MS. CUNNINGHAM: Well good morning. I’m Paige Winfield Cunningham, author of the Health 202 newsletter here at The Washington Post, and I’m delighted to welcome my guest, Dr. Mike Varshavski. He is a primary care physician and a popular YouTube personality with millions of subscribers.

Welcome back to Washington Post Live, Dr. Mike.

DR. VARSHAVSKI: Thank you so much for having me, Paige. That was a very emotional video for me to watch, as I've seen how COVID-19 has impacted primary care and family medicine physicians. It's tough. It's a tough pill to swallow. But I'm proud that we're having this conversation today.

MS. CUNNINGHAM: Well, and I want to go back to the spring for a minute, because I remember talking to primary care doctors at that time and, of course, during the widespread lockdowns many of them had to shut down non-emergency care. Can you tell us a little bit about what that was like for you? And I know a lot of doctors also took a really big financial hit over those couple of months. So, what was your experience like?

DR. VARSHAVSKI: You know, it was a challenging time for us on many fronts. Obviously financially one. That means doctors were losing their jobs. They were losing their ability to pay their rents. But I think the thing that struck us most is we lost the ability to see our patients in person, and that's what makes family medicine and primary care truly a special field, the ability to give someone a handshake, the ability to sit in a room with a patient and feel what they're going through, help them get through those struggles. And when you lose that connection, that doctor-patient relationship, it makes for a very difficult scenario of how to help that individual.

In the beginning, in March time, there was a lot of stress for us in the primary health care space patients were coming in with what looked like to be traditional viral symptoms, but we weren't able yet, at that moment, to identify, was this COVID-19 or something else? So we were there, placing our lives on the line, our staff, our patients, and we were trying to figure out the best way to help our patients, and we had to pivot incredibly quickly in order to maintain the integrity of our practices.

So what ended up happening? There was a major shift in the March-April time frame to telemedicine. We were trying to upgrade our offices, trying to upgrade our clinical workflows so that we were able to continue delivering care in a meaningful way, despite the fact that we weren't able to see our patients sitting in front of us in our offices.

What happened as a result? Well, primary care visits dropped. In fact, there was an article recently in the Journal of the American Medical Association that said despite the huge surge in telemedicine visits we had a drop of 21 percent in overall visits, a drop of 50 percent of blood pressure measurements, and a drop of 30 to 40 percent of cholesterol checks. So, while we're doing our best as family medicine providers to care for our patients, telemedicine cannot replace the one-on-one individual visit with their primary care doctor.

MS. CUNNINGHAM: I wanted to ask you about that. Telemedicine, as you said, it's really increased, but what are the drawbacks to it? And, you know, especially for patients with complex needs, where is telemedicine not sufficient for treating them?

DR. VARSHAVSKI: I think telemedicine has a lot of room for growth, not only from the utility of it, the fact that doctors can make use of it, but also in its technological capabilities. I would love to see more companies put investments in creating devices that patients can have in their homes whereby we can listen to their hearts, we can improve the physical exam that we can do virtually, because right now that's the biggest shortcoming of it.

When a patient comes into my office and I need to evaluate them for chest pain or abdominal pain or ear pain, I can do a proper physical exam, but through telemedicine that's not feasible, so that's its number one shortfall. The second one is nothing will ever suffice or compete with a one-on-one individual visit with a patient in a room. You are able to read their body cues, nonverbal communication. You're able to hug them if you see them struggling, and I think that human connection is lost through telemedicine.

It doesn't mean telemedicine is bad or it's not going to be useful. I think there is a lot of utility for it, especially for complex care where patients might not need to travel two, three hours to get a consultation with a physician. So, while I think it has absolute true drawbacks, I do think there's a huge future for telemedicine within family medicine.

MS. CUNNINGHAM: What's happening in your practice now? When did you see patients start to come back, and to what degree do you think they have fear or hesitation to come back for preventive care, non-essential, non-emergency medicine?

DR. VARSHAVSKI: Within the last month we're starting to see a higher volume of patients, but I still sense that fear, and I hope through our conversation today, Paige, we can ease that fear, because we've made tremendous changes to our practices in order to make them safer for our patients. We've eliminated waiting rooms. We've cut down the times that the patients need to be in our offices.

The way that they even travel through our offices have changed. We've made a one-way workflow where patients enter through one door and continue on to the practice without ever needing to run into another patient. We have delegated where patients go, depending on the type of symptoms they're having, so we're triaging better. We're also doing temperature screens, which is not a foolproof method but it's an added variable in order to keep patients safe.

And finally, something that we all should be doing at home, we're having universal masking in our practices, so that everyone is safe, not only patients but staff as well.

