"Physicians Are Rising For Justice In Medicine" Cover Art Created by Douna Montazer, M.D.

ISSUE 3 | VOLUME 1

APRIL/MAY 2020 2020 IS THE YEAR OF CLEAR VISION FOR PHYSICIANS AND PATIENTS ALIKE

WWW.PHYSICIANOUTLOOK.COM PUBLICATION DEDICATED SOLELY TO PHYSICIANS AND THEIR PATIENTS

Cover art by Dr. Douna Montazer

F R O M T H E P U B LIS H ER

COVID 19’s Silver Lining PHYSICIANS ARE RISING FOR JUSTICE IN MEDICINE

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Wri t t en by D r. Ma rl ene Wu st- S mi t h

onths ago when we launched Physician Outlook I made the decision that the cover art will always be an original work created by physicians. Our first cover featured an eye-catching image (no pun intended) of a surgeon that was digitally mastered by Dr. Dana Corriel, the creator and founder of SoMeDocs. The cover of our second issue was inspired and created under my direction and features Obamaesque renditions of real physicians in personal protective equipment (PPE), inspired by the ridiculous fiasco of our nation’s hospitals not having enough PPE for their workforce.

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The cover of the current issue is titled “Justice in Medicine” and was painted on canvas by Dr. Douna Montazer, a board-certified psychiatrist who dreams of making a difference in healthcare through her work. She is a self-taught artist who uses painting to represent the emotions being experienced by patients and physicians. In the meticulously detailed painting on the cover she cleverly depicts the Caduceus (the universal symbol of healing) as a woman (Lady Justice) in place of the usual central wand or staff.

She is an angelic figure dressed in white, who is weighted down by a heavy anchor, but is in the process of being freed by heavenly doves.

Every time I look at this masterpiece I see another detail that provokes thought and inspires reflection. It is subject to interpretation and to the viewer’s eye whether this lady in white represents a patient or a doctor.

In my mind’s eye she represents a bound and gagged version of myself, a physician who loves her profession and her patients but whose voice and vision has been quieted and blinded by outside forces.

Conversely, the non-medical person identifies Lady Justice as a patient whose vision is blocked by the blue serpent that represents the corporatization of medicine, and whose voice is being silenced

P HOTO COU RTE SY OF IN GRA M IM AGE S

by a green greedy medical system that has become over-wrought by corporate “suits” with Pinocchio-like olfactory systems.

Dr. Montazer’s “Lady Justice” is a truly breath-taking piece that in real life stands 62 inches by 74 inches. One of the coping mechanisms that I am personally employing to deal with the anxiety provoked by our current Groundhog-Day existence is to create a “post-COVID19 quarantine bucket list.” Seeing this beautiful painting in person and giving Dr. Montazer a proper (non-socially distanced) hug is on my list.

What exactly is “Justice in Medicine?” The current coronavirus pandemic

has revealed that we live in an un-just world. In the United States, this evil virus appears to discriminate against our brothers and sisters of color, disproportionately affecting and killing those whose skin is brown or black. Why is that? Is it because people of color have more angiotensin-converting enzyme (ACE2) receptors and co-morbidities such as hypertension and diabetes? Or is it because our healthcare system disproportionately depends on “essential workers” who are economically disenfranchised?

Why are the brown and black of other countries not experiencing the burden of disease we are seeing in the United States? As Dr. Immanuel points out in her piece, there is no ability to socially distance in the over-populated ghettos of Calcutta, yet the burden of disease due to COVID19 in India pales in comparison to that of the United States and other countries The same relatively low morbidity and mortality currently holds true in Africa. We need to stop politicizing possible treatment regimens, and fund more clinical trials in real-time. We also need to expose the complex middleman problem in the U.S. that allows Group Purchasing Organizations (GPOs) and Pharmaceutical Benefit Managers (PBMs) to control the price of everything and our supply chain.

Justice in medicine means giving physicians the FREEDOM to practice medicine. It means giving patients the FREEDOM to choose physician-led care. Physicians are rising more than ever before to advocate for and protect these freedoms - through their art, humor, poetry, writing, ministry. And they are leading by example, harnessing the power of technology for physician-led solutions to the problems putting our freedoms at risk. This is the land of the FREE, and the home of the BRAVE. 1

Dr. Marlene Wüst-Smith Publisher

1st Cover Art By Dr. Dana Corriel

2nd Cover Art By Dr. Marlene Wust-Smith

3rd Cover Art By Dr. Douna Montazer WWW.PHYSICIANO U T LOOK . C OM | 3

PERFECTING THE IDEAL

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A PRI L|MAY 2020

Table Of Contents FROM THE PUB LISHER

COVID 19’s Silver Lining

By Dr. Marlene Wust-Smith / p.2 VIPP SPOTLIG HT

Peter Valenzuela The Doc Behind Doc-Related /p.7 Physician Deaths And COVID-19

By Paula H. Cookson LCSW /p.8 Honoring Physician Trainees Lost To Covid-19

By Dr. Pamela Wible /p.10 SoMeDocs

By JR Hill /p.12 NEW NEWS

Metabolic Strategy: Fasting And Keto During A Quarantine

By JR Hill, /p.14 Pandemic: A Profession In Peril Forgotten Again When They Need Us Most

By Dr. Samantha Brown Parks /p.16 Imagining A World Post-Covid

By Dr. Dalilah Restrepo /p.18 ADVOCACY IN ACTION

Babblings: Until The Curtains Fall.

By Dr. Megan Babb/p.20 Unsettling Revelations Emerge With Walgreens And Labcorp

By Estine Wells/p.22 Leadership In The Time Of COVID19

By Dr. Stella Immanuel/p.24 OFFICE SPACE

Using Technology To Put Physicians In Control

By Dr. Leah Houston/p.26 The Role Of Financial Freedom For A Physician During The Covid-19 Era

By Dr. Christopher Loo/p.30 TIME FOR YOU

7 Therapy Alternatives For The Creative Mind

By Grace Huang /p.32 The Gift Of Time In A Pandemic Through The Eyes Of A Physician Mom

By Dr. Ayushi Chugh /p.36 Why Grow Your Own With Your Kids?

By Dr. Marion Mass/p.38 INT ELLIG ENCE ON T HE MOVE

Quarantine Resources

By Pamela Ferman/p.39

From Medicine To Ministry Coming Out Of The Closet

By Dr. Seema Khaneja/p.40 COVID-19 The Evolution Of A Pandemic

By Dror Rom, Ph.D, Jaclyn McTague, MA, MS, Michael Pol, MS/p.43 WWW.PHYSICIANO U T LOOK . C OM | 5

MEDICINE IS

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Peter Valenzuela The Doc Behind Doc-Related Doc-Related provides a hilarious perspective on the challenges of practicing medicine today as seen through the eyes of physicians and clinicians working in a large healthcare system.

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r. Peter Valenzuela is a nationally recognized physician leader and satirist. Peter has been profiled in journals ranging from Healthcare Design Magazine to Medical Economics to Physician Leadership Journal. He’s also been featured on Docs Outside the Box, Outcomes Rocket and The Happy Doc podcasts.

When not focused on his duties as the chief medical officer of a large

multi-specialty group in the Sonoma Valley or making international presentations on change management, health care innovation and leadership development — Dr. Valenzuela channels his energy into his side project. He is the creator of Doc-Related, an online comic strip that offers a satirical look at the challenges of practicing clinical medicine through the eyes of health care professionals. Over the past year, Peter

has become one of the most sought-after cartoonist in the medical industry.

The Happy Doc has referred to his comics as “Dilbert for Health Care”.

His humorous, creative style has led to him twice being recognized by the Medical Group Management Association and American College of Medical Practice Executives (MGMA-ACMPE) with the Harwick Innovation Award and Physician Executive of the Year Award for meeting the challenges of health care head-on and exhibiting leadership deemed outstanding to achieve exceptional medical group performance.

Peter has practiced family medicine for over two decades. He attended medical school at UT Southwestern in Dallas and completed his family medicine residency at John Peter Smith Hospital in Fort Worth, Texas. He earned a master in business administration from Auburn University in Auburn, Alabama. In addition, Dr. Valenzuela holds a greenbelt certificate for six sigma in healthcare from Villanova University and a healthcare innovation and entrepreneurship certificate from Duke University. He is also an alumnus of the exponential medicine program through Singularity University. 1

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Physician Deaths And COVID-19 Wri t t en by Pa u l a H. C o o k so n LC S W

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s if the healthcare field were not stressful enough, along came the international pandemic, COVID-19. Physicians who were already burdened and experiencing the detrimental effects of the bureaucratic medical system have become absolutely overwhelmed. Droves of deathly ill patients, and poorly equipped facilities, have left medical professionals scrambling to provide critical care; it is a surreal situation; a nightmare that health professionals are living every day. Our medical professionals are getting sick from COVID-19, and many are dying.

COVID-19 has shown us how 8 | A P RI L / M AY 2 0 2 0

misinformation, politicization and lack of proper equipment can result in catastrophic loss. Among those losses include the very people who followed their calling to heal the sick. These medical professionals were also mothers, fathers, brothers and sisters, grandparents and best friends. They had lives outside of medicine; they had loved ones, dreams and hopes. These medical professionals chose the field of healthcare and ultimately their commitment to the health of others put them directly in the danger zone of the pandemic that took their lives. Future accounts of this pandemic and the catastrophic loss of lives will tell the story of why so

many of these deaths could have been avoided. Will we learn from the losses of COVID-19? Will we allow the grief of this pandemic to inform us on better healthcare management systems and prioritizing patient care and physician support on a national level?

Inadequate Personal Protective Equipment (PPE) Physicians and health care workers on the front lines have been doing battle with coronavirus with insufficient armor. Similar to September 11, 2001, when firefighters and police officers had insufficient safety equipment to do their jobs, health providers are in

IMAGE BY ROTTONARA FROM PIX ABAY

the same bind with COVID-19. Insufficient supplies, coupled with utilization of under-trained professionals in some sectors, places health professionals, and the general public, at risk. It is a travesty that in this affluent country that leads the world as an example of freedom and democracy, we have failed our first responders during crisis, yet again.

Helping professions such as firefighters, law enforcement and medical providers are the most difficult and demanding jobs out there, crucial to our safety and stability as a nation. Insufficient access to the tools necessary to do these jobs properly is an insult to their collective professions. Personal protective equip-

ment (PPE) is in such short supply that physicians and other medical providers are being advised to wear masks for one week at a time, well beyond their protective characteristics.

Worse yet, some medical professionals have even been told (by hospital administrators) to remove their PPE all together. Doctors, nurses and other health professionals have been fired for talking to media; others have been threatened with job loss. Medical personnel are having their jobs threatened for self-advocacy and trying to create safety for themselves and their patients. Some physicians have reported that they are being told to remove PPE because it scares patients. It seems as if fear is a healthy response at a time like this, does it not? Providers on the front lines of this viral nightmare are being hamstrung and micromanaged by administration who is more concerned about corporate reputation than lives being saved or the safety of the medical staff.

Is it any wonder medical professionals are dying? As with the general public, older providers and those with underlying health conditions are at higher risk of additional complications and death from COVID-19, but all who encounter the virus are at serious risk. Senior resident Chris Firlit, MD is one example of this tragic outcome, losing his life at age 37. He leaves behind a wife and three children. Neurosurgeon Dr. James Goodrich who famously separated conjoined twins in 2016 also died as a result of COVID-19.

There are countless other tragic losses of physicians on the front lines who have died as a result of this virus. We can placate ourselves by lauding these providers as heroes who gave their life battling this pandemic, but the reality is they are victims of a system that was ill-prepared and willing to trade their safety and ultimately their lives for bureaucratic nonsense. Where’s the compassion? Shouldn’t our hospital administrations operate by the same oath as their physicians, do no harm?

We’re sending our brave front-line defenders into battle with broken b-b guns and water pistols, and they are dropping like flies.

Remember the Sunshine Act? Transparency in the field of medicine is crucial to avoid corruption.

Hence, the Sunshine Act. At a time when supplies are low and lives are on the line, it is time to shine some light on the truth about the mafia-like supply chain that is preventing medical professionals from getting PPEs. World Health Organization has offered guidance regarding the use and distribution of PPEs during COVID-19, including appropriate infrastructure and management of supply chains. The hoarding and improper distribution of PPEs, as well as price gouging that has become the new norm during this pandemic needs to be eliminated if this virus is to be defeated. We’re sending our brave front-line defenders into battle with broken b-b guns and water pistols, and they are dropping like flies. Medical professionals provide care to all; who is going to care for them? It is high time that the people who are “managing” the providers and the business-end of the medical field step up and apply ethics to their management practices. Continuing to neglect the basic needs of providers is passive aggressive; demanding that physicians remove PPE and put themselves at needless risk is abusive.

