Longitudinal: Theresa Cullen

May 10, 2024

Meet the speakers

Shannon West
Chief Product Officer
Pima County Public Health Department
Theresa Cullen

About the podcast

In this Mother’s Day Special episode of Longitudinal, Shannon invites…her mom, Dr. Theresa Cullen, to discuss her work to improve access to health data throughout her career from the Indian Health Service to her role as Public Health Director of Pima County, Arizona.

Full Transcript

<Theme music> 

I'm Shannon West. I believe we all want a better future for healthcare. I've spent much of my career on core issues, serving as the Executive Director for Healthcare at the United States Digital Service, CTO at the Innovation Center at the Centers for Medicare & Medicaid Services, and today, I'm the Chief Product Officer at Datavant. I want to support patients in accessing their medical data any way they can, whether that’s through apps, fax, email, or people walking in the door. On this show we invite guests to talk about exactly that.


Shannon: Hi, mom. 

Dr. Cullen: Hi. 

Shannon: Okay. In honor of mom's day, I thought it would be fun to do an episode with my mom. So, hi. Welcome. 

I'm super excited to have Doctor Theresa Cullen here with me for this special episode. Dr. Cullen is a physician turned informative artist whose career started at the Indian Health Service, where she was eventually the Chief Information Officer. She was also CMIO at the VA, Associate Director of Global health Informatics at Regenstrief, the Pima County health director, and also my mom. 


Dr. Cullen: I'm really excited to do this. Thank you for the invitation. 

Shannon: I love it. So early in my career, I was always “Dr. Cullen’s daughter. Fun fact: I was once working in a hospital that she had been a doctor early in her career in and as I was walking through the halls, someone stopped me and said, “You look so much like the doctor that delivered my son!” Turns out it was my mom! 

I think now, though, I'm very curious, have the tables turned? And are you now actually often “Shannon's mom?”

Dr. Cullen: It is amazing how often I hear, are you Shannon Sartin’s, mom?

Shannon: That's amazing. Tables have varied, and, okay, so maybe let's jump into some questions. 

In your medical school essay. You had a quote: “It's better to light a candle than curse the darkness.”And I'm really curious, how has that quote, which kind of started your career in health care, actually pulled through the last, however many years, now, that you've been working in health care?

Dr. Cullen: Yeah. And we could say how many decades, which is a lot of decades here. You know, Shanny, to tell you the truth, I had forgotten about that quote until you reminded me the other day. And it somewhat stopped me in my tracks, because when I wrote my medical school essay, I struggled with whether I should be who I was in my essay or who I thought they would want to accept into medical school.

And your grandfather, my dad, said, of course you have to be who you are, because why would you want to go there if they didn't know who you were and accepted who you were? So for me, that is a long, long standing thread that I think it's better to light a candle than to curse the darkness. Does that mean I don't curse the darkness? No, I curse the darkness many times, and I have encountered lots of obstacles and lots of darkness in my multiple decades of being a physician and a physician informatician. 

But I do believe I am still optimistic. Usually I describe myself as a cynical optimist that I know things must get better, but I'm a little cynical about the path to get there.

Shannon: I think that optimism is probably what has kept you going all these years, including taking a job as a Public Health Director in 2020 – June of 2020, might I add – but we'll come back to that a little later. I actually want to start with the first step after medical school. You decided to join the Indian Health Service and served as initially a physician in a tiny, tiny hospital on almost the Mexico border in Arizona.

Part 1: Lessons from the Indian Health Service

I'm really curious, kind of in that 27-year career that you had in Indian Health Service, what are you most proud of? 

Dr. Cullen: So I actually started on an Apache reservation in the middle of the state, and then I moved when I was pregnant with you, actually, to the Tohono O’Odham Reservation, which is a reservation on the southern border.

When I moved, there had been days I had been a physician, that I had seen 80 to 100 people a day. And that was because within Indian Health Service. If you go home, there's nobody else coming in, there's nobody else that's going to come see the patients. And that was when, to talk about the data part of this, that was when people literally had shopping carts full of medical records. You remember IHS does birth to death care. So we would have five charts, six charts, seven charts, lots of volumes for individuals that we saw. 

When I went to Tohono O’Odham reservation, we had just started looking at data, and we were trying to do what we call industrial strength triage that's triaging people in a manner that made sense, really, in a way, what people would call artificial intelligence today. And that was really the beginning of my career with data and this understanding how data could be transformative. 

