"Re-Thinking Medicine" cover art by Vic Guiza

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P U B L I C A T I O N D E D I C A T E D S O L E LY T O P H Y S I C I A N S A N D T H E I R P A T I E N T S COVER ARTIST: VIC GUIZA

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The Game of Life in Healthcare Written by Marlene Wüst-Smith, M.D.

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n the popular HasbroR board game of LIFE TM the rules are simple and clear: the game is over when all players have retired.

Whoever has accumulated the most wealth wins.

But what exactly does it mean to “win” when playing the “game” of healthcare?

As members of society, we are expected to play by the rules. These rules tell us that our choices have clear consequences and that the outcomes are our own to deal with.

But what happens when we find out that our choices were made in the context of thinly veiled lies, traps, or deals?

What if the game is rigged to favor certain consequences, creating consistently undesired and unexpected outcomes, even for those who are following the playbook to a “T”?

SHARKS IN THE WATER Some of the players in the game of healthcare have inserted themselves in what used to be a wholesome game played only by patients and physicians. These sharply dressed sharks (who have never practiced medicine a day in their lives but control over 80% of every dollar spent in the US) play by their own set of rules. Many have earned a reputation as bottom feeders, with razor-sharp teeth (which they aren’t afraid to use) and eyes that pierce through dark murky waters, focused only on wealth and profit. These sharks are functionally spineless, with vertebrae made of weak cartilage instead of the strong bones which support the backbones 2 | 2 022 VOLUME 14

of patients and physicians. They may have a place in the vast great ocean, but practically speaking in today’s healthcare milieu, they terrorize everything and everyone they come in contact with. Physicians, nurses, and other members of the healthcare team are choosing to leave the open seas to avoid having to deal with the sharks, leaving poor patients to fend for themselves.

NO LIFE JACKETS FOR PATIENTS We are all playing a game where the published rules are inherently unfair to most of the players. This is especially true for United States veterans who are promised a form of "universal" or "guaranteed" healthcare coverage when they enlist to serve in the military. It turns out, however, that their medical bills are only covered if their medical issues are deemed service-related. An Emergency Room visit for an acute illness (with its typically ridiculously inflated charges) is often completely denied, and patients are straddled with unpaid and unpayable medical debt, and often sent to collections.

These are individuals who choose to dedicate their lives to military life and follow a hard-trodden path of service for our country.

They sacrifice greatly, sometimes literally losing their lives and limbs, to protect without question and with conviction. They are promised that if they serve their country, then their country will serve them. Only they come to find out that their country has limits, and these limits result in them being abandoned, trying to keep their heads above water.

PHYSICIANS as PAWNS What about doctors, who choose to devote their lives to caring for others? The road to medical school and beyond requires an almost 3-decade commitment (sometimes longer) that involves deferred gratification and tremendous financial debt. Physicians for centuries have understood that this assignment is one that requires great personal sacrifice but have nevertheless chosen to play the game. They take an oath to put others before themselves. What happens, though, when-- mid-game--doctors realize that they are being stifled and waylaid by the great Machine of Commerce that prioritizes profits over patients?

HEALTHCARE HEROES TO THE RESCUE The medical debt of veterans is just ONE of the many problems in healthcare, but one that helps to shine a light on the magnitude of the problems that MANY patients and physicians face today.

The issue of medical debt for veterans prompted Physician Outlook to join forces with Jerry Ashton to bring more attention to the plight of veterans plagued by astronomical medical debt. Jerry, a Navy veteran himself, and former bill COLLECTOR-turned-DEBT FORGIVER (who remains on the board of www.RIPMedicalDebt.com, the 5013C charity that was his brainchild) has given Physician Outlook Magazine (and its supporters) a unique opportunity to tackle the game of healthcare headon.

Jerry is co-founder of www.

LetsReThinkThis.com (LRT), an organization that uniquely casts a SEARCHLIGHT on “real-life” change agents whose solutions are yet to be discovered. Ashton identified Physician Outlook as having the potential to do tremendous economic and social good through the magazine’s goal of “taking back Medicine one issue at a time.” Physician Outlook uses art and storytelling to highlight the beauty of the physician-patient relationship, and by so doing, it en-

PH OTO BY YOUN G EON LE E ON UN S PL AS H

gages physicians and patients from all walks of life into becoming “accidental activists.”

