November-December 2018 Colorado Medicine by Colorado Medical Society

November/December 2018

Volume 115, Number 6

STEPPING UP IN OUR ROLE AS

GUARDIANS OF THE MEDICAL GALAXY

DEBRA PARSONS, MD, FACP 2018-2019 CMS PRESIDENT

Award-winning publication of the Colorado Medical Society

contents Nov/Dec 2018, Volume 115, Number 6

Features. . .

Cover story Newly installed CMS

president Debra Parsons, MD, FACP, encourages physicians in their role as “Guardians of the Medical Galaxy.” As she says, physicians are the ones who can help ensure patients can access high-quality health care and we can support our colleagues to restore and preserve the joy of practicing medicine. Read more starting on page 6.

Inside CMS 12 CMS Corporate Supporters and Member Benefit Partners 28 CMS Foundation scholarships 33 COPIC Comment 34 Reflections 36 Introspections

Departments 38 39 41

In Memoriam Medical News Classified Advertising

Colorado Medicine for November/December 2018

Health care costs–A CMS member survey revealed deep concern with rising health care costs and what physicians are doing to help patients.

CMS rebranded–The Colorado Medical Society has a new look, thanks to input from members and a vote by the board.

Mapping the course –The CMS Board of Directors

Problem solving–CMS hosted the first of two multi-specialty physician convenings to develop recommendations on the opioid crisis.

Prescription drug abuse–CMS President Debra Parsons, MD, FACP, led a breakout session at the Colorado Consortium for Prescription Drug Abuse Prevention’s annual meeting in October.

Heal the Healer Symposium–The Pueblo County Medical Society hosted a successful wellness symposium.

2018 Annual Meeting: Opioid crisis–Experts gave an update on the opioid crisis in Colorado.

2018 Annual Meeting: Photos–Check out scenes from the annual meeting, from educational sessions to top-rated social events.

2018 Annual Meeting: Health care costs–Speakers dove into the complicated issue of health care costs, presenting drivers and solutions.

COMPAC luncheon–The two candidates for Colorado lieutenant governor talked health care at a special forum during the CMS Annual Meeting.

Final Word–Past president Gary VanderArk discusses physician burnout, the causes and how we can address this challenge in our own lives and our workplace.

approved an ambitious 2019 operational plan that continues to put member needs at the forefront.

C OLOR A D O M EDICA L S O CI ET 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

2018-2019 Officers Debra J. Parsons, MD, FACP President David Markenson, MD President-elect and Treasurer Alfred D. Gilchrist Chief Executive Officer M. Robert Yakely, MD Immediate Past President

Board of Directors Cory Carroll, MD Curtis Hagedorn, MD Mark B. Johnson, MD Jason L. Kelly, MD David Markenson, MD Benjamin Nance, MS Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD Brandi Ring, MD Brad Roberts, MD Charlie Tharp, MD Kim Warner, MD C. Rocky White, MD

AMA Delegates A. “Lee” Morgan, MD David Downs, MD, FACP Jan Kief, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSc, MD 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 Executive Office Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Fetter, Director, Professional Services, Dianna_Fetter@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org Division of Communications and Member Benefits Kate Alfano, Coordinator, Communications, Kate_Alfano@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org Division of Health Care Policy Chet Seward, Chief Strategy Officer, Chet_Seward@cms.org Gene Richer, Director, Continuing Medical Education, Gene_Richer@cms.org

Division of Health Care Financing Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org Division of Information Technology/Membership Tim Roberts, Senior Director, Tim_Roberts@cms.org Krystle Medford, Director, Membership, Krystle_Medford@cms.org Tim Yanetta, Coordinator, Tim_Yanetta@cms.org Susanna Barnett, Coordinator, Susanna_Barnett@cms.org Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Emily Bishop, Program Manager, Emily_Bishop@cms.org Colorado Medical Society Foundation Colorado Medical Society Education Foundation Mike Campo, Staff Support, Mike_Campo@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. Alfred D. Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Kate Alfano, Assistant Editor; Chet Seward, Assistant Editor.

Colorado Medicine for November/December 2018

STEPPING UP IN OUR ROLE AS

GUARDIANS OF THE MEDICAL GALAXY

DEBRA PARSONS, MD, FACP 2018-2019 CMS PRESIDENT

Colorado Medicine for November/December 2018

Cover Story I have come to recognize that there is no one better than physicians to take charge of the health and health care of our fellow Coloradans. That is why I chose the Guardians of the Medical Galaxy as our Annual Meeting theme and the theme for my presidency. In the cosmic scheme of things, our profession is the gravitational force that can restore wisdom and stability to health care. Despite the disruptions – “intergalactic” pacts and consolidations and “inter-species” tensions – it is our profession that can restore and preserve an orbit that assures that the care we give our patients lands them on the right planet at the right time. And it is our community of physicians that can steer our organizations to provide the necessary support that restores and preserves the joy of practicing medicine. Notwithstanding the cutting-edge technologies and scientific advances that could have been lifted right off the pages of a science fiction script, all of our care is delivered to one patient at a time. As all physicians understand, it is both art and science. What we do as a medical society is harness that expertise and compassion into collective actions. Together, your ideas and our ideas have consequences. We are not in a zero-gravity environment. When others push, we push back as a profession. The mission of the Colorado Medical Society is to “champion health care issues that improve patient care, promote physician professional satisfaction and create healthier communities.” To that end, as your 2018-2019 president, I am committed to fighting to reverse the opioid epidemic that is devastating thousands of lives and communities; I am committed to maintaining and strengthening the body of law governing professional peer review; and I am steadfast in addressing the lack of joy in our colleagues and the burnout in our profession. I invite you to join me and your governing board of directors in fighting these assaults on our patients and our profession.

Mitigating the opioid epidemic One such assault is the opioid epidemic. When Gov. John Hickenlooper launched a task force to attack the massive opioid crisis, we assembled a panel of “been-there-doing-that” experts. These physician experts continue to work with the governor’s highly regarded Colorado Consortium for Prescription Drug Abuse and Prevention as well as the legislative Interim Committee to guide Colorado state policy on opioid use disorder, all the while assuring access to compassionate evidence-based care for our patients who suffer from acute and chronic pain. Through CMS’s committee on Prescription Drug Abuse, a multi-specialty convening on opioid use disorder assembled in early October. Read more about this convening on page 16. I, personally, am deeply concerned with the staggering statistics of opioid deaths and addiction, which is why I developed an opioid clock tool during my fellowship with the Regional Institute for Health and Environmental Leadership that was featured in the September/October issue of Colorado Medicine and is available to view online at http://members.cms.org/clock. This is a dynamic informational tool to educate the lay public, affected individuals, health professionals and legislators on the causes and solutions of the opioid crisis. The tool can be used, with confidence, by anyone – from the uninitiated to the topic expert – to spread the knowledge of how we got here and what we are doing to reverse the crisis. This is a daunting, seemingly intractable, problem and the opioid clock is still ticking. Protecting professional peer review In 2019, the 100 members of the Colorado General Assembly will launch the equivalent of a “massive meteor shower” of amendments that could “punch a thousand holes” in the laws governing medical licensure, malpractice liability and peer review. Legislators will get pulled in opposite directions depend-

Colorado Medicine for November/December 2018

ing on whose turn it is to talk about the “flight path” of, say, raising the damage cap on a malpractice suit or breaching a peer review report. We have once again assembled leading real-world medical experts to respond to and advise our leadership. These experts will also serve to educate the public officials charged with the legislative responsibility to debate, amend and re-enact this vital composition of laws that assure professional accountability and public and patient safety.

“We are organized, thoughtful, deliberative and fully armed to be the Guardians of our Medical Galaxy. It is my honor and privilege to be a part of this guardianship. My ask of you, my colleagues and friends, is to stay on this course of engagement in the public policy space, to reach out and support each other and bring your ideas, wisdom, insights, and concerns to us.” Prioritizing physician wellbeing The literature confirms that physician burnout has reached a crisis stage. Under the guidance of the CMS Committee on Physician Wellbeing, we are prioritizing Colorado physician wellbeing by highlighting, emphasizing and promoting solutions to enhance both wellbeing and joy in the practice of medicine. We will specifically focus on organizational interventions to mitigate unnecessary burdens that bring no value to patients and destroy the

Cover story (cont.)

Meet your new CMS president, Debra Parsons, MD, FACP Dr. Parsons is an internist/geriatrician and president of the Colorado Medical Society. She is a clinical professor in the Department of Medicine at the University of Colorado, having spent two decades in graduate medical education at St. Joseph Hospital where she also served as medical staff president. Most recently, she cares for patients in skilled nursing facilities, serves as a peer counselor for COPIC’s Peer Support Program and facilitates learning collaboratives on physician burnout. Photo: Dr. Parsons gives her acceptance speech at the 2018 Colorado Medical Society Annual Meeting Inaugural Gala on Sept. 15, 2018.

morale of our physicians. Additionally, we will advocate for public policies and educate on evidence-based personal wellbeing strategies which round out the three domains of physician wellbeing.

didates and incumbents on our priorities, our concerns and our patients’ needs. There are no shortcuts to political engagement. Local relationships are pivotal and grassroots work generates the strength.

