Models and Mentors
In Conversation with Seth Ammerman, MD
Dr. Seth Ammerman, assistant clinical professor in the Division of Adolescent Medicine at Packard Children's Hospital, is also medical director of the Teen HealthVan, an outreach program that serves homeless and uninsured adolescents in Santa Clara, San Mateo and San Francisco Counties.
When did you decide you wanted to be a pediatrician?
My Dad was a physician, so I was always exposed to medicine, and it was no surprise that I went into medicine as a career. Plus, I always liked kids, so it was no surprise to anyone who knew me that I decided to go into pediatrics. It was a natural combination. So I knew I had a serious interest in it, and then working in pediatrics during my medical training made me realize it really was what I wanted to focus on.
After graduating from medical school at George Washington University, and completing your internship and residency at the University of Michigan Children’s Hospital in Ann Arbor, you worked in Price, Utah with the National Health Service Corps for two years. How does this program work? Why Utah? Can you tell us a little more about the experience?
George Washington was a very expensive school, and the government helped pay my way. There was, and still is, a public health service program where the government will pay for your schooling if you promise, in return, to work in a medically underserved area. So they paid for two years of my medical school, and after I completed my residency at the University of Michigan, I decided I really wanted to be out west, and so ended up joining this private practice in Utah. It was the only practice in all of southern Utah and western Colorado, so we had a huge geographic referral area for pediatrics. It was a lot of fun, and there was a lot of variety in terms of the kinds of patients and kinds of problems we saw. It was also very interesting to work in a rural setting because I grew up in the suburbs and in the city, around Washington DC. And Utah is spectacularly beautiful, as is that whole part of the west.
You then came to Santa ClaraCounty to work in the Juvenile Hall Medical Clinic and Children's Shelter, and at the Adolescent Clinic at MountZionHospital and MedicalCenter. What sparked your interest in working with adolescents?
I spent some time during my medical school training at the Children’s National Medical Center in Washington DC. They had an adolescent unit, and that was really the first time I worked with teens. And I found it fascinating – the interplay of medical issues, psychosocial issues, and development that all impacted these kids with chronic illness who were admitted as inpatients. Back then we used to admit kids for all kinds of things and keep them in the hospital - things like diabetes and cystic fibrosis. Treatments for these conditions are much better now, and we do much more outpatient, but back then there was this adolescent unit where all these kids with chronic illness learned about their illness and learned how to take better care of themselves. And that was the first thing that really got me interested in adolescent medicine and piqued my interest in working with teens. The University of Michigan, where I did my residency, also had an adolescent unit. And then in Utah, because I liked teens, the other practitioners I worked with often sent me their teen patients because they were more neutral about working with adolescents. So I was definitely developing this focus on adolescent medicine. And then it happened when I came out here that I got these jobs working half time at Juvenile Hall and half time at Mount Zion, and Mount Zion had a big teen clinic as well. So it was really at that point, after being at Mount Zion and Juvenile Hall for a while, that I decided this is really what I should focus on.
Were there any differences in the health issues you saw affecting adolescents in these different settings?
The Mount Zion clinic serves an urban population of poverty, and there was a lot of poverty in the rural population I worked with too. I’ve always been interested in working with underserved youth, regardless of age. I’m sure I get that from my parents, who were very involved in helping those who needed help, and active in community service in a variety of ways.
Some of the medical issues are different – urban versus rural – but the bottom line is a lack of access to health care and to services that kids who are more affluent receive without even thinking about it. That lack of care really impacts development and health.
You also did a fellowship in Adolescent Medicine at UCSF. What were your motivations for pursuing this fellowship?
I did an unusual thing in going from being an attending at a teaching/community hospital [ Mount Zion], to being a fellow. The fellowship, in any field, is much more intensive training in your particular area of focus. Since I decided I wanted to focus my career specifically on working with adolescents, the fellowship really enabled me to do that. If I had not done a fellowship, I could still have been in a pediatric practice, and perhaps have a specific interest in adolescent medicine and see mostly adolescent patients. But in terms of academic medicine - teaching, doing research, as well as seeing patients - the fellowship is really the way to go.
You are currently working as a consulting physician at the Mission Neighborhood Health Center (general pediatric and adolescent clinics), as an assistant clinical professor in the Division of Adolescent Medicine here at Packard, and as director of the housestaff advocacy and the Medical Student Training Program in Adolescent Medicine (not to mention your research and other community projects, including the Teen HealthVan). How do you juggle all of these professional responsibilities?
Well, it’s a good question. It’s kind of the nature of academia to be involved in many different activities. And fortunately I work with very fine colleagues and staff who make it easier to navigate all these things. It is a lot, and I have a variety of research and clinical interests. One interest would certainly be working with underserved youth through the Teen HealthVan program and also at the Mission Clinic, which serves an underserved, primarily Latino population. I also have a big interest in smoking cessation and prevention, and tobacco use among teens. Here in the Division of Adolescent Medicine we also have a big program in eating disorders, so I’m involved with that as well. But I like the variety. I like the mix. It’s nice that you’re not doing the same thing day in and day out. It’s a lot of different things, and that keeps it interesting.
In 1996, you teamed up with Packard to start the HealthVan Adolescent Outreach Program, with the goal of providing comprehensive primary health care services to homeless or uninsured adolescents ages 12-21 in Santa ClaraCounty. How has your involvement with the HealthVan impacted you personally/professionally? What has been the community impact?
Personally, it has been very satisfying. It’s challenging to work with the youth who come to the HealthVan, but we’re able to really help many of them, and that’s what makes it satisfying. It’s also discouraging when we’re not able to help, but that’s just part of it.
