Make all health care organizations nonprofits. Provide universal health care access. Improve science education at the elementary school level (really!). Invest in public health infrastructure. The shift from a volume-based to a value-based care delivery model.
As a part of our interview series called “5 Things We Must Do To Improve the US Healthcare System”, I had the pleasure to interview Dr. Shannon Connolly.
Dr. Shannon Connolly is a family physician and associate medical director at Planned Parenthood of Orange & San Bernardino Counties. She attended medical school at the Keck School of Medicine of the University of Southern California, did her residency at UCLA, and completed a fellowship in primary care psychiatry at the University of California, Irvine. Dr. Connolly serves as president of the California Academy of Family Physicians, which is the largest primary care medical society in California.
Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a story about what brought you to this specific career path?
Launching into my professional career after college, I became a medical assistant in a Planned Parenthood health center — and it was an eye-opening experience that highlighted health care inequities in our local communities. I worked with a very diverse, urban, underserved patient population and learned so much from the patients themselves. For the first time, I understood how hard it is for the average person to get medical care — especially sexual and reproductive health care like abortion and contraception. I developed a more sophisticated understanding of topics like social determinants of health and the role of public policy in shaping whether health care delivery is fragmented. These lessons drove me to pursue a career as a physician because I wanted to address these problems and be a part of a solution.
Can you share the most interesting story that happened to you since you began your career?
The most wonderful aspect of patient care is that you hear important stories about peoples’ lives daily. There are so many, I couldn’t begin to hone in on one alone. It has almost become a trope to say that this last year has been extraordinary — but it really has. For me, responding to the needs of my patients and community during the COVID-19 pandemic has been the greatest challenge thus far in my career, as I’m sure it has been for many health care workers. However, I take solace in knowing that I’m helping my community through my work. That makes each day worth it.
Can you please give us your favorite “Life Lesson Quote?” Can you share how that was relevant to you in your life?
“A ship in the harbor is safe, but that is not what ships were built to do.” As a family doctor, I believe I was built for adventures and difficult journeys in the service of my patients. I try to take on challenges that others may not tackle because it is my job to uplift the voices of those who have been overlooked or marginalized.
How would you define an “excellent health care provider”?
I believe we must expand the definition of “excellent health care provider” to mean far more than a person who is good at patient care. To me, there are three components that piece together into the perfect puzzle: patient care, systems improvement, and advocacy. Obviously, a health care provider must be good at patient care — that’s a given. With that comes intellectual curiosity, technical skill, good communication, and compassion. Those added skills and personality traits, however, aren’t enough.
The healthcare system is very broken, and there is far more that needs to be done. We — as health care providers — must be a part of the solution to fix the system. Partnerships between the administrative and operational sides of medicine will create more functional systems to meet the needs of an increasingly diverse population. Systems issues must be identified by all sides, and advocates from every department can collaborate to develop solutions that truly make a difference. Doing so requires administrative skills and plenty of advocacy, which isn’t taught in medical school. In my career, some of my most important partners have been my administrative counterparts — especially in achieving excellence in patient care.
When everyone in an organization is working together, we are all more successful at delivering an exceptional patient experience. In medicine, clinicians are often siloed away as the “clinical people” while those in administrative roles are the “administration,” and they are often presented as being at odds with each other. It has to stop. We are partners in care delivery and can work collaboratively to innovate. Together, we can motivate ourselves to do things in new and better ways — keeping patient experience top of mind. Becoming adept at this kind of dyad leadership, the union of administrative and physician leaders is critical if we are to solve some of health care’s biggest problems.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
I love a podcast called “The Nocturnists,” where people in medicine share reflections — often very deep and emotional ones, about their patients and work in medicine. The stories are exceptionally well curated, and the people who share them have often done a tremendous amount of self-discovery. Most of all, I am inspired by tales of human resilience and our commitment to each other.
Recently, I read “Compassionomics,” which provides a scientific argument for why compassion may be the most important component of health care, and “Tribal Leadership,” which shares a framework to create workplace environments where people can thrive and innovate. The lessons and insights shared in both books validate my own personal beliefs of how compassion, collaboration, systems improvement, and advocacy can come together for the best patient experience.
Are you working on any exciting new projects now? How do you think that will help people?
We’re very excited to be launching the EveryBODY Initiative at Planned Parenthood of Orange & San Bernardino Counties (PPOSBC). This past year has provided many opportunities for our organization to examine the way that inequity is reified in American health care institutions. As we’ve reflected on the public health implications of police brutality or the differences in mortality rates for various groups during the COVID-19 pandemic, it became clear: we simply must do better. We must identify where people are mistreated, understand intersectional experiences, and develop clear corrective actions. We have made progress in many areas, but we continue to fail people who have overweight and obesity.
Weight bias is as prevalent as racial discrimination. It has significant implications for adverse psychological and physiological outcomes. When people experience weight bias in a medical setting, they are more likely to develop eating disorders and they are more likely to avoid future preventative health care — increasing their risk of medical problems.
