Episode 9- Wisconsin Needs More Pediatricians! Dr Brilliant Nimmer

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Welcome to Pulse Check, Wisconsin. Hello, good morning, good evening, whatever it may be for you. This is Chris Ford again from PulseCheck Wisconsin, and I want to thank you for joining us again today. Thank you so much for subscribing, for liking, for giving us all your comments and questions up until this point. PulseCheck Wisconsin. For those of you new to the channel, what we do is we try to give you information. About the intersection of public health and healthcare in general. So anything that would be useful to keep you out of the ER, give you explanations of things that are going on in the community, both here in Milwaukee. As well as throughout the state of Wisconsin. What I want to do today is I want to emphasize a point that we brought up before, and that is to give folks an idea and to pull back the veil a little bit about what it takes to go into healthcare and opportunities available for folks who are interested in going into healthcare. I was very fortunate to have on a. Colleague of mine, one of my good friends Dr. Nimmer, who is an associate director at children's hospital. She's currently the, Associate program director at medical college of Wisconsin pediatric residency program. She's a pediatrician in the community with children's hospital, Wisconsin, and she currently serves. In the D and I realm at the medical college of Wisconsin. I want to allow her to give you some more information about things that she does and some of her background. It was an amazing interview that I had with her about where she came from here in Milwaukee, as well as think that she's hoping to do in the future and things that she's hoping to continue to build on She has told me once before that she is going to take over post check and become my co host. So we're gonna, we're gonna her to do the. case this week. So with that being said, I hope you enjoy the case presented to you by Dr. Brilliant Nimmer. greetings, PulseCheck Wisconsin listeners. My name is Dr. Brilliant Nimmer, and I am a community pediatrician, and I have the privilege today to present this episode's case. The case is an adaptation from a real patient case with no identifying information. So let's get into this case. The patient is a two month old male infant presenting to a community hospital emergency department for fussiness. First time parents report that their baby has been fussy for the past two days. The baby seems to be in pain. They're always holding the baby, and if they put him down, he starts crying. The crying episodes last for up to one hour. The baby is formula fed and drinks about six ounces every two hours. And parents report that he spits up a lot. He is stooling twice a day, and it's soft. The parents have not been able to follow up with their primary pediatrician since birth because their clinic that was in their neighborhood was closed, and they do not have reliable transportation to the new location. The infant has not received their first vaccinations yet. The parents do not endorse a fever or any other cold symptoms. As you review the history, the infant was born at that hospital at 8 pounds 2 ounces, which is in the 83rd percentile for its weight. The infant was born full term at 39 weeks gestation, vaginally, with no pregnancy or birth complications. On physical exam, the vitals are normal. The weight is now 11 pounds, 6 ounces, which is now in the 30th percentile. The infant is alert, crying tears, and moving around vigorously on the exam table. And the rest of his exam is normal. After wrapping the baby up back in his blanket and handing him to parents, the infant is easily consoled. He feeds well from a bottle and is well hydrated. He's then discharged home with parents with the diagnosis of fussiness and instructed to follow up with his primary care pediatrician. The pediatrician receives the note from the ED visit and contacts Social Work to help parents get transportation to the clinic. Now this is a very common experience that parents have with their infants, especially first time parents. At this time, at two months of age, you're still trying to figure out your baby's needs. And honestly, being a parent myself, infants make some weird sounds and movements that can cause a lot of anxiety. Babies communicate by crying and parents are having to figure out what those cries mean. Does that mean my baby's hungry? Does that mean that they need to poop? Do they need their diaper changed? Do they just want to be cuddled? And then sometimes you start getting worried and you're thinking, Is my baby in pain? Is there something more serious going on? And if you're at this point, it's a good time you should call your pediatrician. Many offices have great nurses that can triage these situations and determine next steps. They can figure out if we can monitor this baby at home, do home cares need to be done, does this baby need to come to a clinic to be seen today or the next day, or does the baby need to go to an emergency department? The parents in this case were worried, and they decided to go to their closest doctor, which happens to be their community emergency department. And I will never fault a parent for taking their baby to an emergency department. However, emergency medicine physicians are trained very differently from pediatricians and are thinking mostly of emergency situations that could be causing the fuzziness in this baby and what needs to happen immediately that would require an intervention or treatment for that baby. So the differential diagnosis for fussiness in a two month old in an emergency center setting is very different than from in a primary care setting, especially if the baby is appearing sick. That doctor might be thinking, is this fussiness or is this irritability? Irritability is different from fussiness. An irritable infant is very hard to console. Now you have to start thinking about things like infection. Does this baby have sepsis? Does this baby have meningitis, an infection in their brain or their spinal cord? Does the baby have a mass in their brain, something like a tumor or a hemorrhage? Does this baby suffer some type of injury? And then the doctor is also thinking about, is this baby spitting up or is this vomiting? Things like pyloric stenosis, which is a narrowing of the opening of your stomach, can cause projectile vomiting in a baby. If you have an obstruction in your intestine somewhere, such as malrotation, volvulous, or intussusception, that can cause vomiting in a baby. Is this baby having an allergy to their formula? Are they just not tolerating their formula? The exam showed that this baby was well appearing and was discharged home and told to follow up with their pediatrician. Most parents leave the situation unsatisfied, especially after waiting likely a long time in the emergency department and feel like the emergency department didn't do anything to help them. However, many People don't understand the expectations of our emergency department colleagues. They are typically triaging multiple patients that require emergent care and do not have the time to take a detailed history and provide education and need to make decisions quickly for patients. Do those patients need to be in the hospital? Are those patients safe enough to be discharged home? Which happened in this case. So the baby ends up following up with their primary care pediatrician. The pediatrician is now thinking, what is causing this fussiness? What is making them spit up, and why has this growth percentile decreased? Additional diagnoses for fussiness in a well appearing two month old in a primary care setting could be, Is this just a normal baby? Normal babies are