VO LU M E 1 1 8 N O . 1 F E B - A P R 2 0 2 1
COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE
C O N T E N T S
Confidentiality in Colorado’s Physician Assistance Program For over 30 years, Colorado physicians, physician assistants and medical students have paid into a state physician peer assistance program that allows them to access necessary physical, mental and behavioral health care, without fear of discovery by the Colorado Medical Board (CMB). It is vitally important for Colorado to maintain confidential access to peer assistance for medical students, physician assistants, and physicians. PAGE 6 ⊲
F E A T U R E S
D E P A R T M E N T S
10 AT THE INTERSECTION OF BURNOUT, COVID AND SYSTEMIC RACISM
18 Reflections: Cadaver as First Teacher
We must make our institutions actively antiracist, writes CMS member Deborah Saint-Phard, MD, in order to bring about actual change and healing for each of us and our nation.
12 CMS SETS THE COURSE FOR THE FUTURE The CMS Board of Directors set priorities for the next oneto-five years to create a strategic plan for diversity, equity and inclusion, protect physicians’ rights to confidential counseling in light of the changes to the current peer assistance contract, and to strengthen membership retention and engagement to increase membership and maintain CMS’s strength as an organization in the long term.
14 MEET YOUR BOARD OF DIRECTORS Learn more about the physicians who make up the CMS Board of Directors and why they have chosen to serve.
(GOODBYE)
(HELLO)
24 FINAL WORD: IT JUST SOUNDS SO… FINAL CMS CEO Bryan Campbell seeks to set a vision for 2021 even as society struggles with so much that isn’t final from 2020. Read his recap of lessons learned and his hope that Colorado physicians again can lead the way to a brighter future.
20 COPIC Comment: Within Normal Limits, A New Podcast by COPIC 22 Introspections: Delivering Health Care to Asylum Seekers I N S I D E
C M S
4 President’s Letter: The Renaissance of Joy
CO LOR AD O M E D I CAL SOCI E T Y 7351 Lowry Boulevard, Suite 110 • Denver, Colorado 80230-6902 720.859.1001 • 800.654.5653 • fax 720.859.7509 • www.cms.org
OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF 2020-2021 OFFICERS
BOARD OF DIRECTORS
AMA DELEGATES
Sami Diab, MD President
Brittany Carver, DO Chris Linares, MD Evan Manning, MD Michael Moore, MD Uchenna O. Njiaju, MD Edward Norman, MD Lynn Parry, MD Monica Patten, MS Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD Brandi Ring, MD Kim Warner, MD Hap Young, MD
A. “Lee” Morgan, MD David Downs, MD, FACP Jan Kief, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSc, MD
Mark B. Johnson, MD, MPH President-elect Patrick Pevoto, MD, RPh, MBA Treasurer Bryan Campbell, FAAMSE Chief Executive Officer David Markenson, MD, MBA Immediate Past President
AMA ALTERNATE DELEGATES Carolynn Francavilla, MD Rachelle Klammer, MD Katie Lozano, MD, FACR Brigitta J. Robinson, MD Michael Volz, MD
AMA PAST PRESIDENT Jeremy Lazarus, MD
COLORADO MEDICAL SOCIETY STAFF Bryan Campbell, FAAMSE Chief Executive Officer Bryan_Campbell@cms.org
Emily Bishop Director of Government Affairs Emily_Bishop@cms.org
Ms. Gene Richer, M Ed, CHCP™ Director of Continuing Medical Education Gene_Richer@cms.org
Kate Alfano Communications Coordinator Kate_Alfano@cms.org
Dianna Fetter Senior Director of Business Development Dianna_Fetter@cms.org
Chet Seward Chief Strategy Officer Chet_Seward@cms.org
Susanna Barnett Membership Coordinator Susanna_Barnett@cms.org
Dean Holzkamp Chief Operating Officer Dean_Holzkamp@cms.org
Tom Wilson Manager of Accounting Tom_Wilson@cms.org
Amy Berenbaum Goodman, JD, MBE Senior Director of Policy Amy_Goodman@cms.org
Krystle Medford Senior Director of Membership Krystle_Medford@cms.org
Tim Yanetta Manager of IT/Membership Tim_Yanetta@cms.org
COLORADO MEDICINE (ISSN-0199-7343) is published quarterly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone 720-859-1001; outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colo., and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance. COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified. Bryan Campbell, Executive Editor; Kate Alfano, Managing Editor; and Dean Holzkamp, Assistant Editor. Design by Scribner Creative.
I N S I D E
C M S P R E S I D E NT ’ S
LE T TE R
The Renaissance of Joy Sami Diab, MD, President, Colorado Medical Society
I slept and I dreamed that life is all joy. I woke and I saw that life is all service. I served and I saw that service is joy. - Khalil Jibran Remember when being a physician was fun, a manifestation of joy? Your last name doesn’t have to be Fauci, for you to have recognized a not-so-subtle change in healthcare since the beginning of the COVID-19 pandemic. For most of us, the manifold forces of the pandemic have suffocated the joy in the practice of medicine. This diminished joy has weighed on me as I reflect on the past four months as the president of the Colorado Medical Society and on the last 12 months since the pandemic started. I feel that the absence of joy is, in no small part, the result of individual physicians feeling powerless in the face of huge pandemic, poor preparation, and not having our voices heard. Let us look at the vaccine distribution and the frustration expressed by many of us on Basecamp as an example of how physicians have less influence on health care than ever. The question I ask myself often is: Can we, physicians, reclaim our central role in shaping our health care system and protect the physician-patient relationship? I truly believe the answer is yes if we work together as physicians. Our voice needs to be united and prolific. Incredible things, both good and bad, can happen when people unite around a common cause. Take for example the recent case of small retail investors taking on the hedge fund barons of Wall Street through stocks like Game Stop. What’s that you say? GameStop stock price has already started dropping. To focus on that is to miss the point of the power of unity and focus. Don’t forget, people took notice, institutions took notice, Congress took notice and hearings are scheduled.
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Physicians often find themselves in the role of the little guy, the retail investor, struggling to be heard against the roar of the big guys – hospital systems, the insurance lobby, and federal and state agencies and health departments. The fragility of our healthcare systems and supply chains, our vulnerability to new viruses and our need for competent leadership have all highlighted the necessity of physicians being at the center of healthcare decisions and policy. Being a member of the Colorado Medical Society (CMS) allows your voice not only to be heard, but to be amplified. I realize times are difficult and some of you may have decided to forego renewing your CMS membership. I understand. However, noble and rewarding as service is, your motivation in joining CMS does not have to be wholly altruistic. When you choose to join CMS, you are choosing to have a voice and a seat at the table. And the more members that CMS has means a louder voice and a bigger table. In the context of enlightened self-interest, having this voice gives you an opportunity to influence and shape the factors that impact your working life. Now, more than ever, we as physicians have a duty and a calling to care for not just our patients but also for our profession. Dissent is okay. We will not always agree – that’s guaranteed. But choosing to unite as members of the most influential physician-led organization in Colorado, means the problems we face today will be solved by physicians. As Ted Epperly MD, past board chair and president of the American Academy of Family Physicians, once said, “All of us are smarter than any [one] of us.” ■
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C O V E R
Confidentiality in Colorado’s Physician Assistance Program: THE VITAL IMPORTANCE OF ENSURING CONFIDENTIAL ACCESS TO PEER ASSISTANCE FOR MEDICAL STUDENTS, PHYSICIAN ASSISTANTS AND PHYSICIANS Polly Washburn For over 30 years, Colorado physicians, physician assistants and medical students have paid into a state physician peer assistance program that allows them to access necessary physical, mental and behavioral health care, without fear of discovery by the Colorado Medical Board (CMB). In any given year, hundreds of physicians, physician assistants and anesthesiology assistants self-refer or are referred to the program, which coordinates support for physical and mental health, substance use, education programs, and other rehabilitation options, experts, and tools.