MS. CUNNINGHAM: Well, and you make a good point about the changes at the doctor's office. I know when I've taken my own kids it feels very different when you go, and certainly you can see those preventive measures in place. But even with those measures are you worried at all that primary care physicians are going to have to go back to a little bit of what we saw last spring, with fewer patients coming in, if we continue to see surges, cases increase over the cold winter months?

DR. VARSHAVSKI: My hope is not, because the more patients prolong their care, meaning they delay care, the more chronic it becomes, the more difficult to treat it becomes. Now we're seeing cardiac cath labs playing catch-up, because patients were avoiding coming in for symptoms of chest pain. And I want to urge everyone at home that if you're having a level of anxiety or a symptom is bothering you, do not hesitate to call your primary care office. It doesn't mean that necessarily you'll be forced to come in or encouraged to come in. Perhaps we can have a conversation through telemedicine. Perhaps your complaint works well for that.

For example, I've had plenty of patients who have had skin issues, that we can diagnose or at least triage through a telemedicine visit where I can see what's going on, they can tell me their history, and we can decide what to do, if they need to come in or not.

So, the future of family medicine right now is largely uncertain because we don't know what's about to happen in these flu months. But the one thing that we all can do is take some of the power back away from COVID-19 by doing what the CDC has been recommending from day one--wearing masks, socially distancing, washing our hands frequently, and the final one that's also really important come flu season is getting a flu shot, because with the amount of stress that hospital systems are going to face with patients being diagnosed with COVID, the last thing we need are more patients getting sick, especially with symptoms that look quite similar to COVID-19.

MS. CUNNINGHAM: I know you live in New York City and you practice medicine in New Jersey, so you were really in the epicenter of everything during the spring. Can you describe a little bit of what you saw as a physician there during that time and how it affected you?

DR. VARSHAVSKI: It was a time of health care heroes, and I'm not talking about myself because I largely work in an outpatient practice. A lot of it was switched to telemedicine so I was practicing from a computer just like this, safe at home. But the health care heroes in the Atlantic Health System, the ones that I work with day in and day out--the nurses, the CMAs, the patient care techs, the custodial staff, the engineering staff--those individuals were putting their lives on the line to adapt and pivot during one of the most stressful times that I can remember in my young career.

I've got to give a huge thank-you to those individuals, because there was a lot of uncertainty. The amount of mental health stress that they took on but continued to show up for work was absolutely incredible. In fact, there was a recent survey done by the Primary Care Collaborative Institute where they said 50 percent of respondents were having a level of mental health burnout that they were putting to the side in order to take care of their patients. And while I think that's noble, I also think that it's going to lead to a lot of problems down the line for these health care physicians, because they're not putting their mental health care first. And we need to talk about the mental health struggles that we're facing as physicians. We need to address it, to make sure that we continue to be able to deliver the best care for our patients.

MS. CUNNINGHAM: I want to ask you a little bit about the obesity epidemic, and I feel like it's kind of flown under the radar a little bit during COVID, although we know that it's one of the biggest risk indicators for having serious COVID-19. And, of course, this an epidemic that our country has been struggling with for a really long time, and in many ways, we've failed to fix it.

But do you think that this pandemic is bringing attention to this problem and may help to put us on a pathway toward at least reducing the level of obesity in the U.S.?

DR. VARSHAVSKI: I think it is and it isn't, simultaneously, because it is in that we're seeing those who have comorbidities of being obese, having a BMI that falls into the range of being obese or morbidly obese, having worse outcomes. So, the research supporting the fact that losing weight will be beneficial to our patients is there, and that's the benefit of it.

However, I've also partnered with the Harvard School of Public Health on a COVID-19 symptom tracker app, and what we've seen is, through these surveys of I believe they have over 4 million users, that people are snacking more, they're eating more, they're consuming more calories, likely because they're spending more time at home. They're also experiencing higher stress levels, and we, as humans, tend to stress eat. And also, because we're home, we're walking less. We're taking less steps. So, all of these things in combination--the stress, the amount of food we're eating, the lack of exercise, the gyms being closed--all of these things are contributing to possibly a worsening of the obesity epidemic. And while the evidence there is being given to us day in and day out, that having the comorbidity of being obese is not good for our health, the practical side of this situation is that it's likely to get worse before it gets better.

MS. CUNNINGHAM: I know that you interviewed Dr. Anthony Fauci near the beginning of this pandemic, and the video got close to 6 million views. How do you view your own role in trying to spread reliable medical information during this pandemic?

DR. VARSHAVSKI: I think what we've all seen is a huge rise in misinformation, both online and in traditional media, whether it's coming from individuals, politicians, and even some journalists. And me, as a physician who educates patients in his office, I thought I could take this and do it on a larger scale and educate people on social media.

In fact, I think it's the fear of being labeled "unprofessional" that's led evidence-based physicians to not be on social media, and as a result we've seen misinformation absolutely thrive. It's gone uncontended. So, what I've done is I've created a platform that's relatable, that gives honest, evidence-based information, and over the last three years making this health content we have over 700 million views, we have over 6 million subscribers that want unbiased information. They want to learn more. And I think when you're honest and humble in your approach in delivering this health care message, people really listen.

