Reimagining the Education-Health Connection: Dr. Ryan Padrez, Medical Director of The Primary School

DR. RISHI DESAI: Hi. I'm Dr. Rishi Desai. Today, on Raise the Line, I'm happy to be joined by Dr. Ryan Padrez, a pediatrician and assistant clinical professor of Pediatrics at Stanford University Division of General Pediatrics. He's also the medical director at The Primary School, where he cares for patients and teaches pediatric residents and medical students at Gardner Packard Children's Health Center. Thank you so much, Ryan, for being with us today.

DR. RYAN PADREZ: It's great to be here with you, Rishi.

DR. RISHI DESAI: Ryan, do you mind just telling us a little bit about your background and what led you to pursue a career in healthcare, specifically within pediatrics?

DR. RYAN PADREZ:  Sure. I think I was part of the class early on, which was a more untraditional pre-medical student. I finished up really interested in health policy and economics. After undergrad, I went to Washington, DC thinking about Medicaid and our Medicare systems, but it was there that sort of lit the inspiration for me to get more engaged in this work from a clinical perspective. I was really inspired by those clinical “on the ground leaders” that were contributing to the systems change and policy work that could provide those perspectives of taking care of patients. 

I thought those perspectives were really important, and I could see myself trying to do that work, so I had to go back to all my pre-med classes and find my way into medical school, where I did fall in love with pediatrics for I think the tenants of being able to help a child early on and the impact of that long-lasting change in health, I think really spoke to me and I also really love working with parents. That's one of the secrets of pediatrics that people need to understand -- It's not just the kids. It's working with the parents as well.

DR. RISHI DESAI: Yes, I totally agree, and sometimes it feels like it's even 80% with the parents and maybe 20% with the kids. 

DR. RYAN PADREZ: That's right. 

DR. RISHI DESAI: Do you mind just sharing a little bit about The Primary School itself and what you do as the medical director?

DR. RYAN PADREZ: Sure. About four years ago now, I got asked to be involved in the design and launch of a really exciting new school model in East Palo Alto called The Primary School. It's a nonprofit preschool and elementary school serving primarily low-income families in our community. I've had the opportunity to work with these families and community partners to develop what we hope is the new school model that's really best supporting the needs of the whole child where we can try to really build that team of adults around the child -- including the parents, the teachers, the pediatricians, therapists, community partners -- so that they can more easily work together to really ensure all our kids can do well and have meaningful emotionally, mentally, and physically healthy lives.

I think part of why we exist is based on some of the challenges I felt as a pediatrician in the clinic where we're trying to navigate, for example, getting speech services or mental health services for one of my patients, and having to really work with our education system, or our County mental health systems. The barriers of communication and coordination around those felt really frustrating to me, and I felt we could come up with a better way or we could do this better. That's what we're trying to really create here at The Primary School, a program where we support our families to be able to get the services they need for their child.

DR. RISHI DESAI: That segues us into the Theory of Change and the idea of the whole child. Do you mind just walking me through that?

DR. RYAN PADREZ: Sure. Our Theory of Change is grounded in three principles or three tenants of what would it take to be a different school model or school approach to do this work? We landed on three things that we're keeping our eye on. First, we need to start working earlier with our children and families. If we're going to be an elementary school, we actually feel we need to start working with the kids shortly after birth and that critical window of development through a variety of programs that support the family to get our children ready, and students preschool ready.

We also are making some investments in support for how we really partner with our parents and support our parents to be well, because we believe that when our parents thrive, our kids can thrive, so we're investing in a wellness coaching program for our parents. That's really interesting.  Then finally, how we really integrate services in a school model so that we support that “whole child”, building that interdisciplinary team at the school and doing this all grounded in a trauma-informed lens that's culturally responsive to the community here in East Palo Alto that we're serving.  I'll just say that we're not trying to be just one special school. Our real goal, our North Star, is how we start to figure out how we can share what's working in this model with public school systems and our healthcare systems so that all kids across California and our country can start to feel how a different school model could support them.