So when I look at what I'm most proud of in my Indian Health Service career, my public health service career, there's multiple things that I feel that I am incredibly grateful that I got to contribute to and or experience. One of them is obviously informatics.

My ability to have been the chief information officer at IHS at a time when no one else had a certified electronic health record in the federal system, and we made a commitment to do that - a lot because of the rewards and the benefits that were coming along with that from the federal perspective - but also with this belief that we could improve the quality of care by improving the quality of care, we can improve the health status of the American Indian and Alaska Native population that we served.

So that's a thread through all of it. I think the thread is that overarching vision. How do you make lives better? What contributes to improving the health status of a population? How do you provide tooling, provide support, provide the ability for providers to want to work in a system because that tooling and that support is there for them, and so they're willing to make a commitment.

You know, I was the Public Health Service officer. I'm incredibly grateful for that. But what I used to say to people is the word service is embedded in that. And this is hard work, I think, a physician, I think healthcare is hard work anywhere. In public health service, it's a little harder. And so the goal was to really make sure people had tools that would make it a little easier.

It doesn't take away the hardness, but it may mitigate it enough that people will stay and continue to provide care. 

Shannon:  Yeah. So I want to pull us forward on this thread, and I'm going to ask you a question that I didn't include in prep for you. 

So post Indian Health Service, you did a couple of different things.

One, working at Health and Human Services for Todd Park. Then the second one was also going to the VA to be the CMO. My question for you is - for folks who don't know, the VA has an electronic medical record called Vista, where Indian Health Service has one called RPMs. They actually were based on the same open source code is my understanding. They are both now officially moving to Cerner. 

What's your take on, how does Cerner impact care delivery and the two most population specific care delivery models that we have in our country? Is it good or is it bad? What happens?

Dr Cullen: I want to phrase this by saying I'm not totally familiar with Cerner. What I am familiar with is delivery of care in both of those systems. So let me, let me, let me respond by saying, what do those systems need? Right. And if Cerner can do it, that's great. What they need their populations… there's somewhat close populations.

You have to qualify to get care. And it's not qualifying for insurance. It's qualifying because of disability or because you're a veteran or because of your federally recognized health state. You're federally recognized as an American Indian or Alaska Native. Both of those systems care for people over a lifetime. The VA can start, you know, perhaps in your early 20s, but it goes till the end of your life.

Indian Health Service cares for you over a lifetime. So whatever system there is, it has to make sure that it can respond to those needs as well as the uniqueness as well as what is the special qualities. What are the things that matter to veterans? What matters to American Indians, Alaska Natives? What do those populations have that are contributing to a large extent to morbidity that may not be being experienced by the “US all races.” We know life expectancy for American Indians, Alaska Natives is the lowest of any racial ethnic group in the United States. We know veterans have a very high incidence of things like post-traumatic stress disorder, TBIs because of exposures during combat. So the system has to be able to accommodate that. At the same time, the system needs to accommodate the providers, the providers in the VA and the providers in the Indian Health.

We're all pretty opinionated. We know what we're doing. We know how to care for those populations. And the health IT system needs to honor and be a little humble about taking input from both the provider and the health care organizations that are providing that care. 

In addition, they both have rural components where there may not be an ICU and where there may not be a lot of providers.

And what do you do in that setting? How do you ensure that you're committed to, once again, a vision that both of them share? Both of them are about service. So they're about providing care. They're about ensuring that there's billing. They're about ensuring that there's collections. But at the end of the day, both of them are driven by a vision and a mission that is the most important part of those organizations.

Shannon: Definitely. I remember working on some of the early transitions to Cerner things and going module by module, looking at the difference between Vista and Cerner and thinking there is no Agent Orange module. And my brain flashed back to early in my career when I also worked at Indian Health.

I remember buying cameras for the sexual assault and rape module in RPMS, and all I could think was, these are problems that are different in this population, that we really need to make sure that we support, both from a justice perspective, from a violence against women perspective, and realizing just the amount of adaptation that would have to happen when you buy a commercial system to support population level care that doesn't really exist anywhere.

