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In this episode, we hear from Alen Voskanian, a palliative care physician, who shares his personal experience with COVID-19. Dr. Voskanian reflects on the mental coping mechanisms he used to try and understand how he contracted the virus and the guilt he felt about potentially exposing his family. He also discusses the challenges of seeking medical care as a physician, including the fear of asking for help and the stigma surrounding seeking care for mental health. Dr. Voskanian ultimately learns the importance of prioritizing his own wellness and encourages other physicians to do the same.

Alen Voskanian is a palliative care physician.

He shares his story and discusses his KevinMD article, “A physician in denial after being diagnosed with COVID-19.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Alen Voskanian. He’s a palliative care physician, and we’re going to talk about his KevinMD article, “A physician in denial after being diagnosed with COVID-19.” Alen, welcome to the show.

Alen Voskanian: Hi, thank you so much for inviting me.

Kevin Pho: We’ll get to the article in a little bit, but first off, briefly share your story and journey to where you are today.

Alen Voskanian: Sure. I came to the United States when I was 19 as a refugee, on my own, and I don’t have a lot of people in health care in my family. So I went to a community college in Los Angeles, then transferred to Berkeley, and was able to get into UC Irvine medical school. I did my primary care residency at UCLA, and after that I did a fellowship in HIV and AIDS. That was the early 2000s. I saw a lot of HIV patients die in a hospice setting and realized that there was a huge need for HIV patients, but also for all patients at the end of life, so I decided to become board-certified in hospice and palliative medicine.

What always drives and motivates me in health care is helping people who are underserved. Initially it was HIV-positive patients, and then I made a career pivot and focused on palliative care. Slowly I started taking on more leadership roles, so currently I serve as a medical director for a large multispecialty medical group. Currently about four days a week I am administrative, so I oversee the running of a medical group, but one day a week I see patients. Actually, my clinical work is focused on identifying and treating anal precancerous cells. I do high-resolution anoscopy, and I have an anal dysplasia clinic, so that’s what I’m really focused on right now clinically.

Kevin Pho: All right. And how did you get interested in that field?

Alen Voskanian: When I was serving patients with HIV, the rates of anal cancer were going up, and I had a couple of patients who were diagnosed with anal cancer. So naturally I started questioning if there were ways to prevent that, and I realized that folks at UCSF were already doing anal Pap smears, or anal cytology. I got interested in getting trained and got training at UCLA and UCSF for this procedure. Again, it goes back to my passion for being attracted to areas of health care where patients are underserved, and I realized that anal cancer screening was one of those areas. Patients were ashamed to talk about it, there was a huge need, and it was something that other doctors were not interested in addressing. So that’s my journey to anal dysplasia.

Kevin Pho: Now, from a patient standpoint, what kind of risk factors or symptoms might they have to ask their doctors to be screened for anal cancer?

Alen Voskanian: Yeah, that’s a really good question. Immune suppression is a big risk factor. It comes in the form of HIV or AIDS, having low CD4 cell counts, but also being on immune-suppressive medications, for example, after a transplant. Being exposed to HPV, especially the high-risk HPV, puts people at risk. Age is another risk factor, and smoking is another risk factor. So those are the main risk factors we look at when we think about who is going to be at higher risk for developing anal cancer.

Kevin Pho: So I’m a primary care physician. What kind of symptoms do patients typically present with in my exam room that would make me think, “Hey, this might be anal cancer”?

Alen Voskanian: Yeah, I think the biggest thing, as a primary care doctor, is that I recommend people not think that everything is hemorrhoids. In the cases of actual anal cancer that I see, patients have been having anal bleeding, their doctor has assumed it’s hemorrhoids, and they’ve been telling their doctor, “Hey, this is not going away,” for months and months and years. Hemorrhoids, as we know, come and go. They get better. Sometimes they’re painful, sometimes they’re not, and they’re associated with constipation. But if a patient says that they’ve been having bleeding that doesn’t go away for a long time, or they’re having pain, that should be a red flag. Then there are also the risk factors: for example, MSM, men who are sexually active with men, or immune-suppressed patients. I think with those, the worry should be less about anal cancer but about anal precancer, like anal dysplasia, and figuring out if they would benefit from getting an anal cytology.