In June 2020, the Department of Regulatory Agencies (DORA) announced its intention to award the program’s contract to Peer Assistance Services (PAS) instead of the current provider, Colorado Physician Health Program (CPHP). When it was revealed that all physicians accessing the program, both mandated and voluntary participants, would be required to sign a waiver to share their medical information with the CMB, the response was swift, strong and sustained to prevent this breach of confidentiality regardless of who the vendor is. CMS has helped to lead the charge, working in collaboration with the House of Medicine, COPIC, Colorado Hospital Association, the Colorado Association of Health Plans, both medical schools, individual physicians, medical students and residents, hospitals, patients and legislators to object. In a letter to DORA, CMS Past President David Markenson, MD, MBA, stated, “Colorado must ensure the confidentiality of physician mental health treatment and not discourage voluntary self-referral by the implied threat to one’s license/job and the loss of professional esteem.”
Few issues have united the health care community so rapidly and feverently, obliterating any misconception that this is a minor disagreement stemming from a contracting dispute. Over 3,200 health care professionals and concerned citizens protested the change by signing a House of Medicine petition to CMB last fall to emphasize that confidentiality protections are a critical component of patient safety and physician wellbeing, and that these changes will negatively impact the practice of medicine in Colorado.
STONEWALLED While the petition reinforces how much concern has grown over the last six months about the integrity of confidentiality protections in the peer assistance program, CMS actually started raising alarms almost two years ago in the spring of 2019. Given the priority nature of the issue, CMS advocacy has proceeded on a number of fronts including direct outreach to CMB, DORA, the governor’s office, legislative leaders and the press.
Continuous attempts to discuss this issue with DORA in order to find solutions have been stonewalled (see timeline on page 9). DORA has withheld CMS communications from CMB members, told legislators and CMB members that physicians are not interested in this issue, and claimed that confidentiality would still be preserved despite evidence to the contrary. The end of last year witnessed a bewildering series of events, including attacks by DORA’s legal counsel toward advocacy efforts by CMS and partners, last minute cancellations of public CMB meetings where confidentiality protections were to be discussed, and a November decision by an administrative law judge that vacated DORA’s procurement decision to award the next contract to PAS, citing direct violation of law because CMB was never consulted. Throughout all of these events, CMS has doggedly emphasized that the issue here is not about which vendor is selected, but rather the importance of protecting confidential treatment for those in the peer assistance services program.
Colorado must ensure the confidentiality of physician mental health treatment and not discourage voluntary self-referral by the implied threat to one’s license/job
6 C O LO R A D O M E D I C I N E
and the loss of professional esteem
None of us — students, residents, faculty, practicing physicians — should hesitate to seek mental health treatment if we need it. No one should ever second-guess themselves or feel ashamed.
HELP FOR THOSE THAT HELP OTHERS In light of the ongoing uncertainty, there have been alarming reports that voluntary usage of peer assistance services have decreased in comparison to past years. Steven R. Lowenstein, MD, MPH, Associate Dean for Faculty Affairs, University of Colorado School of Medicine, is concerned that DORA’s decision adds to the stigmatization of mental illness. “Absent a promise of confidentiality — absent this ‘safe haven’ — students and physicians often fear for their careers and will not seek mental health care --- care that is highly effective, helps them practice safely and may save their life.” The situation is taking place during a devastating pandemic, when medical professionals are suffering more stress, anxiety, isolation and mental illness than ever. Connie Savor Price, MD, chief medical officer at the Denver Health and Hospital Authority, says, “We’re a group vulnerable to mental health issues, and COVID has only exacerbated that. Our profession sees a lot of death, particularly now. We experience a lot of moral distress, we watch cancers go untreated, we see people getting kicked out for not being able to pay, and people dying alone. We have a higher rate of suicide,
depression, and substance abuse in our profession. We want to encourage health professionals to seek help when they are experiencing a mental health issue.” Neill Epperson, MD, the executive director of the Helen and Arthur E. Johnson Depression Center at the University of Colorado School of Medicine, agrees. “They may not be able to see for themselves how they’re doing,” she says. “Doctors are taught to be strong. There’s so much stigma to even say ‘We want you to see someone.’ Any thing we add to make it more difficult will cause more harm.” Dr. Epperson points out that for physicians who get their care where they work, confidentiality and anonymity are especially important. “For too many physicians, they are concerned how colleagues see them, or are worried it could impact their ability to get promoted. If they’re not ensured confidentiality, the problem is they are not going to go.” In fact, a 2017 study by the Mayo Clinic revealed that nearly 40% of physicians say 1 they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure.
33-45%
of medical students suffer anxiety and depression.
A “GAME CHANGER” Dr. Epperson says the peer counseling service has been a “game changer” for some faculty at the University. “To be able to get treatment, retain jobs, do well in their jobs, and just be happier people. That’s what all department chairs that refer someone want. We are not referring people to be punitive. This is to help people feel the best they can feel in difficult situations.” Dr. Jeremy Lazarus, CMS past president, and past president of the American Medical Association puts the issue this way: “If a physician thinks another physician could be harming patients, there’s an ethical obligation to refer him -- there’s a strong collegial credo about that. That’s why having a trusted, confidential resource [to refer them to] is vital.” The service is not just for physicians deep into their professional careers. Brian Dwinnell, MD, FACP, Dean of Student Life at the University of Colorado, says that about a dozen students use the service at any given time. “It’s very important to these students, and the thousands of patients they interact with. For students at the School of Medicine, we talk about getting mental health assistance starting at orientation. We’re trying to remove the stigma for students.” Studies have shown that between 33-45% of medical students suffer anxiety and depression. 2 Dr. Lowenstein says, “In a recent survey, one in four doctors knows another doctor who has taken their own life. None of us — students, residents, faculty, practicing physicians — should hesitate to seek mental health treatment if we need it. No one should ever secondguess themselves or feel ashamed.” PAGE 8 ⊲
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C OV E R A S S I S TA N C E P R O G R A M : C O N T
COMMITTED TO A SOLUTION Moving forward, CMS is pursuing all options to protect confidential peer assistance. “This is a priority for our organization,” says CMS President Sami Diab, MD. “Our physician members have been very clear about the urgent need to find a solution and we will not stop until this issue is fixed.” Advocacy efforts are focused on both the CMB and the legislature. A CMB subcommittee is considering policy options and CMS will continue to be actively involved
in those meetings. That same intensity has driven numerous conversations with legislators statewide over the past six months. The bi-partisan interest and support to ensure confidential peer assistance have been robust. As a practicing pediatrician and a legislator, Rep. Yadira Caraveo, MD (D-31), is not only uniquely positioned to understand why a bill protecting physician confidentiality is necessary, she has also agreed to sponsor legislation this year to fix the problem if necessary. “We have a culture in medicine of ‘heal thyself’ and
Compliments of:
‘powering through’ and that seeking help is somehow showing a sign of weakness. We want to combat that and encourage them to seek treatment. But we need to ensure that it’s a peer treatment program that provides confidentiality... If DORA continues to show reticence to working with the Medical Board and the House of Medicine and continues to push an option that does not include confidentiality and peers, then we will use the powers of the legislature to make sure those two tenets are preserved.” The other co-sponsor, Rep. Kevin Van Winkle (R - 43), says he first heard of the issue of confidentiality from his local physician and CMS. “Almost two years ago now they educated me on the importance of the confidentiality portion and how important the program is to Colorado physicians. I was hoping it could be solved without legislative input, but with the coronavirus raging, it’s the wrong time to injure a program that is working so well for doctors.” As of press time, CMB has created two subcommittees: one to reassess RFP for the next vendor and the other to “consider CMB policy to clarify parameters of voluntary confidential treatments.” The timing of the CMB review, recommendations and ultimate selection are yet to be determined. In the meantime, the State has extended CPHP’s current contract until April 30, 2021.