Addressing the high cost of health care When the business leaders of Colorado launched a sweeping effort this year to develop cost and utilization reform, we brought our extensive experience on system reforms. While others continue to bicker and resist, we have brought thoughtful ideas of what works. What the business community brings to the legislature will also incorporate our ideas regarding administrative burdens, a significant contribution to unnecessary expense and waste.

Like politics, all care is local. This year, in addition to invaluable member-wide surveys and Central Line activities, our face-to-face member outreach will include regional organizational conversations that bring our communities into the same “orbit,” matching our experts with your colleagues where they live and work and, by no coincidence, where those legislators and other influencers of this process also live and work. Central Line brings “on-line” thoughts, opinions and ideas in consequential alignment with the leading physician subject-matter experts and incubates their insights at the grassroots.

I again ask, in the coming “intergalactic wars,” who but organized medicine is best suited to guard our medical galaxy? We will be there, bringing the credibility and strength of physician expertise into this world of political advocacy. Engaging in your medical society We methodically screen and brief can 8

We are organized, thoughtful, deliberative and fully armed to be the Guardians of our Medical Galaxy. It is my honor and privilege to be a part of this guardianship. My ask of you, my colleagues and friends, is to stay on this course of engagement in the public policy space, to reach out and support

each other and bring your ideas, wisdom, insights, and concerns to us. I am deeply grateful to all physician members and leaders of the Colorado Medical Society, including Dr. Bob Yakely, who mentored me during my year as president-elect. I also recognize my support system of family and friends who have encouraged me to seek this office, especially my husband Dave Downs – the love of my life, world’s best life partner and CMS past president – who always challenges me to go further. n

Plug in to your reinvented medical society! Choose interest areas today to be the first to know about new proposed policies. www.cms.org/central-line

Colorado Medicine for November/December 2018

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Features

Membership poll analysis Chet Seward, CMS Chief Strategy Officer

All-member survey measures physician opinions on health care costs, transparency and payer issues Concerns about rising health care costs, price transparency and payer issues continue to roil the Colorado health care system. Colorado Medical Society (CMS) physician members are actively engaged in and have numerous ideas about these issues, as evidenced in the results of an online poll conducted during July and August 2018.

cent) believe physicians can have an impact on reducing health care costs, with 30 percent saying they can have a great deal of impact, and another 36 percent saying they can have some impact. More than one-quarter (28 percent) say they do not have much impact and just 4 percent say they can have no impact.

Health care costs Almost three-quarters (73 percent) of CMS physicians in active practice describe the current situation in Colorado regarding the cost of health care as a crisis that they hear about daily (23 percent) or a very serious problem (50 percent). Physicians in small towns or in rural settings are more likely than others to say this is a crisis.

Physicians are taking active steps to control cost. Significant percentages of CMS physicians are implementing (or have specific plans to implement) various technologies, systems or strategies to contain costs while ensuring quality. Results also show some uptake of various alternative payment models: almost half (46 percent) of primary care physicians and 22 percent of specialists have pay for performance programs, two-infive (38 percent) of PCPs say they are

Two-thirds of CMS members (66 per-

part of an ACO (versus 15 percent of specialists), and 18 percent of specialists say they are using bundled payments. Open-ended responses show a range of physician views about their role in controlling costs. Most, especially primary care physicians, say they are â&#x20AC;&#x153;stewardsâ&#x20AC;? of care. Others emphasize their duty to provide care that is appropriate, or report that they feel pressured to meet patient demands for extensive treatments or to practice defensive medicine. Some point to the fact that they have little ability to control the cost of their visits/ services or of the treatments or drugs they must prescribe. The survey underscores the belief by many physicians that as a group they have little impact relative to other stakeholders on the rising cost of care across the system. Specifically, insurers, medical liability, drug manufacturers, hospitals, tests/labs and technology are seen as contributing more to the problem than physicians. This concern is particularly strong among those who have seen flat or declining reimbursements in their own practice over the past 5-10 years, with skyrocketing overhead to meet the administrative requirements from government and commercial payers. In terms of relative power to affect health care costs, CMS members rank insurers, drug manufacturers and hospitals in that order as having the greatest ability to reduce costs. The business community has become increasingly concerned about rising costs, witnessed by recent efforts by

Colorado Medicine for November/December 2018

Features the Denver Chamber of Commerce (DMCC). The poll explored some DMCC proposals. Physicians support many ideas that would increase transparency for drug manufacturers and PBMs, as well as requiring physician disclosure of financial interests. At the same time, there is soft support – with concern about the details – for solutions such as having an independent database to help determine practice variances. Physicians want interventions grounded in evidence. Price transparency Two-thirds of CMS members (69 percent) believe that price transparency can have a positive impact on controlling the cost of care, with 28 percent saying a great deal of impact and 41 percent saying some impact. That said, details about how to make enhanced price transparency work so that information is meaningful and actionable are points of concern for physicians. Two-thirds feel they do not have influence on the pricing charged for the services they provide in their practices (including 30 percent who say not much and 35 percent who say none), while 15 percent feel they have a lot of influence and 20 percent feel they have some influence. Open-ended survey responses emphasize that physicians want more transparency in the entire health care system. They want efforts to focus on both quality and pricing, but they are concerned that patients will struggle to see the link between the two. Many are worried that small practices would be unduly burdened (from a cost perspective in complying on an ongoing basis, as well as from the point of view of negotiation with payers who now have access to their competitors’ rates). CMS physicians want transparency about the costs of tests, labs and drugs – for which the prices are out of the control of the physician – as well as for patient costs imposed by the insurers and hospitals. CMS physicians continue to work in a climate where they struggle to meet the demands (and associated costs) placed

on them by commercial payers and the government, while trying to balance their patients’ needs with the imperative to control health care costs. Physicians agree that the high cost of health care is a crisis that affects their patients daily and needs to be addressed. Indeed, as stated previously, many already see themselves as stewards of care, responsible for prescribing and ordering what their patients need and can afford, while being mindful of the overall costs to the system and the need to avoid unnecessary or repetitive visits or procedures. They help patients daily with ways to find less expensive treatments or medications, and they have invested in technologies, systems and initiatives for cost

Colorado Medicine for November/December 2018

reduction and quality improvement. At the same time, many are concerned that their impact will be minimal relative to the impact hospitals, drug manufacturers, PBMs and insurers (as well as changes in patient expectations) can have. Given this landscape, it is not surprising that physicians support ideas that would increase transparency for drug manufacturers and PBMs, and would require physician disclosure of financial interests. There is soft support – with concern about the details – for solutions such as having an independent database to help determine practice variances, or a requirement that physicians publish their fee schedules to

Costs (cont.)

CMS Corporate Supporters and Member Benefit Partners While CMS analyzes the quality and viability of our member benefit partners and their offerings, we do not guarantee any product or service will be right for you. Before you make a purchase, we recommend you perform your own due diligence.

AUTOMOBILE PURCHASE/ LEASE US Fleet Associates 303-753-0440 or visit usfacorp.com * CMS Member Benefit Partner FINANCIAL SERVICES BBVA Compass 303-229-1049 or visit www.bbvacompass/mortgages/astine COPIC Financial Service Group 720-858-6280 or visit copicfsg.com * CMS Member Benefit Partner Gold Medal Waters 720-887-1299 or visit www.goldmedalwaters.com PNC Bank 303-606-8315 or visit www.pnc.com/hcprofessionals TSI 800-873-8005 or visit web.transworldsystems.com/npeters * CMS Member Benefit Partner INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit callcopic.com *CMS Member Benefit Partner MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or coloradodrugcard.com *CMS Member Benefit Partner MedjetAssist 1-800-527-7478, referring to Colorado Medical Society, or visit medjet.com/cms *CMS Member Benefit Partner University of Colorado Hospital/CeDAR 877-999-0538 or visit CeDARColorado.org PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit alnmm.com 12

CARR HEALTHCARE REALTY 303-817-6654 or visit carrhr.com *CMS Member Benefit Partner Dynamic Physician Billing Solutions 303-913-0508 or visit dynamicphysicianbilling.com Eide Bailly 303-770-5700 or eidebailly.com/healthcare Favorite Healthcare Staffing 720-210-9409 or medicalstaffing@ favoritestaffing.com *CMS Member Benefit Partner

their patients. Physicians are open to these ideas but want them grounded in evidence. They want to see solutions that take into account the complexity of pricing in health care, the relative lack of influence individual physicians have on these prices, and the inability of patients to translate these prices into meaningful comparisons of cost/quality between providers. Interactions with commercial payers continue to worsen given lack of basic information about the criteria used to build networks and determine physician eligibility (particularly among smaller practices), ongoing administrative burdens related to prior authorization, and insufficient health plan provider-relations staffing and expertise. n