I think oftentimes we get overconfident in our abilities as physicians, as scientists, and while it's important to show confidence and tell patients we're confident in what we're doing, we need to explain why we're confident or why there is a lack of confidence, in order for them to follow along with our thinking. For example, in the beginning of this pandemic we actually were not recommending universal masking, because we thought it gave patients a false sense of security, because it didn't protect them as much, and two, because we're experiencing a huge shortage in our own practices. So, health care providers were at risk, and if the health care system broke, patients wouldn't be safe either.

That being said, after more research came out and we saw those who were not experiencing symptoms actually spread this virus on a mega scale, we now instituted universal masking recommendations. And unless we explain the nuance of that conversation about why we said no in the beginning and yes now, it's going to be very difficult to maintain the trust of the general public. I think certain institutions have done that well, but I also see missteps, even from major institutions like the WHO, who recently was confusing asymptomatic and presymptomatic cases, thereby really confusing the entire conversation to the general public about whether or not masks are effective.

MS. CUNNINGHAM: Well, and as you noted, people sometimes don't know where to look--you're exactly right--because you want to be able to look to these agencies and trust them. But I know, as a reporter, sometimes it has been really difficult as you're kind of moving through all of this, you're learning different things, you're hearing different messages from people, to really be responsible in how you're communicating this to the public.

What kind of advice would you give to your viewers on how to determine what advice is reliable and what isn't, and kind of what questions to ask themselves as they're looking at this advice from various sources to determine whether it's reliable or not?

DR. VARSHAVSKI: I actually partnered with the United Nations on a project called "Take Care Before You Share," and it's a simple piece of advice that when you see some kind of claim put out there, whether it's a cure for COVID or some kind of piece of information that's contrarian to everything you've heard thus far, just take the pause before you share it, and taking that simple five-second pause will really decrease the spread of that potential misinformation. Because too many times we see something completely extreme in a viewpoint and we become emotional, and in that moment, we share it and it becomes very popular and it goes viral. So, if we're able to transition to that convent of the more rational thinking approach in our minds, just by taking that pause, that's going to go a long way.

Also, you need to have a primary care physician, not only to take care of your health, to keep you healthy, to treat your potential chronic health conditions, but also to answer the questions that you may encounter while online. In fact, there's so much information thrown at us daily I can't expect the average individual to be able to fact-check all of these things. So, trust the CDC, trust the WHO, but have your own personal physician with whom you have a personal relationship with as well.

MS. CUNNINGHAM: And there are so many online disinformation campaigns that we've seen. I'm thinking particularly about the Plandemic conspiracy video that went around about Dr. Fauci a couple of months ago. I know that the tech companies have tried to crack down on some of this stuff. What do you think about that? Is that a good move, or not?

DR. VARSHAVSKI: Yeah. I actually work hand-in-hand with YouTube health team to try to figure out how to combat this level of misinformation, from their side, and they're really passionate about making social media a safe place to share information, to encourage individual doctors, nurses, health professionals, to share accurate information online. And we're constantly working on shifting the algorithms without necessarily censoring free speech but limiting the reach of these organizations that are prone to spreading misinformation, that do not have any evidence behind what they're saying.

You know, it's fine to have a contrarian opinion, but it has to be followed by a level of evidence before it's shared. So, I think these social media platforms absolutely play a role here in the spread of misinformation, but me, as a primary care doctor, I see a role here for myself as well. I did a video, a 38-minute video, fact-checking, point by point, that Plandemic video, and it also has over 2, I think maybe even 3 million views at this point, where we give an honest, non-angry, non-emotional explanation of why certain points are right and why certain points are wrong in that specific documentary.

MS. CUNNINGHAM: And I know you make a lot of YouTube videos about health. Do you have any reason to believe President Trump ever watches them?

DR. VARSHAVSKI: I'm not sure. I've definitely done videos combatting misinformation in media and in politics. In fact, yesterday I had a video discussing how the entire President Trump diagnosis has been really hectic, confusing, and the steps that we can take to make it better. And part of it is not politicizing health information and health science. I think when we start politicizing it, it becomes confusing. The public loses its trust in our institutions. I've seen both the president tweet things on social media negatively about the FDA. I've also seen journalists, and even my colleagues, put out messages negatively about the FDA and the CDC. How can we expect the general public to trust these major institutions that they so desperately need to, when we do have a COVID vaccine come out, when both sides are attacking them? I think we need to make these attacks accurate. We need to make them not personal, not politicized, and really stick to the facts without getting offended, because getting offended, getting emotional is only going to make the conversation more confusing and lead the general public astray to make worse health care decisions.

