Ep 18: Building ‘Socially Just’ Systems of Care

with Coleen Kivlahan, M.D., MSPH

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Coleen Kivlahan, M.D., MSPH
Co-Chair, Health and Human Rights Initiative and Professor of Family and Community Medicine, UCSF

Dr. Kivlahan serves as faculty co-lead for the UCSF medical student Human Rights Collaborative and the first-year medical student elective on asylum and immigrant health, Forensic Evaluation and Education of Asylum-Seekers. She is a renowned expert and trainer in torture evaluations nationally and internationally and has worked in conflict zones in Guatemala, Sierra Leone, the Democratic Republic of the Congo, and Syria. Her research interests include patterns of torture, sexual violence, and factors that enhance assimilation and long-term health of refugees and asylum-seekers. Dr. Kivlahan is one of the contributors to the 2020 revision of the Istanbul Protocol, the international best-practice guideline for forensic evaluations of torture and ill-treatment. She also practices primary care in San Francisco, including care for COVID-19-positive patients. She supports the contact tracing program for coronavirus for UCSF employees and their families. 

In her prior role, she served as an alternative payment expert at the AAMC.

 

In Missouri, I had a governor who I had a very early on call with it was quite the honor to get that job, he made a decision to reach into a small health department and choose a young 26 year old with a couple little kids to come in and be a Commissioner of Health for the state.

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Coleen Kivlahan  0:02

One day, I got a call from the governor saying that he’d heard about the work I was doing in child abuse. He made a decision to reach into a small health department and choose a young 26-year-old with a couple of little kids to come in and be a Commissioner of Health for the state. But it was, no question, the turning point.

 

Lan Nguyen   0:22

That was Dr. Coleen Kivlahan, Head of Primary Care and Professor of Family Community Medicine at the University of California, San Francisco.

 

Coleen Kivlahan  0:31

That would be sitting with a military commander, who was incredibly intimidated by, I mean, the AK 47 on the desk. And he had gold chains in addition to his uniform. And right behind him, there were pictures of his daughters. I asked him about how he would feel if his daughters were touched in any way that hurt them. And I think good leaders use what’s in front of them. You have to use what can touch people and help them move in directions, you know, that are where they want to go.

 

Lan Nguyen  1:03

In this conversation hosted by Dr. Joanne Conroy, President and CEO of Dartmouth Hitchcock and Dartmouth Hitchcock Health, we learn about Dr. Kivlahan’s long standing dedication to serving underserved patient populations, and courageous approach to building more equitable systems of care, domestically and internationally. So let’s jump into Her Story, a program where we explore the intersection of women, leadership, and healthcare.

 

Joanne Conroy  1:35  

I’d like to welcome everybody to Her Leadership Story. I’m going to, with full disclosure, tell you that Coleen and I have known each other for a number of years; we work together in DC. And she was the first person I thought of as we were developing Her Leadership Story, because her leadership story is one that is truly amazing and will be an inspiration to all of our listeners. So welcome, Coleen.

 

Coleen Kivlahan  2:23  

Thank you, Joanne. It’s great to be here.

 

Joanne Conroy  2:25  

Well, there are so many places where we can start. But we probably should start at the beginning, and that may or may not include: why healthcare? Where did you get your start? 

 

Coleen Kivlahan  2:36  

I was a young child growing up in a small town in Ohio. I’m the fifth of six kids, and I’m the first girl in the family. We had no health insurance, no primary doctor. My dad was a roofer, put roofs on in our community, and my mom was a secretary. So I had no idea what doctors did, actually. I went to a health department for the first 18 years of my life to get shots, and that’s about it. Was a lower middle class working background, and I was the first generation in college. But at age five, I made a ridiculous decision that I wanted to be a doctor–never varied from that, ever–and I’m thrilled that I was able to achieve that dream. I cared for my grandmother and my aunts and uncles–we had a very large extended family, and as a child, I was the gang leader. I was the person who organized the games and organized things in school and loved learning. And, and I also knew–and I think one of those turning points in life, Joanne–was that I knew that having a really good education and working hard was a ticket out of this small town where I was unlikely to ever thrive or discover all the things I wanted to do in my life.

 

Joanne Conroy  3:52  

Well, it didn’t take you very long from finishing medical school and your residency to land in a political role in Missouri. Talk a little bit about that. 

