Central Line

Episode Number: 145

Episode Title: LIVE from Center Stage with Drs. Wolpaw and Arkoosh

Recorded: October 2024

(SOUNDBITE OF MUSIC)

VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Hi, I'm Adam Striker, editor of the Central Line podcast here at ANESTHESIOLOGY 2024 in Philadelphia. I'm going to pass the baton today to our guest, Dr. Jed Wolpaw of the ACCRAC podcast, who has a special, unique episode for us here on Center Stage. So, Dr. Wolpaw take it away.

DR. JED WOLPAW:

Hello, everyone, and welcome to a live ACCRAC episode. I'm Jed Wolpaw and I'm really thrilled to be here live from ASA 2024 here in Philadelphia, Pennsylvania. I want to remind everything this will be recorded. We will be releasing this on the ACCRAC podcast feed and on the ASA Central Line podcast feed as well.

I am really, really excited both to have all of you, and we look forward to your questions later, but also to have an incredible guest with me today. I have Dr. Valerie Arkoosh. Dr. Arkoosh is the Secretary of Human Services here in the state of Pennsylvania. She's had that job for almost two years. Before that, she was a county commissioner in Montgomery County and was the chair of that commission. And before that, she had a lot of roles I was learning about, including she was chair of the Department of Anesthesiology. She was an OB anesthesiologist at Penn, and she's done an incredible amount of great work and still is. So doctor Arkoosh, thank you so much for being here on the show.

DR. VALERIE ARKOOSH:

Yeah, thanks so much. And it's just an honor to be on the show. This is a pretty awesome podcast, right? And I just want to welcome all of you to Philadelphia. For those of you that aren't from here, welcome to my home turf. So it's great to have you all here.

DR. WOLPAW:

And I forgot the best part, which is that Secretary Arkoosh did an MPH at Johns Hopkins.

DR. ARKOOSH:

Hopkins.

DR. WOLPAW:

All right. Shout out to Hopkins. All right. So we're going to spend about 2020 five minutes on some questions I have for Doctor Arkoosh. And then we're going to open it up to all of you. So we have a mic right here. Think about questions you'd like to hear her answers to, and we'll spend the remainder of the time on that. Before we do, and I'll just remind you, Secretary Arkoosh, we will give random recommendations. So we'll make a recommendation to the audience for something they should check out for fun after we have our serious talk. All right. So let me just start by asking you to talk a little bit about your career path. Obviously, you you are and used to be a practicing anesthesiologist and now do incredible public service work. Talk a little bit about that process, that path and that transition.

DR. ARKOOSH:

Well, I was a very traditional academic anesthesiologist for a number of years. I practiced here in Philadelphia teaching hospitals for about 20 years. And as you heard, I was an obstetric anesthesiologist, and I spent a lot of time on the labor floor talking to my patients because most of the time they're awake. And I heard so many things from them that were consistent and over and over again about the kinds of challenges that they faced in their lives. And one day I was taking care of a woman who was about eight months pregnant, and she had just been diagnosed with very severe gestational diabetes. And so they put her on the labor floor because they were worried that she might go into preterm labor. So I went to see her and was getting her history and all of that. And once that was done, I was just kind of chatting with her, and I asked her what her plan was for when she went home, because she obviously had pretty significant illness at that point, at least. And she just looked at me and she said, doc, I've got a five year old and a three year old and I don't have a car, and I have to take two buses to get to a grocery store that sells fresh fruits and fresh vegetables. And she said, I really don't know what I'm going to do. And it was a real wake up call for me. As someone who'd been fortunate enough to be able to go to a grocery store and, you know, get there any time that I needed to. I just had this moment of thinking that here this woman was in one of the finest hospitals in the country, getting just outstanding care. But the minute she walked out the door of the hospital, she was right back in the center of her problem, and there was nothing that we were doing to help her with that. And so that was really the beginning of a pivot for me, and part of why I went back to school to get a master's in public health.

After that, I got very involved in on what became the Affordable Care Act. I led a national organization of physicians called the National Physicians Alliance, and we worked pretty closely with the Obama administration on that effort. And then I eventually ran for office and served as a county commissioner for the last eight years or the eight years up to January of 2023 through the pandemic and all sorts of other interesting times. So it's been quite a career.

But now I am, as you heard, the secretary of the Pennsylvania Department of Human Services, I lead the largest state agency in the United States. I have a budget of $19 billion and 16,000 employees. We run the Medicaid program, mental health services, services for individuals with intellectual disabilities and autism, individuals with physical disabilities. We also oversee the child welfare system, or the system that responds to allegations of child abuse, and the juvenile justice system, which is separate from the adult criminal system. We provide services for older adults, and particularly services that allow them to stay in their homes. And we also provide subsidized child care for low income working parents so that they can actually afford to go to work. And we provide early intervention services. So it's a very large portfolio. But all of it for me brings together these aspects of my career, and every day I go to work in the Shapiro. Administration. Getting tangible things done to make things just a little more stable, a little easier for folks here in Pennsylvania.