Kevin Pho: All right, let’s shift gears here and talk about your KevinMD article. It was written back in December, and it’s titled “A physician in denial after being diagnosed with COVID-19.” Now tell us, how did this article come about?

Alen Voskanian: Yeah, I thought I was immune to COVID. I got vaccinated, and initially, obviously, like everybody else, I was extremely careful. I have three young children, so we were always putting on masks and always protected. Almost three years passed. We traveled, we started going out, I didn’t get COVID, and I was like, “Oh, maybe there’s something that is protecting me.”

Right when I started letting my guard down and started traveling, I went to a medical conference. I got off the plane and got in a taxi. It was in San Francisco, and right before I was getting in the taxi, I heard the taxi driver cough. I had that one moment of thinking, “Maybe I shouldn’t get in this taxi,” but I felt that would be rude, so I got in, and the driver coughed the whole time. Again, I’m not sure if that was the person who gave me COVID, but two days after I got back from the conference, I got COVID.

I think I was in total denial in terms of thinking that I was immune. Even when I was having symptoms, I was like, “This is probably just a cold.” But the test was positive right away. I’ve been tested over the last couple of years and it never tested positive, but with this one, as soon as I tested, within a few seconds it turned positive. I was like, “Oh, here we go.”

Kevin Pho: So what went through your mind when you tested positive? You mentioned that you took all the precautions, your masks, vaccines, and whatnot. So when you first got that positive test, tell us what was going through your mind.

Alen Voskanian: First I started questioning. I was like, “How did I get it? Who was it?” There are so many variables. I was on an airplane, obviously the taxi driver, but also a medical conference. So first I was questioning, and then second, I started thinking about how this would play out. I had patients two days from then. I was also supposed to travel the following day, so at first I was just worried about going to this conference. I wasn’t feeling as sick yet. I was just having a runny nose, and I thought maybe I could travel. All of those things were going through my head, but then I realized that I just needed to cancel my clinic and cancel my travel plans. So that’s what I was really focused on initially. Because I was feeling OK, I wasn’t too worried about it. I was like, “I’m going to get over it. It’s just going to be like a cold, but let me take care of everything that I need to take care of.”

Kevin Pho: Now, has this episode of you getting sick with COVID changed your mindset about prevention and preventative habits going forward?

Alen Voskanian: Yeah, you know, I feel like it’s a balance between how much we let our guard down. Going out during the holidays, do we go out? Do we celebrate the holidays? It’s been such a long time of not being able to bring teams together and celebrate, and I really miss that. I think a lot of people are missing that social connection.

In some ways, COVID impacted me significantly. My symptoms got worse, I got really sick from it, and the fatigue took a long time to get over, so I don’t want to get it again. But it did give me a little bit of a sense of security: “OK, I just got it, and I just got over it.” So I felt a little bit of relief. I was like, “OK, I can go into the holiday season knowing that I just got it. I have a little bit of natural immunity to get me through it.” But as that natural immunity goes down, I definitely don’t want to get it again at all. It wasn’t like a cold. It was much more severe. I was like, “How come it’s so much more painful to go through this than a cold?” So I think it’s a serious virus. Some people say, “Oh, well, for me it was something simple.” For me it wasn’t, and I don’t want to get it again.

Kevin Pho: Now, did you try Paxlovid or some of the therapeutics after you were diagnosed with it?

Alen Voskanian: You know, that’s why I wrote this article. As a physician, I’m really focused on wellness, and as a physician, I guess I’m not proud of the way I dealt with COVID. I was like, “I’m just going to get over it myself.” I didn’t want to bother my primary care physician, so I didn’t really reach out. I was struggling, and a colleague called me and saw how horribly I was feeling. I was short of breath when we were talking on the phone, and it was like, “You have to call someone and take care of yourself.” I didn’t want to. You know, making an appointment is not an easy thing. We know access is a big problem everywhere in the health care system. I was like, “I’m just going to deal with it on my own.”

