Leadership for the Kids

When Anna Spagnoli was a teenager growing up in Italy, she knew she’d become a doctor. She knew she’d become a pediatrician. But practicing in the United States wasn’t on her radar. Yet, she’s become the kind of caring leader in medicine our country’s medical centers need now more than ever.

As division chief for pediatric endocrinology in the UNC School of Medicine’s Department of Pediatrics, she saw that the way we care for kids at high risk of developing complications due to diabetes wasn’t meeting her standards. Too many children were winding up in the hospital every few months. She wondered how this could be, given the fact that doctors know precisely how to control diabetes.

While continuing her research, her work with patients, and her duties as director of the pediatric endocrinology fellowship program, Spagnoli pursued a fellowship of her own – the Executive Leadership in Academic Medicine (ELAM) fellowship, a highly competitive program at Drexel University designed to prepare female senior faculty for leadership positions at academic medical centers.

As part of her ELAM project, Spagnoli found that the kids in most need of being screened for things such as kidney and thyroid problems were more likely to not get screened. She also found that medical costs related to emergency room visits and hospital admissions were much higher in those children that had uncontrolled diabetes.

When she finished the year-long fellowship, she led a team of UNC physicians to create a new “medical neighborhood” approach to caring for kids with diabetes. Each neighbor – pediatrician, primary care physician, families, patients, school nurses, community services – would have a clearly defined role to ensure proper, individualized patient care throughout the year. The goal was to reduce hospital visits and health care costs while improving the quality of life for kids, especially those on Medicaid.

The neighborhood plan is now being developed throughout parts of the UNC Health Care System.

We sat down with Dr. Spagnoli to ask her five questions about why she became a doctor, her research, and her ELAM project.

Growing up in Italy, what inspired you to attend university and become a doctor?

I love people. I love to take care of others. When I was young I always liked to take care of kids. I was the last one of my family, the youngest of four, but I had nephews and nieces. So it was great to grow up as an auntie to them.

I always knew I wanted to take care of kids. I feel that being a physician is a mission. It’s about dedicating yourself to curing someone – and I mean “curing” in a way that implies innovation, research, dedication, empathy to patients. Being a pediatrician had the right balance for me – providing care for patients, getting connected with patients, and having empathy for patients. Being a pediatrician is a privilege.

How did you wind up at Oregon Health & Science University, Vanderbilt, and eventually UNC in 2007?

I wanted the opportunity to do research in places that had the most advanced biomedical research. Where I was, in Italy, there was no research in the field that I was interested in – how the human growth process happens. So I spent a year in London doing research thanks to an [European Union] Erasmus Scholarship. I was actually the first person in Italy to get one. Then, I came back to Italy to finish residency and applied for a Fulbright scholarship, which allowed me to go to Stanford. My mentor there was Ron Rosenfeld, who wound up moving to Portland to become chair of the pediatrics department at Oregon Health & Science University. When I visited, it was rainy and cold; I joked and told him I’ll never go there.

After Stanford, I took a faculty position back in Italy, which is unusual. Rome now has five medical schools. At the time, it had three. To get a position there, even now, is very difficult. After two years at University of Rome Tor Vergata, I really wanted to do research, and I missed Stanford and my mentor. I missed that kind of exciting research setting in pediatrics. So I was able to return to the United States. I did my second residency [the first had been in Italy] and a fellowship at Oregon Health & Science University. Eventually I became an assistant professor there.

Then my husband and I had to decide what was next. We graduated from medical school together, so any decision about our careers had to involve the two of us. I interviewed at several places and chose Vanderbilt because it was right for my husband, too; he’s a surgeon. He did a fellowship in minimally invasive surgery there.

After that we looked at coming to Duke because my husband was offered a very good job there. But I could tell a job at Duke wasn’t going to work out for me. UNC, though, had a strong tradition of research in growth factors. So, in the middle of us thinking Duke wasn’t going to work out for the both of us, I wound up interviewing at UNC and got the job in pediatrics. UNC has turned out to be a great place for me.

What sorts of research projects have you led at UNC?

Well, I work in pediatrics, and the pediatric bone clinics are really different from the clinics for adults. Mostly, we deal with children with genetic diseases that lead to bone fragility, for instance, brittle bone disease. I follow one of the largest groups of patients with this disease in North Carolina.

In its severest form, kids have fractures all the time. We see them every three months because we have to give them special treatments. Not much can be done for them, so my research has focused on how to speed up the fracture healing of these patients. First, we thought about using stem cells. That’s been the basis of my research – how to use stem cells as treatments.

What we’ve found so far is that we can use adult stem cells from bone marrow to facilitate fracture healing. To do that, we can use FDA-approved growth factors. Ultimately, we’d like to use stem cells in the same way we use them for bone marrow transplants. We want to give these factors to patients so they can make these stem cells become what we want them to become – bone cells. I try to make my work in the lab translate as much as possible to the clinic.

