A conversation with Dr. Tanilla Brown, a pediatrician and Internal Medicine doc who thinks about the challenges of enough time with patients, family-focused care, and the lifespan of transition.
Welcome to this eleventh episode in a series about Young Adults with Complex Medical Conditions Transitioning from Pediatric to Adult Medical Care.
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Pediatric Home Service A Multifaceted Process: Transitioning a Medically Complex Child into Adulthood
Music by permission from Joey van Leeuwen, New Orleans Drummer, Composer
About the Show
Welcome to Health Hats, empowering people as they travel together toward best health. I am Danny van Leeuwen, a two-legged, old, cisgender, white man with privilege, living in a food oasis, who can afford many hats and knows a little about a lot of healthcare and a lot about very little. Most people wear hats one at a time, but I wear them all at once. We will listen and learn about what it takes to adjust to life’s realities in healthcare’s Tower of Babel. Let’s make some sense of all this.
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Tanilla: I think one of the biggest things that I feel like I need when I’m meeting anybody new is time. I wish I could have as much time as I think I need, that the patient thinks that they need to address all the things on my item list, all the things on the patient and the family members item list. It always feels like there’s never enough time to do what you need. Tanilla Brown, MD
Welcome to Health Hats, empowering people as they travel together toward best health. I am Danny van Leeuwen, a two-legged, cisgender, old, white man of privilege, living in a food oasis, who can afford many hats and knows a little about a lot of healthcare and a lot about very little. Most people wear hats one at a time, but I wear them all at once. We will listen and learn about what it takes to adjust to life’s realities in healthcare’s Tower of Babel. Let’s make some sense of all this.
Expecting a lot
Health Hats: So far in this series, we’ve heard from people with complex illnesses and a parent. Today, I’m talking to a physician, Tanilla Brown. Dr. Brown is both a pediatrician and an Internal Medicine doc, a bridging perspective. As we’ve heard in the series so far, the effective transition is a partnership of the whole team, lay members and professional members. The stories lay people tell often range from awkwardness in the transition to extreme frustration. They expect a lot from medicine and are often disappointed. Do we expect too much from doctors and health professionals? Can they really provide what might be needed? Sometimes I think there are similarities to what we expect from schools and teachers. Sometimes we expect teachers to raise our kids. But how can they within the business of education, with testing, with 20 or more kids in the class, with our allergy to taxes? ? How can docs really be effective in transition with 15 minutes allocated for each visit? They specialize in medicine, not life. This interview with Dr. Brown occurred at the Harvard Medical School/Boston Children’s Hospital conference: Young Adults with Chronic Conditions Optimizing Treatment and Transition from Pediatric to Adult Care. The audio quality is fair. Lunch was being served while we chatted. A perspective from a physician.
Introducing Dr. Tanilla Brown
Health Hats: Hello. I’m here with Tanilla Brown. Tanilla, if you were at a social event and you were introducing yourself, how would you introduce yourself?
Tanilla: I usually tell people my first name, Tanilla.
Health Hats: What do you tell them about what you do?
Tanilla: I am a primary care physician in the New Haven area. That means I’m the first person you go to when you’re sick, or if you need help getting regular medical care and I see adults and kids in New Haven who are looking for a home health care home.
Health is fragile. A Giant falls
Health Hats: Couple of different kinds of questions. So personally, what was happening to you in your life the first time you realize that health was fragile?
Tanilla: Let me think about that for a moment? I’m trying to think of the very very first time. Probably the first time it hit me how quickly things can change would be when my grandfather started to get sick with dementia and started going downhill. My family’s from Jamaica. A typical story where the grandfather retired, he’s home. Everybody’s kids went to his house after school. And so he watched me. He made my meals. He was a very important caretaker — a very strong big muscular ex-railroad worker from the island with a lot of personality. I remember thinking of him is so strong and so much bigger than me. I used to think when I was a kid that adults just grew forever into giants. That’s where giants came from because my grandfather was so large. Then, by the time I was going to medical school, I was down in North Carolina. Things declined pretty rapidly. I would come home only periodically because of the distance. It felt like he was shrinking away. Then my mom calls me and tells me that he’s passed on. I was in the middle of my internal medicine outpatient rotation. Being very black and white, factual about it and in the middle of the sentence, I just burst out in tears. Not a preceptor that I had a close relationship with. I think it all of a sudden hit me like, “oh my is really gone.” I was just amazed to see how what a quick impact that had a chronic disease. The strongest giant that I knew.
