Transcripts of Interviews

Transcript of Prairie Public's Interview with Dr. Monica Mayer, New Town, ND

Dr. Monica Mayer left North Dakota in 1978. She lived and worked at a variety of places before returning to New Town in August, 1999. In an interview with Prairie Public's Matt Olien, Dr. Mayer relayed the history of her moves and her decision to return.

Dr. Monica Mayer
I left New Town in '78 on an athletic scholarship. And I really didn't know at that time whether or not I was going to go in medicine. It was a thought but not really any plan of action. I always felt like I would be a teacher. Basketball was my first love. Fortunately for me I got to play with the Tetons and Williston and got to do a lot of traveling and eventually ended up going to Arizona and getting my bachelor's down there and teaching high school.

My father passed away in 1985 from heart disease, and I came home and felt that it was time for me to be home after being gone for five, six years. I had a younger sister who wanted to be a nurse, and so we went to UND. I've always felt that health-care professionals and other professionals are born and raised. They're not recruited.

Our mother was very influential in our family. She was very education oriented and very service oriented and very insistent on getting an education and coming home and sharing your new skill. So my sister and I went to school, and when we finished, we came home. I'm the oldest of 3 girls, and so having finished medical school at UND, I came to Minot 'cause it was the closest to home. And I wanted to train in family medicine to be geographically closer to the patients that I figured I would be taking care of. My sister had already completed her nursing degree so she's the IHS's director of nursing in the field here, and another one is a master's leveled social worker who helps place foster children in homes. We're all home now, and we all have our education, and we're contributing to our community just as my mother had planned. So I think a lot of it has to do with your parental influence on how you go about your journey. A lot is dictated by your parents' influence. In a round about way, you know when you're young. When I left the community, I didn't think I'd come back. I mean I just really was "I'm gonna go off to the big, wide world and make something of myself. I'm never gonna come back to this tiny little town."

Factors besides my parents - my friends and neighbors, had an influence. Here in rural North Dakota there is a need for younger people to come back and pay service to the community, especially as our communities are declining, not only just population but in all areas. Which makes it really unique for me 'cause New Town is a very progressive community in western North Dakota. I think it's very, very unique especially in its demographics with the patient populations. We have the Mandan, Hidatsa, Arikara peoples as well as your Norwegian, German, and Scandinavian populations all mixed because it is an open reservation. And being a person of mixed-half-German, half Mandan, Hidatsa, Arikara, I feel really comfortable in this community as compared to maybe a metropolitan area. And so it's fun actually just to be a part of a community that is expanding and growing and to be a part of that progression. The patient population here has expanded tremendously not just from the non-Indian but the tribal peoples as well because of the economic influence from the tribal headquarters being in New Town. The federal government and state governments have already approved for the new construction of the Four Bears bridge which is going to be a very big economic influence for us here in terms of patient population but also I suppose economic and revenues that will come into the area, and of course the casino has influenced us tremendously. I believe they have roughly around 500 employees there at this time. And the construction of the Four Bears Bridge will also influence the construction of a new facility for the tribal peoples for their clinic services as well.

Another thing that's going to be really influential for us is the national interest in the discoveries of the Lewis and Clark Expedition which I've studied fairly intensely for the past 25 years. About five or six years ago I put together information from the Lewis and Clark journey that was particularly related to medicine. I also looked at the three affiliated tribes ways of practicing medicine back in 1800.It started out as a hobby but now it's become a bigger project than I ever dreamed it would be. Lewis and Clark arrived in this area and wintered with the Mandan, Hidatsa in October of 1804 till April of 1805. The national bicentennial committees estimating 30 million visitors along that trail and this reservation is the only one where there will be the native peoples. I expect we could get you have a third of the expected visitors here in North Dakota. And if that's true, over course of two or three years, the economic impact is going to be tremendous for not just our local area but the entire state of North Dakota. And we'll be here to take care of those who come through here who need medical help.

Prairie Public
Talk about your medical practice here in New Town

Dr. Monica Mayer
Well as a family practice physician having come home, initially it was a bit slow, but that didn't last very long. We have three clinics here in New Town. Presently we're trying to consolidate two of them. Between us, we can easily see 50 patients in a day with two physician-level providers. But family medicine sees such a wide variety. I think it's really essential for North Dakota to have the family practice physician on the frontline because we're able to fulfill all the patient's including pre-natal care, OB, on through. We do quite a bit of that pediatric population as well your geriatric population and any of your acute care situations. We just had a cardiac patient come in the other day, and so we had to run a code out of clinic.You just never know what to expect through your front doors because we don't have a hospital here. We're not hospital-based. We don't have an emergency room. We are it. We are not just the clinic, but the hospital and the emergency room. The variety of patients we see is very, very broad, You have to have the physician who can accommodate all those needs of the rural patients.

