A holistic approach to health care; infectious diseases, then and now; when to see a geriatrician: Upstate Medical University’s HealthLink on Air for Sunday, July 28, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a psychologist tells about the benefit of integrating primary care with behavioral health care.

Brian Rieger, PhD: ... By having resources available in the primary care provider's office to help, we can actually lower the demands on the primary care providers, because we're better addressing those needs. ..."

Host Amber Smith: A doctor reflects on how the specialty of infectious disease has evolved over five decades.

Donald Blair, MD: ... There have been 40 to 50 new or newly recognized, newly activated infectious diseases since I left training. . .."

Host Amber Smith: And a geriatrician explains when it's time for an older adult to consider a visit with a specialist.

Sharon Brangman, MD: ... The majority of patients that a geriatrician sees tend to be people in their 80s and beyond. ..."

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll chat with an infectious disease specialist who's been practicing for 50 years. Then, Upstate's chief of geriatrics tells when older adults may want to consider a visit to a geriatrician. But first, a psychologist explains the benefits of integrating primary care with behavioral health care.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Some health organizations and medical practices across the country are integrating primary and behavioral health care. We'll talk about why with Upstate psychologist Brian Rieger. He's an assistant professor in the department of psychiatry, and he is director of the Integrated Behavioral Health Care Program.

Welcome back to "HealthLink on Air," Dr. Rieger.

Brian Rieger, PhD: Hi, Amber. Thanks. Glad to be back.

Host Amber Smith: Why are health systems and primary care practices moving toward integrating behavioral health services into primary care?

Brian Rieger, PhD: There's a shortage of mental health services available, specialty mental health, and what many people don't realize is primary care providers actually provide overall more mental health care to patients than the specialty mental health care services available, or about the same, but actually slightly more.

However, primary care providers certainly try to do this because their patients need help, but they don't have a lot of training or education necessarily in behavioral health issues. So part of the goal of integrating behavioral health professionals is not only to give access to patients to a mental health professional right in their doctor's office, but also to be a consultant to the primary care providers when they are treating issues like depression or anxiety in their patients, and so many of them are doing that. They're doing it because, again, they kind of have to do it. Primary care is kind of the last stop, or the first stop in some ways, but when there's nothing else available, you go in to your doctor, and you say, "Hey, I need help."

Primary care providers want to be able to do what they can. So we're there to try to support them. So it's increasing access. It's sort of bolstering the primary care mental health services by working alongside primary care providers.

And another thing is that because so many of the issues that come into a primary care provider's office may seem like they're medical but may end up have something to do with sort of a mental health issue. Those can take a lot of time.

And so the research has shown that by better addressing those issues and by having resources available in the primary care provider's office to help, we can actually lower the demands on the primary care providers, because we're better addressing those needs, and so people don't sort of keep coming back with the same unaddressed mental health issue. So it actually helps reduce the demands on the primary care providers, even as we bolster their ability to address those concerns.

Host Amber Smith: So it sounds like there's a benefit not only to the patients, because for the patient, they come to their doctor, and they're able to actually get the care they need, whether it's with the physician or also with a behavioral health person that's there or that their doctor can set them up with quickly.

But there's also benefits to the medical providers because they have a way to take care of these patients that they really didn't have before?

Brian Rieger, PhD: Yeah, and actually reviewing some of the models of integrated care, there are some health systems, private health systems, that don't even worry about billing for those behavioral health services because the increased satisfaction, work satisfaction, that their primary care providers have because they feel better able to help their patients and feel like they have that resource available, it actually helps them to recruit and keep their primary care providers, which is a very expensive proposition.

Here at Upstate, we are hoping to do both. If people have their insurance, there's no reason why we shouldn't be billing for that service if we can, and we do that.

But certainly, I think if you talk to the primary care providers, I think they do appreciate that. Why do you become a primary care provider? You want to help the patients who come to see you, and if you feel like you're not as capable in that area, or you can't connect people with the resources, it's frustrating.

So yes, I think you've tuned in to that very well. The idea is it helps the patient, it helps the providers, and, hopefully, it makes our health care system more efficient overall.

