Rural Health and the Provider-Patient Relationship - Dr. Jean Sumner, Dean of Mercer University School of Medicine

DR. RISHI DESAI: Hi, I'm Dr. Rishi Desai. Today on Raise the Line, I'm happy to be joined by Dr. Jean Sumner, Dean of Mercer University School of Medicine. Dr. Sumner has served as the Hospital Chief of Staff and is a nursing home medical director, as well as a board member, chair, and president of numerous professional organizations. She's also been leading a major telehealth initiative for the school of medicine as Associate Dean for Rural Health. Thanks so much for being with us today.

DR. JEAN SUMNER: I'm glad to be here, and thank you for the invitation. 

DR. DESAI: I'd like to just start out by understanding a little bit more about your background, and what got you interested both in healthcare and also in rural health, specifically. 

DR. SUMNER: Well, I grew up in a small town in Georgia, rural Georgia, the daughter and granddaughter of physicians. My mother had aspirations to go to medical school. In her senior year after my parents were married, she was expecting my older brother. In her senior year of college, she was told she couldn't come to class pregnant. She dropped out with five hours to go, finished college later on, but never followed her dream to go to medical school. My aunt actually was in medical school and was asked in her fourth year—it was in the '40s—to drop out because she married a physician who was going into neurosurgery. The dean thought that it was not good to have two physicians. 

So I really didn't know any women doctors, and I chose to go to nursing school first. I love nursing. I got a master's in nursing, went into practice, but then, I married my husband, and we moved to a county that adjoined the county where I grew up, and there was no healthcare. Coming from a county with great healthcare -- the first place in America that did gallbladder surgery -- to a county with no health care, you realized what health disparities really meant, because 30 miles was a long way if you didn't have transportation or money or anybody that you can go see. 

I had done my pre-medical preparation while I was in graduate school, and when Mercer opened, I applied and was admitted to the first class with the intent of going home. I did go home. I was the only doctor in my county for a while. My family was still in the adjoining county so I had some help and support from them, but you realize very quickly that you can't be the only doctor in an area. You get very worn out. We wrote a grant to get a federally qualified community health center in our county, and we partnered with them. I was in private practice and our practice remained private, but we wrote a grant. That FQHC served a huge need. We shared call with them. They grew now to 14 counties in the region, but we were able to gather with the FQHC and the community to raise the health status in their county from very low to one of the healthiest counties in rural Georgia. 

You realize that a community-responsive position in those counties matters. I spent my life really working to try to bring attention to the issues of rural health. I was on the board. That's how I got involved in telehealth because I saw it as a way to bring access to care and some of these underserved areas, but it was very important to me that that care be equal to in-person care. It was quality telehealth. Eventually, I got involved in helping to write national guidelines for telehealth and the state rules for telehealth to try to protect vulnerable patients in underserved areas from being taken advantage of. I'm a really big supporter of telehealth as an asset and a complimentary part of any practice, but I think it ought to be in the context of a practice. 

I continued to work in that county for many years. Mercer reached out to me about refocusing on our mission. Our mission is that of serving rural and underserved populations. We take that mission very seriously, almost as a sacred trust to serve our state because as we spoke earlier, there's Atlanta and there's the rest of us, and the rest of Georgia needs care. So, we're very focused on providing physicians who will help change the health status in every rural county in our state.

DR. DESAI: What you said is remarkable. Just going back to the point where you said that the level of health was quite low, you made a set of interventions, and you said it was near the top of the list. Do you mind telling me, as specifically as you can, what did you do that caused the health indexes to rise? What specifically were you measuring? What got better? What seemed to help, and what didn't? 

DR. SUMNER: What helped was being present, being available to the community, being in a community-responsive physician. Setting expectations for community leaders to talk about food quality, to talk about exercise, to talk about transportation. The most important thing in rural health is trust. You will not change health status until the community trusts you and knows you have their back and that they can count on you to be there when they need them. We all pledge to answer our phones at night, to make house calls, to advocate for our patients. I'm an internist, so I don't do surgery. If I had a patient that went to a surgical center or went to a city, I knew the doctor they went to. I called the doctor. I kept up with the patient. 

