He took on state’s top public health job. Then the pandemic hit.

Sara Berg, MS , News Editor

From emergency physician to the 170th AMA president, Steven J. Stack, MD, MBA, has taken on many roles during his career. However, nothing would be as challenging as his new role as commissioner of the Kentucky Department for Public Health when, one month in, COVID-19 was declared a pandemic.

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“It’s been like a baptism by fire. It’s been drinking through a fire hose. It’s been all those things,” said Dr. Stack. “I had about three weeks to be a normal health commissioner, where I was learning—and then the whole world changed.”

“My life has been consumed with trying to address and solve unsolvable problems, participating in the shutdown of most of society and then the reopening of some of society in trying to navigate all sorts of unknowns and uncertainties,” he said.

During a recent interview, Dr. Stack discussed how he has transitioned into his role as health commissioner in Kentucky and how the pandemic has impacted his role.

AMA: As an emergency physician, since you're used to thinking on your feet, do you think that helped you with being able to manage the chaos of a pandemic?

Dr. Stack: My specialty background has been incredibly helpful. I actually feel very fortunate that my background gave me a number of different perspectives, which have been useful. Being an emergency physician, my life clinically has been, frequently, making high-stakes decisions with limited, imperfect information and having to still be accountable for a high-quality decision and accept the consequences of those decisions.

My background as an AMA president, an AMA board chair, and in organized medicine for decades, gave me a familiarity with government from the private sector and how to interact with it and how other people interact with the government when they're trying to get things done. It also gave me an appreciation for the complexity of policy and health care policy, specifically.

And then, you know, I have a business degree too. I liked business topics for a long time, but I actually went back in 2017 to get my MBA and I've had to negotiate contracts and create very complicated solutions to difficult problems.

Of course, I love reading and studying about history and I think even that has been helpful for what I've done because with so much disruption in society, having perspective really is helpful. There's a lot in my background that has helped me. Now, all of that being said ... there's just no way to be entirely prepared for the kind of magnitude of things we're having to do right now.

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AMA: I can only imagine being in your shoes and how hard it must be to take on a new role during a pandemic. Have you felt overwhelmed? And have you been able to overcome that feeling?

Dr. Stack: It's been going on long enough now that there have been cycles even within this. There are the weeks where I managed to get enough rest and be refreshed and I feel like a burst of creative energy or I can see a path to maybe try to address or improve some of the challenges. There are weeks where I'm just totally exhausted. It does feel like the movie “Groundhog Day,” where every day is the same thing—wake up really early, you do some reading, you get ready for work, you drive to work. You do work all day long and then the only time I can catch up on emails is after the end of the workday a lot of times—because the day, once it starts, it's just gone with responding to people's needs.

Then you get to the weekend and the weekend is the time to do reading, just to kind of keep aware, like read JAMA, The New England Journal of Medicine, try to catch up on news and lift your head up from underwater a little bit, just to see what else is going on and spend some time with family. Some weeks it feels like it's all you can do just to keep up. Other weeks you feel like you're constantly 10 feet underwater and you never even see the surface, let alone reach to get above it.

AMA: We’ve seen so much regional variation in COVID-19 spread in the U.S. Compared with other states, how is Kentucky faring?

Dr. Stack: Kentucky's done a lot better than a lot of states from the public health standpoint. States like New York and Louisiana got hit really hard in the beginning months. Then Louisiana got hit hard again in later months. Other states like Arizona, Texas and Florida got hit really hard more recently. And still Kentucky, if you look at our graph online, when we started the climb in March, we shut down quickly and we stopped it. And then we settled into a two-and-a-half to three-month plateau. Then we started to climb in early July, and we took steps to require masks and cut informal groups to 10 or less, shut down bars and restricted restaurants again. Now we appear to be stabilized at a new but much higher plateau.

The question will be, if we stay where we are for a while, obviously there's only three options: You go up, you stay flat or you go down. I don't think we know what will happen and now schools are beginning to open. We've recommended they delay their starting until Sept. 28. Most school districts have followed that recommendation, but not all. We're going to see how folks do, but overall Kentucky from a public health standpoint has done very well, much better than you would have historically expected it to perform based on our generally suboptimal performance on public health measures.

