Dr. Carissa Baker Smith is a preventive and transplant cardiologist whose research includes a high concentration of work looking at the social determinants of health and working to mitigate health disparities for patients with congenital heart disease.
She sat down with us when we took the podcast on the road to the 8th World Congress of Pediatric Cardiology and Cardiac Surgery, a biennial gathering of international experts. Dr. Baker-Smith was there to moderate panel discussions on topics ranging from her area of specialty to the need for diversity in the health care workforce, all of which we discuss.
Thanks for tuning in today! How do you go well beyond medicine? How do you celebrate it? Please visit NemoursWellBeyond.org to submit a comment or leave a voicemail — you just might be featured on an upcoming episode of the show. You can also catch all of our episodes at NemoursWellBeyond.org and sign up for our monthly newsletter.
Carol Vassar, producer and host
Carissa Baker-Smith, MD, MPH, MS, Director of Preventive Cardiology
Nemours Children’s Cardiac Center, Delaware Valley
Well Beyond Medicine Episode 29, Transcript
Carol Vassar, podcast host/producer (00:00):
Welcome to Well Beyond Medicine, the Nemours Children’s Health Podcast. Each week we’ll explore anything and everything related to the 80% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar. And now that you are here, let’s go.
Well beyond medicine!
Carissa Baker-Smith, MD, Nemours (00:27):
Well beyond medicine means thinking outside of the walls of the institution, what policies, what neighborhood-level factors, individual-level factors are contributing to that disease prevalence and risk.
Carol Vassar, podcast host/producer (00:43):
Dr. Carissa Baker-Smith is a Nemours preventive and transplant cardiologist whose research includes a high concentration of work examining the social determinants of health and searching for ways to mitigate health disparities for patients with congenital heart disease. She sat down with us in late August when we took the podcast on the road to the 8th World Congress of Pediatric Cardiology and Cardiac Surgery, a biennial gathering of international experts in the field. Dr. Baker-Smith was there to moderate panel discussions on topics ranging from her area of specialty to the need for diversity in the healthcare workforce, all of which we’ll talk about. First, though, let’s set the stage with a primer on preventive cardiology from an expert. Here’s Dr. Carissa Baker-Smith.
Carissa Baker-Smith, MD, Nemours (01:35):
So preventive cardiology really is a subspecialty of cardiology, and as a pediatrician and as a pediatric cardiologist, I particularly focus on the diagnosis, management, and treatment of conditions that predispose or make kids more likely to develop early heart disease, and that’s acquired heart disease. So in pediatric cardiology, there is acquired heart disease, and there’s also congenital, and it’s not that the two don’t overlap, but when we think about etiologies, some of the risk factors, they’re somewhat different. Largely, when we talk about preventive cardiology, we’re talking about lifestyle and environmental factors that contribute to risk. There is some genetic component to it as well versus a congenital heart defect, which is more anatomic, something that we do believe has some genetic contribution to it, maybe a little less environmental, but still some.
So there’s a little bit of a shift in terms of what drives the disease onset. But preventive cardiology is just how it sounds. It’s preventing preventable disease, which is heart failure, myocardial infarction, so coronary artery disease, even peripheral vascular disease in latter childhood, early adulthood, latter adulthood, by identifying those risk factors in kids and treating them.
Carol Vassar, podcast host/producer (03:01):
You noted in your biography, which is online at nemours.org, that your research focuses on, and this is a direct quote, “The intersection between social/environmental stress/deprivation and traditional risk factors for CVD development throughout childhood and adolescence.” Tell us more about that.
Carissa Baker-Smith, MD, Nemours (03:22):
That’s a mouthful. Yeah, so I think that there’s a way that we define or describe someone’s heart health, and we can describe it in terms of behaviors and health factors. So behaviors, things that we think about, diet, exercise, sleep, smoking, or vaping, right? Those are things that you want to optimize to prevent disease. And then there are health factors such as blood pressure, cholesterol, blood sugar, body mass index that are also contributors. But I think that there are many, and I won’t say all. I think some of us realize that there’s an intersection between the presence of less-than-ideal health behaviors, and the presence of health factors that are less than ideal, and some of the environmental, psychosocial community-level aspects that contribute to that risk.
