An Interview with Mary Wakefield, PhD, RN, FAAN

by Beth Blevins

Mary WakefieldDr. Mary Wakefield is associate dean for rural health at the School of Medicine and Health Sciences, University of North Dakota, and director of the Center for Rural Health at the School of Medicine and Health Sciences, University of North Dakota, in Grand Forks, N.D. She has served as Center Director since November 2001.

Wakefield has expertise in rural health care, quality and patient safety, Medicare payment policy, workforce issues and the public policy process. She has presented nationally and internationally on public policy and strategies to influence the policymaking and political process, and has authored many articles and columns on health policy. She was on the editorial board of a number of professional journals, including The Journal of Rural Health, and is on the boards of Nursing Economic$, and Annals of Family Medicine.

Wakefield is a nurse and was a professor of nursing before serving as a legislative assistant and Chief of Staff to Senator Quentin Burdick (D-ND) from 1987 until 1992. From January 1993 – January 1996, Wakefield was the chief of staff for United States Senator Kent Conrad (D-ND). Throughout her tenure on Capitol Hill, Wakefield advised on a range of public health policy issues, drafted legislative proposals, and worked with interest groups and other Senate offices.

From January 1996 – December 2001, Dr. Wakefield served as professor and director of the Center for Health Policy, Research, and Ethics at George Mason University, Fairfax, Va.

Wakefield is married to Charles Christianson, a family practice physician. They live in Grand Forks. Although she lists work as her only real hobby, she also enjoys taking walks and going fishing and ice fishing for relaxation.

For more on Wakefield, see her UND Faculty page, which gives a more extensive biography and includes a list of her projects, presentations and publications.

How did you make the transition from nursing to health policy?

I practiced nursing full or part time from 1976-1985 and taught nursing from 1977-1987 in one form or another. I worked primarily as an intensive care unit nurse and taught nursing at the University of North Dakota. Then I decided in 1987 to try to get a summer experience working on Capitol Hill. Instead of an internship, a North Dakota Senator offered me a job as his health legislative assistant. I’d only been to D.C. once before, for less than 24 hours, so I was completely wet behind the ears. I knew health care and education, but I knew little about the public policymaking process. While a lot of hill staff know the process and have to learn the issues, I knew a lot about the issues but not the policymaking process. Either way, it’s a steep learning curve. I really wanted to continue to practice nursing while I was on the hill but the schedule was just too unpredictable, particularly after I took a chief of staff position a year and a half after arriving in D.C.

It was a major redirection in career. I’d aspired to being a nursing dean at some point but that plan melted away once I was in Washington. What took me to D.C. was the recognition that in practicing nursing or teaching nursing, I could influence six patients on a shift or 30 students in a classroom and, as important as that was, in policy you can influence the health or education of tens of thousands of people. So, I wanted to see what that environment was like.

Why did you move back to North Dakota?

After spending 15 years in the Washington D.C. area, I realized that while there were scores of people with my expertise in that region, there were many fewer in the northern plains. It struck me that I could be making a bigger difference by bringing what I’d learned in the public policy arena back to the region of the country I hailed from. Also, coming back to North Dakota put me much closer to rural health issues rather than my trying to understand them from a distance. In some circumstances, I think there’s a type of credibility one has if they’re working on rural health issues and their mailing address is something other than a major metro area.

Additionally, I always thought I’d return to this region, and when the position at the University of North Dakota came open, I negotiated for over a year about whether and when to make that move. When thinking about leaving the D.C. area, I thought if I were back in a less hectic region of the country I’d have a bit more down time to enjoy other things. I’ve learned that it isn’t so much “where you are” as “what you are.” The pace hasn’t changed at all for me—if anything, it’s probably ramped up.

Before we moved back to North Dakota, my husband was Vice Chair of Family Medicine at Georgetown. I told him that if he really wanted to see how family practice could be practiced in the best possible way he needed to move to a rural area. So, we did.

Now that you’ve moved back, what do like most about living in North Dakota?

What I like about North Dakota are the big open skies, nothing much obstructs your view. I like the white pelicans that nest here by the thousands in the summer, and other birds. It’s a great ecotourism location and you can get out and look at the landscape or birds or anything else just about anywhere. You can’t do that on the Beltway in Washington, D.C.—at least not if you value your life. As a matter of fact, on a recent evening I was driving along at dusk and pulled over to get out and look at a huge great horned owl up on a post. So what if it was 4 below zero, it was a great sight. I also like the fact I can get to and from work in less than 10 minutes—no time wasted in commutes. Much of my work takes me through airports to cities elsewhere almost every week so I get enough of other locations. It’s always great to come back home.

What sparked your interest in rural health issues and policy?