DR. WOLPAW:

That's that's fabulous and sounds like an incredibly rewarding opportunity to really serve a huge population. I've heard people describe the move from kind of clinical work to research as going from affecting a few people to doing something that has the potential to impact thousands or millions. And it seems like that's the same thing. You've kind of gone from having a large impact on a few patients to now an entire state and millions of people. So thank you for the work that you're doing.

Can you tell the audience a little bit about kind of your day to day? What are some highlights that really are rewarding for you and what you get to do on a daily basis?

DR. ARKOOSH:

Well, every day is different. Every 30 minutes to 30 minutes is different. But, um, it involves a lot of planning, a lot of work, meeting with advocacy groups and other stakeholders that are hoping that we will do certain things through our programs. We spend a lot of time listening. We really want to understand what the people that we're serving are experiencing and how we can do that work better. I meet with a lot of my team members regularly. We do a lot of data analysis. We try to make as data driven decisions as we possibly can, and also try to identify where there's gaps in that data, where we really don't have the information that we need to make a fully informed decision. And I travel a lot around the state. Pennsylvania is pretty big. There are 13 million residents here in the state. We serve 3 million of them, a little over 3 million of them in the Medicaid program. And so, you know, almost 24% of the residents here in the state are getting their health care through a system that I oversee. So I take that responsibility really seriously. So I want to make sure that I get out to all parts of the state. My agency has a county office in all 67 counties in the state, and we have multiple offices in some counties. And so we go and visit them. And then we spend a lot of time visiting community-based organizations because they carry out a lot of the work that we do in partnership with us.

DR. WOLPAW:

Yeah, I think it must be so essential and probably a good lesson about leadership in general. Right? Rather than sitting in the capital reading reports, you're getting out there and talking to people. There must also be challenges that go along with such a huge job. Talk a little bit about what are some of the challenges and how you approach that.

DR. ARKOOSH:

So there's a lot of challenges. You know, anything that is remotely connected to government is also very political. And you will have people on all sides of every issue. And so I spend a lot of my time meeting with legislators, Uh, meeting with constituent groups that want us to take a very different approach, perhaps from the one that we're taking and listening and then really trying to share from my experiences as a physician. And I think this is really kind of my secret weapon, to be honest. There's very few people in a position like mine that actually bring almost 20 years, really 20 years of practicing medicine to the table. And so I try to paint a picture for people who maybe just have never had exposure to certain situations or exposure to families that are facing particularly different circumstances. And a lot of times, the decision makers, you know, members of our General Assembly or others haven't always had direct experiences of the challenges that some of their constituents are facing. And so we spend a lot of time trying to connect those dots and really helping people understand why these services that we're providing are absolutely essential to a growing and thriving economy here in the in the Commonwealth, and trying to help them understand how what we now call the social determinants of health, how housing and access to healthy food like my patient needed, you know, so long ago, and clean air and clean water and transportation, how those things are so critical to the health of those individuals that we serve. And that is something that's still not broadly understood by a lot of policymakers, happily, more and more so. But it's something that I find myself talking a lot about and doing just a lot of education.

DR. WOLPAW:

Well, thank you for doing it and trying to overcome those challenges. We all heard this morning, Mr. Quinones. Sam Quinones talked about the opioid epidemic in his books about it. And he he painted a picture of some some hope on the horizon, I think, and you've done a huge amount of work both as a county commissioner and now on the opioid epidemic. And I'm curious to hear a little bit about your thoughts, both kind of what are the things that are making a difference, and what do you think the future holds? Is there hope on the horizon?

DR. ARKOOSH:

I do think there's hope. Um, you know, I think that it started with an understanding and again, very data driven understanding that our, our and, you know, a lot of us sitting here, our absolute commitment to eliminating pain in many cases, for so many of our patients perhaps had some unintended consequences for certain individuals. And so the physician community in all specialties has really stepped up. You know, when I took my kids to get their wisdom teeth out, when I called the person that had been recommended to us, his office just wanted me to know and be very clear that he does not prescribe opioids for teenagers after they get their wisdom teeth out. And I'm like, that's great. That's, you know, that's what I want to take my kids. So that was sort of step one. And we were really making a lot of progress a couple of years ago, because the number of people who were being exposed to opioids and finding that they were unable to stop taking them was really starting to come down. We saw that. And as a county commissioner, we led a multi-stakeholder, multi-agency effort in our county. The county that I lead is the third largest county in Pennsylvania. So, you know, almost 900,000 people. So it was a pretty big effort. And we were seeing measurable year over year decreases in opioid overdose deaths. We made sure Narcan was everywhere. We trained all of our 52 police departments on how to administer it. We used data to figure out where we should be sending teams with resources into the community. We'd follow and track where opioid overdose deaths were spiking. So we really made a lot of progress. And then as Covid hit, that was tough and, kind of simultaneously, we saw just this enormous influx of the semi-synthetic opioids and now the fully synthetic opioids. And and really, I mean, it's whack a mole. And you all probably know that. Every time we think we have a handle on stopping something from coming into this country, they simply tweak it and manufacture it slightly differently. And it comes in in other ways. And as you all know, this stuff is so potent they can put it in an envelope. You know, one envelope can contain 100,000 doses. And so we really are struggling in some ways. But happily, the statistics that have just come out in the last month or two, actually within the last couple of weeks, I think it's been, we are seeing a national decrease in the number of opioid overdose deaths. And we've seen an even more substantial decrease here in Pennsylvania. So we're very, very happy about that. But we have a lot more work to do.

DR. WOLPAW:

Well, I'm glad we have good people like you working on it. I mentioned to you earlier, my sister-in-law runs the addiction medicine fellowship at Penn, and they're really looking for great people who are interested in this. So a lot of people are are really interested in making a difference. Another thing that obviously you were very involved in was the it was the Covid pandemic. Thank goodness we got through that. But I'm wondering what in your role, you must be thinking about what happens in the state of Pennsylvania and of course, the country when the next one comes. Hopefully not for a long time, but we never know. What kind of preparations? What are people thinking about to hopefully make the next one something we're more ready for?

DR. ARKOOSH:

So the pandemic was really tough. I don't have to tell any of you how tough it was. And as someone who was actually in government throughout that period and trying to get, you know, marshal the resources that we need, get our counties in the southeastern corner of the Pennsylvania to work together effectively, it was really difficult. And we learned very quickly where we had a lot of deficits in our response.

There's a wonderful book. If any of you are particularly interested in this, I would encourage you to read it. It's by Michael Lewis and it's called The Premonition. And what was so interesting about that book, first of all, it was very accurate. Like the things that he described were all things I experienced. And he talked about though, that in the George W Bush administration, the president had had a little bit of time off, and he was reading a book about the 1918 flu pandemic, and he came back to the white House and he said to his team, what's our pandemic plan? And everybody looked to the right, looked to the left. There was no pandemic plan. And so the president said, we need a pandemic plan. What if something like this happens again? And so they brought a group of people into the White House. I feel like one of them was from Hopkins, but I can't remember any longer. And they spent some period of time developing a pandemic plan. And from what I could tell, reading this book, it was it was a good plan. But here's the thing. And this is why we need such a strong public health system. And this is probably the biggest, you know, carry through from Covid. When President Bush left office and President Obama came in and then, you know, after President Obama, there's President Trump, there is no mechanism to carry that pandemic plan through to future administrations. So they wrote it. Sounded like it was a really good plan. It got put on a shelf somewhere in the Bush administration. And by the time it got to the Trump administration, the full blown, like fleshed out plan was nowhere to be found. And also, over those same years, public health funding has just been decimated. And that is true from the local health department to the county, to the state to federal resources have been cut over and over again.

And I think part of why that happens is that when public health is working, nothing happens. The water is clean so people don't get sick, the food is safe to eat, so people don't get sick. Most people are vaccinated. So we don't get these huge disease outbreaks. So at least of the diseases that we know about, right. And so when public health is at its best, everything's good. And then people say, well, what do we need to fund this for? What's the point? And so it has just been cut and cut and cut. I wish I could sit here and tell you that policy makers understand this and that they are investing in our public health infrastructure, but sadly, they are not. And I think as physicians, it's a real opportunity for us to raise this up because we're not ready. I you know, I'm watching this, um, this avian flu that's sort of circulating around mostly between animals, but between some animals and people interacting with those animals. And there's no signs that it's it's going to leap out. So I don't want anybody to panic. However, I look at it and I think, you know what? We're really not ready. And I think we need to be honest that we're really not ready for another pandemic. So I hope that this is something we can all be mindful and thoughtful about as we look forward of something that we really do, just like we're rebuilding our roads and our bridges, which had fallen into such disrepair. Our public health infrastructure has too. And honestly, if it weren't for the Hopkins Data Tracking Project, I don't know what we would have done because unfortunately, that data tracking capabilities was another thing that had been disinvested in at the federal level, and we just didn't have it. And they stood up an incredible, incredible data tracking system, which saved a lot of lives.

