EP. 10: IN SERVICE OF A GREATER CAUSE

WITH DEAN WINSLOW

May 11

WITH DEAN WINSLOW, MD

An Infectious Disease Specialist and retired Air Force Colonel shares stories from the front lines of the HIV epidemic and from his military career.

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Episode Summary

Dr. Dean Winslow has led an extraordinarily multifaceted career as an infectious disease specialist and former US Air Force colonel. In his pioneering work at the front lines of the AIDS epidemic, he headed one of the first HIV clinics in the country and created HIV treatments and diagnostics still used today. During his multiple deployments to Afghanistan and Iraq as a flight surgeon, he commanded field hospitals that treated military personnel and local civilians alike. As a long-time professor of medicine at Stanford, he has been a popular mentor to hundreds of medical professionals. In this episode, with his trademark cheerful and humble demeanor, Dr. Winslow shares the colorful, poignant, and amusing stories he has collected over his decades of service.

Dr. Dean Winslow is an infectious disease specialist, hospitalist, public health leader, and retired Air Force colonel. For the last four decades, Dr. Winslow has been at the forefront of treating patients with HIV and has helped develop important tools and medications used to diagnose and treat HIV. He was previously vice chair of medicine at Stanford University and was chair of the Department of Medicine and Chief of the Division of AIDS Medicine at the Santa Clara Valley Medical Center.
Dr. Winslow's distinguished military career includes two deployments to Afghanistan and four deployments to Iraq as a flight surgeon supporting combat operations. Dr. Winslow currently leads the CDC’s COVID 19 Testing and Diagnostics Working Group and is a senior advisor to the CDC Southwest Border Migrant Health Task Force and the Vaccine Task Force.
Dr. Winslow is a master of the American College of Physicians, fellow of the Infectious Diseases Society of America, and fellow of the Pediatric Infectious Diseases Society.
How a college music reviewer came to write for The New York Times - 1:41
• Dr. Winslow’s personal path that led him to medicine and his initial work during the early days of the AIDS epidemic - 2:51
• How Dr. Winslow manages the emotional burden that comes with treating seriously ill patients with HIV - 20:24
• Dr. Winslow’s experiences in military medicine and how they have shaped his medical career - 25:31
• A humorous story on solving a tough infectious disease case through medical detective work - 32:09
• Dr. Winslow’s advice to medical trainees who may be struggling with burnout, and what improvements should be made to the medical system to take pressure off medical professionals - 36:51
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:03] We are joined in this episode by Dr. Dean Winslow, an infectious disease specialist, hospitalist, public health leader and retired Air Force colonel. As a disclaimer, there is no succinct way to adequately capture Dr. Winslow's diverse and decorated career. But here we will try nonetheless. For the last four decades, Dr. Winslow has been at the forefront of treating patients with HIV and has helped develop important tools and medications used to diagnose and treat HIV. He was previously vice chair of medicine at Stanford University and was chair of the Department of Medicine and Chief of the Division of AIDS Medicine at the Santa Clara Valley Medical Center. Dr. Winslow's distinguished military career includes two deployments to Afghanistan and four deployments to Iraq as a flight surgeon supporting combat operations. Dr. Winslow currently leads the CDC, COVID 19 Testing and Diagnostics Working Group and is a senior advisor to the CDC Southwest Border Migrant Health Task Force and the Vaccine Task Force.

Tyler Johnson: [00:02:00] I wanted to say less formally so when I was a chief resident at Stanford, we used to have this meeting once a year where we would get all of the trainees together in a room totally confidentially with no faculty there except for the program director. And we would go through every faculty member who worked with the House staff just to make sure that all of the people who were working with House staff were up to snuff and being really great teachers. So ostensibly the main reason for the meeting was to identify any faculty members who were a problem. But an unintended consequence of the meetings was that we also came up with this list of doctors who were known as the Yoda's of the hospital who were like so universally respected as wise, kind, almost magically talented doctors that everybody always wanted to work with them. And Dean Winslow, who we're going to talk with today, is on the Yoda list.

Henry Bair: [00:02:51] So, Doctor Winslow, as our introduction hopefully illustrates, you've led such a storied career to set the stage for our listeners. Can you go all the way back and tell us what first brought you to the world of medicine?

Dean Winslow: [00:03:08] So, first of all, Taylor, thank you for your kind words. And I'm very honored that you and Henry came up to talk to me about this. And I'd first of all, like to point out, though, for people listening to the podcast that Dean Winslow is just a name, not a title.

