Pulling Back the Curtain: Andra James, MD, MPH

In this edition, Andra James, MD, MPH, shares how she became a specialist in hematology, obstetrics/gynecology, and even Civil War history. Dr. James is a professor in the Division of Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology and a consulting professor in the Division of Hematology in the Department of Medicine at Duke University School of Medicine in Durham, North Carolina.

In Sound Bites, hear more from our interview with Dr. James.

What was your first job?

My first paid job (aside from babysitting) was as a waitress in an all-night diner. I learned how to work the night shift and provide customer service. This ended up preparing me for a career in midwifery and obstetrics and gynecology.

What did you want to be when you grew up?

I wanted to be an architect or a statistician, and I never thought I would have a career in medicine because, ironically, I didn’t think I’d be able to handle the blood.

Was there a specific moment when you knew you wanted to pursue medicine?

It wasn’t until college, when I had the epiphany that I wanted to deliver babies.

I knew I wanted to work with my hands, but I grew up in an era when women were excluded from these types of careers. In high school, for instance, I wanted to learn carpentry, so I signed up for woodshop; the school put me in home economics instead.

Both of my parents were teachers, so they thought I should become a teacher. I was good at math, so becoming a math teacher seemed like the natural path. But after a few weeks in college, I found that I couldn’t figure out how I was going to help people by being a math teacher. I asked that question of my adviser, and he didn’t have any ideas either.

I reflected on what type of career was available to me where I could do two things I knew I enjoyed: work with my hands and take care of people. I concluded that I could deliver babies. But even when I talked to my family about possibly going into medicine, they said, “That’s no career for a woman.”

Then, a public health nurse I met urged me to talk to the head of the nursing program at Johns Hopkins University, Helen McNerney, RN, MSN. She outlined how I could have a career in nursing and train to be a nurse-midwife, and I credit her with starting me on my path.

What eventually brought you to hematology?

It’s a screwy journey: My first job out of college was as a public health nurse. Then I went to graduate school, trained as a nurse-midwife, and completed my master’s in public health at Johns Hopkins University. After that, I practiced nurse-midwifery for 12 years before I went to medical school.

I decided to start medical school because I had patients whose medical needs I couldn’t manage as a nurse-midwife, including some who had massive hemorrhages and one who died of a coagulation disorder.

I trained as an obstetrician-gynecologist at the University of North Carolina, a center of excellence in hemostasis. I was inspired by Gilbert White, MD, and the late Harold Roberts, MD, who showed me that treatment of coagulation defects was not only possible, but potentially lifesaving.

When I went to Duke University for my fellowship in maternal-fetal medicine, my plan was to research diabetes during pregnancy. After a disappointing experience with my first mentor, I talked with my fellowship director about switching specialties. I told him I was interested in coagulation and was connected with Russell Ware, MD, PhD, in the Division of Pediatric Hematology. Dr. Ware was my mentor through my fellowship and took me to my first ASH annual meeting. Like Ms. McNerney, Dr. Ware is another person to whom I owe my career.

What happened in that first mentorship experience that prompted you to switch your research focus?

At my first meeting with this prospective mentor, he asked me about my ideas. When I told him, he said they were ridiculous. Here I was, a brand-new fellow, absolutely humiliated. I knew I couldn’t work with him. He set a good example of what not to do as a mentor.

I had the complete opposite experience when I met with Dr. Ware. He asked pointed questions and clearly had high expectations of his mentees; he was prepared to be a mentor.

After all that training, my first job was as a member of the maternal-fetal medicine faculty at Duke, where I have enjoyed the support of the Division Director of Maternal-Fetal Medicine, Robert Phillips Heine, MD, and the Division Director of Hematology, Thomas Ortel, MD.

As someone who thought her job was to work with her hands and care for patients, hearing that didn’t immediately resonate with me. Eventually, I took it to heart and it changed my career. I became much more productive academically.

Looking back at your career, what has been your biggest accomplishment?