Host Amber Smith: Is there a particular population of patients who are more likely to have both medical and behavioral health needs?

Does it break down by age or gender or socioeconomics?

Brian Rieger, PhD: I think that's a very interesting question, and I don't have a database answer for you.

Having been now director of this integrated care program for a year and a half, and working in three different clinics myself, it's hard to see a medical condition that doesn't have a behavioral component to it. And likewise, I think for those of us who are trained in mental health and not being a physician, I think it's also actually helping us to understand the extent to which medical factors influence people's mental state, not only directly, such as if your thyroid is off, or your blood pressure's causing you to have headaches, that then are making it hard to do what you need to do in your life, and you're not feeling good. That can be depressing, but also indirectly coping with a medical condition.

So one nice thing is that when I'm not seeing a patient in my consultation room, I'm sitting right next to the medical staff and the nursing staff, and we're always having conversations about our patients, and I think we're always learning from each other about this intersection.

So, for example, children: One of the most common presenting complaints to a pediatrician is stomach problems. Well, stomach problems, when they present in the pediatric clinic, are one of those things where there's very often a component of anxiety or stress or an eating issue, and sorting that out can be difficult if you're just a mental health professional working in isolation, or you're just a pediatrician.

But when you've both seen the patient and can talk to each other, you can build your confidence (to say): "You know what? We're really feeling like at this point, we think this is mostly stress related. So no, I don't think we're going to order any more workups for the tummy. We're going to have them get connected with some mental health treatment and see where we get there."

Host Amber Smith: It seems in recent years that we've heard about more and more demand for mental health care. Does that tie back to the pandemic, when a lot of providers left the profession, but also people were under a great deal of stress? Does it tie back to that?

Brian Rieger, PhD: Yes. Again, I can say both anecdotally and (using) some mental health data, there have been some changes in the way some mental health data is collected that coincided with the pandemic. That created a little bit of an artifact in terms of, for example, the increased suicide rate. But even before that, for example, the suicide rate has increased steadily over the last 15 years, well before the pandemic, and I think my own experience and what most of the providers would say is that, "Yeah, we're still sort of dealing with the stress and disruption in people's lives and the lack of care, frankly. People who didn't want to go to the doctor didn't feel comfortable with the doctor or couldn't get in because the system was overwhelmed, and so they didn't get proper care.

So, yeah, absolutely I would say that.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with psychologist Brian Rieger about integrating behavioral health services into primary care. Dr. Rieger is an assistant professor in the department of psychiatry and the director of the Integrated Behavioral Health Care Program at Upstate.

So what is the vision at Upstate for integrating behavioral health with primary care, and how are you going about changing the culture and the infrastructure so that that becomes the norm?

Brian Rieger, PhD: This is what we're really trying to do: Get away from the idea that mental health and physical health are separate.

Many years ago, the head of the World Health Organization, it's a very famous quote, and it's quite old at this point, he said, "There is no physical health without mental health."

But mental health care, and sort of our medical care, has been siloed and partitioned within the health care system, even often right down to our insurance. Often, you carve out your mental health insurance, and it's separate from your medical care insurance. So it's just one example of how the system has sort of put these things in different buckets, but a person is one person, not two buckets.

And so I think part of this is recognizing that mental health care is not something a primary care provider should just be sort of farming out to the mental health system. It should be integral to the way a primary care provider thinks about their patient and recognizing that issues like substance abuse or anxiety or depression or trauma are part and parcel of the care of this patient.

And no one expects primary care providers, by the way, to become psychologists or psychiatrists. But rather, the vision is to put resources in place to support primary care providers' efforts to treat their patients.

And that's a very important point I want to make, and I make it in meetings all the time when I talk about the vision of integrated care. We're not there to take mental health off the hands of the primary care providers. We're there to support the primary care team better meeting the health needs of its patients, including their mental health needs.

And that's how I talk about it. And I am very happy to say, by the way, that not only have the primary care providers and clinics here at Upstate embraced this vision, but they really work hard to help us create an integrated care model. We're far from where we want to be; this is new. But I think there's a lot of agreement on where we want to try and get to.

