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A Summer of Alaskan Health Care

A Summer of Alaskan Healthcare

By Marcus Harmon

From an outsider’s perspective, medical school must seem bizarre. Long before a medical student ever speaks to a patient, you start with pre-clinical coursework. For 18 months you spend as much of your time as you can learning every detail about the human body, and in your “off” time, you think about what you learned, ask questions, and muster the motivation to return to the books. You do this so one day you can be the best physician possible and support your future patients in whatever capacity they need. For those 18 months you absorb as much as your synapses can handle – yet still, by the end of those grueling months, you don’t know medicine, you don’t know how to connect the dots, you don’t know how to address the complex person in front of you. Those skills are developed in the clinic under the mentorship of our role models invested in the future of patient care. The transition from pre-clinical to clinical medicine is fraught with convolutions, and my taste of this process came in the form of one of the most unique medical systems in the nation.

20,000 years ago, Homo sapiens crossed the Bering Land bridge during the Pleistocene Ice Age and settled in Alaska. Since then, the community of Alaska Natives, while separated by vast expanses, has remained a formidable force that time and time again has proven their commitment to preserving Alaska’s natural beauty and caring for one another. The passing of the Indian Self Determination and Education Assistance Act in 1975 resulted in Elders from each tribe uniting to develop a system that would tend to the health care needs of their community. From this collaboration, two major organizations that operate independently, yet in unity, were developed: the Alaska Native Tribal Health Consortium and the Tanana Chiefs Conference. I found myself at the latter last summer, working within the Chief Andrew Isaac Health Center. Organized under the motto “Dena’ Nena’ Henash” or, “Our Land Speaks”, the Chief Andrew Isaac Health Center is committed to the mission of advancing and developing wellness amongst the Alaska Native people while preserving their culture. To accomplish this, visitors are constantly reminded of the principles of Ch’eghwtsen’, a philosophy interpreted as “delivering services from a place of love, compassion, and understanding. “

It’s one thing to have an inspiring and caring slogan engraved on a plaque that hangs outside the waiting room, but it is another to operate by it. The Chief Andrew Isaac Health Center serves an area of 235,000 square miles, just under the size of Texas. Within this expanse are numerous villages that are not connected to the state’s road system, let alone to stable and affordable fresh food or high-speed internet. Regardless, those community members still require access to modern medicine. To provide this, the Elders and governing bodies have developed the Nuka model of health care – a paradigm centered around cultural respect and pillars of patient integration, relationship development, and quick access to care.

The Nuka model reimagined health care with the purpose of “improving access and quality of care for rural and low-income Alaska Native Communities” through providing services such as medical, dental, behavioral and support services with an emphasis on prevention. They accomplished this with the help of expanded rights and funding rightfully earned by Alaska Native people in the Alaska Native Settlement Act of 1971, the Indian Self-determination and Education Assistance Act of 1975, and the Indian Health Care Improvement Act of 1976. During the development of this new system, community engagement was used as a compass to ensure a trusting relationship with primary care services, respect and dignity at the center of care, and the availability of services when needed. Rollout of this plan began in three phases; the first phase focused on primary care and the establishment of customer-owners rather than patients. This fostered a sense of accountability and a constant reminder of who the mission is designed to help. In this phase, each person was assigned to a care team and 50% of a provider’s schedule is reserved for appointments when the customer-owner chooses to ensure timely access to needed services.  The second phase consisted of integrating a multidisciplinary model in which each team member works to the top of their license and RNs are given the unique role of handling provider panels and managing chronic disease. During the third phase, providers from different disciplines joined the care team, but not in a traditional role. Hear specialists consult directly with primary care providers rather then patients to improve time efficiency. This phase also redesigned behavioral health allowing for immediate access and availability of different modalities, including group circles or individual appointments with a mental health specialist.

This novel system seems to have revolutionized health care delivery by putting the power in the hands of those that use it, but the question remains: does it work, and are customer-owners happy? One concern is the scalability of this model and its applicability to larger patient populations. Since 1999, the Nuka system has seen a tenfold increase in users while still maintaining same-day access and staying true to their mission.