DR. WOLPAW:

Well, it sounds like there's a lot of work to do. You know, I hadn't thought about it before, but the way you describe when public health works, nothing happens is actually very much like anesthesia. When we do our job, nothing happens. So a natural connection for you.

DR. ARKOOSH:

Recognize patterns.

DR. WOLPAW:

Exactly. So talk a little bit about what advice do you have. There may be some people sitting in the audience here, some trainees, some medical students thinking, you know, I could see myself going into public service. What advice do you have for them to keep in mind as they go through medical school or residency and beyond?

DR. ARKOOSH:

So I think that as I look back and I think about like, what do I wish I'd known more about earlier in my career? I think one is the understanding of the social determinants of health, how important some of these other factors are -- food, housing, the environment -- to a person's health. I do think that that is a little bit more present in the education of medical students and residents today, but I wish I’d understood that more deeply. And I also wish that I had taken the time to understand how different levels of government work and where we should go to get certain things done, because I think it's very easy for us, particularly in a presidential year. Right. Everybody's looking at Washington and they're looking at the federal offices. But the day-to-day things that impact most of our lives happen at the local level, whether it's your local township commissioner, whether it's your county commissioner. You know, here in Pennsylvania, our county governments provide behavioral health services, and many have public health departments, and they provide services for seniors and for individuals with disabilities. And that we oversee that at the state. But the the counties are actually doing a lot of that actual work. And then, of course, you have your state legislators, right, and your governors, as well as your members of Congress and the president. So it's really worth your time to actually understand where some of these things get done. So if you're trying to advocate on behalf of a patient, or you've got a problem in your own community that you know where to go. And I find that when people do that, they start to see places for themselves. Uh, maybe it's on a local school board, maybe it's as a township official, maybe they want to run for state rep or state senator because they realize that a lot of the funding for health care services flows through these state dollars, and how those state dollars get spent is really, really important to the health of our patients. And so I wish I'd spent more time then, you know. And I had kind of found this work maybe just a tiny bit earlier, but it's definitely something to keep in your in mind.

I, I think it's very important and, and I know every place is different and the culture of every institution is different. But I tended to always work in institutions where talking about politics or government was like a oh, we don't do that. It was sort of frowned upon. And I don't mean talking about politics in a, you know, vote red or vote blue kind of way, but I mean, talking about it in a, in the factual way that if we want more funding for a certain program, it it is a political question. It’s a political decision of how a pot of money is going to be appropriated to be spent on A, B or C. And I think we are doing ourselves a disservice when we don't educate our medical students and residents to understand just how our government works and how you meet with people. How do you make. An appointment with your state rep or your state senator? How do you do that? And then what do you do when you go there? How can you make an impact? How can you carry your patients stories forward? We have to talk about politics. It literally pays for everything that we do. Any patient that you take care of that's on Medicare or Medicaid or has their health insurance through an Affordable Care Act exchange, whether it's the federal or the state-based exchange. And frankly, even all of us that are lucky enough to have private health insurance, all of that is subsidized by taxpayer funding one way or another. Everything we do is touched by politics and by government. So it's just so important to understand it and understand where you can get involved in a positive way to help advocate for the things that you need for your patients.

DR. WOLPAW:

That's great advice. All right. We're going to turn to our random recommendations. But before we do anything that I didn't ask you about that you want to say.

DR. ARKOOSH:

You know, I just always encourage everybody to think about more efforts in public service. We need more physicians desperately running for office. There are only a few at this point in Congress in Washington. We have one in the General Assembly here in Pennsylvania. I am very much a unicorn with my background in what I do. We need more physicians doing this work. And so if it's something that you think might be of interest to you, I am happy to talk to anybody about it. We need more folks with all kinds of backgrounds that have stood at bedsides and really understand what's happening with patients, to be part of the conversation.

DR. WOLPAW:

Fabulous. All right. Do you have something you would recommend that people check out for fun?

DR. ARKOOSH:

I have two things. I couldn't get down to one, but it's two books and I know you all have a ton of time to read, so this probably isn't all that helpful. But I read in the car when I'm driving across the state. But back to the opioid epidemic discussion. There's a book called Demon Copperhead. Demon Copperhead by Barbara Kingsolver. And if you haven't read it and you are interested in learning more about the opioid epidemic, I encourage you to do so. It is a phenomenal book. Have you read it?

DR. WOLPAW:

I have. It's fabulous.

DR. ARKOOSH:

It's and I'll be I, you know, like just want to be clear that I almost had to stop reading it a couple of times. It's so difficult to read. So I want to, you know, may not be for everybody, but I thought it was extraordinary.

