Advancing Health Podcast

00:00:00:04 - 00:00:17:21
Tom Haederle
Welcome to Advancing Health. For families living in poverty, health care can take a back seat in the list of daily priorities. Today we hear about a remarkable partnership in Kansas City that is turning that paradigm around by bringing care to kids.

00:00:17:23 - 00:00:44:21
Julia Resnick
When families are navigating poverty, accessing health care can become just one more challenge in an already complex system. That's why reducing those barriers and bringing care closer to where families are matters so much. In today's episode of Advancing Health, I'm joined by leaders from two organizations working together to do just that for children in Kansas City. I'm Julia Resnick, senior director of health outcomes and care transformation at the American Hospital Association.

00:00:44:23 - 00:01:08:13
Julia Resnick
I'm talking with Dr. Alejandro Quiroga, president and CEO of Children's Mercy Kansas City, and Mary Esselman, president and CEO of Operation Breakthrough. Together, their partnership embeds pediatric care within a trusted community setting, bringing services closer to the children and families that need them most. Ale, Mary, thank you so much for joining me today to talk about this remarkable partnership.

00:01:08:15 - 00:01:09:19
Mary Esselman
Excited to be here.

00:01:09:21 - 00:01:12:10
Alejandro Quiroga, M.D.
Thank you for having us, Julia. Very excited to be here.

00:01:12:12 - 00:01:22:14
Julia Resnick
So for listeners who are unfamiliar with Kansas City, what does it look like to grow up as a kid in the community you serve, particularly related to factors that influence those kids health?

00:01:22:16 - 00:01:45:06
Mary Esselman
Well, I'd love to jump in on this one because I think if you can just picture where we're located, it really gives you an idea. We're located at the corner of 31st and Troost, which is always been known as the dividing line in Kansas City, not only in terms of prosperity, but also in terms of race. So you're looking at a community that has had a long period of time in which there they've been underserved.

00:01:45:09 - 00:01:48:03
Mary Esselman
And so that kind of gives you a visual.

00:01:48:05 - 00:01:49:26
Julia Resnick
Ale, anything you want to add?

00:01:49:28 - 00:02:12:11
Alejandro Quiroga, M.D.
I mean, I think where our community has come through is like many communities in the US. I think we're talking about Kansas City, but like everything that we're going to say, it's something that can be translated to any community in the US. And therefore the responsibility of local leaders, local partnerships to make sure that we serve them in the same way.

00:02:12:13 - 00:02:19:02
Julia Resnick
So what are some of those barriers that families face when it comes to health and education and economic opportunity?

00:02:19:05 - 00:02:39:11
Mary Esselman
Well, I think one thing you can look at is like in in Kansas City, only 18% of jobs can be reached in about 90 minutes. So you can already think about childcare access, transportation. I know, over the last 20 years, I mean food access and food scarcity goes up and down. We do a bus tour called The City.

00:02:39:11 - 00:02:56:28
Mary Esselman
You Never See. And one of the things we ask people to look at is like, as you're driving around the east side, like, where would you get groceries, you know? How would you access services if you didn't have transportation? And I think when you have those kinds of fundamental needs that are missing, health care can oftentimes take a backseat.

00:02:57:02 - 00:03:11:06
Mary Esselman
So instead of creating a proactive culture of health, it's reactive. You're only going when it's absolutely necessary. And then it tends to be to the emergency room, not a trusted physician or health care partner.

00:03:11:08 - 00:03:31:18
Julia Resnick
Yeah. And I think all of that just impacts the long term health of kids and families in your community. Which brings us to the topic of our conversation, which is really Operation Breakthrough. So I've had the privilege of visiting, but I know that many of our listeners have not. So, Mary, can you tell us what it is and how it was designed to meet the needs of kids and families in Kansas City?

00:03:31:20 - 00:03:54:17
Mary Esselman
Well, this year is actually our 55th year, hard to believe. But it actually started in a living room. Two nuns were teaching on the east side. And, you know, they had school aged kids, but parents were like, if we just had someone to watch our younger children, we could work. And so they thought, we can do this. And so four in the living room turned to 40 to 400, and today it's over 780 children and families that are served.

00:03:54:17 - 00:04:10:02
Mary Esselman
But what makes it unique is the fact that it's not just about education or care, it's about social services and health. And that's what I think, where you see that uniqueness going from cradle to career and this tight knit community and everything we do is based on relationships.

00:04:10:05 - 00:04:13:16
Julia Resnick
Fantastic. Ale, anything you want to add there?

00:04:13:18 - 00:04:33:05
Alejandro Quiroga, M.D.
I'll tell you, when I first got to Kansas City, I got the call from Mary. And of course, my team told me that you have to go visit. And it's the most I mean, it's a jewel in the middle of Kansas City of something that is so hard to describe. But when I did tour, my first tour, we walked through it.

00:04:33:05 - 00:04:59:07
Alejandro Quiroga, M.D.
And you see a classroom, then you're all of a sudden across a hallway and you're in the middle of a clinic. Then you cross a bridge and you're in workshop where there's welding of cars that people are learning trades, and everybody is all around this pantry. There's volunteers. It is the most purposeful place that you can see to help this community.

00:04:59:10 - 00:05:11:27
Alejandro Quiroga, M.D.
And as you will hear from Mary, it's actually doing that job. But through relationships in an extremely meaningful way. So it's is a very unique model that more communities should have.

00:05:12:00 - 00:05:32:29
Julia Resnick
Yeah. And when I visited, I was also blown away by, you know, the hydroponic gardens and kids learning how to run restaurants alongside early childhood education, just like how incredible that you've created that space for kids to learn and feel safe and grow. So I want to talk a little bit about the partnership between Children's Mercy and Operation Breakthrough.

00:05:33:01 - 00:05:41:03
Julia Resnick
Can you talk about how that started, and how you realized that bringing health care directly into the community could really make an impact?

00:05:41:05 - 00:05:57:19
Mary Esselman
Well, our founders, you know, Sister Verna was like a little firecracker. You know, if she thought we needed something, she just started it, and she might start it with the volunteer. And then she'd find a way to get everyone who can. And so it actually started 30 years ago, where she said, we have got to have a nurse.

00:05:57:21 - 00:06:35:27
Mary Esselman
And so, you know, what is now an office used to be the place where the nurse was, and we could start to really be more proactive. And then in 2008, we got to do an expansion, and then we got the full clinic. And that's been amazing. And then when you kind of track forward a little bit, which I think was one of the most important things we did is in 2013, we formed a partnership for Resilient Families, and it's something that happens quarterly between, Children's Mercy and ourselves. And everybody from the top of the organization to those directly practicing with families, get together to really talk about how do we help families and what

00:06:35:27 - 00:06:42:18
Mary Esselman
are the current pressing issues that we need to address together to encourage that culture of health for our families.

00:06:42:20 - 00:06:48:13
Julia Resnick
So talk to me a little bit about what the clinic looks like and how does it work. Like, walk me through it.

00:06:48:16 - 00:07:03:19
Mary Esselman
Well, so when you come in, it's like, right front and center. And when the beauty of is it's not just for kids here, although we have plenty of them, it's also for the community. So imagine if you're here for early care and education and then you go off to school, and you may not stay in the program for before and after school.

00:07:03:26 - 00:07:25:29
Mary Esselman
A lot of those families still come here because of those relationships. So you can come in and the clinic is there, they've got core exam rooms. I mean, there's someone that goes and walks kids from class, an amazing telehealth model that keeps parents working. And, you know, one of our biggest challenges for our parents is oftentimes their jobs don't have benefits or accrued time off.

00:07:25:29 - 00:07:44:12
Mary Esselman
And so just making a health appointment, you know, can put their job at risk. And so we were seeing a lot of missed appointments. And now Children's Mercy contacts the supervisor wants to know we're going to need mom for a few minutes to step aside. And, we're seeing a lot more of our preventative care happening, but it's a great space.

00:07:44:12 - 00:08:00:15
Mary Esselman
It's front and center, but it doesn't stop in the doors of the clinic. One of the things I love the most is the fact that there's a school nurse. She makes over 5,000 classroom visits a year. We're actually talking about a second nurse because we just opened the school and, you know, realizing that we have a lot more money.

