The Right Note at the Right Time

One great performance earned Angela Smith a music scholarship to UNC. She’s been in Chapel Hill ever since. Now, as a urologic oncologist, she’s developing an app to ensure her patients get the right information, right on time. Her work has earned her a Jefferson-Pilot Fellowship in Academic Medicine.

The Right Note at the Right Time click to enlarge Angela Smith, MD

By Jamie Williams, jamie.williams@unchealth.unc.edu

Angela Smith, MD, is a “Tar Heel lifer,” completing her undergraduate, medical school, and residency at UNC. And while the Pittsburgh native’s Carolina allegiance is now unwavering, she may never have landed here without a little serendipity and one great musical performance, which originally brought her to Chapel Hill.

A star student and musician, Smith and her family were in North Carolina to visit Duke University, where she had been accepted and planned to enroll. But, while they were in the area, they decided to take 15-501 over to Chapel Hill to have a look at UNC, which she was also considering.

The daughter of a band teacher, Smith played the violin and piano, but her main instrument was the euphonium – a brass instrument that resembles a tuba, only slightly smaller.

While in Chapel Hill with her family, Smith learned UNC bands were in need of euphonium players. She auditioned for the band director and walked away with a scholarship offer.

“That one audition really made it all happen,” Smith said.

At UNC, she double majored in music and biostatistics. Her work in the Biometric Consulting Lab, under the guidance of Gary Koch, PhD, professor of biostatistics, spurred her interest in research and medicine. As a medical student at UNC, she had the chance to work with Raj Pruthi, MD, professor and chair of the UNC Department of Urology. Work in the urology clinic led her to her specialty, urologic oncology, and a constant focus on improving patient experience and outcomes.

Now, Smith is an assistant professor in the department of urology and a member of the UNC Lineberger Comprehensive Cancer Center. She treats patients with bladder, prostate, kidney, and testicular cancer. 

She plays the piano and violin in her free time – it’s tough to play euphonium outside of a large ensemble – and has made playing more one of her resolutions for the New Year.

In this edition of our Five Questions series, we talked with Smith about her work, her motivation, and the project that was recently awarded a Jefferson-Pilot Fellowship in Academic Medicine.

What experiences as a medical student led to your interest in urologic oncology?

In medical school, I met Dr. Raj Pruthi who became an important mentor to me and now, of course, is my chair. Working with him as a medical student on research and in the clinic is what initially sparked my interest in bladder cancer.

I was especially drawn to caring for our bladder cancer patients. Many of our patients are older, and their conditions require major surgery and 4 or 5 days in the hospital, followed by months of recovery. What I noticed was that we were doing a poor job guiding these patients through the discharge process. Since my intern year, and especially since I joined the faculty in 2012, much of my research has been aimed at improving post-operative experiences for these patients because I believe they are particularly vulnerable.

That is the focus of your current project. Can you describe it?

This project looks at the effectiveness of using mobile health to improve patients’ post-operative outcomes. The first step of the project – interviewing patients, caregivers, nurses, social workers and others regarding their experiences – is complete. Based on their feedback, I am creating an algorithm of a variety of symptoms that are commonly experienced by patients after a cystectomy. From that we will build an app that will ask the patient a set of questions each day, and, based on their answers, it may prompt them to come to the emergency room, it may prompt a member of the care team to call them, or it may tell them that what they are experiencing is normal and then offer some education on how to deal with whatever issue they are experiencing. It’s a way for the patient to get the right information at the right time, which is what we are all striving for.

What were some of the experiences that inspired the development of this app?

During my intern year I saw patients being readmitted time after time. Forty-three percent of cystectomy patients are readmitted within 90 days of surgery, so we know that there is a problem. During that intern year, I noticed several issues that prompted readmission could have been avoided if caught early. But the patients were languishing at home for several days before seeking care and at that point they were so sick that they needed to be admitted.

The way that we do discharge summaries is just to send patients home with a laundry list of all the things that can possibly go wrong. There’s not a lot of information on what’s normal and expected.

Following a major surgery, patients and their caregivers are likely very concerned about any possible issues. Is the goal to help put them at ease?

One of the most interesting things we heard in the interviews was that many patients, a few days after surgery, would call their care team to ask about a problem they were having and be told what they were experiencing was normal. Then, when another problem arose, they would assume that was normal as well. But oftentimes that second issue really was a problem that required medical attention. Patients wouldn’t call, not wanting to bother their care team again, and then they would become dehydrated, or develop an infection that required readmission and a few days in the hospital.

The app allows patients to be more confident about what they should be doing. It also gives them a direct link to their care team because the nurses in the clinic will have their own device with the app. If the patient’s answers to the daily questions indicate a serious issue, the nurses will be alerted.

How has working on this project changed the way you communicate with your own patients?

I’ve tried to be much more specific with my patients about what to expect after their operation. But, the fact remains that all providers have limited time with their patients. If I explained every last detail about what could be experienced post discharge, then I wouldn’t have time to see all of my patients. And even if I did provide all of the details, the patient would not likely remember all of it. Part of my motivation for pursuing this project came from trying to reconcile the fact that I have a limited amount of time to spend with each patient, but also understanding that they need more information to navigate the weeks after their operation. This is a way of being more efficient, while also providing more information at a later point when they may be most receptive.

Another issue we run into with patients is that when they see us they have just been diagnosed with cancer and are hearing for the first time that they will need to have their bladder removed. They don’t retain everything because, frankly, they are overwhelmed. Even if I did have the time to explain everything, they aren’t going to remember details because it’s not relevant to them yet.

Again, that gets back to the goal of this project, getting patients the information they need when they need it most, which is when they are at home and experiencing that particular symptom.

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