Tyler Johnson: [00:03:25] Fair enough.

Dean Winslow: [00:03:26] But no. Anyway, I grew up in Dover, Delaware. I went to public high school and love sports, and I loved academics and I really wanted to be a doctor since I was a little boy. And it was very fortunate to have teachers in high school that were really very stimulating and encouraged me to kind of aim high, so to speak. I was very lucky that I was accepted to this Penn State Cooperative five year program with Jefferson Medical College in Philadelphia. So I was just 23 when I graduated from med school. And even though I love surgery and ob gyn and pedes, I would have been happy really doing any specialty. But the reason I loved medicine was because it was the most general of all the specialties. And at least back in the seventies, it was kind of the specialty that you went into if you really wanted to sort of understand pathology and how that related to clinical medicine. Probably the reason I went into infectious diseases as a subspecialty also was because of the fact that it is just so broad and, you know, you're forced to sort of think of of human beings, you know, as whole people with multiple organ systems, you know, not just a heart or a liver or a kidney, etc.. So anyway, after my residency and fellowship training, I went into private practice in Wilmington, Delaware. It was in 1981 and literally saw my very first AIDS patient, that first week of private practice. And again, the disease had really just been described a few months before. So a lot of my, you know, first, like seven or eight years in practice was defined by the AIDS epidemic.

Dean Winslow: [00:05:02] And of course, it was scary back then because at least until 1983 or 84, we didn't really even know what caused AIDS. So that I think was a big thing that affected sort of my development as a doctor. I just feel very, very lucky to have gotten into medical school and to have become a doctor. And it really was my dream. The other thing that I've told people about the perspective of people not to be too discouraged about things was I actually had the lowest college board scores, the lowest SAT scores I found of anybody that ever got into that five year program. So I feel like doubly lucky that I got into medical school, you know, just reading the resumes of people applying for residency or fellowship, you know, as well as medical school, you know, it's not enough like to do what I did, which was, well, I played football and ran track and volunteered at the nursery school, at my church, you know, to take care of little kids in the nursery. You know, nowadays it's not enough that you've volunteered. And worked for an NGO, let's say, during the summer, during a whole year you actually have to start your own NGO. And so the barrier has become incredibly high, I think, to become a doctor. So and I go to work every day at Stanford, just totally inspired by, you know, working with people like the two of you. That's the big thing that keeps me very interested in this wonderful business that we call medicine.

Tyler Johnson: [00:06:27] Well, okay, so I'm grateful to have that whole arc, but now I want to go all the way back to the beginning. You mentioned this very briefly, but for our listeners, I think it's a little bit hard to remember, especially if you're not old enough to have been sort of aware and remembering during the time. It's a little bit hard to even recognize now what it was like to be any kind of doctor, but especially an infectious disease doctor during the very early days of the AIDS epidemic, as you mentioned, I just want to give a little bit of a very brief primer. So HIV is caused by a virus that infects cells in the immune system. And so what happens is that people are infected with it. Usually they don't even know often when they're primarily infected. And then it sort of is hanging out in their immune system, not really causing problems for many years. And then eventually it starts to ravage one particular part of the immune system called the CD4 T cells, which are just a part of the immune system that is really important for battling against certain infections. And so what would happen during the very early years of the HIV epidemic is when HIV has been there long enough and had enough of an effect, then the person actually develops AIDS, which is when the immune system is compromised. And so during the early 1980s, these especially young men would show up with these really serious bizarro infections that you almost never saw, and then you would treat that infection. And then they would get another one and another one and another one. And so when we talk about CD4 count, that's just a way of measuring how healthy the person's immune system is or how much it's been affected by the virus. And then when we talk about viral load, that's talking about actually measuring how much of the virus is in the person's blood. And so the hope with HIV therapies is that you want the CD4 count to go up and you want the viral load to go down because that means they're reconstituting the immune system and then able to fight off infections normally.

Tyler Johnson: [00:08:18] Again, Dean, there was a period where we literally didn't even know what was going on. We even knew what it was. And then even once we did know what it was, there was for a long time, for a number of years, nothing that we could do about it. Right. And it's also hard for us to remember now we have such wonderful treatments and people can avail themselves of such great therapy that it's become effectively a chronic disease like diabetes in developed countries like the United States. But back then it was really, really frightening for patients and I think also often for doctors. So you mentioned this a little bit, but can you talk to us a little bit about what was it like caring for patients with HIV and AIDS during that time? And how did that shape you as a doctor?

