Caring for Community, #81

Deborah Deatrick:

We do know that prevention works. There have been lots and lots of studies that document if you stop smoking, you're going to live a longer life, if you eat a better diet, you're going to be healthier and hopefully have less chronic disease, etc. Public health is largely invisible to most people. You go to your faucet in the morning, you turn on the tap, you get a glass of water and you just think that that water is going to be free from carcinogens, it's going to going to be safe. And those are the kinds of things, frankly, that public health does. We do things that keep people safe, that protect people, et cetera. But it is largely invisible. And so the extent to which people want to pay for those kinds of things I think is diminished.

Dr. Kathleen Fairfield:

We really want to know what you value. Do you really value avoiding getting on an additional medication or do you value avoiding surgery or procedure? But it is a little bit of a change and I think some patients might not be comfortable with it. But what we're finding in general is that most people really want to participate and be fully informed and have, in fact, strong feelings that they might not have shared with their provider had they not been invited to do so.

Dr. Lisa Belisle:

This is Dr. Lisa Belisle and you are listening to the Dr. Lisa Radio Hour and podcast show number 81, Caring for Community, airing for the first time on March 31, 2013. From raising readers to raising awareness for colorectal cancer, Maine has many innovative wellness programs created with the health of the community in mind. Learn more through our discussions with Deborah Dietrich, Senior Vice President of Community Health Education at Bain Health, and Dr. Kathleen Fairfield of the Maine Medical Center Shared Decision Making Program. When I began family medicine training at the Maine Medical center in 1996, our patient information was kept in paper charts. Finding information in these charts was challenging, to say the least. Many of our patients had been coming to the family medicine clinic for many, many years, valiant attempts were made to keep medications, vital statistics and history up to date. But the system had multiple failings. This contributed to a less than optimal patient care experience. Fortunately, we've moved into the modern age and electronic patient information is now readily available at the Maine Medical center and in most medical settings across the state. I've always liked the idea of systems. Medicine is a challenging field requiring thoughtfulness and tenacity on the part of its practitioners. We are called upon to create individualized plans for our patients while simultaneously understanding the health of the family, community and population. Having systems in place enables us to practice medicine more efficiently. I admit systems can sometimes have their pitfalls. Patients are, after all, individuals. There is no one size fits all when it comes to patients. But systems provide us with a start. They are a foundation upon which we can build a better patient experience. This week on the Dr. Lisa Radio Hour, we speak with Deb DIETRICH and with Dr. Kathleen Fairfield. These individuals have been practicing public health in Maine for many years and are doing so in a very innovative way. Practitioners like these enable us to put better systems in place. From encouraging our pediatric patients to read to championing shared decision making about colon cancer between patients and their providers, practitioners like Deb Dietrich and Dr. Kathleen Fairfield help us improve the care of patients in Maine. We have come a long way since my experience with paper charts in 1996. It's an exciting time to be caring for our community. Thank you for joining us today. As a family physician and traditional Chinese medicine practitioner for many years, I've learned a few things along the way and I like to write about these on a regular basis. If you're a radio listener, you can read some of my weekly readings on bountifulpath.com and read some of the blog posts in between and let me know what you think. I think we can start a conversation that could be helpful for building a Better World. That's bountifulpath.com.

Dr. Lisa Belisle:

When life and work intersect, I believe is when we can get sort of the greatest amount of energy behind our efforts in this world. And Deb Dietrich is an example of how my life and my work intersect. Deb and I are good friends and also have worked together, worked together for more than a decade, in fact, at Maine Health. Deborah is the Senior Vice President of

Dr. Lisa Belisle:

Community Health at Maine Health and also

Dr. Lisa Belisle:

a founding member of the Maine Public Health Association. How are you?

Deborah Deatrick:

I'm great. How are you?

Dr. Lisa Belisle:

Very good.

Dr. Lisa Belisle:

You actually were one of the people who got me into public health. I remember as a Young resident in family medicine at Maine Medical center coming to talk to you. And you had this thing called an mph, which at the time wasn't really a degree that a lot of people

Dr. Lisa Belisle:

were thinking about, at least not doctors at that time.

Dr. Lisa Belisle:

Why did you decide to go into public health?

Deborah Deatrick:

I think because I wanted to make a difference. Before I went into public health, I had a totally different career that just wasn't as satisfying from a perspective of, you know, important social issues. I was always very active on political issues in college, even in high school. And public health just interested me. I thought about medicine for a while, but it seemed too focused. I wanted to work on a grander scale, I think. And so I was very interested in sort of the big issues helping people get healthier originally.

Dr. Lisa Belisle:

You're not from Maine?

Deborah Deatrick:

I am not from Maine. I am from away. I'm actually from Michigan and grew up there as the daughter of a pediatrician and moved to Houston after graduate school. Was there for a couple of years and had an opportunity to move to Maine, a place that I had been for exactly one day before I got a job offer to come here. And the one day I had been here, I thought it was the most beautiful place in the world. I had never been in a place that was more beautiful than this. And I thought, wow, if I had the chance to live there someday, I would take it in a minute. And so I actually got a job offer and moved here in 1980. Long time ago.