Famous cartoonist Vic Guiza masterfully brought the healthcare game to life as a vibrant comic strip and LRT is launching a tailor-made “awareness campaign” to bring in the needed capital and awareness to Physician Outlook Magazine.

THE FINISH LINE: #EndVetMedDebt #VeteransMissionPossible Jerry Ashton and LRT’s goals are lofty: to eradicate veteran medical debt AND to alleviate the pain and suffering of veterans who find

themselves sadly contemplating suicide.

Issues in healthcare are complex, and many cannot be solved overnight, but the Veteran Medical Debt issue is one that COULD actually find a resolution. All we need to do is to literally “rally up (AND around) the troops.”

I encourage all of our readers to visit www.EndVeteranMedicalDebt. com and www.VeteranMissionPossible.com to find out how YOU, too, can get directly involved.

Sadly, the issues of medical debt and suicidality are problems for a very large portion of our na-

tion’s civilians as well.

By working with LRT with Jerry Ashton at its helm I know that we can discover and deploy some innovative “out-of-the-box” bipartisan solutions that will not only help our nation’s veterans, but will also give us the unique opportunity to extrapolate and apply lessons learned for our nation at large. ☤ Dr. Marlene Wüst-Smith Publisher & Founder

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PHYSICIAN OUTLOOK MAGAZINE

CONTENTS 2022 | VOL. 14

FROM THE PUBLISHER

GAME OF LIFE IN HEALTHCARE 02. THEMarlene Wüst-Smith, M.D. TOGETHER SO THAT OUR VETERANS DON’T 06. COMING FALL APART By

By Jerry Ashton

BY A THOUSAND MYCHART MESSAGES 08. DEATH Amruti Borad, DO ROAD FROM M.D./D.O. TO D.E.O. 10. THEMark Lopatin, MD STAGE FRIGHT 12. TAMING Maria Simbra, MD, MPH HEAL THE PHYSICIAN? 14. WHOElizaWILLHumphreys, MD, MPH TIME FOR PHYSICIANS TO SELF-ADVOCATE 16. IT’SWendy Schofer, MD RACHEL ROTH: HEALING HEALTH BY UNITING 18. DR. PHYSICIANS By By By By By

By Elizabeth Egan

GIFT 21. JULIA’S Scott Abramson, MD By

SAVE MEDICINE? 22. CANEvePOETRY Makoff, MD DOCTOR 24. DEALERSHIP Liz Antaya FOR PATIENTS 26. SELF-ADVOCATING Stephen Daniel DOCTOR IN PAJAMAS 28. THERobyn Alley-Hay, MD 30. DOCTORS ON SOCIAL MEDIA BUREAU OF THE CURIOUS PHYSICIAN 32. A CASE Teresa Malcolm, MD, FACOG, MBA VETERAN SAYS FISHER HOUSE IS 34. COMBAT ESSENTIAL TO SPINAL CORD-INJURED VETS By By By By

By Dana Corriel, MD By

By Christy Wilcox

LOVES AND SECOND HAND LIVES 36. FIRST Ayushi Chugh, MD By

Coming Together So That Our Veterans Don’t Fall Apart T H E V E T E R A N M I S S I O N P O S S I B L E C A M PA I G N

IMAGE BY JERRY ASHTON, MEDIUM

Written by Jerry Ashton

Pictured: Col (ret) US Army Mikel Burroughs, Jerry Ashton, Navy vet along with his RIP Medical Debt co-founder Craig Antico — NYC Veterans Day Parade 2017

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ost of us have seen the distressing headlines about our veterans: their rate of suicide, homelessness, drug abuse, incarceration rate, debt and more.

Some have also read about the VA attempts via Mission Daybreak to specifically reduce vet suicide — even throwing $20 million dollars in prizes into the mix for organizations that they feel have innovative ways in which to specifically reduce vet suicides.

Several of VMP’s members competed — one successfully: Marine Veteran Rick Johnson CEO of Voi Health and Voi Technology.

But the overall experience was disappointing.

Innovation seemed to be less important than a solution’s ability to fit within the existing VA bureaucratic process. Contestants were put in silos, with no real attempt to create a community or develop cross-pollination. Previous contracts won through the VA moved a contestant’s proposal to the top of the judging stack. To make things worse, only 40 participants out of 1,371 entries “qualified” to share in the pot. Only 40???

