Children living with chronic conditions face unique challenges when they transition into adult medical care, from taking on the responsibilities for self care to potentially losing relationships with pediatricians they may have built over years. Jane Trinh, MD our next faculty spotlight, has first-hand experience with these and other challenges. This week she talks to us about transitions in care, the Med-Peds residency program, and helping physicians identify patients with low health literacy.
How long have you been at Duke? How long have you been at the division?
I came “North” to Duke in 1998 for medical school, having grown up in Louisiana and completed my undergraduate studies at Rice in Houston, TX. After medical school, I chose to stay at Duke for a residency in combined internal medicine and pediatrics.
After graduation from residency in 2006, I worked for one year as a clinic attending at the Duke Outpatient Clinic before serving as the DRH and Ambulatory Chief Resident for the internal medicine residency program. After completion of my Chief Residency, I started in my current position as clinical faculty in the Departments of Medicine and Pediatrics, and as associate program director of the Duke combined med-peds residency program.
What are your responsibilities within the division? What does a typical day for you look like?For my clinical responsibilities, I see patients in the primary care setting in the North Roxboro Street Med-Peds Clinic. I have my own adult internal medicine primary care panel; I also supervise med-peds residents in their primary care clinics and pediatrics and med-peds residents in the pediatric same-day clinic. I also round two weeks a year with the pediatric-inpatient ward teams.
As the associate program director for the med-peds residency program, I work with the program director, Suzanne Woods, MD to promote med-peds locally and nationally, and to advance the education of our residents. We have one of the best programs in the country, which is aided by integration within two strong categorical core programs, as well as a robust continuity clinic experience. I help develop curricula for our med-peds ambulatory rotation and maintain contact through a biannual newsletter with our graduates.
I am very active in resident recruitment, provide mentoring to residents and students, and oversee and manage each of the 23 med-peds residents in their quality improvement projects. I also collaborate on a GME Innovation Grant for faculty development in quality improvement, with several faculty in the departments of medicine and pediatrics, and a Duke AHEAD grant with the pediatric education office on a multidisciplinary approach to step-back mentoring.
One of your specialty areas is managing chronic diseases in both adults and children. How does care differ for these two groups?
The benefit of med-peds training is the broad breadth of knowledge and skills gained in both specialties of internal medicine and pediatrics. We are fortunate with medical advances that patients are living longer, and this includes patients with congenital or child-onset diseases living to adulthood. These patients develop more typical adult medical problems such as hypertension, diabetes; however, these can be more complicated to manage in the setting of their congenital disease, and there are unique challenges in delivering preventative medicine services in patients with chronic childhood and congenital diseases.
I enjoy managing chronic disease and being able to see patients through years of transition. My individual practice is focused on adult care, and it is great to be able to provide primary care for patients with congenital heart disease, type 1 diabetes, cerebral palsy, intellectual disability, as well as other general internal medicine patients. Through my supervisory role in the resident med-peds clinic, I have the opportunity to teach and help families guide their child into a life of increased autonomy and independence with respect to their health care decisions and help guide them through this transition.
What challenges do you face in transitioning children with chronic diseases into adult care?The ability to find a health care provider who is adult-oriented, but also knowledgeable about childhood illnesses, has become a challenge for many families. Many patients and families feel tied with their pediatric providers and subspecialists, which is understandable. There are cultural, parental, patient, and health system challenges in this transition. Adults are expected to be fully autonomous, able to negotiate health care services, and make collaborative treatment decisions. Med-peds training bridges this gap for patients and for specialty colleagues.
You co-wrote a 2010 JAMA article dealing with physician perceptions of patients’ health literacy. What were the major findings of that article? What sort of advances or updates in the field have there been over the past five years?
I was lucky to have been asked by Ben Powers, MD, who was, at the time, a general internal medicine faculty member at the Durham VA, and Hayden Bosworth, PhD, a faculty member at the Durham VA in health services research, to contribute to the JAMA Rational Clinical Exam article on health literacy. Our goal was to review the accuracy of brief instruments for identifying patients with limited literacy.
The literature in this field is rapidly expanding and more and more research demonstrates that patients with limited literacy are at higher risk for poor health outcomes. Physicians are not very accurate at identifying these patients. Tools for identifying these patients existed but had not been studied systemically. We identified several single-item questions, including the use of a surrogate reader and confidence with medical forms, that were effective for quickly identifying patients with limited literacy.
It is reassuring to see that there have been several federal policy initiatives, including the Affordable Care Act of 2010, the Department of Health and Human Services’ National Action Plan to Improve Health Literacy, and the Plain Writing Act of 2010, as well as programs at the CDC, that have brought health literacy to the forefront.
What passions or hobbies do you have outside of the division?
Most of my time outside the hospital is spent with my two daughters, Isabella (almost 5 years) and Lexi (3 years) and my husband, Peter Grossi, who is a neurosurgeon at Duke Raleigh. Pete and I met here at Duke for medical school, and are raising the girls to be Duke fans. I can be seen running with our double stroller around some Raleigh parks on weekends. When we have time, we love to go to Wrightsville Beach but otherwise, just enjoy the many advantages of living in this area!
Dr. Trinh with her husband, Peter Grossi, MD, and daughters, Isabella and Lexi, enjoy a day at the beach.