I can share a little bit also about my role as the medical director because it's a unique position. I see my role as really trying to figure out what it could look like to support this model, so one side of my work is figuring out partnerships with other providers in the healthcare system of how we can do this coordination better with our community clinics. A vast majority of our children go to one Federally Qualified Health Center here in our community. Also, exploring what health services makes sense to bring into a school -- like vision and hearing screening is a very common one that we see -- but can we go a little further and bring in dental screening, asthma supports, mental health services. Also, putting systems in place so that all our children have medical homes and they all go to their well-child visits every year. 

The other side of my work is how we build out and support healthy behaviors for our children. This is about working with and partnering with the teachers and the parents creatively, helping to drive some of those healthy behaviors in the home and in the classroom, so things like nutrition and sleep hygiene and physical activity and how that encompasses the whole child.

DR. RISHI DESAI: Ryan, you mentioned the phrase “trauma” just right now, and we've talked in the past about toxic stress. How does your school think about social-emotional development, and mental health in these young kids? Can you dive into traumas that you see among the kids?

DR. RYAN PADREZ:  Sure. Our model was really built around helping to build and promote resiliency, which is sort of the anecdote to trauma. We've learned a lot in the last 10 years about the physiologic effects of what we call toxic stress -- too much adversity and stress for what the body can handle - and we see that play out in learning challenges and health challenges in so much important research that has come out. 

We not only want to be aware of that -- start to change the narrative around how we support our families and children that may be facing adversity -- but then how do we actually help support them to overcome that? That's really about building healthy relationships with a loving and caring adult and promoting resilience in our children. Part of that promotion of resiliency is strong attention to social, emotional, and mental health support in the school. That's built into a lot of the DNA of the curriculum that we do as well as the sort of culture and climate we want to be building in our school.

DR. RISHI DESAI: That makes a lot of sense. I'm also curious, especially right now with COVID-19, there's more need now than ever to have that mental health and wellbeing as part of the curriculum, and thinking about that with both the kids and the families as well. What are some initiatives you guys are doing around COVID aligned to that?

DR. RYAN PADREZ: This was a huge part of the work we did when we could have kids in our classroom. As we shifted to remote learning, our team had to pivot really quickly to figure out how we could continue these supports for the whole child at home. Our school is using tenets that a lot of others are doing to get our mental health therapists on telehealth and how we use other services in the home via the “Zoom Nation” that we live in. But there's been a lot of creativity in supporting all those other domains -- like nutrition, physical activities, sleep hygiene, even hand hygiene and COVID safety -- using a lot of different outlets.  Those include videos and podcasts and home-based activities, ways we can still foster connections with their other classmates and their teachers and thinking about our more collective activities.  So our theme this quarter has really been about wellness in the time of COVID and thinking really creatively about supporting those activities as intentionally as we are supporting the literacy and math work that's going on at home. 

I think the other thing we've been doing --  and I'm really proud of our team, and I give all the credit to them --  is how we also play out this narrative of supporting the whole family. It's about family wellness. It's all additional to the child. COVID has hit our families in East Palo Alto really, really hard. Many parents are essential workers. They're getting exposed to the virus. They potentially have lost jobs or have a hard time paying rent or putting food on the table. That's adding a lot to their stress. That's adding to this concern that the level of toxic stress may be rising, so our parent coaches have really stepped up in their frequency of checking in with families. But we're also stepping up in the resources we provide to help our families be well, including stress management, podcasts for our teachers about how to stay mindful and just really deep continued focus on our parent wellbeing. For me, COVID has really emphasized this hugely important time where schools can play a part in supporting family wellness to really help them with our support and service for our kids.

DR. RISHI DESAI: That's helpful. You're going through a lot of specifics related to The Primary School and your families and kids. Do you mind now doing the opposite and tell me your thoughts on how COVID affects our healthcare system more broadly and specifically ways that have been made clear to you as things that we need to strengthen essentially?