MS. CUNNINGHAM: You mentioned President Trump being infected with COVID-19, and, of course, that has dominated so much of the conversation over the last couple of days. We had a report recently saying the thought now is that he contracted the virus on September 26th, because, of course, the White House won't say when the president last received a negative test result. If it's true that he first contracted the virus on the 26th, that would put him around day 12 of being infected and potentially out of the woods.

But what's your take on all of that? Are you concerned about kind of the speculation around all of this, and conversely, are you worried about the White House's refusal to share both the information about testing and then also some specific indicators about Trump's health, such as how his lungs are doing and other indicators?

DR. VARSHAVSKI: I'm concerned about two things. First is how the White House has handled COVID-19 messaging. They haven't been clear with their recommendations about supporting the CDC, Dr. Anthony Fauci, recommending masks for everyone. In fact, the first thing that President Trump did when he arrived back at the White House was remove his mask. And I think a lot of these are symbolic gestures that confuse the general public. There are many people who look up to President Trump and I want to reach out to those people, to recommend that they wear masks to protect themselves, their family members, and those around them.

So, I desperately would like to see the White House improve their COVID-19 messaging, to not have President Trump come out and say, "Don't worry. We'll dominate COVID-19. There's nothing to be afraid of," because that's simply an inaccurate message. The truth is we shouldn't be afraid and we shouldn't be taking it lightly. We need to be alert to the facts, to the things that we can be proactive with, and not be anxious, because once we become anxious around COVID-19 that's when we start making bad decisions. In fact, when I started covering COVID-19, one of my mantras was "stay alert, not anxious," and I think it applies now more than ever.

The next thing that really sort of confuses the general public and bothers me in this situation, as a primary care doctor, is the fact that I can't get a piece of accurate information from the White House as to how the president is doing, how fast we can get him back on his feet, whether or not he potentially has gotten other people sick. Like there is a specific timeline we follow at the CDC when it comes to contact tracing, and right now it just seems like it can't be done.

There's also another point, Paige, I'd love to mention here, is having physicians come on these national mainstream media sources and speculate about the president's health. They are not the president's physician. They are not in the room, they do not know the exact diagnoses, the exact doses of specific medications that are being given, and a lot of it is guesswork. And not only is it guesswork, it's also unethical. So, I'd love to see the president's personal physician come out and be more accurate with the timeline, with the medications, with the treatments, where we're going forward, but at the same time I'd like to see less speculation from my fellow physician colleagues, because that leads to more confusion as well.

MS. CUNNINGHAM: Well, and you're absolutely right about the speculation, and indeed from a lot of medical professionals.

This has been a great conversation, but unfortunately, we're out of time so we'll have to leave things there. Dr. Mike Varshavski, thank you so much. It was a fascinating discussion.

DR. VARSHAVSKI: Thank you so much, Paige, as always. Stay happy and healthy.

MS. CUNNINGHAM: We have much more of our program coming up. I'll be back with Dr. Patrice Harris in just a few minutes. Please stay with us.

[Video plays]

MS. LABOTT: Hello. I'm Elise Labott of American University. Today we're talking about physician burnout. Now you're probably thinking, it's COVID. Of course doctors are exhausted. But the problem goes much deeper than that, and it's a serious one. And now United Health Foundation and the Academic of Family Physicians are partnering to find ways to improve physician wellness and ultimately deliver higher patient care.

Joining me to talk about this is Dr. Ken Cohen. He’s the senior medical director at OptumCare, a UnitedHealth Group company, and a practicing internist, and Dr. Catherine Florio Pipas, co-chair of AAFP’s leading physician well-being program and a professor of community and family medicine at Dartmouth’s Geisel School of Medicine.

Catherine, let's start with you. We know that burnout affects doctors across all specialties, but why is this affecting family physicians at such higher rates? I read the data suggests that maybe 54 percent of family physicians reporting some sort of stress and burnout.

DR. PIPAS: Thank you, Elise. Thank you very much for prioritizing this topic of well-being in family physicians, and understanding the factors that contribute to well-being is critical not only to designing solutions but it's also critical to the health of our nation. And what we know, we know that the well-being of family physicians is linked to the well-being of the population. We also know that the burnout in family physicians has an impact, not only on us as individuals but on our health care systems, and as you mentioned, on our patients.

If I'm burned out, I'm at risk for depression and suicide. My health care system has higher costs, reduced productivity, loss of retention and recruitment issues, and my patients will suffer. There's no question. There's poor outcomes associated and decreased satisfaction.

So, there's numerous organizations that are looking at this issue. What are the factors and how do they contribute? And in family medicine, specifically, I'll highlight a few. The National Academy of Medicine just put out a recent significant report on the factors that contribute, one of which is systems issues. And so, as we've heard there are enormous amounts of challenges in our health care system still, and many of the systems do not support primary care physicians. They have a lot of inefficiencies in our flow, even before COVID. We've got workloads that are significantly higher than the workforces that are able to deliver the care, and we still have payment models that don't prioritize prevention, primary care, or even well-being.