HealthTeamWorks 866-401-2092 or visit healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit medteleco.com * CMS Member Benefit Partner Officite 866-508-9176 or officite.com/webcheck/cms * CMS Member Benefit Partner RainTech 844-TEL-RAIN or visit https://rain.tec Rx Security 800.667.9723 email: info@rxsecurity. com or visit www.rxsecurity.com The Legacy Group 720-440-9095 or visit www.legacygroupestates.com TSYS 877-841-0606 or visit transfirstassociation.com/cms *CMS Member Benefit Partner Transcription Outsourcing 720-287-3710 or visit transcriptionoutsourcing.net

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org to learn more about the benefits of becoming a member. For more information, call Krystle at 720-858-6308 or email krystle_medford@cms.org

Colorado Medicine for November/December 2018

Features

CMS rebranded Kate Alfano, CMS Communications Coordinator

Colorado Medical Society Board of Directors approves new logo based on feedback from membership When the CMS Board charged staff to conduct a formal communications audit in 2014 with Communications Strategy Group, one of the recommendations from the audit was to rebrand the organization after CMS had completed its governance reforms and moved to create a model 21st century state medical society. A second outside marketing consultant hired to brand and create the Central Line logo in 2016 also strongly recommended rebranding the CMS logo family once Central Line was well established and the medical society was ready to launch a major membership retention and recruitment campaign. With the hire of Krystle Medford as its full-time membership director this

summer, CMS is preparing to launch that major membership retention and recruitment campaign in conjunction with its medical component society partners. CMS leadership agreed that it was time to rebrand the Colorado Medical Society before spending the considerable resources necessary to create new marketing materials for the campaign. To that end, CMS contracted with multiple graphic design professionals to seek new logos for the rebranding effort and embarked on a series of member polls and staff meetings to finalize three options for the board of directors to review and select a final logo and their Sept. 14 meeting. If you were one of the hundreds of CMS members who voted on the three options for re-

Watch for the new CMS brand on all membership materials. Seen above is the back of the newly redesigned CMS staff business card. branding, thank you for your input as it played a large part in the final decision! See the new logo on this page that will lead CMS into the future. Watch for the rollout of the new brand in member outreach materials, an updated and more functional website and a more modern Colorado Medicine in 2019. n

Colorado Medicine for November/December 2018

Features

Mapping the course Kate Alfano, CMS Communications Coordinator

Fiscal year 2018-2019 operational plan approved Each year the Colorado Medical Society Board of Directors approves an operational plan to focus the board’s work on behalf of CMS members and the medical community, as well as for nonmembers who also benefit from this effort. The board approved the Oct. 1, 2018 - Sept. 30, 2019 operational plan on Sept. 14. Following guidance from CMS CEO Alfred Gilchrist on areas representing the greatest opportunities for progress in growing the organization and advocating for members, the board voted to focus resources over the next 12 months in a variety of ways that put physician wellbeing first. These issues include but are not limited to: • Promote practical things organizations and physicians can do to ensure optimal wellbeing; • Preserve Colorado’s medical professional liability climate; • Reenact the body of law governing professional review and the Medical Practices Act, as well assure the operational integrity and resources for the Colorado Medical Board; • Preserve the state-enacted insurance exchange and enhance aspects of the Medicaid expansion to make the program more attractive to physician participation; • Encourage state investments in opioid addiction intervention, treatment and rehabilitation infrastructure; • Explore health care price transparency; • Collaborate with the employer community on cost mitigation strategies; and • Address scope-of-practice issues.

In anticipation of a series of perfect storms in the 2019 Colorado General Assembly that will almost certainly stretch CMS bandwidth beyond capacity, the board has shifted financial and staff resources to extensive policy preparation and advocacy engagement. This strategy will allow CMS to achieve the goals of the operational plan while also fending off major attacks from medicine’s adversaries. “CMS will continue to rely on carefully picked panels of subject matter physician experts to advise the board of directors and Council on Legislation,” the operational plan states. “CMS member polling continues to show significant differences among member demographic cohorts, which further corroborates the value and importance of our innovative governance model which relies on extensive grassroots interaction with both leaders and policy advisers.” “As we have often observed in the policy development processes of CMS, there are no wrong choices – simply calculated consequences for each

Colorado Medicine for November/December 2018

Get involved! All members are encouraged to engage with your board and medical society colleagues through Central Line. Give your thumbs up or thumbs down to prospective policies that come to your email or by text to your smart phone, designate yourself as a subject policy expert through “interest areas,” and review and vote whether the board “got it right” after every board meeting. Go to www.cms.org/central-line for more information.

choice. The operational plan reflects a pragmatic, evidence-based approach to providing those policy options based on the assumptions stated [in the plan].” The board will monitor progress on this work plan throughout the fiscal year, work with the CEO to make course corrections as needed, and provide input on tactical application as needed. n

Features

Problem solving Chet Seward, CMS Chief Strategy Officer

Outcomes from the first multi-specialty physician convening on the opioid crisis The Colorado Medical Society convened physicians from across the state, representing different specialties and practice types, in a professionally facilitated meeting to help develop future physician-driven strategies to help reverse the opioid crisis. The convening was made possible thanks to a grant from the Consortium for Prescription Drug Abuse Prevention. The Oct. 6 gathering was the first of two planned convenings that are intended to develop specific recommendations to the consortium. The purpose for the convenings is to collectively develop and commit to concrete, meaningful changes that demonstrate leadership in dealing with the opioid health crisis. The October meeting featured a professionally facilitated mix of small and large group discussions in a day-long burst of information sharing, brainstorming and problem solving including: • Identifying examples of prior physician-led efforts that resulted in positive reforms, practices or legislation to identify characteristics of successful approaches; • Providing an update on the latest work of the legislative interim committee on opioids; • Finding agreement on focus areas and related key question in four areas including prevention, intervention, treatment and harm reduction to help reverse the opioid crisis; and • Beginning development of a list of concrete, easy-to-execute actions physicians can adopt that make a positive difference to our selected areas of focus; 16

Top: Anesthesiologist Rachael Rzasa-Lynn, MD, discusses the scope of the opioid issue with CMS President Debra Parsons, MD, FACP. Bottom: Facilitator Jay Cone organizes ideas from the group. Next steps include refining these ideas, sharing them with physicians and using another convening in early 2019 to finalize recommendations to the consortium. Thank you to the physicians

who have already participated. Contact chet_seward@cms.org for information on the second meeting. And stay tuned for a full report in a 2019 issue of Colorado Medicine. n

Colorado Medicine for November/December 2018

Features

Colorado Medicine for November/December 2018

Features

Prescription drug abuse Kate Alfano, CMS Communications Coordinator

CMS president presents at Colorado Consortium for Prescription Drug Abuse Prevention annual meeting The Colorado Consortium for Prescription Drug Abuse Prevention held their annual meeting on Oct. 25 to bring together stakeholders to share and engage in the overall effort to combat the epidemic and contribute knowledge and experience in pain management with and without opioids. An educational event the evening before gave providers the opportunity to learn best practices for pain manage-

ment and addiction treatment. Both events were held at the University of Colorado Anschutz Medical Campus in Aurora. CMS President Debra J. Parsons, MD, FACP, led one of the breakout sessions during the annual meeting. She discussed the recent convening of physicians from across the state from different specialties and practice settings to develop their perspective, ideas and an ultimate consensus on guideline de-

CMS President Deb Parsons, MD, FACP, leads workshop at Consortium annual meeting. velopment, as well as other physician activities and programs. Recommendations will be provided to the consortium as a future strategic pathway for medical professions that contributes to the reversal of the opioid crisis in Colorado. At the annual meeting Parsons asked for ideas from the audience and reported receiving thoughtful responses with many common themes that aligned with the outcomes of the convening. “Overall, the symposium was excellent; the 10 workgroups and staff of the consortium are doing amazing things,” she said. “The two-day meeting was a celebration of the good work and the good people making it all happen. It ended with a legislative discussion with Reps. Brittany Pettersen, Chris Kennedy and Jonathan Singer.” n 18

Colorado Medicine for November/December 2018

Features

Heal the Healer Symposium Kate Alfano, CMS Communications Coordinator

Pueblo County Medical society partners with community to host 2018 wellness symposium The Pueblo County Medical Society partnered with the Pueblo Department of Public Health and Environment and Personal Impact Foundation to host the 2018 Heal the Healer Symposium in Pueblo on Oct. 13. The goal of the event was to give physicians and other providers “practical tools for establishing personal wellness and controlling stress to go beyond surviving to thriving” in their careers through a transformational, interactive experience. “PCMS was proud to host our secondannual wellness symposium,” said Thomas Greidanus, MD, PCMS president. “The reality is that providers locally and around the state and nation are in crisis. We still have much to do to reduce stress and burnout in our health care system, from the individual to organizational level. We as physicians provide our best care when we also care for ourselves, and we as a medical society can do more to identify drivers of burnout and work to reduce them.” Keynote speaker Dan Diamond, MD, spoke about performing well under pressure, pulling from his more than 30 years of international disaster experience that has most recently included deployments to Haiti following their devastating earthquake, and the Philippines following Typhoon Yolanda. After Hurricane Katrina, he played a strategic role as director of the Mass Casualty Triage Unit at the New Orleans Convention Center. “The symposium was a success,” said Cheryl Law, PCMS executive director.