As this pandemic continues to spread and take lives, we need to honor the medical professionals who are at highest risk of infection due to their proximity to COVID-19. Let our grief for the losses of these brave professionals be tinged with anger, since so many of these deaths were preventable had proper PPEs been available. Greed, politics and bureaucracy may be the cause of many more deaths before we wake up and put human lives first. 1 WWW.PHYSICIANO U T LOOK . C OM | 9

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Honoring Physician Trainees Lost To Covid-19 Wri t t en by D r. Pa mel a W i bl e

r. Christopher Firlit, age 37, a PGY6 senior oral maxillofacial surgery resident in Detroit, Michigan, was to graduate in 3 months. He developed a fever and his chief fellow drove him to Providence Hospital where he died on April 3 of suspected COVID-19. He was employed at Ascension MacombOakland Hospital. He leaves behind his wife and three children.

An Anesthesia Resident in New York City has been reported to have died of COVID-19. A mother, she leaves at least one child behind.

An Internal Medicine Resident in New York City has been reported to have died of COVID-19. A PGY1 male, age 26, with no underlying health conditions ended up on ecmo (a heart-lung by-pass machine) at Montefiore Medical Center where he died on April 3 from a catastrophic brain bleed, according to an ICU doctor. As an International Medical Graduate (IMG) from Pakistan, his visa is sponsored by his employer, reported to be Elmhurst 1 0 | A P RI L / M AY 2 0 2 0

Hospital (Mount Sinai Health System).

Recently married, his spouse may now be deported.

It’s been more than two weeks. No media outlets have covered these New York resident physician deaths. Why? Hospitals are censoring doctors—threatening termination for breaching “media guidelines” if they speak to reporters. So physicians have asked me (in emails published with permission below) to honor our fallen physicians: “I am a resident in NYC. We have heard of multiple resident doctor deaths in the past 2 days (outside of my hospital system). We have heard rumors of gag orders being placed, preventing any publicity around their deaths. It is unclear if they had access to PPE. Could you advise how to stop these resident deaths from remaining secrets when they deserve to be honored? Is there a news outlet we can talk to to publicize this?

Please keep me anonymous. Thank you for your help.”

“I am sure others might have contacted you about this issue already because of all of the work you have done on the topic

of resident/student deaths from suicide and how it’s not talked about. I am a member of a COVID-19 group on Facebook that has mentioned possibly 3 or 4 medical residents dying from COVID-19 in the last 7 days. In the news there has been one death acknowledged-—Dr Firlit from Detroit.

I don’t know if there are actually 3 more young trainees who have succumbed to this but I work with residents/fellows/students and am hoping to prevent further devastating loss. Thank you.”

“Dr. Wible, I was wondering if you’ve been hearing about the eerie silence around resident physician deaths (and physician deaths in general) during the pandemic. It seems that every resident I’ve spoken to here on the East Coast knew within a day that 2 residents had died from COVID-19 after being on the frontlines, but our hospital administrators have been silent. In fact, I know a resident who tweeted a text screenshot from a friend who had heard the news, and is now being reprimanded by her department and was asked to delete the tweet.

The most suspicious part of me is concerned that hospitals are working to keep these sto-

ries from getting out to prevent residents from losing morale. Or rather, from realizing more and more that we are being tossed around like possessions and thrown into a burning mess created by the government and hospital administrators’ failure to prepare. We don’t even matter enough to them to deserve hazard pay, like our colleagues in nursing are (rightfully) earning when they volunteer. In the same way physician suicides are covered up, I believe our deaths now on the frontlines are being minimized so as to keep us grinding away, unprotected

by PPE or workers’ rights. Thank you for all your work in amplifying our voices, when people are losing their jobs and lives left and right.”

I’ve witnessed hospitals cover up physician deaths since 2012 when I began investigating why so many doctors were killing themselves inside our hospitals. For 8 years, I’ve been running a doctor suicide hotline. I’ve now amassed a registry of 1,473 doctor suicides. Root cause analysis reveals hazardous working conditions and human rights violations as the culprit. Predating the pandemic, medicine’s well-hidden physician suicide epidemic became the focus of a now newly released award-winning documentary—Do No Harm: Exposing the Hippocratic Hoax—by an Emmy-winning filmmaker. View the world premiere streaming live this Sunday, April 19 at DoNoHarmFilm.com.

I’m very familiar with censorship by medical institutions. Parents who lost children to suicide during medical training have been given honorary diplomas for signing nondisclosure agreements preventing them from speaking about their own child’s death. One mom told me she was offered hush money by the med school to keep quiet about her son’s suicide. Residents have been threatened with termination for speaking about their colleagues’ suicides.

Hospitals don’t want you to know about these hazardous working conditions that are killing doctors—and patients (especially during the pandemic).

Thank you for caring about our healthcare heroes who have died. 1

I BET YOU DIDN’T KNOW THAT: 1) New doctors are forced to work 28-hour shifts for less than minimum wage—and they’re the workhorses in our hospitals. After graduating medical school, residents must work up to 7+ years in hospitals, 80 hours weekly (some 100 or more) while severely sleep deprived leading to medical mistakes that have harmed—even killed patients. During the pandemic, residents have been forced to work even longer without hazard pay, 2) Hazardous working conditions cause new doctors to age six times faster than their non-medical peers. Scientific studies prove that residency leads to serious chromosomal damage and a weakened immune system that places new doctors at high risk for illness— including dying from COVID-19.

3) International Medical Graduates are most vulnerable to abuse. Hospitals bank on the fact that foreign doctors from poor countries can’t defend themselves. If they don’t submit to abuse, hospitals fire them and they’re deported. Without local friends and family IMG COVID-19 deaths are easier to hide. Without a local support system, many have no online obituary and no friends posting tributes on social media. Not to mention, how in the world will grieving family members overseas get their body shipped back with pandemic travel restrictions? Devastated families have no emotional (or financial) resources to defend themselves and their loved ones from the criminal practices of US hospitals.

4) Doctors with inadequate protective gear are infecting themselves—and their patients.

Asking doctors to use the same mask all week is like asking a gynecologist to use the same speculum all week or asking a prostitute to use the same homemade condom (made out of a trash bag) all week.

5) New doctors with shattered immune systems and inadequate protective gear are inhaling large viral loads. Highest risk specialties include the three doctors honored here—Dr. Firlit, who performs oral maxillofacial surgery as well as anesthesiology residents responsible for intubations, and internal medicine residents running COVID ICUs. Doctors who refuse to submit to hazardous working conditions caring for COVID-19 patients, are fired.

6) When residents die from unsafe working conditions, hospitals should face wrongful death lawsuits. If you’re a resident physician, here’s how to protect yourself from hazardous working conditions. If you need help, please contact me here or join our free support group for medical trainees. If you know the names of residents who have died from COVID-19, please share (even anonymously) as these beautiful people who have sacrificed so much of their lives to help and heal others deserve to be honored, not thrown in a body bag and discarded like medical waste.

Note: If anything I’ve written is incorrect please feel free to update me so I can update this with the truth (surprisingly challenging to find out the truth). This is my best guess based on all the people who have contacted me in the last two weeks. Thanks in advance for filling me in on if you know more . . . (there may be more deaths, who knows?)

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P HOTO BY DR. DA N A CORRIE L

VI PP SPOT LI G HT

SoMe

Docs Wr i t t en by JR Hill

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ntrepreneurs come from all walks of life and professions with a variety of expertise and interests and what makes Dr. Dana Corriel unique as both a physician and a business owner is her desire to connect readers and patients with some of the brightest minds and top talents in the medical field through a service she created called SoMeDocs (Doctors On Social Media).

This unique platform showcases practicing physicians who have a presence on social media. Wellness warriors and patients alike can scroll through profiles to find doctors with a specific expertise in a particular field or specialty. Her desire to impact healthcare was partially inspired by her own work and 1 2 | A P RI L / M AY 2 0 2 0

presence online but also because she sees the importance of allowing physicians to connect with their audience and remove some of the barriers that historically make the doctor/patient relationship challenging. Dr. Corriel is changing the way we consume medical information and education from doctors. SoMeDocs is also a platform for doctors to showcase their talents and interests, learn from one another, and increase their presence in print, media, television or through speaking engagements.

The SoMeDocs platform has over 25,000 followers and is FREE for readers and non-physicians. It was established in 2017 and has a growing presence on Facebook, Twitter, and Instagram. You can check it out at www.somedocs.com

In addition to SoMeDocs, Dr Corriel is also a consultant who has worked with dozens of medical professionals and organizations on personal branding, content creation, and finding a voice on social media through her personal site www.drcorriel.com. Here you will find the unique ways in which she is able to share her experience, creations, and fresh ideas as both a doctor and a creative. Be sure to check out her launch of the brand-new virtual competition called Clue Climb where families can participate in a “Clue-Like” challenge in real-time playing against other families. Her lens and the way she sees the world is quirky, out-of-the-box creative and innovative and she can help you find YOUR creative within. Contact her today at www.drcorriel.com. 1

-connections & tools in healthcare social media-connections & tools in healthcare social media-

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producers, conference organizers and others can all find you and link into your work for a fitting List your profile in our Databank sogig that readers, journalists, Consume engaging written and contentcan on social media producers, conference organizersvideo and others all find you Find platforms that connect you with like-minded peers across and link into your work for a fitting gig ALL social media platforms Consume engaging written and video content on social media Find online resources to grow your business and yourself Find platforms that connect you with like-minded peers across (through courses, platforms and other unique ways) ALL social media Get inspired withplatforms ideas...we are chock full of 'em!

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Metabolic Strategy FA ST I N G A N D K E T O DURING A QUARANTINE Wri t t en by JR Hill

Metabolic Strategy: Fasting And Keto During A Quarantine Intermittent fasting (IF) has been around for centuries and has been used by many different cultures and religions for a variety of reasons and durations.

In recent years, this type of restricted eating has caught the attention of many researchers who believe that fasting can help turn back the clock on our internal aging process and offer many metabolic advantages that can extend our lifespan and help us avoid many chronic diseases linked to diet and lifestyle. This is one reason why IF has become a common strategy used by people following 1 4 | A P RI L / M AY 2 0 2 0

a ketogenic diet who are already looking for ways to optimize metabolism.

The last several years have seen a dramatic rise in the use of both IF and the ketogenic diet as a metabolic strategy to improve health, lose fat, decrease inflammation, stabilize blood sugar, and improve markers of aging. While both strategies can be used on their own, many use them together for improved metabolic flexibility.

Old Food Paradigm We are all too familiar with the common food paradigm that promotes eating three meals a day in addition to

healthy snacking to keep the metabolism “stoked” like a fire and able to burn calories at an efficient rate to stay healthy. The reality is this can cause an overconsumption of food in addition to multiple insulin spikes throughout the day. This puts a heavy burden on the liver and digestive system that can lead to metabolic shifts in body composition, inflammation, blood sugar, and cardiovascular markers that leave us tired, overweight and unhealthy.

We continue to see a rise in insulin resistance, diabetes and cardiovascular disease. This is one reason both strategies are gaining so much attention in the research and as a lifestyle choice.

Fasting is a great strategy to push reset on your metabolism and change the way you eat.

PHOTO COURTESY OF INGRAM IMAGES

and repair. One very important benefit of fasting is the initiation of the metabolic process called autophagy where old, damaged cells are eaten by the body as a way of self-cleaning and renewal.

Other notable benefits we see with fasting are an increase in insulin sensitivity, ketone production, and cognition and a decrease in inflammation, glucose, insulin, leptin, CRP, and markers of oxidative stress. What’s more, these benefits are often seen on a low carb diet and when we adhere to the macronutrient manipulation of ketogenic diet which is 70-75% fat, 20-25% protein and 5-10% carbohydrates it makes fasting a lot easier because eating a high fat diet can lead to higher levels of satiation and lower levels of hunger.