In family medicine, and across medicine, we also have a culture that really is stigmatized towards self-care in physicians, and unlike the message that we hear about putting your own mask on first and then assisting others, that's not the case. We still have many who do not believe that taking care of ourselves is the primary way of taking care of others.

So, we have to change both our systems and we have to address our culture in medicine.

MS. LABOTT: Ken, I think Catherine makes an important point that ultimately, if we're not taking care of ourselves that the patient will suffer. And I understand that the shortage of primary care is compounding this problem, the shortage of physicians. I was shocked to read that, like, just about one-fifth of Americans live in areas that have a shortage of primary care providers, and that shortfall is growing. So how do we address this? Is it that they're just joining the field less?

DR. COHEN: You're correct. This is such an important issue. If you examine health care systems around the globe, those that prioritize primary care have better outcomes. UnitedHealth Group is one of the largest employers of physicians in the U.S., and we recognize the critical role that primary care plays in our health care system.

If we're going to recruit high-quality physicians into primary care, we need to solve the barriers that are directing them away. I think there are three major issues that should be addressed. To begin with, as Catherine mentioned, it's estimated that the daily work requirement to manage a primary care patient panel is over 17 hours a day. Next, much of that work is not reimbursed, so primary care physicians earn less. Medical students are leaving school with increasing amounts of debt, and putting all those together, many of them literally can't afford a career in primary care. Add to this the physician culture of valuing workaholics, and we wind up with a poor work-life balance, which just fuels stress and burnout. It's no wonder that primary care is struggling.

In the coming years, the demand for primary care is going to increase significantly as our population ages, and not only do we currently have a primary care shortage, 25 percent of primary care physicians are over age 65. One key solution is to create primary care teams, where family physicians lead a team that includes nurse practitioners and physician assistants, care managers, and behavioral health counselors. Patient care improves in these models, and they have also been shown to significantly reduce burnout across the entire care team, with each member feeling like they're offering a valuable contribution.

In addition to this new team structure, we need new tools that will help with managing complex electronic health records and coordinating care across the health care system so that this doesn't all fall into the lap of primary care physicians.

Specifically, within UnitedHealth Group, which includes both OptumCare and UnitedHealthcare, we are streamlining reporting on quality measures, building point-of-care solutions that give the PCP the latest research in the exam room with the patient, and increasing capacity through the hiring of nurse practitioners and physician assistants. This is all geared to improving the patient experience while, at the same time, making primary care a more attractive career option.

MS. LABOTT: Catherine, let's talk about how COVID has impacted physician well-being. We're all experiencing increased stress, but I can't imagine what it's like to be a doctor during a pandemic, with all that added pressure and demands made on them.

DR. PIPAS: Well, there's no question that COVID has impacted physicians on multiple levels. I mean, first just as individuals. We are experiencing the same number of changes and uncertainties and stresses that every human has experienced. On top of that, as employees, we're working in organizations that have had significant losses, and so the pressures are on. You know, do more, and do more with less.

And thirdly, as providers, it's already challenging to manage patients in this situation, as Dr. Mike earlier mentioned, but now we've got patients who have significantly more stresses that are complicating their health needs, with mental health issues, anxiety, depression all increased.

So, you know, I think one of the challenges in promoting well-being is to say, well, what is going well? And so yeah, there are definitely some disadvantages to COVID but there are also some silver linings. And as we heard earlier, telehealth. It took a pandemic, unfortunately, to bring telehealth to an operational and funded way, but it is. And it will never replace the relationships that we have in family medicine and primary care, but it is serving as a great resource right now.

We also have prioritized this topic of well-being, and not just for physicians but for everyone. And I think that in itself is a silver lining, and if we can step back and all of us say to ourselves that my own health, my well-being, is critical to my effectiveness as, and we can fill in the blank--as a mother, as a spouse, as a teacher, as a clinician, as an educator, as a member of society--then we can begin to buy into the promotion of personal health in order to promote well-being. And we have to do this on a lot of levels. Having this conversation right now is an important piece, educating people is an important piece, continuing our research, and then promoting leaders that have skills in making changes in our systems and changes in our culture, and then ultimately having each of us the skills to apply these evidence-based well-being strategies to promote our own well-being and create more cultures of wellness.

MS. LABOTT: Ken, we're really running out of time here, but just super quickly, I understand that UnitedHealth Foundation and AAFP is starting this new partnership to improve this problem about physician burnout. Just quickly if you could tell us about that program. I know Catherine has been involved in the development of that.

