Written By: Dr. Peter Dahlberg

The way that doctors and nurses practice medicine is constantly changing. In the past, a General Practitioner would see patients with all sorts of ailments, and he or she was able to treat most of them even if it might involve taking out the appendix or fixing a fractured bone. As medical knowledge expanded and treatment of disease became more complicated (and successful), it became difficult for a single practitioner to keep current with the skills and the specialized knowledge required in a general practice. Medical subspecialists in lung, heart, or kidney problems became more common. Predictably, the cost of medical care became more expensive, and rural healthcare programs suffered because it is difficult and expensive to hire multiple providers/surgeons to treat each unique disease. Western Wisconsin Health (WWH) is redefining rural healthcare.

Fortunately, some of the assumptions that specialized and centralized care is better care are starting to be questioned. Being in the trenches – medical doctors treating challenging patients daily, or busy surgeons operating on a variety of conditions – both turn out to be good surrogates for quality outcomes. The successful small hospital administrators of the future realize that at least 90% of medical problems can be successfully managed at smaller facilities.

There are several innovative service lines that are emerging in local communities that leverage the expertise of both the smaller local facilities and the larger health systems. One example is the Breast Program recently launched as a collaboration between WWH and Health Partners. Programmatic breast care in the Midwest was pioneered at the Piper Breast Center by one of my former surgical partners, Dr. Margit Bretzke.

The concept was to bring together in one physical space, the diverse needs to meet the comprehensive services for patients in need of cancer care nurses, radiologists, pathologists, genetics experts, medical oncologists, plastic surgeons, and rehabilitation specialists who were interested and had expertise in the treatment of not only breast cancers but other benign problems of the breast such as infections, lactation related problems, and inflammatory conditions. These pathologists evolved the science of cancer margins and descriptive findings to an art form.

Radiologists and the evolving imaging techniques got much better at telling the surgeons what they needed to worry about and made invasive surgical biopsies a technique only described in outdated textbooks. The genetics experts explained to patients their individual risk in previously undefinable, but now explainable, and precise terms. The medical oncologists helped to define when minimal treatment of breast cancers was adequate and when chemotherapy would improve survival.  Overall, the sum of the individual expertise was vastly exceeded by the collaborative effort.

So, what does a rural health breast program look like in western Wisconsin? The goal is to make it simple for providers to refer patients with screening, benign, suspicious, or diagnosed cancer problems to the program with the assurance that they will be guided with up-to-date practice recommendations.

For example, a young mother experiencing lactation related infectious problems would speak with a lactation consultant who might recommend the patient talk to the surgeon about an abscess that the radiologist would drain a few times to avoid a surgical procedure. Or a 40-year-old woman having her first mammogram would speak with a nurse navigator about her breast cancer risk and whether high risk screening would be appropriate. A perimenopausal patient with a suspicious mammogram who ended up having a cancer diagnosis after a next day diagnostic mammogram would have a genetic test after talking to the surgeon about the plan of treatment for the tumor.

How exactly are these services going to come together from the patient’s perspective in western Wisconsin? Let’s use the example of a newly diagnosed breast cancer patient and the process they will experience with the new Breast Care Clinic at the WWH Cancer Center of Western Wisconsin.

• The patient has a mammogram and receives a “call back” from the radiology department for an abnormal finding.
• A diagnostic mammogram and an ultrasound are scheduled at the next convenient time for the patient. A biopsy is recommended and performed during that visit.
• The positive pathology result from the biopsy comes back to the breast care navigator (Registered Nurse that is the point person for the patient) in 1-2 days, who calls the patient with biopsy results and schedules an appointment to see the surgeon as soon as possible in the clinic.
• The surgeon reviews breast imaging, pathology results, reviews the family and reproductive history, and examines the patient. If there are risk factors such as a young age, strong family history, or unusual tumor markers on biopsy then blood for genetic testing is collected; results take 1-2 weeks to come back.
• A genetic counselor from Health Partners in New Richmond will see the patient as needed, either in person or virtual consultation to review the case and the relevant genetic implications and test results.
• A surgical plan for early-stage disease or additional imaging for more advanced disease is recommended.
• Consult with Dr. Hurley, an experienced oncologist with the Cancer Center of Western Wisconsin, in Baldwin, will occur prior to or after surgery depending on type of breast cancer diagnosis.
• If a mastectomy is considered, one of several Health Partners plastic surgeons would consult with the patient to discuss reconstructive options. Next, a surgical plan is finalized, and scheduled.

After several tests and consults, the last thing you want to do is wait! The goal is to move forward with treatment so that the patient can regain control of the situation. In the best-case scenario, the patient receives a call from the surgeon three days following surgery that the margins and the lymph nodes are negative. Care is turned over to the medical oncologist who recommends endocrine therapy and consults the radiation oncologist at the Cancer Center Western Wisconsin in New Richmond who discusses the pros and cons of radiation therapy. The patient continues to follow up in the clinic with Dr. Hurley and Dr. Findlay for Breast Cancer Survivorship and a year out has a normal screening mammogram.

For most people, one of the scariest moments in life is receiving a cancer diagnosis. The expert team at WWH is here to help patients navigate through this difficult stage of life. For more information, please call 715-684-1111.

Western Wisconsin Health, building a healthier tomorrow, together.