Dean Winslow: [00:08:58] Great question, Tyler. About a year or two ago, I put together kind of a talk with just selected patients with the focus not as much on their diseases, but actually on vignettes about who they were as people. So I certainly do not miss the 1980s in terms of, you know, our treatment for AIDS. And as you mentioned that, you know, HIV, at least in the developed world now is very much a treatable disease. In fact, if you just take your antiretrovirals, you can pretty much live a normal, long, healthy life. But it really was not like that in 1981, when we first started seeing these very first cases, we actually got very close to our patients and in terms of supporting them, because while we could treat their opportunistic infections, they invariably develop more and more serious complications and infections that were ultimately fatal. So we knew that our time was very limited with these folks. And of course, we did go to funerals and memorial services, not on an unusual basis. I remember if you have time, you know, just to tell you a few vignettes. So I did both adult and pediatric infectious diseases back in the seventies. When I started my training, there were very few pediatric infectious disease specialist. So in addition to seeing the very first, the least known adult AIDS patient in Delaware in 1981, I think was 1982, I saw the very first pediatric AIDS patient at the Alfred I. DuPont Nemours Children's Hospital in Wilmington.

Dean Winslow: [00:10:28] So it was hard, you know, breaking news. So I'll just tell you a little bit about this toddler that I saw. It was a two year old Latino boy, just beautiful little boy. And he had a condition called lymphoid interstitial pneumonia or LIP, which had recently been described as a kind of unusual manifestation of pediatric AIDS. And I remember going and talking to the mother after examining the child and reviewing the imaging studies. And I told this lovely young mother, "I'm so sorry, but your baby, I'm afraid has this new disease called AIDS." And of course, we did not have antiretrovirals, really an effective antiretrovirals, that is, until the mid 1990s. So, you know, there was really nothing to do other than, as I said, you know, to be able to for a minute or so, you know, hold this young woman's hand again. I could just go on till you dozens of stories about some of the adult patients I saw. And one of the things I think that made me not just a better doctor but a better person was supporting these people, you know, through just a terrible time. A couple of stories just to to tell you they're a little bit funny, maybe a little bit bittersweet.

Dean Winslow: [00:11:45] But I remember this one, just gentle soul. He was actually, you know, worked, I think, as a florist, again, a young gay man. And he developed a disease called Cryptococcal meningitis. And at that time, this was before we had the orally available antifungal assaults like fluconazole. And so we treated him with at that time the standard of care, which was intravenous Amphotericin B, dioxin oxalate, which we used to call shake and bake because it caused just such terrible fever and rigors. People were just miserable. We actually routinely pre medicated them with not only steroids but Benadryl, Tylenol and even IV morphine, because that would actually stop the the rigors. And again, so he went through six weeks of induction therapy with daily Amphotericin B and five FC because again, all these patients relapsed. If you stop treatment because again, we didn't have fluconazole, then I kind of developed this regimen, you know, that I think a lot of us did. So I would bring him in to the infusion center once a week and give him a dose of Amphotericin B, the Oxy Collet. So I would usually try to time my hospital round, so at least I could swing by on Wednesday morning or whenever it was that he had his infusions.

Dean Winslow: [00:13:07] And I still remember just how gentle his spirit was. And here he is having terrible rigors and just suffering and I feeling bad because I'm like torturing this lovely man, you know, to keep him alive. And my wife had recently given me it was right after Christmas had given me this kind of very pretty lavender colored sweater. And, you know, as I walked in and said hi to my patient and and of course, you know, he's shivering and he turns to me and he holds my hand and he says, Doctor Winslow, that sweater is such a pretty color on you. And I started crying. It's like, you know, here I came to comfort him. And, you know, he's actually comforting me. And I had another story, you know, probably around that same time. And I use the patient's name because, you know, HIPAA doesn't apply actually after somebody is dead. And so I use actual patients names, if I can remember them, as a way to keep their memory alive and to honor them. And this man is about my age at the time, so that would have been probably mid-thirties and his name was Joe Noto. And Joe was again late thirties white guy and he had developed AIDS from injection drug use. He had been like a hardcore heroin addict since he was a teenager and he had been diagnosed with HIV as that point.