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8 C O LO R A D O M E D I C I N E
Proud supporter of:
Whether the process is fixed through CMB policy or legislation, CMS will continue to fight for physicians. So please, if you need help, continue to take advantage of the current program. ■ 1. Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions; Dyrbye LN;West CP;Sinsky CA;Goeders LE;Satele DV;Shanafelt TD; https://pubmed.ncbi.nlm. nih.gov/28982484/ 2. https://www.sciencedirect.com/science/ article/abs/pii/S0883944109001348, https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6696211/
Timeline of steps taken to preserve confidential counseling in peer assistance program May 31, 2019
June 2020
June 29, 2020
CMS, COPIC and the Colorado Hospital Association (CHA) submit a letter to DPO Director Ronne Hines urging the Colorado Medical Board (CMB) to prioritize confidentiality as they consider renewal of the peer assistance program. This letter was never shared with CMB members. DORA announces they have awarded contract for physician peer assistance to Peer Assistance Services (PAS), which plans to require voluntary physician participants to sign a release of information to the CMB, breaching longstanding confidentiality protections. The American Medical Association (AMA) sends a letter to Governor Polis expressing opposition to DORA’s decision given removal of confidentiality.
July 1, 2020
The House of Medicine (HOM), representing 31 organizations and thousands of physicians, sends a letter to Governor Polis urging a reconsideration of DORA’s decision.
July 7, 2020
Colorado Physician Health Program (CPHP) appeals the state’s decision to award PAS the program contract. Appeal is denied by DORA.
September 1, 2020
State Senate leadership sends letter to DORA expressing concern about process to date and the need for confidentiality protections. DORA response denies CMB’s role in choosing a peer assistance program vendor.
October 2020
CMS, COPIC, CHA and the Colorado Association of Health Plans (CAHP) submit a number of letters to DORA requesting an immediate special meeting of the CMB to address the confidentiality status of current peer assistance program participants. DORA first denies and then never responds to the requests.
June-October 2020
COMPAC interviews more than 30 state legislative candidates for the general election, emphasizing the importance of confidential peer assistance, receiving broad support
November 2, 2020
HOM releases petition urging the CMB to protect confidential counseling services.
November 10, 2020
Administrative law judge voids contract with PAS, citing DORA’s failure to consult with the CMB as required by statute.
November 19, 2020
CMS requests and DORA refuses to allow public testimony on this issue at scheduled quarterly CMB meeting. Meeting then cancelled without explanation.
December 11, 2020
Rescheduled quarterly board meeting again cancelled at last minute.
December 15, 2020
CMS, COPIC, CHA and CAHP send another letter requesting that open discussion by CMB and public comment be allowed at next meeting. Submitted petition with 3,242 signatures.
December 18, 2020
CMB meeting held. Two subcommittees created – one to reassess RFP for next vendor and the other to consider confidential treatment policy.
January 26, 2021
During House Health Insurance Committee Hearing, Chairwoman Susan Lontine, along with Reps. Yadira Caraveo, MD, Kyle Mullica and David Ortiz, challenged DORA on the process to date and their commitment to confidentiality. Patty Salazar, DORA executive director, explicitly pledges to preserve protections.
February 5 and February 9, 2021
At press time, CMS preparing to testify at these two CMB subcommittee stakeholder meetings.
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F E A T U R E
At the Intersection of burnout, COVID and systemic racism Deborah Saint-Phard, MD
We must make our institutions actively antiracist, writes Deborah Saint-Phard, in order to bring about actual change and healing for each of us and our nation. My name is Deborah Saint-Phard. I am a Black woman physician who works in a medical academic department and who founded and directs a women’s sports medicine program. And I live at the intersection of physician burnout, the COVID -19 pandemic and systemic racism. In 2016, during my annual review with my chairperson, I stated point-blank, “I cannot think about stress fractures anymore.” Since this had been my clinical area of expertise for more than two decades, that pronouncement was a bit surprising to us both. Instead, I wanted to work on emotional stress fractures, also known as burnout. My exploration led me to discover the epidemic of physician suicide in America. Was this a well-kept secret: 400 physicians in America die each year by suicide? Could it be true that the equivalent of two and a half medical school classes per year die by suicide? I wanted to call out to my former medical school peers and current doctors everywhere to make sure they knew suicide is an occupational hazard in medicine. Female physicians have 2.3 times, and male physicians 1.4 times, the risk of dying by suicide when compared to the general population. In May 2018, I convened a two-day conference in the Colorado mountains for physicians, physicians’ assistants, nurses, CEOs and hospital administrators to learn about this urgent concern. I read articles and presented grand rounds locally and keynotes regionally on this topic;
1 0 C O LO R A D O M E D I C I N E
attended local, regional and national conferences on physician health; joined committees on physician resilience; and worked to implement this topic into our medical school curriculum. My goal was to increase awareness about the new World Health Organization’s International Classification of Disease (ICD) code 11, which is a specific medical diagnosis category for physician burnout, and develop strategies for self-care and self-compassion. The ICD code 11 defines physician burnout as an occupational syndrome -- not a medical phenomenon -- caused by chronic workplace stress resulting in: “a) Feelings of energy depletion or exhaustion, b) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job and c) reduced professional efficacy.” By 2019, I felt that my efforts were meaningful. I had increased awareness of the insidious emotional toll a physician’s work can have on them. Then in early 2020, the infectious airborne pandemic COVID-19 struck us in the United States. Warnings blared about the insufficient amounts of personal protective equipment, or PPE, to keep healthcare workers safe while providing care to infected patients. The rationed PPE, falsehoods and misinformation about the seriousness of this pandemic from leaders responsible for public policy, and lack of a national mandate for social distancing and wearing masks or face coverings undermined my feeling of physical safety. While debates flared about rights
of individual choice versus public health directives to prevent community spread of this virus, I felt my vulnerability more and more acutely. If I became infected with COVID-19, my co-morbidities -- Black person, underlying respiratory condition, hypertension and overweight -- would predict a poorer outcome. As COVID-19 cases accelerated, our ambulatory clinics were closed, and we were furloughed. I was reassigned to help staff an employee-health COVID command center for several weeks to assist with the overwhelming number of calls, tests and dispositions. We were encouraged to use this downtime to be productive academically. We transitioned to providing care via telehealth from home. I saw and felt the emotional toll of the pandemic on physicians, compounding burnout, and read the research showing how providing care during pandemics leaves health-care workers at increased risk for depression, anxiety, substance use and PTSD. And then I learned about Breonna Taylor’s death in March. She was killed by multiple gunshots from police while she slept in her own bed. And then I watched George Floyd’s death on television in May -- his neck unmercifully kneeled upon by a police officer for eight minutes and 46 seconds. Those two events struck at the soul of the nation and broke my heart. They alarmed me to the core: I saw that I could not secure the physical safety of my Black body or those of my Black children.
America’s 400-year history of using Black bodies for capitalistic gains and its unrelenting racism continues to threaten my existence because my skin color. My security system will not protect me. My locked doors will not protect me. My medical degree will not protect me. My Princeton University undergraduate degree will not protect me. My Olympic medal will not protect me. My fancy car will not protect me. Because I am Black in America, I am seen as less than human and am subject to being treated as an animal, just like Breonna Taylor and George Floyd were, along with many others.
