2022 Q3 OnCall

World-class fetal and pediatric cardiology care is coming to Wellington

For more than 70 years, Nicklaus Children’s Hospital has served as a pediatric care leader serving children and families locally, regionally and internationally.

Same-day* and next-day appointments with fetal and pediatric cardiologists will be offered right here at our new Wellington location.

COMING TOGETHER

By Claudia Mason, MD 2022 PBCMS President

The Society’s Strategic Plan calls for both fiscal management and a refresh of our Programs.

Two immediate Program initiatives are in their nascent stages. The Physician in Transition program will build on the skills and expertise of our Circle of Friends and current member mentors to assist members who would like the guidance and expert assistance of vetted vendors. Whether it is your first move from residency to practice, between practices, moving practice, employment, or retirement or reentry, your Society is there for you. As most of us will change in our careers, this valuable benefit is being planned and will be available very soon. Our website will have introductory videos from our vendors and mentors. We have sent out a solicitation for volunteers to mentor another physician through their transition. Volunteer mentors can be short- or longer-term commitments as they choose. Please contact mindit@pbcms.org to volunteer.

The Drug Price Transparency Program is in the planning stages. This program hopes to gather relevant resources, simplify the messaging, and be able to be available to the public. We hope to bring this valuable information directly to the public via community chats and information sessions. Dr. Shawn Baca and Dr. Ramon Cuevas Trisan are leading this initiative. Volunteers to help in the planning and in speaking portions of this program are welcome. Again, contact mindit@pbcms.org to volunteer.

Advocacy is a central part of our mission, and as the Florida Medical Association Annual Meeting approaches, we hope to have a full complement of

representatives to bring resolutions to the floor, debate, and vote. Palm Beach County is part of the South Florida Caucus which includes Broward and Miami Dade. The Caucus has worked on several resolutions to strengthen our position as fully trained physician medical practitioners, reduce paperwork hassles and potentially reduce harm to patients by closing EMR loopholes.

Financially we will look at a mid-year correction to our Budget. Our revenue from dues is not as expected. Over the last two months, we have had to remove over 100 names from our membership roles for lack of dues payment. When asked, please pay your dues promptly. In addition, the Society has started to lease a portion of the office space to increase revenue. We rely heavily on our Circle of Friends, and PBCMSS for support to be able to have the wonderful staff and programs we offer.

Socially, we have started to have in person events. Our Summer Mixer was a big hit, with a tremendous thank you to Jeff Cohen, Esq. We are happily planning for our Gala to be held on December 3 at the Palm Beach Convention Center. This promises to be a delightful evening based on a Venetian Carnivale. Tickets and sponsorships are available now. In a short six months, I will hand the gavel over to our President Elect, Dr. Martha Rodriguez in whose capable hands the Society will continue to grow and flourish.

As always, it is an honor to serve my fellow physicians, Claudia Mason, MD.

TABLE of CONTENTS

President’s Report 2

Welcome New Members

FEATURES

Circle of Friends 2022 5 What We Owe Long COVID Patients

By Zijian Chen, MD and Peter A. Kolbert

The 1919 Society

Founding and 2022 Members List

PBC Physician Leaders Work to Improve Access to Behavioral Health Services

Physician Leadership Academy of South Florida Celebrates Sixth Graduating Class 11

19th Annual Heroes in Medicine

Congratulations to the 2022 Winners 12

The Importance of Advance Directives and the Designation of a Healthcare Surrogate

By Stuart Bagatell, MD 13

On Depression: Physician Heal Thyself

By Louis T. Joseph, MD and Bruce Saltz, MD 15 Physician Suicide

By Stefan Pasternack, MD, DLFAPA, Bruce Saltz, MD, DLFAPA, and Abbey Strauss, MD, DLFAPA 17 Stethoscope Donations

SAVE the DATE - Saturday, December 3, 2022

PBCMSS 2022 Venetian Masquerade Ball Back Sponsorship Opportunities Available Cover

Subscriptions to OnCall are available for an annual rate of $50. For more information contact PBCMS at (561) 433-3940. The opinions expressed in OnCall are those of the individual authors and do not necessarily reflect official policies of Palm Beach County Medical Society or its committees. OnCall is owned and published four (4) times per year by Palm Beach County Medical Society, Inc., 3540 Forest Hill Blvd., #101, West Palm Beach, FL 33406. (561) 433-3940. ©Copyright 2019 Palm Beach County Medical Society, Inc. OnCall Journal is designed and edited by Mad 4 Marketing. Visit us on the web at mad4marketing.com 954.485.5448

BOARD OF DIRECTORS

BOARD OF DIRECTORS

STAFF

Claudia Mason, MD – President Martha Rodriguez, MD – President-Elect Henry Haire, MD – First Vice-President Faustino Gonzalez, MD –Treasurer Andrew Berkman, MD – Secretary Roger Duncan, MD– Immediate Past President

Jose F. Arrascue, MD Andrew Berkman, MD Larry Bush, MD Roger Duncan, MD Henry Haire, MD Marc J. Hirsh, MD

Brandon Luskin, MD Claudia Mason, MD Martha Rodriguez, MD Maureen Whelihan, MD Jack Zeltzer, MD

Kelly Skidmore – CEO

Deanna Lessard – Director of Member Services and Physician Wellness

Karen Harwood – Director of Community Programs

Mindi Tingler – Director of Communications Katherine Zuber – Director of Development, Opioid Education & Events

John James – Director of Public Health & Disaster Services Angelica Cervantes – Lead Project Access Care Coordinator

