 Lakeland Currents, your public affairs program for North Central Minnesota, produced by Lakeland PBS with host Ray Gildow. Production funding for Lakeland Currents is made possible by Bemidji Regional Airport, serving the region with daily flights to Minneapolis-Saint Paul International Airport for information available at BemidjiAirport.org. Closed captioning for Lakeland Currents is sponsored by Niswa Tax Service, tax preparation for businesses and individuals, online at niswatex.com. Hello again everyone and welcome this evening to Lakeland Currents. We're going to talk today about a new concept that's being developed in one of our regional hospitals and I think we're very fortunate in central Minnesota to have a number of hospitals that are really excellent and we have talked about that over the past 12 years. Tonight the concept is, I guess we're kicking it off because it isn't technically open, although it probably will be by the time there's errors in 2019. It's about the Cayuna Range Medical Center's new menopause, what are we going to call it? A menopause center. And my guest this evening to my immediate right is Dr. Christina Kramer, who is a gynecologist, an obstetrician and to her right is Melissa Goble and you are a registered nurse. A women's health nurse practitioner. And what's the difference between that and a registered nurse? With that one you go and and get your master's degree and doctorate degree you can and you're specialized. My specialty is women's health. Okay well welcome to the show it's nice to have you here but before we get into what you're developing let's just talk a little bit about who you are and where you're from. Christina maybe we could start with you. Sure so I'm a native Minnesota and I grew up in Maple Plain Minnesota which is about half an hour west of the cities. I went to medical school at the University of Minnesota and then went out to Buffalo New York for my residency and then moved back home to start working and practicing at Cayuna Range Medical Center. I started in 2014 and so I've been there about four and a half years. I'm one of three obstetrician and gynecologist and we work with two women's health nurse practitioners one of which is Melissa. And Melissa what's your background? I am a native from Brainerd I grew up and raised here I went to get my RN degree and then I worked as a labor and delivery nurse at CRMC for 12 years and just transitioned to a women's health nurse practitioner this spring. You know this whole medical field is just dramatically changing isn't it? I mean even since you started the requirements that you have in reporting I know a lot of doctors and a lot of them talk about how it's becoming so burdensome to have to spend so much of your time doing the reporting for the new Medicare rules and whatever so you've seen a lot of changes but a lot of them are to the good. I'm sure that you're seeing things positive happening to that. Tell us a little bit about how the concept developed of having a menopause center because that's unique. I'm not familiar with that being anywhere else. So especially with the demographics in our area there's a lot of baby boomers women who are kind of in the perimenopausal and soon to be menopausal age group and so really our goal and our design is to kind of have a coordinated set of services with under one roof. So basically we're not reinventing the wheel or reinventing medicine per se but just making a better experience for the patient making it more efficient so being able to coordinate services and radiology labs seeing the provider and doing a little bit of work ahead of the visit in order to make the best experience for the patient and so what we're looking at doing is really kind of trying to make it a one-stop shop and providing the most services that we can for the patient at the time that they come for the visit because we realize we have a lot of individuals that are maybe traveling from a little bit away so we'd like to get them their mammogram their bone scan their labs and their their visit done all at the same time. So not everyone goes through menopause equally do they I mean there are lots of variations to what happens. Could you talk a little bit about what are some of the things you see with patients I mean what are some of the ranges that you see and why do some of them have so many more challenges than others? I think a lot of it goes back to just genetics and perhaps family history. I think one of the strengths of our department and our practitioners is really doing a good piece with the education and counseling and letting women know that I think a lot of patients have a misconception that it's going to be kind of a very tightly time-framed process and hot flashes and other uncomfortable symptoms can start years even a decade before the actual menopause which medically defined as the last menstrual period for more than 12 months and so I think just providing that education and allowing women to know what to expect and perhaps give them some conservative measures they can do at home with exercise dietary adjustments and just that counseling and education piece in order to have a full knowledge going into the process. I think fear of the unknown is probably the biggest thing and if we can empower women with knowledge that makes the process go a lot smoother. So are you going to have an actual center a physical center or is this something that's occurring inside of your existing facilities? More the latter and I'll let Melissa speak to that a little bit. Yeah so it is still going to be within our department inside CRMC in the specialty clinic there and basically we are going to hopefully transition women and to make it more of a comfortable setting for them you know with some booties