July-August 2020 Colorado Medicine by Colorado Medical Society

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C O N T E N T S

Legislature passes laws reflecting “new normal” The Colorado Legislature adjourned on June 15 after an unprecedented 2020 session that included a 53-day recess due to the coronavirus pandemic. Though they reconvened amid a historic budget shortfall, lawmakers passed legislation to expand telehealth, address the opioid crisis, improve statewide vaccination rates and improve the affordability of health care. This year’s wins are a reflection of CMS’s engaged membership and the tireless work of physicians to address the needs of their patients during this challenging time. PAGE 6 ⊲

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D E P A R T M E N T S

10 BENT BUT NOT BROKEN: EVOLVING MEDICAL EDUCATION The COVID-19 pandemic turned life on its head; the realm of medical education is no exception as students adapted to abrupt changes in their learning environments. Some of these changes will continue to affect education in the near term and long term.

27 Medical news

14 COLORADO RESIDENT AND FELLOW PHYSICIANS RISE TO THE CHALLENGE OF COVID-19 Resident and fellow physicians are heroically taking on additional responsibilities during the COVID-19 pandemic while also facing unique challenges to learning, teaching and living. 16 A PRELIMINARY DIALOGUE ON RACE, RACISM AND HEALTH SYSTEM ILLS ENT physician Phyllis Bergeron, MD, explores the topics of racial inequities, social injustices and health equity in the shadow of the COVID-19 pandemic and the death of George Floyd. 20 PERSPECTIVES ON COVID-19 POLICIES CMS President-elect Sami Diab, MD, and co-author Stephen Kantor look at the ethics of hospital policies implemented during the pandemic, and the effects they had on two non-COVID-19 patients and their families. 24 CMS WORKING FOR YOU: CONNECTING PHYSICIAN MEMBERS WITH PPE The Colorado Medical Society worked with partners to meet a critical member need in May: Placing a bulk order of PPE and distributing the orders to members around the state. See photos from CMS PPE Day. 28 RESULTS FROM THE COLORADO COVID-19 PHYSICIAN SURVEY The Colorado Medical Society, in partnership with the Colorado House of Medicine, surveyed physicians regarding the effects of the COVID-19 pandemic on physician practices to guide future action. 30 LEGAL BRIEF: REFLECTIONS ON THE MEDICAL-LEGAL COURTROOM Former COPIC general council Mark Fogg, JD, gives an insider’s look into defending physicians in a courtroom. 40 FINAL WORD: A VERY DIFFERENT END OF MEDICAL SCHOOL Two medical student leaders who completed their education in 2020 reflect on the end of their last semester, virtual Match Day ceremonies and finding ways to help during the pandemic.

• In memoriam: Stuart Gottesfeld, MD • Spotlight on Emily Bishop: CMS staff member is coordinating CMS’s contact tracing volunteer reserve • 2020 CMS Annual Meeting canceled 35 Advantage Partner Spotlight 36 Reflections 37 COPIC Comment 38 Introspections I N S I D E

C M S

4 President’s Letter 19 CMS Corporate Supporters and Advantage Partners 32 2020 CMS election: Meet the candidates

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 2019-2020 OFFICERS

BOARD OF DIRECTORS

AMA DELEGATES

David Markenson, MD, MBA President

Danielle Coleman, MS Curtis Hagedorn, MD Mark B. Johson, MD Jason L. Kelly, MD Evan Manning, MD Edward Norman, MD Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD Brandi Ring, MD Brad A. Roberts, 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

Sami Diab, MD President-elect Patrick Pevoto, MD, RPh, MBA Treasurer Bryan Campbell, FAAMSE Chief Executive Officer Debra J. Parsons, MD, MACP 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 Government Relations Program Manager 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 Professional Services 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 bimonthly 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.

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C M S P R E S I D E NT ’ S

LE T TE R

Moving forward in our “new normal” David Markenson, MD, MBA, President, Colorado Medical Society Pivotal events of 2020 have challenged Colorado physicians to examine our systems of care, shift to adapt our practices to continue caring for patients, and consider further reforms. As always is the case, the physicians of Colorado have risen to the challenge and shown that physicians are trusted leaders in health care, strong advocates for their patients and a key component of our public health system. In addition, while also tested by the challenges of 2020, your medical society has been there to support you, be your voice on critical issues and facilitate a unified House of Medicine. The challenges of the COVID-19 pandemic, the strength and expertise physicians bring, and the hope for the future are well conceptualized in this reflection by CMS Board of Directors member Leto Quarles, MD, a family physician in Boulder: “The pandemic hit me and my patients hard. I quickly transitioned my primary care practice to mostly virtual care: four days a week trying to teach folks how to take care of their chronic health conditions so they can continue to function and stave off catastrophic complications and premature death, and doing my best to address the anxieties of a traumatized, worried, frightened, mourning population through uncertain times. Because much of this work is still unpaid and many people are avoiding everything medical these days, revenues are way down, complicating what was already difficult in independent primary care.” She continued: “Looking forward, I take courage in knowing that I can’t completely know what will happen next – but as a physician, I am uniquely prepared to anticipate, adapt, act and lead during times like these. As scientists, we are trained to navigate relative risks and complexity. As healers, we are masters of resilience and providing comfort. As doctors, we are leaders in our communities. And we’re all going to have to draw on all these strengths to help bring our communities into a healthy, sustainable future.” You have no doubt heard the term the “new normal” used to describe the seismic shift in our lives, and this term is used throughout this issue of Colorado Medicine. I invite you to explore the cover story on the recently concluded 2020 Colorado General Assembly during which lawmakers passed, at the urging of CMS, bills to support your use of telehealth, improve payment for your services, address the opioid epidemic, increase access to care for patients and bolster public health. Many of these reforms make permanent the positive changes to care delivery physicians conceived, improved and then implemented in response to COVID-19.

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Other features bring forth the experiences of medical student, resident and fellow leaders and faculty as they reflect on their “new normal” in medical and graduate medical education. While it has already evolved from my years in medical school and graduate medical education, it now looks drastically different from any other physician’s training to date. In addition to addressing many of the new norms in health care, the issues of health equity and social determinants are key issues on the minds of physicians. The physicians of Colorado and your medical society are continuing to address these issues and advocate for improvements in systems of care for our patients. Another key feature written by a well-known and respected specialty society president opens a dialogue on race, racism and long-standing health system ills, presenting a list of action steps we can all take to create positive change within ourselves, our offices and our communities. As we voiced in a statement in early June, CMS condemns all racism and senseless acts of violence; racism is a social determinant of health. The structural racism we are witnessing nationwide undermines the health of individuals, families and communities we serve. CMS is deeply concerned with the prevalence of discriminatory and racist acts that are resulting in the unwarranted deaths and marginalization of people of color. Our members care for the physical, mental and public health consequences of those impacted by structural racism and discrimination. Individual and community health cannot thrive in the presence of disparities in health care, workforce development, housing, education and criminal justice. For these reasons, CMS has a long history of working to mitigate these health and racial impacts on our patients’ health. CMS, on behalf of our members, commits to promoting and advancing health and social equity through advocacy, public policy and education. As the physicians of Colorado continue to lead through the challenging and ever-changing times, your medical society is here to support you, striving to unite the House of Medicine to solve problems, share resources and education, and inform government officials and state leaders. As physicians we have a role to use our heart and knowledge to advance society, to serve our patients providing accessible and high-quality care, and to educate the public. I am deeply grateful to all members of the Colorado Medical Society for standing together as a profession and stewarding meaningful change. We will keep working and I and your medical society, as always, are here to be your voice, provide resources and support you. ■

C O V E R

Sine die report: Legislature passes laws reflecting the “new normal” DESPITE ROCKY SESSION, PHYSICIANS SEE TREMENDOUS GAINS Emily Bishop, Program Manager, CMS Division of Government Relations

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The Colorado Legislature adjourned on June 15 after an unprecedented 2020 session as a result of the coronavirus pandemic. After a 53-day recess to promote social distancing and protect the health of members, staff and the public, the legislature returned on May 26 to a very different landscape. Facing economic turmoil, a historic budget shortfall, and continued public health concerns, legislators worked to pass priority legislation swiftly. Despite the challenges, CMS continued to advocate for Colorado physicians at the Capitol and championed legislation to expand telehealth, address the opioid crisis, improve statewide vaccination rates and improve the affordability of health care. This year’s wins are a reflection of CMS’s engaged membership and the tireless work of physicians to address the needs of their patients during this challenging time. CMS is proud to represent these interests at the Capitol.

Telehealth expansions adopted during COVID-19 made permanent

A big step toward improving Colorado’s vaccination rates

Colorado’s liability climate remains stable

As demand for telehealth skyrocketed during the COVID-19 pandemic, almost every physician practice either ramped up existing telehealth services or started offering new telehealth services. Restrictions were eased and reimbursement was bolstered on both the state and federal levels in order to ensure more patients could access needed health care services through telehealth. As soon as the benefits of these expansions were seen, CMS began advocating strongly that these advances be maintained post-pandemic and not lost by reverting to pre-pandemic telehealth coverage and payment rules.

SB20-163 was another high priority bill of the 2020 session. The legislation aimed at improving the state’s overall vaccination rates requires the creation of a standardized form and education module to claim a nonmedical immunization exemption for a school-age child. The bill also sets a goal of a 95 percent vaccination rate for each school.

Initial legislation aimed at expanding the potential payout of civil claims by allowing a plaintiff to hold an employer responsible for the actions of its employees in certain circumstances – reversing a state Supreme Court decision and long-held precedent – was waylaid by the interrupted session. HB20-1348 was a bill supported by the Colorado Trial Lawyers Association that met with considerable opposition from the business and health care communities. While it was pulled down due to the shortened session and revised priorities of the legislature, CTLA leadership have vowed to return with the bill in 2021. CMS is working closely with its partners, including COPIC, to educate legislators on the adverse impact of such liability expansion.

This advocacy paid off with the passage of SB20-212, which was not even contemplated at the beginning of the session in January. The bill enables reimbursement for telephone calls, prohibits private insurance carriers from putting restrictions on the use of telehealth and requires Medicaid to cover telehealth more broadly. Upon the governor’s signature, this will be an important win that will increase telehealth coverage, access and reimbursement for all HIPAA-compliant technologies.

While the bill does allow an exception to these requirements for homeschooled children, overall the bill is a huge win that has been long fought over the last several sessions. Heading into the final weeks of the session, it was unclear if legislative leadership would even allow SB20-163 on the calendar over concerns about overcrowding in the Capitol amidst social distancing measures. However, in part because of the grassroots efforts by CMS and its partners, the bill continued through lively debate until eventually being sent to the governor’s desk on the penultimate day of session.

