Arizona Physician Summer 2020 - FREE

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A publication of the Maricopa County Medical Society

Inspired to Fight a Deadly Virus pg. 16

Preparing for COVID-19 during Flu Season pg. 20

Summer 2020


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T:11"

B:11.25"

S:10.5"


SARS-CoV-2

PRIMER

Structure of the Virus The SARS-CoV-2 virus particle is a ball of proteins wrapped in a protective bilayer fatty coating. Each particle is about 100 nanometers in diameter. The S proteins create spikes which grab a human cell. The ribonucleic acid (RNA) of SARS-CoV-2 is the single-stranded molecule that provides the blueprint for virus replication inside human cells. The RNA is stabilized by N proteins. E and M proteins help new particles form1.

Series of images showing how the SARS-CoV-2 virus fuses with a lung cell, created by Veronica Falconieri Hays.

Structure of the SARS-CoV-2 virus, created by Veronica Falconieri Hays, with sources from Lorenzo Casalino, Zied Gaieb, and Rommie Amaro, UC San Diego. Published by Scientific American, July 2020

Attacking Lung Cells Let us follow one SARS-CoV-2 virus. The virus particle floats in someone’s airway until it catches a lung cell that has an angiotensin-converting enzyme 2 (ACE2) receptor. After the S protein spikes bind to the ACE2 receptor proteins, a protease enzyme cuts off the spike’s head. This releases part of the spike’s stem in a spring like fashion that fuses the virus and lung cell membranes. When the fusion machinery inserts itself into the lung cell membrane, it creates a channel, allowing N proteins and RNA to enter the lung cell. About 10 minutes has elapsed since the SARS-CoV-2 virus attached to the lung cell. Using the cell’s ribosomes and endoplasmic reticulum, the RNA replicates more virus. Vesicles carrying new virus merge with the lung cell membrane and open a channel for the virus to exit. About 10 hours have elapsed since the virus attached to the lung cell. Each infected lung cell can release hundreds of virus copies, which infect more cells or are exhaled into the air. 2

ARIZONA PHYSICIAN | Summer 2020

A scanning electronic microscope image of SARS-CoV-2 (round blue objects) emerging from the surface of cells cultured in the lab. Source NIH/AFP/Getty Images. 1 Fischetti M, Falconieri Hays V, Glaunsinger B, Christiansen J. Inside the Coronavirus. Published by Scientific American, July 2020, available at https://www.scientificamerican.com/interactive/inside-the-coronavirus/


VOLUME 2, ISSUE 3 EDITOR-IN-CHIEF JOHN MCELLIGOTT, MPH, CPH

Contents

MANAGING EDITOR EDWARD ARAUJO LAYOUT & PRINTING PRISMA COVER & PHYSICIAN PROFILE PHOTOGRAPHY BEN SCOLARO, scolarodesign.com

Preparing for COVID-19 during Flu Season

ADVERTISING

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MARICOPA COUNTY MEDICAL SOCIETY BOARD MEMBERS: LEE ANN KELLEY, MD President MAY MOHTY, MD, FAAP Past President RICARDO CORREA, MD, ESD, FACP Treasurer SHANE DALEY, MD Secretary JOHN PRATER, DO President-Elect GERALD GOLNER, MD, FAAP KARYNE LIMA VINALES, MD BRENDA LATOWSKY, MD MEDICAL STUDENT REPRESENTATIVE MORGAN REEVE, OMS-III

Features Maricopa County’s 8 COVID Response

10 In Their Own Words... OVID-19’s Impact on 14 CMedicine

nspired to Fight a Deadly 16 IVirus

voiding Medical Board 24 AComplaints

26 Med School in Flux Why Now is a Good Time 28 to Rethink Your Estate P lan

arizonaphysician.com Twitter: AZPhysician Facebook: ArizonaPhysician Instagram: AZ_Physician

In This Issue 2 SARS-CoV-2 Primer 4 MCMS in 2020: Executive Director’s Update Paul Lynch, MD

6 A Stronger Voice for Physicians: Letter from the President Summer 2020 | arizonaphysician.com

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MCMS in 2020

E X E C U T I V E D I R E C T O R ’ S U P D AT E

John McElligott, MPH, CPH

“The best laid schemes o’ Mice an’ Men / Gang aft agley” – from the poem “To a Mouse,” by Robert Burns

Y

ou and your organization probably had big plans for 2020. Maybe you were going to increase patients served, hire new medical staff, or integrate a different tool to improve efficiency or quality of care. Maybe you wanted to merge with another practice or smoothly transition into retirement. Despite the cancellation of spring training baseball, doctors in the valley faced a wicked curveball in March. The SARS-CoV-2 virus and its COVID-19 disease continue to take a heavy toll on the medical community. The Maricopa County Medical Society (MCMS) is here to support you and your team. Please let us know what you need. We routinely email critical information to member physicians. If you are not receiving these updates, then please call us at 602-252-2015 to share a current email address or join.

Moving Forward

If you are interested in donating, then please visit www.mcmsonline.com/page/Academy. Another example of the Academy in action is coordinating free health screenings for students at a local school. Contact MCMS about getting involved.

Medical Student Essay Contest MCMS invited all students in the valley’s five medical schools to submit a short essay on lessons learned from the COVID-19 pandemic to improve medical school education and the practice of medicine. Patricia Bai, who is attending the Mayo Clinic Alix School of Medicine, wrote the winning essay. She will receive a cash prize and have her essay published in a future issue of Arizona Physician.

Arizona Physician Podcast

Like you, MCMS has also adapted to a new way of providing services. Instead of in-person events, we host virtual CME events. Knowing usual suppliers cannot provide PPE, we partnered with other groups to provide access to surgical masks, face shields, and gowns. That effort will continue with PPE available for purchase online at https://actionppe.org/3/mcms/. Get prepared and have PPE shipped directly to you.

We launched a podcast companion to this quarterly magazine. Topics will include a range of healthcare issues and medicine impacting physicians in Arizona. Would you like to be interviewed? Do you have a suggestion for a guest? Please email your ideas and feedback to information@arizonaphysician.com. Listen to episodes on Apple Podcasts, Stitcher, Google Podcasts, Tune In, and Spotify. For more information, visit www.arizonaphysician.com/podcast/.

Revitalized Academy

Bringing Doctors Together

Like the phoenix, the Academy of Medical Science of Maricopa County is rising again. Founded in 1966, the 501(c)(3) non-profit arm of MCMS operates exclusively for charitable, scientific, or educational purposes. The Academy achieved the Guidestar Gold Seal of Transparency for 2020. It will support doctors and the community. One example is having received donations in support of the “PPE for Physicians” program. We used those generous funds to purchase and distribute PPE to member physicians in need.

You are not alone in dealing with the virus and its impacts on the practice of medicine. There are over 11,800 practicing physicians in Maricopa County. The most common specialties include Internal Medicine, Family Medicine, Anesthesiology, Pediatrics, Emergency Medicine, Psychiatry, Obstetrics & Gynecology, Radiology, Family Practice, General Surgery, Neurology, Orthopaedic Surgery, Dermatology, Ophthalmology, and Urology. MCMS remains an organization that brings together

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medical and osteopathic doctors from all specialties in the Valley of the Sun. Americans coalesce when times are tough and lend a helping hand to colleagues and neighbors. MCMS is no different. Founded in a time when physicians needed to share solutions to the pressing problems of frontier healthcare, the outlook remains the same. MCMS is committed to forging stronger relationships among the medical community to solve the issues you face in medicine today. But we do not stop at the present. We look ahead to the future.

