Childhood immunization schedules are designed for children’s young immune systems, helping to protect them from preventable diseases as early and as safely as possible. That’s why it’s so important to stay on schedule – even during the COVID-19 pandemic. Andrea Singh, MD, department chair of pediatrics at Park Nicollet and co-lead of the Children’s Health Initiative, discusses disparities in childhood vaccination rates and how critical vaccines are for keeping kids healthy. Dr. Singh also shares her lifelong passion for teaching and helping people learn, and her experience as a parent and how it relates to building trust with patients and their families.
Childhood immunization schedules are designed for children’s young immune systems, helping to protect them from preventable diseases as early and as safely as possible. That’s why it’s so important to stay on schedule – even during the COVID-19 pandemic.
Andrea Singh, MD, department chair of pediatrics at Park Nicollet and co-lead of the Children’s Health Initiative, discusses disparities in childhood vaccination rates and how critical vaccines are for keeping kids healthy. Dr. Singh also shares her lifelong passion for teaching and helping people learn, and her experience as a parent and how it relates to building trust with patients and their families.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Andrea Singh, MD
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is Off the Charts.
Steven Jackson:
Welcome, everybody, back to Off the Charts: Examining the Health Equity Emergency. And today we're going to be having a conversation with Dr. Andrea Singh, and she serves as our department chair of pediatrics at Park Nicollet, as well as the co-lead of our Children's Health Initiative. Welcome, Andrea.
Andrea Singh:
Thanks, Steve. I appreciate you guys asking me to be here.
Kari Haley:
Thanks so much for coming on our podcast and our show. A huge part of pediatrics, especially in the first couple months, are those immunizations, and part of something we want to talk with you about during the podcast is immunizations. So I have a couple of questions about them one being, how do you talk to kids about immunizations once they're old enough to be able to do the consent-ish type stuff? And then two, disparities, just commenting on it. So there are disparities within vaccination rates and how do we reconcile that? What things do we need to do to build more trust and that we can get those disparities to the lesson.
Andrea Singh:
Yeah. Two really important things. So starting with the first question, I think conversations about immunizations need to be honest and really explain without a lot of subtext what we're doing, we're protecting you against disease. A lot of immunization conversation, whether you have it with kids and parents, or you have it with adults, is about how you present it. We are being preventative in giving you the immunization. And we are... One poke may hurt and you have to be honest about that with kids, you can't pretend it's not going to hurt and then it hurts because next time when they come back, they are definitely going to remember that.
Steven Jackson:
That's right.
Kari Haley:
Yes.
Steven Jackson:
That's right.
Andrea Singh:
But you have to say that, there's going to be a poke and the reason that we're doing it is what you need to lead with, that we're helping to make your body stronger and to fight illness so that you can do things like go to school and not be afraid to get sick all the time or... A lot of it depends on the age of the child you're talking to, because you have to tailor your message as a person that cares for children in the medical setting to their developmental stage. So the way that I talk about a vaccine to a 4-year-old who needs them to enter kindergarten is going to be different than the conversation I have with the 11-year-old. And I'll tell you a lot of times, the 11-year-old conversation is harder and they're more scared than the 4-year-old.
Kari Haley:
Yes.
Andrea Singh:
So I think honesty, being upfront and really focusing on the goal and why we're doing this and that it's about strengthening your body in the same way we recommend that you get fruits and vegetables and good nutrition. We are helping you to face the world. Now, the second question about the big disparity gaps with immunizations is a really important one and we've been really trying to focus on when we look at our work, and I think there are different pieces to that conversation. So unfortunately there are large immunization disparity gaps across the country, and even in our own neighborhoods and our own system. And, and you have to acknowledge that first and foremost, we may think we are trying to do everything equitably. And unfortunately, when you look at the data, there are still gaps.
