https://bit.ly/3vRpoha

Anne Paxton

July 2022—Thanks to more than two years’ experience with SARS-CoV-2, perhaps at no point in U.S. history has the general public been as aware of antigen and PCR testing, and the difference between them, as it is now. SARS-CoV-2 has also raised the profile of emergency departments as critical access points to get patients with infectious diseases diagnosed and in treatment. Yet much remains to be learned about exactly how screening using PCR testing for infectious diseases can improve public health and what role the ED should play in ordering that testing.

Clinical research on nontargeted screening for HIV and HCV in the ED suggests that real-time PCR testing, ordered earlier in the standard screening algorithm for certain patients, can help EDs quickly identify people with those diseases and link them to care.

From May 2016 to February 2022, the ED at Tampa General Hospital, where Jason Wilson, MD, MA, is director of the ED’s clinical decision unit, ran an HIV antigen/antibody test on 99,691 ED patients, of which 1,725 were reactive. That was followed by HIV-1/2 Ab confirmatory testing and, if the first antigen/antibody test was reactive, by an HIV RNA PCR viral load test. He and his team deviate from the currently recommended algorithm by ordering HIV RNA PCR on anyone who is reactive on the first screen, regardless of what the antibody test reveals. “The patient is in front of us, we can get blood if we need it, but also we know 13 percent of our [reactive] patients are equivocal, and of those, one-third are acute positives who have negative or undetectable antibody,” Dr. Wilson explained at a conference this spring on “Advancing HIV, STI, and Viral Hepatitis Testing.”

While the clinical encounter in the ED lasts on average four to six hours, the HIV RNA PCR test has a 72-hour turnaround time, which sometimes means lost opportunity for care. “We’ve really begun to recognize that there’s a difference between screening for HIV or hepatitis C and testing for HIV or hepatitis C,” said Dr. Wilson, associate professor of internal medicine at the University of South Florida Morsani College of Medicine.

In a recent interview and in his presentation at the conference, sponsored by the CDC, Association of Public Health Laboratories, American Sexual Health Association, and American Sexually Transmitted Diseases Association, Dr. Wilson related his hospital’s experience with having the ED play a more effective role in screening for HIV and HCV and getting infected patients into treatment. He and his colleagues have found that an alternative testing strategy, using real-time PCR testing and obtaining results in 91 minutes rather than 72 hours, could mean greater likelihood of success in meeting that goal.

The CDC in 2006 revised its algorithm for HIV screening to a public health model with a multistep approach. “That approach works just fine in the public health clinic or a public event where you’re seeing lots of people and trying to screen as many as possible for a disease state,” Dr. Wilson says. But there is a growing view that emergency departments should be doing public health HIV screening on their patients as well.

The CDC in 2007 funded a small group of 10 emergency departments to implement its algorithm in the ED setting. But as Dr. Wilson was trying to implement the 2006 guidelines in the ED at Tampa General Hospital, there were a few obstacles. “One was that we still had laws in Florida around written consent and pre- and post-test counseling that made it difficult to do this type of work in the ER.”

The main problem was Florida’s opt-in requirement for obtaining consent for HIV testing. When the ED uses a consent form requiring patients to opt in to HIV testing—rather than including HIV testing among the general medical consent tests unless patients opt out—it greatly affects the number of HIV screening tests performed, Dr. Wilson notes. “I would have had to go into the room with a consent form and say to the patient, ‘I would like to test you for HIV. Here are the risks. Here are the benefits. Can you sign this form?’”

“It’s not that we couldn’t do that. But it creates a stigma, potentially, and it’s time-consuming. It carves out HIV as different from testing your white blood cell count or testing your BUN and creatinine.”

In Florida, opt-in was the law until 2015 when the state passed a statute dropping the requirement for separate written consent. After that, “We were able to move to notifying patients of an opt-out test and that’s what we do with the signs that are in every patient room and in other areas that are publicly accessible in the emergency department.”

Moving to opt-out testing was a game changer, Dr. Wilson says. “It allowed us to test for HIV as a nontargeted screening practice. We could start putting that strategy into our routine workflow.”

“We went from doing zero HIV tests in the ER for screening to a handful—five or six a week—to now more than 1,100 HIV tests per month consistently since 2016.” The ED conducts hepatitis C screening during the ED encounter along with HIV screening.

The ED integrated clinical decision support into its screening processes through its Epic EHR. “The way we got to nontargeted high-volume screening is we took the CDC algorithm and built it into the computer. So as that information is gathered during the patient’s encounter and entered into Epic, once the patient meets the screening criteria and has not opted out, a test order will pop up for the provider and say, ‘Please order the test.’”

Over time, the decision support has become more nuanced and more detailed, Dr. Wilson says. “For example, for the patient who has a nonconfirmatory antibody test for HIV, the viral load test order will automatically pop up as well. For a patient we identify as having IV drug use, we will want to order a hepatitis C RNA test because we have a number of patients who may have just acquired HCV and have no HCV antibodies but they do have detectable, quantifiable RNA, so we move right to RNA testing for them.”

Within the first couple of weeks of broad high-volume HIV screening, however, ED clinicians encountered something surprising. “We had had a couple of patient scenarios where the HIV antigen/antibody test was reactive, but then in one of those patients early on there was no HIV virus in the RNA and in the other one there was. So we realized we’re dealing here with clinically equivocal results during the clinical encounter.”

“They can go two ways: Either the person is an acute seroconverter and it’s important we intervene right now, or the person doesn’t have HIV but has a potentially transient p24 reactivity.” Over the past three or four years, Dr. Wilson says, “we thought about that population of people with reactive HIV antigen/antibody tests. Doing 1,100 tests a month, we have 1.73 percent seropositivity and 13.4 percent of those are equivocal.” It is one in every eight patients with a reactive HIV Ag/Ab, he says. “These numbers add up pretty quickly.”

Equivocal results can present a clinical dilemma for emergency medicine providers who see a patient for generally only a few hours. “Some people get admitted but we’re not as worried about the people who are admitted because they’re going to be sticking around,” he says. For those not admitted, “we may have lost an opportunity if we don’t know the true HIV status of that patient during the encounter.” But the other 68 percent of patients—the majority—will be p24 antigen positive for some other reason. If I were to result those patients during the ED encounter, I would likely give them undue grief and worry and my colleagues may not be willing to do the testing.”

He described a recent patient with a reactive HIV antigen/antibody result but a history and lack of risk factors that suggested she was not seropositive. “I would tell her we’re at a coin toss as to whether you have HIV or not; we’ll run the PCR and I’ll get you the result in another two days. But we can easily lose that patient into the transition space as to whether or not she was acutely seroconverted. So it’s a big game changer to know what the specific true diagnosis clinically is for that patient.” For positive patients, Dr. Wilson says, “we have a very good linkage to treatment rate.” But “we worry about these equivocals because we’re not telling them much of anything” before the typical patient encounter is over.

For the past year, on an experimental basis “in the background,” Dr. Wilson’s ED started ordering a GeneXpert real-time RNA PCR test for HIV as soon as a reactive antigen/antibody test result is known. Then the research team measured concordance between the Gene­Xpert qualitative HIV assay (not FDA approved) and the standard-of-care Aptima HIV-1 Quant assay on the Panther; calculated and compared turnaround time on the Gene­Xpert to the standard of care; collected GeneXpert actual run time metrics; reviewed ED length of stay and laboratory TAT data for the standard-of-care test; and calculated differences between Gene­Xpert and the standard of care

2Scientists Podcast recently interviewed me about my work as physician-anthropologist.

That a doctor listens to their patients should not be a surprise, but that they use information from their patients to help improve care, may well be. Enter Dr. Jason Wilson an emergency physician, a graduate trained anthropologist and a man with his finger on the pulse of many projects.

