Baltimore’s health commissioner has plenty on her plate, from the city’s crippling drug abuse problem to high infant mortality. But Dr. Leana Wen, a 34-year-old emergency physician, is taking it in stride. Interview by Logan Plaster
EPM: How did your work as an emergency physician prepare for your role as Baltimore’s health commissioner?
Dr. Leana Wen: We in the emergency departments are on the frontlines of health and healthcare. We see the failures of our healthcare system in great detail every single day. We see the failures of our system when it comes to the focus on reimbursement, the challenges of malpractice, the issues of making quick decisions with very little information, and the lack of support that physicians receive at times.
I remember working in the ED and treating patients over and over again who would come in with addictions. They would come in with the same thing every single time and I would be able to offer them extremely limited medical services. I could give them Naloxone if they were overdosing on opioids. I could give them hydration. But ultimately they needed access to long-term treatments and they needed treatment at the time that they were requesting it, which was something that I wasn’t able to provide. Or I would see a child coming in with asthma. I knew how to treat this medically with inhalers and steroids, but what about the child’s home, family members who smoke, or the fact that she lives near an incinerator? These are all the failures in our system that go beyond what medical care can provide.
So the impetus for my taking a job like this was to change the other factors that troubled me and my colleagues in our work. These are the things that we felt unable to change but that we saw every single day as problems that were making our patients sick. And a job like this enables me to use those frontline experiences, the frustration, and to channel the frustrations that we face in our clinical duties to advocate for and implement larger systems level changes.
Working in the ED is very similar to being on the frontlines of urban public health. When there was the civil unrest in Baltimore, we were faced with chaos in the city and many people had urgent needs. Like in the ED every day, we had to triage needs. It’s about leading a code. There needs to be one person in charge who brings everyone else on board. And the management challenges that I face every day in running an agency of about 1,000 people is similar to the challenges that we would face running a busy urban emergency department.
EPM: There are tens of thousands of doctors who see the same problems that you did and they become burned out and frustrated. They don’t have the opportunity or the skill set to become a city’s health commissioner. But they want to be agents of larger change. What advice would you give to them about treating some of these systemic problems like the opioid crisis? How would advise emergency physicians in their day-to-day work?
Dr. Wen: First, I would say that I understand why people would feel burned out and jaded. We went into medicine because we believed that our training would equip us to assist our patients in their time of need. But what we encounter is a system that seems to work against it. We are limited in terms of time and resources. In the ED we are expected to be everything to everyone. But we can’t be. We can’t be both the doctor and the social worker, the case manager and the infrastructure support system.
In the end, doctors can feel powerless, like there is nothing that they can do. I would respond to that in three ways. The first is that we must simply start somewhere. If you have a patient who is very ill and that person presents to us and we don’t know what’s going on, it’s never an option for us to say that this person is just too complicated or too big of an issue. We all know that if there’s a patient presenting in extremis, we would all start somewhere. And I would challenge emergency physicians to see it that way too; that even if we cannot solve this person’s every issue, let’s pick something and aim to address that one thing, that one time that they are there.
My second encouragement would be that we see every interaction as a point for intervention. There are patients who come to us all the time for what seem like similar complaints. The person who comes in over and over again because of congestive heart failure may actually have an underlying mental health issue. Then there is person who comes in over and over again not for medical care, but because they are homeless. What can we do for that person at the time that they’re in our ED? What kind of services can we connect them to; there are other services that exist in our community. It may not have to be the emergency physician who makes that final connection, but what can we do to connect that person so that we are seeing their one moment with us as the lever for potential change?
Third, start small. Around opioids for example, we started something in Baltimore that’s a 24/7 referral line for anyone with addiction and mental health needs, and for their families as well. It may seem like a small thing, but this is a great resource for emergency physicians too, to be able to give their patients. Even if they don’t have time themselves to make the call, they at least can give the phone number to their patients. It’s a small step, but it’s still an important step because that’s one piece of connection that did not exist before. So see those small steps also as tangible things that we can do.
EPM: What are some of the specific programs that you’ve seen have success in Baltimore?
Dr. Wen: We have a program here for our children who are frequent visitors to the ED, to have a case manager to work with them to reduce their ED visits. And actually that program has resulted in the children who are enrolled in these programs, it’s decreased their ED visits by 95 percent in one year. That’s something that emergency physicians can find out about in their communities; identify those resources and connect their patients to those resources. Those are very tangible things that can be done today.
EPM: What’s the health project that you’re currently most passionate about?
Dr. Wen: The opioid crisis is claiming more lives in our city than ever before. We have more people dying from overdose than we do from homicides. There are approximately two people who die every single day from overdose, which is made even more tragic because we in the ED know that we have one medication, Naloxone or Narcan, that can completely reverse an opioid overdose. And we need to get this into every single person’s hands.
