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A commitment to supporting self-management in patients with diabetes

January 13, 2021 KER Unit Season 1 Episode 12
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A commitment to supporting self-management in patients with diabetes
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KERCasts
A commitment to supporting self-management in patients with diabetes
Jan 13, 2021 Season 1 Episode 12
KER Unit

Join Dr. Victor Montori in conversation with Dr. Steven Smith, ground-breaking endocrinologist and emeritus professor at Mayo Clinic. His professional interests include the psychology of diabetes, measurements of satisfaction and health status, systems of care delivery for people with diabetes to include the relationship between specialists and generalists, and information management and the development and use of the Diabetes Electronic Management System.  In this KER Cast, Dr. Smith shares his philosophy of patient care for chronic disease management as analogous to riding a bicycle, the two-way street of mentor-mentee relationships, and why he regards patients and their families as his most important collaborators in clinical and research endeavors.

Show Notes Transcript

Join Dr. Victor Montori in conversation with Dr. Steven Smith, ground-breaking endocrinologist and emeritus professor at Mayo Clinic. His professional interests include the psychology of diabetes, measurements of satisfaction and health status, systems of care delivery for people with diabetes to include the relationship between specialists and generalists, and information management and the development and use of the Diabetes Electronic Management System.  In this KER Cast, Dr. Smith shares his philosophy of patient care for chronic disease management as analogous to riding a bicycle, the two-way street of mentor-mentee relationships, and why he regards patients and their families as his most important collaborators in clinical and research endeavors.

Victor Montori:

The KERcast brought to you by the Knowledge and Evaluation Research unit at Mayo Clinic. And I'm Victor Montori, your host for today's KERcast. Today we have an incredible guest. Steve Smith, is an emeritus consultant at the Mayo Clinic in the Division of Endocrinology. His clinical research interests include the psychology of diabetes, the assessment of satisfaction and health status, systems of care delivery for people with diabetes, including the relationship between generalists and specialists, and the development and implementation of information management systems for the care of people with diabetes. More importantly, for me, Steve, has been a dear friend and mentor, both clinically and in research. And it's just an incredible, incredible opportunity to have, to have Steve, join us today in the KERcast. Welcome, Steve.

Steven Smith:

Thank you very much, Victor. And welcome everyone else.

Victor Montori:

Yeah, it's lovely to have you today. Steve, we normally start...Go ahead.

Steven Smith:

Can you hear me? Okay?

Victor Montori:

Yes, Yes, we can.

Steven Smith:

Okay, good.

Victor Montori:

We will normally start these conversations by asking you how does one get to be Steve Smith?

Steven Smith:

Well, there is a birth assignment, you know, sometimes. I was born actually in Knoxville, Tennessee, although we didn't stay there very long. My mother was a single mother and we moved to Miami. And so I did a lot of growing up though, in the south, because having been in Miami for a couple years, then we moved Pascagoula, Mississippi, if you've ever, there's two things that they're famous for Pascagoula, I can go over that later, if you want. Then things got in my arena a little bit more when I graduated from high school. In other words, I went off to college at the Military Academy. So I spent my time there for three and a half years. And then from there, I went to Atlanta, to Georgia Tech and then the Medical College of Georgia after that. I had a public health service tour for four years, I worked in an inner city clinic, as mostly an internist. Although when I applied for the positions, they said, "We don't need an internist" and I said, well, I can deliver babies, I've done that before. And I certainly could do some minor sort of resuscitations if I needed to, oh, you don't have to worry about this...Well, I guess I can handle it. So. So obviously, I did a lot of volunteering as well. Volunteering while I was at Georgia Tech in the emergency room as a matter of fact. I did a lot of volunteering once I got to Mayo as well. Time for Katrina.

Victor Montori:

Yeah. Well, we'll get to that. How do you, how do you, when did you find that you wanted to be a physician?

Steven Smith:

Well, the, every one of the 26 people in my senior math class, in high school, was going to go to Georgia Tech, in aeronautical engineering, mainly because that was just the flavor of the day. But there was a couple of them who couldn't get a position that was actually one of me, I was one of them. So instead of necessarily going around to being an astronaut, because I obviously I'm very susceptible to motion sickness anyways. What I figured is, since I also had an interest in healthcare, that I could probably go anywhere and still be a physician and have sort of opportunities there. So that's kind of how it came about. I wasn't born with that desire, but I did have a lot of system interest.

Victor Montori:

When you say I could go anywhere and be a physician. Were you thinking of outerspace as well?

