This week’s episode is a panel discussion on rural pharmacies hosted by the University of Iowa’s Student Association for Rural Health. The panelists included Erin Riffel, Pharmacist in Charge at Cornerstone Apothecary in Marengo, Iowa; Sarah Fitzpatrick, a Clinical Pharmacy Specialist at Washington County Hospital & Clinics; and Jeanine Abrons, a Clinical Associate Professor of Pharmacy Practice and Science at University of Iowa College of Pharmacy.

Speaker 1 (00:06):

Hello everybody and welcome back to From the Front Row. This week we have a little bit of a different episode. We’re actually going to be sharing with you a panel discussion that was hosted a couple of weeks ago. The Student Association for Rural Health out of the College of Public Health hosted a panel discussion with a couple of pharmacists to chat about rural pharmacy. So there’s three pharmacists on this panel. The first one is Aaron rif, a pharmacist in charge at Cornerstone Apothecary in Marengo, Iowa. Then there’s Sarah Fitzpatrick, a clinical pharmacy specialist at Washington County Hospital and Clinics. And finally, Janine Abrams, a clinical associate professor of pharmacy practice and science at the University of Iowa College of Pharmacy. It’s a really great panel. The first question was cut off because the zoom recording wasn’t hit right at the beginning. So that first question just to keep in mind as we move into this is what is one thing that you recently encountered or encountered for the first time? And with that, this is from the front row, hope you enjoy.

Speaker 2 (01:06):

I guess one other thing that I would add that I encountered for the first time, well, not for the first time, but it’s fresh in my mind, working with a patient this week is one thing about rural communities also is that a lot of patients, especially in farming communities, farmers, they’re small business owners, really is how you need to look at them. And so oftentimes if they want insurance coverage, they would have to go to the marketplace to get their own insurance coverage. And if they’ve never had health issues before, they may not see the value in carrying health insurance coverage. And so I have working with a patient who’s brand new diagnosis, uncontrolled diabetes and needs good meds is what I want to get them. But oftentimes it’s not as easy as just like, oh, let’s get you signed up for an insurance plan.

(01:52):

Or a lot of times they don’t meet qualifications for income-based programs because they do have a lot of assets and potentially even good income, but just the access to insurance coverage is still very expensive compared to what they are willing to spend. And so that’s something else that is kind of unique to the rural space is people who can’t afford insurance even though they have good resources. So that’s another struggle that working through of like, okay, well we can’t give you a GLP one because you don’t qualify to get it free from the manufacturer, and it’s way too expensive to pay out of pocket. So we’re left with doing the best we can with other options

Speaker 3 (02:33):

In that particular example, I know talking to a lot of farmers and talking to a lot of diabetics, one thing that has came up is I used to always get into this immediate info dump because we learn all these awesome things in pharmacy school. Were like, let me tell you everything I know in five minutes. But again, it’s kind of like pitching, you want to listen to me because it’s going to be helpful. You want to come back, I want to get you to come back here. So we’re developing that relationship and I also need to know a little bit about you. So you might not be cooking all of your own meals. So if I go into a huge dump on here’s why you have to cut out carbohydrates and here’s how you should shop for your foods. If you’re not actually the one doing that, I don’t have to convince you only I have to convince whoever is doing those things for you that they need to make that change.

(03:31):

Asking multiple people involved and that isn’t just the rural community, but then I also have to know what your life is like a little bit. So even if I’m not a farmer, I might think, okay, if somebody is in harvest season, then they’re going to be in the combine and they’re going to be in the fields. It’s going to be a lot of dust, so I need to think about that in my counseling with sterilizing an area or I need to think about refrigeration. Do they have something that they can plug it into? Do they have a cooler that they can put it in so that I’m making it meaningful to them?

Speaker 4 (04:11):

You have to be relatable. They can’t just go street and fix somebody else. You’re it.

Speaker 3 (04:17):

Yeah, you’re it. So you have to know what is your life like and what is this going to look for you? If you’re giving all these impractical things and they’re stuck at, yeah, I’m going to be in the field for eight hours, then I don’t know where I’m going to put this, they’re not going to follow through and they’re not going to do that for you. So if you want them to want to come back to you to listen to step A, B, C, D, you have to make it manageable and not overwhelming. You have to think through those relationship dynamics and you have to think what is life like on a daily basis.

