EP. 49: GUIDING NEW YORK CITY THROUGH COVID-19

Feb 14

WITH DAVE A. CHOKSHI, MD, MSc, FACP

The 43rd New York City Health Commissioner shares the personal values that drive his leadership and his experiences guiding New York City through the COVID-19 pandemic.

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Episode Summary

In the first half of 2020, New York City quickly became the American epicenter of the COVID-19 pandemic, with over 200,000 cases reported in the first few months. The city came to a standstill as thousands of people died alone in hospitals and bodies piled up in freezer trucks that could not transport them away fast enough. In August 2020, amid this cataclysm, Dr. Dave Chokshi assumed position as New York City's Health Commissioner and began the arduous task of repairing a broken city and restoring public trust among its residents. Prior to this work, Dr. Chokshi led the NYC Health and Hospitals Corporation and was a White House fellow at the US Department of Veterans Affairs. In this episode, Dr. Chokshi joins us to share the core values that drive his public health work and how he navigated the challenges of leading New York City through COVID-19.

Dave A. Chokshi, MD, MSc, FACP was the 43rd Commissioner at the New York City Department of Health and Mental Hygiene, one of the leading health agencies in the world. He led the City’s response to the COVID-19 pandemic, including its historic campaign to vaccinate over 6 million New Yorkers, saving tens of thousands of lives. Dr. Chokshi architected treatment strategies, navigated school and economic reopenings, and served as principal public spokesperson. Under his tenure, the Health Department’s budget grew to its highest-ever level, reflecting investment in signature initiatives such as the Public Health Corps, Pandemic Response Institute, and New Family Home Visiting program. In 2021, the Department also stewarded the launch of the nation’s first publicly-authorized overdose prevention centers—as well as a landmark Board of Health resolution on racism as a public health crisis.
From 2014-2020, Dr. Chokshi served in leadership roles at NYC Health + Hospitals (H+H), including as its inaugural Chief Population Health Officer, where he built an award-winning team dedicated to transforming the largest public health care system in the country. He was also Chief Executive Officer of the H+H Accountable Care Organization (ACO), one of the few ACOs in the nation to achieve high quality and cost performance for nine consecutive years. He has been a practicing primary care internist at Bellevue Hospital since 2014. He is also Clinical Professor of Population Health at NYU and a Senior Scholar at the CUNY School of Public Health and Health Policy.
He trained in internal medicine at Brigham & Women's Hospital, where he received the Dunne Award for Compassionate Care, and was a clinical fellow at Harvard Medical School. During his training, he did clinical work in Guatemala, Peru, Botswana, Ghana, and India. He received his M.D. with Alpha Omega Alpha distinction from Penn. He also earned an MSc in global public health as a Rhodes Scholar at Oxford, and graduated summa cum laude from Duke.
How a college music reviewer came to write for The New York Times - 1:41
• How Dr. Chokshi, early in his life, came to understand the association between health and opportunity - 3:52
• A discussion of how privilege impacts the opportunities available to individuals and how this recognition affects Dr. Chokshi’s medical work - 7:40
• How Hurricane Katrina revealed to Dr. Chokshi the flaws in our existing health systems - 15:48
• Dr. Chokshi’s involvement with Universities Allied for Essential Medicine - 19:34
• An account of Dr. Chokshi’s tenure as New York City Health Commissioner during the height of the COVID-19 pandemic - 24:31
• Dr. Chokshi’s principles of effective leadership - 32:31
• Reflections on the first wave of the COVID-19 pandemic and how indebted society is to nurses and hospital house staff - 37:15
• Dr. Chokshi’s personal philosophy on maintaining a balanced sense of humility - 53:48
• Five lessons for medical trainees and clinicians on staying connected to what makes medicine meaningful - 57:38
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] In the first half of 2020, New York City quickly became the American epicenter of the COVID-19 pandemic, with over 200,000 cases reported in the first few months. The bustling city came to a standstill as thousands of people died alone in hospitals and bodies piled up in freezer trucks that could not remove them fast enough. Amid this raging fire, Dr. Dave Chokshi assumed position as New York City's health commissioner and began the arduous task of repairing a broken city, restoring public trust among its residents, and building its resilience against an unprecedented crisis. Prior to this work, Dr. Chokshi led the New York City Health and Hospitals Corporation and was a White House fellow at the US Department of Veterans Affairs. In this episode, Dr. Chokshi joins us to share the core values that drive his public health work and how he navigated the challenges of leading New York through COVID-19.
Tyler Johnson: [00:01:59] On a personal note, I was classmates with Dave at the University of Pennsylvania Medical School from 2005 to 2009, and I remember a few things about Dave. The first one is that if you're really lucky during your life, you'll meet a couple of people who the more you get to know them, the more you think, "Gosh, I hope that person runs for president of the United States someday." And that was my experience with Dave. I don't think at any time in my training I can think of maybe one other trainee I've known who demonstrated a similar depth of character. But what is really remarkable about Dave is that he's also one of the most holistically intelligent people that I've ever known. And to be that intelligent and that thoughtful but remain as genuinely humble as he is. And I'm not talking about a superficial, self-deprecating appearance of humility. He actually really is humble, which is why his face is turning red while I'm saying this and you just can't see that. But he strikes me as a sort of a moral compass, and I've kind of watched his career from afar and have been delighted to see that he has gone on to do a number of remarkable things and to hold a number of leadership positions. And we'll get to all of that in the podcast. But all of that is just to say that I really couldn't think of a better person to a better person to interview for this podcast than Dave, and we're really grateful to have him here. So thank you for joining us, Dave.