00:08:00:15 - 00:08:21:27
Mary Esselman
But imagine when every day you're seeing a nurse,  suddenly sometimes there's a lack of trust, especially for underserved in underserved communities. But when you're building those relationships as a child and a parent and you have the freedom to ask questions, not just when you're sick, I think it changes everything. So there's just a lot of little pieces.

00:08:22:02 - 00:08:41:20
Mary Esselman
Children, staff from across the hospital pop in on Monday. Word on the street so they can help do other things. And I will say during Covid, we wouldn't have been able to stay open the whole time if we hadn't had Children's Mercy, because the minute that we thought there might be a symptom, we were able to do that testing and keep everyone safe.

00:08:41:22 - 00:08:49:17
Mary Esselman
And even beforehand, just the idea of washing hands and all of the things that we need people to know. Children's was there, hand-in-hand.

00:08:49:19 - 00:08:58:27
Julia Resnick
And, you know, I think it's pretty unique to have a hospital that's so deeply embedded in community. Ale, can you can you share your perspective on that?

00:08:58:29 - 00:09:32:28
Alejandro Quiroga, M.D.
We've been here for 129 years. And for the first 50 years, we operated in the same way that Operation Breakthrough came about. Very organic. One of our founders was a surgeon, the other under was a dentist. And imagine two very strong women with a conviction that pediatric care has to be different. And before they have the right to vote, they founded a hospital before they have the right to practice in the same way that they males did,

00:09:33:00 - 00:09:58:06
Alejandro Quiroga, M.D.
they found that a hospital. And for the first 50 years not a single bill came out of our institution. So when you're asking, like how these two organizations came together. Like, that's not the question. Nothing would have stopped these two organizations coming together and being embedded, because our missions are so similar. We see the world so like alike, of course, we came about. Pediatric health care is quite comprehensive.

00:09:58:07 - 00:10:24:06
Alejandro Quiroga, M.D.
You can go from these type of partnerships to then you're talking about cardiac transplants. And they're all different. And you take different muscles, have different understandings and you have to have the right focus to know where to put your resources and what is being covered by other, partners in the community or other organizations. And I think that's what we're doing here.

00:10:24:09 - 00:10:26:01
Julia Resnick
Mary, anything you want to add?

00:10:26:03 - 00:11:01:03
Mary Esselman
I think it's pretty amazing when you have organizations that have been around this long and you still have those original missions intact that. And I love when you talk about relationships, because in both organizations, everything we do coalesces around building relationships, and you can really see it. The other thing I think for those listening, I think it's important is it shows that you can take, you know, a large hospital system and you can take a smaller, nimble nonprofit and you can find ways - I feel like it doesn't matter what the barriers we encounter.

00:11:01:03 - 00:11:12:22
Mary Esselman
We find ways to, work through them. And I think that's what it takes when you look at the length of our partnership and how we continue to grow and thrive.

00:11:12:25 - 00:11:25:27
Julia Resnick
I love that everything is built on relationships and trust. But really, just like when it gets down to it, what are those elements that you need to get this kind of community clinic running and running smoothly for as long as you have?

00:11:25:29 - 00:11:46:19
Alejandro Quiroga, M.D.
The funding part is really difficult, right? You have to think about how do you allocate funding to that. And that comes in a partnership. We raise funds together, we raise funds separately, we allocate different budgets. And it's a tough conversation. And that's where most of these partnerships will start. You have to be fueled by the mission, but you have to find the funding to be able to do this.

00:11:46:22 - 00:12:10:02
Alejandro Quiroga, M.D.
And this will not be a typical PNO. And most health care systems would get stuck there. So what is the return on investment here? And you have to see the return on investment beyond just a very plain ROI. You have to see moms being able to work. How does this have community benefit in a way that is not traditional?

00:12:10:05 - 00:12:24:06
Julia Resnick
And I'm sure that you see the impact of this every day, whether it is in those health outcomes, whether it's mom being able to work. Do you have any stories about a child or a family that really, reflects why this is so important?

00:12:24:09 - 00:12:44:26
Mary Esselman
One that comes to mind just because we've been talking about it recently is, you know, we get a lot of children that have really high health needs. I mean, when you think about, sometimes it's environmental, sometimes it's multi-generational. And so the ability to be able to serve children with high needs, we had, we had a baby who's now in kindergarten.

00:12:44:29 - 00:13:05:04
Mary Esselman
So you can imagine, I mean, this has been over a span, but, you know, failure to thrive, leading to couldn't digest, produce a lot of medical needs. You can imagine a classroom teacher and the fear that goes with trying to make sure we're providing adequate care and to be able to have a nurse to come in and help with that and be there day to day through that process.

00:13:05:11 - 00:13:26:26
Mary Esselman
And then be able to share jointly when that feeding tube comes out five years later. I mean, those are the kinds of stories, I think, that, really showcase not only from a medical perspective, but just relationships, that create trust amongst children, families, health care workers. What does it take to make this type of a partnership? I think it takes patience.

00:13:26:26 - 00:13:45:23
Mary Esselman
You know, I'm never that patient. So like when I have an idea, I'm ready to like, charge in and make it happen. And I think in both our cases, like the desire and the want is always there. But the mechanics of getting there can be difficult. And I have a little grid on my wall that says find the third way.

00:13:45:23 - 00:14:07:00
Mary Esselman
And I always laugh because sometimes we're on the 30th way, but I feel like we always stick it out and find a way to make it work, because I think we make it sound really easy, but there's we both live in the in the world of licensing and rules. And so as much as we might want something, we still have to make it happen within those boundaries.

00:14:07:00 - 00:14:33:22
Mary Esselman
And I love the fact that we all are back at the table at our meetings as we're working on things. And I love that, you know, I talked about the partnership for Resilient Families, but we also have a weekly call with direct providers. So we're really navigating what's trending in terms of health challenges. How do we communicate it where there isn't a lot of health and literacy and families and to work together on those.

00:14:33:25 - 00:14:54:29
Mary Esselman
And then I think it makes a robust environment for residents. They have made it a priority to have all of their pediatric residents spend two days here. So they're really feeling firsthand how important health is and doing it directly with populations that aren't taking place kind of in a sterile clinic room.

00:14:55:01 - 00:15:05:24
Julia Resnick
You've both been doing this for a while. I'd love to hear your advice to other hospitals, to other community based organizations that are thinking about embarking on this sort of partnership.

00:15:05:27 - 00:15:31:19
Alejandro Quiroga, M.D.
I think when you live within a large health care system, people will see that as a soft call or something that is like a given. The literature will tell you that that is not the case. If you want to get these things, you have to first build trust, build a relationship, get alignment. And you know there is a system of doing that.

00:15:31:22 - 00:15:55:00
Alejandro Quiroga, M.D.
This has falling into an organic way, but we have developed it systems that reinforce that relationship. Relationships have an ROI. Aligning missions across what's important and then using those relationships to deliver better care will have an ROI for the community. You're going to have to be creative, kind of have to think different, but you have to push yourself to do so.

00:15:55:02 - 00:15:57:26
Julia Resnick
Absolutely, Mary, take us home.

00:15:57:28 - 00:16:16:01
Mary Esselman
So for those of the thinking we could do this and you can, it might start out small, but if you're really persistent and you really believe in it, I think I would always say don't wait because you can plan for years and life will have changed three times since then. I think you just have to you have to step in and start.

00:16:16:04 - 00:16:36:26
Mary Esselman
And then I think you have to be willing to engage up and down through the hospital. It can't just be the clinic director. It can't just be the nurse. It has to be something that's shared across the organizations. And it will change the ability to ensure that kids are meeting developmental milestones when you see these kinds of partnerships.

00:16:36:28 - 00:16:54:25
Julia Resnick
And I think that, you know, when you have your missions aligned and you're both committed to the relationship and working through the challenges, you are just a fabulous example of what you can build. So Mary, Ale, thank you both for being here and sharing this work with us and for the work that you both do every day to help the kids of Kansas City.