Andrea Singh:
The rates of Caucasian children that get vaccinated, for instance, with the first vaccines that we do in the first two years, there's about a 20% gap with kids that identify as patients of color. And so there's different things. Some of it is internal systemic stuff that we have to look at. Are we offering the vaccines at the same rate? Are we doing the same kind of emphasis on why they're important? Are you listening to parents and their concerns and adequately addressing them? And there's lots of things that can get in the way that can cause unconscious bias when it comes to these immunizations, whether it is a language barrier that somebody doesn't understand, the explanation that's given and you don't tailor it to what their language needs are or illiteracy, are you using words that don't quite fit and they don't understand, and they're not willing to say they don't understand, or is it just that we are not giving the same opportunities to those individuals, are we not pushing as hard, or recommending as often?
Andrea Singh:
And some of what we've tried to do in our system is make things a little more universal, standardized some approaches to things, to take away some of that unconscious bias. But the second piece is also in different communities there are different hesitations about vaccinations, and I think that's extremely important to acknowledge and to know right off the bat, as a pediatrician, I tell people all the time, 99.9% of the parents that I have come across in my almost 20-year career are parents that love their children. And when parents make decisions for their kids, they're doing it out of love. They think that they are making the best choice. And so when-.
Steven Jackson:
That's a great point.
Andrea Singh:
... a certain culture is hesitant about a particular vaccine we, as the medical providers or the individuals recommending the vaccine, really have to stop and listen and not judge, and not say, OK, well, you don't care about your kid, therefore you're not doing what I recommend. That's the wrong approach that will not help you build the trust that you need to help them understand why you think it's so important.
Steven Jackson:
Yeah, I think honestly you have a hard job because, again, for myself, I build trust with adults for the most part. And then you have to build trust with both the kids and the parents. And if you don't build the trust, then that could be detrimental to the care that's recommended. We often talk about how some folks don't even go to the doctor because they have a mistrust or distrust of health care, or a particular physician, etc. What are any stories that maybe stand out to you that maybe didn't go as well in terms of building trust and developing that relationship with the parents?
Andrea Singh:
When I think about... Every pediatrician has tons of stories, things that went well and things that didn't go well.
Steven Jackson:
I'm sure.
Andrea Singh:
There are absolutely some families that I still have a good relationship with, but they are not ready for certain vaccines or certain recommendations that I might have. It might not even be vaccinations, but oftentimes in pediatrics, it is. And I think what is important is continuing to have the conversation with those families. I can think of one particular family that culturally, they have refused all vaccinations and I've taken care of their whole family of kids since they were born basically. And now quite a few of them are teenagers in that family. And it's not a discussion that I stop having. And they know that my approach to their family and their kids is one of genuine interest in doing what's right for their kids, but I'm not going to push them into something they don't feel comfortable doing, because then I'm going to lose them. They've got a bazillion providers they could come and see. There's nothing special about walking into my door other than I hope we've built that relationship.
Steven Jackson:
Yeah.
Andrea Singh:
And so that mom keeps coming back and she knows every time I'm going to say, "Hey, did you change your mind this time, or what do you think about this new COVID vaccine?" If there's something different, we're going to talk about it. And it has to be a safe place and a safe setting for us to have that conversation otherwise it's going... If you don't talk about it at all, then you know what the answer is, or if you talk about it in a way with animosity, again, they're not going to come back and seek your help when their child is in real trouble.
Steven Jackson:
Well, I think one thing that I think you're highlighting is the fact that health care isn't about us as doctors, it's about the people we serve. And if you were to walk into the clinic with your script, with the clear cut goal of getting them to agree, it's almost like making a sale. I have to get them to say yes, and sign on the dotted line. If that's your approach, well, you're going to miss a lot of people, but walking in curiosity and figuring out, well, OK, they're not noncompliant, they obviously have a hesitation to this recommended treatment or vaccine, whatever the case is, what is it? And learning. And I think people appreciate the fact that you want to know why, you want to know their why, and if you know their why, it might lead them to knowing the why of why you're recommending what you're recommending. I think that's building trust in real time.
