By OMA President Carla McKelvey, MD
It has been a whirlwind trip, and we have been running hard since Friday morning. We are headed back to Portland today but before we leave Ontario, we are going to have breakfast with Sandy Dunbrasky, a pediatrician – and in my opinion, a pediatrician extraordinaire.
I first met Sandy on “paper.” She and I participate in ORPRN (Oregon Rural Practice Research Network). Since we were the only pediatrics practices in the network, our practices were often paired. I was very impressed with what she had accomplished in Ontario and so was excited to be able to have a conversation with her. We had been at conferences together but had never had time just to sit down and talk.
Sandy came from a background where graduating from high school would have been a great accomplishment. Not only did she graduate from high school but she eventually received her nursing degree. She knew that she wanted to be a doctor when at age 12 a family member had a heart attack in front of her. While upset, she was also fascinated about how the human body could change so fast. It drove her to want to know more. As a nurse she would constantly ask questions of the pediatrician, who would tell her to become a doctor.
So at age 37, with the support of her husband and two teenage children, she entered medical school at OHSU. She said she never considered applying anywhere else because that is where she needed to go for her family. She would attend school during the week, drive back to Ontario on Friday night where her family lived, work in the hospital as a nurse on the weekend and be back in class on Monday. During her clinical years, she did the same thing every weekend she had available. It was not until she was a pediatrics resident at OHSU that she gave up her “part-time” job.
Upon completion of her residency, she returned to her hometown, Ontario, to start her own practice. Currently her practice covers 20,000 patients in Oregon and Idaho. Her practice was one of the pilot medical homes in Oregon. The two care coordinators at the practice have succeeded in making emergency room visits unusual for special needs kids. To advocate for the children, the coordinators attend medical visits to specialists along with parents and attend meetings at the school. The practice does this with two pediatricians and five nurse practitioners.
She would like to have more pediatricians and did at one time, but recruiting has been impossible. Like many of the physicians we spoke with, they are finding that new primary care physicians do not want to take call. They are also reluctant to care for patients in the hospital. Most think this is a reflection of the training that students are receiving with hospitalists being their role models and the restrictions placed on their work hours. They feel students do not always appreciate the relationship that can be developed between the physician, the patient and the family.
In these areas, having a hospitalist is not an option. Many times there are insufficient patient numbers to justify not only one hospitalist but the three that would be needed to have a feasible program. They are also finding that hospitals are unwilling to help solve these problems because there is no financial benefit to them. There is a significant level of pessimism as to what the future holds for their practices as well as rural health in general.
Although the sun was bright on the drive back to Portland, it felt much darker. The voices of these physicians had given me and the OMA much to think about. What was our role in these areas? Could we be a voice for physicians who are in conflict with hospitals? Was there a way for us to help them prepare for the upcoming changes that includes Coordinated Care Organizations, Patient Centered Primary Care Homes, and meaningful use demands? In some areas, physicians continued to be concerned about payment issues and in others these issues no longer mattered since they had become employed.
What left me feeling most hopeful were the words of one of the medical students who biked around Oregon to bring attention to the difficulties in rural areas. He said that having visited areas around the state had made him more likely to want to practice in a rural area. He talked of seeing the successes in many rural communities which had come together to solve problems. He told the story of Dr. Kim Montee in Union who flagged them down in the middle of the road to talk about his community and what they were doing.
It is also hopeful to hear the story of Dr. Lisa Dodson, who when told that the community clinic in Elgin was going to lose its provider, and thus close, she volunteered to staff the clinic until they found another provider. She drove from Portland to Elgin every week for nine months through all kinds of weather. She believes in the importance of rural health and so should we at the OMA.