Dr. Lisa Belisle:

Well, actually that was three years after I moved here in 77, so it feels like it was just yesterday. And now you're raising your son?

Deborah Deatrick:

Yep. I have a 15 year old son who is adopted and he is in high school now, obviously, and it's a great place obviously to raise a family and just to be.

Dr. Lisa Belisle:

What was your career path before you

Dr. Lisa Belisle:

went into public health?

Deborah Deatrick:

Well, actually I was in advertising. I was an art director and have spent many years as a professional illustrator. Thought about going into medical illustration. Actually got into one of the two programs at the time at the University of Michigan and then decided that that just wasn't for me, it wasn't working on that grand scale. And so I envisioned my life sitting over a board illustrating hearts and lungs and that sort of thing. And it just didn't have quite the appeal that public health had.

Dr. Lisa Belisle:

It seems to me as though some

Dr. Lisa Belisle:

of this work that you did in advertising and also with visual arts could have an impact on your ability to communicate effectively some of the public health messages that you have approached in the

Deborah Deatrick:

last few Decades, that is hitting the nail on the head. That's precisely why I went into public health, because I think there are ways of communicating with people that are better than others. I think having a sense of how you message, how you approach people, even what kinds of images and approaches that you take, are really, really important. And so a lot of the work that I have done over the years has really been to try to combine all of these elements, both visual sort of thematic elements, engaging messages, et cetera, to move health behavior, oftentimes at an individual level or at a community level.

Dr. Lisa Belisle:

We've talked about public health before with

Dr. Lisa Belisle:

some of our other guests, but for

Dr. Lisa Belisle:

people who are listening, who may not be familiar with the idea of public health, can you describe it for us?

Deborah Deatrick:

The best way that I describe public health is a little story that I actually heard in graduate school, and it goes like this. There once was a river, a very busy river, with a lot of rocks and torrents, et cetera. And there were a lot of people in the river who were drowning, thrashing about, just were being carried down the river and couldn't seem to save themselves. And the ambulances came, the doctors came, the nurses came to the bottom of the river and they were incredibly busy trying to pull people out. A lot of people died. Some people were pulled out and resuscitated on the shore. But the point of the story is that they were so busy pulling people out of the river, they never had time to go upstream to see who was putting them in in the first place. And in public health, it's all about going upst. It's all about making sure that people don't fall into that river, that they have medical care, they have primary care, they have ways of taking care of themselves and their families. They have clean air, clean water, good education, et cetera, immunizations, all the things that prevent people from getting into that river in the first place.

Dr. Lisa Belisle:

My experience with public health is that it can be somewhat thankless at times because we have right now such a financially driven, and probably already always have, to some extent, financially driven health care system. And people will say, well, we know that if you can prevent a second heart attack, you're going to save X dollars. But sometimes it can be difficult to quantify the upstream medicine. What are your thoughts on that?

Deborah Deatrick:

Well, it can be, there's no doubt about that. But we do know that prevention works. There have been lots and lots of studies that document if you stop smoking, you're going to live a longer life. If you eat a better diet, you're going to be healthier and hopefully have less chronic disease, etceter. But what happens is that public health, and I think one of the problems here is that public health is largely invisible to most people. You go to your faucet in the morning, you turn on the tap, you get a glass of water and you just think that that water is going to be free from carcinogens, it's going to be. You can drink it, it's going to be safe. When you go to a supermarket and you buy fruits and vegetables or food, you think that that food is going to be safe and somebody. And those are the kinds of things, frankly, that public health does. We do things that keep people safe, that protect people, et cetera, but it is largely invisible. And so the extent to which people want to pay for those kinds of things I think is diminished, especially since

Dr. Lisa Belisle:

right now we seem to be in a sort of an employer insurance payment situation. So if you have an employee who may or may not be with you for a very long time, it's possible you don't want to pay for things that are going to happen once they stop working for you. So how do you approach that issue?

Deborah Deatrick:

Well, I think for all of us, we need to work together and agree upon the things that really do keep people healthy. And so employers, for the most part, I think now agree that things like helping their employees stop smoking or to exercise on a regular basis is actually a good thing for society in addition to their own employees. And so many more employers are investing in these kinds of things. So if you work for one company and you go to work for another company, those kinds of things are still going to be available to the vast majority of the population. And it's also one of the reasons that we need to invest in public policies that can help everyone. So things like smoking bans, things like efforts to keep the air clean or the water clean, etc. Everyone needs to invest in those. They float everyone's boat, so to speak, and keep everyone healthy. It's one of the reasons that in public health we work at a policy level, we work at an individual level, and we work at a community level. All those things really have to be knitted together.

Dr. Lisa Belisle:

What are some of the initiatives that you've been involved in through Maine Health or through some of the work that you've done in other public health spheres in mainehealth?

