Mental Health and COVID-19 – [Podcast with Vinay Prasad and Lucy McBride]

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Episode title: “We Forgot about Mental Health & Focused only on COVID-19”

Dr. Vinay Prasad had Dr. Lucy McBride on his podcast, where they spoke about the impact of COVID on mental health on people in general, including young children and college kids. The podcast is nearly 1 hour long and is worth listening to, especially if you’re a parent of young kids. If you prefer to read, the full transcript is below.

Most Common Topics & Phrases Discussed

Topic/PhraseTotal Mentions
primary care17
mental health15
long covid8
new york5
blood pressure4
medical school4
san francisco4
college student4
high risk4
public health3
college kids3
grocery store3
flu seasons3
cloth mask3
ventricle thrombus3
human behavior3
dinner party3
primary care doctor3
left ventricle thrombus3
college students2
everyday risks2
higher risk2
severe outcomes2
whole health2
alcohol abuse2
young people2
dinner parties2
ventilated room2
mental health harms2
bone marrow transplant2
new york times2

Vinay Prasad MD00:00I’m back in Plenary Session, Virtual Edition. I’m joined by my friend and colleague Dr. Lucy McBride. Dr. McBride is a practicing internist. She is a great communicator during the SARS-CoV-2 pandemic and someone who has really been synthesizing a lot and giving great practice advice to so many people. Dr. McBride, it’s great to speak with you.
Dr. Lucy McBride00:19Vinay, thank you so much for having me. I’m thrilled.
Vinay Prasad MD00:21I feel like we know each other because we’ve interacted a lot, but we haven’t had the chance to speak face to face. And this is the surrogate for face to face. So be it. Where to get started?
Dr. Lucy McBride00:34There’s so many things to talk about. As I was saying before we hopped on, you are not afraid of putting your finger in the proverbial electrical socket. And you’re like vibrating with electricity. And I’m not either, because I think, as you might agree, when the topic du jour and the national dialogue is in your wheelhouse and when you see so many problems with messaging and with trust being eroded and misinformation being spread, it’s really hard for me, at least, to stand back and watch a train crash. It’s not to say that I know everything or that I have all the answers. And I have learned so much about public health and medicine, and I’ve learned a lot about myself over the last 21 months. But I’m with you. We got to talk about these things.
Vinay Prasad MD01:23Let’s do it. And I think you’re putting your finger on the issue, which is sometimes it appears like a train wreck. Let’s start by talking about college kids because this is a topic near and dear to your heart. You’re only young once, so I hear. And so I’ve experienced. You’re only young once, and you’re only between the ages of 18 and 22 once. And it’s a special time. And I think college is a special place. And the good thing about SARS-CoV-2 is that the risk to 18 to 22 year olds has always been very low. And the bad news is there’s also a vaccine for 18 to 22 year olds, and they have also gotten one dose, two doses, sometimes three doses. And some of these kids have also already had Omicron. In addition to three doses, they’re as protected as you can get. And yet they’re facing, I think, the most strict draconian restrictions on colleges, including they’re not even allowed to go. The college is closed or the college is open, but they have to sit in their room and take their food and eat it in their own room and only talk to their roommate or sometimes not even take off their masks at all. And there’s a penalty for that. It’s not good for them. So I wonder if you might talk about how do you think about college kids, their mental health, their overall health? What do you advise college kids you know?
Dr. Lucy McBride02:34Well, one of them is living in my house right now. He’s my son. He’s a college student who’s virtual right now, despite the fact that he as a 20 year old, he got two shots, Pfizer and Pfizer. Then he got COVID and recovered. Then he got boosted, not because I thought it was such a necessary intervention, but in order to go back to school in the spring, which is now they mandated the third shot. So he got it. And they were going to go back to masks and surveillance, PCR testing, and then they just announced they’re remote. So I think about the risks to college students, the harms of COVID and the harms of restrictions, just like I think about any patient with any illness, I think it’s helpful to think about what is it to be healthy? What does it mean to be healthy? What do we need for our health, our safety and our well being? And in my mind, it’s thinking broadly about that definition. To me, health is about not just the absence of COVID-19, it’s not just the absence of a positive PCR test. Health is about feeling safe, having tools to manage the everyday risks we face in our existence, because, as you know, life is full of risks. Harms are everywhere. And it’s about having an understanding of our own vulnerabilities, our own needs, and then having clear understanding of how to mitigate those risks reasonably. So when you go back to the college student question, every college student is different. You may have an immune compromised college student who is at particularly high risk for Covid. And now, fortunately, we know what risk factors put you at higher risk for severe outcomes. But you also have college students who are at risk for social isolation and the ramifications of ongoing restrictions. Not only on their education, but to their whole health, their mental health. And we’re seeing, as you know, the American Academy of Pediatrics and other expert groups have declared a state of emergency for kids and adolescents, not surprisingly, because kids need school like fish need water, they need their peers. That’s how they develop. That’s how they grow. So I don’t need to tell you that public health is about harm reduction. It’s about recognizing that we live in a risky environment, a risky world, and that we need to understand a broader definition of health and then try to minimize harm when we can without doing undue harm in the process.
Vinay Prasad MD05:15I think that’s so well put. And I think in the case of your son, I feel like it was a false promise of the University. I mean, he got the booster under a promise, and it was a tacit promise that I’m going to do this, even though we can question the medical necessity of this, since I’ve had two doses and COVID and I’m so young and I’m healthy, you can question that. But I’m going to do this. And the promise is I’m going to do this because I need to be back there for my learning, my intellectual growth, my social growth, et cetera. And then the school didn’t hold up their end of the bargain. And that to me is disappointing. And I think it’s disappointing that it would be done by a place of higher education.