When I was on the hill I was one of two nurses most involved in rural health care (Sheila Burke, the other, was at the time Senator Dole’s chief of staff). Dole and Burdick were the co-chairs of the Senate Rural Health Caucus, so she and I co-staffed the Caucus in a very bipartisan way. That was my entrée to rural health policy. It was a “David and Goliath” attitude in the Caucus—urban health care at the time was well represented on key Senate committees and we really needed numbers and commitment to make headway on rural-specific issues on behalf of rural constituents. So, partisan politics hardly entered into the fray, it was much more a rural vs. urban orientation. Anyway, that was my first encounter with serious rural health policy and the issues and commitment to them never waned after that. I’ve always liked that “come from behind” challenge and a view that the cause is the right one. I don’t just work on rural health issues, but they certainly constitute the bulk of my work.

Do you think the David and Goliath attitude of rural vs. urban still holds in public health policy today, or has it changed or diminished in any way over the last 20 years?

Today we have far more research that documents rural health challenges than we did when I worked on Capitol Hill. When I was working there we often operated from anecdotes. That made it particularly hard to argue for policy changes when much of what could describe rural circumstances was washed out in urban-dominated data sets. Since then, more efforts have been made to tease out the impact of policies on rural health care, but there’s still much more to be done. The good news is that we have great champions for rural health in the federal Office of Rural Health Policy, in the HRSA administrator and in the Congress. A strong or tepid commitment to rural health makes all the difference in the world in policy arenas. And, we have individuals and national organizations that have a palpable commitment to strengthening and sustaining health care to rural populations. How we engage that goal going forward is likely through different approaches than we’ve seen applied historically. We have new tools that can be deployed to ensure access, measure quality and plan for efficient care delivery.

How has the Center for Rural Health changed since you’ve been there?

The Center for Rural Health was relatively small when I started here. I inherited about seven staff and we’re now, six years later, over 40 and counting. Our portfolio of activity has local, state, regional and national components and the staff that works on them is as good as any anywhere.

What are some of the major research projects that you and the Center are working on right now?

We have about 30 projects underway at the Center. Some of it is related to specific rural populations like pesticide exposure in children, veterans’ access to health-related information and services, and Native American elder health. Some of our research and projects relate to types of facilities like critical access hospitals or technology like electronic health records. In terms of research, we’re examining the decision-making processes and characteristics that influence rural physicians’ transfer of patients from rural to urban facilities. We’re also tracking, at a state level, the rural health care workforce.

Almost regardless of what project we’re working on, we are very deliberate about viewing our work through a public policy lens. While it’s critically important to publish in peer-reviewed journals, we also have a serious commitment to informing key stakeholders using communications like fact sheets, policy briefs or e-news, which package rural health information in a user-friendly fashion. As important as doing the project or the research is communicating it effectively. We place as much attention on the latter as the former and we’re working to improve on both fronts all the time.

The Rural Assistance Center (renamed Rural Health Information Hub 12/15) recently celebrated its five-year anniversary. What do you consider its major accomplishment of the last five years?

RAC is a great example of harnessing technology so that a project like RAC can be based in a pretty rural area and be at least as effective as if it were in a major metropolitan area. Technology has helped to place rural people and ideas much more prominently on the map. You don’t have to be at the Library of Congress or the National Library of Medicine to be a stellar information resource.

From your perspective as a nurse, an educator, a policymaker and a North Dakotan, what do you think are the major issues and challenges in rural health care in the next five to 10 years?

I think that in the long term, our biggest challenge isn’t rural-specific. We have some leaders in the federal government, as well as key analysts, all projecting a very rocky future if health care spending continues on its current trajectory. For example, in January, an article in the Financial Times (not necessarily top of the stack reading for health care folks) was anything but subtle in describing Moody’s terse statements about the possibility that the U.S. could lose its triple A credit rating in the next decade because of rising health and retirement expenditures. The point is that health care may jeopardize the economic health of the country and a meaningful correction to that trajectory won’t be easy.

In the near term, I think that the question of whether or not rural populations can continue to access health care is being replaced by a different question. It isn’t so much “Can we deliver care?” as “How will care be delivered?” The answer to the latter question pivots off of new delivery models, networks and information technology that were hardly envisioned 20 years ago, but are increasingly commonplace.

We’ll have to shed old models and stop old turf battles. New approaches include interdisciplinary team care, changes in the way care is organized, ready access via technology to the latest quality improvement methods and the latest evidence-based practices. How we create, reimburse and replicate efficient models calls for innovation and innovation isn’t foreign to a lot of rural health care providers. As long as we’re open to new ideas, deploying resources differently and keeping an eye on quality, I think the sky’s the limit.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Winter 2008 Issue