For years, we admitted our own patients to the hospital, and were there for them. We may not provide everything, but what we did, we made sure it was as good as anywhere. Pneumonia in a small town can be treated effectively if you know what you're doing. Trying to recruit good partners and good physicians to come and help lead. It also requires teamwork. There are no turf battles in small towns, because we need everybody. If we had a great nurse practitioner, or a PA, or nurses, or respiratory therapist, those people matter. They really help a physician and help the patient lead a healthy life. We were team-based care before it was a popular term.

DR. DESAI: What would folks do in the era where they couldn't access you quickly? You mentioned that you're answering calls at night. Let's say that they didn't have someone to turn to at night, what would often be the course? What would a typical scenario play out like?

DR. SUMNER: I don't want to overdramatize it, but what happens is people die, and they access emergency care. It's very easy to be critical of over-utilization of an emergency room. I understand that. I understand it's not the best place for primary care, but it's the only place if you don't…you know, you don't have public transportation in rural areas. If you're 85 and you're scared, you call the ambulance and they take you to the hospital. It's not the best place for you.

So, being proactive, helping your patients know that you do answer the phone, you can give real guidance. If they need to go for emergency care, advocate for them with the emergency room or go see them in the emergency room. That doesn't happen so much in cities; it still happens in rural communities. Just because I know their history, sometimes better than they do, and I can present that to the doctor there and help them understand that they had a cath a month ago, and they didn't have any blockages. This is not something to fly them to a cath lab for. That sort of thing. 

Now, there are so many ways that you can impact the health status of people. To help them, direct them to use the system properly. I mean, medication adherence. Just taking your medicine, explaining to them what it is, engaging that local pharmacist because they're frontline health providers, and bonding with all the people in your county that provide health care. Instead of feeling competition from them, feel that they're your partners. That they can call you if they have a question, so they can deliver a better product. Working on health literacy, working through the religious community to work on health literacy. Having health coaches—I know that's common now, and people talk about it now more than they used to. 

To give you an example, in my little county of 9,900 people, there are 77 churches. I found that out and thought it was amazing. They don't all meet every week, but they all consider themselves to be some faith. So we invited, as a community, two representatives from every church in the county to come to a training. It was a two-day training. We taught them, two people from each organization, to take blood pressure and blood sugar. You're too young, Rishi, to remember, but we had Polio Sunday when I was a child. Everybody got their sugar cube. Well, we had diabetes and hypertension Sunday, and the first Sunday we did that, in one small country church, we found 22 cases of undiagnosed diabetes. 

Every person that was trained had my cellphone, had the doctor from the FQHC, had appointments available, and say, "You got an appointment tomorrow and go see this doctor," or "I'll give you a ride." We facilitated care in that way so that each organization had somebody who had connections into the system, somebody they trusted, because they may not trust me if they've never seen me before. That helped you open doors for those individuals who—and I know you know this—but no matter who you are and whatever your status is in life, most people care about their own health, and they care about their family's health. They just need somebody they trust to give them guidance. Your role gets easier as you build that relationship with your patients. 

What we lack so much today, particularly in urban areas, is continuity. You see a different doctor every day or two. It's not that they're bad doctors—they're not, but it's the way the system is set up. In rural communities, we still have that opportunity for continuity, which is huge. Observation over time: we used to use that as a diagnostic tool and now we don't, but it's really an important tool, knowing your patient. Gosh knows, if you really know a patient, voice inflection matters. If you've never seen the person before, you don't know if they're stressed or not, sometimes. So, those things matter.

