Trailblazer in Maine Medicine: Dr. Barbara Crowley

This is Barbara Crowley. She is a leader of the Peter Alfond Endowment Programs at Maine General Medical Center and also trained as a pediatrician. Thanks for coming. You're welcome. Nice to be here. I always enjoyed working with you, Barbara, because your view of health was very much in alignment with my view of health, which is not everybody's view of health. So I guess I want to start there because I mean you're trained as a pediatrician. I'm trained as a family physician, but health is so much more than the clinical interactions that we have with patients. Talk to me about this. So it's interesting because when I first started practicing, I think I concentrated more on the clinical aspects, but I had a wonderful opportunity. The first job I had was on the Navajo reservation, and I came with thinking, I have some skills as an allopathic physician only to find that if you're really going to have an impact on a community that was in the midst of a cultural shift, the native practices were important, you needed to be engaged with them. The conditions in the communities were important. Uranium mining was happening, so I began to see that health was much bigger than just the clinical pieces. I'll also say that I probably was 10 years into my career when I specifically remember being at this conference and we were talking about asthma, and the presenter finally said, well, do you ever ask your patients if they want the inhaler or the therapy? I thought, no, I've actually never done that. I've assumed I have this information. I'm passing it on. And so after that, I began to think, first of all, you need to engage a bit more. You need to understand what they understand and whether this is going to work for them. Now, fast forward to today, and I have an opportunity to be working on with this endowment to improve the health of the people of Kennebec and Somerset counties in Maine. So we take the definition of health to be as broad as we can, and that's when you and I began to interact as we talked about this, but it's not just physical health or mental or even oral health, it's social health, economic health, a much broader definition, and it incorporates what is now being thought of more as a social determinants of health or health related social needs. So now I'm having an opportunity to work outside the hospital, outside the doctor's office on health in the community because I think health resides in the community. One of the background elements in your professional journey was in school-based health. And that to me is such a great example of where healthcare actually resides because this is where our children are a large percentage of the time. So instead of pull 'em out of school, drive them to the doctor's office and assume that in their 20 minutes together that the doctor's going to have the most impact, you actually bring the care to them. So tell me about your experience there. Yeah, it was fascinating. In around 1990, we had wellness teams in the schools and the local school, Maranacook asked me to come talk about what's new in adolescent medicine. So I went and looked it up. I said, okay, let me see what other people are saying. And these school-based health centers were prominent at the time somewhat believing that they could solve a number of adolescent health issues including teenage pregnancies. So I went out and I had a conversation with the wellness team and talked about these school-based health centers, mostly from the literature, not from my own experience. Then the state came forward and had grants to offer to schools, and the wellness committee came back to me and said, we're applying for a grant. We want you to come back and work with us on this grant and be the medical director for the school-based health center. So I did, and within a year we had a school-based health center that was serving children from sixth grade to 12th grade. And while it didn't have full services, for example, we were offering condoms that created probably the biggest stir, and we had 300 people show up at a school board meeting in opposition to this, but 20 students showed up to speak about the need for good information and for them to have this. So the health center has gone on, and it's another place where I learned, I thought I knew some of my adolescent patients, but not until I got to that school, heard the stories from the school nurses who had known them since kindergarten did I really understand the fuller picture of their lives. So I'm a huge advocate for going to where people are to better serve them. So whether it's school-based health centers or working with our people who are challenged with mental health or going into prisons or going into residential care systems, we really need to go to where they are and make the system easier for them. I agree with that and my very strong sense in many years of being in healthcare is that it's an extremely siloed industry and that, I mean, I would actually feel like I was driving down the highway to move into the next phase of my day and is almost like a gate had lifted and let me in, and then I worked during the day and then the gate lifted and then let me out, and then I worked or existed in my life. And yet what we do is with people who live in the world. So we are incredibly siloed and expect people are just going to come and they're going to be let in the gate and we're going to fix the issues and then we're going to let them outside the gate. That seems a little shortsighted. For sure. And to put it maybe a little bit more bluntly, people don't come with one issue, one clinical need, one social need, one problem, and if you don't begin to find ways to help them put that together. Can I give you an example from some of the current work? We now with the endowment programs, we have classes, and we can talk about that in a minute, but we also have a program where we have community health workers and the community health workers are just people of the community who are empathetic and have skills in working with people. And we have them meet with individuals who have one or two chronic diseases, and we simply say to them, what would help improve