Learn more about Jason on his website: tampaerdoc.com and social media: Instagram, Facebook, Linkedin and twitter using the handle @tampaerdoc

Jason spoke with us about making changes for the better: allowing access for patients speaking languages other than English, dealing with the opioid epidemic, gun-related injuries and (naturally) COVID-19.

We are so grateful to Jason’s friend and musical mentor Sulynn Hago and their band Vengeful Spirits for allowing us to use the track “Forbidden Paradise” . Find out more about Sulynn and their projects here: sulynnhago.com.
This is another episode recorded at one of our favorite haunts, the New World Brewery in Tampa.

https://podcasts.apple.com/us/podcast/the-patient-doctor/id699180797?i=1000564915721

Transcript (also available on the 2Scientists site)

Episode transcript

[Background intro music playing is “Forbidden Paradise” by Vengeful Spirits]

Pamvir: Alright, dear listeners, welcome back to another episode of 2Scientists where inspiring scientists share their work with you wherever you like to listen.

Today’s guest is quite the man about town in Tampa, at least in scientific circles. And I’ll explain what I mean, but first Jason Wilson, how are you?

Jason: I’m doing great. It’s great to be at New World and it’s great to be here.

Pamvir: Oh, thank you. And name drop the venue saves me having to do it. so my flippant comment comes from the fact that, we had you on our list from kind of local news sources and we thought he’d be an interesting person to speak to.

And then we recorded with Edelyn Verona last year. And she said, oh yeah, he is my COVID guru. And now you work with her at the, the Center for Justice Research and Policy. But a couple of weeks ago we recorded another podcast with Dr. Carina Rodriguez and she also mentioned, that you’ve worked on trials with her. Is there anyone in Tampa who doesn’t know who you are?

Jason: Well hopefully there are some people, but, uh, you know, we, I do some pretty interesting interdisciplinary stuff. So you end up meeting lots of smart people like Carina and Edelyn.

Pamvir: Yeah. So speaking of interdisciplinary, can you give us like a brief review of your academics and how you got to the position that you’re currently in.

Jason: Yeah. Sure. So, you know, basically I describe myself, which is funny, to say like I describe myself, like, why would you need to do that? But

Pamvir: [Parmvir laughs]

Jason: When you look at like, it’s like a 10 minute conversation about like titles or something. So, you know, I, I call myself a physician anthropologist essentially.

And so what does that mean? That means I am a medical doctor and I see patients and I do other kind of administrative things around regular medical practice, but I’m also a social scientist and I try to, not only do what I do in medical practice with the social science lens, but also formulate questions to move both fields, anthropology and medicine forward with that same perspective.

Pamvir: Yeah. So that’s, that’s really interesting. I mean there, can’t be too many physicians out there with the kind of background that you have.

Jason: Yeah. You know, it’s interesting, you said that when I, um, really kind of realized that’s what I was, you know, I sorta took a look around to see who else was out there. Right.

It’s just something you’d actually do. I think in identity formation, identity seeking, and everyone let’s see, the podcast is probably familiar with the most famous of the physician anthropologists is probably Paul Farmer who actually just died, totally unexpectedly, uh, last week in Rwanda, which is where he’s currently working and, you know, Paul, Paul Farmer’s an interesting, um, physician anthropologist, because he’s very different than I am in many ways.

And then there’s some similarities and, if it’s okay, I’ll just, I’ll take like one minute and talk through that because I think it, it kind of sets a little bit of, um, an understanding of what I do and why, why it’s different and why it’s the same as other anthropologists. So, Paul Farmer was really known for this approach called structural violence in a sort of, part of the discipline of medical anthropology called critical medical anthropology.

And so what Farmer did was he, was an infectious disease doctor and he approached infectious disease by both a physician patient encounter: seeing patients, treating patients really coming of age in HIV epidemic, treating them, and then TB also tuberculosis also on an individual basis, but then thinking about big systems of power and big systems of power and equity, and about how those systems of power and power and equities really were violence put onto a person every time they interact in that system, every time they engage that system and it was a great approach, it was a brilliant approach, right? Because he changed entire systems of care. He changed how we deliver tuberculosis medicines. He changed how the WHO thinks about TB changed how Russian prisons think about delivery medications. Right? So a very important approach. Why I say that what I do is sometimes similar and sometimes, is because I may not approach things so much from the top down, but as perhaps, maybe more from the inside, this is like, make like inside of bottom up perspective.

Meaning I also see lots of patients in the emergency department have that one-on-one interaction for them. And then try to think about how I’m seeing those patients, where their care might be lacking and how we can then build new systems, new systems, perhaps of change and of medical treatment from that.

Pamvir: So, let’s backtrack a little bit, cause obviously I, I was looking through your CV, which makes for really intense reading actually. But, um, you, so you did an undergraduate in anthropology, you went off and did a master’s and then you’d come back to medicine. So why that particular kind of route?

Jason: So it’s funny, you know, now, now it’s gonna sound like a very linear narrative. And of course at the time you’re just a 24 year old kid trying to figure out what the heck you want to do with your life. Right. But in like the hindsight, retrospectoscope, it all makes sense to me now. Um, and in a lot of ways I almost look at it. Like I went out in the field for a long time and came back in from the cold and like spy terminology, right.

Like, you know, it was, um, essentially medical training becoming a, you know, attending fully, you know, self confident physician or whatever. It was just part of this, like overall arc that I had to go through to get to where I wanted to be. Now. I didn’t know that really at the time when I was 24 and decided to go to medical school, when I’m 24, I decided to go to medical school.

I’m at the University of Michigan. I’m there working on my PhD and I’m getting a little bit frustrated by things that 24 year olds tend to get frustrated by, like, I want to do more. I want to be an advocate. I want to affect change. I want to drive change and I’m in a lab or I’m in an office and I’m writing a grant and how could I do this?

And you know what I started seeing where people coming in to, I was in a human adaptation lab space to be specific. And I started sort of seeing people kind of coming through that space physicians, coming into a space who were like going off to the field to not only think about something intellectually, but also to treat people.

And that combo at that age was like super enticing, right? And so that led me to go to medical school and, uh, you know, become a physician. And it was interesting because I, even then I knew I would return somehow. And I was like, it was for, for a decade almost. So it was like poking around about how do I return to this like academic route that I have that I know is part of how I see the world. And is I know is how I ask questions, how do I come back to it? And, you know, we can talk about this at some point in the story, but, you know, eventually it all kind of comes together and I realized there’s this clear path now unfolded as to how to come on back, you know, to the, to the discipline. And I mean, I could, yeah, I could go through that now that I started, like overdrive the questions, but, um, okay.

So, you know, I go off to the University of Michigan. I’m a PhD student. I finish my master’s. I decide to go to medical school. I go to medical school. I’m sort of poking at anthropology the whole time. Right? Like what, where is the anthropology here? You know, I’d gone to Mexico during medical school and thought about doing some work with, um, uh, training, OB physicians, around life saving management that wasn’t there yet, and some of the barriers in care. Met some anthropologists was like, maybe this is it. Maybe this is the thing, but it was like, it was the Goldilocks thing where it just wasn’t quite the right. It wasn’t my question. Right. And it just didn’t have taking time in the field of medicine, being a medical doctor to see where the actual questions sat.

And then the first thing I got really frustrated with was in medicine, we sort of train people the same way over time.

Pamvir: Yep.

Jason: Okay. And yet we all sit around and we recognize that the outcomes aren’t where we want them to be, and that our physicians don’t have the compassionate patient experience in our lenses we want them to have, but if we’re training people the same way, why would they have anything differently? Yeah. At the same time, this is happening, you know, I’m starting to get to a place where I have lots of students asking to shadow me because they need hours.

Students asking to do quote, unquote research. Right. This is like the common, just word that they’re told to go do. Yeah. And they don’t know anything about what that word means. They’re just, they would like to come do the research. Right. They’re told to do the research. They like do the research. Right. It’s like a bike ride. And so, you know, I’ve got, I’ve got these, like, you know, it’s just like pulling my mind in different directions.

