Innovations in Rural Medicine: Endoscopic Services at Cherokee Indian Hospital

August 9, 2016

This article is based on in-person interviews with Drs. Elizabeth Saladin and Executive Clinical Director Richard Bunio at CIH on July 13, 2016

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What were the reasons endoscopic services were launched at Cherokee Indian Hospital, and why is this innovative?

Dr. Elizabeth Saladin was recruited to Cherokee Indian Hospital (CIH) in 2013 straight out of residency training in Family Medicine. She came armed with a skill set not usually encountered in primary care training: endoscopy. During her residency program at University of Arkansas in Fayetteville, she had the unique opportunity to obtain this additional training. She said, “I had been fortunate to learn endoscopy from a General Surgeon as an elective during my residency. Honestly, I did not anticipate that I would put this skill to use, but I discovered that not only did I enjoy endoscopy, I was good at it too!”

Dr. Bunio, CIH’s Executive Clinical Director explained, “When we recruited her as a young, enthusiastic doctor who wanted to do more than see primary care patients, we saw value in that, because a large number of patients would not get endoscopies unless provided here.” According to Dr. Saladin and Dr. Bunio, endoscopy was a service that always had to be referred out to GI specialists in the region, resulting in anxiety and inconvenience for tribal patients.

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Dr. Saladin observed, “When I arrived at Cherokee as a resident, the possibility of doing endoscopy here caught my attention; I could incorporate this procedural skill into primary care. I was credentialed to perform endoscopies at a neighboring hospital under the mentorship of a GI specialist, Dr. Randy Savell.” Initially, Dr. Saladin traveled to Harris Regional Hospital in Sylva to perform endoscopies one day a week for tribal members.  Then, the new Cherokee Indian Hospital was built and the endoscopy unit was included in the plans so that tribal members could get the care they needed right in their own community.

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Dr. Bunio said, “Having Dr. Saladin on staff with this skill set helped us justify a procedure suite in our new hospital so that she could continue her work here and no longer require our patients to travel to Harris Regional. She can provide endoscopy services to patients right in their medical home which is extremely powerful.” Both Drs. Saladin and Bunio emphasized that having endoscopy in the CIH improves population health.  Dr. Bunio noted, “We’ve had great reviews and this [innovation] gives Dr. Saladin the professional satisfaction that she can provide an expanded scope of care, and that’s good for the organization as well.”

What key lessons did you learn along the way? What worked? What didn’t?

The endoscopy suite was literally built from the ground up as part of the new Cherokee Indian Hospital, with support from both Dr. Saladin’s mentor Dr. Savell and leadership at CIH. “Dr. Savell helped me with not just technical and procedural feedback, but has taught me leadership and communication skills that are not always refined as a fresh attending physician. This has been a learning process for all of us. I have excellent nurses who keep the endoscopy clinic and procedure suite running smoothly; without them I could not do this effectively.”

As the clinic evolved, Dr. Saladin learned that a quick turnaround time helped keep patients engaged in follow through. If the time between the initial consult and the procedure was within 2 weeks, the show rate was much higher. She also recognized the need for education regarding guidelines for colon cancer screening and surveillance intervals among her patients and the clinic staff. She regularly presents this information to the medical and nursing staff in hopes of increasing the population’s colorectal cancer screening rate.

Dr. Saladin acknowledges her limitations. As a Family Medicine physician, her aim is to prevent disease. She focuses on screening colonoscopies in asymptomatic individuals who are due for colon cancer screening. All other patients in need of endoscopy are still referred appropriately to GI.

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She says sometimes this work can be frustrating from a public health perspective because “it takes time to see your colon cancer screening numbers move. I try to remember that I cannot do this alone, but this is a hospital wide, team effort.”

What are the impacts/outcomes of performing endoscopies locally?

Dr. Saladin reported that, “I have noticed people are more open to even talking about this screening test. I still encounter fear and my job is to alleviate that. Once they’re done, I try to encourage patients to tell their friends and family that it’s not so bad! And I remind them, ‘you don’t have to do this again for ten years!’ My patients are very grateful in the end.” The preventive aspect of this work is very rewarding to Dr. Saladin. “Knowing that I prevented colon cancer – that’s a good feeling.”

Dr. Bunio added: “It is powerful to be able to receive this test within the medical home. We are probably into our second month of this service, so it’s early for data, but what we do know is that we are getting a very good show rate, and more patients are able to receive this very important preventative care. About half of our patients have insurance and the other half do not. There are a significant number of patients who are Cherokee descendants who do not qualify for referrals outside of the CIH health system. We are unable to pay for them to go somewhere else, but now they can get it here.” Both doctors are very pleased and proud that people who could not get this service locally before Dr. Saladin’s arrival can get it now on the boundary.

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Who were your primary influencers and mentors?

Dr. Saladin credits Dr. Randy Savell as an important mentor in her life. He helped Dr. Saladin get credentialed, plan the layout for the endoscopy suite, and operationalize it. Dr. Kermit Baker was the surgeon who trained her to perform endoscopies. Says Dr. Saladin, “I feel lucky to have learned such a skill, because it is becoming less common in family medicine residency training programs. She is also very grateful to leadership at CIH for the opportunity to practice medicine to her full capacity.

In what ways has offering endoscopies affected your physician-patient relationships?

Dr. Saladin observed that it is trickier to build rapport with endoscopy patients than it is to do so with her panel of primary care patients. As a young, female physician offering a little-known procedure, Dr. Saladin has had to work hard to overcome some strong stereotypes. “I wear my white coat and I present professionally during consults, because I’ve had people tell me that they didn’t want me to do the procedure only because I’m female.” Over time, she has found that patient rapport and trust has improved greatly. “It is a humbling experience to hear a patient you just met say ‘I trust you’ and genuinely mean it.”

In what ways does performing endoscopies at CIH influence joy and meaning in medicine for you?

While Dr. Saladin enjoys her work as a primary care physician treating a large number of long-term chronic diseases, in the endoscopy suite “it’s instant gratification –even if a polyp returns benign, it had the potential to become cancer.” Dr. Saladin also collects quite a bit of data for quality improvement purposes. “I track everything – pathology, adverse events, my adenoma detection rate – for quality improvement purposes and the knowledge that I’m practicing good medicine. We’re demonstrating that there’s a need.” Dr. Saladin derives satisfaction and happiness from being able to experience variety in the workplace. “It’s nice to build my practice here based on my interests. To be able to have this beautiful state of the art equipment is awesome.”

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She also learned that she’s a physician of 1. She’s the only physician in the hospital doing endoscopies. She is in the endoscopy suite once a week. “I do full time primary care in the outpatient clinic. On my day off, I do endoscopies.” This additional day of work is both rewarding but stressful for her because as a mother of two young children, she recognizes that the balance between work and home life isn’t where it needs to be. Her goal is to integrate endoscopy work into her 40 hour work week to find this balance and devote her time to both her passions: family and medicine.

What advice would you give to others interested in implementing your innovation?

Dr. Saladin was pleasantly surprised to be able to use her endoscopy training. She advises residents to learn all they can during residency with the assumption that you WILL use the skills later in practice. She recommends that residents know their worth. “Be confident in your education – even just coming out of residency with lack of job experience, you have a strong knowledge-base – you’re book-smart. Know that you are an asset and don’t let people underestimate you.”

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