Colleague Interview: A Conversation with Renee Crichlow, MD

Renee Crichlow, MD, FAAFP, is the Director of Advocacy and Policy and Assistant Professor, University of Minnesota School of Medicine, Department of Family Medicine and Community Health. She serves as faculty on the North Memorial Family Medicine Residency Program. Dr. Crichlow is board certified in Family Medicine and is currently the President of the Minnesota Academy of Family Practice.

This Interview has been edited for clarity and length.

Please tell me about yourself.

I grew up in Oklahoma, went to medical school in California and did a residency in Family Medicine at UC Davis and then was hired on as faculty with joint appointment in Family Medicine and OB/GYN. I was there for a few years but always wanted to live in Montana. Once I learned there was a residency training program in Montana I called them and we agreed that I should work there. I lived in a town called Red Lodge, Montana that had about 2,500 people. Our residency was in an FQHC (Federally Qualified Health Center) and we had several different sites around the county. I had my son there. But, for family reasons, we moved to Minneapolis. I had an opportunity to check out North Memorial’s Residency Program and found that it had all the aspects that I really loved about UC Davis—a really strong Family Medicine Department and also a really strong community-based hospital, which is what I really loved about Montana. North Memorial has an amazing environment for teaching as we have a large availability of patients, a variety of acuity and we get to serve our community in the clinic, the hospital and out in the community. I think that is a really great way to train residents because so much of what causes people problems is outside of the exam room.

When did you decide to train in Family Medicine?

When I went to medical school, I remember being on campus the first day and someone asked me, what do you want to go into when you graduate? “I want to be a doctor; I want to take care of people.” Like, what specialty? “Doctor. A doctor who takes care of people.” Well, then you probably want to be a Family Medicine doctor. “OK, then I want to be a Family Medicine doc.” I really love taking care of people their whole life—a grandma and her grandchildren. I love babies and delivering babies. I love hospital work and sitting down in the outpatient clinic with my patients that I’ve known forever. I love the continuity and comprehensiveness and I love the opportunity to be involved in people’s life choices for their whole life. I really enjoyed my third year of medical school and every rotation told me that I should go into that specialty. I just nodded and said, thank you, I appreciate it, but I like taking care of all the people and not having to let them go. If I can’t treat what they need at that moment, I can take care of the rest of them. And, I love translating for my patients. When I refer them to a specialist that they need to see, they come back to me to convey what the specialist is trying to say to them. I love not letting them go. I love walking into a room and patients say: “you delivered my grandbaby.” I’ve seen their kids—I’ve been here for 10 years and I’m seeing kids that weren’t even walking. I also love taking care of end-of-life issues. You get to be there

to help them discuss care with their families. A lot of times you don’t get to cure things, but you can help them heal. It’s a sacred honor to be engaging with people at the times of challenge and being their doctor.

Has the practice of Family Medicine changed over the last 10-15 years?

There are many great medications that help patients be in control of their disease, e.g. Metformin for type 2 diabetes, Flonase for allergies, asthma medications, as well as new medications for treating depression and hypertension. What’s been bad is that I think we are living in the worst possible time for the EMR. It’s just good enough to make people crazy. When I dictated or hand wrote notes, my day was finished when I was done with clinic. We’ve trained an entire generation of people that spend two hours to every one hour they are in clinic to just finish their charts in a way that are appropriate for billing. EHRs were built for billing and not for taking care of patients. I think right now we are in a time where things are evolving; Artificial Intelligence (AI) is going to be very big in taking the WAC (work after clinic) burden down, or even remove it. I’m working on a pilot project with folks who have an AI device that is actually in the room with you that compiles your conversation with your patient and fills out your EMR. It engages with EPIC; you tell it to order something and it does it and then writes up a draft of your note; you approve it or change it. I think things like that are going to bring a lot of the joy back into practice. Physicians really need to get involved in the next stage of AI development because we weren’t integrally involved in the development of the EHR and we are paying the price for that. Technology needs to be something we (physicians) are on the ground floor in the development of. Our national academy, the American Academy of Family Physicians, has taken on a multi-year project working with AI companies developing the ground floor technology because we have seen what happens when we let other people design things that get between us and our patients. Any technology should facilitate the care between us and our patients—not obstruct our ability to engage with them.

How does primary care benefit the patient more than having multiple specialists?

If you look at the idea behind primary care, it is comprehensive and there is continuity. Those two things, especially for folks with chronic illness, folks trying to prevent chronic illness, and/ or people who are trying to engage in a healthy life, they have someone who knows them and has a relationship that engages trust. A healthy young person may not need to see me that often, a reproductive-aged woman may come in for her annual exam and if she doesn’t have blood pressure issues, diabetes, etc., she may just need to discuss preventive care every year or two. But, if she gets a cold, she knows she can trust me, and can trust me enough when I say, this is a cold and not pneumonia. That trusting, continuity of care relationship decreases unnecessary tests. I have a lot of patients with multiple chronic illnesses. In one visit I can take care of their diabetes, high blood pressure, reproductive issues and cold. Are you going to four different doctors that day? Or, are you going to talk to me, someone you know, and we’ll work through it? Data shows that primary care provides better health outcomes and lower costs. We can take care of undifferentiated conditions that are not life-threatening. If the patient doesn’t have that relationship with a physician they can trust who is watching for “red flag” issues, it can lead to so many unneeded tests, unneeded procedures. I’m watching for those red flags, so if they show up I can do what is appropriate and refer to the specialist to do their specialty stuff when needed.