This is like, we’re in like 2012, 2013, you know, down the linear narrative. Um, you know, and I’m like, what do I do with all of this? You know, as life does often, I’d gone back to talk to the anthropology students at USF, the undergrads. I ended up running into Roberta Baer, who is an anthropology, a medical anthropologist, and, Robbie and I have known each other, I’ll date her and I’ll date myself, since I took a class of hers in 1997 as an undergraduate. And stayed, you know, sort of in touch or whatever, and, And, you know, we were like, let’s just go have coffee and figure out there’s something to do here.

She, she had always wanted to change medical education. And I was realizing that medical education wasn’t going to change without some kind of different way to train future physicians. And the other thing I was also. This was, this was biting at me and I didn’t know what it was yet, but I, what I knew was that the way we were developing pathways of care, so when I say pathways, you know, what I’m saying is not just a prescribed treatment, but instead how we unfold medical care around a disease state. And so our most mature pathways are things like heart attack, or coronary artery disease. Uh, cancer has some very mature pathways, obviously as well.

And this is not just one treatment. It’s an entire expectation of what care is going to look like for the patient and the way you deliver that care. So it’s okay. I’ve got a patient with a certain cancer. They’re going to need this chemotherapy, this radiation, they’re going to stay at this place, or they need to do it for this long as it takes this many months, or this many weeks, this many years, we’ve got to do these other things while they’re doing it, their families that can be around them for this time, you have to wear a mask during these times, it’s an entire set of contextual elements.

That’s what I mean by pathway. So people will sometimes say: you make an algorithm. No, I don’t an algorithm is like, yes/no, they have this/they don’t. This is you’ve got the disease, what do we do? And, what I have learned is that physicians, whether they can, um, articulate or not are very dependent on pathways, they will basically move to the place the pathway is constructed. And they’ll move away from the place that pathway is not constructed. And so I have a disease state where there’s a clear pathway or clear opportunity for pathway. Uh, there’ll be attraction to that. There’ll be, um, kind of an ease of putting patients to that.

The ICD-10 codes will actually change, right? You’ll actually see diagnoses of that change because there’s a way to deal with it. What we’re trying to do is train to treat people, right? So you’ll see treatment around it, versus things that don’t have very well worked out pathways. Like a lot of things we see in the emergency departments, right?

A lot of things we see in emergency department are not classic new onset cancers or new onset strokes, or, uh, we, we see a lot of sepsis, but new onset heart attacks. There are other more complicated things, that have a lot to have social determinants of health care, driving an outcome that we’re seeing that day.

What do I do with that? That’s messy. I want a pathway. And so where we came back to was, we’ve got to build out some of these pathways in order to get those patients care. And, decrease some of those clear disparities we’re seeing around places, that had mature pathways and places that didn’t. And if you look at the places of mature pathways, what you kind of realize, this was a lot of structural issues as to why they’re matured and the structural issues in this country are often payer related.

They’re are incentivized lined, they’re related to things like compliance organizations, things like the joint commission or AHCA.

Pamvir: Can you quickly define what AHCA is?

Jason: Yeah. The Agency for Healthcare Administration, that’s kind of a, the police of the hospital, right? They have the ability to find you, shut you down, make you change things right. So people tend to do what AHCA says, right? People tend to do what the joint commission says, another type of organization like that, and we call them compliance organizations essentially. And the idea is they have quality improvement in patient safety in mind, and they’re trying to drive variability across care down by doing the best practice.

So their, their mission is a good one, but it does sound. They drive certain pathway developments. So, you know, a part of my overall underlying question became, how could I get at these pathways at some point? And we thought maybe the first place to do that was through medical education. And this was attractive to my anthropology colleague, in the sense that she had a really, always wanted to affect change early on, as we call it shift the clinical gaze.

And I had wanted to deal with all these people were asking me to do research, like ride a bike or something, you know, or go bowling. Like, “can I do research?” And to also deal with these people, want to do quote unquote shadow me, which is like a thing you’re supposed to do a medicine where they kind of just follow you around and don’t really know what to do. You know that, oh, that’s the bathroom. Sorry about that. Dr. Wilson [Parmvir laughs] let me wait till you’re out of that line. Um, it does happen. And so, you know, I was like, maybe this medical education thing is the entryway into pathway change. Maybe it’s the way to over the long game change the clinical gaze shift it over to a patient experience approach. Prime people to be ready for pathway engagement as physicians and bring that kind of model in.

And so we started teaching the class, the patient position or action class. And I, well, we designed it in 2014, started teaching in 2015. And that class uh, went really well, you know, when we designed that class, we were hoping to get 10 or 12 people to take the class. Not really knowing what we were going to get. I, you know, I’d never really had undergraduates doing actual stuff in the ER, you know, I had to credential them and everything. I was like, eh, you know, we didn’t think there’d be much interest. So I was like, maybe we’ll get 10 or 12. That’s about the right number coming up with all of us, 160 applications, or, you know, people were just emailing state the class.

We didn’t realize their application at the time. It became applications essentially. And so that’s how the class ran for the next five years. And it was a very successful class every year. We would do a research project that gave back to the hospital. So we would find ways to improve patient experiences, designed leaflets for patients in the ER waiting room. That really became the clinical anthropology book of all these little projects, all these projects the students did.

And then, you know, I think what that led to though was: great medical education’s important, but medical education doesn’t really change a neoliberal capitalist system of healthcare. Right?

Pamvir: No shit!

Jason: Right, guess what [Jason laughs]

Then it was like, wait a minute. Okay. Education, this is good, we’re priming people. I like that. We’re changing the gaze. Were still following those students, by the way, were following longitudinally now for a year or some of them into their attending life and asking, does this decrease your rate of burnout? Do you still have a patient center lens and are you more likely to engage in pathway creation or some kind of, open approach to medical care.

But ultimately it became a realization. Yes, education is one of the legs of the table, but we also have to get at, incentivize reimbursement, uh, compliance, and, and those pieces. And so that, that I would say is really what changed my thinking as the class went on, is that we had to start bringing in, I don’t want to say more serious students. These are obviously all good students, but professional anthropology students, essentially people who wanted to be anthropologists and drive change that way. And what I kind of think about is like, my work now started with that model, which is really engaging clinical anthropologists or engaging medical anthropologists, to a clinical space directly, not to be agents of critique, but to be actual agents of change with a very partnered approach to that change.

So we brought in Seiichi Villalona as our first student. And, um, he came in and as a graduate student, a master student, he’s now in medical school, he actually went to medical school and has just matched so congrats to Seiichi, he’ll be a pediatrician. But, uh, Seiichi came in and looked at low English proficiency. And that’s, you know, this, this concept that a lot of people, especially in Tampa, you know, in most big cities’ emergency department, English is not their first language, but we’re going to have a very important conversation now in a language, potentially not your first language, that’s, uh, you know, important, vulnerability to get at.

And so if I go back to 2016, the way we had those conversations was often on a blue, old fashioned phone with two handsets that you would try to get to work. A lot of patients we see in our emergency apartment are not in a room by themselves, or is there even a phone jack to have this conversation. Well, what Seiichi did was he tested this idea that video conferencing actually would work.

And, you know, we talked about this beforehand, that like, yeah, what we’re doing right now is better than zoom, but zoom is still better than a telephone, right? At least I can see you and your reactions that if I’m giving you important information or sensitive information, it’s nice to see some eyeballs. And, you know, so the question was really, that Seiichi asked was, is video better? And is it better than a non-trained medical interpreter? You know, the, uh, whoever the nurse, the cleaning person, anybody we could get a family member. And what we found out was clearly patient experience, patient satisfaction was higher when people had a video professional interpreter. Now I point that out because patient satisfaction is really important because it gets to that other table lag I talked about, which is incentivize alignments.

Patient experience, and patient satisfaction are part of really how hospitals get paid now. And it would actually help providers get paid too. So what we hit on was a way that we can improve patient satisfaction by doing a thing, video interpretation, and that led to hardwiring that approach.