The Future of Medicine in the Valley Despite the best-laid plans, we sometimes get curveballs, knocked down, and need to pick ourselves up off the dirt. MCMS will continue to support member physicians as they seek to rebuild from the shock of the pandemic and work together to build the bright future of medicine in the valley. You have read and heard this repeated many times, but it is true. We will get through this together. Please remember the Maricopa County Medical Society is on your side. MCMS can do more for physicians when we have more members. Please consider joining and recruit your colleagues. Annual dues are only $250 for practicing physicians or $100 for physicians working for city, county, state, or federal government agencies. We offer discounted rates and group billing for practices and hospitals. Please contact us to discuss getting your whole team access to the valuable services at MCMS. Email mcms@mcmsonline.com to speak with our staff.

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www.MilliganLawless.co m A highly responsive and proactive Arizona law firm providing comprehensive legal services to health care providers.

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A Stronger Physician Voice Lee Ann Kelley, MD

A

LETTER FROM THE PRESIDENT

s Arizona Physician goes to press, I am reminded government’s leaders for direction and protection and have of Arizona public health expert Dr. Bob England’s been disappointed. We have seen anecdotal information warning about Zika virus in our January 2017 issue: become gospel in certain groups, while research on “What we know about Zika will change by the time you read possible treatments is sprinting (sans traditional peer-review this,” describing constantly flux in guidelines eerily similar to processes) from bench to bedside in what is becoming a those we’re facing with SARS-CoV-2. “We’ve really messed up marathon. How long can we keep up the pace? Exhausted the messaging… with heartbreaking consequences,” wrote Dr. but not defeated, we are increasingly demoralized as our England, who went on to say, “... the effect of this disaster will years of education and experience have been doubted or be felt for generations.” This is true now with COVID-19, as dismissed by lay people who seem to trust political leaders we anticipate years of unprecedented global consequences to more than their doctors for health information. Our medical both economy and health. advice is rebutted by politicians, increasingly opinionated Arizona has the dubious distinction of being the reporters, discredited doctors who possess no license, and world’s pandemic hotspot, with skyrocketing rates of new self-appointed internet experts. We yearn for transparency cases, hospitalizations, ICU bed occupancy, and deaths. and accurate information from our government leaders, Once thought to be a serious illness only in elderly people, while they ignore CDC advice and have let us down in our we now see younger people hospitalized and dying with hour of need. Some of our physician leaders have faced COVID-19. “Recovered” does not mean “healthy” for the death threats and suffered defamatory conspiracy theories survivors, many of whom for speaking the truth, while face prolonged recovery being vilified by others for not and disability due to We must take responsibility for societal speaking up enough. Others in strokes and long-term public health roles are being change and speak out in the areas that blamed for health policies that organ damage. And now, just when we need seem to be made by politicians affect the health of our community. it the most, millions of now, with little input from their Americans face the threat appointed medical advisors. It We should not be afraid to ask our of losing their Affordable is a polarizing time, and in our Care Act insurance which patients if they are wearing a mask in efforts to educate and make our covers pre-existing medical opinions clear, we risk public, just as we ask about smoking alienating some of the people conditions - with no plan to replace it. are most in need of and seatbelts. Praise them if they are. who It is a confusing and hearing our message. We have chaotic time. We are told Educate them if they are not, remind implored the public to wear by our President to test masks in public, but until their less, but we know that role models and like-minded them that their freedom ends where fewer tests do not equal peers embrace the empathic fewer cases. The frustrating another person’s begins, and that doing “I wear mine for you” attitude, delays in getting test results feel we are fighting an their small part in stopping this virus is we renders contact tracing uphill battle. Most physicians - our standard tool of appreciate the Maricopa County in the best interest of our country. public health - ineffective. mask mandate, as wearing We looked to our masks in public is a key step 6

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to controlling the pandemic and preventing economic ruin. As evidence mounts that SARS-CoV-2 is spread mainly via microscopic aerosolized droplets that can float in the air for many hours, we would greatly appreciate enforcement of the mandate, as not enough people are responding to the suggestion. The unwillingness of leaders to make the difficult decisions necessary to contain this virus continues to hurt not only our patients and economy, but also hurts many physicians financially, as well as emotionally and physically as we deal with death and disease on a daily basis. We must take responsibility for societal change and speak out in the areas that affect the health of our community. We should not be afraid to ask our patients if they are wearing a mask in public, just as we ask about smoking and seatbelts. Praise them if they are. Educate them if they are not, remind them that their freedom ends where another person’s begins, and that doing their small part in stopping this virus is in the best interest of our country. Have the difficult conversations, and realize that while we see individual patients, it is in the context of public health.

To slow this virus, we need to stand up and do our part for public health, come together, and unite rather than divide. To this end, let me remind you of Maricopa County Medical Society’s mission to serve as a strong, collective physician voice, which gives us power to bring attention to problems and potential solutions. In the inaugural issue of Arizona Physician, Governor Ducey remarked on Arizona’s “world class medical facilities” and “world class physicians,” telling us that “we value your work and look forward to working with your professional associations as we move forward to ensure that Arizona is a welcoming place for our growing medical community.” Now is the time to join your fellow physicians in the Maricopa County Medical Society to strengthen and amplify our voice. Stay safe!

President, Maricopa County Medical Society

Summer 2020 | arizonaphysician.com

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Maricopa County’s COVID Response

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agencies and partners to supply cloth masks to low income s we enter July, and into the sixth month of the areas to ensure that no one is without a mask due to COVID-19 pandemic, based on Maricopa County’s financial hardship. Emergency Declaration on March 18th, the one thing To combat COVID-19, that has remained consistent Maricopa County received $399 is that the situation is ever Maricopa County provided PPE, million in federal Coronavirus changing. Maricopa County Aid, Relief and Economic is the fourth largest county in testing, and support in long term the country. As the repreSecurity (CARES) Act funding sentative on the Maricopa from the federal government. care facilities, assisted living County Board of Health for This funding must be spent by the Board of Supervisors December 31, 2020 on COVID-19 facilities, jails, homeless shelters response activities not already (Board), I have the honor and other congregate settings included in the budget. I am to work closely with Marcy grateful that we do not have Flanagan, executive director needing testing and infection to make government bigger to of the Maricopa County make a difference. Instead, Department of Public Health. control training. we can use federal dollars to Marcy and her team have improve existing county services. been working tirelessly on Under the plan approved by the county’s response to the Board, CARES Act funds will be distributed as follows: COVID-19 since late January when Maricopa County had its · Health emergency response: $83.5 million first positive case. · Homeless response and prevention: $40 million Our COVID-19 positive numbers have been some of the · Small business and nonprofit assistance: $23 million highest in the nation this summer. On June 19th, the Board · County services: $77.5 million of Supervisors adopted a county wide mask regulation to The Board reserved $175 million to address upcoming slow the spread. We know that it takes time to see the costs such as the anticipated second wave of COVID-19. The results of this regulation. We are working with community 8