Andrea Singh:
Yeah. And I am also fortunate because I am a parent myself. And so for me, I think it's about knowing their why, and actually telling them a little bit about my why, and what decision I made for my own children, because while my circumstance might be different than their circumstance, the common circumstance that we have is that we love our kids and we would do anything for our kids. And so there have been studies that have shown that for parents, one of the most influential factors in helping them change their mind about vaccines or any kind of care is the recommendation of their doctor. And I think sometimes we are hesitant to share our own why, because we don't want to step on any toes, or we don't want to cross a line. And obviously you're not crossing too many lines, but you can... I explain all the time, this is the reason I did COVID vaccine, for example, for my adolescent boys.
Andrea Singh:
Knowing all the data and all the concerns about potential side effects, I felt it was the right choice for my family and my own children, and it's the reason that I'm recommending it for you and your children. It gives people a little bit of food for thought, I think.
Kari Haley:
And I think it's great that you're bringing that humanity piece and one thing that we've always talked to about on the show is we're doctors, but we're also humans. We're also the parent too, we're also... So I've also found in my personal experience that sometimes bringing up the fact that you're a mom, or that this happened to my kid too when they were that age goes, leaps and bounds building that trust compared to you just coming in, as the doctor shaking your finger saying, this is what you need to do, bringing it back home to the, well, when my kid was this age, this is what happened as well. And this is why I thought that doing this was the right thing or not the right thing. And I think that just brings that level of trust instantly almost, as parent to parent almost.
Andrea Singh:
Yeah. Well, you think about it, it's human nature. We oftentimes lament the influence that social media has on everybody, but why are people looking at social media? They're looking to social media a lot of times to form that connection to say, OK, oh, that post was like me or that TikTok, oh, I could totally relate to that TikTok and-.
Steven Jackson:
It's a good point.
Andrea Singh:
... or that Insta(gram), or that Snap(chat) or whatever it is that you're looking at, at the moment. And the fact is we are very privileged as medical clinicians to be able to create that connection in person, with patients in front of us where we don't necessarily need... We can do the same thing that social media does, but in real life.
Kari Haley:
Yes.
Andrea Singh:
And that's, I think the trust that you're talking about, Kari.
Kari Haley:
Yes. No, I think, to me, that's almost brings you that little happy jolt in your day when you get to make that human to human connection, you're like, ah, I think we're on the same page. One of the interesting things that we've heard from other clinicians is their path to where they are right now. So what made you decide that she wanted to take care of little people?
Andrea Singh:
Yeah. I was one of those rare beings that knew right from the get go that my life was going to involve other kids. If you ask my parents in kindergarten I would tell people that I was going to be a pediatrician. I think though really that my lifelong passion has been teaching and helping people learn. And pediatrics was this beautiful blend of science and advocacy and teaching, because that's really what I do every day.
Steven Jackson:
Wow. That's interesting because I think I was the opposite in that I knew that I didn't want to do pediatrics really. We have a slew of kids and I said, I get enough pediatrics at home, but thank you for what you do.
Andrea Singh:
Yeah.
Steven Jackson:
So, this is a health equity show and we explore topics from trust to anti-racism, to partnerships built on trust, things like that. Where are you in this space? Where is your passion? And where does it lie when it comes to diversity, equity and inclusion?
Andrea Singh:
I think my passion lies in helping people advocate for themselves. And that starts with our youngest kids, but the way and the direction, my path toward that passion really came from the fact that my parents were both immigrants that came to this country. They're from a small country called Guyana in South America. And a lot of people don't realize that in South America, there are some countries such as Guyana where there is a mix of people of different backgrounds that were brought as indentured servants to plant sugar and plant rice by the British Empire. And then they landed in the Caribbean. So, we call that area the West Indies. And so my family is West Indian from Guyana.
Andrea Singh:
And when my parents came to the U.S. and landed in Minnesota, they were here for an education. They were here to better themselves and not because they really wanted to explore the 40-degree-below-zero temperatures-.
Kari Haley:
Why not?
Andrea Singh:
Yeah.
Steven Jackson:
It's cold here?
Andrea Singh:
So it was very different than where they grew up, but they felt here was the place where they would have the most educational opportunity. So knowing that my parents came to the U.S. with 25 cents in their pocket and my uncle's phone number, and that was it. When I enter the equity space, and when I have these conversations, to me it's something built in as a brown child that grew up in Minnesota, where there weren't a lot of brown children around me at the time. And my experience in integrating two really different cultures together and figuring out who I was, like where is my place in all of that? It's an experience that a lot of other people have had, but I also take in now that piece about, I know I want to work with kids.