Deborah Deatrick:

Well, the two big ones and the two big predictors of whether or not we're going to be sick or have chronic disease, et cetera, are tobacco and obesity. And so those are the two areas that I think everyone agrees we do have problems here in Maine with both of these issues. We've done a lot of work on both of them, but we have a long way to go. If we can stop people from smoking in the first place, we know they're going to live healthier lives. And certainly for someone who does smoke, helping them to quit and giving them the tools and the resources they need to do that is incredibly important. And on the obesity side, I think we've learned that it's not just about obesity and overweight. It's really about healthy eating and active living. So eating a healthy diet and getting enough exercise. And again, there's a lot of research on both of these issues. There's no question that they both have a lot to do with our overall health. But one of the other things that I often talk about, frankly, in addition to these issues that everybody knows are related to health, are issues that may not be quite so apparent, but have a lot to do with how healthy we are. And those are things like poverty and education. Those are the two strongest predictors of how healthy we are going to be. Whether we have a job, whether we have sufficient income, and also, to a certain large extent, how much education we have. People who finish high school are much likely to be healthier than people who have only finished sixth grade. People who live below the poverty line are much likely more likely to be unhealthy than people who have. Who live, who have a living wage. So all of these things are important predictors of health. So in public health, we have a very, very broad view of what it takes to be healthy. It's not just about doctors and hospitals, although that's really important to have a place to go when we're sick. It's also about our behavior, whether we smoke or whether we eat junk food or fresh fruits and vegetables, and also continuing education and supporting that and also supporting programs that can help lift people out of poverty.

Dr. Lisa Belisle:

When you and I met not so long ago, you were telling me an interesting and startling statistic about the number of children that now are falling within the main care system and how that's risen over the last few years. Talk to me about that.

Deborah Deatrick:

It is a real statistic, and it's a very troubling statistic. We are, we being Maine Health, are doing a lot in the area of early childhood health, education, et cetera, as are many other organizations around the state. And these are children or kids between the ages of birth and 5. And last year 2012 in Maine, almost 3/4 of children in that age range between birth and five were enrolled in the Main care program, which is a very, in my view, startling statistic as you just mentioned. And basically it says that these are kids who are living in low income households who may not have access to healthy food, who may not have access to clean air, who may not have access to all of the things that are needed to create healthy kids, and kids who are ready to go to kindergarten, et cetera. So it's one of the reasons that there is now a lot of focus here in Maine on that particular age group, in providing childcare, high quality child care to kids, in providing oral health and oral health education, in providing health education, making sure that kids get a healthy diet, have clean water to drink, etc.

Dr. Lisa Belisle:

We'll return to our interview in a moment. We on the Dr. Lisa Radio Hour and Podcast hope that our listeners enjoy their own work lives to the same extent we do and fully embrace every day. As a physician and small business owner, I rely on Marcy Booth from Booth Main to help me with my own business and to help me live my own life fully. Here are a few thoughts from Marcy

[Unidentified voice]:

so many times we get sucked into routines and schedules and we forget that each day is truly a fresh start. You just ended a dismal day at the office and can't imagine having to do it all over again. Stop Change your perspective. Tomorrow is a brand new day. It's an opportunity to do things differently, to get to the things you may have been putting off for weeks. Each day gives us the ability to see things differently and open up our minds to new possibilities. It's a chance to discover something new or find an approach to make an old way of doing something better more efficient. It doesn't have to be a profound change each day. Incremental changes or discoveries are all you need to make an impact. Maybe today you decide to run instead of walk, or drink water instead of soda, or finish that project instead of pushing it down the list. All small changes are events, but all have an impact. Each day is an opportunity to grow and learn, to change and to create, to make an impact. So what is your fresh start today? Let's get that fresh start today. Contact Booth Main at 774-4030.

Dr. Lisa Belisle:

In Maine, we have an issue with access to dental care. And from the First Tooth is a program that MaineHealth has gotten behind to address that issue from early on. Why does it matter that we have good dental care from our earliest years?

Deborah Deatrick:

Well, the simple answer to that question is that baby teeth are taking the place of permanent teeth. And so it's really important for parents and even small children to learn how to take care of their baby teeth because they're placeholders for those permanent teeth. And decay abscesses, other problems can really affect oral health in later years, not only as kids but as adults. So it's really important to prevent, again, going upstream that concept, baby teeth from the time a child has his or her first tooth. So this is another initiative where a very forward thinking foundation came to us and said, we know this is a huge problem in the state of Maine and we'd like to do something about it. And so several years ago, a program was developed that's now called from the First Tooth, which is really about taking your child again to that well child visit at your doctor's office. The doctor or the nurse or another person on the team will look at the child's teeth very quickly and no pain, no instruments being used, and then apply something called a fluoride varnish to the child's teeth, which is really just a very thin protective coating of fluoride. It's colorless, it's odorless, it doesn't hurt the child, but it puts a kind of protective shield around that child's teeth, whether it's one tooth or more baby teeth. And that fluoride application will actually protect the child's tooth for many months. The ideal is to have two of those fluoride applications every year during a well, child visit or other visit to the child's physician. And again, we also recommend that a child see a dentist, hopefully by age one, if that's possible. But as you just mentioned, Dr. Lisa, in some areas of the state we don't have dentists who are able to see. First of all, we may not have dentists at all in certain areas of the state. And secondly, not all dentists will see children at the age of one or even two. And so this is kind of a compromise. We're trying to provide some protection for these child's teeth for these children so that when they do get to their first dental visit, they don't have decay and they don't have dental problems.