Dr. Lucy McBride05:50I totally agree. At the same time, I agree. And this is an “and”. I understand because I try to see all sides of arguments, my husband might disagree, but that we have been bathing in a narrative of fear and protect against COVID at all costs for 21 months. And I’m not trying to give an excuse to these institutions for locking down their students and not thinking broadly about the definition of health. But I think it begs the question, instead of me being pissed off at this institution, which of course I am, and sad for my son, who, by the way, is OK compared to a lot of the other kids, like some of these first gen kids on his hallway who can’t go home, who are depressed and anxious and fish out of water to begin with as a first generation kid, they are suffering in different ways than he is. My point is that I think we owe it to ourselves as a society to think about what went wrong. How did this narrative get started? And look, don’t get me wrong. I’ve been accused of being a COVID minimizer. I know you have, too. I’ve had patients die from Covid-19. I have had patients in the ICU for months from Covid-19. I have patients with COVID right now. I have 25 of them. I have patients with long-covid. I have the utmost respect for SARS COV 2. Absolutely. But I also see patients with diabetes, hypertension, alcohol abuse, substance use, dementia, people who are in abusive relationships at home, who in lockdown, have been faced with unpleasant situations in their domestic situation. In other words, we have to think broadly about what health means. And I just think we need to stop and pause and figure out how this all got started, especially now that we have vaccines that take, as Monica says, our friend, take the claws and the fangs away from the virus, turn it into its wimpier cousin. Not that every case is mild, but let’s face it, mild means mild. And most of my patients have mild COVID. And we need to get on with our life. And I think that February and March, I don’t know what you think are going to be a time of real introspection. I hope, individually and hopefully nationally and rebuilding, looking through the rubble and figuring out what it is we need to prevent a pandemic like this, but also the social harms and the mental health harms on young people in particular.
Vinay Prasad MD08:30That’s really well put. And I’m a hemog doctor. I still attend a lot on service, and I run my clinic, and so there are two ways in which I see the harms of COVID-19. One, many of my patients have been affected and some have passed away even very early on in the pandemic. The second way is as a hematologist on consult, I’m often called to the worst cases when there’s runaway thrombosis and what to do. And so like you, I think I know the ravages and harms of severe COVID-19, no one discounts that. But one has to always think….and I put my policy hat on because I’m somebody who works on policy for many years. And when you wear your policy hat, you can’t just think about the tip of the harm iceberg for COVID. You have to think about, as you say, everything, all the people out there and I guess these school policies, they are being done, I think, out of the purported belief that they will slow the spread of Omicron. I think there are lots of reasons to question that. One is, if you look at America, how many places do you have total control, like you have a college campus? It’s not 1%. It’s like 1/10th of 1% or 1/100th of 1%. The rest of America has no control over. So bars are open, restaurants are open, people are out shopping. That’s Omicron running wild. You’re controlling 1/10th of 1% with a great precision. Ironically, the population is the least at risk and the least to gain personally, what will that do for the broader pandemic narrative? Probably not that much, to be honest. That’s one point. The next point, I think, is that those people, for every theoretical case you may advert, there might be three more diagnoses of anorexia neurosa, which is a lethal condition, highly lethal. There might be somebody who commits suicide for every one-one millionth case you prevent or something like that. You don’t know what’s on the other side of the balance sheet or even things that are short of that. Somebody who takes up alcohol abuse becomes an alcoholic because their school was closed, and being an alcoholic can shorten their life and lead to bad outcomes. And so I don’t think we know the full implications of these policies on…we don’t see all the harms because they’re not measurable. They’re not always in the short term. They can be in the long term. What does it mean for, as you say, the first generation college kid, some fraction of them are going to drop out, disproportionately, not complete college. Their life is forever altered. And what are we doing that for? And then the last point I would make is, sorry, one second [pauses]…the last point I would make is a point about numeracy. I think it’s important to think about the numbers and the absolute differences of these policies is often very trivial. It’s really small.
Dr. Lucy McBride10:54So when you think about quantification, what I think of first is how difficult it is to quantify despair and how we can try to measure mental health harms from closures and restrictions on humanity with suicide rates, right? Or suicidal ideation. People who present to the emergency room thinking they want to hurt themselves. But remember that emotional distress knows many faces. I see every single day in my practice, I’m full time practice, I practice every single day, a week of the week. And I see patients every day who aren’t necessarily suicidal or thinking about self harm or aren’t alcoholic or officially addicted to any particular substance, but who are using substances like alcohol, marijuana, other recreational drugs to self medicate, if you will, pain and discomfort. The pain of trying to manage kids on Zoom school and hold down a job and put food on the table. I see people who are wired and tired and exhausted and having a hard time managing stress. That therefore affects their compliance with their blood pressure medicine. It affects how much caffeine they drink. It affects their cardiovascular health in myriad ways. So in other words, I think just because it’s harder to quantify the everyday mental health toll of living in perpetual fear, it’s harder to quantify than it is. Case rates, hospitalization rates, the distance between two desks in the classroom, doesn’t mean it doesn’t matter. And if I will be dead before, mental health is considered just another organ system like every other organ system. And it’s woven into the conversation in the primary care doctor’s office about whole health and where we have unfettered access to every American for primary care as a hub for problem solving and not just gatekeeping and where behavioral health is woven into that conversation. If that happens in my lifetime, I will just be super happy. Yeah, but I mean, 85 million Americans don’t have health insurance, right? So they don’t have a primary care doctors. Probably more now because of unemployment or the great resignation, right? But if you don’t have a trusted guide to help you marry broad public health advice with your everyday existence, like Timmy was exposed to COVID at his kindergarten, and now I have a scratchy throat. What do I do then? What do you do? You go on the Internet and you see people fighting on Twitter and you see Rochelle Wolensky doing her best, but not good enough at trying to message complicated information. I mean, I’m biased because I’m a primary care doctor, but I do think and I wrote about this for MedPage actually back in the spring is we need to really invest in primary care. In my opinion, more people coming out of medical school. We need more people coming out of medical school not thinking that primary care is like a dirty word.
