This Rural Mission This Rural Mission

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.
An

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

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 st

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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 int

*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 o

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 schoo