“What would you like to be when you grow up?” -“I’d like to be a doctor.”
“A doctor, are you sure you don’t mean a nurse?” -“No, I want to be a doctor”
Fern R. Hauck, is the Spencer P. Bass, MD Twenty-First Century Professor of Family Medicine and Professor of Public Health Sciences at the University of Virginia.
Fern’s research is focused on risk factors and protective factors for sudden infant death syndrome (SIDS) and other causes of sleep-related sudden infant death, including pacifier use, infant sleep location including bedsharing, and infant feeding, with particular attention to racial-ethnic disparities. She serves as an advisor to numerous federal agencies and SIDS organizations to assist in SIDS and infant mortality related projects and she is a member of the American Academy of Pediatrics Task Force on SIDS, which develops evidence-based guidelines for safe infant sleep and prevention of SIDS and other sleep-related infant deaths. She founded and directs the University of Virginia International Family Medicine Clinic, which cares for several thousand refugees who resettled in Central Virginia from around the world. In addition to comprehensive primary healthcare, the IFMC team provides educational programming for residents and medical students, conducts quality improvement and research projects, and collaborates with community partners.
For a full list of publications, see: http://www.ncbi.nlm.nih.gov/
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Let’s go back to the very beginning. Tell us about your interest in medicine and how it all began.
Fern Hauck: It goes back to my own GP. Back then, when I was a little kid, we didn’t have family physicians yet, we had GP’s. I had mononucleosis and I was very sick. We didn’t know I had mononucleosis until my GP came to the house. He was kind of eccentric, he had this big moustache and was not your typical family type doctor. To make long story short, he had me jump up and down on my bed to see how tired I would get. After jumping up and down a few times, he examined me. No blood tests or anything like that. And he said, “You have mononucleosis” and I still agree with the diagnosis all these years later now that I’m a doctor. And I was so taken by him. And I loved him. He was just so warm. And I loved the eccentricity. I always did love eccentric people. And that’s when I started thinking, I want to be a doctor just like him. I remember being at a family event when I was about 12 or 13, and someone said to me, “Fern, what would you like to be when you grow up?”. And I said, “I’d like to be a doctor.” And she said to me, “A doctor, are you sure you don’t mean a nurse?” And I said, “No, I want to be a doctor.” Back then, women weren’t going into medicine in quite the numbers that they are going into medicine now. It was considered something unusual. Fortunately, I had parents who encouraged me and supported me and said “You go for it. If that’s what you want to do, go for it.” I have to admit that I didn’t get that much encouragement from my faculty advisor in college, who didn’t think medicine was the right field for women. I ploughed ahead, and fortunately I got into medical school and here I am now all these years later.
“I compared the patients, I compared the lifestyle, the relationships that you develop with your patients, the relationships you develop with your colleagues and your mentors, and I thought, family medicine is really where I feel most at home. “
DMacA: When you went to medical school, I’ve heard you say there weren’t that many women in your class. And you’ve always been an advocate for women in medicine…
FH: In my class in medical school of around 130 or 140 there were maybe 20 women and now most classes are 50% or more women. I’ve always supported women going into medicine and I’ve always wanted to mentor young women. I didn’t do anything formally, although I was recruited as advisor to a lot of different student clubs, including when I was at Loyola University. There was no family medicine department when I first went there and I was in the preventive medicine and epidemiology department. I was approached by students who wanted to go into family medicine so I helped them start a family medicine interest group. But I’ve always kept an eye out for the young women and I’ve continued to mentor them throughout my career both as medical students and residents.