Andrea Singh:
I knew I wanted to be in pediatrics. And I saw, as I moved through my training and my career, how much more diverse Minnesota has become and how much of an opportunity there was to help people understand some of the whole internal conflict that I faced as a child, and maybe not even conflict, isn't the right word, but the internal challenges I faced that might not have been outward facing, but were part of growing up in two cultures. So my passion in the equity space, to get back to your question, is about helping people understand child development and how your identity is framed and how we can use those different, beautiful identities and cultures and background experiences to help people color our world and make the world a better place, but it all stems from respect.
Steven Jackson:
Yeah.
Kari Haley:
Yeah. That's very powerful. I, similar to Steve knew that I probably did not want to do pediatrics, hearing you talk about the respect and the education piece. How do you put both of those together? Because really it seems like, when you're taking care of the child, but you're also educating and helping with the parent as well. So how do you meld those two things?
Andrea Singh:
Yeah. Yeah. I love that. And I also will say right off the bat that I knew right away, I did not want to do ER (emergency room).
Steven Jackson:
Another thing. You're right, get on the list.
Andrea Singh:
I did not want to do ER, that was too scary for me. In a lot of ways when I say that teaching was my thing and that I went to pediatrics, it was because you are teaching two people all the time, from the minute the newborn is brought to you, you're teaching the parents about this gigantic responsibility that they have in front of them, but how wonderful it is at the same time, and how almost everything that a parent does influences that child's life, and what a great responsibility that is. But at the same time as that child grows in front of me as their primary care provider, that I get to see the kids on a semi-regular basis, if they're healthy, I'm helping them grow into themselves and feel comfortable in their own bodies, but in the world. And I think there's an added responsibility as a health care provider to help people feel comfortable in the medical space.
Kari Haley:
Yes.
Andrea Singh:
How many of us know people that are just, the minute they step into a doctor's office they're freaked out? And it's a frightening place to be. And it's also the place where you're most vulnerable. So my theory is, if I can teach them right from the get go to be excited about coming to the doctor, that it's a fun place, that it's a place where they can feel secure and non-threatened and share their concerns, then I hope that, that carries with them after they graduate from me in pediatrics and move on to the adult world.
Steven Jackson:
I think that's amazing. I think that you're doing our work for us, because you get the adults before they're adults.
Andrea Singh:
Yeah.
Steven Jackson:
We talk a lot about trust and building trust. What are some of the things that you've learned over the years, even some key anecdotes in building trust with kids?
Andrea Singh:
Number one, you have to treat kids like they're human beings. I think there is often a misconception that kids won't understand. And so we'll talk over the kids, or we'll talk around the kids, but as a pediatrician, the child is my patient. So, giving them the respect that they deserve to ask their perspective is a really key part of it.
Steven Jackson:
That's awesome. That's awesome. And I'm sure you get questions like, oh boy, should I answer that? But I love how-.
Kari Haley:
Can't say the darnedest things.
Steven Jackson:
They do. I was one of those kids and doctors would use certain terms, kid-like terms to describe very important parts of the body, let's just put it that way.
Andrea Singh:
Yep.
Steven Jackson:
And my mom was like, "Don't use that word. Tell him what it is."
Andrea Singh:
Yep.
Steven Jackson:
And it sounds like you're saying that same thing, because kids are your patients, they're not just kids.
Andrea Singh:
Yeah. Really, I view every interaction that I have with a kiddo in front of me as a teaching opportunity, whether they're there for a broken ankle or a sore throat or a well child visit, which is maybe more obvious to people, but I have a chance to teach them about their body. They're not going to be living with me for the rest of their life, but they're going to be living with their body. So, that's where my focus really tends to be. The best... OK, there's two the best scenarios here. One the best is when you're talking to a toddler and they're like, mom says, oh, they just talk about you every time they drive by, or they want to come visit you.
Steven Jackson:
That's awesome.