Speaker 2 (04:56):

Yes. So the question for those on Zoom if you couldn’t hear was about our payer mix in rural health of who our patients are insured by. I’ll say that my current population is skewed because my first consult that has gone live with my new job is an anticoagulation consult, and so then most of my patients are Medicare patients who can’t afford a D oac. So most of them are Medicare at the moment, but I think as soon as my next consult services go live, I think our health system may be a little bit of a misrepresentation of some other rural health systems because we are rural, but we do still have a lot of local businesses offering employer coverage. So we do still have a good mix of Blue Cross Blue Shield, but definitely in most rural health systems you will see a bigger proportion of state and federal insurance mixes. But I would say in your community pharmacy experience, you might be able to speak more to

Speaker 4 (05:56):

What the kind of payer mix is for you. We do have fairly significant proportion of Medicaid patients where we are and that affects things like the drugs that we keep. We have to follow the Medicaid PDL and they have a lot of brands that are preferred and no one can figure out why. But with the DIR fee change that happened this year, we can’t keep those brands on our shelf. So we have a little sticker that says, this is special for you. We need a couple days heads up before you order that again, because it’s just not practical to keep that amount of inventory on your shelf when everything has to be so tight right now. It also affects those patients how they use the health system because a lot of Medicaid patients view our emergency room in town as their primary care because the steps of making an appointment and getting transportation when it suits their appointment time versus they feel poorly right now and they want care right now. And so we have to sort of help in communication with everybody involved because there is a higher incidence sometimes of multiple physicians for one patient because they’re just getting in where they can be seen quickly.

Speaker 3 (07:16):

Here, most of my patients have zero health coverage or they are going through county health, some like my last immunization clinic, everybody was from a different country whether here permanently or here for a short amount of time. And so I have to know both of these systems and I have to say, well, here’s where you could go to get that medication at this price here is who would stock that? I have to be resourceful with for this type of thing, this is the cheapest option. So we’ve made actually some clinical protocols for mobile clinic that have cost conscious options in it to think about what is an alternative in the same class, but maybe a cheaper option. And then also collaborating with local pharmacies and then also free medical clinics to say, can we have a system where we’re all kind of talking the same language, recommending the same thing, suggesting things because I know that if you have trouble, you’re going to go to the er.

(08:22):

So how do I stop that for you? For us, it is developing a lot of telehealth services and we’ve been working on coding some apps that will allow you to text a blood pressure, a blood glucose level so that we can have a little bit more information to work with. Oftentimes we’re getting snapshots of somebody’s health and we’re trying to make decisions on not a lot of things. So that helps, and both for providers as well working in an interprofessional setting, a lot of the doctors don’t know what the cost of different things are, and so it’s a lot of education of this is going to be really pricey or this is going to have prior authorizations with it. And this isn’t interestingly internationally for me as I’ve worked in the pharmacy, it’s kind of been the reverse over time a little bit. We started at a situation where there was no coverage and there’s actually a system that a group of countries use called gold procurement and essentially it’s putting all your money in the same basket and you’re buying together so you get that bulk discount.

(09:37):

So they use that based on essential medicine lists to lower the cost of their drugs. We started where that was the only system and a lot of times people would not pay their bills on time. There’s no charge for medication. There was frequent stock out, so you were kind of scrambling all of the time. Now they are starting to have more private health insurance, a lot of the small businesses. And so for the first time I had gotten into the mindset of, okay, you’re not going to have health insurance, so I can’t recommend anything where they’re now also going not just in the government system, but they’re going to the private pharmacy and I need to know their formulary too and not every plan, but kind of have an idea of in general, this pays for this or it doesn’t, just to save myself some time in structuring any suggestions I’m going to make to anybody.