What does healthy look like?
Health Hats: Wow. Here, you’re a seasoned physician and you’re straddling these worlds. Has your view of what is the state of health? What does that look like to you now, as opposed to before you’ve had all this experience as a doctor?
Tanilla: You’re right that my understanding of wellness and healthy living has changed after medical training. I think perhaps when I was a teenager, it was mostly informed by television, the media. To be healthy is to be slim and running. Exercising all the time and eating all the right things. I think health now means to me – living your best life. There are going to be people that are healthy that when you look at their outward appearance, they might look frail. They might be differently-abled than me. They might not be able to run a marathon, but they are living their life with purpose. They’re able to feel fulfilled and happy. Any time I could help a patient do that. That’s what I’m after. Right. That’s what I’m trying to get to.
What brought you here?
Health Hats: We’re here at the Harvard Medical School Young Adult Transitioning from Pediatric to Adult Medical Care Conference. What motivated you to come to this conference?
Tanilla: It was on the recommendation of a colleague in the Pediatrics Department. She pitched it after she came back from another Harvard CME. It seemed perfectly suited for what I do since I do see adults and kids. Of the providers in the adult practice, I probably have a younger panel because the pediatricians there know me and they’re familiar with how I am. They know that I’m comfortable with kids. So I get a lot of the straight out of Peds referrals to IM as well.
Health Hats: IM is Internal Medicine?
Tanilla: Yes. I was interested to see what are the specific topics that might help me make those transitions smoother and in particular because it’s also about kids with chronic disease, kids with special needs. So helping reset my barometer about what are the key health care things that I need to be focusing on for this particular special patient population?
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Queen for a day. Changes in practice.
Health Hats: If you were Queen for a Day and you had your magic wand and let’s say a couple of things could change in your practice to help you help young adults and their family members transition? What would those be?
Tanilla: I think one of the biggest things that I feel like I need when I’m meeting anybody new is time. I wish I could have as much time as I think I need, that the patient thinks that they need to address all the things on my item list, all the things on the patient and the family members item list. It always feels like there’s never enough time to do what you need. What drives time? Well, we have to have a certain amount of productivity. We have to see a certain amount of people a day. So time is a constraint. We’re always trying to figure out creative ways of expanding time or making time feel like it’s expanded even though it constricts us. That’s one thing in my world what I feel like I would enjoy the most is to have more time face-to-face with patients. Talking with patients so I could get to the bottom of things in real time instead of having to come back to it later. The other thing I think would help families transition better in my particular site would be a better understanding of who else in the adult medicine/Internal Medicine Clinic is comfortable accepting younger patients. Especially patients with complex medical histories. So there are a lot of correlates between peds and adult medicine like asthma, inflammatory bowel disease, diabetes. I think pretty much any Internal Medicine provider feels comfortable with those topics, but things that maybe don’t get taught as much in Internal Medicine would be G-tube management.
Health Hats: G-tube = gastrostomy tube – a tube that goes directly into the stomach to feed a person with problems with their gut.
Tamilla: What to do if weight is not going up? How to prevent spasticity, ulcers in kids that have mobility restrictions. So one thing is for families to be able to know who else knows that besides just me at our office. The second thing would be helping my internal medicine colleagues who aren’t familiar with those things to become familiar with them to the point that they might feel comfortable taking on those patients or at least getting resources together so that if they felt out of their depth that they know where to go.
