Expert Insights from Program Leaders
March 27, 2022
Season 2: Episode 33 - PAs in Indian Health Services

We speak with Stephen Neal, MPAP, PA-C who serves as the Chief of Staff for the Chinle Comprehensive Health Facility, an IHS facility in northern Arizona. He has worked here since 2016 as a PA in Family Practice and clinical informatics.  We speak about ...

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We speak with Stephen Neal, MPAP, PA-C who serves as the Chief of Staff for the Chinle Comprehensive Health Facility, an IHS facility in northern Arizona. He has worked here since 2016 as a PA in Family Practice and clinical informatics.  We speak about COVID-19 and the impact on the Navajo Nation, the National Health Service Corps, and financial literacy for PAs.

The purpose of this podcast is to provide news and information on the PA profession and is for informational purposes only. The views and opinions expressed in this podcast are those of the speakers and guests and do not necessarily reflect the official position or policy of the University of Arizona.


Season 2: Episode: 33 - PAs in Indian Health Services


patients, ihs, people, pa, underserved, usc, talk, navajo, clinic, indian health services, navajo nation, life, work, arizona, day, vaccine, serving, steve, great, pay



We respectfully acknowledged the University of Arizona is on the land and territories of indigenous peoples. Today, Arizona is home to 22 federally recognized tribes. With Tucson being home to the Ogden and yaki. committed to diversity and inclusion the university strives to build sustainable relationships with sovereign Native nations and indigenous communities through education offerings, partnerships and community service.



Welcome to this episode of the PA path podcast, I'm your host, Kevin Lohenry. We are glad you could join us as we seek to better understand the PA profession.



The way we describe it now to other applicants is Indian Health Services like global health piece for health only you have equipment, labs, and support.



Well, hello, and thank you for joining us today. We're pivoting just a little bit from our international discussion to talk about the Navajo people. And we are going to be speaking with Steve Neil, who is a PA in Indian Health Services in chinley, Arizona. Steve is the Chief of Staff for the chinley comprehensive regional facility. He is also a really great human being who has served as a National Health Service Corps scholar in South Los Angeles and then after completing his scholarship requirements, he chose to continue serving the underserved by moving to the reservation. Steve and I talked about the impact of COVID on the Navajo Nation. We talked about his role in informatics. We talked about financial literacy for PDAs. And we talk about the benefits of working for Indian Health Services. As always, you can learn more about our guests at our website pa path We hope you enjoy the show Good morning, welcome. It's good to see



you. Good morning. Yep, say the net the trees. Good morning. And now though. Say that one more time. Yeah, tick Banette.



Gonna tape with me. That's awesome. That is awesome. Welcome. Welcome. Steve, thanks so much for joining us today. We are so excited to hear about your story, the incredible work that you're doing up in Chinle, Arizona, all the things that you've explored in your career, which is really interesting, particularly given that you have committed to serve underserved populations your entire career, and I just have such tremendous respect for you. From the moment I met you in PA school to falling through your career from afar. I'm what let's start with kind of your story about becoming a PA Why did you become a PA and kind of what's been your path to going down the route of serving the underserved?



Well, thank you so much for that. I appreciate the opportunity. And this is some kind words. So thank you for that. I started my PA career i i took off some time after college and I was a guide and India and Thailand and kind of just wandered around the world for a couple years. And I came back and I got a job as a microbiology, microbiology tech, phlebotomist at a hospital and sort of decided what do I want to do with my life at that point, and my parents were nurses, my dad was actually a nurse practitioner, one of the first, you know, back in like the 70s. Wow. He actually late 60s, he worked at a jail. And so he at a county jail in San Diego. And he, he always had a drive to help serve the underserved. And I didn't realize this he actually passed away in September. And so when we were kind of sternal, we were sort of we were talking about him. And it dawned on me that my dad had a passion for underserved and I think I got that from him. I really do because it's just he always worked at jails or in marginalized, underserved populations. And I found myself you know, I was working at a hospital and kind of figuring out what I want to do with my life. And I saw a PA there, his name Sprague, and I can't remember his last name. And he actually went to USC. And I started talking to him and he just seemed really happy with what he was doing. And I was working with residents and physicians, etc. And he was the happiest guy, you know, of the people that I met. And I don't think he was just inherently a happy guy. I think he enjoyed what he did. And he was like, command in his profession in his field and was in charge and was just doing well excelling his path forward. And I was like, wow, it's kind of interesting. did some research and some homework and stuff. decided I want to do PA school. And for me, I always, I used to work at I used to manage a syringe exchange. So I used to work with intravenous drug users, it was actually at an LGBT institution, which was a really, it was a great job. And so I would do all those jobs kind of at the same time. And I just really fell in love with a population of people that are kind of down and out. I mean, people that for whatever reason, they are, where they are, or they could benefit from, you know, assistance, health service, all those things, whatever you want to call it. So for me, it was sort of a calling. And I think that's what brought me to USC, the most I graduated in 2012. And I can remember when we had our interview, people were like, Well, why do you want to be USC, and a couple people said, Oh, the name and now working blah, blah, like I really don't care about the personally, you know, for me, it was very much the mission. And I think that actually played out well in my rotations and experience that I had. They were an underserved community clinics. So to answer your question, How did I get to being a PA, I saw some pa that were doing a great job. And they were happy and content and had great career progress and potential. And so decided to do that. And I knew that I wanted to work with underserved and USC happened to fit that bill well, and so I applied and got it.