DR. COHEN: Sure. As physician leaders it's our responsibility to lead these efforts, and through this grant partnership, the UnitedHealth Foundation and the American Academy of Family Physicians are committed to achieving world-class physician wellness. With more than half the family physicians experiencing burnout, the goal of the program is to create a movement that changes both the culture and the work experience of primary care.

It is also important to recognize that most primary care physicians now practice in larger health systems, and driving change in these organizations can be difficult. Nonetheless, we need to do this to create a sustainable program that allows the AAFP to build a community of family physician leaders who are committed to clinician well-being. And that's the goal of the grant, to allow the AAFP to support physician leaders as they develop and implement changes within these large organizations.

This grant was initiated prior to the COVID-19 pandemic--

MS. LABOTT: You know, I think it's--

DR. COHEN: The partnership is timely and augments UnitedHealthGroup's commitment. In the end, our hope is that with our support, AAFP will become the leaders of change and the champions of well-being.

MS. LABOTT: You know, I think it's such an important point that we're all exhausted, mentally, physically, spiritually, from the pandemic. Our doctors are no exception, and we have to take better care of them so they can take better care of us.

Dr. Ken Cohen, Dr. Catherine Florio Pipas, thanks so much for joining us. We'll send it back to Paige.

[Video plays]

MS. CUNNINGHAM: Welcome back. If you're just joining us, I'm Paige Winfield Cunningham, a health policy reporter here at The Washington Post, and I'd like to welcome our next guest, Dr. Patrice Harris, who is the immediate past president of the American Medical Association.

Welcome to Washington Post Live. Thank you so much for joining us, Dr. Harris.

DR. HARRIS: Well thank you for having me, Paige. Good to be with you.

MS. CUNNINGHAM: I want to get into talking about primary care providers, but first I want to ask you about something that came out yesterday. The New England Journal of Medicine published an unprecedent editorial condemning the Trump administration for its handling of the pandemic. And we saw a couple of weeks ago Scientific American also endorsed Biden.

Should scientific publications be getting involved in politics in this way?

DR. HARRIS: Well, I have to tell you that am here today, and speaking for the American Medical Association, and what we can do, certainly each publication, each entity, and each institution should have the freedom of speech to endorse whom they like. I will tell you, of course, that the AMA, we are a nonpartisan organization. We are willing to work with whatever partners and whomever we need to work with to move us forward on health care. But undergirding all of that is the absolute critical need to follow the science. All of our interventions, all of our decisions, in a public health crisis or in our day-to-day practices need to be guided by the science and the evidence. I spoke to a national audience about that early on in this pandemic, and the words I said early in the pandemic continue to be true today.

MS. CUNNINGHAM: Talking about primary care providers then, former CDC director Tom Frieden wrote a piece saying primary care in the U.S. is in deep trouble, as providers have had to view the shutdowns during the spring, as we talked about, they have had to cut down on visits, non-emergency visits. What's your advice to both primary care doctors at this time and then also patients who might be concerned about seeking care?

DR. HARRIS: Let me say a couple of overarching thoughts here, Paige, because as I've been thinking, as we've been evolving through this pandemic, I've been thinking about two overarching concepts, and the first is infrastructure. Again, major fault lines have been exposed. We have not had a well-resourced, well-funded public health infrastructure. We have not had a well-resourced, well-funded mental health infrastructure. And we have not a well-resourced, well-funded primary care infrastructure. And so, we really need to focus on that going forward.

But also, there will be great gain as we get through to our "transformed normal"--that's a term that I am using--with making the dense connections between all three of those and really all of the other determinants of health. But clearly, we must have a strong primary care infrastructure, and, of course, appropriately, the public health measures that we had to take early on to mitigate the spread of COVID-19 did disrupt primary care physician offices, and thereby disrupted patient access. And that is why the AMA, along with a lot of other groups, were very strong in our advocacy early on to make sure that physician practices had the resources they need to weather this storm.

And, you know, I don't think that traditionally people think of physician practices as small businesses, in communities, that pay taxes, add to the local tax base, employ other folks. And so, it is very important, and the AMA has been advocating for this all along, that physician practices have the resources they need to weather this storm so that they can be there, of course, as patients' needs continue to increase around issues other than COVID.

MS. CUNNINGHAM: Well, and to your point about primary care physicians being small businesses, I know that, as you know, we do have a shortage of physicians in this country. Are you worried at all that the increased pressures that primary care doctors are feeling, whether that's financial, whether that's health-wise, is actually going to worsen or otherwise affect the shortage of doctors in this country, going forward?

DR. HARRIS: That is a huge worry, and Paige, we were worried about that pre-COVID, because of all the administrative and regulatory burden. At the AMA we've been doing a lot of studies, and one of our studies showed that for every hour a primary care spends with patients they spend two hours in administrative burden, prior authorization, all of the other things that actually detract from good patient care. So that was the state of the state, if you will, pre-COVID, and now we have these additional pressures.

