• FPs in Public Health: Lessons on ‘Tripledemic,’ Trust, Well-being

    (Editor’s Note: A new member resource, “Teaming Up With Public Health: Extending the Family Physician’s Impact From Clinic to Community,” offers practical tips for making connections between the work family physicians are already doing and public health efforts.)

    March 15, 2023, News Staff — In the fall of 2022, health experts across the country began to warn about the prospect of a “tripledemic” of COVID-19, influenza and respiratory syncytial virus. 

    Three family physicians who work in public health recently shared a conversation with AAFP News about the role of family medicine and public health in easing the blow of that tripledemic, how physicians can tend to their own well-being, opportunities for FPs in public health and more:

    • AAFP Board of Directors member Kisha Davis, M.D., M.P.H., health officer for Montgomery County, Maryland;
    • Laura Chanchien Parajón, M.D., M.P.H., deputy cabinet secretary of health at the New Mexico Department of Health; and
    • Jennifer Bacani McKenney, M.D., health officer for both Wilson County and the city of Fredonia in Kansas.

    The conversation has been edited for length and clarity.


    AAFP News: As a family physician working in public health, what effect did you see the tripledemic have on your community?

    Kisha Davis, M.D., M.P.H., AAFP Board member 

    Kisha Davis: Montgomery County is a suburban community outside of Washington, D.C. We have about 1.1 million residents, and it’s very diverse, both racially and economically. NIH is headquartered in our county, and Johns Hopkins has a satellite campus here, so we have folks who really pay attention to what our county is doing.

    When influenza and RSV cases started appearing, even though a lot of folks had started winding down COVID-19 briefings, our county executive never stopped doing them. Because there was already such awareness of COVID-19, it was easy to add influenza and RSV to the briefings.

    In terms of levels of concern, we had the sense that people were over COVID. If anything, the addition of influenza and RSV made people pay more attention to the fact that COVID is still here and still deadly. We had weekly graphics that would show the number of influenza deaths across the state and COVID deaths in our county. It served as sort of an unfortunate reminder that COVID is still here and that people needed to get vaccinated and take precautions. I think in some ways, it helped us get the message out when folks were tired of hearing it.

    Laura Chanchien Parajón, M.D., M.P.H.

    Laura Chanchien Parajón: New Mexico is a state with a centralized public health system, which means that we cover the whole state and do public health surveillance, laboratory testing and provide public health services throughout the state.

    One of the surveillance activities that our DOH does is monitoring respiratory viruses and looking at trends to then take action. In the data, we could see that influenza and RSV cases were rising much earlier than in previous years — which, when combined with COVID, other illnesses and not enough staff, was overwhelming our hospital systems. We developed close relationships with our health systems during the pandemic and with communities, and what we saw was that there were a lot of people in our community worried about medication shortages and not being able to get a hospital bed if they needed one.

    Jennifer Bacani McKenney, M.D.

    Jennifer Bacani McKenney: I’m in Wilson County in southeast Kansas. Our health department is made up of four full-time employees. With something like this, our health department can easily get overwhelmed as they try to keep up with all of the department’s other functions. Our 25-bed critical-access hospital can also get easily overwhelmed when we have so many illnesses happen in one community. As family physicians, we see patients in our clinics, but we also staff the hospital emergency room, so we see patients all the time. At the same time, we’re trying to send people to larger facilities when they need a higher level of care.

    One of the biggest effects of the tripledemic is that it has made care for all of our patients more difficult. We see patients within the clinic every single day with respiratory infections, but we’re still also caring for patients with diabetes, with hypertension; it’s a lot to take care of when so many things are going on at once, especially when we are the health care for the community.

    AAFP News: What role did public health and family medicine play in the tripledemic being less severe than expected? How do we build on that?

    LCP: I think COVID changed the way that people thought about public health in our state. During the COVID pandemic, public health started getting a lot of visibility. Because we were initially involved in mass testing and then mass vaccination campaigns in a very public way, people started recognizing that public health also plays a role in the health care system.

    Since we developed close relationships with our health system partners during the pandemic, we were able to join forces by doing things like having joint press conferences to share messaging about getting vaccinated for flu and COVID, staying home when sick, how to recognize signs of danger, when to go to the ER and when not to go to the ER, and hand-washing.

    Additionally, it also made us recognize that we have lost a lot of health care providers and public health professionals along the way, and we are doubling down on efforts to support our staff and rebuild morale, and also building the health care and public health pipeline with public health, the universities and the health care system.

    JBM: With COVID-19, we found that family medicine and family physicians are everywhere, from providing tests to holding patient care visits in parking lots and saving lives in hospitals and ICUs, not to mention our work in state and county health departments throughout the country. I think the country took notice of that. I know our counties and communities took notice, because family physicians were foundational in the care of patients at every level you can imagine during the pandemic, and we’ve been here doing the same during the tripledemic.

    We know now, as family physicians, that we can do this. We can take care of patients in these extreme circumstances. We have that experience now. I think it’s important for all of us to remember that we’ve gone through worse situations, and whatever comes next, we can do this, too. We can help our patients, and we can personally get through this, as well.