Aliuska Hernandez – Outreach Care Coordinator Pamela Richards – Project Access Care Coordinator

Ivy Faske, MD – President Matt Gracey – Vice President Stuart Miro, MD – Secretary Paul Wieseneck – Treasurer Michael Dennis, MD – President Emeritus

Shawn B. Baca, MD Stuart Bagatell, MD Colette Brown-Graham, MD Larry Bush, MD Ramon Cuevas-Trisan, MD Alec Curtis Michael Dennis, MD James Goldenberg, MD Marc Hirsh, MD Carlos Vergara Sanchez, MD

Jean Acevedo Elaine Alvarez Jose F. Arrascue, MD Brenda Atkins Don Chester Madelyn Christopher Ljubica “Jibby” Ciric John Dalton James Heron, MD

Barbara James Andrew Larson, MD Alan B. Pillersdorf, MD Brent M. Schillinger, MD Mollie Shulan, MD Ben Starling III Maureen Whelihan, MD Jack Zeltzer, MD

BOARD OF TRUSTEES

DEPARTMENTS

Circle of Friends

Acevedo Consulting Incorporated

Acevedo Consulting Incorporated’s team is recognized nationally for its expertise in documentation, coding, and compliance. As a Circle of Friends member for 20 years, Acevedo Consulting has helped hundreds of physicians in Palm Beach County to develop compliance and HIPAA programs, guiding them through Medicare audits, providing documentation, and coding education. The firm is known as a trusted source for coding and compliance information. For more information, contact Laura Hilbert at 561-278-9328, or email lhilbert@acevedoconsulting.com, www.acevedoconsultinginc.com.

AmTrust North America

AmTrust North America (formerly Comp Options) has been a true partner to the PBCMS and Risk Strategies/Danna-Gracey for many years, and now, with the resources of AmTrust – rated “A” (Excellent) by A.M. Best – we are able to provide this exclusive enhanced dividend program like no other for Florida physicians and medical practices. To date, the program has given back over $1 million in dividends to our society members insured through the program. For more details and to enroll in this beneficial program, please contact Tom Murphy at Risk Strategies/Danna-Gracey in Delray Beach, at 561-276-3553, or tom@dannagracey.com.

FineMark National Bank & Trust

FineMark National Bank & Trust offers a comprehensive array of banking, trust, and investment services to clients interested in establishing long-term, high-touch relationships. FineMark is dedicated to providing a culture of service to clients and making a positive difference in the communities it serves. For more information, contact Lauren Blasingim, Marketing Associate by calling 239-461-5956 or emailing lblasingim@finemarkbank.com.

First Citizens Bank

First Citizens Bank understands that your financing needs will change over the years. Whether starting out on your own for the first time, joining an existing practice, or preparing to expand or renovate your practice, we have customizable financing options available. For more information, contact Claudia Rodney, Vice President, Financial Sales Manager III by calling 561-350-8515 or emailing Claudia.Rodney@firstcitizens.com, www.firstcitizens.com.

Florida Healthcare Law Firm

Clients who work with the Florida Healthcare Law Firm are protected by deep healthcare industry experience and fully served by attorneys aligned with their success. The team here doesn’t dabble in healthcare law, we specialize in full spectrum representation of healthcare providers and nearly every type of healthcare business. Visit us online at www.floridahealthcarelawfirm.com or call 561-455-7700 for a complimentary consultation.

Keiser University

Keiser University is one of the largest producers of nurses and allied health workers in Florida. The University serves as a valuable resource to hospital systems and physicians throughout the state and its graduates are filling vital job vacancies in communities throughout Florida. For more information, call Elizabeth Houlihan, MBA Director of Student Services at (561) 471-6000 | elizabethh@keiseruniversity.edu, FREE Job Posting for Employers: www.collegecentral.com/keiser.

Levi & Associates

Levi & Associates can handle all aspects of your non-qualified benefits. During our firm’s 20+ years in the benefits business, we have refined a successful system that produces exceptional results. We have been highly effective in enhancing benefit offerings, often while easing the bottom line commitment, while assisting you with all phases, from planning to implementation to employee information/education meetings about benefits and wellness. For more information, call Jeremy Cohen, SENIOR GROUP BENEFITS AGENT by calling 561-353-1234 x 115 or emailing Jeremy@leviinsurance.com.

MSPB Medical Specialists of the Palm Beaches, Inc. Medical Specialists of the Palm Beaches is the largest multi-specialty group in Palm Beach County and now recently expanded to Broward County. We are committed to providing the best care for our patients. We place our patients first by demonstrating compassion, respect, and expertise In everything we do. For more information visit Mspbhealth.com or call 561-649-7000.

NAI/Merin Hunter Codman, Inc.

As one of South Florida’s leading commercial real estate firms, we understand your complex medical space needs. Lesley Sheinberg, Managing Director, and Medical Site Facilitation expert aims to put you on a level playing field with professionals, landlords, and owners by providing expert advice based on years of medical space expertise, attention to detail, and superior Florida market knowledge. Ms. Sheinberg has worked directly with the PBC Medical Society and their members to assist in a variety of needs including tenant/buyer representation, market data & analysis, relocation studies, investment sales, and more. Whether you’re a small practice or large hospital, downsizing, or looking to purchase, we’re here to help you through every step of the way. To learn more, contact: Lesley Sheinberg, Managing Director by calling 561-471-8000 or emailing lsheinberg@mhcreal.com, www.mhcreal.com.