fussy here and there. We expect that. Is this Fussiness increased. And we think about is this a colicky baby or is this a baby that's going through a period of purple? And the period of purple is a period, a growth period for babies in which they cry a lot more and it starts at two weeks, really gets worse at about two months, and then goes away completely by four to five months. During that period, babies cry for longer periods. They might cry during periods at a certain time, usually at night, and they, for the most part, just want to be held a lot more. Or is this reflux? Is the reflux causing some pain in the baby because they're spitting up so much? Is the baby having milk protein intolerance to their formula? Are parents at this time, struggling with some postpartum depression and the baby's just crying normally, but because the parents are struggling, they think the baby is fussy? The baby is well appearing at their pediatrician visit. Parents are stressed with the transition to parenthood, but feel well supported. They are mixing their standard formula from WIC correctly. They are reassured about the, about the baby, and that the baby is going through the period of purple. It was discussed not giving six ounces, of formula to a two month old. At this time, a lot of parents end up doing that during the period of purple because they think the crying means that their baby's hungry, but that is too big of a volume for a baby for a two month old, so it was discussed to reduce that volume to two to four ounces and then feed the baby more frequently and to come back in a week for a weight check. The baby comes back in a week and he continues to grow well. He's now in the 40th percentile for weight and he's less fussy and spinning up less. What this case illustrates is that families having access to a pediatrician is key for healthy patients and families. Pediatricians have the time and expertise to educate and provide reassurance. I learned that in my medical training, that 80 percent of pediatrics is reassurance. And it's a skill that you really need to have and be able to hone in on as a pediatrician. And I believe it's even become more important now with all the information that you can find on the internet, which you can Google and all the misinformation that's on social media sites. Parents nowadays, I think even need more reassurance and reassurance is so powerful. It helps relieve anxiety and support parents and it encourages them and let them know that they're doing a great job. Thanks so much for letting me discuss this pediatric case today and listening today. I hope you were all able to learn something. Peace. Thank you, Dr. NImmer for sharing the case. And now we're go ahead and transition into our interview with Dr. Nimmer thanks for having me, Chris. My name is Brilliant Nimmer. I am a pediatrician. I do pediatric primary care for children's Wisconsin. And then I'm also have a academic appointment. I am associate program director for the pediatric residency at the medical college of Wisconsin. I like it. I like it. Our alma mater. So just for some background here, and I'm going to try to clean it up as much as I can for this one, but right. And I go back to like day one of medical school, like orientation. Like this was my ACE bro. So without brilliant, I would not be where I am. I could tell you that much. man, likewise man. Like, I mean, like we were, we went way back to like before medical stu started, like this is when Facebook groups were, were a thing. Like things would come full circle for us. So this is awesome. Full circle. Well, I'm very proud of you and thank you for all that you do both in the community. I mean, your whole family is, is paramount to the success of Milwaukee right now. Her husband Shake is doing good things in the communities too. So I'm very proud of both of you all, man. Thanks so much, man, man. Thank you. And thank you. Thank you for coming back to Milwaukee. I'm glad I was able to recruit you back. We need you. My city needs you. So. Thanks for coming back and thanks for doing all you're doing for Milwaukee and the, and the state of Wisconsin. So thanks for everything you're doing in regards to the maps for policy. I think like you've really inspired me to think of things like further down, down the line, streamline things, and really policy is where it's at to really make some, some movements for, for change. So thank you for that. That's what we're gonna make some movement. We'll get it right. Don't worry. Yes. So could you just share like with our audience, like what was your own personal journey to medicine? Like you're from Milwaukee, but like where'd you grow up, your college residency, things like that, just to kind of give anyone perspective from the community. You know what they should be looking out for if they're interested in kind of going the same pathway that you did, right? So yes, I'm a Milwaukee lifer. So through and through, like, I love Milwaukee so much. I am Milwaukee. I feel like hometown glory for sure. I I grew up here. So I actually grew up initially on the south side. I lived in South Lawn. Shout out to public housing. Public housing in a very like diverse community and just a community that really looked out for each other and cared for each other. And I think like that's what really made me really want to stay in the community. I think that being able to live in a community where it's just like the village cared for each other was something that is important for me and important for, for my career. So yeah, that's, Shout out to South Lawn and shout out to the South side. I went to Milwaukee public schools all my life, so I'm a Milwaukee public school graduate and then ended up staying here in Milwaukee for college. I went to Mt Mary university in Wauwatosa, and then I took a, about a four year break in between college and then attending medical school. And during that time. I got to work at the medical college of Wisconsin being a research coordinator in various sections. So I, I worked initially in pediatric palliative care at children's and then ended up doing work in the cystic fibrosis clinic at children's before getting into medical school. And then went to medical school at the medical college of Wisconsin. And decided from there to then go into pediatrics so then did a pediatric residency here at Children's Wisconsin too. And really wanted to stay here in Milwaukee. And a lot of that made me in a lot of my just family to made me really want to stay here in Milwaukee. So really have been a lifelong Milwaukee resident and love Milwaukee. And so my career path, I've been really lucky to just have people that Have cared for me and wanted to see me win in life and really just great mentors in the city. And being able to access a lot of just like the pipeline programs here in Milwaukee to, to make me think about a career in medicine. So I've been really lucky in that. So now I'm looking for children now for about seven years, I've been a pediatrician in the community and I'm so privileged and so honored to do that. And it's really cool because I get to see people that I've grown up with, I've get to see, you know, people that are friends with my mother in law and friends with my brother and just all, all walks of life that I've gotten to encounter throughout my lifetime and then get to see their children and grandchildren or nieces and nephews. And so it's been really cool just to be able to practice in a community where, you know, everybody. It's so dope, man. And so, you know, the, the thing that comes up oftentimes, especially we had a couple of people on like from Milwaukee. We had our former health commissioner Jeanette Kowalik that came on. It was also from Milwaukee. Could you speak to a little bit