Tuesday, July 3, 2012

Alumna Leads Indian Health Clinic Toward Integrative Care

How did alumna Ravyn Ramos, ARNP, ND ('09) prove herself as the first naturopathic doctor at the busy Tulalip Health Clinic? A persistent focus on her patients.

Ravyn Ramos, ARNP, ND ('09), standing in the clinic lobby
Bastyr alumna Ravyn Ramos, ARNP, ND ('09), at the Tulalip Health Clinic

Naturopathic physician Ravyn Ramos, ARNP, ND ('09), guides a visitor through the Tulalip Health Clinic, ticking off all the components required in a truly "integrative" clinic.

She strides past healing rooms where she meets with patients, then the offices of her colleagues — medical doctors (MDs) and nurse practitioners. She traverses a bank of desks where nurses are joking, then passes the X-ray room and diagnostic laboratory. She points out the pharmacy that she has convinced to carry more herbal supplements. She crosses the lobby where patients are signing in — a long, arching room with carved wooden masks and a bank of windows overlooking the slate-blue Tulalip Bay. She passes reiki and massage therapy rooms and the exercise center.

At the minor surgery room, a pristine space with a single treatment table, she pauses.

"I try to do all my own toenail removals," Dr. Ramos says. "Because it's such a good teaching experience for students."

It's an odd statement, but it reveals several things about the successful role she has established as the first naturopathic doctor at the clinic, a primary and family care center on the Tulalip Indian Reservation 40 miles north of Seattle.

First, referrals are an everyday part of an integrative clinic. Dr. Ramos directs patients to her MD colleagues for some conditions. Having earned their respect, she receives referrals from them.

Second, there is plenty of work to go around. Each provider sees 16 to 18 patients most days, addressing chronic conditions like diabetes and acute conditions such as broken bones and the flu. Surgical procedures like toenail and mole removals are rare at some naturopathic practices, but not here.

Tulalip Health Clinic entranceThird, to Dr. Ramos's surprise, teaching has become a major part of her work. That's allowed her to stay connected to Bastyr University, where she earned a Doctor of Naturopathic Medicine degree in 2009. Each quarter, several Bastyr naturopathic medicine students complete preceptorships with Dr. Ramos, shadowing and observing her. Eventually they see patients themselves, completing hours toward their clinical education requirements.

(See our accompanying story about preceptorships and their role in natural-health education.)

"I absolutely love teaching," Dr. Ramos says. "I didn't know that about myself before. It's a big part of my desire to do the work I'm doing here."

The Right Fit

Her interest in teaching may be new, but Dr. Ramos's interest in primary care goes back years. She spent two years in conventional medical school, but she grew frustrated by the absence of classes on nutrition and botanical medicine. She was set to move to Kansas City for her clinical training when she heard about Bastyr. When she learned that licensed naturopathic doctors could provide primary care, she transferred and moved to Seattle.

"Bastyr had everything I was looking for," she says.

She wanted the ability to do everything MDs do — including prescribing heavy narcotics and working in hospitals — so she enrolled in a nurse practitioner program at Seattle University during her Bastyr studies.

In 2009, a classmate put her in touch with the Tulalip clinic. Dr. Ramos learned about the diversity of patients on the reservation and decided it was the right fit. She was drawn to the clinic's ability to serve anyone who lived on the reservation, regardless of their ability to pay. Some patients are low-income, but not all of them. Some struggle with diabetes, heart disease or addiction, but others have the same range of conditions that any clinic sees.

The next task for Dr. Ramos was proving that she belonged at the clinic, where naturopathic medicine was a new concept to some staff. She found acceptance, she says, by focusing on patients.

"I've had to stay very persistent and strong in explaining what I do," she says. "But the minute you get validation from your patients, it's all worth it. And I tend to have good relationships with my patients."

"Patients have been very responsive to her," says Bryan Cooper, a nurse practitioner at the clinic. "We have patients who are frustrated with Western medicine. They might have irritable bowel syndrome, for instance, and feel like they're not making progress. I refer them to Ravyn, and don't see them again because they stay with her. So something is working."

Learning Flexibility

At Bastyr, Dr. Ramos learned to treat the whole person, not just their disease. She might see three patients with ulcers in a week and prescribe three different treatments because one was caused by stress, another by a poor diet, another by overuse of pain medication.

Working with a population with a history of facing injustice, Dr. Ramos has learned the importance of being a listener first and an expert second. She tells the story of a woman with diabetes who came in because of a head cold. Her blood glucose level was "extremely dangerous," Dr. Ramos recalls, but the woman was tired of doctors scolding her about diabetes care. She said she didn't want to talk about diabetes.

"I said, 'Just come back and talk to me,'" Dr. Ramos says. "I knew if I brought up diabetes, she wouldn't come back. I had to wait for her to ask for help. It took six months, but she did."

Dr. Ramos has also learned to provide patients with options that fit their budget and time limits. She persuaded the clinic pharmacy to stock glucose-support bars for diabetes. They're not as good as a vegetable-rich whole-food meal, Dr. Ramos says. "But if you have children to support and you have to work long hours to make ends meet, me telling you to eat a perfect diet may not always be realistic,” she adds. "You just need to put something in your body. These are a start."

She knows that large-scale diet changes will take time — and she takes heart in encouraging signs like the community garden project at the tribal cultural center. Some days the illness and injuries and pain and bad habits still seem overwhelming, she says. Then she remembers that no healer works alone.

"I'm developing a new appreciation for the power of integrative medicine," she says. "I've questioned allopathic medicine and I've questioned naturopathic medicine. Where I've found the beauty is in bringing them together and seeing how much they can do.

"Little by little we're making some changes."

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Learn more about studying naturopathic medicine at Bastyr.

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