Optimum Recruiting Training Staffing

Optimum RTS is one of South Florida’s only dedicated medical recruiting companies that is certified by AHCA to provide key medical staff that will interface directly with your patients. The pillars of our success are found in our Value Statement where we pride ourselves on our core values of Honesty, Service, and Respect. For more information, contact John E. Dalton, President/CEO at 561-408-2192, or email jdalton@optimumrts.com.

Risk Strategies/Danna-Gracey

Risk Strategies/Danna-Gracey is a specialty national insurance brokerage and risk management firm offering comprehensive risk management advice and insurance. Risk Strategies/Danna-Gracey is the only malpractice insurance brokerage firm endorsed by the Palm Beach County Medical Society. We have the ability and national platform to provide the following additional insurance options, including Workers’ Compensation, Cyber, and EPLI. By speaking, writing, and lobbying in Tallahassee, we hope to effect positive change in the healthcare industry. The experts at Risk Strategies/Danna-Gracey are well known throughout society as independent expert specialists in finding the most suitable malpractice insurance and workers’ compensation coverage for individual doctors and group practices. For more information: info@dannagracey.com or (800) 966-2120.

The Doctors Company, TDC Group

Palm Beach County Medical Society has selected The Doctors Company as the exclusively endorsed medical professional liability insurer for our members. The Doctors Company provides Florida physicians with local claims, underwriting, and patient safety services. Palm Beach County Medical Society members qualify for a five (5) percent premium discount, which can be combined with additional loss-free discounts for even greater savings. We encourage you to find out how you can benefit by securing coverage with The Doctors Company. Contact Tom Murphy at Danna-Gracey, murphy@dannagracey.com.

Think Big Health Care Solutions

As a health resource and practice management company we specialize in improving the financial success and sustainability of physician practices through revenue cycle & cash flow, human resource services, compliance, credentialing, business development, marketing operations, practice management, and athenahealth™: project management, ongoing support, chronic care management, and billing. Visit www.ThinkBigHCS.com for a more comprehensive list of services or call 561-293-4304.

Truist

Customized solutions for physicians and medical practices. Banking. Brokerage. Trusts. Practice finance. Streamlined wealth management and medical practice solutions through dedicated planning, proactive advice, sophisticated financial solutions, and guidance. What sets us apart? Not only are our advisors skilled in our profession— we’re also deeply knowledgeable and well-versed in the subtleties and complexities of physicians and their practice groups. We’re dedicated Medical Relationship Managers and Medical Wealth Advisors. And we understand the financial issues and implications of continual changes in the healthcare industry—and the ongoing demands on your time. To learn more, contact Javier Dadan, Vice President, Medical Wealth Advisor, by calling 561-515-1952 or email at Javier.dadan@truist.com. Truist.com/medical.

Visiting Angels

Visiting Angels is a nationally recognized and respected name in private duty, home health services. At Visiting Angels of the Palm Beaches, locally owned and operated, we have a refreshing, and award-winning approach to homecare relationships. We are the private duty, Home Health Agency of choice for several PBCMS member physicians. Let us be a resource for you and your patients – there is no paperwork involved for you or your staff! www.visitingangels.com/palmbeaches, Iseldin@visitingangels.com, 561-328-7611.

WHAT

LONG COVID PATIENTS

By Dr. Zijian Chen, Assistant Professor of Medicine at the Icahn School of Medicine at Mount Sinai, and Peter A. Kolbert, Senior Vice President of Claim and Litigation services for Healthcare Risk Advisors, part of TDC Group.

While treatment has improved considerably for COVID-19, most dialogue has focused on two types of patients—those with severe, even lethal illness, and those with milder symptoms. Yet there is a third category of patients: those suffering from long COVID.

Clinicians recognized the existence of these long COVID patients early in the pandemic. May 13, 2022 marked the two-year anniversary of the opening of the Mount Sinai Center for Post-COVID Care in New York City, a first-of-its-kind unit in the U.S. Since then, long COVID has emerged as one of the biggest but least-addressed medical concerns. Anywhere from 10% to 30% of those who contracted COVID-19 suffer chronic aftereffects, some lasting many months after the initial diagnosis.

Long COVID presents varying and unpredictable symptoms and has no known cure, so with very little information, health-care providers are facing an uphill battle when it comes to providing adequate care to these patients. The absence of a standard set of interventions leaves caregivers vulnerable to liability risks stemming from misdiagnoses.

Diagnostic error is the No. 1 cause of serious harm, making it the top concern for preventing patient injury. Patients need to present clinicians with the full range of symptoms and ask for comprehensive diagnostic tests to be run in order to identify if it’s long COVID or another ailment. In return, health-care providers need to bring experts from varying fields together.

If a patient suspects they suffer from long COVID or presents a variety of symptoms after having COVID-19, their assembled care team—which often starts at the office of their primary care provider—should first rule out a separate underlying illness.

Knowing that long COVID can present as more than 200 symptoms affecting 10 organ systems, health-care providers find it challenging to pinpoint which ailments, if any, were a direct result of COVID-19.

That there are other ailments masquerading as long COVID emphasizes the importance of seeing patients quickly and providing a thorough evaluation.

When signs of long COVID emerged in the summer of 2020, many doctors were skeptical. Even now—two years later—skeptics remain. Consequently, many patients feel that medical professionals are failing them. When health-care providers struggle with doubts about long COVID, they should remember that COVID-19 can result in something other than short-term symptoms or death.