Dr. Lisa Belisle:

You've also worked with an organization that is associated with Maine but does work outside of Maine called Combit Santee. What's that all about and why?

Deborah Deatrick:

Yeah, a great question. Combat Sante. Oh, sorry. Is an amazing organization headed by an amazing person, Dr. Nate Nickerson. The focus of Combat Sante is to help rebuild and strengthen the healthcare system in northern Haiti, in particular in a community called Cap Haitian. And many people from Maine and actually other parts of the country, physicians, nurses, not only healthcare workers, but others too, volunteer their time to go to cap, as referred to, and actually teach some of the physicians, the nurses, the people who work in the public health system there. The public health system in Haiti is run by the government, and there is a public hospital in Cap Haitian where many of the folks from here go to work for a period of time. I've had the honor of going to CAP on a couple of occasions. It's quite an amazing place. And the people who are working in the healthcare system there are incredibly committed, working under the most challenging conditions that you could ever imagine. So it's quite an organization. And I would certainly commend to all of your listeners that There's a website, www.combitsante.org, to hear and see more about it. It's a fantastic investment, again, in global health in one of the most impoverished nations in the world.

Dr. Lisa Belisle:

Why did people from Maine decide that they cared about people from Haiti?

Deborah Deatrick:

Well, I think there's some affinity. Maine is a very poor rural state. We have limited access to resources. Until the last several years, you know, we haven't had a public health school here. We do now have two public health programs in Maine. And I think there was a recognition that. And by the way, there were some individuals here going back many years. Dr. Mike Taylor being one of those who got connected to CAP and some of the folks there. And that has been built upon over the years. And now there's a very strong relationship. Many physicians here travel to CAP maybe a couple of times a year, engaged in projects, et cetera, and it has simply built up. There's a relationship between the city of Portland and Cap Haitian and I think a recognition that we need to lift ourselves out of poverty, that no one is going to do that for us.

Dr. Lisa Belisle:

How can people find out about the

Dr. Lisa Belisle:

work that Maine Health is doing in the area of community health?

Deborah Deatrick:

Probably the best thing is to go to our website, www.mainhealth.org. there is information and links to the Raising Readers program, to the from the First Tooth program and our work in tobacco, which again focuses on helping people to quit smoking for the most part, and obesity. And actually each of these initiatives have their own websites. And I don't know if you want me to go through all of those. But one of the programs that we've talked about a little bit before on obesity prevention, they're really going upstream is called let's Go. And that also has its own website at www.letsgo.org, the now famous 5210 mantra. And you'll find lots more information there.

Dr. Lisa Belisle:

And for our listeners who are with us on a regular basis, our interview with Dr. Michael Dedekian actually is all about let's Go. So you can go back to the podcast on itunes and listen to that show if you haven't had a chance.

Deborah Deatrick:

Right.

Dr. Lisa Belisle:

Well, Deb, I really want to thank you for, well, first of all for being my friend, for inspiring me to go into public health and for being a mentor when I worked at Maine Health for all those years, but also for the work that you've done for the state of Maine over the last, dare I say decades.

Deborah Deatrick:

Decades with an S that would be appropriate.

Dr. Lisa Belisle:

And most recently as the senior vice president of community health at Maine Health. So thank you for joining us today.

Deborah Deatrick:

Thank you, Dr. Lisett. And I will say that you, too have been an inspiration just in terms of your care over the years, becoming a much more highly skilled communicator about health and medical issues. So kudos to you.

Dr. Lisa Belisle:

In the studio with us Today, we have Dr. Kathleen Fairfield, who is not

Dr. Lisa Belisle:

only a medical doctor but also has

Dr. Lisa Belisle:

a doctorate in public health and is the associate chief of medicine and a

Dr. Lisa Belisle:

clinical investigator at Maine Medical Center. Thanks for joining us today.

Dr. Kathleen Fairfield:

Thank you for having me.

Dr. Lisa Belisle:

Kathleen, you and I have known each other for a while. Yeah, we've been sort of following each other as we've gone through our medical education. And I also have a background in public health.

Dr. Lisa Belisle:

But you went and got a doctorate in public health.

Dr. Lisa Belisle:

Why did you do that?

Dr. Kathleen Fairfield:

Well, the group I was working with at the time, I was working on nurses health study and we were doing a lot of quantitative work and I felt like I wanted to make sure I really understood the methods. And also there was other work that was going on around me and it allowed me more time to explore. Explore some of the other dimensions of public health. At that time, I actually was thinking more about research than public health practice. But I do a little of both now in some ways.

Dr. Lisa Belisle:

And you also do clinical medicine?

Dr. Kathleen Fairfield:

Yes.

Dr. Lisa Belisle:

So what do you do for clinical medicine?

Dr. Kathleen Fairfield:

So I'm a primary care general internist at Maine Medical center in the clinics and I have a small patient panel and I also supervise residents in International Clinic.

Dr. Lisa Belisle:

And what does International Clinic look like?

