The director of the new Division of Adolescent/Young Adult Medicine at Johns Hopkins Children’s Center talks about her experience as a pediatrician, her focus on diseases that affect teens’ reproductive health and the impact of racism on children.
What led you to pediatric medicine?
As a child, I planned to become a psychiatrist after watching a family member struggle with mental illness. I majored in psychology in a pre-med program at Yale, served as a research intern for the Institute of Government at Dorothea Dix Psychiatric Hospital in North Carolina, and studied fluctuating dermatoglyphic asymmetry in schizophrenia for my undergraduate thesis project. During medical school at the University of North Carolina, however, I began to care for adolescents in unexpected places. One of my most significant experiences was in labor and delivery at a community hospital where I observed an adolescent deliver her first baby. I remember how difficult the experience was for her, because she was alone and people did not seem to understand how to communicate with or coach her through the birth process. These kind of experiences with young people resonated with me, and my interests began to shift when I realized that I would continue to need behavioral health skills as an adolescent medicine physician.
My plans solidified during my pediatrics residency at Children’s National. The adolescents just picked me. They gravitated toward me in our primary care practice at George Washington and sought me out when they needed care within the main hospital. There was a busy adolescent medicine inpatient and outpatient service, and I loved it so much I rotated through the adolescent medicine service twice as a resident. After residency, I completed an adolescent medicine fellowship at Boston Children’s Hospital and obtained a master’s in public health from the Harvard School of Public Health to prepare for a career in both clinical medicine and research.
And in practicing pediatrics at Johns Hopkins Children’s Center?
Yes. In 2001 after fellowship, I came here for my first job in adolescent medicine as an assistant professor. I literally grew up professionally here at Johns Hopkins — that’s the short story.
The long story?
In adolescent medicine, we were trained to deal with a whole host of issues in adolescent health. My plan was to focus on reproductive endocrine disorders like polycystic ovary syndrome [PCOS], a common disorder characterized by the loss of regular menstrual periods, that can result in infertility issues among affected women. Menstrual cycles are important vital signs for young women and opportunities to assess overall health. I like the detective work of figuring out what kinds of diseases could be disrupting the menstrual cycles of young women, and that disorders like PCOS are important areas of study because of their adverse impact on health-related quality of life. Also, in my practice I partner with the patient, as together we are often able to get ahead of complications and improve long-term outcomes.
What did you figure out?
I realized early on that sexually transmitted infections [STIs] — especially complicated ones like pelvic inflammatory disease [PID] — were a significant threat to reproductive health and fertility for young women in high STI prevalent communities like Baltimore. I have spent the last 17 years trying to develop innovative ways to take care of teenagers with PID. It started with quality improvement work after realizing that providers both locally and nationally did not consistently follow the Centers for Disease Control and Prevention [CDC] treatment guidelines for clinical management. Once we had a strategy to improve the care by clinicians, our grant-funded work shifted to helping affected patients take better care of themselves in the outpatient setting. In the past, we admitted all PID patients to the hospital, mobilized clinical staff to provide support and education, and had a lot of face-to-face engagement as they prepared for self-care. Research later suggested that this approach wasn’t cost-effective. Here I saw an opportunity to review that data and to develop a new approach.
What did you find?
First, we conducted analysis data demonstrating that most of the patients in the adolescent cohort of a national study were not early or middle adolescents, so we still knew little about their needs. We found that adolescents in the study with current disease were more likely to develop chronic pelvic pain than adult women, but that overall, women with PID in the United States were at risk for recurrent disease, chronic pelvic pain and infertility. We then conducted a series of health economics studies that demonstrated the significant direct costs of hospitalization compared to ambulatory treatment. Adolescents still want more careful care than health providers anticipated, and adolescents and parents would trade time and money to prevent the adverse outcomes of PID. Our team realized that despite the shifts in national guidance promoting only outpatient care, we needed to use older strategies in novel ways to meet these patients in the community to deliver the necessary follow-up care.
By using technology-enhanced community health nursing to deliver PID care in the community, we were able to increase the likelihood of receipt of PID care per the CDC guidelines and reduce acquisition of chlamydia and gonorrhea at follow-up. We are expanding this work through collaboration with the Johns Hopkins International STD Laboratory to bring novel diagnostics to our population of patients for more-precise diagnoses and personalized care. We are also examining the impact of personalized PID treatment on the microbial genomics of the vagina, in collaboration with the Institute for Genome Sciences at the University of Maryland.
So, you were looking at technology, too, for answers?
Yes, we have been using advances in technology through text messaging and online platforms to improve patient engagement and to help patients take better care of themselves. We are also moving to virtual formats to bring innovation in health technology to young people who are wired and online.
Another continuing concern has been the impact of racism on children’s health.
Yes, my work addresses the observed racial/ethnic disparities in health and health care related to STIs and PID. In addition to this work, I have been training health professionals in cultural competency for over two decades.
How have we addressed it?
In adolescent medicine, we have developed a program to train health professionals in cultural competency and communication using a variety of teaching techniques. One of the most effective approaches has been to use the Johns Hopkins simulation center to allow pediatric trainees to practice managing cultural communication and use of interpreters. When we engage in this work, we have to ask ourselves if we are working and living in line with the principles we embrace. How do we talk to and treat our adolescents? How do we interface with young people in public spaces? For parents and families, we focus on what kind of advice and guidance around race and racism we should be giving them.