about like what you mentioned? You said that coming from the community, how important that is and the influence that you can have and the perspective that's different. For someone say that is not as now a practicing pediatrician, how does, how do you feel like that has changed your practice and your perspective on things? Yeah, I think it's, it's given me so much perspective. I think Milwaukee is so unique in itself and just like the history of Milwaukee and how Milwaukee kind of came about. And I think, especially when it comes to the segregation of Milwaukee, as many of you know that Milwaukee is one of the most segregated cities in our country. So understanding that and, and living in that, I think and really understanding kind of how that all happened is important. And I think it's important for you to recognize that, especially when you're thinking about your patients and families and the barriers that they have to continue to Experience to access healthcare and any in many other social determinants of health. So I think that has been so key to me being able to care for my patients for sure. And I think that understanding that really helps you really understand what your patients are having deal with a day to day. Yeah. And, you know, nothing that can be more effective than putting yourself in that perspective and kind of walk in that walk with your patients and know those intangibles that we talked about over and over and over again, those social determinants of health things, you know, why is my patient not picking up the medication? Why are they not showing up to clinic? Right? Like all those things are things that you can understand to a certain extent, if you're not from the community, but. to actually have lived that experience and having known, you know, those are legit barriers. You know, if somebody is 15 minutes late because the bus ain't come right, or if they're presenting again and again and haven't followed up, you know, those things are, you know, super important in terms of kind of grasping the whole picture of your patient's health and the overall health. Absolutely. So true. So one of the things that we we we talked about I just recently you invited me thank you so much for inviting me to a lecture with the pediatric residency. One of the things that that you're doing right now is trying to break down some of the barriers and some of the challenges, particularly children's right now in your position. In terms of increasing the amount of diversity again, we talked about to get more providers in that same light of work, walking that experience with their patients and having that that sort of base to touch to have that common ground. What are some of the barriers that you're facing to promote that diversity? What are some of the things that you guys are doing right now in your program? Right. Oh man, that's such a great question. Oh, wow. I think we have to start from the pool of applicants that we have in general. And I think that's an important point to just touch on is that pediatrics is such a great specialty. And however, has now over the past five years, we have now seen a decrease in the amount of applicants that want to train and become pediatricians. So over the past five years, we just kind of got data from what is what is it? ACGME and they pretty much said that for MDs, for students that are graduating from medical degree schools, those the percentage of applicants that are wanting to go into pediatrics has now decreased by about 13%. That's also the same for, international medical graduates. So those that are, that are graduating medical school from a different country. However, we are seeing an increase in the DO students that are wanting to go into pediatrics, which has been a great thing. But overall, over the past five years, we've now seen a decrease in about 16 percent of medical students that are now wanting to go into pediatrics. So when you think about that, just that overall decrease of applicants wanting to go into pediatrics but however, there's still more now medical schools and it's now worrisome. Because now our applicant pool, especially when it comes to diversity, is getting even less. And so really trying to, really before even medical school pipeline programs, we're just now understanding that pipeline programs are really a lot of people are already making decisions about their careers. And so really trying to, Get into pipeline programs is really key. So, you know, the medical college of Wisconsin definitely has programs in which, MPS students get to come to the medical college over the summer and do a summer program. We also have that for college students. We also are trying to get medical students that are underrepresented in medicine. To do a way rotation at our medical school in pediatrics. So we have funds to pay for that because as you know, doing an away rotation costs money for you to go to another institution for a month and be able to do a rotation there. So we, and we understand. You know, students that are underrepresented in medicine typically have more barriers in regards to resources and costs to get these things these experiences and opportunities. So we have that in place. And then also for our residents and medical students were really trying to do a job of recruiting diverse applicants from our school and then introducing pediatrics right away. And so now our alma mater MCW has the fusion program, which a lot of medical student schools do now, where they introduce The first year medical student into the clinical space right away. And so with that, we're hoping that we now will get medical students that will come into pediatrics and be introduced to pediatrics their first year, and hopefully wanting to do pediatrics as a career, because they've been introduced to that earlier. So really trying to, before we even get to the residency application, get people excited about pediatrics. So then we can have a more diverse pool of applicants that want to. Complete residency and training is, is important. I think with Milwaukee, I think we're so lucky with Milwaukee because Milwaukee is such a diverse city. And, you know, now we're like a minority majority city. Right. So like being able, I really use that as a selling point. Like you're going to be able to see such a diverse. population of people. If you come here to, for your medical training, I mean, our institution is a huge institution, you know, with pretty much every pediatric specialty at it. And we have a huge hospital with many floors of ICUs and inpatient and an emergency department where you get a high volume of diverse patients. So I think really Having that I think is, is important for people's medical training in general to experience that. And I think that's a really good way to also recruit some diverse applicants to, to our city. Yeah. Yeah. And you bring up a good point, especially with Milwaukee now officially being majority minority, you know, there, there's going to be that need for more minority applicants and more minority matriculants as well. You know, they, there, there's, Data, which is, you know, standardized and verified, that shows that patients who are seen by doctors who come from the same communities, doctors who share the same community of interest. So religion, ethnicity, things of that nature, those patients have better outcomes. And especially as we're seeing things in Milwaukee. Like infant mortality, maternal mortality, things of that nature. It's going to be even more critical now we're in the quote unquote post COVID era to kind of have those positions in place to improve those outcomes because, you know, we can do as much as we, we, we can from a policy standpoint. But. Putting that seed into kids mind that, you know, this is