DMacA: Well, as you say, at that stage, there wasn’t a lot of family medicine, but you did a family medicine residency…
FH: I started medical school wanting to go into family medicine and throughout medical school I fully expected to go into family medicine. But, I really loved my surgery rotations so I did a couple of rotations as a fourth year medical student, one month in a surgical rotation as the acting intern and one month in family medicine at the program where I eventually ended up doing my residency in Maine, and I compared the two. I compared the patients, I compared the lifestyle, the relationships that you develop with your patients, the relationships you develop with your colleagues and your mentors, and I thought, family medicine is really where I feel most at home. I felt much more at home with the people, with their ways of communicating with patients, and the relationships. Even in just one month as a student at this residency program, I was able to develop relationships with some of the patients. I also sat in and helped with several deliveries and that really did it for me because I just loved doing the obstetrics part of family medicine; the prenatal care, the delivery, and then the care of both the woman and the baby postpartum. That clinched it. And I ended up going to that programme, the Maine-Dartmouth Family Medicine Program, in Augusta, Maine.
DMacA: You must have been a bit of a high flier because you then went on to the Robert Wood Johnson, and Case Western. That must have been very exciting…
FH: Yes, but I want to go back one step to my first job after residency, which was to start a residency program at Dartmouth Medical School in New Hampshire because they didn’t have a family medicine residency program. I was recruited, literally, straight out of residency with one of my faculty preceptors from the program. We went to New Hampshire and designed a residency program, and what the family medicine practice building would look like with education in mind. Can you imagine, my being straight out of residency, they must have been crazy!
I was there for about two years and, unfortunately, it looked like the writing was on the wall that the program wasn’t going fully ahead anytime soon because of some internal resistance at the School of Medicine. So, just at that time, I was recruited to Case Western Reserve and that’s where we get to that Robert Wood Johnson Fellowship.
Dr. Jack Medalie was the chair of family medicine at Case Western at the time, and he called me up one day and said, “I heard about you from one of our other faculty members. We’d love to have you come take a look. We’re looking for a new faculty, especially more women faculty.” So there’s that woman dimension again. He had the most charming South African accent which I fell in love with immediately. And then he started telling me about their Robert Wood Johnson faculty development program. I loved the program and I said, “Can I be in the Fellowship Program rather than come in as a faculty member?” It was wonderful and, other than my year in Thailand where I worked in a refugee camp, I would say the Fellowship was probably one of the happiest times of my career. I’ve had many happy times, but just having the opportunity for the first year to be in classes, doing a research project during the second and being awarded a Masters degree at the end of the program. I studied humanism in physicians and I came up with a humanism scale that we tested out in some patients, and we had some outcomes associated with that. And, I was proud to be able to get my first publication, in the STFM Journal.
At the end of the Fellowship Doctor Medalie said, “Okay, now we’d like to invite you to stay on as a full time faculty member.” And it was at that point that I said, “You know, I’ve always had my heart in global health.” Back when I started medical school, I had the desire, interest, and expectation that I would spend a good part of my career working overseas in underserved areas. And, I was very taken by Doctor Albert Schweitzer, doctor and humanitarian, who worked in West Africa.
And that’s when I switched directions
DMacA: That was a really brave move to leave behind all your academic achievements. Tell us about that decision making process, and did you have any regrets?
FH: Oh, no. No regrets at all. In fact, that changed my life. I’m still very much involved in research but I’ve changed direction with a very strong focus on refugee health care. So, it was one of the best decisions I ever made. But, I have to agree, it was scary.
I eventually found a position with an organization that was running the hospital and outpatient clinics at a camp called Site Two, which served Cambodian refugees on the border between Thailand and Cambodia. It was a militarized zone so the public couldn’t go freely in and out of the area or the camp. It was very interesting. Eye opening. It was my first time ever being in a place like that, in a situation like that. I had practically no orientation and joined the team on day one. I became the paediatric ward supervisor. There were about 15 people on the organizational team that came into the camp each day to work and teach—doctors, nurses and an epidemiologist. The camp was divided into two halves. We were on the south side of the camp with about 150,000 to 200,000 people and we were the health providers for that large population. We gave basic training to the Cambodian people who were in the camp as refugees to be medics so that they would be equivalent to our residents. Then there were nurses and nurse assistants. So again, there was a hierarchy as in our US system. There was a very strong educational program that our nursing staff took over and were responsible for. I was responsible for the paediatrics ward. We would make rounds every day in the morning, we’d see who was admitted overnight, and then we’d talk about treatment plans and all of that. I learned a little of the language of the Cambodians, called Khmer, to be able to communicate with some of the patients directly.
