On the rural Colorado plains, cancer patients with no local options rely on this traveling oncologist

 Dr. Robert Hoyer is a Colorado Springs-based oncologist and hematologist with UC Health.  Photo by Mike Sweeney, Special to The Colorado Sun

Dr. Robert Hoyer doesn’t bother buying groceries or using the kitchenette in the little room at the Holiday Inn Express where he lives for four days every month. By the time he and his staff finish 12-hour days at the clinic, they usually head for enchiladas at La Mission Villanueva or steaks at Tavern 1301. They’ve settled into   routine by now in this small town on the southeastern Colorado plains, where they travel once a month to see patients with cancer who otherwise would have to drive two hours to Pueblo or three hours to Colorado Springs for doctor appointments.

Medical assistant Creston Potts’ mom takes care of her cat, Purdy, while she’s taking care of patients on the road, away from her regular job at UCHealth Memorial Central in Colorado Springs. She’s been working with Hoyer for 10 years now. Nurse practitioner Rose Gates, who retired and then returned for this, is exhausted by the end of the week but knows she would feel “restless” if she hadn’t. She walked through the Lamar clinic while eating a baked potato from the Prowers Medical Center cafeteria because she doesn’t have time to sit down. And Hoyer, known as the “outreach oncologist,” listens to audio books or logs into virtual meetings as he treks 400 miles each month on highways and two-lane roads across rural Colorado. After a long day at the Lamar clinic last month, he was watching his college daughter’s concert on a livestream, since he couldn’t go in person to the performance in Boulder.

On their travel week, the UCHealth team leaves Colorado Springs about dawn on Mondays, driving two hours straight south to Las Animas County, where they visit patients in borrowed space at Mt. San Rafael Hospital in Trinidad. On Tuesday mornings, they drive northeast to Lamar, where they use an empty suite of rooms at Prowers Medical Center. They head home to Colorado Springs around noon on Fridays. In five days Hoyer’s team sees about 130 patients, some to explain their diagnosis for the first time, and others to discuss test results or the next round of chemotherapy.

There is not a single oncologist based in the southeastern quadrant of the state. The hospitals in Prowers and Las Animas counties are community-owned and not part of UCHealth’s 14-hospital system. The rural medical centers partner with UCHealth because, otherwise, residents in their region might either forgo treatment or have to drive hundreds of miles for care.  Specialists of any kind, including cardiologists, pulmonologists and endocrinologists, are nonexistent in many counties on the Eastern Plains. Even family physicians are few and far between. In the 17 counties of the Eastern Plains, there is one physician for every 995 residents, compared with one per 295 residents in urban Colorado, according to the Colorado Rural Health Center.

Dr. Hoyer’s team, based in Colorado Springs, splits time at Lamar’s Prowers Medical Center and Trinidad’s St. Rafael Hospital. (Mike Sweeney, Special to The Colorado Sun)

Hoyer has been traveling to southeastern Colorado since 2011, when he took over for a doctor who was retiring. He attended medical school at Georgetown University in Washington, D.C., worked at the Mayo Clinic in Rochester, Minnesota, and became the medical director of oncology at Memorial in Colorado Springs. He had no experience in rural health care until he was “voluntold” to report to his first day on the job in Lamar. “It really opened my eyes to the situation,” he said, sitting at one of the desks crammed into an old exam room that is now his team’s office space. “I was shocked at how access was so challenging for patients, and how few doctors there are. Coordination of care was very spotty.”

The traveling clinic began as just one day per month and slowly expanded to a full week as word spread about the traveling oncologist, and as the number of patients with cancer has grown.  “The travel element initially was not something that I greatly enjoyed, but recognizing the impact this clinic has had for the patients in rural Colorado, I am happy to do this, and I would do it daily if I had to because it’s such a critical element,” he said. “The lack of specialty providers in this area is really striking.” Patients are coming not just from Lamar, population 7,700, but smaller towns in the region, including Springfield, Walsh, Eads, Holly and Cheyenne Wells. Some of Hoyer’s patients drive an hour just to see him in Lamar.