something that you can attain. This is something that, you know, that needs to be a pillar in the community. Someone who needs to be there to help facilitate that care, you know, it's going to be paramount and going forward. Absolutely. And you're right. Like patient outcomes. I mean, it's life or death for our patients at the end of the day. And so like, that's what I say is that, I mean, having a provider that is. Similar to you or a share interest or of the same racial ethnic religious background is is so key and is really life or death for a lot of our patients. So I especially tell that to, you know, my friends and families that are looking for doctors that let's share that share the same either background as them. In trying to find doctors that are more diverse. I am like, don't feel bad about that. Like, this is really your life or death. Like you will most likely get better care and it's important for your health. Yeah. And just to provide some perspective. So there was a study that was done the aamc, they essentially will Put out like all of their numbers for you know, ethnic groups for age, things like that for the makeup of each matriculating class. But as of 2018, you know, when they looked at the breakdown of ethnicities monks, all the matriculants, all the applicants, you know, 56. 2 identified as white. And if you look down the list in terms of, Hispanic Americans, American Indian you know, African American, we're talking about 5. 8 percent for Hispanic Americans, about 5 percent for African Americans and about 1 percent for, Native American matriculants. So all these folks that are coming into medicine, you know, we're still representing a very small number. Even though, again, as you said, Milwaukee is majority minority at this point in time. You know, I could tell you from the time that we were in medical school, you know, there, there was a handful of us that were in the minority bucket, right. And I will say, you know, it's a little bit more than what we had, but you know, we still have a lot of work to do. And with taking place at the state level, to put barriers in place with DEI. You know, improving that matriculate number, we're, we're something that we're gonna have to continue to work on to, to improve that, because even with DEI in place, even with these pipelines, we're still sitting at about five or 6 percent in terms of that minority applicant matriculants. So one thing that I want to talk about, so I know personally, and you may have felt this too in residency, being the only person in medical school and in medical training and residency of a certain ethnicity or of a certain minority group can be really challenging, especially if you're not used to being in those environments. In the past, probably one of the reasons why we were so close, right? Because like, we come from similar communities and, you know, it was like, Hey, you can come over, you can be my best friend. Right. Can you discuss like any specific efforts, you know, that now that you're a part of the residency program. That the program is doing that you're doing to help create a more supportive environment for residents of diverse backgrounds. Yeah, absolutely. And like one of them is what you just said, Chris, like, Hey, like, come here. Like, we're like, come here. You're my best friend. Like, that's literally something that we're doing for, for our residents. And so for our residents in the DEI space that identify with a certain group, what we're, what we do is we, what's really cool is that our DEI resident committee, which has like, shout out to them, this Committee pretty much after George Floyd was formed and has really done a lot in regards to recruitment of diverse talent to our to our program and just other type of programs to help be more inclusive. At MCW. So one thing that they do is something called pride mentors. And with that, they match up people with shared identities. So in turn with one of the senior residents. And so just to give that person another person to talk to about pretty much anything, like either, whether it's like, where should I live in Milwaukee to, you know, how do I maneuver? You know being at the hospital and that culture at the hospital and how do I maneuver, you know, being the only person of color or like, how do I maneuver all those situations? And so linking up just a peer mentor who in that situation won't be judgmental and be really able there to give them advice. I think Has been great for our incoming interns that have been coming into the class. We also are actually this year starting the same thing for our residents to have then a faculty member. So we are doing the same kind of mentor program, but then also having a faculty member and having that faculty member, especially in case. The residents have any shared interest in regards to research or quality improvement projects or any other type of community organizations that they wanted to work with. So having a faculty mentor and mentorship is, I think, really key when you have people that are coming in and in that DEI space. I think that's so important for them to have mentorship. And so that's one thing that we're, we're doing, as a strategy to really help make people feel like included and belong, but then also hopefully to retain that talent. You know, I think what a lot of programs do eventually is really trying to be diverse and they'll look at numbers and they'll look at people and I'm like, okay, these people bring diversity. But then when it comes to retaining those, that talent, A lot of us have a tough time doing that. And it's because we really don't have that culture in place yet to make them feel included in belonging. And so I think that's something that we, we definitely need to work on at, at our institution in particular. And I think that becomes tricky when you have a medical school and then a hospital system and then a community, like it becomes very tricky to do. But I think that's another important piece that we have to work on. We also make sure that. We do for like during recruitment season. So when we really try in when we do our interview process for our applicants, we are doing a holistic review of our applicants. So You know, you remember those days when we had to apply for all these things and it was like board scores and publications. And what are you the chair of? And are you in certain, societies? Are you AOA? And so, a lot of that we are, we It's on your application and we see it, but we really try and do a holistic review. We're not excluding people because of certain board scores. We're not excluding people because they failed boards. We are really trying to holistically look at applicants and see their strengths in, in, in instead of just looking at scores for everything and what they got in certain classes, if you've got, you know, high passes. I pass. We kind of, we have now. Gotten rid of and really just try and make sure that we all are on the same mission of trying to have, pediatric residents that are going to be able to care for our community. And so I think that is what we look at now more instead of looking at all those scores, which is important. Like you cannot get a, you cannot get a sense of a person from just. An application like you can make it look really great. Exactly. And like coming up, you know, when we came up in medicine, we were kind of like the last class that had the, the, the weighted step one score. So for everybody listening, when you're, when you're applying for allopathic medicine licensing, you have three steps. So step one, step two, step three. that you'll take in order to get your license. And so for us, when we were going through medical school, step one was it, right? So like, if you didn't get a particular score on step