Dr. Blog

OHSU Medical School Orientation

By OMA President Carla McKelvey, MD

Congratulations Class of 2015!

 
What do you remember about your first or second day of medical school? Do you remember being anxious, nervous about the road ahead or were you excited about what lay ahead?

I was thrilled to get into medical school. I had been put on a wait list, so when the news came less than a month before school started that I was officially accepted, it was a dream come true. As I told the students today, the best medical school is the one that accepts you because they have recognized your ability and potential. For me that was the University of Texas Health Science Center in San Antonio.

Standing before a group of medical students is a time of reflection. Why did you go into medicine? Why do you stay in medicine? Sometimes our daily grind overshadows the first question and we feel that we may not be able to have an impact on the system we work within. I hope that the OMA can show medical students how organized medicine can function as a voice for their concerns and issues whether that be related to medical school issues, legislative concerns including health reform, financial concerns, or community health. When we work together we have a much larger impact. They are often full of energy and optimism and can help re-energize those of us who have been in practice for a while.

This year, over 75% of the students are from Oregon. This is good news. The bad news is that they will graduate with over $150,000 in debt. As we continue to face shortages of primary care providers, we must be addressing this issue. It is unlikely that the State will contribute more to OHSU so that tuition can come down. One of the OMA’s goals for this year and moving forward is to more aggressively raise funds for the Oregon Medical Education Foundation in order to increase the number of scholarships that are provided to medical students within the State. I hope you will join us in that goal.

Heading Home

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.

Dr. Gus Tanaka

By OMA President Carla McKelvey, MD

Dr. Gus Tanaka celebrated his 88^th birthday this week. His life story is a remarkable one.

Dr. Gus Tanaka celebrated his 88^th birthday this week. His life story is a remarkable one.

His father, Ben, stowed away in a ship from Hawaii to Seattle. He eventually ended up in Portland and became the first graduate from OHSU of Japanese descent. He was a prominent family practice physician in Portland until the attack on Pearl Harbor. Unfortunately, he was arrested as a Japanese agitator and sent to a federal detention center and was there for six years. According to Gus, his father served as physician for the detention center. When he was finally released, all of his property had been seized so he decided to relocate to Ontario.

Gus was at Reed College but was told he had to leave so he transferred to an East coast “pacifist” college where he received his degree. He then joined the military and at one point was guarding a nuclear research lab, as he puts it, “to keep the Japs out.” He ended up in Japan and spent most of his time teaching illiterate American soldiers how to read. Returning to the United States, he went to medical school and, at the behest of his dad, joined him in Ontario where he was a practicing surgeon until he was 70 years old.

He met his wife, Teddy, in New York where she was a nurse. Teddy was from Ontario, which also played a part in his decision to return to Eastern Oregon.

Dr. Tanaka served as OMA president in the early 1970s. He was concerned by the distance from Ontario to Portland but he attributes his successful term to the outstanding staff led by Bob Dernedde and Jim Kronenberg, who he still remains close friends with to this day.

He is troubled by what he sees a decrease in professionalism by younger doctors. He states he does not understand how a surgeon can operate on a patient and then go home without checking on them because another physician is covering. He, too, is concerned about the difficulty in recruiting and retaining physicians. He says that as long as his life has purpose he wants to continue living, and so far people seem to still need him. Dr. Tanaka is truly a gem, and we expect to need him for many years to come.

Day 2: From Enterprise to Ontario

By OMA President Carla McKelvey, MD

Started the day with a tour of Wallowa Memorial Hospital in Enterprise where Dr. Liz Powers is head of the medical staff. Enterprise elected the Wallowa County Health Care District in 1992 to address the needs of an outdated hospital that was built in 1950. The current hospital, which is a critical access hospital, was built four years ago through a combination of private donations and funding with public grants. It is amazing! Very modern, airy and truly inviting. It is a great testament to the community that they were able to address the needs of their community.

 

Jo and I attended the Oregon Rural Health Association Board meeting at the hospital. Linda Lang from the Oregon Association of Hospitals and Health Systems is the current chairperson. The concerns expressed were those heard through the rest of our trip – can physicians survive in private practice? Will they be forced to become employees because of decreasing payment rates and increased costs, including liability costs? The critical access hospital system has allowed hospitals to go from running in the red to operating in the black. But unless a physician qualifies to become a rural health clinic they do not have the same benefit.

While the financial stability of these practices is a big issue, another looming problem in rural Oregon is the issue of recruiting and retention. Most agreed that lifestyle issues have become the major focus of many physicians. Many small towns cannot offer the amenities that are offered in the city. While J-1 visa physicians have helped take up some of the slack, there remains difficulty in retaining physicians. Issues such as good schools are becoming a bigger barrier in keeping doctors.

