Next Generation Rural Healthcare in Here: How the Practice of Medicine in Changing and Why

Brian Urban (00:22):
Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban, and today joining our show is Dr. Jason Woloski, the associate professor of family medicine at Geisinger Commonwealth School of Medicine is joining our show today, and I'm just so excited to be able to connect with you, Jason, because it's been a few years we've known each other. And now finally, we got you on the show. So welcome.

Dr. Jason Woloski (00:46):
Yeah, thanks for having me, Brian. Look forward to talking with you this morning.

Brian Urban (00:49):
This is going to be a lot of fun. We know each other pretty well on a personal level, with some of our past projects we've worked on together. But for our audience, we'd love to have them get to know you a little bit better. So let's start off with who Jason is before the MD, before all of your years of experience, at a very creative and innovative healthcare system such as Geisinger. So who is Jason, and how did you get into medicine? And kind of take us through the story.

Dr. Jason Woloski (01:22):
Yeah, it's funny Brian. I think growing up everyone asks you that question, "What do you want to be when you grow up?" And I used to always say a doctor, and people would say, "That's nice, that's nice." And it just kind of stuck. And it's funny because in my family, we don't even have a nurse in the family, let alone anyone else. So I was kind of paving the way in the healthcare system when I was pursuing that.

(01:46):
And long story short, I had a great family physician myself who was kind enough to explore that interest with me, allow me to start shadowing him when I was in high school, and really building upon that interest. And here I am today as a family doc, taking care of people from cradle to grave, and providing good primary care.

Brian Urban (02:10):
It's such a humble way of stating your background there. And it's interesting the influence you had growing up, to what led you into practicing medicine. So nothing that was deep-rooted in your family, but just an outside influence, and an intrigue, and wanting to help. And not only are you a physician, but you're also an educator to young residents as well. So you see a lot in your day-to-day work, week to week work. So you've been practicing medicine now for going on or more than 15 years now, I believe, just guessing, doing the age math. But you've seen a lot of different patient populations come in and a lot of different scenarios. So in thinking about today's patient engagement, what's the biggest challenge you see for healthcare providers, and how they can stay better connected with the patients they see, the lives they serve?

Dr. Jason Woloski (03:04):
Yeah, great question Brian. I think if I answered this question a couple of years ago before Covid hit, and now answering it after, you can see the drastic changes in healthcare. I think we in some ways have improved access. So when I say that, I say we have telemedicine platforms that really weren't there a couple of years ago, at least maybe more in the primitive stages. We have portal messages where you can go on and send an email to your care team, and we have questions, and talk about medication renewals. So there's a lot of progress, especially in the IT world, where being able to reach your care team by some other means besides telephone or in person is really some newer technology that we're really capitalizing on it.

(03:53):
I think one of the things that continues to be a challenge is that especially where I am in Pennsylvania, we have a very fast-growing, aging population. Those baby boomers are starting to reach that age where they're starting to have chronic problems.

(04:08):
And we know that in primary care in particular, there's a projected shortage, if not already a shortage in several areas, especially rural areas. And I think sometimes, that continues to be a challenge where in the past, you may have been able to get in a day to see your family doc. And now, there may not be appointments for a couple of days.

(04:31):
And so I think really trying to work as a team to solve that and relying on everyone in the healthcare team, what is able to be done by nursing, what is able to be done by a pharmacist, and expanding those roles. Because we have to somehow figure out if we can't bring you in, how do we make sure that you're not overpopulating our emergency rooms? And really still getting that great primary care that you deserve as a patient.

Brian Urban (05:00):
I love where you took that, and you made me immediately think how the primary care physician now more than ever is a quarterback of care. And having an extension of that primary care pharmacist, like you mentioned, in-home care nurses, licensed clinical social workers, is critically important to feeding back what care needs to be coordinated downstream.

(05:23):
And it's so interesting to hear you talk about just the notion of what your answer would've been before Covid-19 pandemic now after, telemed obviously being a huge access point for a lot of folks going through the pandemic, and even now, and probably going forward. So it's great to understand that there's been a big investment there and there's been a big recognition of a point of service for care.

(05:50):
And you mentioned Central Pennsylvania, mostly rural. What does it mean for how healthcare is consumed in terms of that population? Are there still struggles in terms of the culture of health, or understanding how to access care, or even trust? Take us through a little bit of that side of the world.