“I try to teach our residents and other faculty the same- that you have to be so careful with your language, because the words have different meaning and.. there’s the cultural side of things which is, in my opinion, an even the stronger factor in communicating with our refugee patients and immigrant patients.”
DMacA: One of the things I’ve heard you say, and which fascinated me, was related to understanding and communication. You’ve said that in many of these languages, there isn’t a word for cancer, and there isn’t a word for depression. That’s very interesting to us as family doctors.
FH: That came to me even more when I started seeing refugees in my own clinic here in Virginia here in the U.S. When I was in the camp, I relied a lot on the medics and the local staff to interpret for me so I didn’t necessarily identify some of these communication barriers or the complexities. Once I started seeing patients directly with interpreters in my own practice, that’s when it became clear that there were lots of differences in wording. There was the language and then there was the cultural part. First, the language. As you say, I remember speaking to a patient who was from Myanmar and they were speaking a dialect. I was just taking the typical family history, review of systems etc, and I asked if there was any family history of cancer which you’d think would be a very quick yes or no question. The interpreter was going on and on and I said, “Excuse me, interpreter, I’d like to interrupt. I thought I’d asked a simple question, what are you asking about, or what are you talking about?” He said, ”Well, in our language there is no word for cancer. So we have to try to explain it and come up with a description so that the patient knows what we’re talking about.” And so the way he described it was as ‘the disease that makes you very sick and kills you.’ Can you imagine? I said, “Okay, well, let’s not let’s not use that definition.” That made me aware as I was communicating with my patients and with the interpreters, that I should be very careful with the words I used. I basically banned the word ‘cancer’ pretty much from my conversation with patients. When we talked about prevention or let’s say, mammograms, I would say we want to make sure your breasts are fine, there’s no abnormalities. Same with pap smears. I try to teach our residents and other faculty the same- that you have to be so careful with your language, because the words have different meaning and, you don’t know what the interpreters are saying. Then there’s the cultural side of things which is, in my opinion, an even the stronger factor in communicating with our refugee patients and immigrant patients.
DMacA: You took on these major challenges in your career, but tell us how they transformed you.
FH: Working in the refugee camp was totally a transformational experience for me. Seeing these people who had suffered so much, who had lived through the Khmer Rouge Pol Pot regime in Cambodia, and who fled for their lives leaving everything behind. Yet, they had so much joy. They were such wonderful people, and they had so little, and they were so appreciative of everything we did for them, and the relationships that I built with them. The ability to teach and that they were so interested in learning. That was what was so transformational.And I felt like I was doing something useful. There was a huge learning curve for me. And I had heard from others who’d been there before, to be careful not to try to take on too much, because you cannot fix everything.
DMacA: You’ve talked about the medical aspects of your work with the refugees, but people often come back from working abroad, and they look differently on life at home.
FH: I remember coming back to the US and going into one of our supermarkets, we have these mega supermarkets, and thinking, oh my God, there’s so much stuff, there’s so much commercialism in the US. And I really had, what we call ‘reverse culture shock’. I had it for about six months and the only people I could talk to during that period were people who’d had a similar experience because, you know, no one really wanted to hear me talk about it. They wanted to hear for a few minutes and then move on. It was interesting to have had that reverse culture shock experience, which really taught me, again, to appreciate the non-commercial things in life and to focus on relationships and people and forget about the commercial aspects of consumerism, which is so big in Western society.
“…. while I love direct patient one on one care, and that relationship with the patient, and how I can help that one person sitting in front of me, I really love the opportunity to impact populations. And so that’s where my research and the policy components come together- the ability to affect populations.”
JAMA. 2017;318(4):351-359. doi:10.1001/jama.2017.8982
Front. Pediatr., 10 May 2022 Sec. General Pediatrics and Pediatric Emergency Care Volume 10 – 2022
Pediatrics (2024) 154 (6): e2024066072.