Vinay Prasad MD14:09Right. It should be a value.
Dr. Lucy McBride14:11It should be a value. And where behavioral health is woven into primary care, we need the patient centered primary care, and we need that to be reimbursed. Anyway, that’s my little pitch for the day. But I think because mental health is a universal condition, not necessarily mental illness, but mental health, we all have mental health. You can’t opt out of it like you can a feature on your phone, your home alarm system, you have it. It’s whether or not you connect it to the rest of your health. Do you connect the fact that your stress and your sleep and your relationship to food and your relationship with your spouse or your partner has anything to do with your blood pressure, your cholesterol, your disordered eating or your gravitational pull to bourbon at the end of the day? Yes, it does. And we need to talk about those things so people can then have the tools to manage stress because let’s face it, life is stressful.
Vinay Prasad MD15:07I completely agree with you that I think people underestimate that if a pandemic causes you mental health or disruption, it’ll manifest in your personal relationships, your propensity to be divorced, your blood pressure, your diabetes management, your alcohol consumption, your marijuana consumption. All these are negative externalities of the anxiety and what it’s done. And some of that is due to, I think, legitimate reason to worry about the virus. But some of it is due to the things we’ve done to try to stave off the virus. I wonder if I might pick your brain a little bit about the very young people in our society, kids. You have always been somebody who when you think about schools being open and closed, you’ve been very balanced about it. And you think about the impact on mothers at home who now have to stay home if the schools are closed, the impact on the kids themselves, the risk to the kids. I wonder how you think about it now as we’re entering that wave of Omicron closures or preemptive closures.
Dr. Lucy McBride16:02I mean, I think about it pretty similarly, which is that we have to try to balance the harms of the coronavirus against the harms of school closure. That’s a very broad framework. But it’s 2022. It’s not 2021 or 2020 when we had very little information about this virus and we didn’t have vaccines in 2020. We now have vaccines. We know that the risk to an unvaccinated child, someone who is… I actually have the data right here. For 12 to 17 year old is .042%. That’s a risk of being hospitalized for COVID. And then with one dose of vaccine the risk is 0.006%. With two doses is 0.003%. The limitation on that study that I’m pulling from, I can put it in the chat, but is that was done during Delta. But remember, I don’t need to remind you that Omicron is thought to be less severe, which is not the same as saying it’s not severe in some people. So in other words, at some point we need to be back to normalcy, right? At some point we need to be back to kind of common sense principle.
Vinay Prasad MD17:22I don’t think everyone believes that. I think some people believe that we’re going to in perpetuity be doing these things. But I agree with you, we have to be back to normal. That’s the promise that people want.
Dr. Lucy McBride17:32Now look, there are a lot of things about normal pre-pandemic we don’t want like we could do better, probably mitigating flu deaths. Right? Do we want 40,000 Americans or 60,000 Americans to die every year from influenza? No. I’m hoping that the knowledge about the devastation of infectious diseases will help people get vaccinated. It will help improve ventilation in buildings. It will help motivate people who are particularly high risk to wear a mask in a grocery store when they go shopping. But I don’t think in the future we need to mask in perpetuity because of the harms that you and I have talked about ad nauseam. We need to see faces for social emotional health and well being. I have a friend whose child is deaf. The suffering that that child has experienced or epidemic is enormous. And those are two and a half years of lost time, which for you and me is less because we’re old, but we got to get back to normal. The question is how will the public tolerate the gradual off-ramping? Because ripping the band aid off, no one seems to want, except maybe you and me. And it’s also maybe not appropriate to rip the bandaid off.
Vinay Prasad MD18:47I think that we missed the opportunity to rip the bandit off. I tried my best, but the opportunity was the message. I mean, I would have liked it to be and I’m curious to know your thoughts, but I would have liked it to be. The message was once you yourself get vaccinated, go back to normal. And here’s why I think that would have been a winning message. One, we see right now, vaccine effectiveness against Omicron. Two doses or even three doses. It’s not 95%. It’s 37% in Ontario data. Even when you get three doses, you’re going to get the Omicron anyway. You may not get it next month when the antibody titers are peaking, but you’re going to get it in three months or six months. We’re all eventually going to get an Omicron or the next. Right. And so if that’s the case, once you get your first two doses and you lose weight, get your diabetes under control, you do what you can. That’s all you can do to mitigate your risk like you did the risk reduction. Then I think that’s when society should have opened, we missed the window in January, we went back to masking. I think that was a misstep. And just one point about flu, and then I’ll let you put your thoughts in. My point about flu would be I think you’re right, that we can do a better job. I remember the people who are most vulnerable for flu never really took any precautions. All the prior flu seasons, I mean, even my patients were on B cell depleting therapy, were going to the grocery store with no mask or anything that was just the way the world was. Maybe they can take some extra precautions. But I worry that not maybe 2022, 2023, 2024. One of these flu seasons is going to be catastrophic because you need to keep being exposed to flu so that some fraction of the people always have some partial immunity. Now that impartial immunity fraction is dropped. And so the amount of us who are going to be susceptible to severe flu will be higher because we’ve missed a few flu seasons. I think respiratory viruses, it’s like a sandcastle near the ocean surf. The ocean is going to engulf it.