Dr. Jason Woloski (06:12):
Yeah, thanks for that question, Brian. I think sometimes, we think rural medicine is a little bit separate from what I like to say, underserved medicine. And I think a lot of them go hand in hand. So you could be in a very highly populated area such as Philadelphia who has five medical schools, and lots of trainees, and everything, but still be underserved in terms of care. And I think to answer that question in the short time we have together, as you know, is very complex, because there's so many things that are even outside of patient's control. Maybe they were able to get on Pennsylvania Medicaid during the Covid pandemic, where the guidelines were changed and there were different review of the applications. And now as we've kind of come outside of that, we're seeing many people lose that Medicaid insurance that they had.

(07:06):
And so maybe, the one reason they're not knocking on the door to come back into clinic is because they no longer have health insurance. And if they're able to get it through the health exchange, it's too expensive. And with inflation, they have to pick. Am I going to get the healthcare or am I going to put food on the table? And so these are the challenges that whether you're you're in a rural area or an urban area, I think we're seeing across the board.

(07:34):
I think in terms of access, I think access continues to be an issue, as I already previously mentioned. Only because people nowadays are okay to travel for healthcare in some circumstances. And then there's a large cohort who still does not want to travel for healthcare.

(07:56):
So for example, you might say, "Well, I built this beautiful clinic 20 miles down the road, and it has everything. It's a one-stop shop. And because of that, I closed some of the little area clinics around there so that we can all coalesce in this big clinic." But you don't realize that that 15, 20 minute drive is going to prevent that person from getting there.

(08:20):
So I don't know if I have an easy answer. But I think when you think about access, so much is as you know, determined with the social determinants of health. And I think we need to also, when we talk about healthcare, we need to make sure that whether you're in an urban or rural area, how do we have that infrastructure for transportation? How do we have the infrastructure to make sure that if you don't have broadband internet and you can't do telemedicine, how do we connect with you? How do we get to your house if you can't come out of the house? And so these are the things that I think we're seeing in the rural areas, but also in just underserved areas in general.

Brian Urban (09:07):
I like that you hit on a few really interesting points. With rural medicine, I think a lot of folks across the healthcare ecosystem do put it into a completely different category because of the population, because of the logistical challenges that might exist. Broadband access, even just getting physically to an appointment.

(09:31):
I like that you put it into a better context of, when medicine is being developed for access to different populations, it's the infrastructure that needs to be considered on top of the geography, and then on top of the population that would be accessing the care. It's very thoughtful.

(09:50):
If I didn't already know most of your background, I would've asked, do you have some experience in civil engineering project management for standing up some of these facilities? Because you're clearly very in tune with how Geisinger, your employer, where they're positioned in certain communities. That's just really, really interesting.

(10:14):
I think the Fresh Food Farmacy efforts too, where those locations are positioned has been very helpful for the community. So just stemming off that for a second, it seems like Geisinger is very thoughtful in where they place points of access for care, and not just scaling as many buildings as possible. I mean, do you see that throughout the whole organization in terms of being thoughtful of how care is delivered and where?

Dr. Jason Woloski (10:42):
Yeah. No, I agree with you. I think one of the things, for example, in a town not too far, Pittston, Geisinger invested very heavily in a larger building that has x-ray services, lab services, some outdated surgical procedures. But one of the first things that they insured was that it was a bus stop.

(11:05):
And so whether you're coming from two minutes away or 15 minutes away, even if you may have to transfer two buses, it is a bus stop. And that bus stop makes a big, big difference. Because if it wasn't a bus stop, you would essentially exclude a certain population just in and of itself.

(11:25):
And so those are the things that I think we have to continue to think about, because as great as we're doing, there's always room for improvement, and there's always reasons that people can or cannot connect to certain places. And so I think that's something that we'll continue to focus on and work on.

Brian Urban (11:44):
It's all the different evolving models of care that we're really starting to talk about here. And your amazing chief innovation officer, Karen Murphy had mentioned recently to us on our little show here, the value of in-home care services, the at-home side of Geisinger. And it seems like that's been extremely well adopted. I want to get your perspective from practicing primary care physician family medicine, how that has flowed into your view of treating families, treating individual patients. Have you seen the big adoption continue for at-home care needs? And have you seen different insights pop up now that you're having more clinicians in a home, feeding back to perhaps the primary care physician for more care coordination downstream? Curious on the impact of the at-home care side of things.

Dr. Jason Woloski (12:42):
Yeah, I always think of that. One of the signs you sometimes see in people's houses that say, "My home is my happy place," because I think there's so much that you lose in terms of autonomy and just your individualization sometimes when you're in the hospital, right?