your health? And a great story from this is that one of the first people we encountered, a community health worker met with him in the primary care office, asked that question and he said, oh dear, I have no idea. And she said, well, how about you think about it and I'll come visit you at your house in a week. Well, she went to visit him in a week and he had seven ideas, seven items. Most of them were not clinical. And as the community health workers now who work with individuals for up to six months, most of their needs, maybe 30% are clinical, 70% are, I'd like to get back to fishing and have my buddies fishing with me. I can't figure out these applications. I'm caring for three other family members but don't know how to apply to be a caregiver, and I'm trying to hold down a job. Can you help with that? Lots of different ways in which we can help, but it's a whole person approach. It's not the siloed piece go in one gate. You can't talk about financial things once you get into the office. Well, we can talk about the whole gamut. I can't tell you how appreciative people are. I'll also say that it's a new experience for them, that man being asked such a broad question, giving him so much agency, it took him a while to figure out how to respond. So a piece of this is we're going to have to learn how to conversations with each other to meet them where they're at and to give them the time and the tools to have those kind of responses. Recently I met with the oncologist, the cancer doctor who was working with my father who's been very open about his cancer diagnosis and his journey. She was lovely. She did a wonderful job with our family and it was a whole group setting. And also I noticed that my father, who's been a doctor for half a century, even he seemed like he kind of took a different role when he went through that door and the questions that he felt that I know he might've asked as a clinician, he didn't ask those questions. It was almost like that power differential, whether we realize it or not, I think it shifts the way that we feel comfortable having conversations with people clinically. It's fascinating, isn't it? Because even someone with the experience of your father is subject to that power differential. I also just supported a friend going through a cancer journey and also a prominent physician in the country and began to say, well, have you asked this question? Well, what about she said, oh, I never. So I think it does create, you're in a different place. You're facing a big challenge, so you need people around you to help. Unfortunately, he has you all to help. That's true. I mean, bless his oncologist, wonderful. She had multiple people in the room and also a bunch of us on Zoom, and she handled it very well. I give her so much credit for that. So that is true is that he had all the people around him. I think a lot of times what happens is we deal with patients who really don't have many people around them at all. I mean, there are a lot of patients that I would care for over the years, and it was them, and they were struggling in part because there wasn't somebody to come to the meetings with the doctors with them. Which is another role the community health worker has played. They often will go with their clients to appointments and help be that support person and help encourage a larger conversation, asking questions I didn't really know how to ask kind of thing. I think helping to teach the practitioners, the clinicians on the other side, oh, I guess I wasn't fully having a full conversation here. It's been remarkable. I do think particularly in an area of medicine, but I suspect we can find it in other arenas as well that we do need to break down those power dynamics. Yes, I agree. And I think some of it is communication. I think some of it is changing the way that we educate people, whether it's at the beginning in medical school or PA or NP or nursing school, but also as we go along, continually showing up and saying, is this working? If it's not working, how do we do it differently? So it does work better. I've often said we as physicians worked under what I would call the tyranny of the 15 minute visit. While we didn't always have just 15 minute visits, it was the expected you were supposed to be getting them in and getting them out. There's only so much that can happen in 15 minutes and it is a tyranny. So we do need to change that up a bit. And some people don't need a visit at all. They just need an email or a phone call. Other people need a two hour visit and we need to be able to figure out how to flex in that kind of way. One of the things that you talked about or referenced earlier was this idea that somebody might need help with their apps, for example, healthcare apps. And so for me, I've had a particular interest in digital health literacy and digital health equity, and I think when you describe the email or the portal message or whatever it is that we are doing to communicate asynchronously with people, even learning how to communicate in that space and having a mechanism by which that's valued, I think all of those things are important on our side and also understanding what that looks like on the other side. If you are a person who has no internet or maybe you don't have a smartphone, can we get you to a library where maybe the librarian can help you log into some sort of secure zoom visit with your provider? Are there ways that we can do things differently? So that leads me to a question that I have and that is how has the Peter Aon endowment enabled you and others who are more in the clinical realm to work with community stakeholders? Because clearly we are not going to be able to solve all these issues ourself within medicine, but there are other people working on these things who are outside of the healthcare walls. So how has this been manifested for you? What I would say, if I go all the way back to the work in the school-based health center and the one place was supposed to solve the teenage health issues, not one thing will solve it. You need to have multiple organizations helping to work on that. So as we look at social determinants, health, housing, food insecurity, we are going to need to work with