We’ve really set up a team approach in that we work with many community agencies that provide services to the youth that are not healthcare (like schooling or job training, and a variety of social services). On the other hand, these agencies can’t provide healthcare, so it’s truly a collaborative effort. Without this collaboration, we certainly wouldn’t be doing as well as we’re doing. We’re a nationally recognized model for providing mobile healthcare to underserved youth, and there are now a couple other programs around the country that specifically target adolescents. It’s nice to see our model being utilized as a way to serve hard-to-reach youth.
The success of our program is due in large part to high follow-up rates with these teenagers. In part this is because our whole staff is very sensitive to the youth, and really like working with teens, which is important. But it’s the youth themselves who promote our program, who tell their friends about it, and so on. And the fact that we do have such high return visit rates really speaks more than anything to the success of the program, that these kids who have so many unmet health care needs come back to us for help.
What would you say are the most pressing health issues for underserved adolescents? What strategies do you use in addressing these issues?
Well, in my experience, the big issues are behavioral. They include substance abuse, tobacco, alcohol, and high-risk sexual behavior. They include poor nutrition (particularly with adolescents, nutrition is so important for growth and development). They include a lot of psychosocial issues, and mental health issues like anxiety, depression, and lack of social support. These are really the big issues that we see and that we focus on. We have a registered dietician, a social worker, and I do a lot of risk-reduction behavior counseling. We try to promote healthy lifestyles for these kids, and try to understand the context of their health issues.
In order to change behavior, you really have to understand the context of the behavior, and understand why the individual, in his or her specific circumstances, is engaging in the behavior. And then you have to work very specifically with why they’re doing it, what are their motivations, what are their motivations to change, etc. It’s very clear that behavior change is a process that takes time - you’re not going to do it in one visit. In one visit you may get someone to start thinking about changing a behavior, thinking about consequences, thinking about alternatives to what they’re doing. But that’s why follow-up is so important, because you need time; you need people to think about it, to try it out, and to find out what works and what doesn’t.
A lot of the kids I work with have had negative experiences with many adults, for reasons including frank abuse, chaotic home environments, lack of good parenting, etc. So we spend a lot of time with our patients. It’s typical to spend an hour with each kid. And a lot of that is just getting to know them, and them getting to know us, and building trust. That’s really a key component because once someone feels like they can trust you, and realizes that you really are just there to help them out and don’t have a particular agenda other than health promotion, they’re going to be more willing, particularly as teens, to listen to what you have to say. We’re not authoritarian, we’re not permissive – we’re authoritative. Kids respect that once they get to know you, but it takes time.
The other important issue in terms of behavior change is that we’re dealing with kids who often are engaged in many unhealthy behaviors. And it’s now clear to us that if you try to change multiple behaviors at once, the likelihood of any of them changing is extremely low. The important thing is to focus on one behavior at a time, and to succeed in changing that behavior. Success then breeds success. Typically a kid may choose to focus first on a behavior that I don’t think is that critical, but it really doesn’t matter because if they have success with that then we can say, “Hey – you did it! This is great! How about trying something else?” and then eventually can focus on changing the behaviors that will really have an impact on their lives, and that’s what it’s all about.
We also try to eliminate many of the barriers that exist in accessing healthcare. We provide clothing donations and food, and try to get the kids hooked into services so that they can get these things on a more regular basis. We eliminate transportation barriers because we go to the kids, and we provide medications on site so they don’t have to go to a pharmacy. We eliminate the financial barriers. We’ve worked with a lot of kids who, because they don’t have health insurance, end up only going to the emergency room when they’re sick. And typically what happens in the emergency room is that patients are given prescriptions to go fill somewhere else. Well, if you don’t have any money, and don’t have a way to get to a pharmacy, what are you going to do? So we’re really able to help in that realm – to help kids with chronic illness get their medications, learn how to use them, and get their illness under control.
If you had to be doing something else, in medicine or outside of medicine, what would it be?
Within medicine, I’m really doing what I enjoy now, so I don’t think there would be much else I’d want to do. But I’m very interested in advocacy. I work with Lisa Chamberlain, who is head of the advocacy training program here, and I run the adolescent component of that training. So if I weren’t doing medicine, I’d get into advocacy full time.
Do you have any hobbies?
I’m very interested in art. I like going to galleries and museums, and I collect art. I like to garden, I like to do photography. I love animals and playing with our cats. Those are my main hobbies.
Is there any advice you’d like to pass on to students who are trying to start community-based programs?
First, I would say get input from the community. Not only to find out what’s going on in the community, but also to find out what the community thinks would be helpful.
And then I would say be persistent. The Teen Van program would not be in existence without the support of the Lucile Packard Foundation for Children’s Health and the Children’s Hospital. But back in 1996 when I started this program, it was really a new idea. I had to convince the hospital administration that it was a good idea, and it takes time to do that. They weren’t immediately saying, “This is fantastic! Let’s do it right away!” But, over time, I was really able to make the case. They were always receptive, but they really wanted to hear the case. And I appreciate that because it made me really think about how a program like this would function, who would we need to make the program work, what does the community think about it, etc.
The other issue is that you need to continually make the case. Like every other non-profit that provides free services, we’re always in need of money. We’re year to year. Given that we’re now finishing our eighth year and have a very successful track record, I anticipate that we’ll be continuing along because the hospital is supportive of community outreach and specifically of this program. But you can’t be shy about asking for money, and you have to evaluate the program as you go to determine what works and what doesn’t.
Are there any opportunities for students to work with the Teen HealthVan?
If any medical student has a particular interest in adolescents and community outreach, they should get a hold of me and we can work something out. We also take volunteers, who go through the hospital volunteer training program, so I’m always open to that as well.
Interview by Lauren Cochran
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