Dr. Lucy McBride20:30I was saying to a patient of mine who’s terrified of her six year old, who’s vaccinated getting COVID. I said, I don’t want your six year old to get COVID either. That’s why you got vaccinated. But let’s be realistic. We can’t stomp out the risk of infection. That’s not what the vaccines do, particularly in the face of a highly contagious variant. But getting bugs as children is like flexing your biceps. It’s like working out your immune system, right? It’s like you’re building this layered immunity. And again, no one wants to get sick. No one wants their child to be suffering. No one wants their child hospitalized in an ICU. Obviously, I’m a mother. I’m a person. I’m not a child genocide advocate to all those people on Twitter that accuse me of that. Rather, I’m a realist. And I believe in empowering people with tools to manage the everyday risks that they inevitably face. We cannot make this a risk free world. As long as we have sexual relationships, drive cars, have tornadoes, we will walk out our front door, the risks are everywhere. And so I look at my job as your job probably is to see the patient in front of me. And no two patients are alike. They are as different as stars in the sky. They have different needs. They have different lived experiences. They have different goals. My patients would rather not live till they’re 100. They’d rather live till they’re 80. And I don’t have that choice.
Vinay Prasad MD22:01A clear example of that, Lucy, is that like, if you look at the activities that are popular for fun among our patients, among our friends, our colleagues, skiing, well, that’s not a zero risk activity. Rock climbing, mountaineering, even road biking. I mean, I’m an average road cyclist. The risk of riding on these roads, it’s not zero. Car can hit you. I’m trying to think of an activity that’s very low risk. I would have said golf. Golf is probably on the lower risk of things.
Dr. Lucy McBride22:33It’s like I was talking to my son, my 19 year old who’s in college, and we’re actually talking about the booster shot and the pros and the cons, because my kids, the three of them have a vast understanding now of COVID for better, for worse. And we were talking about it as he was driving. He’s a DJ as he was driving into New York City in a rainstorm to stay with a couple of guys for the weekend in New York. And we were talking about the booster shot. And I’m like, yeah, he’s driving in a rainstorm, going to a nightclub with a bunch of college guys. Like, what could possibly go wrong, right?
Vinay Prasad MD23:04Yeah. That’s much higher risk than the boost. Yeah, right.
Dr. Lucy McBride23:07So it’s all relative. And so at the same time, when I say make sure you’re wearing your seatbelt and make sure you don’t stay up too late or drink alcohol, it’s like, anyway. And that’s actually a good example if you take it a step further, if I said to my child, and plenty of parents do this, you may not drink alcohol until you’re 21. And look, I’m not a believer in underage drinking or buying my kids booze.
Vinay Prasad MD23:33But if you’re an absolutionist, then I think what happens is the kids, they drink a lot more when they’re 21.
Dr. Lucy McBride23:40100%. You may not have sex to your married. So knowing my child, I would lose him. He would be sneaking out the back door and dancing on tables anyway. Now my second child is a real rule follower. He wants to have those guardrails in place because that makes him feel safe. So I tell him, like, dude, you got to get out and do more stuff. So again, parenting is like, akin to treating patients.
Vinay Prasad MD24:10Yeah. It’s like being a doctor. It’s individual.
Dr. Lucy McBride24:13Understand their risk tolerances, understand their particular environmental medical vulnerabilities and arm them with tools to manage. And the other thing to say is, I am not my patient. You are not your patients. I have a different lived experience than many of my patients and many of people out there in the world. Right. So I have to always check my biases and check my ego as well. Just because I think something’s right for patient A doesn’t mean it’s right for patient B or for me. And so that’s where humility comes into play. And that is where to me, one of the beautiful parts about practicing medicine is seeing how little we know about the human condition and how little we can control. We really just don’t have control. Having kids was such a good reminder to me. I went trained at Harvard and Johns Hopkins, where it’s a lot of control, high achieving type A people. And having kids reminded me that we don’t have control over anything.
Vinay Prasad MD25:13That’s so well put. And I think you’re hitting on so many great points, which is that like a good doctor will personalize the recommendation for the person in front of them. And we’ve had that in oncology. I’ve had so many patients who’ve had bone marrow transplant, they come and ask me, should I go to my grandson’s birthday party? He’s a young kid, young kid birthday party. They just had a bone marrow transplant. And as oncologists, we’ve never the answer was never absolutely no or absolutely yes. It was always like, who are you? Where are you in life? Why did you do this? What’s the goal of life for you? You negotiate those things. And yet with COVID, there is an absolute-ism, and the absolute answer is no. But I want to ask you this right now in New York City. In San Francisco, there are some preschools and kindergartens and private schools that are mandating, that kids 4,5,6, wear N 95 grade masks. And what if that’s okay? That’s what I want you to say, because one of the people there’s a New York Times reporter who I think is quite good. She’s the education reporter. She’s asking, where can I get the mask?
Dr. Lucy McBride26:16Where can I get my mask? I feel bad for her because she is mandated, so she has to find it. But she also wasn’t necessarily self aware enough to realize that she was going to get skewered for asking the question.
Vinay Prasad MD26:30But you know what? She’s the reporter, the New York Times, she should go to the school and demand, why are you doing this? Yeah, that’s right.
Dr. Lucy McBride26:36So she should. But how many hours in the day do we have to be outraged? Right? I have a lot of time in the day to be outraged. I make time for outrage. But my point is yes, in my opinion, it should be up to the person whether or not they want to put their child in an N-95 mask. I don’t wear an N-95 with my patients. I mean, most of them are vaccinated. And I wear the KN 95. When I was testing Covid patients, which I still do in my garage before they vaccinated, I had the N 95 mask. But it’s all about gradations of risk. Right. So I don’t think that that’s appropriate. But I also think that if you want to mask your child in an N-95 mask because they’re particularly high risk or you haven’t figured out how you want to balance risk and that’s your prerogative.