How did you determine the answers to those questions?
When I was the former training director of the DC Baltimore Research Center on Child Health Disparities, we conducted a series of listening sessions at large national meetings held by the Pediatric Academic Societies, the American Academy of Pediatrics [AAP] and the National Medical Association. These were partially driven by the crisis experienced with youth in Baltimore after Freddie Gray’s death. These sessions gave us an opportunity to share information and engage pediatric leaders in strategic thinking about how we were going to begin to address these issues. It became clear that to move forward, a policy statement was needed to guide organizations to embrace the work.
Through the AAP Section on Adolescent Health?
Yes, I served on the executive committee for the section for the last 10 years, the last four years as the chair. I was able to work with our leadership group to create a successful proposal to develop a policy statement on the impact of racism on child and adolescent health, and to work with a writing team with colleagues from the Council on Community Pediatrics and the Committee on School Health to develop a product that pediatricians could use to create change for young people. We thought about race from a historical perspective, and examined its impact over time in health, housing, education, justice and childhood development. The policy was released in 2019, around the same time as a gunman in El Paso, Texas, targeting Latinos opened fire in a store, killing 22 people as they went about their day. It was a moment when our team saw the hard work that went into this policy lead to a usable document for the academy to mobilize pediatrician members and others around racism. I am really proud of the research center and the Section on Adolescent Health for taking the lead on this issue. We will receive an award for our work from the academy leadership at the annual leadership forum in August.
What general issues does the policy statement address?
We examine the impacts of structural, personally mediated and internalized racism on child health. We identify strategies that pediatricians can use to dismantle structures girded by racism and to help patients and families navigate experiences using a trauma-informed approach.
How do young children react to discrimination and racism?
Children can see the subtle differences in people around them starting in infancy, so the impact of parental and societal behavior begins early. They see what their family looks like, and as they grow and move through society, they see the variation in packaging that we all have. The problem is that they also start to observe how adults assign value to different groups of people based on their packaging. Racism is a socially transmitted disease because it is taught and passed down, but the impact on children, adolescents and families is significant from a health perspective. Until we start to value the differences in people and to make difference normative, we will not be successful in creating a better world for the next generation.
What is the impact of racism on health and well-being?
There is this ongoing stress of living with racism that can lead to biological changes such as inflammation and hormonal dysregulation. Perceiving that they are living in a threatening world, children may exhibit behavioral characteristics such as hypervigilance and remain in a crisis mode, all the time unable to resolve or predict the next threat. What is quite painful to witness is when children begin to internalize racism — they see so much negativity about people like them that they develop negativity about their own identity. Experiencing or witnessing victimization over time impacts who people become.
What can pediatricians do?
Pediatricians can begin by improving their own behavior in clinical care practice, emphasizing that all children should receive the best quality of care. Doing that requires that we examine our own biases, acknowledge the role of racism in child and adolescent health, and then commit to proactive change that leads to strategies that optimize clinical care, training behaviors and research to reduce the health effects of all forms of racism.
What kinds of strategies?
While the policy statement outlines them in great detail, an easy first start is to make sure that everyone feels welcome in the pediatrician’s office. Are there images of diverse families on the clinic walls and multicultural books, videos and toys in the waiting area? Are staff diverse and able to deliver culturally and linguistically appropriate services to all families? Are you performing quality assurance assessments to determine if your patients are having similar outcomes regardless of race, and are you acting to improve quality when possible? It is also important that pediatricians get involved in their communities to advocate for policies that can improve child health outcomes in other critical areas of development. Many of us work in education, justice settings and public health settings as advocates for the basics such as clean water, access to food, housing stability, educational equity and safe neighborhoods.
How does it feel to be leading this new division of adolescent medicine?
It is really my great honor to lead this division and work with a diverse team to serve the community and build health resources that young people and families need across our region. I am also excited about collaborating with the Bloomberg American Heath Initiative to approach improvements in adolescent and young adult health from a public health perspective.
Any closing thoughts?
As pediatricians, our goal is that every child we care for should be able to reach his or her optimal development. Right now, the world may seem uncertain to many young people, as the COVID-19 pandemic has transformed their everyday experiences with school, social interactions and activities. I have believed, before it was taught to me, that adolescents and young adults deserve a doctor of their own who embraces the beauty in the changes associated with adolescence.
In the Division of Adolescent/Young Adult Medicine, a team of clinicians helps youth and families manage the changes and challenges of adolescence and achieve the healthiest outcomes possible. Division clinicians provide primary and subspecialty care to adolescents and young adults through their 26th birthday in the Center for Adolescent and Young Adult Health Care in the Harriet Lane program and support clinical management of adolescents admitted to Johns Hopkins Children’s Center. In addition to general adolescent medicine, our providers have expertise in STI/HIV management, reproductive disorders (e.g., they provide menstrual management and contraceptive management), male health, substance use disorders, disordered eating, chronic fatigue, and health care for sexual and gender diverse patients. For more information or to make an appointment, call 410-955-5710.