one, and you couldn't apply for certain specialties is because a lot of specialties had that cutoff that bar none. So they've since moved to this standard of, you know, we're, we're just going to do a pass fail for step one, but some programs will still look at step two. But what happens is you get this group of applicants that are really good at taking standardized testing. We know that, you know, for a lot of minority communities and a lot of communities in general, you know, standardized testing may not be a strong point for a lot of people for myself personally, I'm dyslexic. So that ain't, that ain't what I'm going to shine. Right. But, you know, what we need to do, as I remember was saying is we were now moving towards, changing the pendulum saying, Hey, we need to look at the entire applicant because other things are going to shine and many applicants application overall, you're able to see the whole, whole person and you're able to see the physician that, you know, they are going to become. Right. And so you know, I'm glad that a lot of standardized institutions are doing that and having folks like Dr. Nimmer and, and those places and those spaces are, it's going to be key in terms of getting not only the best doctor that the institution can get, but the best doctor for the community and the best doctor for, wherever they're going to be working. Absolutely. And I think We know that we know that like step scores has no correlation to you completing a residency. No, are you passing your boards for that for that specialty. So holistic reviews are really important. And I think that's what we do now, which I'm really happy and proud of. And I think that having Diverse people at the table when it comes to making match lists. I think in ranking applicants is important and so we make sure that we do that at our institution for our residency program The residents are really awesome because they do Dei recruitment mixers, so they'll have these zooms where they have opportunities for medical students to ask just the residents themselves about the experience that they have there and then what kind of opportunities are available in the DEI space, which I think has been a really great place for our residents to shine and then also for us to kind of promote our program to the medical students in a, in a different way. So I think that's been a great thing. We also sent our residents to go to different conferences for the year. So our residents got to go to the SMMA conference this year in New Orleans. So, and then we also try, you know, are recruiting from our medical schools that are HBCUs. And so really trying to find diverse applicants to, in, to come to Milwaukee, I think is, is, is what you have to do to, I mean, like finding those applicants is what you have to do, making sure you're in those spaces and being able to talk about Milwaukee and Wisconsin. I think a lot of people don't know how diverse our city is. I mean, a lot of times you just hear like, what? Like, so even like when we have Our interview days and we talk about Milwaukee. Everyone's like in shock about just the diversity of it all. So I think being able to go out in those spaces and promote ourselves because we're a pretty cool city. And I think we definitely have a lot to show. And so I think going out there and recruiting people is is where What needs to happen to I think it's been really great because really after the, our residents have started their DEI committee since then, we've had about, for the most part, every year since about 2020 now, about a 20 percent of our class is underrepresented in medicine, which is the 5%, but not, you know, up to the 40 percent or 50 percent that our city is at, but still, I think it's, it's an improvement and I think Our program is definitely doing a lot of things to make sure that we're, we're getting diverse talent and hopefully getting them to stay. And that's the thing, right? Retention too. And, and you, you touched on it a little bit but one, one thing I wanted to get into, I know personally kind of coming through medicine you, you, again, being that outsider into a majority homogenous, you know discipline. There are a lot of systemic biases. There's some discrimination that can happen. Both kind of institutionally, as well as, patient interactions, things like that. I won't share all my stories here, but there's been some stories. Everybody who, everybody who's underrepresented in the garbage can or two, you know, it's been a thing, right? So what, what kind of safeguards or, you know program, based things are present of your program that will check for that, or we'll be there to support residents that are DUI. Right. And so that is so huge. And I think that's what really builds like the culture part in, in getting people to stay. I think one thing that the, one of the residents and along the faculty members have started is something at our institution. And is that a, are you A couple other residency programs is we have a microaggression tool and which is a reporting system. So residents have the opportunity in any space that they are training in to report a microaggression. And so that could be a microaggression that is that they have experienced themselves or if they have a witness to microaggression, they can report that to this tool. And which is. Great about this is that it is anonymous. However, if you do want to kind of not be anonymous, you can also just so that we can support you. And with that, it really gives, I feel like it gives the opportunity for residents to, to speak up. And as you know, residents are, it's a power dynamic, right? Like they are training. And so some of the people that are committing the microaggressions are attendings. And so being able to speak up during an, at an attending. is a hard thing for a resident to do, especially when they know they're going to be evaluated by that person, especially when they know that they might have to work with this attending again. And they might be training somewhere for three years. So they definite, it gives them opportunity, to speak up, but then also gives us the opportunity to go back to our attendings or nurses or. Whoever that may be that is, that have been the aggressor in that situation to then educate them. And so we really try to make it a tool where we say like, a lot of times microaggressions are unintentional and you not have any mouse behind that saying, however, like it hurt the person that has experienced it. And so let's educate you and tell you why that is wrong. So why was it wrong that you called a black woman? Physician aggressive in that moment, like, well, it's not that term, you know, so let's talk about why that's why that is hurtful to that person. And so I feel like that is a way that we're trying to impact culture and really get people. To stay and then get people to learn, like, we're not here to be punitive. Like none of that goes to HR or goes any goes anywhere like that. But it, it definitely gives opportunity for, for residents to say something and not have to kind of deal with that all by themselves and then gives us the opportunity to teach people at the end of the day, like we know, like. We know we're going to commit a microaggression. I commit microaggressions too, right? And like no one is above learning and doing better. And so I think that's one way that our program tries to address the culture piece is the microaggressions. We also have. One of our faculty members, you met him at the, our DEI retreat that you came to DeMarco Bowen. So Dr. Bowen also, he does a microaggression upstander training. So it's for all of our residents. And so all of our residents go through this training in which if they, they witness a microaggression that they then. Stand up to that