Quite often most of the patients out here have less accessibility. They have great distances to travel, and so they typically wait till the very last minute before they actually come in. It's reasonable to say that most of these patients are sicker when they do present, and so it's a real skill for one doctor to be able to cover and treat the large variety. And that's why I'm insistent on the family practice physician. There is a trend that is somewhat disconcerting, and hopefully North Dakota's legislators will take a look at that, but I would say a vast majority of our rural North Dakotans are being cared for by J1 Physicians. If the legislators are comfortable with that, that's fine. But if they're not, then I think that they need to take some action.

Prairie Public
Can you explain what a J1 Physician is?

Dr. Monica Mayer
To clarify, I do work with quite a few of the J1 physicians because that's what we have staffing our small town clinics. The J1 is typically a foreign-born physician, trained in a foreign country, who has come to the U.S. to complete their residency. In order to be allowed to remain in the US following the completion of their residency training the J1 doctors agree to practice for three years in an underserved area. North Dakota certainly is an underserved area. For instance in Montrail County, just in one very large northwest county, where I practice, I'm the only female family practice physician. Stanley has, did have two J1s, but now they're down to one. They're in the process of recruiting which is a very difficulty process for these small towns. Tioga has two. Watford City has one. I believe Crosby has one. Kenmare has one. Garrison has one.

Prairie Public
What makes J1 Physicians an issue?

Dr. Monica Mayer
Well the problem is what I call the J1 tornado. I really personally enjoy working with the J1s 'cause they are very fine, good, well-trained physicians. The problem with that for us is it is a Band-Aid for what we need out here. It's not a long-term solution. It's very short term 'cause many of them are here for their three years, and that's it. So, the issues are:

• J1's either move away to larger areas or on to specialized training. I don't want to use the word stepping stone, but this is the case scenario.
  
• Our Scandinavian patients out here, our Norwegian-German peoples, our native peoples have great difficulty in understanding the language. There can't be language barriers. Communication is vital for physicians to be able to accurately diagnose
  
• I think there is always going to be a cultural gap there. That's very hard to fill. So there are problems, and the rural patient first of all typically does not like to come in till the last minute, and if they are not comfortable with or understand their physician, they're just not going to come in. So it becomes an economic issue too in terms of the small clinics survival.

Prairie Public
So what is the answer?

Dr. Monica Mayer
I mentioned earlier, I think most of rural physicians are born and raised. You're not really recruited. I think this is where UND could become much stronger. I think they are attempting to do more because obviously I'm here. I'm a UND product. I was tremendously influenced by Dr. Milton Smith, the family practice director of UND's program in Minot. But most young doctors don't want to come out to the small rural area because we do 24/7. And 24/7 means you really work a lot of hours - hours that aren't just confined to your eight to five clinic. Typically we see patients starting at nine or ten in the morning, but you're not confined to that. You can go to the basketball game, and somebody has a sprained ankle. You can go to the grocery store, and somebody asks you about this. On a weekend when there's nothing open out here, somebody may have lacerated a finger, whatever. They come to your home or they'll call you at two in the morning to let you know "we got this" or "I'm in labor", that sort of thing. I don't think the young physician really wants to work like that. They want to have a life.

Prairie Public
Is 24/7 difficult for you sometimes?

Dr. Monica Mayer
Oh yeah. The burnout can be bad. You have to protect yourself from burnout. You could literally just work yourself right down to the ground. IMore help, that's the solution to burnout-splitting call. I do a call in Stanley which is 35 miles away. It's the nearest hospital-based place. You could say well you're not gonna do it, I'm not gonna do emergency room call, but then you're doing yourself personally a disservice because then you're not keeping up your skill level or hospital care level. For about a year and a half, another physician and I did every other night of call, and it was almost abusive, but you have to do it because there is nobody else to do it.

Looking at North Dakota, it seems that the trend is that there's going to be eight major regional sites eventually-Williston, Minot, Devil's Lake, Grand Forks across the top and then Dickinson, Bismarck, Jamestown, and Fargo across the bottom. And then all the smaller areas such as my particular area would be a satellite of one of those regional sites. And that's the trend that I see happening. I'm a Trinity physician. And Trinity has been kind enough to allow me to come out here. I think that's the trend we'll see in the future .

Prairie Public
Do you see a second physician coming to this clinic?