As an example, so if we think about exercise, which is a commonly described example, which is if I’m a kid who lives in a high-deprivation community, maybe there’s a lot of violence, the streets aren’t safe to play, the playgrounds aren’t readily available, food sources are limited to corner stores, my activity, my diet, it’s going to be very different than they live in an environment where there’s access to good produce, healthy produce, where the neighborhoods are safe to walk in and exercise in. And so those factors actually contribute to less than the ideal and poor health status. And so some of those things they’re remnants of lots of different policies and things that have happened. And so we don’t all start from an equal place in terms of our likelihood of having heart health and being able to preserve ideal cardiovascular health throughout childhood.
And to that point, it’s important to recognize that many of these communities that are high in deprivation also have higher numbers, prevalence of environmental factors that can be pollution, can be environmental toxins, things that are present in the communities that also contribute to risk. And so it’s really looking at the intersection of all of these factors because if we don’t acknowledge those differences and really dissect what the drivers are, then we can’t find the solutions. And frankly, we are losing the war when it comes to cardiovascular disease in the US and globally. I don’t know about you, but I’m not interested in losing in any way, so trying to find those factors really pinpoint them so that we can develop proper solutions.
Carol Vassar, podcast host/producer (06:08):
These are the social determinants of health that we talk so much about and have covered so much on this podcast. What kinds of public health policies do we need to change or bring to bear so that we can address the issues, the many issues that you just mentioned?
Carissa Baker-Smith, MD, Nemours (06:25):
Yeah, I think there’s different approaches. Certainly there’s a policy approach. There’s certainly community-level approaches. There’s individual-level approaches. There’s also healthcare approaches. And so, one aspect of my research is big data, using large data sets to analyze health issues at a population level. But the other component of my research is taking that data and then creating implementable strategies to help alleviate some of the burden of disease. And so what I mean by that is that we’ve taken some of that information and said, “Let’s dissect out how we even diagnose hypertension in kids.” I started my career wanting to contribute to how we define equitable care delivery, and that meant getting involved in the development of guidelines for diagnosing things like hypertension. Unfortunately, there’s what happens in a room of experts, and there’s what happens amongst lay people, amongst patients and providers, and families. And so, being able to diagnose hypertension with fewer visits is something that we focused on as a way to help to alleviate some of the burden.
We don’t want kids coming in to see their pediatricians leaving unsure whether or not they have high blood pressure. We want the providers, we want the patients, we want the parents to know. And so we have NIH funding now to use a different model. We’re testing the feasibility and tolerability of a different model for diagnosing hypertension, not too far off from the guidelines, truncated a little bit, and getting the resources and the training in place to make that happen, and then expanding upon that to see if it can work broadly.
But we focus on high-deprivation communities. We focus on providing these sorts of interventions in communities where that diagnosis is more likely to go missed because, frankly, if someone lives within a community that’s higher in deprivation, it’s not always, but there are lots of other things that are pulling at someone’s time, and the parents’ time. They may have multiple jobs, they have made multiple kids, just a number of factors. And so whatever we can do from a healthcare perspective to make diagnosis and management treatment more succinct, less time-consuming for families, more definite, less doubt, I think can be helpful.
Carol Vassar, podcast host/producer (08:50):
Another aspect of your research, actually a research paper that I was absolutely fascinated by, you co-authored for The Journal of Heart and Lung Transplantation, and that’s about the impact of race and health coverage in listing, in weight listing mortality in pediatric cardiac transplantation. Another mouthful. Give us an overview of that study and its conclusions.
Carissa Baker-Smith, MD, Nemours (09:15):
Yeah, so in transplant, there’s two groups of individuals who will be referred for heart transplant. And this is for kids who have advanced heart failure, not amenable to medical management, meaning that they’re sick despite everything that we can do to optimize their care with medication. And so they go on to be listed for transplant. And what we found in that analysis, and this was data from the Pediatric Heart Transplant Society was that amongst the groups, so the groups that get referred, they either have congenital heart disease, or some have never had a heart surgery, have dilated cardiomyopathy, or some sort of cardiomyopathy. And you would expect that the individuals who had say dilated cardiomyopathy as their primary diagnosis, the reason for heart transplant referral, would do better. But we found that particularly among African-Americans and racial minorities, that in fact that they did worse, and there was delays in referral for transplant, and then outcomes were worse.