This work first appeared in The New York Daily News and online at www. nydailynews.com.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Peter A. Kolbert

Zijian Chen, MD

Jose F. Arrascue, MD

Shawn Baca, MD

Jeffrey Berman, MD

Larry Bush, MD and Maria Vazques-Pertejo, MD

Michael Dennis, MD

Ivy Faske, MD

THE 1919 SOCIETY

James Goldenberg, MD

J. John Goodman, MD and Judy B. Goodman, Esq.

Howard Allen Green, MD

Henry Haire, MD Marc Hirsh, MD

Alan Barth Pillersdorf, MD

Brent M. Schillinger, MD

Ida Sebastian, MD

William Slomka, MD

Robert Tome, MD

Maureen Whelihan, MD

Ronald Zelnick, MD Jack Zeltzer, MD

The 1919 Society members listed below are present members of The 1919 Society

Founding members of The 1919 Society

Jose Arrascue, MD Michael Dennis, MD

The Hippocrates Society Boca Raton Regional Hospital Medical Staff

JFK Medical Staff

J. John Goodman, MD and Judy B. Goodman, Esq. Howard Green, MD

Alan B. Pillersdorf, MD Brent Schillinger, MD Ida Sebastian, MD

PALM

LEADERS WORK TO IMPROVE ACCESS TO BEHAVIORAL HEALTH SERVICES

As part of their project for the 2022 Class of the Physician Leadership Academy, a group of six Palm Beach County physicians collaborated with mentors from the Palm Beach County Medical Society and partners throughout South Florida to improve ease of access to behavioral health services for their patients.

The six doctors (Colette Brown-Graham, MD, Seneca Harberger, MD, Lia Jamian, MD, Heather Johnson, MD, Harish Madhav, MD and Vicki Norton, MD) worked with Karen Harwood and CEO Kelly Skidmore, from the Palm Beach County Medical Society, to identify this tangible problem. The team, composed of physicians from a range of specialties, noted that front-line doctors often struggle to find clear solutions for their patients’ behavioral health needs.

create a robust and reliable directory of services, they came to understand that this work is already being done by a great team at 211 of Palm Beach and the Treasure Coast (available at 211PalmBeach. org). They then shifted their goal to creating a simple and easily accessible guide for physicians to use to rapidly address patients’ needs in the moment of clinical care.

While considering the needs of busy physicians, the team worked with community stakeholders and identified key questions that needed to be answered to connect a patient with the best behavioral health resources. The Palm Beach County physicians developed an algorithm, outlined in the flow-chart below, to address three key areas of need. The first goal is to guide physicians to resources which are most helpful during a patient crisis, the second is to provide resources to support patients struggling to overcome significant barriers to care, and finally to provide a sustainable, reliable database of resources a patient can independently access, if not in crisis or facing significant barriers.

These issues arise, in part, from the growing shortage of available psychiatrists and therapists, especially during the pandemic, when demand has been at an all-time high. The team also sought to understand what resources are available and how physicians could more efficiently guide their patients to these resources. While the team initially aimed to

Using this flow-chart, the team created a simple handout (available at PBCMentalHealth.org) to help guide physicians and provide clear contact information for the appropriate resource.

“This project is just a first step to address our group’s particular concerns regarding patient access

to behavioral health services,” explains group project leader, Seneca Harberger, MD. It is just one contribution to a wide array of ambitious projects taken on by organizations like 211 Palm Beach and the Southeast Behavioral Health Network. This project will undoubtedly require many cycles of feedback and improvement, but the team is hopeful that it will help close a gap they identified. If the program is of any

interest to you, please take a moment to review the resources and provide any input you feel might be useful at PBCMS@pbcms.org.

For

information,

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From left to right: Karen Harwood, Vicki Norton, MD, Heather Johnson, MD, Seneca Harberger, MD, Harish Madhav, MD, Colette Brown-Graham, MD, and CEO Kelly Skidmore.

PHYSICIAN LEADERSHIP ACADEMY OF SOUTH FLORIDA CELEBRATES SIXTH GRADUATING CLASS

PLA Teaches Physicians Critical Leadership Skills

Vania Fernandez, MD and Martha Rodriguez MD, PLA alumni, co-chaired the 2021-2022 PLA program. They share that the experience was so life-changing that they remain involved to support program development and facilitation. The program is offered through a collaboration with the Palm Beach County Medical Society Services (PBCMSS) and the Broward (BCMA) and Dade County Medical Associations (DCMA). Funded through a grant from The Physicians Foundation and endorsed by the Florida Medical Association, PLA is designed to support physicians who want to hone their leadership skills.

Five of the six sessions were held in person, one session moved to a virtual platform due to a spike in COVID19 numbers. In addition to the six sessions, all PLA participants completed group projects. Group projects this year included Physician Wellness, Vaccine Hesitancy, and Resources for Mental Health. Objectives included identifying obstacles physicians encounter related to wellness, Empowering physicians with strategies to address COVID19 vaccination misinformation/hesitancy, and strategies to assist patients navigate mental/ behavioral health resources. The graduation luncheon included a panel discussion with alumni Jennifer S. Capezzuti DO, Dr. Jose David Suarez MD, Ramon

Cuevas-Trisan MD who shared the impact the Leadership Program has made on their professional development.

Since PLA began, 98 physicians have completed the academy, learning such topics as: understanding leadership styles and relationship building, advocacy and physician engagement, presentation skills, crisis management, cultural agility, innovative models of care and ethical leadership. The 2022-2023 PLA program dates are pending.

