The seventeenth episode of MedCast features Drs. Padmini D Ranasinghe & Megan Srinivas. Dr. Ranasinghe is an Assistant Professor of Medicine at Johns Hopkins Medicine. Dr. Srinivas is the host of Project FirstLines Stories of Care Podcast and member of the Iowa State Legislature. They both join Dr. Rockower to discuss infectious disease control.
Dr. Rockower (00:00):
Welcome to Med Cast, the podcast from MedChi, the Maryland State Medical Society. Each episode we'll be doing a deep dive into medicine and taking an insider's view on issues facing Maryland's physicians and patients and healthcare more broadly. I'm your host, Dr. Stephen Rockower. Today my guests are Dr. Megan Srinivas, an infectious disease specialist. She trained at Johns Hopkins and subsequently returned to her native Iowa and won her election to the Iowa House of Representatives from Polk County. We also have Dr. Padmini Ranasinghe an internist at Johns Hopkins. She's an assistant professor of medicine in the division of Hospital Medicine. Welcome doctors, Srinivas and Ranasinghe.
Dr. Srinivas (00:47):
Thank you so much, Dr. Rockower. It's great to be with you.
Dr. Rockower (00:50):
Well, I'm so glad to have both of you here. This is a very special thing for me to be able to talk about infection and infection control and let you discuss Project Firstline, which is one of the things that we need to talk about. I just need to also say that I have a new connection to infectious disease. My son is a fellow in infectious disease in Philadelphia.
Dr. Srinivas (01:21):
I was so glad we convinced him to come on our side.
Dr. Rockower (01:24):
Absolutely. So why don't you tell me something about Project Firstline, why it was created and what it's doing.
Dr. Srinivas (01:33):
Project Firstline was really created as an initiative between the American Medical Association, the A MA and the CDC, the Centers for Disease Control and Prevention. And then they developed almost 45 different community partners through which they have various organizations, universities that come together to discuss what the issues are in infection prevention and control, and how we can educate healthcare workers who are on the front line at all different levels on how they can protect themselves, their colleagues, and their patients.
Dr. Rockower (02:04):
And what kind of programs do they do?
Dr. Srinivas (02:08):
So there's a multitude of things that are done. So we have YouTube video tutorials, so if people have even a five minute break, they can take a quick look and listen to a tutorial. We have a podcast that looks at the intersection between infection prevention control and health equity that discusses with different guests, different cases that come up in different settings throughout the country. We also have online CME and CNE and all types of continuing education credits that you can just go onto the website and look over materials and take some questions and earn some CE in your free time. There are a multitude of ways in which people can interact with this material, and we're always looking for new ways to expand how we can educate the healthcare workers in our field.
Dr. Rockower (02:54):
Is this just for physicians or do nurses and other healthcare providers get involved in this as well?
Dr. Srinivas (03:02):
It's definitely not just for physicians. That's a great question. And that was actually one of the biggest goals with Project Firstline. We have so much out there that are trying to reach specific sectors. We have certain modules that just go to nursing, certain modules that just go to doctors. But we wanted to create something that showed the whole continuum of healthcare and how infection is spread, and prevention can occur at every single level. So our material is meant for anybody in the healthcare field that's interacting with patients, whether that's EVS staff and workers. And actually we did one of our very first podcasts looking specifically at EVS staff and how we can help improve education around infection prevention and control.
Dr. Rockower (03:47):
Could you explain what EVS is?
Dr. Srinivas (03:49):
Of course. Environmental services. So it's the people who are often, unfortunately during Covid, where sometimes those who were most affected by the spread of disease because they might not have been given proper materials or proper education on how to protect themselves and their colleagues. And so the pandemic really gave us a background on, Hey, we really need to do something that's far more encompassing of everybody in the healthcare system, everybody from EVS to physicians and everything in between.
Dr. Rockower (04:23):
Yeah. I listened to your podcast of the head of EVS at one of your local hospitals, and it was a fascinating talk.
Dr. Srinivas (04:30):
Yes. Yeah. She was based out of Illinois and has worked in EVS for about at least 15 years in her current position as an administrator and came up through the ranks, of course, having had on the ground experience herself and her desire to really want to spread that information. And also just access to protective gear to everybody on the front line is so much of the equity issue that we often face in hospitals that needs to be embodied everywhere.