And so one of the take homes from this is that, unfortunately, despite being a wealthy country, we still have pockets of disparity in equity, and for a variety of reasons. Sometimes, it’s knowledge base amongst the providers. Sometimes it’s knowledge-based amongst the parents or the guardians. There’s a number of factors that play a role, but it should not be that someone with, say, a diagnosis, a native chest if you will, they’ve never had heart surgery, they’ve never been exposed to blood product, or patch material that might increase their risk of developing antibodies and making them not as good candidate for heart transplantation, that they should have a worse outcome.
And it is reflective of some of the things we see more broadly, which is that in this country, there remains racial differences in terms of outcome. Some of that is institutional racism. Some of that is implicit bias. Some of that is deprivation. It’s really multifactorial, but it is our job and our duty to figure out why those differences exist and to do something about them. You just never know that kid who has delayed a diagnosis, who had dilated cardiomyopathy, that could be the next governor of your state, the next president of the country. So it is imperative and very important that we figure out why these disparities exist.
Carol Vassar, podcast host/producer (11:45):
Absolutely, and I did take one ray of hope from that publication, and that was that there has been some improvement in this issue due to “Improvement in the recent era associated with the recent US healthcare reforms.” Which reforms do you think were effective in this, and can that be replicated? Can we solve the issue, or am I simplifying it too much?
Carissa Baker-Smith, MD, Nemours (12:10):
I think certainly making it easier for people to access good quality care. Healthcare in general, having a primary provider is necessary. We have pockets of our country where people do not have access to good quality healthcare, and that has consequences. I think we had a session yesterday where we’re looking at global aspects of disparities and policy reform. There, I think the quoted number was about a third of the US has pockets of whether or not OBGYN is available. Think about the mom who or the woman, the young woman who gets pregnant; maybe she does have a cardiomyopathy, or maybe she does have some other predisposing health condition. What is her outcome going to be? What’s that child’s outcome going to be if they have to travel an hour and a half to get healthcare? The same is true for chronic illness. The same is true for risk factors that set someone up for chronic illness. Not having access to healthcare and providers who can diagnose, manage, and treat those conditions early leads to delayed diagnosis and worse outcomes.
Carol Vassar, podcast host/producer (13:30):
So, geographical location is certainly an access issue. How does telehealth feed into that? How does telehealth help that?
Carissa Baker-Smith, MD, Nemours (13:38):
So telehealth is basically the use of technology to provide clinical care, and there are different models for telehealth. We use or have used both the synchronous version of telehealth and asynchronous. The synchronous is real-time. So I use a technology where I’m able to connect with patients who live in a remote area. So Milford, Delaware, is about two hours from my house. And so the patients actually come into the healthcare setting. We’ve trained the nurses and the medical assistants there on how to properly assess blood pressure and vitals. We’re able to provide EKG and echocardiogram, and we actually have a stethoscope there that transmits heart sounds, that converts the sounds, and I can play the heart sounds and listen to the heart sounds before I see the patient. And it happens real time. So, literally within a minute of the patient having the stethoscope applied to their chest, we’re able to generate this document.
It comes to me. I can listen to their heart sounds, and then I log on and see them. So it’s a way of being able to provide care to a remote population. We’re using it for Milford, obviously, which isn’t too, too far away. It’s drivable, but the thought is that there are pockets of the country and the world where care is not as easily accessible. And so the goal is to take this model and then to expand it, to be able to take it to some other areas and provide care to patients that may not have access to care as readily. We’re changing the way we approach healthcare so that we’re meeting a need, less about the health system more about the patients and their needs, and how can we meet their needs and be there for them, even if they’re remote. And rural areas tend to be areas where care is not as readily available.