(12:58):
And then add on a layer of potential isolation in the hospital, say for example, because you have Covid, and people come in these yellow gowns and these masks, and it's scary, and you're kind of in this room. All the emotions, and how that impacts your healing, how that impacts your motivation to heal, and so much so. If we can really safely... I will always say safely because there's certain instances where yes, you need to be in a hospital. But when there are situations that you can safely treat in your home, we should be capitalizing on this. And I think Geisinger as a system is recognizing that, and you can actually improve better outcomes.

(13:40):
I'll give you one quick example. I had a patient a few weeks ago who had a very resistant urinary tract infection, and the only antibiotics that this individual can receive are IV antibiotics. Now you don't need to necessarily be in a hospital and sit there for three days getting pumped with IV antibiotics if you have a means to have someone come to that house, deliver those IV antibiotics, make sure that you're able to have a mobile phlebotomist draw blood work every day.

(14:12):
So that patient was perfect for our hospital at home program, because essentially, why take up that bed? We talked about even shortage of space in some hospitals, right? Overcrowding in the ERs, overcrowding on the inpatient ward. So if you can safely do that in the home, it's a system satisfier, and most importantly, a patient satisfier.

Brian Urban (14:35):
I love that you went that direction again, Jason. Because a little bit of healthcare economics in terms of the shift there that you described. And the patient experience side of it not only is it an opportunity for them to have healing at home like you were describing, versus in a hospital. Logistically it's better, probably better trust is built as well. You don't just let someone come in your home. There has to be an established understanding of who's coming in and how are they going to help me, and how are they going to continue to help me for whatever needs I might have with my health?

(15:11):
So that speaks a lot. Not just with Geisinger in terms of a model, but the awareness of what your opportunities are in terms of a playbook of healthcare. So I absolutely love that, and I hope that continues to grow for Geisinger. It's a valuable avenue for receiving care, building trust, etc.

(15:30):
Thinking Jason, about now I'd say your associate professor side of your brain here. So you see a lot of residents. You are helping mold their understanding, their philosophy toward bedside care, and their approach in delivering quality care for the lives they see.

(15:51):
So when thinking about that side, I'm curious because your background, I think you have three boys now I think, right? So you have a growing family, and you obviously keep yourself healthy, and your time is very crunched.

(16:07):
So I want to think about it in terms of the next generation residents that you help bring on board into Geisinger. How important is it, I guess, in terms of what you teach and what you preach to them, in terms of their own health, but then learning different aspects of healthcare? So exercise, nutrition, medical humanities, we can call it, addressing SDOH. How important is it to educate the new residents on that side, but also for themselves as well, their own health? I want to get your take on, how you balance all of that in there? And then the science of medicine on top of that. Just curious, can you walk me through all that? That's a big question.

Dr. Jason Woloski (16:49):
It's a lot, I will agree. But I think when they designed the path to becoming a physician, I think the duration that some people say, "Oh my goodness, it's so long to finally be out on your own and to be able to do that." I think there's a reason you need that time and you need that extensive training, so you can develop as an individual, as a caretaker, and ultimately as a physician. Who not only preaches wellness, but practices wellness like you alluded to.

(17:19):
I will say just in case some of the listeners aren't familiar, but remember, you get an undergraduate degree. Then you go to a medical school for four years and then a residency. And in family medicine, that's a three year residency. So it is a long path.

(17:36):
So I will say one of the nicest, positive changes in healthcare education is that we're also impacting a lot on the medical school level too. So obviously, medical school's a trying time. There's board exams, you're learning as much as you can in that short time. But how do we make sure that nutrition classes in medical school are just as important as your gross anatomy dissection lab, and how do we ensure that patient communication courses... I sometimes help run some of the patient communication classes, is so important with standardized patients before you get in front of a real patient.

(18:18):
And so I think the more we integrate and evolve training also on the medical school level, then we can build upon that once they become resident physicians and are closer to practicing on their own.

(18:34):
I think over the years, there's been also a lot of moves in a positive direction in terms of work-life balance for medical trainees. So there continues to be discussions about what we refer to as duty hours and the maximum hours the trainee can work in a certain week, making sure that there's protections in terms of, okay, if you pull the 24-hour shift, how much recovery time are we ensuring that you have? Not how much are you saying, "Okay, I'm good, put me back in coach." But mandatory time in between that. And I think that's all positive.

(19:16):
I will say with my residency program, we're blessed to also have a behavioral health specialist. And while she also is involved with patient care and ensuring all of that side of things, she also has protected academic time to really check in with our residents. Make sure that if they're facing burnout or moral injury, how do we address that earlier?