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$83.5 million set aside for public health will be utilized as follows: $25 million for testing services; $15 million for enhanced contact tracing and disease investigation; $10 million for personal protective equipment for health care workers; $5 million to support long-term care facilities; and $1 million for surge capacity at the Office of the Medical Examiner. To support our families and individuals, $27 million of the $40 million is set aside for eviction program voucher payments to assist in the prevention of homelessness. Additionally, we activated an empty Maricopa County building downtown to provide nighttime heat relief for our homeless population through the end of September. We provided PPE, testing, and support in long term care facilities, assisted living facilities, jails, homeless shelters and other congregate settings needing testing and infection control training. The Board also approved $23 million for the Small Business and Nonprofit Relief Grant Program. This program was designed to provide up to $10,000 in grants to reimburse businesses and nonprofits that can demonstrate financial hardship and lost revenues during March and April due to COVID-19. Applications were accepted July 9 – 31, and the program is being administered by the Arizona Community Foundation. Phoenix and Mesa also received

significant CARES Act funding; therefore, this grant program is available to businesses and non-profits in Maricopa County that are outside of Mesa and Phoenix. As a board, we have invested in digital technology to provide better customer service to our residents and meet them where they are. As such, when COVID-19 hit, we were able to operate via virtual counters, online permitting submission, and online payments. We also now understand that many of our employees can work remotely and still provide excellent service. This can be the beginning of rethinking our employment model and creating a more flexible work environment, promoting retention, and an improved work life balance. I am grateful to the physicians, first responders, front line employees, support staff, and public health professionals across Maricopa County who are working tirelessly throughout this pandemic. You are being asked to stretch yourself professionally, personally, and emotionally. Thank you.

By Bill Gates, JD, District 3 Board Supervisor at Maricopa County, district3@maricopa.gov

A legacy of caring Hospice, palliative and dementia care • Support for the caregiver Music, massage and pet therapy • Grief support Call 24/7 to speak with a nurse • As a not-for-profit, we turn no one away Lin Sue Cooney, Director of Community Engagement

(602) 530-6900 hov.org Summer 2020 | arizonaphysician.com

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IN THEIR OWN

words Adrienne Forstner, MD Ann Cheri Foxx, MD Dennis Cooper, MD Jeffrey Edelstein, MD Pamela Murphy, MD Ravi Agarwal, MD Ross Goldberg, MD Shaun Brierly, MD

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T

he COVID-19 pandemic has severely affected Maricopa County physicians working in their own practices, medical groups, and hospitals. Read excerpts of what some Maricopa County Medical Society (MCMS) physicians are experiencing during these tough times.


We have had a 50-75% decrease in patients seen and cared for since the pandemic began. – Dr Forstner

We had a slowdown, initially, interacting with patients, but now we are seeing patients face-to-face and through telemedicine. I am still operating on patients, but everyone gets pre-screened for COVID 2-3 days beforehand to ensure that they are not infected. So the “new norm” is that we are all wearing masks when we speak, but I have still been engaged with my patients. – Dr Goldberg

It shut down my referral sources, patient visits and elective surgery until the quarantine lifted. Many patients were reluctant to have elective surgery even after the quarantine ceased. We still have patients who are afraid of a face-to-face visit (June, 2020). My private oculoplastic surgery practice typically involves problems that may be identified visually. This dovetails perfectly with the recent improvements in telemedicine. We were lucky to be early adopters of telehealth visits that allowed ongoing evaluations of existing patients and offered new patients an opinion about their care needs in advance of a physical visit. Many patients were relieved to have a better understanding about their condition and comforted by offering temporary solutions to prevent their issues from progressing until they could be addressed by traditional measures. I think that remote access to healthcare providers relieved an enormous amount of patient anxiety and helped to reduce the burden on an overwhelmed urgent care/ER system. – Dr Edelstein

Question:

HOW HAS THE PANDEMIC AFFECTED YOUR PRACTICE OR YOUR PRACTICE OF MEDICINE?

After 16 years with Kaiser Permanente, I took our life savings to relocate to Arizona and form a solo direct pay practice. My plan was to open doors in early April. Naturally, that didn’t happen, and the challenges mounted. Aside from the non-urgent shutdown and elective surgery ban, every aspect of practice formation was delayed. Most medical supplies, not just PPE, were suddenly unavailable. Medical reps were furloughed. Crucial equipment languished in shipping crates for months because out of state installers and trainers were prevented from traveling. Even office artwork was trapped in Australia by a force majeure shipping lockdown. As a new practice in a new state without prior billing or payroll, we haven’t qualified for a penny of small business grant or loan assistance. – Dr Brierly

For our small private otolaryngology practice, one of the most detrimental effects of the coronavirus pandemic has been its financial impact. During the initial stages of the pandemic, the restrictions on elective surgery forced us to cancel or postpone most of our surgical cases, and we also limited office visits to enforce social distancing. Our practice was operating at less than 50% of its usual volume from late March until the end of April. This led to a significant loss of revenue. Volume has improved since the stay at home order has been lifted, but the continued need for social distancing and increased sanitizing still limits patient flow, and it is unlikely that we will be able to make up for the loss of revenue in March and April –Dr Agarwal

Summer 2020 | arizonaphysician.com

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Making the commitment to continue to financially support our employees during the quarantine was an easy decision but has certainly been the toughest to implement. – Dr Foxx

I have been forced to delay hiring front desk and back office technicians until patient volume rises enough to pay their salaries. – Dr Brierly

Our national organization demanded that all ophthalmologists stay home until they decided we could restart as we could be spreading the virus. My response was that I took an oath as a physician to take care of problems and not hide from them. Some of the cases I saw certainly were not able to wait two months to be treated through tele-medicine. Want examples? A patient treated over the phone for dry eye who had herpes simplex of the cornea. Another supposed dry eye patient with a piece of steel under his lid. Two very uncontrolled glaucoma patients, again not treatable over the phone. A few retinal detachments and more, with a finale of a new patient in whom I found an unsuspected brain tumor, fortunately in time. Other ophthalmologists have told me similar stories, and in the end, we made our personal decisions about opening or closing. I will not criticize any of them for their decision. – Dr Cooper

Question:

WHAT HAS BEEN THE TOUGHEST DECISION YOU, YOUR GROUP, OR HOSPITAL HAVE HAD TO MAKE DURING THIS PANDEMIC? Figuring out when it would be safe to perform non-essential, elective (i.e.. cosmetic surgery) on patients and how to provide a safe environment for staff. It is a question that remains challenging. – Dr Edelstein

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The toughest decision that we had to make during the pandemic was whether to lay off staff. We have dedicated and skilled staff, who all have families and bills to pay, and we really wanted to avoid layoffs. Fortunately, the CARES act, PPP, and HHS grant helped us maintain our payroll, and we were able to continue operations and keep all our staff. – Dr Agarwal


Question:

ARE THERE POSITIVE/NEGATIVE LESSONS YOU HAVE LEARNED THROUGHOUT THIS PANDEMIC? We started using telemedicine at the beginning of the pandemic, and I have found it to be very useful for follow-up visits and discussing test results with patients. The patients also seem to appreciate it. I suspect that it will continue to be part of my practice post-pandemic. – Dr Agarwal