Dr. Cullen: Well, and just from a demographic perspective, right, American Indian and Alaska Native, there's a lot of federally recognized tribes. Military history really matters, especially to talk about those two things you talked about. Were you aware there was burn exposure? What kind of armor have you been firing? The new things that are coming out about National Guard people or Army Guard and what we may need to be following longitudinally. That data has to be collected in a way that then can be aggregated and used for population health.

And Shannon, you that other thing you talked about, you know, Indian Health Service has this amazing population health module that allows you to create your own cohort on the fly and figure out what's going on with them. That kind of flexibility, way before anybody else had it, is critical to being able to ensure that health status is improving.

It's not enough to just know how many of your individual women qualified for a pap smear and got it today. It is what's going to happen in ten years. How do I longitudinally monitor that? And how do I make sure that I have a data set that will enable me to do that's in the system and at the point of care. It makes my life easier as a provider and ensures that I don't miss what matters for you as the individual person.

Shannon: Okay, I'm going to jump forward to another point in time where having data really mattered. I remember when you deployed for Katrina, and I remember stories about something like commandeering a truck or something…

Dr. Cullen:  …well, you know…

Part 2: Deployments: Katrina, Rita, Ebola

Shannon: Spend two minutes on Katrina. 

What was it like when you were on the ground? Also having to make a plug for everyone here to read Five Days At Memorial. What was it like inside? 

Dr. Cullen: Well, you know, I deployed for Katrina / Rita. I actually was a public health service deployment asset. You know, I have a big mouth. Sometimes I get in trouble.

I quickly got deployed from being a national asset to being a state asset, because I was causing so much trouble about, “We can't do it like this. We have to do it better.” So it is true. We landed in an airport that has the same name as a large airport, and people thought that there was a car rental place at the airport.

There was no car rental place, but there was a wonderful truck dealer. And we went and we said, “Can we have three of your trucks? We promise you're going to get them back.” And they gave us - they gave them to us. And then we drove at the end of that deployment - the last part I did, I was actually in Waco, Texas.

I helped stand up at a Walmart, an abandoned Walmart or an unused Walmart, a big shelter where people came in from everywhere. 

What we saw was data would have really mattered. We didn't have access to data. The VA system did have access to data, because remember, they had a centralized database and were able to go and lots of kudos during that time of deployment to all the military people that were deployed, to the public health service, to the VA, lots of civilians deployed with us. But it was this ability to recognize that if you had had data, you could have done things differently. 

So, for instance, in this warehouse that we made into a shelter, we started doing a clinic. It wasn't clear we were supposed to do a clinic, but I was like, well, we're doctors. How can we not do a clinic? So we did a clinic and we were seeing people, a lot of people that had been evacuated initially for Katrina, now evacuated for Rita again into Texas from the southern, the southern states down in Louisiana, who we knew had conditions. They knew they had conditions. They had none of their medics. They were really a little unclear about what they were supposed to be on when they were last seen.

And the other thing, let me just do another plug here. We took care of people that did not have access to care in their life. And now they're in a shelter. And we gave them access to care, and we did some diagnoses of people of things that should have happened before. You don't grow a goiter, a thyroid condition, overnight, but we are seeing you and go, oh, you know, you have the severe condition of goiter.

No, I didn't know what this was. Nobody ever spent time or told me what it was. So it once pointed out, and I think in that book they do talk about the - this horrible phrase in some ways, but the “underbelly of America,” the parts of America where people are really not getting care, they don't have access to care, they don't have good care. And if and when they can get that care, they will take care of themselves. This resilient nature of human beings that you see all the time post-tragedy. 

Shannon: Yeah. Okay. I want to fast forward to another tragedy. I feel like a theme in my life is when there is something happening in the world, I think my siblings and I all look at each other and are like, well, one's mom going to sign up to go. Ebola.

I remember hearing about Ebola on the news. I remember sitting in the living room at your house. I remember my brother and sister and I all looking at each other and being like, you know, it's time. Christmas is coming. When is she going? And sure enough, you did. 

I remember you coming back, but would love to spend a little bit of time on when you deployed, what you were doing, what tools you got to use to help and and what should have gone differently.

Dr. Cullen: Yeah. I will remind you that when I walked out into the living room and I said, you guys, I have to go, you said to me, “We were just waiting for you to tell us, mom. And we knew you needed to go.” 