Ibram X. Kendi, author of “How to Be an Antiracist,” defines a racist as one who is supporting a racist policy through their actions or inaction or by expressing a racist idea. He defines an antiracist as one who is expressing the idea that racial groups are equal and is supporting policy that reduces racial inequity. Kendi says, “It is the system, not a racial group, that needs to be changed. And then we spend our time, we spend our funds, we spend our energy challenging racist policy and power.” We must educate ourselves and then take action right where we are. Systemic racism undermines all diversity and inclusion goals that our institutions may have.
FIGHTING THE EPIDEMIC OF SYSTEMIC RACISM My physician parents immigrated to the United States from Haiti when my brother was a toddler and I was a baby. They worked in Baltimore and New York hospitals until they secured residency positions at Menninger’s School of Psychiatry in Topeka, Kan. They raised us speaking French at home and instilled in us the virtues of God, family and education as our beacons to follow as we grew up. I believed I had agency in America to pursue life, liberty and happiness. But this idealism has faltered as I acknowledge the immense strain of living at the intersection of an epidemic of racism, the COVID-19 pandemic and a surge of physician burnout. In 2020, Joe Biden was declared the 46th president-elect to lead this nation. Biden chose Senator Kamala Harris to be the first Black woman ever to serve as vice president of the United States of America. Watching this happen gives me hope. It gives me hope that I will find my voice to stand with Black, Indigenous and people of color (BIPOC) to change our institutions. Now my inspiration is for BIPOC to feel comfortable as our patients and in our hospitals, medical schools and graduate level training centers. The intersection of physician burnout and suicides, the COVID-19 infectious pandemic, and the epidemic of systemic racism in America increases the urgency of making our institutions actively antiracist.
Please do the following in order to create a more equitable America: work to be antiracist. This will bring equity to differing racial groups. Each of us leading our institutions to become antiracist will be the beginning of actual change and healing for each of us and our nation. Read and execute “The Business Case for Investing in Physician Well-being” by Tait Shanafelt, Joel Goh and Christine Sinsky. Tell everyone everywhere to wear masks, wash their hands regularly, practice social distancing to stop community spread of COVID-19 and get the vaccine once it is available. Read and implement “The Mindful Self-Compassion Workbook” by Kristin Neff. If we all do these things, we have a chance to heal these emotional stress fractures while mitigating the medical profession’s most dangerous occupational hazard: suicide.
Deborah Saint-Phard, M.D., is an associate professor at the University of Colorado School of Medicine in the department of physical medicine and rehabilitation and department of orthopedic surgery. She is also chair of the well-being committee of the Colorado Medical Society. ■ Originally published by Inside Higher Ed. Reprinted with permission of the author. https://www.insidehighered.com/advice/2020/12/18/intersection-physician-burnout-covid-and-racism-heightens-urgency-making
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C O LO R A D O M E D I C I N E 1 1
F E A T U R E
CMS sets the course for the future BOARD OF DIRECTORS AFFIRMS STRATEGIC PLAN Kate Alfano, CMS Communications Coordinator On Saturday, Sept. 26, the Colorado Medical Society Board of Directors held a facilitated virtual strategic planning retreat that included CMS staff and physician members of the CMS Strategic Planning Committee. The group identified many potential priorities that they narrowed down to three. Staff then developed an operational plan for achieving these three priorities incrementally over the next one year, three years and five years. The highest priority identified by the board is for CMS to create a strategic plan for diversity, equity and inclusion. The Board believes that for CMS to be the best and most representative organization for Colorado physicians, a culture change is needed, but change must be made thoughtfully. Another extremely high priority is protecting physicians’ rights to confidential counseling in light of the current changes to the current peer assistance contract and the challenges of the COVID-19 pandemic. The third-highest priority involves membership retention and engagement, and increasing membership, which will maintain CMS’s strength as an organization in the long term. All Colorado physicians are encouraged to join CMS or renew membership today at members.cms.org/join. CMS STRATEGIC GOALS GOAL 1
GOAL 2
GOAL 3
Professional Satisfaction: State-of-the-art advocacy will focus on member priorities to positively impact rewarding physician careers.
Efficient and Effective Communication: Dynamic exchange of information with members will ensure timely action on their priorities.
Organizational Excellence: Continued transformation of CMS will increase member ship value and make CMS meaningful and relevant to a diverse physician population.
CMS STRATEGIC PLAN
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STRATEGIC PLAN FOR DIVERSITY, EQUITY AND INCLUSION
1-Year SMART Objective: By July 2021, CMS will have a Strategic Plan for diversity, equity and inclusion. Operational Plan: In order to effectively meet this objective in a timely fashion, the following benchmarks will need to be achieved: • November 2020 • RFP for facilitator • January 2021 • Selection of facilitator • Budget creation • February 2021 – April 2021 • Stakeholder engagement • Meeting preparation • April 2021 • Strategic Planning for Diversity, Equity and Inclusion Retreat • April 2021 – May 2021 • Write Strategic Plan • Stakeholder feedback • July 2021 • Adoption and implementation of Strategic Plan 1 2 C O LO R A D O M E D I C I N E
3-Year SMART Objective: By September 2023, CMS will have implemented the Diversity, Equity and Inclusion Strategic Plan 5-Year SMART Objective: By September 2025, CMS will have achieved the benchmarks established in the Diversity, Equity and Inclusion Strategic Plan
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HELPING PHYSICIANS WHEN THEY NEED HELP/PANDEMIC RESPONSE
1-Year SMART Objective: CMS will help to ensure that physicians have the right to confidential counseling by July 2021. Operational Plan: • November 2020 • Work with DORA, CMB, Governor's Office for potential administrative fixes • Continue to solicit support for a legislative fix • Draft legislation • January 2021-May 2021 • Introduce legislation • Educate legislators on issue • Communicate with membership regarding process and outcomes
3-Year SMART Objective: By September 2023, CMS will be recognized by physicians in Colorado as the primary source for assistance when they are in need. Operational Plan: • Establish a baseline metric using a survey tool to determine: • Physician needs • Perception of CMS value to meet those needs • Environmental analysis of how those needs are currently met/not met • Create organizational structure to analyze needs vs. CMS capacity/capability • Develop business model to match needs to capacity 5-Year SMART Objective: By September 2025, CMS business model to meet member needs is profitable.
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MEMBERSHIP
• Retention • Growth • Increasing engagement 1-Year SMART Objective: CMS losses in membership revenue will not exceed 15% in the 2021 billing cycle.
3-Year SMART Objective: CMS will have membership growth exceeding attrition for the 2023 billing cycle. 5-Year SMART Objective: CMS membership will exceed 10,000 members by the end of the 2025 billing cycle. 2021 Operational Plan: • November 2020 • Dr. Diab personal outreach to members across the state • Personalized communication to any/all members who choose to discontinue membership • Increase member engagement through open meetings • January 2021 • Development of membership communication marketing plan • Continue in-person meetings • Leverage legislative agenda for large-group meetings • Development of hospital-based physician section • Physician-based communication to non-renewing members • Annual membership survey • March 2021 – September 2021 • Consideration of special dispensation for member hardship • Implementation of membership marketing plan • Close loop on CEJA membership discussion ■
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F E A T U R E
Meet your Board of Directors be exercised equally with your head.’” (From Aequanimitas, by Sir William Osler)
somewhere with less “hustle and bustle” and began practice in the Western Slope of Colorado in 2012. He has been an active participant in Colorado organized medicine through the Mesa County Medical Society as well as the Colorado Medical Society, currently serving as secretary/treasurer for the CMS Board of Directors.
