{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/6w96689w5b/manifest","type":"Manifest","label":{"en":["Dr. Paul Lazar"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Date"]},"value":{"en":["2020-10-29 (created)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}},{"label":{"en":["Format"]},"value":{"en":["video"]}},{"label":{"en":["Subject"]},"value":{"en":["Covid-19 (topical term)"]}},{"label":{"en":["Keyword"]},"value":{"en":["family medicine","pandemic","nurses","nursing home","HIV"]}}],"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/collection_resource_files/thumbnails/000/203/994/small/PaulLazar%2810-29-2020%29.mp4_1691512897.jpg?1691512899","type":"Image","format":"image/jpeg"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2334/collection_resources/103885/file/203994","type":"Canvas","label":{"en":["Media File 1 of 1 - Paul_Lazar_(10-29-2020).mp4"]},"duration":1723.12,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/collection_resource_files/thumbnails/000/203/994/small/PaulLazar%2810-29-2020%29.mp4_1691512897.jpg?1691512899","type":"Image","format":"image/jpeg"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2334/collection_resources/103885/file/203994/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2334/collection_resources/103885/file/203994/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/203/994/original/Paul_Lazar_%2810-29-2020%29.mp4?1691512897","type":"Video","format":"video/mp4","duration":1723.12,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2334/collection_resources/103885/file/203994","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2334/collection_resources/103885/file/203994/transcript/47254","type":"AnnotationPage","label":{"en":["Transcript of Dr. Paul Lazar interview [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2334/collection_resources/103885/file/203994/transcript/47254/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Crystal Bauer: Good morning, Dr. Lazar. Today is October 29th, 2020. Please confirm for the record, that you are aware that this is being recorded and that you are giving your permission to do this interview.\n\nDr. Paul Lazar: I'm aware and I give my permission.\n\nCrystal Bauer: Great. Would you please give your name in full?\n\nDr. Paul Lazar: I'm Paul Lazar. I'm a family physician.\n\nCrystal Bauer: And what is your present title?\n\nDr. Paul Lazar: I'm one of the attending physicians at McLaren Family Medicine Residency in Flint, Michigan.\n\nCrystal Bauer: Could you tell us a little bit about your education? Where did you go to Medical School?\n\nDr. Paul Lazar: Michigan State College of Human Medicine.\n\nCrystal Bauer: And where did you complete your residency?\n\nDr. Paul Lazar: At Cook County. I was one of Prieto's people.\n\nCrystal Bauer: Okay. What is the name of the current medical residency program you are associated with?\n\nDr. Paul Lazar: McLaren Flint Family Medicine Residency.\n\nCrystal Bauer: And could you speak about your current position and what you do on a daily basis?\n\nDr. Paul Lazar: Right. Well, most of my work is precepting. And then, the academic part, I teach some of the academic half-days in cardiology, EKG, some geriatrics, and we have a board review based on the AFP and I teach that. And I also do some faculty development work.\n\nCrystal Bauer: Great. Could you tell us a little bit about the types of patients that are treated in your program? Who they are and where they come from?\n\nDr. Paul Lazar: Sure. We have a pretty wide mix. Flint is a small city and we're far enough from Detroit, that we're kind of close to rural areas. So, we have people coming in from the surrounding small towns and countryside, as well as urban people. Most of our patients would be considered underserved and under-resourced and everything else you would want to put in the category, of lacking social determinants of health.\n\nDr. Paul Lazar: Although we do have a mix of patients. We have some people who have been coming to see us for many years, who have steady jobs and good insurance, as well as people who have no insurance.\n\nDr. Paul Lazar: We had, for a long time before the Medicaid expansion, we had Genessee Health Plan,  it's basically a county health plan that paid for primary care, a limited formulary, and not much else. And so, we had a ton of patients in that.\n\nCrystal Bauer: What unique challenges do you and your program face with COVID-19 and what are the barriers or obstacles you've come across, so far?\n\nDr. Paul Lazar: Oh, tons. First of all, our FMP was closed down, according to the state order, in March. We had to switch immediately to telephone only visits. And I think we were in phone-only for three months, so that definitely presented some challenges. One of my pieces in precepting was, at that time, was the nursing home.\n\nDr. Paul Lazar: We had a rotation when residents would be there five mornings a week, and then with Covid that stopped. They didn't want the residents to come in, which I agreed with. I didn't think it was a good idea to have anyone coming in who could become ill from working in other settings.