DR. WOLPAW:

Totally agree.

DR. ARKOOSH:

And then I don't know if you know, but this doctor here was a history teacher before he went into medicine. So in honor of that, there's a really great book called Democracy Awakening by Heather Cox Richardson. And she also has a newsletter and a podcast. And she is a historian and a historian of American history. And she does just an incredible job of contextualizing current events in American history. And you can read the book, you can listen to her podcast, you can get it. She has a free daily newsletter. I have found it over the last number of years to be extraordinarily helpful in trying to understand some of the things that are going on in the United States right now. So Democracy. Awakening, Heather Cox Richardson and Demon Copperhead.

DR. WOLPAW:

Fabulous. Well, I haven't read the second, but I will. That sounds amazing. Um, all right, so let's open it up to all of you. What questions do you have for Secretary Arkoosh? All right. Alexis.

DR. ALEXIS MOTES:

Hello. My name is Alexis Motes. I'm one of the CA3s at Hopkins, which is why Jed knew me when I stood up. So I have noticed in healthcare leadership, especially in government, a rise of anesthesiologists participating. We just had an anesthesiologist surgeon general. So my question to you is what makes anesthesiologists as a profession suited to the role of leadership in the government? What gives us the unique qualifications to help affect change in that department?

DR. ARKOOSH:

Thanks for asking that. I think that we have a number of qualities that make us very well suited to this work. First of all, we're very used to being members of teams. We're used to working with lots of different personalities in lots of different kinds of situations. And, you know, I was always trained like, you're the one that has to be the calm one in the room no matter what. Right? When the anesthesiologist starts to show that they're upset, then people know it's really bad. And I think that we all carry that. And so we're very good at navigating difficult decisions, navigating different types of personalities. We work in high pressure settings and we have to make decisions quickly, which is often the case of the types of jobs that we have in these government settings. And I think that because as anesthesiologists, we work in so many different places in a hospital or in an outpatient setting or in a pain clinic, we just bring a wealth of exposures and experiences to the table. And certainly during your training, and for many of you during your practice life, you're also working in settings where patients from every type of background come to be cared for. And so we also have the opportunity of seeing, you know, kind of everything, you know, from I can still remember, you know, being on the labor floor and being at places, you know, one of my more recent house was where we did fetal surgery, and you'd have, you know, a woman in one room getting this incredibly high tech, sophisticated fetal surgery. And in the room next door to her is a woman in labor who's unhoused. And and the juxtaposition of those two things and, and having to make sure that you presented yourself to both of those patients in a way that they could see you and feel respected and find ways to make sure that both were being treated with dignity. And so we just carry all those skills. You probably do a lot of that without even thinking about it. And those kinds of things make it possible.

There's another factor which I think is relevant, which is that we have a little more control over our schedules than office-based practitioners do. And so a lot of times what comes up in work like this is particularly early on, you might be viewed as a relative expert in something, and you might get a phone call that says, hey, can you come next Wednesday and testify before a committee? Well, as anesthesiologists, we can probably work that out most of the time, right? But if you've got a full day with 50 patients scheduled, you have to say no. And so our specialty affords us a little bit more flexibility in our scheduling that I think sometimes just simply makes us available. And oftentimes being available is is that first step, because you start to meet the people that are some of the decision makers and leaders in those fields, and then when they see you do a great job, then you get asked again. Right. And then somebody says, hey, have you ever thought about doing this? And it kind of goes from there.

DR. WOLPAW:

Thank you. Other questions for Secretary Arkoosh.

SPEAKER:

Hello. Good afternoon, Dr. Arkoosh, Dr. Wolpaw, and everybody, I’m… I'm an international medical graduate. I'm from Nepal, a different part of the world compared to us and in our hospital setting. It is not idealistic and the infrastructures are not adequate. And most of the patients, they like to leave the hospital before they are medically cleared. And but I have been in the US and I've been doing some US clinical experience for a couple of months. I noticed some of the patients, despite being medical care, they're hesitant to leave the hospital, which can be understood, as you said, because the hospital setting here is really, really wonderful and the care that they get is really idealistic. So what are the plans as a public health work worker to bridge that gap?

DR. ARKOOSH:

Yeah, that's a great question. So, um, historically in our Medicaid program. And Medicaid is the program that low income individuals have. Medicare is the program that people 65 and older have. So I just always want to clarify that, because sometimes folks haven't had a chance to sort all that out yet. But in our Medicaid program historically, the program was only allowed to fund actual health care itself. But under the Biden-Harris administration, there has been an opportunity created to apply for something called an 1115 waiver. You don't have to remember that. But to use Medicaid dollars for health related social needs. And so we're actually in the process of doing that right now here in Pennsylvania.