00:16:54:27 - 00:17:03:09
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:02 - 00:00:22:28
Tom Haederle
Welcome to Advancing Health. People facing psychiatric or substance use disorders have enough to deal with without the added burden of shame or stigma attached to their challenge. Today, we hear about the power of a large health care organization that's decided to push back against stigma and the difference it's making.

00:00:23:01 - 00:00:50:25
Rebecca Chickey
My name is Rebecca Chickey, and I'm the vice president of behavioral health and trustee services for the American Hospital Association. It's my honor today to be joined by three exceptional behavioral health leaders from CommonSpirit. Dr. Sapra, who is the system vice president for behavioral health, Kathy Krebs-Dean, who is director of behavioral health expansion and development, and Robin Conyers, vice president of CHI’s Behavioral Health.

00:00:50:28 - 00:01:16:29
Rebecca Chickey
Thank you so much for joining us here today to talk about your incredible stigma reduction campaign as it relates to the stigma surrounding psychiatric and substance use disorders. The treatments for those and the individuals who suffer well from those conditions. So, Dr. Sapra, I'm going to ask you to kick us off for those people for whom CommonSpirit is a term they'd never heard,

00:01:17:02 - 00:01:31:12
Rebecca Chickey
doubtful if they're in the health care field. But sometimes we get non-health care, listeners to our podcast. Tell us about CommonSpirit's footprint. Just give the listeners a sense of when I say CommonSpirit, what that means.

00:01:31:15 - 00:01:57:00
Manish Sapra, M.D.
Yeah. So, CommonSpirit is one of the largest health systems in the country. It was formed in 2019 with the alignment of Catholic Health Initiatives, or  with CHI and Dignity Health. And together, these institutions bring over 150 years of combined experience, with focus on providing compassionate health care, especially to vulnerable populations. We have a broad national reach.

00:01:57:02 - 00:02:18:22
Manish Sapra, M.D.
Approximately 1 in 4 Americans live within the CommonSpirit service areas. And we operate over 160 hospitals in 24 states. Our national footprint and the dedication to our core priorities, like compassionate care, high quality health services, and social justice position us uniquely to confront behavioral health disparities.

00:02:18:25 - 00:02:41:29
Rebecca Chickey
I really appreciate the fact that you continue to talk about the mission and vision, and how because of that CommonSpirit has dedicated a number of resources related to behavioral health. So I'm going to turn to Kathy, though, because today, the focus of our podcast is really the journey that CommonSpirit has been on to reduce the stigma surrounding behavioral health.

00:02:42:01 - 00:02:52:06
Rebecca Chickey
And, Kathy, I'm going to put you on the spot, ask you to share, you know, why did CommonSpirit make such a strategic investment in an anti-stigma campaign?

00:02:52:08 - 00:03:03:28
Kathy Krebs-Dean
This is a system wide effort to address and reduce the stigma that's associated with substance use disorder. And it's intended to improve patient care and outcomes. It has three main components.

00:03:04:06 - 00:03:31:16
Kathy Krebs-Dean
First and foremost, there is a data driven foundation. We surveyed over 500 providers to get a sense of knowledge, attitudes and beliefs. And the results that we obtained confirm there's a high recognition of substance use disorder as a medical condition and strong support for medication assisted treatment, and also help to inform some of the targeted interventions that we're doing including our anti-stigma education campaign.

00:03:31:18 - 00:04:02:00
Kathy Krebs-Dean
So that campaign has been phenomenally well embraced by our associates and providers. It's a voluntary training and, we also have a train the trainor component so that there's an opportunity to help us scale this further. There's aspects that include impactful storytelling. So we created a video series to share the powerful impact of stigma and its reduction from the perspective of both patients and then also from providers.

00:04:02:03 - 00:04:26:16
Kathy Krebs-Dean
And, we're also dovetailing with some of the work that we're doing around the clinical care. So there's an intersection with some of our community commitments, such as increasing access to care to our emergency department, addiction care, for people that are impacted by opioid use disorder. And then last but not least, we have this focus on language and culture that's woven in.

00:04:26:19 - 00:04:41:26
Kathy Krebs-Dean
And this is made possible through our partnership with the American Hospital Association and the 'People Matter Words Matter' campaign. And that's all about promoting consistent use of non-judgmental language across our facilities and then upholding this culture of understanding and support.

00:04:41:29 - 00:05:03:21
Rebecca Chickey
There is such a broad swath and different types of stigma as Dr. Sapra mentioned earlier, I think that makes so much sense to focus on one core piece and make an impact on reducing the stigma around addiction, because I do believe in many cases and perhaps your survey showed this - be interesting to know if it did - that

00:05:03:23 - 00:05:28:24
Rebecca Chickey
often there's more stigma around addiction or substance use disorders than, let's say, major depression or anxiety. If that is the case, then you picked a tough nut to crack, as they say. And, just really, I'm so grateful that your going down that that journey. I'd also like to thank you for mentioning People Matter, Words Matter.

00:05:28:25 - 00:06:05:25
Rebecca Chickey
That was an initiative that the American Hospital Association started back in 2021. It's a series of posters. The first one surrounded on people first language and the importance of that. We worked with member organizations around the country to create these posters, to help educate around what words or phrases are stigmatizing and perpetuate that, and then offering solutions and alternatives for our own workforce to know so that they can choose their words and use their words more carefully to reduce the stigma.

00:06:05:28 - 00:06:29:21
Manish Sapra, M.D.
Yeah, I think it's really goes back to the values that I was describing, right. And, you know, I feel like how we ended up here is understanding the value  of large organizations inability to affect stigma. And, you know, to understand that we probably just need to understand stigma a little bit more. You know, stigma comes in multiple layers or contexts.

00:06:29:23 - 00:06:57:06
Manish Sapra, M.D.
For example, this cultural stigma that we all sort of know, which is societal or community beliefs, values and traditions that view mental health as shameful, taboo or sign of weakness. And there is institutional stigma, right? Or a structural stigma that affects policies and laws and regulations which may lead to like lower funding of mental health, whether it's research or services or within the organization, you know, helping grow these services.

00:06:57:09 - 00:07:19:25
Manish Sapra, M.D.
There's, of course, the interpersonal stigma that we feel towards, you know, family, friends or coworkers. Even into professional stigma, right, where for folks who have had a history of mental illness working together with us, I think the employers or organizations have a lot of responsibility in busting the stigma. CommonSpirit really looked at it as an institutional priority.

00:07:20:03 - 00:07:37:29
Manish Sapra, M.D.
And again, as a responsibility of what a large organization, especially in health care, which is providing behavioral health, which includes substance use, as you said earlier and took that initiative. And I'll ask, Kathy to chime in here and just give us the history of when this program started about three years ago.

00:07:38:02 - 00:08:15:07
Kathy Krebs-Dean
Well, I would say that this work has been deeply aligned with our mission, our focus on compassion and our tagline: Hello, Human Kindness. There's no greater kindness than fostering a culture of non-judgment. So it definitely supports a culture that is supportive not only of our patients, our providers, but also our wider communities that we serve. And then there's been this catalyst from our philanthropic partners, this investment in helping to create and sustain this work over the last three years.

00:08:15:09 - 00:08:39:13
Kathy Krebs-Dean
And they helped us to create, for instance, some wonderful content, the video series on the impacts of anti-stigma and the reduction of that. The training program that we're utilizing. So all this has helped to create this momentum, and this interest across our system and then finally, without a doubt, it's been incredible to see the passion of our associates and our providers.

00:08:39:16 - 00:09:00:12
Kathy Krebs-Dean
This has been sort of a bit of a grassroots movement in that it's, been widely embraced by people. And I think it's because of the fact that many people have been personally impacted by substance use disorder. They realize just how widespread it is and how, how it impacts so many lives. And there's a lot of enthusiasm about being part of this transformative work.

00:09:00:15 - 00:09:19:26
Kathy Krebs-Dean
And that manifests in ways like some participating in training, some teaching the training, and then, utilizing our videos as as reflection and in meetings and that sort of thing. So it's been incredibly impactful. And I think we've been seeing a lot of interest in continuing the work.