Meaning now it’s on my phone. I can put it on my phone, put a video interpreter, on my phone, walk up to a patient, a hallway bed, put a video of whatever language they speak. Really it’s basically every language you could imagine is on [interpreter service]. And I could put that language on the phone and have at least somewhat of a conversation where they can look at a human being, which I think does add something to that, that encounter.

So, you know, from the loneliest proficiency work, what we realized was we might build a build out pathways, meaning actual integrated change into operation clinically, that align with some of these other pieces of healthcare. So we can hardwire change over time. And Seiichi’s work was really the first example of that.

Pamvir: Yeah,

It’s very, very cool work. But the first thing that comes to my mind is I come from a country with a centralized national health service. Right. So if you do research into a particular thing, there seems to be a reasonable way that you could implement this across the country. How the hell do you do that in the U.S?

Jason: [Laughs] Yeah.

You know, and I, I figured out a while ago I could go in two different ways. I could, you know, spend a lot of time, really trying to advocate for the obvious changes that we need and overall how the healthcare is spent down. But I felt that my role as a practicing physician put me in a different space because I work within a system where I really understand the alignments and all the incident pieces.

I, I get those, I practice in them and I get those because I act as an administrator in them.

Pamvir: Yep.

Jason: And, you know, my thought early was okay. I could have a noble cause of probably banging my head against the wall and hoping for gigantic system change. Or I could leverage a lot of these things, I really understand pretty well, that drive physician behavior and hospital behavior and try to enact change at that level by really advocating for patients and driving from the bottom up.

And that’s, really what I’ve chosen to do over these last six or seven years. Now that doesn’t mean that sometimes it doesn’t mean having to reapproach things from the top down, right? Certainly it does. But for the most part, most of our pathways that we assemble, they tend to happen from the culture that generated between a patient and a physician. Having the interaction that over time, every single time encounter, generates ideas that we latch onto to create new pathways for change.

Pamvir: That’s very cool. But presumably this is the kind of stuff that also gets published and other people will read at some point?

Jason: Yeah. You know, so I think that’s obviously the goal and with this kind of stuff, if you want to scale this up, we want to hardwire these types of changes.

And I think our most mature work right now is probably our work around opioid use disorder. You know, our work on opioid use disorder came to us very organically. I had started an HIV, hepatitis C screening program in 2016. Uh, Hillsborough county, this county is still a hot spot for HIV. And I had been interested in getting HIV screening, and our emergency department started since, uh, the CDC changed recommendations when I was a medical student in 2006, which said that everyone should do non-targeted screening, meaning screening people who come into the ER and it took me until about 2015 or 16 to actually enact that change.

Pamvir: Oh wow.

Jason: It took a long time. And the funding I got to knock that change actually came with hepatitis C screening.

Pamvir: Right.

Jason: Now, I’ll tell you at the time I didn’t care at all about hepatitis C screening. I was not interested. The ironic part within about a year and a half of my program, my viewpoint had totally shifted. HIV screening and HIV treatment has a very mature pathway.

So I go back to that because we have Ryan White funding, federal funding, there’s an easy button that physicians can hit, got an HIV positive. Okay. They get linked to DOH or to one of our partner organizations. They’re gonna get anti retroviral therapy. They’ll start within a week. It works out great. Everybody gets, you know, good care.

Hepatitis C though. The reason why that got funded was because at the time new drugs were coming around with hepatitis C. Those drugs were made for Medicare patients, patients over the age of 60. That’s who people thought of as hepatitis C patients, but guess what? The world is a crazy place. And that ain’t what happened.

What actually happened was as soon as those drugs came out, an opioid epidemic started. And the opiod epidemic drove an entirely new hepatitis C epidemic. And that hepatitis C epidemic is all in what we call non age cohort or people who are young. Young people in their twenties or early thirties.

Well, now I started recognizing that in front of me, 2016, every hepatitis C positive person’s, um, are baby boomers, right. That’s the word? So a baby boomer. By 2017, wait a minute. These are all 20 year olds now with new hepatitis C. Why do they have hepatitis C? Oh, because they use opioids. People inject opioids.

And basically by definition, at this point, if you have hepatitis C new transmission in this country, it’s from, you know, opioid injection drug use. And so now things got really interesting because I was like, well, we’ve got a pathway for HIV. That’s established. It’s cool. I’m glad we have it. We’re doing great things for patients. Half the people who have HIV don’t know they have HIV. So we’re helping with that. That’s important. It’s a great, great stuff.

But these hepatitis C patients, we were really struggling to link them to care. There was no pathway for them and they didn’t care because they were using opioids. And so that we had other things, going on in their lives where they were not caring about their hepatitis C. Right. So a very complex from social determinants here. So we had a linkage rate for HIV of over 90%. We had a linkage rate of hepatitis C of less than 30%.

Pamvir: Oh wow.

Jason: It was horrible. And then the people who actually got linked for hepatitis C, the ones where people would actually put them on medication for hepatitis C treatment was less than 3%.

Pamvir: Oh, really?

Jason: Abysmal. So what were we doing with these patients? Right. We were doing, we were neglecting them. There, we’re creating a disparity in front of us. We were making a disparity. So we realized we had to change that. So I brought in a graduate student, Heather Henderson, who just defended her PhD one week ago, congrats to Heather.

Um, and Heather came in and she first spent her master’s degree in the ER, thinking about why do patients use opioids and what is going on here? And why don’t we have better systems of care around opioid use disorder? And it was interesting because she came in and she thought of it as sort of a stigma model classical we call it a critical medical anthropology model. And you know what she learned her ethnographic field work and her master’s degree was actually, this is more complicated. There’s a sense of learned helplessness amongst the patients. Okay. But there’s also sense of learned helplessness amongst these providers.

It’s likely to shut down when you talk about opioids. You talk about heart attacks, they’ll get right up and do everything they can. And they’ll, they’ll come up with a really good treatment strategy. But you talk about opioids, it’s like, they’re like third graders again, like they can’t, like, process it.

Yeah. So there’s, there’s this like learned helplessness. They don’t really get addiction that can, can be treated. And they don’t really understand this is a process, just like any other process. And so that led to her PhD work, which is where we co-developed this pathway around treating people with opioid use disorder in the emergency department with a, it’s a medication called buprenorphine, which stabilizes in an evidence-based way, people with opioid use disorder. And that led to really the first in the state ED based opioid use disorder stabilization program using buprenorphine. And what was amazing about that is we saw providers’ perspectives on opioid use disorder change almost overnight.

Once I gave them tools. Here’s how we prescribe buprenorphine. Here’s a peer: a peer is a person in recovery themselves. We’re going to employ them in the ER, they’re going to engage patients. They’re going to do a lot of the legwork for you. A lot of these conversations they’re going to have, they’re going to come to you when a patient’s appropriate for this medication.

You’re going to put them on medication. They’re going to follow up at this site. Now we’re starting to build a pathway. And now all of a sudden people find joy and value in treating opioid use disorder where they didn’t see that joy or value before because they saw conflict in patient interaction before that’s all they saw was room six is conflict, room seven, broken bone, I got that one. I’m going to room seven, right?

Now all of a sudden room six is like, oh, I might be able to save that patient’s life by giving the opioid use disorder treatment buprenorphine. But you know what else is really interesting. I might be able to get them to get linked to care for their hepatitis C. I’ll come back to that in a second, cause it kind of moves us off topic for a second, but hepatitis C and co-treatment with opioid disorders is a whole interesting topic of its own. So from there, Heather’s work really built out this pathway about opioid use disorder, which has now grown to really a coordinated system of care with a second syringe exchange program in the state of Florida is here in Hillsborough county operated by us.

And it also the, um, obviously the medical assistant therapy program, which is still going on.