Dave Chokshi: [00:03:34] Thank you so much. Tyler. That is incredibly gracious and not at all deserved, but I continue to try to live up to the beautiful sentiments that you described, and I'm just thrilled to have a chance to speak with you and Henry. So thanks for having me.
Tyler Johnson: [00:03:52] Of course. So, Dave, can you begin by telling us how did you end up being a doctor? What brought you into medicine?
Dave Chokshi: [00:04:00] Yeah, well, I was not one of those kids with the Fisher-Price stethoscope, I guess, is how I'll begin. I was the first doctor in my family, and that meant that I didn't really have role models for what it meant to practice medicine. I didn't know the day to day of taking care of patients in that way. But what I did know and sort of observe through my childhood and young adulthood was all of the ways in which health was connected to opportunity. You know, I experience this personally as a kid growing up with with asthma, watching how the diagnosis of diabetes affected my father and his life, and then having some early formative experiences that showed me just how tightly linked health and opportunity were. There's one that that comes to mind. It was a summer that I spent as a college student in Mumbai. Actually, all of my extended family lives in Mumbai, India. It's where my parents grew up and I had the chance to work for a nonprofit organization called Committed Communities Development Trust in Kamathipura, which is one of the red light districts in Mumbai. And this was around the turn of the century, about 2000. And the organization was providing child care for the children of commercial sex workers in Mumbai, many of whom had been infected with HIV as a result of being a sex worker and many of whom had transmitted that infection to their children.
Dave Chokshi: [00:05:52] I thought about the lot of the kids that we were taking care of, and I thought about how little separated their life and the opportunity that they would have in their lives from mine. You know, if things had just been slightly different with respect to my family and and their path, I could have very easily been in the shoes of the children that we were trying to take care of. And I saw everywhere from that experience, from a few others that I had early in my career, that it's not just a connection between health and opportunity, but it's often a cycle. What I think of as as either a vicious cycle or a virtuous cycle. Ways in which illness can beget other problems, often economic problems, sometimes poverty, but also the ways in which good health can can beget opportunity in a in a positive way as well. So it's all to say, you know, I was sort of propelled to a career in medicine because because I cared about health and I found it so fundamental to people's life prospects, whether it was in a red light district in Mumbai or where I grew up in Baton Rouge, Louisiana.
Tyler Johnson: [00:07:20] Can I just ask Dave as an aside: we talk a lot on this podcast about deeper philosophical, metaphysical questions, and we talk- I feel like since we were in med school together, a term that has become very popular in the lay press and even in politics is 'privilege.' And part of what I hear you saying is that it really is so striking to think about the differences in inherent privilege with which a person is born depending on their zip code, their parentage, their social capital, their family situation, and on and on and on. And there have been many studies recently demonstrating, for example, that one of the most determinative forces in a person's life in the United States, anyway, is the zip code in which they're born. Right. Which makes sense when you think about the schools to which a person has access and and on and on and on. But I guess from a philosophical perspective, that relatively early recognition that you had been endowed with enormous privilege because of where you had been born and what your parents did and and educational opportunities and all the rest, that was so much greater than so many other people in the world. What do you do with that philosophically and or how does that help to shape how you practice as a doctor?
Dave Chokshi: [00:08:46] Yeah, that's a really thoughtful question. And first, Tyler, I have to say, I remember our conversations in med school so well. I actually remember we would sometimes have coffee in the bookstore on Penn's campus and try to puzzle through some of these questions together. And I'll just pick up on one of the words that you used, which is 'endowed.' And I think that just as you pointed out, many of us are endowed in a positive direction. We have the advantages that you described in terms of family and education and sometimes health as well. But I think the realization that that endowment is not equally distributed and that so much of life circumstances are in some cases random in other cases represent the intergenerational transmission of things like illness or poverty. It makes me assess endowment in a different way as well, which is that it generates it endows us with some responsibility to recognize the structural forces that we've talked about, but then ultimately to try to close some of the gaps that we see in in our world. One of the ways that I think about this is the difference between inequity and inequality. And the distinction that I always keep in mind is that inequity is a difference that is avoidable and unfair. And when we see inequity in that way, those of us who have the privilege to occupy spaces like we do in medicine or in other sectors, it's our responsibility to take up those inequities and actually change the trajectory, change the direction in which those inequities cause illness and cause lack of opportunity.
Tyler Johnson: [00:11:00] Yeah. You know, I have thought about that idea a lot in the sense that one of the most striking differences that results from these different endowments that people are given is who gets a voice at which table. Right? And there are so many tables where important decisions are made and often, ironically, the people whose lives are most affected by the decisions are the very people who are least likely to have a seat at the table. Right? Because the people who have a seat at the table often get to live by sort of a different set of rules. Right. They get to kind of float above the fray to some degree, if you will, because of their money, social situation, education, etc.. And so I think that oftentimes our political discourse is phrased in the context of rights. But like what you were saying, I find to be to have a lot more moral valence, which is to talk about responsibility. And I think that if you have a seat at the table thinking about having a responsibility to act vicariously on behalf of the good of people who don't have a seat at the table is a really important moral idea. And I feel like in medicine, that's a place where that is particularly important because medicine deals with such a- right, We often don't even think of health as a thing separate from ourselves. It's just part of ourselves. It kind of defines who we are. Right. I can imagine that as a kid with asthma, you know, asthma wasn't a thing outside of you. It was part of how you existed in the world. Right. And I think that idea of of vicariously offering a voice for the voiceless is really important.