00:09:19:28 - 00:09:23:08
Rebecca Chickey
Thank you for making that idea kind of come alive

00:09:23:11 - 00:09:49:08
Rebecca Chickey
across the footprint of CommonSpirit, because that's where the real work is, in your organizations, in your hospitals, day in, day out. And to see it spread across the country. Robyn, let's turn to you now. Cathy described the overall anti-stigma campaign across the footprint of CommonSpirit. But it's my understanding that it was really your grassroots efforts in your own organization

00:09:49:08 - 00:10:17:26
Rebecca Chickey
that really was where this initiative was given birth, as they say. So can you help the listeners understand how AHA's People Matter, Words Matter substance use disorder posters have been used? What that looks like, physically, would they see posters? Would it be on screenshots? Really help paint a picture for the listeners - how you rolled this out at your own organization?

00:10:17:29 - 00:10:37:25
Robin Conyers
Sure. So being members of the AHA and having the listservs and the communication come out, we heard about, People Matter, Words Matter initiative. And I was just so intrigued by the impact that it could have within our organization and really even beyond. In behavioral health, we're always looking for ways to educate and to break down stigma.

00:10:37:27 - 00:11:15:15
Robin Conyers
And these posters, the series of posters that have come out and have continued to be refined over the years are just such a simplistic way to educate and to bring it into a layperson's terms, if you will, of being able to have conversations. And so as I was reading these posters, obviously overseeing behavioral services in the Omaha, Nebraska area and southwest Iowa, this was an easy way to work within our organization to say, hey, we're a large footprint of behavioral health, but yet we know behavioral health patients see primary care, they see ObGyn, they see orthopedics.

00:11:15:15 - 00:11:36:17
Robin Conyers
They have, you know, oncology and a variety of areas. And is there a way that we can speak these words and this platform of the emphasis that people matter, words matter. Again, such simplicity that the AHA came up with, how can we work with outside behavioral health with our partners to educate? And so I met actually met with our vice presidents of patient care,

00:11:36:17 - 00:11:58:22
Robin Conyers
so our chief nurses within the organization to see if they had an interest in owning that for their campuses or within our primary health clinics. I met with our marketing teams, and what we ended up doing with our marketing teams was we partnered with AHA to - all of a series of posters - to put the AHA logo if you will, along with our CHI health logo on the bottom of the posters

00:11:58:22 - 00:12:19:05
Robin Conyers
so that show in partnership of this work that's together. And then we also paired the variety of the posters with the months. So there's a eating disorder month, there's mental health awareness month, there's posters specific to suicide awareness. So there's pertinent p posters that align very nicely with, if you will, areas of the month of focus across the country.

00:12:19:05 - 00:12:47:14
Robin Conyers
And so, as we put those posters together, we tied them, if you will, with a focus of the month, a topic of the month that paired well. And then we also designed the ability for posters, table tents in the dining areas. The other unique thing that we did within our marketing department is recognizing that perhaps a poster of focusing on eating disorders may not be top of mind that patients or families are coming in for treatment in regards to orthopedics, but they're seeing their orthopedic provider, if you will, in their clinic.

00:12:47:16 - 00:13:04:18
Robin Conyers
Yet recognizing they could put those posters up in those clinics so that individuals could see them while they're waiting for their provider to come in. But it allowed the nimbleness too for those clinic leaders to pick the posters that are pertinent to their areas. So we're not putting something up that really has not no applicability to the patients they're serving.

00:13:04:21 - 00:13:26:15
Robin Conyers
But there are other broader topics of recognizing caring for the caregivers, suicidality, substance use disorders that could have applicability across the board. So we started that grassroots, really in the Omaha area, piloted it, met with our executive leaders, within CommonSpirit Health in the behavioral health service line, talked about how this could have a broad implication within all of CommonSpirit Health, if you will.

00:13:26:17 - 00:13:48:11
Robin Conyers
And so then what we did was we worked with our national teams, took those posters, and we have them now digitally readily available for any leader within CommonSpirit Health can go in, pick whatever subject they want, whatever poster they want, and they can also then choose their markets or the their name of their hospital or their clinic, and they can put that at the bottom of their poster as well.

00:13:48:11 - 00:14:14:03
Robin Conyers
So it shows a nice collaboration amongst the AHA initiative and tying it into with the department, if you will, in market that we're in. So because as Dr. Sapra talked earlier about our broad brush and where we're at within, across the country, to this day by launching that beyond just the Omaha, Nebraska - Council Bluffs Iowa market, we have over 2000, materials that have been downloaded within CommonSpirit Health.

00:14:14:03 - 00:14:25:20
Robin Conyers
So we have a broad brush across the country, that really has a vested interest in adopting these materials as well. So it has grown way beyond just the Nebraska-Iowa markets.

00:14:25:23 - 00:14:36:05
Rebecca Chickey
So, Robin, now that the initiative has been in place for a year or more, what impact have you seen? Has there been a change in culture?

00:14:36:08 - 00:14:43:13
Rebecca Chickey
A change in tone? Have you seen people actually using the different words that are suggested on the posters?

00:14:43:15 - 00:15:00:23
Robin Conyers
The visibility alone, if you're in an elevator, reading the information that's there while you're waiting for, you know, to go up and down the floors or you're waiting for your provider to come in your clinic setting. I actually was just in my primary care clinic last week, and as I was sitting for the provider to walk in, I look to the right and there's a poster on the door.

00:15:00:26 - 00:15:22:24
Robin Conyers
But I have had nurses across our organization actually not in behavioral health, but when we posted these out on the internet and again and they're available. I have had nurses email and just say thank you, you know, I don't work in behavioral health, but I do care for behavioral health patients in critical care or in you know, the NICU or excuse me, in OB or in the emergency department.

00:15:22:24 - 00:15:41:05
Robin Conyers
And this was such an easy tool for me. I had no idea that that I was being kind of disrespectful in some ways of not being conscious of the words I was choosing. So, for example, of saying that, well, the patient's an addict, that person is an addict. Well, actually, we're encouraging to say this person has a substance use disorder.

00:15:41:06 - 00:15:58:11
Robin Conyers
And one has said, and when I give report, when a patient's going forward to critical care to detox or they're going up to behavioral health because they have suicide ideation and maybe have a substance use component to the treatment, I have found myself saying, now there you have substance use disorders. I don't refer them. This is an addict that now has to be detox.

00:15:58:11 - 00:16:06:07
Robin Conyers
So just that shift in nomenclature in words matters. And it gives me goosebumps to think to hear that.

00:16:06:09 - 00:16:28:18
Rebecca Chickey
So as we bring this podcast to a close, I'd love to have each of you think about what call to action you would suggest for the listeners. What should they do? What first step or second step should they take to perhaps go on their own anti-stigma or stigma reduction journey at their own hospital or health system?

00:16:28:21 - 00:17:01:00
Manish Sapra, M.D.
There are ways to address this, issue of stigma. And large employers, especially in health care space, have that responsibility to do that. And there are ways that that they can create a culture, the language, the culture of well-being and treating each other kindly and with awareness of these you know, illnesses in a way that we can bring that whole culture of compassionate care.

00:17:01:02 - 00:17:24:17
Manish Sapra, M.D.
And also when we're dealing with each other as health care workers, that we are being kind and compassionate. And there are initiatives that can be very effective in this space. So I think the call to action is do to see that this works. And it is a responsibility of our large organizations to take this on.

00:17:25:16 - 00:17:55:25
Kathy Krebs-Dean
One of the first steps would be recognize stigma associated with substance use disorder as something that can impede a person's progress in seeking the care that they need. It's a condition that impacts millions of people every year. And when we are more supportive and recognize substance use disorder as a medical condition versus something like a moral failing, we know that people are more apt to get the care that they need.

00:17:55:27 - 00:18:14:08
Robin Conyers
When I think about caring for individuals that have substance use disorder or mental health challenges, I think that nobody woke up one morning and said, okay, Lauren, hand it down to me, I want the substance use disorder. I want to be called an addict. I want to have those suicidal thoughts. I want people to be afraid of me. I want people to judge me

00:18:14:08 - 00:18:35:19
Robin Conyers
because it's all my fault that I've lost my job, or I'm homeless, or because of choices that I've made. Nobody woke up and said, hand me that. I want to be stigmatized in that way, or to be thought of in a different light. And yet it's our job to be able to recognize that mental illness, substance use disorders has no demographics.