David Markenson, MD, MBA, CMS Past-president,
Dr. Pevoto is married to Deletha Assenmacher, and lives in Fruita, Colorado. He has 3 sons, 1 daughter, and one granddaughter. His interests include tennis, golf, music, camping/ hiking, reading, and writing.
Sami Diab, MD, CMS President, is a medical oncologist with
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Rock y Mountain Cancer Centers in Centennial and Aurora, and is passionate about ethics and palliative care. Following a fellowship in medical oncology, he stayed on as faculty at the University of Texas at San Antonio for four years before moving to Colorado in 1999. He enjoys playing tennis, skiing and painting. He is married to Liliane, also a physician, and has two children, Nicholas and Christopher. I serve on the CMS Board of Directors because physicians have to be involved to regain the influence we have lost in health care!”
Mark Johnson, MD, CMS President-elect, served as the
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executive director of Jefferson County Public Health (JCPH) for 30 years before his retirement in October 2020 (delayed from June due to the need to help coordinate COVID-19 response). He has served as a member of the CMS Board of Directors since 2016 and has served in many other leadership capacities within the medical society – leading committees, councils, workgroups, task forces and as a delegate to the former policy-making body of CMS – continually since 1993. His wife and daughter are nurses and his son is in hospital administration. His hobbies are bicycling, reading and writing, and he teaches a history of public health class at the Colorado School of Public Health. I find joy in medicine because ‘the practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will
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has dedicated his career to improving hospital and health system quality, improving the approach to pediatric care, disaster medicine and health care emergency management, and advancing EMS and emergency medicine. He serves as the chief medical officer of Red Cross Training Services and chair of the National Scientific Advisory Council for the American Red Cross. In addition to medicine, he has had a love of aviation from a young age; he has his pilot’s license including an instrument rating and has over 3,000 flight hours. He is married to Heidi Markenson, PhD, and has three children: Emily, Rachel and George.
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I ser ve on t he CMS Board of Directors because I recognize how important the house of medicine is to assuring physicians can practice as they want to and should, and our patients receive the care they need and deserve.”
B r i t t a n y C a r v e r, D O, District 13, is a board-certified
Patrick Pevoto, MD, District 12, was born in Port
Arthur, Texas and received his degree in Pharmacy from UT Austin. He then matriculated to UTMB Galveston for his medical degree, followed by his training in obstetrics and gynecology, also at UTMB. Dr. Pevoto returned to Austin to practice obstetrics and gynecology for 25 years. Over time, he began to have a desire to practice
I discovered a long time ago that the level of joy and fulfilment in my life has been directly related to opportunities for service to others. I am grateful to the Colorado Medical Society and the physicians of Colorado for the some of those opportunities!”
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emergenc y medicine phy sician currently working with SCEMA at Parkview Medical Center in Pueblo. She is a Pueblo native, South high school graduate, and CSU-Pueblo alumna who completed her Bachelor of Science degree while playing D-II women’s soccer on scholarship. Her medical degree was obtained at Rocky Vista University. She briefly left Colorado to complete her residency in Oklahoma City. The Pueblo community is particularly important to both Brittany and her husband Ronnie Romero. She spends most of her time on family, and enjoying the outdoors. I practice emergency medicine because it offers me the unique opportunity to be the calm for people in the middle of chaos. I get to be the person who sees patients, unfortu-
nately at their absolute worst, on their worst day. I love having the ability to provide help for those who need it most, as well as the variety of people I get to connect with, all the way from babies and new moms and dads to the elderly.”
Chris Linares, MD, District 5,
has been in practice in the Denver area since 2000. She completed medical school at Howard University College of Medicine in Washington, D.C. followed by a family medicine residency program affiliated with Mount Sinai Medical School in New York City. She is Board Certified in Family Medicine and has been an active member of the American Academy of Family Physicians since 1997. She is the Chief of Family Medicine at Sky Ridge Medical Center. Dr. Linares is on the Board of Arapahoe-Douglas-Elbert-County Medical Society and is active in promoting primary care and the patient-centered medical home concept.
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degree focusing on rural health disparities and exploring the unique public health challenges of a rapidly growing state. His work in health research and advocacy prompted his application to medical school, where he became involved in organized medicine as the president of the medical student section of CMS. He is now in internal medicine residency at CU representing residents and fellows on the board. Outside of medicine, Evan is one of triplets and keeps close relationships with his family who live locally. His hobbies include home brewing with his brothers and sharing all Colorado has to offer with his colleagues. I serve on the CMS Board of Directors because health advocacy and organized medicine are integral to our patient’s well-being even at the very beginning of a career in medicine.”
Michael Moore, MD, District 9, grew up in a family who
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vacationed across Colorado, so it was an easy decision for him to move here for a reproductive fellowship. In his OB/GYN residency he fell in love with scopes and what was possible long before it was called minimally invasive surgery. He has accomplished a lot in his field but realizes he can contribute even more. Through involvement in the Colorado Medical Society, he has received a new medical education, saying “We have to protect our patients and ourselves from those who would pass legislation without regard to their, and our, wellbeing.” I serve on the CMS Board of Directors because I can advocate for my colleagues and patients. I am making time to give back to our profession. I hope to help change how medicine is practiced in Colorado. We need to stop corporatePAGE 16 ⊲
Dr. Linares loves spending time being active and traveling with her three beautiful girls. She has been a Girl Scout Leader for the past five years. She enjoys hiking in the mountains, skiing and sitting on her patio with a good glass of red wine. I serve on the CMS Board and am also president of my county medical society, ADEMS, because I believe it is important for practicing physicians to unify in support of the medical profession and advocate to improve the delivery and quality of healthcare to our patients.” Favorite Healthcare Staffing belongs to the Colorado Medical Society Partner in Medicine program.
Evan Manning, MD, Resident's Section, is a Colorado
native who attended the University of Denver for a Master of Public Policy C O LO R A D O M E D I C I N E 1 5
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style medicine and the excess greed of the hospital systems and pharma. Doctors need to make patient care decisions, not MBAs. If we do not initiate changes the legislature will. I invite you, my colleagues to also become more involved. Be at the table and not on the menu.”
available, he rigorously (his son may say maniacally) maintains three acres with a weedwhacker, chainsaw and mower (darn thistles!). In addition, he continues to hike nearby trails with his dog (usually) and family.
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Uchenna O. Njiaju, MD, FACP, District 10, is a hema-
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tologist and medical oncologist with a particular interest in breast cancer. She is a champion of patient education and self-advocacy in health matters. Dr. Njiaju holds an MBChB with Honors from the University of Zimbabwe School of Medicine and Public Health. She completed her internship and residency at Johns Hopkins University and a fellowship at the University of Chicago. She has been a staff hematologist and medical oncologist with UCHealth/Colorado Springs since 2013. She has lived in 11 cities in three different countries, on two different continents! She is a blogger and author and, so far, has published a self-help manual and two biographies for family members.
practices neurology in West Denver. She grew up in Los Angeles, went to New York for college and medical school and returned to LA for medicine, neurology residency and a fellowship in geriatrics. Until she and her husband, Dr. Herb Fried, started looking for real work after training, Colorado had been part of that “strip of land” between LA and New York. A delayed interview in Denver and a weekend in Rocky Mountain National Park was all that was needed to make both realize that Colorado was the true center of the Universe.
Ted Norman, MD, District 11, completed his undergraduate
degree at CU Boulder, attended medical school at the University of Colorado in Denver (the old campus) and completed his residency in Madison, Wis. He has worked as a traditional internist and then hospitalist in Loveland since graduation. He remains engaged in the Medical Societ y, having been on the county board for 20 years and is on his second tour of duty as a CMS director. With free time 1 6 C O LO R A D O M E D I C I N E
I serve on the COMPAC and CMS boards of directors to give back to the small number of organizations that keep the practicing physician’s needs, challenges and perspectives at the forefront of medical practice in the state.”