I am proud to be one of the co-founders, along with Barbara Konkle, MD, and Roshni Kulkarni, MD, of the Foundation for Women & Girls with Blood Disorders. Since 2010, the Foundation has been an opportunity for us to educate health-care providers about this unique patient population and their needs at every stage of life. We have focused primarily on raising awareness about hematologic issues among obstetrician-gynecologists and about reproductive issues among hematologists.

We were compelled to start the Foundation after noticing the knowledge gaps in the care of women and girls with blood disorders. There are so many patients whose medical needs overlap hematology and obstetrics/gynecology, but our disciplines are siloed in a way that those integrated needs were not being met.

Do you think that has changed since you started your career?

I would like to think that there are more multidisciplinary opportunities, but I have also seen hematology become more subspecialized. At the same time, we have witnessed an explosion in molecular biology, which means there is a huge knowledge base to grasp. To be the best in one’s field, hematologists must become exceptionally knowledgeable about one particular area.

The potential downside is the silo effect. There must be enough crosstalk between the sub-subspecialties to put our expertise into context and determine how that knowledge can be used for the benefit of our patients.

In my practice, I have cultivated close relationships with cardiologists, rheumatologists, and other specialists whose patients require anticoagulation. For hematologists, interdisciplinary communication is a natural inclination: Blood goes everywhere.

Tell us about your family – did anyone share your career in medicine?

My husband and I have three grown children – a son, a daughter, and a stepdaughter. Our son is a criminal attorney in private practice, and my stepdaughter is an accountant here at Duke. Our daughter is an orthopedic surgeon; I like to say that she became the carpenter I never was because she works with screws, drills, saws, and whatnot every day.

She is also the mother of my two grandchildren, so I look forward to FaceTiming with them every week.

My husband is a retired electrical engineer. He worked in research and development in cellular communications, so I was the only one in my medical school class with a cell phone. Of course, they all laughed at me because it was the size of a brick, but I had young children at the time, and the only way anyone could reach me was on this giant phone. I told them, “You just watch – some day you’re all going to own one, and your children are going to own one.” They thought it was impossible. Obviously, I have been vindicated.

What do you enjoy doing in your time outside of work – if you have any?

I am getting better about creating time to do things for myself. I like to read Civil War history.

When I moved to Durham, North Carolina, my passion for this era of American history really took hold. The trigger was a visit to the Bennett Place State Historic Site, the location of the largest troop surrender of the war, when Confederate General Joseph E. Johnston surrendered to Major General William Tecumseh Sherman in April 1865. I became a docent and tour guide for the site and, to be the best tour guide possible, threw myself into learning everything I could about the Civil War.

Surprisingly, my work and personal interests have collided. A couple of years ago, I was asked to speak at the South Carolina Obstetrical and Gynecological Society. When I accepted the offer, they asked me to provide a list of topics I would be able to talk about, so they could choose the best topic for their members. I sent them a list of seven subjects: thrombocytopenia in pregnancy, sickle cell disease in pregnancy, heavy menstrual bleeding in women with underlying bleeding disorders, acute abnormal uterine bleeding that presents to the emergency department, thromboembolism in pregnancy, thrombophilia update for obstetricians and gynecologists, and – just as a joke – the end of the Civil War.

They responded with their selections: “We want the thrombophilia update, heavy menstrual bleeding, and the Civil War.” They assured me that even though I was kidding, they were not. So, on a Sunday morning at a meeting of the South Carolina Obstetrical and Gynecological Society, I talked about the end of the Civil War.

I even draw on my knowledge of this era of American history for some of my coagulation-focused talks. You might not expect it, but the coagulation cascade can look an awful lot like the battle map of Antietam.

If you could have dinner with one person from history, who would it be?

It would have to be Ulysses S. Grant. Right now, I am working my way through the third biography of Grant that I’ve read in as many years.

I would ask him about the keys to perseverance in difficult times. From what I understand, he was a man of few words, so he might not be an ideal dinner companion, but I’ve read enough about him that I think I could keep the conversation going.