The thirteenth episode of MedCast features Dr. Ilse R. Levin, a board-certified Internist from Silver Spring. Dr. Levin discusses her background as a DO, addiction medicine, and the AMA.
Dr. Stephen Rockower (00:01):
Welcome to Med Cast, the podcast for MedChi, the Maryland State Medical Society. Each episode will be doing a deep dive into medicine and taking an insider's view on issues facing Maryland's physicians and patients and healthcare more broadly. I'm your host, Dr. Stephen Rockower. Today, may guest is Dr. Ilsa Levin, an internist in Silver Spring, Maryland, and also a member of the Board of Trustees of the AMA. Welcome Dr. Levin.
Dr. Ilsa Levin (00:30):
Thank you.
Dr. Stephen Rockower (00:32):
Well, what I'd like to do is start off with a little bit of biographical data. So tell us about, you know, where you grew up and where you went to medical school and your training and how you got to Maryland.
Dr. Ilsa Levin (00:44):
Sure. So I was born and bred in Baltimore City, Maryland. Went to school at Friends School in Baltimore City. I went to undergrad at Boston University where I studied Marine Biology. Then I traveled to Australia to do my master's in Public Health and Tropical Medicine at James Cook University. And after a brief break, working as an epidemiologist for a few years, I went to medical school at Western University in Pomona, California.
Dr. Stephen Rockower (01:23):
Okay. And how did you get back to Maryland?
Dr. Ilsa Levin (01:26):
A long route. Of course, I went to residency at Baystate Medical Center in Springfield, Massachusetts, and I was a national health service course scholar, and my husband was also a medical student and was finishing medical school doing his payback to the Navy. So we were trying to figure out how to make our both of our payback times work. And the easiest place was southern Maryland, DC, Northern Virginia. So that's how I ended up back here, initially working for Unity Healthcare, which is a nonprofit in DC. And my focus back then was working with incarcerated populations.
Dr. Stephen Rockower (02:09):
Yeah. Well, I'm fascinated about the incarceration stuff because that's not what a lot of physicians are, are doing, you know, tell me about some of the problems that you ran into with with that.
Dr. Ilsa Levin (02:22):
Sure. It was you know, it's interesting. I was drawn to it from medical school. This is a group that is incredibly underserved and often has not been given the same access to care that much of the rest of our population is received. And so I had this wonderful opportunity where I spent half of my week working in the DC jail both on the women's side and on the men's side. And the other half of the week I spent running a clinic for people who were getting out of jail or prison or being sent to the halfway houses throughout DC and I became their primary care physician. And, you know, working with incarcerated populations or formally incarcerated populations, it's very different. You often don't have access to all of the specialists you normally have access to. And so you have to become more versatile at what you can, at your knowledge and what you can perform.
(03:22)
For example, I didn't have access to an endocrinologist or a rheumatologist, and yet I had to treat someone with extremely severe sarcoidosis. And what would happen is physicians working at some of the universities like Howard University and GW, who were those specialists, would often on a volunteer basis, help me out, give me guidance. And that was really invaluable to me when otherwise I just didn't have the specialists. The other amazing part of it is seeing how someone can really turn their lives around and how if they get that help and support and those opportunities, maybe it can really make a difference. So it, when I was working in the reentry side of things, I had a number of patients who had been incarcerated for over 30 years. I believe the longest was 42 years. Wow. And yeah, when you get out after that, imagine the world stopping at that point, and then suddenly you jump forward all those decades.
(04:28)
And often there is not much of a support system when you get out. And so it's figuring out the most basic things in life. It's not just making your doctor's appointments, but it's how do you make a phone call when you've never used a cell phone and you're used to payphones everywhere? How do you open a car door when you're used to pressing that button in on the handle? I had one patient who couldn't figure out how to get the car door open. And so opening a bank account can also be really difficult. Finding a job, finding housing, all of that can become overwhelming when you've been institutionalized. And so what I did was, I had two social workers who worked with me, and every patient I saw also saw a social worker.
Dr. Stephen Rockower (05:18):
Right. I what I was gonna ask about social work too.