Andrea Singh:
That's awesome because it means that you've done a good job, again, making them feel comfortable. But the other best is the teenager that doesn't talk to anybody and then comes into the office and says, "Dr. Singh, can I spill the tea?" And I'm like, "Yeah, spill away. Let's chat."
Steven Jackson:
That's great. That's great. On the subject of immunizations, I have a question. Do you call immunizations shots? In your office, what do you say because when I hear shot-.
Andrea Singh:
It's a good question.
Steven Jackson:
... I'm north of 45. OK?
Andrea Singh:
Yeah.
Steven Jackson:
Now my age is out there. Anyway, I'm not a 10-year-old, but I hear "shot," and I think about something negative. So, what do you say in practice?
Andrea Singh:
Yeah, it's a good question. I guess I've never really thought about it. I think most often I will use the term vaccine.
Steven Jackson:
OK.
Andrea Singh:
But I will-.
Steven Jackson:
Pretty smooth.
Andrea Singh:
... but I will say shot because if they don't understand what a vaccine is, again, it's the no surprises factor. I'm not going to say, oh, then staff will be in, in a minute to give you your vaccines and then set them up for failure because somebody's walking in with a bunch of shots.
Steven Jackson:
And that might hurt trust next time you see them.
Andrea Singh:
Yeah. Exactly. No, no, no. I need to make sure that they... So oftentimes I'll reflect what the parent has used. And so, because most of the time the parent has talked about it, or the parent has used some term. And so I will reflect that back in my explanation of why this is important. We'll use those terms. That's probably what's being used at home.
Steven Jackson:
Interesting.
Kari Haley:
That is really interesting.
Steven Jackson:
Shot.
Kari Haley:
What is your favorite age to take care of? I'm sure that's a very hard question actually-.
Andrea Singh:
It actually is-.
Kari Haley:
.... because they're all so different, but-.
Andrea Singh:
... a really hard question. Honestly, I love 5-year-olds. Five-year-olds are just the best, because a lot of times they're just so full of energy and they're right at that place where they're going to start kindergarten and school is still exciting and fun and they want to tell you all about it. And fortunately, most kindergartners are not yet jaded by the world, or having other issues. We're seeing it more sadly, but I think I really like the 5-year-olds.
Kari Haley:
Five-year-olds are pretty cool. I have one.
Andrea Singh:
Yeah.
Kari Haley:
Pretty cool.
Steven Jackson:
Yeah. I had 5-year-olds. Now they're a little older than 5 now.
Andrea Singh:
And I should say I love my teenagers, I really do. I think that there's just such a different level of conversation you can have, and my kids are teenagers now. I think it's really fun to hear their perspective on things and they teach me a lot, all the kids teach me a lot, but especially my teenagers.
Steven Jackson:
Do you feel a sense of responsibility to, what's the word? Not necessarily co-parent, but you're obviously a very important figure in a kid's life. You're their doctor and you said when they see you, it's probably a really good day, or a really not so good day. And the whole concept of trust, we're talking about a lot of things in that dynamic. Talk about maybe a potential sense of responsibility that you feel in terms of your role in your patient's lives.
Andrea Singh:
It is a big sense of responsibility. There was a study that came out, I believe it was in the '90s that talked about the fact that children that were able to identify one trusted adult in their life were much less likely to have mental health issues. And obviously we're facing a child mental health crisis right now. That's a whole topic for a different podcast, but being a trusted adult in the child's life, I'm not trying to take the place of their parent, I got my own kids to parent, and that's a whole different situation, but I can play the role of somebody that they can trust and turn to for questions about their own life or for support in that moment. And bringing it back to the equity conversation, I think one of the things that I find personally very important is helping kids, especially kids of diverse backgrounds see themselves in me.
Andrea Singh:
So when I have a child in the office and they go on, I walk in and they're sitting in my chair, I point out the fact that maybe someday they will be Dr. So and So, or maybe they'll come join me, or-.
Steven Jackson:
That's great.
Andrea Singh:
... or spend some time-.
Kari Haley:
That is great.
Steven Jackson:
That's great.