other community-based organizations. So health systems are going to have to have different relationships with community-based organizations. So we right now are meeting with 15 community-based organizations in our area to look at multi-sector collaboration. What would that look like? How could we work together to better have the resources that are available connect with individuals needs? Because in some cases the resources are there, but the path to them for the individual is unclear if we could make that clearer. So we're talking about have not made a decision, but we're talking about this idea of a community hub. So people who might come to you and have a conversation about their housing needs, you also need to talk to them about, well, what about your healthcare coverage? How are you getting food? How are you getting childcare? So all those things maybe we can bring together in a place, or it might be digitally on a platform. We don't know exactly how this is going to look. We do know that it's about connecting resources. It's about connecting the resource to the individuals who have the need. And we think we can do it better than us all sitting in our separate offices if we can have a better conversation and maybe a connecting platform. All of that is still up in the air, but we have a wonderful group of 15 organizations that includes people like the United Way and Spectrum Generations and the Hollowell Pride Alliance and domestic Violence all coming together to say, how could we better serve our clients and help you better serve yours? So if there's ever been a time where we need to talk about community and how to connect better as community, this is it. And so it's really gratifying to work in this area. I think it's really gratifying to hear that this is happening in part because I know that along with social determinants of health being becoming more of a focus, particularly as a result of covid, it has put the squeeze on what was already the tyranny of the 15 minute visit so that health systems were being asked to all of a sudden address all of the stuff that had anything to do with health at all, which we never had the resources to do anyway. I mean, if somebody's issue is literacy, for example, we are not the people who can do that. That's not what we're trained to do. So it's those pathways and creating a way for people to access the resources that is important, but that actually takes the relationships with people in the communities and trying to figure out what that looks like. Exactly. And as you well know, primary care physicians have a lot on their plate. They can't remember all these different possibilities that might exist for a patient, but if we can have support for them, social workers, community health workers, care managers who can help connect them to the resource, we can hopefully take that off their plate. It's not fair to ask primary care to solve the ills of the community, but we can work with a community and see if we can't help. Now, I feel like there ought to be both. There's both a public and a private connection that needs to happen here. The Peter El Fund Foundation and the endowment is philanthropy coming into that equation as well. So I think weaving these things together with clearly saying what's our goal and keeping that goal in mind. Here's an example I'll give. We want the individual, we want the person we're trying to help to have agency, and if we end up having a platform, we want them to have access to that platform that creates a whole realm of security issues. So we're going to work through that. But the principle is you need to have the individual be engaged and have power over the journey that they're going to take and the choices that they're going to make. But it gets complicated and we're going to commit to working through that. It is complicated. And when I worked for the VA, I saw all these fantastic resources that the VA would have and has acupuncture, whole health pain management, integrated behavioral health, and also the system. And I don't think I'm calling out the VA, I think everybody kind of understands this. The system isn't necessarily set up to be able to make it possible for people to get those. So it's almost like seeing that resource over on that island over there. You don't have a boat and you can't swim. And so I think that that conversation is really important. And I know one of the things that the Peter Alfond Foundation does is other ways of helping people to engage in their health. For example, food is medicine and group visits and classes. So talk to me a little bit about that. So let me differentiate one item here. There is a Peter, Alfond foundation, and it does work in Maine as a state and also in Puerto Rico. The endowment we got from the Peter Alfond Foundation at MaineGeneral is called the Peter Alfond Prevention Healthy Living Center. And that's the work I'm going to talk about, which is at the center. Now. Early on we created classes, classes in healthy eating mind, body and physical activity and created something called the Healthy Living Resource Center, which is now combined with prevention to be the prevention Healthy Living Resource Center. And over time, what we've understood that the purposes of these classes is to help people change their behaviors in a way that helps them be healthier. So learning how to cook really delicious meals on a budget is one of the things. Maybe learning how to slow down and take a walk in the woods, do some yoga, et cetera. So those work really well for people who like coming into classrooms, but there are a lot of other people in the community who, A, they can't because they don't have the time or the transportation, maybe they didn't have great experiences in classrooms. So we're now taking these programs out into the community. We're at 39 different sites, head starts to food banks, to community centers, libraries, libraries have asked us to come in with these kind of programs. And the purpose though is we don't change our behaviors by one class. You really need a number, either a repetition, a social group that is giving you some peer pressure and peer support, I would say. So we're now going out to employers and doing