    We also realized from the pandemic that family physicians are the people that other people trust. If they’re going to trust anybody, they’re going to trust their family doctor and ask about getting tested or wearing masks. They’re also going to ask about vaccines and flu shots. I have been so impressed with how many family physicians take care of patients every day but also serve as a health officer for their state or county or community. It shows how family medicine is such an important and versatile specialty for every community at every level. 

    KD: Laura and Jen said it so well. The tripledemic forced us to dust off many of the things we had done when COVID was really bad and mobilize quickly to be able to offer vaccines and testing and support our hospitals.

    There were a few weeks during the pandemic where things got pretty bad. We opened up a supplemental hospital to relieve the case load at our main hospitals. This is where you saw connections between public health and family medicine. We could see that hospitals were filling up, that wait times for ambulances were extending.

    Public health takes care of the masses, but for individualized care, you want to go to the person who knows you. So we started sending the message to people that if they were sick, they didn’t necessarily have to go to the hospital. They could see their family physician, and with telehealth, they wouldn’t even have to leave home. We reminded people to lean on their family physician or primary care physician and turn to them for help. That would free up space in the hospitals not just for people with COVID, but also people who had strokes or were in car crashes or situations like that.

    AAFP News: What have you been doing to take care of yourselves during the tripledemic? What advice do you have for other family physicians who may be feeling stressed?

    JBM: I have read and seen that many doctors in general are burned out, maybe even more than during the pandemic, but in a different way. I can absolutely see why.  It was so intense during the pandemic. We had this mission of helping people. We’re still doing that, but it’s different now. You have the effects of the pandemic, but many people are trying to get life to return to normal.

    I feel OK, myself. I feel good.

    In terms of advice and self-care, I think it’s important for people to share (things like the fact) that I started talking with a therapist during the pandemic through telehealth visits. I hope other family physicians are doing similar things, because we also need people to care for us. Sometimes the burdens we carry are not physical. The mental burden can be very heavy, and so I hope family physicians are talking to someone they feel comfortable with or reaching out to others.

    One important thing I learned from my therapist was that I can’t help everybody. I want everyone reading this to know that. As family physicians and public health officials, our purpose is to try to help everyone. Sometimes we can’t, and it’s OK to feel like we don’t have to save everyone. We can try our best and work hard, but we can’t take it upon ourselves to feel like we save to the world. I think we have to be able to release some of that burden, some of that stress, and look for help, as well.

    KD: We were at a senior leadership meeting at the health department and were joking with the director about him getting gray hair or losing his hair or gaining weight from the stress of his job. All of a sudden, a person stopped us and said that it wasn’t funny. And that person was right. It’s not funny, the amount of stress we carry around. We shouldn’t normalize that dysfunction of feeling under-resourced or burned out or unappreciated.

    So we started instituting things like mindful moments before meetings to help people center themselves. It could be anything — an expression of gratitude, a person talking about what feeds their soul, even a brief talk about what people did over the weekend. It’s an opportunity for people to normalize the idea that doing something to take care of yourself is a good thing.

    It’s not lost on me that the three family physicians here are all women, and there are the extra burdens that come with caring for families and children. I’m a wife, mother, family physician and public health official, so you have to be intentional about finding things that are meaningful and taking time to take care of yourself. It sounds clichéd, but we all tell it to our patients: If we aren’t good to ourselves, we can’t be good for anybody else. I try to be intentional about taking walks and listening to audiobooks.

    I think trying to model that for staff is really important. If you send an email late and don’t want your staff to do anything about it, then I delay sending it because I don’t want them to worry that it’s something they have to answer right away. I try to do those things as a leader that model the good health practices you want your folks to pick up.

    There are always going to be emergency situations where folks have to rally, but when you have fortified yourself, you’re more available to respond when those emergencies come up.

    LCP: I totally agree with what my colleagues have said. To share a different perspective, I think the pandemic also resulted in a lot of chronic stress and trauma, and we should take time to recognize the impact of this on us as individuals, as families and also as organizations. The more we take time to connect with each other and listen to each other, the more we can rebuild some of the things we lost during the pandemic.

    AAFP News: There’s been a lot of concern about loss of trust in public health. What can be done to regain that trust?

    JBM: This is a great question. It’s really bad in Kansas right now. In February, a state senator introduced a bill that, if passed, would prohibit any public health officer in the state from issuing quarantine orders; they could only make recommendations. One of the senator’s comments was, “Recognize your inadequacy in the field of public health.” That’s how bad it is here, to have a state senator say such horrible things about the people who worked really hard to keep everybody alive and safe over the last few years.

    I think we have to speak up, as well. We have to advocate for ourselves. If that senator is the only voice that people hear, then more people might start to believe it. We have to be our own advocates and speak out against these terrible bills and other things that people might say.

    In my own town, it feels like we’re still repairing fractured relationships. These are people who have been my friends and patients and neighbors, some who I’ve known since I was a kid, so it’s hard to go through what we all went through and then try to rebuild that trust. I think it comes down to being a family physician, being that person who others have trusted for so long, continuing to do what we do, and hoping that people will understand that we’re trying to help keep them safe and alive.