From left, Christopher Urbina, MD, MPH, Dan Diamond, MD, and Lance Long, DDS, answer questions from the audience. “Our keynote speaker, Dr. Dan Diamond, received high marks from providers and made quite an impact due to his energy, interaction with the audience and stories used to explain his approaches used in dealing with natural disasters. Providers liked his use of metaphors to our current health care crisis and repetitive summaries throughout his presentation.” “The attendees were also very impressed with Dr. Lance Long, DDS,” who gave a talk on building community through well-being, Law continued. “He demonstrated amazing vulnerability sharing his personal story about seeking help and services toward wellness which proved to be extremely deep and profound, moving, and real to the audience.” The other speakers – trainer Tinece Riley; mindfulness expert Deanna L.

Colorado Medicine for November/December 2018

Robinson; nutritionist Nicole Cawrse, MS, RD, CLC; and PDPHE chief medical officer Christopher E. Urbina, MD, MPH – were also well-received and provided great practical information for all attendees, she said. Attendees praised the symposium, with one reporting that he will try to become more engaged with team leaders, be a “powerful giver” by addressing his team’s needs and asking for feedback, and practicing daily self-care and assisting his team with the same. Another attendee said she better understands the importance of mindset and implementing simple acts that can lead to improvement. And another attendee said he will work on being “present in the moment” with team members and patients rather than seeing these people as just employees or their medical condition. n

Features

2018 Annual Meeting Kate Alfano, CMS Communications Coordinator

Valuck and Hoppe give update on the opioid crisis While Colorado’s health care communities have worked closely with public officials and the highly regarded Colorado Consortium for Prescription Drug Abuse Prevention over the course of the last six years to successfully slow the pace of opioid and other substance abuse, there is still a great deal of work that remains. Giving an update at the 2018 CMS Annual Meeting on the latest in the opioid crisis were Robert Valuck, PhD, RPh, FNAP, director of the Colorado Consortium for Prescription Drug Abuse Prevention, and Jason Hoppe, DO, co-chair of the consortium’s Prescription Drug Monitoring Program

Committee and a clinician-researcher, medical toxicologist and associate professor in the Department of Emergency Medicine at the University of Colorado School of Medicine. Valuck gave attendees a better understanding of the economic consequences of the public health crisis caused by opioid abuse and misuse, and the role of physicians in addressing it. Physicians are familiar with the sobering statistics: 76,000 people died from drug overdoses in the United States last year and two-thirds of those were related to prescription drugs. In Colorado there were more than 1,000 drug

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overdose deaths last year, 560 of which were opioid related. “There’s a myth that overdose deaths are mostly caused by illicit drugs but that is incorrect,” Valuck said. “That was a way to reassure ourselves [as prescribers] that our role in this is over and it’s not.” Drug overdose mortality continues to trend up. Valuck explained that after the first non-medical use of the drug, it takes a person an average of between nine and 13 years to fatally overdose. So for those patients who died from prescription drug overdose in 2017, their first non-medical use likely happened between 2004 and 2007.

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Robert Valuck, PhD, RPh, FNAP, presents the first part of the annual meeting session, “Alternative Approaches to the Opioid Alien Invasion of our Communities.”

“It’s good that prescribing of opioids is going down but it’s going to take a while before we see the decrease in prescribing translate into fewer people becoming tolerant, dependent, addict-

Colorado Medicine for November/December 2018

Features ed, overdosing and dying,” Valuck said. “The numbers will go up before they go down. We project that 150,000 people in the United States will die from prescription drug overdose before the numbers turn downward. We’ll see it in about eight to nine years. We have to do things urgently to keep people alive.” In terms of the economic impact, for every one overdose death – and there were 560 in Colorado last year – there are 10 treatment admissions for abuse, 32 emergency department visits, 130 people who meet diagnostic criteria for substance use disorder, and 825 people who admit to non-medical use of an opioid in the past year. The estimate from the Centers for Disease Control and Prevention using 2013 data is that this costs the economy $80 billion per year in medical costs alone. The president’s council of economic advisors estimated the cost to the economy as $504 billion per year using 2016 data and accounting for lost productivity, taxes, criminal justice and the value of a statistical life. Altarum, an independent think tank, estimates that over the past 15 years the epidemic has cost society in the United States $1 trillion and that over the next four years it will cost society an additional $500 billion in its impact.

while maintaining quality care and cost control. “We owe it to our patients and the community. The public believes that this is up to medicine to fix.” Hoppe said the way to change physician behavior is through education and feedback, correcting perceptions and clarifying standard of care, and making it easier to access services and treatment options. n

CMS .ORG CMS ORG CMS.ORG CMS ORG Colorado Medical Society

Access the CMS website at www.cms.org to stay current on the latest news affecting your practice.

Look for our website redesign early in 2019. 9258_CMJClinicalGuidelinesAd_Resizes_060718_x1A.pdf 3 6/7/18 4:49 PM

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“It’s a huge problem no matter how you slice it,” Valuck said. “It’s a tremendous cost.”

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Hoppe spoke about improving prescribing decisions and the treatment of conditions with alternatives to or with fewer opioids. “I don’t like the term ‘alternatives,’” Hoppe said. “I think opioids should be the alternative and we should consider everything else first. We had been taught that opioids have as high of efficacy and safety as other drugs and that is not correct information.”

Who should take the training? Health Care Providers Health Educators WIC Providers Clinic Nurses Nurse Family Partnership and PN+ Nurses/Educators Visit Colorado.gov/CDPHE/marijuana-clinical-guidelines to take the 20-minute course and get additional resources, clinical guidelines, patient facts, and more.

The medical community, he said, must share responsibility for the crisis. We will have an active role in the solution but we need direction in how to improve our practices to balance safety Colorado Medicine for November/December 2018

Report from the 148th Colorado Medical Society Annual Meeting By Kate Alfano, CMS Communications Coordinator

hysicians and guests who attended the 2018 Colorado Medical Society Annual Meeting in Vail had a wonderful time socializing at great events, learning in general session and small-group workshops, and enjoying the beautiful fall colors of the Rocky Mountains.

Concurrent with CME for physicians on health care costs, physician wellness, the opioid crisis and more, was a medical student track with tailored talks on finances, career choice and public policy.

rs from “Guard Character acto in rta te en y” ax ians of the Gal the inaugural guests before gala. n, Curtis Hagedor CMS members MD; g, in R MD; Brandi MD; JT Boyd, y jo en ; D M , er amm and Rachelle Kl t. gh la Saturday ni the inaugural ga

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ns who mark those physicia r no ho rs be Mem medical niversary since their 50-year an ; Jeremy Laza D. Garfein, MD school. Arthur . D L. Berry, M MD; and Jack rus,November/December Colorado Medicine for 2018

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he social highlight of the annual meeting was the President’s Inaugural Gala, featuring live music from the Nacho Men, roving character entertainers from “Guardians of the Galaxy,” and the sumptuous COPIC dessert bar.

Colorado Medicine for November/December 2018

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ado 148th Color iety Medical Socting Annual Mee , 2018 Sept. 14-15 Vail Marriott sort e Mountain R do Vail, Colora Colorado Medicine for November/December 2018

Features

2018 Annual Meeting Kate Alfano, CMS Communications Coordinator

Expert panels on health care costs explore why costs are high and what’s coming to reduce them Two sessions during the 2018 CMS Annual Meeting featured an all-star panel of experts who explored health care costs and the role of physicians in the cost debate. The panel included Bill Lindsay, principal of Lindsay3 health care reform consulting firm; Michele Lueck, president and CEO of the Colorado Health Institute; Tamaan Osbourne-Roberts, MD, chief medical officer of the Center for Improving Value in Health Care (CIVHC); and Brian Shiozawa, MD, regional director in Region 8 of the U.S. Department of Health and Human Services. According to a survey conducted by Kupersmit Research this summer, CMS members agree that the high cost of health care is a crisis that affects their patients daily and needs to be addressed. Many already see themselves as stewards of care, responsible for prescribing and ordering what their patients need and can afford and access, while being mindful of the overall costs to the system and the need to avoid unnecessary or repetitive visits or procedures. CMS physicians and their staff daily help patients navigate co-pays and deductibles and to find less expensive treatments, medications and imaging studies. Many CMS physicians have invested in technologies, systems of care, and education to reduce the cost of care while ensuring quality in their practice, often at significant financial cost. Lindsay put into perspective the recent work of the Denver Metro Chamber of Commerce (DMCC) and other chambers and business coalitions to help

An all-star panel led a discussion on health care costs. From left: CMS Chief Strategy Officer Chet Seward (moderator), Bill Lindsay, Tamaan Osbourne-Roberts, MD, Brian Shiozawa, MD, and Michele Lueck. drive efforts to contain costs via legislation, regulation and voluntary efforts, marking the first time in decades that many chambers have meaningfully engaged on health care issues. These efforts will occur whether or not there is consensus on solutions by other stakeholders. “From the business community standpoint, we’ve been talking about this for years,” Lindsay told attendees. “This time it’s different. Employers are demanding change and employees are demanding change because at the end of the day it’s the employee who is shouldering the burden.” Osbourne-Roberts explained CIVHC’s Total Cost of Care project, which found that Colorado’s total costs across all health care services were 17 percent higher than other states, and substantially higher with respect to outpatient