Vinay Prasad MD27:28I agree. I mean, I think that’s the key point, which is that if you want to mask your child that way, you should be able to I mean, that’s your child. I think the mandates are crazy. But I do really worry about one scenario, which is that if a three year old or four year old falls asleep wearing a cloth mask, they’re going to get a little gunk on it will get pulled aside. But some of these masks are literally really rigidly tied to the face. That’s definitely not safe. I think if you have a mask that is taught against your face with no gap and a little kid falls asleep, I think it’s a risk that, look, it’s such a risk that they would never do it in Europe. They don’t do it on airplanes.
Dr. Lucy McBride28:06They don’t. It’s a risk. But so is some kid in our community died from choking on unpeeled grapes.
Vinay Prasad MD28:16Correct.
Dr. Lucy McBride28:16Kids, they’re prone to accidents. That’s not something I’m losing sleep over at night. But the other thing I’m losing sleep over is the toll on kids from repeated…sorry. The thing I lose sleep is the emotional, social, educational toll on kids from ongoing restrictions. That’s not mutually exclusive. With my concern about the virus. We can do both. We can walk and chew gum at the same time. I have a patient I saw earlier this week who has dementia and diabetes and depression. So I don’t pick one of those diseases to treat. I don’t pick the depression. I don’t say, oh, let’s treat your depression and go eat all the sugar you want to rev the engine of your diabetes, right? I don’t pick an antidepressant that disrupts this person’s sleep. That’s going to make their cognition worse. We have to thread that needle. Similarly, I don’t say to a diabetic patient, never have alcohol, never have sugar. Even at your 60th wedding anniversary, don’t have a bite of cake. No. Absolutism does harm. It’s not realistic. It’s akin to the mannequin studies for masks. You can say that masks work because there’s a mannequin. But like, my kid doesn’t behave like a mannequin. I’d be really handy if they did all the time. If they just sat there and didn’t do anything.
Vinay Prasad MD29:44Yeah. I wanted to ask you about this on Twitter. You’re somebody who’s very nice. I mean, your disposition and temperament. You’re a sweet person and you have pushed back on some people in a sweet way. And this was without getting into the person. Let’s just say what the content was. The content was something like, imagine you’re a little kid and you get COVID and you get sick and you end up being hospitalized. When you go into the hospital, your parents, they see you in, then your parent gets sick, your parent gets hospitalized, your parent dies and you’re discharged to one less parent. It’s quite a story.
Dr. Lucy McBride30:26That was a tweet by a doctor.
Vinay Prasad MD30:28And you were appropriately critical.
Dr. Lucy McBride30:31And I pushed back on it because I see adolescents as patients. I start seeing patients at age 15, and I see parents and I am a parent, and I will tell you that parents are in a lather. I mean, some parents are. It depends on what part of the country you’re in. But I’m in Washington, DC, which is a liberal mecca. Right. Very cautious people. People are so anxious, and I don’t find that kind of messaging useful. I’m not clear what the purpose is. So I simply said and what I thought was a kind way. Could you please explain the purpose of this tweet? In my mind, it’s stoking fear, and it doesn’t do anything to advance the conversation. If you’re trying to motivate vaccination, for example, if you’re trying to scare people to get vaccinated, I would suggest a different tack. So that’s what that was about. I was trained to speak my mind. I was trained to…it’s not just my personality.
Vinay Prasad MD31:37Well, you were at Hopkins. Yeah.
Dr. Lucy McBride31:41I can’t sit around and watch medical professionals stoke fear when fear itself is driving so many health problems we’re seeing right now. Fear is why so many of my patients are drawn to alcohol while they’re not sleeping, while they’re having heart palpitations and surges in their blood pressure. I mean people have gone to the E.R. for heart attacks and strokes.
Vinay Prasad MD32:02It was fear, but also it was putting the burden on children. I don’t know. No child should ever feel guilty for getting their parents sick with a for 1 million years baby, human beings have been getting their parents sick. That’s part of it. But that’s one, two, the empirical data, if a child in the household is sick, the probability of parents are going to get sick. Thank goodness it’s not as high as if another parent is sick. It’s lower. And we’re not talking about majority. It’s like far less than 50% different estimates put it between 10, maybe 5 to 30%, depending on the variant may be higher with Omicron, but the probability that they would get sick and spread. I’m hypothetically assuming it’s a Delta, because that’s the more lethal variant. It’s low. It’s not helpful. It’s kind of a contrived story. I saw something else from the same person and it said something like, if you think covid and kids isn’t scary, three words for you, left ventricle thrombus. And I was like, look, left ventricle thrombus is scary. I’ve been there. You know, when the EF goes to zero very quickly and you have a failing ventricle, you can get a clot in there and it can easily embolize somewhere else. That is the end product of a body that’s dying. When you get left ventricle thrombus in a very young person, it’s the end product. It’s part of the bad things that happened before death. That’s very bad. It’s terrible. But then you get people in the comments saying, oh, my boy, he’s got the sniffles. He’s got Omicron. Is he going to get a left ventrical thrombus? What should I look out for? And I was like, my goodness, you’ve put panic in people’s minds. There’s nothing to look out for. If your boys feeling good, let them get rest. Give him Orange juice and chicken soup and let them get rest. Life ventricle promise is what you worry about in somebody’s in the ICU, and they have multiple pressers. That’s when you worry about that. So it was so unhelpful. And I thought it’s just unhelpful.