Dr. Kathleen Fairfield:

This is a once a week clinic where we do new intake for new refugees who are entering our system of health care. In Portland, we link with Catholic charities in the public health system. So the public health nurses bring the patients in and we do comprehensive new intake visits and try to assess their health needs and get them established in care in the medical clinic. With partnering with our residency program, you've

Dr. Lisa Belisle:

been able to marry what I think

Dr. Lisa Belisle:

most people would be considered.

Dr. Lisa Belisle:

Two very different worlds. Research and also clinical practice or taking care of patients. How has that worked in your own life?

Dr. Kathleen Fairfield:

It's busy. And like a lot of people who like you, a lot of people who do multiple things, they inform each other. And so I think being a researcher makes me a better doctor and being a physician makes me a better researcher. And sometimes I do a little bit more of one or a little bit more of another. Patient care always takes precedence as you know, somebody needs something. And that's the great part about the research that I do. It doesn't usually involve human subjects that are sitting in front of me so I can set it down when I need to.

Dr. Lisa Belisle:

So what is your research right now?

Dr. Kathleen Fairfield:

There are two major tracks. One has to do with shared decision making and using tools to help patients make better decisions that are aligned with their own preferences and values and also fully informed about the risks and the benefits. And the other piece is using large data sets, including SEER Medicare, which is a nationally available cancer data set, to look at patterns of care. This is the field of health Services research where we're trying to make sure that people are getting care that's consistent across systems and minimizing disparities and differences in healthcare by region and race and ethnicity and gender.

Dr. Lisa Belisle:

For people who are listening, who don't have much of a background in research or statistics or some of the things that you're talking about, but they do of course, have health needs, how would the research that you're doing be relevant to them?

Dr. Kathleen Fairfield:

So the research that we do in shared decision making probably feels the most kind of proximal for patients. And it actually really crosses over into quality improvement as well. Where, for example, we currently have a grant from Maine Cancer foundation to do work with shared decision making around colorectal cancer screening choices. So in the practices some people have done work with shared decision making and asking patients about their preferences and values, mostly at the point of care when the patient's sitting in front of you, which is a really nice way to do it because there can be a nice back and forth. But as you know, time directly with the patient in the office is really tight already. So much to counsel them about in terms of prevention and their current medications and other other things, questions that they have that we often run out of time and it gets deferred to the next visit. So the model that we're trying out is to look at our patients when they're not sitting in front of us, to identify the patients who have need, for example, are unscreened for colorectal cancer screening or overdue, and to send them a decision aid, which is a video tool and a booklet so that they can think about their choices for colorectal cancer screening, including choosing in an informed way to not pursue screening or to pursue one type of screening over another. Then we have someone from our office or one of the offices we're working with call them. So an RN or medical assistant, call them and do decision support. So help them understand, answer questions, help them understand their options, and then refer them for screening as appropriate. So it actually, for patients they've had a chance to look at decision aids, process them, think about them with their health care team, and then make a better decision. So it's pretty direct in that way.

Dr. Lisa Belisle:

The idea of shared decision making is

Dr. Lisa Belisle:

kind of counter to the way medicine

Dr. Lisa Belisle:

has been for quite a long time, where it was bit more top down, where somebody would come in and say, this is what I think. This is what I think you should do. Now we're saying, here's some information. This is how this impacts your quality of Life.

Dr. Lisa Belisle:

And you're really attempting as the physician

Dr. Lisa Belisle:

or healthcare provider to have a dialogue with the patient and make this decision together.

Dr. Kathleen Fairfield:

Yes, I think it is a little bit of a paradigm shift. And I think a lot of excellent providers, physicians and other caregivers have been doing it for a long time. It's a little bit more explicit, I think, in some ways of saying to the patient, we really want to know what you value. Do you really value avoiding getting on an additional medication, or do you value avoiding surgery or procedure and help them reflect on their own values and their preferences? Some situations are very clear. A patient can pursue surgery, say for a knee replacement, or spend more energy doing physical therapy and being willing to take anti inflammatory medications, for example, and other decisions might be something like screening, where you revisit it annually, for example, or every 10 years in the case of some colorectal cancer screening choices. But it is a little bit of a change, and I think some patients might not be comfortable with it. But what we're finding in general is that most people really want to participate and be fully informed and have, in fact, strong feelings that they might not have shared with their provider had they not been invited to do so.

Dr. Lisa Belisle:

Why colorectal cancer?

Dr. Kathleen Fairfield:

Colorectal cancer we chose because it's a good example of it's a malignancy that we can screen for and make a difference. We can reduce colorectal cancer deaths by screening for it and taking out polyps that might later transform into malignancy. We have one of the lower rates of colorectal cancer screening compared with some other screening tests like mammography or cervical cancer screening, partly because the tests are unacceptable to a lot of patients. They're not willing to undergo a colonoscopy, as you know, they're the prep and the procedure itself feel more invasive, for example, to a patient. And we thought there was an opportunity there to provide education to patients about what the tests are, why we're recommending them, why they might choose one over the other, and to be more informed, particularly about that choice.

Dr. Lisa Belisle:

How big a problem is colorectal cancer?

Dr. Kathleen Fairfield:

Colorectal cancer is the third most common malignancy for both men and women.