or lab robes and stuff like that and make it just it's going to be within our center there and we will provide the care there for the women and then have them transition to other areas like lab if they need to mammograms. So what will the ages be of the of the women that you're going to see in your facility? Yep so the menopause center will be for 40 and older for women who are experiencing menopausal symptoms 40 and above menopause the average age of menopause is 51 but like Dr. Cramer said it can transition women a decade before they can start to have symptoms. One of the speaking points I got here from Peggy is this is an opportunity to get women back into the health care system what does that mean aren't they mostly in it already? Yes and no as a whole women are better at seeking medical care and doing preventative services as compared to their male counterparts but a lot of patients if they're feeling well after they stop having babies kind of stop going to see a provider because they're not having any issues and so why go and I think that's another strength and what we're really passionate about at CRMC is providing that education piece and preventative medicine and that's what a lot of patients ask me well why do I have to come in and see someone I'm feeling well I don't have any symptoms I'm up to date on my pap smear and for us it's a lot more than that and there's some different conditions that start to kind of manifest in the menopausal age group and so hopefully either educating patients on what to look for or helping treat conditions that a lot of patients associate it with just a normal part of aging and there are things that are uncomfortable to talk about for example incontinence, pelvic organ prolapse, difficulty sleeping, pain with intercourse, libido issues, things that they may not necessarily bring up unless we ask them directly and that's a really important part of menopausal medicine is not just hey I do having high blood pressure do you have diabetes yes or no but those other things that perhaps we're the only provider that a patient might feel comfortable discussing this with or maybe the only provider that actually asked the patient if they're suffering any of those symptoms. So when a patient comes in to see you you're going to have a it sounds like a fair amount of time spent on educating the person so what will is that going to be like classes or just one-on-one conversations or how do you how do you plan to start doing that educational piece. Sure so as we're rolling this out we're going to have community seminars just kind of as an intro what sort of conditions are we talking about just kind of getting that conversation going with patients or women out in the public actually with our patients in the center we would be looking at we have written materials audiovisual materials videos probably kind of a set rolling video what the patients are going to see and watch just to kind of get that conversation going reaching out to the patients ahead of time to see if there's any main questions or concerns that they want to address so that we can kind of tailor the visit sort of have a custom-made physical for that patient while being around the questions and concerns they have and then a lot of one-on-one time with the provider and discussing you know treatment options things that are out there things that the patient can do on her own at home to help treat some of these conditions. Now obviously most hospitals have components of this but it sounds like your approach is unique in having a center just focused on this do you know of any others in the area in the region that are doing something like this or are you unique to the to the concept that you know of. With the NAMS providers there is a regional need for that there is only three about three northern NAMS providers. So NAMS is the North American Metaposal Society so you go and you get information and then you can test and become what's called the NAMS provider and there's only three north of the cities as far as like the closest probably metaposal center it's going to be about the cities so there is a regional need in this area for that and for the providers as far as like the education that the docs get even in their residency and stuff that's very minimal and so it's kind of advancing that education and gaining education for everybody involved as well. So how many on staff will you have involved in this concept when you really get off and running? Currently right now we have the three OBGYN doctors, two nurse practitioners and then we have three full-time nurses that are staffed with us currently. So a lot of times these metaposal issues create a lot of psychological issues don't they so you have someone on your staff that will be dealing with that specialty or is that something you kind of deal with as a group? So that's kind of the idea with having a center with the idea of the center not being a physical building per se but more the idea and coordination of services and really the idea behind it and we're not completely reinventing the wheel but it's really without the legwork to kind of bring all the different specialties and departments together I think that's the major strength with the service line that we're rolling out but to directly answer your question we'll be working directly with other allied health providers so psychologists, counselors, sex therapists, nutritionists, some of the psychology will be focused on sleep, behavioral health issues, physical therapists as well as the providers, did I miss anyone? Cardiology and our family physicians as well so really kind of trying to unite everyone for the care of these women who I would say and to echo what Melissa said kind of are sort of maybe lost in between their