Speaker 2 (10:39):

One other kind of insurance related difficult scenario that came up for my health system this fall was I am sure when you’ve been out and about on rotations, samples are kind of few and far. You say that word across the street and they’re like, no, they don’t let a drug rep walk through the door. But we had historically allowed samples because I think a lot of the providers felt like it was a service to their patients to be able to give them these expensive medications. Well, we had a change in electronic health records this fall and there was no way to track these samples. And from a pharmacist perspective, this kind of unregulated closet in a clinic somewhere is the worst nightmare of who’s responsible for this and making sure that things are not recalled or expired or anything like that. But it was a difficult decision, I think for our healthcare team to make because it’s like, well, we think we’re doing a service by providing these medications for free, but are we really helping our patient if we start them on a medicine that we can’t guarantee that we know that they cannot afford on their own if they don’t have samples?

(11:48):

And then if this drug rep doesn’t come by, we don’t have these samples to give, are we really harming them more than we’re helping them by getting them started on something that’s just not a reasonable option

Speaker 3 (11:59):

With the international perspective. So internationally, that pooled procurement system, it functions based on forecasting and just like you’re talking about ordering a drug for a particular patient, you’re not going to order if you’re not going to have people take it. If you have somebody all of a sudden donate a really expensive medication and they give a whole bunch and you have samples and they give it to everybody, then that’s screwed up all the forecasting for the other medications. So now I’m not buying as much from the manufacturer as I said it was, and my price was dependent on that. And so the next time I go back, the samples have run out and now even the things that were affordable are less affordable. So we have to do some education with that. When people are thinking, okay, I wanted to donate a product, we have to say, okay, how can you buy something locally or how can you look at the price comparisons locally because it might have some downstream effects that you’re not even thinking about just trying to do something good. Again, it comes from a very empathetic place, but it has some larger repercussions.

Speaker 2 (13:22):

We just got Epic this fall, which is amazing, but they have, it’s called Surescripts. I dunno if anyone’s ever seen that, where you can see patient’s pharmacy fill history and see, oh, you’re filling this at Walmart, you’re filling this at Hy-Vee, you’re getting this from mail order, and you can see all that history, and that’s a good way to keep things straight at least when you have it available. For me,

Speaker 4 (13:46):

We try to start with the patient because if they have some background knowledge that can save you time from making all those phone calls, that’s helpful. And that depends on the patient, of course, if their recall, if they remember to keep everything on the same page. Otherwise, it’s a lot of phone calls and leaving messages and faxing things and lots of notes in the bag so that if you’re not the person that’s there when they pick up that what you’ve been working on still gets answered and conveyed to the patient so that you can just try and keep everybody in the loop.

Speaker 3 (14:23):

Okay. How many of you have heard me complain about my electronic health record for mobile clinic at some point? Yeah, we started out with a free system because we wanted to organize patient information and it was touted with us as, oh, it’s going to be so easy to use and you can share different things. False. Once things went in there, nothing came out. It is like the abyss of information and figuring out trends or figuring out information. Horrible. So we had to look into, does anybody know what open source systems are? So open source systems are essentially where the code is kind of shared so people can build on it and grow it. And so there is another component to that. There are free systems like that that are often used in global and international health. So this is an example of where I looked at what the free systems are that are available internationally.

(15:27):

I talked to some other friends of global health that we’re using the systems both in West Lafayette and Purdue and here I looked at student run free medical clinics and we picked a system that now we are kind of building out ENC coding a little bit. So it starts with kind puzzle pieces I would say, and then you pick the puzzle pieces to go into the system and you build your own EMR kind of thing. As we’re doing that, what we have to think about is we’re going to have a lot of students who are going to work with us, so how do we make this really easy? We have a lot of language issues, so how do we make sure there’s a lot of language components and cultural components and then we know you’re going to need that information and you’re going to need that information.

(16:22):

We know that we’re probably not going to get the information back from a bigger system like Epic, but we want our system to be able to talk to those systems so that even if we can’t get all the information on our end to help us, we’re helping our patient out overall with putting that piece together. And so then we’re always thinking, what is the cost with the patient? What is the cost with us? We have to use those free systems because for our clinic, we’re either running on Doc Dash or action auction or a small budget of, I think we’re at 10 grand for 14 clinics, so we have to make the money go extensively. And then we also have to know that because we’re dealing with a lot of different rural spaces, each of those patients might have a different access challenge. So we started with writing down pharmacy talking, right?