Ketogenic Diet The ketogenic diet restricts carbohydrate intake so your body uses both stored fat and consumed fat for fuel. It is a high fat, moderate protein and low carbohydrate diet that results in a metabolic state of nutritional ketosis characterized by the production of ketones for energy. If you think of the ketogenic diet as the blueprint of WHAT to eat, IF represents WHEN to eat. There are many different types of fasting that are characterized by the number of hours to fast and the number of hours to feed.

One of the most common fasting types used with the ketogenic diet is the 18/6

fasting window that represents fasting for 18 hours and eating within a 6-hour window. An example of this is having your last meal by 8PM and not eating again until noon the next day. If you are new to fasting that may seem almost impossible, but rest assured it is something you can easily work up to if you start by fasting for 12 hours, then 16, and finally 18 hours. Once you master 18/6 you can try a 20/4 fasting window or a full 24hr fast 1-2 days per week.

Benefits Of Fasting When we give our digestion time to rest it can use its energy for healing

Family Quarantine: Blessing Or A Curse?

For the time being at least, many parents are at home with their children either working from home and juggling homeschool or they have no job and are contemplating the next step. There’s no doubt this is a stressful time for many people. For some, having 24-7 access to the refrigerator and pantry is not a good idea. This is an opportunity for you and your family to take charge of your health and use this time together to encourage and support one another. Fasting is a great strategy to push reset on your metabolism and change the way you eat.

Try skipping breakfast a few mornings a week and put down all the sugary carbs you typically eat in the morning. Give your kids snacks like nuts, seeds, and cheeses if they tolerate dairy. Break your fast at lunch with a fresh salmon salad with some healthy fats like avocado, chopped eggs, and plenty of greens and watch your energy soar!! It won’t matter that your kitchen is open all day because you won’t be hungry. 1 WWW.PHYSICIANOU T LOOK . C OM | 15

P HOTO COU RTE SY OF DR. SA M BROWN

N EW N EW S

Pandemic: A Profession In Peril FORGOT TEN AGAIN WHEN THEY NEED US MOST Wri t t en by Dr. Sa m a n t ha B ro wn Pa rk s

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hen I was still in clinical practice I saw the decline of respect for our profession coming at me in the distance like a thunderstorm moving to shore from across the sea. We went from a (relatively) highly revered position with a few perks (doctor’s lounge, physician parking, once a year doctor appreciation dinners) to being treated like a glorified clerk seated behind a computer screen documenting necessary bullet points for reimbursement and doing anything necessary to improve our Press Ganey scores. Some of us happily “jumped 1 6 | A P RI L / M AY 2 0 2 0

through the hoops” and “took one for the team” to keep the status quo and keep conflict at a minimum. A few (including myself) finally jumped ship and moved on to less fulfilling roles outside of the traditional clinical practice that we loved.

If you are not acutely aware, physicians, in general, are pleasers. We want to help. We want to cure. We did not go to medical school for financial reasons. In fact, in 2007 in Primary Care I earned ONE TENTH of what many of finance colleagues earned. We did not go to medical school for the glory. We

went to medical school because we had a drive to solve problems and to help. It is our purpose. We will fight, at our own expense, to do what we feel is right, what is just, and what saves the most lives.

However, in this pursuit of honorable virtue we have given up the very tools we need to successfully complete our jobs. We did not stand up to administrators who forced us to see more patients in less time. We did not stand up to ridiculous metrics that treated us as producers and the patient as “clients”.

We allowed non-clinical individuals to step in and remove the attributes that

make us special- the compassion, the personal interaction, the LOGICAL INDEPENDENT thought process. We allowed them to change us from being physicians to being PROVIDERS. But this is not new! If you have picked up a journal or read social media, you are already aware of the battle with physician extenders encroaching and the degradation of the clinical visit with government mandated regulations and paper-less paperwork.

Thanks to a tiny bit of spikey, enveloped RNA our profession has been called to task. As our country and possibly our world face economic failure and terrifying disease, the same people who have disrespected and mistreated us are demanding that we take center stage and again do what is right. They want us to solve the problem. They want us to save their grandparents. They want us to make this go away so they can be normal again. They ask us to use our skills and our gifts to keep alive the very hospitals that discarded us just months ago. And will we do it? Hell yes we will because we are built to do it. It is who we are.

Here is where things get trickier.

We should NOT be doing it for FREE!!!

Our sacrifice is being seen as expected instead of respected. Short of a few “HEALTHCARE HEROES” memes absolutely NOTHING is being offered in return. Are you being paid more? No. Are you being cared for? No. Are you even being given the common courtesy of proper PPE? NO! The $2 TRILLION of assistance does not offer ANY aid to the ONLY PEOPLE in the world who can actually help the problem. It does offer substantial benefits to the hospitals, the elected officials, and a variety of random services not related to the pandemic. As an extra kick in the teeth you don’t even get the one time lump sum payment to help pay for quarantining your children away from you by staying in a motel when you aren’t working or buying your own PPE because some fool stole the supply from the ED.

Douna Montazer MD A

PHYSICIAN WHO DREAMS OF MAKING A DIFFERENCE IN HEALTH CARE THROUGH HER ART

TO ORDER PRINTS VISIT: WWW.DM-PHYSICIANARTIST.COM/PRINTS

@PHYSICIANARTIST

@ARTISTPHYSICIAN

Your investment bankers, lawyers, and hospital administrators are not on the front lines and they certainly are not doing ANYTHING for free. As much as it pains us to not help, I encourage you to be as vocal as possible and stand your ground. Putting your health at risk is not worth it. Demand proper PPE. Demand an increase in pay. Most of all, demand the respect that you are LONG OVERDUE! 1 Stay Safe, Sam WWW.PHYSICIANOU T LOOK . C OM | 17

Imagining A World Post-Covid Writte n b y D r. D alilah Re s tre p o

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e (healthcare workers) were already suffering the consequences of “moral injury”, working for years in a broken health system, going home at the end of the day knowing the 15 minute visit is not enough because people need more time to get to the root of problems.

That the endless documentation of irrelevant facts to comply with a billing system or liability defense was occupying the core of the note instead of the medical documents’ intended purpose which is to describe an illness and communicate it to other treating clinicians.

That despite us being the ones who understood the disease best, our power to choose diagnostics and therapies was controlled by insurance companies willingness to pay for them and so our job became more that of advocating and fighting for our patients behind the scenes, this while being the face that delivered the news and for this, we took all the punches meant for another.

Moral injury results in feelings of hopelessness, negative self thoughts, 1 8 | A P RI L / M AY 2 0 2 0

guilt and shame, basically the “imposter syndrome’s” building blocks.

To that backdrop, along comes COVID, highlighting every fault and exposing the inadequacies we have been talking about ad nauseum but that has fallen on deaf ears.

We were already overcrowded, working at capacity, underfunded and resources were scarce.

How we deal with COVID-19 will determine whether we emerge victorious, i.e. ‘post-traumatic growth’ . I am optimistic that the private sector will become interested in science again and that this collaboration can result in innovation so that our hospitals will have better equipment. This social distancing can be training for reinventing the archaic 9-5 schedule; perhaps work shifts will be staggered and less rigid in order to accommodate workers’ different lifestyles and family dynamics.

This crash course in public health and microbiology will reinforce basic concepts of preventive medicine, the importance of vaccinations, of hygiene

PHOTO COU RTESY OF DR. DA LIL A H RESTREP O

N EW N EWS

practices - especially in overcrowded living conditions and with that the societal responsibility everyone carries when you choose to live in a big city. Maybe the big city is no place for selfish individuals after all because when you have millions of roomies you will be expected to do your share.

If nothing else, this pandemic has taught us WHO are the ESSENTIAL WORKERS in a society and for that I am grateful. I would like to imagine the world will learn these lessons and our priorities will shift for the better. 1

There Is A "Secret" Message On The Inside!

EXCLUSIVE

AT

P HYSIC IA NO UTLO OK.CO M Email Hello@physicianoutlook.com For An Order $35 + shipping and handling WWW.PHYSICIANOU T LOOK . C OM | 19

P HOTO COU RTE SY OF IN GRA M IM AGE S

ADVO C AC Y IN AC TIO N

Babblings UNTIL THE C U R TA I N S F A L L .

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Wri t t en by D r. M ega n B a bb

ome days are harder than others.

Some days are filled with lighthearted discussions allowing smiles to naturally emerge. Other days they don’t come as easily. Being a physician is different than what I thought it would be. I didn’t know that it would also require the art of acting.

The clinic, the hospital, our stages.

Our patients, the audience. Corporate healthcare, our director. The practice of medicine, our performance.

Most of us who go into medicine do so for the love of science coupled with a desire to give back to our society.

We spend years learning basic sciences 2 0 | A P RI L / M AY 2 0 2 0

and then further our education by mastering the disciplines of anatomy, physiology, pathophysiology, etc. We are given no time to learn the art of acting yet our performance heavily depends on it.

This is where our directors have failed us as they dictate our actions yet do so without any valuable direction.

For me, today’s performance consists of many acts, twenty-two to be exact. There will be no intermission. I go from room to room each as a different character. The director has me assigned to play every character in this performance. I wish I had more supporting actors however my director tells me I

am enough and so I must morph myself into the image my patients require.

The hallway will be my dressing room.

I will have mear minutes to complete each costume change as I go on and off the stage, from exam room to exam room. All the while knowing that with each movement I make, my audience is judging my performance. Knowing that with each decision I make, my director is evaluating my craft.

The first patient is ready. I walk into the room, the curtain goes up. The performance begins.

I took an acting class once when I was in college. For me, as a forensic

chemistry major, this class was meant to be easy, chosen to fulfill a random undergraduate requirement. The irony, it actually was one of the hardest classes I remember taking. My professor was a self-proclaimed B-list actor who had his first break in the mid 70’s with a recurring role on Charlie’s Angels. He would later go on to tell us that the death of his character would foretell his future as an actor. Luckily he was an excellent professor with a doctorate in filmography and found a nitch teaching those who had aspirations to be either on the stage or in Hollywood. Many times he would say, “To be a good actor is to be the ultimate pretender. So much so that one is able to convince others not that they are an incredible actor but that in fact they have become the character they are portraying.”

Act One: The Depressed Patient Scene: Patient in the exam room alone with increased psychomotor agitation. She is laying on the exam table uncontrollably crying. Her mother recently died in a car accident. Enter my character: The Empath This patient needs time. A fifteen-minute visit will not suffice. My director will not allow me more time, however. I pretend this time is sufficient though I know it is not. I move through the visit, through my performance, as best as I can all the while wishing I had the time to sit and be a shoulder for this patient to cry on for however long she needed. My director would never allow such a thing. I can hear him in my mind as if connected to him through an earpiece, You must move on, you are moving too slow.

Act Two: The Uncontrolled Diabetic Scene: Patient in the exam room with a 64-ounce cup of Pepsi sitting next to him. He acts sluggish though completely unaware of the ever-increasing ketones in his blood. Enter my character: The Jack of all trades.

This patient needs… everything.

This act should be an hour-long but like

Act One I do not control my time, my director does. I have eight minutes because the patient was seven minutes late.

I pretend that I am not rushed. I try as hard as I can to perform the role of physician, nutritionist, pharmacist, social worker in the allotted time but it is impossible, I run over. This man will avoid the ED, and further, avoid the ICU and will go on to live but the consequences of my running behind will be that soon my audience will become impatient.

Act Three: The Man Cold Scene: Patient in the exam room with a runny nose, no fever, and normal vital signs. Symptoms started one day ago. He is visibly upset due to waiting thirty minutes. Like the audience in Act One, he too has psychomotor agitations but for different reasons. Enter my character: The Apologetic One This patient needs to be a telehealth visit but my director will not permit such a thing. I am running behind due to my previous performance running over and now he is mad. I have to pretend to be sorry. But I am not sorry because this is not my fault. I wish I could tell him that I just spent the last thirty minutes teaching a man how NOT to die from diabetes. I wish I could tell him to take a Benadryl, a shot of whiskey, or a bite of wasabi, anything he wanted to clear out his sinuses and be done. I wish I could tell him that either way, it didn’t matter to me because he suffered from a man-cold, nothing that Google couldn’t have told him. I breathe. I take one, long, deep breath.

I can’t tell him that. I can’t because my performance is judged by my audience and he is my audience. What he says determines my worth and ultimately my paycheck. While I want to be frustrated at this patient, it is not him I am mad at.

It is the system. It is my director. It is my forced performance that has me upset.

