Models and Mentors
In Conversation with Janet Shalwitz, MD
Janet Shalwitz, MD, is director of the Adolescent Health Working Group (AHWG), a San Francisco-based community collaborative committed to improving adolescents’ access to quality health programs and services. She has been a guest lecturer in the student-run course on Physicians and Social Responsibility and in the core seminar in Community Health and Public Service.
After graduating from the University of Wisconsin with an undergraduate degree in sociology, you returned to your hometown of Buffalo to start medical school at the State University of New York. For how long had you known that you wanted to go into medicine?
Actually, when I started out in college I was a sociology major and I started doing pre-nursing coursework. But instead of taking pre-nursing courses, I ended up in the premed courses. Maybe there was a grand plan, but I was the last to know about it. I was also greatly influenced by my dad, a general practitioner who became a family practitioner and clinical preceptor for med students. Medicine was always background noise as I grew up, and I was very familiar with the rhythm and sounds of it. Sometimes the medical students and my dad’s colleagues came over for dinner, and different things like that. So I had a familiar feeling about the profession. And he really urged me to do medicine and not nursing. I guess I finally made the decision the summer before my senior year in college.
How did you decide on pediatrics? Were there any other specialties you considered?
I was always interested in adolescent stuff. And, at the time, pediatrics was the most commonly accepted way to go into this new field of adolescent medicine. I had done work with adolescents, homeless and runaway youth, and I did peer education and peer organizing work when I was in high school. Teenagers were important to me. By the time I was doing my clinical rotations, I definitely knew what I wanted to do.
Although I have to say that when I was in pediatrics, I did become very attached to the nursery. It was kind of a surprise. I was 38 weeks pregnant when I graduated from medical school, which was quite unusual at that time. So I started in pediatrics with my baby, and I was very oriented towards babies, always in the nursery taking care of babies, holding babies. I also really liked the technical stuff, the mechanics of it. There was this tremendous sense of accomplishment in it, whereas in adolescent medicine it’s much more about process. It was a lot of fun (I loved tweaking those blood gasses!), but after five months in the intensive care nursery I’d had enough. I knew I wanted to do adolescent medicine.
It seems like you went straight from fellowship to working with the San Francisco Department of Public Health, at the San Francisco Youth Guidance Center. How did you find this job? What kind of work did you do as medical director of this organization?
Actually it wasn’t even after my fellowship. During my fellowship, I started moonlighting in the juvenile detention facility Youth Guidance Center (YGC). We were doing Chlamydia studies, and the public health nurse at the facility wanted to start an outpatient clinic, so it was a great match! There were so many kids that really needed follow-up for STDs or birth control or whatever and they never followed up on the outside, but they would come to see their probation officers all the time. So I started an outpatient follow-up clinic for kids on probation with her. It was really my first opportunity to develop a little clinic and work with juvenile justice folks, and work outside of the healthcare setting.
So I was already involved, and in doing that I became a Public Health Department employee. Also, in the second year of my fellowship, Charlie Irwin (the director of the UCSF Division of Adolescent Medicine) and Dick Brown (the chief of Adolescent Medicine at SF General Hospital) received a Robert Wood Johnson grant with a plan of establishing model systems of care for youth who were homeless and involved in the juvenile justice system. It was based on the concept of The Door in New York, a wonderful multi-service center for youth. So I was hired after my fellowship to become the medical director of the Youth Guidance Center as part of that project. And that started a 20-year career in the Health Department!
Since I was working with youth with so many problems and systems that were fraught with problems, there was no shortage of issues to be extremely concerned about. I became very involved in activist issues around kids in detention, deinstitutionalization of status offenders, homelessness, youth engaged in survival sex, crack cocaine, gay youth, HIV/AIDS, etc. It was just non-stop activity, not just locally, but also at the state and national levels.
The other thing that was important for me is that I started my career in an administrative role. I wasn’t just there to practice medicine; I was there to run health services. I loved it and hated it. At first I had this idea that we would all just hold hands and work together as friends and fight for the kids. And it was a rude awakening for me that we couldn’t just sing Kumbaya and everything would be great. I learned about unions, I learned about personnel, I learned about accounting, I learned about bureaucracy. And we were healthcare providers in the criminal justice system, which has its own set of politics that are big and sometimes ugly and nasty. Nevertheless, I felt that we were practicing cutting-edge medicine in these programs. We proceeded to develop not just the services at YGC, but also clinics for homeless and runaway kids. We had a very talented cohort of professional people and we felt proud of our work.