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C O V E R LE G I S L ATI V E R E P O R T: C O N T

Pain management alternatives get coverage boost Colorado Medical Society’s continued collaboration with the General Assembly’s Opioid and Other Substance Use Disorders Interim Study Committee, the Colorado Consortium for Prescription Drug Abuse Prevention, the Colorado Pain Society and others has led to more progress in the fight against the opioid crisis. CMS’s Council on Legislation supported all five bills that came out of the 2019 Interim Committee and all were passed by the legislature, though budgetary constraints forced modifications to be made. The five bills address prevention, treatment, recovery, harm reduction and the criminal justice system. Of note is HB201085’s requirement that private insurance carriers provide increased coverage for atypical opioids and nonopioids without barriers – like step therapy or prior authorization – as well as increased coverage for alternatives to opioids like physical therapy, occupational therapy, chiropractic visits and acupuncture visits. The governor vetoed HB20-1085 due to concerns the mandated coverage of services would raise health insurance premiums.

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Legislative declaration on hospital visitations balances safety and patient needs HB20-1425 was a late bill introduced in the f inal days of session, which addressed visitation for patients during the coronavirus pandemic. While the bill sponsors had good intentions in addressing a challenging situation, CMS and its partners raised concerns over respecting patient-centered care, existing hospital visitation policies, and autonomy of clinical decision-making. After emotional testimony, the bill was amended to a legislative declaration calling for hospitals to revisit their policies to ensure that loved ones can safely visit patients as the pandemic continues. CMS committed to collaborate in this work.

Public option delayed but health insurance affordability addressed Perhaps the most anticipated bill of the 2020 session before the coronavirus pandemic was the state affordable health insurance option, sometimes referred to as the public option. HB20-1349 was introduced just a week before the legislature took their temporary recess and was deemed too complex and controversial to tackle when the legislature reconvened nearly two months later. The sponsors pulled the bill down but vowed to return in 2021 with a renewed effort. Before the shutdown, the CMS board had voted to take a monitor position on the bill and will continue to be involved in the stakeholder process throughout the interim. However, as the COVID-19 pandemic wore on and shutdowns caused unemployment to surge, a new bill addressing health insurance affordability gained momentum. SB20-215 establishes the Health Insurance Affordability Enterprise to assess a fee on health insurance premiums and an assessment on hospitals for two years to fund the state’s reinsurance program and provide subsidies to lower health insurance premiums on the individual market. As a result, more patients will have coverage and physicians can expect less uncompensated care.

COMPAC endorsed 71 candidates running for state House and Senate districts, and 70 won their primary races.

Practice acts continued without dangerous scope expansions

Tobacco tax on the November ballot to fill budget shortfall

The 2020 session saw sunsets of the practice acts for the Nursing Board, NPATCH, Naturopaths and Board of Chiropractic Examiners. The CMS Council on Legislation, with the advisement of the Scope of Practice subcommittee, carefully monitored the legislation to ensure no dangerous scope expansions were included.

HB20 -1427 put s a measure on the November ballot asking voter s to increase the tax on cigarettes, tobacco products and nicotine products (including vaping) starting next year. Revenues from the tax will be used to backfill some of the state budget shortfall, support tobacco education programs, and fund affordable housing and preschool programs.

HB20-1216 continued the Nurse Practice Act, aligning the act with that of other health care professionals, eliminating articulated plans, and allowing delegation of certain patient care to qualified health care professionals in very specific circumstances. CMS fought hard against an initial proposal for the bill to also reduce the number of experience hours to zero for an APRN to obtain prescriptive authority. After extensive negotiations between the bill sponsor, nursing groups, and physician organizations including CMS, an agreement was reached to reduce the required hours to 750.

As CMS worked to close the truncated 2020 session with positive outcomes for physicians and the patients you serve, the bipartisan COMPAC was also working behind the scenes to interview candidates before the June 30 primary election. COMPAC endorsed 71 candidates running for state House and Senate districts, and 70 won their primary races. Find the latest list at cms.org/advocacy/compac-endorsements with final endorsements included in the September/October Colorado Medicine. The great work that has been done on behalf of our members and your patients is thanks in large part to the relationships physicians build during these campaigns. If you have not already contributed to COMPAC, there is still time and your support is critical. In addition, we strongly encourage you to contribute to the Small Donor Committee that is exclusively used to support candidates who have committed to protect Colorado’s stable liability climate and enact comprehensive liability reform. Go to cms.org/contribute for our secure payment platform. ■

CMS worked closely with naturopathic doctors on HB20-1212 to continue their registration and practice act. The bill adds a pediatrician and a physician representative of a statewide, multispecialty medical society to the Naturopathic Medicine Advisory Committee. The bill also limits any formularies that can be added by rule to biological substances. C O LO R A D O M E D I C I N E 9

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Bent, but not broken: The 2020 medical student experience

Danielle Coleman, Rocky Vista University College of Osteopathic Medicine Jacob Leary, University of Colorado School of Medicine

Danielle Coleman

Jacob Leary

The COVID-19 pandemic has turned life in our country on its head, the realm of medical education being no exception. Like a whirlwind it came through – shaking up all of our plans, then bringing everything to a crashing halt. As with many other Americans, students were forced to make an abrupt transition to working from home, all while worried about the safety of our loved ones and the security of our careers.

The first wave pushed us to adapt to the unexpected and prepare for an uncertain future. This was a tumultuous time, as each class of medical students faced their own set of challenges. First- and second-year students, whose learning was still primarily campus-based, transitioned to watching pre-recorded lectures from home and completing small-group work and skills labs via Zoom. In an ef for t to protect trainees and conser ve PPE for frontline workers, students in their third and fourth years of training were rapidly pulled from clinical rotations. This left many of the third1 0 C O LO R A D O M E D I C I N E

year students, class of 2021, wondering whether they would be properly prepared to apply to residency programs in the fall. Many still face an uphill battle in their effort to secure sub-internships without the necessary letters of recommendation that would have come from their core clerkships. Others are scrambling to find new ways to augment their skillsets and expand their networks sans the opportunity for away rotations. These rising fourth years from both Rocky Vista and University of Colorado will also be forced to choose their future residency program having never visited it, as all upcoming interviews will be held in a virtual format.

For the class of 2020, the Match Day and commencement ceremonies that typically mark the culmination of years of hard work and dedication for students finishing up their fourth year were transformed into anticlimactic virtual ceremonies. Celebrations too were socially distanced from the community of friends and classmates who had made the arduous journey together. In addition to readjusting to learning from home, students preparing to take medical licensing exams this summer were thrown into another whirlwind as test reservations they had secured months in advance were suddenly canceled with

minimal communication from both the testing centers and medical examination boards. Even after the initial “culling” of 50 percent of reservations across the country, students still live with the uncertainty of whether or not they will have a seat when they show up on exam day. This is especially troubling for students who have had their preparation perpetually extended from weeks to months or those who have spent the money on air travel and overnight accommodations to take their exams outside of Colorado. Along with the many obstacles the pandemic created for our academics, the societal implications have been profound. Increasingly, misinformation seemed to spread like wildfire on various media platforms and people began questioning the validity of medical research as well as the recommendations of physicians for health and safety. Protests sprang up calling for the reopening of businesses and a return to pre-pandemic normalcy, creating conflict between economic interests, personal liberties and public health. We are disheartened by the growing disregard for the advice of experts, painting a bleak picture of society’s trust in physicians. It saddens us to think that after years of hard work and countless sacrifices made pursuing our call to this profession, we would be met with doubt and even ridicule by the very people we’ve been entrusted to care for. At the same time that we were grappling with this reality, reports emerged showing disturbing disparities in COVID-19 outcomes for racial and ethnic minority groups compared to White patients. According to a study by the Centers for Disease Control, Black patients with COVID-19 represented 33 percent of hospitalized individuals while comprising only 18 percent of the surrounding community, compared to White patients representing only 45 percent of hospitalized patients and making up 59 percent of the community.1 Data from New York in May 2020 also suggests that mortality rates among Black and Latino patients are double that of White patients.2 These differences are appalling, yet frustratingly unsurprising. Communities of color are challenged by a multitude of contributing forces, including housing segregation and discrimination that lead

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F E A T U R E S C H A N G I N G M E D I C A L E D U C ATI O N : C O N T

to more crowded living conditions in urban settings; higher rates of public-facing employment; and a disproportionate burden of underlying comorbidities that can in major part be attributed to systemic and institutional racism, to name just a few. We are taught in medical school to treat all patients with equally high standards of care and to strive for the best possible outcomes for everyone we treat. These data trouble us deeply. Our Black and Brown classmates have been forced to try to maintain focus and composure, while grappling with these disparate findings in the backdrop of the ongoing murders of people of color at the hands of police. The ensuing protests and calls for action to reform our society have united students with a common goal, but also laid bare certain tensions, and have led to personal reflections that in many cases cause discomfort as we realize our own intrinsic biases and harmful behaviors. Moving forward, constant adaptation to ongoing uncertainty is the name of the game – it’s our new normal. Rising thirdand fourth-year students are increasingly returning to clinical spaces as PPE supplies become available and state case numbers have stabilized, with most of the standard training experiences in places like operating rooms and emergency depar tments becoming reality once again. However, significant caution is still asked of us when dealing with possible or confirmed COVID-19 patients, and some hospitals continue to restrict student interactions and accessibility. Telemedicine curriculum has taken a more prominent role, as we try to maintain contact with patients who are doing their best to avoid unnecessary in-person clinic visits. Though this may be different than what our predecessors experienced in their clinical training, it is vital for us to prepare as telemedicine takes a prominent role in

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daily practice – even outside the context of a pandemic. Meanwhile, students in their first and second years of medical school will proceed with primarily virtual curriculum moving into the new semester. That being said, CU and RVU campuses are both reopening in phases. Some, but not all, small group case-based learning will be returning in the fall at CU, and labs that require more direct interaction and hands-on training will be adjusted to maintain social distancing at RVU. For those struggling with the lack of face-toface contact, this will provide a welcome respite that should ser ve to benefit mental health and strengthen classmate connections. Finally, our friends belonging to communities of color have been unfairly tasked with fighting for equal treatment in both health care spaces and the eyes of the law, protesting to finally be seen and negotiating policy reforms at the school and governmental levels to enact justice that is long overdue. Those of us not directly threatened by these racial injustices, meanwhile, must now commit to the essential work of examining our own privilege, understanding our implicit biases, and becoming the allies that our friends and future patients need and expect us to be. These challenges arguably are far greater than those posed by COVID-19, and will likely continue to impact us long after the pandemic has subsided.

Moving forward, constant adaptation to ongoing uncertainty is the name of the game – it’s our new normal.

The first half of 2020 caught our society off guard. Between COVID-19 and the fight for racial justice, the adversity that we’ve faced has given us an unexpected opportunity to learn rapid adaptation to ever-changing conditions and mentally prepared us for an uncertain future. The biggest question right now: Are we ready for a second wave? ■ 1. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:458–464. DOI: http://dx.doi. org/10.15585/mmwr.mm6915e3external icon. 2. NYC Health. COVID-19: data. Accessed May 7, 2020. https://www1.nyc.gov/site/ doh/covid/covid-19-data.page

Thoughts from Colorado medical school faculty Brigitta Robinson, MD, FACS

When it comes to the current hospital restrictions, it is difficult to consider how one would teach any aspect of medicine remotely. Surgery, being more hands-on, requires in-person learning more than most other specialties. At RVU we found a way to deliver as much information as we could in the time of COVID-19. Remote lectures are always a part of the curriculum but more details were added to help fill in the void left by being out of the hospital. The surgery skills weeklong course we teach was a truncated course via Zoom. Then suturing, tying, scrubbing, gowning and gloving were done with permission in person one morning with our seven students, in masks at the school. We are all hoping that the restrictions are fewer as we move into summer. We are doing the best we can, but it is not what we owe our medical students. COVID-19 has changed so many in so many ways.