(17:23):

They’re going to have to go to the pharmacy to pre-medical clinic, what are they using UIHC? How does their system work? Where are they going to end up because we’re going to try to keep them from getting to the ER or other places, but we’re not going to be their only care provider. So just kind of presenting things as a pro and then thinking about again, where do you want to go to access that care and how is it going to, as you’re saying, hurt or help that system continue to have resources for you? I know a lot of pharmacies have shifted to different models, and right now one of the things that I’ve seen a little bit of is the cost plus model for having cheaper access to medications, completely bypassing some of the insurance things. So that’s always something that I talk about too of when have you in the past ended up buying things out of pocket versus buying it on your plan, and how are you paying attention to that? So you think, oh, I had to do this 20 times. Maybe the first year they got me and they signed up for the Advantage plan, but year two, no, I don’t want to do that anymore.

Speaker 2 (18:37):

A part that I hadn’t considered until working on a publication with Dr. Kanako this fall about the RS V vaccines is that sometimes, so the RSV vaccine is covered under the Part D benefit, and if they didn’t, depending on their advantage plan, they might not actually have that piece covered. And so explaining those things to people who are used to it, you just go to your doctor’s office to get a vaccine of like, no, this is covered under the Part D benefit is kind of complex waters and people don’t understand why they can’t just get the vaccine anywhere they want and that kind of thing, not advantage plan wise. But the other thing to think about in rural areas is before I was in an ambulatory care space, I worked for our local independent pharmacy, which is also owned now by our hospital system. It’s called Beans Pharmacy.

(19:24):

And Beans Pharmacy has a wonderful reputation in our community. Patients love it, but the thing about it is, is that the little guy also doesn’t have the same contracting power with insurance plans as the big corporations can. So a lot of patients, as much as it breaks their heart when we sit down with them in the fall and also look at insurance plans with them, we do say, well, it will save you 500 to a thousand dollars a year. If you go to Hy-Vee, they’re like, well, I don’t want to, but money talks. And when budgets are tight, a lot of times it does mean going to different pharmacies just because of their marketing power of being a larger corporation to get better insurance contracts.

Speaker 4 (20:05):

So that was a change. Initially we received our Covid vaccine supply from the national supply, I guess, and it was at no charge. And then when we billed people’s insurances, it was just for the supplies the time. So once that supply was used up and we have to order the vaccine from McKesson and Bill it just like any other vaccine, a lot of insurances that allowed the billing for the first round because they didn’t really have to pay anything considerable. They now have things in place that if you get the vaccine with us, it’s not a covered product for you. You have to use sometimes a CVS minute clinic or very specific guidelines with their physician’s office potentially that weren’t in place for the first round. And so that’s a hard thing to educate on when I was just here for the last one and you took care of me and I’m comfortable here, and then we have to tell them, no, that’s a difficult conversation.

Speaker 3 (21:05):

And for me, getting the vaccine without the insurance, I have to explain that, okay, COVID Vaccines, we got free when there was an emergency declaration, but when that ran out, now I have to apply for something called the Bridges Program and that doesn’t, there’s only a handful of locations and places that will cover that. So this vaccine, I can’t get this other vaccine. Have you ever heard of Vaccine for Children? So the VFC program is a program that is run through the state that will give free vaccine to kids, which is awesome. A challenge though is now that there are more Medicare plans and different things like that, we used to be able to say, you can get it through this program if you are underinsured and if you are not insured in general, and then you meet some demographic criteria. Now we kind of basically have to say most plans have some sort of immunization coverage.

(22:12):

It might not be the coverage you want. Again, it might not be the location that you want, so we can only give that to you if you have no insurance. So then I’m having to explain to my patients, in this case, I can get these three medications and immunizations in this program. These from here, these from here, these I can’t afford. And I even tried with the covid vaccine to work with the U work with bigger health systems that was going to be $85 out of pocket per dose per patient. And so we couldn’t offer some of those things initially until we could find another alternative.

