people gaining access to opioids through the emergency room. In the five years this policy has been in place, the McKenzie Health System has seen a 90% reduction in the number of prescription opioids provided to patients. But more importantly, staff and physicians found their jobs less stressful, that patients were easier to discharge, and that their interactions with patients were of higher quality than in previous years. And can I just say that this was a dynamic way to build community. What gave you this idea? I mean, obviously, you're the leader of this hospital.

It was not my idea.

It wasn't your idea?

No. It was the medical director for our emergency department, Dr Hamed. He was reading an article about policies in the state of Washington where they were moving EDs into an Oxy-free environment in order to reduce traffic. He had an interest in doing that locally, so he came in and talked to me about those unintended consequences and would we support it as a hospital? And I said, yeah. And so it just began to roll out from that point in that way.

Part of the program that we implemented, which is fairly common today, was if there was a legitimate acute pain problem and the physician had accessed the MAPS software and could tell that this particular patient wasn't moving around and hadn't acquired multiple prescriptions, then they have the option of administering some narcotics for that patient, for that problem. But it would be a limited supply, maybe two or three days.

And the more important part is that they had to follow up with a primary care provider and so there was a contract established that required that to happen, and if it didn't happen and they showed up again, then they weren't going to see the same kind of prescription being administered. They either have to move on or they have to get help or something has to happen that's different than what they were doing before.

Now let's narrow down our discussion. Reducing access to opioids is one way to combat the crisis, but even without access through the emergency room, there are still people living with chronic pain and addiction. Dr Klee is a physician in Northern Michigan and the residency director at the Munson Family Practice Residency Program. He and his team have developed a better way of managing patients who have chronic pain or who use opioids. But when you hear what it is, I'm sure you'll agree it's the common sense approach that has not been very common.

You know, this is a big problem nationwide and Michigan for sure is one of the areas that is involved significantly. You know, in 2016 we had 11 million prescriptions for opioids in Michigan, which is more than the amount of people we have in Michigan.

Here at our residency we decided we wanted to try to address, how are we managing our patients with prescriptions? So what we did is we developed an algorithm to help all our providers and to figure out how we were going to manage our opioids. That starts with seeing our patients in the office and talking about non-opioid pain relievers.

So we started with that, asked people to make sure that we maximize these non-opioids and then if we are considering going on to opioids to use a validated risk assessment such as the Opioid Risk Score that looks at people's personal family history of addiction issues to see if they're someone that's more likely to become addicted and if opioids are really a good idea for them.

And we combine that with a functional assessment saying, all right, what can you not do right now because of your pain that we want to try to improve with opioids? Because a lot of times it may be we gave opioids for this issue, their pain's still not controlled and we haven't improved their function and so really we haven't added benefit with opioids. We just added potential complications.

And then if we are considering we want to progress to using opioids, then we're running a MAPS report, which is the Michigan Automated Prescription System report that's now mandated by Michigan law and also getting urine drug screens.

Have you noticed that it's an increase in workload to do this with patients?

Yeah, it is, but it takes a little bit more time with this to be able to do a good job with it. But I think we're doing a better service to our patients when we have these discussions and we do a little more regimented assessment of their risk and benefits.

One of the things that we do when we decide that we're going to be using opioids is we have a contract that we sign with the patient and we renew that every year and it is kind of the rules of engagement on using the narcotics. That includes doing annual, at least annual, urine drug screens on patients coming in to see us every three months, you know, not selling their medications and things.

With that agreement, when we do our urine drug screens or we have these visits, if we're seeing that the patient has broken the contract or they're positive on a urine drug screen for other issues, then it's a form where we can then say, all right, we can't continue to prescribe you opioids, but it does appear that you have an opioid disorder, use disorder. And so what can we do to help you with that? How can we help you combat that addiction?

You know, we care for people and these people have addictions and so if they fall out on the contract that they're not able to use the medication because they didn't comply appropriately by not using other medicines, we don't fire the patient. We just say, okay, we can't use these controlled substances, they're too risky for you, but we'll still be your physician. We'll still take care of you and we need to help manage all your medical problems including helping you have access to addiction services.

What comes to fruition as you're graduating from medical school is that now you're actually taking care of patients. You're not taking care of the heroin in room three. You're taking care of Johnny in room three that overdosed with heroin. I think that's an important part, is that we realize that these are people and learning about how to manage their blood pressure's important, but also learning about how to manage people's pain and how to address addictions and not to bring the biases that a lot of times that we do with that and not to internalize those biases.

But it can be a challenging group of people to work with, but it can be very rewarding too in being able to help some of these people and be the providers that are there that aren't turning their back.

Our final story takes us all the way down to the individual level. In preparation for this podcast, I spoke to a number of persons who are in recovery from drug addiction, but there was one story that struck me. To protect the identity of our next interviewee, I'm going to call him Ray.

Ray is now more than four years clean and owes much of his recovery to a recovery program called drug court, an alternative program that instead of putting people with substance abuse issues in jail, they are provided with opportunities to get clean, stay clean, and avoid charges that could keep them in a loop of drug abuse and poverty for the rest of their lives. Here's Ray's story.

I grew up in a loving home. Issues just like anybody. Just normal, you know? My dad wasn't real affectionate but he also wasn't abusive. But I grew up not understanding the feelings that I felt inside. I grew up not understanding why I felt so different, despite all the love and all the good qualities of my family. Excuse me. But then I just, I just couldn't be okay, so I started out acting out at school. Finally, my parents are trying to figure out what to do with me because they don't understand, because I don't understand. Really, nobody understands why I'm acting the way I am.