Host Amber Smith: Do you think, because some patients, there's a bit of a stigma (to) mental health care, do you think that presenting it as part of a package does a lot to get rid of that stigma?

Brian Rieger, PhD: It's precisely one of the reasons why primary care providers become the front line for mental health conditions, because a person is much more likely to go to see their doctor and ask for a doctor's visit because they don't feel well, versus, and probably lots of people have said, "Well, I think you're depressed. You should call a mental health guy."

Well, they're just much less likely to do that, and frankly, even when a primary care provider has a conversation with a patient, encourages them to seek help in a mental health clinic, there's still a reluctance to do that.

So going back to your very first question, we're right there in the clinic to meet patients, and I can tell you several patients I've worked with where I feel like my job has been to give them a little good experience about what it's like to work with a mental health provider and then help to persuade them that "Look, here in the primary care clinic, we're sort of limited in how much we can do for you because we have so many patients, just like the primary care provider, we're treating a population. But I think you found this work helpful, and I can guarantee you that there are providers in the community who could pick up where we're leaving off here today and keep you going."

And I think because they've kind of almost had an introduction to what it's like, hopefully a good experience with our team, we found that some people who may have been reluctant are now willing to engage more.

Host Amber Smith: Well, that's encouraging. So let me understand from the patient's point of view how this works.

If they come to their primary care provider for their checkup, say, and it comes to light that maybe there's some symptoms of depression, the primary care provider may suggest that they stop in and see a behavioral health care person before they leave?

Brian Rieger, PhD: Let's talk through that. That's a good starting point.

So we have a patient in front of you and, again, part of our goal with integrated care is to improve the screening and detection of things like depression in the primary care clinic. And that's one of the things we talk about in our work groups. So we have integrated care work groups in each of the clinics that have all the different disciplines. So nursing and the administrative side and the provider, the physical providers, and the physical health providers, mental health providers. So in those work groups we talk about these things.

So let's say a patient comes in, they've been given a depression screening tool, and that raises a red flag that there's a concern about depression. So the goal would be for that provider, that primary care provider, to have a conversation. And then there's several different ways that can go. They might decide that maybe it's a good idea to start some medication, and they can go ahead and do that, and they might offer, let's say, "And you know, I think you might benefit from some counseling."

The patient says, "All right, well, I'm not so keen on that."

(The provider then says) "All right, well, why don't we start with the medication, and we'll see where we get with that."

And so that might be one outcome. Another thing, you might have a similar conversation with other patients that might say, "I'm not so keen on medication," or "Is there anything I can do for myself?"

"Well, we do have our integrated care staff. If one of our psychologists or social workers are available, would you be willing just to meet with them today?" And they could explain what we have to offer right here in the clinic and see if you'd be interested in an appointment."

We call that a warm handoff, and the reason that's important is because the patient trusts that PCP (primary care provider) already. So by bringing us into the room and introducing us, he's pulling us into that trust circle, and that goes a long way to breaking down that reluctance to open up to, or even seek help from, a mental health provider.

We're going to explain what we do, we're going to offer, "Maybe, if you're willing, we could have you set up an appointment to come to see me, and we could dive in a little deeper to find out what's going on and see what you really need." So that would be kind of the warm handoff.

Or if one of us is not available because we're tied up with our own patients, they might just place a referral, and then our care manager would contact that patient and do sort of the same thing over the phone: "Hey, here's what we have to offer. You know, your doctor referred you because they're concerned about some depression, and would you like to come in and see one of our folks?"

Or, sometimes people, maybe they've already had treatment, and we know we need really to connect them with more significant treatment, so that care manager will jump right to helping connect them with the resources in the community.

And the reason that's important, again, is rather than just giving them a list of providers and saying, "Here, go make some phone calls."

I mean, it's really hard to access mental health care, not just in Syracuse, but in the country. There's a shortage of providers. They have waiting lists. There's forms that need to be filled out. So it's kind of a barrier.