Dr. Ilsa Levin (05:21):
Yeah. It, it, social work is so needed. And often I think we don't have, we don't use it enough. We don't have access to it enough in these situations. I couldn't see a patient without a social worker because there was so much that I didn't know and so much that I couldn't do without their help.
Dr. Stephen Rockower (05:38):
Absolutely.
Dr. Ilsa Levin (05:39):
So it's really a two-way street.
Dr. Stephen Rockower (05:41):
Yeah. You know, I understand a lot of that. As you may know, I also volunteer my services at a free clinic in Germantown. And these are people without insurance, and yes, they maybe have more services available to them than what that did. And I know how frustrated I get trying to get things done you know, getting people's surgery or getting people medications, you know, and just even getting people x-rays and MRIs. So, you know, it's all over.
Dr. Ilsa Levin (06:17):
Yeah. And it's often working in in areas where you wouldn't normally work to coordinate things. So if I had someone who had unstable housing after they got out of the halfway house, often I would still try to help them out. And sometimes it was working with our contacts on the street to reach them. I had one man who had advanced liver cancer, and, you know, at the end of the day, he was really deciding whether or not he wanted hospice, but he was on the street, and he was very open about, he said to me, you know, if you give me the prescriptions for narcotics, I'm gonna sell them for heroin. And I said, okay, you know, I'll still be your doctor. I'm not gonna do that. You're, you tell me that you would prefer the heroin, but I am gonna be your doctor, and I am gonna help you as much as I can, and I am willing to get you into hospice and get you help that way. And, you know, unfortunately, his decision was that he wanted to stay on the street and use heroin because that was how he wanted to end his life. And I think there's a point where you have to put aside your judgments and just respect that's what someone chooses sometimes. And sometimes it's not. Sometimes they're forced into it. I think in his case, I'm not sure that he had that many options. At the end of the day, it was how he decided to die.
Dr. Ilsa Levin (07:48):
It sounds very harsh, but it's also one of those hard realities when you're working in that setting where you have to respect that sometimes what you want for a patient is not what they want.
Dr. Stephen Rockower (07:58):
No, I think that that's, that's for all of us, you know, whether in that population or in a better served population, you know, we really need to respect the wishes of the patient to do what's most comfortable for them.
(08:16)
Right.
(08:17)
Within, within limits, you know, I don't want to get into you know, ivermectin and other crazy things. But, you know, stuff like that that you're describing is, is certainly, you know, very important to make the patient feel better.
Dr. Ilsa Levin (08:32):
Right. And for me, I had to draw a line that I wasn't, I, I knew where he was actually getting the heroin from. It was down the street from my clinic. You know, and, and I knew that if I gave him the prescription, he would fill it and go exchange it for drugs on the street. And, and there's a line that I have to draw.
(08:51)
So I could offer him the hospice, and I could offer him the medications that I could write prescriptions for, but I couldn't do something that I knew he had outright said was gonna cause more harm. And, and I think he respected that as well. We had a very open discussion multiple times about this. And he also understood that, that there were limits to what I could do. And so I think if you can get your physician patient relationship to that level where you can have that open a discussion, it's a lot more meaningful. And at the end of the day, it was actually my team that found him because we went out looking for him when, when he died, so that he didn't die and go unidentified.
Dr. Stephen Rockower (09:34):
Right. And, and that sort of leads me into your association with the Society of Addiction Medicine. I think that tied those things tied together. Can you talk about that some?
Dr. Ilsa Levin (09:47):
Yeah, absolutely. So when I was working for Unity Health Care in the DC jail, we didn't have access to addiction specialists. And while I had had interest in this, in some training in Suboxone treatment, in residency I just hadn't, I had not been trained as an addiction specialist, but I realized there was no one available other than those of us who were providing the primary care and the chronic care. And so along with a couple of other people, I completed my training in Suboxon treatment, and I started treating patients for opioid addiction. And it was very interesting because the patients I got, you know, initially some of them really were having a tough time. I had, I think about one of them who was a prostitute, and she's very smart, but she just, you know, no one chooses to be an addict.