Thus, the emergence of VMP and its energetic cadre of risk-takers and out-of-the-box thinkers and their supporters who were among the 1,340 who didn’t win a spot. We decided to create a community out of this disparate group. And, to locate and invite others also with good solutions but who were not aware of Mission Daybreak to join with us in a campaign that runs from 11/1/22 through 1/31/23. Veteran Mission Possible.

We intend to equal or better in featuring our members’ impactful solutions. But, how?

The importance of media

Equal to the need to ferret out and refine the thought leaders and their solutions is to see that their inventions and approaches are brought to public attention and especially to the ultimate recipients — the veteran in need and their advocates.

If they don’t know about you, they can’t do anything about you.

To ensure that needed awareness, VMP is constructing a web of media specialists and journalists within and outside our community to tend to this. Nothing beats a press kit containing recent newsworthy items.

In the works:

Military Veterans in Journalism (MVJ) is working with VMP to develop an onsite and online “media pool” of experienced professionals whose efforts will be harnessed to write those stories and do those interviews. Today, Veteran’s Day 2022, I will be attending their discussion on military, veterans news coverage at the National Press Club — featuring an appearance by former Navy veteran Bob Woodward.

Cary Harrison, VMP Director of Broadcasting and Streaming Media, is using his sway as a highly regarded radio personality to develop in tandem with famed KPFK 90.7fm in Los Angeles a weekly one-hour program devoted to veterans issues and their spokespeople for distribution through Cary’s affiliate stations

across the U.S. “The emphasis will be on solutions, not just the problems,” as Cary describes it.

Cary and KPFK on Veteran’s Day last year featured a one-hour fundraiser for the RIP Medical Debt charity to bring attention to veteran medical debt. Enough funds were raised to abolish almost $500,000 in such debt. Imagine this promoted nationally — with veteran debt as the sole focus!

Host of “Ask a Doctor” on VoiceAmerica Radio Virgie Bright Ellington, author of Crush Medical Debt and an VMP benefactor interviews me about our mutually (un) favorite subjects of medical debt and veteran suicide just in time for Veteran’s Day. Visit this site and skip over the first part to start this latest segment at 32:27. You will not be put to sleep.

In fact, the overall approach of VMP and its allies and supporters is to Wake America Up! In the most gentle but urgent ways possible to the wrongs that need to be righted and the actions that need to be taken. More details for those who might want to be part of this campaign can be found here: https://veteranmissionpossible. com/.

Don’t dawdle, a veteran needs your help. More than one veteran, to be exact. Thousands of them. ☤ A version of this article was first published in “Our Newspaper” on LetsReThinkThis.com and is being printed with permission from the author.

Death by a Thousand MyChart Messages Written by Amruti Borad, D.O.

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t was one month prior to the first COVID19 Omicron Surge when I thought to myself: “If I have to write one more note, sign one more order, or respond to one more MyChart message (the patient message portal within our EHR), I think I might leave medicine.”

This thought frightened me, disappointed me, and angered me.

Why did I spend the last umpteen years preparing to become a Family Physician, only to end up feeling this way? How could medicine let me down?

My relationship with medicine turned from finding the love of my life to a tragic sudden break up (If you haven’t heard the Chris Stapleton song, “Cold,” take a listen. This is precisely how I was feeling).

“What am I supposed to say If anybody asks me about you?

I guess I’ll tell ‘em I’m without you How am I supposed to live When I built my life around you?

- Cold, Chris Stapleton I felt lost.

I had already spent hundreds of hours reading about burnout (also

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1.

My thoughts create my feelings, and I have control over my thoughts.

aptly described as “moral injury”) and listening to every podcast under the sun, hoping to find my way back to the excitement I felt on my first day as an Attending Physician.

And then I came across an article that discussed a few unique ways of addressing this “epidemic” of physician demoralization which included Coaching, mentorship, and peer support programs.1,2 Coaching stood out to me as I had already been considering it for a few years and by chance, I met a Physician Coach within my own department. It was time to invest in myself, and I did.