I think that was my motivation for writing this article, because I wish I had just been a better patient, called my doctor, and gotten care. I think I would have recovered faster. But it took my friend saying, “I’m going to call our other friend, an infectious disease doctor, to call you, and you need to get Paxlovid.” I needed that push. My symptoms started getting better when I got Paxlovid. So if I had to do it again, I would just be a better patient.

Kevin Pho: So how long did you have symptoms from this episode?

Alen Voskanian: As soon as I got Paxlovid, a lot of my headache and my shortness of breath started getting better. The fatigue lasted for a long time, I would say a good month.

Kevin Pho: Are you still feeling fatigued? Are you still feeling the effects?

Alen Voskanian: I think I do feel fatigued, but it’s my baseline fatigue. I wake up very early, so I’m back to my normal baseline level of fatigue. But the fatigue that I was feeling from COVID required me to go to sleep much earlier than I usually do, like around 6:30 or 7. I was like, “I’m done. I need to go to sleep.”

Kevin Pho: Earlier on, you talked about that balance between public health safety, like masking, versus that social connection, and that’s really the crux of the issue, right? Different people have different values in terms of how much value they place on public health and how much value they place on the other end of the spectrum, with that social connection. Now, you briefly talked about some of the questions that you asked yourself in terms of determining where you stand on that spectrum. For those people who are listening, take us a little bit deeper into your thought process. How can one navigate that going forward, in terms of how much protection they should continue to have and maintain, versus going out, going on vacations, and having that social connection, perhaps sometimes in unmasked settings? How does one navigate that?

Alen Voskanian: Yeah, it’s very complex. I think some of it is an individual decision, but some of it is looking at the trends of positivity, where we are. As trends change, as the rate of positivity goes up, I think we should be increasing those measures that are going to protect us and protect the public.

You know, I have three kids who go to school where no one is wearing masks. We’re in a public school district, and my kids are also very social, and they engage in a lot of physical activity with other people. I realized that the toll of the separation and isolation, the toll that was taking on my kids, was significant. So I wanted them to start engaging in some of their physical activities and to go out as much as possible. You know, we’re trying to protect them, and for me, public health is that if my kids have any cold symptoms or any symptoms, they’re not going to be going to school, and they’re not going to be putting other people at risk. I’m hoping other people would do the same.

Kevin Pho: We’re talking to Alen Voskanian. He is a palliative care physician, and his KevinMD article is titled “A physician in denial after being diagnosed with COVID-19.” Alen, for those people who are listening to this and read about your story, what kind of messages do you want them to come away with?

Alen Voskanian: I think the takeaway is that as a physician, I’m sometimes not the best patient. I guess my takeaway was to seek out and get help if you are experiencing symptoms, instead of just thinking that it’s going to get better, whether it’s COVID or a lot of other things.

I’ve been really focused on physician wellness and burnout and did a lot of research, and I experienced burnout before. I know that there’s so much stigma for physicians seeking care, whether it’s medical care or care for their psychological well-being, and I think that’s unfortunate. I understand there’s a lot of history and many valid reasons why there is that fear to seek out and get care, but I guess my takeaway message is that we are human beings, even though we’re physicians, and there are times we’re going to need care and to reach out and get care.

My passion for the well-being of physicians comes from my desire for patients to get the best care, and for patients to get the best care, they need to have physicians who feel well, who are not burnt out. That’s the reason I was motivated to write a book about my own experience of burnout and finding wellness, and the experience of other colleagues and physicians who went through that journey of burnout and found a way to have joy in practicing medicine.

Kevin Pho: What’s the title of your book, and where can readers and listeners find it?

Alen Voskanian: The title of my book is Reclaiming the Joy of Medicine: Finding Purpose, Fulfillment, and Happiness in Today’s Medical Industry, and they can find it anywhere they buy their books: Amazon, Barnes & Noble. It’s published with any of the standard booksellers.

Kevin Pho: All right. Thank you so much for joining me and for sharing your story.

Alen Voskanian: Thank you so much, Kevin, for having me on. Thank you.