Trusting your instincts for maximum impact with Dr. Christina Cruz

0:00 Welcome to the Clinician Researcher podcast, where academic clinicians learn the skills to build their own research program, whether or not they have a mentor. As clinicians, we spend a decade or more as trainees learning to take care of patients. When we finally start our careers, we want to build research programs, but then we find that our years of clinical training did not adequately prepare us to lead our research program. Through no fault of our own, we struggle to find mentors, and when we can't, we quit. However, clinicians hold the keys to the greatest research breakthroughs.

0:40 For this reason, the Clinician Researcher podcast exists to give academic clinicians the tools to build their own research program, whether or not they have a mentor. Now introducing your host, Toyosi Onwemene. Hello everyone. Welcome to the Clinician Researcher podcast. I'm your host Toyosi Onwuemene, and I'm delighted to be here today because I have a very special guest, Christina Cruz. Dr. Christina Cruz, welcome to the show. Thank you so much for having me. Well, Christina, you are an amazing, phenomenal physician scientist, and I'm so excited to have you on the show.

1:24 And I just want you to just introduce yourself to the audience, especially kind of give us the story. How'd you get here? How do you get to do this thing called being a physician scientist? Well, again, thank you for having me. So I am a child psychiatrist at UNC Chapel Hill and a global mental health researcher. And a lot of my work centers on a therapy I invented that teachers can deliver in the classroom while they're teaching students to try to increase access to care in places in the world without mental health professionals. How I got here is a longer story. I actually, once upon a time, was actually in business and a management consultant and had an aha moment when I was with my firm in a hospital where I had wanted to actually be on the other side of the interaction where the healthcare was happening and not consulting.

2:17 So I quit my job, went back to school to go into medicine, was fortunate to get into med school and then promptly realized that medicine was imperfect and that I needed to work towards the health of others outside of medicine. And so I took a year off to get a master in education. And at that time, a friend had approached me about potentially doing school mental health in Darjeeling and I was already interested in psychiatry and school mental health with a master in education, thinking about how schools could be a platform for mental health. So as a med student, you don't often get to do cool things. And so I immediately said yes.

2:58 And that was the birth of Tealeaf, the therapy that I created. And so now we're 12 years out and Tealeaf is across 40 schools in Darjeeling, India, where it was born and raised, I like to say. And we're newly expanding now to Manila and the Philippines, which is a country that holds important my family. And so I'm excited to talk to you about the journey and what it's been like, because it's been, I'll confess, a bit roundabout. And to be honest, research was actually never on the mind until it was clear that it was the way to go. Okay, you said a lot, Christina. And the thing that I just want to pause and double down on is Tealeaf.

3:39 Oh, tell me about that. Yeah. So Tealeaf stands for teachers leading the front lines, mental health. It is a nod to Darjeeling, India, where it was born and raised, like I said, and that that's the local industry. And so we wanted to ensure that anything we created was very clear that it is a Darjeeling product, given that the communities who wanted this. And so my med school classmate at the time is now also a physician, and approached me about going to Darjeeling to think about school health, school mental health, rather. He and his wife were teachers in Darjeeling for a couple of years, and they were going back to start a nonprofit around school health.

4:23 Kids were dying of diarrhea at higher rates than the world was. And so they really wanted to tackle that issue. But as teachers, they also very much knew that mental health was in the classroom. The prevalence is about one in five kids after COVID. Now it's closer to two in five kids with mental health concerns. But there are no resources really locally in Darjeeling to address it. And so I was really convinced with my friend's name is Mike Maturja and Dana, his wife, that teachers would be a way to kind of get in there to provide care. But it had to be done in a way that could be sustainable, because there are obviously teachers who are there to teach, not to be mental health clinicians. So I approached my master's in education with this idea in mind and started to craft it over a couple of years until it got to the point where we made therapy interventions that could be done in 30 to 120 seconds.

5:20 When teachers are already supporting their students with mental health concerns, what they're doing right now is providing informal support. And what we've done is craft cognitive behavior therapy and dialectical behavior therapy, CBT, DBT techniques to be used in those moments. So informal moments of support become doses of formal care. So that's Tealy. I love it. I love it. Okay. So even going backwards, businesswoman turned clinician and evolved into a researcher. What an amazing story. So you are creating, you're crafting, you're building, you're molding.

6:01 Who's been guiding you along this process? How is this all? Where did you find the mentoring to do all of this? Well, it started in part in medical school. I had the really good fortune to have role models who were very busy, but started me on this path of thinking about global health, global reach, and how does one do something big? And I'll credit actually the individuals, they're famous. One is deceased, one is Jim Kim, and one is Paul Farmer. They were professors of mine in medical school. And I got to know Paul Farmer, not well, but just enough where he became somewhat of a mentor. And he obviously, I don't know how much folks on the podcast know, it's just a huge presence in global health.