Dr. Rockower (04:58):
Okay. When you speak about equity, are you speaking about problems related to race or female physicians or various classes of healthcare workers? What are you specifically speaking about?
Dr. Srinivas (05:12):
So equity encompasses just an overall sentiment of making sure that everybody has what they need to be able to succeed. It's not necessarily focused on race or gender. It's focused on a multitude of things. So one of our issues in the past has been disabilities. So we recently had on one of our episodes a physician who is hearing impaired herself and discussed how during the COVID pandemic, it created a huge issue and being able to lip read for her patients because everybody had to wear a mask.
(05:48)
Oh, absolutely.
(05:49)
Exactly. And so they had to think of ways in which they could accommodate disabilities without detracting from the ability to deliver patient care, but also keeping everybody safe from an infection control prevention standpoint. So one perfect example was having masks that were clear in the front so everybody could still be understood. And it's just that mentality of wanting to ensure that we have tools in place that help everybody get the best care possible, whatever those tools might be needing to accommodate for. And that's the whole premise of equity.
Dr. Rockower (06:24):
Okay. Lemme ask Dr. Ranasinghe how some of these programs might work in Hopkins Hospital or in the rest of Maryland.
Dr. Ranasinghe (06:35):
Oh, first of all, thank you so much for having me, and also glad to share the podium or this forum with Dr. Srinivas, whom I know for a long time. So first focusing on Maryland. So Maryland Department of Health has partnered with CDC in regards to providing this same educational tool to Maryland healthcare workforce. Again, from nurses to doctors, to all the other staff who has encountered with patients. And then additionally, they do actually visit certain facilities and they give onsite education as well. So that's Department of Health, Maryland. So it has been quite successful. And then Maryland Department Health activities were featured on CDC website. When it come to Hopkins, I mean, Hopkins being a large organization and very reputable organization, they have a robust infection control department. We call it HEIC - Hospital epidemiology and infection control. And they look at available evidence, and then the CDC guideline. They have placed all these into our day-to-day practice. It's right there for you. So it's already as a procedure or process, not necessarily we have to learn immediately, it's there for you. So that's the beauty of working in such a larger organization. But in regards to in Maryland though, the Department of Health has been the key player in providing this education.
Dr. Rockower (08:04):
Okay. Can Project Firstline be used to be outreach to the public in general so that they might know about infection control and maybe prevent the next pandemic?
Dr. Srinivas (08:21):
The information is accessible to anyone who wants to get it. It's free for everybody, but the material and the way it's covered is definitely directed to people who have some understanding of how a healthcare system works. So it's really geared towards healthcare workers at all levels, but of course, anyone can access the material.
Dr. Ranasinghe (08:40):
Just to add to that, I think some of the modules just talking about basic understanding of what infections are, infection control could be. So I think even teachers and then some of the frontline people who have access to mass groups, I think maybe can get benefited from this kind of educational tool because it's very short and available wherever you go.
Dr. Rockower (09:09):
So what kinds, without going through an entire infection control residency, what types of things can other physicians do to help control infection?
Dr. Srinivas (09:23):
There are so many things. One of the basic issues that we talk about is just hand washing - simple interventions that we often take for granted every day, and just highlighting the importance of why these interventions exist. But then in a lot of our modules and in our podcasts and YouTube videos, we get into specific subjects. So one specific subject that we talked about was how certain populations of people based on where they live, may or may not have access to the same resources that we take for granted in a hospital system. So if you are a physician or a nurse practitioner or a nurse or a dietician, whatever level you might be, when you're working in a rural hospital system, you have to adapt to your local tools. And that's where the equity piece came in on this conversation. But it was talking about how you can look into the local tools and what the need is, why we are doing certain things in one hospital system, and how we can take those same principles and apply them in a place that has more limited resources and still accomplish the same goal. So it's really about getting into that thinking of this is what we're trying to prevent, and these are ways in which we can do it. Now, take this knowledge system and try to apply it in different settings.
Dr. Rockower (10:42):
Are you able to use this information and teach your fellow legislators the value of medical education and infection control and healthcare in general?
Dr. Srinivas (10:57):
That is definitely always an under goal. And I mean, from my work with both you, Dr. Rockower and Dr. Ranasinghe for many years, that is always the goal. How can we make things more digestible to everyone?