Act Four: The Pregnant Teenager Scene: Patient in the exam room sitting stoically though on the inside feeling uncertain as the pressure comes

I don’t want to be the actor required to morph into someone new because the system that employs me does not value who I am or the education that has made me. from the boy who does not love her to do what she is unsure of, all the while feeling judgment from her parents who don’t know she is waiting to speak to someone. Enter my character: The Maternalistic One This patient needs guidance. She needs to be reassured that it is okay to be unsure. She needs a system that supports her, one that supports women and their autonomy. My director will not allow our system to provide her with what she may need. I must pretend that this does not infuriate me. I must pretend that despite the scientific data saying otherwise and my system stuck with backward beliefs that a God leads the decision making though corruption is deep within, that I am not enraged. I must be there for her as she is all that matters.

This continues all the way through until Act Twenty-Two when the performance is over. Each act requiring me to jump into a different character. This continues until finally, the curtain falls and I no longer have to act. I no longer have to pretend.

I want to be me: the physician with no strings attached without any costumes or make-believe characters. I don’t want to be the actor required to morph into someone new because the system that employs me does not value who I am or the education that has made me. I want not to be on a stage nor my day to start behind a curtain waiting to rise. I just want to practice medicine.

But for today the performance has ended and I get to be me.

Until tomorrow I will do it all over again and will continue to do so until the curtain falls once more. 1 WWW.PHYSICIANOU T LOOK . C OM | 21

ADVO C AC Y IN AC TIO N

Unsettling Revelations Emerge WITH WALGREENS AND LABCORP

arge corporations must be held accountable for unnecessary obstacles hindering patient wellbeing. Upon discharge from the Intensive Care Unit with a sepsis diagnosis, Patient X received a prescription for Monurol, a drug with no generic and no substitute.

Having many known drug allergies, Patient X needed this to recover and overcome sepsis. Taking the prescription to Walgreens, the Patient X’s preferred Medicare pharmacy provider, led to a series of events I have never encountered.

The pharmacist refused to accept the written prescription stating that Medicare would not cover it and that she was following “protocol.” I assured her that I would get it covered, but she emphatically reiterated that it would not, and she insisted that I take back the prescription. I asked her how much 2 2 | A P RI L / M AY 2 0 2 0

it would cost if Medicare denied it. It would cost $1,025.69 for three doses as shown below.

Feeling confident that I would prevail, I took the written prescription back. The following morning I notified the office of the wonderful prescribing physician and asked that they request an

exception from Medicare. They promptly complied. Checking back later in the day, I was told nothing had been received from Medicare. I, then, entered the fray.

Spending an inordinate amount of time on the phone, on hold, being transferred, and being given other numbers to call, my quest became more urgent. In the

PHOTO COURTESY OF ESTI NE WE LLS

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Wri t t en by Est i ne Wel l s

P HOTO COU RTE SY OF IN GRA M IM AGE S

meantime, I searched the internet for other options. I found several pharmacies which had the drug in case it did not get approved. Wegmans and others had it for $99 per dose with GoodRX. I took it to Wegmans, where I could pick it up the next day.

Back to my Medicare marathon phone call, I finally reached a representative in the Medicare Part D, Optum Department. Without hesitation, I was told “Seven day turnaround for review.”

With that, I asked him to spell his name in case Patient X passed away. Under cause of death on the death certificate, it would have Medicare Part D, Optum, and the agent’s name. Like magic, the agent asked me to hold for a moment and then told me “If you want to save the life of the patient, have the physician’s office call and escalate the request to pri-

ority status, urgent.” I did so, and the office kindly obliged. Shazam! The next morning I received a call that it had been approved in record-breaking time. The copay $117.

If this did not provide enough angst, my next experience emphasizes the need for large corporations to concentrate on assuaging the anxiety of already anxious patients. Adding additional stressors to patients dealing with chronic illnesses causes great harm.

My second hurdle to overcome was the LabCorp debacle. It is regarding the same Patient X with another unnecessary and formidable challenge. An electronic submission of a prescription for lab work was sent to LabCorp. There was a crucial window of time which existed because of a follow up appointment with the referring physician. Being extremely immune

suppressed, Patient X arrived at LabCorp only to be told that he/she was not in their system. While in a crowded waiting room, Patient X was thwarted with every reasonable attempt to resolve the issue at hand. As the advocate, I intervened and spoke to the representative. She told me that she was following “protocol,” and that the test could not be performed.

In addition, she told Patient X that the prescribing office would now need to fax the request. I spoke to the physician’s office, and they did everything possible to quickly mitigate the dire situation. Clearly, the physician’s office was able to pull up the electronic entry without difficulty.

Finally, after being stressed, mistreated, disrespected, and marginalized, Patient X received the test. LabCorp’s agent delayed efforts to address and correct the problem. The struggle is real! After this occurred, I called the office of the top administrator only to reach the complaint line telling me to leave a message and my call would be promptly returned.

I heard nothing, so I called the following Monday or Tuesday. My language was somewhat stronger this time, perhaps, they feared I would go public with the information. Regardless, I received calls within minutes. Those with whom I spoke offered apologies and agreed that the errors were egregious. My response was to address the issues. Delving deeper into how and why this happened, I was told that staff needed to be better trained and that these were ongoing problems with respect to the electronic submission glitches. Knowingly having an ongoing software issue is unacceptable.

Large corporations must be responsible for helping, not harassing, the public to seamlessly navigate the turbulent waters of healthcare in today’s landscape.

Further compromising the well-being of immune suppressed patients, and the public at large, needs to be addressed immediately. Price gouging and system errors cannot continue to rob us of our health. Additionally, I would suggest calling LabCorp prior to showing up to make sure your electronic prescription is in their system. Till next time, be well! 1 WWW.PHYSICIANOU T LOOK . C OM | 23

O F F IC E S PAC E

Leadership In The Time Of COVID19 T H E I M P O R TA N C E O F LEARNING TO WALK A N D C H E W G U M AT T H E SAME TIME Wri t t en by D r. S t el l a Imma nu el

D

r. Stella Immanuel is a physician who is desperately trying to save the lives of COVID-19 infected patients at her outpatient clinic in Houston, Texas. Many of her patients are undocumented immigrants who fear deportation if they step foot in a hospital. Not only is Dr. Imanuel keeping her patients out of the hospital, she is making them better with off-label use of anti-malarial drugs, often within 24 hours of presentation to her.

As a nation we do have leadership but no one listens to our leadership.

If our current President encourages something, anything, the left and the media will rebel against it just “because.” Some say that they suffer from “TDS” (Trump Derangement Syndrome). I believe it.

If the President says something “off” many on the right will support it blindly, just “because he said so,” or because they saw it on Facebook, even if it is dangerous. We are seeing this now with people gathering to protest 2 4 | A P RI L / M AY 2 0 2 0

their inability to go back to work. People are rebelling and not listening to the importance of social distancing to protect our most vulnerable. The media will only show the public parts of an entire speech, and solely blame our President.

For leadership to work there have to be people willing to follow who understand the reasons behind statements the leader is making.

So to blame leadership when we specialize as a nation in rebelling does not make sense.

When the President said he had the authority to open the nation, the media went berserk.

When he delegated to the governors, the states complained that the federal government is not leading. The media went bananas.

When the President promoted hydroxychloroquine (a medication which many of us physicians have used for many years) the left and the media went crazy and even reputable doctors who

have used it for years went on tv saying “it can kill you.”

India has 1.4 billion people and the death toll is less than 1000 because they are using hydroxychloroquine extensively.

But no one wants to talk about that.

Many rapid tests that were intended to be used in an in-office setting (with physician-led counseling about the significance of the test result) were denied FDA approval so that the Abbott test can be the sole source provider. Follow the money.

The masses are asked to wear masks and protesters are screaming “do not make us wear masks like China.”

How can you lead a population that is constantly in rebellion without much knowledge of why they are rebelling?

When the leaders in South Korea speak, their people listen.

Why don’t we ask why in India people are not dying, where their people are often packed like sardines in their cities?

They cannot even socially distance in the slums of Calcutta. In France some doc-

when by the mechanism of action it’s better used early?

Why did they approve its off-label use (where a discussion must be had between the doctor and the patient) but you cannot find the medication at the pharmacy?

tors are using anti-malaria drugs to keep people out of the hospital.

There is an agenda, it’s not left or right.

It’s not lack of leadership.

It is evil. And America the great will be the first to fall for it.

We as physicians took an oath to do no harm.

We as physicians need to be the advocate for the people.

Why are we intubating patients when 80% of them die (as per NY Governor Cuomo)?

Why do we bypass less invasive methods of oxygenation such as using a non-rebreather, CPAP and BIPAP and go straight to intubation?

Why are many hospitals nationwide empty, doctors and nurses jobless, people in pain from postponed surgeries, patients dying at home because they are afraid to go to the hospitals?

Why did the FDA approve hydroxychloroquine to use in hospital patients

Who is hoarding it?

As I research I find that many companies including Teva, Mylan and others have donated millions of doses to the government. Why are all these doses not being distributed to outpatient pharmacies by the government?

Every day another study is released saying that hydroxychloroquine isn’t working when it is given in the hospital.

Of course it doesn’t! These people are already very sick. Their lungs are already fibrosing. Only the sickest of the sick are showing up in emergency rooms. The Secretary of Veterans Affairs Robert Wilkie has reported that the drug appears to be working in middle-aged and younger veterans in observational studies.

The time to try hydroxychloroquine is when the patient is first diagnosed. A full course is 20 pills. If we were able to give it to everyone that is positive there will still be a lot left over. Why are they sending positive patients home to come back only when they are very ill instead of giving the HCQ and Zithromax early?

Patients with lupus and Rheumatoid Arthritis who take hydroxychloroquine daily (at much higher doses than would be used for COVID19) for 5 years or more are not dying. They are being monitored and not being found to have significant side effects.

Yet, for political reasons, licensed physicians will take to the media to scare the public from taking something that could potentially help them.

Every drug we take has to be evaluated for inherent risks versus benefits.

How come we equate the risk of having a possible irregular heartbeat with death from Covid19? Why have we not allowed the patients to make an informed choice? Why are doctors who have used this medicine themselves not speaking up?

Why are we doctors taking it when we get ill and even as prophylaxis if we thought it was so dangerous? Why are we giving patients for years if it was so dangerous? Why have they not made hydroxychloroquine readily available like other nations and let the decision to use it off-label be between the patient and their doctor?

Why do we think shutting the economy and killing jobs is less fatal?

Have we assessed the morbidity and mortality associated with increased rates of child abuse and domestic violence, the increase in suicide, obesity, increased alcohol and tobacco abuse while we focus on inpatient care of Covid19?

I ask these questions because I believe we should transcend this division and do what is best for the people.

We are physicians and should be advocates for our patients.

We are the generals in this war, why are we allowing civilians to direct a war they know nothing about? Are we being the best advocate for our patients or we are allowing politicians to make decisions?

I recommend that we continue to protect our most vulnerable by maintaining reasonable social distancing.

Everyone should wear a mask in public out of common courtesy, should wash their hands and we need to get people back to work.

We need to reopen our hospitals for elective procedures but enforce strict visiting policies on nursing homes.

Instead of ticketing people for going to the park, ticket them for not wearing a mask. If you hate masks, stay home.

This is what they did in Czech Republic. It worked.

We can walk and chew gum at the same time.

We can’t just sit on the couch and chew gum.

We have to get back to work and still continue mitigation.

Many more will die from poverty-related issues if we do nothing.

Let’s get up and chew that gum. 1 WWW.PHYSICIANOU T LOOK . C OM | 25

O F F IC E S PAC E

Using Technology To Put Physicians In Control

O

Wri t t en by D r. Lea h H o u st o n

ur healthcare system is failing.

It costs more and has overall worse outcomes than any other industrialized nation. It is failing because those on the front lines of healthcare the physicians - have no say in how the system is run.

Distributed Ledger Technology (DLT) - otherwise known as blockchain - has the ability to change that.

DLT is about decentralization, disintermediation and eliminating censorship by removing the need for a third party in any transaction. We need no middlemen between us and our patients and this technology has an ability to make that our new reality. Our failing healthcare system is run by middlemen, 2 6 | A P RI L / M AY 2 0 2 0

so the potential of distributed ledger technology to disintermediate those middlemen yields potential to improve the failing system.

Healthcare is one industry that has experienced increasing consolidation, vertical integration, and centralization over the years and it has heavy regulatory oversight. The slow regulatory capture over the practice of medicine has been achieved through laws that have been pushed through congress as outlined in the historical summary later in this article. As a result, healthcare has become radically inefficient, and in many cases borders on a monopoly.