Dave Chokshi: [00:12:42] Yeah. And I think it, again, puts the onus on people who bear witness in a way to observe keenly to make sure that we understand. And I guess the way that I would put it is to move from sympathy to empathy, right? To push ourselves to more deeply walk in the shoes of the people that we aim to serve in order to bring as authentic a perspective as possible to the tables that that you describe. And I just have to share, I mean, what you were saying brought to mind for me. I had the privilege of serving as a White House fellow in 2012-13. This was in the Obama administration not too long after the Affordable Care Act had been passed into law. And as a White House fellow, I was assigned to the Department of Veterans Affairs. So the secretary of the VA asked me to be the representative on the Interagency Working Group on implementing the ACA. And I remember going to my first meeting of this working group, and it was in the Roosevelt Room of the White House. There's one of these moments where I looked around at the mahogany table and the portraits on the wall, and I kind of pinched myself like, Is this actually happening? Am I am I actually here? But, you know, my my second sort of reaction was I took a look at the people who were around the table, and I realized that with my sum total of three years of residency and four years of medical school, I was the most clinically experienced person in the room.
Dave Chokshi: [00:14:34] You know, it's it's about making sure that because we have this unique privilege in medicine to bear witness, to understand our patients lives in a depth and a color that is very rare in many other professions, that we take that with the gravity that it's due and we bring it into rooms like the one that I was in. It's something that I talk about with my wife a lot. My wife is an educator, and there are just so few other careers where you have the chance day after day to walk shoulder to shoulder with someone who may have a completely different arc of life than you do, a different set of life experiences. And your charge is to understand where they're coming from and to try to remove barriers from them going forward. But it's not just in clinical practice, it's also in, I think, sublimating the frustrations that we see in the exam room and bringing them into the halls of power so that policies and structures can also be changed.
Henry Bair: [00:15:48] So I really appreciate your elaboration of this very mission driven approach to health care leadership, whether it's about health care, equity or empathy. But I'm also wondering whether you could just walk us through your journey in this leadership career from finishing medical school all the way to becoming the New York City health commissioner. In particular, what was it like to step beyond the clinical setting to engage in the broader public conversation and tackle massive systemic issues?
Dave Chokshi: [00:16:22] I always describe myself as a primary care doctor with a public health heart. And by that I mean I love practicing medicine. I love taking care of patients. During my clinical training, I focused very intensively on becoming as good a clinician as I could possibly be. But it was always with an eye toward reaching for health and remembering that medicine is but one force in people's lives. And particularly if I as an individual, but more importantly, if I wanted the system that we're all a part of to really care about health beyond health care, it meant engaging beyond- beyond a clinic, beyond a hospital, even beyond a health care system- to address all of the other fundamental drivers of health that we've spoken about a little bit. And so my path was I came to medicine from health in the way that I described beyond the the experience in India that I relayed, I had a number of other early formative experiences. For example, my first experience in public health was working for the Louisiana Department of Health. I grew up in Baton Rouge, as I mentioned, and Hurricane Katrina was one of my first experiences where I saw a natural disaster not just wreak the devastation that we know that they can, but to have it intersect with my own life in a way that I felt it very viscerally.
Dave Chokshi: [00:18:09] You know, it was my neighbors whose homes were destroyed and whose lives were interrupted. And so I had the chance to work at the health department before and after Katrina. And I sort of ingested some lessons from that as well, particularly the idea that people who were already living on the margins were the most likely to be further marginalized during a time of crisis. And so I saw all of the ways in which our existing systems were falling short, whether in a crisis like Katrina or the prior pandemic, the HIV/AIDS pandemic that I described. And so I really came away from those experiences believing that it is our obligation to, yes, work as well as we can to take care of patients who are in our charge, but then ultimately to not allow that to end, when we see the barriers and the structural constraints that our patients have by virtue of our imperfect systems. And that's what really drove me to to pursue leadership positions at the policy level in a health care system and then ultimately in public health as well.
Tyler Johnson: [00:19:34] Dave, One of the things that has always impressed me the most about the way your mind and heart work together, I guess, is the ability that you had, even from what I gather, starting in college to marshal significant resources in unusual ways to try to affect good things at the end. But in a sense, that required a lot of complex coordination to get there. So as a way of trying to illustrate what I'm talking about. Could you talk a little bit about Universities Allied for Essential Medicine, sort of what that where that came from, how it came into being, how you conceived of it and sort of what what the idea is behind it, how it works?