(10:50)
It happens to them, and for many reasons. And so I decided she needed a lot of intensive support. So we were meeting weekly, and we went very slowly at first. You know, she had come in every week to get a prescription from me because she was very tenuous. But during that time, she was starting to go to meetings and she started to clean herself up. And she, it was, it was slow. It was not an immediate stopping all drugs, but she did stop narcotics. And eventually she was able to stop cocaine too. And what was amazing was once she did that, she was able to get a job and she got an apartment and obviously stopped prostituting. And she went back to college because she had started college, and she actually got her degree in computer science. And she was one of those wonderful examples of, if you have an intense support system system, if you have an intense support system that is built for you, you can thrive. And she didn't have one from her family or friends, so we had to build one for her with our social workers and with me. So a lot of times, I think in addiction medicine, it goes so much more, it goes so much farther than just writing a prescription. It is being there, it's being able to talk openly about the issues and take away that shame as much as you can so that the person can talk about what they're going through.
Dr. Stephen Rockower (12:27):
No, that's, that's fascinating stuff. I'm in the middle of reading a couple of books on narcotics and, and opioids of the Sackler family and you know, pain clinics in Florida to, you know, and open my eyes to see, you know, what abusive narcotics can do.
Dr. Ilsa Levin (12:49):
Yeah. And when I was working in the DC jail, we were very limited. And so we had to get a lot better at using non narcotics for pain control and really looking at all the options out there. And, and I think that made me a better physician overall. You know, now I'm a hospitalist, and I really think about how do I treat my patient's pain and balance that with the side effects of narcotics, and, you know, what are the other options? What are the other ways of delivering the narcotics? What are the discussions I have with patients before I give them these medications? And so it definitely changed my approach.
Dr. Stephen Rockower (13:30):
Yeah. And, and you're also not only working in the local area with individual patients, but you know, I note that you're on the board of the American Medical Association and you're one of the only you're the only D.O. on the board, first of all, let's, let's talk about the differences between a D.O. And and an MD and you know, why people confuse them.
Dr. Ilsa Levin (13:58):
So it, it, so so first of all a do is a physician, just like an M.D. I always, I refer to them as allopathic and osteopathic medical schools. And they have much the same training. my husband is actually an allopathic physician, and we went through medical school at the same time, but obviously at different medical schools. And we had the same books for most of our classes, like anatomy, biochemistry, all of that. And we had most of the same rotations as well. The difference was one in osteopathic manipulation, which we learned in both our first and second years. And we have throughout our exams, which is really a hands-on approach to treating someone and dealing with things like pain in a different way, using another modality. And we found that it can be incredibly effective and a great way to sometimes avoid medications with all of their side effects.
(15:03)
But it is part of all of the different treatments that we offer. It is certainly not the only one. I think one of the other things, and and I often, you know, I speak to a lot of osteopathic medical students about this, and one of the things that I found out, I'm one of those many people who got into both allopathic and osteopathic programs. I chose Western University for the school. It really called, to me, it really felt like it was the right fit for me. And I chose it because of the philosophy, the more holistic approach to medicine, which I feel like honestly these days, more and more medicine in general in the U.S. is moving more towards the holistic approach. But you know, I, that really called to me looking at the big picture and stepping back and seeing that you know, I remember in my first year, one of the first things any professor said to me was, a headache is not always just a headache.
(15:59)
So step back and look at the big picture, try and gather the information and then make the determination. Just don't just jump to the treatment. And like I said, I think we do that more and more now, but there is a lot of self selection for the personality of schools, the personality of trainings. And that was what led me to be a D.O. I am the first to ever be on the board of trustees for the AMA. And with it, I think comes a lot of responsibility to educate people about who we are, our training, what we do maybe to educate away from the stigmas and these ideas that came out of just not understanding our training. And so I've been working on that And, and it's a process when you're the first one, it's always a process. Right.
Dr. Stephen Rockower (16:57):
And trailblazers are, are hard.