It made sense for me to go. I'm a family medicine doc. I've done emergency room. I was a public health service officer. I've been deployed. If people had to go through, who I was made sense for me to go. And I had a wonderful family. And you're right. It was, early, probably. I think, like, probably around your birthday that I left to go. I did deploy with Partners in Health as a volunteer. 

I was initially sent to Liberia, and then I was asked to go to Sierra Leone, and we took a UN flight into Sierra Leone, landed at Freetown.

I was initially there, then deployed up to Port Loko, and after I'd been there 2 or 3 days, Partners in Health had been asked to open a maternity care Ebola holding unit in Freetown at Princess Christian Maternity Hospital, which was the only maternity hospital at that time in the country. 

And, to be frank, I didn't want to go.

I knew enough to know that Ebola has one of the highest concentrations in amniotic fluid and blood, and there's no way you can go to a maternity area and not be exposed to amniotic fluid and blood. And I remember someone saying to me, I had done a lot of obstetrics, obstetrical care in my life at the family medicine doc, and they said, well, if you don't go, somebody is going to go who's never done any of this.

And I said, okay, I'm in the car. So we went through multiple checkpoints driving into Freetown at night. We set up the holding unit. There were two expats, people not from Sierra Leone, that were there with us originally. It was almost all staff from Princess Christian Maternity Hospital and you'll recall there were chlorine sprayers.

Chlorine was what we used to kill the virus. So we had lots of support there. We were right outside Princess Christian Maternity Hospital. The lead physician at that hospital was alive. He was an OBGYN. Almost all of his friends had died from Ebola. So I remember people said he should come in the unit and I said, he shouldn't come in the unit. All his friends have passed. Look, we're here. We're going to do this. 

It was a really difficult time for me. There was a lot of tragedy and death and this unsupported belief that I was the physician from America, and I could save people. I couldn't save people. 

But, you know, we made a commitment, and it's not going to sound like a lot, but it was a lot to try to have people not die alone, and not not die covered with body products, that they would die with dignity. And that didn't always happen because we couldn't be in the unit all the time. But we did things. People were comforted. We comforted each other. We cared for each other. 

The data part is really important because at that point we didn't know about Ebola. Everybody was publishing, the New England Journal was coming out and “give people four antibiotics or three antibiotics, blah, blah, blah, blah.”

And remember, we have a subset of people with Ebola. We have women who are pregnant or postpartum. So we started collecting a lot of data. Excel spreadsheets are really valuable in areas when you don't have a lot. And we were able to determine quite early on that fever that if you were pregnant, you did not need fever to have Ebola.

And you, your listeners may remember some of this, that the way you got in the algorithm for Ebola was you had fever. And it turned out in pregnancy based on our limited data set. But about 50% of women who were pregnant, who ended up with Ebola didn't have fever. 

So that  kind of data, just think of how powerful that is, being able to transform it collected on an Excel spreadsheet.

But knowing, not really knowing what data to collect, but collecting some of it. 

I do want to share one story though, that there was. It was tragic, and you may recall, Shanny, and I came back and your daughter wouldn't wouldn't hug me because I asked her if she wanted a bowl of rice and she said no. And I said, why don't you want it? She goes, “I don't want Ebola rice.” So she missed those words together. 

But there was a moment where the woman had twins and she didn't. We thought she didn't have Ebola. Remember? It took 2 to 3 days to get the test back early on. Tragic lesson learned there. If you have people that may need operative intervention, you have to get blood test back really quickly.

And we learned that CDC will learn that. But she delivered a baby. And then I realized she had another one. I was like, oh my goodness, what are we going to do now? We have another baby in there. We didn't have any ability to instrument or do anything, and one of the chlorine people, a chlorine sprayer was their role. He said, oh, we're going to dance and sing this baby out. And I'm like, what do you mean you're going to sing the baby out? So there's like 6 or 7 women in another room and he goes out there. He has is, you know, we literally had like cleaning materials. He's dancing. He’s dancing and singing and everybody's clapping, and come on. And, you know, obviously non-English. 

But she then delivered this beautiful baby. They were both little guys. They went to the peds Ebola unit, and she turned out she didn't have Ebola. And it turned out both her babies went home three weeks later. So it was this wonderful celebration in the midst of tragedy. 

Shannon: Yeah. I think it's really hard to find those moments of hope or moments that feel like that.