childbearing years and kind of the health conditions of some of the older elderly women they're kind of in this gray zone in between and sort of don't really know that some of the conditions they may be suffering with aren't just kind of a normal part of aging and that there's providers out there that want to help them. So most of this would be covered by health insurance or by Medicare most of what you're doing is not outside of the norm for health I mean for health care is it? Correct. And what is the time that you think this will be up and running? What's the time period you're looking at? You said 2019 but do you have a a month in mind where this will be kind of an official opening? Our official opening is going to be January of 2019 so we're rolling it out okay but that doesn't mean people can't come to you now correct correct so if they want to come to you with these kind of information out of they still have to go through a regular doctor no no they can just call you don't need a referral to see anyone in our department and that's kind of the nice thing about the OBGYN specialty is we kind of walk the line between surgical specialists but also a fair amount of primary care so we kind of yeah basically walk the line and patients don't need a referral from their primary care provider if they're having issues with some of those conditions I mentioned hot flashes menses they're becoming irregular heavy bleeding abnormal bleeding pelvic pain pain with intercourse incontinence and that's just to name a few we'd be happy to see those patients and those are patients we're already currently seen right now the idea with the menopause center is again just to kind of provide a more of a one-stop shop at that same visit so now when women have these kinds of issues they just would go to their practitioner I would guess who may or may not be an expert in this some of them are going through their regular primary care provider some patients are already seen we're seeing those patients already I think the main thing and this is something I share with my patients on a daily basis is a lot of patients with more personal conditions for example urinary or fecal incontinence they've done studies that show it takes women an average of seven years to bring that concern up to a provider really and so unless we directly ask a lot of people aren't willing to talk about it right away just because it is such a personal and embarrassing condition really that's that's interesting yeah um technologies affecting our health care drastically are you going to be looking at new innovations in technology at all I know just to give an example I know there's a lot of movements towards getting wired at home you know in one form or another are you looking at anything in that area I think yet or is that maybe beyond what you're doing right now I would say it's kind of um something we're probably already doing with being cutting edge with advances in medical technology um you know we're under the umbrella of the memis institute at our facility or the minnesota institute for minimally invasive surgery so the gynecology surgery that we do embodies that principle as well um my partners do a procedure called inner stim which is um kind of the gold standard for refractory urinary urging continence that hasn't responded to medical therapy and dr michael katie is in the top tier of the number of providers in the country with um his experience with that procedure so I would say that's something that isn't commonly done by gynecologists and to have someone locally that does it is pretty impressive so it's a real team approach isn't it which is making it unique and I know a lot of hospitals are moving towards team approaches even just with your primary primary provider sometimes you can't even talk to that person you have to work through a member of the team and at least in the hospital and I go to now um so this team approach is going to focus more heavily on each other than probably historically I mean would historically you would come to your doctor and if you were a woman sometimes your doctor was a man and maybe you didn't feel comfortable talking about all the things that could be happening whereas this will give them opportunities to talk to other people it's the it's the silver uh tsunami is what a lot of people have called it and I'm part of that silver but the thing that's interesting to me is how much dementia and Alzheimer's we're seeing I see that's one of the topics that you've got down here what's happening in that area and I know you're not here as experts on Alzheimer's or dementia but but what are you seeing are you seeing any changes coming are you seeing medications that are helping at all or are you looking at other ways to deal with it I mean like exercise and the health the diets and that sort of thing how are you approaching an issue like that I think in medicine in general we're all becoming more aware of the impact on diet and behavioral things have on our health in general I think particularly in our specialty you know the neurology or neurobiologists would really be the the providers prescribing medication or treatments for those dementia Alzheimer's patients but what I've noticed is either these patients themselves or their family members their daughters their sisters are patients and sometimes we have more of a long-standing relationship with these individuals who maybe aren't aware or kind of fighting that diagnosis and I think that that's probably one of the harder things for the family is just the stigma attached to that and so having a provider that they're maybe comfortable with kind of gently broaching that subject is really one of the main roles that I see within our specialty and then also working with these patients who