Pedia Pain Focus

Metaphors have long been used to explain complicated and unfamiliar subjects. Use of metaphors, especially in pain management lends itself naturally to improved understanding, patient empowerment, treatment engagement and ultimately better outcomes.

In this episode, I review the concept of metaphors in pediatric pain management, along with giving you several metaphors to get you started right away, on the road to efficient and effective pediatric pain management.

Takeaways in This Episode

• What are metaphors and why they matter
• Who are the metaphors relevant to and who all should use them
• Why are they uniquely suited to pediatric pain management
• Whether all metaphors good in pain management and how language plays an essential role
• 3 essential areas to use metaphor sin when dealing with pediatric pain
• Specific examples of metaphors in these 3 areas
• Additional resources

Links

Clubhouse

Episode #49. Putting Pain Care Skills in Your Patients and Families' Hands.

Episode #53. Are You Making the Most of Your "Golden Half-Hour" with Your Pediatric Pain Patients?

Episode #27. InterDisciplinary Pain Education is Necessary to Change the Face of Pediatric Pain Care

Clinical use of metaphors in the treatment of chronic pain in children.

Clinicians Pain Evaluation Toolkit

Proactive Pain Solutions

Have you ever judged yourself even before letting anyone else even have a glimpse at your capabilities? Or talked yourself out of something that later you've felt you could've or should have done. You're not alone! As you'll hear Asha Padmanabhan, MD, FASA discuss how even the most accomplished professionals create labels and barriers for their own progress, often unwillingly and subconsciously. More importantly, though, she walks you through how to recognize when we do that and how to turn those upside down and shake them out to reveal whether they are a reality or an assumed identity. She talks about how NOT to let us get in our own way!

She especially mentions some of the unique challenges faced by the women physicians and healthcare professionals. Despite the increasing numbers of women entering the medical profession, this hasn't actually translated into more females in leadership roles.

Be the successful and resilient professional (or person) you are meant to be as Dr. Padmanabhan, a Board Certified Anesthesiologist and a physician coach, who has been in leadership roles for many years, joins us to talk about the challenges real or perceived and how to tap into your success potential and thrive!

Takeaways In This Episode:

• Her experience and perspective on the challenges of being in a leadership role as a woman
• How she landed in the leadership role and the experiences in navigating these leadership positions
• The internal versus external challenges
• The uniques challenges that women physicians and healthcare professionals face
• Dr. Padmanabhan talks about the limiting beliefs, where they come from, and what to do with them
• Getting past the limiting beliefs and getting out of your own way
• Differentiating limiting beliefs and false bravado
• Dr. Padmanabhan's experience with coaching and how it had been critical to her own progress through limiting beliefs

Links

Asha Padmanabhan, MD, FASA

Connect with Dr. Padmanabhan

LinkedIn, Facebook, Website

The Leadership Rx for Women Physicians Podcast

Work Life with Adam Grant

Clinicians' Pain Evaluation Toolkit

Proactive Pain Solutions

About the Guest:

Asha Padmanabhan, MD, FASA

Asha Padmanabhan, MD, FASA is a Board Certified Anesthesiologist juggling a full-time clinical career with Administrative responsibilities, while being active in leadership at the State and National levels in anesthesia.

Having been in leadership for over 10 years, she realized that women physicians in leadership or aspiring to be leaders have a unique set of challenges. After years of running workshops and mentoring young women physicians, being coached helped her realize coaching was the very foundation to building skills to achieve career fulfillment and be a resilient leader.

She is passionate about empowering women physicians to be the leaders they can be, whether it's with a title or not.She coaches women physicians in leadership development, career transformation and career resilience. She is also an entrepreneur with a thriving side gig in online retail.

Dr. Jennifer Rabbitts, MD a Board certified pediatric anesthesiologist and prolific pain researcher studies pain and health outcomes including the influence of sleep and other factors on pain outcomes in the short and long term.

Sleep and pain have a bidirectional relationship, but it appears that sleep has the upper hand determining the sensitivity, intensity and duration of pain. Sleep as an important pillar of health, exerts its influence in many domains and many ways.

In this episode she discusses her findings on the salient ways in which sleep influences pain and other health outcomes of children undergoing surgery, both in the immediate peri-operative and post-operative period.