Has the medical school’s curriculum prepared incoming residents sufficiently?

A big change is communication with patients. The University of Minnesota does a pretty good job in getting students engaged in communicating with patients, taking H&P’s and building relationships. I think that they are coming to us with a little more nuanced approach to patient communications, so I really like that. I don’t know if they are getting as many procedural chances as I did when I was in medical school, but we can teach them that once they get to residency.

Have the expectations of the residents changed over the last 10-15 years?

Work hour rules have changed a lot. There is more shift work and I think that is just a part of the culture now. The EMR came out at about the same time as burnout was being first talked about. Throughout the whole country everyone is stressed. Is there more burnout? We probably identify it more and our residency engages in proactively teaching resilience and building resilience into our program. We allow people to recognize it now.

How much OB, operative OB and Surgery is being taught in residency?

We have a very high-volume OB residency training for our residents. All our residents graduate with the ability to go into non-operative obstetrics if they want to, and, if I remember correctly, 40% of our grads continue OB in their practice in some manner, especially for those who go rural. Most of the doctors who go rural continue their OB practice. To do operative, c-sections, people get further training. We have an amazing prenatal and OB panel where we have a very high risk, high acuity panel of patients, but we also have one of the lowest c-section rates, even throughout the country, and even though we have a very high-risk

population. It is one of the things we can be most proud of is that we manage complicated cases and get the most successful vaginal deliveries—and then we take care of their kids. We have a very large pediatric population in our patient panel.

Do you use non-physician care providers? If so, how is this working?

I think team care is necessary now and will continue to be in the future. Non-physician clinicians, including Physician Assistants and Nurse Practitioners are a great asset to the primary care team. Collaboration is very important and we respect everyone on the team as they practice to the level of their license. We are all part of the team and it is a good practice.

Please address patient safety and quality outcomes, especially in non-metro areas.

Having been someone who practiced rural, I would say that it is an interesting situation when you are a distance from high level acuity care. The number one thing we teach is how to stabilize and mobilize; knowing what you can care for and knowing when a higher level of care is required. It’s a complex set of issues and I don’t think there’s an easy answer. North Memorial Health is a Level 1 Trauma Center. You can’t have Level 1 trauma centers everywhere, therefore the best thing you can do is to match the patient condition with access and resources available. I think everyone is doing their best. Family physicians cover the majority of greater Minnesota and we have some of the best healthcare outcomes in the country. The system is not perfect here with a lot of opportunities for improvement, especially in our health inequities (both urban and rural) but, we have the best components to be the best healthcare systems in the country.

You are the founder of The Ladder. What are the objectives and what inspired you to start it?

The Ladder is a mentorship organization. We call it a “cascading mentorship” for kids in the low wealth communities interested in healthcare careers. It was started in 2012 for people ages 9-99. The goal is to get kids engaged before they get into middle school and then we recruit high schoolers, undergraduates, medical students, practicing physicians, nurses and pharmacists who all come together the second Saturday of every month to build an organization of support, resiliency and encouragement, because at each of those levels you need support, resiliency and encouragement. One of my friends calls it “near peer mentoring.” One of the things that I found when I was younger is that you learn most about medicine, life and careers from the people 2-3 years ahead of you. So, our goal is to get this sort of ladder of folks in the pipeline of medical education and help each other get to the

next level. The high schoolers are there as great examples for the middle school students and the college students are great examples for the high school students and they are able to tell them, you need to do this to get your applications in on time, do this test prep, etc. A large portion of attendees are people of color who are underrepresented in medicine. I have medical students who love coming to The Ladder as it is one of the places where they are not the only brown person in the room—it helps them to continue on in medicine. Every second Saturday we come together, we eat together, we tell stories. We always put up two quotes and you have to choose one of the quotes and tell a story about it, such as: Fall down 7 times, get up 8; or, you have two hands —one to help yourself, the other to help another. I like the Fall down 7, because I went to three different undergrad institutions before I graduated medical school and I now teach at one of the best medical schools in the country. So, younger students are seeing that failure is a part of growth and success. Our real goal is to just support each other at every single level and encourage each other to get to that next level. Some of these kids are at a place where it’s not easy being a smart kid; at The Ladder it’s great being the smart kid. We have tons of smart kids and kids who don’t know how smart they are yet. After we eat and tell stories we do rotating stations where they learn how to use AEDs, read chest x-rays, learn how to splint something. Last month it was learning how to do surgery, how to suture. Hands on learning keeps them excited and keeps them coming back. It’s really about support, building resilience and encouraging each other. Everyone volunteers their time and everyone gets something out of it. Today there are four active chapters throughout the country.

How has Broadway Clinic impacted North Minneapolis?

As an attending and preceptor, we say hi to all patients in the room and thank them for coming to Broadway Clinic. We hear from the patients that we are a part of their lives, a trusted part of their lives. There are a lot of good clinics in our community; our graduates come back to practice here and stay in North Minneapolis. It’s considered a trusted, safe place by the people who we care for and I think that’s important.

What’s your role in the Minnesota Academy of Family Practice?

I am the current MAFP President. MAFP is the largest single-specialty physician organization in the state of Minnesota. It’s awesome. We are membership-led and policy development is through membership engagement. Our vision is that all Minnesotans will have the best healthcare outcomes and Minnesota will be the best place to practice Family Medicine. Currently, we are working in collaboration with many stakeholders and other organizations on prior authorization issues, workforce development, and payment reform. I love teaching and practicing Family Medicine and so this has been an honor to serve.