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Phone visits, health equity, vaccines: One physician recounts his pandemic year

For Cuong Pham, M.D., 2020 was a year of change, advocacy and seemingly endless work.

Dr. Cuong Pham
As co-founder of Minnesota Doctors for Health Equity, Dr. Cuong Pham has become a more visible presence at the university, where he’s been a member of the medical school faculty for 10 years.
Courtesy of Cuong Pham

For Cuong Pham, M.D., 2020 was a year of change, advocacy and seemingly endless work. As a Minneapolis-based physician specializing in pediatrics, internal medicine and addiction medicine at the University of Minnesota Medical Center and Community University Health Care Center (CUHCC), he’s been working on the front lines, assisting patients struggling with COVID-19, with substance use disorder and with the range of mental health concerns that have accompanied this most stressful of years.

“I have worked more in my life this past year than I have worked in any other year of my career,” Pham told me. He believes that part of that busyness is driven by his personal and professional focus on diversity, equity and inclusion, on making sure that his patients, many of whom come from historically disadvantaged communities, get the care they need.

As co-founder of Minnesota Doctors for Health Equity, a statewide coalition of physicians and other health professionals working toward health equity for all Minnesotans, Pham has become a more visible presence at the university, where he’s been a member of the medical school faculty for 10 years.

Pham said he believes that the statewide focus on issues of equity and inclusion inspired in part by the events following the killing George Floyd has played a role in pushing him into the limelight: “Suddenly, more than ever, I am an important person at the university. I’m happy to be more visible if that helps.”

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Recently, Pham took time out of his busy schedule to talk to me about how his life has changed over the last 12 months.

MinnPost: First off, what can you tell me about your work?

Cuong Pham: In my clinical practice, I work at the University of Minnesota Medical Center in the internal medicine wards. At the hospital, I have taken care of patients with COVID-19. In the past year, I’ve seen patients die from COVID, and I’ve also seen patents who’ve recovered from COVID. During the other part of my days, I work at CUHCC with children and in addiction medicine.

MP: How is your work at CUHCC different from your work at the hospital?

CP: The majority of my work at CUHCC has been with people with opioid use disorder (OUD). In that clinic, we take care of many people who are marginalized and underserved. The majority of people who come to CUHCC are immigrants and refugees who don’t speak English.

A lot of my work is centered around health equity. For the last three years, I’ve also chaired the University of Minnesota Medical School’s graduate medical education, our trainees’ residency and fellowship, around diversity, equity and inclusion. I also work with a lot of residents. And I’ve been doing a little bit of research around OUD in the Native American community, working on learning how to make suboxone treatment more family centered.

MP: Do you remember what you were doing a year ago, when COVID hit the United States? 

CP: A year ago, as we were getting news reports from China and across the country, I was trying to make the decision if was going to fly to New York for a trip with a group of friends. I had to cancel it, because CUHCC’s director called an emergency meeting. That was when we decided that we were going to shift to telemedicine.

The other thing that was happening at the clinic at the time was that we had just switched our electronic medical record system, which took a lot of energy. We were relearning a new system that they were throwing at us.

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MP: I’ve heard that switching to a new medical record system can be pretty intense. Then throw in a global pandemic and a rapid switch to telemedicine. It must’ve been tough.

CP: Yes. Before I knew it, I was working at home at all hours of the day.

MP: How did the quick shift to telemedicine work for you and your patients at CUHCC?

CP: The option of telemedicine can really free things up for patients. Even before COVID, not every individual liked to come into a clinic. With telemedicine, they don’t have to worry about bringing their kid to a babysitter. It’s so much quicker: They can see their doctor over lunch break. I’m happy to see patients this way. I want to meet my patients where they are at. This pandemic is forcing us to think about different and creative ways to implement care for our patients.

When you say “telemedicine,” most people imagine video visits. But at a clinic like CUHCC, video visits can be a barrier for many of our patients. Because of that, over the last year, I’ve actually been doing many of my visits over the phone. Having the option of phone visits opened up options for my patients. My show rate has improved because I can just call a patient and they’ll pick up.

MP: For many people, the option to see a physician remotely over platforms like Zoom has been a lifesaver. Can you explain why that approach wasn’t working for your patients?

CP: I’m doing some video visits at CUHCC, but for many of my patients it usually is a technology-equity issue. If we’re going to do a video visit, I need patients to at minimum have a smartphone or, even better, a desktop or a laptop computer. They also have to have fast-enough internet. Many of my patients at CUHCC don’t have access to that level of technology. Most have cellphones, but most of those phones are pretty basic. And many don’t have access to high-speed internet. In some cases, we try to use video, but it doesn’t work. Then I have to log off and on again. I only have 20 minutes to see each patient. If I am spending 10 minutes troubleshooting, that can be a big issue.

MP: So how do your phone visits work? Isn’t it hard to determine how a patient is doing when you can only hear their voice? With patients in the suboxone clinic, you’ve got to rely on their word — with no visual confirmation that they haven’t been using.

CP: We focus more on harm reduction, knowing it is more important that our patients take their medication than worrying about what happened with them from one visit to the next.

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For some of my patients, phone visits have worked well. For other patients, it was really hard to tell how they’re doing over the phone. I am listening to their voice, their words. In person, I can see how they look, if their pupils are dilated. I can see if they have track marks on their arms.

MP: How has your approach to your work changed from the first days of the pandemic to now?

CP: Initially, I think in the first couple of months, we had to make assumptions about how the virus would pass from one person to the next. Everyone at work was hypervigilant about PPE. I remember my heart racing when I entered the hospital rooms of people who were expected to have COVID. But most of the hospital staff is vaccinated now, and that has all changed.