in that moment is really what we are encouraging residents to do. If, you know, they, they don't feel comfortable doing that because of power dynamics or whatnot, or just because of the situation you know, we definitely tell them like, you have the opportunity to come back to that situation to discuss it to stand up for the person that is being microaggressed is important. And so we're training. Residents on how to do that, too. And so I think giving our residents the opportunity to practice that and then to say, like, we want you to do that. Like, we are, we are encouraging you to do that in these situations, I think is important, too, because I feel like a lot of times they feel And a lot of us in medicine feel like we have to assimilate and, you know, not say anything and just kind of put our heads down and get through the day. And, and so I think giving them that, that tool to do it. And then I think encourages them to, to change and stand up and say something. Exactly. And I know, you know, we, we can kind of speak from personal experience. You know, there are people who we went through medical school with that didn't make it right because they had an interaction with an attending or professor or whatever. And a lot of that has to do with, you know, kind of that, that perspective that, that how you deal with disagreements in one community may be different than how you deal with it in another. Right. And so, you know, having Discipline having, you know, organizations like this in place having barriers in place like this that can allow a safe space to, you know, allow both sides to kind of, you know, learn from the experience and, and, and offer, you know, a place that is not punitive. Like you said, this is not going to get anybody's job taken. This can save another pocket of positions that we may have been working with. We may have called them our colleagues, right? Like if everything had gone a certain way. So yeah, those, those are valuable and it's really good that children's and that you are spearheading that too. Yeah. So I think that's, I think that's a great way to impact culture. We also really try and support our, our DEI space. We do have like a budget for residents to go to conferences. We also have, we also encourage our residents. for certain DEI leadership programs that are with certain organizations. So we do have a budget for that. And so we've had every year, at least two of our residents go through the association for pediatric. Program directors aims program. And so really encouraging our residents to Get into that space and See what and do some career development in that I think is is important to like to show them like what kind of careers are available For you, what can you do with that? Is Really great for our residents, and I'm glad that our program is able to support our residents in that space. I think one of the big things that we're really trying to get our residents to do, they have, they get a community pediatrics rotation that they are able to do that, that everyone is actually required to do. It's, it's four weeks out in the community, and they go to various places. They go to WIC, they go to, you know, the schools, they go to really a lot of community community organizations, they go to the health department and they experience what's out in the community. And I think we'll, we're really trying to do is trying to get more kind of community connections and giving the. Residents, more opportunities to be out in the community. It's something that we really are trying to work on this year because they really love that experience. And I think you know, caring for our community, they need to know what community organizations are out there to, to really impact our patient's health, like so many of our organizations here are doing so much for our, for our patient's health. So really having the opportunity to have those resources and to be able to build those connections, I think is, is key to for our residents. Absolutely. And kind of on the other side of that coin with regards to the organizations in the community educational institutions. Are there any that you guys are working with to kind of help shut students into the healthcare field or into pediatrics? I don't know if there's any in particular. I know. I know our groups does things with and I know that during the community pediatrics program, they do things with an extra foundation. They do stuff with a with a younger school age kids. They also do things with the Milwaukee Academy of Sciences. And so I'm not quite sure on what other organizations that The residents are working with currently but those are the two kind of school age based kids that they get to work with currently, which is great and those are huge. Like, especially I just did a an event with black men, white coats. And one thing that we talked about. Was, you know, you can't be what you can't see. Right. And so I know myself growing up, you know, I was very fortunate to have both of my parents that were very much advocating for education and how they can get you out of circumstances, etc, etc. But I can, you know, only remember one African American doctor. That I saw, like, in the entirety of my childhood, right? And so they could, my parents could only advocate to a certain extent, but they didn't know, you know, what it was like to study for the MCAT. They didn't know, you know, why I was in a library for eight hours, right? Like, trying to put in, put in this work, right? So, but, you know, having someone that you can see and that you can model that you can ask direct questions, you know, what is AMCAS? Like, what is, you know, what, what are these applications we need to do? What's the personal statement, right? Like all those things are invaluable and things that other communities have already in place, right? There's pipelines for schools and for folks who have parents that are physicians, et cetera, et cetera. But to have that now with those programs, even at that age is, is paramount and kind of changing the numbers that we're having right now. Absolutely. And it is so important. You're right. Like just that, that advice for our young people, I think, especially now with, you know, the Supreme Court making a ruling in regards to affirmative action and, you know, what, You know, really trying to shine in those places. Like, and honestly, some GME places now blind everything in regards to diversity. So there are some residency programs out there that because of their institutions, policies, or, and they are blinding applicants. Diverse information and demographics. And so telling them ways of how to, you know, describe themselves and their personal statements and other ways to get around really trying to show how diverse people are is man, that advice is so important for our young people nowadays, because they really are going to have to maneuver a lot because of that ruling. Yeah, absolutely. And, and what's going on states that too, right? Like there's a huge polarization in this movement away from it. And as we said before, at the top of the hour, you know, a lot of it is even with those parameters in place to improve, you know, matriculation and improve DI opportunities, we're still at five or 6%. So you putting this in place, so, so that's too much for you? Like what do we say Exactly, exactly, exactly. Like that's just gonna be another barrier for Right, for our. Students trying to get into college now and trying to get into other graduate programs. And so really having to be mindful of how to get through that nowadays is, is. It's something you people need like really good advice on and really how to make themselves shine on their applications in different ways to show how diverse they are is going to be something