Speaker 2 (22:52):

And on the note of the Vaccines for Children program that it’s so wonderful that we have that opportunity. But the other, it is another barrier to care. Sometimes patients who have Medicaid coverage, they can’t receive their vaccines in clinic. They have to go to public health where the Vaccine for Children program is offered. And sometimes even just getting these parents in with these children for their well-child checks can be already a barrier just to get them in the door to the clinic. And then the fact that we can’t just take care of their necessary childhood schedule at the same time can be very difficult. And so then you have to familiarize yourself with the catchup schedules and things like that too, to make sure that we’re still getting these vaccines for kids.

Speaker 3 (23:33):

So we actually went to things like back to school clinics high yield, and then that solves Sarah’s problem. My problem is procurement and storage, so I can procure a whole lot all at once, and then I can do a back to school clinic and I can catch everybody up or make sure they’re there. You also might have to think about different partnerships. So for example, we have worked with Johnson County in the past, safe Steward some medicine or they’ll get that for us and then we’ll go get it from them. So we know the systems. We’ve also had to work with some groups that go to the schools. And so maybe you can’t get every patient individually there, but you can say, okay, I’m going to see if Johnson County or Washington County will come out to the school for a day and do a catch-up clinic. I’m going to come there as a representative of the hospital. So I’m providing information, but they’re providing the vaccine service. So I’m kind of building it out in this weird way that kind of works for everybody.

Speaker 2 (24:39):

Okay.

Speaker 5 (24:40):

I have a question specifically for you, Sarah, and your residency, unless you guys also do residency, you guys can talk on this. What made it stick out for you in a rural setting, doing residency, and then the good, the bad, the ugly one at all?

Speaker 2 (24:54):

That’s a great question and one that I think I learned some lessons the hard way when applying for residencies. So I knew from the get go actually, well, basically I’m the poster child of never say Never, I guess because I came to pharmacy school and I hated the idea of a residency. I was like, I’m never doing a residency. And yes, I was like, I’m going to go back. I’m going to work at beans. This is what I’m going to do. And then over time then I’m like, okay, well maybe I do want this ambulatory care thing. I really like being able to practice at the top of my license like that and still do everything I love about community pharmacy and build those relationships. And I’m like, okay, well, there’s one thing that I said I would never do, and I did. I also said I would never date another pharmacist and then now I’m married to one.

(25:41):

So with that, when I was applying to residencies, of course, because I knew I wanted PGY one and PGY two ambulatory care training. And the main reason for that that I wanted that is I knew I was going to be on my own and I needed to fully trust my abilities to be able to practice independently. And after one year of residency, would I have been ready maybe. But having that second year under my belt, it’s amazing when you look back and just how much you learn in residency, and I had a thought this a few months ago, I’m like, gosh, I kind of wish I could go back. It’s just amazing how you don’t realize how awesome it is to just be plugged into the experts in every area and you’re just learning all the time. Not that I want to be back in the grind of things, but it was just so nice to have such up to the minute information and be learning from every direction.

(26:36):

So that was why I wanted to do a residency is just because I knew that I had to know my stuff and be able to also for my own position as well. So one thing like billing, a lot of the billing conversations about my position, I was the one telling our billing department what you can and can’t do for pharmacists based on what I’ve had to go out and learn. And a lot of that, some of it came from residency, but a lot of it also had to come from certificate programs through a CCP and A SHP to learn what you can and can’t bill for as a pharmacist. Because when you’re working in a big institution, they’ve already gotten it figured out and the people doing the work every day often don’t know why or how or can we bill for this? It’s just been established for them like, yep, we drop a charge for this or we don’t for this.

(27:26):

And then where I learned the hard way with residency is then a couple of the places that I applied, because there’s not residencies in small towns. For example, I applied at freighter in Milwaukee and I had a 15 minute, and I totally know what I did wrong. They’re like, oh, tell me what you want to do. And I’m thinking, I’m selling this great pitch of I want to go back to my hometown and be a rural health ambulatory care pharmacist. And they’re kind of looking at me like, okay, but we’re in Milwaukee and I didn’t draw the lines. And so I learned from that. And by the time I came and interviewed at UHC, it also is an easier connection to make in Iowa. And you just get a couple of minutes out of town and you’re in a cornfield. And so the rural health piece was easier to explain to the connections here at the university, but that is something too of if you’re looking for hands-on training in a rural health setting that just right now doesn’t exist.

