Dealing with a Pandemic When You're the Only ID Doctor in Town

Paul Sax: [00:00:12] Hi everyone. This is Paul Sax. I'm editor in chief of clinical infectious diseases. And welcome to the Let's Talk ID podcast. Today we're joined by Dr. Yomi Agbebi, who is clinical section chief and ID fellowship program director at SSM Health Saint Louis University Hospital in Saint Louis, Missouri. Yomi, welcome.

Abayomi Agbebi: [00:00:31] Thank you for having me.

Paul Sax: [00:00:32] Yomi is also the author of a very compelling piece in our voices of ID series, which has just started in CID. It's called "Dealing With the Pandemic When You're the Only ID Doctor in Town," and we'll get to that in a minute. But first, I'd like to start these interviews off by asking the guest to tell us a little bit about themselves. Tell me, Yomi, what's your background? When did you know you wanted to go into medicine? Any inspirations or mentors?

Abayomi Agbebi: [00:00:58] I am a child of Nigerian immigrants to the United Kingdom, so I spent my formative years really between the UK and Nigeria. I always like to say that for Nigerian families, there's only a few degrees account. It's either law or medicine and maybe they'll allow you to be a banker. But those are the degrees that count.

Paul Sax: [00:01:20] [laughs]

Abayomi Agbebi: [00:01:22] So having an interest in science, that was kind of always the direction I would go in. I had the opportunity to have some cousins who were already in the medical field, and there was the interest there, and that's what took me in that direction. Because I was between the UK and Nigeria, I went to boarding school in Nigeria and medical school there. While I was in medical school, I had a friend who was taking American license exams. I said, you know what, I think I'll sign up for that. And that's kind of the first steps against the U.S. I had returned to the United Kingdom, and I worked in the National Health Service for a couple of years before moving to the United States.

Paul Sax: [00:02:02] What was the NHS like?

Abayomi Agbebi: [00:02:04] The NHS was for me, it was a positive experience. I worked in a hospital that was specifically geared to HIV.

Paul Sax: [00:02:16] Interesting.

Abayomi Agbebi: [00:02:16] The Mildmay Hospital and the Mildmay Organization had programs in the UK and in Uganda. It provided full spectrum HIV care, respite care for families and everything else, and that was really where I knew I wanted to do infectious diseases. The challenge with the NHS was just the fact that training took forever. I definitely thought I would want to go to the U.S. To train.

Paul Sax: [00:02:42] Did you have family in the United States to welcome you

Abayomi Agbebi: [00:02:45] I had cousins of that relatives that came by. All my family lives in the UK. I was the one who wanted to run away. I definitely didn't like British weather, so I always knew that I would be the one who wanted to try something else.

Paul Sax: [00:03:01] So tell us about your training here in the United States.

Abayomi Agbebi: [00:03:05] For me, the first step was even just coming here. I was lucky enough to see an advert in the British Medical Journal for a residency program at Tufts Baystate Medical Center, and I thought it was a joke when I saw it, because that's not the usual way you get into the U.S. So I went for this interview in Belfast, walked into the room and the chief of medicine at Tufts Bay States was someone called David Longworth. He was an excellent infectious disease physician. And I walked in and he spoke to me in a Nigerian language to say hello. And I thought, how did he know that? And he said, oh, I had been in Nigeria as a student and learnt a few words and had a great time there. So once I said I want to do infectious diseases, he said, come with me. I got the opportunity to do a residency there and also to do elective rotations with him as well. And he was just an excellent clinician, not just as an ID physician, but an all-round clinician. So it was just a great learning experience.

Paul Sax: [00:04:08] Well, I'm going to give you an incredible coincidence. When I was a medical student doing my very first inpatient rotation in medicine at Beth Israel Hospital, back in the 1980s, my very first attending was a young ID specialist named David Longworth. The very same!

Abayomi Agbebi: [00:04:25] The very same. Yeah. Just watching him work and the thoroughness and the detail was just inspiring for me. Yes.

Paul Sax: [00:04:32] So after Worcester, Massachusetts, and I say Worcester, Massachusetts. Great accent. Where'd you head?

Abayomi Agbebi: [00:04:38] Springfield, Massachusetts. They won't be happy with you on that one.

Paul Sax: [00:04:42] Oh my goodness, I'm embarrassed as a New Englander, I guess I'm showing my Boston roots because I'm not able to look out beyond route 495.