So what our care manager does in those cases is really trying to facilitate, support and work with the patient to get them connected to that community-based service. So we kind of have a menu of options, and we try to meet the patient with whatever item on that menu seems to be appealing to their appetite that day.

Host Amber Smith: And then I like how you described it's like a team. So if this patient has side effects from the medicine or is having other issues that pop up, the team kind of discusses that? Are you able to facilitate back to the physician?

Brian Rieger, PhD: Not only are we able to, it's our job to communicate back to the primary care provider.

And I might see a patient, say, they were reluctant to try medication. I've seen them for three visits, and I've spent some time talking about the benefits of different treatment options, and they'd actually like to give it a try, so I told them I'd let you know. They're not scheduled to see you for another three months, but I told them you might want to bring them in sooner and have that conversation.

And so I will either literally go find the provider and have that conversation face to face, or in Epic. There are all sorts of ways within our electronic medical record, which we use here at Upstate -- Epic -- that we can communicate. We can message each other, there's a sort of instant chat function, like texting, through the medical records. So we have all sorts of ways to communicate.

And that's one thing, Amber, I will say that we've started on both sides to learn the best ways to communicate with each other and to learn what issues we should be bringing forward more quickly versus what can wait till we sort of bump into each other and catch up. And that's part of, again, us all learning together how to do this.

Host Amber Smith: Are you aware of other health systems in Central New York where this sort of integration is becoming common?

Brian Rieger, PhD: Yeah. Actually the University of Rochester is ahead of us on this a little bit.

They have developed an integrated care system. And when we put our system together, I think we have a number of physicians that we have trained who work at the University of Rochester, so we have some connections. And so when I was hired as director, my goal was to sort of try to get this thing off the ground a little bit, working with my colleagues in psychiatry Dr. (Seetha) Ramanathan, our medical director, Dr. (Thomas) Schwartz, the chair there, they had already had conversations with Rochester before.

Now, I will tell you one of the things that I've learned, and the VA (Veterans Affairs system), by the way, has been doing this longer than anybody, and the national headquarters for integrated care in the VA system is in Syracuse, so I've accessed those resources as well. But I will tell you, anybody who works at Upstate knows that Upstate is a different animal from a private hospital like the U of R or from the VA. We have our own culture, we have our own rules, or New York state sort of thing.

So we've been able to learn from those systems, but really we've sort of learned where they've had the greatest gains. And we've tried to figure out how do we learn, how do we take that and make it work within our system? And that's been, I think, the challenge for us.

Host Amber Smith: Well, it's really interesting, and I'm appreciative of you taking time to tell us about it. Thank you so much.

Brian Rieger, PhD: Sure.

Host Amber Smith: My guest has been psychologist Brian Rieger. He's an assistant professor in the department of psychiatry, and he's also the director of the Integrated Behavioral Health Care Program at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

Reflections on a 50-year career in infectious disease -- next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Dr. Donald Blair is among the 1,200 Upstate employees honored at Upstate's annual Employee Recognition Day this year. He's a professor of medicine specializing in infectious disease, and he's been at Upstate for 50 years. I invited him to talk about his career.

Welcome to "HealthLink on Air," Dr. Blair.

Donald Blair, MD: Thank you.

Host Amber Smith: So you started at Upstate in 1974. Where did you get your medical training before coming to Syracuse?

Donald Blair, MD: I went to pre-medicine in Cleveland, Ohio, Western Reserve University, and then went to their medical school as well, graduated in 1965. And from there I went to University of Michigan in Ann Arbor for my internship. That brought us to 1966, which was when the Vietnam War was active. And so I left there for three years and came back in 1969 and did my residency in internal medicine, and a fellowship in infectious diseases and clinical pharmacology.

Host Amber Smith: So what interested you in infectious disease and pharmacology? Why do you think you were drawn to that specialty?

Donald Blair, MD: I've always sort of assumed that it was because in that three years that I was gone, interrupted my training, I spent two and a half of that with the Peace Corps, mostly in Ethiopia and a couple months in Yap in the South Pacific. And then I went to Washington and was with the Food and Drug Administration for about eight months or so. And I did research in clinical pharmacology there.