AMA: Even though Kentucky has a statewide mask mandate, there may still be objections from people. How do you get more people to mask up?

Dr. Stack: One of the most important things is consistency of messaging. We've been very clear that it's a public health measure. That it's what we need to do in order to get Kentucky open again, to keep people safe, and get people back to school, to work, to play.

Now you can get cotton masks and all sorts of different kind of masks. We didn't have all that in the spring and people were trying to use medical masks and that was a problem because they were competing with health care providers. Now we're at a very different place, because you can get these other masks and now there's more and more evidence that—even with the tradeoffs associated with them—they appear to be a really simple, but very powerful, tool.

All that’s old is new again. If you look at pictures from the 1918 influenza epidemic there are people wearing masks in those pictures all over the place too. We are essentially doing the same. So, modeling behavior and being consistent in your messaging is really important. The mandate did matter because we told people what we needed them to do. We told them for weeks and they didn't do it. You know, we put in place a mandate—compliance went up dramatically.

AMA: A lot of the public health topics right now are being politicized, such as wearing masks and physical distancing. How do you make it apolitical?

Dr. Stack: Well, by saying it—pretty much. We've said over and over and over, “This is not about politics. It's purely about public health and if we don't do it, we're going to pay a consequence and more people will get sick. When they get sick, they'll go to the hospital, some people will die.” We made the point that it really isn't about any ideology. And what you have to do then is try to enlist people, a diverse array of people to show that it's not politics. So that includes diversity in gender, ethnicity and social status. You need a variety of people modeling the behavior.

This is a time when it's an all-hands-on-deck moment for leaders—whether they're elected political leaders, appointed people like me, physicians, nurses, teachers, principals and superintendents of schools, CEOs of businesses. All of us who have the capacity to understand just how serious this is have a responsibility to model these behaviors and consistently message why it is so important in order to depoliticize it and remove it from ideology and identity politics.

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AMA: When these topics of mask wearing, physical distancing and going back to school come up in the emergency department, exam room or at the bedside, what’s your advice for practicing physicians?

Dr. Stack: It's three major things: watch your distance, wear your mask and wash your hands. We've done hands, face, space. So, wash your hands, cover your face and keep your space between people. You just have to drill that in over and over and over so people will internalize it and then normalize that behavior. We have to really get this done as quickly as we can so that people don't think anything unusual about someone wearing a mask, they don't feel uncomfortable wearing a mask and everybody knows it's just what we have to do. This is really pure and simple public health. Whether you agree with schools opening or schools staying closed or bars opening or bars staying closed, there really shouldn't be any doubt that wearing a mask, washing your hands and physical distancing are necessary one way or another. That's a message I think all physicians, regardless of their opinions on other issues, should be able to come together on and be consistent.

AMA: With the mix of sad news and vexing public health challenges you’re facing every day, what keeps you going?

Dr. Stack: It’s a balancing act of you need to maintain hope and optimism for when we'll get through this with the realities that it's not going to happen soon. I traveled the country and the world in AMA leadership and I liked those activities. We didn't have the AMA Annual Meeting and we won't have the in-person Interim Meeting—I miss those. My emergency physician friends and I don't get to go to our meeting because that was canceled as well.

My wife and I have enjoyed going out to restaurants for the whole time we've been together and we can't do that now. So, I look forward to the time when hopefully we get a vaccine or vaccines that can help us to neutralize the threat and we can start getting back to these other activities that we so much want to do, because right now it really is quite an altered world and all of us want to get back to the things we used to know and enjoy.

As an emergency physician, as a public health physician, as a former AMA president, thank you to all the doctors for all they do because it's not always easy to be a physician, but now it is particularly difficult in many ways. So, thank you to all the physicians for all they do, very much from the bottom of my heart, in the various roles I've had the privilege to be part of in our profession