RCHC Community Project Abstracts

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Perceptions of Place, Health, and Illness Among Longtime Tillamook Residents
Date of project: 3/16/2009

Cultural competence within health care systems and among providers is an increasingly important issue as public health officials and policy makers look for cost effective means to improve health. Cultural competence of medical professionals within rural American populations is particularly important in efforts to attract health professionals to rural areas, to augment the success of public health interventions, and to improve health outcomes and patient satisfaction. With this project, I added to cultural knowledge that bridges the urban medical community with rural, specifically Tillamook, Oregon, communities. I interviewed six longtime Tillamook residents who have lived in Tillamook for at least 50 years. I asked each of these participants a series of questions designed to elicit their perceptions on diverse topics, including personal history, geographic and cultural identity, occupational health, expectations of health care, experiences of illness and grief, and beliefs about depression. Three important, recurring themes included Tillamook residents’ positive perceptions of rural lifestyle and of Tillamook; their self perceptions as being independent, self-reliant, and stoic; and their shared belief that physicians should be skilled at developing high quality relationships with patients and that rural doctors are more successful at this than are urban doctors. These findings enhance our understanding of rural patients as ones who desire highly individualized health care with respect and support of their cultural values that include hard work, self-reliance and self-healing.

A Long Road Ahead: Barriers for the transition to a patient-centered medical home model of care in the rural setting
Date of project: 2/9/2009

The “medical home” concept has emerged in recent years as a potential solution to make quality health care more affordable and accessible. It is defined as a patient-centered team effort to provide comprehensive and coordinated care over a sufficient duration of time to foster a strong level of patient-physician understanding and trust. The literature has demonstrated that this model has the ability to improve quality, reduce errors, and increase both patient and physician satisfaction. The team is a fluid network of health care professionals whose composition changes over time to meet the patient’s changing needs, with the primary care physician always operating as the team leader. The patient-centered medical home (PCMH) model also involves payment reform that compensates primary care physicians for productivity that has previously gone undercompensated, all while containing overall health costs. For small practices without pre-existing technologic or staffing infrastructure, the transition to a PCMH identity may by overwhelming or even seemingly insurmountable due to the potential for decreased productivity, financial strain, and personnel shortages. While working in the Tillamook, OR community, I investigated some of the barriers that a particular practice, Bay Ocean Medical, or others like it, might encounter should they opt to acquire that designation.

Hospice and End of Life Care In Tillamook
Date of project: 3/17/2008

Hospice care embraces a philosophy of high-quality, comprehensive end of life care. My experience in Tillamook, OR made it clear that hospice is also, in fact, a very natural extension of the strong sense of community that exists in a small town. Through a series of home visits I learned about one Tillamook woman’s experience with hospice care at the end of her life, and via interviews with hospice nurses, the hospice medical director (my preceptor) as well as other users of hospice I found that hospice care in a small town-setting may have advantages over a larger city setting, however issues remain such as reduced use of hospice in rural areas and the financial vulnerability of small hospice facilities. I also discovered that this patient’s case may actually serve as an example for a more efficient use of health care dollars in the final months of life, and as a contrast to more common spending practices in our country’s current health care system. In my five weeks in Tillamook, I was exposed to multiple end of life issues with other patients in the clinic and in the hospital, and I found that more than any previous experience in my third year, the hospice environment and our home visits to a dying patient allowed me to find greater meaning and personal solace in my interactions with these other patients.

The Storm of Users: How can physicians actively participate in identifying and treating addiction without falling into the common pitfalls of either ignoring or contributing to this growing problem?
Date of project: 3/19/2007

Substance dependency in this country is continuing to grow at epidemic rates. Some estimates indicate that twenty percent of primary care patients are affected by substance use or dependency, with upwards of fifty percent of emergency room visits being related to drugs or alcohol. The overwhelmingness of this problem has left our healthcare system fractured without clear roles for providers. This project attempted to explain how physicians could actively participate in identifying/treating addiction without falling into the common pitfalls of either ignoring the problem or contributing to it. Data was collected through informal interviews of key individuals with some role in substance use/dependency, recover, treatment, prevention, or enforcement. Collaborating data was collected from the Oregon Department of Human Services, National Institute on Alcohol And Alcoholism (NIAAA), and the National Institute on Drug Abuse (NIDA). Results found that the enormity of the problem is paralyzing. The consensus of individuals interviewed was the substance dependency is a growing problem with no signs of slowing in the future. At present due to the lack of a uniform approach, appropriate training, lack of time and resources, physicians are often tempted to ignore the problem or even add to it by careless prescription practices. Proper identification of the problem, education, and treatment with whatever means available (inpatient, outpatient, 12-step, individual, group) is key to future efforts.