So in Ethiopia, I saw a lot of infectious diseases. I saw two of the last cases of smallpox in the world. And I saw lots of leprosy, tuberculosis, of course, and then malaria was a constant problem, hepatitis A was kind of embedded in infectious diseases for the volunteers. I mostly took care of the volunteers. And I think that carried over to when I returned to Michigan.

Host Amber Smith: So what was it like at Upstate 50 years ago when you started here? Do you remember anything about your first day?

Donald Blair, MD: I can't honestly say I remember the first day, but I do remember my first impressions. It was a new situation, of course. And I was impressed by the fact that there were the three hospitals in such close proximity, with Crouse Hospital being connected to Upstate, and the Veterans Hospital just across the street.

And, that was so much more convenient than we had in Ann Arbor, where everything was a car's reach away. And, this resulted, it was a major factor, I think, at that time in providing a real variety of training sites and in a convenient way for both faculty and for the residents and students.

Host Amber Smith: I'd like to have you tell us about the field of infectious disease over the past 50 years. AIDS was something you dealt with earlier in your career. Do you recall what it was like at the beginning of the AIDS crisis?

Donald Blair, MD: Well, before going to AIDS, I should show where my mindset was. When I left Ann Arbor and came to join the faculty at Upstate, I sort of thought that all of infectious diseases had been discovered -- maybe a rare exception -- but probably we just had to concentrate on good diagnostics, better treatment, better management, good epidemiology, public health and so forth.

Nothing can be further from the truth, of course. There have been 40 to 50 new or newly recognized, newly activated infectious diseases since I left training.

One of the first three I encountered was legionellosis. We don't think much of legionella now, but it has become a routine thing we test for when pneumonias of certain types come into the hospital. And, it was a big deal at that time. It may be before your time, Amber. I'm not sure. But it was, it was the first, and we realized, well, maybe it's not all over.

Another one, babesiosis, which is now, you can catch in Green Lakes (State Park) and elsewhere in Central New York, was just being discovered on the coast of New England, particularly Block Island. A lot of people here know Block Island, and it became a hotbed of babesia. So that was the setting that I ... I wasn't really prepared for all of the new diseases.

And then as you mentioned, the big one came. We didn't know it was human immunodeficiency virus at first. It wasn't called that. It wasn't even clear that it was a virus. We went through a whole variety of possible etiologies (causes) as we were dealing with it. We had our first case that we recognized at the time in 1981. Now, 1981 was a year that the CDC -- Centers for Disease Control -- published a report of five or six cases of pneumocystis pneumonia in their publication, called the MMWR (Morbidity and Mortality Weekly Report).

In retrospect, we had a case in about 1977 or '76. It was a man from Africa, West Africa. He came in to the hospital, crashed (quickly deteriorated), went to the intensive care and died. We hadn't the foggiest idea of what was going on with him. But later, when the testing became good, we were able to retrieve his tissues from the pathology department and demonstrate that he had HIV disease.

The earliest case in the United States that I'm aware of was a young man in St. Louis in 1968. But in terms of Syracuse, we had one case in 1981, and then it doubled the next year, but that's only two. But by 1986, we were seeing quite a few. And around 1986-87, we started the Designated AIDS Center because we had enough, we had to have a dedicated clinic. And we started doing research on treatment, and it was important to have a clinic.

Host Amber Smith: But it took, it sounds like, years to pinpoint what this was and ...

Donald Blair, MD: Yeah. It did.

Host Amber Smith: ... what to do about it.

Donald Blair, MD: It did. I well remember, I think it was 1983, I went to a conference in Rockville, Maryland. It was a two-day conference, and they had a half hour to two hours dedicated to all kinds of theories: It's herpes virus, it's cytomegalovirus, it's the chemicals used for birth control, and just any number of theories because no one knew. And, by that time, actually, by the time (of) that meeting, one of the theories was that it was HTLV-3, which was a human T-cell lymphoma virus, which later the name was changed to HIV.