    KD: I started (my public health role) in December 2022 and have the benefit of not having gone through the worst of COVID. The previous health officer resigned in September 2021 partly because things had become toxic. It took over a year to find me to fill the role; in the interim, other people were interested but when they were offered the job, decided it wasn’t something they wanted to walk into. 

    Now, I have the benefit of being in a community that is mostly supportive of public health. I still see people wearing masks in the local grocery store and many of our buildings. On my first day on the job, I had a voicemail and an email waiting for me. One asked me to please not resume the mask mandate; it’d be the worst thing ever. The other message asked me to please acknowlege that COVID cases are on the rise again, and how could you not do that? We still face that tension and mistrust.

    I think you could flip the question and ask, “Why should they trust us?” Prior to the pandemic, most folks in the community had no idea what the health department was or what it did. They didn’t have any trust in it because they hadn’t interacted with it.

    So, we’re doing two things. One is trying to build that trust ourselves. The other is using a lot of community partners who already have the trust of the community to go out and deliver those messages on our behalf. We have a large Latinx community. We developed focus groups with them and created a social media campaign centered around family, the importance of getting vaccinated against COVID-19 and staying safe from infection. That was a really effective campaign because it used an approach our partners thought people would be responsive to, it was reflective of the community, and it wasn’t us trying to tell them what to do. It definitely helps to have a community that supports public health and isn’t fighting you every step along the way. That makes a huge difference.

    AAFP News: How can family physicians become more involved with public health agencies in their communities and tap into those resources?

    KD: First, know that the resources are there and we look to our family physicians to help translate and spread the message. Our health department does a lot of messaging to create resources that primary care physicians can use with their patients. Just knowing where to go to send patients for things is really helpful to help translate that message.

    I don’t know about other jurisdictions, but we have a lot of boards and commissions, which offer opportunities for people in the community to sit and weigh in. A lot of those folks are physicians, so I think finding ways to be a part of the conversation on the health of your community is a great way for an FP who doesn’t want to do public health full time, but wants to see where things are going and have some influence.

    I think being active in your state chapter is important. The Maryland AFP has a state lobby day, and we often go to the statehouse and talk about public health issues.

    Finally, I would ask my colleagues to not throw stones. We’re physicians, too, and we’re looking out for the health of the entire community, which may look different than looking out for the health of the individual. I think walking a little bit in a public health official’s shoes and seeing how to partner with public health would be very helpful.

    LCP: Since I also teach in our college of population health and our family residency, I have worked with a lot of family medicine interns and residents who were interested in helping out during the pandemic. At the department of health, we were able to work with family medicine interns and residents on projects based on improving the health of populations — not individuals. I think giving interns and residents in family medicine the opportunity to see how people can not only affect individual health but also population health is a great way that family medicine and public health can work together. 

    JBM: One thing family physicians can do is become familiar with what their health department does and what resources are available. I was pleasantly surprised to find out everything that was available through our health department that I did not know about when I started practicing. I know the health departments and our friends in public health would love to partner with us.

    Whenever we try to implement things at the county level through the health department, we eventually realize that patients aren’t necessarily showing up at the health department to quit smoking or lose weight, they’re showing up in our exam rooms. That partnership with family physicians is so important, and I think a lot of public health can be carried out through FPs. Even if they’re not technically in public health, the work they do is integral to public health. We’re the only specialty that focuses on the family unit and the community. It’s inherent in what we do as physicians, so partnering with local public health officials would be a dream situation for health departments.

    AAFP News: What else should family physicians know?

    LCP: I agree with what everyone’s saying and would also add that we need more family physicians in public health. Many of us went into family medicine because we love taking care of the whole family in a clinical setting, and while I still love doing that, I also recognize that access to health care is only 10% of what makes someone healthy. And while we all get taught in medical school about the importance of social determinants of health and the environment where people live, work and play, we don’t get as many opportunities to actually contribute to that as a busy family practice doc in a clinic. Being able to work with our public health departments, though, allows us to go from helping individuals and families in our community, to naturally progressing to helping the populations and the environment around you.

    By working with our local public health programs and their services, family docs we can do a lot to help with integrating public health and primary care, and I encourage young family physicians out there to connect with and learn more about what your public health department does. It may not end up being something you do for your career, but it’s a place where you can really make a difference.

    JBM: I would advise our fellow family physicians that you don’t have to be an expert in public health. I do not have my M.P.H., but a lot of us become health officers, especially in smaller communities, because of the need for someone who is willing to take care for the community.

    Any family physician can do the work or learn to do it. We learn new things every day. Family physicians care for people. That’s what we do, and this is something any family physician can do if it interests you.

    KD: I’ll echo what they said, and I’ll add the obvious: Public health needs you. Public health needs more family physicians.

    I think the way family physicians are trained to look at patients and the world is so simpatico with public health. They are linked, and I think the way we think about the world, our patients and their families and communities — that is public health. If you’re interested, we need you.

    And you don’t have to be a city, state or county health officer to have a role in public health. Even the conversations you have with your individual patients and your help in educating them on broader public health issues — it makes a huge difference.