Small Actions, Big Impact: Dr. Ranney on Creating Meaningful Change

Introduction and guest background 0:00

Welcome to Heartline, conversations with healthcare changemakers following their heartline. I'm your host, Dr. Andrea Austin. I'm an emergency medicine physician, coach, and educator. I believe that healthcare needs to improve the quality care that patients receive and that supporting the workers is at the heart of this transformation. I am so excited today to have my friend and colleague, Dr. Megan Ranney, on our podcast. She is a practicing emergency physician, researcher, and national advocate for innovative approaches to public health.

She is the academic dean at the School of Public Health at Brown University, the Warren Alpert Endowed Professor of Emergency Medicine at Alpert Medical School at Brown University, and the founding director of Brown Lifespan Center for Digital Health. You probably know Dr. Ranny from Twitter, if you're on there, and she's a very informative and interesting person to follow for all health-related information and someone I turn to as a practicing emergency physician. And you probably have also seen her on CNN.

She's a regular contributor. So I'm really excited to be sitting down with her during some very tumultuous times in the United States, the world, and I'm looking forward to catching up and hearing some wisdom from you because you're such an innovative and thoughtful leader during this really difficult time. Thank you, Andrea. That means a lot, and it's just a joy to get to see you and spend time with you, even if it is virtual. Yes, I was just reflecting the last time we saw each other was February of 2020 in Chicago at the Summit for Affirm Research right before the pandemic began.

It feels like yesterday, but also like a decade ago, doesn't it? Absolutely. And that's really why, where I want to start our conversation because that's how you and I got to know each other is I distinctly remember I was in my apartment in LA while I was working at LA County and I was taking care of a lot of patients that were injured by firearms and I'm also a veteran and I was still in the military at that time. So. Obviously, there's a big problem with veteran suicide. And I don't remember where I first heard about a firm.

I don't even think I was on Twitter at that point. Maybe it was an email, but your contact information was in there. And I emailed you and I said, I want to get involved. I want to help.

Founding A Firm and firearm suicide awakening 2:54

And you called me. and we had a conversation about your work at a firm. So let's start there. Tell us about your journey to being a founding, well, a founder of a firm and what work you do there. Absolutely. So I remember that conversation too. I actually remember the email from you and I'm so glad I reached out. But my journey into this work, goodness. So I've been doing work around violence prevention since before I got to college. It has been something that I've spent so much of my life trying to think about, create programs for, and drive forward.

Early in my career, much of my work was around gender-based violence, so sexual assault and domestic violence. And I continued to focus on that during my time as a resident. But I think like any other emergency medicine resident took care of more than my fair share of shootings and stabbings and just accepted those as part of the bread and butter of our practices of emergency medicine. That view of firearm injury and of penetrating injury as acceptable started to shift towards the end of my residency.

actually went and did a fellowship in injury prevention. And very early in my fellowship, on a warm weekend evening, took care of a young man who was a victim of a GSW who really started to change the way that I thought about firearms and firearm injury prevention. Long story short, although you would expect on a warm summer evening that he was a victim of community violence, he was actually the head shot himself in the head and didn't survive. And at that point, it was the first case of firearm suicide that I'd ever seen in the emergency department.

Turns out I've seen a few more over the course of my career, almost 20 years later, but none of them have made it. And that case made me start asking questions about firearm suicide in general, about why we don't talk about firearm injury as preventable when I talk about other kinds of violence as potentially preventable. And also starting to think about the structural racism that's inherent in our response to gun violence or firearm injury, because that young man was white. And my colleagues and the community's response to him was so different from what I see most Friday and Saturday evenings in the ED.

So I started to work at that point, Andrea, kind of behind the scenes around starting to think about how do I incorporate work around firearm injury into my larger kind of group of violence prevention, community involvement, research, etc. And then, because I was told very specifically, you can't actually talk about firearm injury. This was like back in the mid-2000s when there was pretty much no federal funding for firearm injury prevention. I was someone who was trying to create a career as an NIH-funded researcher and was told, this is a no-go.