So by '83, we knew what it was but didn't really know that yet. We knew what became known as the virus. And another year or so, it was widely known, and we could test for it accurately and quickly.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Donald Blair. He's a professor of medicine at Upstate specializing in infectious disease, and he's celebrating 50 years at Upstate this year.

What impression did you have about COVID-19 when it began emerging?

Donald Blair, MD: I became aware of it in January of 2020 and was following it, of course, as everyone was, but I had no particular knowledge of it from, we hadn't seen any yet in Syracuse. And I well remember as in March, I was in the Atlanta Airport, and three people went by with masks on. Those were the first masks I saw. And, we went on home. We were supposed to leave in a week and go out to California. And just in that period of time, the amount of disease increased so greatly that we canceled that trip. And, you know, I didn't get to see my grandson for over a year. So, my thoughts were, this is really bad. We don't know exactly what we're dealing with here.

I had lived through SARS, the severe acute respiratory syndrome disease that had come out of China a few years before and was aware of MERS, the Middle Eastern coronavirus disease, (Middle East respiratory syndrome). And so when this came out, as SARS type 2, also known as COVID-19 I was concerned that this was going to be a pandemic. And indeed that's what materialized, and well, we all experienced that. We know how bad that was.

Host Amber Smith: People are talking about bird flu now. Are you concerned about bird flu affecting more humans?

Donald Blair, MD: Bird flu is a very interesting one. Influenza, of course, has been around, and we even could test for it when I finished my training. I first became aware of bird flu maybe 30, 35 years ago or thereabouts. It's a variety of things. Flu is a designated "h-this" and "n-that," (referring to two kinds of proteins, hemagglutinin and neuraminidase) And, the bird flues, there've been, I've seen at least a half a dozen, and I'm not sure just how many there are, of different types.

They are a big problem in the poultry interest industry. And then the wild birds. And they can spread. And our latest iteration of this, where it's spread to the cows and to at least three farm workers is just an example of what we saw before with other types of bird flu in Vietnam and Cambodia and so forth.

Right now, this exact one, I think there's very little danger of it spreading to many people without very close contact. But, it does not take much in the way of mutations to convert it to a rapidly contagious and easily contagious virus. And yes, I am concerned about that.

Host Amber Smith: So that's one to keep an eye on?

Donald Blair, MD: Very, very, very much so. And if it follows the way other influenzas have, and if we meet this same kind of mindless resistance to a vaccination that we've encountered, there will be a fearful toll to pay for that.

Host Amber Smith: So a bird flu that was spreading in humans could be more devastating than COVID?

Donald Blair, MD: It could be. Yeah. There's no way of predicting that, of course. That's pure speculation. But it could be.

COVID is a very bad clinical disease, same as with flu in this sense: 1,000 people get infected, some of them have no symptoms at all, and some of them die. Flu versus COVID, different percentages died, and different rates of mutation, different speed of transmission, and there are differences. But both have the capacity for pandemics, and all we have to do is look at the great influenza epidemic in 1918, '17, and we can realize what can happen.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break. We'll be right back with more from infectious disease expert, Dr. Donald Blair.

Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith, talking with Dr. Donald Blair about his 50-year career in infectious disease.

Can you talk about how the field of infectious disease has changed over 50 years?

Donald Blair, MD: I would say that the biggest changes in infectious disease involve the ability to diagnose things and, increasingly, to treat, be able to treat things. We had influenza when I was an intern resident. We had what became known as mycoplasma pneumonia, so-called walking pneumonia. We had, of course, pneumococcal pneumonia. We had a lot of things like that. But now somebody comes into the hospital with a pneumonia, and they get a sputum specimen, and you can test within an hour or two for 23 different etiologies, for different pathogens. That's pretty cool. Still not enough. That still leaves over half undiagnosed.

But it does point, it's pointed, to some dramatic things. I mentioned mycoplasma. We used to think that most of these so-called "viral-like pneumonias" were really due to mycoplasma. Turns out they aren't. Turns out they are viruses that do it. There's a lot of coronaviruses other than COVID that cause serious infections. And of course there's influenza, and then there's a bunch of others as well. So I think diagnosis is one of the big ones.