That stem cell / bone fragility research is one part of my lab. The other part works on how we can change the human growth process in some endocrine or genetic diseases. And in this, we found something totally unexpected. We were looking at one growth factor with idea it would have an effect on growth. But it would up having an effect on cartilage. We were working with mice and saw that tweaking a certain growth factor played a role in the formation of joints.

This gene we thought we could limit to study the mechanism for human growth actually led us to study how joints develop. So now we’re using this finding to study how joints degenerate during osteoarthritis.

Why did you pursue a fellowship in the Hedwig van Ameringen Executive Leadership in Academic Medicine Program at Drexel University College of Medicine and what were some of the major benefits of this fellowship?

I wanted to have the skills to be an effective leader and planning for the next step in my career. UNC is a wonderful institution but it’s big. It’s hard to create networks beyond research or clinical interests. Also, I think that connecting women through mentoring for career development is challenging.

ELAM offers training on leadership skills, networking with women, and the possibility to develop a project that is significant for the fellow as a leader within an institution but also significant for the institution.

What sort of ELAM project did you develop?

My project is something that is outside of my research interests. I decided to do that as a challenge. I’m division chief of pediatric endocrinology, and that means largely diabetes. The way we care for patients with diabetes has changed over the past five or six years. There’s been an increase in demand for clinical productivity, which means a decrease of time dedicated to patients.

On the other hand, we know exactly how we should deliver care for diabetes patients. Every three weeks, patients should talk to their endocrinologist. There should be a full assessment of the disease every two or three months. Patients need a dietitian, sometimes a social worker. The school nurse should help monitor blood sugar.

We know there’s a very nice biomarker we can test for that shows if the diabetes is being controlled properly. This marker predicts what kind of complication a patient is at risk of developing 20 years down the road.

Every three months, patients should check this marker. We know exactly what kind of care we should provide so patients hit that marker – and this kind of care requires a team approach. Unfortunately, we found that a limited number of patients receive proper care to help them hit this marker. In our preliminary study it was only 20 percent.

For instance, if you look at three major patient populations – those at low risk, medium risk, and high risk of developing complications because of diabetes – you will see that100 percent of the people in the low risk group receive the annual thyroid screening. About 70 percent of the kids in the medium risk group get screened. And about 40 percent of the high-risk kids get screened. Why is this? Because doctors only get 15 to 30 minutes with patients.

This is heartbreaking. All of the kids should be screened. The patients that are not screened are also the ones that have most poorly controlled diabetes and end up in the emergency department or admitted to the hospitals even every few months.

So, what can we do? For my ELAM project I developed a plan to create patient-family-centered medical neighborhoods that involve the pediatric endocrinologist, the primary care physician, school nurses, social workers, family members, community services. Everyone in the “neighborhood” is responsible for some aspect of care. We have started the project by partnering UNC pediatric endocrinology with Sandhills Pediatrics, a large, community-based primary care physician group that sees patients in Southern Pines, Seven Lakes, and Raeford.

I think the medical neighborhood effort will reduce ER visits and hospital admissions while improving diabetes control and screening for complications. Eventually, I think it will reduce hospital costs. We’re now working with the largest network of Medicaid patients in North Carolina to implement this plan at a larger scale.

Also, I think this project is in line with the intent of the Affordable Care Act; the idea is to deliver high-quality, cost-effective, integrated care to children.

This has been one of the most rewarding things in my career. This is why I went to medical school; to help children in a meaningful way. The best way would be to cure patients, but for diabetes the cure is not around the corner. On the other hand, as a clinician, I started to see these statistics about who’s getting screened properly and who isn’t, and who’s admitted to the hospital and who isn’t, and I thought, ‘we can make a difference here. Are we really doing what 40 years of research on diabetes has told us we should be doing?’

In the current health care system, there’s no way a doctor can see a patient for two hours, but we can involve others to help our patients – school nurses, social workers, etc. And we can think on how to transform our care to children with diabetes by providing more integrated, high-quality and still sustainable care.

This project gave me the perspective that some changes need to happen from the top down. ELAM gave me the opportunity to see things from the top of the mountain; it helped me to see the whole picture. It’s difficult, but seeing things as a leader gives you the courage to address problems. It helps you meet with the right people at the right time and the courage to do what’s needed.

As a researcher, I was always very comfortable collaborating with others because they’re my peers. But when you start to think about being a leader, you need to go outside of your comfort zone sometimes. It’s a challenge, but I really love it. It’s very important for the patients, for my colleagues, and ultimately for me and my institution. I’m very passionate about this because I think I can make a difference.

Anna Spagnoli, MD, is a professor in the department of pediatrics in the UNC School of Medicine. To partake in the ELAM program, she received financial support from the Department of Pediatrics and the UNC School of Medicine.

Media Contact: Mark Derewicz, 919-923-0959, mark.derewicz@unchealth.unc.edu.