If you start talking about guns, you'll never kind of create a funded career. And then Sandy Hook happened. And I think for many of us across the country, Sandy Hook was kind of another wake up call that we couldn't be silent. You know, I had a almost four year old at that point. And I remember sitting, I was actually sitting in my departmental annual faculty meeting. I have a big kind of annual three hour thing when the images started coming across my feed on my phone. And I walked out and said, I've got to do something more.

I am not going to accept that I'm going to just somehow quietly integrate work around firearms into this larger body of research and activism and community involvement that I wasn't part of, but that we needed to actually talk about firearms themselves as a public health problem. And that started me on the road that led to my founding of a firm almost four years later. We led conferences and deep talks and I connected with a few other researchers across the country that were doing this work and started to connect with people that weren't researchers but had lived experience or were working with community groups and started slowly, slowly, slowly building the foundation for changing the way that our country, our profession, and hopefully our communities think about and address this horrific epidemic.

I think that story is so powerful and I'm already seeing a theme among our guests. that there's a pivotal point in their life where they decide the things that they've been told, the way they've been doing things is no longer working. And many times they're told that the change that they're proposing will end their career. And I have yet to have no guests. on my show that has their career is not ending. It is doing the exact opposite and taking off. So what would your advice be to, we're also suffering this horrific wave of burnout and women leaving the workforce.

And this is a podcast focused on women physicians. What advice would you have about how you really took the bull by the horns and made some hard choices? And I'm sure you had to have some hard conversations with people. I did. I actually sat down with my chair before I started doing this work and told him that I really wanted to start writing and speaking about eye worm injury. and got his blessing. I will call him, Brian Zink, who's now at Michigan, was, you know, I do think about what if he had said no?

What if I'd had a different chair?

Building coalitions and amplifying existing work 8:51

Would my career be different? Would I have stepped back or would I, you know, it's tough to know what I would have done. So I think the first thing is to make sure that you do have some protection somewhere, especially if you are junior. The second is to create coalitions. So I did not do this alone. I had Garen Wintemute, who's at UC Davis, who served as kind of a senior mentor. Emmy Betts, who's at University of Colorado Denver, who is become a fast friend and longtime collaborator. And then other folks across the country, right, that network group.

And that was the whole point of then creating a firm was to create that network, to create that support for each other. And so I think to me that's the biggest thing is to use these transition moments as chances to reach out and maybe find folks who you did know or who you didn't and to kind of create that community of practice. Sometimes with folks who are far, far away from you, who can serve as supports and people to bounce ideas off of and also people to help sometimes rein you back when you're going a little too far too fast or to push you forward when you're going too slow.

That's such a great message and something I've really leaned on during my career as well is sometimes you're lucky to have great mentors and sponsors at your own institutions and you need that really to move your career. But you also need that network that goes beyond your institution and across the country and across the globe, especially for these really complicated problems. And I think the second part of that, Andrea, is that in creating that network to not duplicate what others, right? So one of the things about the networks that I've always held dear is that it's a chance to amplify other folks who are like, your work is extraordinary.

I will never try to repeat or, you know, like we can, I can help enhance or amplify the stuff that you're doing. And then that also becomes, I learn from it and am able to incorporate parts of it into my work. But there is this sense of. You know, A, you don't want to recreate the wheel, but B, sometimes there are folks with real expertise and lived experience who are out there who you can learn from and benefit from. And so the kind of the corollary to creating the community and the network is to look and see what communities and networks are out there.

And I think that many of us, especially in emergency medicine, our instinct is to go create something new. And you don't always need to go and create something new. Sometimes you can join in and help amplify and help enhance. or even transform something that's already there where your added value is exponential. Interesting. So what you're saying is sometimes, well, frequently the first step is to lean back and listen, see what else is going on, and where does your unique skill set fit into that?

That's exactly right. And sometimes it does require you to create something brand new and forge a path that no one has ever been on, but you'll often find that there are other people that are at least walking that path along with you. And that you can, you know, I think about, I mean, gosh, there are so many examples. And I know we're going to talk a little later about a latest, the Dobbs decision. But I think about that as a great example where I'm. tremendously passionate about reproductive rights and about abortion as healthcare.