(28:27):

And then the next also in the same token that comes is my institution is already talking about your services getting so busy in a couple years, we’re going to need to grow this service. But right now the whole state of Iowa is only putting out two pgy, two trained ambulatory care residents every year. Most of the time there’s five ambulatory care positions at the university that are going to swallow those up. And there’s very little, unless you lived there like me and wanted to go back to your hometown, it can be hard to find residency trained individuals to fill the need. And there’s a lot of interest from people at IPA and things like that about how do we get, use my position as a model and make this happen in more rural health systems. But then it brings up the problem of we’re not putting out enough people with the training to go out and do what I’m doing. So yeah,

Speaker 3 (29:24):

I was similar. So we were just talking about going to school if somebody emphasized residency training. And for me at Drake, kind of not really. I talked to a lot of the clinical professors that I loved and they said, oh, you’re just going to be so bummed if you don’t do residency training, you’re geared to this. If you don’t do it, you’re not going to make it. You won’t get that. And then I also worked with the research folks and they were like, oh, you just have to do this. If you’re not going to do this, then you’re going to hate yourself and you’re going to need to go back. And I thought, I don’t know what the heck I am supposed to do because how do you make that decision? I actually got offered a residency and I turned it down because I got a full ride to graduate school and I thought, what skill sets are going to be harder for me to get in that moment?

(30:20):

And for me in that moment, it was the research components. There was even fewer people that knew research components. So I worked relief all over Wisconsin. I worked in a whole bunch of different clinics and rural hospitals. It gave me the training to know how did they solve all those pieces and to kind of say, how do you incorporate this in? And then I found the long-term acute care hospital. The preceptor had been the PGY two critical care residency director at UW Madison. And so I said, well, you teach me everything. And she did. So I got all of that training not doing that. So I always say, residencies are really good, and exactly what you said, if you have a good program, you’re going to have people that challenge you that present you with that information, but that’s also up to you to be motivated to receive that.

(31:25):

So Sarah also is not sharing that she was always a superstar and challenging herself in that way. In doing that, she had that drive, and I fully believe she would’ve made those things happen if she met people in different places. Also, a residency, if you’re there and you’re not motivated, you’re not going to get that component out if you don’t do it and you find yourself in a circumstance where you say, either I’m done or I don’t want to get this, it’s important to know that there are certificate programs, there are additional things that you can get training. If you look at any of the professional organizations, they have those pieces. And then Sarah’s kind of mentioning IPA as a resource, but I think that’s important to mention too, is you need this phone of friend of like, Hey, who do you know? I know this person.

(32:28):

How do I do this? Can you figure it out? Because you’re not going to be able to anticipate every single variable. So whatever training you go to, whatever situation you’re in, use your resources that are there and then also think about where you want to end up too. I did not think, Sarah, I was like, there is no way in heck I’m coming back to Iowa. I was like Iowa to Wisconsin, peace out and then to New York, I’m done. And then it was like, wait a minute. I’m spending all my vacation time to come back to Iowa, and what’s really important to me is my family. I probably could have guessed some of these things if I would’ve thought how close I was to my grandparents and how much growing up on their farm and doing all those things shaped me, but I didn’t. And so I think you want to think about what skills do you need to do the job of where you want to be and what you want your life to look like too.

Speaker 4 (33:35):

I didn’t pursue a residency. I was ready to practice. I wanted to go back to my hometown. The pharmacist that mentored me was ready to retire. We just kind of had it all set up and just like you said, my parents are here, my grandparents are still alive. I didn’t want to lose any of that time by ending up back at home. I just wanted to serve the people who had helped to raise me. And I had some hesitancy at first because I thought, gosh, if somebody remembered pulling my pigtail when I was five, maybe I would lose some professionalism with them. I had that in the back of my head, but immediately I found the opposite was true because like you said, if you sit next to someone in church or if you run into them in the grocery store, they feel that you are looking out for them as a whole person, that you’re not going to push something on them just because it makes you a buck or that you are more genuine or it builds a much nicer rapport than if someone’s just a name for you have

Speaker 3 (34:38):

Some street cred.