Steven Smith:

Well, I figured I could. Except that I probably wouldn't just again because, you know, the boats that go in and circle at the fair where you have your kids on them, I can't even watch those things. It gets me all sick. So...

Victor Montori:

Well, despite the motion sickness you've been, you've been a professional in, with substantial motion, with substantial movement forward. The, where does, so one could imagine your passion for systems emerging was it from the from the Georgia Tech experience or from the military academy?

Steven Smith:

Both actually.

Victor Montori:

Yeah. Was there a seminal experience that made you think oh this, this sort of a systems approach is something that, you know, did you know that is going to, was going to be part of your medical career, not not just sort of your undergraduate experience?

Steven Smith:

That was, it wasn't well planned in that perspective. What I would say is the, the fact that I am had a little bit of interest in biological sciences to begin with, and the fact that I had some interest in the outerspace issues, the astronomy, in particular, because that was on the ground, that I could certainly plan in that way. The minute, West Point, the way I ended up going there is because our next door neighbor in Atlanta, graduated from there. And I was out goofing off and he says, why don't you apply to West Point? And I said, well, okay. Of course that was sort of the end of the Vietnam War and so I figured I it might have been attractive in that sense as well, although I wasn't terribly militaristic. So it worked out that, you know, I applied, and after I got accepted, it's a little hard to give it up, especially since we had the benefit of the scholarship aspect of West Point.

Victor Montori:

You almost have answered my, my, my usual question related to this journey of becoming Steve Smith? Which is was it planned? Or was it a series of opportunities, you know, lucky, lucky breaks and opportunities that one would not have necessarily predicted? Sounds like you had a series of, of maybe a combination of luck and opportunity?

Steven Smith:

Yeah, I have a, I think a personality gene that makes me join in or try to join in on everything that I get exposed to, you know, so I get really enthusiastic about whatever I'm doing. And as I say, you know, while I can't even say that I've had a long history of wanting to go to the military academy. It did fit the purpose at that time. So yeah, it was a combination of things probably opportunistic opportunity.

Victor Montori:

Being able to take advantage of what, what, what presents?

Steven Smith:

Yeah, keeping my eyes open and saying, Okay, this is next, if you know what I mean, but but not necessarily being able to tell you that, you know, by the time I finished the Public Health Service, I'm going to be this or that.

Victor Montori:

Oftentimes, people that have told us about taking advantage of opportunities and also, will talk about having difficulty saying no, to opportunities that come up, you know, and then living their lives a little bit on the overwhelmed side of saying yes to almost everything. Has that, has that been part of the story as well.

Steven Smith:

You have to be careful about over, overdoing it, that's for sure. Now, I have said that my wife is an enabler. The fact is after the Public Health Service, especially because I then did a fellowship, I'm particularly interested, with Don Zimmerman, in pediatric endocrinology. I was thinking because I originally had an idea that I would be the pediatrician in the primary care setting. Gosh, Don Zimmerman is the smartest guy I've ever met and it was so exciting. And I think I came home and talked to Lynn and she said, No. Because I had gone and I guess we were living in three and four year blocks of time.

Victor Montori:

So you end up, you end up pursuing endocrinology anyway.

Steven Smith:

Yeah, well, I didn't have to do a pediatric fellowship, as well, as well as the endocrine fellowship. But you know, one thing, one things interesting, some colleagues at Mayo for some period of time were short handed and Sean Dinneen and myself actually filled, filled in a case. When we went to Katrina, the first time there was no one that wanted to see pediatrics. So I saw actually, the kids who they came as well.

Victor Montori:

You you eventually managed to get back. This, how did you get into endocrinology?

Steven Smith:

Sort of a disjointed life, you're asking me about this, there was a very, very, very good clinician and teacher at Georgia Tech. There was similarly several individuals in Chattanooga, where I was assigned, and also at Savannah. And these are places that were, you know, there's one endocrinologist, you know, and still kind of primary care, but not necessarily very basic science or anything. So the fact that I can actually manipulate, manipulate myself around and get accepted, was kind of surprising I think. This is a bit of a disadvantage, probably not to have had some of that background.

Victor Montori:

So but you were attracted to endocrinology, because of, there were some people around, there was a need that you were able to see, or was there something about the content of it that was attractive?

Steven Smith:

Well, it is a scholarly approach to medicine...I didn't see myself being much different than an interest in particular. So

Victor Montori:

Yeah, I presumed that some people get attracted to endocrinology, because it offers a also a system, a way of thinking about sort of systems connected to each other within the body as the body adapts to itself and the environment. I, that seems to be a connecting point. Am I stretching it too far?