And what we have applied for is funding that would help us help people who are unhoused and have medical conditions, find housing and help them get stabilized, and then eventually sort of hand that off to a county or a community-based organization. Similarly with food. There's a very real understanding now of the importance of food as medicine. And so our program would help provide six months of medically tailored meals to individuals who've been recently diagnosed with a food sensitive condition, like diabetes or cardiovascular disease, and who were food insecure. It would also provide food to pregnant people and actually to their family, because many pregnant people, if they have children, they'll feed those children before they feed themselves if they're hungry. And so, again, a data driven approach to this, to provide food for food insecure pregnant people antepartum and then for a period of time postpartum, also making sure they're connected to Wick and other programs like that. So we're hoping to get approval to use these dollars to help bridge some of those gaps. In fact, we actually call this program Bridges to Success because we know that there's just these gaps, and their gaps that, you know, patients really can't navigate. Another part of our waiver, if we get it, would allow us to create a set of programs for individuals who have been incarcerated and are returning to their communities. They find it incredibly difficult to rent an apartment, you know, or to get that first job. There's so many barriers that stand in their way. And if they, particularly if they have a substance use disorder to keep that medical care steady so that they don't have a relapse. And so we're looking at this very holistically to do exactly what you said, which is close those gaps.

DR. WOLPAW:

Well, I just… it's such a great example of what you can learn if you collect data and go out and talk to people, because I never would have occurred to me that giving food to the pregnant mother wouldn't be sufficient. But but you learned that actually she's going to give that food away right to her other kids. So you have to do the whole family. I mean, what a great example of what you can learn when you actually pay attention. Connor.

SPEAKER:

Hey, my name is Connor. I'm a CA1 at Hopkins. I'm originally from South Carolina and growing up there, it kind of frustrated me, you know, kind of how the government interacted with healthcare and a lot of the decisions they made, like not expanding Medicaid and also restricting women's access to healthcare. It's very frustrating being in that state and having what seems like your government working against you and being a health care provider and kind of what are your what are your thoughts in approaching, you know, this state government to try and get them to make better decisions for us to help the patients?

DR. ARKOOSH:

So this goes back to my “you have a secret weapon as a doctor” approach. So a couple of things. The most important thing that you can do is share your patient stories. Policymakers have many meetings every day, and I can promise you the things that stick with you are the stories. And when somebody can really share a compelling story about their patient and why, whatever it is that you're advocating for would help their patient. Um, it sticks with people. It really does. So that's very, very important. And something that as caregivers, you can do uniquely well. Right? You have this power to share these stories in a way that most other advocates don't, quite frankly. You also then have to couple it with some other things. And Medicaid expansion has been a really interesting thing. We still have about, I think it's 11 or 12 states that have not expanded Medicaid, and depending on who you're talking to, there's a bunch of different arguments you can make. And this is where knowing your audience is important. And this is actually another secret power I think we have. Right. We meet patients all throughout the day. We have like ten, if we're lucky, 15 minutes, right? To actually get them to feel like we have a bond with them and we understand them and make them feel at ease. And so a good anesthesiologist can talk to a total stranger and in 10 or 15 minutes, have some kind of rapport with them. Right. That makes them feel safe going into that operating room. So it's using that same skill and listening to what the other person is reflecting back to you and figuring out is the economic argument for expanding Medicaid going to work with them? Is the, um, what it would mean for our workforce in our state to have a healthier population? Is it what we can do to save money by reducing unnecessary emergency room visits and hospitalizations? Right. It's like maybe doing a little homework before you talk to them, understanding what makes them tick, and going in with those arguments that are going to touch what you know are important for them. But the story is the most important thing. Like you have to have the story with that and then use those things together. And listen carefully, which is another superpower we have as doctors. We know how to listen. And there's not enough listening going on these days, I don't think. I think we could all be better listeners.

DR. WOLPAW:

So thank you. Other questions.

SPEAKER:

I'm …, I'm from Nepal, and I'm also having here some US clinical experience. And I would like to ask like in Nepal and developing nations also have this pandemic. They also suffer from this pandemic. And we also often have natural calamities. And from your perspective on public health, how can we better prepare and what would be your suggestions for developing nations? Thank you.