Meet Me In The Woodshed A Tragedy in a Small Town: Recognizing and Preventing Suicide in the Elderly
Date of project: 1/1/2007

Elder suicide is major issue in Oregon and the United States. Suicide rates among persons age 65 years and older are the highest compared to any other age groups. In 2003 in Oregon, the suicide rate per 100,000 in people aged 65 years or more was more than twice the rate in people aged 15 to 34 years old (27.14 versus 13.41). This project aimed to quantify the problem of elder suicide, identify risk factors both generally and specific to Oregon and Tillamook County, and propose prevention strategies for the community and physician. Data sources included research studies on elder suicide, census and CDC statistics, and interviews with community professionals involved with suicide prevention and treatment. Risk factors for elder suicide overall include chronic disease, social isolation, and the misconception that elder depression is a normal part of aging. Oregon has the 4th highest elder suicide rate in the county and some factors specific for the elder Oregon population include living in a rural setting, “rugged individualism”, and firearm ownership. Physicians can help prevent elder suicide by encouraging a warm and trusting relationship with patients so that they feel safe sharing depressive thoughts. Physicians have tremendous power of influence with their patients’ health care decisions and can strongly recommend counseling and treatment for patients at risk. In the upcoming year, the Oregon DHS plans several community meetings to develop prevention strategies specific to the local area. Finally, a refrigerator magnet with important contact numbers for outreach and counseling services was designed for elder patients to have at available at home. The hope is that in the future, elder patients considering suicide will contact his friend, doctor, or counselor to begin their path to recovery.

“The Effects of Pharmaceutical Direct to Consumer Marketing: a Comparison of National Data With a Rural Community in Oregon.”
Date of project: 5/1/2006

In 1997, along with the alteration of some existing FDA regulations on pharmaceutical advertising came an entourage of direct to consumer (DTC) advertising by drug companies. Money spent particularly on television broadcasts soared as did the revenue from the medications most commonly marketed. The beneficial outcomes for the sales of pharmaceutical companies demonstrated an obvious cause and effect relationship. However, the effects on patients, the patient-physician relationship, and public health in general remain obscure; they are left largely to the opinions of those involved which are derived from sparse survey data at best. Proponents of DTC advertising assert that it serves as patient education, increases autonomy, and encourages pricing competition. Opponents counter that patients should not be made consumers, risks and benefits of a medication are not accurately portrayed in the advertisements, and overuse of prescription medications is encouraged ultimately increasing costs. National survey data raises many concerning factors, especially in regards to public health. A survey of patients from a rural community in Tillamook, Oregon and an interview with local providers suggests that the effects of DTC advertising and the opinions regarding it are similar to those reported in the national data save a few differences. It is likely that the effect of DTC advertising on patients differs somewhat between demographics. However, this information suggests that the detrimental consequences on patient education, autonomy, prescription drug use, and the cost of health care can be generalized even to differing communities. Therefore, the FDA is urged to place some restrictions on the recent trend towards increasing DTC advertising.

The Tillamook Safe Hunting Initiative: Assessment of the Hunter Education Program and Strategies for the Future
Date of project: 3/20/2006

As hunting continues to be a popular recreational activity in Oregon’s Tillamook County, emphasis on safe hunting practices is necessary to ensure the safety of all persons who enter the wilderness each autumn. This study aimed to identify what safety awareness programs are available for Oregon residents in this region and to investigate the efficacy of such programs in preventing hunting-related accidents. In addition, an effort to recognize areas for improvement within hunter education was undertaken. Data on Oregon’s hunter education program was obtained through direct communication with the Oregon Department of Fish and Wildlife, personal interviews with hunters native to Tillamook County, and extensive web research. It was determined that emphasis on hunting safety (via formalized courses or independent learning) has led to a significant decrease in the number of hunting-related accidents over the past few decades in the state of Oregon. While firearm handling continues to be the mainstay of safety awareness, Tillamook County residents expressed an interest in basic life skills training and the importance of wearing hunter orange. Therefore, this project would not only provide an assessment of the Oregon hunter education program, but would also focus on the development of a small brochure providing tips on accident prevention and treatment.