Dean Winslow: [00:14:32] We did have a blood test by 1985, about two years before he was not only a patient, but because he had a car and still had a job. At that point. He was one of our best volunteers and he would actually, because we didn't have very good public transportation in Wilmington, would swing by people's house and pick them up early in the morning to bring them to clinic and then take them home again. And he volunteered, you know, in the soup kitchen of one of the local churches. And so he was just this lovely person. And he finally developed a disease called Disseminated Mycobacterium Avium or disseminated Mac, as we sometimes call it by shorthand. And even though we had antibiotics to treat the disseminated Mac, you know, similar to what we use now, the fact is, though, that it was really one of the last infections that you would get before you finally died of lymphoma or some infection that wasn't treatable. So Joe had disseminated Mac and his CD4 count, I remember, was six, and he was my last patient in clinic that morning. And I had, you know, a little bit of extra time before I had to go back to my lab.

Tyler Johnson: [00:15:40] Just to interpose for our listeners really quick, a CD4 count of six basically means that his immune system was shot he had no immune system to speak of anymore.

Dean Winslow: [00:15:48] Exactly. Tyler Yeah. The normal CD4 lymphocyte count in someone without HIV is like 1000, typically. So anyway, the at the end of our clinic visit, I had a few minutes too. And so I said, Joe, and I was by myself. I didn't have a fellow or a resident with me that day. I said, Joe, you know, this diagnosis is kind of bad news. And, you know, I'm just I want to be real honest with you that you don't have that much time left. And Joe, who had just had this lovely sense of humor, again, you know, he grabs my hand again and, you know, the tears are coming down my cheeks. And he said, he goes, Doctor Winslow, you know, goes, "Don't cry." He said, "Yes, I know my T-cell count's low," he says, "In fact, I'm on a first name basis with all six of my T-cells," you know, and again, I really then I really tear up and, you know, I said, "Joe, you're just such a lovely man and I'm just so grateful to you for all you've done for the clinic and for us." And he said, "Doc, don't cry for me." He said, "You know what?" He said, "If I hadn't gotten AIDS two years ago, I never would have gotten sober." And he said, "in these last two years of my life have been the most precious, meaningful two years that I've lived in my 35 years."And of course, that made me cry even harder. And I got tears in my eyes just telling you guys that story. So there were a lot of stories like that in those days.

Dean Winslow: [00:17:19] The other kind of last sort of funny story, and this is maybe a little bit politically incorrect, but this is also a pace clinic probably around 2010, not that many years ago. Patient was get about my age or a couple of years older and he was an openly gay man that lived in San Jose and, you know, very adherent with his medication. And I never really knew him that well. He was one of these people who was just very quiet. It was kind of hard to get him to open up. But again, this one day after our visit, it just I picked up this energy that he seemed kind of sad. So, you know, I said to him, hey, Bill, you know, I've got some time. And I was worried that he was depressed. And, you know, we should get him to see our psychiatrist to we had a full time psychiatrist in our clinic. And I said, "Bill, you seem sad to me. You know what's going on?" And there was this long pause. And neither us said anything for several seconds. And I said, "Bill, you can tell me." And he goes, "Well, Dr. Winslow. He goes, I'm going to be real honest with you. He said, I'm not really depressed or anything. Don't worry about that. He said, But just it's a lonely existence being a conservative gay man in the San Francisco Bay area."

Dean Winslow: [00:18:33] It's like I say, not every story is heartbreaking. But anyway, I love being a doctor and you know, I love kind of getting to know my patients. And we never worked together, I guess, on the wards. But have I sure that the house staff, they they probably roll their eyes because I take longer in the patient room probably than I should. But the problem is I get sidetracked, you know, like I remember, gosh, just a couple of years ago, there was this African-American lady that was homeless. And again, she was about my age. So again, it's easier to talk to people who are my age or older because they have these rich life experiences that you can often relate to. Whereas I think when you're younger and you haven't had the life experiences yet, it's a little harder to small talk with old people.