Jan Kief, MD

I feel optimistic about medical education post COVID. I teach in the pre-clinical years of medical school. While there was already great progress in re-imagining medical school education, we can use what we have learned about virtual capabilities and how disruptive innovation can lead to some very positive change to deliver a quality medical school education in an efficient, effective and safe way. Students and faculty have answered the challenge with effective ideas that will help the education process. Didactic information can be provided in a more cost effective and timely manner, and new simulation platforms can be a valuable addition. I believe clinical encounters can be accomplished, provided there exists adequate amounts of PPE, in a structured, concentrated and safe way. As physician leaders, we can break through these challenges and deliver a very valuable education.

Deb Parsons, MD, MACP

A s medical school and residenc y educational curricula evolve to meet the needs of the future physician, the core principles of professionalism, humanism, and patient-centeredness as well as the core values of providing safe, affordable and equitable care, will continue to be foundational.

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F E A T U R E

Colorado residents and fellows rise to the challenge of COVID-19 Kate Alfano CMS Communications Coordinator Resident and fellow physicians face unique challenges during the COVID19 pandemic: They are delicately balancing expanding their medical knowledge, teaching those in training years beneath them, and altering established care protocols for all patients regardless of COVID-19 positive or negative status – all in the shadow of the highly contagious respiratory illness about which information is still evolving. Training years are already acknowledged as some of the most challenging of a physician’s career; in this new health care environment, surrounded by uncertainty, physicians and trainees must develop their skills as clinicians while constantly adjusting daily routines and embracing new norms.

have had their training and jobs delayed, board exams moved or canceled, and their institutions, facing budget shortfalls, are cutting cost of living adjustments and other benefits such as wellness days and CME allowances. “CMS must stand up for our trainees, for residents at the front lines who are asked to take on this additional responsibility while spending time getting pulled from their own specialties,” she says. Finances are a top concern; resident salaries are low compared to those of other health workers, though they may experience some of the highest risk situations for exposure to COVID-19. Evan Manning, MD, resident representative on the CMS Board of Directors, says that housing for the upcoming year is uncertain and cost of living increases have been deferred for the next academic year but he has seen great generosity from the Anschutz Medical Campus area as leaders leveraged additional pools of money to help residents make ends meet even as moonlighting was banned. And one measure in the Coronavirus Aid, Relief, and Economic Security (CARES) Act affects those with medical student loan debt: The legislation suspended payments and accrual of interest on most federal student loans through Sept. 30, 2020.

Daily lectures and grand rounds have been moved online. Elective surgical cases have been suspended, morning rounding limited to attendings only unless the patient is critical. Specialty and orga- “It’s been a challenging time for our resinization educational conferences have dents and fellows,” Manning says. “But been canceled or postponed, reducing somehow when the road gets steeper, oppor tunities for career-advancing everyone still finds a way to overcome poster presentations, lectures, mentoring the obstacles. I am very proud of how and the face time that allows faculty and residents and fellows from so many trainees to develop new collaborations different disciplines stood up to fight this and future job networks. Elective rota- pandemic.” tions are tenuous as residents may be called on to help in the internal medicine He continues: “We are fortunate in some or emergency departments, particularly ways that our employment has not been in the case of a surge. And many patient affected and our salaries are secure. But visits are now conducted by video confer- these are still trying times to be a trainee ence to reduce exposure and conserve and many residents have sacrificed elecpersonal protective equipment, increas- tive opportunities, surgical training and ing the potential of missing key indicators other extremely valuable learning expeof a diagnosis or other issue – as also riences to serve on the COVID wards. But can be a concern for physicians in active no matter what, serving those in greatest practice. All of this exists in the setting of need is the backbone of our profession. constant worry that they may bring this It’s a great time to be a doctor.” virus home to loved ones and put them at risk just for doing their job. "CMS is actively involved in understanding the challenges faced by residents Brandi Ring, MD, an obstetrician-gynecol- and fellows, and we are advocating and ogist in Denver and a member of the CMS willing to work with training institutions to Board of Directors, reports that across the assure they are supported and their traincountry residents are struggling. Some ing needs are met," says CMS President 1 4 C O LO R A D O M E D I C I N E

David Markenson, MD, MBA. "It is essential that all realize that while residents and fellows are at facilities for education they are integral parts of the care team and our essential future workforce. As such they must be allowed access to all aspects of care even during this pandemic. In addition, while novel approaches may be needed we cannot compromise their educational activities. It is also important to work with sponsoring institutions to develop innovative methods to account for the challenges caused by the pandemic in volume of patients and surgical cases that residents and fellows have had. This could include simulation and shifting rotations to needed cases now and more elective cases in the future. Lastly, we need to assure that the financial support needed for residents and fellows is maintained, especially the minimal salary they receive, continuing education funding, housing support, and loan forgiveness and support." ■

Resources from the AMA The American Medical Association has curated resources to assist residents and medical students during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events. View the list of resources at: www.ama-assn.org/deliveringcare/public-health/medicaleducation-covid-19-resource-guide Additionally, the AMA is offering residency programs access to transcript tracking capabilities and six modules from the GME Competency Education Program through Sept. 1, 2020, including: • Creating an Effective and Respectful Learning Environment • Physician Health: Physicians Caring for Ourselves • Working Effectively within an Interprofessional Team • Patient Safety • End of Life Care • Patient Handoffs Go to: edhub.ama-assn.org/gcep/ pages/covid-19-access

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F E A T U R E

A preliminary dialogue on race, racism and long-standing health system ills magnified by the COVID-19 pandemic Phyllis Bergeron, MD President, Colorado Ear, Nose, and Throat Society

It is hard to imagine that our COVID-19-ravaged nation is now presented with another crisis. The death of George Floyd on May 25, 2020 has led to civil unrest and a global acknowledgement of the racial inequities and social injustices that have plagued people of color of our nation for hundreds of years and are not experienced by other groups in our society. In 1999, Congress requested that the Institute of Medicine assess the extent and source of racial and ethnic disparities, and to suggest interventional strategies. In 2002, their report “Unequal Treatment” confirmed that “racial and ethnic disparities in health care are not entirely explained by differences in access, clinical appropriateness or patient preferences. Disparities exist in the broader historical and contemporary context of social and economic inequality, prejudice, and systemic bias”. 1 Issues of social determinants of health (racism, food deser ts, lower socio economic status, residential housing segregation, poorer education with lower health literacy), violence, systemic/ structural racism, disproportionate policing, and police violence in communities of color have made minorities’ access to health care and their health outcomes worse than White patients. Of those in the U.S. without health insurance, 50 percent are people of color. Even for 1 6 C O LO R A D O M E D I C I N E

those with health insurance, this system with very few minority providers engenders distrust of the medical profession, reinforced by the public exposure of the institutional treatment of Henrietta Lacks2 and the Tuskegee Experiment. 3 This in part has led to a hesitation in accessing health care assistance in critical situations, or even preventative services when available.

the rate for Whites; and 2.2 times the Latino rate. In some places, however, the multiple between Black and White mortality rates greatly exceeds those numbers.

It is no surprise that COVID-19 deaths have been disproportionately higher in people of color relative to their population throughout Colorado and the United States (see table on page 16). In Colorado, African Americans make up 4 percent of the population but account for 7 percent of COVID deaths. In the U.S. – where African Americans make up 13 percent of the population – they account for 37 percent of COVID deaths.

Even before COVID-19’s destruction of jobs, health and life, these marginalized people lived with a lifetime of chronic stress and have a different reaction to stressors, which often manifests as chronic illnesses, infant mortality (twice the rate in African Americans than in White, Asian and Latino infants), and a shortened life expectancy (40 percent higher breast cancer mortality in African American than White women), worsened by the additional burden of their lack of voice in our society. These outcomes may be in part due to or exacerbated by racism or implicit bias at multiple levels, including in the individual physician-patient interaction.

The overall COVID-19 mortality rate for Black Americans is 2.5 times as high as the rate for Asians; 2.3 times as high as

Racism can be defined as a belief that race is the primary determinant of human traits and capacities, or a

system that produces inherent advantages for a particular race, including a power advantage. Systemic racism takes the form of doctrines, political programs or social systems. Institutional racism includes differential access to services, medical care, education, representation or healthy living spaces based on race. Racism can be personally mediated, as differential assumptions an individual makes about another’s abilities, motives or intent based on their race. And it can lead to internalized racism, in which there is unconscious mental assimilation by the stigmatized race of those negative messages about their own abilities and intrinsic worth. Each level of racism will likely lead to health disparities and negative outcomes if allowed to continue.

at least implies contentment with our own situation. It is especially important to listen, even when it may be difficult to understand. Those affected by racism include our colleagues, our patients, our staff, our front-line and essential workers. What may appear to be a small change in our actions can lead to a big impact on Colorado, and hopefully can become part of a larger national impact.

Racism can be defined as a belief that race is the primary determinant of human traits and capacities, or a system that produces inherent advantages for a particular race, including a power advantage.

PAGE 18 ⊲

Implicit biases are thoughts outside a person’s conscious awareness, unintended habits of the mind, learned over time through repeated personal experience and cultural socialization. Bias is present in everyone and can be affected by your particular group membership, the dominance of your group in society, and fear. Implicit biases are pervasive, predictive of behavior and are highly resistant to conscious change. Cognitive biases, however, may not have the same constraints and may be amenable to change. In the current COVID environment, that will mean being especially vigilant in those communities with higher infection rates, ensuring increased testing, contact tracing, inclusion in research studies on vaccines and their efficacy, and inclusion in the planning and rollout of public policy initiatives. If we are truly committed to improving the health of our patients and to improving the delivery of health care in Colorado and in the U.S., there is no room in our practice of medicine for discrimination or hate of any race, ethnicity, gender, sexual orientation or religion. As a medical community, it is up to us to show leadership in the charge against these injustices. We cannot allow the status quo to continue because it seems easier to ignore the suffering, unequal access, unequal treatment and poorer outcomes of those entrusted in our care. We hold a powerful and revered position in our patients’ lives. We can no longer ignore our marginalized neighbors or remain ignorant. Silence or absence from the discussion implies consent, or C O LO R A D O M E D I C I N E 1 7

F E A T U R E S R AC I S M : C O N T

Everyone can create positive change within themselves, and within their homes, offices, hospitals and local communities. Here are some ways to have a positive impact: • Ensure

that our medical protocols are equitable and are not auto m a t i c a l l y exc l u d i n g o r l e a d i n g to poorer outcomes in our most vulnerable populations.