The Nuka model’s focus on primary care services is not only aimed at improving life quality and quantity, but also at reducing costly emergency services. From 2000 to 2015, the health care system has seen a 36% decrease in hospital admissions and emergency department visits. Does this correlate to an improvement in the quality of care? Since its inception, the Southcentral Foundation, which encompasses the Nuka model, has exceeded the 90th percentile in multiple Healthcare Effectiveness Data points. These metrics include diabetes care, LDL levels, CVD control, HPV vaccination, and multiple cancer screenings. With such positive efficacy data, some may next question of the model’s sustainability. Funding for Nuka comes from two main sources, the federal Indian Health Service and Medicare/Medicaid. Massive restructuring allowed the system to abandon the limitations of the traditional American Medical System and attempt new resource utilization strategies such as the approach to specialist care. In this way, more resources are available to primary care just as the customer-owners requested.

My experience working within this model differed from my pervious clinical experiences in a couple of different ways. First off, the patient population seemed more engaged in their care than I have witnessed before. While each customer-owner still experienced their own individual battles outside of the clinic, everything was taken care of within clinic walls. There was no hesitancy to get tests, imaging or to make a follow up appointment due the relief from the financial stressors of health care. There was also a system in place to help address battles outside of the clinic, such as food and housing instability. To cover such a vast geographic area each day, the physicians call the various satellite clinics and review each case with an onsite health care professional. This ensures quality care is delivered to people where they are both physically and mentally, allowing them to stay with their families and in their communities. This seemingly simple act boosted morale and aided the patient recovery process, while physicians and staff did everything within their power to help make the right decisions for their customer-owners without sacrificing quality care. Despite epic proportions of burnout within the medical community, this clinic seemed to be immune. Without the burden of fighting with insurance companies, providers were free to be with the patient and deliver truly patient-centered care. The ability to do this frees up emotional space on the side of the physician, allowing them to spend more time addressing health concerns and less time juggling between what is medically necessary and financial limits.

This experience was personally unique to me because, for the first time in my medical career, my role on the health team shifted from a supporting role to being in the exam room directly caring for individuals. As I navigated through the Phase 1 curriculum and learned every detail of every disease that I could fit into my head, I assumed that the transition to clinical delivery would come naturally within the weeks to come. Throughout my 6 weeks in the clinic, my development felt stagnant. Within my first week I came to the realization that while I knew I had a handle on the curriculum, I was still lacking in key areas – the first of which was my illness scripts. Through practice questions and the way information is presented in school, you pick up on a prodrome of key words and scenarios used to describe specific diseases. However, when dealing with real people, this is not the case. Due to this I felt out in the weeds during my encounters just trying to fit their story with the stories that I held in my head. This process was very mentally taxing and prevented me from feeling fully engaged in the appointment. As I was letting valuable information whirl past me, I spent so much of my mental effort trying to logic my way through disease processes and connecting symptoms to underlying causes, slowly losing the ability to actually care for the person in front of me.

During the period prior to attending medical school, I spent as much time as possible in front of patients doing whatever I could to help the physician provide complete care. The area that I got the most fulfillment out of and a skill that I thought I could rely on was my ability to build rapport. I was amazed at how fast my ability to do this seemed to dwindle as soon as my mind was fully devoted to thinking clinically. When this happened and I did all I could just to keep up, I listened to the patient but seemingly only for the bits of information I thought useful to the case, and this caused me to miss the person in front of me. With me missing key points about their lifestyle, their personality, and their values, I forfeited the skill that I thought of as my safety net. Because of my lack of clinical experience, I was offering very little to the customer-owners. After this realization, I took a step back and started breaking down every aspect of my appointments and tried to make a guideline to follow that would allow me to organize my thoughts, history, and exam with time for reflection dispersed throughout. Getting back to the clinic I was quickly brought back to reality and while I had some improvements was still performing below my threshold for success. Struggling with this realization and receiving evaluations that confirmed my fears, I turned to my mentor who has been my guide for many years. From his wisdom I took that these things take time and patience. Upon hearing this I was overcome with mixed opinions. At first it was reassuring to hear that I was at an appropriate spot for my training and that with time and dedication I could grow into the physician I aspire to be. Second, I still felt disappointed with my current performance and did not know what to do in the short term to increase my efficacy.

My summer experience at Tanana Chiefs Conference and insight from my mentor and support system convinced me that the path forward should be lined with self-patience and understanding. As I begin my transition from Phase 1 to Phase 2, I feel an odd preparedness. Not because I have clinical knowledge or have refined my approach to appointments, but because of the lessons I learned at TCC – to be patient and trust in the process and in the short-term focus back to the patient and truly listen and be with the person in front of you. Armed with these lessons I hope to lay the framework for becoming the physician I aspire to be and continue my journey of making a difference in people’s lives.

Marcus Harmon is an M3 at UICOMR.