Dean Winslow: [00:19:20] So anyway, so I'm talking to, you know, this African American lady and I don't know how we got on the subject. I guess I asked her about what did she do, you know, when you were younger going to work. And she said, Oh, I was one of the backup singers in Motown. And it's like, oh, my God. You know, it's like, that was the music of my generation, you know, growing up in the sixties. So that was so cool at the time, if you remember it. But they used to give like rich people at Stanford Red Blankets. Even though I used to be a Republican, I would find that, you know, a little bit sort of classist, I guess is the word. So I'm showing my liberal colors here. But anyway, this one patient who actually was a red blanket patient, Ken, was a really nice guy. In fact, he had actually flown bombers in World War Two. And I said to him, I said, Hey, I got lady in the next room and said that we just love that red blanket. He goes, Yeah, I got a couple of these at home. You got to take it. So anyway, so I gave the homeless lady the World War two bomber pilot's red blanket to take home with her.

Henry Bair: [00:20:24] Thank you very much, Dr. Winslow, for sharing all these stories. It's really quite remarkable that you were able to remember such vivid details about your patients and hearing a lot of your stories. I can't help but recognize that many of them are bittersweet, as you've mentioned. I have to imagine that taking care of these very seriously ill patients day in, day out, must exert some sort of emotional toll on you. So I'm hoping you can tell us how you were able to manage those emotional responses. What do you do to make sure that when things get tough, you're able to continue going forward and meeting patients where they are at?

Dean Winslow: [00:21:15] So I think, you know, I handled it in a number of different ways. So I've always sort of pop philosophy that I share with students and residents, whether they want to hear it or not. But my simple minded way, there's sort of three parts to us as human beings. You know, there's our physical bodies, there's, you know, our emotions and our connections with people that we love. And then third part that some people believe, including me, that there's a spiritual aspect to who we are as people. And I think, again, the challenge as a person is to try to keep those three things in some sort of balance. And it really helps if you have children like I did. So in a way it made me a better dad because, you know, I would see so much sad things during the day in the hospital or in the clinic that it made me love my children even more and sort of cherished them. So I think, you know, having a supportive family is really helpful. Honestly, though, it's also really important, I think, to take care of yourself physically. And, you know, as I mentioned, you know, I've been an athlete in high school and college both. You know, in fact, as soon as you guys leave, that's one reason I'm dressed in PT gear.

Dean Winslow: [00:22:25] I'm going to do 45 minutes on a bike or go for a run, you know? So I think taking care of yourself physically is really important. And, you know, again, I also think that for some people, there may be a spiritual part of your life and realizing that all of us are on the earth for such a short time and to really be grateful for kind of the things that we're given. Some of that also was the fact that my mom and dad were both from the Midwest and were real do gooders. I mean that in a positive way. You know, like my dad was on the board of Delaware's NAACP. My mom learned Spanish when she was in her forties and worked in the Migrant Ministry, you know, which is, you know, largely Latino workers in Delaware's fields and farms. And they were both very. Active in the church and with volunteer activities and in Dover, then later in Wilmington when they moved up to Wilmington. So, you know, to me, being a doctor is the best job in the world because it's not only intellectually challenging and exciting, but you get to help people every day. That's your job.

Tyler Johnson: [00:23:31] So, Dean, one of the things that I wanted to ask, I think one of the things that you're known for among the residents and one of the things that we can hear just listening to you, I mean, I feel like it's remarkable to do anything for 40 plus whatever, it's been years that you've been doing it and to still be able to say that you love it and it's the best job in the world. Right. And one of the things we talk a lot about on the podcast and one of the reasons for the podcast is because we all hear about the epidemic of burnout. And I think a lot of doctors, frankly, are disillusioned with the profession and don't find that same magic and joy in it that they once did. And so the thing that I sense from you is that it feels to me that every time you walk into a patient's room, it's like you view it as a privilege. You're excited about it. You know, there's this sort of anticipation of discovery both about the person and about whatever is going on Pathophysiological and whatever you can do to fix it. But across the many decades of your career, how have you cultivated that? Like, how do you still have this sparkle in your eyes and this spring in your step on very, very busy in-patient services at Stanford? How have you managed that?

Dean Winslow: [00:24:40] Well, talking to my wife, Julie Parsonette, she might actually say that the reason I sort of still have a young person's outlook is because I haven't matured beyond about eight years of age, you know, so that's one explanation for it. But, you know, again, as I mentioned to you, though, I literally am grateful every day that I got into medical school and basically was able to pursue a career of my dreams. In fact, it's even been beyond my dreams. You know, I couldn't have planned out, you know, the different twists and turns in my career if I'd done it deliberately. And again, that's another bit of unsolicited advice I give to medical students and residents and fellows is don't be too worried if your career is not linear, because sometimes those diversions or turns in the road end up being better than anything you could have planned up front.