• Have

a conversation about race, inclusion and compassion with your children. To further understanding, consider watching a PBS series on African American history with them.

• Be open to cross-cultural mentoring • Seek of a child, student or resident, for the benefit of both parties. Contribute to their education by giving support to scholarship programs for minority students.5

• Educate yourself on the role unconscious bias plays in the exam room and in day-to-day life.

out volunteer oppor tunities in communities of need, to expand understanding and build connections.

• Know your elected officials. Connect

with them to advocate on behalf of the disenfranchised. Support those officials and policies to affect change.

Table: Aggregated death rates from COVID-19 across all states and the District of Columbia as of June 24, 2020

1 in 1,500 Black Americans has died

1 in 3,200 Latino Americans has died

1 in 2,300 Indigenous Americans has died

1 in 3,600 White Americans has died

1 in 3,100 Pacific Islander Americans has died

1 in 3,700 Asian Americans has died

or 65.8 deaths per 100,000

or 43.2 deaths per 100,000

or 32.7 deaths per 100,000

or 31.1 deaths per 100,00)

or 28.5 deaths per 100,000

or 27.7 deaths per 100,000 ■

Source: “The color of coronavirus: COVID-19 deaths by race an ethnicity in the U.S.;” www.apmresearchlab.org/covid/deaths-by-race; June 24, 2020

References / notes: 1. Smedley BD, Stith AY, Nelson AR (Eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academy Press; 2003. 2. Henrietta Lacks, during a cervical biopsy at Johns Hopkins in 1951 was the source of the first immortalized human cell line, the HeLa cell. The consent to culture her cells was not obtained, and the family was not compensated for their extraction or use and was not notified of the existence of the line until 1975. 3. The Tuskegee experiment began in 1932 at the Tuskegee Institute. Six hundred African American men were enrolled in the research with the free medical care in return, 399 with latent syphilis and 201 without syphilis as the control group. They were told only that they had “bad blood,”

Additional resources: and given aspirin and mineral supplements, even though penicillin became the recommended treatment in 1947. Doctors from the U.S. Public Health Service (PHS) continued to monitor the full progression of the disease of untreated syphilis and perform autopsies at death. The study was forced to end in July 1972, when a PHS venereal disease investigator leaked the events to the press. At its conclusion, 28 participants had died of the disease, 100 had died of related complications and 40+ spouses contracted syphilis and passed it on to 19 children at birth. 4. Cora Bramble Ted Talk July 10, 2014, Allegories on Race & Racism. 5. https://giving.cu.edu/fund/mile-highmedical-society-endowed-scholarship-fund

Dawes Daniel E. (2020) The Political Determinants of Health. Johns Hopkins University Press Project Implicit - implicit.harvard.edu “The Neuroscience of Fair Decision-Making by Health Care Professionals: Defining the Challenges and Implementing Concrete Solutions,” Online course by Kimberly Papillon Esq. kimberly.papillon@gmail.com Banaji, M.R., & Greenwald, A.G. (2013) Blindspot: Hidden Biases of Good People. New York, NY: Delacorte Press. Allen, Brenda J. (2011) Difference Matters: Communicating Social Identity. 2nd edition, Long Grove, IL: Waveland Press, Inc. The Center for African American Health caahealth.org How to contact your elected officials usa.gov/elected-officials Colorado Department of Health & Environment Office of Health Equity - colorado.gov/pacific/ cdphe/ohe NAACP Legal Defense and Education Fund www.naacpldf.org

1 8 C O LO R A D O M E D I C I N E

Equal Justice Initiative - eji.org

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C O LO R A D O M E D I C I N E 1 9

F E A T U R E

Perspectives on COVID-19 and resulting policies KEEPING SIGHT OF THE HUMAN DURING A PANDEMIC; INSIGHTS INTO THE PRESSURES COVID-19 PLACES ON MEDICAL STAFF, PATIENTS AND FAMILY MEMBERS

Sami Diab, MD

Stephen Kantor

Sami Diab, MD, CMS President-elect, and Stephen Kantor As a practicing physician in Denver, Colo., Dr. Sami Diab has experienced the impact of COVID-19 both as a front-line medical professional and as a carer. Dr. Diab is an oncologist who is also board certified in hospice and palliative medicine, and has a fellowship in integrative medicine from the Andrew Weil Center for Integrative Medicine at the University of Arizona. This education and many years of medical practice help shape and inform his passion for the vital role of hospice and palliative care in patient care. These factors also underpin his knowledge of the substantial empirical evidence of positive patient outcomes and cost savings derived from the effective integration of hospice and palliative care in health care processes. His co-author, Stephen Kantor, has experienced the family impact of COVID-19 as his father passed away in a Denver-area hospital, albeit not directly from COVID-19.

Behind their respective medical cases – behind all medical cases – are vital, valuable human beings.

2 0 C O LO R A D O M E D I C I N E

...family was allowed to visit him, bringing about a With the passage of time, the COVID-19 pandemic may prove to be an epochal event in medicine with its seismic ripples reverberating into all facets of life. Even in the most benign circumstances, the practice of medicine cannot help but raise ethical concerns. The COVID-19 pandemic is most assuredly not a benign set of circumstances and has raised a panoply of ethical issues not only for the medical community but for society as a whole. The following stories speak to some of the ethical issues raised by the COVID-19 pandemic. On May 30, 2020, Dr. Diab received a phone call from Adeline, wife of his close friend Elias, informing him that Elias was severely injured in an automobile accident. The clinical result: severe spinal injury including severe spinal stenosis, fracture of the C2 vertebrae, and spinal cord contusion. In short: acute spinal cord syndrome. On Feb. 19, 2020, Stephen Kantor drove his father, George, and stepmother to a Denver-area hospital where his father would ultimately be diagnosed with complications from acute myeloid leukemia (AML). It is vitally important that we see these two men as more than two disparate medical cases. Behind their respective medical cases – behind all medical cases – are vital, valuable human beings.

You make your own path In 1956, at the age of 15, having witnessed horrors no 15-year-old should ever have to witness, George fled Hungary. He and his traveling companions managed to cross the border into Austria and ended up in a refugee camp. He settled in England, then South Africa, then many years later Denver. George is a man of incredible will, self-confidence and self-determination. Throughout his life he worked constantly – harder than anyone else possibly could – to provide for his family and ensure they would never know the deprivations that he has known. By 2020, George is enjoying a long-delayed and well-earned retirement. Paralyzed and alone Following his automobile accident, Elias finds himself paralyzed and alone in a Denver-area Intensive Care Unit (ICU). In a cruel instant, he has been transformed from physically independent and emotionally connected to physically dependent and emotionally isolated. Owing to COVID-19, his family is not allowed to visit him in the ICU. Elias in a

complete transformation. state of panic and desperation. As the situation is a grey area with different treatment options, disagreement on a treatment plan occurs among the trauma team, the ICU team, the consulting neurosurgeons, and Dr. Diab himself, who has been added to Elias’s medical care team at the request of Elias and his family. Because of a divergence of opinion, Elias receives multiple sets of conflicting information within a very short period of time. This exacerbates his psychological distress and he is consumed by fear and loneliness, isolation and emotional deprivation. Elias becomes very needy and cries out constantly for attention from the nursing staff. Dr. Diab, by sitting with him most of Saturday, has been reclassified as a caregiver and is denied re-entry to the hospital, only rejoining the care team through careful and measured negotiation. Dr. Diab is able to facilitate communication with Elias and his family and his doctors, easing his distress. He was eventually moved out of the ICU and family was allowed to visit him, bringing about a complete transformation. PAGE 22 ⊲

Life is good Elias is a 79-year-old geophysicist and was still working prior to the accident that instantly changed his life. He was in excellent health, very independent, very sociable and people oriented. In fact, Elias was enjoying a quality of life for which anyone, 79 years old or otherwise, would be grateful. He was born in Palestine. In 1948 his family left Palestine and moved to Lebanon. Elias moved to the U.S. many years ago and has many fascinating accounts about the Israeli-Palestine conflict. He is loving family man with two daughters and six grandchildren, all of whom are his pride and joy. Given the pivotal role of family in his world, Elias is completely dependent on his family for his emotional and psychological needs and well-being.

C O LO R A D O M E D I C I N E 2 1

F E A T U R E S P E R S P E C TI V E S O N C OV I D - 1 9 : C O N T

You must have COVID-19 As COVID-19 tightened its grip and panic occurred across health care systems, the hospital at which George was being treated seemed determined that he had COVID-19. At one point the hospital decided they wanted to move George from the oncological ward to the COVID19 floor. As George was severely neutropenic and without any immune system to speak of, his family viewed this as tantamount to a death sentence. His family begged hospital decision-makers to reconsider the decision to move George to the COVID-19 floor. A follow-up chest X-ray and CAT scan were performed and showed the initial chest X-ray was inaccurate. The hospital relented and did not move George to the COVID-19 floor. Dr. Diab, in his capacity as an oncologist, met George twice. In addition to his medical interest in George, Dr. Diab took the time to talk with George as a person and got to know something of the wise, optimistic, cheerful and mischievous human being behind the tubes, IVs, pic lines and AML. A few days later, however, the hospital amended its COVID-19 policy and no longer permitted any family visitors. This marked the beginning of a steady decline in George’s physical and emotional condition. While accepting that correlation is not causation, it would arguably be disingenuous not to conclude a very real connection between these two events. In a horribly Pyrrhic victory for George and his family, his worsening condition eventually resulted in the hospital allowing one family member to make one limited visit per day. In the very early hours of April 11, George was rushed to the ICU. His wife was able to visit him in the ICU as a result of his perilous condition. At 6:30 a.m., George’s wife left the hospital to go home and get some much-needed rest. His son, Stephen, was already waiting at the hospital and at 7 a.m. was ushered into George’s ICU room. Stephen was advised that, owing to COVID-19, if he left the room he would not be permitted to re-enter. Consequently, Stephen began a 12-hour vigil until George passed away at 7 p.m. This simple recounting of events cannot possibly convey the complex emotions of 2 2 C O LO R A D O M E D I C I N E

George’s entire family. COVID-19 meant that that no other family members were able to be at George’s bedside in his final hours. To add insult to terminal injury, George’s wife was in the hospital waiting room unable to see her husband as she was deemed a high risk for COVID-19 owing to her age. She sat for anguished hours, a few hundred feet away from George, separated by hospital walls and doors and the omnipresent insurmountable wall of COVID-19.

A very frustrated Dr. Diab wonders why, seemingly, no thought was given to or preparation made for addressing the absence of the family caregiver role in the health care equation. Dr. Diab is aware of physicians wanting to volunteer to help fulfill that role, to spend time with the lonely, the sad and the scared, knowing that their families cannot be with them. To help, to some extent, meet patients’ psychological and emotional needs in the absence of family.

Patients are people, not just cases

Conclusion

Because of COVID-19, some hospitals forgot the human beings behind the medical cases. By denying families across the country and around the world access to their loved ones because of COVID19, hospitals inadvertently took away the vital caregiver role that families fill in every patient’s treatment and potential recovery. They took away the family role and were not able to replace it. The catastrophic consequence, albeit unforeseen and unintended, was the dehumanization of patients and their families.