So, we are worried. We know that physicians are retiring earlier. We know that we do not have the residency slots we need to make sure that we are keeping up. From the federal government perspective, I know some states are funding residency slots, but we need to make sure we are keeping up with the need and the demand, as I talked about early on, for that primary care infrastructure. So that is a worry. It's been a worry, and we will continue to need to amplify and highlight that concern.

Now we can use innovation, right, because, you know, there are short-term solutions and longer-term solutions. I was on a panel yesterday, talking about growing our own and starting in K-12, if you will. That's certainly a longer-term solution. Funding for more residency slots I would say is potentially a medium-term solution. But right now, we can use innovation. We are using telehealth. Of course, we have to make sure that the regulatory burdens are lessened. CMS did reduce some of those regulatory burdens. We have to make sure there is pay parity, and, of course, it's not just CMS with Medicare but also our commercial payers and in Medicaid, which as you know and the audience knows is a state and federal partnership.

So, it really is going to take an all-in effort, looking at all of these issues, so that we don't worsen an already primary care physician shortage.

MS. CUNNINGHAM: What are you seeing on the ground as you talk to primary care doctors? Do you see their kind of normal patient, you know, load kind of resume to normal, pre-pandemic levels? Are people coming in at the same rate that they used to, or do they seem concerned? And do you think that there is a worry--is there a worry among primary care physicians that people are maybe unduly concerned about venturing out to the doctor's office and are consequently missing out on really important preventive care?

DR. HARRIS: So certainly, based on the physicians that I've talked to, people are not back up to their pre-pandemic levels, and that's a worry. And I know that the AMA and the AAP and others have partnered to make sure we get the word out that offices are safe. They are safe to come back. Physician offices are doing whatever they can do to maximize safety. I heard earlier your conversation physician offices are having, you know, one way in the door, and I went to my physician and my temperature was checked at the elevator, and again, the seats were spaced.

And so, I do want everyone to know, because this has been a concern for several months, we of course are appropriately focused on COVID, but we cannot forget the other issues. We cannot forget chronic conditions--hypertension, diabetes. For the children, for the pediatric population, we cannot forget that we need to make sure that their immunizations are up to date.

So, no, I hear from my colleagues that we are not back up to our pre-pandemic levels, but we do, of course--and most offices are screening. There are some things that can be managed through telehealth, but there are some issues that require an in-person visit. And I know that people are worried, and I'm not going to say it's undue concern. It's appropriate concern. But what you do when you have appropriate concern is you develop an action plan. And I know that the physician community has developed action plans. Of course, it's based on their particular practice. But we want everyone to know that when you think you need to come in to your doctor's office, please know that physicians' practices around this country are doing all that we can to mitigate the risk of spread of the novel coronavirus.

MS. CUNNINGHAM: Well and we talked about and I know you mentioned conditions, preexisting conditions, one of them, of course, being obesity. And I asked this to Dr. Mike earlier, but I want to ask you too, because I think the issue of obesity has kind of flown under the radar a little bit, even though we know it's really tied to serious cases of COVID-19. Do you think that the pandemic is putting any more attention on this issue and might put us on a pathway to try to solve it?

DR. HARRIS: I actually agree with you. I have not seen a lot of attention paid to obesity as a risk factor, but we need to continue to get out that information. This is science- and evidence-based information. Of course, obesity. Of course, high blood pressure, diabetes, if you are immunocompromised.

But I do want us to really think about obesity, and of course there are conversations that you have in the midst of a crisis and then there are larger conversations that we will have to have as we get on the other side of the crisis. And I really want us to think about obesity, I have to really say all of these issues, in a broader context. Because often, Paige, when we think about these issues and they get lumped into behavior category, and then the next group of thoughts I hear tends to blame people.

And so, I want to talk about choices. I have always talked about choices. But I remind us all that the choices we make are based on the choices that we have, and if we want our patients to make healthy, nutritious choices and to have optimal ways of managing their weight, we need to make sure that those choices are equitably available, those resources and supports are equitably available.

And so, we need to continue absolutely to talk about obesity and all of the factors, but we have to have these conversations in their fullest context.

MS. CUNNINGHAM: You mentioned mental health as well, and particularly the mental health concerns of doctors. And I know you're a psychiatrist by profession. Do you feel like the system is doing enough to address the unique mental health needs of front-line workers during the pandemic, and also just primary care doctors in general?

DR. HARRIS: Well, I know that the system, and many systems, particularly those hospitals who were hit hard early on in the pandemic, many systems did quickly see that this was an area that they had to address. And so, we saw many systems implement what I call routinized wellness rounds. You didn't have to ask for help. There was proactive help available. Certainly, there were opportunities at the end of shifts to debrief. There were opportunities to ask for support and help, 24/7.