still have some of the other medical issues that any other menopausal woman would have as far as the pelvic pain or incontinence and being sensitive to that that we choose treatments that won't either interact with or diminish the efficacy of those medications they may be on for their Alzheimer's so Melissa you're a nurse practitioner so how do how do you work with the team what is your primary responsibility in that field so with the new menopause center coming up I will be calling the patients kind of questioning them getting an intake and so that I can direct their care and do the team approach with that and you know if it means ordering an ultrasound before because they're having post-menopausal bleeding or if it means getting their lab work done so that we can assess it and go to approach that way if they have high cholesterol or if they have a history of cardiac disease and getting that set up at the same day so cardiology can see them and kind of approaching it so that it can be a one-stop shop for these patients currently right now I help them assist them in the clinic also see patients on your own and kind of do rounding and stuff for them to make their lives a little bit easier hopefully and that trend in the medical field is expanding a little bit even into the dental field now but nurse practitioners the physician's assistants are getting a more and more responsibility for doing that thing I know the dentist that I go to in Staples has an assistant now who's like a dental or is I forgot the dental therapist I think is what the title is which is doing that kind of a team approach and he can do some fillings and some of the more minor things so right and we're I think we're so fortunate here in Crosby Brainard Staples and even in Wadena in that we have really pretty good health care systems for a rural area and it's just amazing to me how many skilled people there are in the hospitals here I know in Staples we have about 200 specialists that come through that facility in a given year and I know you have this similar thing you have that minimum evasive surgery center in Crosby and you're all doing unique things where is this leadership coming from when you're doing these kinds of things I think the benefit of rural health care and smaller facilities is that the providers and the practitioners have a lot more not just autonomy but a really good working relationship with the administration and the people in the hospital to basically enact change and so I think that that's something that we're very proud of at Coyne Regional Medical Center is that good working relationship between the medical staff and the administration and I would assume that that's probably the case for other local facilities as well how what's one of the the what are some of the real obstacles you see to having women come to you is it because they're just ashamed to talk about some of these issues what do you what do you see I mean I suppose that someone's out there and they don't want to talk to you don't even know they exist anyway but how do you sort of break that barrier to get them to come to you I think that that's kind of a loaded question in a sense that there's no one answer I think part of it is the conditions we deal with and the specialty we're in is more maybe of a personal or kind of private nature I think that as a whole women tend to be the caretakers and make sure that their children spouse significant others extended family are seeking the medical care getting the medical care they deserve and a lot of patients will tell me that you know it's taken me years to come in here because I'm finally getting around to taking care of me and so hopefully you know those are the patients we really want to try to make it an easier process for them because they don't have time to be coming you know every couple months for six to twelve months we want to try to make those services as coordinated and as efficient as possible I would say another thing is maybe just the patients again being caught in between they're done with childbearing they don't feel that they have all the medical issues of someone who's a little bit older and so what's the point I feel fine why do I have to see a provider and that's kind of a passion of mine is really keeping people who are healthy healthy and out of the doctor's office and so doing more on preventative care what are lifestyle things that they can do to take care of themselves providing that counseling or education piece for what might be normal symptoms or these are things I would need to see you back for how about the men how do they fit into this good question so obviously for some of the issues that we're dealing with you know pelvic pain painful intercourse there's more than just the patient at stake and so I try to talk to my patients you know I think this is the message you should communicate to your partner once in a while actually have that partner in the office and so it's helpful for them to bring their concerns or perspectives or these are my concerns I see for her unfortunately in our specialty I can't I don't take care of men so I can't prescribe medications or do things like that but I can kind of gently nudge hey well why don't you talk to your doctor about x y or z so it's not that men aren't welcome it's just a different paradigm in our specialty clinic you've mentioned pelvic pain a number of times what are some of the symptoms that cause this for women it kind of depends on the age group so and that's where when I start thinking about someone who I see on my schedule pelvic pain the first thing I look at is the age and that kind of helps steer me into what might be going on so how I think about it or compartmentalize it is most of the time of people are saying it's in this