The preceding has dealt with the some of the emotional impacts of COVID-19. However, as a doctor and scientist, Dr. Diab is deeply concerned that the COVID-19 pandemic resulted in the suboptimal use of hospice and palliative medicine in favor of western pharmaceutical and physical treatments. We must learn from these experiences and do better in the future. ■

The data on the effectiveness of hospice and palliative care are extremely clear and well documented. According to the American Hospital Association:1

12 MILLION ADULTS

400,000

CHILDREN

12 million U.S. adults and 400,000 children are living with serious illness

68% 68 percent of Medicare costs are related to people with serious illness 1. American Hospital Association. Changing How We Think About Palliative Care. www.aha.org/center/ performance-improvement/palliative-care. Accessed June 6, 2020. Following are a small sample of articles speaking to the effectiveness of hospice and palliative care: Parikh, RB, et al. N Engl J

66% There is a 66 percent reduction in symptom distress reported by palliative care recipients

BILLION Savings of $6 billion per year are possible if hospitals nationwide implement quality palliative programs Med. 2013;369:2347-51. Fadul N, et al. Cancer. 2009;115:2013-21. Maciasz RM, et al. Support Care Cancer. 2013;21:3411-9. Bakitas M, et al. JAMA. 2009;302:741-9. Vanbutsele G, et al. Lancet Oncol. 2018;19:394-404. Ferrell BR, et al. J Clin Oncol. 2017;35:96-112.

COVID-19 OR 2019-Ncov

DAYS

HOURS

PLASTIC

CARDBOARD

STAYS IN THE AIR FOR UP T0

DAYS

HOURS

STEEL

COPPER

PREVENTION

CLEAN & DISINFECT REGULARLY

Sources: National Institute of Health https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces

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F E A T U R E

CMS working for you: Ordering and distributing personal protective equipment when you needed it Kate Alfano CMS Communications Coordinator

From the beginning of the COVID-19 public health crisis, the Colorado Medical Society heard repeatedly from physician members about the shortage of personal protective equipment (PPE) that was putting you and your patients in danger. CMS took this message to key state and federal stakeholders, hearing in the course of our regular advocacy work that rural hospitals and nursing homes were also facing severe shortages. The national stockpile was depleted and states had to act to obtain supplies. Though outside of our normal scope of work, it was clear there was an eminent threat and need and we as a medical society had to act to help our members secure PPE. In classic Colorado fashion, the community came together to get it done. In early March, Gov. Jared Polis tapped Noel Ginsburg, a well-respected local manufacturing executive and founder of CareerWise Colorado, to oversee procurement of critical PPE needs in the state. Energize Colorado was soon born to meet these needs, as well as to support rural health care providers and the restart of business and industry. The organization is backed by Mile High United Way; the Colorado Health Foundation, who provided a refundable grant for use as working capital; Colorado State University who tested and vetted products; and two for-profit companies that provide procurement, warehouse space and distribution assistance. Powered by passionate volunteers from the public and private sectors, as well as universities, Energize 1 On-site signs provided by Center Copy Printing were stationed at each pick-up location, including this one in Pueblo. 2 David R. Scott, MD, of Allergy & Asthma Center of Western Colorado in Grand Junction, accepts his PPE delivery. 3 Boxes of masks were carefully labeled and portioned at the donated warehouse space of Tewell Warren. 4 Brian N. Bailey, MD, of Bailey Dermatology in Louisville, picks up his mask order from the Boulder distribution hub. 5 Boulder County Medical Society Executive Director Judy Ladd staffs the Boulder hub. 6 Foothills Medical Society CEO Stephen Boucher volunteers at the Denver distribution hub. 7 CMS staff spread out throughout the state to bring masks to the various regions; here, CMS Government Relations Program Manager Emily Bishop helps in Boulder. 8 Jean Depperschmidt picks up masks in Loveland on behalf of Medical Metabolic Specialists, the practice of James Hendrick, MD.

2 4 C O LO R A D O M E D I C I N E

Photo by Joel Holland on Unsplash

Helping Colorado Return To Work Safely.

Purchase PPE and other supplies for your healthcare institution.

Go To www.energizecolorado.com

Sanell Hand Sanitizer

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Colorado turned out to be the key partner to CMS in meeting physician PPE needs. With the addition of Andi Rugg as the general manager of the PPE Marketplace and Jordan Monk, a former CareerWise Colorado apprentice, Energize Colorado kicked into high gear. To deliver as quickly as possible, CMS joined Energize Colorado, the Colorado Hospital Association and the Colorado Healthcare Association to commit to placing a bulk order for PPE on behalf of physicians, rural hospitals and nursing homes at roughly half the cost of market value at the time. Given tight deadlines, CMS had to rapidly collect prospective PPE orders to determine how much product CMS members needed. The response from physicians across the state was tremendous. In four days, spanning the first weekend in May, hundreds of thousands of KN-95 masks, surgical masks, level 2 gowns and nitrile gloves were ordered totaling more than $200,000 with delivery

Disinfectant

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The goal is to ensure that Coloradans are able to return to work and are protected in their place of employment. This marketplace is limited to Colorado institutions and re-sellers may not purchase. The vendors to the marketplace go through a thorough vetting process to ensure that only quality product is available. We are committed to keeping prices as low as possible.

Energize Colorado is a nonprofit bringing our diverse professional community together to provide relief to local small businesses, supporting them in recovering from the economic impact of COVID-19

PAGE 26 ⊲

C O LO R A D O M E D I C I N E 2 5

F E A T U R E S C M S P P E DAY: C O N T

scheduled for three to five weeks later. The size of the bulk order helped to bolster the purchasing power of Energize Colorado amidst the global rush for PPE, which in turn benefited other providers and communities across the state. As the delivery date approached, CMS staff coordinated the logistics of payment, storage and distribution of physician orders. We gratefully welcomed volunteers from CMS component societies and their local contacts, plus donations of warehouse space from Tewell Warren and on-location directional signs from Center Copy Printing. In what has become an all-too-common situation given globally disrupted PPE supply chains, the first shipment of KN-95 masks failed CSU’s quality testing. Safety and quality were priorities from the start of the initiative,

so Energize Colorado quickly pivoted to secure a second order that ultimately passed inspection in late May. With just days to prepare the f inal details of the first wave of PPE product delivery, CMS coordinated PPE pick-up sites around the state on May 28 to fulfill the mask orders. In addition, CMS staff personally delivered orders around the state, with CMS Chief Operating Officer Dean Holzkamp clocking more than 1,000 miles across the Western Slope and southwest Colorado. The delivery of level two gowns occurred on June 23 and the delivery of gloves is expected in mid July. Moving forward, physicians are encouraged to place PPE orders through the Energize Colorado PPE Marketplace: energizecolorado.com/ get-ppe-and-supplies. ■

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10 9 The Denver distribution hub saw lots of traffic from metro-area physicians. 10 Mark Gaughan, MD, FAAD, of Durango Dermatology & Dermatologic Surgery in Durango, accepts his mask delivery. 11-12 Bags of masks await their pickup in Pueblo. 13 Volunteers help at the Denver hub; from left: CMS CME Director Gene Richer, IT/Membership Manager Tim Yanetta and ADEMS Executive Director Andrea Chase. 14 Cheryl Law, MNM, MA, CEO of the Pueblo County Medical Society, prepares her distribution site. 15 Mike Ware, right, CEO of the El Paso County Medical Society, and Jodi Landfair, EPCMS Member Care Manager, lead the volunteers at the Colorado Springs distribution hub. 16 ADEMS Executive Director Andrea Chase helps get PPE to a Denver-area physician. 11

D E PA R TM E NT S M E D I C A L

N E W S

In memoriam: Stuart Gottesfeld, MD RENOWNED DENVER OB/GYN PASSED AWAY JUNE 14 Obstetrician and gynecologist Stuart Gottesfeld, MD, 85, passed away on June 14, 2020. CMS members fondly remember him and his gifts to medicine, calling him a “wonderful soul and a ‘doctor’s doctor.’” He was born in Denver and went to East High School, attended Amherst College, and graduated from the University of Colorado School of Medicine. After his residency training at Mt. Sinai Hospital in New York, he served as a physician in the United States Army for two years before returning to Denver. He established a successful private practice associated with Rose Hospital that eventually included his two younger brothers and, later, his oldest son. He served on numerous boards, including the Colorado State Board of Medical Examiners and the Colorado Health Foundation, and served as president of the Medical Staff and Vice Chair of the Department of OBGYN, both at Rose Hospital.

D E PA R TM E NT S M E D I C A L

Gottesfeld retired from clinical practice after nearly four decades, by that time having delivered thousands of babies. He was active on the Colorado Medical Society Council on Legislation. Until earlier this year, he continued to contribute to his profession through his passion for teaching, advocating for women’s health and meeting with the University of Colorado OBGYN residents several mornings a week. His commitment to education extended to volunteering as a science teacher and administrator at Keshet of the Rockies in support of special needs children at Jewish schools in the Denver Metro region. While known as an excellent surgeon, teacher and clinician, he was also a committed husband and devoted father and grandfather. Gottesfeld is survived by his wife, Marilyn, of 58 years; sons Marshall, Stephen and Jon, and their spouses; grandchildren Julia, Max, Laura, Ben, Eli, Sam, Oliver, Sarah and Mae; sister Phyllis Gottesfeld Knight and brother Ray Gottesfeld. He was preceded in death by his brother, Kenneth Gottesfeld. ■

N E W S

Spotlight: CMS program manager coordinates contact tracing effort Emily Bishop, program manager of the CMS Government Relations Division, has spearheaded the effort to coordinate volunteers for COVID-19 contact tracing around the state. She has represented CMS and all member physicians on the Colorado Public Health Workforce Collaborative, a partnership of Colorado organizations working to provide structure and support for state and local contact tracing systems. As Colorado heads into the “new normal” stage of living with the coronavirus pandemic, tracing the spread of the disease is vitally important to ensure new infection epicenters do not emerge and spread unchecked. The term contact tracing refers to the age-old public health practice of identifying persons exposed to a disease by contact with an infected individual, thereby tracing and controlling the spread of the disease. Colorado’s contact tracing system is decentralized – local public health agencies (LPHAs) are responsible for conducting this work in their counties and communities. In many cases, these LPHAs are overburdened and do not have the resources to recruit and train the workers needed to operate an effective system. This is where the collaborative steps in – doing the work of recruiting and training paid and volunteer tracers so LPHAs

D E PA R TM E NT S M E D I C A L

have a roster of trained individuals ready when need arises. Bishop began recruiting volunteers from the ranks of physicians and medical students in April. As of early June, nearly 200 volunteers have signed up through CMS to be tracers or assist isolating individuals in navigating necessary resources. CMS volunteer Gene Sherman, MD, who is working as a contact tracer with Tri County Health Department, wrote on the Basecamp discussion platform: “Emily and the Colorado Medical Society have done a great job finding opportunities for interested volunteers. I was fortunate to be picked to be part of the first group of volunteers at Tri-County Health Department. We are now actively engaged as case investigators. It is highly satisfying work and as they bring on more volunteers, they will branch out to contact investigations as well. Tri-County is keeping track of all volunteer hours and it will be important to show how much time volunteer physicians and other health care professionals have donated to these efforts.” LPHAs all over the state are tapping into this pool of dedicated volunteers and the collaborative recently launched their first round of training, with CMS’s volunteers among the first to take part. If you are interested in volunteering as a contact tracer, please contact membership@cms.org. ■

N E W S

2020 CMS Annual Meeting canceled Due to the uncertainty of the COVID-19 pandemic, the Colorado Medical Society Board of Directors has canceled the 2020 CMS Annual Meeting and Inaugural Gala that was originally planned

for Sept. 26. We hope to once again hold a large event in 2021 when it is safe to gather. ■

C O LO R A D O M E D I C I N E 2 7

F E A T U R E

COVID-19 Survey Colorado Medical Society partnered with component and specialty societies from within the House of Medicine to conduct a statewide physician survey to determine how the COVID-19 pandemic has impacted physicians and their practices. The survey was conducted from May 15-22, 2020.