(19:40):
Because the last thing you want to do is invest all these years of education and training, and then you go see a physician for the first time, and that physician's already burned out before they really hit the ground running. So I think some of the things you touched on, we're definitely aware of it. And same thing, it'll continue to grow and be an evolving process. But I do think we're headed in the very right direction.

Brian Urban (20:05):
And from your time entering residency to now as what you are helping guide with residents, how much has that experience changed for what you can reflect on and what you see now?

Dr. Jason Woloski (20:18):
Yeah. In a short time, quite drastically. It's like when your parents used to say, "Well, I used to walk to school barefoot up the hill in two feet of snow and now you get snow days." So I think sometimes, I don't want to inflate how bad it was, but at the same time it was different.

(20:38):
So especially when you talk about personal wellness and behavioral health, I feel it really wasn't front and center. Duty hours were a thing that you logged, and maybe you manipulated a little just so you didn't go over, but really you were going over, because you didn't want to cause any alarms.

(20:59):
So I think now, when you frame it in a sense that, "Listen, this is not because we're going to be mad that you went over your duty hours. It's because we need to ensure that you're safe." And it all turns back into really patient safety too.

(21:14):
When we have these discussions, people say, "Well, with trainees, and of course it should be tough. It's medical school and I want a good doctor." Yes, you want a good doctor, but you want a good doctor who's in the right mind and physically awake enough to see you, and really be able to have that critical thinking, because part of being a physician is really that no case is just like a textbook. You have to apply that critical thinking. You have to individualize that care to that patient. And so you have to be in the best health and mindset to do that.

Brian Urban (21:47):
I like that you said that in particular, because there's a lot of patients, we'll call it those that are healthcare consumers overall, that don't see it that way, and then don't see the human side of healthcare. And that goes both ways. But I like that you said that, because there's so much consideration that has now been put in place in the most recent years on how well health-wise our physicians are, and how well then they're able to perform in terms of delivering care.

(22:18):
So it's great to know that things have changed for the better and will continue to do so as well. You're part of that big generation of continual change. I want go back to the Jason side of Dr. Woloski. I want to look at, how do you balance things or weave things naturally in life? Because you have a big family, a family of four, of five. And you want to be able to spend time with your children, with your wife, and be able to understand, "I want to go on a vacation," or, "I want to do home projects," things like that. How do you fit everything in? I'm just curious.

Dr. Jason Woloski (23:00):
Yeah, that's a great question. And I can't say I'm always an expert. I think I'm still learning that too. My wife has an app on our phone where we're able to integrate our schedules, and I think that was the biggest-

Brian Urban (23:11):
Share that app with me.

Dr. Jason Woloski (23:13):
Yeah. So long story short, I think as a physician, one of the things that has changed, especially in family medicine, is really now we focus on some of the things we talked about earlier, team-based care. So as much as I would love to see my diabetic patient every day, and overbook them, and be able to tweak this and tweak that, in all reality, it's probably not even good for the patient or myself to try to navigate that. And so relying on our diabetic pharmacist specialists to really say, "Listen, we're a partnership. We're working together. I know what your goal is, and let me, who has maybe a little bit more availability and flexibility, kind of tweak things and work on things under a collaborative agreement, and then reset with you and kind of go forward." I will say over time, I think also, it really has become a team approach to even some follow-up visits.

(24:15):
So that has been a change that not all patients necessarily love. So for example, one of my patients may have a return visit in two or three months with a resident physician or a physician assistant. And so sometimes they feel that, "I wish I could only see Dr. Woloski every time."

(24:36):
But I think in the end, you realize we have to use the resources we have wisely. And when you actually look at outcomes, this team-based approach where a physician is kind of there and then managing a team, the outcomes are better and people will succeed. And I think as that evolves and patients realize, "Hey, this is actually for my benefit and this is actually going to get me to my healthcare goals," I think that discussion will get easier as we progress.

Brian Urban (25:10):
That's really interesting that you mentioned the team-based approach. It sounds like one, it builds capacity for people to have a life outside of their career in medicine. And two, it allows for outcomes to improve, because you're having different perspectives on a patient's condition or a patient's needs. So it's not just siloed to yourself, but it's spread across a lot of different team members and specialists as well.

(25:38):
So the team-based approach, as much as it is a care coordination model, is it also a mindset too to be able to say, "Hey, I can't do everything. I have to be able to be resourceful and use the talent of my team around me"?

Dr. Jason Woloski (25:55):
Yeah, absolutely. And I think for the new generation of trainees, I think it just becomes so natural, because we're training them in this approach. I mean, from early on, there's even workshops where medical students, and pharmacy students, and nursing students get together and say, "Okay, where are my roles and where do I fit?" But for someone who's been around a little bit, I will admit it was hard sometimes to kind of loosen the rings and say, "Oh wait, so you're going to change that med for me? Oh wait, you're going to make that?"