Speaker 2 (34:43):

Yes, and I do. You kind of learn how to work every angle of that of, because not every patient is like a farmer or whatever, but for the couple that when they do come in, I’m like, oh yeah, well, what’s your family up to right now? This is what my dad’s complaining about. Oh, are you going to get any rain? Try to work the angle of each of your patients to build that street. Cred is everything with these patients, everything. So

Speaker 5 (35:13):

We talked about farming a little bit earlier, but in areas where farming is extremely prevalent, do you notice there’s a difference in type of demand for medications or over the counter stuff? I know my grandpa is anti meds at all and he’s a big farmer and he is like, Nope. Or any other just different products that the pharmacy needs to carry that you guys noticed.

Speaker 2 (35:34):

Since I’m in the clinic setting, I don’t notice. I’ll let them speak to the caring in the pharmacy side, but one thing that you never think about is your patients who use veterinary medications because they can get it cheaper from their vet. Yes. So always ask about that too when they’re like, oh yeah, I take ibuprofen 800. I’m like, I don’t see that prescribed for you. Well, I get it from my vet. I’m like,

Speaker 4 (35:59):

Okay,

Speaker 2 (35:59):

Okay. Then from a farmer’s perspective, yes, absolutely people who don’t want to take any medicines, but also there’s people who I guess where I was going with this, so farmers and then also truckers is something to keep in mind too, and especially going back to the diabetes scenario of patients on insulin and also needing to have their A1C stable for, I think it’s like six months or not being able to use insulin and be an overthe road trucker. And so those are all things to keep in mind too that is kind of unique to the rural areas.

Speaker 4 (36:37):

We keep kind of a range of over the counter items in the store for people, like you said, that they’re not quite willing to go to the doctor, but they have a complaint that they would help with. And so we have the cheapest retail price bottle of supplement that we can get from McKesson, but we also have a professional line of supplements that we believe very strongly in so that you can give people an option that if they aren’t ready to commit today, they can still leave with something. We have a dollar store in our town, so we don’t want people to go there, purchase that, bring it in because they couldn’t get any advice at the dollar store register, and they still want to pick your brain about something. So we try and whether the person doesn’t want to go to the doctor or they don’t believe in pharma as a whole, they want to seek other avenues for their health that we can serve every person no matter where you’re at on that spectrum, whether it’s essential oils or just different things that we want to make sure they get the right information.

(37:37):

If they tear a page out of a magazine or something on an infomercial, we don’t discredit that, but we want ’em to know that there’s an option here in the store that has some research behind it that can potentially get them better or similar results without having to seek all those other places that you can get all the things.

Speaker 3 (38:02):

So my exposure to this started when I was in high school and I had a boyfriend who was going down a water slide without water, just FY. I never do that because it pushes you around the water slide. And so he went off the water slide onto unfinished concrete, and his family were farmers. So I learned very quickly the hospital was going to have to provide care very regularly for him, and they were going to have to clean that wound, and they were concerned about the farm just because they were thinking about different exposures that you’re going to have to veterinary animals, dander, different things in that environment. So my family took care of him, and at that point I had to learn wound management. And so I started to get good at what type of gauze do you need? And again, I’m not an EMT, but where are people going to go to get those supplies?

(39:02):

They’re going to come into the pharmacy and be like, I need this cream. I need this gauze. See this? I am going to show you this. I said texts. I have all the texts that I get from different images. And so you’re going to have to say, okay, triage, that’s bad. Wow, you need to go to the ER right now, and this is a hospital level issue. Ooh, that’s starting to look bad, but here’s what you could do and here’s when you know it’s that bad, you need to go to the hospital. Oh, that’s easy. Let’s clean it out. Let’s put some super glue or a hydro seal on it, be resourceful or think what they’re going to do. I say the super glue because I’ve also found myself in that working with farmers in Dominica, they’ll get a cut either from plant or from taking something out or from machinery, and they’ll have a wound.