6:46 Unfortunately passed away last year, but really, I think changed the face of how you can think about your impact as a clinician through both research and programming that can become global. So it started there. And then I've had different mentors along the way who have helped me to flush out ideas, such as in the education school, thinking about a pediatrician who is there who thought about school health, or now at UNC where I'm still early career faculty thinking about my mentor here who helps me think about task shifting, which is what Tealife is, is having community members deliver professional care on some level.

7:28 But it's not been one person, I would say, who's really directed everything. It's been my ability, thankfully, to know when I don't know what's happening and having to turn to someone, find someone who can help guide me through those moments or those problems. I love it. I highlight many things that I find valuable and I highlight on this podcast, which is number one, you were talking about mentoring networks, there was not the one person that you could point to, even though you had Paul Farmer as a mentor, you didn't have one person that you could point to and say, this is the person who led me all the way through. And that it kind of shows up in your career because you've built something that's unique that I think draws from all of these strengths to make something pretty amazing.

8:16 And so there's the concept you draw on about of mentoring networks. And then the other piece is self-direction. So you are actually leading your career. So where do you get the, I think maybe the word is hudspah to do that. Like, where does that come from and how dare you? You got right to my heart. So I'm a New Yorker actually and a New Yorker in North Carolina and I use hudspah about once a week as a word. So yes, how dare I? Well, I will just say that I think it comes from a deep belief that may or may not be naive that I can do something useful.

9:02 And it's not that I don't respect the systems that are out there, however imperfect. In fact, I've come around to really respecting them in that it's years, sometimes like hundreds of collective years of people's knowledge and wisdom, putting something together the best they can. And so I see those as really important in terms of working within, but also learning from. But knowing that they're imperfect and that in my heart of hearts, having expertise kind of across three different, very different fields, business, medicine, and education, that there are ways to put them together that might create something new that others may not see simply because they don't have the background to see it.

9:52 And so that's where the hudspah comes from. It's just kind of enough confidence in myself, though let's be clear, lots of imposter syndrome happens to be able to bring something into the world that I'm pretty sure others haven't done because no one's put the three together. It's an experiment. Yes. Is it working? I think so. That's what the evidence is showing as I've learned how to be a researcher to show that in fact works. I love it. I love it. You are owning your own strengths and the spaces in which you shine as the expert. And what you've done is instead of saying, well, this is what's popular.

10:35 I'm not the expert in that. Let me keep trying to make this work. You said, no, where do I have expertise and how do I create something that I understand and can move forward? That's pretty impressive. You are very kind. Thank you. I will confess, all started in medical school when I was having finished third year, which we all know is our hardest year as a med student and just looking for something else. I had finished surgery. I'm a psychiatrist. Again, surgery is very far from my daily life right now. And I needed honestly a pick me up and having had a consultant kind of brain, this was a great way to put everything together to think about how systems come together in a way that I knew hadn't really existed.

11:23 Though of course, tenants did exist such as exceptional children's or special education. Some of it's based in that. Some of it's based in CBT and DBT. These are all in existence, but it was rejuvenating and grounding to be able to come to a project like this after having gone through what I call the slog of third year. Yeah, it definitely is a flag. And what I hear you saying is that you were searching for the meaning in all of your experience and where you didn't necessarily find it in the way you wanted, you created it. You created meaning out of your experience and looking to really make an impact.

12:03 And I think that's why many of us come to medicine. I mean, we're clinicians first because we really want to make a change in the lives of our patients. And so you saw opportunity and you're making change happen, which is amazing. Now you make it sound easy. You're like, I did this and then I went across the world and I started this thing that's now in 40 schools. So what have been some of the challenges along the way? There have been many. I think to get into the weeds, there are always logistical challenges, working internationally, understanding different laws, cultures. I'm sure everyone's experienced it on some level as you even just managed both being a clinician and a researcher.

12:49 I think the biggest challenge though to step back that that kind of forms the foundation of is by creating something essentially no one has done this before. And it is both thrilling and terrifying to think about what my next step might be. Every day I wake up and I have to make my own list of what I'm supposed to do and think through is this important? Is this not? Is this going to further tea leaf? Is it not? Am I wasting my time or does someone need to do this? So there are all these, I think it's the decision making that really has been the most challenging because it feels as if not but there haven't been innovators before, of course, but no one's done exactly this.

