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John Cullen: A Rural Family Physician’s Perspective on Healthcare

Today we get a rural family physician’s perspective on healthcare from John Cullen. He joined the Perspectives on Healthcare Podcast with Rob Oliver from his office in Valdez, Alaska where he serves a community of about 5000 people. John is a member of Generation X. His community is located over 250 miles away from any other hospital.

Here are 3 things that stood out as John Cullen shared a rural family physician’s perspective on healthcare:

· His practice serves rural people and they have the same issues as people in the “big city” (they may have some issues that are more prevalent because of the fishing industry)
· Part of quality healthcare is doing the training to be prepared for whatever your patient’s presenting issue is (with such a small sample size, he faces a lot of statistical anomalies)
· Sometimes it is easier to bring in a team of medical experts to treat the patient than to move the patient

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Rob Oliver: Thank you. And I appreciate you being with me today. I really feel like I’ve got a unique perspective coming into today’s program. His name is Dr. John Cullen. He is a family medicine doctor. He practices in Valdez, Alaska, which is a fairly small and rural community. And when I say rural, I mean, he’s away from the big city. Let’s just put it that way. Listen, John, welcome to the show.

John Cullen: Oh, thank you.

Rob Oliver: Absolutely. So tell me a little bit about yourself and your role in health care, please.

John Cullen: For the last 27 years, I’ve been practicing a full scope family medicine in Valleys. So this is a community that is about 4000 people. We’re 300 miles away from the nearest tertiary care hospital, where we do all our referrals about 260 miles away from any other hospital at all. It’s an incredibly beautiful place. I’d love to kind of point the camera out the window, but the sun is just barely coming up right at the moment. But as beautiful as it is, we also have some of the worst weather on the planet, and so we can go for several days without being able to transfer anybody. And so we have a ten bed critical access hospital. And with that, we are actually doing like I said, it’s full scope family medicine, which includes obstetrics, including cesarean sections. We do surgery, cover the emergency room and have our clinic. And it’s been a fascinating place to practice. You never know what you’re going to get. I think that one of the things that happens in rural communities is that we see exactly the same things that are seen in a big city. It’s all the same stuff. We just had somebody with a bleeding aortic aneurysm. We had delivery just this last week. So we’re taking care of all the same things, all the same emergencies that you would see anywhere else. It’s a little bit different. We’re a fishing town. And so we see a lot more fish injuries than a lot of other places and ice injuries. But otherwise, it’s all really the same kind of thing. But because of where we are, we actually have to have a much more robust response for taking care of our patients than you would expect for it in that critical access hospital.

Rob Oliver: Okay. So I think that your point is well made that people are people and no matter where they are, they’re going to experience similar issues when it comes to the condition of being human. And then you’re also, I think making the point that there may be some particular injuries or particular things that you’re dealing with, especially because of the nature of what goes on in your area and also mentioning Valdez, Alaska, you get the black name of being associated with the Exxon Valdez, Unfortunately. But as you’re delivering health care, tell me, what does quality health care mean to you?

John Cullen: I have to look at this from a rural lens. And again, from the perspective of the time that I’ve been practicing. But for us, quality means being able to handle whatever comes in the door for as long as we need to do it. Within our community until depending on the circumstance that we can transfer where the patient gets better, what that means is that we have to be able to handle everything from heart attacks to major trauma to obstetrical emergencies. And so for me, quality health care is just having that robust response to whatever is coming in through the door. And we have to do that with an extremely stuck small staff. So we have currently four family physicians, and that’s it. We don’t have any other specialties or other providers as well as a nursing staff. And so together we need to provide that double of care. Our numbers are small. One of the problems in a small community like ours is that our end is really tiny. And so you get these weird statistical flukes like I’ve had two years, two acute colonysocitis in the last 24 hours. I haven’t seen one of those in about a month. And so it’s just odd how things going to happen. But because of the small numbers, we have to do a lot of other things in order to maintain our competency. So in terms of quality, that’s the second part is that maintaining that training level to handle whatever it is that’s coming in the door, even if we haven’t seen it in a while, and we do, I think a fairly good job of that part of that is that we do a lot of drill and training. Our nursing staff actually has every certification you can get, and as well as the physicians, we have to have all of the certifications, but not only that, but we actually have to practice. And when I first moved to Valdez, we actually did not do C sections except for an emergencies. And that was the wrong time to try to figure out how to do a Csection. And so we practiced and practiced and practiced. We actually got out the recession and did hundreds of C sections with a recession just to get everybody up to speed. And the next time we had an emergency, we were actually able to take care of when the emergency came through. And we do that with everything.