DR. DESAI: Just chatting with you right now, it's obvious that there are so many lessons that all of healthcare can learn from what you've been able to do in rural medicine. I think one theme I'm hearing as you speak is that you need to have a stable human connection, because a lot is gained from that stable human connection over time. Like you said, in urban centers, there's so much turnover with relationships, that you don't have that stability to kind of lean back on and be like, "Hey, I know that this is this person's baseline," or, “They say they're not hurt, but they're hurting, and I know that that's why they're here.” I guess I'm curious how that's tied into Mercer University today. You tracked out for me that you were there, the first class, you're the dean several years later. How does that get tied into how Mercer teaches?

DR. SUMNER: Mercer's mission is rural and underserved populations. Mercer was the first medical school in the United States to start patient-based, case-based, small group tutorials. From day one, our students -- and many medical schools do this now -- but they start with a case. Even though they dig into the basic science that's related, it goes down deep to the cellular level but comes back to the patient. It starts a thought process that I think helps make you a better doctor. It makes you think that if you can identify a clinical problem, you can take it down to the cellular level, to think of the mechanism that contributes to that and build it back up and tie the pharmacology, and the physiology, and the pathophysiology to it. It makes you a better diagnostician. It makes it more relevant to those students. Sometime in the future, they're going to go, "I had a case like that," and it matters. 

It's a good way to learn, but we also focus on clinical skills, the ability to really take a comprehensive history, do a thorough physical exam. Think about the social determinants in that exam, their environmental exposure, their work exposure, their stressors, their over-the-counter medicines. We try to educate our students to really see that as the game-changer. The ability to really know your patient well, gather that information, and then, by the time you finish that, you'll at least have a differential diagnosis. 

Once you have that, you can work through those scenarios. Being able to have a broad range of skills. You know how much exposure internists get to trauma in their training? Not much. But as an internist and the only doctor in the county, I saw somebody that was run over by a cow at least once a month with serious injuries. You're called to automobile accidents because you're the only doctor in the county. I delivered 14 babies. Is that optimum? No, it's not, but I had enough experience and I know who to call to guide me through those. I'd rather have a woman's health person. I'm never going to have a trauma surgeon in those areas but I know how to call the helicopter and get them out of there and stabilize them. So having that broad range of skills is really important, and I think we've gotten away from it. We've narrowed. There are reasons that you want a subspecialist. Those are great individuals. But there are equal reasons why you want somebody that's broadly trained that can function in that space of pre-hospital to early hospital care. There's a benefit to that.

DR. DESAI: When I was a resident, we had a program where -- and I trained in the city of Boston; it's very urban, like you're saying -- we spent one month in the country of Lesotho. We flew literally halfway around the world. I believe, strongly, I learned more in that month than I learned in the other 35 months of residency. I was basically on my own, and the only help I had was a phone. I called, like you're saying, with telehealth, it was the same concept. I'm curious whether there are similar projects taking place on a much bigger scale now where you don't have to fly to Lesotho for that experience, where you can take trainees, your residents or fellows, and train them in rural parts of this country and give them an experience like that. Is that happening? 

DR. SUMNER: Rural tracks are sort of becoming in vogue, but if anything good has come from the pandemic -- and I don't know that this is a good thing -- but it certainly opened eyes to the lack of care in rural communities, because rural communities have had the highest percentage of deaths. Georgia has the not-so-good distinction of having six of the top 20 counties. They're all rural, and they're all communities of color. What they're lacking is primary care. Had they had primary care, were they going to take care of a sick COVID patient in the hospital? No, but they could have diagnosed the COVID early enough to get them somewhere, to open doors, or to start initial medicine. The death rate is from untreated chronic disease, diabetes, hypertension, obesity, the things that primary care does best. 

Telehealth has so much potential. My father was a physician, and as he aged his patients would go to the nursing home. When I showed up, my older brother, who's an internist, said, "I don't want the nursing home. Now you're the nursing home doctor." You know, you just came out of residency. The last thing you want to do is go to the nursing home. I ended up loving that. It was just such a gift to be able to know these older people who did so much for our country, all ages. At one point, I had 10 or 12 people over a hundred who were sharp as tacks, who taught you so much about life and resilience, and the things they had overcome were incredible. Our goal was to take excellent care of them but to keep them out of the hospital if you could, because they just didn't need to be there. The nursing homes can do so much that helps that person. It prevents delirium. There are so many things you can do by keeping them in a familiar environment if you don't have to send them. 