Pamvir: Yeah. So, I mean, you kind of inadvertently answered one of the questions that occurred to me while you were talking, because to me as a cynic, I wondered if, you know, part of the, the reticence of people was just because, “uh, they’re taking opioids, they’re junkies, like, I don’t even want to have to deal with this”.

Like, do you think there’s potentially that bias as well? And by you giving them an option to say, well, actually you can treat someone. It changed their viewpoint.

Jason: Yeah. So here’s where I’m at with that now. As physicians, we are so treatment oriented that if we start from a treatment lens and work backwards, our interest in the patient population goes up.

And so if you really dig down for a second on any disease, state disparity in this country, it’s often because of social determinants of health or racism. Those are kind of your two major drivers of disparities in this country. And so let’s talk about coronary artery disease for a second, cause everybody can relate to that one. It’s obviously a major epidemic this country.

But yeah, there, there is a subset of patients who just have, they got a bad gene lottery, right? They got APOE 4 gene, their cholesterol is going to be high and they’re going to have cholesterol related plaque. Fine. Okay. The vast majority of coronary disease in the country is not from right genetic lottery. It’s from things that we put into for a lot of reasons, structural and otherwise, right. Things that happened to us over our life trajectory. Yeah. Um, so if you really dig down to it, it’s really not that different than the opioid patient. Where the patient has the heart attack is really not that different from the patients injecting drugs. There’s a lot of things that happened structurally, culturally and personally, a lot of trauma, a lot of structural stuff that led to those decisions. Let me put this way, I realize we can get to that understanding if we start with a treatment.

Pamvir: Yeah.

Jason: But if I tell you to deal with that patient, you got nothing, right. I send you the gunfight, you got no gun. And I don’t wanna send anybody to go to fights or have any guns. I’ve just used that analogy. Um, but then what are you going to do? You’re going to be upset, right? I always call it net negative.

This is my patient experience terminology I use. Um, if I send you to room six and there’s a patient that you know, that you have no training for, and that you have no tools for, but you see in high volume, your interaction with that patient’s already at net negative, Your patient satisfaction scores already below zero, right?

You’re already pissed going into that room. Now, the sickle cell disease patient, who you don’t understand how to use opioid therapy for, or the patient with a non-fatal gunshot wound or the patient with opioid use disorder. You walk in that room upset about the whole situation and you can call it whatever you want. You can, you can express that. I think we do. And we express things we don’t understand how to deal with by terms like junkie, right? Drug addict. A drug seeker, pain seeker, right? All these terms. They arise out of the fact that I’ve see 30 patients a day in a busy shift and it’s really stressful. And I gotta, you know, do a lot of things that cause trauma to me, and trauma to patients.

And so when I have that interaction, how can I dismiss it in a way that I can box it up and leave it alone? Yeah. But what you find is when you start to develop pathways for these things, when you assemble new pathways that people couldn’t imagine before, oh, all of a sudden this isn’t so bad to treat and wow we really helped that person.

Pamvir: Yeah. That’s super interesting. And it’s really kind of flips the idea on its head of how you should be handling particular cases.

Jason: Well, that’s it. I think flipping the idea on its head is the key part. So the way I think about it is, I was trained to read, you read the textbook, you read the, you know, whatever the professor tells you to read, to train, right. To get ready for what you’re suppose to take care of in the ER. And that’s what you go in expecting. When I took my boards, right, there was a core competency, a set of like, you know, 200, whatever key, critical things I have to know in and out. And that’s what I go in thinking my model of an emergency medicine physician is right, is the core curriculum things I was trained to do.

But the reality is those aren’t necessarily the things either (A) I just know how to do those so well, I don’t even think about them cognitively. They don’t give me stress, but (B) the majority of interactions I have are not in the textbook. Yeah. So if we flip it on our head, maybe we should let patients, right, this is the ultimate patients in our place to get to the macro patient place to get to is why don’t we let patients define what emergency medicine doctors do, because it’s patients who are coming to see us. So why don’t we just respond to what this structural system has given us, which is we’re the ones who are there 24 hours a day. And they’re the ones who are coming in with the thing. And what they come in with is opioid use disorder, alcoholism, uh, effects of tobacco over time, effects of poverty, effects of racism, effects of nutrition insecurity. That’s what we see. And so let’s get better at treating those things.

Pamvir: Yeah, I have to say, so I tweeted flippantly earlier that my only knowledge of emergency medicine comes from the TV show, ER, which to probably gen Z, it doesn’t mean an awful lot.

Jason: I’m a Kovac guy.

Pamvir: [Laughs] You are?

 So this is, this is definitely not what happens in the show. You know, this is, this is a completely different experience for me in a completely different interpretation of what emergency medicine actually means.

So David has another question for you. He says you were doing a PhD in anthropology. How much does your medical work feed into that and how much does it not? Um, if so, where do you find the time?

Jason: Yeah. So it goes back to the thing of, um, if there’s an obvious clinical question, if there’s an obvious question that it all hits on all cylinders and it makes sense to do it, right? So there’s a lot of medical anthropologists, don’t have a PhD. There’s no reason to have to do this, but what happened was there was a clear place where I felt like I could make a theoretical contribution and a clinical contribution that kind of arose to me. And I was like, you know what? It probably makes sense to finish this out with, with that.

And plus, I mean, part of my career now is I really enjoy mentoring students. And I really enjoyed having a PhD student, which is obviously got some awkwardness and ironic ness to, you know, I’m now starting a PhD and I had a PhD student, but whatever, you know, this is, this is such as life and I’m comfortable with awkward weirdness.

Pamvir: [Laughs]

Jason: But, yeah, so the, the PhD, um, so I started thinking a lot about what it is we’re doing with pathways. And you know, what we’re doing with pathways is, really a place that I don’t think has been done before clinically or anthropologically. So anthropologically there’s this concept that’s been introduced pretty widely now public health knows about it, and epidemiology knows about it as this concept of syndemics. And this concept of syndemics basically says you’ve got two disease states that go together because of a social reason, right? Some, some social determinate reason. Um, the classic one is SAVA, uh, Substance Abuse, Violence and AIDS. That was the classic you know, first description of it.

So there was that on the table and I’ll put this all together. A second. There was that on the table and there was also this concept in anthropology around assemblages and how, how assemblages are forming and how sort of things both are together already, but also get put together because of different structural forces.

Um, so I started thinking, wow, I think I could maybe think about some of the work we’re doing around pathways in that framework and maybe move that theory a little bit forward. And I think I could also, do this clinically in a way that would, drive some really positive change for patients. And so what I really started thinking about what we were doing, if we take a patient that’s got opioid use disorder. And they’ve also got hepatitis C let’s return to my original problem. Right. It’s always great when things are problem-based, cause it just, you you’ve got a real motivation. Right? My funding was based on linking hepatitis C patients. I was not doing a good job linking hepatitis C patients right. See the problem.

So it was like, wait a minute. So if I, if I take these patients with hepatitis C and I treat their opioid use disorder, I get my hepatitis C linkage rates up to 70%, remember I said they were down below 30%. And that’s great. I wonder if I could also treat those patients with direct acting antivirals, which are a medication that came out to treat hepatitis C in around 2015 or so, just like we do with HIV, but people weren’t doing.

If I treat a person who is actively injecting with hepatitis C medicines, I can decrease transmission of hepatitis C and cure them for their hepatitis C. Well, they’re not very interested in going to a infectious disease doctor or a hepatologist, right? They’re 24 year old kids who are using IV drugs. So that’s not on their radar.

Pamvir: Yeah.

Jason: Now they might be interested though. Getting those medicines. If they’re also getting opioid use disorder medications to help with their, if we just order medicine. And as a matter of fact, let’s push it further. If I’ve got a place I trust. Yeah. That’s, they’re nice to me. They’re giving me buprenorphine, which the medicine for treating this and they also happen to say, Hey, would you like some medicine for your hepatitis C too?