Dr. Ilsa Levin (16:59):
Yeah. Yeah. It's, it can be lonely when you're the only one in the room. But what I also find I'm seeing more and more is that people hear what I say, and I see more and more DOs becoming engaged, more and more osteopathic medical students becoming engaged. And with that, seeing the yes, they too can be leaders. And there is nothing that holds them back. And I think previously there was this feeling like perhaps you couldn't get to this point if you were a D.O.
Dr. Stephen Rockower (17:35):
How has that helped or hindered you in your role as a trustee in terms of getting the trust the board to move in one direction or another?
Dr. Ilsa Levin (17:51):
You know I always think about it like with any other group. When you have a representative that you haven't had before, instead of talking about them, as a separate group, suddenly you have someone there who's speaking up for us. And that group that was separated becomes part of the bigger group, and their interests become much more important than they were when they were, than when they could be seen as separate. Right. So our board, now, I'm very proud of us. This, our board is very diverse, by gender, by race, by religion. And now we have a D.O. And, and I only see that continuing. I think the AMA has really evolved and it is a place that welcomes everyone. And I found that there are times when the AMA was interested in an issue, but it had to do with osteopathic physicians, and they would come to me and discuss it with me. Whereas before, I don't think there was anyone to talk to about it necessarily. And the relationships weren't there. And the other benefit of me being on the board has been really improving those relationships across the board with osteopathic physicians, with the AOA, showing that we are the group that represents all physicians and not just allopathic physicians.
Dr. Stephen Rockower (19:18):
Let's take a break for a moment. We're speaking with Dr. Ilsa Levin, a physician and who is on the board of the AMA. Funding for this podcast has been made possible by Figure One, a digital platform created solely for physicians to gain knowledge, securely, share real medical cases, and improve outcomes. Learn more about figure one and join the MedChi private group at figureone.com.
(19:48)
Welcome back to Med Cast, the podcast from MedChi, the Maryland State Medical Society. We're continuing our discussion with Dr. Ilsa Levin, as she discusses her role as a osteopath on the board of the American Medical Association. I wanted to ask how things have changed in U.S. healthcare with the pandemic and, and your role in it.
Dr. Ilsa Levin (20:12):
So, I had the interesting an eye-opening experience of being a hospitalist throughout the pandemic. I work for Mid-Atlantic Permanente Medical Group, and I'm primarily based in southern Maryland at Holy Cross Hospital. but I also work at some of the other hospitals in the area. And I will tell you, it was interesting to watch it. So I'm an epidemiologist as well, and I watched, you know, in January and February of 2020, this wave as it slowly was spreading around the world, and you could see this wave of infection as it was coming towards us. And as it got to New York, you could see it coming closer, and it, it seemed almost unreal. You know, you watch something on tv, but if you're not a part of it, it's hard to really get a sense for what it's like. And I'll never forget my first case of identifying someone with Covid.
(21:14)
Back then, it took about a week to get a diagnosis. And what I learned was that often people don't present the way you would expect them to. At least back then. in my first case was someone who had pyelonephritis without a UTI, and it was a really strange presentation. And my colleague had repeated the CAT scan because something wasn't clicking with him, something didn't make sense. And he asked me and another colleague to follow up on it later that night. And so we pulled it up and we noticed that the bottom part or sorry, the top part of the CT was showing the lower part of the lungs. And in 12 hours, the patient had gone from having completely clear lungs to ground glass covering the lungs. And we both stopped right there. We were in the same office at the time.
(22:06)
And we stopped right there, and just both of us said, oh my gosh, this is Covid. And immediately, you know, went into action, putting her into isolation, getting her family out of the room. But we just didn't, we didn't know what we were doing. And for the next few months, we really didn't have treatments that worked. And so we ended up having a lot of communication that was grassroots between physicians. We had Facebook groups, we had other groups where we would discuss what we were seeing and what we were learning. And this was not just in the US, this was international. So some of the information I learned from what they were seeing in Spain and the ICUs, and that's where some of the first reports that I saw on patient in a prone position occurred. Mm-hmm.
