Transcription of Kathleen Fairfield for the show Caring for Community, #81
Lisa: In the studio with us today, we have Dr. Kathleen Fairfield who’s not only a medical doctor but also has a doctorate in public health and the Associate Chief of Medicine and a Clinical Investigator at Maine Medical Center. Thanks for joining us today.
Kathleen: Thank you for having me.
Lisa: Kathleen, you and I have known each other for a while. We’ve been sort of following each other as we have gone through our medical education. I also have a background in public health but you got a doctorate in public health. Why did you do that?
Kathleen: The group I was working with at that time, I was working at nurse’s health study. We were doing a lot of quantitative work and I felt like I wanted to make sure I really understood the methods. Also, there was other work that was going on around me and it allowed me more time to explore some of the other dimensions of public health. At that time, I actually was thinking more about research than public health practice but I do a little of both now in some ways.
Lisa: You also do clinical medicine?
Kathleen: Yeah.
Lisa: What do you do for clinical medicine?
Kathleen: I’m doing primary care, general internist at Maine Medical Center in the clinics. I have small-patient panel. I also supervise residents in international clinic.
Lisa: What does international clinic look like?
Kathleen: This is a once a week clinic where we do new intake for new refugees who are entering our system of healthcare in Portland. We link with Catholic charities in the public health system. Public health nurses brings the patients in and we do comprehensive new intake visits and I try to assess their health needs and get them established in care in the medical clinic with partnering with our residency program.
Lisa: You’ve been able to marry what I think most people be considered two very different world, research and also clinical practice or taking care of patients. How does that work in your own life?
Kathleen: It gets busy. Like a lot of people who, like you, a lot of people who do multiple things to inform each other. So I think being a researcher makes me a better doctor and being a physician makes me a better researcher. Sometimes I feel a little bit more of one or a little bit more of another. Patient care always takes precedence, as you know, if somebody needs something. That’s the great part about the research that I do. It doesn’t usually involve human subjects that are sitting in front of me. I could set it down when I need to.
Lisa: What is your research right now?
Kathleen: There are two major tracks, one has to do with the shared decision-making and using tools to help patients make better decisions that are aligned with their own preferences and values and also fully informed about the risk and the benefits. The other piece is using large data sets including SEER-Medicare which is the nationally available cancer data set to look at patterns of care. This is a field of health services research where we’re trying to make sure that people are getting care that is consistent across systems and minimizing disparities and difference in health care by region, and race, and ethnicity, and gender.
Lisa: For people who are listening who don’t have much of a background in research or statistics or some of the things that you’re talking about but they do of course have health needs. How would the research that you’re doing be relevant to them?
Kathleen: The research that we do in shared decision making probably feels the most proximal for patients. It actually really crosses over into quality improvement as well where for example we currently have a grant from Maine Cancer Foundation to do work with shared decision making around colorectal cancer screening choices. In the practices, some people have done work with shared decision making and asking patients about their preferences and values mostly at the point of care when the patient is sitting in front of you which is a really nice way to do it because that can be a nice back and forth.
As you know, time directly with the patient in the office is really tight already. There’s so much you counsel them about in terms of prevention, and their current medications, and other things they question that they have that we often run out of time and it gets deferred to the next visit. The model that we’re trying out is to look at our patients when they’re not sitting in front of us, to identify the patients who have need, for example, are unscreened for colorectal cancer screening or overdue, and to some of the decision aid which is a video tool and a booklet so that they can think about their choices for colorectal cancer screening including being … in an informed way to not pursue screening or to pursue one type of screening over another.
Then we have someone from our office or one of the officers with working with call them, so an RN or a medical assistant call them and do decision support to help them understand, answer questions, help them understand their options and then refer them for screening as appropriate. It actually, for patients, they have a chance to look at decision aids, process them, think about them with their healthcare team and then make better decisions. It’s pretty direct in that way.
Lisa: The idea of shared decision making is kind of counter to the way medicine has been for quite a long time where it’s a bit more top down where somebody would come in and say, this is what I think, this is what I think you should do. Now we’re saying, here some information, this is how these impacts your quality of life, and you’re really attempting as a physician or a healthcare provider to have a dialogue with the patient and make this decision together.