And it's, it's interesting, because I seem to recall, it was October 5 2010, I was interviewing for the job as a director, I ran a Trojan, Trojan all three, which you guys had just moved there, I think that August, and and all sudden, like a bunch of you started looking at your phones, because you just been received a notification from the National Health Service Corps, that you receive the full scholarship. So you want to talk a little bit about your your kind of alignment with the NHSC and why you went that route, and maybe share a little bit about what that meant for you going to a school like USC to be able to have that be a free ride.



Yeah, um, oh, man, that was a great day. I remember I was in your interview, you were interviewing for the job as director of VA program. And, and I went like, you know what, I raised my hands in the air. And I'm like, I gotta go call my mom.



So that was an awesome, awesome moment.



And so for me, I, you know, I've loved working with the underserved, but I've also had sort of like a good fiscal understanding of life. And so I, I've sort of, I don't think that you have to choose a path of working with underserved and also choose like, poor pay, lack of financial self stability and financial independence, like there are ways to mitigate and address primary care generally doesn't get paid as well. Working with the medical owner serve, sometimes it's not reimbursed at the same rate as like private practice. You know, that's just kind of a fact of life. But that doesn't mean it has to be like, you have to make less or you have to, there are ways to mitigate that. And so USC happens to not be that it happens to be on the higher end of the expense ratio, the expense spectrum. And so the crap, I really got to pay for this, you know, and I've been on my own financially since a team. And so I was like, Well, I've worked many jobs in my life. And then I've had like, 30 plus jobs in various areas. I was like, I could work more, or I could just continue to do what I love, and apply for programs, scholarships, etc, and try and get paid for. And luckily, the NHSC was there, and I got it on my second year. So my second and third year were paid for. And I actually went ahead and I still had that first year to pay for and I did the NHSC loan repayment. So I've done both the scholarship and loan repayment, and I just the financial trajectory, which you know, money is a tool, it is not happiness, but you know, using that tool in an appropriate way to set myself up to where, like, money is not an issue in the regard of, I'm not worried about debt, I'm not worried about like, I'm gonna be okay, things are fine on the financial front, which is not everything, absolutely not, you know, I mean, if your other areas of your life are not taken care of, and those are arguably more important, but having that taken care of was just a huge piece of it. For me, it was valuable because I got to do what I wanted to do. Like I wouldn't have changed what I was going to do, because I wanted to do that.



I think that's why Estes had such great, great outcomes with the NHSE because our mission as a program is in great alignment with the National Health Service Corps. So a lot of the applicants who are getting into our into that program are in fact already in alignment with what The NHS he's looking for. Right. And, you know, it certainly helps a program director sleep better at night when a good chunk of the students are getting through, you know, with limited debt, so and a lot have done the loan repayment as well. So I've seen a lot of grads who didn't get the scholarship when they were in school, but then they ended up still working in primary care applied for the loan repayment. And, you know, they received that for years and years until they get free.



I mean, I think I only made 25 grand is roughly what I can, in the backwards math of what I think I paid for my USC education because of the scholarship. And that's like rent like those years of my life cost 25 grand, not just yeah, the tuition, etc, someday. So ballpark, which is totally reasonable.



Absolutely. I agree. I agree. And so when you left USC, where did you go?



So after that, I worked in South Los Angeles, and my girlfriend at the time, who eventually became my wife was in residency, and she had a year left. And so I worked in South Los Angeles community clinic. And it was a bit of a grind. It was It was rough. But whenever I talk about it with people, I'm like, Yeah, you know, it's really tough, who's not the best support 20 to 25 patients a day, no admin time? You know, it was it was rough, but at the same time, would I have done it? Again? The answer is yes, I would have because I came out pretty strong. I really do feel that I came out. I mean, I was up to date, and I were best friends. Sure. My my girlfriend, now wife at the time was great for whenever I truly had questions that I would, you know, really do my due diligence and research. And then if I had questions that I would ask her, and then I also work with the USA, a US CPA along at that job, who was really helpful. And she kind of took me under her wing, which was really sweet of her. And so because of that, I felt because I made it through the fire of sorts. I, I there's like a sense of I can do anything in that regard. Like, I have an I had some really sick, complicated, difficult patients. And it was a great experience. So you know, I actually, like I said, I would do it again, ultimately. So when people ask me about it, I tell them, it was tough. I mean, I will tell you, just you and me, between you and me, and no one else. That, you know, I almost put myself on antidepressants, because it was tough at times, and everything else in my life was fantastic. You know, I had a great relationship with my girlfriend, wife. And then I had an excellent friend group, I lived in a beautiful place doing my weekends are fantastic. So I think that really helped me through having a good support network, etc. But I wouldn't have done it again, in hindsight. So