Promoting Women Physicians in Tillamook County
Date of project: 2/13/2006

Tillamook County not only has a shortage of primary care physicians, but it also has a shortage of women primary care physicians. There are a disproportional number of female physicians in Tillamook County compared to urban areas. 83% of primary care physicians are male in Tillamook county despite a strong demand for female primary care physicians. Dr. Parsons has repeatedly tried to recruit a female internist with no success. There are many barriers to recruiting female primary care physicians to rural areas, specifically partner job unavailability, role of primary caregiver in the family, overfeminization/overloading of their practice, and gender stereotypes/community receptivity. This paper examines these problems in depth and offers some further solutions to these barriers. It also summarizes how a program was set up to encourage young women in Tillamook to pursue scientific professions, such as physicians, in hopes that they would someday return to practice in their own community.

Medicare Part D in Tillamook, Oregon and Its Implications: Both Financial and Ethical
Date of project: 1/2/2006

January 2006 has ushered in a new era in American health care with the institution of the Medicare part D prescription drug benefit. Its promise is to improve prescription drug coverage for seniors. It has been championed as the financial savior for the elderly, but it may pose more problems than it could ever solve. There are actually many cases where the new program hurts the people it is meant to assist. This scenario became evident in a small town, Tillamook, Oregon, during my rural healthcare rotation. In talking with my prceptor, Dr. Parsons, it seemed there were many reasons why Medicare Part D may actually be doing our seniors a disservice. This new drug benefit may also carry with it some ethical issues as well, specifically, is this new program allowing physicians to do the most good for their patients? While Medicare Part D has the potential to ease the financial burden of healthcare for millions, it may pose hidden costs to both seniors and physicians.

Dual Relationships in a Rural Community
Date of project: 4/25/2005

Dual relationships are a complex and sensitive issue, as they commingle two of the most cardinal aspects of life: Health, and loved ones. The literature describes dual relationships as personal relations, familiar or social, with a patient outside of the office. Historically, medical associations' ethical guidelines recommend against this. Yet there is a paucity of research considering whether this is practical, or even opportune, in small communities. Moreover, short and long-term data on the effects of dual relationships is likewise lacking. This study utilized key informant interviews with 10 physicians and 10 patients in Tillamook OR, in order to assess the prevalence and perception of dual relationships in a rural environment. The hope is to gauge whether these relationships are interpreted as beneficial or detrimental, and to assess the need for future education or intervention.

The Impact of Alcoholism in Tillamook County and the Resources Available for Alcoholics.
Date of project: 2/7/2005

Unhealthy alcohol use can be associated with multiple economic, social, and medical problems. This project will assess the impact of alcoholism in Tillamook County and assess the resources available for alcoholics. To assess the impact of alcoholism, community members who were dealing with alcoholism either directly or indirectly were interviewed. Statistical information was gathered by the Oregon DHS, National Institute of Alcoholism and Alcohol Abuse, and Oregon Crime Data websites. According to the Oregon Department of Human Services, the rate of adult alcohol abuse or dependence in Tillamook County is roughly similar to the state average (7.5% vs. 7.8%). The rate of alcohol related arrests in Tillamook County is significantly higher than the state average (182.5 vs. 48.6 per 10,000 in 2002) however, and this might be attributed to the influx of tourism during the summer and the lack of public transportation in the evening and taxicabs. However, in a 2004 survey, the rate of binge drinking among North Coast County (Tillamook, Clatsop, Columbia) eighth graders, the rate of binge drinking was 39% versus 29% statewide. A barrier to treatment in Tillamook County is a lack of a formal detox center. Individuals hoping to detox must drive over one hour away either to Lincoln County or Portland. However, there are also some great resources available as well, including AA, which has 21 meeting times a week and Tillamook Family Counseling Center, the primary mental health and alcohol/drug service. Physicians can take a proactive approach by screening patients with the AUDIT questionnaire, engaging in brief interventions, and providing medications when necessary.