Rob Oliver: The breadth of knowledge that you have to have in order to be able to treat everything. Just from my own curiosity, how big I know that your Valdez, the town itself, only has 4000 people in it, but I’m assuming that you would also kind of be a magnet for the towns around that don’t have access to hospitals like that as well. How big of an area do you serve?

John Cullen: It’s actually about the size of Ohio, but there’s not very many people. So we’re looking at maybe 1000 people outside of the city limits within that whole area. A lot more embarrassed than people, actually, but it’s not that big of a draw. So maybe 5000. All told.

Rob Oliver: Okay. You gave us somewhat of an example when you talked about Csections, but can you give me any specific examples about what is quality healthcare, an example of quality health care?

John Cullen: Well, I think that kind of following along with that. I can give a specific example. It was actually written up in US News World reports, but I had somebody who was pregnant with twins. We knew she had twins, and the plan was to have her go up to Anchorage on Monday. I saw her on Friday. Everything was fine. She was 31 weeks at that point. She came in on Saturday, already dilated to 7 CM. And then her membranes were hourglassing through her cervix, and they were filled with a cord. So she had actually ruptured the membranes. Then she would have prolapsed the cords from one or both of the babies. And we actually took care of that here in Valdez. We did bring in the neonatal team. It took us seven or 8 hours to do that because the weather was just terrible. So we maintained her pregnant for about 7 hours. And then when we got neonatal team in, we did see section in Valley delivered both premature infants. And they are now six years old. And just these delightful twin girls. That was actually the second set of twins. And I had never planned on doing any twins whatsoever. And the other set of twins actually had a prolapse court as well. And the fact that we were able to handle those emergencies, it was not a fluke. It was because we had been preparing not for that particular case, but for those kinds of cases, basically for the previous 15-20 years.

Rob Oliver: Right.

John Cullen: So when they actually happened, we were ready.

Rob Oliver: Yeah. The anticipation of what might happen. Sounds like there are certain elements of that where you can definitely be prepared for it. Okay. And just on a side note, I’m the proud father of triplets and very similar circumstances for us in which my wife was, I think, 34 weeks and doing very well. Her mom needed a break because she was helping out. And so her mom had a place in Florida. We sent her to Florida. She arrived. My wife went for a regular doctor’s appointment. The doctor said, You’re becoming toxic. The babies have to come. And my wife informed him in no uncertain terms. They’re not coming until my mom gets home because she has to be here for this. But that’s a story for a different day. The question is, what do you wish people understood about your role in health care. And if you don’t mind, I’d love to hear you answer that from two perspectives. Number one, the people in your community, what do you wish they understood about your role in health care? And number two, the people that are outside of your community, what do you wish that they understood? Is that a fair way to take that question?

John Cullen: Sure. No. I think that certainly is in terms of our community. A lot of times my patients expect us to be able to have more capability than we actually have. And so, for example, both patients who had a cuolicosystitis has asked me to do the Invalid, which I had to defer, and then they need to go to Anchorage for that particular procedure, partly because that’s not something that needs to be done emergently. And we really are trying to focus on providing emergent procedures. But I think that sometimes their perspective of what we can do here is much greater than what we actually can do. But it’s interesting because I think that I don’t worry about people calling me in the middle of the night. I don’t worry about them giving me enough space. I’m in the phone book. My phone number is in the phone book. I give my cell phone number out to my patients, and nobody abuses that. And so outside of just sometimes the expectations of what we can provide, that’s really about it from outside the community. I think that there’s two parts to that. First off is that when I’m talking with specialists in the big city, a lot of times, their perspective of what we can do also is something that we need to either they think that I’m operating out of the back of my pickup truck or that we can do heart surgery, and they don’t see that middle ground somewhere between there. So I think that’s part of it. The other part is that unfortunately, a lot of times again, the Metropolitan specialists have a tendency to think that all health care should be provided in a Metropolitan area, and it can’t be because about 20% of the population lives in rural communities like mine. And all of those rural hospitals need to be able to provide a robust level of care. So I think that there’s again, just that perspective of what we can provide. And I would love for specialists to come out and see what we’re doing just so that they have a better perspective.

Rob Oliver: I think that you’re right on with that. That so many of the, quote, unquote big city hospitals, big city doctors to be able to see to have a realistic understanding of what your capabilities are. And I think it would provide them with an understanding of the fact that you have an operation that is equipped to handle most of what happens in your area. So it’s not outside of the back of your pickup truck, but at the same time you don’t have access to the same level of equipment or things like that that the folks in the Metropolitan hospitals would have. Ok. I’m in Pittsburgh, and I think the same thing happens in which we have our community hospitals, and someone is in the community hospital until something major happens, and then they’re transferred from there to one of the big city hospitals, because even though it’s a suburban hospital and you’re only 10 miles outside of the city, those community hospitals aren’t equipped to handle the same level of care that some of the bigger city hospitals are. Does that resonate with you?