Henry Bair: [00:25:31] We've talked a lot, Dr. Winslow, about your experiences treating patients with AIDS. But there's this whole aspect of your career that we haven't even begin to explore, and that's your military career. You joined the Air Force in the early eighties and rose through the ranks until you were colonel. And I know that you've actually published many stories about your experiences treating patients in the battlefield, and we'll be sure to link those in the description to this episode. I'd love to hear about your reasons for initially joining the military. Can you also tell us in what ways your military experiences have shaped who you are as a doctor and impacted your career subsequently?

Dean Winslow: [00:26:24] Yeah, well, thanks so much. And again, I just love being an Air Force officer and an officer in the Air National Guard. So just going back to kind of how I got into that. So I loved airplanes as much or even maybe as more as I love medicine. So I learned how to fly. In fact, I soloed in a glider when I was 14 years old. It was two more years before I could legally drive a car. So I have just loved aviation and airplanes my whole life. I still do. I don't know if you ever flew with me, but some of the House staff have gone up an airplane that I keep at Palo Alto Airport.

Tyler Johnson: [00:26:58] Apparently, I was a resident too early. Well, 3 hours. Three years later, yeah.

Dean Winslow: [00:27:03] Your kids are old enough that they would enjoy it. But anyway, what a flight surgeon is, which is what I became, is a doctor who has special training in aerospace medicine. It's only like a 12 week course, plus a couple more weeks of air crew survival school. What your main job is, is to care for aircrew, both the pilots and navigators, you know, the officers who fly, but also enlisted aircrew if you're in a transport squadron of some type. So being able to do sort of my civilian career and then have this part time career in the Air National Guard was just wonderful. Reason I didn't go directly into active duty was I finished my training kind of right after the Vietnam War wound down. And so they were downsizing the medical corps, you know, the Army, Navy and the Air Force at that time. So they didn't really need more doctors in the active duty military, and it worked out just great. So again, my first unit that I was assigned to when I went into the Air National Guard in 1980, I was still doing my fellowship in New Orleans, so I was assigned as a flight surgeon to, frankly, the best fighter squadron in any guarded reserve unit, maybe in the world. We initially flew the F-4 Phantom, and then later we were the first Guard and Reserve unit anywhere to convert to the F-15 Eagle, which was the front line fighter at that time.

Dean Winslow: [00:28:24] And I still keep in close touch with most of the pilots that I flew with during those years. I transferred to the Delaware Guard in 95, which is a C-130 unit, you know, a transport unit. Again, you know, wonderful friends and great memories there. I was actually going to retire in 2001 because at that point I had 21 years of service, so I could have retired from the Guard. But 9/11 happened and they needed flight surgeons who were physically fit and were capable of deploying with combat units. So being the optimist I am, I thought that the war in Afghanistan would last at most a year or two. I'd deploy once and then I'd retire. But President Bush had different ideas, and so one war wasn't enough. So we started another war in Iraq. So I ended up deploying twice to Afghanistan and four times to Iraq during that time, and finally retired from the Air National Guard in December of 2015. But again, those were rich experiences in so many ways. You know, number one, you have this tremendous sense of camaraderie with the people that you serve with both officer and enlisted. And part of it is that you have this this sense of mission, this sense of purpose.

Dean Winslow: [00:29:34] And I guess maybe that's another reason why I love still clinical medicine after all these years is, you know, you go into the hospital and you're making rounds and, you know, you've got wonderful nurses, you know, who are skilled and knowledgeable and care deeply. You've got clinical pharmacists. You know, you've got your laboratory technology colleagues down in the lab. And I'm sure you feel the same way, Tyler, knowing you. So again, it's this sense of mission, the sense of purpose that adds a lot to it. And of course, again, being deployed downrange, as we say, you know, when you're in a combat zone, it can be very intense. I was an ER doctor and flight surgeon assigned to what was called a EMEDs, which is an expeditionary medical squadron or a small level two combat hospital in Baghdad during those six, which was before the surge. So, you know, again, there were a lot of heavy fighting and, you know, we were taking a lot of casualties, sadly. So, you know, that was pretty intense. And then I went back in 2008 as the commander of that same Unit. Again, the positive thing was that we had 55 or so assigned personnel, a mixture of active duty guard and reserve people, all who were volunteers that really wanted to be there took care, of course, Obviously, a primary mission is to take care of coalition forces, you know, American soldiers, sailors, airmen, Marines. But we also took care of allies and we took care of a fair number of third country nationals, you know, contractors from other countries and also host nation nationals or Iraqis. And that was also very gratifying. The US Army Special Operations ran a small clinic at their civil military operations center just outside the wire of our base in Baghdad, and most of us volunteered there at least twice a week, particularly when things were quiet and we took care of a lot of Iraqi civilians, you know, with either injuries or just medical illnesses, because, again, the health care system really went downhill after our invasion in 2003. So, again, you know, a lot of intense experiences, of course. Certainly when, you know, you have a young person who's been terribly injured in combat and you can't save their life, you know, that's, you know, a heartbreaking experience. And particularly being a little older and being a father and knowing that many of these young soldiers or Marines are the same ages of my kids makes that tough. But again, you have this sense of purpose and this feeling that what you're doing is you're supporting a cause greater than yourself.