Colorado Medicine for November/December 2018

services (30 percent higher). Colorado’s overall high costs were driven by both higher use of health care services and higher prices for those services when compared to other states. “We know where we spend health care dollars; it’s less clear where we spend too many health care dollars,” Osbourne-Roberts said. “Colorado tops other states in spending primarily because of higher utilization. Higher instate spending is driven by differences in price, although utilization is important, too. And data needs to be utilized to develop actionable strategies.” Shiozawa presented the priorities of the U.S. Department of Health and Human Services: opioids, health insurance reform, drug pricing and valuebased care. “What we won’t settle for in this country and state is bad quali-

Costs panel (cont.) ty,” he said. “The question is what’s the appropriate cost and utilization. Compared to other industrialized nations, we’re leading the pack and it’s not an amiable pack.” HHS plans to encourage value-based care by maximizing health information technology, improving transparency in price and quality, pioneering bold new models in Medicare and Medicaid, and removing government burdens starting with a comprehensive review of regulations. “As doctors, let me give you a shout out,” Shiozawa said. “Doctors are clearly the foundation of health care. Without physicians, hospitals, organizations and clinics can’t function. Businesses literally can’t survive. There has to be a balance between physician services and costs. Drug pricing is out of control.” The agency has pledged to address high drug pricing with improved competition, better negotiation, incentives for lower list prices and lowering out-ofpocket costs.

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Finally, Lueck talked about payment reform. It’s not only advancing, she said, “it is here, and we can anticipate your practices seeing it more and more over time.” She explained: Payment reform has bipartisan support at the federal level, the Medicare and CHIP Reauthorization Act (MACRA) will affect most physician reimbursement for Medicare starting in 2019, and Colorado Medicaid will begin paying primary care physicians based on their performance in 2018. “Physicians are the most trusted component of the health care system,” Lindsay said. “You see the challenges and can effectively communicate the burdens you are facing. You understand the interconnected components of health care and can identify changes that can occur within the medical provider community.” “The play for you is your continued involvement,” he concluded. n

Colorado Medicine for November/December 2018

Features

COMPAC luncheon Kate Alfano, CMS Communications Coordinator

Physicians welcome lieutenant governor candidates for health care forum during 2018 CMS Annual Meeting COMPAC, the bipartisan political action committee of the Colorado Medical Society, held its annual luncheon during the 2018 CMS Annual Meeting. Christopher Unrein, DO, COMPAC chair, introduced the event. The lunch began with a special video presentation of some of the challenges medicine will face in the upcoming 2019 legislative session and a call to contribute to COMPAC and the Small Donor Committee. Members then approved nominees to the COMPAC board of directors, ensuring diverse geographic representation. The highlight of the event was a health care forum with the 2018 candidates for Colorado lieutenant governor, the honorable Lang Sias (R) and the honorable Dianne Primavera (D), moderated by Floyd Ciruli. Sias, the Republican nominee, currently represents House District 27 in the Colorado House of Representatives. Primavera, the Democratic nominee, who was elected Nov. 6, served four terms as a state representative before becoming CEO of Susan G. Komen Colorado. Ciruli is the founder of consulting firm Ciruli Associates and director of the Crossley Center for Public Opinion Research at the University of Denver Josef Korbel School of International Studies. “Health care is the number one issue in the country right now,” Ciruli said. “It has just taken over the economy partially because we feel the economy is doing pretty well right now. We’re now able to look at other issues and one of those issues is health care: quality cost, access, insurance, everything you [physicians in the audience] deal with on a daily basis.”

The Honorable Dianne Primavera (D)

The Honorable Lang Sias (R)

The candidates were asked about the most critical elements of their health care platforms, how they view the balance between regulation and market forces, whether they support confidentiality provisions in the Professional Review Act, if they would expand the monetary value of malpractice suits, and how they would build on the previous administration’s work to address the opioid crisis.

son lives in a certain zip code, whether they have certain income, whatever their race or sexual orientation, gender identity or current state of health, should never preclude someone from being able to afford high-quality health care. We both believe passionately in universal health care and we will never give up on that idea until we reach that goal. As we work toward it we need immediate action to lower the cost of care for consumers and small businesses to expand access and improve quality. Any ideas that meet the goals of that, Jared and I will embrace.”

“We recognize that this system is not working for everybody and there is a need for reform, particularly in the area of cost,” Sias said. “What we want to do is focus on specific areas where we can bring about reform and not break things that are working in order to fix things that are in fact broken.” “Jared [Polis] and I both believe that every Coloradoan has a right to health care,” Primavera said. “Whether a per-

Colorado Medicine for November/December 2018

The candidates then took questions from the audience. COMPAC will need your support going into 2019 to continue effecting positive change for physicians and their patients. To join COMPAC, go to www.cms.org/ contribute. n 27

Inside CMS

CMS Foundation helping students Michael J. Campo, PhD, support staff Colorado Medical Society Education Foundation

CMS Education Foundation 2017-2018 scholarship recipients Congratulations to first-year students from the University of Colorado School of Medicine – Christine Krentz, Brandi Krieg, Reilly Quist, Hayley Specht and Emily Wolverton – who were each awarded scholarships from the Colorado Medical Society Education Foundation (CMS EF). First-year students from Rocky Vista University – Leah Levulis and Pariss D’Spain – were also awarded a scholarship from CMS EF; each received $3,500. CMS EF, a 501(c)(3) private foundation, has a mission to render financial support to select first-year medical students at the University of Colorado School of Medicine and Rocky Vista University. Student scholarships are based on criteria such as the student’s financial status, academic achievement and desire to practice in rural or underserved areas upon graduation. Beyond scholarships, CMS EF supports education programs such as the Colorado State Science and Engineering Fair and the Education Program at the CMS annual meeting. As CMS EF Board Chair Jack Berry, MD, stated “The CMS EF Board is thankful for the generous financial contribution and support from CMS members and others who make our education scholarships possible.” The 2017-2018 scholarship recipients are as follows. Pariss D’Spain Pariss is a first-year medical student at Rocky Vista University, class of 2022. She graduated with a Bachelor of Sci 28

ence in Biochemistry from Fort Lewis College in Durango, Colo. Pariss loves the “small town” lifestyle and enjoys outdoor activities such as mountain biking and backpacking with friends and family. While completing her undergraduate degree, Pariss worked in three different research labs and was awarded the NIH MARC-U*STAR award. Throughout the summers of 2013 and 2014, she worked in an Alzheimer’s Disease research lab at Harvard Medical School studying amyloid-beta plaque formation within the Alzheimer’s diseased brain at Massachusetts General Hospital. In addition to her passion for scientific research, Pariss has cared for underserved communities while working as an ophthalmic technician and more recently as an EMT for a community mental health practice that serves five counties of rural southwest Colorado. With her work experience and dedication to small-community care, Pariss aspires to provide health care for underserved and rural communities as a future osteopathic physician. Christine Krentz Christine spent the early years of her life living in rural upstate New York before her family moved to Routt County, Colo., in 2005.

Christine received her Associate of Science from Colorado Mountain College along with her high school diploma in 2014. Christine then attended the University of Denver from 2014 to 2017 and graduated with a Bachelor of Science in Biology and a bachelor’s in Chemistry. While at DU, Christine did research in atmospheric chemistry with the Huffman Lab Group. She was a resident assistant for two years, worked ski patrol at Granby Ranch, and founded an EMS club on DU’s campus. Christine now works as a full time EMT at Stadium Medical. In her free time, Christine is an avid outdoorswoman who loves to ski, backpack and rock climb. On rainier days you’ll find her reading, painting or baking to satisfy her sweet tooth. It has been her dream since seventh grade to not only become a doctor but to specifically attend CUSOM. Her future goals involve working as a rural physician in Colorado. Brandi Krieg When she was a kid, Brandi was determined to become strong enough to lift her saddle onto the back of her horse Jack, who stood all of 14 hands tall. She struggled with hurling 40-pound bales of hay onto the back of the trailer. There was no nonsense her father could rattle off that would discourage her from turning a bottle-fed calf into a house pet. Later on, the stubborn-farm-kid training paid off and she went from breaking a six-minute mile

Colorado Medicine for November/December 2018

Inside CMS

running to securing a Division I scholarship. Halfway through college she decided that she wanted to be a doctor, though not certain what kind until she explored several other health care opportunities in her education and career. Throughout all of her life, she has dared to chase greatness, failing over and over until she succeeded. Great doctors are molded from those who will chase the challenge in front of them believing there is everything to gain from even the smallest opportunities. That is the type of doctor she intends to become. Leah Levulis Leah was born and raised in Colorado and has had a strong support system comprising her mother, boyfriend and three brothers. Her hobbies include mountain biking, rock climbing, kayaking and camping. She has always had a passion for helping others, science and the human body. However, Leahâ&#x20AC;&#x2122;s desire to work in the medical field became evident after countless visits to the doctor with family members with serious medical conditions: She adamantly decided at age 6 that she would become a doctor so her brother would never get sick again. This passion for science and medicine fueled her throughout her undergraduate and graduate education, and for the past seven years she has worked and volunteered with individuals with developmental disabilities as a patient advocate. She has also volunteered at Open Bible Medical Clinic, a free medical clinic that provides services to the underserved in my community. These experiences formed her desire to work with underserved populations in medicine and, specifically, as a primary care physician in underserved rural areas of Colorado. She believes that everyone should have access to quality primary care and she hopes her future career will help alleviate shortages. She feels blessed and excited to attend a Colorado