I want to sound and it sounds like a key a key aspect of being an HSC scholar, when you graduate and you're practicing is to make sure you have a strong support network with you. Oh, my



goodness, yes. If you because I don't know that there's a single NHSC site that doesn't have challenges and doesn't have, you know, probably some significant challenges, however you want to read it, like you're gonna learn quickly. And that's sort of how I became an NHSC. Site, you're gonna have to, you know, put your nose to the grindstone for a bit. Yeah, they're hurting. Right, right. And that's like, part of the gig, is you go somewhere where it's and so, but it was totally worth it. In hindsight, it was like, fantastic. And like the financial trajectory of life. It's just I can't, it's remarkable how different my, you know, if I was still paying off loans, then it's just two completely different paths and numbers, right. And again, for me, it was what I wanted to do. So it's easy, wasn't that?



Sure? I mean, when you think about compounding interest, right? Is, are you putting that you know, 1500 to $2,000 a month towards your loans instead of towards your investments? It's a huge difference when you retire.



Yeah, I I've actually gotten really into the financial independence retire early. And I actually don't know that I want to retire early personally. But I want the option to do what I want to do. So if I want to take a lower paying job eventually great, because I want to do it, because I don't care what the pay is so much, you know. And so for me it like having that independence is actually more just giving me options, and giving me sort of a tool, you know, using money as a tool to have a happier more what I want in life, whatever. That's true.



So Steve, a lot of people who do their NHSC scholarship tour, if you will, they do the tour and then they had right off into private practice. Not everybody but but a fair amount. Yet you chose to head to Norway double down



to a higher hipster score.



Yeah, talk about that decision. And that's been quite a while now. So yeah, I would I was at about,



I did three years in South Los Angeles. And then I've done six years in February. So six years a month in Indian Health Service in chinley, Arizona, in the middle of the Navajo Nation, you know, for me, so we were in LA, and we were just kind of feeling the grind of Los Angeles a little bit above it. La, fantastic. California is great. Like, it's beautiful, wonderful, etc. But I think I just wanted something different. And so when I was actually at an NHSE conference, early on, I there was an Indian Health Service recruiter, and I remember just hearing him out and talking with him. And it was, he was like, No, really, it's a great job. You do great things. It's your urine, underserved community. Well, this is the same thing, only blah, blah, blah, we kind of the way we describe it now to other applicants is Indian Health Services, like global health, peace for health, only you have equipment and labs, and support, etc. So you're doing global health, essentially, we actually have two fellowship programs, UCSF and university, Utah, that send their Global Health Fellows to here in Chile, and they work with us in the hospital. And they do half their time here to pay for the other half when they're abroad. And so they do Global Health here in Chile, and then they go abroad to many different countries. And it's been a great we've actually had numerous people come and work here afterwards from those programs. And so if you like that global medicine that working with underserved in that ability to actually you know, I mean, if you're working at a, at a HIV clinic, and in Malawi, you're going to treat everything as TB and HIV, you're just going to you're not going to be able to diagnose what's going on, you know, cuz you don't have MRI, CT, double blind, extensive labs. Here, we have those services. We have MRI on site, we have an incredible team of providers here. And so my take it back to your question. I finished my three years in Los Angeles, and we wanted something different. I remember this recruiter talking about IHS, and I was like, Hey, I told my wife. I said, What do you think about going to Indian Health Services and she just laughed at me and thought I was lazy. She thought it was the most crazy idea that she's ever heard of. And then she started talking to people that weren't me. And her husband thinks I should do IHS and she one of the people that she really respected at UCLA where she was doing residency said, and I actually completely agree with the statement that IHS is the pinnacle of their personal and professional career. And wow, it actually is it's I call it the Goldilocks job. You know, it's not too hot, not too cold. It's just right. I feel like I work the right amount. And I feel days I feel stressed. But I always feel satisfied with what I do. I always feel like I'm making a difference and things are better. And you know, after six years, I've been the Chief of Staff for the hospital here for approximately three and a half years now. And it's been a really rewarding experience. There have been challenges, of course, but it's I talked to some of my other friends that are working elsewhere. And it's a great job. We have like it's a great system job. And our patients are fantastic. We a lot of the pressures in medicine don't apply here. We treat patients as they need to be treated. And we really do have a high standard of care, which is fantastic. It's been it's



fantastic. So the insurance barriers that many others face in modern US healthcare. It's a little different for you. Absolutely. So



all I mean 80% of our population is on Medicaid on state Medicaid and some are on about 15 are on Medicare and five are uninsured. But IHS has a significant purchase referred care program. So they have money set aside for people that do not have insurance. And they have many million set aside like Ford Shem lease. So if I need an MRI and I just get the MRI, someone will pay for it, it will be taken care of one way or the other. Yeah. And so it's it's it's very rewarding. Great job.



