Public Health in Action – Asking the Right Questions

forestI’ve been fortunate enough to meet people from all professional and cultural backgrounds.  I’ve heard their journeys into a myriad of careers.  Some knew what they wanted to do from an early age and did everything they could to achieve their goals.  Others, like myself, had less direct paths.  An evolution of interests and career goals is a common theme that I’ve seen more and more.

I attended the Inaugural Forum on Population Health Equity at Harvard in early September in Boston.  The Forum was organized to provide attendees with a variety of perspectives, both domestic and international, on the social determinants of health.  Research, policy and interventions on various sectors were presented and followed by an engaging discussion between speakers and the audience.  During one of the breaks, I met Ana Progovac, a post-doctoral research fellow based in Boston.  We briefly talked about her research interests and how she made her way into public health.

Ana’s story is an illustration of how some make it into the field of public health – through an evolution of career and personal interests.

Now, onto the interview!

Me: How did you end up doing the work that you’re currently doing?  Describe your journey from college and into your PhD with a focus in health services research.

Ana Progovac: If you want the whole story, here goes. What drove me into health services research is a pretty simple question I like to ask myself often, which is: where can I make the most impact? Sometimes I think people know this instinctively, because they have a natural talent or gravitate heavily to one area; other times, as in my case, we may rely heavily on logic. I’ve never felt I had a singular “talent” in any one area; but I’m hardworking, so when I put my mind to something I find I’m usually able to do a fairly good job. In high school, I was torn between two areas I really liked (and felt were at odds with each other): science or writing. In college, I chose “science” but was lucky enough to go to a University which stressed well-rounded students. I not only got to take literature classes in my first year, I was required to. Something that I always knew, though, was that I was going to go to graduate school. This probably comes from having two very educated parents, and simply believing that graduate school was the next logical step for me after a bachelor’s degree. I had thought I would do Genetics or Neuroscience for the longest time, but then I started having these nagging questions about how my work would impact actual, real people in the long term. We were looking at genes that were jointly implied in risks for depression and risks for cardiovascular disease. Important and very interesting work. But I started asking questions like “How will this be used by doctors who are seeing their patients?” and “How will knowing a patient is roughly 3% more likely to have depression prove useful to treating a patient?” My mentors informed me that these were questions to be answered by other types of researchers more downstream from basic science research.

So, I resolved to be a downstream researcher instead. I took a few public health classes during my senior year (also about the vaguest possible way to describe an amalgam of very disparate fields!), and really enjoyed them, and by that time had already decided this was the right career shift for me. Around the same time, I was lucky enough to hear a valuable piece of advice from a colleague and one of my mentors: don’t do the same thing for graduate school that you did for undergrad. This went against everything I thought I knew then. Don’t you go to graduate school to become a super-expert in one area? I think the answer is yes and no. And for me, the answer was no. I went to graduate school because I wasn’t satisfied with number tools in my toolbox and not because I felt the tools I had weren’t sharp enough.

What I learned was that as an undergrad, I didn’t have the slightest idea of the number of tools that existed. And at first, this was a struggle. Coming from a “hard science” background, I think you really have to work to cast off the (erroneous) idea that other types of science, for example social science, are not as valid. Public service announcement: every type of science is flawed. Every type of experiment or observational study has its limits. We do a disservice to not only our colleagues but also to “science” itself by believing that we have found “the right way” to look at things. So for me that first semester of graduate school was a struggle to accept that these new things that I was learning about, like how much policy depends on politics, was just as important as learning about gene transcription factors. And depending on what aspect of the human condition I was interested in improving, even more so.

Me: What inspires you on a daily basis, especially when things get hard?

AP: As a health services researcher, a lot of what I do day-to-day is secondary data analysis, which can be fun, but it is difficult for someone like me (who likes to see results right away) to stay motivated. I think researchers with clinical duties have an advantage here in some ways, because seeing patients can be a constant reminder of why your work matters. But I find more and more that I draw a lot of my day to day inspiration from colleagues. Having a team that’s committed to a project and and that is made up of genuinely good people helps keep me going too. Even when things aren’t going right. Because I want to work hard for them as well. So this is a nice thing about our field I think: the collaborative nature means your group helps keep you focused and grounded even when a paper gets rejected or a grant doesn’t get funded. And a lot of what we do is try to figure out what works or doesn’t work, so that it may one day be translated into policy that does work. But what if you just keep finding things that don’t work, or don’t work as much as you’d hoped? That can be discouraging. And for me, one of the things that pushes me to keep trying is the commitment to the collective efforts of the group.