that we have to really advise our advise our young ones on what to do. Yeah. Speaking of kind of diverse backgrounds, one of the things you mentioned was that there is support for folks that may be coming from international programs, what additional kind of additional challenges or barriers do folks that are coming from that international applicant pool, what, what are some of the things that they're facing? And what are some of the things that you guys are doing to help support them in those in those application cycles? Right. I think that I think that is a space that really meet like deserves more work, especially at our institution. If you're an international medical graduate, it is very, it requires a lot of work just to get over here. Honestly, I mean, the visa process is you. Is very tricky trying to maneuver a visa process and then really what you need to just live here after that, you know, like making sure you're able to get your driver's license and like things like that is very complex. And I think that's a whole issue just figuring out how to that visa process and how to get here, I think, is something that, you know, our. Medical school and our graduate medical education does, but I think once our international medical graduates get here, I mean, entering our culture is very shocking. And, and I think it's something that our international medical graduate students like. struggle with so hard is, is now you're entering this country with, and I, and in a lot of people do not understand just like the racism that is entrenched in every single thing and every system and those interactions, like they have a very hard time understanding that. And I think that's the hard part for our international medical graduates is really understanding like how much racism is really entrenched into. Everything that happens in this country. Everything. Period. I think that's a hard one for them to understand. Because, you know, like I've had students from, you know, Nigeria and they're like, they're in shock. Like, they're like, why do they call everything, like, this is the first black person that did this? And I'm like, they're like, Every black person in Nigeria has done these things. Like we've had black doctors and black scientists and like, so they're kind of in shock by like how much race is involved in a lot of what we do. And so I think that's a piece of it that is very hard for our international medical graduates to kind of deal with. And I don't know if we have a good thing in place for, to support them, honestly. And I, And I've seen, you know, programs. I mean, there was a program in New York, maybe a couple of years ago where they're entering class like for, you know, for their, International medical graduates had died by suicide just, and it was just like, what are we doing to really support, to support that? I know there was a lovely, I went to a conference recently in Chicago and there was a there was a lovely mentorship program and then they had like, you know, weekly, not weekly, monthly dinners and just like having that community, I think is really important for, for people. And so I think we need to do more of that though. We definitely, especially because now, especially in pediatrics, we need to recruit more from international medical group graduates and DOs to support that. I think we really need to do a better job of figuring out ways on how to support them when, when they come to this country. It's a shot coming into this culture and then having a medical culture on top of that, right. Like I remember when I first, when I first came to Milwaukee from Chicago, I was fortunate to have Brillant and Shake showed me the ropes and everything. So like that, just go from Chicago that I couldn't even imagine what it was like, like for international students to come here and then be immersed in, you know, a lot of the barriers that are in place right now. From an historical standpoint, even here in the city, Milwaukee, is one of the most segregated cities in America, right? Period. Bar none. And a lot of that has to do, with redlining over time with the companies that were placed for home ownership in Milwaukee. And so these are things that are generationally generational barriers for a lot of our patients. And so, kind of like we talked about in the beginning. They don't understand, you know, how to, how to, how to walk in those shoes. Why aren't you getting that medication? Why aren't you doing these things? Right. But all of those things are in the context of those historical barriers that have been in place and trying to help them navigate that first off, and then navigate in some cases, the language barrier and some places, the socioeconomic barrier. You know, all those things are things that institutions like children's and institutions like MCW you know, are trying to put resources in place and mentorship in place to kind of help with. Yeah, and, and I do, I do, I do a noon conference with the residents and we talk about all that in Milwaukee, just like the red lining and how that, you know, Cause segregation here, but just even like how the freeway system was built here. And like, like that is like now really concentrated poverty to the central city and how people can just drive around that and not even recognize and understand the level of poverty in Milwaukee in regards to big city is like the second after Detroit. So I think people don't even recognize that that five minutes from your house, it is, is a pretty impoverished community. And That needs resources and how concentrated that that is here in our city with regards to leadership opportunities. Let's say like if you go to Children's and you have hope to be like chief resident one day or, you know, be in your position right now. What, what, What rules are put in place and what kind of programs are put in place to make sure that residents or applicants are able to receive equitable opportunities and advancement at a place like Children's. Right. I think, and I really, I think the residents have a great opportunity to get beyond that, you know, that Dr. Ford but I think, and I think we're being more mindful of that, honestly, now now, and I think we are really Making sure that our residents have opportunities and making sure that we're saying that our diverse residents have opportunities because we understand the inequities that lie with even going to a conference, you know, like making sure that we're able to send our residents to a conference, like the cost of that, like having to put that on your credit card for a month, you know, like, that's that's a lot of time. Yeah. So, like, making sure that we have, like, we have those things in place for our residents to make sure that they're able to present their research, go to conferences, go to career development programs. Like we have, That in place for our residents. And then we also have like committees for our residents to gain leadership into. So we really want to make sure that our residents are our, our leaders of their committees. And so really we want to work with them and then, but we really want to say like, these are your committees. We want to support you in it, but we really want you guys to take the lead and really strategize your priorities for the year. And And giving them those opportunities to say what they need from our program. And then from our committees, I think are, is really key. And I think that's something that our program does a great job of is giving our residents a voice in those committees for sure. And so I think giving them those opportunities to do that is. important and we really need to make sure that we're giving residents those opportunities. It's hard as a resident because like, man, you're working like 70 hours a week. You