Dr. Monica Mayer
Yes. There were two separate hospital bases in Minot, and there was a merger that occurred earlier this spring. The former UniMed merged with Trinity to form Trinity/UniMed. For clinics here in town there's the Indian Health Service Clinic, UniMed, and Trinity. Now UniMed and Trinity Clinics will be merging and consolidating we'll have two physicians and one PA. And we're looking at bringing in another provider. We do have physical therapy out here in our clinic, and so we're looking at expanding on that too, which is a very unique situation particularly in western North Dakota. All other towns are declining in population, and the need for physician services is reduced whereas this particular community is expanding, growing at a very accelerated pace. In order for us to continue to accommodate those patients, we also need to grow along with them and that's where we're at right now in this community… which is different from others.

Prairie Public
You told us reimbursements are low. How so?

Dr. Monica Mayer
First of all it's hard to get the rural doctor out here. When physicians do come, they have longer hours. And the reimbursement level is a problem.

The pendulum swings back and forth. For awhile many small bed hospitals survived without much difficulty - Stanley, Watford City, Garrison - and we able to provide obstetrical services do deliveries, etc., which is vital to the survival of the small bed hospital of 25 or less beds. In the last decade, I would say all of the facilities in our local area have stopped doing OB obstetrical services, and no more babies are delivered at the small bed hospitals.

In New Town we deliver only in an emergency situation. The last one was just within the last six months, and that was just because the patient wasn't able to travel the hour and 15 minutes away and make it in time so.

But back to reimbursement issues - even things such as a simple pneumonia - a patient with the same diagnosis, same treatment, same services exact would be reimbursed at different rates. Using hypothetical numbers, in the Stanley small bed hospital, we'd get $2,000 for those services while in Fargo it would be $4,000 or $5000 for the very same treatment, same number of hours, etc. The reimbursement we're getting back from insurance companies, Medicaid, Medicare is less because supposedly, our costs are less. Again through the legislative process we have to make sure that physicians and clinics and hospitals in rural America are being reimbursed for their services equally with metropolitan facilities. And that's just one small part of the problem in rural North Dakota.

Prairie Public
Is it important for the Native people who come into this clinic and get served by a Native American physician?

Dr. Monica Mayer
I'd like to think it means a lot. The Indian Health Services (IHS) started in 1955, but didn't get to this area till around 1958-60. The New Town Minato Health Clinic was constructed and opened in 1972. I was just a young girl at the time. If you were a Native person, you went to this clinic. If you were a non-Indian patient, you went to the non-Indian clinic. I didn't like that. I would rather have gone to the non-Indian clinic. A vast majority of our patients on the reservation don't have a lot of faith in the ability of the IHS to meet our health care needs.

Now, it seems that the individual tribes are trying to become more responsible for their tribal peoples health care. The Three Affiliated Tribes have the potential to be successful because of the gross revenues that come into this particular community. I do some emergency room call up in Belcourt periodically one weekend every other month. There are five physicians up there that I went to school with at UND, and so you know they're now chief medical officers. I had mentioned to the chief medical officer in Belcourt that I felt very strongly that soon even the reservations will have to link. They are North Dakotans. They are North Dakota citizens, Native North Dakotans, and they must be involved in the solutions for rural North Dakota health care issues because we are part of that. I think the reservations need to be linked up regionally just as all these small towns are being linked up. I had told her that one of the things that I pride myself in is that my clinic serves all people regardless of color. And as a child growing up, I promised myself that that would be an issue that I would go after

Prairie Public
What happens with referrals?

Dr. Monica Mayer
We don't have surgeons. We don't have orthopedics. We provide your basic care. When a patient gets referred to Bismarck, they sit in the same waiting room as everybody else. Here in our hometown, they now sit in the same waiting room as everybody else. The medicine we're practicing here is not prejudicial medicine. The separation was like the South in the 1960's where if you were black you drank out of this fountain. If you were white, you drank out of that fountain. It just promotes segregation. It promotes prejudice. It promotes discrimination. Our clinic really prides itself in the fact that we serve all peoples. There'll be many people coming to our community because of tourism and the bridge construction, and I'm really proud that we do meet everyone's needs. I think the Native American patient coming to this clinic knows that they're going to be well taken care of and that we will do just as well as we would do with anybody else. And so I think that gives them more confidence, more trust. We can build our rapport with them. And, it's to my advantage that I'm half German and half American Indian. It's a unique situation for me that I can capitalize on that to establish rapport with all patients.

I'm very satisfied with my employer. Trinity's been very supportive to me to do what I need to do out here. And my basic mission is to improve the quality of care and services to all people that come to our clinic, and I believe we're doing that. And we're growing and expanding along with our community. As we grow, maintaining the quality of care and level of services that we're able to provide is our goal.

Prairie Public
Do you see yourself staying here?