Practice Management of Tillamook’s Bay Ocean Medical Office: An Overview
Date of project: 1/3/2005

The majority of medical practices are owned and managed by the physicians. Yet in medical school and residency, no course covers the skills and steps necessary to set up one’s own practice. The goal of this project was to provide an overview of the business of a medical practice based on internet resources and interviews with office personnel. In a small, rural medical practice, each staff member performs a number of duties in order for the office to run efficiently and provide quality care for the patients. Managing a medical practice requires not only seeing patients, but also understanding many other details that are never taught in medical school.

Transportation for Veterans to Portland VA Medical Center
Date of project: 3/29/2004

Tillamook County is home of more than four thousand US Veterans. However, this is the only county in the state that does not have a van to provide transportation for its veterans to the Portland VA Medical Center. In order to have a van, the county must raise $25,000. Although the county does not have the funds to appropriate to the purchase of a van, the money can be obtatined through private sources.

The Tragic Loss of Dr. Craig Roberts: Grieving Within the Medical Profession
Date of project: 1/5/2004

A short time ago, Tillamook County lost a beloved member of their medical community, Dr. Craig Roberts, in a motor vehicle accident. This paper attempted to describe the medical professions’ experience with this tragedy and examine their grief response. A questionnaire was distributed to various members of the medical community who knew Dr. Roberts, including physicians, emergency department (ED) nurses, Emergency Medical Technicians (EMTs), and medical assistants. The questionnaire acted both as a means to gather information as well as a therapeutic intervention. The responses from the questionnaire were examined and a paper was written describing their grief response and how this compared to grieving reported in the literature. It was found that the grieving pattern and coping mechanisms of the medical community were very similar to previously reported studies. However, the incident was quite severe for those involved, due to the fact that they had to remain in a caregiver role and had little time for grieving.

How does a county hospital in a town of 4,000 people afford a full-time MRI? A case of rural hospital success.
Date of project: 11/10/2003

MRI is an powerful and important diagnostic tool but is a luxury that many rural hospitals cannot afford. This project focused on one such rural hospital, Tillamook County General Hospital (TCGH), that is currently completing installation of a full time MRI scanner. This rural hospital serves a population of just over 24000 people, yet it has managed to foresee economic viability for this expensive imaging modality. Interviews were conducted to MRI technicians at each of the 11 Oregon hospitals serving the Oregon Coast to establish the type of MRI services available, the number of patients scanned per week and per month. MRI cost analysis and comparison among the Oregon Coast hospitals was done via Health Care Financing Administration and American Hospital Association data made available on the world wide web. TCGH shows a slightly higher rate of MRI utilization than the average of the 11 Oregon Coast Hospitals, but Tillamook does have a higher proportion of it's residents as over the age of 65, based on Census 2000 data. Tillamook has the third lowest average cost per MRI ($451) of the seven Oregon Coast Hospitals with available MRI cost data. Only Gold Beach ($350) and Coos Bay ($128) have lower average costs per MRI, while the other reporting hospitals show charges of up to $600 and even $800 dollars. Budget data obtained by interviews with the TCGH administrators demonstrate confidence in the projected financial viability of the MRI scanner; further confirming that the timing is right for TCGH to implement a full time MRI scanner of its own. This will certainly increase access to this valuable diagnostic imaging modality while concurrently providing a revenue boost to ensure overall hospital viability at TCGH.

Life After Cardiac Surgery: Cardiac Surgery in the Elderly "An Assessment of the Post-Operative Quality of Life of Tillamook's Elderly Population"
Date of project: 5/5/2003

The fastest growing age group in the developed world are those aged 65 years an older. As this elderly population grows, so does the number of people limited by coronary artery disease. It is estimated that between 25-50% of people aged 65 years old and older are limited by some type of heart disease. As such, more and more elderly people are undergoing major cardiac surgery. Much investigation has been done to determine the risk vs. benefit of open heart surgery on older patients. Tillamook, Oregon is a small coastal town with a very large and active older population. However, a large number of older Tillamook residents have undergone cardiac surgery. In this physically active and independent older population, how well are older patients recovering their quality of life and independence after cardiac surgery? This was investigated using a survey to assess functioning and chest pain before and after surgery.

