A pediatric infectious disease physician shares his pandemic lessons [PODCAST]

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“COVID-19 has changed nearly every aspect of society as we know it, and doctors in hospitals across America are at the forefront of those changes. As a pediatric infectious diseases doctor who also writes curriculum to help the next generation of doctors prepare for their medical exams, I’ve seen firsthand how this current pandemic is changing our roles with patients, shifting what families and communities expect from us, and expediting advances in training and information sharing across the field.

While my work at a children’s hospital is obviously focused on children and adolescents, the shifts I’m observing and the lessons I’ve learned impact doctors in all areas of practice who want to provide exceptional care to their communities.”

Nicholas Rister is a pediatric infectious disease physician.

He shares his story and discusses his KevinMD article, “3 lessons I’ve learned as a doctor during the pandemic.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Nicholas Rister. He’s a pediatric infectious disease specialist, and he wrote the KevinMD article “3 lessons I’ve learned as a doctor during the pandemic.” Nicholas, welcome to the show.

Nicholas Rister: Thank you for having me, Kevin. It’s a pleasure to be here.

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

Nicholas Rister: I grew up on the East Coast, in Norfolk, Virginia, Virginia Beach, and there’s a big children’s hospital there named Children’s Hospital The King’s Daughter. So growing up, that was always part of our community, and when I went to med school, pediatrics kind of called to me, so I definitely went that route pretty quick. I tell people I chose infectious diseases along the way because I couldn’t decide what part of the hospital I wanted to work in. I wanted all the cool cases all over the hospital, from the NICU to the CICU, so I’ve really enjoyed that.

I traveled up to Washington, D.C., to Children’s National for fellowship, and then recently made the move out a couple years ago to Fort Worth, Texas, to Cook Children’s, where I’m practicing as a pediatric infectious disease doctor. And then also out there, there’s UWorld, which is a company that a lot of us are familiar with for our board prep, that works out there, and I spend a lot of my time doing test prep materials with them as well. So I get a good balance of inside and outside the hospital.

Kevin Pho: Now, over the past year and a half during the pandemic, paint a picture. Tell us a story about how that has affected you as a physician.

Nicholas Rister: Well, I think it affected me a lot, like a lot of stories you’ll hear from everyone in this. Going back to the beginning, where you’re hearing these stories of this virus appearing in China, the concern that this might be a much bigger thing starting to rumble, and then seeing that emerge. Especially being on the infectious diseases side of this, we do a lot of the hospital epidemiology, we do a lot of the hospital protocols for contact tracing and all that, and that was a whirlwind. I mean, I remember early in this cycle, even leading up to January, February, it felt like every single week we were changing plans. Best-laid plans, but suddenly the next day, it doesn’t apply anymore. So it’s just been a whirlwind for that.

Now, at the same time, I’m so proud of how well, as a community, we’ve been able to rally behind this and get some semblance of consistency in a disease, in a world that’s changing so rapidly. So for me, every week has been different, but I think we’re starting to see some consistency in our responses to COVID, and certainly in how we manage those patients in inpatient and outpatient settings. So it’s been fascinating but exhausting at the same time.

Kevin Pho: We’re speaking towards the end of July, and I just read a paper that the Delta variant of the coronavirus is approaching 70 to 80 in the United States. Now, from a pediatric infectious disease standpoint, what would you say are some of the biggest challenges now and going forward in the foreseeable future?

Nicholas Rister: Well, it’s going to be interesting for us, because children have been a relatively protected part of our population, not only in that they do remarkably well with the virus, and that’s still true even with the Delta variant. Even though it’s more contagious, patients aren’t getting sicker as far as we’re aware at the moment, and that applies for children as well. But what’s different is that we’re not behaving the same way with our children. Children are now going outdoors, they’re doing those play dates, they’re going back to school, which are all great things, but it means that protected segment, because during the worst of this epidemic, they’ve been staying home. They have been cocooned more than any other part of society, but they’re not anymore. So you’re going to see a much larger proportion of children getting COVID going into the fall, especially since vaccines aren’t available for a large portion of the population as of today. So it’ll be bigger numbers for them, for sure.

Kevin Pho: And then, what’s your forecast for the vaccine in children younger than 12?

Nicholas Rister: All the major vaccines are currently doing those studies, some down to even six months of age. So I think in the next couple of months, we’re going to hear about that, and we’re going to hear when that’s going to be approved. I expect the data is probably not too exciting. It’s probably very similar to adults: very effective, very safe. But they have to do those studies, and it’s harder to enroll younger kids, especially those younger kids down to six months. Not a lot of people want to enroll their infants in a drug trial, so as you can imagine, they move a lot slower, and the numbers aren’t nearly as robust. But I think we’re going to have data on that coming out in the next couple of months, and I think it’ll be a pretty rapid approval coming after that.

Kevin Pho: And as the school year approaches in the fall, any advice or messages to parents from your world in pediatric infectious disease?