Dr. Rockower (11:13):
Yeah. Well, as you know, I've spent a lot of time speaking with legislators here in Annapolis and trying to teach them the ins and outs of healthcare so that they can craft a better healthcare policy, and obviously you've got that job to do there. We have a few physicians in our legislature now. And are you the only physician in Iowa that's in legislature? I don't know that.
Dr. Srinivas (11:43):
There are two of us. I actually went to med school with the other person. So we have a great relationship with Austin.
Dr. Rockower (11:49):
Terrific.
Dr. Srinivas (11:50):
But he has not been involved in organized medicine in the past, and so it's definitely, we have our different niches that we try to work together to fill in the gaps.
Dr. Rockower (12:00):
Okay. Well, we're always interested in promoting organized medicine, as you well know.
Dr. Srinivas (12:10):
And I agree, organized medicine is something that is a tool for us all to take advantage of that is often not taken advantage of in every part of this country as it should.
Dr. Rockower (12:20):
So what other topics have you gone through in your podcasts or in your videos that some of our physicians who are listening in would be interested in listening to?
Dr. Srinivas (12:32):
Well, many people who are involved in Med Chi have an interest in health policy. And so we had one episode where we looked at the policy impacting access to monkeypox vaccination.
(12:48)
And it came out about a year and a half ago. It was really right after we had that huge surge with monkeypox reappearing, and there was a concern around vaccine allocation. And we noticed that some of the same mistakes that had been done in the past with messaging that creates stigmatizing language was initially rolled out with the monkeypox vaccination information and how we had to learn from our past to reduce that type of messaging to enhance uptake of CDC recommendations when it comes to protecting yourself and your community. And so it was a discussion of that evolution and then how that was applied into a small healthcare system within Chicago, but then how they were handcuffed, because a lot of the local policy would only allow them to treat people who lived in a certain county. The minute they got a patient from across county lines, they weren't able to get the same vaccine funded, and so they couldn't deliver it to that person merely because of their zip code. And so it was discussing really a lot of those policy issues that arise that when people who make the policies don't necessarily have those concepts in mind, they don't understand how those policies impact patient care and delivery.
Dr. Rockower (14:08):
You bring up vaccines. And then that sort of makes me think about all the vaccine hesitancy that is out there in the world and misinformation and disinformation that many people in the social media do, and even some of our physician brethren, what can we do to promote vaccines and their use across the board?
Dr. Srinivas (14:35):
And I know Dr. Ika, you've had a lot of experience with this too, with your direct care delivery at Hopkins. So I'd love to hear your thoughts. One of the big things that I always tell people, it's about education, not about judgment. And so working in a rural population, I work a lot in rural areas. I always focus on having people establish that trust with me. And if I'm their care provider, their care practitioner, we establish that relationship and I introduce the concept, I talk to them about the concept, and I ask them what their hesitations are without any judgment and try to address their concerns. And it's really an evolving conversation that over time, I was often and have been often able to convert about 60% of my patients who started out as very resistant to a covid vaccine I've been able to do over time, convert them into actually taking the vaccine because we just have that conversation from a very nonjudgmental basis.
Dr. Rockower (15:38):
Well, that's good. And because even past the Covid vaccines, there are the measles vaccines and the pneumococcal vaccines and all the others, and that people and pediatricians are fighting their families when they come in not wanting any vaccines at all.
Dr. Srinivas (15:57):
It's very true, unfortunately. And it's one of those things where social media can be utilized as a good tool for spreading information, but it can also be utilized for spreading mis and disinformation about a gamut of scientific principles, including just all types of vaccines. So it's really about trying to encourage people for getting their information from reliable sources, and regardless of where they get it, ask them what it is that they're hearing, so that way we can help to reverse misinformation through our trusted relationships. But then in the inpatient setting, that's an even harder feat because you're only having such a short time with patients. Dr. Ranasinghe, I'm sure you could comment on some of those experiences.
Dr. Ranasinghe (16:39):
Yeah. So inpatient setting, where I work clinically, I think the main thing we could do is to educate and then plant that seed saying, okay, immunization is helpful. They are in a vulnerable position in the hospital. I think that they will get it a little bit more than when they are outpatient because they understand the gravity of the issue, though this is that they're facing. But the key is now the healthcare systems are so now driven more outpatient setting. So how do we transfer this patient clearly to outpatient setting? They can continue to follow? So in the hospital though, we give flu vaccine to everyone. It's available. And if you do meet them where they are and tell them why we give and what the evidence are, sometimes they're receptive. Of course, there's a group that we may need to go about and beyond to explain them what the benefits are, then they can choose it.