 

Coleen Kivlahan  4:02  

I was 26, and I was just out of residency working in a small health department in the morning doing child abuse work–which I was unaware would have such a major impact on my life–and in the afternoon doing primary care. And one day I got a call from the governor saying that he’d heard about the work I was doing in child abuse. We had created a network of physicians across the state who were as ignorant as I was about forensic evaluations in children, and in adults. And he said, would I come down and talk about the future of our very conservative state, Missouri. He’s a Democrat. And he made a decision to reach into a small health department and choose a young, 26-year-old with a couple little kids to come in and be a Commissioner of Health for the state. So it was one of my greatest honors working for him and, no question, was a turning point. We had two or three things going on in those early 90s. One of those was health reform. And that was during the early Clinton reform with President Clinton as well as Hillary running healthcare at the national level. But we also had a flood in Missouri that was an epic flood–more than anything that had happened in two years–and it flooded about two-thirds of the counties in the state. We had an abortion ban, and the AIDS epidemic was beginning. So it was quite the baptism by fire, if you will, in that setting as a Commissioner of Health.

 

Joanne Conroy  5:34  

Talk a little bit about how you infiltrate a bureaucracy that was probably not used to a lot of women leaders, and they also weren’t really used to young women leaders. So how did you actually create change in an environment that could be perceived as hostile to a lot of people?

 

Coleen Kivlahan  5:55  

It was hostile. But the department was about 1700 people, and I had never led more than a few people in my life. I spent a lot of time understanding what it meant to have a large data set for a state to be able to make good decisions, what it meant to have an infrastructure of tiny health departments in hundreds of counties in the state. So I listened a lot. I was the first woman and I certainly was the youngest Health Commissioner in that setting. I ended up loving the complexity of that level of decision making. And we took one problem at a time and worked its way through, I met with leaders of the St. Louis Post-Dispatch and the Kansas City Star to develop a comprehensive plan for the whole state for improving, and by the end of the four years, we had dramatically improved the health outcomes in the state.

 

Joanne Conroy  6:48  

What do you think it was about you that made you successful, because there is probably some personality or character trait you have that the governor noticed, and people around you noticed and knew that you would be successful.

 

Coleen Kivlahan  7:04  

I think as they say, in Missouri, I’m not the sharpest knife in the drawer. You know, I’m a hardworking person who learned that from my parents, I am disciplined around data, and I’m tremendously persistent. And the word passionate is often used for women leaders. That can mean a variety of things in a variety of states and in a variety of organizations. In Missouri, that meant that you had strong opinions about things. I think one of the most interesting things that have happened in the last couple of days, Joanne, I got a call from someone who’s actually been appointed to a very high position in the World Bank. And she called me and said, “I’m not sure that I know who my leader is. And how important is that taking this job?” And I was able to reflect back on all of the leaders I’d had in my career and talk to her about someone who – how do you begin to understand when someone really has your back, when someone believes in who you are, and is willing and ready to go out on that branch? In Missouri, I had a governor who I had a very early-on call with, it was quite the honor to get that job, but not sure it was the right opportunity for me. And so had the dialogue about, how long can the branch be? And how far can I go on the branch before it starts to fall, and you’ll still be there? And, and had a very clear and transparent discussion about that. And I’ve had that in every job since that time. And this friend from, looking at the World Bank, wasn’t sure she had had that conversation. So I would say that’s one important part of being accepted in any organization is to be clear about what they need, what you can offer and see if there’s a match.

 

Joanne Conroy  8:50  

I’m sure that was a trait that was immediately validating. Talk about one of the toughest things you did in Missouri, and what you learned about yourself from it.

 

Coleen Kivlahan  9:01  

I made an assumption that the state was ready for health reform, and spent a lot of political capital and a lot of time and resource developing a strategy for that rural state of five million people to really move forward, including our hospitals and our health systems and our physicians, all of them were positive about it. What I underestimated was the level of vehemence, even then, of the status quo–of the unwillingness to move forward and really look at health reform from a more comprehensive, population-based model. It was too early. So I had misjudged the ripeness of the issue. And the level of personal attack was significant and lasted for an extended period of time. It ended up that we did pass something in Missouri that was much more consistent with the statewide dialogue, rather than the national dialogue. And I think nationally, we see the same thing, right? We passed a little bit in the early 90s, but not much. And it took till seven years ago before the ACA was passed. 

 

Joanne Conroy  10:08  

40 years later, but the lessons are still the same. 

 

Coleen Kivlahan 10:33

Exactly. 

 

Joanne Conroy 12:16

So after your four years in Missouri–then I know you went to Cook County in Illinois. Talk a little bit about your passion for taking care of people who are probably not just unrepresented, but they’re not fully integrated into how we look at healthcare in the country. 