Not only did coaching help me navigate and grow as a novice Clinic Medical Director and a Department Wellness Director, but it also brought back the joy of clinical medicine, consistently reinforced my “WHY” in both my professional and personal life, and drew me into a world of endless possibility. It also allowed me to “pay it forward” by bringing coaching (both formal and informal) to my colleagues in need and to our department.

Here are my takeaways from my coaching journey (Right): In the end, the only person looking out for you is…YOU. Choose yourself.

Find a Coach. ☤

2.

In every situation, I either get the resut I want, or the lesson I need.

3.

It is possible for me to be vulnerable; vulnerability is a sign of courage.

4.

5.

6.

I can do do difficult things.

My voice matters.

I am on my own path and I have my own back.

7.

I ask for what I want.

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8.

9.

I respect myself.

“Should” has no place in my vocabulary.

It is “could” with shame.

Resources: 1. Effect of a Professional Coaching Intervention on the Well-being and Distress of Physicians https://jamanetwork. com/journals/jamainternalmedicine/fullarticle/2740206 2. The Business Case for Investing in Physician Well-being

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. I can set boundaries and not feel guilty about it.

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. I engage in self-compassion in order for me to just be myself.

12

. A relationship is only what I think about the other person.

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. All I have to do is take the next best step.

A graduate of Pitzer College, Dr. Borad attended medical/osteopathic school at the Western University of Health Sciences and completed her residency in Family Practice at the David Geffen School of Medicine. She has worked as a practicing physician and Medical Director for UCSD’s Rancho Bernardo Primary Care Clinic for several years. In the Fall of 2022, she accepted a position within UCSD’s Health Primary Care Concierge Medicine practice, where she can practice medicine in the way that she finds most rewarding: spending time with her patients and their families so that she can understand what brings her patients their sense of purpose. Her hope is not only to treat what ails them but also to help PREVENT disease from occurring in the first place.

Passionate about physician and practitioner wellness, she is a free-lance faculty member at Practicing Excellence. This mission-driven organization is committed to supporting and developing healthcare teams that create enterprise-wide results in team wellness, patient connection, and leadership effectiveness. She is also a student at The Life Coach School, with a goal of becoming a Physician Coach herself to help colleagues avoid burnout.

In her free time, Dr. Borad enjoys playing the piano, songwriting, meditating, training to be a life coach, reading non-fiction, playing with her loving golden retriever and golden doodle, and attending concerts and traveling throughout the U.S. with her husband. She has also begun passively investing in real estate, applying the lessons learned from participating in the wildly popular Leverage and Growth Summit hosted by anesthesiologist Dr. Peter Kim, founder of Passive Income, MD.

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The Road from M.D./D.O. to D.E.O. Written by Mark Lopatin, M.D.

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et’s look at how documentation has exceeded actual patient care in level of importance. Documenting what you have done as a physician is essential, but it has gotten entirely out of hand. I have jokingly commented that my degree should be changed from an MD to a DEO, as I have become a glorified data entry operator. Getting the right answer no longer matters. Instead the focus is on whether a physician has shown their work and appropriately justified the reasoning for a particular diagnostic test or treatment to a third party. Documentation that is unsatisfactory to a third party may mean denial of a particular test or treatment or result in inadequate reimbursement. The electronic 1 0 | 2022 VO LUME 14

health record (EHR) has become nothing more than a billing tool.

The price we pay is that the more time physicians spend documenting, the less time we spend engaging patients.

Documentation should be focused on explaining a physician’s thought processes, but instead the emphasis has been placed on quantifying data. For example, as a rheumatologist, one of the key things I must assess is pain. Pain is subjective and cannot be quantified using a 1-10 numerical scale.

Physicians, however, are forced to use such a scale to satisfy one of the insurer’s criteria for reimbursement. The problem is that one person’s “8” is another person’s “2”. Furthermore, pain levels

are different at different times, in different places, and for different conditions. Physicians are expected to provide one number at each visit to quantify a patient’s pain experience.

Physicians are also routinely required by insurers to not only provide a number to define a patient’s pain level but also to document if a patient’s pain is better or worse.

The question is, since when? Since the initial diagnosis? Since their last office visit? Since last week?

Since yesterday? How do I record the pain level for a given condition, if it is better than it was last week, worse than it was yesterday, and about the same as it was at her last office visit a month ago? How should I document improvement

Furthermore, much of the documentation is required for billing purposes, rather than patient care.