For the first few months, I wasn’t sure about anything. I did everything extra-carefully. I had to make sure my gown fit right, that my N95s fit right. We had to save the masks. It was awesome to see how much work went into that. I don’t think that at any point in time I felt like we didn’t have enough PPE at the hospital. It was more of a question of, “How safe is it to enter this room?”

Now, I feel way, way more comfortable overall. I’m vaccinated. Even if I were to get COVD, I wouldn’t be very ill. I wouldn’t be hospitalized. I won’t die from it. I’m also pretty young. I’m not over 65. The data clearly shows that it is older individuals who mostly get sick and hospitalized and die. I still take precautions, but it feels less stressful overall.

MP: Outside of work, how has COVID impacted the way your friends have been living their lives over the past year?

CP: My high school friends and I have this Slack group. We’ve been using it to communicate and talk about this pandemic for the past year. At the beginning, some of my friends were so frightened that they never left their house. Everything that was shipped to them, they’d clean top to bottom. Some of them have now gone in the opposite direction. They’re out there, going to restaurants, interacting with people outdoors.

MP: How about your patients? Have their behaviors changed as the pandemic has shifted?

CP: Depending on what news sources they follow, my patients’ response to COVID varies. Most of my patients at CUHCC don’t have a lot of control of their lives. They don’t really have choices about making “safer” decisions. If their job tells them they have to go into work, they have to go to work. Because of realities like that, a lot of communities, especially communities of color, have suffered more in this pandemic year.

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MP: Once the pandemic recedes, do you think you’ll continue to offer telemedicine as an option for your patients?

 CP: The state Legislature is going through bills right now, figuring out what telemedicine will look like going forward. The phone-visit part is in question. If phone visits are no longer reimbursable, that will impact my patients the most. I’m a huge advocate for phone visits. In many cases, I believe they work.

Dr. Cuong Pham at a rally at the Minnesota State Capitol.
Courtesy of Cuong Pham
Dr. Cuong Pham at a rally at the Minnesota State Capitol.
Ninety-five percent of the time I can care for a patient by listening to what they tell me. Phone visits can function well enough for most issues. On the phone, a patient might tell me, “I’m stressed out. I’m anxious.” Maybe during an in-person visit I could learn more, but if phone is the only option that we have for working with this patient, and if they are willing to honestly tell me their story in this format, I believe I can help them out.

MP: The pandemic has sparked a number of mental health issues. Have you worked with patients who are struggling to cope during this time?

CP: One of my patients is a Native American woman in her 40s. She grew up in Minnesota. She is treating her OUD and is in my suboxone program. She’s suffered from anxiety for a long time. A lot of her anxiety stems from PTSD caused by systemic racism and personal reactions to the murder of George Floyd. This has impacted her physical and mental health. After COVID came to the state, she became hypervigilant and afraid of going outside. She missed a lot of appointments with me because she was afraid to leave her house.

Telemedicine allowed this patient to feel like she was in a safe place. She didn’t have to dress up just to come in for her appointment and that helped her feel more comfortable. I was able to listen to her and her story and learn more about her fears. During those visits, I wasn’t as focused on her OUD but more on why she was feeling anxious. After we spent some time in conversation, I was able to get her in with a psychiatrist and a therapist at CUHCC. She eventually got to a place where she was able to walk outside in her neighborhood with her family.

MP: How did you convince that her it was OK to leave the house?

CP: I explained to her, “There are ways you can be safe and go outside and not get COVID.” The combination of me listening to her and being a person of color made her more comfortable. We were able to talk about George Floyd, and she could tell me parts of her story that she did not feel comfortable telling other people.

MP: Have you been able to help your patients get access to the COVID vaccines?

CP: Because CUHCC is a federally qualified community health center, we have more of a direct connection to the state. My initial concern with the vaccine rollout was the racial health-equity part. The qualifications that were listed for priority vaccination status didn’t directly involve race, but we know from the data that Black Americans, Latinx individuals and members of Indigenous communities have higher rates of death from COVID. I was concerned that the state was putting some health issues above socioeconomic status.

Another area of concern for me was the fact that COVID impacts people of color at a younger age overall. When the state decided to open the vaccine to all people age 65 and over regardless of race, that also had an unfair impact on communities of color.

At CUHCC, we were able to roll out the priorities faster and focus on social determinants of health. I was able to say, “You are eligible” to patients who wouldn’t have been eligible anywhere else. It was rare for my patients to tell me they didn’t want the vaccine. If they did, I could convince them why they should take it.

MP: How do your patients react to being vaccinated?

CP: When I see a patient who’s had the vaccine, they just give off this sense of relief, this feeling of joy, smiles. They talk about the things they’re looking forward to being able to do again. It’s totally amazing.

MP: A year in, are you feeling like we’re finally getting closer to the end of this pandemic? Can you imagine your life one day getting back to normal?

CP: I’m feeling way more confident now than I did earlier in the year, just seeing the number of deaths go down. There was one day not that long ago where we had zero COVID deaths in Minnesota. That was an important milestone. The cases feel different now. With so many older people getting vaccinated, cases are more likely to be seen in younger people, who can more readily survive the virus.

Even with all those good signs, COVID may still continue to have a negative impact on communities of color and other marginalized groups for some time. The virus might still exacerbate health-equity issues. So many things are unpredictable.

We’ve been living with COVID for a whole year. Any time someone asks me how I’m feeling about it, my response changes from day to day, but I can say that right now I’m way more optimistic than I was in the middle of the winter.