DMacA: Now, let me turn the conversation around and talk about a completely different area of research; sudden infant death syndrome.
FH: Yes, I often feel like I have two jobs. I have my refugee work, which is literally a full time job. Plus, I have my research, which is also a full time job. But I love both. I love my research and I have been doing research into Sudden Infant Death Syndrome, also known as Crib Death or Cot Death in different parts of the world. It’s now morphed into Sudden Unexpected Infant Death. But let’s just use the word SIDs because I think most people know that.
When I was at Loyola University, I got a call one day from one of my contacts at the CDC, and she said, “We got a request from the public health department of the City of Chicago. They want to look at reasons why they have such high rates of SIDs, particularly in their minority population. Are you interested? ”So this was something that literally fell in my lap. I said, “Well, you know, I don’t know that much about SIDs other than what I learned in medical school and residency and I’ve never personally even had a patient who had a SIDS loss.” So, I said, “Tell me more about it…” It ended up that I put together a proposal, meeting with the public health department to see what we could do, and we designed a case control study, looking at SIDS cases and controls. The NIH got interested. They said, “We’d really love for you to work closely with the medical examiner, collect some tissue, and develop some protocols around autopsy and tissue collection.” So, I came up with protocols for a death scene investigation, for autopsy, for tissue collection, and designed a large case control study, still the largest case control study of SIDS in the U.S, particularly focused on a Black population. About three quarters of the infants who died over this two and a half year period we studied were African American.
DMacA: You’ve done a lot of work collecting tissue and the genetics, but you also did a lot of work on the policy implications and the educational implications of this work.
FH: First of all, based on our original study, we did find a lot of the risk factors associated with SIDS in an African-American population. And we found that the risk factors were similar to other studies that had been published from New Zealand, England and other countries. But we also found that a lot of the participants, the parents, had not been told the correct position to place their infants in, or some of the other safe sleep practices that they should have been told about. We identified this disparity that was contributing to their higher rates of SIDS – they weren’t following the safe sleep guidelines compared to other groups. That led to a lot of great policy implications around education and doing more both in the city and nationally to focus on education and dissemination of the safe sleep message to all communities, particularly those who are at the highest risk.As a result of this work, I was invited onto the American Academy of Pediatrics Task force on SIDS. And that has been quite an amazing experience. We are the group that comes up with the recommendations periodically in the U.S that are adopted by the NIH and CDC and doctors and hospitals throughout the United States. Other countries also often look to our guidelines. So as part of that task force we review all the evidence, all the various case control studies, and the best evidence that we can find and make those recommendations. So that’s where you see the guidance to place babies on their back to sleep, to sleep separately but in the same room, and all of those things you’ve seen promoted for safe sleep. That’s been an amazing experience that has strong policy implications. And I feel in some ways, while I love direct patient one on one care, and that relationship with the patient, and how I can help that one person sitting in front of me, I really love the opportunity to impact populations. And so that’s where my research and the policy components come together- the ability to affect populations. My emphasis has been particularly in underserved communities and minority communities in the US, and really trying to narrow and eliminate that gap in infant mortality and in particular, SIDS.
DMacA: That’s a fascinating link between personal care and the public health impact. And this has been recognized by the American Academy of Family Physicians where you were given a major award this year: The American Academy of Family Physicians Public Health Award.
FH: Yes. I was really moved by that award. And, you don’t think of family medicine as public health although on the other hand, we are very much part of community health. That’s been a huge part of our discipline from day one. But, to be recognized for my work in public health, particularly the refugee work, was very moving. You get awards through the years but this one really meant a lot to me. I was given the opportunity to go to Phoenix, where they had their annual meeting. The award was presented at a luncheon and I was able to invite a couple of my former residents to come. And it was a really nice celebration and as I said, I was very happy to receive this particular award.
DMacA: Thank you very much for talking to us today. It’s been absolutely fascinating to hear about your work with refugees and sudden infant death, together with all the public health input. That’s just wonderful. Thank you very much.