We put telehealth in all those nursing homes. At two o'clock in the morning when they call me and said, "Miss Jones has a fever, and she has a cough," I could literally examine that patient from my kitchen. I knew her well enough to know she looked okay, her pulse was okay, and her O2 sat was fine. I didn't need to send her to the emergency room. I could see her the next morning. I could be telling them what to do and feel like I was giving her good care, and she never had to be sent for evaluation. Consequently, those organizations had some of the lowest rehospitalization or hospitalization rates in our state because of those telehealth units. 

I think that telehealth offers a lot. In my practice, we did psychiatric care, to start with, with telehealth. We had great psychiatrists who were based in Miami, Florida, and Atlanta. Now, those guys knew the community. They knew where the resources were for mental health in Georgia. They had personal relationships with those institutions because they set them. They were the doctor. When that patient came to my office to see the psychiatrist, if he got in trouble at 8 o'clock at night, he didn't have to call me. He could call the psychiatrist, because he had a number. He had continuity. If they saw a patient in my office that needed to be sent emergently to the psychiatric facility, they'd fax a 1013, call the ambulance, and get them there. Patients loved that. It allowed them to intervene early in the course of illness because there was a trust there, even though they lived in Miami and Atlanta. It was continuity that made the difference. 

Telehealth is coming to the home, and I think the pandemic has shown that it can be done safely at home. There are so many devices like this little stethoscope that has superb quality acoustics equal to my $400–$500 Bluetooth stethoscope. There are devices that I've been testing lately that let you do ears, nose, throat, heart, and lungs. It's cheap and it really works on a cell phone signal. It's great, and it's coming to market soon. Hook it on your cell phone, and your doctor can look in your ears, nose, throat, listen to your heart and lungs, get your O2 sat, and get your temperature. Say you call me, and I have more patients than I can see. I've seen you for five years, and you call me and say, "I just don't feel good." I can look at you, or you can save it, and I can look at it at 5:30 and call you and say, "Sam, I looked at this, and this is what I want you to do. I want you to go get a chest X-ray in the morning. I'm going to call this in for you." That makes a big difference. Or my partner, who may be in a different town, can cover for me as well and see my patient without having to get up and go somewhere. 

Those things matter. I think you'll see telehealth really expand. It's coming. It's here, and it's been here, but for the first time, doctors have been forced to use it. I don't think it compromises care as long as it's done in the context of a practice, which I think is really important. 

DR. DESAI: That's an important distinction because I think a lot of folks see it as kind of a replacement, and that's not what you're advocating for. 

DR. SUMNER: It will not, and it should not, ever replace that human connection. People really come see you because you're somebody that cares about them, and they need your help, and they want to see somebody. But telehealth -- if I'm doing it to my patients or you're doing it to organizations or patients -- it helps expand access, and it's a good thing.

DR. DESAI: You've touched on a lot of important topics, especially as it comes to what it means to offer quality care in today's era, and you seamlessly blend technology in with caring for people. I think, often, people think of it as a trade-off: it's either technology or human touch. You're showing clear examples of how you can do both. I'm curious if there are some misconceptions or myths that you come across on the regular from any audience, where you think, “Hey, if they just knew X, Y, and Z, they would maybe see it differently.” Are there any things like that that you can help share with our audience?

DR. SUMNER: About technology? 

DR. DESAI: Yes, I was using that as an example, but it could be on any topic that comes up frequently for you.