Dave Chokshi: [00:20:23] Yes. And thank you for the opportunity. Universities Allied for Essential Medicines, also known as UAEM, was a student nonprofit organization that I became involved in in college and then in grad school and med school. And the fundamental thrust of it was to try to improve access to medicines in developing countries. We saw during the HIV/AIDS pandemic that we had these miraculous medicines. They were described as having a Lazarus effect for how remarkably they could change people's lives and bring them back to health. And I remember being so puzzled and then dismayed and frustrated by the fact that despite the fact that we had these medicines, they weren't getting to the places where they were most needed, places like India, you know, where where I saw the devastation that that created across generations, but also sub-Saharan Africa, parts of South America. And for me, this was this was one of the first instances where I saw in such sharp relief that it's about implementation and not just innovation. We, the scientific endeavor, particularly in the United States, has brought to bear miraculous medicines like antiretrovirals or the curative therapies for hepatitis C, But we haven't done the same thing with respect to getting them where they are most needed. So sometimes referred to as the fact that we are all breakthrough and not enough follow through. So UIM was a chance to try to take on that problem and to do it in a way where where students actually have a locus of power in universities because universities often held some of the fundamental intellectual property rights, patents and licenses that went into creating those medicines in the first place.
Dave Chokshi: [00:22:34] And for me, this was a chance to organize some of my fellow students. You know, when you just look at the facts of the matter, it becomes so clear what an injustice this represents. But sometimes being confronted with injustice is paralyzing. And you say, what can I, as a student possibly do about this, this giant global problem? And this is one thing that I've tried to take with me from that experience is. The notion that it's better to light a single candle than curse the darkness and to start where you are, you know, to start with the place where you do actually have some standing, some power. In our case, as students in university campuses and then trying to expand out from there, if more people did that, if all of us did that for the problems that we are confronted with, the injustices that we bear witness to, then we would live in a different world. And so the obligation starts with us. And what I've always found is that when you are clear eyed about the problem and the injustice that you're trying to take on, very often there are other people who will be inspired to join you on that campaign, and there's a lot of joy in that beyond you, beyond the mission of that work.
Tyler Johnson: [00:24:04] Yeah, I'm. I'm brought to think when you mentioned the. Problems being that we have so much innovation but not enough implementation. There was an article in The Atlantic. It was in the last month or the month before that edition talking about that very issue. We do such a fabulous job of bringing to the market incredible ideas, but then have great difficulty in making sure that they're implemented widely, let alone fairly.
Tyler Johnson: [00:24:31] Can you talk a little bit then, Dave? So certainly for all of the leadership positions that you've held in various places, certainly the most public leadership position that you've held was that you were the New York City Health Commissioner for much of the pandemic. I don't remember off the top of my head the name of the person who preceded you, but I know that there was this kind of tornado of controversy about a number of problems with the New York City health office and that person left- I don't know that we would say in scandal, but certainly in the middle of controversy. And then right as the pandemic is at its crest, you're brought in both to repair the bridges that had been burned from the controversy from your predecessor, and then also to deal with a hopefully once-in-a-century pandemic. Right? To to deal with something that I mean, you mentioned HIV/AIDS, but of course, that was a little bit different because of the mode of transmission. And it was in some ways more of a slow burn than a raging fire. But here we have this pandemic that was the first thing like it since 1918. Just take us inside, like when you arrived on the ground in the health commissioner's office and are presented with this gargantuan dual task of repairing relations and managing the pandemic. What was it like?
Dave Chokshi: [00:25:50] It's the hardest thing I've ever done, Tyler, And maybe the hardest thing that I'll ever do in my life. But just an enormous privilege to to have been asked to serve in the first place. I was asked to serve in August of 2020. I had been one of the leaders for the public hospital system during the really tragic first wave of COVID in New York City in March and April of 2020. I can share some more about that. But briefly, I was working on our surge strategy as well as things like our telehealth initiatives and meeting some of our patients social needs amidst everything that was happening beyond the direct effects of the virus. And because I was one of the leaders of the public hospital system, I, I became known to City Hall as well as the then mayor, Mayor Bill de Blasio, through that work. I had never been in the spotlight in the way that was called for in this job. And, you know, I'll just admit very candidly, I entered into it with a lot of trepidation. You know, as you alluded to, there were multiple facets to the job that were each of them were quite daunting in and of themselves. I was brought in to heal a rift between the public health care system and the health department, which was playing out in the front pages of The New York Times in a way that you just don't want to see for the the government agencies that are charged with the response to this once-in-a-century pandemic.
Dave Chokshi: [00:27:31] I was thrust into doing daily press conferences before the the New York City media gantlet, and I was taking the reins of an agency that was somewhat beleaguered, had encountered some criticism, and was carrying this huge responsibility on our shoulders with respect to pandemic response. Oh, and by the way, everything was virtual, you know, so the entire workforce that we were trying to trying to lead and create a new day for. This was all done by Zoom and Teams meeting. So it was it was just incredibly challenging. And, you know, the only real comparison that I had to it was those first few weeks of internship, you know, where you are so reminded of all of your shortcomings at every corner, everything that you don't know, all of the ways in which you're not strong enough. You know, you're not good enough, you're not fast enough, but you put one foot in front of the other. I remember I had a senior resident who was seeing me, like, fumble with my pager that was exploding one evening on the general medicine night float service, and he kind of put a calming hand on my shoulder and he said. "You're one person, you know, you just need to do what you can in this moment and then take the next moment and then do the next admission and then take the next admission."