And just as they were like, really trying to help, I was sexually abused by an uncle, you know, and it changed my world. I felt like everybody could see me, see it. So I was like, okay, how can I be a man if I was sexually abused by a man? I remember having these thoughts. And it was just, it happened once.

How old were you?

10. I was 10. And I couldn't remember the pain, the physical pain, but like, it was instant humiliation, you know?

And then, man, my dad was sick all the time, so I begged my parents to let me go hunting with some other uncles. And they introduced me. You know, I remember drinking one night and I just, I can remember it like it was yesterday. Alcohol never became my drug of choice, except for if I didn't have any other drugs. But the feeling of being outside of myself and not having to care about what anybody thought, was the first time I ever drank. Nobody knew I was sexually abused. Nobody knew I was scared. So I was Superman.

After the years of drug abuse, failed relationships, minor offenses, and a spiral of depression and hopelessness, Ray was charged with running a meth lab and larger drug possession. But strangely enough, this is where the story takes a better turn.

21 year old kid walks up to me, he says, hey, you look like you want to die. And I said, you have no idea. Because that's what I was doing. I was literally trying to figure out a way to kill myself in jail. So I'm in jail, I'm cleaning up, and everything that I had done during those drug induced hazes became a reality. Real hard. He says, hey, let's go to this meeting with me tonight. I'm like, what's your name? Like, why are you ... He says, my name's Tucker. He's a good kid. He said, you look like you're in a lot of pain.

He takes me to this meeting and it ends up being an NA meeting. This guy across the table's telling me he's been, he was a drug addict and he hasn't done drugs in 20 years, and he's smiling. And I said, you lying son of a bitch. Nobody smiles about drugs. Maybe you weren't a drug addict like I was a drug addict. And then this guy started telling my story. He started talking and I'm like, how could you know that? What is this? What is this? What is recovery?

And I was sitting in jail and every Tuesday I was holding this NA book and every Tuesday I'd be there, just waiting for this guy to come in. How did I not know about this? You know, I've been on felony probation for seven years and I'm not trying to say that in a [inaudible 00:19:58] way, you know? I know it was my choice to pick up the first time. I also know that after the first time I picked up, I didn't have a whole lot of choice.

But I'm looking at three to five in prison with a 40 year tail. [inaudible 00:20:18]. They sent some guy in there and he's supposed to interview me and I lock up because all those old feelings come back. He talks to me and he says, tell me why I should let you on my program? How do I deserve that program, you know? I've been sexually abused, abusive father, like I got all these thoughts rolling through my head. Like, I don't deserve that.

At that time, nobody in my life had known I was sexually abused. I probably told the counselor like, three days after that because I finally broke and told someone. It was like, it was like the whole world helped open up to me. Drug court accepted me. The guy came back and interviewed me again. Drug court let me on. I didn't know the world of recovery existed. I didn't know people cared whether or not we lived or died, as addicts. In our world and I know it's a sad thing, but in our world where we live, in here in our heads or in the streets, nobody cares. We're the enemy. We're dirty. We're all these things.

When I hit drug court, that was the first time I really thought there was help out there and that the world wasn't against me. It was also the first time I didn't, the first time I remember feeling like God didn't hate me, if there was a God. I was convinced that He hated me, you know?

Then I got a taste of recovery. They sent me to a treatment center. I didn't know for a second. It's a treatment center. I didn't even know they existed. And then you get to love life. It was like, almost overnight. It was like a whole new world I didn't know.

How do I feel about myself? I feel I'm helping change lives. I don't feel like that would be an option if it wasn't for programs like that.

Let's go backwards now. Ray is a person. A person with real trauma that led him down a spiraling path of drug abuse. It wasn't until someone saw him for who he really is that he was able to start getting help for the hurt that drug abuse and addiction was masking.

Dr Klee and his residents are intervening in the lives of their patients to not just manage their pain but their needs. Treating the person and not the symptom. The McKenzie Health System is taking a look at the issue of opioid use at the community level and trying to help people when they need it most, but also helping the larger system by keeping more drugs out of circulation.

The point of all of this is that people are helping people. This is how we're going to combat this crisis, by taking it one system at a time, one practice at a time, and one person at a time.

You know, we're all Michiganders here and we have to understand that we have our differences, but we also have a lot of similarities. One patient may have, a person may have an opioid addiction, but other people may have their own crosses to bear and so we have to work with each other and take care of each other.

Thank you all for listening today. As always, I want to thank Dr Andrea Wendling for making this podcast a key priority of our program and for allowing me the flexibility to interview all of these different individuals.

There were many others that I interviewed for this particular podcast that you didn't hear today and I want to thank all of them. I want to thank Steve Barnett and Sandusky for taking time away from being a CEO to talk to me. It's always a pleasure to meet with him and this was no exception. I want to thank Dr Klee for also taking his lunch hour to give me a call and talk to me about his program.

I also want to thank Ray. Ray and I spoke for hours and hours and it was one of the most powerful conversations I've had to date. It was such a privilege to hear his story and for him to share his story with all of you and be so vulnerable. Ray, we thank you for all that you've done and are continuing to do in your sobriety and all the people that you've impacted with your story, your life, and your care.

Thank you to all of you. The opioid crisis doesn't seem to have an end in sight and every year the results and the statistics seem to be staggering as to the level of need and the level of care that is needed to combat this issue. With that, if you are considering a career in healthcare or you're considering a career in criminal justice, then I have one simple thing to say to you. Please consider making rural your mission.

Music today was provided by Bryan Eggers. Find Bryan's music on Spotify, Facebook, and Youtube.