Doctors Christopher Notte and Neil Skolnick have noted, “The patient’s chart, once considered a sacred

Reprinted with permission by the Author from his book Rheum For Improvement: The Evolution of a Health-Care Advocate

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Am I the only doctor who is sick and tired of being told how much my time is worth? I have to justify my time and substance of visits for each payment. I am spending more time documenting my visits than I am seeing my patients. If I see a patient for 30 minutes, I have to document for 30 minutes why I spent that time. I get the distinct honor of coding the assessments and then I get to code quality measures. AND LORD FORBID I DON’T—then I don’t meet the standard of care. Just whose standard is that?

text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient no matter how mundane or trivial.” The demand for documentation results in long computer-generated notes that contain little practical information.

It is not uncommon for a 16-page progress note to contain only one paragraph of useful information.

We have seen tremendous advances in science and technology, but the take-home message needs to be that being a physician and caring for patients is inherently a human experience. This is where we need to be placing our focus, not on documentation for documentation’s sake. How a physician relates to their patient may well be the most critical aspect of easing the patient’s suffering and is not something that can be quantified.

The corporate takeover of medicine is extracting the humanity out of health care at an alarming rate, resulting in unprecedented levels of physician burnout.

I assert that the best doctors are the ones who genuinely care about their patients as opposed to the ones who know the most. Medicine needs to be filled with “H”s: Helping, Humor, and Humility as corollaries to Healing, but Humanity remains the most important “H.” Hopefully this message will come through in this book. The need for documentation is just one example of how humanity, and therefore health care, is being compromised.

when the pain in one joint is better, but pain in another joint is worse?

What if the pain from her rheumatoid arthritis is worse, but her pain from fibromyalgia is better? Am I expected to document the pain at each visit, in each location, in each time frame, and for each condition? The amount of time it would take for me to document all of that would preclude me from actually providing medical care. Time spent documenting measures such as this is time not spent truly caring for patients.

Even documenting the diagnosis has become difficult. Physicians must use an alpha-numeric code for each diagnosis, and the number of codes expanded from 13,000 to 68,000 in 2015. These diagnostic codes often must be specified based on factors such as onset of the problem, an underlying cause to the problem, chronic versus acute, with or without complication, left versus right, initial versus subsequent visit, and so on.

This excessive need for documentation detracts from physicians’ ability to care for patients properly. The key word here is

“excessive.” Documentation is important, but not to this degree. As noted by one physician, “Dr. Mom,” on the medical blog “Sermo,”

☤

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ing about k in h t f o d a te “Ins wrong, think o g ld u o c t a h w go right!” ld u o c t a h w t abou

Taming Stage Fright Written by Dr. Maria Simbra

3.Watch what you eat and drink

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hen your hospital or department asks you, “Could we put you on the schedule to present Grand Rounds?,” do you break out in a cold sweat?

You aren’t alone. Nearly eight out of ten people have some level of fear about speaking in public.

Nervous energy isn’t always bad.

It can help you prepare for a big presentation, whether it’s Grand Rounds, a conference talk, a community event, or a media interview.

But if you find yourself with an extreme case of stage fright, here are five tips to make public speaking less scary.

1.Remember that you are valu1.Remember able to the audience.

You’ve been selected to speak because of your expertise. The world needs what you have! Harness your generosity. Think of your presentation as a gift.

Organize your talk with three main messages. If you have more than that, no one will remember, If you have fewer, you’ll sound repetitive.

2.Know that the audience is

rooting for you!

Instead of viewing the people in the audience as your critical adversaries, think of them as your friends. They want you to succeed as much as you do. Smile! Make eye contact! Speak as if you’re having a conversation with just one person.

With that in mind, use stories

before your presentation.

Caffeine can make you shaky and jittery. Carbonated beverages could make you burp. Alcohol might make you fuzzy. You know what agrees with you and what doesn’t. Be mindful of that on the day you are speaking.

Some people take benzodiazepines or beta blockers to help them get through a speaking gig. If this is part of your routine, okay. But don’t take the pharmaceutical route for the first time before you go on. You never know how you might react.

4.Visualize success.