00:18:35:21 - 00:19:11:15
Robin Conyers
It has no impact on age. It has no impact on career. We see it all across the board. And so the ability to just be kind to one another and to have a curiosity in how we care for people as whole, not just as patients, but people as whole. So to be curious in the way of how you can self educate so that when your friends, your family members, your colleagues are reaching out to you in times of, of struggle or in times of sadness or feeling hopeless, the ability to just in a very simple way, to be curious, and how to educate yourself so that you can show it better for them.

00:19:11:18 - 00:19:22:17
Robin Conyers
And the People Matter, Words Matter campaign is again, as I mentioned, it's a very simplistic, non-confrontational way to, if not this, do that.

00:19:22:19 - 00:19:36:27
Rebecca Chickey
Well, thank you very much. Thank you for partnering in this effort. Thank you for, as they say, taking the ball and running with it. Really appreciate the inspiration that you've shared for our listeners today to take a look at People Matter,

00:19:36:27 - 00:19:58:13
Rebecca Chickey
Words Matter as one way of beginning to reduce the stigma, in this case around substance use disorders. But whatever they might want to go on their journey. You're changing culture one word at a time, and that is difficult work. So, applause and thank you for being here with us today.

00:19:58:15 - 00:20:06:26
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;04 - 00;00;13;24
Tom Haederle
Welcome to Advancing Health. Coming up in today's podcast, why isn't a normal phase of life that affects all women met with more understanding and attention by the medical community?

00;00;13;27 - 00;00;39;23
Julia Resnick
All women who are fortunate enough to live till middle age experienced menopause. Yet for something that impacts half the population, menopause remains one of the most overlooked areas in health care. It's time for that to change. I'm Julia Resnick, senior director of health outcomes and care transformation at the American Hospital Association. On today's episode, I'll be talking with two leaders in menopause research and practice from University of Illinois at Chicago's College of Medicine.

00;00;39;25 - 00;01;03;22
Julia Resnick
Dr. Pauline Mackie is a professor of psychiatry, psychology and obstetrics and gynecology. And Dr. Makeba Williams is a professor in the Department of Obstetrics and Gynecology. Together, they are the leaders of the Center for Health Awareness and Research on Menopause. Also known as CHARM. We'll be discussing why menopause awareness matters and how hospitals can step up to provide better, more responsive care to women as they age.

00;01;03;25 - 00;01;10;13
Julia Resnick
So let's get right into it. Dr. Williams, Professor Maki, thank you so much for being here for this conversation.

00;01;10;15 - 00;01;12;08
Makeba Williams, M.D.
Thank you so much for having us.

00;01;12;10 - 00;01;13;17
Pauline Maki, Ph.D.
It's great to be with you.

00;01;13;20 - 00;01;26;18
Julia Resnick
So let's do a little bit of level setting for our listeners. How does menopause affect women's health as they age and why should health systems and clinicians be paying closer attention to it? Dr. Williams, let's start with you.

00;01;26;20 - 00;02;04;23
Makeba Williams, M.D.
We know that about 1.5 million women will become menopausal every year, and that's half of the world's population. Menopause follows the aging ovary and we see declines in many of those hormones, namely estrogen. Estrogen has an important role throughout the body, binding to more than 300 receptor sites. And as a consequence of the changes in hormones, the changes in estrogen, and the eventual decline, we can see changes throughout many of the organ systems within the body.

00;02;04;26 - 00;02;40;28
Makeba Williams, M.D.
We see changes to our cardiovascular systems, our neurocognitive systems, our muscles, our bones, our urinary systems, brain mood, you name it. There can be many changes. And these changes also present at a critical, pivotal time in a woman's life. And we see this as a window of opportunity to optimize health, to optimize and minimize disease - states that may present during this critical midlife window.

00;02;40;29 - 00;02;54;23
Makeba Williams, M.D.
So this is an important area of health because these symptoms, unaddressed symptoms, can impact overall quality of life, well-being and have social and economic consequences as well.

00;02;54;25 - 00;02;57;16
Julia Resnick
Professor Maki, anything you want to add to that?

00;02;57;18 - 00;03;13;06
Pauline Maki, Ph.D.
I think it's really important for women, both in their immediate lives - what can I do right now to feel better - and also to understand the long term consequences of the decisions that we make at this point in our lives for our long term health.

00;03;13;08 - 00;03;22;19
Julia Resnick
Half of the population experiences this, and it seems like right now menopause is kind of having a bit of a moment in public conversation. Why do you think that is?

00;03;22;22 - 00;03;58;11
Pauline Maki, Ph.D.
I think most of this started when there was an introduction of the first FDA approved, highly effective non-hormonal medication for hot flashes. And with that came advertising at the Super Bowl and the Golden Globes. And people were like, what is VMS?" Paired with that was a highly influential article that came out in the New York Times Sunday Magazine saying, women have been misled about menopause.

00;03;58;13 - 00;04;30;18
Pauline Maki, Ph.D.
And that was the number one gifted article of all articles in The New York Times that year. So women were asking questions. There was a new solution that might have addressed women's fears about using hormone therapy and possible risks to their health. And we hit it. And I would say it's beyond a moment now. It is everywhere. And I think that's a beautiful thing because we're not feeling the stigma that we used to feel about menopause.

00;04;30;19 - 00;04;40;08
Pauline Maki, Ph.D.
We're having the conversation. So now we just need to meet the questions with the appropriate evidence-based answers.

00;04;40;10 - 00;05;07;12
Julia Resnick
Yeah, and I've definitely noticed that too. Like talks of the estrogen sticker are everywhere. And you know, 40 isn't old anymore. It's our generation who's using Instagram and all the other social media to elevate these issues beyond just medical encounters with doctors. Despite all of this, I know there continue to be gaps in awareness in research. So what do you think those gaps are and how can we help fill them?

00;05;07;14 - 00;05;46;21
Makeba Williams, M.D.
Well, we certainly see that there are gaps in medical education, medical training that have left many clinicians, whether it's a physician, a physical therapist across the healthcare spectrum have been left underprepared to meet this increased awareness, the increased demand and self-advocacy that we see many women and patients expressing during this time period. We know that we have to work really hard to meet those existing gaps in medical education and training, so that we are better providing care for women.

00;05;46;23 - 00;06;01;24
Makeba Williams, M.D.
Additionally, we know that there's more research. My colleague Dr. Maki can certainly address that, but there are some clinical and research questions that we also need to be answering while we are meeting these unmet needs and training.

00;06;01;26 - 00;06;04;29
Julia Resnick
Professor Maki, can you talk a little bit about what those are?

00;06;05;02 - 00;06;35;16
Pauline Maki, Ph.D.
It's important firstly to recognize that we do know a lot about menopause. I think we hear, oh, we don't know anything about menopause. And that's just not true. We have guidelines that are, you know, 3 to 4 inches thick because of the amount of evidence-based information we have on menopause. And of course, we need to know more. We know a lot from the Gold Standard Natural history study, which is the study of women's health across the nation, or SWAN.

00;06;35;18 - 00;06;57;11
Pauline Maki, Ph.D.
And that really told us what happens to our bodies that's due to menopause versus the fact that we're getting older versus a combination of the two really important information for women to know. Because if a symptom or a change is menopause related versus if it's aging related, sometimes that can tell us that the treatment is different depending on the cause, right?

00;06;57;11 - 00;07;24;24
Pauline Maki, Ph.D.
So that's really important. But that study was initiated back in the mid 1990s. And our population has changed. Thankfully our scientific methods have changed. They've gotten better. And we also have a better sense of what biomarkers. What should we be measuring in the blood? What should we be measuring in my own work in the brain, for example? And so I think we're ready for an overhaul of kind of the next generation of science on this area.

00;07;24;25 - 00;07;55;15
Pauline Maki, Ph.D.
And in addition, we have some really important clinical questions, a lot of questions about hormone therapy. I think we have a very good understanding of what it's good for and what it's not good for. We have perhaps less of an understanding of the perimenopause. This really for some women and not for all, clearly, 29% of women sail through menopause without a problem, but for some women the perimenopause is really problematic and you know, we don't have any FDA approved medications for symptoms in the perimenopause.