In addition to the oncology team, UCHealth has five cardiologists who hold clinics in southern Colorado, including in Lamar, Springfield, Eads, La Junta, Walsenburg, Trinidad and Cañon City. Rocky Mountain Cancer Centers sends oncologists to Burlington and La Junta. There are about 90 oncologists in Colorado with active licenses, according to data from the Colorado Medical Society and the Colorado Department of Regulatory Agencies. Nearly all of them are along the Interstate 25 corridor, with a few scattered on the western side of the state, including in Durango and Grand Junction.

Shelby Casper, a family nurse practitioner, opened her practice in Wiley in 2022 when she decided to move back home to the Eastern Plains after years studying and practicing medicine in Pueblo and Denver.  She has 1,900 patients. To see them all, Casper works 10-hour days Monday-Thursday, then spends Friday on administrative tasks, including paying the clinic’s bills and her staff. “There is such a lack of care and it’s hard to turn people away,” she said. “I’m maxed out.”

Casper said she has been trying for months to hire another medical provider for her office in Wiley, a tiny town northwest of Lamar with a population of about 430. She’s hoping for a nurse practitioner but she will take what she can get.  “We are constantly looking for providers,” she said. “It’s very challenging to get people to understand this way of life and come to this little rural part of Colorado. They tend to come to this area and there is just not a lot to do. We surround a lot of our fun around our family. We create our own fun. They are used to urban life and shopping at their fingertips.”

Her patients are complex, often with multiple risky conditions, including heart disease, diabetes, arthritis, obesity and pulmonary disease. And because of the lack of specialists, Casper helps them manage all of those illnesses. There is no doctor at her clinic. “If people have to travel out of town and can’t afford to do so, they just don’t,” she said.

Casper is grateful she can at least refer patients with cancer to the clinic in Lamar. “Obviously that’s a relief when they are facing such a challenging and scary diagnosis,” she said. “They can stay close to home.”

Prowers Medical Center in Lamar hosts UC Health’s traveling oncology clinic – photo by Mike Sweeney

Chemo mixed under complex safety protocols, driven to Trinidad

Smaller, rural hospitals don’t often have an infusion center in part because of the complex process of mixing chemotherapy.  In Lamar, the Prowers Medical Center has a specialized pharmacy with the required ventilation and safety protocols for hazardous materials, so it can mix chemotherapy for Hoyer’s patients. For Trinidad, however, the chemotherapy is mixed in Colorado Springs and driven to the Mt. San Rafael Hospital, a 25-bed hospital owned by the nonprofit Trinidad Area Health Association. The timing of the transport is imperative, since patients must receive the chemo within hours of its production.

Behind the scenes, what patients don’t see is that Hoyer and his team are creating chemotherapy plans for their patients with the help of UCHealth’s electronic medical records system. Each patient’s dosage is tailored to them, and it depends on what other medications they are taking, their liver and kidney function, allergic reactions and a host of other information, said Dr. Wells Messersmith, chief medical officer for oncology services at UCHealth. “It’s not like someone is just writing their prescription,” he said. “These are very, very complex calculations that have to happen.”

Hoyer writes infusion orders in his laptop in Lamar and Trinidad, and those orders are subject to drug interaction checks, organ function checks and other safety checks that are built into the system, all vetted by committees of highly specialized physicians, Messersmith said.  The system of safety checks means that patients in rural areas are getting the same quality of care as those visiting much larger urban hospitals, he said.   “If you think about the burden of cancer in terms of someone’s lifespan and whatever symptoms they may have, the burden of finances and time is something that we often don’t take into account,” Messersmith said. “For a patient to be able to continue to work and to be involved in the lives of their family members and their community, it’s difficult to calculate that. Many patients tell us that it’s incalculable.”

Hoyer, 49, contemplated retiring from clinical work and focusing on other interests, including lifestyle and longevity medicine. He is one-half of a podcast called “2DocsToc,” which focuses on physical activity, sleep and stress resilience. But he isn’t ready to step away from his traveling doctor duties in southeastern Colorado, so he’s stepping back from work in Colorado Springs but keeping his once-a-month travel schedule.