So let's talk just for a second about your role as a PA in the life in the day of a PA and chinley. And then let's then maybe we can shift gears and talk about your role as chief of staff because you know that I'm not aware of any MPAs in the country that are serving as a chief of staff currently there may be but I think that's an it really impressive accomplishment. So so let's talk first about the prior to being Chief of Staff, what's your typical day light?



So we show up at a we we see a patient every 15 minutes, but the load is 20 patients a day. I work in family practice. So in family practice, we happen to have diabetes educators in clinic so anytime There's any diabetes related thing, they are in the room with us. And they help translate frequently. We have integrated behavioral health and clinic. So if there's any psychosocial issues taking place, we can bring someone into the room to help with that. There. What else? And we have, we're a closed system. So kind of like the VA, where if a patient needs to get labs done, I'm like, yeah, go down the hall and get the labs. And so they can go down the hallways. And so if I have to do like an urgent care type workup, they go get the labs done, and they come back and I tell them, we're gonna hear your results, here's what's going on, or here's your chest X ray, and so radiology. And if it's too complicated, I can send them to the ER, and it's just down the hallway as well. Or when the ER is too full to handle a patient that's acutely ill, I'll fly them out from clinic. And so about once a month, we'll actually fly someone out from clinic. And we'll call and arrange the transport, talk to the nurse supervisor who arranged with a medivac company, and then call the receiving institution and say, Hey, this is what I have. Do you have a bed? Okay, great. And so we work on that, you know, that doesn't happen all the time. But it happens, because we have a pretty sick patient population overall, there's a high burden of disease across the board. Just overall poverty index is pretty high. So we, I would see 20 patients in a day, we have noon to one off, and then one to 420 is my last patient. And so, you know, with our we have a relatively high no show rate of like 20 to 30%. And that varies day to day, some days, I see all my patients, some days I see 10, you know, generally it's about 16 to 18 is sort of ballpark wise where I ended up. They are complicated, and they are complex, and there's a lot going on. So it's a it's frequently a big visit. And there's can be a lot going on. It's rarely just a better refill. But yeah, sure, I guess I'm used to that by now. Because when you're working in the underserved population, it's kind of like it's to be expected to start any Yeah, and so you are the resource. And one thing I'll sort of comment on, having worked in urban poverty, and then worked in rural poverty, they are not the same, they have similarities, but rural poverty is it there's just fewer resources across the board. And it's, it's a different animal altogether. So it's, we have more resources here. Because of that, at our hospital, and our institution in our institution is mission driven. So even if we don't make money on something, we do it frequently. And our diabetes educators we don't build. So it's valuable to the system, it helps the providers, it helps the patients. So that's kind of a typical day of being a PA, Indian Health Services, we work three days a week, out of a four day shift. So one of those days is admin. And we obviously mix it up. It's not like a full day. So we do six half sessions, so three full days. And then we have Thursday morning, the whole hospital is on administrative tasks, or public announcements, meetings, etc. And then we have our own it just administrative session throughout the week. Sometimes it varies. So it's a decent amount of admin, it's 25% of your time is administrative to accomplish.



So you can so you feel like you can you can stay on top of things. Yeah, yeah, you



  1. You do. I mean, it's still a challenge, you know, of course, but I compared to other jobs and other friends of mine that have had gigs elsewhere, we have a very generous amount of tight to complete our job. And you know, as you show up in the administrative ladder of having more administrative stuff, like I have less time now, but I also they've also protected my I have less clinic as well, because I have to do things. So that's evolved over time.



What's been different for you when you took on the role of Chief of Staff.



I mean, there's just the whole medical stuff bylaws for one, understanding how PA is and everyone works in an institution. IHS is unique in the sense that for the chief of staff physician, it's not required to be a physician. It can be any of the staff, medical staff members. So we've had an optometrist of this position in the past, we've had physicians in this position in the past, so it's a unique governance in that regard. And being a part of IHS, so there's not a whole area which we are a part of we work with, they have sort of a governance ability over us, but then there's headquarters as well. But then there's we're federal and there are tribal entities as well. So there's just many different styles of governance within IHS and there's sort of strengths and weaknesses of those styles. For me, just the ability to have these opportunities and this growth I'm on I have a lot of national exposure with IHS headquarters etc. Because they need someone from Chileans beyond their or I happen to have that skill set. I'm finishing a master's in informatics as well. So I do a lot of our informatics things here and try to share with IHS at large, which has been a great experience.