I might be willing to take that because I trust this place. I’m already engaged in clinical care. I already got to come get my other medicine. Anyway, maybe now I take this, I retain care. And I cure my hepatitis C. So I started thinking was, wait, this co-located care thing. I think this is like a new way to think about syndemics if you really look at syndemics the way it has sort of in, I don’t know if stuck is the right word, but, um, utilized is a descriptive epidemiology, uh, concept, meaning it basically shows how things are connected.

That’s super important that drives hypotheses. That, that, that is definitely. But could we do more of the concepts? And you know, what I really thought about is our new assemblages of care, allow us to really take this endemic model and expand it to a co-located care space. In other words, we expand syndemics from description to treatment and that’s really what the PhD is all about is that idea of expanding syndemics or description to treatment.

Pamvir: So you just answered his next question, which was: and why would a doctor need a PhD?

Jason: Really, it’s become really part of my, my personal career is, uh, having students and, and trying to help them think about these ways to drive change specifically, you know, with the anthropology students, my, my goal and role over all this big, the big picture concept is when I was in the ER, you know, five years ago, we had zero anthropologists working in the ER directly. We have four anthropologists working in the ER now, right. Working in the ER, developing pathways, seeing patients. So, you know, now this is sort of, a runaway train around this new concept of, um, or revitalized concept of clinical anthropology.

Clinical anthropology is not a new concept. The way we’re doing it’s different. Um, clinical anthropology died as sort of a sad death in the early eighties. What happened was, people who called themselves clinical anthropologists in the like late seventies, early eighties, what they were really doing was trying to find ways to get patients, to do what the doctor said.

And that’s not what we’re looking to do. Right. This is very, I think what I’ve described so far on this podcast is not clearly not that right. I’m responding to patient’s needs and trying to come up with a pathway for them. Right. So very different. And so I think, critical medical anthropology appropriately critiqued clinical anthropology of the mid eighties, early eighties. And so it sort of went away. And then what you saw as really the rise of these critical medical anthropology approaches, which were about really power system, uh, critiques, which are all warranted, all fair, but it kind of left a gap of, well, what do we do with the patients though, remember them?

They’re still coming. Look, I want to change the world too please do, but today I gotta see 30 patients. So going back to Seiichi’s work for example, um, patient satisfaction scores for providers get pretty stuck in the mind.

You know, it’s really hard, it’s not impossible, but it’s really hard to move them. And we’re talking, you know, people tend to like their doctors a little bit, at least.

Pamvir: [Laughs]

Jason: So talking about moving the scores, we’re talking about moving from good to like excellent, right? Like not being on the Olympic team to be on the Olympic team.

Pamvir: [Laughs]

Jason: That’s the kind of like numbers we’re talking. So it’s going to take like some different ways, right? It’s going to take a whole different lens directly in that to get pathways to change. When my incentive is to, and my thought my training, my education is to go deal with heart attacks, it’s going to take a whole nother lens to try to show how do we build new systems of care in completely different ways than we had done before.

And that’s what most of my anthropologists I’ve got work in the ER, doing they’re building new systems of care in just totally different ways that we would have before. They’re critiquing the system, but I always joke they’re doing it, not just at the physicians, but with the physicians now instead. And that to me is the big, big difference right they’re, engaging our healthcare staff, even administrative staff, to jointly critique and drive for change in a way that doesn’t bankrupt the hospital doesn’t you know, keep us from seeing patients and, uh, can help us on a daily basis and the big picture.

Pamvir: Yeah, I think that’s the ideal for interdisciplinary work, right?

Jason: I hope so. Um, you know, it seems to resonate. You mentioned in the podcast, how many people I’ve kind of worked with, so it seems to resonate and even so even being involved in the Center for Justice Research and Policy has been interesting because a lot of that work that I do is really around the legal aspects of setting up an opioid use disorder pathway. Right?

I mean, I started a needle exchange in Tampa. Look, I would not, if you told me 10 years ago, I was gonna start a needle exchange, I would not have believed you. I mean, I’d be like, oh, I’ll get arrested.

Pamvir: [Laughs]

Jason: Right. I mean, this isn’t going to happen. And, we did, right. We’re, you know, some other things we’d like to do you know, fentanyl strips are still illegal to give out to patients, which is killing people by the way, just it didn’t pass in the state house and Senate, this last legislative session. And that will kill people this year. I just wanna make that clear to people as if that that’s the ability to have a patient test their own, or a person tests their own drugs and make sure there’s no fentanyl in there. And we can’t distribute those, but these are the legal issues we face. And that’s a lot of the work I do at the CJRP and with Dr. Verona and Dr. Fox, and, uh, you know, that and the gunshot wounds stuff as well. We’re doing a lot of qualitative work around interviewing people who’ve not been shot. Our thought was, um, look, we’ve got a front seat to parry violence essentially.

And what public health has done is very important in terms of telling us about populations and like making it clear to people who are reading that there’s a problem with guns in this country. And that a lot of people die from guns and, you know, 40 to 50,000 people die a year of guns. We’ve got two different problems. You have a suicide problem and a violence problem. And, that’s important to point out, but what we don’t know yet is what do you do about it? Right. And we feel like our ethnographically informed work with patients is going to lead us to some really informed interventions that maybe have not been there previously, or have not worked previously because they weren’t informed by the patients who’ve experienced that violence.

So it’s that same model we used in opioid use disorder, we built a pathway based on what patients were telling us. We’re trying to build the same pathway out now, based on what people who’ve been injured by gunshot wound violence either now or in the past, uh, what they would, how they think change might be effective, what they would tell us.

Pamvir: Yeah. That, that seems like an important audience to be taking into account here.

Jason: Yeah. I would argue that there are some examples of that audience sometimes being involved in, operation of a system that’s been designed. But I would say that their involvement in creating the system that you want to test has been not as good.

Pamvir: Yeah.

So, unfortunately it feels like with most of the podcasts we record these days, all roads lead back to COVID. Right.

Jason: [Laughs]

Pamvir: Um, and so you have been kind of, particularly within the Tampa bay area a voice for, you know, what the response has been to COVID like what, what the requirements are, what we need to do.

So there are a couple of things that I was thinking. And the first is what was your experience like as an emergency room doctor dealing with people coming in? Um, what did it look like? Because I, I can’t imagine, like for the majority of us, and this is one of the things that I think people brought up is that, if we all felt this on a very tangible level, maybe the response would have been very, very different.

Like if we’d seen the patients coming in, like how would we have responded? David and I have been pretty isolated throughout this experience. We’re still wearing masks and stuff. So, what was it like for you essentially on the front lines of this thing?

Jason: Yeah. And it’s been exactly two years now, you know, that we really hit got hit with COVID and it’s a life of its own. It’s a changing story, right? I mean, I remember, uh, March 13th, 2020, was our first COVID positive patient. And we had decided to do testing at Tampa general, which was a very controversial and inside controversial decision, by the way, because we didn’t want to be the testing place at the time, but it actually, it ended up being a super important decision, which we in retrospect is obvious now, because we could understand the epidemiology in ways that were not politicized. Right. We could have control of the data. And there’s so many people at our hospital that we had a pretty good handle of what the data in this whole area looked like, regardless of what other sources might be telling us. We knew where we were on the curves. Right.

But anyway, it’s been exactly two years since our first patient. And I remember that first patient, the test came back positive at about two o’clock in the morning I was home and I got a little ding on my phone that the first test’d came back positive and I flipped out. I was like, oh my gosh, it was a positive test. The patient’s gone home. There’s a positive in Tampa. I recall I called the Director of the Department of Health. And, you know, I was like, Hey, there’s a positive test. And they sent like, you know, uh, epidemiologically, intelligence service people to the house and like, you know, quarantined the patient.