The other obvious one is treatment. To a great extent, we've been chasing our tail. I was born the year penicillin was first used in a human, 1940. And, the story of antibiotics and bacteria is, first we treat them, and then they develop resistance. And it's kind of a lock-step proceedings, all the way up. And so now, we have these fancy, very expensive antibiotics, and we know full well that next year, the following year, they'll be resistant, and we'll need others. So our original model -- which is treat the pneumococcus with penicillin, then treat whatever develops with new antibiotic -- that's a bad model, and we need something better. And we don't have that yet. So that's where we need to go, is a better diagnosis and better approach to these infectious agents.

Host Amber Smith: I'm wondering if more medical professionals are attracted to infectious disease after COVID. Are you seeing more interest from students?

Donald Blair, MD: The students, I think, are more interested. I think that is true. But as far as I know, and this could be quantified and I just don't know the numbers, there's not actually an increased number of medicine residents going into infectious disease. As fellowships (training programs) go, it lacks a procedure. And we pay physicians in this country best if they do procedures. And that procedure can be a scoping of some kind or a surgery or catheterization of some kind. Well, infectious disease just doesn't have one. And we also get some of the most complex, difficult cases to diagnose, which is actually why I was attracted to it, because it was a fun discipline for me, but it's not that attractive to those who are a little more focused than I was on a good income, I guess.

Host Amber Smith: You had a lot of duties over the decades. You were chief of infectious disease for 21 years. You oversaw the medicine residency program for doctors going into medicine. You took care of patients. You've done research. What's been the most fulfilling for you?

Donald Blair, MD: Well, I've enjoyed it all, frankly, including running the TB (tuberculosis) program for the (Onondaga) county for a decade or more. But the most gratifying, and sometimes this sounds trite, but truly the most gratifying is to work with students and residents, and then -- and that's good; that's gratifying in real time -- but then learn later how much you contributed or how much they feel you contributed to their education, their career, and so forth. I just found that immensely gratifying over the years.

Host Amber Smith: So is it a field that you would recommend new graduates to consider?

Donald Blair, MD: Oh, absolutely. I don't think anybody would be foolish enough to conclude that there's going to be no more infectious diseases. Just the opposite. We now see that as the population gets denser and denser, there are going to be more and more and more infections. And, I would urge anybody who likes problem solving. If you don't like problem solving, then it would be more frustrating than rewarding. But if you enjoy the process of problem solving -- which many of us do. I think it's a characteristic of infectious disease physicians -- go for it.

Host Amber Smith: What about the public? Do you think the public understands infectious disease?

Donald Blair, MD: I think that people should, the population really needs better training in infectious diseases and the pathophysiology (causes and consequences) of it, not to treat, not for anything like that, but to develop a reality-based appreciation of what we're facing. I hear comments that just make me cringe because I think, "Boy, you just really don't know the score, do you?" And it's hard to communicate. We have not, as a culture, developed a approach that will not turn people off. We'll educate them and allow them to then consider things for their own welfare as well as the well-being of peers. It's a tough problem.

Host Amber Smith: You mentioned the mindless resistance to vaccines, and there doesn't seem to have become a solution yet. Do you have any ideas? I mean, what do you say to people that are just vaccine resistant?

Donald Blair, MD: I have not personally discovered what you can say to them. They seem so resistant, and there may be a core issue below that, and that is, I'm not sure how many are aware of the scientific method. That is posing questions, testing hypotheses, assessing the results and basing your therapies and approaches on the result of the scientific investigation. Science is being rejected, broadly, in our culture, and this really is a social science venue to try to solve, I think.

I can tell you, my own family ... my brother died of COVID-19, my older brother, trusting that God would protect him, and not getting the vaccine. Now, how big a failure can one be to lose your brother because he just absolutely will not listen to anything science-based? So, it's a very difficult issue. Very difficult.