Dr. Lisa Belisle:

And is this something that we've seen rising the rate of colorectal cancer over time?

Dr. Kathleen Fairfield:

I actually think it's been fairly constant,

Dr. Lisa Belisle:

but it's something clearly that we need to be paying attention to. Because it causes death.

Deborah Deatrick:

Yes.

Dr. Kathleen Fairfield:

So it's one of the. It's an important malignancy, again, because it's the third most common we also have an opportunity because of if we diagnose polyps, we can take them out and prevent a person from actually getting the malignancy. Or if we diagnose it at an early stage, it's curable through treatment versus later stage tumors are much harder to cure and it becomes a disease management situation.

Dr. Lisa Belisle:

What are some of the responses that

Dr. Lisa Belisle:

people have had when asked to participate

Dr. Lisa Belisle:

in this shared decision making project?

Dr. Kathleen Fairfield:

We've had a whole range of responses and some patients, patients haven't wanted to look at the materials that we've sent them. They would rather get information directly from their physician. We've had some people look at it and say they really appreciate it. They've had some questions when they get the phone call and they have in fact chosen to be screened when before they were reluctant to be screened. We've had patients choose a simpler stool test that they can do at home and mail in called high sensitivity stool testing. And in fact, not realizing that that was an option, they had only been offered colonoscopy before. And so they do have to understand that if the stool test is positive, they then need to go on to colonoscopy. And so we making sure that people are fully informed about their choices. We've had a lot of people say they really appreciate the information and the chance to participate in the their care.

Dr. Lisa Belisle:

And as a primary care provider yourself, have you been able to use this information on shared decision making in your own practice?

Dr. Kathleen Fairfield:

Yeah, so we've done. MaineHealth has been part of a grant that Dr. Neal Corson and myself have had in working on throughout the MaineHealth system with many practices trying to engage primary care practices and shared decision making along with their patients. So we've been working on this where we can refer patients, for example, to the Maine Health Learning Resource Centers to view one of the decision aids about a variety of conditions and then they come back to their next appointment and talk about it. That's different than the way I described that we're doing now through the Maine Cancer foundation grant where we're mailing out materials. We're also doing a pilot in medical clinic at Maine Medical center where we're using an iPad and doing some point of contact care decision aids where a physician or a nurse practitioner during the office visit can say, hey, would you like to look at a decision aid right now after your visit? And so we're trying to make it accessible to patients in a lot of different ways. And I've referred my patients through all three of those ways of trying to get the materials to patients when they need it and when they're ready for it.

Dr. Lisa Belisle:

We'll return to our interview in a minute. First, let's take some time to explore the connection between health and wealth, something that I firmly believe in and have tried to promote on this show. Joining us is my friend and personal financial advisor, Tom Sheppard.

[Unidentified voice]:

The healthiest communities are the ones that have figured out how to develop new and unique structures to support needs and wants at many different levels. When we look at a healthy school, it supports the needs of the individual, the classroom, the building, the district, the community, and therefore the family as a whole. Building a plan for financial health and well being is the same. What we can learn from managing a portfolio of assets is that sometimes one part of the plan needs to address the risk that allows another part to pursue opportunity. This three step dance of preserve, manage and pursue is the core of good design. If you are part of an organization that is struggling with how best to evolve to a better place, we can help. Send us an email to infoepherdfinancialmain.com and we'll help your organization learn how to evolve

Dr. Lisa Belisle:

You described this decision aid, so what would that look like to a patient?

Dr. Kathleen Fairfield:

So decision aids can take a lot of different forms. They can be pencil and paper, they can be something that they read on a computer. For example, the ones that we're using are created by the Informed Medical Decisions foundation in Boston. It's a foundation I've been working with as a medical editor for many years. They are very high quality decision aids. They're balanced. They have a lot of patient vignettes, they have a lot of pictograms to show patients about risk, using images to help them better understand what their benefits and risks are. And they also have a booklet with them so patients who have low literacy can actually watch the Video instead of looking at the booklet. Some patients prefer to read to get information. Some would do both.

Dr. Lisa Belisle:

Has literacy been a barrier that has been recognized?

Dr. Kathleen Fairfield:

Yes, great question. Literacy is a huge barrier. Health literacy in the United States is very low in general and certainly is low in Maine. And having materials that are at the right reading level, such as about sixth grade, is, I think what the materials that we have, that's important. But also health literacy in general is. And I think there's a lot of myth in general too out there. And not everyone has access to high quality health information. We think it's particularly important that it's unbiased. It doesn't feel like they're being, the patients are being sold anything or that anybody has any financial benefit from using these tools really is to get the patient to make the very best decision for them.

Dr. Lisa Belisle:

What has the response from physicians been?

Dr. Kathleen Fairfield:

The physician response has been great, including again, we work in teams generally now. And so I think the teams have, have enjoyed the process of learning about shared decision making. We have especially found that our process of mailing the decision aids outside of the office visit has been well received by the teams because that way when the provider sits down with the patient next time, the patient's already seen the material and kind of processed it and they can have a better discussion about the choices that the patient has at that time. It's hard to find the right time to give the information to the patient. Ideally might be right before the office visit, but as you can imagine, there are a lot of logistics that make that very hard to do.