Imagine you are a patient arriving at your doctor’s office for a routine pap smear, and upon entering the waiting room, you discover that the seats have armrests that make it impossible for you to fit in them, so you must stand. Finally, a medical assistant calls you to the back and attempts to weigh you on a scale in the hallway — except the scale shows an error reading because it is not able to measure a weight over 500 lbs. You are brought into an exam room, and the medical assistant has to leave the room to get a “thigh cuff” because the large blood pressure cuff does not fit your arm. The assistant then gives you a gown to change into and leaves the room, but you soon discover that the gown is too small and leaves your breasts exposed.
Things only get worse when the physician arrives to do your pap smear. The examination table is not appropriately rated to accommodate your weight. The leg rests do not support your thighs. The speculum is the wrong size and the doctor struggles to do your pap. The clinical team has to “troubleshoot” at every step because there are no existing processes in place to ensure a patient-centered experience.
Now imagine that you are also a person who has experienced childhood sexual trauma — because childhood sexual trauma is twice as common in people with obesity — are a person of color, have a long history of struggling with body image, and struggle with a mental health condition, which requires you to take a medication that causes weight gain. This scenario is a nightmare. It is also the daily experience of many people with obesity.
Recently, the COO of my organization shadowed a number of clinical encounters in our family planning clinics. She observed that our clinicians were really struggling to have conversations with patients about their weight. They were well-meaning and coming from the perspective of health promotion, but these conversations were challenging to hold. It was awkward and uncomfortable.
She brought this experience to our Patient Services team and made fixing this problem a top priority in our organization. Out of this came the EveryBODY Initiative and an excellent example of administrative and clinical teams coming together to develop a better patient experience.
The EveryBODY Initiative seeks to transform our clinical spaces into places of healing, comfort, and health promotion for people of all body types by changing the very culture of care delivery. We believe that we can achieve this by educating our staff, examining our policies and procedures, creating physical spaces that accommodate people of all body sizes and types, and ensuring that we have the medical equipment and knowledge to take care of our patients in ways that are affirming and do not cause shame. We believe this is a deeply needed intervention that we hope to spread across health care systems throughout America.
As we started looking into this work, we realized there were so many opportunities for positive change. We needed to train our medical assistants on how and when to take a patient’s weight, as well as how to respond when a patient expresses discomfort at getting weighed. We shared with our clinicians how to frame conversations about healthy nutrition and physical activity in ways that are confidence-promoting and harness each individual’s personal strengths. We addressed the causes of obesity, which are often rooted in social, educational, economic, political, and environmental factors. We created educational modules for clinical staff to explain that toxic stress increases levels of a hormone called cortisol, and high cortisol levels actually promote obesity. This means that people who have experienced and continue to experience high levels of stress are more prone to obesity than those who do not. This is perhaps why there is such a strong correlation between trauma and obesity. People who experienced abuse as children are 30% more likely to have obesity as adults, even after adjusting for all other factors.
We also learned there was a need to systematically evaluate our physical spaces and equipment to ensure we could accommodate any body type or size. We realized new furniture in waiting rooms was a must, scales had to be capable of weighing people of any weight, gowns had to fit a diverse set of body types, different ways of measuring blood pressure was necessary, and different equipment for gynecological exams and procedures could make all the difference in an excellent patient experience. We also needed to educate our staff on anticipating the needs of people with different body types and automatically adjust to accommodate them in such a way that it did not call attention to their bodies.
Perhaps most importantly, we discovered — nearly on a daily basis — a new way in which our processes and spaces could work better for our patients. Each of these “aha moments” continues to teach us the importance of pursuing this work. We are encouraged by the responses of our patients. I recently saw a new patient with a number of longstanding medical problems and symptoms who had only just worked up the resolve to come to a doctor’s office to get evaluated. She had a history of childhood sexual trauma and weighed over 300 lbs. and told me about her last visit to a different doctor’s office — several years ago. The gown they gave her didn’t fit, the doctor body-shamed her by pointing to the fat on her thighs, she had a panic attack, and left mid-visit.
She told me that Planned Parenthood having a patient gown that fit meant so much to her because it immediately served as a contrast to her prior experience. She thanked me and my medical assistant through tears for having the right gown. For her, that small thing represented safety. It made her feel that we cared and would support her health journey.
The work of the EveryBODY Initiative makes my heart full because it is one way we can push back against a body shaming narrative that is so prevalent in our society. We can be more compassionate in health care. We can do better for our patients and promote healthy habits in ways that empower and do not cause shame. We can change our culture to be kinder and more inclusive.
The EveryBODY Initiative is also a perfect example of dyad leadership between clinical and administrative staff. The very idea for the project came from not one of our clinicians, but an administrative leader. Then, the brainstorming, collaboration, and planning required a close partnership that spanned across departments. We needed support from everyone including our facilities team, health educators, purchasing department, and clinical trainers. It has truly been an organization-wide effort that would have never been possible without a very committed collaboration between different types of leadership.