Lynn Parry, MD, District 8,
I find joy in medicine through focusing on each patient as an individual, and always remembering to consider their preferences and concerns.”
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Monica Patten, District 14,
Dr. Parry has long been an advocate for the inclusion of patients in decision-making—from the bedside to the level of policy in health care. She supports ongoing work to improve the quality and safety of care in all areas of health, whether it is in the workplace, the physician’s office or the hospital. Dr. Parry is the proud parent of a daughter who is a freelance curator of contemporary art in Los Angeles. However, Dr. Parry also recognizes that, unless we rein in costs and align incentives, none of our children will be able to afford coverage. Working with colleagues to make the gifts we share with our patients more joyful is the reason I returned to the Board.”
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is a medical student at the University of Colorado School of Medicine, class of 2023. She is a Colorado native from Steamboat Springs, and has been skiing since she learned to walk. Although she is from Ski Town, USA, she played ice hockey from the age of 7 through college. She played at the NCAA D-III level for SUNY Oswego before transferring to CU Boulder to play club hockey and graduate with a BA in Integrative Physiology. I am a CMS member because as a Colorado native, I care deeply about the health and wellbeing of my fellow Coloradans and the physicians who serve them.”
Leto Quarles, MD, District 7,
a board-certified family and community medicine physician, has spent over a decade in medical training and two decades working as a physician with patients, hospitals, clinics, international medical teams, teaching students and residents, and collaborating with specialists and healers of many areas of expertise. She has cared for patients in offices, homes, hospitals, nursing homes, and even prisons. She’s led teams in bustling cities and tucked-away villages on three continents and across diverse barriers of language, culture and technology. Born in the Bronx, Dr. Quarles claims descent from Helen of Sparta and bands of shtetl partisans. Today she makes her home in the foothills of the Rockies, where (whenever she’s not doctoring) she enjoys hiking, gardening, and puppeteering. “I am a CMS member because I believe in the power of diverse, s t r o ng , i n d e p e n d e n t t h i n ke r s coming together to share our strengths and our perspectives to build solutions and systems that
are better than anything each of us can create alone. Whether we’re shaping policy or clinical practice, our strength in numbers and our diversely nuanced expert perspectives build not only resilience, but anti-fragility. Which is exactly what health care needs today.”
Brandi Ring, MD, FACOG, FAWM , Dist ric t 6, i s a
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board- cer tif ied Obstetrician and Gynecologist. She developed a deep passion for serving the underserved and developing health policy and became an advocate for patients and physicians through her work with the American Medical Association in medical school. Dr. Ring actively advocates for her patient s, her colleagues and her specialty. She can frequently be found in state and national Capitols discussing health policy. Her specialty interests include high-risk and low-risk pregnancy, perinatal mental health, family planning, wilderness medicine, disaster preparation, LGBTQ care, well-women care and preventative health. I ser ve on t he CMS Board of Directors because it gives me the chance to share some of the unique perspectives in medicine: a private-practice voice, a female voice, a young career voice, a first generation physician voice, and to advocate for all the voices we don’t have at the table and find ways to get them there.”
Kim Warner, MD, CPMG Section, has been an OB/GYN
physician with the Colorado Permanente Medical Group (CPMG) for 21 years. She has served on the CMS Board of Directors and as Board Chair for CPMG, on the Denver Medical Society Board of Directors,
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as OB/GYN Depar tment Chair at Saint Joseph Hospital, and on the Board of Directors for the Center for Personalized Education for Physicians (CPEP). She serves as the Legislative Chair for CPMG. Dr. Warner has traveled multiple times to Africa to aid in women’s health organizations. She is married to Rick May, MD, and has three teenage daughters. She enjoys running and coaching her daughter’s lacrosse team. Women’s health is my passion. I feel I was placed on this earth to take care of and educate girls and women.”
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component society, Mt. Sopris Medical Society. He is a U.S. Army veteran: he joined the Army through a medical scholarship program, completed residency in San Francisco at Presdio/Letterman Army Medical Center, and then proudly served our country, including tours of duty in South Korea, before receiving an honorable discharge in 1994. He married his high school sweetheart, Rosario, and they have a daughter, Secia. I serve on the CMS Board of Directors because I love being a physician, caring for my patients, and want to maintain and improve that experience for my fellow Colorado physicians.” ■ Colorado Medical Society District Map 789 11 2
Hap Young, MD, Districts 1 & 2, has spent the last 21 years as
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part of Mountain Radiology covering northwest Colorado. He has served in numerous leadership positions for Valley View Hospital (Glenwood Springs) and within CMS and his
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1250 Connecticut Ave., NW Suite 700 Washington, DC 20036
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Reza Ghafoorian, MD, JD (202) 656 8387 rghafoorian@g2zlaw.com
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D E PA R TM E NT S R E F LE C TI O N S
Cadaver as First Teacher Laura Meimari
Ref lec tive writing is an impor tant component of the CU School of Medicine curriculum. Beginning in the first semester, medical students write essays, stories or poetry that reflect what they have seen, heard and felt. Reflections is edited by Steven Lowenstein, MD, MPH, and Tess Jones, PhD. It is dedicated to the memory of Henry Claman, MD, Distinguished Professor of the University of Colorado, founder of the Arts and Humanities in Healthcare Program, and original co-editor of this column.
Laura Meimari is a first-year medical student at the University of Colorado School of Medicine. She graduated with a degree in Chemical Engineering from McGill University in 2009 and enjoyed a career in the mining industry that allowed her to work and travel all over the world. After completing the Post-Baccalaureate Pre-Health Program at the University of Colorado Boulder, she is thrilled to now be following her dream of pursuing medicine.
In-lab assignment. U sin g yo u r c a dave r, p er fo r m t he following tasks: Identif y the erector spinae muscles. Consider the times these erector spinae have stood tall: weddings, graduations, in pride. In defiance. Identify the intercostal muscles. Consider the deep breaths these intercostals have drawn. Consider the moments that took breath away. Consider these intercostals recovering from uncontrolled laughter. Identif y the latissimus dorsi muscle. Consider the loved ones this latissimus dorsi has pulled into a hug. Consider this latissimus dorsi being the last to let go. Identify the vertebral column. Consider the scoliosis of this vertebral column.
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Consider the doctor’s appointments, the waiting rooms, the x-rays after x-rays tracking the curvatures of this vertebral column. Consider the difficulties, the discomfort, the pain imposed by this vertebral column. Identify the deltoid muscle. Consider what this deltoid has reached for: the top shelf at the grocery store, the box of keepsakes stored high in the closet, the monkey bars. Identify the pectoralis major muscle. Consider the children this pectoralis major has picked up to comfort. Identify the brachialis muscle. Consider the groceries this brachialis has borne. Consider the platters carried to the dinner table. Consider the suitcases lifted. The adventures taken.