Steven Smith:

Well, no, no, I think that that's definitely one aspect. There was a time where I was focused on learning new things, especially for the molecular biology, interest and when I was going to medical school, it was much more traditional, not genetic gene, upstream promoter regions, and things like that. So actually, I spent my research time at Mayo with Eric Wieben who's an actual molecular biologist, just to make sure that I could not only learn that information, practically, but also decide, you know, that'd be exciting. So I'm intrigued and have always been intrigued about the relationships between cellular function and care delivery. At Georgia Tech, you know, the state of Georgia and the institute itself is funded, because all there basic science courses are applied. So I have my degree from Georgia Tech, in Applied Psychology, not just psychology, but Applied Psychology. So it does require you to sort of think a little bit differently.

Victor Montori:

So you have this combination of interests between biology and psychology, physiology and psychology going on, which, you know, as a trainee, because I mean, the one thing that brought us together is I, when I ended up thinking, I'll be an endocrinologist, and I needed to do research and I looked around and the only person that stepped forward or didn't step back fast enough to be, to be my mentor that was you and, and it was quite striking that there was this person that was interested in and I had seen you in conference have deep knowledge of the physiology and mechanism and treatment of endocrine disorders. So very strong biological expert, who was keen on understanding the psychology of the patient and at the same time, could also see the organizational issues, the systemic issues the, the the different parts of the healthcare system, coming together to serve the patient. So that was a, it's a very unique way of seeing of seeing the world, a way that that, that you know that you opened the doors for me to be able to see it with you. So it's it's...

Steven Smith:

There's two things to consider. One is, you know, there's three shields for the Mayo Clinic there is the clinical, there's research, there's education, I've always argued that there needs to be a fourth shield: administration. And the reason being is because if you do any administration in any organizational aspects of your care, either your studies either in medical school or fellowship, or even an undergraduate school, it takes a lot of time to do that, as well. And it's not publishable stuff, usually at the New England Journal level, it's more of just nuts and bolts, which goes into the...Patients, young adults and children and that sort of thing. And of course, I know, personally, and I'm not gonna reveal too much, but we had some long conversations about whether internal medicine or endocrinology was the thing to do. Yeah, and I think you made a good choice, but...

Victor Montori:

Yeah, it was, it was a, it was very clear to me that I was not going to be a good fit, no matter what I chose. And so I had to, I had to adapt better and you helped me tremendously with that. If you think about the values that have pushed you forward, what would you say would be those values? I mean, I, in our research unit, we have patient centeredness, integrity, and generosity as some of our core values, what would have been your core values that have pushed you forward?

Steven Smith:

Well, you know, I can't disagree with the values that you've already mentioned. I would say that I get excited about trying to help people. And that's very satisfying to me. Medicine is the kind of thing where, even if you have a bad outcome, you have a good opportunity to meet people and understand their, their efforts. And also it's, I don't wish bad outcomes as being a good thing, but it's one of those things where you can, you can be in the molecular lab and work for days, and it's one sentence in the manuscripts. We develop this assay. Where as you know, care for people is just ongoing for most of their life, usually.

Victor Montori:

Although, it seems I mean, since you and I take care of patients with chronic conditions, the, despite of sometimes feeling very good about ourselves and what we can do, our contribution to people's lives is often not even a sentence in the story of their life. Right?

Steven Smith:

Yeah, absolutely. Fact is, if you think about mentoring, if you think about the discussions that we had, you know, and I certainly think that mentoring is a two way street. Most mentors, get something out of and something incredible from the relationships and discussions and working with the person. And that would be the patient, as much as anyone so the patient can actually be the second, or the first, probably the first expert in the room when they're discussing options and decision making and that sort of thing. So, so I think it does go both ways. It's not a single one way trip into being a mentor.

Victor Montori:

You, I know you're very keen on mentorship, and I'm very lucky to have had you as my mentor and have you as my mentor. Do you see the relationship with patients as a mentorship relationship?

Steven Smith:

Oh, yeah, I think I've mentioned on several occasions to several people that is it possible that patients themselves can serve as mentors. For themselves, Yes. But I just wonder, could we think through strategies for that? I mean, there are what I call ambassadors, that try to help people make decisions and help people supporting their decisions. So I think it may just be a semantic thing in terms of whether it's a patient doable thing or not, I do think sometimes, it doesn't work out, but most of the time it's a pretty successful thing. And I think if you go to very many groups, settings, you know, with people with chronic illnesses like diabetes, you'll find that they they help each other quite often.