Dr. Monica Mayer
I was talking to a couple friends of mine. Some didn't think I was making such a wise decision when I decided I was going to come to New Town, North Dakota. Most of my classmates went to the metropolitan areas with better salaries, better hours, and more things for their spouses to do in terms of theater and recreation, having a life so to speak. Coming home for me was going to mean more hours, probably lesser pay. But I was insistent that coming home would give me a unique opportunity-I don't believe there's a better opportunity than the chance to take care of your own family, your friends, your relatives, your neighbors, and people that you've grown up with. You already know most of their past history. It's very advantageous for us. And having family and friends is very important to most of our family practice physicians. It's an integral part of our medicine, our lives. You can get that here in rural North Dakota. It's worked out pretty well for me. And if you want fame, you can get it out here.

Matt Olien
Tell me about finding fame as a doctor rural North Dakota.

Dr. Monica Mayer
I was on call in August of 2000, and a five-year-old female child with Down's syndrome came to the emergency room with her father. She lived down by Mandaree on the West Side of the Missouri River. Her father had seen her playing by the bales of hay and thought that she had fallen and broken her hand 'cause it was swollen. He put her in the pickup and drove 20 miles from his farm to New Town. But there's no after-hour care, so he drove another 35 miles to the nearest facility in Stanley where I was a physician on call with one nurse and one LPN. So he brings her in at roughly 9 p.m., and we take an x-ray and don't find any broken bones, and I started thinking, "Gee this does not look like it's broken 'cause it's pretty swollen." Some of the tissue started to look a little necrotic so we examined her more closely. Lo and behold we found two little fang marks right between the fifth and the fourth digit, and my first thought was she got bit by a rattlesnake. So I asked the Dad, "Have you seen any rattlesnakes around in the yard," and he said, "No, we haven't yet, but everybody else is reporting sightings." And he told me that she was playing in the bales of hay. Well, having grown up here I knew August is the time that the rattlesnake sheds its skin. They like to hide in cool areas like the hay, and when they're shedding their skin, they can't see, and they strike blindly at just any kind of motion. And so I strongly suspected that this is what had happened. We transferred the girl to Minot with a preliminary diagnosis of a rattlesnake bite. She received five vials of antivenom. It was a very, very critical situation for this child. She was then taken by jet to Denver Children's Hospital. When she arrived there, she was given more vials of the antivenom that we did not have available to us at the time here in North Dakota. And she did survive, and she's doing well a year later now, and what started out to be a very, very critical situation ended up with a happy ending for us. But several of the physicians down in Denver had called and wanted to know how I came to my diagnosis, and I think a lot of it has to do with just having been born and raised in this area knowing you know-one of them thought it was a scorpion. I said well that could be except that we don't have scorpions out here in rural North Dakota. We have rattlesnakes though. So just knowing your area, your demographics, you geography, the people, the family, your family, your neighbors really helps provide for good medicine. And that case went all over the United States, and I do believe it will be written up in the journals here. It usually takes a couple of years before they actually get all the information together to get published. Many of the head departments, pediatric head departments in Children's Denver-they wanted to know more demographics as they were going to write up the article. One of the comments one of the metropolitan physicians made to me was you sure are brave to be way out there in the middle of nowhere with very little to work with. And my first response was, "Gee they must really think we're hillbillies out here in rural North Dakota." But actually I felt that isn't it nice that the good Lord has a place for all of us to be. We can-people like me who are North Dakota born and raised, trained and educated, are out on North Dakota's frontlines providing care, and that's where I'm most comfortable. I would not be comfortable in a big city with lots and lots of machines, and how nice that it is that everybody has a place that they can fit into. And so I think that's a good testament to show that UND School of Medicine does produce good, solid family physicians. Now we need to retain them for their services out in the frontlines in rural North Dakota. I feel really fortunate that I was trained not only at UND, but I was trained under Dr. Milton Smith who was very, very influential in my decision to become the rural doctor that I am today. He really was such a good mentor for me and still is. I still call him, maybe once every two months to let him know what's going on. He still guides me and mentors me, and hopefully some day I might even get him to come out here once in awhile to bring residents to train with us out here on the frontlines.

The North Dakota legislators could look at other incentives for rural communities to assist them with recruitment-loan payment and forgiveness. There could be so many other incentives and ways for us to get our UND graduates out here to the rural areas and provide them with a good experience. They say that the best way to do that, and Washington's University is doing it - is to place their medical students in a clerkship out in a rural area which is less than 5000 people, and they have to stay there for six weeks. And they get just the taste of the experience of being a rural doctor, and they like it, and that can be the deciding factor for them. So I do know North Dakota does do that at some of the sites, but I think it would be nice to bring them to very remote areas like here and underserved areas. Not that I'm trying to squeeze out the J1 physicians because I think they are providing what we need right now. But I do believe North Dakota citizens would really like to have their own out in the prairie caring for their needs.

Funding for Life Support is provided by a grant from USDA Rural Development