So, we are on our journey, right, as we address many of these issues. Again, I think we always have to start with where we were pre-COVID. There are a lot of barriers, and we don't have time to talk about them all today, but there are a lot of disincentives for physicians and other health care professionals to even ask for help, even questions on licensing questionnaires and certification exams.

I was actually, as you stated, a psychiatrist. I'm very happy to hear a lot of folks, on Twitter, yes, but a lot of credible folks on Twitter, physicians, talk about their own journey, their own diagnoses. And so, we really have to look at any policy that is disincentivizing physicians, or again, any other health professional getting the help that they need. And again, stigma is still there. It's there across the board, perhaps even more so in a couple of communities, communities of color, and the physician community.

So, I believe, I am hopeful, but we will have to make sure, we will have to be intentional. We will have to be intentional about a lot of conversations as we get on the other side of this, and mental health care, in general, that infrastructure that I talked about at the beginning of our conversation, and then particularly in the physician community, will need to be at the top of the list.

You just had a great panel on burnout. Again, pre-COVID-19 we were seeing issues of burnout. We were seeing increasing rates of physician suicide, increasing rates of depression and anxiety. And we have to make sure we are having conversation, in their fullest context, and making sure we support those who ask for help.

And almost getting back to the obesity conversation, because not blame the individual. When we first started to hear about physician burnout the conversation was around, physician, if you just eat right, get more sleep, exercise, you know, this burnout thing will go away, and clearly--and you heard from the previous panel--it's about systems, solutions to burnout. We will need systems, solutions to obesity, actually really the health and wellness of everyone in this country, with really a lot of stakeholders involved.

MS. CUNNINGHAM: You were president of the American Medical Association at the outset of this pandemic. How would you characterize the U.S. response, and what do you see as the biggest mistake we made?

DR. HARRIS: Well, I would say when you look at our response in relation to other responses, we were delayed. You know, the first issue that came up, and really one of the earlier issues that the AMA talked about was PPE, that personal protective equipment. And we, early on, called on the administration to quickly invoke--and not just invoke the act but make sure that it was implemented--to make sure that those on the front line had the equipment that they need.

I think people have heard this over and over, so what I'm about to say is not new, but we still don't have the testing strategy that we need. You know, testing strategy includes surveillance and diagnostic, and making sure that testing is equitably available, easily accessible. You know, we have to, in general, invert the burden. Sometimes our systems and our interventions are so difficult to navigate. And I think those of us on the system side--and I will include myself in that--need to always think about how to easily navigate the system.

So, you know, we still don't have the testing strategy that we need. We did not have the contact tracing strategy that we need, and early on we saw that COVID-19 was disproportionately impacting Black and brown communities. Some communities were collecting data; others were not. And that's why, at the beginning of the pandemic, the AMA called on the CDC and HHS to begin to collect the data, but not only collect the data to disseminate the data, but I can tell you that I think everyone realizes that we need more coordinated strategy, and needed a more coordinated strategy in all of this--getting the equipment that we need, our testing strategy, making sure that we could quickly deploy resources to where they were needed, and most of all, making sure we had good data, reliable data, that actually was coordinated and consistent across states.

You know, at times during this pandemic it's been very difficult to compare even regions or even counties within states because we did not have a standardized level of data collection. So, we certainly will do, and must do, an after-action review when we get on the other side of this pandemic, but certainly there are things that we know we can do right now.

MS. CUNNINGHAM: Americans, of course, are looking to President Trump and health officials to inform them about the pandemic. Do you trust what President Trump and the heads of the CDC, HHS, and other health agencies are saying?

DR. HARRIS: Well from the beginning I can tell you the American Medical Association wanted to be a credible source of information. We know there's so much disinformation out there, in both traditional media and social media. So, we wanted to be that credible source of consistent information. And, in fact, as I mentioned earlier, I gave that national address to talk about the need for credible information, to talk about the need to delink, if you will, politics and public health. Because in my experience as a public health director, people in this country can handle the truth. They want us to, as public health officials, as leaders, we should be about telling the truth, saying what we know, and also being candid about what we don't know, and then saying, well, here's what we're going to do to address any gaps in information.

So that's where we have been at the American Medical Association. We continue to call on our elected officials to be transparent, to ensure that there is no political interference in data, in the science and data collection, and we will insist on that transparency as we move forward, when we make recommendations to our patients.

MS. CUNNINGHAM: Well this has been a great conversation and thanks so much for joining us. We are out of time, but I really appreciate you being with us, Dr. Patrice Harris.

DR. HARRIS: Thank you for the opportunity.

MS. CUNNINGHAM: If you would like to watch highlights from today’s program just head over to WashingtonPostLive.com.

Please come back and join us here tomorrow morning at 9:30 a.m. Eastern when my colleague, Bob Costa, will be talking to former presidential candidate, Pete Buttigieg.

I'm Paige Winfield Cunningham, and thanks for watching.

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