DR. ARKOOSH:

You know, I think that, um, we've seen from responses to the pandemic, for instance, in lots of different settings around the world that you don't have to spend a ton of money to be prepared. You know, it's really in countries that have a different level of resources and a different, maybe access to technology and other things than we do. For instance, here in the United States, that community health workers, they're extremely important here in the United States, but they are even more important in communities like what you're describing. And well organized on the ground community health workers can play an incredibly important role. What I would point you to as an example for that is what's been done in African countries around Ebola. Again, very low resourced countries, not a lot of sophisticated IT or data gathering systems. But they have used a very robust system of on the ground, in the community, health workers that know that when they see certain things, they should take certain steps and they should call a certain person. And then that person, you know, there's a whole response that's triggered. And it has been remarkably effective at preventing these widespread Ebola outbreaks like we used to see a few years ago. So there's some great models out there for you to take a look at.

DR. COOPER:

Hi, I'm David Cooper, I'm a surgical intern at Johns Hopkins. I kind of related to your story about, you know, talking to the patient and realizing that those resources aren't available for them outside the hospital. We kind of become focused on just treating the patient, getting them out the door. Definitely at the surgical level, you know, when you're overwhelmed with a patient population, 50, 60 patients and you're trying to get patients out in a reasonable manner, it's I found that the limiting factors, you know, getting them transport, making sure they can get follow up appointments, social work. It seems kind of spread thin at Hopkins, which, I mean, I think that's everywhere. I think it's very tough to be able to get all these patients and resources they need. Is that something that we can advocate for at the legislative level? Thank you.

DR. ARKOOSH:

So let me tell you what we're doing here in Pennsylvania. And it's still getting off the ground, but it's starting. So we have developed something called PA, for Pennsylvania, PA Navigate. And the whole you know, one of the primary purposes is to make it really easy for people to connect with resources, including physicians. And so when it's fully implemented, physicians will be able to have a link to PA Navigate in their electronic medical record. And so if when they're talking with a patient, they realize that that patient is food insecure, for instance. Just as you would click through to order their blood pressure medicine, you'll be able to click on a PA Navigate page, type in their zip code, and actually send a referral to a food pantry or a community based organization that is near them. And then that community based organization will receive the referral. And when the patient shows up, they'll be able to write back and say, we saw Mr. Smith today, and here's what we did. So it's a closed loop referral system, and we're starting to see it implemented. It's actually being implemented through some of our health information exchanges, our data sharing. You know, that many of our hospital systems are using. So it's slowly but surely I wish it was faster. But the point that I try to make to folks is that it's really easy to write a prescription, and it's really hard to refer somebody to healthy food and get them connected to healthy food. And we're all people, right? We don't want to ask if somebody has access to enough food, if they admit, which is always hard, right, that they don't, and then you don't have an answer for them, right? So we want to make it as easy for doctors to prescribe food as it is to prescribe a medication. And that's really the vision of this system. And it's in the EMR. So it just becomes part of your day. And it could be food, it could be housing, it could be transportation. PA Navigate has all of these resources in it and all zipcode based. So we're really trying to make it easier. Because you know, you can get a social work consult. But yeah. Right. So we want you to be able to do it. So that's our vision. And we're we're on our way. We're on our way there. But check back in a couple of years.

DR. WOLPAW:

It sounds fabulous. And as I'm hearing you say this, I'm thinking if this all happens in Pennsylvania, other states should copy it because it sounds amazing. And I'm wondering, do you interface with secretaries of other states?

DR. ARKOOSH:

Yeah we do. You know, I haven't actually been in my position for that long. So as I said, I'm just it'll be two years in January, so I haven't had a lot of spare time to actually do a lot of that interfacing yet. I've really spent my time going around the state. But yes, those meetings do happen and I look forward to being more participatory in them.

DR. WOLPAW:

Great. Giftty, did you have a question?

SPEAKER:

Hi. Good afternoon, I'm Gifty. I'm a CA3 at Hopkins, and my question is just for those of us who are interested in public policy, what how early can we start getting involved and what sort of things can we do even early in our career?

DR. ARKOOSH:

You know, it's never too early. Um, there's so many things you can do from just writing a short letter to the editor of your local paper about an issue that you think is impacting your community, to submitting an op ed, to meeting with your local legislators. It's just never too early. And so, you know, it's good to have a buddy if you're going to go and do one of those things. And of course, there's, you know, lots of resources. Our medical societies and things like that can also help do some of those things. But you don't need to go through them. You know, if there's an issue that you think is really important to your community, you can just easily look up your state representative or state senator or your local township leadership and reach out and ask to make an appointment. It's not that hard. And it's actually usually pretty easy to get an appointment with them compared to, like, your United States Senator or your member of Congress that represents you. And the one just, um, thing to think about is look at their schedule for when the legislators are going to be in session, meaning they're going to be in your state capitol voting on things. Don't try to go see them, then try to see them when they're in their at home in their district office, which is when those, uh, legislative sessions are not scheduled. And that's when it's actually pretty easy to meet with local people in particular. Yeah. It's never too soon because you have experience and you have a perspective that's really important.