Nicholas Rister: You know, I tell parents there’s no one-size-fits-all. It all depends on your family and your situation. I think everyone’s aware of the mechanisms that prevent spread: the social distancing, things like masks, being aware of who your children are around when they’re sick, and trying to avoid that. But how you do that is different for every family. Some families, everyone works at home, and they have six kids. Some families have one kid, and someone’s at home who can stay with them. I mean, the responses those families are going to have are just going to have to be very different.

So I think the best thing you can do is sit down with your family and your pediatrician and chat with them about what works best for you, because it’s all about managing risk. You can’t make it zero, but I think you can do your best for your family to keep things manageable. So I always encourage people to start that conversation early, before things get busier, for sure.

Kevin Pho: All right, let’s transition into the KevinMD article that you wrote. It’s titled “3 lessons I’ve learned as a doctor during the pandemic.” Now, for those who need to get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Nicholas Rister: Going into this COVID pandemic, I saw it from two angles. There was the education side of me, where I was doing this work with UWorld, where I’m trying to think how is the best way to teach people about this topic. And that really got me thinking down the road, because that’s going to be something: Once we have this knowledge base, how do you disseminate that? And we’re still figuring COVID out, so it’s fascinating to me. We talked about how many years down the road until we really start testing people on COVID to make sure they know this stuff. But at the same time, how do you start to inch this material into basic lessons for physicians, or just CME, to make sure everyone’s getting disseminated information as best as they’re able to?

But then I thought, OK, well, in the short term, how does this apply to my patients, educating families? And the biggest thing with this pandemic is that when something’s emerging, it’s new; you don’t have the information people want. I mean, I had so many families come in and say, “What’s the chance my kid’s going to get this? What’s the chance I’m going to give it to them? What’s that going to be like?” And I didn’t have those answers. I don’t think in the beginning anyone did. You had ideas.

And I think the key thing I wanted to get in that part of the article was the transparency. You have to be honest with families, and you’ve got to explain to them that we’re going to work through this together, but there’s a lack of information, and as we get more, we’re going to change our plans, and those plans are going to change, and they’re going to change again. But the important thing is that you’re honest and open about that, because this isn’t something where you give patients anticipatory guidance one time and you’re done. This is going to be an ongoing conversation. I don’t think in the beginning I thought it was going to be so ongoing, two years out, but it is, and those conversations have changed along the way.

And the other big thing is that, as pediatricians and doctors, we always think our patients are going to do their best to listen to us, and I think they try, but we’re not always the major mechanism of training change. Someone’s neighbor, their family member, someone there they trust out in the community, almost always is going to be who they’re going to be listening to, especially when it comes to things like treatments and vaccinations. So engaging those members of society, going out and finding the schools and the teams there that are talking to families, going out and talking to the church groups and other folks that really kind of have their finger to the pulse of their community: Those are the members in your community who are going to drive that change.

I think reaching out beyond just the medical community, this community, was key, and I think we see that in areas that do a good job reaching out and making community-driven health care initiatives. Those are where you’re seeing higher vaccination rates, for sure. But this is a very difficult topic, and everything, to broach, so sometimes, despite everyone’s best efforts, it’s still very, very hard to do that. But that’s another key thing I wanted to point out, and I’ve learned: There are just so many resources we don’t traditionally think about in medicine that you can utilize to get information out and get patients to really take heed.

Kevin Pho: When it comes to patient education, I think vaccine hesitancy, of course, has been at the forefront, and we live in a society, as you know, that’s very polarized, very politicized, and a lot of people are kind of entrenched in their own beliefs. So against that backdrop, what are some of the techniques that you use to help educate patients, specifically with the vaccine?

Nicholas Rister: Yeah, I mean, the biggest thing is, first, you’ve got to listen. You’ve got to understand why someone says, because oftentimes it’s not exactly what you think about. It could be someone thinking there are microchips in a vaccine, or it might just be someone who’s just unsure because it’s not formally approved yet. That’s a very different conversation. So before you walk in, when you walk in the room, make sure you’re understanding what the concern is. Listen to it.

The other thing is, you may not get them to do it that day, but it’s a long-standing relationship. A lot of times, like we do with so many things, if you bring it up repeatedly, if you reach out, if you ask them where they’re getting their information from, and potentially if that’s through different Facebook groups or through a church or something, you can sometimes even reach out to those groups and offer some expertise or answer questions. Sometimes you can use that as a jumping-off point to really reach out to a broader group and get them talking in a different way, which can help.

And at the end of the day, as we’ve had the vaccine more and more available, try to make sure you know exactly how to tell them to go get it, because there’s a good proportion of folks out there that don’t get the vaccine, but they’re not necessarily resistant to the idea of it. But they’re not going to go that extra few steps sometimes to go get it. So it’s really making the vaccine as available as possible. If that’s in your clinic, wonderful. If that’s just letting them know, “Hey, you go right down the street, you make it right there, you get it at this time,” or tell them, walking through, sometimes that decreases that barrier enough.

And I think, of course, as pediatricians, the biggest thing is trying to go over the why: why I feel so comfortable that this is going to work for your child, but I think it’s safe for your child. As is so common in pediatrics for us, we often have less data than in the adult world, but we do have good data. So it’s important to sit down and try to explain that, because in a world of misinformation, that can be really tough, because there is always less information with pediatrics.