Physician Leadership Academy Graduating Class

Broward County Alia Abdulla, DO Carmel Celestin, MD

Dade County

Palm Beach County

Raul Grosz, MD

Estelamari Rodriguez, MD, MPH Audrea Vaughan, DO, MPH

Colette K. Brown-Graham, MD, MPH Seneca Harberger, MD

Lia S. Jamian, MD

Heather M. Johnson, MD

Harish T. Madhav, MD, MPH

Vicki Norton, MD

For more information, contact Karen Harwood, director of Community Programs at karenh@pbcms.org or 561-433-3940, ext. 119.

Left to right – Jim Sugarman, Karen Harwood, Jennifer Capezzuti, DO, Jeffrey Block, MD, Antonio Wong, MD, Vicki Norton, MD, Colette Brown-Graham, MD, Raul Grosz, MD and Seneca Harberger, MD.

Next Row: Left to right – Carmel Celestin, MD, Alia Abdulla, DO, Estelamari Rodriguez, MD, Kelly Skidmore, Audrey LaNoce, DO and Ann Marie Font, MD.

Front Row: Left to right – Audrey Vaughan, DO, Ramon Cuevas-Trisan, MD, Vania Fernandez, MD, Carmel Barrau, MD, Heather M. Johnson, MD and Angel Bosch-DeLeon.

HEROE S MEDICINE

We celebrated our HEROES IN MEDICINE on May 26, 2022

Thank you to our Mistress of Ceremonies, Liz Quirantes

PHYSICIAN HERO Jay Peitzer, MD Trustbridge Hospice Care

BRUCE RENDINA HERO Mark Di Corcia, PhD Charles E. Schmidt College of Medicine, FAU

COMMUNITY HERO El Sol Jupiter’s Neighborhood Resource Center

HEALTH CARE PROVIDER (NON-PHYSICIAN) HERO

ICU Nurses VA Healthcare System, WPB

LIFETIME ACHIEVEMENT AWARD

Larry Bush, MD Wellington Regional Medical Center –Comprehensive Infectious Disease Group

HEROES IN MEDICINE FINALISTS

Major Jeffrey Frankart, PT Founder, The Fix Henry Haire, MD Charles E. Schmidt College of Medicine, FAU

Shamilla Lutchman Florida Department of Health, WPB Pam Tahan, CEO Wellington Regional Medical Center

Jay Peitzer, MD Mark Di Corcia, PhD

Larry Bush, MDEl Sol ICU Nurses

THE IMPORTANCE OF ADVANCE DIRECTIVES AND THE DESIGNATION OF A HEALTHCARE SURROGATE

Stuart Bagatell, MD

ETHICS CASE STUDY

A 77-year-old man was evaluated in the hospital for the treatment of a non-healing wound of the right foot. The patient had a history of coronary artery disease, heart failure with reduced ejection fraction, type 2 diabetes mellitus, hypertension, a history of stroke, and a history of vascular dementia. Diagnostic imaging at the time of admission demonstrated significant peripheral arterial disease and osteomyelitis involving the posterior portion of the calcaneus. Vascular surgery and podiatry teams recommended a below the knee amputation. However, because the recommended procedure was not considered emergent, consultation with psychiatry was sought to determine if the patient had capacity to make decisions and they deemed him incapacitated. The patient did not have an advance directive outlining his preferences for care nor had he designated a healthcare surrogate, but a nephew that resided outside of the United States agreed to act on behalf of the patient. However, when the team caring for the patient attempted to communicate with the

nephew to outline the risks and benefits of the proposed treatment plan, he would not answer his phone. An ethics consultation was requested.

CASE DISCUSSION

Questions about who is able to make decisions on behalf of an incapacitated patient is a common reason for an ethics consultation. The best-case scenario occurs when a patient has completed an advance care directive and has designated a healthcare surrogate, as the healthcare team and the designated surrogate are obligated to carry out the known wishes of the patient. Primary care doctors in the outpatient setting are best suited to have advance care planning conversations with their patients and can be reimbursed for their efforts by using CPT codes 99497 or 99498. The situation gets complicated when there is no advance directive. Fortunately, Florida Statute 765 outlines a process that should be followed when faced with this dilemma, but no law can anticipate every situation that may arise in the complex world of practicing medicine. In the case outlined above, the care team was struggling to do no harm while providing the most benefit to their patient. Without the ability to have a dialogue with the patient to fully elucidate his own goals and wishes, the care team was forced to follow the

“WITHOUT THE ABILITY TO HAVE A DIALOGUE WITH THE PATIENT TO FULLY ELUCIDATE HIS OWN GOALS AND WISHES, THE CARE TEAM WAS FORCED TO FOLLOW THE “BEST INTEREST” STANDARD.”

“best interest” standard. The care team (which after several weeks in the hospital included specialists from internal medicine, infectious disease, neurology, critical care, nephrology, cardiology, psychiatry, and palliative care) continued to provide supportive care, but during his nearly two-month hospital course he developed irreversible complications.

Finally, a healthcare proxy was appointed per Florida Statute, the difficult decision to withdraw lifesustaining treatment was made, and the patient died. Having these difficult conversations before patients are in extremis, using tools like the Conversation Project or Five Wishes, will go a long way in preventing the pain and suffering that patients as well as the healthcare team endure in the last days of a terminally ill patient’s life.

MEDICAL SPECIALISTS OF THE PALM BEACHES, INC.

We are honored to celebrate the past 20 years of medicine in Palm Beach County and we look forward to the future.

Medical Specialists of the Palm Beaches

is the largest group of primary care and multi-specialty physicians. Today, we have 25 locations and over 70 physicians along with 15 mid-level providers. Our highest priority is our patients’ health and well-being.