Dave Chokshi: [00:29:14] And it was such a straightforward piece of advice, and it was a powerful reminder of the fact that that's the only way that you can navigate through chaos that feels overwhelming is to, you know, take hold of yourself, check your own pulse, as they say, and then be steady through all of the work that awaits you. And that's that's what I tried to do at the health department. I knew a big part of it was about earning trust, earning the trust of my colleagues who who were under a new leader that they were trying to figure out what I stood for. And so I was very upfront about what my core values were and why those core values had served me well and would continue to be my my guiding lights during this difficult period. And then we had a chance to organize our vaccination campaign, you know, the largest vaccination campaign in the history of the city. And this was so important, I think, to be able to turn some of the narrative around for public health, certainly for the health department that I was leading, because it gave us a chance to not just be the "Department of No", as I sometimes said, you know, to say, we we shouldn't be doing this. You know, your holiday gatherings are dangerous for this reason, and we need to have these protections in place and to organize what I think is public health at its best, you know, to have a massive infrastructure that's based on being in the community and bringing something that can very tangibly benefit the health of the people that were charged with serving.
Dave Chokshi: [00:31:14] So hopefully that gives you a little bit of a of a flavor. I guess the last thing that I'll say in just this initial reflection on the health commissioner job is in one of my last speeches to our beloved city, to, you know, to New Yorkers, the way that I put it was that there are jobs, there are careers, there are missions, and then there are callings. And for me, it was undoubtedly a calling to have been asked to serve as health commissioner during this time. I was never short of motivation when I woke up in the morning as exhausted as I usually was on most days, because I knew that every single thing that we did a little bit better, a little bit faster, in a more equitable manner, each of those things would translate into averted suffering and into lives saved. And so I look back on it as, yes, a very intense and difficult period, but with a huge amount of gratitude that I had the chance to to serve people in the way that we did.
Henry Bair: [00:32:31] Earlier you talked about how one of the most important things you had to do as you stepped into this role of New York City health commissioner was to rebuild that trust between the public and the government. I can imagine this being a really daunting challenge, especially since you, by your own admission, hadn't really taken on any sort of public facing role like this. So I'd like to know what was your strategy going in? What was going on in your mind?
Dave Chokshi: [00:33:06] Yeah. You know, the aspects of leadership that I have to offer are pretty... they're pretty anodyne. We've heard them before, but it was about trying to genuinely execute on them. So I'll just give you a couple of examples. But but a lot of it boils down to number one, core values. Number two, communication and the number three, demonstrating care. So for core values, I mentioned this earlier, but I really credit my my wife with having the foresight to have engaged our whole family in a core values exercise where if if your listeners haven't done this before, I highly recommend it. You can just Google core values exercise and find the formal way to do this, but it helps you sort of winnow down to the values that are at the heart of what makes you as an individual person tick. For for some people, it's about integrity. For others it's about compassion. For me, the three core values were truth, justice and kindness and being up front about the fact that those were the things that I turn to in the most difficult decisions that I encountered, whether personally or professionally. I found that people respond to to knowing that that those are my touchstones in moments of of crisis. And that kind of relates to the second piece of it, which is communication. This is so cliché as to almost be boring, right? Yes. Everyone talks about communication, but what I find that people don't appreciate particularly about communication and public service is that it's not what each of us was trained to do with respect to communication, particularly when you come from an academic background, fancy places like Stanford University, your prized for your originality, your prized for being the person who has a clever new take on a problem or a different frame for talking about it.
Dave Chokshi: [00:35:30] Communication when it comes to leadership, at least in my experience, is far more often about persistence, about being willing to say that exact same thing 400 times and not get bored of doing that. And actually, the 400th time that you say it, you say it with as much passion and authenticity as the first time that you said it. So anyway, so that's that's another piece of it. And then the third part is demonstrating care. I mean, you we know this from our clinical practices, but I find that the way that you engender trust among teammates, among colleagues is just quite simply to care about them and then to demonstrate that care, to know about the family struggles that people might be going through, to understand the anxieties related to a professional endeavor, you know, that you're intersecting with them on and then to just be human and kind in particularly the best moments as well as the worst moments where you cross paths with someone that is sometimes not particularly in our American culture associated with strong leadership. But again, in my experience, it's the thing that that means that people will be willing to follow you even when times get tough because they know that that you care about them and that you're in the trenches with them.
Tyler Johnson: [00:37:15] Dave, I your answer about being the New York City health commissioner. I knew that you were not the commissioner when the pandemic started. I had forgotten the precise timeline. But even though you were in a slightly subordinate leadership public health leadership role when the pandemic started, I still did want to ask you if you can talk a little bit more. I remember in February of 2020 when we started to see the reports come across the wire from Italy about what the first open western nation, because, of course, we had no access to information about what was going on in China at the time, what was happening in the first Western nation that really got hit. I remember seeing that. And as more information came out and it became clear that there was pretty easy human to human transmission, and then there was this latency period. So people were infected and they didn't even know and were and were spreading it presumably to other people. I just remember having this kind of waking dream one night where I felt like I was as a doctor standing on a beach and watching this tidal wave sort of approach the shore, but just not knowing exactly when it would arrive or how big it would be or sort of how terrible things would get.