00;07;55;15 - 00;08;13;03
Pauline Maki, Ph.D.
So I think that in particular is an unmet need in women's health. What's the best way to treat the perimenopausal woman who is having a new onset of cognitive symptoms or mood symptoms. How do we best help women along the life course of the menopause transition?

00;08;13;06 - 00;08;30;03
Julia Resnick
Absolutely. And how do we help women so they don't have to suffer through this period of several years? I'm sure that there are differences in how people experience menopause in different communities, in different populations. Can you speak to that at all? And what factors might drive those differences?

00;08;30;06 - 00;09;02;09
Makeba Williams, M.D.
The study of women's health across the nation was a multi-site, multi ethnic cohort study that looked at various groups of women: Chinese women, African American women, Hispanic women, as well as white women to detect differences and how women were transitioning into menopause. We looked at seven different cities across the nation. Cities like Chicago, Detroit, Pittsburgh, Newark, Oakland and Los Angeles.

00;09;02;10 - 00;09;40;01
Makeba Williams, M.D.
And from this study, we gleaned that while menopause is a universal event experienced by women who live long enough with their ovaries, the ways in which these women experience it is very unique. So we saw some differences. Where we saw that women of color, African-American women will experience these hot flashes and night sweats for a longer duration. In fact, it was about ten years compared to white women who experienced these symptoms for 6.4 years.

00;09;40;03 - 00;10;07;19
Makeba Williams, M.D.
We saw differences not only in the duration of symptoms, but also in the intensity as well as the frequency. And though this study is more than 30 years old, we are continuing to glean differences and there is more yet to be learned, because that was seven cities across the country. And we know that the demographics of our country have changed.

00;10;07;19 - 00;10;21;02
Makeba Williams, M.D.
So there is much more to learn. But we know that this is a very unique experience, and we need to pay attention to those cultural factors that drive these differences.

00;10;21;04 - 00;10;38;11
Julia Resnick
My one sentence takeaway is that women are complex, and the experience of being a woman differs by woman. Care needs to be individualized to that person. So I want to make sure we talk about CHARM, the center that the two of you lead. Can you tell us about what that is and what you're learning through it?

00;10;38;13 - 00;11;05;12
Pauline Maki, Ph.D.
So the Center for Health Awareness and Research on Menopause was launched last March in an effort to really consolidate everything that we've been doing in this arena in those mission areas. So we've been raising awareness both individually and through our engagement with different societies. Dr. Williams is the president-elect of the Menopause Society. I'm the past president of that organization.

00;11;05;13 - 00;11;37;12
Pauline Maki, Ph.D.
I'm also the current general secretary of the International Menopause Society. And so it's really important that we have these academic medical society partnerships and raising awareness. And we also recognize that the University of Illinois, Chicago, we serve the underserved in Chicago. And so consistent with our mission, we want to do a lot of awareness raising and research and education that address our patient population's needs.

00;11;37;14 - 00;12;01;06
Pauline Maki, Ph.D.
And this is who we focus on in our studies. This is who we focus on in our educational efforts as well. So we want to continue the research that we've been doing -imagine now for more than 25 years of continuous NIH funding. So we're considered old guard. We've been doing this, it's our bread and butter for quite a long time.

00;12;01;09 - 00;12;41;29
Pauline Maki, Ph.D.
And as one of the largest medical schools in the nation, we're in the top three depending on the year. We have a responsibility to make up for these decades of lack of education. And so we're really paving the way, leading efforts to get funding to introduce the medical school curriculum that all of our medical students need, so that the kinds of stopgap measures that Dr. Williams mentioned, you know, training current providers in the field can really be something we do for just a few years so that the actual training is integrated more into medical school and residency training.

00;12;41;29 - 00;12;52;17
Pauline Maki, Ph.D.
So we have an active portfolio of research and activities in all of those mission areas in an attempt just to do better by women.

00;12;52;20 - 00;12;55;28
Julia Resnick
Fantastic. Dr. Williams, anything you want to add?

00;12;56;00 - 00;13;28;23
Makeba Williams, M.D.
You talked about health care system access. One of our initiatives in CHARM is to look at our clinical care delivery models. With increasing demand for menopause care among women and providers that have been underprepared, this presents a challenge, a challenge to access. When we look at where our gaps in care, it would be accessing providers who are certified menopause providers who have been appropriately trained.

00;13;29;00 - 00;14;07;01
Makeba Williams, M.D.
And so while we are working on training and educating the workforce, we're also looking at deploying creative clinical models that can scale the access gaps. Looking at how do we deploy care right at the point of need in the way that communities need that. That might look like shared medical appointments or group medical appointments so that we can deliver community based cares. Working with community health workers, using innovative technologies and telehealth to meet the rural needs of menopause women.

00;14;07;02 - 00;14;17;09
Makeba Williams, M.D.
So that is part of what we do at CHARM is to serve as a think tank, a testing ground for these innovative care delivery models.

00;14;17;12 - 00;14;37;26
Julia Resnick
So you are clearly looking towards the future of health care in your work, whether it's those care models or training the next generation of the workforce. So as you look ahead to the next to the next guard of menopause care and advocacy, how would you like to see care evolve? And also, what is one thing that you want women to understand about this stage of their lives?

00;14;37;29 - 00;15;12;07
Makeba Williams, M.D.
Certainly, we need to get menopause care out of silos. Menopause is it cuts across organ systems as we talked about, and it can't be relegated just to the obstetrician or gynecologist. We need the dermatologist on board. We need the physical therapists on board, the pharmacists on board, so we need to make sure this care is recognized and delivered across specialties and across disciplines.

00;15;12;08 - 00;15;50;07
Makeba Williams, M.D.
So raising that awareness is critically important so that we can have an all hands on deck situation when it comes to menopause. And I would also like to see that the those experiencing menopause see this as an opportunity to optimize health. Women are going to spend more than 40% of their lives during this time period. So recognition by health care providers and those who are experiencing menopause of the grand opportunity we have to improve health overall is essential.

00;15;50;07 - 00;15;53;03
Makeba Williams, M.D.
And what I would like to see in our future.

00;15;53;06 - 00;15;55;25
Julia Resnick
Fantastic. And Professor Maki?

00;15;55;27 - 00;16;20;17
Pauline Maki, Ph.D.
I couldn't agree more with that. You know, menopause care should be primary care. It's a universal phenomenon for women, right? So that's how we view menopause care at term. But at the same time, we know that if you're a woman with a clotting disorder or with a history of breast cancer, you need a professional like Dr. Williams who really knows how to treat these special and more complicated cases.

00;16;20;17 - 00;16;57;18
Pauline Maki, Ph.D.
So we envision a future where women will be referred when necessary to a menopause specialist, but that really the workforce will be trained en masse to do better by women and to understand the basics of menopause care. This is critically important. I see two technological advances that will help women. There are new technologies that will allow women to measure hormonal dynamics in their home environment, to wear, you know, sensors and wearable devices that will be able to feed objective data forward to their providers to help in their care.

00;16;57;21 - 00;17;28;20
Pauline Maki, Ph.D.
I think we need to be united on the types of symptoms and systems that we measure routinely in women and understand, are we making a difference? We need to measure menopause care effectiveness and to deploy models that really show a high return on investment, both for women's overall well-being and for a hospital system writ large. Because the World Economic Forum estimates that it's $128 billion opportunity in GDP annually.

00;17;28;20 - 00;17;52;27
Pauline Maki, Ph.D.
Imagine that. That's the cost of menopause, largely because women are not performing as well at work and presenteeism and absenteeism become issues. So even if one isn't like we are a cheerleader for women's health, there's just a strong economic argument to be made here. And so we need investment from all sectors.

00;17;53;00 - 00;18;09;24
Julia Resnick
Well, thank you both for being such incredible trailblazers in this field, for raising awareness, for training the next generation of the workforce, so that all women can live long and healthy lives. I really appreciate your sharing your expertise with us. And thank you. Thank you for being here.

00;18;09;26 - 00;18;11;24
Makeba Williams, M.D.
Thank you for having us.

00;18;11;24 - 00;18;14;22
Pauline Maki, Ph.D.
Thank you. It's been great to be with you today.