Andrea Singh:
... because they need to see themselves in that place, and some kids don't hear that, for whatever reason in their environment, they are not looked upon as having the potential to do that. And I will tell you, any kid has potential to do anything. And so-.
Steven Jackson:
That's powerful.
Andrea Singh:
... when they see me, I want them to see themselves, just a normal person that has this job, where I get to help people all the time, because that's all it comes down to. And so that's where I see the power in this role and the power in teaching these kids about themselves. I was telling my department the other day, or maybe it was just my colleagues locally, but that one of my new favorite questions to ask kids of all ages is what are you good at? And that's not a question that I typically was asking before, and I realized a lot of these kids can't answer that question and they may not be asked that question very often in their home environment. So you know what? I'm going to ask it and I'm going to let them answer and give them the space and to think about themselves in a different way. These days kids don't want to even answer that question because they either think they're bragging if they say that they're good at something, or they honestly don't see themselves as good at something.
Andrea Singh:
And so I'm asking that question and forcing them to think about that, because again, it's about building them up from the inside so that when they do come to the adult world and they do have to problem solve for themselves and live life that they've got the tools in their toolkit to be able to do it and approach life in a way that allows them to have resiliency and power and be who they are, not an image of somebody else.
Kari Haley:
That's an amazing message I think for kids, but also adults and the general population at this time. I'd love to hear a story about one of your favorite success, what you would consider a success, be it, you convinced someone to do something that they were hesitant to do before, or this kid just went from underdeveloped to excelling, or whatever it may be.
Andrea Singh:
Yeah. Since we're talking about immunizations, I'll give you an example about immunizations. And this relates to the COVID vaccine. I had a family that came in, again, a family that I have been taking care of their children for a long time, and it's an African American family. And they had a lot of questions about COVID vaccine and whether to do it. I had noticed prior to them coming in that they hadn't gotten it for either one of their kiddos yet, they have a boy and a girl. And actually, I think the young lady was too young for it at that moment in time, but the son was old enough to get it. And they were coming in for a checkup.
Andrea Singh:
When they came in I asked the question, I said, "Hey guys, let's talk about COVID vaccine and see... We know that this is an awful illness and that the vaccine's really effective," we talked through that and the dad looked at me and he said, "Dr. Singh, we've been waiting to talk to you about this, because I really wanted to hear what you had to say and whatever you say we're going to do." And I said, "Well, I don't want you just to do whatever I say. That's the wrong thing, but let's talk about the reasons why I think it's a good idea." Again, brought in my own sons. This is the reason that I did it for my boys and here's my recommendation. And the dad and the mom looked at each other and they were like, "Well, yeah. Junior's going to get it. And you know what Dr. Singh? You convinced me, can I get mine too?" And dad got his vaccine that same day, which was super cool.
Steven Jackson:
Oh, that's awesome.
Kari Haley:
That is super cool. That is amazing.
Andrea Singh:
Yeah. I know. I wish they were all good stories like that, but we have our ups and downs, but we just try our best and you hope that people walk away with something.
Steven Jackson:
Well, you're obviously making a powerful impact in communities and we're very fortunate to have you in doing what you're doing. And even that story, it just highlights the fact that you put in the time, I'm sure that didn't happen overnight, but for a patient or patient's dad to say, "Whatever you say we're going to do," well, that's the epitome of, I trust you. I think about the trust game, people close their eyes and they just fall back. It's like, well, Dr. Singh is going to catch me. And so we're so appreciative of what you're doing and want to say, thank you for your time today.
Kari Haley:
Yeah. Thank you so much for being on the podcast. Thank you so much for taking care of all of the children out there. They are so lucky to have you as their doctor. And just as a little shout out, if you have any thoughts of future subjects or people you want to hear on the podcast, please give us an email at offthecharts@healthpartners.com.
Andrea Singh:
And thank you both for what you're doing. And this podcast is wonderful. And I encourage everybody to keep listening.
Steven Jackson:
You hear that?
Andrea Singh:
You learn a lot.
Steven Jackson:
Keep listening. Take care doctor.
Steven Jackson:
Off the Charts is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.