But I am also going to follow the lead and work in partnership with folks that have been doing this work day in and day out for months, years, decades, other than going and trying to create my own network to do it, you know? Right. Well, let's go there since we're already there right now. Friday was a really strange day for me because my husband was actually out of town. So I was alone a lot of the day. And it was such a. surreal and just difficult day.

Dobbs decision, reproductive rights, and response 12:40

So A, how are you doing? And B, what are you doing? Because you do have a national profile and a lot of people are looking to you for how we can get involved and what the next steps are. So I was shocked by how much that decision affected me. I mean, I think we all knew it was coming. And nonetheless, I just felt gutted. I think the words in the decision went so far beyond the worst that I had anticipated, a very explicit outlining that this is just the first of the rights that are kind of, for lack of a better word, in the target of the current Supreme Court majority.

Rights to birth control, to marry who you want, to have romantic relationships with who you want, are also all potentially endangered. And I, I was actually flying back from a conference on Friday. I was at Aspen health ideas and I had the greatest of intentions to do a lot of really overdue, but important work on my plane ride. And I couldn't, and I couldn't really do much all weekend. I just let myself sit with my frustration and fear and anger and sadness on behalf of. our generation, on behalf of my mother's generation, who worked so hard to preserve this right for us, and on behalf of my kid's generation.

You know, I have a girl and a boy. And assuming this decision stands, both of their lives are going to be changed. You know, this is not just a women's issue. This is an all of us issue. And so I sat with that fear and frustration, and then I started to look to my colleagues who have been doing work in reproductive rights for a very long time. I know I am a passionate organizer and advocate and communicator and researcher, and this is not my primary area of work. And so I will use my voice to help speak out and amplify and bring people to the right networks.

But I also want to, again, enhance the work and amplify the work of those who have been in this space for so long and to learn from them. as well. And so things that I'm doing are kind of highlighting things that I'm learning or already new, but great kind of resources that have been shared about what to do next, how to approach this and not approach this, to not make this, you know, the handmaid's tale because that others can black and brown women who are particularly going to be affected by this decision to think about how to incorporate trans rights onto our response to Adobe's decision, how to think about how to create liaisons between communities, and how to donate to those networks that are already out there.

One thing that I think is really important for us, Andrea, is that I think all of us want to post something on social media about being available for someone to come and come to a camping trip in our house, but that actually can be harmful and puts folks at risk. And so donating to the National Network of Abortion Funds, they're a very well-organized network with extensive resources. And so kind of donating to them and then listening to those who are showing places to show up, whether it is beside the State House, in op-eds, through our monetary donations, or when needed as volunteers.

The last thing is, you know, locally, one of my colleagues here is organizing trainings for emergency physicians, how to both manage complications of home abortions, of electric abortions, how to identify some of these things that most of us have never seen or trained in, but also potentially how to help facilitate safe abortions for patients coming through our EVs. Yeah, I've really been reflecting on how little I know about this because I've always relied on having colleagues that have done this work.

And I'm thinking about living in California right now. Initially I felt very safe, but the more I've been thinking about it, they're anticipating just a skyrocketing number of women coming to California for abortion services, reproductive health care services beyond abortion. And there's not going to be enough OB-GYNs available to do this work. So I've already reached out to one of my friends as a director for Planned Parenthood in the area and said, let me know, call me, text me when you're hiring emergency physicians to prescribe medical abortions.

And I'm willing to learn procedures and expand my scope of practice when invited to do so. And I think that's exactly it, to work with those experts that we know to help, right? Think about how annoyed you'd be if someone came in and was like, I'm going to take over emergency medicine, right? That's not our space or our place, but we can be supporters and advocates and help expand services. Absolutely. And help create systems that keep families safe and kids wanted. support full spectrum of healthcare for all folks.

Absolutely. I mean, I think that's one of the most frustrating things for me is we want to be able to support everyone to have the lives that they want and deserve. So, you know, that if people do have a child, that they have, you know, family leave and that they have access to great healthcare. I mean, you know, the more it's absolutely embarrassing, our maternal mortality rate in the United States. So, you know, that all has to be addressed. And maybe, I mean, I'm not even gonna say silver lining, but I am hopeful that we really take a more expansive look at this as healthcare for everyone, that everyone deserves access to great healthcare.