Carol Vassar, podcast host/producer (15:28):
While you’ve been here at the World Congress, you have moderated two panel discussions. One had to do with diversity in the workforce. From your perspective, how is Nemours doing in this area, and what can healthcare in general do to diversify the workforce, and why is that important?
Carissa Baker-Smith, MD, Nemours (15:48):
Yeah, thank you for that question. It’s interesting, and I’ll just be blunt here. When I first started at Nemours, I didn’t see a ton of people that looked like me when I walked through the door. And I came just before COVID started, and I definitely have seen a growing number of individuals of different backgrounds who are now carrying the Nemours badge. I think that there’s twofold. One is there’s obviously the importance of having a diverse workforce, and diverse means diversity in terms of background and experience. Look, we see people, and kids, and families in some of their most vulnerable moments, being able to have someone there who understands, who maybe communicates with you in a way that you’re comfortable with, and that does not isolate it to race or ethnicity. Sometimes that’s language or sometimes cultural background, but diversity in the workforce matters for diversity of perspective.
And look, no one has the right answer all the time. I think it’s always interesting to me as I work in groups to hear different perspectives. And it is enlightening, and it does give you ideas of different ways to do things. In terms of ways to improve diversity in the workforce, I heard I was recently talking with some colleagues at a different institution, and they have a system in place where they were actively seeking and recruiting individuals from the surrounding community to train as nurses. And so they were able to increase some of the diversity within their workforce by basically getting individuals from the community to become a part of their health system. And that’s important for multiple reasons. One is if you have at least one person in your family who is educated in terms of healthcare, the healthcare system as a non-employed person can be difficult to navigate, where to go, who to talk to, what some of the terms are.
I remember being a medical student, someone telling me the first part of being a medical student is the expansion and the vocabulary. Can you imagine being a layperson and just the amount of information that you’re bombarded with, especially if you have a sick child? So, I think efforts to bring the local community into the healthcare establishment through training, education, jobs, I know that there are efforts that are ongoing within Nemours. I know I saw a post from Kara Odom Walker talking about some of the initiatives that Nemours is leading to do that. I think those are important because they’re not only providing jobs and good quality careers, I should say, not even just having a job. It’s having a career to individuals, allowing the next generation to see someone who looks like them in professions they may not have thought about. It’s also addressing a paucity.
We have a nursing shortage. We never have enough sonographers. So getting individuals who might be interested in those areas and the proper training, making them aware that these jobs and these careers actually exist is important. And then you’re educating a family. You’re giving them access to a system, to a knowledge base, to things that they might not have known existed. Sometimes I think we as a society forget that, but for the grace of God, would be there. I would be as well. I think that so much of what determines where we are in our lives, and what we have access to, and opportunities is just some of it’s knowledge, and some of it’s somebody taking the moment to share it with you and say, “Hey, what about this path? Did you think about this?” Because many people are very hardworking, and they want to make a difference, and they want to contribute to society, and they want to be valued, and they want to provide value, but it’s giving them the opportunities to do that.
And I think that that’s part of actually bringing it back to the research that I do. One component of the deprivation index that I study is the neighborhood-level education. What percentage of the population in your neighborhood and census block group level is educated above a high school level? That matters because that education means there’s a greater awareness, even basic things. I think about it in my own neighborhood. There’s a sharing of information that happens from parent to parent, where to go, who to talk to, what things need to be addressed. It’s the difference between just so many different things, speed bumps in your community, making sure things are happening the way they’re supposed to, just so many different levels to that. But education is key. And so if you raise the education of the neighborhoods by getting people involved in careers and training, that gives them greater education.
Then they’re educating their families, are educating their communities, and that’s good for everyone. For those who live maybe not in deprived areas, we all pay for the downstream effects of those who don’t get those same opportunities. We pay for it later. And so I think that it really is imperative to give voice to those things that still exist within our society that are contributing to the healthcare inequities, which are ultimately contributing to the inequities, and mortality, and morbidity, but ultimately contributing to cost and everything else within our society, and frankly, limiting opportunity. Like I said, that child who gets delayed healthcare, that could have been the next fabulous governor or next fabulous President of the United States, and they’ll never get that opportunity. So I think we have to think about it that way.