Yeah, that's fantastic. Let's talk a little bit about that cultural transition for you. Because I know you're somebody who takes that very seriously. So what was that like for you to kind of evolve through working on sovereign nation land?



It was, yeah. So you know, working with underserved marginalized populations, there's always a learning curve. You know, in South LA, I learned a lot patients taught me quite a bit and coming out here, there's just the degree of learning was a lot more, because it's totally foreign to me, I really did not know that much about Native Americans. So it was a great learning experience, some of the learning moments that I had were in Navajo culture, you don't speak about negative things, because it's as if you're wishing them upon someone. And I remember talking about a screening colonoscopy with someone. And the patient took it very importantly, like they thought I wanted to give them colon cancer. And I was like, no, no. And that was very early on, thankfully, and I corrected, and now I speak like, we want to make sure you are as healthy as can be, we'd like to do this to make sure that your health is as good as possible.



That's kind of a nice way to look at life. Right.



Right. Exactly, exactly. So it's, um, I kind of I view it as two things. One, you know, in the workplace, there's like, the culture of the workplace is mission driven, and focus on our patients, we really, really care. And we really put a priority of being culturally sensitive and making sure that the patient's needs are addressed in code like we, if a patient would like to speak with NATO medicine, I go get them an agreement in the room. And I'm like, stop. Alright, cool. Let's do that right now. Just be very accommodating those regards. And then there's the cultural component of just learning the different aspects of the culture of the workplace that and then the cultural components of greater Native American reservation are just so cool. They're really fascinating. It's an A, which is the original name for the Navajo have a lot of great teachings, a lot of great people and great activities and great things that they do in life and their philosophies. For example, family here is not at all how Bella Ghana which are right people feel or think about family. Bella gonna feel that it's like my brother, my sister, my aunt, my uncle blood relations. Here, it's all by clan. So there's roughly 50 Odd client 50 or so clans and the Navajo Nation. And you are married, you're a product of your father's clan, and your mother's call. And you are made of two clans, everyone in those clans is your brother or sister. They are your relation. And so sure we first came here, you know, people were like, Oh, my, my sister's getting married. Oh, my brother's getting married. Oh, I have to go to a funeral my cousin of mine Buffalo. And I'm like, can you have it? How big is your family? It just took me a while to sort of comprehend but you keep referencing family members. And I think I don't know how that's possible. And they were like, oh, it's by mm, I finally learned but it's by clients how they define it. And that really matters in you. Sort of COVID for example, COVID. There's not a single member here that hasn't had dozens of family members that have had significant negative outcomes, or significant problems or significant consequences from COVID. And they view them as family. So imagine if your brothers or sisters were negatively had a negative outcome, some regard, you know, so it's really affected the community not to bring it back to COVID. But like that concept of family is a cultural component. You know, it's just really important, and something that was really valuable to me.



And you live on the reservation, correct. It's just a way to



the colloquial phrase is we're deep breads. So we live in the middle of the Navajo reservation, which is the size of West Virginia. And we are as middle as it gets worth roughly three hours from a decent sized city. Biggest sized city is Flagstaff, Arizona, and that's, you know, just under three hours away, and that's roughly a 50,000 person city. So it's, I don't think anyone call it a huge city. That's where a lot of our patients have to go for specialty care. Albuquerque is roughly four hours. Phoenix is six Denver's nine. So we're in the Four Corners region. We're pretty close to it. We're like an hour and a half away.



That's a very big, big territory. I drove through there last year to bring my daughter from Colorado back to Phoenix and it's it's a long drive thru It's beautiful, beautiful country. Oh, gorgeous, just incredible. Yeah, you're right by Monument Valley, it's not too far away.



It's not nothing's too far away your whole concept of distance and driving, like my kids who are two and three, they can do a four hour car ride. You know, because you're doing all the time, you know, and yeah, it's funny, I actually did the math when I first got out here. And I actually probably drive as much as I did in Los Angeles, I just do it twice a month. You know, it's not daily, it's it's just twice a month. You know, it's






it's one big drive with a podcast or having really good conversation with my wife or my kids, etc. So it's not it's not the same asleep, but it's probably the same in the car. So yeah, yeah. Going to have you open a road. No traffic.



Yeah, exactly. So you brought up COVID. Let's talk a little bit about COVID. Because obviously, the initial part of the virus just decimated your community, yet, you all did some really unique things to try to get on top of this and turn the tide, so to speak. So do you want to talk a little bit about your, your learnings from the early on experience at COVID? And what you all have been doing with technology to really make a difference?