So I issued a blanket prescription in October of 2015, so that every resident in our city can get access to this, as long as they go through a basic training. Since then we’ve done over 23,000 trainings, including we map out where it is that overdoses are occurring, the hotspots in our city. We target our trainings to these areas, including in markets, on street corners, in bus shelters, in public areas. And everyday residents ¬– not counting paramedics and the police who we also equipped with Narcan – have saved over 800 lives. Laypeople with no medical training have saved over 800 lives.
Last month we got the law changed again, so that Naloxone is available essentially over-the-counter. I signed another blanket prescription, a standing order, so that you no longer even have to show that you have the training. So that anyone can walk into any of our pharmacies in the city and get the medication of Narcan without having a prescription and without showing that they have a certificate for training. So it’s essentially over-the-counter.
Getting Narcan is one important step, one that we’ll keep on pushing. One of my staff revived someone who was overdosing just outside the Health Department recently. But we also recognize that this is a complicated issue, so we are working with doctors in the city to reduce the prescribing of opioids, to increase alternatives for pain treatment.
We are also working on increasing access to treatment for substance use disorders. So we’re starting something in the city called a stabilization center, which is the equivalent or just the beginning of a 24/7 behavioral health ER. You can walk into an ED for physical health treatments any time. It’s not as straightforward for behavioral health issues, and we think you should be treated in the exact same way. It’s going to be an ED diversion that is EMS protocol driven. So individuals who would have otherwise ended up in our hospital EDs will now be diverted to this facility in order to get specific behavioral health treatment. That will also reduce the waiting times and the burden on ED staff who may not be the most well-equipped for behavioral health issues. And it will provide the best treatment possible for these individuals who may not be best served in a traditional ED. I mean, we all have had the experience in the ED of patients, especially Friday and Saturday nights, who came in for intoxication or who have acute mental health needs. These individuals may end up waiting a long time because there are traumas and other acute medical patients who need to be seen. As a result, they may not get the best treatment. They may have to wait until the morning to see a social worker, and then they don’t end up seeing the social worker because they may be withdrawing by then. Instead, we want to give these patients an alternate place to be seen, such as this stabilization center.
We also have a program in our city to do SBIRT, which is: screening, brief intervention, referral and treatment for patients coming through our EDs. We screen them and then refer them to treatment if they are identified as having a substance use disorder. We have an overdose survivors outreach program. So if somebody is coming in with an overdose, they immediately get connected with a social worker or case manager to assist them and to prevent them from having this overdose in the future. That person sits in the EDs to assist. And we’re now piloting induction of buprenorphine in our EDs as well.
EPM: Does your job allow you to reach into even earlier phases of disease? Do you have an opportunity to move upstream to solve health problems?
Dr. Wen: The nature of public health is that we aim to go as early and as upstream as possible. The problem is you cannot only focus on upstream interventions when there are people dying right now. When there are people dying and there is something that we can do very tangibly right now, we also have to focus on those interventions. So getting Narcan to everyone is the latest intervention possible, other than resuscitating someone who is about to die in the ED. But it is an important first step. And then the second step is getting treatment to everyone. And then the third is reducing the overprescribing and preventing addiction in the first place. So we are focusing on every one of these elements but showing short-term success through the lens of saving lives is an important first step to take.
One upstream intervention that we’re very proud of here is a program called B’more For Healthy Babies, which is a public-private partnership that involves over 150 partners led by the Health Department. Together with all of our hospitals, our federally qualified health centers, and community organizations this program has reduced the infant mortality rate in our city by nearly 40 percent in seven years. Fifty babies that would have died in 2009 are now able to be alive today because of this intervention. It has also reduced teen birthrates by 36 percent and cut the disparity between black and white infant deaths in our city by our 50 percent. And that to me is an example of upstream intervention because we’re focusing on our youngest and our most vulnerable.
Similarly, I launched an initiative called Vision For Baltimore. And that program is to get every child glasses who needs them. We estimate that up to 10,000 children in our city actually needs glasses but are either not screened and identified as needing them or they’re screened but for whatever reason are falling through the cracks and not getting glasses. That is an upstream intervention that will improve educational outcomes and much more down the line.
EPM: Do you see a role for telemedicine in this challenge of increasing access in a city like Baltimore?
Dr. Wen: Sure. We are working on some telemedicine initiatives, including in our schools. Currently, I oversee school health services in every one of our 180 or so schools. And twelve of our schools have a full school-based health center, which is a high level of care that’s staffed by either a physician or a nurse practitioner. But the rest of our schools have a nurse or a nurse aide to do more routine care. We are now piloting telemedicine in these other schools, so that everyone can have access to a physician or nurse practitioner when they need it. I think that telemedicine should be used not only for rural underserved areas but also for urban underserved areas, including ours, and that there is tremendous potential and tremendous need.