Kathleen: Yes, I think it is a little bit of a paradigm shifting. I think a lot of excellent providers, physicians, and other caregivers have been doing it for a long time. It’s a little bit more explicit I think in some ways of saying to the patient, we really want to know what you value. Do you really value avoiding getting on an additional medication or do you value avoiding surgery or procedure and help them reflect on their own values and their preferences. Some situations are very clear. The patient can pursue surgery say, for a knee replacement, or spend more energy doing physical therapy and be willing to take anti-inflammatory medications for example.
Other decisions might be something like screening where you revisit it annually for example or every 10 years in the case of some colorectal cancer screening choices but it is a little bit of a change. I think some patients might not be comfortable with it but what we’re finding in general is that most people really want to participate and be fully informed and have, in fact, strong feelings that they might not have shared with their provider had they not been invited to do so.
Lisa: Why colorectal cancer?
Kathleen: Colorectal cancer we chose because it’s a good example of, it’s a malignancy that we can screen for and make a difference. We can reduce colorectal cancer death by screening for it and taking up polyps that might later transform into malignancy. We have one of the lower rates of colorectal cancer screening compared with some other screening test like mammography or cervical cancer screening probably because the test are unacceptable to a lot of patients. They’re not willing to undergo a colonoscopy, as you know the prep and the procedure itself are, feel more invasive, for example, to a patient. We thought there was an opportunity there to provide education to patients about what the test are, why we’re recommending them, why they might choose one over the other, and to be more informed particularly about that choice.
Lisa: How big a problem is colorectal cancer?
Kathleen: Colorectal cancer is the third most common malignancy for both men and women.
Lisa: Is this something that we’ve seen rising, the rate of colorectal cancer, over time?
Kathleen: I actually think it’s been fairly constant.
Lisa: But it’s something clearly that we need to be paying attention to because it causes death.
Kathleen: Yes. It’s an important malignancy, again, it’s the third most common. We also have an opportunity because if we diagnosed polyps we can take them on to prevent them from actually getting the malignancy or if we diagnosed it at an early stage, it’s curable through treatment versus later stage, tumors are much harder to cure and it becomes a disease management situation.
Lisa: What are some of the responses that people have had when asked to participate on these shared decision-making project?
Kathleen: We have a whole range of responses and some patients haven’t wanted to look at the materials that we’ve sent them. They would rather get information directly from their physician. We’ve had some people look at it and say, they really appreciate it and they had some questions when they get the phone call. They have, in fact, chosen to be screened when before they were reluctant to be screened. We’ve had patients choose simpler stool test that they can do at home and mail in called high-sensitivity stool testing and try to not realizing that that was an option, they had only been offered colonoscopy before.
They do have to understand that if the stool test is positive, they need to go on to colonoscopy. We are making sure that people are well informed about their choices. We’ve had, a lot of peoples say, they really appreciate the information and the chance to participate in that care.
Lisa: As a primary care provider yourself, have you been able to use this information on shared decision making in your own practice?
Kathleen: Yes. We’ve done … MaineHealth has been part of a grant that Dr. Neil Korsen and myself have had and working on throughout the MaineHealth system with many practices trying to engage primary care practices and shared decision making along with their patients. We’ve been working on this where we can refer patients, for example, to the MaineHealth Learning Resource Centers to view what are the decision aids about variety of conditions and then they come back to the next appointment and talk about it. That’s different than the way I described that we’re doing now, through the Maine Cancer Foundation Grant, where we’re mailing out materials.
We’re also doing a pilot in medical clinic at Maine Medical Center where we’re using an iPad and doing some point of care decision aids where physicians or a nurse practitioner during the office visit can say, hey would you like to look at a decision aid right now after your visit? We’re trying to make it accessible to patients in a lot of different ways. I’ve referred my patients to all three of those ways of trying to get the materials to patients when they need it and when they’re ready for it.
Lisa: You described this decision aids. So what would that look like to a patient?
Kathleen: Decisions can take a lot of different forms. They can be pencil and paper, they can be something that they read on the computer for example. The ones that we’re using are created by the Informed Medical Decisions Foundation in Boston. It’s a foundation I’ve been working with as a medical editor for many years. They are very high-quality decision aids. They are balanced. They have a lot of patient vignette. They have a lot of pictograms to show patients about risks, using images to help them better understand how what their benefits and risk are. They also have a booklet with them. Patients who have low literacy can actually watch the video instead of looking at a booklet, some patients prefer to read to get information and some would do both.
Lisa: Has literacy been a barrier that has been recognized?