I love that. And I'm actually going to then bring the conversation back to firearm injury, which is that also highlight the fact that there are a thousand things that need to be done for every one of these issues. So if we're talking about access to reproductive health care, to abortion as part of health care, to supporting families, folks who are pregnant, children, there is a huge number of things abortion, yes, birth control, yes, and, and, and, and that all need to be worked on.

Firearm injury, policy, and multiple entry points 19:28

And the same thing is true for firearm injury. And I think that that's one of the things that you and I have spent a lot of time talking about is that, yes, there are policy changes which can reduce, that can absolutely reduce the incidence of firearm injury and death in this country. The policy alone is for firearms too, not enough, right? It is a necessary but not sufficient part. And there is so much else that each of us can be doing in each of our communities, regardless of what our state policies are that are going to be needed, whether or not those policies ever become part of our states or our federal legal system.

And in fact, there's lots of evidence that even when policies are passed, that if they're not enforced, if they're not supported by education, if the community norms don't back them up, they can be useless or worse. And so I think that that's kind of an additional element of all of this discussion that I think is so critical is to identify the space where your unique skill set can help move the issue forward. It may not be The kind of high octane kind of thing that all the media commentators are talking about but that's okay they've got that like maybe yours is and for firearm injury that it is you know working with big brothers big sisters those mentorship programs are actually one of the.

most evidence-based violence prevention strategies that are out there. Maybe it is working as you do kind of with the military to destigmatize mental health and mental health treatment and to help folks at help and adequately secure their service weapons when needed. You know, there's just a thousand entry points into each of these issues and none of us can do all of them. But if each of us take one, that's where we start to move the needle. And sometimes we don't know which one to take. And again, that's where you look to the experts.

So I want to turn to your role in media and advocacy and From somebody looking on the, you know, sidelines, it seems like your media presence started to grow with firearm injury prevention, but then really accelerated during the pandemic. So, and that clearly was a conscious choice, or at least continues to be, you're making a choice to lean into that space. Maybe could you unpack the decision to increase your media profile? But it's not like all you do is media work. You have a lot of substance behind it.

You're not a face. You're not a, you still work in the emergency department and do serious research. So how are you balancing that? And why did you take on the media presence? That's a great question. So the first thing, it was actually not as intentional as you make it out to seem. It was really a little bit of happenstance. It was mostly this determination on my part that folks need to hear about the things that we're facing in the emergency department. And folks need to hear the true facts around firearm injury, around PPE, around, you know, name the problem.

And there have been a couple of times where I've been fortunate in organizing responses to major public health issues to have that kind of cross the threshold of awareness on the part of the media. And then, and this is going to sound really like silly and self-facing, but I don't mean it truthful, which is like, I must have done a good job because I got asked back. And then I came to enjoy it. I like that ability to translate. You know, I think of it as talking to my parents or my neighbors or my kids and trying to translate what is the latest scientific evidence?

What is the latest controversy? How do we make sense out of these things? And there's both the very short form kind of on live TV part of it. And then there's the longer form written pieces. You know, I went into academic medicine because I love writing and I love giving talks. That's part of why I chose to be an academic emergency physician. In another life, I would have been a journalist. And so this is just a chance to take my love of writing and sharing information and do it with a different and very needed audience.

How do I balance it?

Media, advocacy, and translating science 23:58

It's gone in waves up and down as COVID has grown or as national attention to COVID versus to other things has grown, ditto for firearm injury. I find it a fun challenge to think about how do you frame the issues in ways that do catch national attention but are still tied to the data. But at the end of the day, I am first and foremost a practicing emergency physician, a researcher, and the academic dean of a school of public health. I mean, I'm doing this podcast with you from my office, right? I am going to be here for probably a couple more hours than I should be today, although I'm trying to set clear boundaries over the summer months because summer is short here in Rhode Island.