Dr. Lisa Belisle:

Does it enable patients to also spend more time researching a given topic before they go in and visit with their doctor?

Dr. Kathleen Fairfield:

I think so. I think a lot of patients have been coming more informed with materials. They may be found on the Internet about certain things they might want to try or they're thinking about. This is a chance, I think, to help patients prepare, particularly around things like screening that they might not have realized the physician was going to bring up during the visit. Or particularly in the case of colorectal cancer. As we were saying, the screening tests seem unacceptable to some patients. And so it gives them a chance to think more about what that might be like and then ask questions that are a little bit more targeted for their provider.

Dr. Lisa Belisle:

The type of medicine that you've gone

Dr. Lisa Belisle:

into, where you're doing clinical medicine or

Dr. Lisa Belisle:

seeing patients, and also research based medicine

Dr. Lisa Belisle:

and public health related.

Dr. Lisa Belisle:

It isn't the type of medicine that

Dr. Lisa Belisle:

most little kids think about when they're thinking, what do I want to be when I grow up.

Dr. Lisa Belisle:

When you were younger, did you have

Dr. Lisa Belisle:

any sense that this might be the direction you'd go in?

Dr. Kathleen Fairfield:

No, I. I didn't. In fact, I wanted to be a veterinarian. When I started thinking about medicine as a career, I think I thought about primary care, family medicine, because I really wanted to be sort of the regular physician that had a long standing relationship with patients. I could get to know them and take care of them over time and have a trusting relationship. That's been great. As you know, face to face patient care is wonderful and very rewarding, but sometimes you wish that you had better information for patients or that some of the barriers to getting care done would go away. And so that's the wonderful thing about doing research too, is that sometimes you feel like you can solve problems that come up in everyday patient care and maybe make things a little bit better

Dr. Lisa Belisle:

so you can get a little bit of distance from some of the in the trenches work that you're doing.

Dr. Kathleen Fairfield:

Yes. Yeah. It's rewarding to do both. And the challenge in research always is feeling like it's quite slow. And sometimes translating findings into actual clinical practice takes much longer than anyone would ever think.

Dr. Lisa Belisle:

Kathleen, you and I have been in medicine for roughly the same amount of time, and we've seen a lot of changes. I think when I first came into medicine, there were a lot more independent physicians and a lot fewer that were employed by healthcare organizations. And I think people are really seriously considering whether medicine is a good career path for them. What would you say to somebody who is thinking about going into medical school?

Dr. Kathleen Fairfield:

I think medicine is still a wonderful career path in that, you know, most people work hard in their jobs regardless of what they do. It's nice to go home at the end of the day and think that you helped people, even if you provided someone with some comfort and not necessarily a big cure, which, as you know, doesn't happen that often, particularly in primary care. I think that a lot of the changes in medicine have to do with standardization, which is a really good thing, because we don't want to be practicing the kind of medicine that feels too artful and too unique. I think it's good and comforting for patients to get the same answer from one provider that they would get from the other provider. And I think that we're also doing a better job with integration, where all members of the care team are participating, communicating with each other. I'm not talking about just primary care and specialists either, but our nursing colleagues and physical therapy and mental health et CETERA So I feel like we're moving toward a more cohesive model. That makes a lot of sense. I think some of the, and I hope that patients perceive that as well.

Dr. Lisa Belisle:

You have a daughter who's the same age as my daughter, Sophie, 12. Would you suggest that she be a doctor if she wanted to?

Dr. Kathleen Fairfield:

Well, it turns out she wants to be a veterinarian. So I do think that, I do think for women in medicine, it's a really interesting question about the balance with work and life and caring for kids or elderly parents or participating in other things in the community. It's a difficult career, as you know. It's very time consuming and the field of medicine for women has been much more open in terms of specialties, accepting women, I think among their ranks and people being able to adjust job descriptions and tailor their profession to some of their needs at home, as you know. However, I think it's still hard and I think there's still a lot of bias there. And for example, a year ago I was actually on a show, the On Point show, as part of an NPR show about the woman anesthesiologist who talked about part time careers in medicine for women and how she thought that that was very negative and that it was a waste of resources to train women and then allow them to go part time. It was very controversial. It made a huge splash. It was an op ed in the New York Times and it's nice to have a chance to talk about that again. I think that women are at a great dimension in medicine of warmth and understanding where our patients are in their lives, in their journeys. I think a lot of men do that as well. But I think that it's, I think it's a time of growth in medicine for women and we're still trying to find our way. In some ways, I think the most important thing is supporting each other in all of the different options that people choose, including part time work or full time work or shared practices or every other model that you can think of. And that's one of the most important things, I think in women succeeding in medicine is being allowed to change their direction as they need to, to care for their families.

Dr. Lisa Belisle:

What challenges have you had in being the mother of two, a 12 year old and a 10 year old and also a doctor?