 

Coleen Kivlahan  12:34  

It was a shocking experience, actually. I had gone from rural states, relatively unpopulated really, and most even in the urban areas, relatively small population, in trying to understand systems of care in rural America to the middle of a very large city with six million people in the city. And in the surrounding area. The lines in the pharmacy were immorally long, two to three days to pick up a prescription. If there were dysfunctional systems at all levels, there was the lack of strong leadership at many levels, and the majority of patients and the majority of clinicians working for me were people of color. And I was a young white girl in Chicago trying to learn their system. Again, requiring the same skills of deep listening, deep understanding of where the gap was between their desire for a great health system in the current reality. When I got there, there was a thriving business for mock coach purses in the radiology unit, and not many x-rays going on. And I met with the team there and I’m and I found them a new place to sell their coach purses. And we developed a new radiology unit next to a unit in which we had people with malignant hypertension and uncontrolled diabetes, a very, very large group, and they came together and developed group visits because we couldn’t possibly see people one on one, the volume was so high. So, very, very powerful model that immediately changed the dynamic to one of energy and positivity.

 

Joanne Conroy  13:48  

So Coleen, your focus on, really, healthcare needs and underserved populations, at some point shifted from domestic populations to international populations. You became very involved with physicians for human rights. Talk a little bit about how that happened. 

 

Coleen Kivlahan  14:21  

Cook County was a dividing point in my life and in my career. And on one hand, it was beginning to understand the role of payment systems in how healthcare really works, and being able to use those payment systems to alter population health. And the second part of that diverging path was my deep awareness of the, of the impact of injustice in our health system and watching people who were people before color who, there were no chairs in the pharmacy line, and people would wait eight hours, and then come back the next day and line up again. So at that point, really made the decision that health justice needed to be a significant part of my life, and I couldn’t continue in Health Leadership without focusing on that. So my work in the Congo began with children and women who were victims of sexual assault, frequently, multi-victim, multi-perpetrator crimes, with hundreds of women being sexually assaulted simultaneously. We were able to create systems of care, we were able to create rapid training for providers and document forensic injuries.

 

Joanne Conroy  15:30  

I do remember you telling stories of going, yourself, to the Congo, and, you know, walking into rooms where you had judges, lawyers, prosecutors, and policemen, and soldiers that did not know how to prosecute rape, which, 20 years ago–just 20 years ago–was declared a war crime. And you were white woman from the United States that was educating them. But you had some incredible ways of really making the issue real for them. 

 

Coleen Kivlahan  15:59  

You know, again, I think good leaders use what’s in front of them. And so as I would be sitting with a military commander, who I was incredibly intimidated by, I mean, the AK-47, was on the desk, and he had gold chains in addition to his uniform, and right behind him, there were pictures of his daughters. So I asked them to meet his daughters, and I wanted to see them and tell me about them. And when we did, I asked him about how he would feel if his daughters were touched in any way that hurt them. And of course, he responded like all fathers would, and it began the exercise of personalizing what we were seeing that was occurring in his troops. And for the judges, it personalized what it meant for them, and many of them did have family members who over time were impacted by the war. And so using what’s in front of you, has always been a strategy, especially in resource poor areas like Cook County, like the Congo, and like Syria, where there’s not much else there. You have to use what can touch people and help them move in directions, you know, that are where they want to go.

 

Joanne Conroy  17:00  

In your career, you did a little bit of a sidestep, which we all do, and went to work for Schaller Anderson, which was a private insurer that later was acquired by Aetna in the southwestern part of the state. Why, going into what some people would call the dark side, although I don’t think anything that educates you about payment systems is bad education, I think is all good, but why that move? 

 

Coleen Kivlahan  17:33  

Without understanding at a deep level, from my perspective, what are the movers, what are the factors that most impact the health system? We’re just rearranging the deck chairs. And so in Missouri, actually, I got a call from that organization, Schaller Anderson, who called and said, “We’ve watched what you’ve done in Missouri, come do it for the country, in what we’re doing with revising Medicaid, and improving access and quality.” So I initially thought I would just go consult, and they talked me into staying and I stayed there for seven years. And I guess what I learned in that setting are several things that I make use of every day, and one of those is the power of large data. The ability to look at trends over time in a large amount of people helps us make good decisions as leaders, and the discipline around the data in the private sector is far greater than anything we see in most public hospitals or public states.

 

Joanne Conroy  18:20  

So when you came to the AAMC, you could tell you were really outstanding in execution. For those of you that may not know, Coleen really led our alternative payment group and helped launch bundled payments at the AAMC where we were a facilitator convener, for I think, 24 academic medical centers across the country. Have you been able to use what you learned, really, almost being an intermediary between the federal government and academic medical centers, because we did learn a lot there?

 

Coleen Kivlahan  18:41  

We learned so much, Joanne, from, from the power of good decision making, as people made the first steps into this new payment model. What are the motivating factors for making good decisions around completely revamping the way we do healthcare, is what actually led me to my current role at UCSF. I watched UCSF make early decisions that we all believed were probably not great ones, and I watched them pivot, once they got data, watch them pivot into more credible and more effective, actually, decisions, that they’re now still implementing that work. So it’s been really fun to get involved in UCSF initially in the inpatient side, and now for the last four and a half years on the primary care side to look at redesign in that way.