Dr. Lucy McBride33:46I mean, we as physicians have been given this opportunity right this moment. And I look at it as a privileged opportunity to be able to help a wider audience of people who don’t have a doctor, who don’t have access to facts based real time information, who are on either WebMD or reading what Dr. Oz says or looking at political your Senator.
Vinay Prasad MD34:11Your future Senator, by the way.
Dr. Lucy McBride34:14They’re trying to find information. And this is true before the pandemic, right? It’s like people who don’t have a doctor, or even if they do, they don’t feel well and they’re on the Internet buying a whole bunch of pseudoscience. So I feel that I have this privileged sacred ability and little mini platform to be able to message real time, fact based information that’s balanced and that is helpful and hopefully moving the ball forward and not Fanning the flames of anxiety or peddling outrage. You could you have a much bigger platform than I do when I on Twitter. But you could be like, oh my God, I could tell people about my patient who developed pancreatic cancer. Vegetarian, marathon runner. Why would I need to tell people about that? And what does that do? There’s a story every single minute of every single day. The question is, how are we helping people out there? I mean, aren’t we in the helping profession? I don’t know. That’s sort of foundational.
Vinay Prasad MD35:15I agree with you fully. Let me ask you this. How do you walk the line on long covid? I mean, it’s a tough subject.
Dr. Lucy McBride35:21It’s a tough subject. And as you know, there’s abundant data to show that vaccination not only helps reduce the risk of severe outcomes from COVID, it helps reduce the risk of long COVID. I see long flu. I see long RSV. I see long everything. I mean, I have a nurse right now who had COVID and has long covid as more strictly defined, which of course, is not strictly defined, but she has clear saclela, I have a patient who developed rheumatoid arthritis. Is it correlation or is it causation? I don’t know. But she didn’t have any autoimmune conditions, and then post-covid she developed RA. But here’s the thing about long covid. When people are worried about their child, for example, getting COVID-19 because of the potential risk for long covid, I say to those people, I’d rather not deal in the world of what ifs, I’d rather deal in the world of right now and right now our children, many of them, are suffering from not having normal school, not having social interactions, and those have real consequences that are harder to measure. So again, it’s all about framing risk and then being clear about the data. It’s funny to me that long covid has gotten a lot of attention, and I think it needs to be further fleshed out and clarified. But it’s not something I spend a whole lot of time worrying about for my patients.
Vinay Prasad MD36:48Yeah, that’s well put. And I guess the only thought I would add to that parent who is worried that their kid will get COVID and get long COVID, even though the child may have been vaccinated, the thing I would say to that parent is you can make your kid wear whatever mask you want and keep them at home and keep them out of daycare parties, I can’t promise you…well, I say they might not get Omicron this month, but they’re going to get Omicron. And so if Omicron has some propensity of having long COVID, they’re going to get that a year from now or they’re going to get it next month. But it’s not like they’re not going to get it. It’s not an option. It’s either now or later, whatever that brings. But in the meantime, you’re going to really make that kid suffer.
Dr. Lucy McBride37:27Yeah. It’s not a question of if, it’s a question of when. And so the NPIs are really just postponing the inevitable. That said, Omicron is surging right now, when Omicron has taken a sharp right turn, as it will do. Hopefully in February, there’ll be less Omicron in the air. Right.
Vinay Prasad MD37:52But we all know that there’s going to be another variant or it’ll come back. I think what happens with this? Why does the pandemic have this dynamic? We think it’s like our restrictions, like shelter in place, that do it. But the truth is, when you watch the news and you see cases double, double, double, we all change our behavior, even though we don’t admit it to ourselves. We’re less likely to go to dinner parties. We’re less likely to have dinner parties. We’re less likely to go out. And people with more money and means will curb our behaviors more than people with less money and less means and recurb our behaviors. Omacron will plummet, but Omicron may blow up again in March or April or May. We don’t know it’ll have that sort of periodicity to it that pattern.
Dr. Lucy McBride38:28Right. It’s the dance between the virus and human behavior. And again, we do not have control. We can try to control vaccination, ventilation, masking if you’re high risk. But at the end of the day, we can burn a lot of energy and political will and capital by trying to control the uncontrollable. And that’s really one of the things I spend a lot of time helping patients with, whether it’s with diabetes or dementia or whatever. I love alliteration. So I say diabetes, dementia. I can’t reverse the fact that you have a genetic predisposition for diabetes, but I can help you manage the way you eat, the way you exercise, and the way you think about your everyday habits vis-a-vie your blood sugar. Let’s accept the fixed realities and let’s work on the things we can change. As you know, I wrote this article for The Atlantic in the fall about the COVID serenity prayer. It’s really bad. It’s about accepting the things that we cannot change, knowing what we can change, and then also realizing where the difference is. I’m not really a religious person, but, I mean, maybe I should be.
Vinay Prasad MD39:40Maybe this thing will change us all. But you’re really putting it really well. And I like that. Calling it the dance. It is a dance between the virus and the behavior. Yeah. I just want to make one point about ventilation, which is that ventilation, to me, is very different than the masking, because one is like, if you ventilate a room, it doesn’t affect the we can have a dinner party in a ventilated room or not ventilated room, and many of us won’t be able to tell the difference. It’s the same dinner party, so it has less of a burden on us. That’s one, two, there is probably a reason you should have been ventilating these schools better for like decades, right? Nothing to do with this virus, but we all like to be in houses. When you go to your, you know, you go to a cabin that no one’s been in for many months, first thing you do, open all the windows, let some fresh air in. There is a value to that. And I think there are studies that show it affects cognitive performance, etc. That there is a virtue to that. And very likely it will prevent or slow future respiratory viruses in the future that spread in schools and sorts of things like that. It’s a good thing to have well ventilated classrooms no matter what. COVID or no-COVID.