Kathleen: Yes, great question. Literacy is a huge barrier. Health literacy in the United States is very low in general and is certainly low in Maine. Having materials that are at the right reading level such as about sixth grade is I think what the materials that we have. That’s important but also health literacy in general is low and I think there’s a lot of myths in general too out there and not everyone has access to high-quality health information. We think it’s completely important that it’s unbiased. It doesn’t feel like they’re being, the patients are being sold anything or that anybody has any financial benefit from using these tools really to get the patient to make the very vest decision for them.
Lisa: What is the response from physicians has been?
Kathleen: The physician response has been great including, again, we work in teams generally now. I think the teams have enjoyed the process of learning about shared decision making. We have especially found that our process of mailing the decision aids outside of the office visit has been well received by the teams because that way when the provider sits down with the patient next time, the patient has already seen the material and processed it and they can have a better discussion about the choices that the patient has at that time. It’s hard to find the right time to give the information to the patient ideally might be right before the office visit but as you can imagine, there are a lot of logistics that make that very hard to do.
Lisa: Does it enable patients to also spend more time researching a given topic before they go in with a visit with their doctor?
Kathleen: I think so. I think so. I think a lot of patients have been coming more informed with the materials they may be found on the internet about certain things they might want to try that they’re thinking about. This is a chance I think to help patients prepare particularly around things like screening that they might not have realized the physician was going to bring up during the visit or particularly in the case of colorectal cancer as we were saying, the screening test seems unacceptable to some patients. It gives them a chance to think more about what that might be like and then ask questions that are a little bit more targeted for their provider.
Lisa: The type of medicine that you’ve gone into where you’re doing clinical medicine or seeing patients and also research-based medicine and public health related. It isn’t the type of medicine that most little kids think about when they’re thinking, what do I want to be when I grow up. When you were younger did you have any sense that this might be the direction you’re going?
Kathleen: No. I didn’t. In fact, I wanted to be a veterinarian and I started thinking about medicine as a career. I think, I thought about primary care family medicine because I really want to be the regular physician that had a long-standing relationship with patients. I could get to know them and take care of them over time and have a trusting relationship. That has been great. As you know, face-to-face patient care is wonderful and very rewarding but sometimes you wish that you had better information for patients or that some of the barriers in getting care done would go away. That’s the wonderful thing about doing research too is that sometimes you feel like you can solve problems that come up in everyday patient care and maybe make things a little bit better.
Lisa: You can get a little bit of distance from some of the in-the-trenches work that you’re doing?
Kathleen: Yes. Yeah, it’s rewarding to do both. I knew the challenge in research always is feeling like it’s quite slow and sometimes translating findings into actual clinical practice takes much longer than anyone would ever think.
Lisa: Kathleen, you and I have been in medicine for roughly the same amount of time and we’ve seen a lot of changes. I think when I first came into medicine, there are a lot more independent physicians and a lot fewer that were employed by health care organizations. I think people are really seriously considering whether medicine is a good career path for them. What would you say to somebody who is thinking about going into medical school?
Kathleen: I think medicine is still a wonderful career path and that most people work hard in their jobs regardless of what they do. It’s nice to go home at the end of the day and think that you helped people even if you provided someone with some comfort and not necessarily a big cure which, as you know, doesn’t happen that often frequently in primary care. I think that a lot of the changes in medicine have to do with standardization which is a really good thing because we don’t want to be practicing the kind of medicine that feels too artful and too unique. I think it’s good and comforting for patients to get the same answer from one provider that they would get from the other provider.
I think that we’re doing also doing a better job with integration where all members of the care team are participating, communicating with each other not just primary care and specialist either but our nursing colleagues, and physical therapy, and mental health etc. I feel like we’re moving toward a more cohesive model that makes a lot of sense. I think somebody … I hope that patients perceive that as well.
Lisa: You have a daughter who’s the same age as my daughter, Sophie, 12. Would you suggest that she’d be a doctor if she wanted to?
Kathleen: It turns out she wants to be a veterinarian. I do think for women in medicine, it’s a really interesting question about the balance of that with work, and life, and caring for kids, or parents, or to participate in other things in the community. It’s a difficult career. As you know, it’s very time consuming. The field of medicine for women has been much more open in terms of specialties accepting women I think among their ranks. People beyond adjust job descriptions and tailor their profession to something they need at home as you know. However, I think it’s still hard.