Athletes use the technique of visualization to enhance their performance –they mentally rehearse making the basket, doing the flip, scoring the goal. Simply envisioning doing it perfectly can aid their performance, even if they don’t touch their racket orball.

This can be helpful in public speaking, too. Imagine walking onto the stage, standing at the podium, connecting with the audience, progressing through your slides.

Imagine radiating confidence and warmth. It will shine through when you do it for real.

If you’re still feeling nervous, breathing and relaxation exercises, yoga, meditation, or going for a walk can help you release some of the tension.

5.Practice, practice, practice.

Practice out loud. Do the words sound natural and conversational?

Arethe slides easy to read for the audience? Where do you trip up,

and why? It can be helpful to have someone else listen to your talk.

See if your colleagues will indulge you. You could also work with a presentation coach.

The Q&A can be a source of stress for some speakers. There are techniques for handling the tough questions and the questions for which there are no good answers. You can also practice Q&A with colleagues or a coach.

Instead of thinking about what could go wrong, think about what could go right! While most people find public speaking uncomfortable, just about everyone will have to do it for their job at some point.

When you do it well, it’s a win-win for you and the audience. ☤ IMAGE BY DR. MARIA SIMBRA

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to make a connection. The human brain is primed to process stories.

Wrap the facts into a story, and your audience will remember what you say.

Don’t fret about screwing up.

No one is expecting perfection. If you stumble on a slide or a comment, acknowledge and move on.

The fact that you are a human, and not a robot, is endearing.

Dr. Maria Simbra is the coach, consultant, and principal at Dr. Maria ON Speaking, LLC. She is a neurologist, turned TV medical reporter, turned media and presentation coach for doctors at DrMariaONSpeaking.com

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Who Will Heal the Physician?

THERE IS HELP AFTER THE TRAUMA OF AN UNEXPECTED EVENT

Written by Dr. Eliza Humphreys

I

was a third-year medical student in 1999 when the landmark report titled To Err is Human was released by the Institute of Medicine (IOM), unveiling the uncomfortable truth about the fallibility of physicians and our medical system.

I remember it vividly. The publication’s scandalous revelation that nearly 100,000 preventable deaths occurred in hospitals each year shocked me. I recall feeling simultaneously offended and defensive at the implication that doctors could be wrong. Medicine, after all, was a noble profession requiring hard work, sacrifice and intellectual rigor.

It was a calling to heal and serve. It seemed incongruous with my world view that a physician might actually cause harm.

I had been exposed to medicine by my father, who practiced nephrology and ran the dialysis unit at an urban county hospital. He was trained in an era when physicians were predominantly male and of a skin color to match their pressed white coats, and the physician-patient relationship was best characterized by the adage “doctor knows best.” I came of age at a time when the rigors of medical education coincided with the advent of protocols, algorithms, metrics, and evidence-based medicine. The IOM report rightfully fueled the patient-safety movement in conjunction with an accelerated interest in research and systematic change to avoid unnecessary death and medical errors. Twenty-three 1 4 | 2022 VO LUME 14

years after the report’s publication, however, our healthcare system still struggles to address medical error and its ramifications at an organizational and system-level. Importantly, our system hasfurther failed to adequately address the human struggle faced by individual clinicians confronting such errors.

Medical errors exist at the far end of a continuum of unexpected events in clinical practice and they are devastating for all involved.

Even when care is attentive and patient compliance perfect, unexpected outcomes occur in medicine.

Unanticipated diagnoses, delays in diagnoses, premature death—these are all included in the realm of “unexpected events” even if nothing has gone “wrong” in medical care.

These events cause physicians to suffer self-doubt, worry, shame and guilt, sometimes exacerbated by the magnitude of the event, the temperament of the clinician, and the

Emotional distress is common after a medical error.

The threat of medical malpractice forces a provider to also deal with uncertainty and fear surrounding legal sequelae of an unexpected event. An article in the New England Journal of Medicine (NEJM) from 2011 suggests that by age 65, 75 percent of clinicians and upwards of 90 percent of surgeons will have faced a malpractice claim.