Prescription Costs in Tillamook Oregon Searching for Keys to Education & Compliance.
Date of project: 3/24/2003

Background: In the 4 years preceding 2002 medication costs increased at a rate of about 30% yet over that same time frame social security benefits increased only 9.4%. How do the ever-increasing cost of medications affect the lives of those who take them? Do these increase costs have an effect on patient compliance? Do people know about programs that are available to help low income seniors with the increasing costs of medication? These questions were attempted to be answered. Methods: An anonymous questionnaire was obtained in two locations in Tillamook, OR. Total surveys returned were 58. An attempt was made to correlate medication expense with patient medication compliance. An additional attempt was also made to compare the difference in response between the in-clinic and out-of-clinic settings. Results: It was determined that as monthly costs rose patient compliance decreased. The average patient expenditures for medications was $162 while the average for the self-reported non-compliant patient was $276. There was about an equal percentage of patients in the clinic and out who knew about programs from drug companies but in the clinic only 38% wanted more information on these programs while outside the clinic (at the senior center) 88% of patients requested more information. Conclusions: As medication expense rose compliance decreased. This shows a need for decreasing the overall cost of medications. Also patient education goals are not being met. Only 50% of patient were knowledgeable about reduce cost drug programs. This leads us to conclude that our education methods at present are insufficient in office and desperately inadequate in the general community. It is the feeling of the author that informational material should be better displayed in the clinic and a program be established to make at least some basic information available to those in the general community. This information that might be made available was reviewed under the programs portion of this paper.

Awareness of Osteoporosis in an Elderly Population in Tillamook, Oregon
Date of project: 12/30/2002

Osteoporosis represents an important public health problem. The prevalence of this disease and its complications are particularly high in the elderly population. This study attempted to evaluate the level of knowledge and awareness of osteoporosis in a rural community that has a large proportion of senior residents. The second objective was to compare differences in the knowledge level between men and women and identify their source of information. Participants, 18 men and 27 women with an average age of 75 years, were invited to complete a questionnaire. Ninety-three percent of subjects were aware of osteoporosis and 75% gave the correct definition. In contrary to the general thinking that men are not as well aware of osteoporosis as women are, there was no difference in the levels of knowledge between the two sexes. The sources of information used by the two groups were different. Men relied most on television whereas women obtain information from their doctors. The main risk factors for osteoporosis reported were low vitamin D and calcium intake and lack of exercise. These data showed a high level of awareness of osteoporosis in this elderly population in Tillamook.

Unlicensed Off-road Vehicle Injuries in Tillamook County
Date of project: 11/4/2002

It is said by health care professionals that unlicensed off-road vehicle associated injuries are numerous in Tillamook County. Despite testimonials, no study has looked at the frequency and degree of injuries associated with these vehicles. This is a retrospective chart review study of all patients presenting to the Tillamook Country General Hospital Emergency Department in the first 11 months of 2002. Demographics were looked at including; age, sex, driver or passenger, need for transfer to a level 1 trauma center, and injury location and severity. There were 131 patients, with a mean age of 24.92±12.21 (2-57), and 76% male. Injuries are divided into anatomic location and severity. The classification scheme is described. There were 85 (64.9%) patients with "minor" injuries, and 46 (31.1%) "major" injuries. The later included 15 (11.4%) trauma system entries that required transfer to a level 1 trauma center. Age, adulthood, driver vs. passenger and sex did not significantly predict degree of injury. In conclusion, unlicensed off-road vehicles in Tillamook County cause a sufficient number of injuries to warrant a more comprehensive study that looks at crash variables, longer-term outcomes, the effectiveness of public service efforts and the use of alcohol.