There are single health systems dominating entire geographic areas1, leaving

little to no choice for patients. Third party administrators are gaining market share and driving up the cost of healthcare through consolidation deals and price obscuring practices. Consolidation regulation and exploitation of the healthcare markets have created mal-aligned incentives. All of these things could be eliminated through decentralizing technologies like DLT. For example: Pharmacy benefit managers are merging with insurance companies, as with the recent 2018 CVS – Aetna and Express scripts and Cigna mergers.2 This creates a situation where the one controlling the supply of the medications will be negotiating the payment

P HOTO COU RTE SY OF IN GRA M IM AGE S

and pricing for those medications.

With the creation of in-pharmacy minute clinics they can then also hire, employ and control the prescribers of those medications by giving them protocols to follow.

Large health systems are attempting to merge with physician staffing companies such as the recent attempt at an HCA-Envision Merger in order to control the entire supply chain of physician services.3 Often in order to work for one of these systems you must sign a non-compete. This leads to physicians being trapped in these systems, unable to move and fearful of retaliation if they don’t comply with practice guidelines enforced upon them.

Physician practices are being bought up by private equity firms –and at times the physicians are being replaced by less qualified personal to save money- example Children’s Health in Texas where the group was purchased and the physicians were replaced by non-physician practitioners in order to save money.4 Health systems also merge, leaving little choice in where people in geographically isolated areas can get their healthcare.5 Hospitals also own other third-party administrators (TPA’s) around the pharmaceutical supply chain, such as the group purchasing organization (GPO) Intalere owned by Intermountain Healthcare. Intalere is one of the 4 GPO’s in the country that control the in-hospital supply chain of prescription drugs. Interlare was formerly Amerinet, demonstrating an example of the tactics these organizations use - frequently changing names in order to obscure the truth around their economic strategy and market share.6 Intermountain Healthcare claims to be “fixing the problem” by making their own medications - because they own the TPA’s that administer and decide on medications and devices, they profit on both ends at the expense of the patient.7 Mergers like this not only leave patients with little choice, but drive up the cost of healthcare because it creates lack of competition in the markets. It is for reasons outlined through the examples above that decentralization enthusiasts are turning to DLT in hopes that this technology will disrupt the trend. The lack of a need for a trusted third party to broker a deal is especially interesting for healthcare considering the mal-aligned incentives and back door deals that plague our healthcare system.8 DLT has the potential to revolutionize how healthcare is delivered and paid for, but only if it is implemented properly. The question is how can we create an optimal and truly decentralized healthcare system for the benefit of the majority? How do we make sure not to create new mal-aligned incentives in the future? It is two step:

Step 1 “We must first let go of the idea that we need to work within the current system, and integrate with current legacy systems….”

Those systems are the very systems that need to be decentralized. There are inefficiencies and mal-aligned incentives that can be addressed in nearly every aspect of the healthcare system.

Step 2 “We must put the physicians back in charge of healthcare at every level, while restoring privacy and agency to the physician patient relationship” The only true solution is to completely reorganize and decentralize power away from the consolidated third parity stakeholders such as the health systems, pharmaceutical companies and insurance companies and towards the individual people who consume, create and utilize healthcare. To simplify who these people are; it is the caregivers, and those receiving care. In other words, the individual people who utilize, consume and created the current healthcare system will now collectively build the new decentralized system, because the new system will be community driven.

Right now, both physicians and patients are frustrated with the current system, so it makes sense that the solution lies with them, and it may be the optimal time for them to take that initiative, in order to build a new system they can be proud of. Physicians must be willing to take that step, to advocate for their patients and make a change by considering themselves part of the solution. This inefficient system is in need of a change especially because the bureaucracy that lead to these costs and disappointments are the result of layers of regulations that have been stacked on top of one another over the years.

WWW.PHYSICIANOU T LOOK . C OM | 27

Here Is A Brief Historical Summary Outlining How The Practice Of Medicine Has Been Regulated: 1929 First Employer sponsored health insurance created for teachers- later gave rise to Blue Cross 1946 The McCarran-Ferguson Act was passed that exempts the business of insurance from most federal regulations including anti-trust laws in some instances.

1965

1971/1972

1973

CMS created- Center for Medicare and Medicaid – the United States Taxpayer sponsored healthcare coverage for the elderly disabled and the poor created from the amendments to the Social Security Act of 1935.

More social security’s acts amendments widened enrolment in CMS HMO’s Health Maintenance Organization act of 1973- incentivized the privatization of insurance

1981 ACGME created to fund advanced medical education – created because VA hospitals could not staff –created a way to get cheap labor from highly trained physicians.

1982

EFR A Equity and Fiscal Responsibility Act of 1982 - created more government incentives to utilize the for-profit HMO’s

1986

EMTALA Emergency Medical Treatment and Labor Act -requires every patient to be screened for an emergency regardless of ability or willingness to pay.

1991

OIG HSS2 safe harbor law that protects PBM’s and GPO’s from anti-kickback laws

1992

Current Procedural Terminologies (CPT’S) Diagnostic Related Groups (DRG’s) and Relative Value Units (RVU’s) and International Classification of Diseases (ICD’s) all created in an attempt to control costs by monitoring and controlling how physicians spend healthcare dollars – all controlled by the AMA (American Medical Association)

1996

HIPAA was created - The Health Insurance Portability and Accountability Act of 1996 which created standards for the electronic exchange, privacy and security of health information. Final privacy rule published in 2000

1997

SGR- sustainable growth rate created. A freeze on graduate medical education was created which has contributed to the current physician shortage

2003 Changes made to HIPAA eliminated patients' right to control the disclosure of their own medical records.

2009 The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009 to attempt to address the privacy and security concerns associated with the electronic transmission of health information, in part, through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules 2010 ACA “Affordable Care Act” incentivized everyone to have insurance coverage by penalizing those that do not.

2014/2015

MACRA The Medicare Access and CHIP Reauthorization Act of 2015

2016 PQRS- Physician Quality Reporting System – ended 2016 and became MIPS 2017

MIPS Merit Based Incentives Payment System- attempts to tie payments to “outcomes” and replaces PQRS – a “patchwork collection of programs” according to CMS

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Despite efforts by the government to regulate and control the healthcare system it continues to get more expensive and less efficient. Considering our laborious legislative process, the likelihood for major change within our current system is low. Special interests who have a lot to lose, spend money on lobbying to keep their interests in favor. Furthermore, many of the above policies took years to create, and with the acceleration and advancements we are making in technology it is becoming impossible to create policies in a timely enough fashion in order to keep up.

So how do we fix this? The answer lies in putting those with the appropriate competency, training and compassion back in charge: the physicians! Join us next month for physician-led solutions to the problems impacting our freedom to practice medicine. 1 1 https://www.usatoday.com/story/news/ nation/2018/03/30/sutter-health-lawsuit-california-hospital- consolidation/474742002/ 2 https://www.wsj.com/articles/justice-department-nearing-antitrust-approval-of-health-mergers-combining-cvs- aetna-cigna-express-scripts-1536171360 https://www. healthcarefinancenews.com/news/aetnaceo-mark- bertolini-resign-post-after-merger-cvs-health 3 https://nypost.com/2018/06/04/kkrmakes-final-offer-for-envision-healthcare/ https://www.bizjournals.com/nashville/ news/2018/06/06/report-hca-makes-finalbid-to-buy-envision.html 4 https://dfw.cbslocal.com/2018/05/23/pediatricians-losing-jobs-health-clinics-close/ 5 “Kaiser Permanente Partners with Emory Healthcare” Modern Healthcare by Alex Kacik June 13, 2018 https://www.modernhealthcare.com/article/20180613/ NEWS/180619960 https://www.kaufmanhall. com/news/2018-hospital-merger-and-acquisition-activity-continues-rapid-pace-30- announced-transactions 6 https://www.npr.org/sections/healthshots/2018/09/06/644935958/hospitalsprepare-to-launch-their-own- drug-company-tofight-high-prices-and-shor 7 NEWS RELEASE For Immediate Release Contact: Daron Cowley Intermountain Healthcare Daron.Cowley@imail.org 801-442-2834 Intermountain Healthcare Reaches Agreement in Principle to Acquire ARI Ownership in Amerinet Salt Lake City, May 18, 2015 8 Identifying the Root Cause of Drug Shortages A Call to Action", John G. Brock-Untie MD, PhD Anesthesiology News October 25, 20189 “Why Doctors Hate Computers” The New Yorker by Atul Gawande Nov 12, 2018

AHIMSA

D R. D ES IG NED , K ID AP P ROV ED SAFE, ECO-FRIENDLY AND FUN!

WWW.AHIMSAHOME.COM WWW.PHYSICIANOU T LOOK . C OM | 29

O F F IC E S PAC E

The Role Of Financial Freedom For A Physician DURING THE COVID -19 ERA

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Wri t t en by D r. C hri st o pher Lo o

0 years ago, if one followed the well-followed paradigm of getting into a solid medical school, residency, and fellowship, a practicing physician was almost guaranteed a prosperous economic livelihood. In the meantime, one could start building a family, buy a large house, save for retirement, finance their kids’ private education. A physician could then use the remainder to afford the luxuries of life. 50-60 years later, one could “retire”.

However, somewhere along the way, all of that changed.

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With globalization, the internet, technological disruption, shifting marketplace dynamics, generational differences, managed care, and unsustainable business models, coupled with “black swan” events including 9-11, the 2008 Financial Crisis, and COVID-19, it is rapidly becoming apparent that the concept of “job stability” that was highly touted as a benefit among the medical profession is a myth that no longer exists.

The current model of healthcare in the United States is no longer viable and is unsustainable. It is extremely expen-

sive with outcomes that do not justify the expense. There is undue influence by pharma, medical device, insurance companies, regulatory entities, Washington D.C., and Wall Street.

In the upcoming decade, there is a predicted physician shortage. To make up for this shortage, medical schools across the country are increasing their enrollments. However, the ACGME is only marginally increasing the number of residency positions each year. As a result of this, there are going to be more and more graduating physicians forced to pursue alternative means of income.

PH OTO COURTESY OF INGRAM IMAGES

More frequently, these entities are failing physicians. Too many of today’s physicians are living paycheck to paycheck, have little to no savings, with large liabilities, with families to support.

What if that source of income was eliminated by no fault of their own? - just look at COVID-19.

We need to shift paradigms, and break out of traditional modes of linear thinking that our profession is so accustomed to. Now, more than ever, it’s not just about having a single high-income wage. A physician now must have multiple backup sources of income outside of their traditional clinical work. This will provide insurance against future existential calamities. Contrary to customary belief, the only key to job stability in today’s age is one’s ability to create their own “job stability”. Therefore, the importance of a solid financial education in order to achieve financial freedom and independence is now more important than ever for the physician in the COVID-19 era. 1

Adding to this dilemma is that hospitals are in dire need of physicians on the frontline. As we are witnessing firsthand with COVID-19, a crisis can easily overwhelm the hospitals. In the midst of all of this, hospitals are laying off or furloughing thousands of employees, demanding that staff risk their lives (many of them volunteers), yet failing to provide adequate PPE, and punishing those that speak up against the system.

Even worse is that these CEO’s, administrators, and executives are being compensated many times in excess of million-dollar salaries.

Physicians have undergone over a decade of schooling and training, taken on excessive student loan debt, worked backbreaking hours for low pay, risking their lives, paying excessive malpractice premiums, often times getting nothing in return, yet they are expendable by the system having to answer to bureaucrats, administrators, insurance companies, politicians, and lawyers.

Not only are their incomes tied to a job, boss, corporate, and regulatory entities that do not have their best interests in mind, their health insurance, retirement, and other benefits are tied to their jobs.

Author’s bio: Christopher H. Loo, MD-PhD is a physician entrepreneur, investor, TEDx speaker (October 2020), and health care digital technology advisor. He received his MD-PhD from the joint Baylor College of Medicine and Rice University Department of Bioengineering. He subsequently matched into an orthopedic surgery residency at Rutgers University before embarking on a full-time career as an entrepreneur achieving F.I.R.E. at the age of 38 using real estate, equities, and options, allowing him to pursue his true passions in the digital health startup space.