Tyler Johnson: [00:38:24] And in California and in northern California anyway. It was actually a little bit strange because we really didn't have a wave hit us in a serious way until almost a year later. It was really early 2021 when at least this area really got hit. But I remember watching during that time the the reporting coming out of New York and just feeling what I can only describe as a dark chill. Right. These these pictures of like they couldn't line up the mortuary trucks, the freezer trucks for the corpses fast enough to get the bodies out of the hospital. And, you know, there was the sort of famous report of a woman who is a doctor there who committed suicide, at least in part because of the overwhelming emotional burden of caring for people when there was really almost nothing that you could do for them and all the rest. And so I guess all of that is just to say, as somebody who was working in public health at the time, what was it like to be, so to speak, at Ground zero for the United States anyway, or one of the ground zeroes during such a dark period?
Dave Chokshi: [00:39:31] Well, you described it well, Tyler and like so many other health workers who experienced it here in New York City in spring of 2020, the memories are just seared on my brain in perpetuity. You know, it was horrific. It was harrowing. It was humbling. The sounds are what I remember. I live in a part of New York City called Queens, a neighborhood called Jackson Heights. And one of the public hospitals in the system that I was a part of was Elmhurst Hospital, one of the hardest hit areas early in the pandemic and a hospital that was particularly that was particularly overwhelmed. At one point, we had 80 patients intubated in the emergency room, which was designed to hold two, maybe four patients who were intubated in in normal times. So the sounds that I remember. Where I live, close enough to Elmhurst to where I can just walk to it. And so I would walk down the street and everything was shut down. You know, the normal din that I associate with walking down the street in New York City was absent. And you don't even realize, right, that that's just the background soundtrack of your your normal walk through the city until it's gone. And then you step inside the hospital and it's a totally different type of din. You know, the the alarms blaring. I remember going on the COVID wards and. Just seeing the ways in which individuals shorn of their families in terror because we didn't know exactly what was going on.
Dave Chokshi: [00:41:36] And that juxtaposition, the silence outside and the cacophony inside, it sort of represented what we were going through because it was hard if you weren't in a hospital, to really understand, to fathom what was happening, know just from watching your your television screen. And it was just. I mean, there were so many moments that just break you down. I remember speaking with the residents at Elmhurst who told me what it was like to do pre rounds. You know, at the height of of that first wave, they would do their morning pre rounds, enter into their patients rooms and pronounce two or three or four patients dead. Multiple days in a row. You know, this is something that never once happened to me in my entire clinical training. And so I just put myself in their shoes for a moment and thought about what it must be like to step into the room, to reach under the patient's sheet, to check for a pulse, and instead to sense the coolness of a hand bereft even of the warmth of the touch of a loved one for one last time. And to have that be the hour by hour reality. I practice at Bellevue Hospital, which is another one of the public hospitals and. One of the memories from Bellevue was one of the dialysis nurses who was particularly beloved in the way that some of the nurses who have who have been working in a place for 20 or 30 years are.
Dave Chokshi: [00:43:28] And there was this kind of standing vigil for the nurse while she was in the intensive care unit. A steady stream of. My fellow colleagues at Bellevue just. Visiting. Giving good wishes, sending healing vibes, and thinking about what that meant to see their colleague, whom they had been interacting with just a few days earlier, and also kind of realizing for themselves that this was the risk that they were taking on by virtue of being in the hospital each day and imagining what that would mean for their family if, if it were them who were in the ICU bed or, God forbid, in one of those freezer trucks. So. So, yeah, those those are some of the really harrowing parts that I remember. I guess the other part that I will relate, just so that it's not not all darkness because it wasn't all darkness is the ways in which people truly rallied in a way that, you know, any time I'm feeling down like that's a place where I go to remember what what people did with the mountains that we were able to move when there was the volition to do so. Also in Bellevue, I remember walking through the waiting room of an endoscopy suite one morning and then literally within hours I walked by again in the afternoon and it had been turned into a fully functioning ICU because we needed that space to be an overflow space for the ICU or the work that we did to address food insecurity among low income people whose livelihoods were, of course, threatened by the pandemic as well, and who are very worried about having enough money.
Dave Chokshi: [00:45:32] The taxi drivers, like all of the restaurant workers who were waylaid by the pandemic and the way in which people banded together to organize food drives and food delivery for people, or shifting our entire system to telehealth, you know, overnight so that people could continue with the ambulatory care services that they needed. So there were so many examples like that that I, I remember because I saw the ways in which false barriers to progress melted away in the heat of a crisis. And, you know, I'm afraid that we have forgotten that along with so much else over the years of the pandemic and forgotten what we are capable of when our backs are against the wall. And and people really need us, because certainly so many of my colleagues, so many people showed the ways in which they can step up and deliver in a time of great duress and need.
Tyler Johnson: [00:46:36] I remember in high school reading an essay reflecting on William Faulkner's "The Sound and the Fury," where the author of the essay talks about how the depth of moral darkness highlights the brilliance of moral light. And I remember as much as of all of the people that I can think of during the pandemic. The two groups that best exemplify that for me are nurses and house staff, right? So nurses, people who are not in health care, I think just can't have an idea how frankly gritty and gross of a profession nursing is, right? It's dealing with bodily fluids, excrement, phlegm. It's being like right up in the grill of the people that you're taking care of, Right? You're not in some far away room putting orders in a computer. You're like, right up there, close and personal with your patients. It's hard to do that on a normal Wednesday and 2027 or in 2017, Right? But to do that, knowing that every interaction that you have with the patient carries the risk of you contracting a deadly virus is. And then to just do it anyway is hugely heroic. And by the same token, I think people who haven't been medical training, it's very who haven't been through medical training, it's very difficult to appreciate what it's like to go through medical training. Right. People think of doctors as people who have kind of a cushy lifestyle and earn a lot of money.