Victor Montori:

Yeah, I think there's a substantial, now that it's more visible through social media, I think there, the networks of support that surround patients with chronic conditions extend, visible social media and in part, thanks to social media, we can see networks of support that extend far beyond the patient's immediate family to include peer patients, you know, patients that have maybe are further along in their, in their story of disease and coping and mastering self management, that are an incredibly rich source of advice and support for patients. And I have found oftentimes much more informed and much more pertinent information than the one that we can provide since except a few of us who have it, but most of us have not necessarily lived through all the kinds of, you know, daily circumstances that challenge your ability to care for yourself.

Steven Smith:

Agree, Agree a lot.

Victor Montori:

Yes, Steve, you've been the longest leader of the Center for patient education at Mayo. And I think that is also another another example of your commitment to support that activity, you know, of tooling up patients so that they can live their lives without being hindered by by disease or treatment. That's been a that's been a core component of your professional activities, in addition to everything else we've mentioned, right?

Steven Smith:

Well, I think one of the, I think when you ask many people what they were looking for, from a physician and of course, you're going to be the expert on one side, and I'll be just less of that...to say, but I think if you can listen to what's going on in their life, empathize with them as well, because you know, you do have to have some positive relationships there. And then the third sort of component, I've always thought it's just being able to explain to them what is going on, so they can have a better idea about decision making and that sort of thing. I think they feel much more competent. So listening, empathy, explanations, I think. So that's why I come up with these little models that I've done before in terms of people say, Oh, yeah, that makes sense. You know, that relationship makes sense.

Victor Montori:

Yeah, in fact, one of those models that you've, you've been known for, is based on the idea of a bicycle, do you want to you want to share that with our audience.

Steven Smith:

We know, historically, we have had a fairly top down approach. physicians have had a top down approach to care and all but if you think of a bicycle, it's a horizontal relationship, just like the mentoring that I mentioned earlier. There's direction that sometimes we try to get folks and that's kind of the front wheel of the of the bicycle. There's the energy and the work that it takes to be a patient with diabetes or chronic illnesses, so that the back end of the, if you stop pedaling your bicycle, what happens? You fall off, you don't go anywhere. So I think there's some aspects of trying to even just describe the framework of the bicycle and what the front wheel and the back wheel are connecting. So many, many of that framework could be things like pharmacy, nursing, things that will actually tie them together and work in the same direction is what they are trying to do with the bicycle in general.

Victor Montori:

Who's holding the, who's holding the steering?

Steven Smith:

Well, it depends, I think I'm certain the context, you know, whether it's physician, patient, mother, you know, that sort of thing, and of course, there are different kind of bicycles too, right? Although I think I guess bicycles implies two wheels. But you got four wheels, you got tricycles, that try to again meet the contextual sort of situation.

Victor Montori:

Yeah, I once fell off a bike and broke my arm. As I was doing a race with a girl in my neighborhood, and her bike had training wheels, and my front wheel got stuck between her training wheel and and her main back wheel. And then she turned and I flew off. So these training wheels can be really dangerous. A1c measurement as a measure of quality of diabetes care. I've always equated it with training wheels for the health care system to learn about quality, learn about measurement, learn about what, what, you know, what we could do for improvement. And it's quite unfortunate that we got stuck on those training wheels judging both the quality of the work that we do as clinicians, and the work that patients do as patients judging all of that with a single measure, like A1c that that's been a disaster, hasn't it?

Steven Smith:

The more you talk, the further I get ahead, to sort of think of things, I want to mention one thing, you know, Sean Dinneen, he used to say that he didn't want to go in to the room, knowing what the A1c was, that he didn't want to see it. He just wanted to talk to the patient. Now, eventually, he did see it, but I mean, in his encounter with the patients, no, no he didn't. And the other thing I was going to mention is, you know, there's a lot of external factors, and you can take this bicycle analogy to the enth degree, but there are a lot of external factors that might influence the, the safe riding of the bicycle to include people who almost running off on their tricycles.

Victor Montori:

Yeah, I, you know, not having access to the A1c ahead of time, prevents you from being judgmental, or using that or letting that number, a single number, inform a judgement about the support that you're giving the patient the patient's ability to self care, right? I mean, it's that, that's been challenged.

Steven Smith:

Yeah, well, you know, and this still is going on, but the A1c has been sort of the holy grail, in one sense. And it really has been something that's not necessarily part of a person's life on a day to day basis, until they walk into the office with the physician now there is a commercial on TV, that's nowadays that says, my A1c is less than seven percent. But you know, you don't get there by anything other than hard work. And even then you can actually have a poor A1c, and you can actually be working quite, quite a lot to be able to do it. So it's sort of like a grade on a test, you know, you can actually have a test that's, you know, fairly challenging, and not necessarily get the same grade.