know I think those are so needed. And I really think, I mean, as a physician, like you will always be a leader and you really need to make sure we are getting those leadership skills. for our careers and I think I really think that like all of us honestly like in as physicians our leaders are really I really try and think about leadership and and igniting leaders and just like igniting those skills for our leaders and for our residents that are gonna one day become attendings. Absolutely. And are going to be the people that are going to continue to push, you know, to, to a more equitable future for all of us. Right. That's, that's the goal. That's my goal. That's the goal. And I mean, like, and I'm inspired by them. I think the, the future is bright for sure. Like they the residents, I think are. I think this generation has been very just outspoken about many, many things. And so I'm really encouraged about just how they speak up about our physician well being. I think really great in, in their advocacy for saying like, Hey, like, It's not right to work on his hours like it's not safe, you know, like it's not normal. It's not a normal relationship, right? Our well being is important. You know, I think they've really even gotten into great, great conversations about compensation. And really like advocating for compensation. Our, our last group of residents, like signed contracts and they all shared their salary numbers with each other. So to make sure that they're like, Hey, we're getting paid. Like, and I think that's important. I think that, you know, when we were coming out of medical school, it was like, Oh, don't speak about your salary. No, nothing financial, nothing financial at all. Right. Which is totally asinine, especially like you consider we come out essentially illiterate about finances. Like everything is medicine, medicine, medicine. We don't know how to think the bill. We don't know how to, you know, preauthorizations. I didn't learn about that until I came out. Like, what are you talking about? What are you calling me for? Right. So these are things that, you know, like you said, your residents are talking about now, and that puts them in a better space and a better mindset to actually make a functional change. Right. Right. Exactly. So I'm really, I'm really encouraged by them and I'm really glad that I get to, like, continue to learn from, from our, our next generation. They, they definitely inspire me too. So I'm really glad that yeah, they're speaking up and they're doing a lot of good stuff. Absolutely. Well, I'm gonna close it out here. So, you know, for anyone out there who is interested in pediatrics, wonderful for you. What is any advice that you want to leave anybody with? Parting advice that you would have for for anyone interested, anyone in the city who has interest in medicine or doing anything in a secondary education? Right. Oh, my gosh. Oh, great. So man, I'm going to say like, I love being a community pediatrician. I think it's honestly the best job in the world. I think being able to watch a child grow and having the privilege to like be a part of that and be a part of it. Like families and watching a child grow is like one of the greatest shows on earth and people, you know, people that are parents will definitely like definitely probably feel the same way. But I think having that the honor to do that is something that is so rewarding and something that I definitely like if. If you're in one do medicine, or I would definitely say like pediatrics is where it's at. Kids are so funny. They're so hilarious. They say that they're so great to work with. And so I think pediatrics is also just so fun just brings me so much joy and being able to see kids bring me so much joy. So if you want our career that's just going to be Just joyful to, I think, pediatrics is, is a great career. In Milwaukee, I, man, like, there are just definitely a lot of opportunities at the Medical College of Wisconsin for, and I would say, like, go on their website, look at all the pipeline programs, apply for one. And then I also just like within our, I know a lot of the Mocky, some of the Mocky public schools also have pipeline programs at it. So if you are a student at one of these schools, make sure that you're attending them, make sure that you are listening at them definitely do that. I think there is also just opportunities for you to, you know, go to. The hospital volunteer at the hospital volunteer at a community organization, like get out there in the community. I think it is so important for, for you because you know, medicine is, is great. And a lot of what medicine is really understanding like what's happening. For our patients outside of the clinic doors and understanding that man, 80 percent of that is what is determining our patients health. And so really going out in the community, I think, is something that I would encourage people. That want to go into medicine to do because you have to really understand the community to, to make it a medicine. Absolutely. And we need y'all man. Come on out. Yes, yes, we need you so bad. We need you out here. Man. Me and Dr. Ford need to retire guys, like we need to be a wrap, bro. We need to be out of your 80. Well, I appreciate you coming out. Dr. NImmer is always we will make sure we post any resources that you want to provide for anyone, any of those programs, things like that. So. Again, thanks as always. I'll see you soon. I would imagine. Yes. Yeah. Yeah. Oh my gosh. Thanks for having me. Oh my gosh. This has been such a great time. I am still kind of upset that you didn't give me a budget for this episode. Cause I did, I did want my own podcast studio for this, but It's you, bro, bro. Have a good one. So I want to thank Dr. Nimmer today for coming out and joining us here at Pulse Check. As always, thank you, thank you, thank you so much, Dr. Nimmer, for everything that you do in the community, as well as for being an invaluable friend And again, I'm so grateful for everything that she and her family has been able to do, throughout the city of Milwaukee all the great things to come. So looking forward to have you. Dr. Nimmer back on the show at some point in time to help us dig into some of the issues that are affecting us here in the city of Milwaukee, as well as throughout the state of Wisconsin. I want to thank\ you for listening today. Please join us for our next episode. We're going to have more hard hitting healthcare topics that affect you in your day to day. We want to make sure that this is interactive. So feel free. To reach out to us, feel free to subscribe. We got a new YouTube channel that is up and live as we're now moving more so towards our video production as well. Our video end of the podcast. Feel free to reach out to us as social media, feel free to reach out to us on the website. I'm going to have some information up for you guys about some of the information that Dr Nimmer spoke to today regarding how to get involved in some of those programs or some of the summer programs of you or any of your kids or anyone that you know is interested. Medical College of Wisconsin has many programs that are available that get your foot in the door for anyone like myself. If you didn't really have that much healthcare experience beforehand, before you decided to go into medicine or go to medical school, this is perfect for you to get involved in. And this is perfect for you to, again, put a name to a face and get your foot in the door. You never know where these connections will lead you, especially if you have an interest in going into healthcare. So again, I want to thank everybody for listening. As always, be sure to take care of yourselves, be sure to take care of each other, and if you need me, come and see me.