Tyler Johnson: [00:48:08] But for House staff, many House staff earn ten to 11 to $12 an hour, work 80, 90, 100 hours a week and work sometimes 30 or even 36 hours at a shift. And that was even more so the case during the pandemic, when a lot of the normal workout restrictions had to be sort of temporarily suspended because of emergency conditions. And so the fact that those people that you mentioned who would show up at work in the morning and pronounce death after death after death, just kept showing up to work every morning to take care of people who in many cases, they really had nothing they could do to take care of them in the first place, I feel like nurses and house staff equally reflected heroism, genuine heroism during that time in a way that, you know, that that was one of the things I will admit that made it so enormously frustrating to me to see the public chafe at restrictions on public gatherings and whatever, as much as I totally, totally get that because I miss public gatherings as much as the next person. But it was just quite the contrast to see that there were people who had difficulty with that difficult but doable thing while you had these other people who were demonstrating such genuine self-sacrifice and heroism.
Dave Chokshi: [00:49:19] That's really well said. And I think the the other common thread that I saw, particularly among nurses and house staff and, you know, the other workers who, as you said, showed up every day just to make the hospital run that we that we assumed would continue to do that despite the great dangers to them and their families is all of the ways in which it's so hard to measure and appreciate how they provided dignity often in the last breaths for for people who were not surrounded by their loved ones, who were not able to hug their parent or their child for the last time. And the small things that they did, whether it was, you know, like spending a little bit of time making sure that a video call was actually connecting for a patient, even when there was another patient in dire need of their services and the next room, sitting at their bedside and holding their hand, you know, trying to rustle up a favorite food so that someone would have that little spark of joy amidst their suffering. Just countless examples like that, which, as you say, there was so little that we had to offer patients with COVID-19 and those early days. But as usual, it was it was nurses, house staff. Those were the people who provided those those small moments of dignity, which meant the world for for people as they were going through an unimaginable time.
Tyler Johnson: [00:51:11] Yeah, I remember this very distinct moment during the early pandemic when I was in the hospital and I was in a patient room and I watched a person who worked as part of the custodial staff come in and remove the liner out of the trash can where people were putting their used gloves and gowns and masks. And like everybody at the time, especially health care workers, I was thinking a lot about dynamics of transmission and how things flow through the air. Right. And so I see this person pull the liner out and then go to tie the the top of the trash bag together, which, of course, all of us have done that at home or whatever a thousand times and never think about it. But all of a sudden, in the context of the pandemic, I thought, oh my gosh, what if the way that they tie it out creates this woosh of air that comes out and carries with it viral particles that are then washing over them. And this is a person who does this probably 1000 times every day, is probably never been recognized, let alone thanked by anybody else for what they do. They're almost entirely invisible for what they do in the hospital. And yet, as you point out, if that person and others like him were to just say, this is too dangerous, I'm not doing this anymore, the hospital would grind to a halt in a matter of hours. Right. And there's an entire cast of people like that who remain almost entirely nameless and invisible, but without whom none of them are visible. Heroism of the doctors and nurses would have even been possible.
Dave Chokshi: [00:52:43] That's that's absolutely right. You know, the one other thing that I'll say on this is that we shouldn't forget that we had it, particularly in New York City. I know in other places we had that 7 p.m. Applause, You know, which which sort of petered out after a few months and they're still going. You know, our our health care workers are still going and in most cases haven't had a real break since those really arduous times early in the pandemic. And for people who aren't in a health care environment, that is something that is I know maybe a bit foreign and can be difficult to comprehend because in part, you know, I think it's our responsibility as people who have experienced that, to make sure that we're sharing our stories through through outlets like this one. But it really matters when we think about the health care system that we want going forward, because there is no system without those people that we rely on every day.
Tyler Johnson: [00:53:48] Well, Dave, we're we're nearing the end of our time, but I want to ask you to personal questions to finish. The first one is that and I recognize that because of the nature of this question, you may be uncomfortable talking about it, but I'm going to ask you anyway. One of the things that has always struck me the most about you and that I admire the most deeply is that you are, as I said at the beginning, one of the most- I've always thought you were one of the most intelligent people I've ever known. And now you're also one of the most accomplished people that I know. And yet, in spite of that, you strike me as genuinely humble in the sense that you are not impressed with yourself. You're not impressed with the power of positions that you've had, and you're able to maintain a firm grip on what actually matters the most. In spite of all of the successes and whatever that you've had. And so I wonder if you can talk about how do you do that? Like, how do you cultivate that sense of humility that I think differentiates you to a great degree from many other people who would be similarly gifted or accomplished?
Dave Chokshi: [00:55:07] That's. That's very kind of you, Tyler, but I. What may look like. Humility is just a very realistic assessment of my capabilities. And I can say with confidence that there is no one more expert than I at my limitations and fallibilities, of which there's not a day, an hour that goes by that I'm not reminded of them in some way. You know, the measure of ourselves should be stacked against the problems that we're trying to solve. The degree to which we are in service to our fellow human beings and the real change that we can ascribe to ourselves. And by all of those measures, man, we we all have so much that we need to do. There is so much that remains unjust and imperfect about this world that we live in. And so that's that's where the idea that we have to be better and work harder comes from, because there's there's still far too much that is within the control of humanity that that we have not changed. And I have to just kind of connect this to our conversation about COVID 19, because one of the things that. Helped me get through those really dark days early on in the pandemic was the notion that finally things would change. The conversation about universal health care and our country would take on a different valence and we would understand the need for massive investment of public health in a way that is categorically different than before. And fast forward two and a half years later and I have to admit that that's not the case. We have not been shaken out of our complacency, even as our society has been shaken to its very foundations with over a million lives lost in our country alone. So when we think about the scale of the challenge that remains for us, I think there's no appropriate response other than deep humility.