Dr. Lucy McBride40:44Absolutely. And on that note, nature is beautifully well ventilated, which is why these outdoor masks mandates, like in France, that’s just bananas. It’s like the pens, the pens that are clean and the pens that are dirty. Who is cleaning the pens at the end of the day?
Vinay Prasad MD41:05They just dump one into the other. At the end of the day.
Dr. Lucy McBride41:08Clearly, I want like a candid camera on the person who’s actually washing the pens because they’re not washing the pens.
Vinay Prasad MD41:16Now let me ask you about this. It feels like we’re living in two countries and let me give you an example and see what you think. So I’m in San Francisco at the present moment, but I’m not always in San Francisco. When I’m in San Francisco, I walk outside, it’s like 50% outdoor masking. You go into a grocery store, 100%. 100% of the restaurant, 100% of people from the door to the seat, they wear it, they take it off, then they wear it to the bathroom. 100% compliance. I drive 1 hour outside the city. Everything falls by half. I drive 2 hours outside the city. It falls even more. Most people are not wearing masks in gas stations and grocery stores. And I went 3 hours outside the city and I walked into a Target and everyone was staring at me and I was like, oh, boy, what did I do? And then I saw that I was the only one wearing a cloth mask. And then I quickly took it off and I was like people. I was like, I’m the person who doesn’t think this cloth mask is effective. I’m not the one who supports this. Come on. I wrote the article in the Cato Institute. Anyway, but it feels like we’re living in two countries. The gap between elite, Liberal coastal cities and everywhere else in America. What are your thoughts on this? Do you see it in your patients?.
Dr. Lucy McBride42:24I mean, 100%. I mean, as you know, Coronavirus has no party affiliation, yet we’re behaving totally differently in different parts of the country. So it’s another example of how human behavior is dictated by our internal narratives, like, based on how we were raised and our risk tolerances and our values. And politics plays a huge role in that. And it’s not just politics, it’s what everybody else is doing, right? Like, you felt the urge to take that mask off because you didn’t want to be like the uncool kid. Let’s face it, we’re all sort of victims of like, what everybody else is doing, right. But that’s why group think is so dangerous. And that’s why, again, like, if I teach my kids nothing else, it’s like, be nice, be respectful, listen more than talk and think for yourself. And look at the primary data and think about your opinions before you go putting it on Twitter. First of all, and think about it. If it differs from the group, that’s okay. Yes. This is a politicized pandemic. It’s one of the biggest tragedies of our time, as is the moralization of human behavior, as is the mistreatment of children and the absence of understanding about mental health and how relevant it is to our physical health. Those are the things that I lose sleep over.
Vinay Prasad MD43:48You’ve been good this entire pandemic on so many issues, and I’m your biggest fan, and a lot of people are, too. But I have this question for you, okay?
Dr. Lucy McBride43:59Please. Am I really nice in person?
Vinay Prasad MD44:01No, I’m sure that’s the case.
Dr. Lucy McBride44:04Not always. Let me know.
Vinay Prasad MD44:05Well, of course none of us are. But here’s my question for you, which is like, a lot of people agree with you, but as you point out, there’s always, like, a few people who disagree with you, but many of them are anonymous. Who knows these people? But there’s got to be somebody in your life who maybe is fervent pro mask, pro N 95 and kids pro boosting every day until I don’t know what you’re titrating it to the tropones. Maybe. I don’t know. They just want to boost all the time. There’s got to be the most COVID strong person, and there’s got to be someone in your life maybe even more sort of lazy fair about covid than you are. And I guess I’m curious at an interpersonal level. Like if you meet somebody who you went to medical school with or you’re friends with from some activity and you disagree, how do you navigate those conversations one on one? How’s that been for you?
Dr. Lucy McBride44:59That’s excellent. It’s an excellent question, and I love it, actually, because, for example, I am counseling a number of schools in the DC area on reopening, and I am like the outlier. I consider myself very moderate and balanced, and I try to listen, but I’m really an outlier. So it’s like pushing a boulder up a mountain to try to get people to…not agree with me, but to see the issue in a different way. And I hope that I try to see the issue in their way as well. I mean, that’s the point of these conversations and why there’s not one person guiding these schools. But at the end of the day, it’s about one on one conversations. And that’s why I love my job, because it’s one on one. Like convincing a country full of people to believe that COVID is real and not a hoax, or convincing people in the entire United States that the vaccines work, even though we’re surging with Omicran, is more challenging in a way than having a trusted relationships. Whether it’s with your spouse, your partner, or someone you’re on a school committee for, is founded in mutual respect, trust, humility, listening and presenting data. As you know, I love the phrase “In God we trust, everyone else must bring data”. And so here’s the data. Here’s the information that I’m looking at. The problem is that data can be interpreted in many different ways, and data is changing. But if you present someone with data and you present it in a respectful way, with humility and a shared conversation, and you make sure you understand the other person’s point of view and you verbalize that back and you present the frame around the data, it’s not just true that kids are at lower risk for COVID-19. It’s true that kids are at risk for other things. COVID is only one threat to their health and well being. So you have to frame the whole conversation not just about the data, but about what is the point of this conversation? Because again, if we mask in perpetuity, then we’ve lost sight of what our actual goals are as educational institutions.
Vinay Prasad MD47:26Correct. And if we do that, I also wonder why we didn’t evolve to have a flap over our lower part of our face, because if that’s really what’s going to do with the difference, we could have evolved to have the flap. If you want to do it.
Dr. Lucy McBride47:36That would be a really interesting look.
Vinay Prasad MD47:38Yeah, really interesting, because obviously this is a spreader of disease, so it’s surely been selected for. But let me ask you this.