Documenting a disparity between the musculoskeletal knowledge and skill requirements of primary care physicians in Tillamook County.
Date of project: 3/25/2002

Musculoskeletal problems are a major source of pain and disability in our society. The purpose of this study was to determine if there is a disparity between musculoskeletal knowledge and the skill requirements of primary care physicians within Tillamook County. The number of musculoskeletal complaints evaluated and treated in a primary care physician's office was recorded over a one-month period between 1 April and 30 April 2002. Additionally, self-administered questionnaires comparing physician confidence with common musculoskeletal disorders and common medical issues were distributed to all primary care physicians in Tillamook County. The prevalence of musculoskeletal disorders was 17.9% (n=49) among 274 office visits. Survey results suggested that physicians felt more confident managing common medical issues than common musculoskeletal disorders (avg. confidence score=9.0 and 4.2). Specifically, physicians felt most confident with the principles of cardiac rehabilitation, performing comprehensive cardiovascular examinations, and indicating/interpreting flexible sigmoidoscopy (avg. confidence score=9.0, 9.6 and 9.6 respectively). They felt least confident with the principles of bracing and casting, performing comprehensive musculoskeletal examinations, and indicating joint injections (avg. confidence scores=3.6, 7.0, and 3.0). The results suggest that a disparity between skill requirements and musculoskeletal knowledge exists among primary care physicians in Tillamook County. Competence in managing musculoskeletal disorders is a necessity for any primary care physician. To appropriately address this disparity, a new curriculum addressing common musculoskeletal problems should be developed which could be implemented at any, or all, levels of medical training.

Mental Health Care in Tillamook County
Date of project: 2/11/2002

Despite a popular perception that rural America is a wholesome and healthy place to live, many studies have shown that this is not necessarily the case. Although approximately one forth of all Americans are rural residents, almost one third of the nation's poor and 29% of the nation's elderly reside in rural areas (Human, et al. 1991). Rural residents are also disproportionately affected by chronic illness, are more likely to live in substandard housing, and have more days of disability and missed work (Murray, et al. 1991). All of these problems - advanced age, poverty, and chronic illness - predispose rural residents to a higher risk of mental illness, yet research done over the last decade indicates that this same population is less likely to receive adequate mental health care than urban residents (Badger, et al. 1999). Studies have shown a number of reasons for this. First, rural residents are less able to pay for mental health services. Many rural areas have remained economically depressed since the late 1970's following a decline in the farming, manufacturing, and natural resource based industries such as mining and logging. Rural residents have a higher rate of uninsuredness and, because they are more often among the ranks of the working poor, are less likely to qualify for programs such as Medicaid (Human, et al. 1991). Second, rural areas suffer from a profound lack of mental health care providers. For instance, 77.5% of counties with fewer than 100 persons per square mile lack a single registered psychologist as compared to only 2% of counties with a density of greater than 400 persons per square mile (Murray, et al. 1991). Another study found that only 10% of outpatient psychiatric clinics are located in rural areas (Abraham, et al. 1994). As a result, rural patients with mental illness are forced to seek help from their primary care physicians.

The Safety of the Logging Industry in Tillamook, OR: A Comparison of Today and Yesterday.
Date of project: 11/5/2001

Logging has long been a mainstay of industry in the Pacific Northwest and in Tillamook Oregon, the history spans back through generations. Many families harbor a long line of loggers and with this comes many tales and scars to show. The logging industry is known as one of the most dangerous industries in the world. The annual fatality rate is more than 23 times that for all U.S. workers and the injury rate is nearly twice that of the entire private sector. The purpose of this project is to compare the present day safety measures and attitudes among the people in the industry with those of the first half of the century.

Stage At Diagnosis Of Lung Cancer In A Rural Community: Is There A Need For Earlier Detection?
Date of project: 7/2/2001

There has been recent evidence to suggest that the stage at which a lung cancer initially presents may be related to proximity to a major city or metropolitan area. Currently, the majority of lung cancers worldwide present with desseminated disease (Stage IV). However, several recent studies have indicated that people living in rural communities may present with more advanced disease. This study examined if this conclusion was applicable to Tillamook County, a rural Oregon community with a large smoking population and considerable lung cancer mortality. A random population of lung cancer patients was selected from an internal medicine clinic to determine at what stage their malignancies initially presented. Of 24 patients with lung cancer, 54% presented with widely disseminated disease, a proportion that consistent with the nationally observed estimates of lung cancer stage at diagnosis.

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