(17:38)
But generally speaking, what our role in the hospital is somewhat limited compared to this is a continuum of care needed for until they get the vaccine. So I think it is, as you said, the information should be getting from a trusted sources is a key. And then medical society like MedChi is actually working with Department of Health is doing a great job. I mean, you all remember during Covid how much they were resourceful for, not necessarily for physician and the community, and then larger Maryland population. So those kind of activities I think will be useful. Can I say something about other aspect related to Project Firstline?
Dr. Rockower (18:24):
Absolutely.
Dr. Ranasinghe (18:25):
Yeah. So the other thing is when you consider in the hospital setting, so this is definitely valuable. We see a lot of antimicrobial resistance and emerging new infection. It may be like respiratory viruses or other, so if you do practice good infection control methods, and then we'll have other benefits of preventing other infection. Some of them are hospital acquired infection. And then those will touch on patient safety quality and then also the cost of patient care. So I think that we as a physician community, how to actually emphasize the important of infection control and physicians and all the healthcare providers.
Dr. Rockower (19:08):
Let's take a break. We're speaking with doctors Padmini Ranasinghe and Megan Srinivas, discussing infection control. Funding for this podcast has been made possible by Figure One, a digital platform created solely for physicians to gain knowledge, securely, share real medical cases and improve outcomes. Learn more about figure one and join the MedChi private group at figureone.com.
(19:40)
Welcome back to Med Cast, the podcast from MedChi, the Maryland State Medical Society. We're continuing our discussion with Drs. Srinivas and Ranasinghe as we discuss infection control.
(19:53)
Well, as you know, I've been an orthopedic surgeon and an infection control was one of my bugaboos because an infection in my setting would've been a major disaster for joint replacements and all that. And I was always scrupulous about doing things to prevent infection and treating them aggressively when I had something. But actually, Dr. Ranasinghe, you anticipated my next question of what can we do to anticipate and prepare for disease X? The next big thing coming.
Dr. Ranasinghe (20:36):
I'll start. So I think, yeah, so depend on what the disease is and the root of transmission. So I think there are all sorts of diseases now emerging. And then what I think still, it goes back to our drawing board, what are our principles in infection control like handwashing and proper masking if needed, or any other methods that we use in the hospital? We have to do it diligently. And then I feel like the key is system level intervention. It's similar to physician burnout. So if you do have a system, accept those and then put those into practice, and then we can actually go a long way. Of course, there are smaller outpatient settings, and then we need to be careful and maybe educate more on those things. But my sentiment is it has to be done at a higher level in terms of education to practice change to acceptance risk. I don't know, Dr. Srinivas, if you have anything to add, like next super ( ), anything, how to prevent that.
Dr. Srinivas (21:49):
Unfortunately, there's no prevention of the next whatever it might be. There's always going to be something evolving just with the way that our society utilizes medications and antimicrobials and exposure and travel and everything of that nature. But the best thing we can do is really prepare ourselves. And I would actually say that a bottom up approach is the best way for preparation. Empowering everybody to be at the table, speak about what they see and what they do, and then utilizing their experiences to educate each other. And a lot of the time what has happened in typical infection prevention and control is we see it happen in a hierarchical manner that leaves out certain fractions of the healthcare population and doesn't realize how to best apply the principles to different people in different types of jobs on the front line. And that is one of the biggest things that Project Firstline is trying to do is overcome that barrier and involve everyone at all levels, and also get a better understanding of how the system works from different people's perspectives so we can utilize that information to better prevent spread in the future. And one of the biggest things we have to do is honestly learn from our history. And as humans, we are not the best at learning from history, but we have a perfect time period now to analyze and study so we can really make our systems more robust for the future.
Dr. Rockower (23:22):
Those who do not study the past are doomed to repeat it.
Dr. Srinivas (23:28):
Too true. Too true.
(23:29)
Yes.
Dr. Rockower (23:31):
One of the things that you brought up that really impressed me during the whole Coronavirus epidemic was how everybody in the hospital really played a part in infection control. And not only the environmental service workers, as we talked about, but the healthcare people who were, I'm sorry, the food service workers who were going in and out of the patient's rooms all the time and the security and everybody in the hospital had to be aware of what they can and shouldn't do to keep everybody safe.