Victor Montori:

But also, if you just study to make the grade, you may not learn anything. So similarly, if you're just trying to ace the test, you may actually not be better off.

Steven Smith:

So there was a young woman who I was caring for a number of years ago, had type one diabetes. And she had asked about an insulin pump on several occasions, to individuals, actually an our department. And they said, No, no, no, you can't have one, you're not going to be able to handle it. Because your A1c is always way too high. And you're just not paying attention to what's going on. And there's a lot of responsibility for the... So, so we had one visit, after she had been going through our clinic, you know, for several years, I said, Oh, shoot, you don't have the tools that you need to try to help you. Because she was having hypoglycemia and I think that was the reason why she was reluctant to do much better than what she was doing. I saw her after we switched her over to a pump, and she actually did quite well. I saw her in Hyvee, our local grocery store, and she, one day and she said I got an A1c less than 7. So...

Victor Montori:

Like the commercial...

Steven Smith:

Just to reinforce the fact that it's not an A1ctotally. And even though I'm guilty of having written a chapter on that. It's how you get there.

Victor Montori:

The, this, this leads to my next question, which is what has been your favorite collaboration, your best collaboration?

Steven Smith:

Again, it can be contexts if you know what I mean. The individual if you know what I mean. I actually I had, I appreciate the opportunities to interact and have a strategy that incorporates the family and the patient themselves. In Kasson, we had some offline educational efforts, fairly traditional, patient education lecture type things with the help of the family, we were actually able to do it at a local church, as opposed to the traditional sort of medical arena. So I think there are a lot of things that we can work with, that the patient can be empowered to ask for, maybe with a little help and ask for, and hope to sort of arrange some of these opportunities for them, as opposed to say, No, no, you can't use a pump, you know, that sort of thing.

Victor Montori:

So patients are your favorite, patients and families are your favorite collaborators.

Steven Smith:

Yeah. Although I'd also say I, because it's real difficult for me to say that I don't have a strong sense of working with primary care.

Victor Montori:

So as a specialist connecting with primary care clinicians?

Steven Smith:

Yeah, they seems very, they're very receptive now. That's after about 10 years worth of networking. I would say that when we first, when I first was doing this, there was two things that I actually I always bring up. I was in a meeting with some individuals with HCPR, healthcare policy and research, they have some primary care representatives. And I was talking to them about the virtual consultation concept. And from the back of the room, there's this person that says this smacks of research. And then, of course, the opposite side of the coin is when we were, when I was submitting a grant, and having some help in reviewing it with some of our colleagues, one of them, one of our colleagues said, do we really want to do this? I mean, do we really want to have primary care taking care of diabetes, they don't know anything. So it's the Hatfields and the McCoys, you know that we're sort of working against each other. But I think that's changed a lot. But I think it's probably based on a lot of time spent helping them understand both sides. What value there can be in working together.

Victor Montori:

I've seen you build two bridges, which in an era of building walls, not bridges is remarkable. I've seen you build that bridge of trust and communication between specialists and primary care and generalist. And you've always used this line, which is we need to help the people that help the patients with diabetes, and that that will be a better use of specialist information and expertise and resources is to support the people that are already supporting the patients. And this was, I think, years before, it became clear to everyone that most patients with diabetes have other chronic conditions. And so the ideal location not just by virtue of volume, by virtue of continuity and, and the context sensitive care is, is primary care with with specialist providing, providing support, and the other bridge, and then of course, that you not only build the bridge with relationships and communication, but also with resources, the evidence project that you led, where you could review charts from primary care and offer tele advice with evidence based nuggets added to that advice was an example of using your systems thinking, your technology interest to really support that bridge with not just with the relationship, but also with just-in-time, expert advice. And then the other bridge I've seen you build, which is, I think has been quite remarkable is the bridge between quality improvement and practice intervention and research. So today, there is a very robust field of health services research and but when you were at it, you were talking to researchers that were much more familiar with the basic science aspect of that research, wouldn't bring into the practice, to use scientific methods to understand questions of how to organize and deliver care. And then when you went to the practice, you know, why are you bringing all this research stuff into the practice? We're here to take care of patients. And so you had to bridge two areas that had no interaction with each other. Am I saying that correctly?