00;18;14;24 - 00;18;23;05
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:03 - 00:00:13:18
Tom Haederle
Welcome to Advancing Health. Trauma is not a word we hope to associate with childbirth, but it is a reality for many new moms. And it's time we pay attention to it.

00:00:13:20 - 00:00:39:14
Julia Resnick
Welcome to today's episode of Advancing Health. I'm your host, Julia Resnick, senior director of health outcomes and care transformation at the American Hospital Association. Childbirth is usually a joyful occasion, but for some women, it's the beginning of something much more complicated. Even when parents bring home a healthy baby, the birth experience can be traumatic. And when that trauma goes unrecognized or untreated, it can have lasting impacts on both physical and mental health.

00:00:39:17 - 00:01:01:06
Julia Resnick
Today, I'm talking with the directors of Oregon Health and Sciences University's Perinatal Trauma clinic. Doctors Katie Au and Katherine Jorda will explore how trauma shows up during pregnancy, birth and postpartum, and what it takes to build a model of care that better supports healing and recovery. So let's jump right in. Dr. Au, Dr. Jorda, I'm so happy to be here with both of you today.

00:01:01:08 - 00:01:05:15
Julia Resnick
To start, can you help us better understand what perinatal trauma is?

00:01:05:18 - 00:01:27:15
Katie Au, M.D.
Yeah, I'm happy to start. Thank you so much for having us. It's really a pleasure to be here today. So perinatal trauma can really encompass someone that's had a traumatic birth experience. Which about 1 in 3 parents, are considering their birth experience to be traumatic. So that's a lot of pregnant people and new parents.

00:01:27:18 - 00:01:40:10
Katie Au, M.D.
And about 10% of birthing patients go on to develop the perinatal PTSD, which is like a little bit more of a persisting condition, that can affect folks postpartum and sometimes years after the event.

00:01:40:13 - 00:01:48:00
Julia Resnick
That is a huge proportion of people who give birth. And yet, as a society, I feel like we barely talk about this.

00:01:48:02 - 00:02:13:15
Katie Au, M.D.
Yeah, I would definitely say that that's true. And if we think about, you know, pregnancy and birth, it is one of the most monumental milestones in someone's life. Everyone remembers the moment that they became a parent or met their new baby. And the majority of pregnant patients are people that are young and that are healthy and have never needed to be in a hospital or have an IV, or maybe have never had a surgery before.

00:02:13:17 - 00:02:36:03
Katie Au, M.D.
And many of those things can happen in the childbirth process. And so, a lot of those things can be unexpected. Most people, when they become pregnant, don't anticipate having a complication or something that is difficult or challenging in their birth. And so it's hard to prepare for those things. And for many folks, it's the very first time that they have interacted in the medical system in this way.

00:02:36:03 - 00:02:51:27
Katie Au, M.D.
And it can be extremely challenging. And, when you experience those things at the very same time as becoming a parent for the first time, it can feel really isolating and, you know, be an extreme challenge, in the journey of becoming a new parent.

00:02:51:29 - 00:02:54:27
Julia Resnick
Absolutely. Dr. Jorda, anything you want to add there?

00:02:54:29 - 00:03:17:05
Katherine Jorda, M.D.
I do think some of the societal norms around pregnancy and birth are very rosy, and I do think it makes it hard when a patient finds that their experience is not rosy. They're like, what just happened? Has this ever happened to anybody else? This was not my expectation. And it can come out of left field for a lot of patients.

00:03:17:12 - 00:03:38:23
Julia Resnick
Yeah, I think a lot of people are not prepared that pregnancy and giving birth is really a major medical event. And so when something does go wrong, they feel like it's abnormal when actually it's more the norm. So when we talk about perinatal trauma, it can really look different from person to person. So what are some of the ways that it shows up both during pregnancy and during postpartum?

00:03:38:25 - 00:03:59:12
Katherine Jorda, M.D.
Yeah, I think for a lot of patients, it can come up in a lot of different ways. I think patients who have had a traumatic birth sometimes don't even want to get pregnant at all. They don't necessarily want to come back to the hospital or the clinic where they had a traumatic birth, so they might be lost to follow up.

00:03:59:17 - 00:04:10:22
Katherine Jorda, M.D.
And if they do decide to get pregnant, they might be very hesitant to interact with medical system again after a prior negative experience.

00:04:10:24 - 00:04:13:29
Julia Resnick
Dr. Au, anything you want to add there?

00:04:14:02 - 00:04:36:17
Katie Au, M.D.
I would say that, you know, having a perinatal mood issue can be really common. But that can also be common with a birth that goes really well without complications. So for some patients, we see postpartum blues or anxiety or postpartum depression. With perinatal PTSD, we often see patients that have symptoms that last longer than a month postpartum.

00:04:36:17 - 00:05:01:26
Katie Au, M.D.
The perinatal PTSD symptoms, often show up as reliving a traumatic event or having some more intrusive thoughts, or maybe nightmares. Many folks have trouble with sleep and might have avoidant behavior. And sometimes we see folks that really have trouble bonding with their infant and their child, and those can persist throughout the that first year, that first postpartum year of life.

00:05:01:28 - 00:05:17:27
Katie Au, M.D.
But often many years afterwards. And it's not infrequent that Dr. Jorda I see patients who maybe have changed plans for their families or have decided to delay childbearing, or maybe just have their one child because they're still affected by their symptoms many years out.

00:05:18:00 - 00:05:28:25
Julia Resnick
So I know that your perinatal trauma clinic is one of only a few of its kind in our country. Can you walk us through how the clinic works? What it's like for patients who come to you for care?

00:05:28:27 - 00:05:56:00
Katherine Jorda, M.D.
Sure. Kind of started a few years ago. Both Doctor Au and I worked at the Portland Veterans Administration's hospital. And so unfortunately, a lot of veterans have experienced military sexual trauma. And we had to learn about trauma informed care, which is a framework of taking care of patients, recognizing that prior traumatic experiences might be impacting their current physical and mental health.

00:05:56:05 - 00:06:28:03
Katherine Jorda, M.D.
But we received a lot of on the job training and experience there, and it wasn't really a part of our formal medical student or OBGYN resident curriculum. And we took care of a lot of patients and realized, gosh, there is a role for trauma informed care, too, in obstetrics. Let's set that up. We submitted a grant to start our clinic, and we made the case that patients who've had a traumatic birth need more of a multidisciplinary approach.

00:06:28:06 - 00:06:59:19
Katherine Jorda, M.D.
We are lucky at our institution that we have a robust reproductive psychiatry department, and so patients who've had a traumatic birth would go see our psychiatry colleagues, and then they would see us in obstetrics for either pregnancy care or postpartum. But we found that they were having to tell their story multiple times to different providers. And sometimes patients would ask me about mental health issues that I could try to field, but didn't have as much experience as my psychiatry colleagues.

00:06:59:21 - 00:07:43:06
Katherine Jorda, M.D.
And the same for my psychiatry colleagues. They'd get questions about their birth, and they were like, I just don't feel equipped to answer that. And gosh, could we get all the same players in the room so that the patient could share their story just one time and have both kind of aspects weighed in. And so we started a multidisciplinary clinic where we see patients who have had a history of a traumatic birth or delivery planning and we see them in our clinic, both general OBGYN, myself or Dr. Au, and one of our reproductive psychiatrists or psychologists all together in the same room to do a longer more comprehensive visit.

00:07:43:13 - 00:07:58:28
Katherine Jorda, M.D.
So typically, these visits are twice as long as our routine prenatal care, because we found that we needed the time to delve into both an obstetric history and psychiatric history and develop a plan for the future pregnancy.

00:07:59:01 - 00:08:02:10
Julia Resnick
That's wonderful. Dr. Au, anything else?

00:08:02:12 - 00:08:44:06
Katie Au, M.D.
Yeah, I would just say that, you know, we find that medical care is so siloed and it's like that in so many different specialties or aspects of care. And that's the same for reproductive health and mental health care. And, you know, Dr. Jorda and I would frequently see patients postpartum who really wanted to talk about how it felt to have postpartum hemorrhage or to have an unplanned C-section, and were really good at talking about why someone had extra bleeding or what exactly was happening in the room during their C-section, but not as well equipped to handle the mental health aspects and help folks process that.