But to me, it's just, it is an extension of my job rather than a replacement for it, at least at this point in my life. So. It's really frustrating to me that we have people like like you that are such effective communicators, you're clear, you're kind, evidence-based. And we still ended up suffering so much miss and disinformation during this pandemic. You know, it's such a paradox of our times that we have access to such world renowned experts and really people that are effective at translating this information.

yet I still have patients that yell at me. about ordering a COVID test. So I know that's a really complex question, but what is your take on why that's still happening and what can any of us do? I mean, honestly, and I'm a little embarrassed to say this, but I've pretty much just stopped asking my patients if they have the COVID vaccine because I just, emotionally, it's becoming too much to have the conversation and I'm embarrassed to say that and it's gone in waves during the pandemic. But what is your take on why this happened and what we can do about it?

So I'm going to be super clear about why it happened. It happened because it was a very well-funded and intentional campaign by folks with either self-promotion motives, people made a lot of money off of it, or a desire to destabilize the system. You look at the quote-unquote dirty dozen, the 12 people that have shared the misinformation means and themes that are most common. You look at the very coordinated Twitter bots that put out the same message over and over again. There is a true kind of intentionality there.

There is a difference of intentionality behind the true disinformation. And then the lack of knowledge or lack of information, which allows disinformation to take hold, but which is often not malicious or intentional. And that part is something that I think. we as physicians can really make a big difference on. The first one, the frank disinformation. It's actually an area of academic study. We have an information futures lab here at the School of Public Health at Brown that is specifically looking into that.

That's a whole other kind of topic for folks that want to take that on. There are some great work that some fellow physicians are doing around centering docs that are spreading frank disinformation, but I'm going to leave that one aside. What we as individuals can do is to serve as arbiters or sharers of good information to fill that void. We can do it around COVID, COVID vaccines, COVID prevention strategies. We can also do it around firearms. When you actually look at the information around firearm injury that's available online, it's almost all, you know, sensational stuff around mass shootings.

There's very little around the most common forms of firearm injury, like suicide. Right. Which is on an average year respond about two thirds of GUNDA last year was barely more than half because homicides went up by so much. We can serve as folks that share kind of real, honest, truthful, effective evidence-based data. And to me, that's a very important role that we can play, whether in our social media communities or real life communities. And then in our practice, you and I are both emergency physicians.

I imagine many people listening to this podcast have clinics or patient panels and thinking about what are the strategies, either from your specialty society or from other affiliated groups. Where are the trusted places to get information that makes sense for your patients? And then that leads to the third one, which is affiliating with trusted messengers. We as physicians have a really important role to play as do public health professionals, but we alone are not sufficient. And one of the things that I have learned most strongly over the course of COVID and the work that I do in firearm injury is not just the value, but the essentialism, essentialness, of working with folks from the community and having trusted permanent relationships rather than just opportunistic relationships, but making sure that the voices, perspectives, messaging strategies, imagery, language of the community is reflected in the messaging that's put out.

You know, my Twitter feed is a more kind of scientific or physician-based feed, but I collaborate closely with folks across the country who are neither scientists nor physicians and have a wealth of experience I get to learn from every day. And I think that that's that third part of how we really can make a difference. You know, if it's going to health fairs or working with our local schools or working with pastors or, you know, going to the barber shops and working there,

Misinformation, trust, and trusted messengers 29:38

you know, you're getting your hair braided, you're sitting in the chair for hours. If you are going every week to get a haircut and a shave, you're going to see that barber rate over and over. And so thinking about how do we involve those other trusted messengers. How do I work with, you know, veterans groups? How do I work with groups that help folks find housing? Those are all parts of it. Something I've been thinking a lot about is these conversations take time. And part of the problem in American healthcare is people don't have time with their physicians or other clinicians.

It was interesting, part of my practice during the pandemic involved telemedicine and the company I worked for, I was paid per visit. So, but I had a decision on how much time I spent with the patient. So of course I'm incentivized to see people. I think the average visit was seven or eight minutes, not my average, but across the board for telemedicine physicians in my company. And then we could see somebody for up to 15 minutes and then extend the visit for an additional 15 for free to them. But I'm still compensated the same amount, whether I spent seven minutes with them or 25. During the pandemic, when I was having these conversations with patients, I actually felt more comfortable having conversations about the vaccine and treatments for COVID because people were in their house.