Yeah, we've had a great, I mean, COVID has been terrible. And it's just really decimated a lot of this community. And a lot of the cultural norms and sort of traditions have been squashed. Because channel gathering groups and ceremonies were really common here, rodeos are very common. It's just really made it everyone's just kind of depressed. And that's everywhere. But you know, in a rural community where there aren't as many social gatherings, it really takes its toll. We, I think for the first six to eight months of COVID, we were the top 10 per capita. So per capita, we have been in the top 10 the entire time, for the most part, our rate of positivity was just sky high. And part of that is, we have large numbers of people living in one house in a congregate setting multi generational and poor at, you know, 25% these numbers may be a little dated, but the 25% don't have access to water power. Actually, I think it's a third for water. So it's just really hard to wash your hands all the time to maintain social distancing in those in that environment in that context, let alone that concept of family. Oh, it's my brother, who, you know, when you have a very large family, let's just my brother, you know, he's okay. Now he works as a welder in Phoenix and happening with Brock COVID. So we our response has been pretty remarkable. And when we look at when I talk to other people about COVID, or family members, even the response of Southern California has not been nearly as good as it has been here. And that's partly, maybe it's a closed system and our own inherent advantages in that regard. But we were I was vaccinated December 17 over a year just over a year ago. So we had the vaccine early on, and we pushed it hard and historically Navajo have never been resistant to vaccines. And our theory on that is that the disease burden of vaccine preventable illnesses has so high here and if people remember, meningococcal disease people remember I have patients that are in their early 20s that suffered from it, like vaccines did not truly arrive here until the late to mid 90s. And so there wasn't widescale vaccination. So a lot of those illnesses are here. So when the vaccine derived, everyone got vaccinated at a higher rate than anywhere else, or most other places. Native Americans have been very quick to adopt that immunization when COVID first came on, and it was just really scary and things were challenging. We had been preparing to start a telemedicine program. It was actually my project, being an informatics I wanted to start a telehealth program because I feel that Native American populations are the best population for telemedicine. You know, I mean, the two things that telemedicine has been proven show is reduced travel burden, and the cost of that of childcare, etc, etc. You know, it's really been shown to do those things well, and it's three hours one way to some specialists, you know, that's pretty valuable for a six hour round trip, let alone if it's a chronic disease, you have to go quite regularly. So what we did is we took we scrapped our telehealth program, and we made a COVID telehealth clinic on site. The reason we did it on site is a couple of reasons. One, there's no internet here like we are in both A literal desert and a broadband desert there. We just don't have access to high quality broadband. It doesn't exist. So the only real reliable internet is at the facility. So we set up we took down or we modified a couple rooms, and we would screen the patient's room them into our women's health department that had to get modified and became our respiratory clinic. And we would remotely see the patients and we were concerned how the patients would receive it. You know, because this is kind of a big jump from in person to now you're talking to a television screen.



And they were really excited about it partly because they thought we would give them. They were worried that writers were higher risk. And so we didn't get a single complaint about it, either. And we saw over 12,000 people via that that respiratory clinic, this small area, I mean, that's roughly probably a fourth of our visits in an annual year. So it was just able to preserve PPE, able to address the needs of the community, and rapidly triage to get someone to the emergency room, tickets, services, etc. So that was a pretty we were because we had the equipment on hand, I think we launched it March 25, is when we were ready to go. And I don't know that other IHS facilities were able to do that, or gas station viewer was fortunate. Very fortunate. It's really awesome. He was really was. And so we were able to sort of hone that process pretty early on. And it was just a machine that was able to address the need well. And then we've also had great access to monoclonal antibodies, our pharmacies very proactive. We also really, as I mentioned, we got high priority of getting the vaccine here, because we were always in the top 10 per capita hit spot, they shut down the whole rest. I remember, my wife was actually pregnant in the first part of COVID. And she's like, Man, I just, I just need to get off, I need to go somewhere I need to do, we have been at home for like four or five months straight, and haven't left the house. And they closed the gas stations, like gas stations weren't giving gas. So we had to borrow some gas from a neighbor to just to get off friends. Yeah, cuz it was that serious of the water. And that was June. You know, that wasn't like early on in the paper. I guess. Now it was. But so our response has been, we really have worked together as a team, I think having a mission driven organization with a public health mandate is just paramount to success that will make it work. Like if it pays for itself, great. If it doesn't, well, we got to do it, it needs to be done. And that attitude and mentality of our my colleagues and co workers has been fantastic. We have excellent leadership here, which is probably why I really liked my jobs, because I work with great people. And we've been able, when you have a great team, you attract great talent, we have infectious disease, here, we just we had cardiology, and they're actually coming back because they don't like the private practice world as much as they like here. A lot of options and opportunity. And some of our providers have been here for 30 years. So there's like an in depth institutional knowledge of, you know, they were working here when the roads won't really pay. Practically, there's like a good depth knowledge and experience and breadth of just people I some of my best friends here are, you know, 6070 years old. And because we all get old timing in there's some people if you don't get along, you kind of learn to work around it. And oh, I really, you know, sure I disagree with so and so on these subjects or these things, but I work with them their quality. And like, I feel like this is what America used to be where everyone kind of works on their differences and comes in mutual insurance. And so with all of those things were strengths for us to respond to COVID. And thankfully, it it was much better. And now it's just going crazy. We have hundreds of positives every day. Everyone's vaccinated, we do have monoclonal antibodies. So it's kind of a different, it's a different experience.