Takeaways in This Episode

• How Dr. Rabbitts became interested in children's pain management
• Why it is important to be studying the relationship between sleep and pain
• Host of factors in the hospital which influence the quantity and quality of sleep during the peri-operative period
• The American Academy of Sleep Medicine recommendations on the optimal amount of sleep for children and adolescents and whether it should be altered around surgery
• Duration and stages of the impact of sleep disruptions after surgery
• Whether and how sleep may play a role in development of persistent and chronic pain
• How much reduction in sleep is needed for impacting the pain outcomes after surgery
• A surprising finding that completely surprised me about sleep disruption and opioids in adolescents
• Recommendations for change in clinical practice around sleep and surgery
• Differences in the peri-operative outcomes of children with sleep disordered breathing/sleep apnea and children with acute sleep disruptions
• Dr Rabbitts' recommendations for clinicians around sleep in the peri-operative period

Links

Jennifer Rabbitts, MD

Contact Dr. Rabbitts : Email, twitter

American Academy of Sleep Medicine

Clinicians Pain Evaluation Toolkit

Proactive Pain Solutions

About the Guest

Jennifer Rabbitts, MD

Jennifer Rabbitts, MD is a board certified pediatric anesthesiologist and pediatric pain researcher at Seattle Children's Hospital. She's an Associate Professor of Anesthesiology at the University of Washington.

Dr. Rabbits completed her medical school in South Africa and her residency and fellowship training at the Mayo clinic. Her work is focused on prevention and management of acute postoperative pain in children. Studying risk factors that predict which children will develop severe and longer lasting postoperative pain and investigating ways to modify them.

Her research has earned her several awards even from her residency days and she's also been the recipient of the young investigator award, the future leaders in Pain research award from the American Pain Society.

Today most of us conduct major chunks of our lives digitally and social media has now become a major tool for people to consume news, health information and even create community and connections. For us as physicians and Healthcare Professionals, this tool can connect us with peers from around the world to share information, collaborate, and make an impact, but it can also make or break our professional credibility, with or without our participation.

Join me in conversation with Dr. Jay-Sheree Allen, MD, a practicing Family Medicine Physician and learn the ins and outs of social media engagement, it's impact on healthcare professionals professional and person lives and how to own your digital footprint.

Social media is not all good and it's not all bad either, but one needs to be aware of the power and pitfalls of this powerful tool in today's world. Listen to Dr. Allen as she drops many beautiful gems throughout the interview and that you NEED to know to successfully navigate social media as a healthcare professional.

Takeaways In This Episode

• The different Social Media platforms, and how to use the them effectively.
• The unique offerings of Facebook that make it the tool of communication, connection and influence for one-third of the world's population.
• Whether physicians and healthcare professionals have a preference of any particular social media platform(s) and why
• Influence of social media on medical education and professional collaborations
• The uniques aspects of LinkedIn, why physicians NEED it and how to maximize it for best outcomes
• What social media uniquely offers for healthcare professionals
• What is your digital footprint and narrative, how and why it is important to take ownership and control of your digital footprint for your professional and personal well being
• The common pitfalls to be aware of in successfully navigating social media
• Dissemination of credible information on social media, while maintaining the primary focus on excellent clinical care and avoiding unproductive landmines and the gaslighting culture.
• Using social media to make a larger impact, efficiently
• Best practices and what not to do when you're on social media
• Resources and ways to get started and effectively navigating the social media quagmire.
• Dr Allen's advice to social media novices as well as experts.

Links

Jay-Sheree Allen, MD

Connect with Dr. Allen on ; Twitter, Instagram, LinkedIn

Pedia Pain Focus Episode # 56. Making Pediatric Pain Matter: Delivering a Transformation Action

#Medtwitter

Canva - Free Graphic Creation Tool

About the Guest

Jay-Sheree Allen, MD

Dr. Jay-Sheree Allen is a Board-Certified Family Medicine Physician and National Health Service Corps Scholar currently practicing in Central Minnesota. Dr Allen is committed to improving the health of millennials, both locally and globally, through the promotion and practice of Primary Care and Preventive Medicine. Recognizing the power of media to deliver relevant and timely health messages, she has published with ABC News Health, she is a contributor on Hippo Education's Primary Care Reviews and Perspectives podcast and co-host of the new series Race and Medicine. She is also the creator and host of the Millennial Health Podcast.

