Only five U.S. states have their own surgeon general. In California, the most populous state, Diana E. Ramos, MD, MPH, MBA, FACOG, holds that title. Her leadership and initiatives in public health are nuanced and varied in ways that reflect the many facets of patient needs—and the many facets of the health care professionals who provide patient care.
As California’s surgeon general, she gives high priority to reproductive health, perinatal disparities, contraception, abortion access, and reproductive rights, which she says are “So timely in terms of where we are in California and nationwide.” Less predictably, perhaps, her work also focuses on mental health in youth ages 16–24, who are in a key stage of developmental vulnerability. In addition, she has championed the incorporation of adverse childhood experiences screening—typically the province of pediatrics—into routine adult care too, with trauma-informed follow-up. This attention to early exposures and their connection with lifetime risk of chronic physical and mental health conditions is rooted in obstetrics and gynecology.
“As ob–gyns and primary care professionals, we’re the ones that patients will tell their stories to,” says Dr. Ramos, who is a past chair for District IX. “In my practice, I thought, ‘Wow, how could this 70-year-old have never told anybody she’d been sexually abused?’ But that patient felt comfortable enough with me to share it. Every ob–gyn probably has a similar story of patients sharing their most intimate trauma. I think we sometimes don’t realize the value of that.”
Physicians bearing witness to patients’ traumatic experiences may ask, what, realistically, they can do. “We listen,” says Dr. Ramos. This lesson was imparted to her by Vincent Felitti, MD, co-lead investigator of the Adverse Childhood Experiences Study. “[Dr. Felitti] told me people self-medicate with food and drugs because of sexual trauma and childhood trauma, and all we need to do is listen. That’s it. As physicians, we sometimes have a hard time just listening, because we’re taught to treat. Listening—the fact that you’re not turning them away—is in and of itself healing.”
Challenges in patient–physician encounters can manifest as measurable public health issues. “In a recent CDC study, one in three women of color reported mistreatment by clinicians during pregnancy and delivery. Part of that is not being able to talk,” says Dr. Ramos. Overall, one in five women who participated in the study said they had experienced mistreatment, such as being scolded or ignored. Forty-five percent had held back from asking questions or sharing concerns. That CDC report emphasizes the importance of respectful and responsive care. “Listening is part of respectful care,” says Dr. Ramos. “I completely understand we only have 10 minutes, 20 if we’re lucky—but sometimes we have to spend those extra minutes, and that can be the beginning of a patient’s healing.”
Patient empowerment is a recurring theme in this surgeon general’s portfolio. To tackle disparities in maternal mortality and morbidity, she assembled a crossdisciplinary team, including leaders in business and technological innovation. The team identified three priorities, including helping patients self-assess their potential risk before becoming pregnant. “This is completely novel,” says Dr. Ramos. “We’ve been focusing on the health care system, equipping hospitals. Patients usually find out they’re high risk during their prenatal visits; we’ve never given them the ability to be part of this conversation before they become pregnant.” Other priorities involve promoting validated risk assessment in health care settings and reestablishing patient trust, which centers listening.
As a practicing obstetrician–gynecologist, Dr. Ramos applied her own experience growing up underprivileged—raised by a single mother in a lower-income part of Los Angeles—to providing culturally sensitive care to her patients. She believes that physicians’ own formative experiences need to be shared, too, as a means of steering the profession toward culturally enlightened practice. “When I was growing up, I sometimes went to the ER late at night with my cousin—she was more sickly than I was—in the car with her mom and my mom. I couldn’t understand why we always went at night. When I was older, I realized it was because our moms worked all day. We never had preventive care. When I share my personal story, people will remember it and the message behind it.”
The transition from patient care to population care generates comparable rewards, says Dr. Ramos, whose previous roles include assistant deputy director of chronic disease prevention for the California Department of Public Health, and director for reproductive health in the Los Angeles County Department of Public Health. Each area of focus operates on its own schedule, however. “The endorphin rush of delivering a baby is fantastic, immediate. You get to hand the baby to new parents, that’s part of the joy,” says Dr. Ramos, “I would equate public health more with the pregnancy, the gestational period to 40 weeks or post-term. The outcome is not right there, but it’s beyond two people. Depending on your scope of influence, it could be a county, a state, a nation. Your impact is broader, your reach greater. Both patient care and public health are similarly gratifying, but getting to that point is very different.”
Diana E. Ramos, MD, MPH, MBA, FACOG, is the California surgeon general. She is the immediate past chair of ACOG District IX, secretary for the executive board of the National Hispanic Medical Association, and cochair of the Women’s Preventive Services Initiative implementation committee.
The thoughts and opinions observing Women in Medicine Month reflect experiences of individual ACOG members and do not represent official organizational opinions of ACOG.
Four Career Strategies for Women in Medicine
By Diana Ramos, MD, MPH, MBA, FACOG
1. — Prioritize
2. — Negotiate
3. — Collaborate
4. — Incorporate