Steven Smith:

Yeah. If you take the example of the primary care person that said that it smacks of research, I said, oh great what an opportunity, so that when we would round, when I would round with you know interns and fellows and residents in the hospital, and they were having a particularly bad day because their patients that are having bad days and they're expecting, you know, I go in and I should correct it for them and I'm, if I don't, I'm a failure. But I said, you know, every time you see someone take the opportunity to think, what aspects scholarly could I do to sort of think about helping this person out? So, the other thing I was going to go back to just, just for a second, because I know you'll appreciate this. If I have a sense that there's been a particularly difficult situation for that collegial cooperation at all I usually, the fact is, this happened in patient education quite a lot since I was medical director and I'd say, we're going to take a subterranean approach. And, of course, the one of my favorite songs from Bob Dylan is the subterranean blues. And so it's, it's one of those things where you, they end up telling you, Hey, I got this great idea, when you've actually been trying to foster that idea, along the way

Victor Montori:

So, to convince, to have them be, feel that they came up with it by virtue of influence, rather than telling them?

Steven Smith:

Absolutely.

Victor Montori:

So this is, this is lovely, Steve. When you think, when you, one of the things that is remarkable about your career was, and you've mentioned it already, when Hurricane Katrina came through the south, particularly New Orleans, creating significant devastation the, you know, Mayo, without the Mayo Clinic without much fanfare, start putting on a number of resources to help respond to that. And you went, you went down there as a volunteer on, with the Mayo crew. And I understand that initially, their response was, we're probably going to see a lot of trauma. And we're going to have to see acute care, you know, a lot of you know, injuries from the devastation. But you saw a lot of chronic disease and more, less surprising and more important for your expertise, a lot of unintended chronic disease that dated way before the hurricane hit. Am I saying that right?

Steven Smith:

Yeah, the thing is, I, I went to Katrina twice, both times supported by Mayo, the second time I was a bit more in charge. And actually, I think it's because of the chronic conditions. And that's what people anticipated that most of the need would be sort of in the diabetes, hypertension realm of things. But gosh, the first time I went down, we would be in vans with tetanus, and other immunizations, and drive by the docks at the Gulf, get out and give immunizations. So we had both or I have both experiences to tell you the truth/ I would give a lot of credit to Mayo as I usually do. Because that was a particularly generous, I think, supporting activity, because there was not a small number of people that are about 36 or so individuals that participated in it as a group. And they did that for four weeks on, on tasks. So I was there one week, and then the fourth week I was there. So I had the opportunity to kind of see the chronic illness, the, as opposed to the more acute immunization issue. So for kids, and the children, it was interesting to note that the fourth week, is with pioneers, you know, people coming in and trying to set up things and recover and that sort of thing without the kids, but the kids were actually then kind of more part of that first trip to New Orleans. And so it was just really interesting to know the, the what is it the when you're looking for behavior that has to do with groups and organizations.

Victor Montori:

So when, the second time when you're focused on the chronic condition, I think I recall you telling the story that you would be there early early in the morning, and there would already be a line of people waiting to see you is that right?

Steven Smith:

Yeah, yeah. The other story I always like to kind of tell is one of the patients that was sitting waiting to be seen, you know, while we were in these tents, you know, fell off and actually had sudden loss of breathing and I did actually mouth to mouth resuscitation of the guy because he was right in front of me. And I remember John Morris sent around a note to everyone in the division saying, this is what happened to Steve. But he's he's okay because we tested the patient and they were...it was crazy.

Victor Montori:

What, what made you, what made you volunteer for this?

Steven Smith:

For the Katrina?

Victor Montori:

Yeah.

Steven Smith:

Well, it was more of a, that sounds like a great idea, because I didn't come up with the ideas originally. As far as the the need to network, the administration to sort of have enough monies to support the, the effort. So and of course, that effort was just as much subterranean as the other populations of people that I would meet, but I think it was really more, maybe the fourth time was based on the fact that the first time I had shown some leadership issues...

Victor Montori:

But, what made you go there in the first place?

Steven Smith:

I grew up grew up in Pascagoula, Mississippi, I did promise that I would tell you two things that they were famous for.

Victor Montori:

I am dying to hear what those are.

Steven Smith:

There was a newscast some time ago, about two gentlemen who were picked up by Martians at the grain elevator down, down near the Gulf. So they actually made it to the national news. And they were from Pascagoula. And then the second issue was that you remember that barge from New York that had all the garbage on it? That was floating around trying to get rid of it. Pascagoula took it.

Victor Montori:

Well, so you, you had to go back, you had to go back. You had to go back and serve when Katrina hit?