Carol Vassar, podcast host/producer (21:33):
You mentioned a phrase, the deprivation index. What is that?
Carissa Baker-Smith, MD, Nemours (21:37):
So, the deprivation index so there’s a quantitative measure of assessing or describing how deprived a community is, and there are different deprivation indices. The one that I use is the Area Deprivation Index. That’s census block group-based. That’s more of the neighborhood level. There’s the Childhood Opportunity Index, which is the inverse of the Area Deprivation Index. And there’s a Neighborhood Deprivation Index. There’s a Social Vulnerability Index. The Area Deprivation Index takes about 17 variables into consideration and creates a score that’s on a range of zero to a hundred, where a hundred is most deprived. And it basically tells you about the level of education, resource, access to resources within a neighborhood, and you can then study how that impacts various conditions. And so, I studied the area deprivation and the relationship with hypertension diagnosis. So we had a paper that was recently published this year in JAMA, a network where we demonstrated higher deprivation was associated with hypertension diagnosis in kids.
And so we have other studies that are coming out subsequently as well, and I’ll present some data at AHA using two of the indices and seeing similar relationships, not just hypertension, but overall cardiovascular health status is worse the higher the deprivation of the community for kids. Healthcare is not a silo, so it’s not just you come into a certain space, you get a diagnosis, you get a medicine, and you go about your life. Especially for prevention, so much of preventing disease and the conditions that we diagnose and treat have everything to do with the environments, the psychosocial aspects, the socioeconomics, the policies that exist that contribute to those conditions. And obviously, there’s a genetic component, too, but well beyond medicine means thinking outside of the walls of the institution, what policies, what neighborhood-level factors, individual-level factors are contributing to that disease prevalence and risk.
Carol Vassar, podcast host/producer (23:51):
Thanks for listening to our wide-ranging conversation with Nemours Pediatric Preventive and Transplant Cardiologist Dr. Carissa Baker-Smith and learning more about her research on health equity and inclusion, which surely goes well beyond medicine.
9,000 plus Nemours Associates, just like Dr. Baker-Smith, go well beyond medicine each and every day, all in slightly different ways. Here are some voices from our recent Florida Well Beyond Medicine Day explaining how they live those words in service to Nemours patients.
Sarah Dillard, Nemours Children’s Health (24:27):
I believe that the Quality and Safety Department promotes going well beyond medicine by leading with safety every day and promoting our mission of Mission Zero, being zero harm for the patients that we serve. We believe that this is possible and attainable, and we throw this in everything that we do in our daily rounding and our promotion of safety and quality throughout the organization.
Kaitlin Danzig, Nemours Children’s Health (24:48):
My department focuses on the patient experience and surrounding around the specific needs of each individual patient. We focus on not just equality but equity, making sure that all of our patients have access to the necessary resources they need. Our overall goal is just to make sure that all of our families understand recommendations, understand diagnoses, and know what to do after they’re discharged from a visit. We really want to make sure that all of our children and families have the best paths forward for a healthy future.
Matt Lee, Nemours Children’s Health (25:23):
Well beyond medicine to me means going that extra step beyond just taking care of what the question or the reason why the patient came to see you, but it’s giving that extra effort and trying to come up with a plan for all the other aspects of their health, and how you can contribute to that.
Carol Vassar, podcast host/producer (25:41):
The voices of ear, nose, and throat Physician’s Assistant Matt Lee, Patient Experience Clinical Partner Kaitlin Danzig, and Quality Improvement and Safety Director Sarah Dillard, each with their own interpretation of well beyond medicine. How about you? What do those three words mean to you? Leave us a voicemail at nemourswellbeyond.org with your thoughts. That’s nemourswellbeyond.org.
Thanks to Che Parker, Cheryl Munn, Allison Micich, and Susan Masucci for their help with producing this podcast episode. Join us next time as we hear from the Nemours Florida Leadership Team. Until then, remember, together we can change children’s health for good well beyond medicine.
Well Beyond Medicine!