So your morbidity, mortality is much better than it was early on.



No one is intubated. Currently, you know, and we used to fantastic before we used to have 2520. I think 30 People intubated for 55 bed hospital. No rest. You know, the reason we had that many people is because every other hospitals for Arizona's capacity at that time was 90% of the ICU beds were full. And so we were looking at truly doing rationing care. It got really close. And luckily we avoided that. It got we did some creative. Like we had people boarding in the ED longer than they should things like that. But we kind of had to do we had to do. So yeah, we had to get creative. We had a great team on the ground to do so just so overall, it was a fantastic. I mean, it was a fantastic learning and growing experience. I would have loved to avoid it. But But to get test we have always had anyone to get tested at any time just walk up and we would give you testing or vaccine even if you're not native anyone my father in law and mother in law were visiting and they got vaccinated because in Sri Lanka, they did not have access or they they actually they were able to get access to vaccines here. They're so sure time. So it was it's been great in that regard, just how well we could do and function as a team.



So Steve, as we kind of wrap up, I wonder if you could share With just a couple of the key key cultural things that you've learned that maybe you think would be beneficial for healthcare providers to think about, um, yeah, so



one thing I've learned is when a patient says that they don't want to do something, or like just engaging resistance to be like, Okay, well, let's talk about that. Let's explain. So for me, one of the, there's been a couple moments of where a patient was not interested in something. And it was because, for example, I had a very depressed patient. I'll just give you hard examples. And they, I was like talking about an SSRI. And they're like, no, I'd rather do a ceremony. And it's actually legal for the Native American church to do peyote. And I was like, okay, great, go ahead and do that. Let's see you back in a while, and they came back, and they felt great. They felt like it truly helped them. And, you know, so I guess one of the cultural things is, the goal is the start with the end in mind. And if a patient can get to that good place, whatever, that is a good outcome, then that's what's important, and not necessarily how they get there. You know, so sure, I was going to give them an SSRI, but they were like, No, I don't want to do that. I was like, Okay. And they so just engaging with them on what they're willing to do. Like, working with them as much as you can, and then finding out what is appropriate for them. You know, and that patient has, I've seen them a couple of times, and they've done great, so that that ceremony that service, work for them, really spoke to their needs, their cultural identity, or cultural desire. And so just embracing it. Fantastic. That's great. That like, I guess, not being rigid in your approach, and being flexible with it with an understanding, the goal is for a healthy outcome for them to get to the space where the disease is improved. Yeah, and if they can do that through many other mechanisms, I had one guy that was in a rodeo, and rodeo culture out here is a big deal. And he was just killing himself. But he said it was a way of life, I can't not do it. I'm like, alright, well, can we do this? Can we buy better seats? You know, things like that, hey, don't do this section of the rodeo, things like that. So mitigating those risks and working, you know, LGBT patients that are performing high risk activities, you know, be like, hey, well, can we start prep? Can we do this. So just really working with patients for that goal, and especially their cultural desires, customs, and accommodating? Because if you win that, if you are willing to do that with them, then they'll trust you. And they'll, they'll, you're a partner in their process towards help. So yeah, yeah,



that's a great lesson for all of us, regardless of where we're practicing, it really is about the patient. Right? Hey,



and willing to just work with our cultural components are, I mean, there's just so many, it's been a great experience, just learning all the little things up. One thing I'll kind of tell anyone lessons that I have found incredibly useful is try to learn a little bit of a language of whatever language you're working with, you know, in I remember, I had a couple patients that spoke several million dialects in South Los Angeles. And I would try and learn a couple of those, they nicknamed me sub t, which means bearded guy, and so which was great. And like, like, just putting forth that effort was, it's so valuable. When I go into a room I say, Yeah, Tisha Ma, and when I say goodbye, which means Hello, grandmother. And so, all of the grandmothers get tickled. And I do that they're just like, it puts a smile on your face. They know that I've invested in the community, I'm invested in learning their language and investing and helping them. So just little efforts like that. And it's not that hard to learn that or when I say goodbye, I said, I go on a hug machine, which just means like, understood, Goodbye, thank you for coming in, and I do a terribly, they laugh at me every single time that I try. And they like any Navajo person that's listening to this is gonna be like, Oh, dear, that's terrible. But it's the effort. It's it's the desire to meet them where they're at. And yeah, recognize, okay. Welcome.