In the long term, I have to say I have always gravitated to mental health-related research because I’ve seen first hand how difficult life can sometimes be for people with mental illness. I think it might be hard to find someone these days, actually, who hasn’t had their life or inner circle touched by mental illness in some way. And because of the way my brain works, I always get very frustrated when things “don’t work right,” which is a very research-oriented phrase that I think I’ll work into more grant applications. You know that feeling you get when you’re waving your hand in front of the sensor of an airport bathroom faucet, and it keeps turning on just as your hand moves away from the spout? Take that feeling of frustration and multiply it several thousand fold, and that is the feeling I have when I hear stories about people suffering unnecessarily because their insurance doesn’t cover the psychiatrist they want to see, being told they’ll just have to live with really uncomfortable side effects of an antidepressant, or frankly, ending up jail, because on the outside they don’t have the resources and support to get the medications they need. I think I was pulled into this area partly because I saw some of this suffering first-hand, and I remain in this area because it continues to frustrate me endlessly how many barriers people with mental illness seem to face. Less often (but often enough), I am also encouraged that we seem at least to acknowledge we need to think harder about how to fix these things. A healthy balance, then, of frustration and encouragement, is what keeps me going at work. It’s a similar push-pull, I suppose, that keeps me going to the gym.

Me: What do you think it will take for our healthcare system improve?

AP: When I entered the field of public health (relatively naively) in graduate school, I thought the idea was to find the things that worked (made people healthier) and just “do them.” I was coming from working in a lab, and the “hard scientists” often like to think of politics as silly frivolity. But I have a much better appreciation now for the ‘what’ and ‘how’ of what works, in the sense that sometimes it’s not finding the thing that works that is the most difficult, but figuring out how to get it disseminated to the people who need it. So in healthcare, this means to me now: how to prove things work but also that they make (or save) somebody money? Is there someone who is a big enough healthcare stakeholder to help us make things happen? This may sound crass, but I think this is how the world works. I think what it will take for our system to improve is getting people with the creativity to think of innovative solutions to old problems and to have them work with people who can help them do the analyses that show this not only improves health, but also someone’s bottom line, and then have both those people figure out how to get this word out to the right stakeholders or policymakers. We do a pretty bad job right now as researchers making our work accessible to policymakers and the general public. We are shooting ourselves in the foot by doing this, at least those of us who rely on grants to keep our work going. In the same way we have to prove some new drug or intervention works (and saves money), I think we often forget we need to prove the value of our own research – to policymakers and the public. Bridging this gap between research and those making policy is, I hope, the way that we’ll continue to improve the healthcare system.

Me: Tell me more about your research and research interests and how they could inform policy or interventions.

AP: My focus is mental health services research, and I’m still in flux with the projects I’ll be doing for the next few years. But I’m particularly interested in implementation of new models of care (such as primary care-mental health integration), so I’d like to get more experience in implementation science and how to study integrated care. I think this goes right back to my interest of taking what we “know” works and figuring out how to get it out to the most people. There’s evidence that offering basic mental health services in the primary care clinic works great for adults if done properly. But taking something that’s been tested in a research setting and trying to implement it in the real world introduces all kinds of new challenges. Often we don’t know what the most critical part of an intervention needs to be. And in the real world, we need to get insurance companies to pay for the things that “work,” but it will take more than a few studies to change those practices! So I’d like to help narrow down what the important elements of these new team-based care models are, and further study whether the effects we’ve seen so far in more careful studies are replicated when we roll these things out with less research and operational support in the real world. An important aspect related to that is the question of whom do these new care models work (or work best?), and do these new care models help alleviate health care disparities based on race, ethnicity, or income? The populations that each clinic serves can be so different, and the demands to implement the “new, better” way of doing things so exhausting, that I think it’s our job as researchers to find the biggest impact of our work, and then make sure those findings get to the patients that it helps the most. In our line of work that also means involving stakeholders like insurers and payers. Luckily, they’re interested in improving the health of the populations they are covering.

Me: What are the current needs in Boston (or where you’re from or Pittsburgh), as they relate to social determinants of health (i.e SES, poverty, access to care, transportation, safety, etc.)

AP: The Center I primarily work at now during my post-doc at Harvard Medical School is part of the Cambridge Health Alliance, which plays a major role as a safety-net healthcare provider. Cambridge, Somerville, and Everett are among the 3 primary communities this system serves. This population hits probably most of the big “health needs” flags: many served at CHA are low-income, for example, and there’s also a good deal of racial/ethnic diversity among CHA patients. Many do not speak English natively. I think this demographic make-up is relatively common in urban centers, and presents unique challenges for care delivery. But as researchers it also means we have just the right group of people to ask, “How can we make things better?”


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