OUR DOCTORS SPECIALIZE IN Family Medicine | Internal Medicine | Geriatrics MSPB Gold Concierge Healthcare | Cardiology Dermatology | Hematology/Oncology Neurology | Endocrinology

For more information, send an email message to pbcms@pbcms.org or call 561-433-3940.

OUR SERVICES INCLUDE Nuclear Stress Test | Laboratory Electrocardiography, Holter and Event Echocardiography Monitoring

Please visit our website www.MSPBHEALTH.COM for more information or call (561) 649-7000, option 5. Let us help you choose the right MSPB doctor and welcome you to the MSPB family.

ON

PHYSICIAN HEAL THYSELF

By Dr. Louis T. Joseph, MD and Bruce Saltz, MD.

Bruce Saltz, MD

Nearly all of us have treated someone with clinical depression. Some of us have suffered from it ourselves. As we know, it is incredibly common. Research demonstrates that people have a 1 in 5 chance of being afflicted over a lifetime. Physicians are not immune. Physicians are considered an at-risk profession for suicide and depression. The pandemic has not helped, increasing risk factors for depression, including physician burnout. Interestingly, data suggests that it is depression and not burnout, defined by the AMA as an occupational syndrome, which results in a higher risk for suicide. It is in this environment of systemic stress that a recent call to action was made by the Surgeon General in May 2022 to address the burnout and mental health crises evident in the health workers of this country. In light of such efforts, I remain cautiously optimistic that such initiatives will translate into improved physician mental well-being.

Physicians have historically been a group that is averse to seeking formal medical treatment, including seeing a primary care provider. However, in many respects, physicians also live healthier lifestyles than the general population. Treatment privacy is of the utmost concern

to physicians, even more when they seek treatment for mental illness. For decades, many physicians have been reluctant to pursue mental illness treatment given the potential ramifications such treatment can have on their ability to practice and maintain their livelihoods. Every physician is aware of the infamous list of benignly worded, routinely appearing questions on every medical license and credentialing application. Questions that usually start with phrases such as, “Have you ever…..“ or “Within the past two years have you…..?” Many are also aware of the Kafkaesque stories of a fellow physician who self-disclosed on one of those questions only to find themselves later appearing before a medical board or some other bureaucratic committee explaining why they are fit to continue their practice of medicine. Such incidents undoubtedly create an unimaginable magnitude of shame, self-doubt, and anxiety over real or anticipated financial and hardship and in essence bolster the risk of Physician suicide. I have served on many such committees over the course of my career in defense of Physicians. In my opinion, it is frankly a perverse dilemma. In purportedly attempting to ensure public and patient safety, governing bodies have created

Louis T. Joseph, MD

“EVERY PHYSICIAN IS AWARE OF THE INFAMOUS LIST OF BENIGNLY WORDED, ROUTINELY APPEARING QUESTIONS ON EVERY MEDICAL LICENSE AND CREDENTIALING APPLICATION.”

a misguided social deterrent for the healers of our society to pursue healing themselves when they fall ill.

However, there is good news. The tide is turning. The public is increasingly realizing the self-defeating nature of such questions. Calls for reform are underway. There is some data suggesting that the stigma of mental illness has been effectively decreasing over time. For example, in the past several years, the Florida Board of Medicine has narrowed the scope and time requirements for questions about past illnesses. For instance, instead of asking about a lifetime history of mental illness treatment, the timeline has been shortened to the past two years. More importantly, a qualifier for disclosure has been added, only requiring disclosure if illness impacts one’s ability to practice. In light of such trends, I maintain hope that my professional colleagues will seek the treatment they need and deserve should they become afflicted.

Locally, if physicians find themselves struggling with depression, addiction, anxiety, stress, burnout or any other emotional ailment, they can seek help through The Palm Beach County Medical Society Physician Wellness Program. Information regarding this program can be found on the Medical Society website. The program is geared towards providing physicians with counseling from psychologists and licensed mental health counselors who have experience working with physicians. Should one want to pursue psychiatric care and psychiatrist delivered psychotherapy, they will have to reach out to a community psychiatrist, some of whom can be found on the Medical Society website. As a practicing psychiatrist, I care for physician patients by way of medications and counseling. I offer night and weekend appointments along with other measures aimed at accommodating physicians’ life demands and enhancing their privacy.

clearing-confusion-physician-burnout-and-depression. Accessed June 17th, 2022.

4. Dutheil F, Aubert C, Pereira B, Dambrun M, Moustafa F, Mermillod M, Baker JS, Trousselard M, Lesage FX, Navel V. Suicide among physicians and health-care workers: A systematic review and meta-analysis. PLoS One. 2019 Dec 12;14(12):e0226361. doi: 10.1371/journal.pone.0226361. PMID: 31830138; PMCID: PMC6907772.

5. Florida Board of Medicine. Medical Doctor Application for Licensure. https://flboardofmedicine.gov/apps/medical-doctor-app.pdf. Accessed June 17th, 2022.

6. Johns G, Samuel V, Freemantle L, Lewis J, Waddington L. The global prevalence of depression and anxiety among doctors during the covid-19 pandemic: Systematic review and meta-analysis. J Affect Disord. 2022;298(Pt A):431-441. doi:10.1016/j.jad.2021.11.026

7. Kalmoe MC, Chapman MB, Gold JA, Giedinghagen AM. Physician Suicide: A Call to Action. Mo Med. 2019;116(3):211-216.

8. Kessler et al. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012 September ; 21(3): 169–184. doi:10.1002/ mpr.1359.