She completed her residency training at the Mayo Clinic. While there, she was a member of the Mayo Clinic Alumni Association Board of Directors, President of the Mayo Fellows Association and recipient of one of the Mayo Clinic's highest student honors: The Barbara Bush Award. She graduated from Meharry Medical College in Nashville Tennessee where she was the recipient of the Family Medicine Leadership Award and served as Miss Meharry, the institution's community ambassador. She received her Bachelor's degree in Psychology, Magna Cum Laude, from The City College of the City University of New York where she was a Colin Powell Fellow.

She founded Women of Excellence, Strength & Tenacity (WEST) an organization dedicated to empowering young women to live up to their highest potential. She continues to support philanthropic efforts in medicine, through volunteering locally and abroad. She serves on the American Academy of Family Physicians Foundation Board of Trustees, the Center Clinic Board of Directors and is the West/Midwest Regional Leader for the Global Jamaica Diaspora Youth Council.

She was named a 40 under 40 Leader in Health by the National Minority Quality Forum, she was featured in the book Against All Odds: Celebrating Black Women in Medicine and most recently was awarded the 2020 Townsend Harris Medal by the Board of Directors of the Alumni Association of the City College of New York.

Dr. Jay-Sheree Allen is Jamaican born and New York raised. She lives with her husband Dr. Joseph Akambase in Minnesota.

The highest goal in healthcare is to provide high-quality care, safe and effective care for our patients that facilitates the best possible outcomes be it after their surgery or any other part of their healthcare journey. Pain and its management is one of the top determinants of quality of care, speed of recovery and the patient/families satisfaction.

Join me in this episode with Dr. Elizabeth Ross. MD as we talk about how ERAS (enhanced recovery after surgery) pathways have not just revolutionized the peri-oprative care of patients, but their pain and entire healthcare experience throughout the system!

Dr. Elizabeth is a pediatric regional and acute pain service anesthesiologist at the University of North Carolina Children's Hospital.

She explains what ERAS is all about, how to get started, identify partners, increase team engagement, collaboration and the widespread quality, efficiency and financial gains as result. Ultimately, it improves satisfaction for patients/families and healthcare professionals, alike.

Takeaways In This Episode:

• What ERAS is.
• How Dr. Ross became involved in the ERAS work.
• The difference between a protocol and a pathway
• What the standardization of pathways/ERAS mean for clinical judgement and hoe it affects clinicians' autonomy in caring for their unique patients
• A step by step breakdown of the ERAS pathway process
• Engaging the multidisciplinary team members in coordination and delivery of consistent, high quality, safe and cost-effective care
• Other areas of healthcare which benefit from the ERAS approach
• Measuring the right outcomes when utilizing and assessing the impact of ERAS
• How to get started with implementation of ERAS in your area of care
• How ERAS is great for building team collaboration between interdisciplinary teams of healthcare professionals

Links

Elizabeth Ross, MD

ERAS

FREE Clinicians Pain Evaluation Toolkit

Proactive Pain Solutions

About the Guest

Elizabeth Ross MD

Dr. Elizabeth Ross is a pediatric anesthesiologist at UNC-Chapel Hill where she has been on the faculty for the past 7 years. She's a member of the Pediatric Acute Pain Service, and specializes in regional anesthesia. She leads the ERAS efforts at UNC and also serve as the Trauma Liaison for pediatric anesthesia.

She's also active in her department's Diversity, Equity and Inclusion committee, and serves as a University Ally. She plays a key role in the medical student, resident and fellow interviews, selection and education.

Sink or swim or trial and error may be acceptable strategies in some situations, but they are hardly applicable when considering a much needed radical transformation in culture of health and wellness. Instead what we need to adopt is what many other fields have clearly relied upon for going from good to great; Coaching!

Somehow coaching has been conspicuously missing from a field that is high stakes, high stress and also high yield. Physicians, and clinicians for that matter, are left to figure out everything all on their own once they finish their clinical training.

In this episode, Dr. Elizabeth Brill, MD MBA, a highly successful clinician, a Physician Executive and a certified coach shares her own experience with coaching, the integral role it plays in a physician or clinician's professional and personal life.