Ok, thank you for that. Let’s now jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
Perhaps most obviously, there are so many people in America who do not have access to health care. Even after the passage of the Affordable Health Care Act, so many still fall through the cracks. Until health care is accessible to everyone, we cannot achieve health equity in our country.
Our health care system is perversely incentivized. We pay providers for volume, not value, and invest more in fixing health problems rather than preventing them. Health insurance companies are mostly for-profit, and they make more money when they cover less care. We spend enormous amounts of money in the last week of life and very little on primary care.
We treat health care like it’s a product that can be purchased rather than a necessity for a successful society. Pharmaceutical companies market their drugs directly to the public so people go to their doctors and ask about specific products rather than relying on their health care providers’ knowledge and expertise to select the most effective treatment.
As a society, we are focused on the most cutting edge technology as the solution to our health care problems, and in doing so we forget that from public health or population standpoint, the most impactful measures are very simple: access to healthy nutrition, regular physical activity, basic preventive measures like vaccination, avoiding harmful behaviors like smoking.
We politicize health care in such a way that important public health interventions become controversial. Violence is a public health crisis. Masking and COVID-19 vaccination will save lives. We have to be able to present these messages as nonpartisan, non-political, and in everyone’s interest.
As a “health care insider”, if you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
- Make all health care organizations nonprofits.
- Provide universal health care access.
- Improve science education at the elementary school level (really!).
- Invest in public health infrastructure.
- The shift from a volume-based to a value-based care delivery model.
The COVID-19 pandemic has put intense pressure on the American health care system, leaving some hospital systems at a complete loss as to how to handle this crisis. Can you share with us examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these issues moving forward?
The pandemic has really highlighted three big problems: inadequate funding for public health infrastructure, significant health inequity for many communities, and a lack of understanding or trust in science by a significant proportion of our population. These are each enormous and very complex problems that will require a nationwide effort to correct.
But from the perspective of a person at just one organization, I can tell you how I’m thinking about each problem. For health infrastructure, at PPOSBC we recognized early on that our most valuable tool in the pandemic was our health care delivery workforce. With that in mind, we had to protect them at all costs so they could take care of the community. We were one of the first organizations in our community to start masking at the beginning of the pandemic, and we radically changed our care delivery model by implementing telehealth and drive-through minimal contact care within the first few weeks. We also fought hard to get vaccines for our employees. Our staff was vaccinated well before many other health care organizations in our community because nothing was more important. With our staff well protected, we were able to have a significant impact in taking care of the community.
For health inequity, it starts with acknowledging the role of racism in our society and understanding the systemic ways that it plays out in health care delivery. We have much to do to address inequity, but it starts with identifying it, measuring it, developing benchmarks, and then seeing if our interventions are making a difference. For the COVID-19 vaccination, as an example, measuring vaccination rates in different populations is a start, but then taking those numbers and seeking to understand the root causes informs the appropriate intervention. For public education, we’re working to teach our staff how to educate the community about vaccines. It starts with developing trust, demonstrating that you are a source of accurate information, and truly working to understand why there is hesitancy. At the end of the day, we all want the same thing, we want to be healthy and not have illness. There just exists a lot of disagreement and confusion about how to get there.
How do you think we can address the problem of physician shortages? How do you think we can address the issue of physician diversity?
We need to invest very aggressively into the health care workforce development pipeline, and unfortunately, the problem is far upstream. If we want health care providers to come from the same communities that they serve — and we do — then we must eliminate the barriers to entry into health professions. That starts with primary education — high school, middle school even. It also requires plenty of investment into making education affordable. Physicians today routinely graduate from medical school with half a million dollars of debt, just for their education. Not a lot of people are willing to take on that kind of a financial burden — and it deters many from a career in medicine.
I’m interested in the interplay between the general health care system and the mental health system. Right now, we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?
The fragmentation of care delivery, particularly between physical health and behavioral health care, is a huge problem. As a health care system, we are simply not serving our patients well by treating these two as different, unrelated problems. Good care is integrated care, and that’s the direction I hope we will move toward as a system. At PPOSBC, we recently launched a behavioral health program that uses telehealth, but is also integrated with our primary care services. That way, the patient, primary care provider, and therapist can work together to address behavioral health concerns.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
If I had to pick just one movement, I would put it into education at the primary and secondary school level. I believe if we invest in education to really make it accessible and public, we will find genius in the communities that are currently being left behind. We need that genius to enhance our society.
How can our readers further follow your work online?
With over 230,000 visits last year, Planned Parenthood of Orange & San Bernardino Counties provided birth control, cancer screening including Pap tests and breast exams, STI testing and treatment, and abortion services to the community. Services are high-quality, confidential, and affordable. No one is turned away, regardless of insurance, income, or immigration status. Learn more at www.pposbc.org or via social on Facebook, Twitter, YouTube, and Instagram.
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.