(22:54)
And that was incredibly helpful because we realized if we intubated patients, that for most of them, about 80%, they were gonna die. And my whole work experience changed with that because suddenly our ERs became empty because people were afraid to come to them. And our hospitals became filled with people with covid, and if they didn't have covid, they were dying of cancer. But it was those really big, bad things. Those were the only reasons why people would come into the hospital. And so I used to admit, I, I admit patients at night, and what I would do was with my colleagues who were working at night, we would literally walk the halls turning patients on their stomachs to try if they needed it, if they were desaturating, to try and keep them from going into respiratory arrest. And it got to the point where any hospitalist would respond to a code blue, because there were so many, and we just couldn't keep up.
(23:59)
And what I saw was nurses who I'd known for years, who were suddenly being put in positions where they had to be ICU nurses, and they were never trained for that before, and hadn't planned on that. I had a psychiatric nurse, who suddenly was working on the floors. And I had other physicians that I'd worked with for years who were being pushed to the brink. You know, how many times can you watch patients die before it gets to you when it's over and over and over again? With no families present, and our communication with them was by phone, you know, trying to explain to them why they couldn't come in to say goodbye.
(24:43)
Nobody understood those things then.
(24:46)
No. And, and beyond that, we didn't have the PPE that we needed a lot of the time.
(24:53)
I will say I was very blessed because I worked for Mid-Atlantic Permanente Medical Group, and they brought us PPE when there wasn't enough. And that way we didn't have to take what stock we had at the hospital, and we did have more PPE. But that being said, I had to use an N95 for a month at one point. I remember, you know, I had another mask over and it popped in the ICU. So you know, but it worked. And I didn't get covid and I didn't bring it home to my family, and I was very relieved of that. But trying to work through it and explain it to people and the trauma that was causing to everyone who was working in that inpatient setting was tough. And so, you know, what I see now is that so many nurses and physicians and techs have left the field, and we often don't have enough nurses or doctors.
(25:59)
No. I mean, I, you know, I've had times when we've had a quarter of the nurses we should have working, or we've had so few physicians in a specialty covering a huge number of patients. And the thing for I think, the public is that I've seen that covid was a disease of perspective, and it depended on where you worked. And the after effects depend on where you work and what you see and how you see it. So it's not anyone being lazy, it's the fact that there aren't enough doctors and nurses out there, because so many just were pushed to the brink. And, and I don't blame them for leaving. It was incredibly hard. So it's finding ways to do better, and get our infrastructure built back up again.
Dr. Stephen Rockower (26:53):
Yeah. And I know that you know, both MedChi and the AMA were very instrumental in providing information for physicians and working the system as much as possible to help out.
Dr. Ilsa Levin (27:08):
Absolutely. In fact, that brings up a whole other effect of the pandemic. So while there was always misinformation and disinformation, and I used both of those terms because misinformation is really unintentional, disinformation is intentional. And unfortunately both occur. And what we saw with the pandemic was that this increased exponentially, on a dangerous level to the population. I'm very proud of the work that MedChi and AMA has done and continues to do to educate the population, or to educate the public, about various health issues, about treatments, about preventions. But it is an ongoing battle. You know, who do you trust? And I think if you can identify certain specific groups that put science and medicine first beyond any personal interests. I look to places like the American Medical Association and MedChi.
Dr. Stephen Rockower (28:15):
yeah. And, and it continues and it continues. Okay. Let's, let's do a few other things right now.
Dr. Ilsa Levin (28:22):
Okay.
Dr. Stephen Rockower (28:25):
What would you be doing if you were not a physician?
Dr. Ilsa Levin (28:29):
Dr. Stephen Rockower (28:50):
Yeah. I noted on your that you were in Myanmar for a while.