VIABILITY

2/3rds

are very concerned about the financial viability 2/3rds of Colorado physicians are extremely or very concerned about the financial viability of their practice during and after the pandemic

IN RESPONSE TO THE PANDEMIC COLORADO PHYSICIANS: STAFF

56% 36% 27% 10%

Reduced staff and/or physician hours

PRACTICE IMPACTS PATIENT VOLUMES

40%

30%

Made salary reductions for staff and/or physicians Implemented furloughs for staff and/or physicians Laid off staff and/or physicians

26-50% drop

51-75% drop

FINANCIAL HELP

43% 17% 15% 13%

Applied for a loan created by the CARES Act from the Small Business Administration or EID loan Took out personal or temporary business loans

Almost 40% have seen patient volumes drop between 26-50%, with almost one-third seeing drops between 51-75%

Applied for Medicare Accelerated Advance Payment Program Used personal savings to keep practice open

ALL LINES OF SERVICE

40%

30%

SERVICES AND OPERATIONS

45% 39% 19% 5% 1%

Reduced the types of services offered Delayed purchase of equipment, supplies, medications, technology Closed some locations (for practices with multiple locations) Closed the practice temporarily Closed the practice permanently

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26-50% drop

51-75% drop

Almost 40% have seen a drop of 26-50% in practice charges across all lines of service, with almost one-third seeing drops between 51-75%

PPE AND TESTING

67% SAY

Access to COVID-19 testing has been challenging, with 67% saying their access is either poor (36%) or fair (30%).

COVID-19 TESTING POOR OR ONLY FAIR

57% SAY

Access to PPE continues to be a significant concern for many physicians, with 57% saying their access is either poor (23%) or fair (34%).

PPE ACCESS POOR OR ONLY FAIR

26%

As they continue to serve on the front lines of health care, a quarter of physicians (26%) are also worried about liability for COVID and non-COVID related care delivered during the emergency.

ARE WORRIED

ABOUT LIABILITY

TELEHEALTH SURGE The pandemic spurred adoption and use of telehealth services:

33% RAMPED UP

Telehealth’s future: When asked about the future of telehealth and use/regulations reverting to pre-pandemic levels:

66% STARTED NEW

33% increased existing telehealth services

77% WANT EXPANSION

66% started new telehealth services

77% want medical societies to devote a lot/as much attention as possible to telehealth expansion, ease of use and reimbursement parity

NEW NORMAL: TOP CONCERNS Moving forward there are a number of issues that physicians are both worried about and focused on:

65% Personal and family health

64%

60%

Ability to respond to a second wave of the pandemic

48% Patient volume

Viability of their practice

ORGANIZED MEDICINE’S FUTURE FOCUS

79% Preparedness for future emergencies/pandemics

81% PPE supply chain’s ability to handle future emergencies/pandemics

72%

43%

Viability of physician-owned practices

Appropriateness of health professionals' scope of practice

C O LO R A D O M E D I C I N E 2 9

F E A T U R E

Reflecting on 30 years in the medical-legal courtroom Mark A. Fogg, JD

“I had a terrible experience with my daughter’s doctor,” the potential juror said. “The doctor would just not approve an operation that my daughter desperately needed. My daughter got really sick from the delay in the surgery. The doctor didn’t care.” I tried not to express an audible sigh that could be heard throughout the courtroom. It had become more and more frequent during my last several years of representing doctors in medical malpractice jury trials that potential jurors would lump my client physician together with their disdain for the third-party payer system that requires, among many other things, pre-authorization for certain procedures. To this potential juror, my doc was the face of the entire health care system and was responsible for the delay in getting the procedure for her daughter. Maybe I should brief ly explain the jury selection system in civil medical malpractice trials in Colorado. A judge brings 30-40 individuals into his or her courtroom from the general jury pool who are called to service through voter registrations and drivers’ licenses. The bailiff will then call 14 potential jurors “into the box” so that questions can be asked of them by the judge, the lawyer for the plaintiff patient and the lawyer for the defendant physician. Each side gets four peremptory challenges, meaning they can remove four potential jurors without giving a reason. This reduces the jury to six individuals which is standard for civil trial cases. A potential juror can also be removed “for cause” by the judge when a person voices bias in response to questions to such an extent that they are unable to be a fair and impartial juror.

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Medical malpractice lawyers develop a repertoire of questions to accomplish several things – obtain information about potential jurors’ backgrounds, star t educating the jury about their case and to identify that handful of potential jurors who may harbor strong feelings that will come out during jury deliberations to the detriment of their client.

became mega-giants and the hands representing positive experiences often became outnumbered by the negative hands. We painstakingly tried to parse our physicians away in the jurors’ minds from the challenges of the ever more complicated third-party payer system. However, at times, it seemed society’s faith and trust in physicians had ebbed away.

One “litmus test question” is to ask whether a potential juror recalls a particularly positive experience with a physician or an especially negative one. Attitudes seemed to have shifted over the last several decades. Twenty-five years ago several hands immediately shot up and individuals would describe the selfless acts by physicians who treated them or their loved ones. Of course, we defense law yers loved those positive hands. However, during the 1990s and early 2000s, health care insurance companies

I knew better. After representing hundreds of physicians, I understood the compassionate care they administered over long hours and how they agonized over their patients. Physicians sweat blood for their patients. When I speak with medical residents, which is often, I always reinforce the importance of establishing this trusting physician-patient relationship and how this is a cornerstone of health care.

I always reinforce the importance of establishing this trusting physician-patient relationship and how this is a cornerstone of health care. It is also the greatest protection against a lawsuit being filed or a patient complaint being made. I emphasize to residents that when a physician-patient relationship is formed, they have legally taken on the highest duty the law requires, a fiduciary duty, to that patient. A fiduciary has a duty to act primarily for the benefit of another person in matters related to that which gives rise to the duty. It’s at the core of being a professional.

It is unfortunate that it often takes a crisis to renew our faith. The COVID-19 pandemic has stripped away what we take for granted in our culture and laid bare what is essential. Our faith and trust in our physicians are essential. All over the world people are acknowledging the bravery, dedication and altruism of our health care providers who are on the front lines fighting for their patients. An extraordinary time reveals the extraordinary character of our physicians and other health care providers.

My 31-year-old daughter is an oncology nurse in a local hospital. Last week, she sent me a picture with her personal protective equipment on. It caused great concern as a dad, but it also stirred a deep sense of pride. It will be good to see all the positive hands again. ■ Mark Fogg was General Counsel at COPIC from 2011 to 2020. He returned to private practice at Childs McCune LLC in Denver and can be reached at mfogg@childsmcune.com.

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C M S

CMS members: You will elect your presidentelect and AMA delegates in August

Get to know the candidates running for CMS leadership positions in advance of the August 2020 CMS election by reading their candidate statements in this magazine. See their CVs and candidate profiles on the CMS election page, cms.org/ articles/2020-cms-elections. The following CMS physicians are running for office. President- elect (one candidate running for one position) • Mark B. Johnson, MD, MPH AMA Delegation (two candidates running for two positions) • Katie Lozano, MD, FACR, incumbent • A. Lee Morgan, MD, incumbent The election will be held in August and all ballots will be cast electronically. Do you receive CMS e-newsletters and email blasts? If not, you may need to update your contact information to receive a ballot; email member ship @ cms.org with any new information. All CMS members are encouraged to use this opportunity to vote. We also ask you to consider seeking a leadership position next year. More details on the 2021 nomination period will be available in September. Taking the opportunity to vote affirms the significant commitment of our organization to engage all members in the governance process. Do you have questions about voting, nominations or leadership opportunities? Don’t hesitate to reach out to membership@cms.org.

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CANDIDATE FOR PRESIDENT-ELECT Mark B. Johnson, MD, MPH

Traditionally, two of the five major milestones which marked an occupation as being a profession were the creation of a local association and the establishment of a national code of professional ethics. Being a professional meant joining your professional society. But nothing is so clear-cut and straightforward in America today. Today, our profession is divided by such things as specialty area, political party, social ideology, geographical focus, income and practice pattern. While a recent CMS survey concluded that the three most salient issues of importance to our members were communication, advocacy and education, each of these areas raises potentially divisive questions and issues of its own. As Americans and as physicians, we are inundated with communications of all sorts from all angles. CMS must determine what areas are of most value to the practicing physician and then focus its communications on those. This is vital to the health of the organization even though it is made much more difficult by the myriad practice patterns through which our members provide services. The strong advocacy by CMS at the Colorado Legislature for patient safety and physician autonomy has preserved, to a large extent, the ability to practice medicine in Colorado in conditions that are mutually beneficial to us and to our patients. However, physicians appear to be as evenly divided over social and political issues as is the public at large, and even on some issues which might appear to be more health-related in nature we have significant divisions. When the AMA endorsed the passage of the Affordable Care Act there was a significant loss of membership. When the AMA supported Dr. Tom Price for the secretary of Health and Human Services, who advocated overturning the Affordable Care Act, there was a significant loss of membership. In Colorado, end-of-life care, reproductive rights, the use of marijuana, gun control and many other health-related topics have caused controversy and division among our ranks. Using Central Line and other communication strategies, CMS must be able to quickly and accurately assess the positions of its membership and be willing to advocate and provide strong leadership by taking sometimes unpopular stands in the support of the health and safety of our patients and the success of our members’ practices. To do otherwise is to abdicate our role as health care professionals. Although physician education was one of the main stimuli for the initial formation of state medical societies, they are no longer the most significant sources of this service. Most physicians now receive much of their continuing education through specialty society conferences and resources. At CMS, we must prioritize our educational opportunities to ensure we are providing pertinent information in a timely fashion. I would be honored to serve as the President-elect of CMS. If elected, I will work with our officers, our board and the CMS staff to make certain we are providing the resources our members most need to succeed in providing high-quality care to our patients in practices that provide health and wellbeing to each of our members as well. We must maximize the impact of our communication, advocacy and education.