And we were in full containment mode right. To where we ended up. Right. Which is like, okay, so a positive COVID test. Right. It’s amazing to watch that, like, just like watching that transition happen and, you know, watching like, remember in May, 2020, like where we were all like in our houses, like even people who became kind of, um, not as reasonably complacent to public health models, those people are in their houses too in May 2020, the whole world kind of shut down. And our case numbers were incredibly low in May, 2020. And then you look at that summer of, uh, you know, that summer where they kind of went up and then, you know, you think that’s gonna be the worst it is, and you get Delta. And Delta’s really, I think, where it was really bad for us, you know, Delta, we were already tired, right. Cause we had been at a year and it was the worst of it. Right. The sickest people, there are vaccines available, right? So we were, I always joke, you know, I’m a white guy, probably for people who are listening just so they know what they’re listening to.

Usually the way the world works, if I walk into a patient room in the south and they’re over the age of 60 and I say, get up and jump up and down four times, they’ll say yes, then get up and jump up and down four times, that’s just the way this world is right down in the south of the United States. This was the first time where even I, as a white guy could walk in the room and there was clear vitriol, clear like this guy, oh, this guy, what is he going to tell you night?

And you know, so much so that I’d have patients, I remember who were in our COVID unit sitting next to each other and adamantly against the vaccine, but were up like advocating for the monoclonal antibodies to each other. Like, Oh you got to get those. And me thinking as a physician, you know, the risk calculation here.

I’m not saying, don’t get, please go get monoclonals if you have mild to moderate COVID, but I mean, still you, you would think the, the safety data for vaccines compared to monoclonal antibody, synthetic monoclonal antibodies is like I4 driving versus like airplane, you know, commercial airplane flight.

Pamvir: [Laughs]

Jason: So it’s just like, we’ve had no bad reactions please go get monoclonal antibodies, but I’m just the, the level of understanding around that risk was incredible. So then you have sick people plus that going on. And, you know, I don’t, I still don’t know if people understand I mean, we had a third of the hospital was people with COVID know, at one point, a third of a big level one trauma center, urban hospital.

 That’s a lot, that’s a big number.

Pamvir: Yes.

Jason: You know, and so it’s all these little things you don’t even think about. Right? Putting people on oxygen and you know, having to worry about the oxygen supply lines. Do you have enough compression.

We never had to do this, but we had early conversations about, well, who would we put on oxygen? Who would we put on ECMO? ECMO is a way to perfuse people without a tube in their mouth. We never had to do that here, but the fact that we even had these conversations, the fact, I’ll say what really hit me, and I remember texting my family about it. We have, a disaster space built under our ER it’s for a mass casualty situation. So it has, you know, air zones, you know, different places for people to assemble. It’s got showers that come down in case of chemical attacks, all those things, right? It’s a very well-designed disaster space.

I’ve drilled in that space every year, over the last 15 years of my life, or so I’ve never used it in real life. And April of 2020, we opened it, not pretend opened it, not a drill opened it. It was the most surreal experience of the COVID thing for me, because it made it like seeing, I mean, it must be what Ukrainians are like, thinking where like they’re like, I live in a modern city and there’s someone bombing my house.

Like, it’s just like, I can’t believe this is actually like happening. You know, we’re actually going to use this space. And, and the next day I remember walking out. And opening the door. There’s a door that kind of goes down to it. I remember opening the door looking outside and there were just people lined up, you know, as far as you could see, and they were like that from 8:00 AM until 3:00 AM just, you know, lines and lines of people. We had a 30% positivity rate that day. I remember.

 And now it’s, you know, it’s two, our two years then it’s basically just become really a part of my clinical life, which I could not have even imagined beforehand because these are like the scenario to train for. But what we’re really in now is a two year mass casualty situation because it’s hit everything, right. It’s hit our staff, it’s hit our workforce. Right? All the reasons why workforces are affected by these things have unraveled themselves, right? These other pandemics of poverty and unemployment and, and everything else. Those have all unraveled too. And so now we have all those issues that have come to bear and they sit here still with us two years later.

Pamvir: Yeah. And I hope people are going to recognize the fact that the reason I couldn’t see my primary physician just for like regular checkups for six months is because of this. Yeah. Right. They had to reduce the amount of time that they were seeing people. And so many other complications in the way, like you had to cancel the appointment.

I had to cancel an appointment six months just to go and get my annual physical.

Jason: And we’re still dealing with the ramifications of that. Right. So when I cancel those appointments, what do you think happens when COVID right now calms down a little bit? Right. I have no staff, no nursing staff, no EVS staff, housekeepers things like that. No phlebotomy staff. So all these people come back in for their elective procedures, for their, uh, visits for their encounters. Right so now your volume still feels like it did during COVID, it’s just not COVID anymore. And you still have those same stresses and struggles because there’s no staff and there’s limited hospital resources and everybody’s got their other eye on COVID still cause you know, VA 2 is out there and UK has got a little blip and what’s going to happen next.

Pamvir: AAaaaaaah! No!

Jason: Just go get vaccinated

Pamvir: Oh please. Yes.

So I have very much enjoyed talking to you today. I don’t know what I expected from this podcast, but it’s been, it’s been enlightening. It’s been a really interesting experience.

 But before we leave, because I hate ending up on a kind of sour note. Can you say something positive before we leave? Just to kind of…[both laugh]

Jason: I will say something positive. I, I, you know, okay. Where we are right now, I think is an interesting place where people are open to new models of care and new models of care delivery.

And people have recognition of the vulnerabilities that humans face. I think that has become much more clear. Um, and I think we can capitalize on not only some of the COVID pieces, but some of the other structural issues that have been brought, I mean look like a year and a half ago we were riding our bikes. There were lines of nice cars getting food. And I think everybody saw that. Right. And so I think there is some recognition right now that there are some, you know, serious disparities, not just healthcare wise, but economically in this country. And that we have some clearer structural cause we’ve used structural means to solve some of them.

Right. We did that. And so there’s like at least that exposure to that. That helps us when we build our pathways. Cause it helps us, with our opioid use patients. And we, we do have that. If I look back, you know, five years ago, we weren’t giving out Naloxone. We didn’t have a needle exchange. We weren’t, you know, treating people with opioid disorder in a non stigmatized trauma-informed way. There were no grants available for this stuff and all those things are there right now. So I look at that as some light in the tunnel that people at least have recognition right now that people are struggling and need some help, uh, even from scientists.

Pamvir: That sounds like they even need help from scientists. Yeah. No, thank you. That was, that was tremendous. I really, really enjoyed that. Thank you for meeting us today.

Jason: No, thank you for having me. It’s been great. And I got a Bell’s two hearted ale out of it. [Everyone laughs] So it’s been good..

Pamvir: There you go, you’re a cheap date.

[musical interlude]

Jason: I’m on a board, um, for a healthcare plan and we had a new board member and I missed the meeting where she was introduced. So I had no idea what she did and we were thinking about expanding the healthcare plan to St. Petersburg and, you know, during this conversation and I have some connections over there and I was like, oh, I might be able to help with that.

And, um, I’ve got some connections I formulate over there and, you know, everybody’s like nodding and everything. And I, it turns out this, this other new board member is the VP of Bay Cares, community relations. And, you know, basically the person who knows every single person who can do anything in St. Pete, right.

And she was so polite. She’s like, oh, this nice doctor, he knows a couple people. Right. I’ve got the mayor and the county commissioners and all the billionaires on speed dial. Right. Like, sure. Yeah. She had, she was, she was so nice. You know, like here’s some more rope for you.

[musical outro]

Well, you never seem quite real on Zoom. You know, you’re kind of like a fake person I’m talking to, like, I’ve just set you up there, to like have someone to speak with, you know?

There is a national blood shortage. I am happy to help TeamHealth get the message out there that we need blood donations across the country to save lives! #blooddonation

This past weekend, I completed the American Association for Physician Leadership® 3 1/2 day Certified Physician Executive (CPE) capstone after taking the 150 required hours over the past few years.