Owned and operated by the Colorado Medical Society and backed by a 50-year history of physician ownership, MTC is uniquely focused on the needs of its clients. Serving medical professionals is all we do. MTC's management team has over 50 years of experience in medical answering services. Our operators are professional, friendly and expertly trained to handle any client situation. We offer a full range of customizable services to ensure your patients enjoy personal, timely communication while you stay on top of your busy schedule. MTC proudly received the prestigious 2009 Award of Excellence for the fourth year from ATSI (Association of TeleServices, Intl.), a service-quality award based on test calls placed over a six-month period. MTC is a member of the Denver/Boulder Bettter Business Bureau, ATSI and Telescan Users Network (TUNe). MTC particpates in the Colorado Medical Society's Disaster Preparedness Program by contacting volunteer providers in the event of a large scale disaster. In addition we collaborate with CMS every six month in testing the response time of the volunteer providers.

Colorado Medicine for November/December 2018

Foundation (cont.) medical school whose mission is aligned with her career aspirations.

a primary care physician in the small town in which she grew up.

Reilly Quist Reilly grew up in a family of 10 in Delta, Colo. She attended the University of Colorado Denver and graduated in May with a degree in biology. Reilly was the captain of the CU Denver club basketball team, of which she had been a member since her freshman year. She also spent three years working in a pediatric nutrition lab at the CU School of Medicine researching the link between obesity in mothers and their children. While not attending school, Reilly volunteered at Roundup River Ranch as a camp counselor and a program leader for horseback riding, boating and the ropes course. After graduation, she spent the summer at Roundup serving on their summer staff as a cabin leader. She is attending CU School of Medicine to become

Hayley Specht Hayley is excited to join the CUSOM class of 2022. She knew CU was the school for her based on its dedication to rural and underserved populations in Colorado. She was born in Lamar, Colo., a town of 7,500 people, and graduated from a class of 26 in Wiley, Colo. Growing up in a rural, medically underserved county in southeast Colorado, she has a thorough understanding of the struggles of rural residents to obtain and maintain relationships with medical and mental health care providers. In an effort to help create long-term medical and mental health services and relationships to rural Colorado residents, she pursued and obtained a bachelorâ&#x20AC;&#x2122;s in psychology and a masterâ&#x20AC;&#x2122;s in professional counseling, with additional completion of

medical school prerequisites. She will apply the skills and knowledge she has learned and will learn at CUSOM in professional counseling to provide wellrounded, holistic, and long-term health care and doctor-patient relationships to rural Coloradans. Emily Wolverton Emily was born and raised in rural Colorado. She earned her Bachelor of Science in Biology from the University of Denver along with minors in leadership studies, chemistry and business administration. Her hobbies include skiing, hiking, road biking and playing volleyball. Before entering medical school, Emily participated in a health-focused Spanish immersion program in Guatemala. She studied the Spanish language and Latin American culture for five months to improve her language and cultural competencies in preparation for a career serving Spanish-speaking populations. In this gap year, she also worked as a varsity volleyball coach and substitute teacher. These experiences deepened her passion for education. Through community-health initiatives, Emily plans to continue teaching throughout her career in medicine. Emily is interested in pursuing a career in rural medicine and plans to return to the Rocky Mountains after completing her medical education and training. n

Plug in to your reinvented medical society! www.cms.org/central-line 30

Colorado Medicine for November/December 2018

Compliments of:

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Colorado Medicine for November/December 2018

31 Colorado Drug Card

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Colorado Medicine for November/December 2018

Inside CMS

Ted J. Clarke, MD Chairman & CEO COPIC Insurance Company

A fond farewell: Lessons learned as COPIC’s CEO As I work with Dr. Gerald Zarlengo in preparation for him to take over as CEO, he consistently asks me what I learned during my 14-year tenure. I reiterated that experience is the best teacher, and the best experiences are rooted in learning from your mistakes. I have no doubt that Dr. Zarlengo will do an excellent job and here are a few words of wisdom I shared with him. Mission, mission, mission It is your true north. Whenever you try to address a problem or initiate an effort, always ask whether the solution or objective adds to COPIC’s mission. Quality pays for itself as patients with good outcomes are not litigious. I have always thought that the ultimate confirmation of our mission would be when our policyholders proudly advertise that they are COPIC-insured. Articulate your vision To use an analogy from Jim Collins’ book, Good to Great, you are the bus driver. Your passengers include our board, our staff, our customers and a variety of other stakeholders. Everyone wants to know where the bus is heading and, as you look around, you will find that all eyes are on you. Your vision and COPIC’s vision must focus on where we are going. Listen You have more than 9,000 doctors, more than 160 facilities and numerous stakeholders who may have answers for current challenges. Listen to what they have to say because you never know where a solution may emerge and what perspective you may not have considered. You are a doctor, and I believe you should stay a doctor My predecessor and mentor, Dr. Jerry Buckley, strongly encouraged me to keep my hand in medicine. He correctly reasoned that such involvement would increase my awareness of the issues confronting the health care system, and this has proven to be true. Trust your team As a physician and surgeon you had to develop an independence. “The buck stops here” is a surgical mantra, and believing and accepting that you are ultimately responsible underlies much of one’s success in medicine. However, your role at Colorado Medicine for November/December 2018

Ted Clarke, MD, instructs physicians at a medical staff leadership training session. COPIC will be far different. You are working with a staff of more than 100 who have been recruited for specific company needs. There are times when it will seem overwhelming, primarily because it is. But trust those around you; they are here for a reason. Be true to yourself You were picked for this position in part because of your values. Your resume attests to your commitment to the health care delivery system, and your numerous activities outside of medicine confirm your commitment to our community. You were also picked because of your personality that fills the room with your warmth, enthusiasm and humor. Just as you nourish your brain by learning new ways and mastering new challenges, so too must you nourish your soul to maintain and grow your inner self. Enjoy your time (it goes by fast) I hope you have as much fun with this job as I have had. Somehow, I imagine you will. Dr. Clarke was named COPIC’s chairman and CEO in 2005 and has served on its board since March 2002. During his tenure, COPIC reinforced its role as an industry leader in patient safety and risk management, expanded services into multiple states, and successfully grew the COPIC Medical Foundation to support health care initiatives. n 33

Inside CMS

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.

Judas Kelley University of Colorado School of Medicine

With clueless gestures With subtle positivity I made you feel like things could get better. They couldn’t. This path had been set in motion Years before we met.

Judas Kelley is a fourth-year medical student who is currently applying to become an orthopedic surgeon. He is a nontraditional student who found his way to medicine after singing in a rock band and serving the city of Denver as a Public Safety Cadet. He enjoys spending his free time with his wife and two small children who have inspired him throughout medical school. This poem is about his first experience telling a patient about their poor prognosis.

When I came back with “our team,” I had only sadness to share with you. Before stepping in your room, I had been educated. I truly understood how sick you were. My “team” decided I needed to tell you You would not live to see a new year. I had about four minutes to process this. Four minutes to accept and be prepared to explain We are not going to fix you.

When the liver and kidney give out

I put on my bravest face and delivered the news As best I could. I will carry this guilt.

I’ll always feel like I didn’t prepare you the way I should have. I promise It wasn’t because I didn’t think you deserved better.

I’ll always feel like I blindsided you. I promise It wasn’t because I didn’t think you deserved better. n

When we talked that morning, I was so fresh So naïve. My lack of knowledge is what misled you. I am sorry for that. I did not understand how bad things had truly become.

Colorado Medicine for November/December 2018

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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.

Audrey Jaeger Rocky Vista University College of Osteopathic Medicine Audrey Jaeger is a second-year medical student with a passion for women’s health care. She grew up in Casper, Wyo., and has lived in Colorado for the past 10 years. She received a bachelor’s in the Fine Arts and a master’s of Biomedical Sciences from Colorado State University. Besides corralling a determined toddler, she enjoys painting, yoga and home improvement projects with her husband.