The lifespan of transitions
Health Hats: Interesting, I told you that I’ve been interviewing young adults and their parents. One of the themes that they have is that there isn’t one transition. There’s a series of transitions and that one of their challenges working in the medical system is that doctors and clinics think black and white. Nineteen years old – time for a transition. As opposed to six years old and there’s a transition. Ten years old and there’s another transition. That age isn’t necessarily the right signal that it’s time for a transition. So you bridge both worlds. How how do you see that?
Tanilla: I think you’re right. It might come in as well from insurance changeovers and things like that. We get this age cutoff, but development is a spectrum that happens throughout the lifespan. The way that I interview and examine newborns is different than how I would approach a two-year-old; is different than how I would try to interview five or ten-year-olds. You’re right. There is a lifespan transition that’s happening. One of the things I’m picking up from this conference is to make that a bit more concrete to pediatricians that I work with and the families that I work with to say to be thinking earlier on: “you’re ten now. You’re getting into that adolescent range. I want you to start thinking about having your own list of things you want to bring to the table.” It’s one thing that the conference is prompting in me is about discussing this earlier. So because it is a spectrum and we think there are benefits to starting to introduce that topic earlier. It’s not supposed to be so black and white. If we can make it a little bit more pastel and watercolors, it won’t feel so jarring to family. One of the other concepts that have been brought up is about this abandonment idea. I don’t think on the provider side it’s hard for us to and I don’t think we want to let go. When you’re the internal medicine doctor receiving, you want to have a good relationship. You want to have a good vibe with the patient. We don’t want anybody to feel like they’re being cut off and tossed to the wind. I think part of making it less of a distinct endpoint and softening it a bit would sometimes help with families feeling so alienated from their old provider.
Perceptions about Internal Medicine
Health Hats: So last question, then I’ll let you go. Here we are at this conference. What should I be asking you about, related to young adults who are transitioning from pediatric to adult care?
Tanilla: I would most like to address would be the perceptions about Internal Medicine being uninviting to families or harsh for families. I’ve heard this before. I’m Med/Peds-trained. I spent 50/50 of my time three months in Pediatrics, three months in Internal Medicine. Back and forth for four years, all throughout my residency training. You hear it on both sides, What are pediatricians like? What are Internal Medicine doctors like? So I’m familiar with that idea. I want young adults to know that the internal medicine clinics are full of very smart and friendly and fun to hang around people who aren’t going to be mean or harsh and that we value families very much. Family participation is as important as in pediatric clinics. We involve or emphasize families in a slightly different way. But I haven’t met anybody, so far, in my internal medicine colleagues or in my training where they wouldn’t want family involvement or that they’re going to all of a sudden like put the smackdown on a teenager. If anything, it’s to let people know that, we’re excited to meet you in the internal medicine world. We’re excited to meet young adults and help them live their lives as well as they can. Families are welcome. We do still think of the comprehensive patient, the whole patient, which means their relationships with their families. I think parents are welcome as well. We may want you to speak up more for yourself maybe than the pediatrician might. But it certainly is a welcoming environment for family involvement. It’s a team that helps you be well in the real world. That’s what I want to say.
Health Hats: Well, that’s brilliant. Thank you.
Tanilla: Thanks for talking with me. Yeah, really is a pleasure. Thank you.
Closing: The time is gone
Health Hats: I appreciate that Dr. Brown, Tanilla, brought up the issue of time. When I did an unscientific survey of people who were managing (making decisions) about chronic pain, the most common frustration was not having enough time with doctors who listen and work together to find solutions with people with pain. Now, as I work on a project about patient-centered clinical decision support (fancy words for using electronic tools in making decisions together) the subject of time comes up. There is this idea that technology might make things more efficient (run more smoothly and take less time). I have my doubts. Can anything replace the moments of mutual engagement, face-to-face? Yes, video chats, text messaging, online frequently asked questions, a plan that anyone a person chooses can use and access all help. But they take time to learn and the state of sick is a bad time to learn. We still need time, more time. This is a function of the business of healthcare and of policy. It’s also another topic for another day. Still, I appreciate Dr. Brown recognized and highlighted this frustration.