Steven Smith:

Yeah, it just it seemed like a perfect opportunity to, to see how people fit together and work together. And I'm impressed with not only the staff, but also the fellows and residents that we had, there were three other individuals other than myself that were actually either hypertension or diabetes. And so it was, but then there was still the total group was about 36 or 40 people.

Victor Montori:

Among the several awards that you've received, Mayo has given you a Humanitarian Award and one of the things that, that makes me, makes me think is to connect you, you know, when I was your fellow and I was actively under your supervision and learning from you, all these things that we're now sharing with others. One of the things that impressed me was that you, you you had a an admiration for Jimmy Carter, and I'm from Peru, what do I know what I knew about Jimmy Carter, You know, he didn't do very well, you know, there was, but, you, you, you showed me a side of Jimmy Carter that was actually has proven over the years, to be right, and to be more enduring than some of his political issues and just like him, I see you as somebody that is a humanitarian above all, of course, you're both from the south. What what makes you admire Jimmy Carter?

Steven Smith:

Well, first of all, and I know we're not supposed to bring up political things right now.

Victor Montori:

I just did Steve. So go ahead.

Steven Smith:

I'll take the opportunity to say, think about it. Jimmy Carter, and then our current, current president, which do you think is going to have the long term impact on society? How many people build homes after they'd been President of the United States? And then he had often a subterranean route as well. I actually had a chance to meet him because he was governor at the time when I was at Tech, and their offices were just right across the street almost, you know, so. So it's always been something that I think he has a demeanor, knowledge, you know, he's actually a nuclear scientist. He, when he ran for governor in Georgia, he was a peanut farmer. But people did find out that he also worked on nuclear submarines. So I just think he is a quality guy, a quality guy.

Victor Montori:

And so are you Steve, so are you. This is so meaningful for me. If you think about the meaning of your work, what do you think has been the meaning of your work?

Steven Smith:

Good question. It has some direction and some control it was not totally laissez faire, as I might imply, you know, with the next opportunity, but I would have to say, the meaning of my work is helping people mostly. And recognizing that if I work hard, I can probably do just about anything I set my mind to at least so far. Sometimes we have things that come about that we don't have that much control over and thats pretty relevant sometimes as well. But I think it's helping people is the best thing. Doing a good job, you know, being very conscientious about the responsibility that you're taking on.

Victor Montori:

Yeah, I was gonna say that you've shown me the importance of being conscientious, doing a good job helping people. But I would say two things have also, you know, stand out. One is thinking about what is the right thing to do here. And doing the right thing, I think has been very important to you, and having fun.

Steven Smith:

Absolutely having fun. That's actually part of my criteria for a good grade. For, when we round in the hospital at the end of the week, Mayo, always questions everyone about how they think you did and others do, so they even grade us. But usually what I'll do is that towards the end of in service, I'll say, Well, you know, how did you do? You know, how do you think you did? Did you have fun? Because that's because I usually tell them, that is the most important policy that I think you need to be aware of.

Victor Montori:

When, you know, this series is about making care fit in the lives of patients. And what do you think is the, what are the next steps in the work that we do, particularly with our patients with diabetes, to make care make more sense in their lives, intellectually emotionally, practically, so they will fit better and they'll interrupt or disrupt their lives better? What do you think is the, is on the to do list to make care fit better?

Steven Smith:

You know, I'm still having a little bit of audio difficulty as far as I mean, I know I don't speak very loud. But you guys aren't speaking very loud, either at this point, but I'm not sure. Are you, qhat direction for the patient? Are you pointing my....

Victor Montori:

So as you think about well, as you think about your, your, your research activities and your practice activities, you're interest in systems and other things. In general, the goal was to support the patient better, right, build a better bicycle and offer better direction. As, what, what is left on the to do list on that task. What do you think I'm asking you about the future? Because one of the things that's been impressive about you, Steve has been the fact that you were, you know, among the first people to get on to machine learning and AI among the first people to get about electronic medical records in support of people with diabetes, you know, you have a number of firsts, or at least, you know, early adopting of these ideas and bringing them from different fields. So I'm actually quite keen on knowing what else is there coming up that I have not seen and others have not seen? That could be quite inspiring for people listening to us. What do you think is next in helping care fit better in the lives of patients?