Momming in Med School There comes a time in every person’s life when they read a text and experience an intense, guttural, snot-producing laugh…followed by guilt for laughing. A few weeks ago, I received a text from my husband that said “So, I let Zeke play in his water table with water. Then his diaper got all wet, well he then started playing in his stroller and decided to play with his poop filled ultra-soaked wet diaper.” My son is just under two years old, and I had just dodged a poopfilled bullet. Medical school came later in the game for me, and I didn’t start my pre-medical education until I was 23. It took me six years before I was accepted to RVUCOM, and like many women in their late 20s, I also wanted to have a child. I finished my master’s program at eight weeks pregnant, interviewed at 37 weeks, and began this rollercoaster ride called medical school with a six-month-old named Zeke. I had five months of child-rearing experience, so I knew I was fully ready to balance medical school and parenting. I had the daycare, the diaper bag, the breast pump bag, my 36

lunch bag, my backpack bag … really just a lot of bags. My focus was set on being a mom and a med student, compartmentalizing those two aspects of my life (ironically contradicting the many compartments I was carrying with me). Like a good mom, I was going to breastfeed my child until he was twelve months old – the gold standard of mom-dom – and that required pumping every two hours to keep up my supply. At first, I couldn’t find a safe room to pump. We had a cry room for parents, but no lock, and it took a few weeks to secure a permanent lockable space. I couldn’t pump enough. Class was four hours every morning with ten-minute breaks, but I took fifteen minutes to complete the job. My supply went down. Zeke was placed on formula as a filler, and he only breastfed for eleven months. His needs were being invaded by medical school, let down and travesty. Joking aside, this is something that I imagine many medical-school moms go through. Mothers are bombarded by the medical community and the motherhood community with the concept that, if you can and are planning to breastfeed, it is THE way to feed your infant and you SHOULD do it for 12 months. Unsurprisingly, I encountered quite a bit of conflict between my motherhood persona and my medical persona: as a mother I wanted to breastfeed my child, but I also knew I was working against a schedule that did not align with my milk-making clock; as a future provider I knew that 12 was the magic number of months to breastfeed, as recommended by the American Academy of Pediatrics. The rules were clear. However, there is one more persona I’ve had to develop: my reasonable persona. As my desire to feed my baby according to the rules clashed with a frankly unworkable med-school schedule, I began to accept that reality couldn’t care less about the rules. Out of necessity, I would need to work within a reasonable set of guidelines, about which I promised to be nice to myself. My feelings of guilt for not reaching the breastfeeding finish line sometimes resurface, but I’ve learned to counteract them with reason and care. I did my best. With a master’s degree in anatomy, I knew I was going to rock med school. I had a recent and thorough background Colorado Medicine for November/December 2018

Inside CMS in the sciences, and I was ready to take on the work. Sure, Zeke had been constantly snot-nosed from attending daycare, I kept getting colds, and he preferred screaming to sleeping during test nights. But it’s cool, I’ve been sleepdeprived before. I was ready. I chose this. Then Zeke started running daytime fevers, and I had to pick him up (required attendance be damned), followed by the horrors that are teething nights. And who cares if I want to go to any social events to better connect with my medical peers and mentors? Zeke does not care, that’s who. Slowly and begrudgingly, I began to realize I couldn’t separate being a med student from being a mom. No matter how I managed our days, no matter how many boxes I checked off before Zeke was packed into the car (Where’s the diaper bag? Where’s the flash drive?!), I couldn’t control all the details, and Zeke slowly invaded med school. This was tough. At points in time, all I wanted to do was perform at the top, recreating my previous academic experiences. With the ever-present needs of my son weighing on my mind, I’d sometimes feel regret and frustration for choosing to have a child in medical school. These feelings could be amplified in the reverse direction with the desire to go home and hang out with Zeke anytime I would get a “free” weekday afternoon. I wanted to play with him, feed him and snuggle him during the day, but if I did, I would be cutting my studies short. Balancing these feelings of remorse and inadequacy for both of my obligations was taxing. How was this going to work? Well… it just does. Medical school interrupts motherhood and motherhood interrupts medical school, and you just have to roll with it. For example, I mostly don’t study in the evenings at home, so I can spend time with Zeke and my husband. On the rare nights I do, I’ll sternly attempt to lock myself in the bedroom to study, and inevitably every 15 minutes (toddlers have actual internal clocks for interrupting) I hear banging at the door and a crescendo song of “mama, maMA,

MAMAAA!!?!?!” Conversely, my day to study is Sunday and even though I love going to the park with Zeke, I have to leave the fun to my husband, so I can take care of school. Luckily, my husband sends me lots of pictures on those days. I often hear people tell me, “I just don’t know how you do it,” and I usually respond with a self-deprecating, “Sometimes I wonder the same thing.” Truthfully, it’s not just me and I have the support of my husband as a parent and a spouse. He’s stopping the gremlin at the bedroom door, feeding and watering said gremlin, and cleaning poop off strollers. At times he can be the fulcrum of balance. Honestly, there is no perfect balance, just a balance that works for that moment in time. When I spend a full 12 hours at school to rock that cardiovascular test, I miss out on time with my husband and son. When I spend a full day with my family, I’ve lost out on an opportunity to keep my grades up. This is the reality of the teeter totter that is being in med school. Momming in med school has taught me to accept that life happens regardless of the schedule on the calendar, and whether you have a sick child, a family emergency, a fender bender or a really bad day, you CAN do this. You will figure out a balance that works with the reality of life. We are all learning to adapt to the unexpected and expected alike, allowing life and medical school to take the reins when needed. We are practicing a new form of resilience, preparing us for the rigors of physician-hood ahead. Med school invades life, and life invades med school – sometimes in the form of a really hilarious text. n

CMS Education Foundation Help send a student through school. Call 720-858-6310 for information and to donate.

Colorado Medicine for November/December 2018

Departments

In Memoriam Remembering former CMS Executive Director Sandi Maloney Honoring a true Colorado Medical Society legend Former Colorado Medical Society Executive Director Sandi Maloney passed away on Oct. 2, 2018 due to complications from COPD. Sandi grew up in Ludlow, SD. She said her work ethic came from experiences on her father’s farm and her dedication from being a championship-level barrel racer. She accomplished much in her life and served as a leader for numerous causes. Sandi had a long career in health care administration. She started at Blue Cross Blue Shield before moving to the Colorado Medical Society in 1985. In August 1990, after a nationwide search that drew 87 candidates, Sandi became the first woman executive director in the history of CMS. She served in that position for over 14 years, working to better the practice of medicine in Colorado. Starting in her role as assistant execu-

Plug in to your reinvented medical society! Choose interest areas today to be the first to know about new proposed policies. www.cms.org/central-line 38

tive director of the physician services division of CMS through the end of her 14-year term leading the medical society as its executive director, Sandi’s leadership led to the passage of legislation too numerous to count that positively impacted physicians as well as the patients and communities they served. Following her time at CMS, she worked for the Senior’s Resource Center, continuing to serve the health care needs of her community for more than eight years. Sandi is remembered as being fierce but kind, and a beacon of light to all those who knew her. She had a deep love for her family and friends and was always willing to lend a compassionate ear or a shoulder to cry on. She will be missed greatly. Sandi is survived by her older sister Ella Mae (age 83), sons Timothy (36) and Greg (40), and grandchildren Ashlyn

Sandi Maloney, 1952-2018 (14) and Ethan (11), all of whom reside in Colorado. The family expressed gratitude to Wheatridge Manor Care Center and Compassus Hospice, whose providers cared for her at the end of her life. Funeral services were held Oct. 13 in Wheat Ridge, Colo. n

New member benefit for CMS members only! Know Your Legal Rights database Physician practices have rights under Colorado law that can be exercised to mitigate health plan barriers to care. These rights have been summarized and incorporated into a members-only online database – Know Your Legal Rights – at www.cms.org/kylr for easy access. The members-only tool is searchable, and will help physicians and practice managers understand what their rights are in disputes with health plans. Colorado Medicine for November/December 2018

Departments

medical news CMS recommends changes to licensing application questions on mental health and substance use disorder The Colorado Medical Society recently joined Colorado’s two medical schools, the Colorado Psychiatric Society and others in sending a letter to the Department of Regulatory Agencies (DORA) recommending updates to the mental health and substance use disorder questions on professional licensing applications.

question if the condition or behavior is already known to the Colorado Physician Health Program (CPHP).

The Colorado medical licensing application includes a question about whether the applicant has been diagnosed with or treated for a condition that may impair his or her ability to practice in a health care field, as well as a question about having “abused or excessively used” alcohol or other habitforming drugs now or in the past five years.

However, recognizing that not all Colorado health professionals and trainees can establish a relationship with CPHP, the signatories are advocating for changes to the current medical licensure questions so that they focus on current functional impairment: “The screening question about past mental illness diagnoses should be eliminated. General screening inquiries about past psychiatric diagnoses and treatment are overbroad, discriminatory and have little predictive value concerning an applicant’s present ability to function competently and safely in his or her professional role.”

The organizations stated strong support in the letter of the provision that applicants can answer “No” to both the alcohol/substance use question and the mental illness/neurologic condition

“Our primary concern with a requirement to disclose prior mental health or substance use disorder diagnoses as a condition of state licensure is that it discourages physicians, medical

students and resident trainees from seeking needed care. … Physicians with untreated mental health or substance use diagnoses pose a greater risk to the public than those who have sought and received successful treatment.” The organizations recommend using the following questions to inquire about the applicant’s ability to work safely. Question: Are you currently using narcotics, drugs or intoxicating liquors to such an extent that your ability to practice [law / medicine / other profession] in a competent, ethical and professional manner would be impaired? (Yes/No) Question: Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical and professional manner? (Yes/No) n

Colorado Medical Society testifies before opioid committee The 2018 House-Senate Opioid and Other Substance Use Disorders Interim Study Committee has met throughout the late summer and early fall to continue their work to address the opioid epidemic in Colorado. On Aug. 22 and Sept. 24, the bipartisan legislative group heard testimony from physicians, including that of Colorado Medical Society liaison Donald Stader III, MD. Stader, a practicing emergency medicine specialist, testifying specifically on draft legislation under consideration by the Interim Study Committee, emphasized that the physicians of Colorado stand with the members of the committee and are committed to collaborate in sustained, systematic efforts to reverse the opioid epidemic.