John Cullen: It does, especially in the light of what’s been happening here in the last couple of months, we had a huge covet surge to the point where the hospitals, the big city hospitals were completely full. So for about three weeks, we were unable to transfer anybody. That made it a really an interesting experience in terms of having to extend what we could do beyond what we felt comfortable because we ended up having to keep people for extended periods of time.

Rob Oliver: Yeah, you’re so right in that. And it’s such an interesting situation to be put into. What excites you about the future of health care?

John Cullen: I think that technology, the advances that we’re seeing again, from my perspective, as being providing rural medicine is extraordinarily exciting. And I’m thinking about everything from mRNA vaccines to the developments in ultrasound technology to even some of the advances in artificial intelligence. All those things are actually going to really help our practice here more so than I think, than just about anywhere. And I think that as far as rural physicians go, I think we’re taking advantage of as much of that as we possibly can. When I first started doing ultrasound, for example, it was like looking through a really dirty stained glass window, and I just really couldn’t see anything. The quality of the images that I can get just with ultrasound that plugs into my phone are just incredible. I mean, anybody can read those. And so I think that that has been amazing, just the availability of information on the Internet and the advances in telemedicine. We use telemedicine all the time. It’s important to recognize that with telemedicine that it’s not really a solution. It’s a tool. It’s just a way of discussing cases. One of the best examples I have is we had somebody who was crumbling at 02:00 in the morning in the middle of a snowstorm. And this is the first time we actually had the teleco set up, and they’ve been sort of gathering dust in the corner for about three months, and we didn’t even know it was hooked up. So I was going in because my patient was becoming increasingly respiratory distressed. It was getting ready to intubate. And it was just me and two of my female nurses. And all of a sudden, I heard this deep voice go, looks like she’s decompensating. And it’s 2:00 in the morning. I’m looking around trying to figure out where this voice is coming from and hoping it wasn’t the voice of God.

Rob Oliver: Right.

John Cullen: And then when the voice said that, you probably need to intubate, it’s like, yeah, I know. But that’s when I realized that we had turned on the tele ICU and I had somebody watching over my shoulder, and that felt really good. That was really a nice thing. But I think the point is that no matter how good he was on the other end of the telemedicine, he could not reach through there and intubate my patient. And so you need to have people with skills like what we have here to be able to really utilize telemedicine as fullest capacity. It’s not a solution for finding enough providers for rural communities, but it is a great adjunct.

Rob Oliver: Sure, it makes a lot of sense. And there are the concept of robotic surgeries that can be performed remotely and everything. But still, what you’re talking about is you can get advice and you can get insights from remote doctors. But the skill to actually implement what you’re hearing is going to be available on the local end. What is one thing medical professionals can start doing today to improve the quality of health care?

John Cullen: I think that one of the really exciting things, too, which I didn’t really talk about is just the development of quality improvement initiatives and really using data to look at what you’re doing. I think that data and team based approaches, I think, are really critical. So one thing is to really emphasize the team approach. For example, this morning, early, I was at the hospital. I went through all the patients that we had discussed what was potentially coming in. We discussed our B patients that were out there. We made plans for everything just so that we wouldn’t be surprised. And we know that there’s things going to come walking in the door that we hadn’t anticipated, but we did as much as we can. When the patients arrive. We have a huddle. We talk about the case, both of the physicians and the nurses, and then we have debriefings on a regular basis. All of those really serve to improve the quality of care in every single case that we have, even though our numbers are small, is an opportunity to learn so that we can do better next time. And so I think that from a quality perspective, it’s a really active process. It’s not a passive one, but developing those high functioning teams, I think that’s probably one thing that we can do.

Rob Oliver: Yes. And I will just add this comment from my perspective. The patient has to be considered part of that team as well. In order to have a health care solution that works for everybody, the patient’s got to be included. Listen, Doctor Collin, I feel like I could talk to you all day. I really appreciate you being here. Your stories are fascinating. I just thank you for coming on the show and I appreciate your perspective on healthcare.

Disclaimer: All opinions expressed by guests on the Perspectives on Healthcare Podcast are solely the opinion of the guest. They are not to be misconstrued as medical diagnoses or medical advice. Please consult with a licensed medical professional before attempting any of the treatments suggested.

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