We are down staff members and unfortunately, we may not be able to replace them. – Dr Forstner

How important it is to be armed with PPE; to read COVID-19 updates daily focusing on pediatric cases and management; reading daily and weekly hospital updates for changes in policies. Understanding my schedule will be relatively open for shift changes since all my travel vacations were cancelled. Yet, most importantly encouraging everyone I know and interact with on social media to wear masks!! – Dr Murphy

This is not my first rodeo, and the same is true for many of us older physicians. I was an intern during the 1971-1972 Hong Kong Flu pandemic when we lost 100,000 Americans when our population was 200 million instead of our current 320 million. I personally lost 30 patients in 30 days. Physicians and nurses just showed up, plugged in gaps as some of us became ill and worked overtime doing the best we could. For me, that is the key. We are physicians, WE SHOW UP! – Dr Cooper

While telemedicine gets a lot of press, I think there’s much more positive change we can effect. Huge, crowded office waiting rooms with multiple repeat visits for testing and “exams in stages” were never satisfying to patients. Now that approach is less safe. Prioritizing one-stop visits with same day exams, testing and procedures can reduce inter-patient interactions and decrease daily traffic going through the front door. Patients may actually receive more attentive, one-on-one care in this new environment. Even behind a mask and 6 feet away. – Dr Brierly

My hospital has excellent leadership that is transparent and collaborative with their approach. Clinical leadership has had input while these decisions are being made and we are all “hands on deck” on ways on providing high quality care while still being mindful of the financial stresses the hospital is going through. Being at the only public hospital in Arizona, we have dealt with resource shortages in the past, so we are usually good at adapting to the ever-changing environment. – Dr Goldberg

It is important to remain hopeful and positive despite the challenges. I have found creative and innovative solutions by remaining committed to our patients and our mission. Although I have had fewer in-person interactions, I feel more connected to my community than before the virus. The common struggle has brought us together. One example is the very positive experience I have had with Maricopa County Medical Society which has implemented programs that have been impactful to my practice. – Dr Foxx

Summer 2020 | arizonaphysician.com

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COVID-19’s Impact on Medicine

P

hysicians throughout Arizona have been hit hard by the SARS-CoV-2 virus and its impacts on patients, private practices, and hospitals. We wanted to put some data behind those stories.

Fewer Patients and Employees Based on a survey of physicians in Maricopa County, with many respondents being in private practice, we found most medical practices or employers (87%) saw fewer patients. Some practices or employers temporarily closed (16%) or considered permanently closing (13%) because of the pandemic. Other ways the pandemic harmed practices or employers included decreased hours, court closures which led to no forensic work, cancelled hiring for physicians or other medical staff, and clinical trials were cancelled or put on hold.

Telehealth/Telemedicine Increases in Use During a crisis is not the best time to test new technology, especially when it deals with the health of your patients and ensuring your team generates enough revenue to keep the doors open. Physicians throughout Arizona needed to quickly sift through a plethora of telemedicine options and select a platform which fit their specialty, could be easily used by patients, was compatible with electronic health records, and worked with insurance carriers and payers for reimbursement. Most physicians (71%) have used a telehealth/telemedicine platform either several times or daily during the pandemic.

Managing the Stress Being a physician can be stressful on normal days. During the pandemic, it can feel overwhelming. Most physicians manage stress by speaking with family or friends

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(71%), exercising (68%), or getting adequate sleep (68%). One third of respondents (32%) use their hobbies to decompress. About a quarter of doctors meditate and eat better (24%). Other ways physicians manage stress include breathing techniques, virtual counseling sessions, prayer, watching streaming movies, hard physical labor, playing guitar, binging on TV, and household repairs.

Personal Protective Equipment It seems like you can never have enough PPE or the right kind. From March to May, physicians closed the gap of PPE and felt they had more adequate supplies on hand. I would like to think one reason was the ActionPPE network, which the Maricopa County Medical Society has leveraged for its members.

Preparation for the Outbreak and Second Wave While infectious disease researchers and epidemiologists have been raising the alarm of highly infectious viruses and the need to prepare our health systems, it is difficult to predict which specific pathogens will pose the greatest risk and then to stockpile enough preventive and treatment measures. On a scale from 0 (not prepared at all) to 10 (very well prepared), our survey respondents averaged a 7 for how well prepared they were for the COVID-19 outbreak. That is pretty good. Unfortunately, respondents averaged a 6 for being prepared for a second wave of cases later in 2020.

Lessons Learned Many of the comments we received focus on concerns of the PPE supply chain, a lack of effective leadership for the pandemic response, the value of telemedicine, and the importance of keeping medical staff and patients safe during appointments. Here are some examples of what physicians had to say.


11% 8%

Fewer Patients and Employees

Used daily

39%

Used several times

32%

Never used

16%

Used once

13%

21% 87% 58%

58% ¤Fewer patients seen

¤Fewer office hours

¤Cancelled procedures

¤Employees furloughed

¤Employees laid off

¤No negative impact

Based on a survey of physicians in Maricopa County, with many respondents being in private practice, we found most medical practices or employers (87%) saw fewer patients.

“We are basically on our own and must hope that organizations like MCMS bridge the gap where support is necessary.”

Most physicians (71%) have used a telehealth/telemedicine platform either several times or daily during the pandemic.

Resources or Information Requested

“Patients don’t trust what they are being told and think most of this is a huge inconvenience.” “Save money and continue to build strong relationships with staff, colleagues and patients.” “Be nimble and resilient.” “The strong push for telehealth is a huge positive with long-term potential.” “Some of the media hype exacerbated the situation. The restrictions may have no or very little benefit.” “Shutting down or severely curtailing medical practices is not a sustainable option in dealing with COVID-19 or future pandemics.” “I am more aware of the safety of staff and patients, like improved screening of patients before admitting them to the office.” “We have an inadequate and broken supply chain for PPE. Having to depend on China to get masks is frightening and absurd.”

We asked physicians what resources of information they needed to continue practicing medicine and keep their doors open. Here are some responses. “I appreciate the help with getting PPE. It was a lifeline.” “Guidelines of how to safely run a medical office during the pandemic.” “Succinct status updates and recommendations of how to manage amidst the crisis.” “Summary of emerging literature on the virus and disease.” “Information on the sensitivity and specificity of different tests should be easy to find, and it’s not.”

By John McElligott, MPH, CPH, Executive Director at Maricopa County Medical Society (MCMS), john@mcmsonline.com

Personal Protective Equipment

100%

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% March

April n A Great Deal

n A Lot

n A Moderate Amount

May n A Little

Telehealth/ Telemedicine Increases in Use

From March to May, physicians closed the gap of PPE and felt they had more adequate supplies on hand.

n None At All

Summer 2020 | arizonaphysician.com

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INS

TO F

DE

VI M

ost Americans alive today list the 9/11 terrorist attacks as a watershed moment. Many draw inspirations from that tragedy to help others. Paul Lynch, MD, is one of those people. As a fourth-year medical student at New York University, he saw the iconic twin towers fall in lower Manhattan. Paul went to Ground Zero to care for the wounded but learned all patients were being taken to St Vincent’s Hospital. Since few survived, the hospital told him there was not much he could do. It took Paul years to process his experience of seeing the loss of human life and feeling paralyzed to assist. Yet, that traumatic experience instilled in Paul a commitment to care for patients. Fast forward 19 years and a new national tragedy has befallen our country. The COVID-19 pandemic has crippled our many resources, our economy and most importantly killed over 132,000 people. That didn’t stop Dr. Lynch, now a Scottsdale-based pain intervention physician and anesthesiologist, to temporarily leave his successful practice Arizona Pain Specialists in March and head back to New 16

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York City to volunteer at Bellevue Hospital, America’s oldest hospital and where he had trained. His former colleagues reached out asking for help and reinforcements. Jumping at the chance to help, his volunteer application was approved, and Dr. Lynch received an emergency license in New York.