You have since spent a lot of time with the SFDPH, including acting as director of Special Programs for Youth, medical director of the Children, Youth and Families Section, and Adolescent Health coordinator. Can you tell us more about these projects? Is there any particular project that stands out in your mind?
I was very involved with HIV - not just HIV prevention, but caring for HIV infected people. In the early stages of the epidemic, it was not well understood or appreciated that young people had different issues than adults. Those of us who were working with young people with HIV were really trying to bring attention to the issue. We wanted their particular issues to be heard, acknowledged, and supported. And we tried so many different things. We had seroprevalence studies, we had data, we had emotion and we had the kids. It was really frustrating! I had a little grant money left over, and finally I just decided to recruit young people with HIV and find out what they could do about their own issues. So we hired four amazing young people, and an adult HIV/AIDS activist who could guide them and be there for them. We had a tiny budget and an old air raid shelter at the detention facility for their office. I don’t even know how we got phones down there! It was skuzzy but it was their place. We told them, “Hey – you’ve got four months to let the world know about your issues. Go for it!” and they were just incredible. By the end of the four months there was a hearing before the board of supervisors, there were meetings, people from the news stations were out interviewing them, they were on the talk shows, they had photos taken of them by Annie Leibowitz for an AIDS Foundation campaign. They did all kinds of things. And as a result, there was tremendous attention brought to the issue of HIV, locally and on the national level, and it really transformed how people worked with youth. We realized how much we needed to partner with them, coach and support each other, not just look at them as our patients.
What do you think are the biggest problems that pediatricians or family practitioners face in terms of working with adolescents?
We don’t have enough time. The biggest problem is that it takes time and nobody has time. It requires talking, establishing rapport, making a connection, developing trust. It’s sort of an exchange, and it’s very difficult for people in the frontlines to do that. Now there are some people in the frontlines who have more time, like people in school-based health centers, and people who work in multidisciplinary teams who can afford to spend more quality time with each patient. But for people in the trenches by themselves or with a very lean office staff, they’re overwhelmed. Some clinics and offices have managed to care for babies in a very efficient almost conveyer belt type fashion, but there’s no conveyor belt that works for teenagers.
Also, providers are not happy about their reimbursement rates. Managed care has really soured people in many ways, and there’s nothing like getting a homeless person, getting a young person…people who don’t fit in and make it difficult for the healthcare provider. And adolescents are kind of goofy. They push buttons, they’re smelly, they don’t follow the rules, they’re not “compliant”. That makes them more challenging to deal with as well.
What was your motivation for organizing Health Initiatives for Youth (HIFY)?
The spark was being an employee at the Health Department - a huge bureaucracy. I was always feeling frustrated about what I could accomplish in the Health Department, and always being the rabble-rouser was hard. I think most people were happy that I was extremely productive and hardworking, but they could have done without my mouth. And my work with youth on HIV just touched me beyond belief and was a major turning point for me in terms of where I wanted to go. So I had the notion of developing an organization where young people partnered with health professionals, where we could learn from each other and make huge change and push issues. So that’s what happened. I got some money, hired staff, and started the organization.
It was wild, but was not always easy. It was really exciting for about three years and then I just burned out. I had become an administrator again. I was operating a small business. I didn’t want to worry about the legal stuff, liability, dealing with the board, personnel, accounting, software. What are we going to do about the plumbing problem, the problem with our lease? I didn’t want to be saddled with that stuff. I was also spending no time with my family at a time when my kids really needed me. The good news is, the organization still exists today and, actually, they’re our [the Adolescent Health Working Group’s] fiscal agent. So I am an employee of HIFY.
But here at the Adolescent Health Working Group, there’s none of that. Also, because it’s a collaborative, we’re working with other people, which I think is better. I don’t like to work in a vacuum. And I don’t want to operate a business.
Interview by Lauren Cochran
Posted 6/2/05