\n\nCrystal Bauer: Right.\n\nDr. Paul Lazar: But obviously, that was bad, in terms of their education. A lot of challenges.\n\nCrystal Bauer: Can you describe how COVID-19 has impacted your current work? You've spoken a little bit about that, but maybe, in more detail.\n\nDr. Paul Lazar: Well, as far as the nursing home practice, we had a major outbreak. So, that was just plum scary. In terms of the patients I took care of, more than 10 either died or were hospitalized. And some of them were, for many weeks hospitalized and then had long-term rehab issues.\n\nCrystal Bauer: Sure. Sure.\n\nDr. Paul Lazar: Many of my patients had a lot of serious complications. A lot of the patients came back with... This hasn't been widely reported, but the older adults, a lot of them had real problems with appetite and eating. And of course, the ones who really weren't able to tell us much about how they felt. They couldn't tell us whether it was because they were having pain in their mouths, sores, or having difficulty swallowing. Or if they had lost their sense of taste and smell or all of those.\n\nDr. Paul Lazar: So I had to handle a lot of people. We had to do all kinds of crazy interventions, tube feeding and it was really just, the clinical side was very challenging. We were taking care of problems we just never faced before. Because a swallowing study, normally we could just send the patient over to the hospital for a swallowing study. We didn't want people going back and forth. There were a lot of clinical challenges that were a lot different from anything we've had to deal with before. Of course, we couldn't send the patients out to specialists for consultation. So I was dealing with the medical problems they had with the best I could with what I knew and using perfect serve (secure messaging) to pick the brains of the specialists  who knew something about their condition.\n\nCrystal Bauer: How do you see COVID-19 impacting the learning of students and residents in family medicine? And do you think these changes will be permanent?\n\nDr. Paul Lazar: It's interesting. It's definitely a mixed bag because there are certainly things that would have been part of their normal curriculum that they missed or couldn't be delivered in the normal way. On the other hand, particularly for the residents, there was an accelerating effect, for the ones who actually participated in the care of COVID units and the critical care units. Because we had to help the critical care team at our hospital. We basically tripled our critical care bed capacity.\n\nCrystal Bauer: Wow.\n\nDr. Paul Lazar: Yeah. So instead of having one ICU team mostly staffed by internal medicine residents, we had three ICU teams or maybe even four... I think it was three times the normal capacity and we had maybe four times our normal capacity.  What they ended up doing, was pairing a family medicine senior with an IM junior or family medicine junior with a senior. And then they discussed each case with the intensivists who were their supervisors.\n\nDr. Paul Lazar: So there was just this rapid acceleration in their critical care knowledge and skill.  For everyone who did that... It was on a voluntary basis, so not everybody did that.\n\nCrystal Bauer: Sure.\n\nDr. Paul Lazar: But the ones who did participate... And most of the residents went voluntarily. The ones who didn't, mostly  they had some risk condition. They were pregnant or had small kids and didn't want to take the chance. And they were functioning with a lot of independence.  Where I trained, it counted. The attendings never saw the patients, for the most part. That was a different era, with different rules about supervision. We were the last line of defense for those patients. To whatever extent we were able to figure out what was wrong and learn and do the right stuff and be advocates for them. That determined the quality of care they got.\n\nCrystal Bauer: Right.\n\nDr. Paul Lazar: And during COVID I think, that period, of March to May, we were kind of quote unquote \"overwhelmed.\" Because there were too many patients and too few intensivists, so the residents had to work with very limited supervision.\n\nCrystal Bauer: What have you learned through this pandemic?\n\nDr. Paul Lazar: Lots of odd stuff I never thought I would have to know about just because of the inability to send people out.\n\nCrystal Bauer: What do you think your students have learned?\n\nDr. Paul Lazar: They don't normally practice great infection control. It takes them a minute to get it. You know what I'm saying?\n\nCrystal Bauer: Yeah.\n\nDr. Paul Lazar: They're so used to having these fantastic antibiotics to fix everything, that they don't have the respect for infections, we learned during residency. I think for residents at the time of the HIV... We didn't know anything about it. Of course, eventually we figured out that we had to treat everyone like they had it. No symptoms and the disease still transmitted. So, it's the same way with COVID. But then, it took people some time to understand, to integrate those practices, into their daily lives. So it was the same for our residents.