Dr. Lucy McBride47:49It’s I love this is like therapy. This is great.
Vinay Prasad MD47:51Okay. I feel my impression of you. Well, is that pre-covid, I suspect, you are a very persuasive person face to face. Why is that? Because you do all the things you enumerated and you put your point of view out, I think, in a very nice way that doesn’t make someone feel put off, but is also firm, I think. And you take advantage of all the sort of things that we do. When you’re face to face, when we’re face to face at a dinner party and you tell a story, people are going to like your story and see your point of view very clearly. But in the world of COVID, you have to do it through this postage stamp, like how you’re like two inches, three inches across on my screen. It makes it harder. I think it makes it harder to persuade. So I guess I’m curious if you feel like one of the barriers to some of these meetings you’re in where you’re trying to shift a consensus to something. I do think you’re a centrist. I mean, you’re the COVID centrist you’re the center point. You’re not extreme in any direction. It’s that a lot of other people are extreme, but you’re trying to pull everyone back to sort of central position. Is it harder that you don’t have the luxury of being able to do all the face to face stuff?
Dr. Lucy McBride49:05100% because I am a gesticulator. This is going to sound we’re not going to get arrested for saying this. I like touching my patients, like laying on hands. When we couldn’t see patients in person. Remember March 2020, right. And then we finally were in person after a month because I’m a doctor. Right. And I laid hands on patients. It was so nice for them and for me to be able to put my hands on someone’s shoulders and say, look, I’ve got you. It’s going to be okay. I think that it’s not that I do that with all the people on the school board, by the way, but I’m just saying that being in person is part of how we relate to other people. And absolutely, I think you can be convinced convincing with your words. You can be convincing in little sound bites on Twitter. But I think in person relationships are what we need to move forward.
Vinay Prasad MD50:02Yeah, I feel the same way. I feel like of all the ways I’m persuasive, I’m most persuasive face to face, and so that’s been totally taken out of the equation.
Dr. Lucy McBride50:10The other thing that I think I grew up in a really funny family. Like, humor was always valued. And my kids are really funny. I think they’re smart. And it’s like dry, clever. And humor to me is crucial. Not making fun of vulnerable people or moments. But if you can’t have levity during crisis and have the emotional intelligence of when to know that’s appropriate or not appropriate, then that makes life harder. So one of the ways I connect with people is by a sharing my own vulnerabilities. I don’t go around, like, sharing my dirty laundry with people necessarily, but I will talk about myself with my patients, and I will talk about my own vulnerabilities, which I have many of, to patients and other people because I don’t claim to be. Just because I went to a fancy medical school doesn’t mean I’m not human. I mean, I have vulnerabilities, too. So I think sharing vulnerabilities, having facts, framing, conversations, listening, those are all the ingredients to healthy relationships. And hopefully we can do more of that in the public square as we clean up the rubble from COVID.
Vinay Prasad MD51:29You put it so well. And I think you’re on to something, which is that, and I think there’s a literature that shows that sometimes it takes a well timed joke to get someone to see the absurdity of their fanaticism. And so when you’re face to face with someone and they’re taking a really hard line position, you’re like, as long as you’re that hardline, you might as well do that. We put a little poke fun at them and then they instantly see, yeah, maybe I am a little too uptight about this or et cetera. Lucy, I want to give you the last word, but I just want to close by thanking you. We covered a lot of the things I wanted to cover. Mental health, colleges, your thoughts on kids, balancing risk, the whole person. You’ve done a marvelous job of kind of conveying these to the general public. I hope to continue to follow you in the months to come. Although I hope it’s not about COVID, I hope it’s something about something other than COVID.
Dr. Lucy McBride52:14Let’s talk about something else. For the love of God. Let’s talk about rebuilding primary care, putting mental health in the doctor’s office.
Vinay Prasad MD52:21Oh, I have a thought for you there. So here’s my thought on the primary care thing. Okay. I think you’re right. And the future of American health care will only be achieved when we realize that primary care is the focus. As far as I see it, the reason primary care is not the focus. People spend all this time talking about burnout, et cetera. There’s two things. One, it is underpaid compared to other specialties. So you need to change the RVU scales. And these scales were created that, why is urology so sought after? It’s because they have engineered an RVU that’s favorable and primary care RV is poor to fix that. The second thing is Primary Care cannot be the place where you put a boot on the neck of doctors. And what do I think is a boot? All the mandatory modules and quality metrics and all this sort of these policy, people come and they put the boot on the neck of the primary care doctor, and they say, we’re going to gauge you by your mammography referrals or your PAP smears. We’re going to keep track of you. They never go to the electrophysiologist and say, we’re going to keep track of you based on your Wolf Parkinson white ablations. No, they always impose the burden on primary care, which makes it feel like you’re losing autonomy. So I’d say fix the pay, fix the autonomy, and it will be the best specialty
Dr. Lucy McBride53:29And make the relationship and a dialogue the commodity, right? Like the relationship, the trust, the ability for someone to tell me, you know what, I am drinking too much, I’m worried, or I’m in an unhealthy relationship at home. That doesn’t come out of people’s mouths unless there’s trust and space. So if you make the relationship and the time spent with the doctor for counseling and empathy and that’s cheap.
Vinay Prasad MD54:04That’s the classic the doctor’s hand on the doorknob and then the patient says something, that’s the moment you want and it doesn’t happen with every doctor. It only happens with the good ones. Lucy McBride.
Dr. Lucy McBride54:15Yeah make empathy great again is my final word and let’s make primary care great again and thank you, Vinay. You’re an inspiration and I’m glad to know you.
Vinay Prasad MD54:27Thank you so much.

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