Abayomi Agbebi: [00:04:54] So after doing a residency in Springfield, then I went to do a fellowship at Barnes-Jewish hospital, Washington University in Saint Louis. I did my fellowship with a focus on HIV, and from there I went on to work at a University of Maryland medical center as my first faculty job, and it was while I was in Maryland. It was a great experience. I got to work with the PEPFAR grants, do some traveling, to Haiti to train and do HIV treatment. That was fun. I had younger kids and I didn't want to travel as much. And also as well. I think that one of the things that I was also a thing that I used to see as a junior faculty was I used to hear senior faculty complain about their pay. So it was a great experience for me. So at that point, I just kind of made the pivot. Two things. One, I didn't want to travel and I thought, oh, I got young kids. So I had an opportunity to start a practice in North Carolina, Salisbury, North Carolina, and that's how I ended up in North Carolina as the first infectious disease physician at a almost 300 bed community hospital, took over, built up that practice and that program for that community.

Paul Sax: [00:06:03] How long were there before the pandemic started?

Abayomi Agbebi: [00:06:05] I had been there for about, I think, about eight years, seven-eight years before the pandemic came along.

Paul Sax: [00:06:10] And what was the practice like before the pandemic?

Abayomi Agbebi: [00:06:13] Before the pandemic, it was basically, what was interesting was. It was an example of not knowing the value of ID until you have it. So initially it was like, uh, infectious diseases. Maybe we need it for some people, but over time, it became an essential thing because we I got involved with antimicrobial stewardship with one care and I basically was taken care of pretty much most people in the community, either directly or indirectly. And because it wasn't such a large town, I always had the privilege of people saying, oh, you took care of my brother or my cousin or my friend, as well. And for the hospital, I became a resource for pretty much both the infectious disease things and the infectious disease adjacent questions. So there was a system because we're part of a system and we had ID pharmacists, but a lot of the time for locally I was. The primary care doctors had my phone number. They could call me with questions. I was there for the hospital. Over time, because of the work and the volume, I did have some excellent APS advanced practitioners who helped me out with that, but I was still "tag you're it" for everything.

Paul Sax: [00:07:35] Yes, you got to do not just clinical ID, but you also got to do infection control, antibiotic stewardship, the whole the micro lab, right? Pretty much everything.

Abayomi Agbebi: [00:07:44] Yeah. Just call like.

Paul Sax: [00:07:46] So I'm going to ask you a question that, that I find fascinating. When I ask every doctor this, they all have a moment where they realized that this thing Covid-19, was coming for, for them or coming for us. And when was it for you?

Abayomi Agbebi: [00:08:03] For me, they were really kind of two points. The first kind of red light was watching news in Italy. And seeing the rapid spread and the deaths that were happening in Italy at that time. That was the first red flag. And then the second point where I really knew we were going to get the brunt of it was when we started having cases in Washington, Washington State. When I saw those cases by then, I grew up, you know, between different continents. So travel is something I'm used to. I didn't think the virus was going to stay in one continent.

Paul Sax: [00:08:45] Yeah. You know, think about it. We were so lucky with SARS, weren't we? I mean, it's amazing. Kind of kind of never had a case in the continental United States. It led to some of our complacency, certainly. But you know, you knew. You knew since you were a traveler that you can't keep these viruses at the border. So you describe a very big change in your interactions with patients and colleagues during the course of the pandemic, going from, you know, friendly pre-pandemic to now, confrontational. And I'm just going to quote from one of your examples. You write, "I vividly remember a man in his 70s in the ICU whose wife was two rooms down from him on a ventilator, and he was yelling at me as he gasped for air that he didn't have Covid, he was going home this very minute because his son was coming to get him. Never mind the fact that he was on maximum oxygen support and was about to be intubated." Why do you think this change happened?

Abayomi Agbebi: [00:09:39] I think there are multiple reasons. I think the first thing for me is that I'm a student of history. Pandemics are always political. We did have a failure of political leadership. When you look back at the history of pandemic flu, you can actually see pictures of people arguing over masks at that time as well. So it's not a new thing. Pandemics are political. They change economies. They change civilization. That's something that I think was there. So that's the first thing. Then take on the fact that there was a lot of fear that came to the equation. And then the last thing I think the piece that once the fear was there, there was really no trust. And then finally, I think, and this is a difficult thing and no criticism to the people, had to do the communication. It is really hard to communicate about a disease about which you're also learning in real time. I always teach medical students that if you're dealing with a physician, if they know everything, be worried. To communicate to the public that you're not entirely sure, but this is the best approach, doesn't sound very definite or confident inspiring. In an atmosphere where most institutions don't have a lot of trust, this was a perfect storm of a time to have a pandemic.