\n\nCrystal Bauer: So, do you see a lot of parallels then, having gone through the HIV epidemic and now through COVID? Do you see a lot of the same sort of skills needed, then, to ...?\n\nDr. Paul Lazar: Yes. Crazy thinking, magical thinking. Never been this way before, thinking. And with people being ostracized, because they were sick, it was terrible.  “It's a blue state disease. We won’t get it here.”\n\nCrystal Bauer: Yeah. So overall, what have you learned through this pandemic?\n\nDr. Paul Lazar: Well, I learned a lot of yoga moves.\n\nCrystal Bauer: So, some self care. That's good.\n\nDr. Paul Lazar: Yeah. My wife is a yoga teacher and I was lucky enough to have her and she made me do yoga basically, for stress and to keep down the crazy. That was helpful.\n\nCrystal Bauer: Sure.\n\nDr. Paul Lazar: I don't know. What else did I learn? You learn from what you see. So, I've learned all kinds of things about how people suffer. About kidney failure. I've learned all kinds of things about medications I never heard of before. So, it's kind of random. [crosstalk] You had to learn from the patients. I mean, you didn't know something they needed you to know, you had to learn it. It's not any particular skill or... I didn't work in the critical care setting myself, learning how to intubate people again, or any of that stuff.\n\nCrystal Bauer: Sure. What do you think your students learned from this?\n\nDr. Paul Lazar: Well, it depends on the individual, to tell you the truth. I think some of them have learned a lot of life lessons, a lot of humility. Well, obviously, the critical care skills. But some of them, I don't know. I'm not sure.\n\nCrystal Bauer: Okay. Hey, that's enough. That's an honest answer. I understand.\n\nDr. Paul Lazar: I mean, it's always a mixed bag of residents. Some people are like little sponges and others, you kind of have to beat it into them. And you can only beat so much in so you focus on the things that they need to know, for the people you're dealing with right then, and hope they pick up the rest another day.\n\nCrystal Bauer: Sure, sure. If you could start this year over again and do things differently regarding COVID-19 care, what would you change?\n\nDr. Paul Lazar: Oh gosh. Well, the leadership would be the only thing I would change. Obviously, that wasn't within our realm. [inaudible] I think I was trying hard not to use foul language] We had an opportunity to contain it at the beginning, but we missed it. We had a guy come in in early March, it was like two weeks before we had to be shut down. Typical symptoms of Covid, and he was a bus driver. Of course, we had no tests. The only place we could test him was the health department. So, we called the health department and said, \"Can you test somebody?\" They said, \"Oh, yeah. Bring him over. But he never went. [crosstalk ] I suppose he was afraid he'd have to be off work. I don't know. I don't know what happened. If they tracked him down, the health department, they had their hands full. I suppose they had that kind of thing, everywhere, because we didn't have the resources to test the people. [inaudible] and isolate them. So...\n\nCrystal Bauer: So, who are the people you've worked with most closely during this pandemic and impressed you during the time? And why? And were these established professional relationships or new relationships?\n\nDr. Paul Lazar: I will tell you, who impressed me the most were the nurse aids and the mostly LPN nurses. At the nursing home. Because they were in there all day, every day, with no PPE to speak of. I mean, these people were wearing dime-store ponchos, as their isolation gowns, that they bought themselves. I mean, I was too. I had my 10 dollar Cubs poncho. They had surgical masks, but didn't have N95s. I think it was maybe four weeks after the outbreak started before they had proper PPE, and by then, most of them had gotten it.\n\nDr. Paul Lazar: And they're in there with disabled patients and demented people, who have to have their diapers changed. You can't keep a mask on them because they're demented. I had a lady... It's kind of funny but really sad. I went in to see her because she had a fever. And I asked her if she had a cough and, \"No, I haven't had a cough.\" Immediately after she said that she coughed one of those, wet coughs that you can see the sputum fly across the room. I'm like, \"Okay. Thank you\" So, that woman actually survived. She didn't even need to be hospitalized, actually. She was in her nineties. She did great. She did fine, but  a lot of the others, not so much.\n\nCrystal Bauer: Do you feel right now, that those frontline staff, do have the right equipment now to better protect themselves? I mean, has that gotten better, as the pandemic...