Those courses provided me with a solid foundation in healthcare management, finance, and human resource issues – all needed for leadership – but the capstone event itself was such an important part of the training that included the chance to solidify my leadership philosophy, values, style and reflect on competencies and prior accomplishments with excellent cohort leaders Michael Canady, MD, MBA, CPE, FACS, FAAPL, FACHE & Ron Nutting M.D., CPE, FAAPL as well as an awesome cohort (Steven Davis, MD MS FCCP, Wasseem El-Aneed, Michael Mentakis MD, MBA, CPE, FESC, FACC, Robert Shulman, Jeffrey Carlsen, and Jeanne Rowe.

So cool to meet 35 other physicians ready to move healthcare forward and great to be part of an organization committed to physician led teams.

Special thanks to Richard Paula, MD, CPE for suggesting this path to me at a lunch 7-8 years ago. Thanks Rich!

Tampa General Hospital

“A provider has thousands of encounters with patients. To the provider, this is a typical day and the patient’s health issue is a typical issue. But a patient’s perspective is different. Everything is foreign and even scary. Remember that time is relative and passes differently for a provider compared to a patient. When a patient goes home, they begin to remember fragments of the visit and formulate questions they meant to ask the providers. As a provider, we need to approach every encounter with our patients understanding their fragmented experience and address it with empathy and patience. We need organize new information in understandable chunks that create a linear process for the patient. Providers can give power back to the patient in a number of ways.

• Let patients know what to expect as much as possible
• When visiting patients, give an immediate explanation of your role
• Always obtain a patient’s permission prior to exam. Remember to ask rather than tell.
• Little actions give dignity and a semblance of control to a patient who feels they have little control in this environment

Consider when your mom calls you and tells you she’s in the ER. Take the feelings and emotions you have in that moment and realize the patient has those same feelings. Whoever they call is their version of you. Ask yourself, what do you need to give the patient to put them at ease and decrease their confusion?”

-Jason Wilson, MD

Special thanks to PhD student Bree Casper who conducted 20 client interviews and assisted with the writing of the results.

Qualitative Findings:

In order to understand the broader impact the SSP is having on individuals and communities, we collected qualitative data through individual interviews with participants and program volunteers.

While the data is currently being analyzed, we (Romero-Daza, Rigg) present some of the preliminary findings below.

SSP Participant Interviews:

From November 19^th, 2021 to January 7^th, 2022 we conducted 20 semi-structured interviews with participants of IDEA Exchange Tampa across two exchange locations (University Mall and Ybor City).

Of participants interviewed, 45% identified as male, and 55% identified as female. Participants racial/ethnic breakdown included, 75% of participants who identified as white, 10% of participants who identified as Black, and 15% of participants identified as Hispanic.

Semi-structured interviews lasted between 10 and 30 minutes and engaged participants on the following topics: history of use and how they used to get safe injection supplies, experiences since joining the exchange program, and critiques of the program.

When referring to their past use, participants often noted that they got needles from “mom & pop” pharmacies (local, non-chain pharmacies who are willing to sell to people who inject), or by buying them from dealers and friends at an upcharge. Few participants were able to purchase needles and supplies online (through websites like Amazon). All participants learned about the exchange through word-of-mouth. When asked how the exchange has changed their use, most participants noted that the exchange made their use safer and they benefited from access to safe injection supplies (in addition to clean needles). As some participants noted in their interviews:

“It definitely made it [injecting drugs] safer… there has been lots of time where I had to reuse needles. You know, recently before I came here, I actually had one [needle] break off in my arm because it was so old and I just had to keep reusing it.”

“Before I would never use an alcohol swab or cotton. I would just kind of wing it and hope I don’t die. And the Narcan also just really helps. Narcan was always so hard to get. Someone would OD. You guys have probably saved so many people with Narcan.”

Many participants told deeply emotional stories about how the Narcan they got at the exchange saved themselves or their friends.

Participants have self-reported 1,350 reported overdose reversals to date. Referral services offered at the exchange (such as MAT treatment and HCV/HIV treatment) were noted and appreciated by participants, but not many had used the referrals offered to them at the time of the interview.

When asked if there was anything we could do better, participants noted that the only shortfall was the sometimes-inconsistent inventory experienced in the last three months of the year.

 “The inventory…the first time I came you guys had a better variety.”

Finally, one of the standout comments from almost all participants was the community and lack of judgment they felt at the exchange.

 “Y’all are discreet. You don’t make us feel like we are less than or any different then you guys.”

 “You guys are very helpful, you offer needles, but you also offer ways to get in rehab…you guys are not judgmental. You guys are very welcoming.”

“You guys are there for us in a way that you don’t even understand you are… and that to me is the definition of selfless and admirable, and it only promotes positive public health effects, and I can’t see a negative to any of that.”

SSP Volunteer Interviews

In addition, we conducted semi-structured interviews with five USF students who have volunteered their time to the SSP since its inception. The participants were all second-year medical students in their mid-twenties and included four who identified as female and one who identified as male. The responses from the volunteers echoed some of the themes that emerged in participant interviews, including the clear benefits of providing clean needles and other needed materials, and of offering Narcan to help reduce the number of potentially fatal overdoses.

Likewise, all the volunteers commented on the respectful and caring service provided by the staff that run the program.

“You can definitely see that when people come to the exchange they are treated like equals, they are never made to feel like they are less than anyone else just because they use drugs. You can see that they [staff] really care and are truly committed to the cause.”

Volunteers also highlighted the benefits their involvement in the SSP operations offers them as future medical doctors.

Notably, they mentioned that volunteering with the program has allowed them to get a better understanding of the complex nature of addiction and to put a “human face” to the statistics they often read about in their classes.

When asked about ways to improve the program, three of the volunteers mentioned the need to disseminate information about the services through various channels, including social media and through ads in utilitarian spots such as benches in public bus stops.

Table 1. Descriptive Statistics among IDEA Tampa Syringe Service Program Clients

Characteristic	IDEA Tampa SSP (N=546)
Age (mean, SD)	40.9 (10.2)
Gender
Male	313 (57.5)
Female	228 (41.9)
Non-Binary	3 (0.55)
Ethnicity
Non-Hispanic	362 (80.6)
Hispanic	87 (19.4)
Race
White	464 (87.6)
Black/African American	43 (8.1)
Asian	6 (1.1)
Native American	8 (1.5)
Multiracial	5 (0.9)
Unknown	4 (0.8)
Educational Attainment
<8th grade	20 (3.7)
Some High School (no diploma)	68 (12.6)
High School/GED	234 (43.4)
Some College	134 (24.9)
College Degree	57 (10.6)
Advanced Degree	4 (0.7)
Vocational Training	22 (4.1)
Housing Status
Experiencing unstable housing	229 (42.5)
Stably housed	310 (57.5)
Substance Use (non-injection)
Benzodiazepines	42 (7.7)
Marijuana	184 (33.7)
Cocaine	50 (9.2)
Crack-cocaine	49 (8.9)
Methamphetamine	149 (27.3)
Barbiturates/Tranquilizers	10 (1.8)
Pain killers	19 (3.5)
Heroin	65 (11.9)
Prescription Opioids	33 (6.0)
Fentanyl	37 (6.8)
None	173 (31.7)
Other	57 (10.4)
Substance Use (injection)
Heroin	341 (62.5)
Prescription Opioids	49 (9.0)
Cocaine	55 (10.1)
Methamphetamine	263 (48.2)
Crack-cocaine	16 (2.9)
Speedball (heroin/cocaine)	24 (4.4)
Fentanyl	157 (28.8)

Table 2: Program-specific Metrics

Number of individual participants served	546
Number of used needles and syringes received	114,821
Number of unused needles and syringes distributed	113,991
Syringe Return Ratio (>1 = more syringes in then out)	1.01
Number of persons receiving HIV testing	187
Percent testing HIV reactive	2.7%
Number of persons receiving HCV testing	178
Percent testing HCV reactive	44.4%
Number of naloxone doses distributed	1243
Number of overdose reversals performed	1108