lunch and learns, and there's some peer support that comes with that or going into the Cotton Mill apartments where people co-live and there's peer support there or out to other places where people socially aggregate. And then we need repeat messaging. But we are beginning to have people absolutely change how they're able to cook, how they're able to move, and to actually develop some healthier behaviors. So the long run, this is a big endowment and my interest is to set up work and programs that will go for generations. So it's about the long game. It's about helping to move the dial on health in Kennebec and Somerset. So they're two of the healthiest counties, not only in Maine but across the country. That's the goal. And it will go well beyond my lifetime, but that's the plan. Talk to me about the potential challenge of needing to prove outcomes because I know in medicine that becomes a big thing and everybody wants to hear, they want the quantitative data, the "that's nice, but we really want to see the numbers." So if what you're talking about is we're going to put these programs in place and it's going to be generations, how do you show immediate value so that not only the Peter Alfond Foundation feels good about it, but also the medical community feels good about it? That's a great question. So when I chose to accept the endowment and to lead this work, I was really emphatic that we need to have an evaluation component partly just to be a good steward for this. If you're going to do this and say, I'm going to change the health of Kennebec and Somerset County, well prove it. How are you doing that? So we now have a whole data plan to measure who are we reaching and what difference are these classes making. Now, let me say for the reasons we talked about before. If you take a single class, we'll be glad to know who you are and ask you how the things went. But we're really not going to start asking you, did it make a difference in your health behaviors until you've taken at least a series of three or maybe longer classes, or you've worked with a community health worker for six months? Then we're going to begin to say, what difference did it make in your life? And that's the data we're going to be bringing forward and showing in the end, it's going to have to show in the county rankings that we're making a difference and that people, less people are overweight, less people have cardiac disease, less people have high blood pressure, those kinds of things. That's a decades long project. That's the long game idea. I think you and I share some similarities in that we're probably not your standard doctor. Yes, we both went to medical school and we both ended up with medical degrees and we both took on primary care specialties, but there are some people who go into clinical medicine, they sort of go into practice and they do most of the same thing for most of the time that they're doing it. And for me, I have always wanted to kind of tinker with things and see what can I do differently so that I can have of a better relationship with my patients or so that my patients can enjoy a better interface with the healthcare system. And does that mean staying inside or going outside of medicine? Does that mean doing something from a population health standpoint or does that mean offering acupuncture to my patients, for example? And I know that where you went, your pediatrician, you worked on a reservation, you did school-based health, you've done this work, you've done a lot of different things. You've probably had to kind of have some internal wherewithal to keep you focused on that path. Like, yes, I am still a doctor and I'm still doing great work even though I may not be doing it the way other doctors do it. I guess one way I would speak to that is I remember a conversation. There had been a man who was one of the first pediatricians in Maine, and his name was Harry Davis, and he died in his sixties, but his wife didn't die until she was 104, but the family came in 2005 to a group of us and said, we'd like to do something to improve pediatric family medicine in Maine in honor of our grandparents. And so I began to talk with one of the grandsons about the whole system of healthcare. And I like thinking at the system. I think it's fascinating. I like thinking about how the pieces fit together, about how individuals have agency and what role can I have to maybe make this better or different. And I remember the grandson saying to me, how did you get to think that way? And I said, I don't know. I think there's some of us who just, that's where I do look at details. I do like details, but it's not where I live. I live over at the 10,000 foot level. So I've always enjoyed that. I've always enjoyed how the pieces fit together. And in the end, that work that family wanted to do to further pediatric or family medicine has now become the children's Oral Health Network of Maine. And I've been part of that since 2005. And it too is sort of taking the big picture look across Maine with a big goal of reducing dental caries in children in Maine. So it's just how I roll and I think you do as well. I think that's true. And for me, it's always a question of, well, if I only do it from this vantage point, then it's just going to have a limited impact. And so in order to actually have the best possible work done on behalf of the patients and with the patients, really not on behalf of them, you actually have to take everything into consideration. But it's a hard thing I think for people who may be trained in a very straightforward medical model, which tends to be very linear in many ways. I think it's a hard thing. I think so. And I think one of the roles that I've had as a physician leader for other physicians is to try to also speak to them about where are their interests? What do they really care about? And try to use their gifts in a way that helps them fit in. And so if they really just care about making sure that every soldier shoulder they operate on does well, then we have a place for them. But if they actually want to think a little bit about how to prevent shoulder injuries, we also have a place for them and we have some athletic trainers they could work with to