He is the author of 4 Amazon bestsellers, creator of the online digital course Multiple Streams of Passive Income for Physicians, and owner of the growing private Facebook group - Financial Freedom for Physicians. He is a keynote speaker, has been interviewed by top physician influencers and has contributed to high profile physician social media sites including KevinMD. His upcoming TEDx talk in October 2020 will cover the top three strategies for flourishing during these extremely challenging times.

Dr. Loo can be reached on social media (@ drchrisloomdphd), or ChristopherLooMDPhD@ gmail.com for speaking, coaching, and consulting inquiries.

LinkedIn Profile http://bit.ly/2SrQcOY Facebook business page http://bit.ly/2Uc7gKF Autobiography https://amzn.to/2LSsBGJ KevinMD article https://bit.ly/3a5jhYV WWW.PHYSICIANOU T LOOK . C OM | 31

TIM E F O R YO U

7 Therapy Alternatives FOR THE C R E AT I V E M I N D

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Wri t t en by G ra ce H u a ng

e all encounter moments in life where our emotions and thoughts may become overwhelming. Our mind can begin to swirl with ruminating thoughts and we can feel the emotions running rampant throughout our body. Particularly now in this time of social isolation and in the midst of a pivotal moment in the history of humanity, we must learn to take care of ourselves - filling our own proverbial cup first before we can be of service to others.

For some of us, these tumultuous states seem to appear more often than not (shoutout to my fellow anxiety-prone friends) and often, we are at a loss for how to stop these energies from taking over our day.

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Maybe a personal project isn’t going as planned or work is becoming increasingly stress-inducing. Perhaps interactions with loved ones at home are triggering unhealed wounds or we feel isolated in our struggles (self-quarantine, I’m looking at you).

At these times, it can be challenging to know how to best handle these turbulent states in order to accept and subsequently overcome these mental hurdles.

It is no surprise that in our disconnected, chaotic society, the therapy industry is alive and well. For many, speaking to a therapist on a regular basis can prove beneficial for mental wellness. I had an amazing therapist that I worked with during a weekly ap-

pointment until I felt that the therapy was no longer as effective for me.

This doesn’t mean I have forgone therapy altogether; I simply decided to take matters into my own hands at this point!

For those who have tried traditional therapies such as cognitive behavioral therapy, psychotherapy, or dialectical behavioral therapy with little or no progress, here are 7 alternative therapies for those who better process experience and emotions through a more creative avenue.

1. Art Therapy Pick up a pen, crayons, some paint, and go to town! Need to scribble wildly? Do it! Want to haphazardly fling a

P HOTO COU RTE SY OF IN GRA M IM AGE S

bunch of paint at a canvas? Go for it!

(Just be mindful of any clean up process as paint can be tricky to get rid of once dried.)

One form of art therapy I find interesting is the use of color. In this kind of art creation, I like to select colors that appeal to my mood at the moment. They don’t necessarily have to fit a scene or color palette, they just need to speak to me in the moment. After finishing the session, I take a few moments to reflect and write down how I feel the colors correlate to certain emotions and where those emotions stemmed from in the situation.

For example, if I used a lot of blues in the art, I examine what about my current situation is triggering sadness or in-

hibiting me from speaking my truth. If I used darker colors, I reflect on where I may be feeling withdrawn or discouraged.

Another way I used to incorporate art therapy was in finding a replacement coping mechanism to self harm. Rather than punishing myself by cutting, I would draw a small animal, flower, or alien on the area I wanted to self harm and envision that creature coming to life until the overwhelming urge had passed.

In this way, I perceived that I was creating beauty rather than causing myself harm.

The point here is to encourage self expression through art of some kind whether that be through drawing, playing with watercolors, making a collage

from magazine cut-outs, or doing some cool sidewalk chalk doodling - it’s up to you!

It’s important to remember that the way each individual chooses to express themselves will be vastly different. Expression is a subjective thing! Follow your intuition as to how your emotions may be flowing through you during this experience and why you are feeling them.

2. Music Therapy Put on your favorite tunes and sing, yell, dance, bang on some pots and pans if you need to! If you are musically inclined, pick up your instrument and go to town with it!

In many African and Native cultures, the use of music is strongly tied to spirituality and music is often central to community bonding events. The idea that is central to these cultural staples is music can stimulate mind and heart. It can even affect learning and neuroplasticity and change how you engage your emotions and memory.

Music with a strong, fast-paced beat can stimulate the release of feel-good neurotransmitters into the body that cause the heart rate to increase. Calming music can help to lower blood pressure when in a state of agitation.

This was one of my favorite therapies when I was in inpatient and outpatient programs. I absolutely loved the drum circles because it was a community like event in which people could participate as they felt comfortable. The feeling of not being alone and joining creative energies through drumming with others was remarkably healing and therapeutic.

Some may suggest listening to “happy” music in order to change your current state. I agree that music is a powerful mood influencer and can be used in this way when the desire of the practice is indeed to alter the emotional-mental state.

However, if the desire is to understand and process the emotion at hand, defaulting to a “positive vibes only” mindset can be a harmful philosophy to WWW.PHYSICIANOU T LOOK . C OM | 33

PHOTO COU RTESY OF IN GRA M IMAGES

adopt because in refusing to acknowledge undesirable emotions, we enstrange ourselves from them.

In essence, we walk further away from truly understanding why we create these energetic states within ourselves.

In failing to understand and address the root cause of these states, we cannot effectively create lasting change and growth.

So listen to whatever you feel strongly drawn to at the moment! If you feel like listening to thrasher metal or heartbreak ballads, do it! Be cognitive of your reasoning behind the music you choose.

This can be key to understanding how we contribute to emotional patterns.

3. Exercise Therapy Throw on some sweats and hit the road, grab your yoga mat and head to a studio (or during self quarantine, a spacious area in your abode), sign up for a free virtual kickboxing demo class!

Feeling restless? Some cardio heavy activity such as running, rowing, cycling, or swimming can release some of the built up energy stores to help you find your relaxation zone at the end of the day.

Feeling angry? Martial arts may be the perfect way to channel and discipline some of that potent anger energy productively. Feeling scattered? Try a grounding practice such as yoga or tai chi to get 3 4 | A P RI L / M AY 2 0 2 0

more in touch with your inner peace.

Physical activity works really well to release pent up emotions, particularly anxious energy. Engaging in exercise helps us to become more present in our bodies rather than being trapped in a state of powerlessness from limiting thought patterns.

Emotion is energy in motion and anxiety tends to build when we are inactive. Anxiety is a funny thing. Often it prevents us from doing the very thing that would in fact ease our anxiety - taking action!

Obviously there are specific circumstances that can trigger anxiety and panic attacks that may not be effectively addressed by exercise therapy. However, for the built up anxiety and stress that tends to occur within me after working all day, exercise is the perfect way to unload some of this so I can better unwind during my downtime in order to be a better me the next day!

4. Meditation Therapy Find a quiet spot in nature or in your own space and set some time aside for no-interruptions, me-only meditation!

Notice the thoughts that are running through your mind as you focus on your breath. Are the thoughts self-defeating?

Worrisome? Self loathing?

Try and challenge the negative thoughts that arise by asking questions like, is this true? Am I truly a failure or am I living a life of constant comparison? Is this useful? Does trying to live up to the expectations of others help me or hurt me? What is this emotion trying to tell me?

The key here is to tune in to your inner voice and connect with your higher guidance and intuition. We want to sort out the noise our minds make in order to process the emotions we are feeling.

Introspection and reflection is a powerful tool to become your best self!

Give yourself time to sit with, fully experience, and accept your feelings.

There will likely not be magical results overnight. The fruits of this practice are earned over consistent time invested, much like talk therapy also does not resolve issues in a single session.

5. Role Play Therapy Grab a friend or two, via an online platform of course, and slip on your perspective glasses to give role play therapy a whirl!

Sometimes it can be impractical to solve all of our issues alone, single-handedly. Especially when the nature of the issue involves more than one person. Role play therapy can be rather eye-opening when dissecting the nature of our interactions with other people in our lives.

Let’s say you’re having relationship challenges with a significant other. Have a trusted friend or loved one role play the perspective of you while you play the perspective of your significant other. Act out a recent disagreement or conflict in that relationship and really try to step into the shoes of your partner.

Try to approach the exercise from a place of understanding and love for your partner. Having a neutral friend play the role of you can be revolutionary in identifying where you are contributing to the problem.

Many times, we are so caught up in a conflict that we forget that it takes two to tango! We fail to acknowledge that

both parties are responsible in favor of the “I win, you lose” mentality.

Role Play Therapy exercises can also be incredibly effective for sorting out internal cognitive dissonance as well.

If, for example, one of my primary issues is procrastination, I would ask my partner or a trusted friend to play the part of myself that consciously wants to procrastinate while I take on the role of the part that hates my procrastinating behavior. I would converse with the fragment of myself (played by the friend) in order to better understand that part’s perceived contribution to my life.

I may find that the fragment of myself that cannot tolerate the behavior is actually a parent’s voice that was instilled in early childhood. I might ask myself, is it necessary to be so harsh towards myself as long as I get the work done? I may discover that the procrastinator’s perception involves the delay of perceived pain of being productive - for instance, being productive only to find that my work is not good enough.

I may challenge those thoughts with further questions in order to get to the root of the problem, such as “who do you perceive your work is not good enough for?”

Rather than judging others and ourselves by trying to “win” or “be right” in external and internal conflicts, this form of therapy can help us come to a place of mutual understanding. We can then begin to address the issues within ourselves or in our environment.

6. Nature Therapy Toss on some shoes (or not!) and head out into the great outdoors!

Nature therapy is excellent for practicing mindfulness and becoming present in the current moment. If you’re adventuring with a buddy, make sure to practice safe social distancing during this time.

It has been shown that regular contact with nature reduces anxiety, anger, and fear while increasing feelings of wellbeing and contentment. Being immersed in nature can actually decrease the pro-

duction of stress hormones such as cortisol as well as promote healthy blood pressure and heart function.

One way to incorporate nature therapy is through earthing or grounding - the practice of making direct contact with the Earth’s surface.

This means getting rid of those pesky shoes and socks for a few minutes and really feeling the Earth beneath our feet!

In this way, we allow the flow of Earth energy into us while releasing (grounding) some of our less fun energy into the Earth.

Earth and everything in it, including humans, are conductors of free electrons.

When we connect our bare skin to the Earth, we take in free electrons from the Earth which are critical antioxidants and can help stabilize the body’s biological rhythms, neutralize damaging free radicals in our bodies, and eliminate chronic inflammation and pain.

Earthing can be done by lying on a soft patch of grass and running our fingers through the blades. Walking along a beach barefoot. To incorporate some animal therapy, bring along your best furry, scaled, or feathered friend! (If conditions permit, of course.)

The human species has grown increasingly disconnected from our Earth and all our Mother does for us. It is this lack of connection to our planet, the world, and subsequently ourselves that allows for the issues we are currently having in our society - greed, corruption, intolerance.

A person who sees the Earth and others as extensions of themselves is far more likely to treat others with the love, respect, and acceptance that they themselves desire.

This connection to the planet and other creatures that inhabit it are vital to our health and sense of belonging.

7. Youtube Therapy Curl up with a blanket and a comforting beverage and fire up YouTube on your mobile device or computer!

This one might seem a bit odd to some. However, I think most of us can

agree that some days, all we want to do is lounge around and recharge in our own solitude.

There was a period of time not so long ago where even just getting through the day seemed borderline impossible for me. I’d often spent days on end in my bed, leaving only for occasional food and shower time. The mere thought of creating, exercising, or even eating properly would have sent me into a crippling bout of panic attacks.

I lament about the woes of technology quite often, but the fact remains that technology is simply a tool - it all depends on how we use it. In the case of a person who is severely mentally ill, it may not be reasonable to expect them to throw on some hiking boots and trek out into nature to resolve their issues with the infinite divine.

When trying to help ourselves or a loved one to cope, it is important to remember to hold back unreasonable expectations and allow time to heal before encouraging growth. If the desire to heal is present, we can address this need with whatever energy level we have at our disposal at the moment.

So What About Traditional Therapy?

This is not to discourage anyone from a traditional therapy route, as that can be highly beneficial for many individuals.

These alternatives are simply things we can do on an individual level to further contribute to our self discovery and growth, with or without the help of a therapist. These methods can even expedite the process when used in conjunction with seeing a therapist regularly who is right for you personally.

There is nothing shameful or embarrassing to admit when we need help from others! In fact, it is important and necessary to seek help should we need it.