Tyler Johnson: [00:57:38] So the animating idea behind this podcast, everyone, of course, is familiar with the epidemic of burnout in the health care workforce. And to be clear, there are many factors contributing to that, including systemic ones, which we acknowledge. We also feel, though, that. There is at least a part of this that is a problem with health care workers keeping in touch with what makes medicine meaningful for them. So especially for trainees, medical students, early career physicians, people who are coming up into the prime of their career. What advice can you give in the midst of all of the many? Some of them very difficult things that you've discussed that you have done in your career. How have you kept in touch with, like on a nitty gritty, logistical, day to day basis? How have you kept in touch with what makes medicine meaningful?
Dave Chokshi: [00:58:29] I love that that is the raison d'etre of your podcast. And I think it's why you've you've achieved so much resonance with people because there are a number of forces that are eroding that meaning in medicine. And so I'm just grateful that that you have this forum for those of us who are trying to countermand that. So I thought about this a little bit in advance. I have five lessons that that come to mind, particularly for trainees, so I'll just go through them, hopefully relatively briefly. The first and I think the most important one is when we're young, and particularly as we talked about before, when we're young and privileged, we spend far too much time burnishing our credentials and not enough time nourishing our convictions. And it's really simply about making sure that we're spending our time nourishing our convictions through conversations like this one, but perhaps most importantly, by staying grounded with the family members, the close friends who remind us of what our convictions are, when sometimes our hold on them gets a little bit wobbly, or we find some of those external forces pushing us away from them. And I think there are other ways, particularly that are more sort of in solitude to nourish one's convictions through reading and through the wisdom, particularly in in ancient traditions, religious or otherwise, that allow us to clarify for ourselves what the most powerful and deep seated convictions are. And the reason that I talk about this one first is that, you know, in my experience as the health commissioner during most of COVID, I can tell you it was my convictions far more than my credentials that carried me through in terms of responding to a crisis.
Dave Chokshi: [01:00:31] So that's the first one. The second one is what I think of. As for people who aspire to leadership positions, and I hope there are many because we need more and better leaders in our world. There's an evolution in leadership that that I've experienced in my career thus far in a couple of ways. The first way is from having the right answers to asking the right questions. Again, we're often like, think about how we learn in medical education, pimping on rounds, and making sure that we have all the knowledge to pass step one, etc.. But actually, when you get to a point in leadership, you're not the one who needs to have the answers, but you do need to know what questions to ask and be very thoughtful about formulating those questions in the right way. And the second piece of this is is related, which I think of as a move from an evolution from task focus to people focus. Again, we early on, we're very efficient as interns. We have our boxes that we're checking off and those tasks matter to take care of people. But then you become a resident and an attending, and even outside of the clinical setting, you realize it's about supporting everyone else and demonstrating care in the way that I described earlier. The third lesson that I wanted to mention is when in doubt, go proximate. I learned this early in med school when we were together. Tyler, go see the patient with your own eyes. Don't just get the pass off from the emergency room, Doc. Upstairs in your in your residence lounge.
Dave Chokshi: [01:02:28] Go down to the E.R. yourself and go see the patient with your own eyes. Again, even outside of clinical settings, this notion has been so valuable for me to get to ground, to not take for granted the experience of actually being in the the place and with the people that you aim to serve. Fourth lesson is never forget that a routine day for you is often the toughest day of your patient's life. When I think of the ways in which we sometimes lose empathy and myself included, it's when we lose sight of this, of this lesson, and we treat something that is catastrophic from someone else's perspective as just routine. And then the last one, particularly for people who are interested in public service, is a little bit of a football analogy. And I beg forgiveness because I acknowledge that football is a barbaric sport. But as someone who grew up in Louisiana was surrounded by it, it's the notion that public service is like being a running back. You know, they say a good running back always keeps their legs pumping. And that's what you have to do to succeed in public service. Any time that I feel like we were able to achieve something, it was because we kept pressing forward. There are always obstacles, but then all of a sudden the field will open up and you have a chance to to run through and you have to be ready to take advantage of those opportunities. So always keep the legs pumping. So I hope one, one or a couple of these are useful or speak to your listeners and thanks for the opportunity to share them.
Henry Bair: [01:04:19] Well, we can't think of a more fitting conclusion to this wonderful conversation. Dave, thank you so much again for your time and for sharing your insights. It's been a true privilege talking to you.
Dave Chokshi: [01:04:32] Thank you. Henry Thanks, Tyler.
Tyler Johnson: [01:04:34] Thanks, Dave. Great to have you on the show.
Henry Bair: [01:04:38] 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 theDoctorsArt.com. 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: [01:04:57] 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: [01:05:11] I'm Henry Bair.
Tyler Johnson: [01:05:12] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.