Dr. Srinivas (24:15):
It's so important. And that's also something that as an infectious disease physician myself, I'm so trained to think about things from the way that I learned them, the way that I work in the hospital on consults. But we forget about all of these small little areas of introduction of infection and spread of infection just because it doesn't have to do with our daily life, but in reality, it's what the food service workers are doing. It's what the security people are doing where there are a lot of areas where we could either enhance, spread or enhance prevention of spread. And so that's why it's so critical that we really do this bottom up approach of having everybody involved so we can understand the pathways that bacteria travel, viruses travel within our systems, and also making sure that people feel protected. Because one thing I really loved about many of the healthcare systems in which I've worked, where I've trained, where I went to school, was they wanted to make sure that everybody was included and that everybody was thought of.
(25:21)
So they went and included all these different parts of the healthcare system as priority people to get vaccinated. And I thought that was so important. I thought it was such an important message to send out there and also overcome some of the vaccine hesitancy by including people who just weren't physicians or nurses, but also making sure that the first people vaccinated were part of the EVS staff. Were part of the security, were part of food service because oftentimes they're the ones who were exposed more often because they were at the bedside at all times of day.
Dr. Rockower (25:55):
Absolutely.
Dr. Ranasinghe (25:56):
And I would add is I think they should be heard and supported, and they should be empowered to say something if they see. So I think now we are creating a culture that people can voice their opinion and anything that can be improved. So I think that's where we should be actually moving towards any healthcare setting.
Dr. Srinivas (26:21):
Yeah, I could not agree more. Exactly. Right.
Dr. Rockower (26:24):
Okay. Well, let's change gears just a little bit. We'll start with Dr. Ranasinghe. I. What would be the best advice that you've ever been given?
Dr. Ranasinghe (26:36):
Are you referring to a patient or anyone,
Dr. Rockower (26:40):
Anything along your training?
Dr. Ranasinghe (26:42):
Yeah, I think proper hand washing just before meals or after any other activity. So if you do clean your hand and don't touch your face that much, you can prevent a lot of infection that we see around right now.
Dr. Rockower (27:04):
Okay. Dr. Srinivas?
Dr. Srinivas (27:07):
I would say listen to people's stories. That has always been kind of the guiding principle that I was taught early on in my career and that I find the most beauty in is everybody has a unique story. Each patient, each colleague, and understanding a patient's story and the individual they are is the most critical part of getting somebody whatever they want as their goal in the end of their care.
Dr. Rockower (27:37):
Absolutely. And that's a personal thing of mine, to listen to the patient and examine the patient. Don't just go by all the tests. Although I guess in infectious disease, you got to go by some tests, but you got to
Dr. Srinivas (27:58):
Definitely use a test, but you would be impressed. It's the story that diagnosis, 95%,
Dr. Rockower (28:02):
The patient tells you what they have.
Dr. Srinivas (28:04):
Yes, exactly.
Dr. Rockower (28:06):
One last question as suggested by my son, the infectious disease doctor, what's your favorite microorganism?
Dr. Srinivas (28:15):
For me, that's Malaria.
Dr. Rockower (28:16):
Malaria
Dr. Srinivas (28:18):
Okay. Yeah. Yeah. I fell in love with ID because of research I was doing in Southern Africa, and it was an area that had one of the highest rates of Malaria. It's nicknamed the malariosphere. And it was there that I realized the gap that existed between those who actually were creating the policies and those who were doing the frontline work, who understood what the policies did. And so that's what made me want to be a doctor.
(28:48)
Good.
Dr. Rockower (28:48):
Dr. Ranasinghe,
Dr. Ranasinghe (28:51):
I'll start with Sri Lanka eliminated malaria, which is great. So in regards to my favorite bug, I always worry about hospital acquired infections, so none of them are favorite for me, but I would say I'm very fascinated about how this MRSA can be. MRSA can be something very virulent in some patients. At the same time, something could be colonized and it is pretty commonly available nowadays.
Dr. Rockower (29:26):
Okay. Well, thank you very much to doctors Megan Srinivas and Padmini Ranasinghe, who have been our guests on MedCast, the podcast from MedChi, The Maryland State Medical Society. Tune in next time as we continue our conversations with the leaders of medicine in Maryland to discuss the issues facing physicians and our patients. For all of us here at MedChi, I'm Dr. Steven Rockower. Thank you, and goodbye.