13:35 And so what do I do day to day? What is the long-term vision? It all kind of rests on me and my team. I do of course have a team, but together that's it. There are no checks. And on some level, like I said, it's terrifying in that at the end of the day, I feel like we're taking children's wellbeing into our hands, but happily we've shown enough that children do in fact improve that I can sleep at night trying to chart a new path because ultimately my goal is of course to get care where I can when I can. Sure. So the obstacles I'm hearing are the real challenges of doing research across country lines.

14:20 I mean, we struggled to do research with our colleagues in the same division. You've managed to do it across country lines. And then also just thinking about the fact that this is brand new. And so in a way you're making it up as you go along and it's like, are we doing the right thing? Are we doing the right thing by our patients? And that challenge of making sure that you are honoring the rights and respecting your patients as well. I like that. Absolutely. So tell me about what, for someone who wants to do work in, I mean, this is global health, global research, right? People want to do this. If you could kind of create a new playbook for someone who's just starting, what would you recommend now that you've kind of done it and made the mistakes?

15:04 How would you do it over again? That is a really, I think, interesting and difficult question in that I consider my path fairly atypical, particularly having come to research as almost a fourth career. So what I will say though, with regards to global health is I do think it's important to find, I'm going to call them an advocate rather than a mentor in that you've discussed how I've had more of a network of mentors rather than a mentor. And so I would start with finding someone who you can just bounce ideas off of, or who can help you with thinking about projects or sites because the world is really large and it can be overwhelming to think about what you might do.

15:58 And you might not quite know what is needed somewhere else, or even if it's say like the next town in the United States, right? So I think that having some guide, some advocate is helpful. I also think that I would suggest folks think through what is their goal? What does the community need? And then how does it come together? Because I think what I've learned from Tealeaf is that it took a few years for it to really become honed in on this 30 to 120 second interaction with teachers. I despite being a consultant, my strongest training at the time and still is, is now medicine and psychiatry.

16:40 And so I came at it from a diagnostic angle of teaching teachers how to think about diagnoses, but actually it turned out not that they don't care, but they don't need to know that. They need to know what to do in those moments when the mental health symptoms are escalating. And so it really took thinking about what was my goal? What did the community need? And then coming together. And I still think it would have taken a long time to get to Tealeaf, for example, but maybe it would have been faster had I been much clearer on exploring with the community exactly what they were looking for and then helping them through, because they probably also don't exactly know either.

17:20 So I would say to summarize an advocate, as well as really exploring on the big meta level, what do you want to do? What does the community want to do and how do you come together? I love it. Now tell me about partnerships. So I mean, one of the things that's important, and I think you mentioned is just the importance of collaborators in this process. So how do you go about finding collaborators? Is it all serendipity? Yes and no, it's serendipity in that I think, excuse me, one second. It's all serendipity in that you may not know when that opportunity is going to come.

18:04 And so at some point it will feel like, gosh, wasn't I really lucky to come across this? But I think the reality is that you make it happen. You set up the environment, you set up what you're looking for to reflect or to try to bring that opportunity up. And so for example, with my experience, Mike and I had been friends throughout med school. There was no business transaction to be had or NGO to be started. It was simply, we both had similar interests. We had a group of friends with similar interests and we would just talk.

18:45 And then we would talk a lot throughout third year with not knowing what the future held, except that I needed to get up by five in the morning the next morning to ensure I could retract skin for the surgeon. And that's really all I knew. But we would have these shared experiences where then when we both came to what we next wanted to do, which was me thinking about school mental health and him going to Darjeeling to start school health, then he knew exactly who to turn to. His friend who had shared experiences with shared philosophy and was going to do the other thing that he was interested in.

19:25 And it was easy for me to say, I knew him and I knew that he was a good person doing good work. And it was an opportunity for me that I had been looking for. So it felt it feels like on some level, it's still lucky. I don't doubt that, but I sure did. And so did Mike and a lot of people create the environment and stay on the lookout for these opportunities so that when they do happen to come, you know, that's it and you go for it. I love the way you put that. It's the people who are prepared in a way have set a trap for opportunity. Essentially, that when it comes along, they're more likely to catch it.

20:08 That's right. I love it. So it is it is preparedness because you know, the if you weren't if you weren't thinking actively about how to make use of it, it might have passed you by and you would have missed the opportunity as well. Yeah, yeah. And to look for and to recognize it because I could have also said, you know, I'm going to get my masters this year. Thank you for this wonderful chance, but I'm going to focus on this thing. But and it was overwhelming to all confess because I was pregnant with my first child and about to deliver. So there are a lot of things happening, which is a theme in my life, a lot of things happening. But it was one of those moments where I sat down and thought, no, this this is a good one. Like I need to try.