I do remember, like I said, I  remember coming home. I think one thing that probably Ebola, plus Covid really taught us is the amount of support that we need to give to care providers when they're in these positions in pandemics, epidemics, really taking care of a population that is overall struggling to survive.

Part 3: Regenstrief and Informatics

So after you came home from Sierra Leone, you went to Regenstrief shortly after, right?

Dr. Cullen: Maybe it was like a year. Yeah, yeah, I went in 2015. I went to Regenstrief for three years, and I did global health informatics health system strengthening in low and middle income country. Some of that was because, but because of my experience in Sierra Leone. But it was also that I did spend that year at HHS, reporting to the CIO and to the CTO at that point.

And, I remember the CIO said to me, you should do global health. That's the one thing you haven't done, so you should do that. So I did, for three and a half years, and it was a wonderful, wonderful experience. Regenstrief was a great place. I ended up not intentionally being the interim director for LONIC, co-director for LONIC.

So I learned everything I ever wanted to know about LONIC, and I knew a lot about standards, but I didn't know about the intimate workings of how you build a LOINC code, and I learned that very well. Yeah. So that was a wonderful time. 

Shannon: And in that time period, you were also working on open MRS, right? Which is the open source EMR that's used pretty broadly.

Dr. Cullen: I think millions and millions of people use it. It started out in Kenya, really built primarily to provide care for individuals, had HIV and then expanded. It's still expanding now. It's well supported. It's really the true open source model in that it's a community. It's a community that makes it better, that proposes enhancements, works on those enhancements together.

And, many of the people that founded it, Burke Mamlin and Paul Biondich are at Regenstrief. 

Shannon: Yeah, that's awesome. 

Do you think open source still has a place in healthcare overall today? 

Dr. Cullen: I think open source has to have a place in healthcare. And, if we wanted to go into that realm of artificial intelligence, which I think is what many of us have been doing for 20 years, but now it has a phrase that goes along with it and it's obviously, more developed than it had been.

But, if we don't know what those those that coding is doing, if we don't understand what the algorithm is querying, if we can't see and all we have is a black box, I think we have huge risks in the society from, from a justice and equity perspective, from unintentional consequences. 

And I also think that if we really want to look, how do we get health equity in this country? How do we get health justice? We have to be able to have people that are working with data, need to have tools that enable them to do that. Public health is a little lagging behind there. we're hoping that it accelerates soon. But open source I think is a critical component, not for everything, right, but having the open source option really makes a difference. 

And you know what makes the difference? It's not because nobody's paying a license fee. It's because there's a community. There's a commitment from a community to support open source. 

Shannon: Totally. Yeah. But also make a plug to that. Actually, Vista and RPMS are open source and used by Jordan and I think in other countries as well that have adopted it.

So that was another interesting thing in the transition to Cerner was, what actually happens to that open source community> 

Dr. Cullen: Yeah. Well, and you may recall, I worked with the country of Jordan. A few times I've been over there and they have not only taken Vista, but they've expanded Vista to meet their needs. Jordan, a country of around 9 million people, huge number of refugees over the years, really has decided that they needed a national solution. And it made sense for them to take Vista. And what they've done is really expanded it to meet the needs of their population. Once again, similar to what you saw with the Indian Health Service and VA. If you have a part of a population that has a need that you really can't just buy off the shelf, right?

It's not just a non-proprietary pharmacy system, but I need to do this one special thing. I need a solution to do that. And if you can code and develop your own application, then you can do it rapidly and get what you need. 

Shannon: Yeah, totally. Okay, so let's move to your current role. I will never forget in 2020 when I'm just thinking about Bob convincing you to lead the Pima County Public Health in June of 2020, a little insane to say yes at that point in time, but here we are.

And you are still there.

Part 4: COVID in Pima County

What has that journey been like at Pima County when you stepped in in the middle of a global pandemic, in a community that really needed [help]?

Dr. Cullen: Now, I don't want people to think I'm really crazy. I applied for the job. I applied for the job before the pandemic was noted. It was in December of ‘19.

Of course, I thought something was happening because I was paying some attention, but I actually started May 1st of 20. You may think I was crazy, I didn’t pull my application out in those five months that I did. And so I went in. I think none of us really realized the extent of what was going to happen with Covid and the impact on the community, the state, the country, the world.