DR. WOLPAW:

And maybe can you give us an idea for a statewide official like yourself or the governor or a senator? I always wonder my wife sends she emails them all the time. And I always wonder, does it make a difference? You know, how much of a difference do letters and emails I get to a, you know, a district representative in a city that's obviously, you know, there's a very relatively small number of constituents. Statewide? Is that still an impactful way to do it, to send an email, or are there better ways to kind of have your voice heard by your statewide officials?

DR. ARKOOSH:

So emails at the state level, um, aren't terribly effective. Um, to be honest. We we do notice if there are a lot of emails coming in on a particular issue, then we know that, um, this is obviously getting people's attention, but sometimes they're like a cut and paste job. And so that loses the impact, right? Because you're like, I've gotten 50 of the exact same email. And so you don't tend to pay a whole lot of attention to that. But that's where if you if you can find the time to build a relationship, just get to know some of these folks a little bit. And that can happen when they're on the campaign trail. You know, you can go to an event and introduce themselves and offer to be a resource if they have questions about health care in your community. Um, if if you know them and you email them, that obviously has a lot more impact. And then if you don't know them, you can always again ask for that meeting and go in with some colleagues. What's even more impactful is if you go in with others. So I'll give you an example. Um, let's say that you think it would be a great idea for a school in your community to have a school based clinic that would actually see kids at that school right there at the school. So if you go in as a physician and you bring a teacher and you bring maybe the school principal, and you bring a parent and you all come in together as a coalition and say, hey, we all agree that this would be a fantastic opportunity for our school to do this. That has a big impact. Sometimes we tend to go in with just doctors and that's that's important. It's very important. But what really has an impact is when it's multiple people from a community coming in to say, we all agree that this is important.

DR. WOLPAW:

Great. We probably have time for one more question if someone has one.

SPEAKER:

Hi, I'm Lisa. I'm a fourth-year medical student. Hearing about your story has been incredibly inspiring. I would love to know if you have a particular mentor or a role model who has inspired your journey in public service. Thank you.

DR. ARKOOSH:

That's a great question. And I don't have like, a particular person. Um, lots of different people and pieces of what they've done, I've kind of cobbled together, you know, as a as a path. But I think the thing that for me, what it has always come down to, is solving a problem. No different than I would do in the operating room. You know, somebody's blood pressure is down. Well, let's go through the differential of why their blood pressure might be down. And if A doesn't work, then we try B, right. And if B doesn't work then we try C. And that's sort of been my thing. So you know when I was first started practicing it was before the Affordable Care Act. And on any given day, 20 to 25% of my patients didn't have health insurance. And they came into the hospital much sicker. And, you know, with disease progression that was unnecessarily advanced because they just didn't have access to health care. You know, moms with no prenatal care. I mean, you know, the list is long. And so it was like, how can these people get health care, right? And then it was the food and it was it's been like one thing after another. And so I sort of I felt like I made some progress solving at least access to health care issue.

Obviously we still have a ways to go in this country, but we've made a lot of progress with the Affordable Care Act, particularly the fact that pre-existing conditions are no longer an exclusion to insurance, which was a huge problem for so many people. And then it became this growing understanding of these social determinants of health. And, well, how can I work on that? I can't do that as a clinician. I actually have to do something different if I'm going to do that. And so that was a pretty big leap of faith, I'll be honest. It was a little lonely out there for a while. Um, kind of had to create a new tribe, you know. But but it's just been like, okay, so at this level I can solve these things. But now, that's why I wanted to make the move that I did to the state, because as a county commissioner, I saw a lot of opportunities to do some things better to improve the coordination at the state level. And so now I've got the opportunity to do that. So it's just been like solving one--methodically right in the way we do as doctors--solving one problem after another in a very sort of measured like data driven way and figuring out where do I need to be to solve that problem?

DR. WOLPAW:

Well, thank you, Secretary Arkoosh. Thank you for your knowledge, for everything you're doing. And thank you for taking the time to come on the show today. I want to thank all of our audience to thank you for coming out. And we'll end, as we always do, by saying, I know that all of you are working incredibly hard, especially the residents in the audience. You are working harder than anyone, and it sometimes can feel like that is a thankless job. But I know I speak for Secretary Arkoosh and definitely for myself when I say that what you are doing out there every day is incredibly important and it is truly, truly valued. So thank you all. Have a wonderful rest of the conference and we look forward to seeing you around.

DR. ARKOOSH:

Thank you.

(SOUNDBITE OF MUSIC)

VOICE OVER:

Subscribe to Central Line today wherever you get your podcasts, or visit asahq/org/podcasts for more.