20:49 I might fail a lot. I might take a long time to get there because it's everything happening. But I think I have to try and I just will put out there to my potential. You know, now, Koki, I this is what's going on in my life. But I really think this is important. Can we work together based on these constraints? And it so far has worked out. All right. So I'm hearing something that I just want to double down on. So you were busy, overwhelmed. There was a lot going on in your life. But still, when this opportunity came, you had the mental space to sit and consider that it was a unique opportunity that made sense to take advantage of.

21:30 And so it sounds like you probably have to move some things out of the way to make room for this, but you really had the mental clarity to recognize it for the opportunity that it was where in the in the place that you were, you could have easily said, I'm too busy. There's no time for this. It's not the highest priority, but you recognize the uniqueness of the opportunity. So tell me about what what what created those that space for you that you were able to do that well. Well, I think a couple of things like very concretely, my husband's always been a very supportive person and has always encouraged me to reach farther than I think I could reach.

22:14 And so it's it's just kind of part of how we operate together. So I think that's the basis in which I am fortunate to have that so that I can pursue things despite everything happening in my life. The other piece that I think is really important is that I knew in my heart of hearts that I wanted to have a global impact. I wanted to have the chance to do something that would affect the U.S. and beyond if only I could find it. But I had known this coming into medical school, which I alluded to in that I turned to medicine already as a second career, and part of my reflection was that as a management consultant, the impact I was having, which is, of course, improving a business, just wasn't the impact I was looking for.

23:07 And so when I did my own thinking through what am I going to do now with my career, it was clear to me that a global impact through health was what I was searching for. And so I knew that from the beginning. And so even though there was a lot going on, there was some part of me in the back of my mind that knew to look out for this. And so when it finally came, it was clear to me that I was going to do something that was important to me, and I knew that I was going to do something that was important to me.

23:50 And so when it finally came, it was clear to me that I was going to do something that was important to me. And so even though there was a lot going on, there was some part of me in the back of my mind that knew to look out for this. And so when it finally came, I did need to take a moment because my first reaction was, Mike, are you kidding me right now? I had no choice, I don't know that you had any other friends doing this kind of thing or would do it for free. So. Sure. No, no, no, that's really, that's amazing. That's amazing. It's that you had a very clear internal compass on what you had imagined for your future. And so when this opportunity came along, it aligned with that.

24:31 And that's why you had the opportunity to really give it some consideration. That's beautiful. That's beautiful. All right. So we're almost out on the end of our session and I want to give you the opportunity to say something that we've left on set. Someone's looking at you and they're like, wow, Christina's career is so amazing. What insight do you want to share with them about how they can think about their own journeys? I would say the biggest one is to go with your gut. I will say I have followed my gut almost the whole time and it has mostly not led me wrong. You do have to check it a little bit because it is your gut and there are real constraints in the world or things that might be fantastical, but aren't necessarily possible.

25:22 But I think to listen to what you think is right and then trying to figure out a way to do it is really the way forward, at least for me. And I think that's why my route was so circuitous yet landed on something so meaningful. So I would say go with your gut, work with it. As I mentioned when I was talking about the tea leaf offer from like sleep on it a few days, that helps. But generally speaking, by going with your gut, which I think is a reflection, it sounds cheesy of being true to yourself. That's how you can move forward because you will have to be internally motivated to be a clinician researcher. Tony Ose talks about this on all the different podcasts on the website about how it can be really hard and sometimes a lonely journey.

26:12 And so I think to have yourself to motivate yourself every day is most important. And that happens when you're true to yourself and listen to your gut. I love it. So beautifully said, there's just nothing more to add to that. You're so kind. Oh my goodness. Christina, it has been a pleasure, a pleasure to be on the show. Thank you for being here. Thank you for having me again. Well everyone, you've heard Christina, you've got to trust your instincts. If you know it just feels right, you got to explore it. At the very least, explore it, investigate it and see how can you make it possible. Someone's got to hear this episode. And so I want to ask you to just find one person, just one person who's even thinking about global health research and share this episode with them.

27:01 And definitely, I think more clinicians just need to be moving forward, moving forward the research ideas that they have, whether or not they're supported, but finding the areas of support where they can find them. All right. It's been a pleasure talking with you today. We look forward to the next episode. Thanks for listening to this episode of the Clinician Researcher Podcast, where academic clinicians learn the skills to build their own research program, whether or not they have a mentor. If you found the information in this episode to be helpful, don't keep it all to yourself.

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