But I went in because I said to my boss at that time, okay, I'm going to make Pima County one of the healthiest counties in the United States. What's important to note is we have a really high SVI Social Vulnerability Index. It's about 0.88 or 0.91, depending upon who you look at. That means we have a lot of problems: social determinants of health problems.

We have a lot of poverty, lower education, and access to services is more limited. However, I'm a little audacious and a little arrogant believing that you do make things better in lives. 

So COVID gave me a run for my money. Probably one of the hardest things I've done. Lots of work happened. But you know what? I was really lucky I was in. I had an administrator who I would go to him and say, we have to do this because what you're asking me, I said, what's going to cost money? Well just do it. And I remember one time I asked him what I should do, and I subsequently have told people this. And he looked at me quizzically and he said, I don't know why you're asking. You should do what's right. What a gift, right, to have someone you work for… Now it did help that we had federal money coming in. I must admit, without the funding it would have been really difficult. 

But to eliminate every single barrier to anybody getting tested, getting shelter if they needed it at that time, getting a vaccine. We were known throughout the country for the work that we were able to do, and the access we gave to individuals. We didn't collect insurance information. We made a conscious decision it was not worth it. What we wanted to do was just get people tested, giving them the resources they needed to isolate if they needed to isolate, help them quarantine their family, if they needed to, make no difference between what your race or ethnicity or economic status or insurance status was as we come out and we've come out.

What we see is a community that's resilient, a community that we've been able to work with, develop relationships with, that we have never had before and engender trust. Now is that everybody in the community? No. But overall, I think what you see, and I know we're telling you about data, but in some ways, at the end of the day, the ability to share data depends upon you trusting me, the ability to want me to support you.

It's trust, it's community, it's collaboration. It is knowing that together we have a shared vision, a shared mission. 

I would argue the whole US has a shared mission and vision. Nobody wants to see anyone suffer. And the reality is, if you do this well, you lessen suffering. 

Shannon: I often think about, you know, I'll be in rooms even now and with my former government friends who are still in government, and they might be running a pilot or doing something. And I swear, like, I'll be hiding in a corner and I'll hear, we have to call Dr. Cullen, she'll do it. She'll do it. I do think a big portion of being able to achieve that mission that you said about making Pima County like the healthiest county is because of that willingness and ability to raise your hand and pilot things.

And I think you saw that with, I don't remember what the product that US Digital Service and CDC did, but like flights to do that. And it does revolve around being a physician and having an informatics background where you can say, actually, here is how data can change the way that we think about making community healthier, not just from a traditional epidemiology perspective, but in terms of how you think about care, access to care, every piece that comes along with that.

Dr. Cullen: Yeah, that was simple reports. But I will tell you, I'm trying to recruit a physician right now. And he said, well, what about change? I said, oh, my staff says, I've never met an innovation I didn't want to do. That's not really true. But, you know, the reality is you have to seize the moment and you have to be willing to fail.

And I will give credit to OMB about this when I was the CIO at Indian Health Service, I remember I was sitting with OMB one time about my budget and they were like, oh, this didn't work, this didn't work. And I said, you know what? You have to acknowledge that 10% of what I do isn't going to work, and you need to give me that latitude, because if you give me that latitude, I'm going to find 90% that really works.

And so I do think in informatics, being a physician, being a bureaucrat, being a leader, it requires you to take risks. And obviously it's calculated, right? You don't just grab everything, though sometimes I may be a little calculating, but this ability to know that change requires not only fortitude and faith, but it requires a leap. And sometimes you just gotta leap. When I look at public health right now, we got a lot of leaps we got to make. We got a lot of hopscotching we got to do to catch up with the clinical community. 

I'm actually in cities, I'm in Atlanta today at a meeting where we're talking about some of the things. Can you, you know, interoperability - interoperability is still there. And as soon as you throw public health data in that mix, it becomes a stew that is not well cooked. And what I know now, having done four years of public health and I feel really grateful for this opportunity, is that public health is as important as clinical care.

The data have to be merged. We have to figure out how to work together, and we have to understand that an individual's life includes clinical care, public health care, the environment, social determinants of health. And we keep talking about that. But we need to embrace is this ability to create a patchwork quilt that's well sewed, that has all those data sources there, so that whoever sees you and they see you within the context of your family, within the context of your community, within the context in my county, of the county that we know what's the best thing for you, and we can make that decision with you and with your loved ones.