He presented recommendations that the CMS Prescription Drug Abuse Committee developed for the legislators' consideration for possible next steps to address the opioid crisis: • Increase access to care and decrease use of opioids using multi-modal approaches and alternatives to opioids; • Ensure that insurance coverage works for opioid addicted patients; and • Bolster the clinical workforce that operates as a team to care for patients and families experiencing substance use disorder (SUD). He also shared CMS concerns about mandating e-prescribing of controlled substances, mandating opioid-related CME as a condition of licensure, and

Colorado Medicine for November/December 2018

extending the three-year timeframe on prescription fill limits and PDMP checks passed into law this year, all under consideration by the interim study committee. This portion of his testimony also included support for several of the draft bills under consideration. Finally, Stader gave an update on the work physicians are doing in close collaboration with the Colorado Consortium for Prescription Drug Abuse Prevention to help develop and drive best practices across specialties. Regarding the testimony on draft legislation, Stader said, “our comments were well received. Our good relationship with Rep. Pettersen and the stellar continued work of our lobby team help us get our perspective on issues heard.” n 39

Departments

medical news Federal CMS agrees to improvements in E/M documentation, delays “collapse” of levels to 2021 In the 2019 proposed rule on the Medicare Physician Fee Schedule (PFS), the Centers for Medicare and Medicaid Services (CMS) proposed revisions to the E/M documentation guidelines intended to reduce administrative burden on physicians. In addition, the federal CMS proposed coding and payment changes to new and established office visit services. The AMA led the development of a joint comment letter from 170 physician and other health professional organizations calling for the agency to finalize several proposed changes to E/M documentation guidelines for CY2019. “The AMA is pleased to report that

the federal CMS is implementing the documentation policies, which will significantly reduce administrative burden and allow all physicians to spend more time with their patients,” the AMA stated. The agency has also acknowledged the work of the AMA’s CPT/RUC Workgroup on E/M and has postponed any coding and payment-related changes for E/M office visit services until CY2021. This delay in implementation will allow the CPT Editorial Panel to consider the workgroup’s proposal in February 2019 prior to prompt consideration by the AMA/Specialty Society RVS Update Committee (RUC).

On page 584 of the rule, the federal CMS states: “We recognize that many commenters, including the AMA, the RUC, and specialties that participate as members in those committees, have stated intentions of the AMA and the CPT Editorial Panel to revisit coding for E/M office/ outpatient services in the immediate future. We note that the two-year delay in implementation will provide the opportunity for us to respond to the work done by the AMA and the CPT Editorial Panel, as well as other stakeholders. We will consider any changes that are made to CPT coding for E/M services, and recommendations regarding appropriate valuation of new or revised codes.” n

Colorado Medicine for November/December 2018

Departments

2019 nominations now open Nominate yourself or a colleague to run for CMS office next year The nomination period for the 2019 CMS all-member election is open through Jan. 31, 2019. The Colorado Medical Society asks all members to consider nominating a colleague or self-nominating for a leadership position: President-elect (one position), AMA Delegates (four positions) and AMA Alternate Delegates (four positions). The CMS Board of Directors would like to see contested elections and encourages multiple candidates at each position. Below are the physicians who have currently declared their candidacy: President-elect • Patrick Pevoto, MD, MD, R.Ph, MBA AMA Delegate/Alternate Delegate • David Downs, MD, FACP, incumbent • Carolynn Francavilla, MD, incumbent

• Jan Kief, MD, incumbent • Rachelle Klammer, MD, incumbent • Tamaan Osbourne-Roberts, MD, incumbent • Lynn Parry MSc, MD, incumbent • Brigitta Robinson, MD, FACS, incumbent • Michael Volz, MD, incumbent The election guide, available on www.cms.org, provides important information on the duties, eligibility, terms of office and honorarium for each open position, as well as candidate requirements, campaign guidelines, election process and more. Potential nominees can review the position descriptions and qualifications for office starting on page three of the election guide and the candidate requirements on page five of the election guide. Email CMS COO Dean Holzkamp at dean_holzkamp@cms.org if you have additional questions. n

classified advertising Publication of any advertisement in Colorado Medicine is not an endorsement by the Colorado Medical Society of the product or service. Colorado Medicine magazine is the official journal of the Colorado Medical Society and is authorized to carry general advertising.

➤ PROFESSIONAL OPPORTUNITIES PART-TIME CLERKSHIP DIRECTORS – MEDICAL SCHOOL Rocky Vista University, an osteopathic medical school located in Parker, Colo., has two part-time opportunities for Clerkship Directors in Family Medicine and Psychiatry. The Clerkship Directors will oversee third-year medical student core clerkships by overseeing the delivery of all components of the clerkship curriculum. These positions are part-time for about 10 hours per week. For more information and to apply for the positions, please visit http://www.rvu.edu/careers/ .

CMS Education Foundation Help send a student through school. Call 720-858-6310 for information and to donate.

Support the CMS Foundation with your tax-deductible donation

The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans. The CMSF Board of Trustees is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado. We need your help to meet our goals.

Consider giving a tax-deductible donation of $25, $50, or more to help CMSF continue its mission. Questions? Call 720-858-6310. Colorado Medicine for November/December 2018

Features

the final word Gary VanderArk

Be aware of burnout, acknowledge stress and pursue a healthy work-life balance There is a terrible epidemic in medicine today. It’s called burnout. JAMA recently published a review of all the papers on the incidence of burnout in physicians and concluded that it is 72 percent! Burnout is a state of emotional and mental exhaustion caused by excessive and prolonged stress. Burnout in physicians is a disaster. It results in poor judgment, hostility toward patients, medical errors and difficult relations with co-workers. It produces depression, anxiety, sleep disturbance, fatigue, broken relationships and early retirement. It costs each hospital in America $1.3 million per year. What’s causing this? Physicians are faced with too many bureaucratic tasks, too many hours at work, lack of respect, increased computerization and insufficient compensation. Being a doctor is stressful. There is great responsibility with little control over outcomes. We work with sick people all day. We have a hard time maintaining boundaries between work and life. We may not have asked to be leaders but we’re the ones giving orders. It is no wonder that we are exhausted! It’s no wonder that we fail to connect to others. It is very easy to become calloused and cynical. At times the work is overwhelming and seems without value or meaning. We can’t always be all things to all people. We know that our careers are supposed to produce feelings of fulfillment and satisfaction. How do we achieve true meaning for our lives? I now spend my time teaching medical students. I promise them that being a 42

physician can be the most wonderfully rewarding way to spend their lives but that they need to be aware of making it an all-consuming full-time job. They must be aware that it is easy to ignore the possible problems of stress. Burnout is even a problem for medical students and residents. We all need to acknowledge and assess the problems of this evil. Everyone needs to develop a community of support. We are not in this alone. Everyone needs a system of dealing with stress. There have to be organizational practices and policies that help us develop a balance between life and work. We have to control the number of work hours. It is imperative that we control work. There has to be a focus on work activities that provide the most meaning. We all need to work on leadership ability. We can’t always have others telling us what we must do. It is possible to reduce clerical work and improve efficiency. We must learn to delegate. But the most important factor to prevent burnout and have a successful life is to have a balance. Our lives must have more than just work. There must be a physical aspect, a spiritual aspect and a relational aspect. My friend and fellow neurosurgeon, Joseph Maroon, has written a wonderful book: Square One: A Simple Guide to a Balanced Life. In this book we have the answer to burnout. The physical side of our lives must include exercise and a proper diet. We must think about what we are putting into our bodies. We should keep track of the number of hours that we are sleeping. We should never use elevators un-

less we are pushing a stretcher. Make time for vigorous workouts. The spiritual side of our lives must provide time for meditation. Keep a gratitude journal. We must never lose sight of the purpose of our lives. Be mindful. Then the relationship side of our lives is absolutely critical. We must know the language of love: words of affirmation, quality time, gifts, acts of service and physical touch. Have you told anyone that you love them today? And it is not just your spouse. We must all have a cadre of colleagues that support us. The practice of medicine demands that we must have people that we can tell about our difficult patients, our frustrating tasks, and our conflicts. We all need friends. Cultivate community in the work place. Health care is a team sport. Burnout is not inevitable, but be aware that we are in an epidemic. So stop for a moment and make sure that it will never happen to you and that you will never let it happen to your friends! n

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Access the CMS website at www.cms.org to stay current on the latest news affecting your practice. Look for our website redesign early in 2019.

Colorado Medicine for November/December 2018