9. Liselotteet al. Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions, Mayo Clinic Proceedings, Volume 92, Issue 10, 2017, Pages 1486-1493, ISSN 0025-6196, https:// doi.org/10.1016/j.mayocp.2017.06.020.

References:

1. Beck M. Checking Up on the Doctor. Wall Street Journal. May 25th, 2010. https://www.wsj.com/articles/SB1000142405274870411350457 526436412557450/ Accessed June 17th, 2022.

2. Berg S. When doctors ponder suicide, depression—not burnout—is key driver. American Medical Association. December 29th, 2020. https:// www.ama-assn.org/practice-management/physician-health/whendoctors-ponder-suicide-depression-not-burnout-key-driver. Accessed June 17th, 2022.

3. Berg S. Q&A: Clearing up confusion on physician burnout and depression. American Medical Association. March 3rd, 2021. https:// www.ama-assn.org/practice-management/physician-health/qa-

The practice of medicine is a highly STRESSFUL PROFESSION.

Physicians carry a high degree of EMOTIONAL TENSION, and they tend to seek help to a lesser degree and at a much later stage than other professionals.

Complex trauma manifests itself with early retirement, disengagement,

If you or a physician you know is struggling with substance abuse or other mental health conditions, please contact the strictly confidential PBCMS Physician Wellness Program for help. You can visit the "Physician Wellness" section at www.pbcms.org anytime. Telehealth and in-person appointments are readily available.

PHYSICIAN SUICIDE

Physician suicide is a serious national problem. Overall, suicide has been increasing in the USA for the last 20 years with as much as a 30% increase in some states. It is now the 12th leading cause of death in the general population with over 45,000 a year. It is estimated that 1.2 million people made a suicide attempt last year. Every year we lose 300-400 physicians to suicide. When one of us commits suicide we inflict traumatic bereavement on family, friends and frighten and demoralize patients and healthcare colleagues throughout the whole community. How can we understand and prevent this tragic loss of life? Closer to home, could it happen to you? We have treated suicidal physicians over the course of long careers and offer this perspective.

While every case is unique there are multiple common contributing risk factors leading to any suicide. First is the physician’s personality. To succeed we are compulsively attentive to detail and work very hard. We suppress our emotions and adopt a stoic attitude about our hardships. We become perfectionistic to insure the best outcome. We tend to challenge and question ourselves and are often harshly self-critical when we feel we have not

lived up to our highest expectations. We have “super -ego problems” and struggle with irrational guilt when things go wrong. We squeeze in extra patients, work later to the point of alienating our spouses and children, and ignore our own emotional and physical needs. These habits and style of coping set us up for burnout and depression. As we learn more about the ravages of work stress, take part in wellness programs and seek a better balance between work and personal life, we can reduce our risk of burnout, depression and suicide. But there is only so much we can do improving resilience to protect ourselves from the stress of the worsening medical practice landscape.

The second group of risk factors arise from the worsening practice environment. We have lost autonomy, must struggle with the EHR and computer systems, are burdened by prior authorizations, and suffer more Medicare regulations and reduced reimbursements. These and other practice problems cause us to feel overwhelmed and lead to burnout and depression. The COVID pandemic topped it all off causing us all to face endless complications, tragic death of patients, loss of revenue, endless overwork and serious risks to our own health. Unfortunately, many of us physicians ignore our own care. Since 25% of us do not have a primary care physician, they miss out on the annual examinations, depression screenings and chance to confide their problems to their own physician and avoid isolation. Another toxic risk factor is the fear of

WE HAVE “SUPER - EGO PROBLEMS” AND STRUGGLE WITH IRRATIONAL GUILT WHEN THINGS GO WRONG.

Bruce Saltz, MD, DLFAPA

Stefan A. Pasternack, MD, DLFAPA

Abbey Strauss, MD, DLFAPA

stigmatization. Even when a depressed physician knows he or she is in trouble they avoid seeking help because they fear being labeled as mentally ill and having to report any psychological diagnosis and treatment on hospital privilege applications. Even among a sample of psychiatrists who should have known better, fear of stigma kept many from seeking help and led them to self-medicate. Thus, concerns about confidentiality, shame, guilt and fear of revealing their problems even to a trained non-judgmental mental health professional deters doctors from getting help amid a worsening practice environment.

Finally, there is also the ever-present threat of a malpractice lawsuit, one of the most depressing and stressful experiences we can suffer.

Over time, the noose of stress and burnout slowly tightens as external stressors and internal reactions of guilt, shame, feelings of inadequacy and fears of failure mount up. Keep in mind that suicidal ideation is both conscious and unconscious. Long before a person is consciously aware of thinking of suicide, they have many unconscious warning signs of it. These often manifest as unexplained sadness or anxiety, alienation, psychosomatic symptoms with aches and pains, poor performance, social isolation, substance abuse and marital problems. As awareness of the danger occurs, someone consciously thinks about suicide and can tell others of their danger and may do so if asked. However, a profound sense of aloneness, shame and fear of humiliation and despair -may cause a potentially suicidal physician to hide their suicidal ideation. Then another setback or blow to self-esteem- such as marital or financial problems or worst of all a malpractice lawsuit- can set off a cascade of quiet hidden destructive thinking. Reality testing is impaired as a physician sworn to fight for life loses perspective and concludes suicide is a perfect solution to a life crisis.