In Baker City, we had lunch with Doctors Nancy Hutnak and Steve DeLashmutt. Nancy was late because the cattle had gone through and ruptured an irrigation line and she had to repair it before joining us. Like Pendleton, there were concerns about how physicians were going to collaborate with the new hospital system. As employed physicians, they are not concerned about payment issues or liability reform. They are looking for assistance in how to evaluate and negotiate contracts. One health care system owns the hospital while another owns physicians’ practices. This situation adds to the complexity of other issues such as recruiting new physicians and creates questions as to how health reform will impact them.

As Jo and I turned the corner leaving the Geiser Hotel where we had lunch, I ran into two colleagues from my hospital, Bay Area Hospital. It is always a shock to run into people you know when you are from a small town especially when you run into them in another small town. Just a reminder that it is a small world.

End of the Trail in Enterprise

By OMA President Carla McKelvey, MD

The initial inspiration for this visit was the three second year OHSU medical students who decided to travel around Oregon to highlight access issues in Oregon. I am pictured with Matthew, Weston and Nathan. At the end of the row is Daphne, a first year veterinary student who joined them on their journey which ended in Enterprise today. They traveled almost 1000 miles.

 
The trip was co-sponsored by the Oregon Academy of Family Physicians (OAFP), the Oregon Office of Rural Health at OHSU, the Oregon Rural Health Association and the Oregon Area Health Education Centers (AHEC).

“We have a provider shortage today, and it will only worsen as patients and doctors age. Projections show that Oregon will have 5,473 primary care physicians in 2020; but to meet Oregonians’ needs, we must have 6,841. This means we must recruit 1,355 additional physicians in the next 10 years,” says Kerry Gonzales, executive director of the OAFP.

The students were impressed with what small communities can accomplish when the members work together and have a shared goal. It is in small communities that innovation is a necessity and hopefully, can be utilized by other communities. As one student stated, these small communities can function as pilot projects for larger communities.

There was a good turnout at Lear’s Main Street Pub and Grill including Kerry Gonzales, Lisa Dodson, Scott Ekblad and Liz Powers as well as family and friends of the bicyclists. Their accomplishment is quite remarkable. There were many areas of the state they did not get to see (including Coos Bay) so they hope that a group of next year’s medical students will continue the journey and highlight this important issue.

Tomorrow we will be attending the Oregon Rural Health Association board meeting and will get a special treat – a personal tour of the hospital by Dr. Liz Powers, a family medicine physician whose reputation precedes her.

First Day on the Road

By OMA President Carla McKelvey, MD

I have the most amazing view from my window at the Enterprise Bed and Breakfast of snowcapped mountains. The drive from Portland was impressive – always surprised by the geographical diversity of our state and you certainly get the full range driving from Portland to Enterprise.

We started out in the cool, misty city and then traveled through the historical Columbia Gorge where I always think of Lewis and Clark. The Gorge becomes more desolate with sheer rock walls on the Oregon side and tall, but grassier hills on the Washington side. At one point you are actually surrounded by the windmills – slowly turning in the breeze. There are several dams along the river and windsurfers.

As you progress it becomes more desert until you roll into Pendleton where the temperature was 103 degrees when we left – incredibly hot for a coastal girl. But it was a dry heat and as a comedian once stated, “The oven is a dry heat but you don’t put your head in it, do you?” Finally up Cabbage Hill and Deadman Pass and you enter high desert which looks a lot like the area around Bend. And then at LaGrande, you make the transition from desert to mountains until finally you land in beautiful and quaint Enterprise.

The day went well. We visited with several physicians in Pendleton. Rural physicians have many of the same concerns with most focusing on how to best provide care for their patients. There are continued struggles with recruiting and retaining physicians, a shortage of primary care physicians, no psychiatrists in Pendleton, lack of access to specialists such as Cardiology. Technology can only cover so many of those shortages. You will notice that we traveled through two counties today – Sherman and Gilliam – that have no Primary Care Providers and the next two – Morrow and Umatilla - are woefully understaffed.

They say all politics is local and the same is true with health care I believe. Pendleton has a population of approximately 16,000 people and is adjacent to the Umatilla Indian Reservation. It is served by St. Anthony Hospital, a Catholic Health Initiatives hospital and a critical access hospital.

We had the opportunity to visit with Russ Deminew of the Pendleton IPA (in the photo with me) and Bruce Carlson, MD.

 

You would think that small town, rural health systems would have similar issues but it seems the challenges that each area face are unique. Relationships between specialists and primary care physicians, hospitals and physicians run the gamut with some more collegial than others. So a one size, fits all solution will not work and to assume that all initiatives in rural areas will be equally successful would not acknowledge the differences that exist.

It is important for us to find common ground and to ensure that if possible we at least all have a fair start but beyond that it gets back to the basics – the physicians, the healthcare facilities they work in and, most importantly, the patients we all care for.