Identify the median cubital vein. Consider the blood drawn from this median cubital vein. Consider the nervous anticipation of the needle. Consider the nervous anticipation of blood test results. Identify the supinator muscle. Consider the doorknobs turned by this supinator. Consider all the doors opened. The thresholds crossed. Identify the flexor digitorum profundus muscle. Consider this flexor digitorum profundus wrapping fingers around a tennis racket, a hairbrush, a stirring spoon, a husband’s hand, a garden trowel, the railing of a hospital bed. Identif y the intrinsic hand muscles. Consider the pens these muscles have held, the letters they have written. Consider the sewing needles held, the holes mended. Consider the
paintbrushes held. Consider the colors selected with careful intention. Identify the iliac crest. Consider the babies that have been balanced on this iliac crest. Identify the iliopsoas muscle. Consider the races this iliopsoas has run. Consider this iliopsoas running for the bus, into someone’s arms, to shelter from the rain. Identif y the gluteus medius muscle. Consider the miles this gluteus medius has walked, the miles and miles walked. Early in the morning, at dusk, on a treadmill, on a trail, around a lake, around the neighborhood, across the parking lot, down the aisle. Identify the metatarsals. Consider the shoes these metatarsals have slipped into. High heels, ice skates, roller skates, hiking boots, ski boots, cowboy boots, ballet shoes, bowling shoes, running shoes, galoshes, flippers, moccasins. Identify the four layers of plantar muscles. Consider these plantar muscles aching and throbbing at the end of a long day. Identify the primary bronchi. Consider the air that has passed through these bronchi. Fresh clean air on a quiet trail. Hot smoggy air in a lively city. Salty humid air on a crowded beach. Air with the scent of pines. Air with the scent of perfume. Air with the scent of a newborn. Identify the lungs. Consider the primary tumors on these lungs. Consider the oncologist’s office. Consider the oncologist’s eyes. Consider the words lingering in the air. Consider knowing. Identify the atria and ventricles of the heart. Consider this heart pounding with excitement. Consider this heart pounding with fear. Consider this heart swelling with pride. Consider this heart breaking. Consider the last beat of this heart. Consider the first beat of this heart. Consider the love housed within this heart. Consider the life powered by this heart. Consider the life. ■
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D E P A R T M E N T S C O M M E NT
Within Normal Limits A NEW PODCAST BY COPIC Gerald Zarlengo, MD, Chairman & CEO COPIC Insurance Company
COPIC has launched a podcast called “Within Normal Limits: Navigating Medical Risks.” Hosted by Dr. Eric Zacharias, an internal medicine specialist and COPIC physician risk manager, the podcast provides a new way for us to connect with physicians and medical professionals and share our insights. Each episode is brief (around 20 minutes) and focuses on honest, open conversations between Dr. Zacharias and other medical experts/ physicians about current challenges in health care. Here are some of the episodes we have released so far:
Episode 3: Sepsis — A Bad Infection That Can Get Worse Sepsis is a common syndrome, and although our knowledge of how to treat it has improved significantly, this bacterial infection can be lethal if not caught early. Dr. Susan Sgambati, a colorectal surgeon and COPIC’s medical director, joins Dr. Zacharias to review some sepsis case studies and discuss why early recognition is critical, the value of clinical judgement and vital signs, and how pain out of proportion to what you are seeing can be a key indicator.
Episode 1: Med Mal 101 — Heads, Hearts, Bellies, and Bugs
Episode 4: Informed Consent — The Joy (and Pain) of Shared Decisions
Our first episode draws upon decades of medical liability experience to distill down the key areas where we consistently see malpractice lawsuits—heads (neurologic), hearts (chest pain), bellies (abdominal pain), and bugs (infections). We examine why physicians sometimes misdiagnose symptoms that seem obvious in hindsight, but in actual practice, are not so simple. Our guest is Dr. Dennis Boyle, a rheumatologist and physician risk manager with COPIC. Dr. Boyle and Dr. Zacharias walk through some sample scenarios and offer guidance on how to avoid common risks while enhancing patient safety.
Informed consent shouldn’t be viewed as just an obligation to get a signed form, but rather, an opportunity to engage patients in shared decision-making. Dr. Jeffrey Varnell, a surgeon and COPIC physician risk manager, joins Dr. Zacharias to talk about the process of disclosing essential information during the informed consent process so that patients understand the recommended treatment and indications, risks, benefits, alternatives, and risks of not proceeding. In addition, they review the importance of not delegating this process to those who aren’t performing the procedure, and assessing a patient’s understanding. Episode 6: Burnout from COVID-19: Moving Forward with Resilience
talks to one of COPIC’s exper ts on physician burnout, Dr. Dennis Boyle. They dissect the root causes of burnout and three key parameters to consider— depersonalization, emotional exhaustion, and feelings of low accomplishment. They also look at other influential factors, such as EHRs, workplace culture, and personality traits as well as the omnipresence of grief in health care. In addition, they talk about how the trend of prescribing “simple mindfulness” can be a challenging practice to put into action, and what steps can be taken to effectively approach this. Episode 7: Navigating Conversations with Patients About Guns Some providers may draw a stric t boundary about discussing guns with their patients (or not think about it). But research has shown there are situations when access to firearms is a potential risk factor and raising this issue can be not only appropriate but necessary. Dr. Michael Victoroff, who is a firearms safety expert, addresses some scenarios associated with guns that can arise in the clinical setting. These range from imminent danger (e.g., suicide risk) to general considerations that vary from household to household (e.g., storage methods). Dr. Victoroff offers guidance on how to approach this topic with non-confrontational questions and suggestions for credible resources for health care providers.
“Within Normal Limits” is available on Apple Podcasts, Google Podcasts, Spotify, and Amazon. You can also visit our website at While burnout is a long-stand- www.callcopic.com/wnlpodcast for more ing issue in health care, the information. New episodes will be posted co m p o u n d e d i m p a c t o f throughout the year, so we encourage you COVID -19 has heightened to subscribe. It’s another example of how its prevalence and the impor- COPIC continues to look forward, push tance of efforts to address the innovative ideas, and put our mission of well-being of medical providers. “improving medicine in the communities In this episode, Dr. Zacharias we serve” into action. ■
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D E PA R TM E NT S I NTR O S P E C TI O N S
Delivering health care to asylum seekers Critical reflective writing holds a prominent place in the Medical Humanities curriculum at Rocky Vista University, College of Osteopathic Medicine. Beginning in the first semester of Medical Ethics, students engage in critical reflection to explore their own assumptions and biases and how their values impact their practice. This submission is selected and edited by Nicole Michels, PhD, chair of the Department of Medical Humanities, and Alexis Horst, MA, writing center instructor.