DR. RYAN PADREZ: Yes. I feel COVID has really illuminated, or perhaps the better word, has exposed some challenges in our healthcare system that I think I've been thinking about for a while, and now it’s just become really clear. A few of them that come to mind are our employer-based health insurance system. Many of our families at The Primary School lost their job, and with that, they lost their insurance.  It makes us really need to rethink what an employer-based insurance system looks like here in our country. 

Clearly top of mind is the disparities that we've seen from COVID play out with different people of color. Even before the pandemic, there were really troubling trends regarding these inequities in our healthcare delivery, but COVID’s just made these profoundly more clear. When we look at who is getting sick, who's dying, who's needing the hospital services, the numbers are disproportionately really high for African American and Hispanic populations here in the country. We’re seeing that in our community around us here in East Palo Alto. 

The first step to improving that is accelerating awareness, but we need to keep a really keen focus on access, so back to that insurance question. Also, I think we need to start talking about accountability and how we hold certain stakeholders accountable for some of these disparities we've seen in terms of health plans and systems. 

A few more ideas that have been illuminated to me are just the real importance of public health. Before this pandemic, most people didn't know the name of their County health officer. Now we all do wherever we live, and just how critical our public health infrastructure is to keep our country safe and open. As our colleagues at the New England Journal of Medicine recently shared in an editorial, we could've and should've done much better at responding to this as a country. It just elevates the importance of a well-funded public health structure.

But one that's playing out really tangibly for me in my role at The Primary School is just the connection and dependencies between the education system and our healthcare system. As schools shut down, we learned just how important schools are for providing so many health services to kids, including mental healthcare and other social-emotional, health benefits to our children. In addition, there are so many kids out there who are losing other access to health services that were being delivered in our school-based health clinics.  Schools are a really important delivery arm for healthcare, but we need to think about how we fund schools better to do that work that they're doing. Also, with this kind of looming decision about how we reopened schools, I think it's being elevated of how closely our school systems need to work with our public health and our community clinics to come up with good safety protocols, make sure there's access to testing and good communication.

This need for healthcare and education to work more closely together is not a new problem. It's just one that's been again, illuminated really clearly today. I hope that after we move on beyond COVID, this pressure and need for our two systems to work together will remain. There are going to be continued health barriers to learning that we need to address for a lot of our kids -- including asthma supports and mental health supports -- so how can we start to really build school-friendly health systems out there that foster this coordination better?

DR. RISHI DESAI: I think it's safe to say there's a lot that we've learned in terms of how we can make our healthcare system better. I agree that COVID has helped to make it clear how important public health infrastructure is both in the classic sense but how much gets done in schools as well. With that in mind, is there anything that you can illuminate in terms of any myths or things that people typically don't think about? You know, we’re a teaching platform, so we're always looking for opportunities to learn. Anything you'd love to teach our audience would be appreciated.

DR. RYAN PADREZ: I think from a teaching standpoint, one question that I get asked often is how we're going to get our schools reopened and what we know in terms of the evidence right now about community spread and transmission in kids and what role schools will play in this.  So maybe we'll just talk for a minute about what the evidence is. The first caveat in this is we missed a really big opportunity in our country and in the world, I would say, to study the impact of spread in schools by not setting up a number of randomized controlled trials around this. We closed schools around the world. At the same time, we did a number of other interventions to mitigate and slow the spread. Now, we're at this moment where a lot of new papers are coming out almost on a weekly basis, looking at school openings in different countries and different communities. I think fortunately the evidence is sort of converging on similar themes, which are that we're really lucky that so far we've seen kids getting sick less and with less severe symptoms, and that those kids that are under 10 especially are probably contributing to community spread less than older children or adults. This is really, really lucky.