Tyler Johnson: [00:32:09] Can I ask Dean for those who maybe are not totally initiated into medicine yet? Of course there are many different specialties. But among all the different specialties, if you had to choose to, at least in adult internal medicine that are dedicated to solving medical mysteries, I think it would be general internist or hospitalists and infectious disease doctors. Infectious disease doctors are sort of they get teased even among internists, as being the people who, you know, dig up obscure facts about people having visited foreign countries or been exposed to strange foods or bugs or whatever, and then using that to figure out an elusive diagnosis. So you are both right. You're a hospitalist or internist and also an infectious disease doctor. So I was hoping you could tell us maybe from your last ten years, the time you've been at Stanford, about a patient that you saw in the hospital, that the case was really a tough nut to crack, figuring out just what the heck was going on, but where you did figure it out, and then it led to maybe a happy outcome for the patient that wouldn't have been there if not for that elusive diagnosis.

Dean Winslow: [00:33:17] Yeah, that's a great question, Tyler. You nailed it. I mean, one reason why I love internal medicine and also love the subspecialty of infectious diseases is just figuring out the mystery. I'll be honest, though, I've also, you know, completely missed the diagnosis many times. And that's very humbling. And that's the other thing is I try to reassure the House staff that, you know, hey, that's why they call it the practice of medicine. You'd actually never get totally great at it. You know, you're always practicing trying to to get better. Actually, I remember a patient that I think your service may have seen was a patient who came in with a fever and had retroperitoneal, had an apathy and also had hypercalcemia, which we finally were able to put it all together. The patient actually had a B-cell lymphoma that causes the conversion of D2 to D three, which is very unusual. And actually that was the first time I had seen that particular combination. You know, it wasn't the more common, you know, hypercalcemia malignancy with bone metastases. You know, it was this actual very interesting mechanism of disease. So I think that's one that kind of comes to mind immediately.

Dean Winslow: [00:34:28] I remember, though, going back to a case that I saw in Delaware, and again, this was a patient with actually at that time, pretty well controlled HIV. I think the patient was on AZT and DDI. It was before we had protease inhibitors, but he was doing pretty well. But he came in with actually a cavitary pneumonia in his right lung. And I still actually have a slide of the tomogram of it. That was a technique we used before we had body imaging. It was sort of a poor man's CT. Anyway, You know, I admitted him to the hospital and I got pulmonary to see him right away and we bronch'ed him and he had all these gram positive kind of coccobacilli on gram stain. And what the heck is this? And I think I probably started him on Ampicillin Sulbactam, you know, thinking, well, it's probably some weird anaerobe or something. Well, anyway, it grows out. This organism that I'd only heard of but didn't even think of in the differential called Rhodococcus equi and Rhodococcus equi gets a gram positive organism that causes pneumonia in foals, you know, young horses and mastitis in sheep, I believe. So it's a zoonotic infection. But then I went back. And got a much better history. And if I'd been a better ID doctor, I would have gotten the history up front and then made a brilliant diagnosis and not even had to bronch the guy. But it turns out that his job was he was a groom at a racetrack, and part of his job was sometimes to give medicine to horses. So he said, "Yeah, doc. He goes, Yeah, I'm all the time putting these NG tubes down these horses, they're as big as a garden hose. And he said, and of course, the horse snorts all over me." And so anyway, so that solved the mystery. So if I'd been a really good diagnostician, you know, that I would have, like, figured it out. I would have gotten a better history. But the other thing, of course, you know, that's, you know, ID doctors get teased about and they t even make fun of themselves is if you put like five infectious disease doctors in a room to discuss a case, you'll get at least ten different opinions because we can all argue both sides of whatever it is. So I like that.