Shannon: Yeah, I love it. Okay, I want to ask one more public health question. 

How do we create healthier communities with data? But specifically, I want to talk about it in the context of the opioid epidemic. What are you guys doing in Pima County or what do you wish that you were doing in Pima County to handle the opioid epidemic?

Dr. Cullen: So what we know is there are things we need to do, and everyone needs to do that. We need to embrace harm reduction. We need to make sure that individuals that are at risk have access to what they need. Things like naloxone, which everybody cares about, fentanyl test strips. We know we need to do prevention.

We need to talk about the youth and other people that are not using providers that are dispensing, and make sure we're protecting people as much as we do from a data perspective, linkages to care and retention and care are critical. 

Those are two steps that we struggle with. And that's because people link into care in multiple different ways. They link into care from a community based organization, from an emergency room, from a first responder, from a family member and then they start on their journey. 

Human centered design. 

This is a really complicated data journey. It is a really complicated, individual journey. Until we can synthesize that journey and we can figure out what are the points to push on - for you as an individual - but also for a community and for a population, I believe we're going to continue to see the numbers that we're seeing. A 737 or 747 worth of people are dying every day. That's the number of people dying from opioids and overdoses right now in the United States. Every day. 

If you look at where we are now with patient safety and clinical safety, we have come light years in the past 20 years. We are in a totally different place. There's always times in the O.R. when people stop and go, let's walk around. Let's make sure we're doing the right thing. If you look at what we're doing with opioids and overdoses, we are only at the beginning, and we need those kinds of resources applied, those kinds of brains, that kind of mindset, kind of reflection to really make a difference. 

However, am I overwhelmed? No, things will get better. They will.

The other thing with opioids is so much of it, Shannon, you know, is pain and suffering, emotional pain, psychic pain, intergenerational trauma, lives that feel empty, individuals that have a sense of enemy. And we have a responsibility as a society, as individuals to touch those lives today.

Part 5: Shannon’s Lightning Round

Shannon: Yeah. Okay. So we're going to close with a lightning round of questions.

And I have a bonus one for you that I'm really excited about as well. 

The first one was how would you fix American healthcare in two sentences or less? 

Dr. Cullen: Well, I would make healthcare for all be real. Okay, I'll just go back to my medical school essay. Not only did I say the thing about lighting a candle, I also said I believe healthcare is a right, not a privilege. 

Shannon: All right, that's it. Okay. 

What are you most optimistic about in healthcare or the healthcare technology space? 

Dr. Cullen: I think the healthcare technology space with artificial intelligence will give us the opportunity to eliminate the mundane, accelerate what providers hate doing, things like Prior Auth off and give us the tools to, hopefully understand early sentinel awareness and know what's coming around the corner.

Shannon: Totally. Okay. 

Three books you think everyone in healthcare should read.

Don't worry, we can come back to this one. 

Dr. Cullen: You assume I still read healthcare. I read trash novels. 

Shannon: I remember one time you gifted me Dreaming in Code

Dr. Cullen: Yeah, Dreaming in Code. What a great book. That was awesome. Because I was dreaming in code at that time. That's why I had to give you that one. 

Shannon: RPMS. My bonus question. 

Do you think you'll ever retire? 

Dr. Cullen: You know what? I read this, I - okay, more than two sentences - I read this thing on a blog today, a public health blog where the lady was talking about, she was 88, and she thought that there was prejudice against old people. She was working two jobs. I thought, that could be me. I could have two jobs that when I’m 88! 

No, why would anyone retire? If you think that you can still contribute to the world and make it better, I'm blessed. 

Shannon: And you can still hike on the weekends with your husband.

Dr. Cullen: My husband would like me to retire. Your father. 

Shannon: One day. One day. Okay. This was so much fun. I'm really glad that I get to share so many of these stories that I know and have heard over my lifetime with other people who will listen to this, and also just your wisdom and brilliance.

So thank you for being… 

Dr. Cullen: And I love that now I'm “Shannon’s Mom.” 

Shannon: It is a fun transition. Yeah. Awesome. Thank you, thank you thank you love you lots. 

Dr. Cullen: Happy Mother's Day to everybody! 

Shannon: Happy Mother's Day birthday with your families. I loved this.

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