Remember, what works for one person may work differently for another!

The way in which you learn, heal, and grow is valid.

Have you tried traditional or alternative therapies? Share your story on our website or social media. 1 WWW.PHYSICIANOU T LOOK . C OM | 35

TIM E F O R YO U

The Gift Of Time In A Pandemic THROUGH THE EYES OF A PHYSICIAN MOM

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Wri t t en by D r. A y u shi C hu gh

t’s past midnight, I lay awake beside my little one, gently caressing his forehead, as he nestles into gentle slumber. Sleepless, anxious, I begin to contemplate these days in the Life of the New Normal as the world is faced with a pandemic.

I somehow wish, there were more hours in a day.

The kids’ bedtimes have become different: sans nuzzling, kissing, close cuddles, no touching faces. Just a quick, rushed storytime, or catch up, if at all, for often it’s way past ‘usual bedtimes’. We parents are but novices in the art of homeschooling, which in its light brings a somewhat structure-less day. Perhaps it was to ease the burden of ‘agendas’ we humans had so strict3 6 | A P RI L / M AY 2 0 2 0

ly enforced upon ourselves. For many an ‘essential worker parent’ it’s guilt mixed with hope, that upon leaving for work, our kids would faithfully fend for themselves at the cost of dwindling parental discipline and perhaps complete their lessons (in between electronic distractions) as had been planned hastily the night before.

and rest our tired minds. Time to binge some entertainment, self care, home organization, workouts, gardening, reconnecting with nature, itself. Life has become different...perhaps Mother Nature intended to reboot and cleanse itself off of our selfish abuse and overuse of its bounties. Perhaps the Earth wished it could rotate a little slower.

Wish there were more hours in a day.

As many around me wonder how to pass their time, I wonder how to stretch my minutes. So much to do, so little Time. Time to sit with patience and teach our little ones, perhaps how nature intended of all its species to teach their young. Time to cook enriching meals, or play lazy board games

Wish I could stay home and re-boot with the rest of humanity.

But Duty calls and Sleep evades me as I then wish I could stretch my day more, to gorge down this information overload, hoping to help my patients and community, hoping to create awareness of prevention better than cure, to preserve life. I try to stretch myself beyond

PHOTO CREDIT DR. AYUSHI CHUGH

As many around me wonder how to pass their time, I wonder how to stretch my minutes.

So much to do, so little Time.

the hospital walIs and seek to empathize with an emotionally hurt, sometimes ignorant and economically broken society, fearful of the unknown, but words fail me. I sigh and check my inbox and visualize unopened emails of ever changing pandemic guidelines, policies from world and state authorities, updates from hospitals and neighborhood societies, all flash in quick succession. I quickly flag them and move on to the next, only to find they have been revised day after day. Shamefully ignoring pending specialty medical education resource updates that now seem somewhat ‘frivolous’ and given a backseat in the context of the burgeoning tasks a pandemic brings in its wake. Medicine has taken a backseat. Patients with non pandemic

illnesses have taken a backseat and they sit in waiting, as suddenly priority procedures seem ‘elective’. Patients put on hold their screenings, surgeries, imaging, stroke time windows,flaring chronic illnesses. All of humanity waiting with bated breath for this even higher emperor of maladies to release its grip off the world.

I feel the urge to learn and relearn, just like my peers. But I am dizzy with information overload and perhaps under-load for the truth seems blurry. It feels as though Truth is in hiding from those it matters most to, from those who bravely show up to protect humans and humanity.

Hoping to escape and frantically be in touch with some ‘normalcy’,

I scroll through social media, but solace evades me. More information with tinges of misinformation. While my peers and I seek to make life and death decisions by day, these pictures, images, priorities,”challenges” posted on social media bring up an ethical disconnect.

These all seem distant, as though they occurred in another birth, in another lifetime. Along with my peers, often confronted with whom to admit, or whom to keep away from the scourge of a hospital stay, all the while simultaneously ‘hand-holding’ frontline colleagues navigating this unforgiving virus. Everyone judiciously attempting to ‘treat’ while economizing on equipment, keeping foresight on who might benefit from a future artificial breathing device or not. Tearfully prognosticating beyond our ethics, I suddenly feel dismembered from the ‘social’ world outside the hospital walls. Hastily, I refocus my mind to the task at hand, so as not to lose touch with this new reality. It’s like I am chasing to measure the girth of an ever expanding belly of a giant while going around in ever enlarging circles.

Wish there were more hours in a day.

Exhausted, I begin to hear the birds stir and chirp at the crack of dawn and make my way back to my own bed.

As if in telepathy, my son mumbles in his sleep, “Mom, will they find a cure?”

I caress his forehead back to sleep.

Wish there were more hours in a day, my little one.

Hope sustains the world, as research is underway. For today, let us be thankful we see the light of another day and the Gift of Time that it presents 1 WWW.PHYSICIANOU T LOOK . C OM | 37

TIM E F O R YO U

Why Grow Your Own With Your Kids?

PHOTO CREDIT DR. MA RION MA SS

Wri t t en by D r. M a ri o n M a ss

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hy Grow your Own With Your Kids? I don’t want to write about the obvious benefits (it tastes better, less pesticide exposure, sense of responsibility, sense of accomplishment) of getting your kids to help you grow organic produce.

It is the things I never expected that you need to hear: You are fostering common sense.

You can’t buy it at the world’s best Universities!!! Neither of my parents went to college. So I had a little of the “do I belong here?” feeling in my first weeks at a top tier medical school. It went away. A little common sense can car3 8 | A P RI L / M AY 2 0 2 0

ry you through many a challenge, but how do you help your kids get it? One way is by cultivating an appreciation for the natural (common) world. As we morph into an increasingly techno-rich world, we need to hold on to common sense!!!

You are also fostering problem solving. My 8 year old son and I were out in the garden during one of the early years. The whole top of a tomato plant had been gnawed back. “Stupid deer, “ I muttered. But my son was looking at the ground below the chewed leaves.

“What is this stuff? It looks like tiny animal droppings” He began to look

above those droppings, and found a 3 inch tomato-leaf colored tomato hornworm (our introduction to the culprit) camouflaged in plain sight. He went to go read all about hornworms, and together we protected our crop. Couldn’t have fixed the problem without him.

Getting dirty is beneficial! Studies show that kids who grow up on farms have lower rates of asthma, food allergies and seasonal allergies. (It’s nice to know that SOMEONE has lower rates!)

Why? It’s called the hygiene hypothesis. The arm of the immune system that responds to parasites (commonly found in the soil ) is partly responsible for the allergic and asthma response pathways.

The increasing lack of exposure to parasites has this part of the immune system ready to respond to other issues, such as environmental allergens, etc.

Keep in mind, it still is a good (common-sense) idea to wash off your hands after gardening. Aim for exposure, not ingestion!

They will try and eat more vegetables. Even the ones they think they hate. These past two summers, my daughter and her friends have been growing and selling produce from our garden for charity. Two of the girls hated tomatoes when the project started.

No longer!

It’s a great time for communication, especially with the pre-teen/teen crowd. I know you hear that advice, talk to your kids in the car. There is something about that time that doesn’t feel like an interrogation to them and they talk. It works even better in the garden. When they are bent over the bush beans, or searching for ripe peppers, they relax, let down their guard and open up.

Do you need any more reasons? It really is easier than you think! Start small…. A window box, a 4 x 4 plot.

Expand as you become comfortable with gardening. Start planning now by gathering advice from blogs, websites, books (gasp!) local gardening clubs and extensions. You will reap more benefits than an armload of beautiful produce!!! 1

IN TELLI G EN C E ON T HE MOVE

Quarantine Resources T H AT E N R I C H L I V E S I N M O R E WAY S T H A N O N E Writte n b y Pam e la Fe rm an

This month at Physician Outlook Magazine, we have put together a list of great websites or podcasts to help all of our readers through various components of interest or struggle during the COVID-19 pandemic.

FOR YOUR FINANCIAL CONCERNS

Get Rich Education

While over 28 million Americans are without employment and uncertain how to move forward out of this economic downward spiral, we are left questioning how to recover financially as well as how to make sure we are more financially secure in the future. In Keith’s podcast “Get Rich Education,” listeners are provided with actionable tasks to take control of their current financial situation and discover strategies to empower your future. With an emphasis on real estate investments, Keith answers the key questions we all have on our minds – particularly as we hope for a more stable economic future.

FOR YOUR MENTAL HEALTH CONCERNS

Talk Space

While we are all taking extra precautions to protect our physical health, this can also be a trying time mentally. Stress, the inability to gather with friends and family, unable to see your usual therapist, uncertainty for the future – can all play a factor in compounding anxiety. Whether you would prefer to seek out a licenses therapist through text, phone or video chat, Talkspace allows for various subscription plans to meet your needs. Another reason why we love it: Right now, Talkspace is offering free services for all heathcare professionals and discount subscription for other users.

FOR THE KIDDOS

Circletime – Circletimefun.com

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POSITIVE PERSPECTIVE: SELF IMPROVEMENT

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WWW.PHYSICIANOU T LOOK . C OM | 39

I NT E L L I GE NC E O N TH E M OV E

From Medicine To Ministry COMING OUT OF THE CLOSET

D

Wri t t en by Dr. S eema K ha nej a

o you ever feel like you lead a double life?

There is one life which is your public personality that you share with your colleagues, in your office practice, or in the hospitals. And another, that stays hidden, because you don’t feel comfortable expressing your authentic self for fear of ridicule, shame, or being excluded from the main group.

I believe that deep down, we all have a real desire to belong to something bigger than ourselves. I also believe that to truly belong means that we feel validated by this bigger community.

But what if we feel that we have to hide and pretend to be something we are not to fit into the accepted mold?

How can we truly thrive and express our innate potential if we don’t feel safe to be ourselves?

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For me, these themes of public and private persona, belonging and not belonging, played out while I was training in medical school and even during my residency. Ever since entering an accelerated medical school program at the age of 17, I felt this conflict between being a doctor of this world and being a doctor for God. A physician of medicine versus a physician for inner peace.

My journey in medicine As a young medical student, and even later as a resident, I didn’t even have the vocabulary to express this inner conflict. All I knew is that I often felt sad, confused, and lonely. I had a deep calling to be of service as a doctor, but I also felt a burning desire to give up medicine completely and give myself over to a life devoted to meditation,

prayer, and spiritual exploration. To resolve this inner conflict, I studied many different complementary and alternative health modalities. I discovered that most of these healing systems addressed inner psychosocial and spiritual aspects of healing. I even traveled to India and Nepal, so I could explore yoga and meditation as well as Ayurveda.

All of these experiences helped to nurture my vision of a more expansive healing system that honored the power of the mind and intention along with faith-based approaches to healing. My path eventually led me to practice integrative medicine for over a decade, where I worked with children and adults facing complex medical and mental health issues. I shared homeopathy, yoga, meditation, Ayurveda and Reiki with them. I found that in cases where the traditional

It was time to sing my song in the way only I could sing it.

FROM MEDICINE TO MINISTRY CREDIT MARIA CHIARA MIDURI

one practically face a stressful situation such as the corona pandemic where there is no place that truly feels safe? Where does one find this way to connect to the relaxation response and find this inner locus of control? Is this even possible?

medical model failed to help, many responded favorably to these alternative modalities. In 2015, I transitioned to becoming a coach, and in the Spring of 2019, I became a commissioned minister with Living Church Ministries.

Why I chose to become a minister In becoming a minister, I felt no desire to add another title to my name.

Nothing really changed in my outer life either. However, I felt that I was honoring my strong inner calling to go deeper with my commitment to God, or Love, Light, or whatever name we would give to that place within us that is our true Self- beyond the external mask of our superficial personality selves.

Yet even then, years out of medical school, now established in my own coaching practice, I still felt hesitant

sharing about being a minister with more than just my close circle of family and friends. I still feared being judged or made fun of, that somehow, I would be labelled as a Jesus or God freak, and less of a real doctor.

And then the coronavirus pandemic hit which changed everything.

How do we heal the mind and body when we face stress?

We know in medicine that the stress response can aggravate most if not all of our experiences with illness, perceiving illness in the outside world, as well as caretaking of another who may be ill.