area immediately people think it must be a gynecologic origin which isn't always the case what I tell my patients is there are a lot of things that have to share a very limited amount of real estate there so it could be the gy n things the uterus the ovaries you could have a cyst you could have a polyp you could have a tumor which doesn't mean cancer it could be benign as well you have the bladder and the urinary system there you have the gastrointestinal system so there's things inflammatory bowel disease irritable bowel syndrome chronic constipation chronic appendicitis gallbladder issues kidney stones kidney infections bladder infections those can all contribute musculoskeletal issues so if someone's had a history of surgery or perhaps trauma things like that I'm thinking about that as well and then there are certain conditions that can kind of exacerbate any of the other things I've mentioned certain psychological disorders chronic pain syndromes fibromyalgia things like that can come into play as well the reason I ask it just seems like we're seeing so many hip surgeries hip replacements knee replacements and I think there's a lot of reasons for that obviously but obesity is certainly one of the challenges we have and you've got obesity is one of your talking points to hear how do you dress obesity with women when they come in and they are obese I think a lot of it depends on their lifestyle you know as postmenopausal women actually one of the things that happens is you end up gaining weight because your estrogen levels decrease and so therefore you have a decrease a lot of times a decreased appetite but your muscle mass also decreases which is a big energy burner and it turns into your subcutaneous fat so therefore you have these obese women and I think we need to approach their lifestyle what are they eating you know what's their diet like are they eating a lot of unhealthy carbs are they eating not very many fruits or vegetables because those are our primary things that we need to transition and eat with healthy carbs fruits vegetables and the other thing is exercise as we become older and transition through metapause our lifestyles changes you know we're not chasing children around anymore we're probably not getting outside as much as well and so we become more sedentary so it's working with those but maybe transitioning to not necessarily maybe going out for a run but using a more of like the weight bands and doing a lot of weight lifting to help increase that muscle mass and decrease the loss of it which is going to burn more energy and burn more calories then you both have specialties in this concept what's the one thing you want a woman to know that's watching the show tonight if you could say one thing tonight that's really important what would it be from both of your specialty areas I would say mine is just the importance of preventative care and not just assuming that conditions or symptoms a patient is having are so called normal that there are things to help especially with incontinence I think that's one that women who have had babies before just assume that's a normal part of being a woman and aging and that's not necessarily the case and so even though it may be a difficult thing to talk about we're certainly sensitive to the fact that it's not an easy thing to talk about with a relative stranger but there are options out there to help you feel better and so we'd like to see you if you're willing to come in that's a good answer how about you Melissa I think you would have to echo on that is bringing these women back the silver tidal way back into the healthcare system and we hear it all the time women have been suffering for you know 10 plus years with their issues because they think that it's quote unquote normal when it's not in a sense and so it's bringing them back seeking their care earlier preventative health is going to be huge in this essence and even with their care you know can we prevent them going from going into cardiac arrest or heart disease by educating them prior to heart disease is the number one killer of women so it's just educating them and educating the population and bringing them back in you know we hear that and I know it's on the news a lot but it seems like most people still won't buy into that right they think it's a problem for men but not for women yep and their their symptoms are different when they're having a heart attack aren't they what would a woman be expecting if she's having a heart attack could you give us a quick rundown of what the symptoms could be yeah most of the time women are going to have more of like the jaw pain and kind of neck pain and not a lot of like chest or down the arm pain they're going to have kind of the vaguer symptoms it could be fatigue shortness of breath feeling tired just not feeling like themselves and it could be of any age just like men right correct you do tend to see a spike in cardiovascular disease after menopause again because of some of the hormonal fluctuations so menopausal status would be something to consider as well as a patient's family history and for most women or for the averages when does menopause hit them so for an average woman but you know non-smoker average age of menopause in the united states is about 51 so late 40s early 50s is kind of that age group when we're thinking menopausal perimenopausal we're out of time and thank you for jumping on with us it's a very interesting concept and we'll have to follow you and see how it goes looking for the opening of your center in probably january of 2019 correct thanks for jumping on appreciate it great job thank you thank you you've been watching lakeland currents where we're talking about what you're talking about i'm rick gildow so long until next time