New York City during the crisis The conditions at Bellevue were not for the faint of heart. The first thing he saw were bodies being put on trucks. “Not just one or two, but 20 trucks in a row, semi-trucks with long trailers. The city had nowhere to put the deceased,” says Dr. Lynch. On the first day he arrived in early April, NYC lost 3,000 people. It was like 9/11 happening each day for the first three days after he arrived. Dr. Lynch was immediately trained and added to an airway team. On his first day, a 12-hour shift, they intubated 10 patients. That is ten times the average he had experienced on anesthesia teams over a week! They airway team went room to room and floor to floor to intubate patients.


SPIRED

FIGHT A

EADLY

IRUS

The original plan of doing screenings outside in tents failed quickly. The volume was too high. The tents were used to treat staff who became sick. Wave after wave of patients crashed into the ER. Initially, each room had two patients who shared one ventilator. That was not keeping people alive. They shifted to keeping two patients in one room if they each had a ventilator and infusion pumps in the hallway. Dr. Lynch says, “As you walked down the ICU, you would see 12 rooms, 24 Christmas trees with infusion pumps, and about 10 infusions going.” On his fourth day, the U.S. Navy sent close to 200 anesthesiologists and nurse practitioners. With additional personnel, they modified ICU staffing to three to four teams of four which included a critical care fellowship-trained physician, a senior anesthesiologist (like Lynch), and either two physician assistants or physician interns per shift. That model worked very well. Yet the problem is, as Lynch states, “I’m describing one 24-bed unit, we had 10-12 going at the same time. At any one point, we had at least 100 people intubated!” Dr. Lynch has worked in intensive care units for years.

This was very different. On a normal basis, an ICU would have 12 beds, maybe 9 being used, and one bed with a critically ill patient. The rest were kind of transitional, watching people, and mostly everyone would survive. Over an entire month, he maybe saw one death. During the COVID-19 outbreak in New York City, Bellevue had three or four people dying per shift. His experience coincides with data published in the Journal of the American Medical Association (JAMA, 2020;323(20):2052-2059), which showed that, of 5,700 patients hospitalized with COVID-19 in New York City, 88% of people who were intubated ended up dying. Personal protective equipment was available but hard to come by. Supplies would run out quickly, including oxygen. Even coating before shifts became difficult as gloves and gowns ran out. Bellevue was at twice its capacity. Dr. Lynch is thankful for the countless out-of-state physicians, nurses and technicians who came to help. The largest initial need was senior critical care physicians, anesthesiologists, and nurses. When reinforcements arrived, everyone really felt supported. Focused on intubating patients, adjusting tubes, and providing anesthesia, Dr. Lynch felt fulfilled in doing his part. After 18 days at Bellevue, Dr. Lynch tested positive for COVID-19. After quarantining in New York, he returned to Arizona and quarantined for another week without symptoms.

Telling his story Dr. Lynch explains he really likes to document his experiences. After speaking with a mentor during quarantine, he decided to put together a 15-page document to inform Arizona hospital administrators of his experience in New York. It focused on direction of patient flow, turning negative pressure rooms into positive pressure rooms, and all the decision making. Then came YouTube, where Dr. Lynch posted two, four, and five-minute videos speaking to his perspective. As he kept making videos, Lynch noticed his personality taking over, and confidence building in what he would say. The responses to his videos, both positive and negative, have been overwhelming but they helped him avoid post-traumatic stress, as the encouragement from positive responses fuels his desire to care. You can find his YouTube channel by searching for “Paul Lynch.”

After New York Having to leave the Big Apple because he got sick was hard on Lynch. Anyone who practiced intense medicine over 18 days during a pandemic would be affected in some way or another. If any volunteer healthcare professionals experience COVID stress, Lynch hopes they will seek and receive any help needed. Because he always felt so supported in New York, Dr. Lynch does not believe he will have any negative side effects. In one of his videos he mentions, “If nurses would get a thousand people to tell them how amazing they were, they wouldn’t have emotional stress from their jobs.” Summer 2020 | arizonaphysician.com

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Now back in Arizona, Dr. Lynch hopes to dispel misconceptions in the news. For example, he states, “A lot of people believe only the elderly die, but that’s not true.” Lynch believes we still need to be mindful of social distancing, wear face masks, wash our hands, and remember young Americans also get sick but act as vectors for the virus to spread. People saying the opposite are spreading false information. His mentor mentioned something profound to Dr. Lynch, saying, “It’s impossible to make someone appreciate the pandemic when they haven’t seen the devastation. To them, it’s an invisible virus in a faraway place like New York and everything is different in Arizona.” Lynch feels blessed to have seen it with his own eyes, to stop misconceptions from spreading.

Let’s rewind At the age of 15, Paul Lynch was inspired by a mission trip to Honduras. People were travelling eight or nine miles to seek medical care. While taking blood pressure and giving out antibiotics, he witnessed the inadequacy of a third world medical system. One day, he saw a man get hit by a car. The medical staff held a makeshift funeral on the same table where he was treated. A feeling of being overwhelmed give Paul the idea he could make a difference by treating people. Paul initially wanted to become a psychiatrist, since his father is a licensed social worker. He majored in psychology as an undergrad and entered medical school. Yet, tragedy struck during his fourth year, as his mother-in-law was diagnosed with pancreatic cancer. She was in terrible pain, with seven fractures in her spine. Paul was asked by the family to research pain options. He found incredible ways to take away her pain, like a kyphoplasty used to treat fractures in the vertebra. He learned of the celiac plexus block, injections of medications to relieve abdominal pain. Touched by all that could be done for pain, Paul shifted career tracks and got admitted to the anesthesia program at NYU. Arizona entered the picture with a job at the Mayo

“Not just one or two, but 20 trucks in a row, semi-trucks with long trailers. The city had nowhere to put the deceased.” Clinic. Although impressed by Mayo’s integrative approach, Dr. Lynch heard a calling to enter private practice. In October of 2017, Lynch and his best friend Tory McJunkin, MD, started Arizona Pain Specialists. Knowing more data showed opioids hurt more people than they helped, Lynch and McJunkin were confident they could make a positive impact in pain medicine. Dr. Lynch also draws inspiration from tragedies closer to home. Seeing his younger brother battle a heroin addiction for eight years, Dr. Lynch connected his brother to an addition specialist in Arizona who helped save his life.