We also know that studies show that those who feel that they have an internal locus of control often are more resilient in the face of stress than those with an external locus of control. But how does

Stepping into my ministry As I found myself connecting with clients, friends, and family in the States as well as across the world struggling to face this unprecedented pandemic, I felt impelled to step out of medicine and into ministry. I could feel that the public and private persona of Seema needed to merge into one whole where what I felt, believed, and knew in my heart were expressed through my words, writing, and actions. I felt like I was part of a huge orchestra and it was time for me to play my part in the music with my instrument in the best way I could. It was time to sing my song in the way only I could sing it.

After joining with my trusted circle of friends and family- who always knew my heart was in ministry- I decided to offer an online video call daily for 21 days where we would all gather in a safe space for healing.

What I discovered in my journey over those past three weeks Creating a daily zoom call lasting about 90 minutes was a wonderful way to offer an anchor of comfort and support to the participants. Many shared how they scheduled their day around the call. Having it daily, providing recordings, and offering this on a donation basis allowed there to be no barriers to access.

Our circles became safe havens where on the average about 20 men and women of all ages from all across the globe gathered to share their fear, worry, doubt, anger, pain, and hurt openly and transparently. There was no judgment WWW.PHYSICIANOU T LOOK . C OM | 41

and no attempt on anyone’s part to fix anyone. The purpose of the call was not to be positive but rather to allow everything that seemed to stand in the way of inner peace to be shared openly and honestly.

Often, there was anger, frustration, fear, sadness, and many, many tears.

But I always kept our purpose clear in mind: to allow our deepest inner wisdom to use this global pandemic for healing, transformation, and miracles.

I called the events Coronavirus miracles healing zoom circles. And at first, just associating coronavirus with miracles seemed strange to some. Yet to many, this was the first shift in moving out of paralyzing fear into relating to this experience in a different way- from one of resistance and terror to moving towards allowing, acceptance, and trusting that there was a way to move through this challenging time together.

The participants began to understand that the miracle was not about trying to shift something in the external world- where we do not have control. But rather, the miracle was always a shift inside the mind to relate to the experience before us in a more expansive and open way: from less judgment and fear to one of acceptance and allowing. From this new lens, we could begin to expand our vision of ourselves to include much more than how we had defined ourselves before. In fact, the whole corona experience forced many of us to let go of the everyday way we were used to showing up in the world.

With most of us being asked to shelter in place, we finally had the time to connect to a space of shelter within that was independent of all things external.

Many tools were used to help us open to this more expansive and open state of mind which included videos, poems, stories, music, along with guided meditation, prayer, and self-reflection. The participants had time to share, express, and also receive one-onone coaching with myself during the call as well. Guests with a background in meditation, mindfulness and the 4 2 | A P RI L / M AY 2 0 2 0

teachings of A Course in Miracles were also invited to share their perspectives.

It is really important to emphasize that these groups were not about doing a spiritual bypass and avoiding the pain and tragedy we often witnessed in the news. Nor were we ignoring the guidelines around social distancing, handwashing, and accessing medical care if needed. In fact, being a doctor, and having many friends and colleagues working on the frontlines, I would share stories of nurses feeling worried about working with Covid-19 patients amidst shortages of masks, gowns, and gloves. I would talk about an ER doctor working at Elmhurst Hospital (where I did a bulk of my clinical training as a medical student) who broke down in tears because she was not feeling that her staff had the support and infrastructure they needed to adequately care for the burgeoning Covid-19 cases in NYC. We also talked about the doctors in Italy facing ventilator shortages and feeling they were no longer doctors but selectmen- having to decide who got to live based on who got the ventilator.

However, we always used these stories as a springboard into looking deeply into our own minds where we hold our own beliefs in lack, suffering, guilt, punishment, feeling alone, feeling unsupported, or not safe. We were not joining to change or fix anything in the outside world. Yet we knew that by finding our inner source of comfort, refuge, and peace, we could be of greater service to everyone by first allowing our own healing.

At the conclusion of our circles We concluded our zoom circles with a special Easter service with live music, meditation, and a lot of sharing and discussion. In three short weeks, we all could feel how deeply we had healed.

I had watched participants who initially felt anxious and worried about possibly having Covid-19 feel comfortable and safe at home self-monitoring their symptoms while they stayed in

We knew that by finding our inner source of comfort, refuge, and peace, we could be of greater service to everyone by first allowing our own healing touch with their doctors. Just having a daily group where they could connect and check in was very reassuring. Others found the group a safe space to share about their fears and worry about a loved one hospitalized for non-Covid-19 related illness whom they could not visit. One woman from Italy joined us almost daily and found that our group helped her immensely to feel supported and anchored in love and peace in contrast to the social panic and isolation she witnessed in her own country.

In three weeks, we witnessed that our focus had shifted from worrying if we or a loved one would contract Covid-19, or what would happen to our future economic security or when we would go back to our normal lives.

Instead, as I looked upon the faces of the 25 or so participants in our circle, I could feel that they felt a deep sense of being supported from within and from each other- that while they sheltered in place, they were able to connect to the space of shelter, refuge, and peace within and extend that to each other.

In their smiling, shining faces, often through tears and laughter, I could see that finally I had fulfilled my destiny which I carried within me since I first entered medical school. Now, I truly can say with joy that I am a physician for inner peace, a doctor who leads her patients to the Inner Healer within.

The corona pandemic is in no way over. Yet I do feel that while my colleagues serve on the front lines, I too am joined with them across space and time, serving in the way that is mine to serve. And for this, I am deeply grateful, honored, and privileged to be a doctor. 1

P HOTO COU RTE SY OF IN GRA M IM AGE S

I NT E L L I GE NC E O N TH E M OV E

COVID-19 The Evolution O F A PA N D E M I C

L

Wri t t en by D ro r Ro m, P h. D, J a c l yn M cTa gu e, M A , M S, M i cha el Po l , M S

ockdowns, quarantines, and measures of social distancing have become the new normal as the world makes a concerted effort to stop the spread of COVID-19. How did a virus originating in Wuhan, China evolve from a local outbreak, into a regional epidemic, and finally into a global pandemic? Furthermore, how can we expect the pattern of infections to continue to develop?

To understand the initial acceleration of the outbreak and how it will progressively evolve over time, it is first necessary to understand some important epidemiologic concepts. The reproductive rate, represented by R0 and pronounced as R-naught or R-zero, describes the speed in which an un-

mitigated infection spreads throughout a community. R0 is measured by the number of person-to-person transmissions that occur from each infected individual. For example, if an infectious agent has an R0 of 2, it means that every infected person will transmit the infection to 2 other people, these 2 newly infected people will each transmit to 2 more, and this pattern of spread will R0=2

continue. Based on this definition, it becomes clear that R0 describes the speed of the infections and the higher the R0, the faster the transmission rate.

Figure 1 displays two different patterns of person-to-person infection spreads.

COVID-19 is thought to have an R0 of about 2.5. For comparison, the H1N1 swine flu virus had an R0 of about 1.5. Figure 2 illustrates the imR0=1

Figure 1. Comparing reproductive rates: The person-to-person spread of an infection.

WWW.PHYSICIANOU T LOOK . C OM | 43

Day 1

Day 4

Day 10

Day 7

R0 = 2.5:

R0 = 1.5:

Figure 2. Comparing reproductive rates: The community spread of an infection.

pact of R0 with respect to a community-based infection spread. The difference between the two cases is dramatic. With only a 1-point higher R0, the COVIDlike infection can affect an entire community of thousands of people, while the H1N1-like disease affects far fewer within the same span of days.

It is important to note that the R0 of an infection typically does not remain constant. That is, R0 will evolve over time due to various factors such as weather, available vaccinations, and social distancing. In the early stages of a pandemic, an infection’s R0 will be at its peak. This means that infections will spread most rapidly because the aforementioned factors have not yet played a role. Because of COVID-19’s high unmitigated R0, the number of new infections began rising at an exponential pace.

As community methods of control are implemented, R0 will begin to decline and this will affect the pattern of new infections. When R0 is lowered to 1, meaning that, on average, each person transmits the virus to 1 other person, the number of new daily infections will become constant. This will change the pattern of new infections and cause the number to rise linearly instead of exponentially. A sign that the spread of the pandemic is slowing is the straightening of the curve of the number of new daily infections. The inflection point is the time in which the curve turns from a convex (upward) to a concave (downward) curvature.

To ultimately contain a pandemic, R0 must be brought down to less than 1.

Without an available vaccine, this can be 4 4 | A P RI L / M AY 2 0 2 0

done by other methods such as physical separation and sanitation. Communities that strictly practice these methods of control can reduce the speed of the pandemic as was proven in various countries (e.g. China and South Korea) when COVID-19 initially began to surface.

Figure 3 illustrates the general pattern of outbreak data.

The number of new daily infections, as reported, is most likely inaccurate.

There are several reasons for that, most notably, it reflects only those who were tested because they may have passed the criteria required for testing. Another reason is the lag between the time of the transmission and the time that the test returned a positive result. These reasons all suggest that in the early phase of a pandemic, the number of new daily infections markedly under-estimates the

true rate, especially when the pandemic is like COVID-19 and has a high unmitigated R0. On the other hand, when the rate of infections is slowing down, the number of new daily infections tends to overestimate the true rate. This is important to understand because it means that when an inflection point is observed, the actual inflection may have already occurred.

The inflection point can be estimated to help predict when the number of new cases will begin to decline. Because the inflection point indicates a change in the pattern (the number of cases is still rising, but not as dramatically), the knowledge of when it occurs can translate into the knowledge that a decrease in cases should follow shortly. Our strategy for estimating the inflection point is based on a statistical model to eliminate the variability in the reported numbers. We estimate the slope of the curve of new infections with a statistical regression that models a group of 5 daily points at a time. We compare these slopes sequentially until several successive slopes show a reduction in trend.

Once an inflection point has been identified, we then develop a statistical model to incorporate the day-to-day variability and project the future number of new daily infections.

Number of New Daily Infections Linearization

R0=1 R0<1

Inflection point

R0>1

0

10

20

Figure 3. The evolution of daily infection rates.

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Italy New Daily Cases Analysis

United States New Daily Cases Analysis 40000 -

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Figure 5. The evolution and prediction of daily infection rates in the United States.

United States New Daily Death Analysis

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USA: Death Rates The death rates in various countries that exhibit a large number of infections vary widely, ranging from 1% to >10% of those patients with positive test results. In the USA, death rates are 2-4% of those testing positive. The variability is due to

USA: Infection Rates Towards the end of March, the USA became the worldwide epicenter of the

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16Mar

pandemic. While the number of daily infections grew exponentially during that period, at the time of writing this article, some states and cities show a slowing in the number of daily infections as a result of social distancing, ‘stay at home’ orders, more testing, and other measures.

Assuming the trend follows the Italian trajectory, the number of daily inflections is projected to fall between the middle and late April.

Italy: A Case Study Throughout March, Italy had been the epicenter of the Covid-19 pandemic in Europe. After exhibiting an explosion of new cases, the country has implemented various containment methods which are helping to curb the growth of new infections. Analysis of the data suggests that an inflection point has occurred in Italy in mid-March. On March 21, our model projected that within 10 to 15 days, the number of new daily inflections will peak. On March 28, a flattening of the number of new infections was noticeable.

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Figure 4. The evolution and prediction of daily infection rates in Italy.

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09Feb 16Feb 23Feb 01Mar 08Mar 15Mar 22Mar 29Mar 05Apr 12Apr 19Apr 26Apr 03May 2020 Spline Interpolation Death Projections (w/ Lower and Upper Bound)

Figure 6. The evolution and prediction of death rates in the United States.

regional demographics of the population, other background illnesses, and the availability and quality of medical care. It is also apparent that the deaths lag behind the onset of the infections. We are using a statistical model to correlate the death rate as a function of the infection rate.

Our model suggests that there is a strong correlation between daily deaths and infections occurring up to 10 days prior to death. From our model, we can project future death rates with good accuracy up to 30 days. As shown in Figure 6, our model for the number of daily deaths suggests a sharp drop in the second part of April, although it will be variable across the USA. The Covid-19 pandemic will continue to evolve over time, and new outbreaks are expected. We continue to monitor this evolution and continuously update our projections as more data becomes available.

All illustrations and graphics are with permission from Logecal Data Analytics.

Logecal Data Analytics and its parent company, Prosoft Clinical, provide full pharmaceutical product development and clinical trial management services, as well as FDA regulatory representation.

For more information about available services and details about the Covid-19 pandemic, visit www.logecal.com or email d.rom@prosoftclinical.com. 1 WWW.PHYSICIANOU T LOOK . C OM | 45

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