This is a complete shift in our mental model. We typically think of kids as the vectors for viruses and colds, so it's really hard for us to shift to this idea that they may actually not be one of the biggest vectors for spread. Thus far, what we've seen for the schools that have been able to open -- especially for the younger kids with whom we might do this safely with the right protection protocols and mitigation practices in place - is that they're not contributing to widespread community outbreaks. For those schools that have opened at different places in the country where a spread has happened in a school, it's often because the rate of community spread around that school is really high. There's lots of debate about whether kids can spread it, or are they super spreaders? There have been highlights in the media. Absolutely. Kids can catch it and can spread it, maybe not as aggressively as other populations, but I think the times when that happens are when the community rates are really high around the school. 

As I hopefully support The Primary School and other schools around my community start to open up, I just want also to share that the operations and logistics to do this are really daunting. It's a whole new activity that schools need to take on. To be able to know the protocols of how to respond to different symptoms or contacts and students, and just to put all the different mitigation and prevention strategies in the school takes a lot of work, so we're going to have to support our schools with the right resources, funding, and hopefully, our physician community can support them as well.

DR. RISHI DESAI: As families come in, they obviously have to trust that you're doing everything to keep their kids safe. Then as those kids go back home, there's a risk that other family members can contract COVID, so are you sending any messages to the families about like, “Hey, if you choose to have your kids here, then this is your pod, this is your cohort. Don't try to have other cohorts to extend the risk.” Do you know what I mean? 

DR. RYAN PADREZ:  It's a great point. I think what you're alluding to is when and if we can open up schools and classrooms, the level of trust and adherence to rules is really, really important. We're leaning on the messaging that we need to keep our communities safe. It's about hopefully minimizing the interaction with other pods and students outside of the school, and also being really transparent and honest when there are symptoms or potential contacts that have happened. That takes a real level of trust that needs to be put in place, but it's critically important. So, yes, we're trying lots of different messages, to really elevate why this is so critical.

DR. RISHI DESAI: It's interesting, too, because the school becomes the extended family, essentially, in a very real way and the risk goes both ways. You want to protect the teachers. They want to protect the parents, things like that, so that makes sense.

DR. RYAN PADREZ: It's funny you used that word because we said that a lot, even before COVID, “this is your school family,” and I have a lot of hope and optimism that they will treat it as their family and we will have some good adherence to doing safe practices.

DR. RISHI DESAI: Yes, and a ton of trust. You really have to trust them, not just for something that feels a little more abstract, like math or English, but trust with their health, which is critical.

DR. RYAN PADREZ: Yes, exactly.

DR. RISHI DESAI:  We have a lot of folks in the audience that aspire to health careers. They probably look at a career like yours and say, “Hey, that sounds really interesting. I wouldn't have thought of myself in that role.” Do you mind just giving advice on how you got to where you're at and where you're going for someone that may be just starting their journey?

DR. RYAN PADREZ:  Sure. It's a good question. I think some of our hardest health challenges, or maybe some of the most important questions that we need to address to help keep our community healthy, kids healthy, even adults, I think are going to be solved not within the walls of the clinic or the hospital. They’re about how you work in the community in partnership with other organizations. That is something that I learned early on in my career around the importance of interdisciplinary work, so that's a theme that I want to maintain throughout my career, hopefully.

I hope that there are more people that are going to medical school or graduating that want to keep the same interdisciplinary lens to their work. They want to work across the education sector, social services, community nonprofits, even our non-health government programs. I think my time at The Primary School has only fueled that belief around the importance of interdisciplinary work. I think that's how we're going to really move the needle on some of these health outcomes that we want to change.

DR. RISHI DESAI: Yes. That makes a lot of sense and probably is a really good note for us to end on. Thank you so much for joining us, Dr. Ryan Padrez, from The Primary School. I really appreciate your time.

DR. RYAN PADREZ: Thanks, Rishi. It was fun to be here with you.

DR. RISHI DESAI: Awesome. I'm Dr. Rishi Desai. Thank you for joining today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.