That's one of my greatest lessons in life. I had a, I practice medicine in a private practice in the western suburbs of Chicago. I had a small Hispanic community of patients that would come to us. And I did the same thing, right? And I would say to the one this one family comes to mind I would say to them, let's set you up to come in at five o'clock for your appointments so that I can stay late. And we can work through the language barriers together and really take time to under And what your challenges are. And you know, literally a couple years later, they named their first child after me the first. And, and it was just such an incredible honor and such a little thing that I was doing to try to help make their experience better. And it also, you know, selfishly made my experience better, too. So, yeah, yeah. So I'm glad to hear that you were able to help



them get to a better outcome. And like it was a relationship,



which is what we're supposed to be doing anyway. Steve, is there anything else you were hoping to share that today? Before we sign off?



I think you and I talked about briefly. So being in the chief of staff role has just made me realize like how challenging leadership is and how you're not going to please everyone, and you're gonna have to make difficult decisions. So I think that the PA profession needs more leaders and needs to like that higher level of executive and getting up to Chief, whatever the because it's so enlightening. And I've been on several big calls. And I've actually received messages like it's so great to see a PA in this role. And to see a PA sort of doing that. It's it's funny, because I was like, I'm just doing my job going forward. And yeah, but it's been remarkable how much it's been to people in and out of the profession, that I hope that there's more opportunity for more, and I'm sort of trying to advocate for that as much like he is. I think



it's amazing. I think, you know, in speaking with Stanford a few episodes ago, there's, there's, they have a sociologist on their team, and I was talking to her about the differences between the average PA and the average, whatever, you know, whatever the health profession is, and I just had to just there is something different about us generalizing, there's something different about us sociologically. And I think we're wired differently in the way that leadership roles and being able to navigate and get along with a lot of different personalities might come a little bit easier to some of us. And it's a good reminder to be nice to your leaders, because it is a lonely job sometimes like



it is, uh, you know, it's funny, I never thought that, in fact, I probably thought the opposite. I'm like grumbling like, oh, it's easy. It is not, you know, I have truly learned it is difficult, you know, and having to sometimes do things that you really don't want to do at all. But it has, yeah,



it has to be you have to do the right thing. Sometimes the right thing is, is tough. Well, Steve, thank you so much. This is fantastic. I know the audience will be really delighted to hear your story and and what a great opportunity. If you if you want to get rid of some of that stress from medicine and still make a difference in the lives of people. It sounds like IHS is a great place to go.



It's awesome. If anyone wants to reach out. I don't know if you guys have a footnote thing that



we do on our on our website. We can put that on there and I'll be happy to do that. I'd like to thank our guest Steve Neil for sharing his insights into the rich nature of serving the Navajo Nation. And also let the insights of the culture and the impact of working with Indian Health Services to men next week as we speak to Dr. Daniel Park, who is the director of the postgraduate fellowship program in urology at Keck medicine at USC can talk to us about his role about what residents are doing and what the benefits of a postgraduate fellowship program may be. Until next time, we wish you success with whatever path you are walking in life, and thank you for joining us. The purpose of this podcast is to provide news and information on the PA profession and is for informational purposes only. The views and opinions expressed in this podcast are those of the speakers and guests and do not necessarily reflect the official position or policy of the University of Arizona.

Stephen Neal, MPAP, PA-CProfile Photo

Stephen Neal, MPAP, PA-C

Chief of Staff

Originally from Southern California, Stephen Neal attended Physician Assistant school at the University of Southern California Keck School of Medicine. He graduated in 2012 and worked at an FQHC in South Los Angeles as a NHSC scholar for 3 years after graduation. He also completed NHSC loan repayment at the Chinle Comprehensive Health Facility, an IHS facility in northern Arizona. He has worked here since 2016 as a PA in Family Practice and clinical informatics. Since 2018 he has participated in hospital leadership as the Chief of Staff for the Chinle Service Unit. In this role, he leads credentialing, quality review, and represents over 300 medical staff at the three sites that comprise the Chinle Service Unit. Mr. Neal is nearing the completion of his master’s degree in clinical health informatics through Oregon Health Science University School of Medicine’s Department of Medical Informatics and Clinical Epidemiology. In response to the COVID-19 pandemic, he has presented for HHS telemedicine hackathon, Northwest Portland Area Health Board, University of New Mexico summit on telemedicine, and several project ECHOs. One of his missions is using technology to improve healthcare services delivered to the underserved, marginalized patients he serves.