 

Joanne Conroy  18:20 

Talk a little bit about your work in social justice and equity, because I know that it’s still a real passion for you. And you have some thoughts about how you could actually stand up something that would make a difference to citizens in California through the UCSF infrastructure. 

 

Coleen Kivlahan  18:41  

When I look in Africa, and in the Middle East about the number of borders that have been created artificially by other states and powers, they produce war and conflict and ongoing stress and distress for people. So one of my missions is to understand the role of global migration, which is increasing dramatically with conflict and with climate change, and how that will reshape our health systems. At UCSF right now, I’m honored to be working with the medical students who really are catalyzing the health justice movement. About one third of the medical school students at UC USF are first generation asylees or refugees. And what we’ve done together is create a human rights clinic that’s similar to 18 other academic medical center human rights clinics in which we do forensic evaluations for rape, and female genital cutting, as well as torture. But what’s bigger for me is that in another couple months, we are likely to see our borders open again. And when that occurs, we will have hundreds of thousands of people who have been waiting at the border. And without the interaction of the health system. They’re coming with diseases, and they’re coming with infectious diseases, as well as long term chronic illnesses. And without our engagement to try to sort and manage that group and to try to figure out how we understand the international law, which allows every one of us to leave our country if we feel that we are persecuted and enter a second country. And if we’re not ready for that, we really risk not integrating some of the most amazing people and future leaders into our country. We know that doctors and nurses can make a difference in welcoming people, my hat says, “Make America Welcoming Again.” And the opportunity to recognize that our future is invested in having a diverse society where everyone can work, and everyone can have safe and healthy families. And I believe that our organization has a responsibility for that. And to our first asylum, successful applicants, Marcelo, who has allowed me to use his name, came from Brazil. He had conversion therapy, for showing tendencies of being gay at that point and wearing pink at times, and he had electroshock to his head every week, for years, in addition to sexual violence, that he continued with the police. And in college, he also had sexual violence, came here with a chemistry, chemistry degree. And by the time he came to our southern border, was HIV positive. I met him, he was homeless, and we admitted him into a long-term rehab hospital, his AIDS got better, his infections got better. And as of last week, he showed me just a text of the keys to his new apartment, he got a full-time job at one of our hospitals as a care coordinator, and is teaching folks as well as doing contact tracing for Spanish speaking patients on the weekends. So that’s what can happen with this sort of social justice by health systems with our communities.

 

Joanne Conroy  22:03  

Yeah, well, you’re an inspiration, calling to not only your patients, the people that work with you and the people that work for you. Now, we do have a few signature questions, although I think you’ve answered a lot of them. Are you an accidental or an intentional leader? 

 

Coleen Kivlahan  22:17  

I am totally intentional. It started at a young age, so I don’t think there’s anything accidental about this.

 

Joanne Conroy  22:23  

What piece of advice would you give that 26-year-old new Commissioner of Health that you know now that you wish you’d known then?

 

Coleen Kivlahan  22:33  

I think I did know it now, I did know it then, but I think I forgot it many times, and that is, continue to do what’s right. If you put your patients and your citizens in the front of you at all times, and you make informed decisions about what they need, everything turns out okay. And if it doesn’t, you apologize. And I guess the other thing I would say, Joanne, is that expect periods of ambiguity and vulnerability in your life. And whether that’s because personal circumstances have occurred, or external circumstances occur, there are moments when we feel knocked down and less effective than others. And those are moments for deep reflection on our lives, and for me, that’s been around COVID. And the sense of vulnerability and the ability to really look at what resilience means is a gift.

 

Joanne Conroy  23:26  

To end on a little bit more of a humorous note, we talked about the title of your book, or maybe on our tombstones. What would be the title of your book or your epitaph?

 

Coleen Kivlahan  23:36  

It started with a card that I got in high school, and I still have it. And it’s a card of a doctor’s office with a skeleton waiting. And at the bottom of it, it says, “Kivlahan time.” And at the top, it says, “Just give me five more minutes.” And so, since that time, my, my epitaph has been, and remains every day, just give me five more minutes. I can do a few more things in these few minutes. And we can make a difference together.

 

Joanne Conroy  24:03  

Well, thank you, Coleen, this has just been wonderful. I was so thrilled that I can share who you are and your fabulous stories.

 

Coleen Kivlahan  24:11  

Hmm, that’s a gift for me. Thank you, Joanne.

 

Lan Nguyen  24:15

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