Running a business It is not easy. Dr. Lynch explains how running a practice is both stressful and incredibly rewarding. “Just because you have that inner drive to create, to do your own thing, it’s important for any physician to truly weigh his or her options beforehand,” says Lynch. Balancing their personalities to being either employed or an entrepreneur is important before moving forward. He says, “Once a physician decides to follow that entrepreneurial spirit, they should understand they will have to work at least 60 hours per week, 40-45 hours of direct health care and at least another 20 hours of running their business.” The difficult of running a practice, he believes, is connected to the lack of training. He remembers doing a lot of speeches on practice management as one of his earlier practices grew dramatically from 2007 to 2010. He was having close to 1,000 patient referrals a month within 3 years. He had 60 employees before knowing he had to have employee files. It was truly “drinking from the fire hose.” Dr. Lynch says,

Prisma would like to thank all of our healthcare workers and first responders for keeping us safe. 602 243 5777 prismagraphic.com

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“You will make mistakes, but it’s incredibly exhilarating and fun along the way.” Success breeds success, but what keeps him going is the passion to improve patients’ lives.

Fast forward When it comes to COVID-19 and his role in medicine, Dr. Lynch wants Arizona to proceed slowly. He believes Arizona must continue to lean on telehealth until the virus is extinguished. Telehealth platforms will help to protect the elderly and vulnerable populations. So do masks worn by patients and staff. He says, “Physicians are leaders. When I wear a mask in the clinic, my staff will follow suit because I’m showing them the right behavior.” Dr. Lynch believes physicians have an incredible opportunity to emerge from the pandemic in a positive light. They can show the best of what medicine has to offer. That includes volunteering in hot spots. He hopes patients realize their doctors want what is best for them. “90% of doctors would wreck their businesses and give up everything to protect their patients and I think that’s really cool,” says Lynch. The pandemic makes it more difficult to answer questions about the future for physicians in private practice. Dr. Lynch believes preparedness will be key for the next 12-18 months. Instead of a linear approach of seeing patients in the clinic, there is going to be a triangulated approach of seeing patients in the clinic, by telehealth, and through home visits. His practice adjusted by rolling out telehealth services in March, before the state government shut down

elective surgeries. His team realized some patients needed to be seen at home whether it was an inpatient visit, doing drug/urine testing, or just to show them how to use devices that could help with their pain. He believes there is a financially viable home model. That may include some adjustments of private practice physicians working with more nurse practitioners and physician assistants. “Ultimately, patients need to be seen and physicians cannot just shut down their clinics. They will have to adjust to having patients come in and going to see them,” says Lynch. From a mission trip to Honduras to caring for COVID-19 patients in New York, Dr. Paul Lynch remains passionate and as committed as ever to his patients and helping other physicians succeed. Doing so requires staying healthy to care for patients. He offers some simple rules. One, wash your hands. Do it a lot, and use hand sanitizer. Two, wear face masks. That applies to medical staff and patients. Three, observe social distancing of six feet away from each other. Four, screen staff and patients for fever, checking for symptoms. Follow these tips and physicians will have done their best to protect staff and patients.

By Edward Araujo, Communications Coordinator at Maricopa County Medical Society (MCMS), earaujo@mcmsonline.com

ON THE PERSONAL SIDE WITH PAUL LYNCH, MD 1. 2.

3.

If you can describe yourself in one word, then what would that be? I’m passionate! Family? Pets? I have 5 children, I have 3 cats, depending on the time of the day or week, 3 to 5 snakes my boys catch/week gopher snakes. My boys are all very good golfers, my nine-year-old came in 7th place in the world last year. My freshman is one of the best golfers his age, he wants to be a professional golfer. So drive them around tournament to tournament, I enjoy it. Hidden talent that most people would not know about you? I can Beat Box!

4.

Career you would be doing if you were not a physician? I’d probably be a minister. 5. What book are you reading now, or recently? Incredibly Loud and Extremely Close 6. Favorite movie? Fight Club 7. Favorite food? Sushi 8. Favorite local restaurant? Pure Sushi 9. Favorite sports team? The Kentucky Wildcats 10. Favorite activity outside of medicine Golf Summer 2020 | arizonaphysician.com

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ASU BioDesign researchers validating and reconfiguring nasal swab collection samples.

Preparing for

COVID-19

DURING FLU SEASON 20

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A

ugust typically marks the return of Arizona students to their classrooms and college campuses for the fall semester, the early promotion of the influenza shot by pharmacies and clinics, and the start of seasonal residents planning their return later in the year. Amid the COVID-19 pandemic, these annual markers serve as a reminder of an uncertain future as physicians and hospitals prepare for a potential new wave of COVID-19 cases that would coincide with the peak of flu season. “I think there’s going to be a volume problem,” said Dr. Shane Daley, a urologist with Arizona Urology Specialists. “Flu season taxes the health system, and you will have two major viruses at the same time.” Dr. Nick Staab, medical director of the bureau of epidemiology and disease control at the Arizona Department of Health Services, said his office is planning for an expanded influenza vaccination program. “Under routine conditions our health care system is near capacity in a usual fall and winter season, especially given the influx of winter residents to Arizona,” Staab said. “Add to that the ongoing transmission of COVID-19, and careful monitoring of the health of our health care system will be important to maintain function.”


Brenda LaTowsky, MD, of Clear Dermatology and Aesthetic Center.

With health experts predicting a second wave of COVID-19 before a new coronavirus vaccine is available to the public, physicians may have to halt elective surgeries if hospitals do not have adequate capacity or staffing, adapt to fewer patient visits and absorb a financial hit that could lead to furloughs or layoffs.

Adapting for today and the future At Clear Dermatology and Aesthetic Center and Valley of the Sun Dermatology in Scottsdale, Dr. Brenda LaTowsky said her practice responded in the early weeks of the COVID-19 outbreak by treating only the most urgent patients in person and converting as many patients as possible to telemedicine. Patients were asked to submit photos of any concerning spots and lesions. Oncology cases were deemed most urgent and continued, while other outpatient procedures were postponed. “It really impacted us administratively; we had to figure out the best platforms for us and a new way of seeing patients,” said LaTowsky, who has been following the American Academy of Dermatology guidelines. “We were seeing a decreased number of patients which does affect our bottom line, but patient safety is our primary concern.” After about six weeks, more patients were being seen in the office but with stricter protocols for employees and patients, including required masks and greater use of personal protective equipment and distancing among patients. If the fall and winter prove to be as or more disruptive, LaTowsky’s practice, like so many others, has policies it can fall back on. Summer 2020 | arizonaphysician.com

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ASU Biodesign Institute researcher Joe Miceli gives a demo of the saliva sample collection procedure.

“It’s really about being educated about Arizona numbers and being educated about COVID-19 itself,” LaTowsky said. “Over time we have discovered much more about symptoms, antibodies, the incubation period. By staying on top of new information coming out and the incidents in Arizona, we can be flexible and change as needed in the future.” Daley, who also serves as assistant professor of urology at University of Arizona College of Medicine-Phoenix and as secretary of the Maricopa County Medical Society board of directors, said the majority of his practice switched to telemedicine during the initial COVID-19 lockdown. Daley, who receives daily updates from hospitals, expects physicians will be adapting their practices through the fall and winter until a COVID-19 vaccine is available. “It has dramatically affected us largely because our surgeries are elective,” Daley said. “Kidney stones and prostate- and kidney-cancer surgeries are not considered emergencies, but many are urgent.” Staab said the state’s primary method of communicating urgent information to physicians is via the Arizona Health Alert Network. He said the state also created the Arizona Surge Line, a centralized bed placement system that enables COVID-19 patients to be transferred to a hospital with the capacity and staffing to treat them. “No single hospital, practice or provider should feel like they are alone in managing the care of their patients,” Staab said. “While there may be obstacles and 22

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crises along the way, ADHS is committed to helping all practices approach this outbreak with the best tools we have available.”