I was in my house. I wasn't being exposed to COVID. So I felt very safe and I think they felt very safe. So I had a couple of conversations with people that were very at the start of the conversation. Like, I don't want to hear about this. I'm not even going to get tested or I don't want my daughter tested. Very adversarial. But as we would keep talking, I had people by the end of the conversation being like, well, I work at a grocery store and we have the vaccine. So what do you think? Which one should I get?

I actually got people there. But it took time and there wasn't, you can't do that in seven minutes and people resist being rushed. Being rushed is one of the rudest things and I feel like in emergency medicine, I have to do that so frequently. And it really bothers me. So I'm a little bit on a soapbox here, but when I think back to my family doctor growing up, they were embedded in the community. We saw them at football games on Friday nights. I didn't feel rushed when I was in their office. And I think Because there was time and space and they were in our community, it was easier to have trust.

And what I'm seeing is we have a fundamental breakdown in trust where people don't see physicians necessarily as the person that takes the time and holds the space to have these conversations. Amen. Yes, everything you just said, Andrea. I think, funny, someone was asking me the other day, you know, what's the next big public health crisis? You know, what's the next big thing? And my answer was trust. Our healthcare system is not set up anymore to allow it. And you say, you know, we as emergency physicians don't have time now to do our primary care colleagues or our OB colleagues or, you know, name the specialty.

None of us do. And social media, as much as I love it, is not the place change folks' minds. It is those sustained relationships and conversation, which is then where the trusted messengers come in. But also, again, it's going full circle to this podcast discussion. It goes back to that having a network also and having both a local and national network of folks that can rely on each other. In this increasingly virtual world, there are spaces to create trust that are not Twitter or Facebook. Well, I know we're running short on time and the question I most frequently close the podcast with is what is your advice for the physician that's listening to this podcast and clenching their hands on their steering wheel, going towards their shift and just like, I don't even know how I'm gonna do it today.

I'm just so overwhelmed and so frustrated. So what's your advice for finding some sort of sanity in these crazy times? So the first thing is to give grace to yourself, to allow, you know, the whole kind of trauma-informed care approach that we all know and try to practice with our patients, but allow yourself to feel those feelings. Right? Do not like, they're real and they're honest. And the more you try to push them down, the worse it gets. So let yourself feel your anger and frustration and sadness.

And then the other thing that we know builds resilience is to feel a sense of control or hope. And so then find one small thing and it may be in your clinical practice, but just as likely it's something adjacent or even are removed that you feel like you can do something about and can have an impact on and can help lead forward. And it might be, again, joining a bigger group. There might be some small activity in your neighborhood. It might be something really big that takes your life in directions that you couldn't have imagined.

But essentially, again, part of the reason I got involved in doing firearm injury prevention was because I was so frustrated and hopeless and it felt like it was something I could do, the actions that I started taking. And so find that one small thing and see where it goes. Well, that's a beautiful way to end today's episode, Find That One Small Thing. And we're here at Revitalize to help you find that one small thing that may lead to that big thing.

Finding one small thing and closing remarks 35:48

So thank you so much, Dr. Megan Ranney, for being on our podcast. Where can our listeners connect with you? So they can find me on Twitter, at Megan Ranney, M-E-G-A-N-R-A-N-N-E-Y. I'm also on Instagram, which I'm trying hard to kind of be better about, and that's at MegRanny. Always feel free to reach out. But I can't promise that I give calls to everybody these days, unfortunately, but I do try to respond to folks. And I'm just so appreciative of what everyone is doing across this nation and across the world to help make the world a better place.

Thanks for listening to Heartline, conversations with healthcare changemakers following their heartlines. I'd so appreciate it if you could take a quick moment and hit the like button and also the subscribe button that you'll find within your podcast app or platform that you're listening on. It also really helps if you can leave a review. I would certainly appreciate a five star review and a few comments about what you liked about this podcast. Don't forget, you can also forward this to people in your network.

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If you're an organization interested in supporting the well-being of your people, I'd love to connect on innovative solutions. Schedule a strategy session at andreaaustinmd.com. Sound editing services are provided by Better Podcasting Services, and you can find their website at betterpodcastingservices.com. And I'd also like to thank our future doctor, Caitlin Dinn, who is the production assistant for this podcast.