I think there’s still a lot of bias there. For example, a year ago, I was actually on a show, the On Point show. It’s part of an NPR show about that woman anesthesiologist who try to have part-time careers in medicine for women and how she thought that that was very negative and that it was a waste of resources to train women and then allow them to go part time. It’s very controversial and made a huge splash. it was an up ed in The New York Times. It’s nice to have a chance to talk about that again. I think that women are at a great dimension in medicine, of warmth and understanding where patients are in their lives, in their journeys.
I think a lot of men do that as well. I think that it’s a time of growth in medicine for women. We’re still trying to find our way in some ways. I think the most important thing is supporting each other in all of the different options that people choose including part-time work or full-time work or shared practices, every other model that you can think of. That’s one of the most important things they’re thinking no woman succeeding in medicine as it being allowed to change their direction as they need to to care for their families.
Lisa: What challenges have you had in being a mother of two, a 12 year old and a 10 year old and also a doctor?
Kathleen: I think, you know it’s always deciding how long to stay at work and how much more you can get done for the day or what’s for next year or five years away. If I had worked harder, I could have published a lot more papers by now for example. I get that very big patient panel. There’s a lot more that you could always do. I think being able to feel comfortable with what you’re doing and not look back and say, I wish this or that. There will always be opportunities, I think, to work and do more professionally but when your kids are younger, it’s also really nice to be there and be able to participate in the things that they’re going through. Getting home at the end of the day is in a way … and feeling not completely overwhelmed by work is one of the most important pieces.
Lisa: Did you take into consideration the fact that you wanted to have children when you did this research track and when you got a doctor in public health?
Kathleen: No. I think my plans were all a little unclear then. I was thinking about my education and making sure that I took the time to finish all the education that I thought I needed at that time. I was fortunate that I could get that all done before I had kids. A lot of other people do it the other way really successfully where they start having kids in residency and find a way to make that balance work. I think that would have been harder for me because I’m not sure. It’s just the kind of person I am but everybody, I think, needs to take into account how much time they have for family planning and what they want to accomplish in their careers. Again, it’s not a race. There’s plenty of time and everyone have their own path I think.
Lisa: You have a medical degree and a doctorate in public health. Arguably, you could be employed anywhere at any of the big medical centers or training institutions in the country. Why choose Maine?
Kathleen: I grew up in Hallowell, Maine. It was coming home for me. About 10 years ago, my husband and I were both in Boston in medicine and decided that we wanted to raise our family here. The Maine health system has been fantastic for me to be able to practice and do research. Maine Medical Center and Maine Medical Center Research Institute has been very supportive of my research and has allowed me to do everything part time. Just take care of patients and do teaching and do research. That’s a wonderful thing. I think it might be harder at a major academic center where I think a lot of people are forced to pick their path and spend the majority of their time as a clinician or maybe in education or in research. It’s very hard to strike that balance, I think.
Lisa: Does your husband also feel as if, also being in the medical field, as if he’s being able to strike a balance?
Kathleen: I think so. Yeah. I think he works full time as an endocrinologist. He’s very busy but I think being in Maine allows us to be home at the end of the day with our families and feel like we’re accomplishing all our goals personally and professionally.
Lisa: How can people find out about the shared decision making program that you’re doing or the work that you’re doing with colorectal cancer specifically?
Kathleen: They can visit the MaineHealth website which has a lot of materials about the things that we’re doing with shared decision making and links to other places including some decision aids are available online. Also the Informed Medical Decisions Foundation which has funded some of the work at MaineHealth. It has an excellent web site and it’s Shared Decision Making Month, the month of March 2013. There are links to other materials there as well including some Podcasting.
Lisa: It’s also, I believe, Colorectal Cancer Awareness Month too.
Kathleen: Yeah.
Lisa: It’s appropriate for two you’re talking to us about that …
Kathleen: Good alignment. Yes, it’s Colorectal Cancer Awareness Month. It’s a great opportunity for people to think about their screening options whether they might want to be screened and to find out about the choices. The Maine CDC has a program for low-income patients to get screening which is wonderful. It used to be only breast and cervical cancer screening. Through a lot of workup by others, it was extended to include colorectal cancer screening. We’ve been fortunate in Maine to be able to have good access to a lot of colorectal cancer screening options.
Lisa: I’m very pleased that you took the time out of your busy schedule to sit in here and have this conversation with me today. I think it’s been a while since I’ve seen you. To know that you’ve gotten your doctorate in public health and you’re a successful medical doctor and Associate Chief of Medicine and Clinical Investigator at Maine Medical Center, it’s very gratifying to spend this time with you and thank you for joining us.
Kathleen: Thank you so much for having me, Lisa.