“In oncology, because we’re taking care of patients who aren’t going to have a normal lifespan through many of our clinic days, it can be tough sometimes, and you do start to think about, ‘What is my impact on the world? What is my contribution?’” Messersmith said. “For Dr. Hoyer, this is part of what is filling his bucket, and knowing that he’s made a direct impact on so many people.”

Rose Gates came out of retirement after a career as a nurse practitioner to work with UC Health’s traveling oncology clinic, serving patients in southeastern Colorado. (Mike Sweeney, Special to The Colorado Sun)

Nurse Practitioner Rose Gates – photo by Mike Sweeney

Rural patients are more appreciative

When UCHealth first started the oncology clinic in Lamar, the oncologist arrived by small airplane and stayed one day. Hoyer, who took the job when that doctor retired 14 years ago, prefers to avoid the bumpy flight through southern Colorado wind patterns. On smoother, more scenic car rides that take him to the foothills of the Sangre de Cristo Mountains and through miles of rolling hills and farmland, he has time to ponder deeper and broader questions about the future of cancer treatment and how to help patients live better.

Earlier this year, Hoyer gathered more than 26,000 signatures on a Change.org petition pushing Medicare to continue paying for virtual telehealth visits from his rural patients’ homes. The federal government has considered limiting the visits, which have been covered by Medicare since the COVID pandemic, a move that would force patients to drive to the hospital in Lamar just to connect with the doctor virtually in Colorado Springs. The virtual visits are part of the coordination of care that he’s helped build on the Eastern Plains, a system that includes allowing patients to have all their labs, imaging and infusions done at their local hospitals. The technology, and Hoyer’s willingness to drive to their communities, gives rural patients access to one of the top medical systems in the country. “We bring the care, essentially, to the patients,” he said.

 

For a patient to be able to continue to work and to be involved in the lives of their family members and their community, it’s difficult to calculate that. Many patients tell us that it’s incalculable.

— Dr. Wells Messersmith, chief medical officer for oncology services at UCHealth

 

During his career, treatments have become more targeted to specific types of cancer, with better outcomes. One of Hoyer’s patients with breast cancer could complete only about one-quarter of the chemotherapy he prescribed because of intense side effects, yet her cancer is gone — because the drug was so effective.

Hoyer believes further advances, including artificial intelligence, will lead to a cure for cancer by the late 2030s. The AI used today is “just a fraction of what we’re about to witness,” he said. In the next decade, computations that can read and connect genetic mutations, and match them with new drugs, will increase exponentially, he said.   “It’s going to be revolutionary,” he said.

Working with Hoyer is so energizing that Gates, the traveling team’s nurse practitioner, came out of retirement in March to join the team in Lamar and Trinidad. Gates was a nurse in the U.S. Army for 20 years before her career eventually took her to Colorado Springs. While she was retired, for three years, she took her grandkids to the Bahamas, her daughter to Japan and spent more time with her husband. After knocking some things off her bucket list, she was ready to see patients again.  She had worked with Hoyer at UCHealth Memorial, so when she heard he needed help in his rural clinics, she took the part-time job.

At 73, Gates has seemingly endless patience for explaining test results to older patients who don’t use the internet or a smartphone, which is more common in rural areas. She recently talked through all 13 test results for a patient who doesn’t have an electronic patient portal. “They’re older. They’re in their 90s right now, and they’ve never used a computer before, so that’s harder for them,” she said. “A lot of patients don’t have cellphones.”

Working with rural patients is more rewarding, she said, because they are regularly thanking her for coming to their town.  “I like my patients everywhere, but I think the patients here just appreciate the fact that we’re coming out here,” she said. “That’s the difference. A lot of them can’t drive. A lot of them can’t afford to pay money for gas. They’re saying, ‘If you guys weren’t coming, we wouldn’t be here.’”

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Original article by Jennifer Brown – The Colorado Sun – jennifer@coloradosun.com.

Editors note:  This article was edited for length and reprinted with permission from The Colorado Sun. 

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