Suicidal ideation is like a Staphylococcus septicemia-it can spread in rapid “toxic” fashion. Deep psychic pain, feelings of futility, inadequacy and hopelessness take hold. Shame, anger, and self-hatred turned inward erupt in a blinding state of frantic helplessness with no overt sign of the crisis until moments before the suicide attempt. All too often surviving spouses and friends of a physician who killed him or herself say “He/ she seemed ok, just tired. I did not see it coming.” This

was exemplified by the tragic suicide in 2020 of a young emergency room physician at New York Presbyterian Medical Center who was so overwhelmed by COVID deaths that life seemed unbearable.

So, what can we do? First consider this: Solving burnout and preventing physician suicide will take more than increasing our resilience through wellness programs. That is of course important: each of us must seek a healthy balance between work and personal life and foster mindfulness and self-care. But we must also bring pressure to bear on all health care organizations to improve the work environment and implement wellness programs, involve physicians in making decisions that impact how their organizational systems work and how many patients they must see each day. We need a system to grade healthcare organizations and large group practices (especially those controlled by venture capital investment groups) regarding the “wellness” of their work environment. This will enable physicians seeking employment to find the best work environment. This may motivate health care organizations to do a better

SUICIDAL IDEATION IS LIKE A STAPHYLOCOCCUS SEPTICEMIA-IT CAN SPREAD IN RAPID “TOXIC” FASHION. DEEP PSYCHIC PAIN, FEELINGS OF FUTILITY, INADEQUACY AND HOPELESSNESS TAKE HOLD.

job at promoting wellness. All healthcare organizations and accountable care groups should take part in the AMA “Joy In Medicine Recognition Program.” (see the recent On Call Magazine on Physician Burnout: The Role of Health Care Organizations.) This program is designed to encourage healthcare systems to foster physician wellness and to improve their work environments to reduce risk factors for burnout. Both the Mayo Clinic and The Southern California Permanente Group have done so, setting an excellent example for other groups. It is important for people in the trenches to know that the leaders of their health care groups hear them and care about them.

Finally, as a Medical Society we have to keep up our efforts to heighten awareness about stress in practice, burnout, how to improve coping and resilience skills, how to improve our work/life balance, and to deal with the stress of a malpractice law suit. Take any suicidal ideation seriously and seek help promptly. We also have to provide information about forms of psychiatric treatment that can help us avoid depression, anxiety, burnout and suicidal ideation and to overcome the stigma

of treatment. The PBCMS has taken an important step with the Physician Wellness Program.

By Stefan A. Pasternack, M.D. DLFAPA, Bruce Saltz M.D. DLFAPA, and Abbey Strauss, M.D. DLFAPA.

The authors are Distinguished Life Fellows of the American Psychiatric Association and have been active in the Physician Wellness Program at PBCMS.

STETHOSCOPE DONATIONS THANK YOU

The Palm Beach County Medical Society is supporting the Florida Atlantic University Charles E. Schmidt College of Medicine incoming class of medical students with the presentation of a new stethoscope at their “white coat” ceremony. Thank you to the following who have so graciously donated money to support our incoming FAU medical students.

Patricia Anastasio, MD

Jose Arrascue, MD

Stephen Babic, MD

Jeffrey Mark Berman, MD

Larry Bush, MD

Anthony Campo, MD

Yefim Cavalier, DO

David Dershewitz, MD

Howard Doyle, MD Roger L. Duncan, MD Judith Dunn

Ivy Faske, MD

Allison Ferris, MD

Finemark Bank Joseph P. Goldberg, MD

Howard Goldman, MD Mark A. Goldstein, MD

Faustino Gonzalez, MD

Kwamena Goodin

James Heron, MD

Marc Hirsh, MD

Reuben M. Hoch, MD

Gordon L. Johnson, MD Stuart Katz, MD

Kitonga Kiminyo, MD

Joseph Z. Krause, MD, PA Ricardo A. Leano MD, MBA

Claudia Mason, MD

Casandra Mateo, MD

Medical Specialists of the Palm Beaches Tom Murphy Vicki D. Norton, MD

Stefan A. Pasternack, MD

Alan Pillersdorf, MD

Scott Raffa, MD Phillip Scott Rice, MD PhD Martha Rodriguez, MD PA Mark Rubenstein, MD

Zbigniew Scheller, MD Brent M. Schillinger, MD Debra A. Schwinn MD David Shulan, MD

Mollie Shulan, MD Kelly Skidmore Joshua Solano, MD Ben Starling III Mark Stein, MD Rowena G. Uy, MD Maureen Whelihan, MD Dr. Michael & Mrs. Denise Zeide Jack Zeltzer, MD

the new Workers’ Comp Insurance rate decrease that took effect on January 1, 2021, there is no better time than now to switch to AmTrust

There is no better time to move your coverage. Rates have dropped as of January 1, 2021, and should you decide to switch, you have nothing but upsides:

• Take advantage of the NEW decreased rate

• NO penalty should you decide to switch coverage

• You can carve out coverage from your PEO

• Pay-As-You-Owe workers’ comp premium automated payment solutions through AmTrust

• Potential dividend of up to 30% of your premium

AmTrust North America has been a true partner to the PBCMS and Danna-Gracey for many years, and now, with the resources of AmTrust - rated “A” (Excellent) by A.M. Best - we are able to provide this exclusive enhanced dividend program that is like no other for Florida physicians and medical practices.To date, these programs have given back over $9 million in dividends to Florida medical society members insured through these programs.

For more information on the workers’ compensation insurance program, contact Tom Murphy of Danna-Gracey at murphy@dannagracey.com or 800.966.2120 .

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