Kevin Pho: We’re talking to Nicholas Rister. He’s a pediatric infectious disease specialist, and he wrote the KevinMD article “3 lessons I’ve learned as a doctor during the pandemic.” Nicholas, you mentioned that you work for a test prep company creating test prep questions, so that’s something I’m interested in delving more into. So how did you get involved with that industry?

Nicholas Rister: It really was, I was finishing up fellowship, and as everyone does near the end of fellowship, you’re like, “Oh, crud, I’ve got to get a job.” So you start looking everywhere for jobs, you start talking to folks, and you start paying attention to job postings. So I saw the UWorld job posting. I recognized UWorld because I used the materials when I was studying for my boards, and I said, “Hey, this could be, you know, what is this thing? This could be interesting. What’s the harm in reaching out and seeing what it’s all about?” And I did. And as we got to chatting with the group over there, I’ve been a lifelong nerd. I was one of those people that didn’t mind studying for Step 1. I don’t know if I liked it, but I didn’t mind it. And so it was kind of like-minded folks, and it really seemed like a good complement to my clinical career.

A big part of what we do there is not only test prep but having that grounded in real-world practice. Almost every single person that’s writing those prep materials is a practicing physician, and that’s really important, because I think that keeps us grounded. Because sometimes, if all you do is test prep, you forget what you’re really doing as a doctor day to day, and that’s incredibly key to bring into the training. So that’s really what it was: kind of an organic meet and greet, and then it evolved into a job offer. And it’s just gone really well, balancing that and my clinical practice.

Kevin Pho: Now, walk me through the workflow of a typical test prep question, say, from conception to the final product.

Nicholas Rister: Yeah, I mean, one of the biggest things you do is you try to anticipate what’s going on with the test materials you’re having people study for, because at the end of the day, you want to make sure people are passing their tests. But you also want to make sure they’re not just passing the test today. You want to make sure they’re going to be passing the test that might be coming out years from now, and kind of prep for that. So you’re not always having an evolving product, but you also want to make sure that what you’re teaching them is useful information.

It used to be, even when I took the Steps, there was so much memorization, where there were so many acronyms, where you really just kind of had to memorize a lot of information and then regurgitate it, and then you could vent a lot of that information. You don’t get away with that so much now, for, I think, good reasons. I think now tests are much more geared towards critical thinking, coming up with thoughtful differentials, doing the sort of thinking you’re actually going to do as a practicing physician.

So the workflow really is coming up with, OK, what’s a topic that’s tested on this exam? What are the key pieces of information about that topic? Oftentimes, we’ll study a topic even before looking at the test questions you might get about it, to see what we think is really important, where we think this topic is going. Then you start designing questions, and there’s an art to questions. I’ve been doing it now a little over two years, and I don’t think I’ve got it down at all. I mean, we have folks who have been doing this for decades, and they just have an art mindset to it, of crafting these questions and making sure you’re having a thoughtful way to get someone to think about a presentation and what you really want them to core down to as far as learning objectives.

But that’s really how it goes, because it starts from bedside practice and researching the topic, and then trying to come up with these test question ideas that are consistent with the level of exam that you’re taking. And the form of that can change, and it always does change year to year.

Kevin Pho: As someone from the other side of the curtain, what’s the single biggest piece of actionable advice that you give to medical students and physicians when they’re taking board exams?

Nicholas Rister: You know, it’s so silly, but whenever someone’s sending you, whether it’s a recertification or your primary board exam, they really do release those documents to tell you their vision for the exam: what percentage of things they’re going to be testing on this exam, big-picture ideas, what the test questions are going to look like. And I think that’s incredibly important. We do our best at UWorld to keep our test prep stuff up to date, but things change so fast. So looking at, year to year, the document for the test you’re going to take, just that fundamental at the start of your test prep, is incredibly key, because the last thing you want to do is spend weeks studying something that’s 1 percent of the exam.

So I see people all the time struggling with certain topics, and I’m like, “Make sure your struggle is in balance with how much of this exam that is.” So those are incredibly key. And I was guilty when I took these exams without reading that. I was like, “I’ll just study everything.” But you can be so much more efficient with your time. I think as practicing physicians, especially folks doing research and seeing me, it’s important to try to not overwork yourself in areas if you don’t have to. Make sure you have time to study your interests, but plenty of time set aside for exams.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Nicholas Rister: Never stop learning. One of the best things about the way my career has gone is that I have this balance of test study prep with my clinical practice. I always have my list of things I want to look up the following day, and I know it’s so hard for us sometimes, at the end of the day, to look into those things. But having that time for myself to really delve into topics and feel like I’m constantly learning and improving is so key. I find that that keeps me grounded. It helps prevent burnout, that I set aside some time to make sure I remember that this can be fun, this can be interesting. Because there are some long days ahead, but it’s nice to make sure you carve out that time to remind yourself why you enjoy doing this in the first place.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Nicholas Rister: Sure. Thank you, Kevin.

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