(40:04):

And so my job now is to teach them how to watch that and care for that so it doesn’t get more serious. Sometimes people are really motivated to do that, and you can generally tell, unfortunately, we’ve had examples of people that end up being amputees because they progress in that situation. So again, kind of learning what are some of the environmental risks are really important. I see a lot of rashes with chemical exposure and different things like that. If you’re thinking about Roundup and other things like that that you could maybe get there, a lot of ocular things just because stuff is flying in your eyes. So you need to think about what drops do I have and what is this like for that person? A lot of allergies as well. So just because somebody is a farmer doesn’t mean that they’re not having symptoms when all that grass and wheat, corn, soybeans is tilt up. So just kind of thinking about the seasonality of things that might be happening too.

Speaker 2 (41:16):

And then I have two kind of flip sides of a coin here about farmers and being a farmer’s daughter, I feel like am speaking about my own family. So on the one side, there’s the story of the scariest thing is a farmer in the ER in harvest season because they don’t, timing is everything with farming. You have to work when the conditions are right, and so during certain seasons, yes, they don’t prioritize their health maybe because they are prioritizing their livelihood. My dad, case in point, on the flip side though, something that I don’t think about often is that a lot of farmers, they use similar skill sets to a pharmacist. So with diluting chemicals that they’re putting on the crops or feed rations and how to mix certain amounts of feed. So I always try to make sure that you are talking to that because many farmers are like, oh, I’m just a dumb farmer. I’m like, that’s not true. You’re a very smart farmer. And so making sure you talk to them and kind of empower them and make them realize that they know more about these things then might meet the eye, can be really helpful and help engage ’em in their care by not just playing further into the dumb farmer narrative and by making them realize how smart they actually are.

Speaker 4 (42:39):

Yeah, like you said, it’s all about schedule. So it’s not that they don’t believe in a flu shot, it’s that that’s a really busy time of year. So have a mobile flu shot bag. It’s got an EpiPen in it. I mean, you can take care to them and they’re very, very appreciative. And that also when you talk to them in that moment about a follow-up, we will look at these three other vaccines that you’re due for. Let’s knock this out today. And then once you’re done in the field, then come in and we’re going to chat about these other things, and they remember what you did for them, and so they’re very open to other things that you want to suggest knowing that they can do it on their terms or when it rains, you get everybody in the door. So just being able to anticipate that is they appreciate that.

Speaker 3 (43:24):

And we’re kind of weird too. We have done things, so I had a guy that worked for the College of Public Health and did a lot of sustainability in agriculture and ran all the Johnson County Grove Johnson County Farms, worked for the Iowa River Valley Consortium is one of the smartest people that I know now in grad school in Minnesota. He’s working with us internationally with the farmers because we do a lot with traditional healing and medicinal plants. And so he’s helping them to think about what they’re eating in their environment and what life is going to be like and has amazing skill sets that I’m like, please help me with this. It is not so much about making the assumption of you are like this, and I assume this, but clueing into what would make your life easier and then being adaptable to get it there.

So it is like I gave immunizations and a aiaa and covid because that was the easiest place to go. It is kind of thinking, what is the challenge and the hurdle that you’re facing? What are you telling me that you know about these medications or these situations, and then I’m going to adjust my approach to you. So I think that’s an amazing point, Sarah. Yeah, you get to a point where it’s like, this person might be super motivated and super knowledgeable. Don’t treat them like they don’t have that knowledge to figure out what they know. Well, thank you

Speaker 6 (45:04):

For joining us, everybody with the Student Association for Rural Health.

Speaker 1 (45:10):

That’s it for our episode this week. Big thank you to the SAR Association for inviting us to share this panel today. And then for the three panelists that shared their expertise, it’s nice to change up the format every once in a while. So I hope you enjoyed the panel format, and if you want to see more like this, let us know. This episode was hosted and written by the Student Association for Rural Health and Edited and produced by Lauren Latt. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple’s podcasts and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health, have a suggestion for our team. You can reach us at cph grad ambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.