Takeaways in This Episode

• Dr. Brill's journey as a physician, an Physician Executive and as a coach
• The benefits coaching offers in healthcare and for the healthcare professionals
• The different types of coaching in healthcare
• Qualities that make one ideally suited for coaching and the kinds of situations which particularly benefit from coaching.
• The difference between mentorship and coaching
• Can or should mentorship and coaching combined and what the effects would be.
• Why coaching seems to be restricted at the executive and the "C suite" level in healthcare
• Elements of the physician/executive coaching, what it entails, and what the sessions look like
• Qualities to look for in a coach look for in a coach

Links

Elizabeth Brill, MD, MBA, FACOG

Hudson Institute of Coaching

FREE Clinicians' Pain Evaluation Toolkit

Proactive Pain Solutions

Women's Empowerment and Leadership Initiative

About the Guest

Elizabeth Brill, MD, MBA

Elizabeth Brill MD, MBA, FACOG serves as the Chief Medical Officer, at the Office of Community Care and Senior Advisor to the Acting Assistant Undersecretary for Health for Community Care at the United States Dept. of Veterans Affairs.

An Obstetrician and Gynecologist by training, Dr. Brill has not only been a highly successful clinician, she has successfully held many executive and administrative roles serving as the Vice President of Surgical Services, the Chief of Staff at the Cincinnati VA Medical Center and the COO at Ohio Health.

She is also a Certified Coach through the Hudson Institute of Coaching, has been coaching physicians both through a national initiative, Women's Empowerment and Leadership Initiative, and also coaches physicians and executives independently.

With decades of experience as a clinician and having served in many administrative and executive roles, she understands the landscape and the unique needs of physicians at all levels.

Frequent does not mean trivial and simple does not mean easy! Says Dr. Chris Eccleston, PhD, director Center for Pain and Research at the University of Bath.

A primary goal of medicine is to relieve pain and suffering. Sadly though, this is poorly achieved, especially when it comes to pediatric patients, despite ample evidence for the detrimental longitudinal effects of poorly managed pain in kids. Children's pain should also be prioritized, yet why is is so hard to do that? How then do we make pediatric pain matter, visible, understood and better?

In this episode, Dr Eccleston joins us to talk about how we can deliver transformative action in pediatric pain and make it matter.

Dr. Chris is a Professor of Pain Science at the University of Bath in the UK, and he runs the Center for Pain and Research at the university. His contributions to clinical and research aspects of pediatric pain medicine are immense. He has extensively written and published scientific and educational articles and stories that help the reader think from a new perspective.

And today, we're discussing the paper/commission he wrote for the Lancet Child and Adolescent Health, including the behind the scenes story of that commission, and what inspired them to write it!

Takeaways In This Episode:

• How Dr. Eccleston got interested in pediatric pain management
• Reasons why for pediatric pain or chronic pain in general does not get acknowledged and therefore not addressed
• Factors that contribute to sustained conversations and attention to an issue.
• Why we may have a propensity to diminish others' pain
• The starting point for making improvements to pediatric pain.
• Discussion about the Lancet Commission paper on pediatric pain and what inspired Dr. Eccleston to write this about pediatric pain
• How we deliver transformative action in pediatric pain
• The 4 transformative goals
• What does equity mean when it comes to pain and how must we work on making it an important issue
• What to expect from this Lancet Commission article and what Dr Eccleston's hopes are.
• Dr Eccleston' advice for healthcare professionals, the importance of serendipity, community and connection

Links

Christopher Eccleston PhD

The Lancet Commission - Delivering Transformative Action in Pediatric Pain

Center for Pain Research

FREE Clinicians' Pain Evaluation Toolkit

Proactive Pain Solutions

About the Author

Christopher Eccleston PhD

Christopher Eccleston PhD is a Professor of Pain Science at the University of Bath in the UK and the Director of the multidisciplinary centre for pain research.

His work has been focused on evidence based pain management, therapy development, technology innovation, and behavioral science. He has authored over 280 peer reviewed scientific publications and 3 books in the general field of pain, interoception, evidence based medicine, pain management, and digital therapeutics.

He was awarded the British Pain Society Medal in 2012, the Pain Champion Award for Contributions to European Pain Policy from the European Pain Federation in 2018, and the 'Ronald Melzack' award for pain science from the International Association for the Study of Pain in 2018.