Universities developing new tests to track virus New methods of testing being developed by Arizona’s universities could become more accessible for physicians in the coming months, playing a critical role in slowing the spread of the new coronavirus. Staab said he has contacted the Biodesign Institute at Arizona State University to discuss expanding the availability of its newly developed PCR saliva test. The test requires a person to spit into a screw-top tube through a straw. It is less invasive and costly than the NP swab tests, requires less personal protective equipment, and can be done in the workplace, schools, or even at home. In June, ASU began pilot testing its students and staff in anticipation of the fall semester scheduled to begin in August, with plans to increase availability using a fully automated robotic system and point-and-click IT infrastructure for testing and reporting, said Joseph Caspermeyer, an ASU spokesman. ASU plans to develop partnerships with hospital practices and health care systems, schools, cities and counties, businesses and nonprofits, and community organizations. Caspermeyer said the potential is there with the saliva test to collect samples from any hospital or private physician’s practice.


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Brenda LaTowsky, MD, and her team at Valley of the Sun Dermatology.

Staab said the state health department works closely with all of Arizona’s universities and research institutes and is in regular contact with commercial labs to discuss testing availability. The Phoenix-based Translational Genomics Research Institute, in collaboration with Northern Arizona University and University of Arizona, is working to genetically sequence as many Arizona positive samples as possible to build a statewide genomic map to track the virus as it appears and moves through different communities. Staab said the serology test developed by UArizona is being used by the state to test high-risk workers in health care and corrections for the presence of antibodies. All of which will become even more critical as Arizona physicians prepare for what lies ahead. “Increased rapid testing and the reporting of results, followed up by contact tracing of any positive cases, is the key to getting out ahead and preventing the further spread of COVID-19, especially as we enter the first full season where both flu and COVID-19 will impact the community,” Caspermeyer said.

By Brian Powell, Communications Manager at Flinn Foundation, BPowell@flinn.org ASU BioDesign researcher.

Summer 2020 | arizonaphysician.com

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F

Avoiding Medical Board Complaints

or many physicians, a Medical Board complaint is more concerning than a medical malpractice lawsuit and with good reason. A lawsuit is designed to financially compensate an individual for damages sustained. The chances are very good that the physician will prevail. If not, the insurance company will generally cover the entire cost of the proceedings, including the settlement or verdict. On the other hand, when a patient files a Board complaint against a physician, the intent is to punish, ostracize, or humiliate the physician. The result may be disciplinary action against the physician, which often leads to interference with the physician’s ability to practice medicine or, in the worst-case scenario, the end of a medical career. The complaint is an affront to the physician’s competency, integrity, and livelihood. Most Board complaints are resolved without disciplinary action to the physician, i.e., most complaints are dismissed or conclude with an Advisory Letter (a warning). Even so, there is no way to compensate the physician for the anxiety, sleepless nights, time expended, and costs that are part and parcel of a Board complaint. In the final analysis, Board complaints are best avoided. The purpose of this short article is to consider some practical ways to decrease the likelihood of receiving that Board letter in the first place. Note that this is not legal advice and may not directly apply to any individual or circumstance (the usual disclaimer).

1. Behavior Physicians know they must behave professionally and conscientiously when dealing with any matters related to medicine. But what about behaviors during off hours when the physician is not on duty and has no professional commitments? Sorry, but the expectations regarding physician behavior do not change very much whether you 24

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are working or not. The bottom line is that your conduct is held to a higher standard. That is the price of being a professional - the price we pay for being granted the privilege of practicing medicine. First, do not drink and drive. Not a drop. You do not want to have alcohol on your breath when you drive. Most people believe their blood alcohol must equal or exceed 0.08 to be convicted of DUI. That is incorrect. The combination of impairment and almost any level of blood alcohol is likely to precipitate an arrest and charge for DUI because the law is unforgiving, “impaired to the slightest degree.”1 Once charged, the physician has 10 business days to report the infraction to the Medical Board. And do not forget to report because failure to do so creates an act of unprofessional conduct by itself. The self-report leads to a Board complaint and an investigation. The physician may be sent for a local evaluation or an expensive multi-day stay in an out-of-state facility. The case can result in a practice restriction or required monitoring and testing for two to five years. My solution is to drink absolutely no alcohol if I am going to drive. Or have a designated driver. Having seen the pain that physicians endure after a DUI case, I stay away from alcohol entirely when I drive. And you should too. Here are a few other behaviors to avoid. Refrain from physical assault or domestic violence. Your neighbors could call the police. Be very careful about dating or engaging in sexual conduct with former or current patients. Take a close look at the Medical Board’s rules before you do. 2 Avoid unprofessional conduct in your medical practice. Keep patient confidences and limit storytelling in the staff lounge. Do not ignore your patients. If you are going to discharge a patient, be careful to take the appropriate steps or risk charges of patient abandonment. Do not let incomplete or unsigned charts pile up at the hospital or the


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surgery center to avoid restrictions on your staff privileges. Those restrictions may be reportable to the Board. Your medical records do not have to be works of art, but they should be reasonably complete and decipherable. Electronic medical records have a habit of repopulating the record with old information at every visit. Make sure the information is up to date, including current medications. And did you know that, at the patient’s request, you are required to send medical records to physician assistants, nurse practitioners, podiatrists, chiropractors, naturopathic physicians, and homeopathic physicians?

Gracias

2. Bills It is unprofessional conduct to charge or collect a clearly excessive fee. For a costly service not covered by insurance, it may be advisable to have a written contract with your patient that clearly specifies the fee and the service to be rendered. In general, patients change physicians for three reasons: they move, they change insurance, or they become dissatisfied with their care. I have never seen a billing complaint filed by a satisfied patient - only dissatisfied patients file complaints. Here are two billing suggestions to consider when dealing with dissatisfied patients. First, think long and hard before you send a patient, who has encountered a medical or surgical complication, to collections. If you decide to do it, think about it some more. The risk of a complaint from an angry patient may not justify the revenue. Second, while you may legally charge a patient a reasonable fee for reproducing medical records in certain circumstances, I do not believe it is worth it. It makes mad patients even madder, and I have seen a $25 or $35 fee precipitate a Medical Board complaint on several occasions. If the patient’s record is lengthy, put it on a CD, and mail it.

3. Opioids Do you have an interest in pain management? Have you taken extensive training or continuing education on opioids? Are you willing to navigate the labyrinth of requirements and documentation that chronic pain management requires? If your answer is “no” to any of these questions, I strongly suggest you avoid prescribing opioids for anything other than the occasional acute problem. Having defended a significant number of complaints related to opioid prescribing, including seven opioid–related death cases, it is rare in my experience for a physician to have dotted all the I’s and crossed all the T’s. Most physicians do not seem to find pain management engaging or satisfying. The patients are difficult, the care is time-consuming when done appropriately, and the financial remuneration is typically inadequate. Practice the kind of medicine you enjoy.