Host Amber Smith: Well, thank you so much for making time to talk about your career.

Donald Blair, MD: Sure. Well, thank you very much, Amber. I appreciate it.

Host Amber Smith: My guest has been Dr. Donald Blair, a professor of medicine at Upstate for the last 50 years, specializing in infectious disease. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from geriatrics chief Dr. Sharon Brangman. When should a person seek care from a geriatrician?

Sharon Brangman, MD: Well, typically, the age of geriatrics is 65 and above, and that was a number that was arbitrarily set a couple of generations ago when people who were 65 had usually done very hard physical jobs and had a lot of injuries and illnesses. But now, with the advent of a lot of public health and different jobs and a different kind of medical care, we can postpone that aging process a little bit. And some of those chronic diseases now are happening later on in life so that the majority of patients that a geriatrician sees tend to be people in their 80s and beyond. And these are people who have multiple chronic illnesses. They may have some trouble getting through the day. They may have some memory problems.

Geriatricians are experts in managing the complex long list of medical problems and medicines that a person may have, and then helping the patient and families figure out the best way to get that care, whether it's in your home or in another setting. We really like to have people stay in their own home. We really like people to be at the highest quality of life that they can have in the best setting for them. So we can help families make that determination.

Depending on where you live, geriatricians can be your primary doctor or they can be your specialist. In Syracuse, at Upstate, we are specialists. We work with the primary care doctor, and we help the primary care doctor optimize their care. And then we help the family make decisions about care for that loved one if they need care at home or at a higher level of care.

But we also do other things. You know, older adults accumulate a lot of medications as they get older, and sometimes those medications can cause side effects that can make somebody look sicker or have more medical problems than we anticipated. So we can help work on the long list of medications to make sure they all make sense and they're not interacting with each other. We look at someone's physical function to see what we can do to help support them so that they can maintain as much independence as possible. And, of course we help people who have memory problems to help them also optimize their function for as long as possible.

We work on the principle of a comprehensive geriatric assessment. So we look at the whole person. We look at their past medical history. We look at their current medical problems. We look at their cognitive status, their mood, their medications, and their functional status. And then we help them come up with a comprehensive plan for moving forward. So we don't just make a diagnosis. We actually make a diagnosis and then help them set up a care plan.

And in our office we have a team of social workers who can help families identify resources in the area. And we have a team of nurses who are experts in taking care of older people and can help families walk through some of the issues that might come up where you just need to talk to someone and ask a question. So our practice is really geared toward specifically helping people with chronic illnesses and the aging process where they all kind of come together. Because aging itself is not a disease. It's a natural process that we are all going through.

Host Amber Smith: You've been listening to Dr. Sharon Brangman from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Jamie Wendt is an author of a poetry collection called "Fruit of the Earth." She gave us a beautiful portrait of a father-daughter relationship in her poem entitled "Fathers."

Father and daughter stitch their shoulders

together in the hospital room after

her mother/his wife escapes her body. How

does the lover's loss listen

to the 16-year-old's piercing silence?

They each break inside a future, without.

One of them places hands on knees,

bends a body, vomits into a bucket. One of them curls

fists, opens bluish lips as skin turns ashen, a rapid pulse. Life

is a conscious effort in a hospital room.

The daughter inhales antiseptic, the waxy polished floor,

yellow skin fainting to musty gray, tumor scented.

What do the eyes of a grown man

see at the loosening fatigue of his daughter?

Her wordless stare, her arms and legs collapsing

like an old, wild and silent tree.

Who is she?

Can he be a father alone? How does a man do that?

Children have lost fathers to wars. It is 1949.

His fingertips pace across the floral wallpaper.

Losing a devoted mother is a fairy tale,

a haunted, meat-infested forest

ripe and full of honeybees.

In a few years, she will marry

the young truant man who swing dances, tells embarrassing jokes.

Sitting at home at the curtained window, a father

digs a grave for the rest of his life.

Plans a wedding. Pays bills.

Keeps perfume bottles on his desk like gold.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," what you need to know about basal cell carcinoma and melanoma.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.