\n\nDr. Paul Lazar: My hospital is part of a bigger system. And they bought a stake in a company that makes PPE. We have adequate supplies of PPE now. We have enough where we're supposed to wear an N95 for any patient contact. All day, I don't even take it off. Take it off for a minute, when I'm eating lunch in my car. So, thank you very much. \n\nDr. Paul Lazar: But, at least we are able to get a fresh mask every day. And I know that's not true for all the country. And certainly, during the peak of the pandemic, no. The only reason I had a N95 was because one of my wife's friends gave me some he had left over from a construction project. So, they're the ones you buy in the hardware store. I didn't even have a mask for the first couple weeks. My daughter ordered me a face shield made out of a page protector online. The face shield I had within a month. And then finally by the end of April one of the residents swiped some gowns and face shields from the hospital for me.\n\nCrystal Bauer: Slow process, getting all that stuff.\n\nDr. Paul Lazar: Yeah, it was, well, yeah, we weren't prepared. It was just criminal. Anyone who read the paper knew in January we were going to have a big problem and would need a lot of that stuff.\n\nCrystal Bauer: Oh, sorry. Looking to the future, what is your sense of where family medicine is going?\n\nDr. Paul Lazar: Well, it's interesting. One of the things that happened, after all the whole spring of infections or the big outbreak and got things settled down, the middle of July, the administration in the nursing home told me that her corporate had decided to have all the patients do a telemedicine [inaudible] So, we basically lost the nursing home practice and the shots at the end of July. So, I think one of the things that I've seen is the reality doctor patient relation are becoming increasingly de-valued and patients are being treated like sacks of potatoes. Their care is literally being parceled out, sold to the low bidder. So,  I'm getting ready to retire after 38 years, most of it doing deliveries and home visits and inpatient care along with office. And they're not necessarily going to have someone who replaces me doing that whole patient continuity care.\n\nDr. Paul Lazar: So, in telemedicine, one of the things the residents have noticed and I've noticed it too, is that when you're doing telemedicine, particularly if you have a video link, you get a different window into the patient's life. You see their home. You see what's in their home, who's in their home. You see their pets.\n\nDr. Paul Lazar: So in a way, it changes, it pretty much more humanizes the relationship. And so it gives them a lot more insight into the fact that patients are in different situations. I don't remember who wrote the article but it described a distinction between patients problems and their predicaments. Patients may have a simple problem that should respond to a simple intervention. But patients have predicaments. They have for example, an overuse syndrome because of some repetitive motion at work. The predicament is, they need that job. So, you tell them, \"Don't do [whatever that motion is].\" They're doing it because it's their job. But the telemedicine, the good side of that is sometimes you can see their predicament. Their house is too crowded, or they have no privacy to follow whatever instructions you  gave. The bad side is doctors can do telemedicine from anywhere. And so that exposes them to the risk of seeing whoever, whenever.\n\nDr. Paul Lazar: There's all these sites popping up now, where you could... I'll probably do it myself from home. You sign up and practce medicine from home. Random people call in for I don't know how many dollars it gets you. Then for five minutes you listen and you prescribe something that may or may not be appropriate if you had the whole picture.  Is that what we should be doing? Probably not. But the fragmentation of care, I think, is going to become worse and worse and worse. That's a challenge that I don't think our society is able to do anything positive about.\n\nCrystal Bauer: Yeah. Are there any last thoughts that you would like to add? This is your opportunity to share your thoughts with future generations, listening to this recording. Or to set the record straight on anything you feel might be important to address?\n\nDr. Paul Lazar: Well, I'm not sure that I can think of anything.\n\nCrystal Bauer: No problem at all.\n\nDr. Paul Lazar: I do get plenty of opportunities to pass things on to future generations, because I teach the young doctors.\n\nCrystal Bauer: Sure. Which is great. That's good. Well then, thank you so much. If you have nothing else to add, this will conclude our interview and I'd like to thank you so much for taking the time to do this interview.\n\nDr. Paul Lazar: Oh, thank you for doing this. It's a good project. I'm glad you're doing it.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2334/collection_resources/103885/file/203994#t=0.0,1723.12"}]}]}]}