do that. So I think we can all sort of think about and reach out and talk to physicians in the same way we were just talking about patients, meet them where they're at, but also help them see the system and how they're fitting in and how they could better fit in even with their gifts. I mean, that's a great answer because I think you, you're absolutely right. Honestly, if you are a surgeon and you like to repair shoulders and people come out of surgery and they have a functioning shoulder, that is fantastic. And it is about giving everybody the opportunity to, I guess, best use whatever gifts they have. So that ability to just understand where everybody might fit in the larger picture. When you worked as an administrator, you were the Chief Medical and Transformation Officer at MaineGeneral. How did that transformation side of things go for you? I guess what I would say is healthcare needs a lot more transformation. So I do think that the way the American healthcare system is set up right now doesn't help us do the work we were just talking about doesn't help us cross over these silos. The way the payment structure comes is difficult. It keeps people having to live within rules and creates barriers to people getting sometimes the care that they really could use. So I would say we might've made some progress, but I don't think a lot, I actually will tell you that I feel a whole lot better about the work I did as a pediatrician in terms of helping families and always trying to look at them as families and what they have as gifts to support those children. I still think there's a lot of work we need to do in healthcare, but I'm really gratified to be able to have this endowment that allows me a clear amount of resource to help do this work. And then as we evaluate it, we're talking very strongly about being a learning organization. So what's the data showing us? How do we get more employed men, single moms families, which kinds of programs help? We're also now going out into the community and doing focus groups with different populations, the unhoused veterans so that we can broaden the demographics of who we can interact with, engage with, because we're not going to improve the health of Kennebec or Somerset if we don't actually try to engage as many as we can. One of the things that I learned about you, and you were so kind, is to respond to our questionnaire that we sent out was that you background in weaving, and it's so you've already used weaving in your terminology today in our conversation, and it's such an interesting metaphor. I mean, you have this background weaving things together in healthcare, but you actually know how to weave and you actually have a loom that you were saying you had kind of put aside the weaving and then you came back to it pretty recently. So let me hear about the weaving aspect. In college, and I was in college a long time ago in the sixties and seventies, an old West Virginian woman in Ithaca, New York taught weaving, and I went and began to learn and over time became her apprentice and helped set up looms, and she paid me in fiber so that I would have more fiber to weave. But then I went to medical school and had a career and had a family, and the weaving sort of went to the side. But about eight or 10 years ago, I met a couple who were downsizing and had a big old floor loom that they wanted to move on, and I took it on and it sat in my house for a little while. I watched it until a friend who's a weaver came and said, we're going to put this together. So I'm weaving again, pretty simple, but it's just really a lot of fun. What I particularly like is just playing around with color and seeing what happens to color. When you put it against different colors, it changes. Right now I'm weaving on the warp is made of one color thread, but then I'm weaving fabric through it. So what happens when you put different fabrics in? What happens when you're all, it's just a lot of fun, and I actually try very hard with that to have no specific end goal that I have to have. It's more about the process and the fun of doing it. Who knows? I've given away some of the towels and my kids love the towels, but we'll see. I don't know how much I'll actually produce, but I'll just have a good time doing it. I'm married to a man who was a ham radio operator when he was younger and put it aside for literally decades, and then came back and is now doing ham radio again. And when I see how much joy that brings him, it becomes an interesting question for me. What things do we put aside that bring us joy for many years as we're being householders and paying the mortgage and such parenting perhaps? And then we pick back up again when we understand, oh, this is something that I don't really have an outcome for this, but I like doing it, so I'm going to give myself the space and permission to do that. This is another example. I also quilt, so I work with fabrics and I have a huge flannel wall that you can just put fabric up on and play around with it. I will say particularly after some difficult days at work, coming home and just playing with the fabrics and seeing how they look different, depending upon what they're next to, we all feel different depending upon who we're next to that kind of thing. But now passing that on to my grandchildren, letting them play on the wall, letting them play around with this, I agree with where you might've been going, which is why do we let go of these things for these more intense parts of our lives when it could have been so helpful to us. But we're back. We're back to it. He's back to ham radio, I'm back to, there you go. Weaving. Yes. And from what I understand in remembering, you have a child that went and was part of a circus for a while. I do. I do. I have a daughter who's in the Portland school system who's a leader in the Portland school systems, and I have a son who's a, he and his wife are both circus performers, so that I've had friends say to me, how did you allow that? Well, you don't allow that. You support them in the direction they want to go. He graduated from college with a BA in economics, but said to me that day, the circus is really what I have to go do. He had been helping build the c