Steven Smith:

Well, I think technology can be a frightful thing sometimes. And I think, if people don't ease into it, it can be pretty overwhelming. As far as me personally, um, the laundry list of things that I think would be exciting to still do, despite the fact that I'm getting to an age where maybe I can't do as, as well. I can sort of mentor people though I think through that, and actually even yesterday, I was talking to Nilay, Nilay Shah in HCPR. And there are several people in the institution, including one person he is working with for AI and I think that's a mysterious issue. But it seems to have a lot of purpose in getting information in a way that you can do more population studies as well. We've always been more of an individual, the individual and I think we can think about the population that that might be a nice way of trying to add to what we've been doing.

Victor Montori:

You've mentioned that you're getting older, and what, what have you learned about getting older and being a patient that you wish you knew earlier in your career as a, as a physician?

Steven Smith:

Another good question. You know, we need to be aware that we are part of the decision making process, if not the sole decision maker, with a lot of influence from people who have interest in my life. So if you take the AI, for instance, I imagine if I have the opportunity to help out in any way, it would probably be providing the clinical aspects of things that might otherwise have application if they're this mysterious neural network kind of stuff, if you know what I mean. I think we kind of use buzzwords a little bit too much, we don't really know for sure what, what sometimes people mean At West Point, you can never use contractions, you know, they would harass you if you did. So I think you just have to be, as I've done most of my life, just keep my eyes open, and see where there are opportunities and if they're appropriate to try and engage, not being too afraid. Some of my early, some of my early research efforts were actually in thyroid. So now, if you had all the other institutions that I've been in the fact that I'm getting older, and I have a particular interest in thyroid disease as well. So it's one of those things where i think it's, it's just the interest in helping people in a very scholarly way.

Victor Montori:

But yes, and that's as a professional, but I was asking you as a patient, I was asking you about the experience of living as a patient? Has there been any insight into that experience that oh, you know, it's, you now have a special appreciation for that you wish you had known, say 20 years ago?

Steven Smith:

Well, I hope I'm interpreting the question correctly. But I would say my, my daughters were particularly influencing in my life, and are never, we used to do homework together, obviously, as well. And one of them did some simultaneous equation, things math was particularly interesting to me. So we framed it and put it on the wall, the solution, if you will. So a scary thing. But with support, you know, with, with someone who has an interest, which I think I did, even though there were times when things got a little bit testy. I think that that's what I would probably try to engage people in taking advantage of what they see around them, and not be afraid about trying to sort of speak up for instance, if you, you know, you always hear about the person who brings in the Google. Well, I actually do the same thing now. I get an illness. Lynn and I, my wife, Lynn, and I usually are looking up things and being empowered, having the right to sort of be able to do that. I think that's those are important

Victor Montori:

Yeah, well, it's a, you've always been an things. advocate for patients. And I think that this notion that sometimes things get difficult, but you get by with a little help from your friends and family is, is a key component. And I think a key, a key part of that bicycle model that you speak to that not, not, the frame is not just the health care system, it gets the strong support from family and friends. And, and again, once again, the the role that we play a clinicians is really to provid support for the people tha support the people that have th problem. Right. And so, Steve we're coming to the end of ou conversation and, you know it's, it's an opportunity for m to, to really look at and loo back and at my own career i discussing these things wit you. And I'm interested i asking you one last question

Steven Smith:

You know, I've always been an applied person, You know, as you know, one o the work, one of the projec s that we're involved is in tryi g to change healthcare to be mo e about the careful and kind ca e of patients, and less about t e industrialization of, you kno , the processing of people comi g through your, your care f patients, which I, some of th m I've now picked up, you know, s soon as you retired, has been a good example of that careful a d kind care. What, what do y u think is next, in maki g healthcare more careful a d kind? If you were to choose one thing, if you have to have a magic wand, and you were to try to change something about health care, that you think will make it more likely that patients will will have careful and kind care? What would that be? you know, so there are some nuts and bolts to things that I can ever recommend to people. It's though making sure that you're not disappointing yourself in terms of how quickly it does, i takes to turn the Titanic, yo know, to, to get people to b more sensitive to it. I thin it's can be a cultural issue you know, which I think i probably the single best thing Who our mom and dads are, is important. So choosing your mentor wisely, is even more important. So, and as I s

Victor Montori:

So it takes a village, and it takes time, and id, mentors, mentoring, as with our last name, goes both directi it takes patience, and there's no magic wand.

Steven Smith:

That's right.

Victor Montori:

Steve, it's been a pleasure. And it's been fun, at least for me to have this conversation with you. I would like to thank everyone for tuning into the KERcast and looking forward to welcoming everyone to our next one. Steve, thank you so much.

Steven Smith:

Thank you.

Victor Montori:

Bye bye.