Paul Sax: [00:10:58] And would you describe your location as rural or urban? Let's say, I'm just going to say left leaning or right leaning?

Abayomi Agbebi: [00:11:06] It was interesting. I would say it was a semi-rural. We were literally just a 40-to-50-minute drive from Charlotte, but geographically it was definitely semi-rural. It was definitely more right leaning. But the interesting thing for me was that I had so many relationships with so many of these patients, and for most of the people I dealt with, and I knew I could get them to say, you know what? This is the best approach. This is what we need to do. But for people who had not had any contact with me, there was a first experience. Whatever baggage they came in with was what they had from watching the TV or listening to radio and everything else. The trust wasn't there. One of the challenges was making sure that you had to, in a short period of time, build some level of trust with people who were afraid, angry, and really did not have any trust in anything or anyone. That was a challenge. I mean, I remember already kind of two anecdotes that kind of describe that for me were I had a lady in her late 60s who had Covid and kept having increase in oxygen requirements, and this was during the time when I was trying to sign up people for trials. We were trying to do the convalescent plasma trial I kept. I talked to her probably about 2 or 3 days, and she told me, no, this is an experiment. You're trying to make money off me, and if I die, it won't be Covid. You're going to say it's Covid to make the numbers look good so you get paid.

Abayomi Agbebi: [00:12:41] She said this probably 2 or 3 days in a row and the oxygen requirements are going up. We're doing everything else. And then finally she said, you know what? I'm going to do the trial. The controversies around plasma aside, she recovered. A few days later, I had a younger man in his 20s come in, and I had, you know, I walked around carrying my consents forms with me and I said, you know, I need consent you for the plasma trial. And the guy said, no, no, don't tell me about it. Just give me the form. I'll sign it. And I said, no, no, no, I need to talk to you so you understand why I said, no, no, no, just give me the phone. And I was like, why? And he said, my grandma told me that when that black doctor comes in your room, whatever paper he gives you to sign, just sign it. The trust for her was based on her experience of interacting with me. Highly subjective, but that was a lot of what we saw. I also had situations where we had patients in the hospital who brought in their own ivermectin, the animal version, and they kept it under their pillows, and we didn't know about it and actually had ivermectin poisoning in the hospital.

Paul Sax: [00:13:52] Now, one thing you mention is that despite your growing frustration, you quote, never yelled at anyone. That kind of emotional self-control "is a basic survival instinct for a black man." How do you think the pandemic ended up changing how patients viewed you as both a doctor and a person of color, and especially in the South?

Abayomi Agbebi: [00:14:13] Yeah, it was interesting because in all my years in our community treating patients, my color was never an issue. But I think during the pandemic, it was just part of the toxicity that just came in with everything else. It was more an issue of just trust more than anything else. I never really felt that the reason people weren't going to do something was for the color of my skin. It was more about the color of my coat. That was the real issue. It was more the white coats. I don't think there was a trust for health care at all during that period of time. That was a primary thing for me from a personal level, having worked in, you know, different environments, the self-control is essential because everyone has their own assumptions. You have to make sure that you don't reinforce the wrong assumptions for patients. So that's a challenge that I was already used to. And if I want to build trust with these people, the last thing that I needed to do was lose my cool.

Paul Sax: [00:15:19] Well handled. But you know, we all were under an enormous amount of stress and many of us developed coping strategies to manage it. What did you do? I mean, you already mentioned you have your kids and, you know, I happen to know from chatting with you before that you're married to a doctor. So what did you do to manage the stress?

Abayomi Agbebi: [00:15:37] The biggest thing for me was actually going to a different level in terms of running. Before the pandemic, I wasn't a runner. When I was younger, I couldn't run a mile, but I started trying to exercise because I didn't have the self-discipline to go to the gym regularly. But during the pandemic, I really leaned into running a lot more. It helped me to get calmer because a lot of the time, it wasn't that I wasn't angry or upset because there was just a cognitive dissonance between what was going on outside the hospital, what was going on inside it, and also with some of the conversations I was having with patients, because a lot of the time was spent addressing a lot of misinformation. So it was frustrating. So I found running allowed me to be able to kind of vent off some of that. And also it calmed me down and there were just so many things we were juggling at that time that I found that running was a time when I could step back a little bit, and I got quite a bit of clarity from it. So it was good therapy for me.