(26:30):
But I think sometimes, like I said, at the end, it's about is the patient outcome improving? And not only that, is it being done safely? And I think when you really look at the data, it is.

(26:46):
And so at the end of the day, my goal is to get my patients on the road to better health. And if I'm succeeding in that goal, then by all means, sign up as many team members as you want. I'm on board now.

Brian Urban (26:59):
The way that you think astounds me just to take a step back. Because not only are you always a physician, but you're also always a teacher too. So being able to share what you've learned and your experiences is really valuable I think to our listeners. Because it's not just applying the approach, but it's being able to say you're flexible to learning, and it's evidence-based. Everything you've been sharing is evidence-based in terms of just our conversation. But I appreciate that about you very much.

(27:35):
So I want to look into the future. We talked a little bit about rural healthcare in the beginning, just that as a specific cut of care across the whole ecosystem, a very particular population there. So where is healthcare going in rural USA? Is there more demand, harder to reach patients, education is evolving, is trust evolving as well on the patient provider connection side? Take me through what you think rural healthcare is going to continue to evolve into over the next several years.

Dr. Jason Woloski (28:17):
Yeah, thanks Brian. I think when you look at the rural areas, I think one of the things that it'll never be a discussion that we stop having is, how do we ensure access? Because we know that that's a population where sometimes it's very difficult to recruit physicians to, it is difficult to recruit providers to. And not to digress too much, but long story short, there are initiatives in place that we are working on at a state level, to ensure that we are trying to be mindful of that.

(28:51):
So one of the new up and coming things is teaching health centers. So these teaching health centers are actually opening up new residency programs. And the idea behind it is if we can take a small rural hospital, a small rural setting, get the trainees there for residency who clearly have an interest in rural underserved medicine, or they wouldn't choose to go to residency there, then they're more likely to stay. I mean, statistics say that you're more likely to stay within a 20, 30 mile radius of where you do residency. And so how do we capitalize on that?

(29:26):
The other thing, it's no lie that medical school is expensive. If you imagine that you come out of undergrad with debt and now you're paying 60, $70,000 a year for medical school, you could imagine that maybe that higher repayment in a more urban area rather than a rural area may attract you to one place versus another.

(29:50):
And similarly, the Department of Health in Pennsylvania has been developing some loan forgiveness things. And then one of the coolest things that I just always like to throw in there is that Geisinger has this great program called the Abigail Scholars Program. And so if you come into medical school and you commit to a primary care specialty, which is primary care, internal medicine, family medicine, and they also included psychiatry because we all know that mental health is in such high demand, that you will actually go for free. And there will be no debt when you leave medical school, with obviously the agreement that you'll stay within the system and practice for these patients.

(30:38):
So when you talk about rural medicine, I think really to get back to your question, access continues to be an issue that I think we're all going to continue to work on, I think as we do expand things like broadband and really reaching out to those individuals. It doesn't mean you could do everything, telemedicine, but it's definitely going to open the door for a little bit more capability to reach those patients.

(31:02):
And then I think in general, we know that as a whole, there's a lot of consolidations of healthcare systems, there's a lot of joining of efforts. And so we see a lot of the smaller healthcare systems kind of coalescing into these larger groups.

(31:19):
And in a way, if you can have like-minded people doing similar things, and expanding the footprint, and expanding the services that you can reach to these areas, that might be actually beneficial to reaching these underserved patients.

Brian Urban (31:39):
It kind of astounds me based on everything you shared there, where we're going in rural health. Geisinger's known for innovation. I really think Geisinger should be also known for their creative risk-taking abilities. Because the recruitment tactics, talent acquisition, being able to afford medical students a free education based on them staying in the system and delivering care to the population in central, rural Pennsylvania, that's different. You don't see a lot of urban city metropolis based systems doing those types of things. I think they have more... Which is fine. Everyone has a different type of risk-taking ability. But the creativeness of Geisinger really speaks to, I think feeding the innovation, and how you're known for being innovators in the space of healthcare.

(32:35):
So it is just something I'm taking away based on everything that you've shared, and the vision ahead seems bright. And I'm just so thankful that I was finally able to lock you down on a podcast episode here, Jason. So thank you very much for joining our little show here today.

Dr. Jason Woloski (32:52):
Thanks so much for having me.

Brian Urban (32:53):
And for more exciting insights and excerpts, please visit us at finthrive.com.