He has chaired the University of Bath ethics and integrity committee (2018-) , and have held key editorial positions as a senior editor in Cochrane (2010-2020), and as the field editor for psychology in the journal PAIN (2010-2020).

His work is rooted in his beliefs;

"I aim to put the body back into psychology and psychology back into medicine. I'm interested in ensuring that the science we do is rigorous, and that integrity is assured in research and publication practice."

Neuropathic pain, especially in children can be extremely challenging to recognize and treat. Dr. Alyssa Lebel MD, a dually trained pediatric neurologist and pain physician, provides a step by step explanation of neuropathic pain across the pediatric age groups and provides practical tools for how healthcare professionals can recognize and treat it effectively.

Takeaways in This Episode

• Dr. Lebel's personal connection to and her journey into becoming a pediatric neurologist and pain physician
• The unique features of pediatric nervous system and neurocognitive development
• Features distinguishing pediatric neuropathic pain from that among the adults

• What are functional neurological disorders or pain presentation of these disorders, and the findings on imaging (Hint: it's not just made up or feigned symptoms)

• Why and when neonates and infants develop neuropathic or chronic pain

• Correlation between colic, headache, and/or abdominal pain

• Ways to prevent the triggering of the central nervous system

• Guide to an early recognition of neuropathic pain

• Strategies to treat children's neuropathic pain

• What the family/patient needs in addition to the treatment options.

Links

Alyssa Lebel MD

FREE Clinicians'Pain Evaluation Toolkit

Proactive Pain Solutions

About the Guest Speaker

Alyssa Lebel MD

Dr. Alyssa Lebel is the Co-Director of Headache Program, and a Senior Associate in Pain Medicine in the Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital. She's an Associate Professor of Anesthesia at the Harvard Medical School.

Dr. Lebel is fellowship trained in pediatric neurology and pain medicine. After her training Dr. Lebel chose to devote her clinical practice primarily to the treatment of patients with significant pain, initially in both adults and children with cancer, and then in patients of all ages with intractable neuropathic pain. Early in her career, she sought additional training in regional anesthesia and rehabilitative medicine to provide a comprehensive service for challenging referrals. Concurrently, she maintained a general pediatric neurology outpatient clinic and served as a teaching attending for the Department of Neurology. In Philadelphia, she continued to work for the Departments of Anesthesiology, Pain Division, and Neurology, on the inpatient and outpatient services as well as within a partial hospital program for pain rehabilitation, ultimately focusing on pediatric care while at Children's Hospital of Philadelphia. Currently, at Boston Children's Hospital, she has increasingly focused on patients with chronic headache. She has written extensively and lectured nationally and internationally on both the mechanisms and treatment of pediatric headache. She established and directs a multidisciplinary pain-management program for patients with chronic head pain. She is recognized by her colleagues as an expert in the comprehensive assessment and management of pediatric and young adult patients with headache and cranial neuralgia.

COVID-19 led to closure of nearly all schools in the United States, affecting more than 55 million students. Efforts to continue children's education have been highly variable, ranging from remote learning, hybrid and modified in-person instructions. Return to school safely for children and staff is being implemented, again variably. Along with the safety concerns, there are significant concerns about the disruption to the learning process, mental health, nutrition and even safety.

I'm in conversation with Dr Anita Gupta, DO, PharmD examining the challenges, risks and considerations in ensuring safe return to school of children nationwide.

Takeaways in This Episode

• Why it is important to weigh the risks, benefits and challenges to safe return to school.
• Factors integral to ensuring safety of children, school staff and the community
• Who needs to be involved in the planning to ensure a safe and expeditious
• The CDC's policy to guide opening schools safely.
• What mitigation measures should be required
• What parents can do to support their children's physical and mental health.
• How parents can ensure a good learning experience for their children.
• Collective responsibilities to educate and ensure safety
• Who are the children at even higher risk even beyond the learning challenges.

Links

Dr. Anita Gupta DO, PharmD

JAMA article on Data & Policy to Guide Safe Opening of Schools

FREE Clinicians' Pain Evaluation Toolkit

About the Guest Speaker

Dr. Anita Gupta DO, PharmD

Dr. Anita Gupta is a globally recognized leader, Hopkins anesthesiologist, pharmacist & policy expert.