DR. SUMNER: I think that, probably, the most important thing in health care that we're lacking today is the doctor-patient or provider-patient relationships. I think that is imperative, and we've got to get back to them. The value of the history in physical has been minimized because you think, "Well, I'm going to get a CT," or "I'm going to get these tests." It's not just about testing. I also think in rural health, very commonly, doctors are looked down upon or you ended up there because you couldn't go anywhere else, but a lot of rural physicians just enjoy that lifestyle, are from there, want to go home. What we've tried to do is restructure our admission process where we accept young people from rural communities and give them the skills to go home and try to keep student debt to a minimum and serve the most underserved. 

Mercer has been a leader in the percentage of our graduates that serve underserved populations and also the percentage that stays in their home state. We're proud of that. We also are putting clinics in those areas to give our graduates the opportunity to go someplace and really serve their communities. I think every physician owes it to their community to be community responsive. I don't mean political. I'm not talking politics. I'm talking about health and access to health and quality of care and protecting the vulnerable against people who want to take advantage of them. Everybody deserves access to care and it's up to us to find a way to provide that.

DR. DESAI: Your point is well taken that there's a greater mission here beyond politics. I think that often gets conflated these days all the time, especially in the state of Georgia, where you're from. That has become this national focal point from all sides. A lot of our audience are young professionals and students, and your career has been phenomenal. What would you say to someone that's coming along right now in terms of how they might want to think about clinical practice, especially, coming off this year of COVID and a lot of change that has come through that year?

DR. SUMNER: I'm inspired by our students because they really do care, and they really do want to change the world. They really do. They want to change Georgia. You can change the world, one county at a time. In rural Georgia is what I was doing. I think that they have to believe and they do. We have to, as leaders, give to them that opportunity because they don't have the money or the resources to put a clinic in South Georgia. Can Mercer put one down there and let them work there and pay them well and facilitate that? Yes. Can other organizations do that? Yes. This state desperately needs a rural health infrastructure. A physician in these rural communities is an economic development tool. It's like bringing in an industry because it creates jobs, but more importantly, it does recruit the industry. A business is not coming there without health care. Children do better in school with health care. We owe it to rural Georgia to build that infrastructure. 

I was a nurse then went back to school and went to one of the poorest counties in our state, and somehow, made my way back to being dean. I'm not saying that's the path you should take but I got into telehealth because I thought it'd make a difference in my community, and realized that I can make a difference by really elevating that bar a little bit in demanding excellence in telehealth. Just follow your heart. You’ve got to make a living. I got that. But don't think about income. Think about service and doing the right thing. You will never have to worry about your income if you go serve these individuals and really be the kind of doctor we need. 

In these clinics that we put up, it amazes me the ZIP codes we draw our patients from. In some ways that's amazing, but it's also disappointing that people have to drive that car. A ZIP code in rural Georgia is a heck of a lot further than in Atlanta. If you change ZIP codes, it may be 3 counties over, to think that somebody would have to drive that car even now to see a physician. We need care in those communities. We need to recognize the value of other providers. We need to quit battling over turf. If somebody can do it well, they should be able to do it. Pharmacists…don't undermine their practice because it's very important to have them out there with medication. Nurses, PAs, whoever, respiratory therapists, whoever's out there, help them fill that gap. Together, we can make a difference. 

DR. DESAI: That's a very inspiring note to end on and a good point about the fact that it requires a strong dose of humility and a sense of teamwork to get things done.

DR. SUMNER: In physician leadership, as a leader, do what you're supposed to do, but encourage others to help because we need everybody. Don't rule out rural communities because rural communities are resilient, and they're tough, and they're diverse. The difference is that in a rural community, everybody needs each other. So, we just don't have the battles that sometimes you see in more urban areas. 

DR. DESAI: Yes, that's a really good point about the solidarity that comes from a day-to-day reliance on your neighbor. On that note, I sincerely appreciate you sharing with us your wisdom and your experience. That was fantastic. 

DR. SUMNER: Thank you for the opportunity. It's nice to be with you. 

DR. DESAI: Absolutely. I'm Dr. Rishi Desai. I want to thank our listeners for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.