Dr. Kathleen Fairfield:

I think, you know, it's always, it's deciding how long to stay at work and how much more you can get done in a day or what's for next year or five years away. If I had worked harder, I could have published A lot more papers by now, for example, I could have a very big patient panel. There's a lot more that you can always do. And I think being able to feel comfortable with what you're doing and not look back and say, oh, I wish this or that. There'll always be opportunities, I think, to work and do more professionally. But when, you know, when your kids are younger, it's also really nice to be there and be able to participate in the things that they're going through. And so getting home at the end of the day is, in a way, and feeling not completely overwhelmed by work is one of the most important pieces.

Dr. Lisa Belisle:

Did you take into consideration the fact

Dr. Lisa Belisle:

that you wanted to have children when you did this research tract and went and got a doctorate in public health?

Dr. Kathleen Fairfield:

No, I think my plans were all a little unclear then. And I was thinking about my education and making sure that I took the time to finish all the education that I thought I needed at that time. And I was fortunate that I could kind of get that all done before I had kids. A lot of people do it the other way, really successfully, where they start having kids in residence and find a way to make that balance work. I think that would have been harder for me because I'm not sure just the kind of person I am. But everybody, I think, needs to take into account how much time they have for family planning and what they want to accomplish in their careers. And again, it's not a race. There's plenty of time and everyone has their own path. I think

Dr. Lisa Belisle:

now you have a medical degree and a doctorate in public health, and arguably you could be employed anywhere at any of the big medical centers or training institutions in the country. Why choose Maine?

Dr. Kathleen Fairfield:

I grew up in Hallowell, Maine, and so it was coming home for me. About 10 years ago, my husband and I were both in Boston in medicine and decided that we wanted to raise our family here. And the Maine health system has been fantastic for me to be able to practice and do research. Maine Medical center and Maine Medical Center Research Institute has been very supportive of my research and has allowed me to kind of do everything part time, take care of patients and do teaching and do research and that. That's a wonderful thing. I think it might be harder at a major academic center where I think a lot of people are forced to kind of pick their path and spend the majority of their time as a clinician or maybe in education or in research. It's very hard to strike that balance, I think.

Dr. Lisa Belisle:

And does your husband also feel as if also being in the medical field as if he's able to strike a balance.

Dr. Kathleen Fairfield:

I think so, yeah. I think, I think he works full time as an endocrinologist. He's very busy. But I think being in Maine allows us to kind of be home at the end of the day with our families and feel like we are accomplishing all our goals personally and professionally.

Dr. Lisa Belisle:

How can people find out about the

Dr. Lisa Belisle:

shared decision making program that you're doing or the work that you're doing with colorectal cancer specifically?

Dr. Kathleen Fairfield:

They can visit the MaineHealth website, which has a lot of materials about the things that we're doing with shared decision making. And links to other places, including some decision aids, are available online. Also, the Informed Medical Decisions foundation, which has funded some of the work at MainHealth, has an excellent website and it's Shared Decision Making Month, the month of March 2013. So there are links to other materials there as well and including some podcasts.

Dr. Lisa Belisle:

And it's also, I believe, Colorectal Cancer Awareness Month too.

Dr. Kathleen Fairfield:

Yes.

Dr. Lisa Belisle:

So this is appropriate that you're here talking to us about that.

Dr. Kathleen Fairfield:

It's good alignment. Yes. Colorectal Cancer Awareness Month. So it's a great opportunity for people to think about their screening options, whether they might want to be screened and find out about the choices. The Maine CDC has a program for low income patients to get screening, which is wonderful. It used to be only breast and cervical cancer screening. Through a lot of work by others, this was extended to include colorectal cancer screening. And we've been fortunate in Maine to be able to have good access to a lot of colorectal cancer screening options.

Dr. Lisa Belisle:

I have. I'm very pleased that you took the time out of your busy schedule to sit here and have this conversation with me today. I think it's been a while since I've seen you, so to know that you've gotten your doctorate in public health and you're a successful medical doctor and associate Chief of Medicine, Clinical Investigator at Maine Medical Center. It's very gratifying to spend this time with you and thank you for joining us.

Dr. Kathleen Fairfield:

Thank you so much for having me, Lisa.

Dr. Lisa Belisle:

You have been listening to the Dr. Lisa Radio Hour and podcast show number 81, Caring for Community. Our guests have included Deborah Dietrich and Dr. Kathleen Fairfield. For more information on these guests, visit drlisabelisle.com the Dr. Lisa Radio Hour and Podcast is downloadable for free on itunes. For a preview of each week's show, sign up for our e. Newsletter and like our Dr. Lisa Facebook page, you can also follow me on Twitter and Pinterest Dr. Lisa and read my take on health and well being on The Bountiful Blog bountifulpath.com We love to hear from you, so please let us know what you think of the Dr. Lisa Radio Hour. We welcome your suggestions for future shows. Also let our sponsors know that you have heard about them here. We are privileged that they enable us to bring the Dr. Lisa Radio Hour

Dr. Lisa Belisle:

to you each week.

Dr. Lisa Belisle:

This is Dr. Lisa Belisle hoping that you have enjoyed our show on Caring for Community. Thank you for allowing me to be a part of your day. May you have a bountiful life.

Dr. Kathleen Fairfield:

Sa.