She's the first appointed woman physician anesthesiologist to pioneer the expansion of the only opioid overdose antidote, naloxone, at the U.S. FDA. Also, the first woman physician anesthesiologist to Co-Chair the American Society of Anesthesiologist Committee on Prescription Opioid Abuse. First woman anesthesiologist-pharmacist alumnae of both Princeton University School of Public and International Affairs and Harvard University School of Business.

She is committed to addressing global public health, drug safety and policy. She's been appointed as an advisor to the U.S Food and Drug Administration and the U.S. Department of Defense.

Dr. Gupta has been featured on the cover of Philly Biz magazine as Top in Healthcare, international editor of three books by Oxford University Press.

Featured as a recognized healthcare thought leader for the Washington Post, Forbes, CNN, on emerging threats including the Coronavirus crisis, the Opioid crisis, Zika crisis, catastrophic train crashes, and high profile expert medical cases involving: Tiger Woods, Bill Cosby, Jolie, Prince, Lady Gaga, Beyonce and others.

She completed her pain fellowship from Johns Hopkins University, medical residency in anesthesiology at Georgetown University School of Medicine, and clinical physician scientist training during her medical residency at National Institutes of Health, NHLBI, doctorate in pharmacy at Rutgers University, medical school from Rowan University (formerly University of Medicine and Dentistry of New Jersey) and professional education from MIT in drug technology, masters in public policy and certificate in health policy from Princeton University and general management from Harvard Business School.

Dr. Neil Schechter, MD, shares what the patients and families report as the most important and helpful elements during their pain care visit and what they desire from clinicians.

Additionally, he shares the practical tips to engage patients and families and how to effectively provide feedback during a pain evaluation even for the most complex patients.

Takeaways in This Episode

• Dr. Neil Schechter's journey from developmental pediatrics to pediatric pain management.
• What parents of children with chronic pain report as the most important and helpful elements in their pain care visits
• Why these elements are felt to be equally if not more important than any medications, procedure or treatments modalities
• Providing context of pain and its nuances for parents and healthcare professionals.
• The impact of what healthcare professionals say to patients and families.
• Importance of feedback during a pediatric pain care visits
• 3 Key components of feedback for patients and families during a pediatric pain care evaluation
• Ways to create a lasting impact from your feedback
• Keys to professional longevity with particular tips for pediatric pain professionals.
• Dr Schechter's advice for healthcare professionals caring for children's pain

Links

Neil Schechter, MD

Pedia Pain Focus Episode #8. What Patients Want More Than Any Scripts or Tests

The Golden Half Hour in Chronic Pediatric Pain-Feedback as the First Intervention

ChildKind International

Chronic Pain & Illness Workbook for Teens

When Your Child Hurts

Clinicians' Pain Evaluation Toolkit

Proactive Pain Solutions

About the Guest Speaker

Neil Schechter, MD

Neil Schechter, MD is the Director of Chronic Pain Clinic; Senior Associate in Pain Medicine, in the Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital. He's an Associate Professor of Anesthesia at Harvard Medical School.

Dr. Schechter received his medical degree from the University of Connecticut. He completed pediatric training at the University of Connecticut and fellowships in psychosomatic pediatrics and developmental pediatrics at Children's Hospital and Harvard University in Boston. He has authored over 120 articles and is the senior editor of Pain in Infants, Children, and Adolescents, the major multi-disciplinary textbook in the area of pediatric pain. He has served on a number of editorial boards and expert committees in the area of pediatric pain including the World Health Organization Expert Committee on Pediatric Pain and Palliative Care, the Task Force on Chronic Pain in Children of the American Pain Society, and the Rome IV Committee on Pediatric Functional Gastrointestinal Disorders. He has given numerous named lectureships and received the Jeffrey Lawson Award for Advocacy in Children's Pain Relief from the American Pain Society.

Dr. Schechter's initial research focus was on documenting the under-treatment of pain in children and attempting to understand its origin. He then became involved in issues of pain associated with chronic disease where his research focused on sickle cell disease and on painful procedures in children with chronic disease. Most recently, he has become interested in the more common pains associated with pediatric practice such as injection pain and functional pain syndromes as well as developing strategies to alter pain-related practice patterns in health care providers and institutions.

He is the President & CEO of ChildKind, a global initiative to reduce pain in children's healthcare institutions.