Tyler Johnson: [00:36:33] I just want to say that the young man getting a pneumonia from the horse sneezing on him has to be the ID-est case I've heard.

Dean Winslow: [00:36:41] Yeah. As I said though, I had to get pulmonary to bronch him to get the diagnosis is very bit a really good ID doctor. I would have just put it all together based on the history.

Tyler Johnson: [00:36:51] So the one last question I wanted to ask, so part of the reason, as I mentioned earlier for the podcast, is because we really do sense this almost sort of existential level angst from the medical community right now. And part of that, I think, is having you traverse through the pandemic, which is hard for everybody. But I think there's just this sense of many of us have become disconnected from what brought us into medicine in the first place. Right. That keeping a sparkle in your eye and spring in your step, I think is hard for a lot of people. And so if you were talking to a young person who maybe was just starting out in medical school or just, you know, in a really hard part of their residency or whatever, and was starting to feel a little bit of that already. What would be your advice for them or what would you counsel them to do?

Dean Winslow: [00:37:39] It's really tough, Tyler, to answer that in a lot of ways because, you know, as I shared with you before we started the interview, that the fact that I am in my sixties now and my children are grown and I didn't have the responsibilities during the COVID pandemic of child care for my kids, you know, I'm sure that was a huge stress. Plus, your children are often unhappy and they're missing out on normal growth and development that they get from socialization. So, you know, I'm preaching to the choir, so I really appreciated that just how hard it was. It's hard, I think, to fix at least some of the stresses, you know, that happened during the pandemic. And I'm optimistic that we're kind of coming out of the other side. I do think, though, that and this is not a criticism of Stanford. As I said, Stanford has been so good to me and I'm very grateful for it. But there I think there is sometimes an aspect of corporate medicine that may be a little different now than it was before. Part of it is I honestly believe that because our health care system is so in a way inefficient and expensive, that there is more pressure, you know, to sort of focus on the bottom line. And I'm not saying this is a criticism of the administrators, but I actually was very lucky. My wife and I, you know, got to spend half a year teaching at Oxford, as visiting faculty a few years ago. And we actually every Wednesday afternoon, you know, we actually attended grand rounds at the JR hospital, you know, which is the teaching hospital right in in Oxford.

Dean Winslow: [00:39:13] And I didn't sense the same sort of burnout in doctors of all ages, you know, in the national health care system that they have there. And I think part of the reason is, is that there isn't this pressure, you know, to generate RVUs and the fact that health care is completely paid for, for everyone, you know, and literally, even as an American, you walk in with a problem or, you know, you need a supply of blood pressure medicine or something like that, and you don't pay anything or just this tiny co-pay. So I think that having a more sort of gentle and efficient health care system would actually have a paradoxical effect maybe of reducing burnout because there would not be such pressure, I think, on doctors. So I think there's system improvements that could be made to reduce burnout. And then also, though, I think is the importance of self care. You know, as we talked about before, you know, taking care of yourself physically, emotionally, spiritually helps you become more resilient. But I'm also very careful about saying that because sometimes I look at, you know, when people talk about resilience, that can also be victim blaming, too, you know? So I think you've got to be careful there. But I do think that there are system issues that could be fixed to reduce the pressure and the burden and reduce burnout in doctors and nurses.

Henry Bair: [00:40:35] Well. Thank you very much for taking the time to meet with us, Dr. Winslow. I think it's remarkable that despite your long and illustrious career as a leader at the frontiers of HIV treatments, the stories you've shared are those about the small but deeply human moments of your interactions with patients. The fact that these are the instances that stay with you the most, I think, speaks volumes about what makes medicine meaningful. I can only hope that I maintain your sense of joy and wonder as I continue with my career and into my clinical practice.

Tyler Johnson: [00:41:09] Yeah, we really appreciate you having us in your beautiful home here among the redwoods.

Dean Winslow: [00:41:13] Thank you both. It's a real honor.

Henry Bair: [00:41:18] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the doctors art. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:41:36] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.

Henry Bair: [00:41:50] I'm Henry Bair.

Tyler Johnson: [00:41:51] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.