Dr. Ilsa Levin (28:54):
Yeah. Yeah. I did my thesis work there. It was a very, you know, I, it's interesting. It's one of those moments where I tell students and residents when I meet with them often you don't plan for the path you end up on completely, but when opportunities come, don't be afraid to take them. So I was a 22 year old graduate student in Australia. I moved myself over there. I didn't have any family over there. I just said, you know, this looks like a really interesting program. It's very hands-on. And so I was the youngest student in the program. And I was walking around some of the offices at one point talking with different professors about opportunities. And one of them said to me, you know, would you be interested in doing a research study in Myanmar working with us and the World Health Organization studying treatment programs for lymphatic psoriasis? And I was 22. I had no idea what any of this meant, but I said, yeah, that sounds great,
(30:05)
And you know, I to be honest, while I had traveled a bit at that point, I certainly had not traveled to the level that I've traveled now, and I did not know exactly what I was gaining into with Myanmar. I describe it as almost as closed as North Korea. Not quite. But it was pretty close. And when I called my parents and told them what I was doing, I remember they were both a little concerned, but said, you know, if you feel like this is what you need to do, just make sure that you register at the consulate. I was the only foreigner in the state of Magwe at the time. And I had minders everywhere I went, and everything was very controlled. But that being said, because of the program and some of the people behind the program who were higher up in the government, I had more access to a lot more villages and areas than perhaps I would've otherwise, from talking to colleagues who've worked over there with NGOs.
(31:12)
Okay. And it was really eye-opening for me to see really for the first time how healthcare was delivered in a setting where, in that state there was no indoor plumbing at the time. So it was very interesting, very eye-opening for me. I certainly appreciated everything I had after that. And you know, I also appreciated, it's easy for us on the outside to comment on countries and how things are done incorrectly, but we don't see the pressure that is put on individuals who are fighting governments, their dictatorships and how hard it is for them. the people working with Aung San Suu Kyi and Aung San Suu Kyi yourself really had very little power ever as, as far as trying to make change. And I, you know, as I watched what happened later with the Rohingya, it was heartbreaking. And at the same time, having been there, I knew that she really didn't have much power to change what was happening.
Dr. Stephen Rockower (32:28):
Yeah. And I was there in the little bit of time when, when she had more power, and I could see what was going on. And now it's all changed. It's back to sort of where it was.
Dr. Ilsa Levin (32:43):
Think it was always very tenuous. Yeah.
Dr. Stephen Rockower (32:45):
I, I think you've already answered this question. What is the best advice that you've received?
Dr. Ilsa Levin (32:51):
You know, I'm lucky. I've had so much support, so much wonderful advice over the years. But I think I actually go back to a comment a friend of mine made many years ago when I finished undergrad, and I was looking at what to do. Whether I should go to grad school in Australia or whether I should just do something that was easier in the US not upping my entire life and leaving and, and taking a lot of risk with it. And she said to me, you know, it'd be easier to stay here, but you will always question yourself if you don't take this opportunity. And that actually led to so many of my decisions in my path to where I am now, that I'd always remember those words and step back and think, you know, if I don't do this, what am I missing out on?
Dr. Stephen Rockower (33:49):
Right. You know, the travel and taking different types of risks when you're young is very, very important.
Dr. Ilsa Levin (33:57):
Yeah.
Dr. Stephen Rockower (33:59):
And finally, what are you reading or watching or listening to right now? What do you, what do you do in your spare time?
Dr. Ilsa Levin (34:06):
So, I love to read. I wish I had more time than I do. I'm always overscheduled, overbooked, but I'm actually reading two books. One is The Tattooist of Auschwitz. I don't know if you've ever read it, but it's the story of Lale Sokolov, and his experience working as he was imprisoned in Auschwitz and he worked as a tattooist, and that's how he survived. It's a heavy book, so
Dr. Stephen Rockower (34:37):
I can imagine.
(34:38)
Of course, I mix it with another somewhat heavy, but not quite as heavy book, which is When I Fell From The Sky, which is the story of Juliane Koepcke, if I'm saying her last name correctly, who survived an airplane crash mid-air, where she fell to the ground and yet somehow survived that. And her experience of survival, and not only survival, but thriving and going back to that area and working to protect that area and the environment from outside forces and how, you know, they're both about overcoming adversity, but in very different ways.
Dr. Stephen Rockower (35:23):
Thank you to Dr. Ilsa Levin, who has been our guest on MedCast, the podcast from MedChi, the Maryland State Medical Society. Tune in next time as we continue our conversations with leaders of medicine in Maryland to discuss the issues facing physicians and our patients. For all of us here at MedChi, I'm Dr. Steven Rockower. Thank you, and goodbye.