Paul Sax: [00:16:41] Plus, plus it was outside.

Abayomi Agbebi: [00:16:43] Yes, absolutely.

Paul Sax: [00:16:45] You might remember from, from your time in New England that hockey's very popular here and hockey turned out to be a terrible from a Covid perspective.

Abayomi Agbebi: [00:16:52] [laughs] Oh yes. Yes, oh yes.

Paul Sax: [00:16:54] Ultimately, Yomi, you know, the job turned out to be overwhelming. Not surprisingly, you're the only ID doctor in this town. And there's all of this chaos associated with Covid. And you went to the administration and asked for help. What did they say?

Abayomi Agbebi: [00:17:09] Yeah. Pre-pandemic, I was, one of the things when I say all of a sudden, people realize they need ID, was we were already dealing with significant patient volumes pre-pandemic, and that was fun. I liked being available. I like being a resource, and my view has always been that the standard of care that I wanted people to get in a community hospital had to be just as good as if they were in an academic medical center. I had been a fellow at a large academic center, so I already knew the snobbery of being the guy at the teaching hospital and looking at that medical charts and thinking, what were they thinking? I did not want to be that person. So the standards I wanted were really high, and it meant that I had a lot of relationships. Infectious diseases is such a relational specialty, with lots of providers who had trust in my care. So we had a lot of volume. Even before the pandemic, they had told me, oh, you're an outlier in terms of volumes. And I said, yes, I'm the only provider here. That had been a conversation that had happened, which I didn't really know how to handle. And when I spoke with a lot of my colleagues in ID, they were like, that's the first time we've heard of anyone talking about you seeing too many patients.

Abayomi Agbebi: [00:18:22] That's normally not the problem. When the pandemic was over, and I thought to myself, you know, I do not want to go through a pandemic alone in this specialty. When I had the conversation, at first it was, you know, for you it would probably mean a loss of income. And I said, you know, I don't mind. And then it really was a case of, you know, we don't think we have the budgets to have another physician. And I think part of that is also the dilemma of infectious diseases. We make things work. I had made it work under those circumstances and situations. So if it ain't broke, why improve it? So to speak? That was an issue as well. Once I knew that there wasn't going to be an opportunity to have a partner, to kind of spread the work onto, it was difficult for me because I had to begin to think about my own well-being. While I had so many staff working for me and a community that I cared about. So it was a tough decision.

Paul Sax: [00:19:21] Well you know your piece, it ends on a hopeful note. You left that position. You're now the section chief and ID fellowship program director at your hospital. So what's different? And what's the same in this new job of yours?

Abayomi Agbebi: [00:19:34] I think the first thing that I always joke about, I told my wife the same thing I tell my friends, the same thing is I actually have someone who helps me with my administrative stuff. I have administrative assistants. I have someone who tells me, you can't sign up for that meeting. Your calendar is full, so that's kind of first thing. Administrative support, because I did everything in my previous job, both clinical and administrative. I just did it. So that's the first thing. The second thing as well is just having colleagues. It is isolating when you're the only one there. I had my text groups of ID colleagues and friends who we texted back and forth, but it's not the same thing as having colleagues around you that you can bounce things off being in a conference, learn from. So that's the second thing I'm glad about as well. And then the third thing is having colleagues also means that when I log out of epic and I'm not on call or I'm on a day off, I am really not logging in as the electronic medical records.

Paul Sax: [00:20:36] And have a little bit of decompression time.

Abayomi Agbebi: [00:20:38] Absolutely, yes.

Paul Sax: [00:20:39] So just one last question, people. Where you worked before, have they read your piece and if so, what have they said?

Abayomi Agbebi: [00:20:47] Oh, the response has been just overwhelmingly positive. A lot of them messaged me and said, you know, just to thank me first. It's like we miss you. We wish you were here. That's always been, that was always even before the piece. But after the piece, there was an appreciation. It was also we miss you, but we're also glad that you did what you did. Your choice. You made the decision for your family. I mean, I even had people who I didn't know who reach out to me with emails to thank me for writing the piece as well, because it resonates with them as well.

Paul Sax: [00:21:20] Well, Yomi, thanks so much for for joining us on this podcast. And once again, I've been talking with Dr. Yomi Agbebi from SSM Health Saint Louis University Hospital in Saint Louis. He's written a piece for CID called "Dealing with the Pandemic When You're the Only ID Doctor in Town. It's available on the CID site and in print soon, and I highly encourage everyone to read it. Thanks so much for joining us.