00:08:44:08 - 00:09:06:17
Katie Au, M.D.
Same for a reproductive psychiatrist. They're so wonderful at, you know, accessing those mental health resources and tools and making sure that patients are safe and have a plan for follow up. But they didn't really understand why someone had a hemorrhage or why someone had an unexpected C-section and had a hard time answering questions that the patient would naturally have about, you know, will this happen to me again?

00:09:06:19 - 00:09:31:27
Katie Au, M.D.
What would it look like if I got pregnant again? And we just found it to be so incredibly valuable to all be in a room together where we could go through someone's birth experience if or when they feel ready and answer all their questions about what happened during their labor or their birth, or why certain things happen the way that they did, and real time be able to support them best in a mental health capacity.

00:09:32:00 - 00:10:07:18
Katie Au, M.D.
So it just felt really nice to be able to bring those services to patients at the same time. And as Dr. Jorda mentioned, you know, not having people have to relive their trauma multiple times and tell their story to numerous people, was extremely valuable. And I think that's been one of the strengths of our program is that we've identified a safe space so that patients know that they can have someone who's both knowledgeable about the obstetric details, and then also someone who is attentive to the mental health aspect of care, because really, birth trauma is all encompassing like that.

00:10:07:18 - 00:10:11:11
Katie Au, M.D.
And we needed a space to be able to address all of those things at the same time.

00:10:11:13 - 00:10:25:24
Julia Resnick
Absolutely. And I can imagine that there is a like, you need to rebuild trust with patients so that they're trusting the medical system again. What does it take to create that trust and sense of safety, so that you're not just retraumatizing someone with their next birth?

00:10:25:26 - 00:10:50:05
Katie Au, M.D.
I think it all stems with having an open mind and not being defensive about the care that someone has had, or the outcome that someone has had. You know, I can't tell you how many times Dr. Jorda and I will see a patient and they feel really guilty saying that they had trauma related to their birth, or that they were disappointed in their experience because maybe their baby was perfectly fine and very healthy, and they were perfectly fine too.

00:10:50:05 - 00:11:08:09
Katie Au, M.D.
But that doesn't change the fact that the C-section was really hard or really traumatic. And someone feels guilty for sharing those thoughts, or feeling like it was a traumatic experience when, you know, family members will say, but you're healthy and your baby is healthy and your baby's fine, and you guys are both alive, so it's okay.

00:11:08:16 - 00:11:29:10
Katie Au, M.D.
It just brushes off those complex feelings that people have, because you can be really happy about an outcome, and you can really love your family and really love your baby. And you could at the same time be very traumatized by the experience. And both of those things can be true. And I think it just starts with acknowledging that and letting patients know that those things can both be true.

00:11:29:10 - 00:11:34:20
Katie Au, M.D.
And you recognize that you understand that, and you're here to help them.

00:11:34:23 - 00:11:51:27
Julia Resnick
Really normalizing their experience. Hopefully that helps with some of that guilt. So I'd love to talk a little bit about the impact that you've seen. Either through data you're collecting or patient stories. It really illustrates the difference about what this type of care can make for patients.

00:11:51:27 - 00:12:18:20
Katherine Jorda, M.D.
I can think of one patient who is a nurse by training and had a traumatic birth and delivery. We were seeing her for postpartum care and kind of processing all of that, and she had so much guilt about it. She's like, I'm part of the medical field, and I thought that knowing how the medical field works, I should be able to advocate for myself.

00:12:18:20 - 00:12:38:03
Katherine Jorda, M.D.
And I'm a nurse. I advocate for patients all the time. But when you're a patient and you're laboring and you're trying to push out a baby, I mean, those are a lot of identities colliding, and it can be really hard to advocate for yourself, even if you know what the medical system is like and you are a patient.

00:12:38:11 - 00:12:42:00
Katherine Jorda, M.D.
And our patient population often doesn't necessarily interact with

00:12:42:07 - 00:13:13:05
Katherine Jorda, M.D.
the medical system unless they're giving birth. And so I think it can be a really unfamiliar position for patients that can be very, very challenging to navigate. There's also that element of during my pregnancy I had control, I could exercise, I could, you know, optimize my health in preparation for this pregnancy and birth. But now I'm trusting these individuals in this hospital that I may or may not know the delivery team, to help me get through this.

00:13:13:05 - 00:13:40:03
Katherine Jorda, M.D.
And so when things start to go sideways or, gosh, this C-section for this reason wasn't part of the plan or expectation, it can be very difficult for patients. And so as we talked about this person's experience, we tried to normalize and share that. Yeah, maybe you are a nurse, but you're not a nurse and you're a patient at that time, right?

00:13:40:03 - 00:14:03:26
Katherine Jorda, M.D.
Like you can't have such high expectations for yourself and, try to kind of lift that guilt and kind of put it in a perspective. And so we were able to talk and plan for the next pregnancy. And when patients see us, they can continue seeing us for routine prenatal care. Or it can be a one time consultation to develop a trauma informed care plan.

00:14:03:28 - 00:14:25:05
Katherine Jorda, M.D.
So this patient continued on with us and we were able to be there for this patient's delivery and see them postpartum. And it was just really nice for her to have that shorthand of, hey, I've shared my experience with this team. They know what were the activating factors, they know what was hard for me as a nurse.

00:14:25:10 - 00:14:34:10
Katherine Jorda, M.D.
And here's what we did as a team, and here's a plan, and here's how we can kind of mitigate some of those things that had come up in her prior delivery.

00:14:34:13 - 00:14:53:02
Julia Resnick
That is a really powerful example of you know, what happens when you can integrate behavioral health and physical health. It's better for everyone. So not all hospitals are so fortunate to have a perinatal trauma clinic like yours. So for those who don't, what are some practical ways that providers can recognize and respond to trauma?

00:14:53:04 - 00:15:18:20
Katie Au, M.D.
You know, I think it really goes back to naming it, calling it out, recognizing it and asking about it. So, I mean, if, you know, 1 in 3 birthing patients is experiencing some amount of trauma or dissatisfaction with their birth, that's many of the patients that we're seeing. So we need to ask about it. We need to, you know, it's pretty routine to do, you know, anxiety, depression, mood screening and postpartum visits.

00:15:18:20 - 00:15:41:10
Katie Au, M.D.
But I wouldn't say that it's routine for everyone to be asking how a patient's birth experience was like, how satisfied were you with your care? Are you having trouble sleeping? Does it make it difficult to think about a next pregnancy? But I, I think we should be asking those questions and making sure that patients questions are answered about their birth experience as well.

00:15:41:12 - 00:16:04:12
Katie Au, M.D.
I can't tell you how many times we've seen a patient who you know is scared to get pregnant again. But if someone had just explained what it was that happened to them last time, and that that's not likely to recur again, or you know, even just understanding what it was that they went through their mind is sort of blown in a way that they're like, wow, I had no idea that that was, you know, something that likely wouldn't happen to me again.

00:16:04:12 - 00:16:30:28
Katie Au, M.D.
And I think about pregnancy in the future in a completely different way. So I think talking about it, you know, recognizing it, I mean, it's something that's just so common and yet there are so few people addressing it. It's a disservice to birthing families. And we really need to be addressing these things. And from a systemic perspective, thinking about how do we prevent birth trauma and how do we treat it in a respectful and compassionate way?

00:16:31:00 - 00:16:55:07
Julia Resnick
And I am sure if there are any new parents who are listening to this who have had a traumatic birth experience, they will feel less alone. And hopefully providers will hear this and realize that there are some straightforward things they can do to help their patients feel safer to create better birth experiences for everyone. So Dr. Au, Dr. Jorda, thank you both so much for the work that you do for your patients, for sharing your expertise with us.

00:16:55:09 - 00:16:59:03
Julia Resnick
This has been a really great conversation and I just appreciate both of you.

00:16:59:05 - 00:17:00:11
Katie Au, M.D.
Thank you so much.

00:17:00:13 - 00:17:01:23
Katherine Jorda, M.D.
Thank you.

00:17:01:25 - 00:17:10:06
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.