CANDIDATE FOR AMA DELEGATION Lee Morgan, MD, FACOG, incumbent

I have had the honor and privilege to serve the physicians of Colorado in multiple capacities over the past 30 years. I have served as President of the Pueblo County Medical Society, the Colorado Gynecology and Obstetric Society and the Colorado Medical Society (CMS). I currently Chair the Colorado Section of the American College of Obstetrics and Gynecology. I have participated on every major council of the CMS. I have served as chair of the Council on Legislation for nine years and currently still serve on the committee. I am a past chair of the COMPAC Board of Directors as well. I have served on the Physicians Congress and the ad hoc Committee on Patient Safety and Physician Accountability, to mention a few. I have been a member of the AMA since 1978 and an active member of our AMA delegation for 17 years. I ser ved as co-chair of the Colorado delegation to the AMA for two years and now have, for six years, served as chair of the delegation. At the AMA I have been active within the prior Western Mountain States Conference having served as Treasurer and Chair. I played an active role in the merger of the PacRim Conference with the WMSC into the PacWest Conference, currently serve on the Nomination Committee and am the Councilor representing District 4 (Colorado, Wyoming, Idaho and Montana) on the PacWest Governing Council.

ered a primary care physician and at times a specialist. This varied background gives me the ability to look at all sides of an issue. Though I no longer practice full time, I do volunteer work at Doctors Care. My position as a physician risk manager doing patient safety and risk management at COPIC enables me to travel the state regularly and visit with physicians in a variety of practice situations and locations, thus allowing me to stay up to date with the concerns of Colorado physicians. I have the leadership experience, the experience of listening to multiple points of view and helping forge consensus, as well as strong interest and concern about the issues that affect the practice of medicine today. These last decades have been a time of many changes and challenges for physicians. It is more important

now than ever that we work together as a cohesive force in organized medicine on a local, state and national level. I have a long interest in legislation affecting the physicians of Colorado and the nation. One of my aspirations at the AMA is to become a member of the AMA Council on Legislation. I believe that, with your support I can continue to contribute significantly to organized medicine on a local, state and national level. It is for this reason that I ask for your vote to return me to the AMA as one of your delegates so that I can continue to represent you as we move forward in these interesting and difficult times. PAGE 34 ⊲

I have served on Reference Committee B and have chaired it. I have been on Reference Committee F for the past two years and this has given me the opportunity to meet with the AMA Board of Directors and Finance Committee twice yearly over these two years. My practice experience includes a large multispecialty group as well as a smaller single specialty group. I have practiced in both a large urban environment and a more rural environment. As an Obstetrician/Gynecologist I am at times considC O LO R A D O M E D I C I N E 3 3

I N S I D E

C M S 2 02 0 C M S E LE C TI O N S : C O N T

CANDIDATE FOR AMA DELEGATION Katie Lozano, MD, FACR, incumbent

Thank you so much for electing me to serve on your board of directors from 2008 to 2018, as your treasurer from 2010 to 2015, as your president 2016-2017, and as your AMA alternate delegate since 2016. I have significant experience in advocacy, leadership, and networking in CMS and in the AMA, and I respectfully ask for your vote for me to continue to represent you at the AMA. I ran successful campaigns on a national level to serve as delegate and chair of the AMA Young Physicians Section, serving for five years on their executive council from 2008 to 2013. After serving for two years as the sole delegate representing the AMA Young Physician Section (YPS) as a young physician and coordinating our testimony across the AMA, I have extensive experience representing a diverse group of physicians with differ-

ent practice types and different practice goals. Effective work with and within the AMA is a long-term investment and I have invested many hours, days and years in both the AMA and CMS. One of the strengths I will continue to bring to the Colorado delegation is broad networking contacts across the House of Medicine in the AMA, given my partnership over years with physicians of all specialties when we worked together for many years in the Young Physicians Section. My service to the medical profession through my work with numerous boards, committees, commissions, task forces, and legislators is carefully considered as an investment in enhancing communication between and amongst those organizations and the people and patients involved.

As a strong patient advocate with an interest in medical ethics, I served as co-director of a medical student-run free clinic in Galveston in the late 1990s and have served since 2007 on the board of Doctors Care, a nonprofit Denver area clinic for the uninsured and underinsured, now serving as vice-chair of the Doctors Care Board of Directors. Given my work with the CMS Council on Ethical and Judicial Affairs from 2006 until now, my specialty society’s Ethics Committee from 2002 to 2016, and Ethics and Patient Advocacy Committees when I was an intern, one of my goals in the AMA is to someday serve on the AMA Council on Ethical and Judicial Affairs. We have a number of challenges before us at CMS and at the AMA, but we also have many opportunities to improve patient care. We also have a strong history of turning challenges into opportunities to improve patient care and the practice of medicine. I would like to thank you all for everything you do for your patients and communities, through your daily (and nightly) work, and through your work with your county and specialty societies, patient advocacy and volunteer organizations, and CMS. I ask for your vote for me to continue to represent you and your patients in the AMA. ■

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5 things every savvy doctor knows when picking a commercial real estate agent Perry Bacalis, CARR

A commercial real estate transaction can either catapult or cripple your business. As one the highest expenses of a health care practice, a real estate negotiation needs to be handled by an expert. This is especially the case for lease renewals, which can be more complicated and often more confrontational than a typical real estate transaction. As you can imagine, the difference between a properly or poorly negotiated lease renewal can benefit, or cost, a practice tens to hundreds of thousands of dollars. Whether you are thinking about a new office, purchasing your next office space, or renewing your current lease, protect yourself and your business by identifying these five warning signs that you might be working with the wrong real estate agent.

1 The agent has listings in your desired market. If the agent has listings in the market you are looking in, they have a conflict of interest in representing you as a tenant or buyer and should be eliminated as an option to represent you. That agent is financially incentivized to push you towards their listings. Also, they have existing working relationships with landlords in your market. If negotiations get tough, does your agent’s loyalty lie with the landlord or you? You might miss the ideal property because it is listed by your agent’s biggest competitor.

2 The agent is on the flyer of the space you are looking at. You are entitled to representation. If the agent you are working with has a listing agreement with the landlord, their fiduciary responsibility is to maximize that landlord’s profit. They cannot represent the landlord and adequately represent your interests as well. Avoid conflicts of interest by signing an agreement with an agent that specializes in buyer/tenant representation.

The agent is asking you questions about your business that are obvious to anyone who knows your industry.

The agent only shows you one property at a time. As a business owner, your time is extremely valuable.

Questions like, “What do you want to offer? How long of a term do you want? And how long does your construction typically take?” These are red flags that demonstrate that they do not know your industry or the needs of your business. Medical offices have specific electrical and mechanical needs that need to be addressed up front or they could be very costly. Also, if they do not understand your business and industry, they can’t sell the landlord on your value as a tenant.

You should be looking at multiple properties and evaluating them simultaneously. This gives you leverage in your negotiations, back up plans in the event your first choice does not work out, and a snapshot of the market in a competitive environment. Every landlord is different in their willingness to earn your business. Even when it is your intention to simply renew your lease, it is critical to have multiple options (whenever possible) so you do not miss out on the most favorable terms available.

4 Reputable professionals in your industry cannot vouch for their experience. Building a medical practice is a collaborative process between your equipment specialist, contractor, architect, lender, and real estate agent. If your agent is not in sync with those professionals, it can turn your project into a nightmare.

Just like medical professionals specialize, so do real estate agents. The real estate agent who handles your transaction will impact the trajectory of your business for the next 20 years in either a negative or positive way. Choose wisely! Visit CARR.US to learn more and find an expert agent representing health care practices in your area. ■

CARR is the nation’s leading provider of commercial real estate services for health care tenants and buyers. Every year, thousands of health care practices trust CARR to achieve the most favorable terms on their lease and purchase negotiations. CARR’s team of experts assist with start-ups, lease renewals, expansions, relocations, additional offices, purchases and practice transitions. Health care practices choose CARR to save them a substantial amount of time and money, while ensuring their interests are always first. C O LO R A D O M E D I C I N E 3 5

D E PA R TM E NT S R E F LE C TI O N S

Identity in the time of coronavirus Ariel Kiyomi Daoud

Ariel Kiyomi Daoud is an MD Candidate and Scholar’s Year student at the University of Colorado School of Medicine. She studied Social Studies at Harvard College and hopes to serve communities as a family physician, psychiatrist and social scientist.

First, you are given a short white coat. And then you enter the wards. Then, you hold a human heart in your hands. You are taught to forget the words Mastery of your new language is tested. you once knew, “boo boo,” “belly,” “funny You do your best to change your scales bone,” and are taught to speak anew, to match the environment, demonstrating “laceration,” “epigastric,” “ulnar nerve.” your ability to adapt and look, if not play, You resist associating with this profes- the part you’re in. sion, its hierarchy, its history. You wonder about the point of that time – all the book Patients call you, “doctor.” learning without context. But you find your people and cram knowledge in your “Gracias, doctora.” brain. You sit for an eight-hour exam and leave feeling as low as you’ve ever.

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They bring you gifts. They hold your hands. You’re there when they’re born and when they die. One day, everything has changed. Your coat hangs in the closet. Your stethoscope begins to memorize its folded shape. There’s no reason to set your alarm earlier than 7 a.m. Who are you when you are not allowed to be that person you were training to nearly be? ■

Reflective writing is an important 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.

D E PA R TM E NT S

C O M M E NT

COPIC’s continued support during the COVID-19 crisis Gerald Zarlengo, MD Chairman & CEO, COPIC Insurance Company

It is still a little surreal when I walk into COPIC’s offices and find myself alone. The quietness is a reminder of the sustained impact of COVID-19. Like others, I’ve adapted to this new environment and embraced ways to remain connected to COPIC’s employees and the medical providers we insure. My discussions now are a mix of optimism and caution toward the next phase of the pandemic, and conversations with other physicians have shifted from “what do we need to do now” to “how do we prepare for what comes next.” “There is so much talk of ‘endings’ and ‘after this’ and even of ‘returning’ to some way that we used to be. None of those imagined times and places feel real to me. Only this timeless space feels real. This is the pause before a new beginning,” said Rana L.A. Awdish, MD, a pulmonologist and noted author, in a recent New England Journal of Medicine article.1 “In this state, we’re constantly processing this new reality, suspended from a vantage point where we can look in all directions, behind us and ahead. We can even look in the directions we may not wish to go. We can anticipate grief. We can begin the process of reframing this experience.” I think this quote captures the complexity of what we are experiencing. It also reinforces the need for continued collaboration and dedicated support to help medical providers move forward. At COPIC, we recognize we stand in a unique position and are committed to serving members of the health care community as we move through this next phase of COVID-19. Guidance about returning to practice Stepping back into practice has brought about new challenges and added levels of COVID-19 requirements. One of COPIC’s key areas of focus has been helping our insureds make sense of ever-changing guidelines and understand what they need to consider during this transition.