Taylor Harp
Kailey Stiles
Taylor and Kailey are third-year medical students in the Global Health Track at Rocky Vista University College of Osteopathic Medicine. Kailey completed her undergraduate degree in Biology at Baylor University and plans to pursue a career in Pediatrics. Taylor completed her undergraduate degree in Integrative Physiology at CU Boulder and hopes to pursue a career in Internal Medicine. Taylor and Kailey work together on many projects to improve medical care for underserved populations, including founding a branch of American Medical Women’s Association at RVU, researching VTE risk in pediatric patients, and advocating for policy change to provide medical care for asylum seekers. During the hot Texas summer of 2019, a young couple carried a sick and weary infant into an overcrowded warehouse located along the Texas/Mexico border. This young couple, both graduate students from Guatemala, fled extreme violence in their home country with the small hope that they might be able to provide a better life for their child in the United States, where they would apply for asylum. This resilient family of three set out on a dangerous two-month journey through Central America where they were robbed of their belongings and had minimal food and shelter before arriving at the warehouse in Texas. An asylum seeker is defined as a person in the United States or arriving at a U.S. port of entry who is hindered from returning to their home country due to the threat of violence or mistreatment. There are asylum seekers who are detained at the border, and then there are non-detained asylum seekers like this family. Non-detained asylum seekers are asylum seekers who are released after initial screening by Immigration and Customs Enforcement (ICE) and may be waiting for up to a year before their court date. There is minimal information on this vulnerable population, but the studies that do exist state that there were an estimated 338,000 non-detained asylum seekers awaiting their court decisions as of June 2018.1 This family’s story is not very different from stories of other asylum seekers coming to the United States, though not all are 2 2 C O LO R A D O M E D I C I N E
lucky enough to pass through a shelter with volunteer medical providers. The hot and crowded warehouse provided a 48-hour safe haven for 750 non-detained asylum seekers, providing them with basic food, showers, a cot with an itchy blanket, and a phone call to connect them with their “sponsor.” Asylum seekers are required to have a sponsor: a friend or relative already living and working in the US. Sponsors may live anywhere in the US and are expected to provide the asylum seeker with finances for travel and lodging while they await their court date. After 48 hours, the goal is to connect the asylum seeker with their sponsor in the US, but they are not routinely given the resources to travel to their sponsor. As medical students volunteering in the free makeshift clinic in the warehouse, we helped provide simple, appropriate antibiotics for the sick child’s condition. We were caught by surprise when we witnessed the infant’s parents weeping over their son with tears of gratitude. We saw the relief in the father’s eyes as he told us that this was the first time in months that he’d felt safe and the first time he felt a little bit of hope that his family’s situation might actually get better. The response of this young couple showed us the magnitude of grief, pain, and suffering that this family had endured. There remains a large deficit in healthcare provided for non-detained asylum seekers crossing the Southern border of the United States, as shown by this family’s experiences. Though there aren’t many
statistics more recent than 2018, it is estimated that the number of non-detained asylum seekers has drastically increased, in part because nearly 50% of the Department of Justice Courts have halted cases for processing non-detained asylum seekers due to COVID-19.2 The little medical care we helped provide to this family was the first healthcare they’d received in months, and we all knew very well that it could be the last they’d receive for a long time once they’d left the warehouse. Unlike asylum seekers detained in ICE facilities or refugees, there are no protocols in place for non-detained asylum seekers to receive any access to medical care. In fact, there are many barriers to receiving care, as they do not qualify for insurance coverage such as Medicaid and often have difficulty receiving care from government-funded programs. This is especially problematic because non-detained asylum seekers are disproportionately affected by psychological illnesses such as post-traumatic stress disorder and chronic pain syndromes; infectious diseases such as influenza; and chronic diseases such as diabetes. 3 Therefore, decreased healthcare access for non-detained asylum seekers poses a public health threat involving the spread of infectious disease and places a burden on the U.S. healthcare system due to unmanaged mental health issues and chronic diseases. Although the Customs and Border Patrol policy is to validate and replace migrants' medications upon entry to the United States, this does not always happen, and medications are
often confiscated without replacement. This means that many migrants are left without needed medication in a country where they have no accessible means to obtain more.4 This contributes greatly to the progression of chronic illnesses to emergent states, making the point-of-entry to the US healthcare system an emergency room visit for most non-detained asylum seekers. As healthcare providers, it’s our role to help provide this family with their right to access medical care. Changes need to be made and policies should address and ensure access to basic healthcare, replacements of confiscated medications upon release, and independent physician access to medical records obtained during the health screening in order to maintain continuity of care. The father asked us if we minded if he prayed over us. As individuals who don’t pray publicly, we were taken by surprise and humbled by this gesture. We were immediately reminded of the importance of not taking for granted what we have and of not making assumptions in medicine: don’t assume that antibiotics are no big deal and remember to always respect another’s culture. We didn’t feel as though we had done anything to earn the gratitude of this man in the presence of his God. Giving antibiotics was how we knew how to help him and praying over us to his God was how he knew how to help us. We cried together and for a moment forgot all of the chaos happening around us in the warehouse; for a moment, we were just humans caring for one another. This reminded us of the reason we in medicine do what we do: not simply to get the job done, but to help others realize their right as humans to a healthy life. ■
D E PA R TM E NT S I NTR O S P E C TI O N S
Non-verbal dependency Hayley Hawkins, MS, third-year medical student at the University of Colorado School of Medicine
A nurse. A resident. A patient. A medical student.
The patient Laboring, in pain Have made a connection A wordless connection
Two minutes goes by, The patient Unable to communicate Desperately searches for help For direction
In sync Contractions come The eyes search for help The student sees…
Contraction by contraction The mere student has learned The silent, desperate call for direction A connection is made without a word The medical student Unqualified
Silently hears, silently answers A baby enters the world A new mother cries with joy The first words are uttered In a language foreign “Thank you.” ■
1. Meissner D, Hipsman F, and Aleinikoff TA . The U.S. Asylum System in Crisis: Charting a Way Forward. Washington, DC: Migration Policy Institute. Published September 1, 2018. Accessed December, 2020. 2. EOIR Operational Status During Coronavirus Pandemic. The United States Department of Justice, Published August 17, 2020. Accessed December, 2020. 3. Stockman, JA. International Migration and Immigration Issues Related to the United States. Pediatric Clinics of North America. Published February 3, 2019. Accessed December, 2020. vol. 66 (issue #3): pp. 537–547. 4. Halevy-Mizrahi N, Harwayne-Gidansky I. Medication Confiscation: How Migrant Children Are Placed in Medically Vulnerable Conditions. Pediatrics. 2020;145(1): e20192524
C O LO R A D O M E D I C I N E 2 3
F E ATU R E F I N A L
WO R D
It just sounds so… final
(GOODBYE)
(HELLO)
Bryan Campbell, CMS Chief Executive Officer
Today I don’t feel very final. It seems like the interminably long and painful 2020 has creeped into 2021. I am typing these words on Wednesday, January 20, 2021. This morning we had our Colorado Medical Society staff meeting (over Zoom, of course) to discuss the big issues we are facing right now in our state: vaccination plans, physician confidentiality, the looming legislative session, and more. I was reminded that I was asked to write this issue’s Final Word; to perhaps put a bow on 2020 and set a vision for the future in 2021? Where to begin? There is so much that isn’t final. The COVID-19 pandemic rages on. The social unrest following the murder of George Floyd and so many others created a call for change, but there is so much work to be done. The most contested and controversial election in American history kept the nation divided for months and spilled into this year. Then Amanda Gorman took the stage. The poet took the stage at the Presidential Inauguration of Joe Biden to recite the poem “The Hill We Climb.” This stirring recitation ended with the following verse: “We will rebuild, reconcile and recover in every known nook of our nation, in every corner called our country our people diverse and beautiful will
emerge battered and beautiful. When day comes, we step out of the shade aflame and unafraid. The new dawn blooms as we free it. For there is always light. If only we’re brave enough to see it. If only we’re brave enough to be it.” As my emotions stirred, I was reminded of the great words of the Roman philosopher Seneca (or the 90’s rock bank Semisonic)” “Every new beginning comes from some other beginning’s end.” That captures the moment perfectly. As you grapple with what we believe to be the beginning of the end of this public health crisis, we see the new beginning of medicine reimagined. With the access and reimbursement for telehealth services permanently changed, practices have forever changed the way they do business. Decades old policies on dealing with pandemics are being rewritten,
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modernized, to help us prepare for a future crisis… …and Colorado physicians continue to demonstrate their resilience, their strength, and their dedication to protecting and preserving public health. Despite some real challenges along the way, Colorado continues to be one of the nation’s leaders in COVID immunization rates. Colorado physicians continue to contribute to national policy on keeping schools and communities safe. Colorado physicians continue to lead. Now we begin new work, taking a comprehensive look at some of the inherent racism and bias in the health system and the Colorado Medical Society itself. The CMS Board of Directors has approved the creation of a five-year strategic plan to analyze these factors and create a strategic plan for diversity, equity and inclusion. This is bold and challenging work. COVID19 brought to the surface the persistence iniquities in healthcare in Colorado. It shined a light on the difference between equality and equity. Colorado physicians again can lead the way. I’m hopeful. This is not the final word. This is a new beginning. “For there is always light. If only we’re brave enough to see it. If only we’re brave enough to be it.” ■
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