4. Informed consent There is more to informed consent than having the patient sign a carefully drafted, legally airtight, encyclopedic recitation of the risks, benefits, and alternatives of a medical intervention. Make sure that someone in your

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office, preferably you but possibly a staff member, explains in simple terms that all medical interventions have risks, and results can never be guaranteed. It is better to under promise and over perform. Without that conversation, many patients will expect perfection and miracles. Setbacks, delays, side effects, and surgical complications may be interpreted to be a result of negligence, incompetence, or distraction. This question always comes up, so I am going to give you my take on it. Do you need a lawyer when you get a Board complaint? Yes. Enough said.

Ariz. Rev. Stat. § 28-1381(A)(1); See https://www.azleg.gov/ ars/28/01381.htm 2Unprofessional conduct includes “engaging in sexual conduct with a current patient or with a former patient within six months after the last medical consultation unless the patient was the licensee’s spouse at the time of the contact or, immediately preceding the physician-patient relationship, was in a dating or engagement relationship with the licensee.” Ariz. Rev. Stat. § 32-1401(27)(aa) 1

By Steve Perlmutter, MD, JD, LLM at Perlmutter Medical Law, steve@healthcaredefender.com

Summer 2020 | arizonaphysician.com

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in flux

MED SCHOOL 26

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t is safe to say this year has not gone as planned. The COVID-19 pandemic has resulted in a nearly complete overhaul of methods of teaching and engaging students. In the past several months, medical schools have had to balance the unmatched benefit of hands-on experience with the risks involved in sending medical students into hospitals and clinics, increasing exposure to SARS-CoV-2. For those in the first or second year of their medical education, the changes have not been drastic. Instead of dressing in business casual clothing and frantically taking notes in a lecture hall, many students have transitioned to rolling out of bed and staying in their pajamas to watch online lectures. This alteration to what is an already stressful didactic phase of medical education may result in a feeling of isolation due to the lack of camaraderie and peer support. In the long run, this may have a notable impact on students’ mental health, especially when considering the already frightening rates of depression among medical students. For those of us who are out on clinical rotations, the difference has been stark. Starting in late March 2020, medical schools across the country pulled their students from in-person rotations due to both the shortage of PPE as well as the unknown risk posed by the novel coronavirus. For those who graduated this past Spring, their last few months was completely hands-off. This left them perhaps a bit rusty in their clinical skills just before entering their intern year of residency. For students just entering their third or fourth years, the return to clinical rotations has been rocky. Rotations scheduled months in advance had been canceled by facilities just weeks before they were meant to begin. Many hospital systems and clinics still refuse to take on students, and while their caution is understandable it is quite difficult to find the hands-on opportunities we so need at this critical point in our education. Students are eager to be in the clinics and hospitals helping where possible and using this as a valuable learning experience. The pandemic has also impacted board examinations. Starting in late spring, board exams were cancelled due to testing facilities’ uncertainty in their ability to provide a safe environment. Once scheduling became available again, there was a scramble across the country to snatch up testing dates. This disorganization left many students with exams scheduled for months later than originally planned, forcing them to make changes to their carefully planned out schedules which had been tailored months in advance for residency applications. Add to the confusion the cancellation of USMLE Clinical Skills and debate on whether to continue with COMLEX Performance Evaluation board examinations this year. Even the pathway to residency has been altered in the wake of the pandemic. Many schools and residency programs are encouraging students to take fewer audition rotations and to limit their out of region rotations to prevent students from acting as viral vectors between

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hospitals and across state lines. Most interviews will be held via video conferencing programs such as Zoom, leaving some students concerned about the impersonality of the process and their ability to fully sell themselves within a thirty-minute virtual chat. While these measures are understandable, it changes the game for this residency application season. Overall, as someone early on in their medical career, it has been disheartening to watch the public’s distrust in medical experts and organizations such as the WHO and the CDC that has arisen in the wake of the pandemic. Disheartening, but not unexpected as fear has not been shown to be conducive to logical thinking. The changes in our society have not been easy to adapt to for anyone, whether it be the loss of employment, loss of a general sense of safety, or loss of a loved one. As I have said to many a concerned patient in the past several weeks: this too shall pass… eventually, but it will require all of us to do our part in the meantime.

By Morgan Reeve, OMS III, at A.T. Still University, sa195201@atsu.edu

Summer 2020 | arizonaphysician.com

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Why now is the time to rethink your estate plan

N

ow might not seem like an ideal time to consider long-term plans, but for several reasons, it might be a good time to re-evaluate your estate plan. The disruption caused by the COVID-19 pandemic coupled with a favorable tax environment makes transferring assets more cost-effective, and this unique scenario might not be around for very long. Here are three reasons why you might want to rework your estate plan sooner versus later.

1. Valuation Changes The market swings and economic shifts during the COVID-19 pandemic have temporarily lowered the value of many business and real estate assets. While the long-term economic effects remain to be seen, it is clear that financial markets and business values are depressed. This makes estate planning especially timely for individuals with real estate holdings and those who own closely held businesses. The level of business uncertainty may mean that transferring business interests in the current environment may allow for larger discounts for lack of marketability and minority interests.

2. The 2020 Election Tax reform nearly doubled the thresholds for estate tax and gift exemptions when it went into effect in 2018. While the expansion of the lifetime estate tax exemption and annual gift tax exclusions aren’t set to expire until 2025, some speculate that a shake-up in Washington this November could lead to changes sooner than 2025. If you’re planning to take advantage of current exemption thresholds by gifting directly to your beneficiaries, now is the time to start thinking seriously about making gifts. The depressed value of assets may help you transfer more assets now significantly reducing or potentially eliminating estate or

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generation-skipping transfer (GST) tax. Trusts and other forms of gift structuring may also be used to minimize GST liabilities.

3. Charitable Giving Changes The Coronavirus Aid, Relief, and Economic Security (CARES) Act makes charitable giving even more favorable for estate planning. For 2020, it changes the deductibility of charitable contributions for individuals who don’t itemize their federal tax returns. Individuals can take a new $300 above-the-line deduction for cash contributions to a qualifying charity. For individuals who itemize, cash contributions to qualifying charities are deductible up to 100% of the taxpayer’s adjusted gross income (AGI), up from 60% of AGI.

Stay Flexible Additional information and economic relief measures related to the COVID-19 pandemic continue to emerge as new legislation is passed and more is understood about the long-term economic impact of the pandemic. If you are planning to make adjustments to your estate, keep in contact with your advisors so that you can incorporate emerging developments or relief measures into your strategy and reap what benefits may be available during this unprecedented time.

By Bailey Tocco, CPA, Managing Director at CBIZ, btocco@cbiz.com



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We can’t say it enough. Thank you to all the healthcare professionals on the frontline of the COVID-19 pandemic. Mutual Insurance Company of Arizona 2602 E. Thomas Road Phoenix, Arizona 85016 602.956.5276, 800.352.0402 www.mica-insurance.com