• Direct access to a team of experts – There is reassurance

in being able to talk to a peer and/or expert whom you trust. COPIC’s team of physicians, attorneys, and other professionals are constantly reviewing COVID-19 information in order to distill the important details, provide clear insight, and highlight actionable steps that should be taken. Our insureds have direct access to this team through our 24/7 Risk Management Hotline for urgent matters and our Legal and Human Resources Helplines during normal business hours.

• A shift to digital resources – Across health care, resources

have moved into digital formats that can be shared via technology platforms. In line with this, COPIC developed new webinars, such as “Returning to Office Practice During COVID-19: Practical Considerations” and “The Short Route to Telecare,”

that speak to prominent issues and are easily accessible through our website. We are also adapting our educational programs to meet current needs and maintain the ability to share our knowledge.

• New tools for a new environment – Besides adjusting existing resources, COPIC is looking at new resources that may be helpful. An example is a “special consent form” template that COPIC developed for elective surgeries and procedures performed during the COVID-19 crisis. The form complements standard consent forms, sets forth the information and risks associated with COVID-19, and when used in tandem with patient education materials, helps emphasize the importance of shared decision-making that underlines the informed consent process.

HR expertise for medical practices and facilities In addition to clinical and regulatory issues, many practices and facilities are dealing with employer/employee issues caused by COVID-19. These range from evaluating options of furloughing staff to obligations under the Coronavirus Aid, Relief and Economic Security (CARES) Act. COPIC’s HR team is able to provide guidance on how to approach these situations and ensure compliance. Our HR Helpline connects insureds directly to experts who can help navigate the risks and concerns involved with managing employees. Extension of COVID-19 Physician Program coverage COPIC has extended our COVID-19 Physician Program through Dec. 31, 2020. The program provides temporary liability coverage for 90 days for physicians who do not have other available insurance coverage, who are not currently covered physicians under a COPIC policy, and who will be providing professional services to a COPIC-insured practice or facility to assist with addressing COVID-19. I am confident that medical providers in Colorado will continue to rise to the challenges before them. Aligned with this, COPIC is committed to elevating our efforts to support providers so they can deliver the best patient care and feel confident in knowing that we stand beside them to address the impact of COVID-19. We will get through this together. 1. www.nejm.org/doi/full/10.1056/ NEJMp2012147?query=featured_coronavirus

COPIC has posted an open-access COVID-19 Information and Resources page on our website at www.callcopic.com/ covid-19-information-and-resources. We will continue to update this information on a regular basis. ■ C O LO R A D O M E D I C I N E 3 7

D E PA R TM E NT S I NTR O S P E C TI O N S

Medicine: Gains and losses in meaning Theresa Sanborn 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.

Theresa Sanborn is a rising third-year medical student at Rocky Vista University. She received a Bachelor of Science at the University of Colorado Denver. Her Colorado upbringing and curiosity has inspired a love for hiking and adventuring throughout the state with all it has to offer. Her thirst for the unique aspects inherent in nature and fostering the wellbeing of others has translated to a particular interest in providing medical care to underserved populations, nationally and globally. She plans to return to Upala, Costa Rica, for medical mission work, looking forward to opportunities for connection and growth.

I’m living through the COVID pandemic. I never thought I would live through anything so impactful in history. This will one day become a multicolored story I tell my kids and grandkids. I imagine their wide eyes and disbelief, their claims that I’m “exaggerating,” just like how I felt whenever my grandmother spoke about living through the Great Depression, or whenever my mother talks about growing up without phones or computers. Medical school “socially distances” you from the world by default. There’s no time for a job, for home visits with family, for long conversations with friends outside of medical school over Sunday morning brunch. Over breaks we pack these “normal” activities in, but all too soon we are back to the robotic dance of study, eat, shower, work out, study. Medical school really strips life down to the bare minimum to ensure time for all the learning. It can be isolating for sure. This quarantine is feeling pretty similar, with its mandated limitations to experiencing

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the world in all its diversity and wonder. I’d say I’m one of the lucky ones: this quarantine is happening during my didactic years of medical school when really all we need as students is a desk, computer and time to study, and that’s all very much attainable during this pandemic. Roughly the same deadlines and amount of work fill our lives. As a student, I feel that the pandemic has really plugged me into the realness of medicine before I was to realize it in rotations. Learning about a disease without the context of a patient story and interaction makes me depersonalize these diseases because there are so many facts and “don’t forgets” and “when you see this, think (blank)” coming at us at once. Within each disease there are so many nuances that I cannot focus on the patient presentation and experience. For these first two years, the emphasis is on the numerous scientific details without which we, as developing student physicians, would be useless in medicine.

But we would also be useless without an ability to understand and integrate the patient experience into our day-to-day, and quite frankly, we would go crazy – all this information and nowhere to apply it. Our dean says our place is not on the front lines of this pandemic, but I can’t avoid feeling, at times, a duty to do something. For the first time in my life, the hard science begins to blend with the emotional messiness of medicine. In the past months, I’ve found myself imaging tragedy in my family, prompting me to “reverse parent.” I advise Dad to no longer go to work and joke that no one is allowed to leave the house, even for groceries. I plead with my parents to protect themselves as much as humanly possible, because the facts are the facts: they could die and I care deeply for them. I don’t want to regret not having said something when I had the chance and have it be too late. I want them to leave this world having done all the things they set out to do. I NEED them on days where I feel hopeless and need to vent.

I want to care for them in their old age. All included, these are the gifts of life. These personal accounts with my family seep into my professional life and all the hopes, goals and dreams contained within my passion of medicine. I have this understanding that my patients will have families who carry a similar connection to their loved ones. Without tuning into this emotional side of medicine, health care loses its meaning. It seems as if the gap between health care professionals and laypeople has reduced. People have been forced into understanding or at least realizing what public health is and how everyone collectively contributes or doesn’t contribute to it. Rather than isolated pockets of disease, health and wellness now have more to do with if I stay healthy, then you stay healthy.

And this may extend to influencing others to make different lifestyle decisions that may change disease incidence outside of infectious realms, say, with mental health or metabolic diseases. Time will tell whether the public will respond with a more collaborative approach to health. The firsthand accounts of this globally impacting pandemic have changed the lens with which we see medicine – we now see it considering everyone around us, not just isolated instances of disease. I think this may change how educators teach, how doctors treat, how students learn and how patients take charge of their own health, in a way that disease management presents on a global scale. In my own medical education, I have been taught to educate patients to see this kind of connection, to encourage

patients to see how they are connected to their health care team, and to work with them to implement changes for the better. And now we must learn to educate and motivate everyone to be ready and aware of the potential changes and the potential far-reaching consequences of actions. The pandemic connects us, like invisible strings linked between. The question is, how does the health care community help foster this outlook and allow it to survive and grow into the future? The roles of health care professionals will continue to shift as a result, and the up-and-coming students and educators will have to adapt by understanding how to approach a patient population where overall, health and wellness may very well likely no longer be taken for granted. ■

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F E ATU R E F I N A L

WO R D

Taking a moment

Halea Meese, MD, MS University of Colorado School of Medicine

To say medical school ended differently than I expected is an understatement. My class missed our Match day celebrations, our last-hurrah vacations, our graduation, and most significantly, a chance to say goodbye to the most impactful people in our journey to become medical professionals. During the last several months, I’ve had people approach me and say “You must feel…” sad, disappointed, slighted, you name it. But instead, the end of medical school has made me more determined, heartened and hopeful. These feelings come with a disclaimer: that my loved ones and I have NOT been the ones most endangered by this pandemic over the last few months NOR the ones most affected by police brutality, institutional racism and violence over countless years. That’s my privilege. With that privilege, I’ve been able to take a moment. A moment to coordinate 600 health professions students in a response to the pandemic and to be humbled by their selfless giving; to work on a project that ensures our colleagues and patients have a voice at the ballot box, not just in our exam rooms; and to start the long work of educating myself to be a better advocate and physician for Black, Indigenous and other patients of color. If this pandemic had never happened, if George Floyd’s murder had not been caught on film, I and my fellow graduates would not have seen loss so closely, nor would we know what it is to wonder if you’re going to be drafted early into a fight with an invisible enemy. So, “inauspicious” – that might be the right word for graduating as a member of the class of 2020. But with the help of our families, colleagues and mentors, we have recommitted to making our next moment better. ■

“You must feel…” sad, disappointed, slighted, you

F E ATU R E F I N A L

WO R D

It is my turn

Iris Burgard, DO Rocky Vista University College of Osteopathic Medicine

While reflecting on the last few months transitioning from medical school to residency one word comes to mind: unexpected. I had several things planned amidst Match Day, graduation, international trips and recharging before residency; things that were not included in my anticipation were a global pandemic or protesting racism in the streets of my city. However, this unexpected turn of events has offered me the opportunity to recharge for residency in a whole new way. As I sat as a privileged bystander and watched the way that COVID-19 disproportionately affected communities of color, low socioeconomic communities and other vulnerable populations, I yearned to do more. As I take the time to learn and educate myself about medicine’s history in racism and the role that the medical community has played in ensuring communities of color are less healthy than their white counterparts, I long to be in front of patients and do my part to build a better system. No, I did not have the last couple months of medical school that I thought I would, but I have also never felt more confident and sure of my passion to serve my community and the people in it. I sat as a bystander this spring watching the news and the time tick by with a voice in my head saying “not your turn yet.” However, as I write this with my first day of residency in a mere 48 hours, now it is my turn. And the unexpected part of this spring is the reason that I can say with confidence that I am ready. Some may look at this time as hopeless, but I see a huge opportunity in front of myself and my colleagues: the opportunity to continue to work toward a better system for all patients. And I believe whole-heartedly in the people who are a part of it and am so excited to be joining them. ■

name it. But instead, the end of medical school has made me more determined, heartened and hopeful.

No, I did not have the last couple months of medical school that I thought I would, but I have also never felt more confident and sure of my passion to serve my community and the people in it.

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July-August 2020 Colorado Medicine

Articles inside

FINAL WORD: A VERY DIFFERENT END OF MEDICAL SCHOOL Two medical student leaders who completed their education in 2020 reflect on the end of their last semester, virtual Match Day ceremonies and finding ways to help during the pandemic

CMS WORKING FOR YOU: CONNECTING PHYSICIAN MEMBERS WITH PPE The Colorado Medical Society worked with partners to meet a critical member need in May: Placing a bulk order of PPE and distributing the orders to members around the state. See photos from CMS PPE Day

PERSPECTIVES ON COVID-19 POLICIES CMS President-elect Sami Diab, MD, and co-author Stephen Kantor look at the ethics of hospital policies implemented during the pandemic, and the effects they had on two non-COVID-19 patients and their families

BENT BUT NOT BROKEN: EVOLVING MEDICAL EDUCATION The COVID-19 pandemic turned life on its head; the realm of medical education is no exception as students adapted to abrupt changes in their learning environments. Some of these changes will continue to affect education in the near term and long term

COLORADO RESIDENT AND FELLOW PHYSICIANS