Despite the prevalence of statistics shared in the above-mentioned publications, doctors don’t talk much about this side of medicine. Why not? In part, the answer may lie in the fact that the culture of medicine discourages personal disclosures of this nature. Doctors are meant to project composure and remain free of emotional entanglements, which might cloud medical judgement. Perfection is expected, which leads to a zero-tolerance policy for mistakes, since, obviously, when treating humans there has to be an emphasis on getting it right. In such a culture, an error or unexpected outcome invariably can lead the tending physician to feel to shame and guilt. A sense of isolation often accompanies these feelings, exacerbated by theunwritten coda that one should not discuss any potentially litigious details with peers that may be judged to reflect a lack of clinical competence or that may surface as evidence in later legal proceedings.

Reflecting on my two decades in clinical practice, it remains uncommon to explore the ramifications on the individual physician’s well-being after an unexpected event.

This lacuna has prompted my interest in promoting discussion about risk and uncertainty in medicine. Given the prevalence of unexpected events, medical error and malpractice, why are we not talking more about how doctors

feel? Of the staggering number of physicians who report burnout or of those who die by suicide, how many have experienced an adverse outcome that may have affected their well-being, contributing to these troubling outcomes? Burnout is common, with research suggesting patient-care suffers in its shadow.

Similarly, depression scores have been associated with increased risk of medical error. Is the same true for the physician preoccupied with a past mistake or adverse event?

How many of us have a graveyard of patient experiences comprised of moments that did not go well and in which we felt some culpability— even if we assumed an unrealistic share of the perceived responsibility? How many of us have learned of a differing diagnosis on a patient made outside our exam room and then scoured our records to make sure we did not miss something?

Our negativity bias, carefully honed through years of training to anticipate the uncommon yet worst outcome, serves us well professionally while detrimentally turning inward, amplifying the voice of the physician’s inner critic.

There are antidotes on the individual and institutional level to attenuate the toxic distress that occurs downstream of an unexpected event. First, publications in the medical literature on second-victim syndrome have added language to describe the experience of clinicians, or second victims, involved in an unexpected event and its sequelae. Second, there is research to support the practice of Mindfulness and Self-Compassion (MSC) and its benefits on well-being and productivity. Psychologist Kristin Neff, PhD, the first to define self-compassion operationally, explains that the primary goal of MSC is treating yourself as you might treat a dear friend.

MSC provides the opportunity for greater self-awareness of thought patterns that are highly critical and a pathway to metabolize them. Third, on an institutional level, programs

such as Dr. Jo Shapiro’s Peer Support program based at Massachusetts General Hospital (MGH) aim to change the culture of medicine and provide immediate support to those requesting it after an adverse event.

Trained peer physician counselors are available to offer a supportive framework for a clinician in distress.

Finally, physician coaching is another avenue to cultivate awareness and manage self-destructive thoughts. Though an unregulated industry, coaching programs for physicians have been associated with decreased burnout and emotional exhaustion and an increase in resiliency scores and quality of life.

For the physician practicing today these tools are worth cultivating.

After all, for most physicians, confronting the inevitable unexpected event requires resilience, reflection and insight in order to recover and best serve our patients—and ourselves. ☤ IMAGE BY MULYA DI, UNSPL ASH

institutional climate in which these events occur.

This article was originally published on KevinMD.com and printed with permission of the author.

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It’s Time for Physicians to Self-Advocate Written by Dr. Wendy Schofer

It’s time that we take an active role in our own self-advocacy. What does that look like?

It starts with taking care of our individual needs, not waiting for someone to change the system, not waiting for someone else to act on our behalf.

Taking pee breaks News flash: doctors have physiologic needs too.

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IMAGE BY LUIS MELENDEZ, UNSPL ASH

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e live in an age of advocacy. Grassroots initiatives are all around, from firearm control, to educational support for our children, to environmental protections, to orphan disease research and treatment.

What about us? Physicians.

What are we advocating for?

Oh, absolutely… the patients.

We are always advocating for our patients… prior-authorizations, becoming the case manager when there is none, calling in prescriptions, and calling schools to obtain the accommodations that our student-patients need to work at their best.

But how do we advocate for ourselves?

Our professional organizations have advocacy missions and resource centers. The AMA has a full Health Care Advocacy center outlining all the ways that they are advocating for key health care issues impacting patients and physicians.

I’m guilty: “I can’t go pee right now, I have to see another patient now.” Yes, this is an advocacy issue. As physicians we often overlook and flat-out rationalize why our needs aren’t as important as others’ needs. Taking a legit lunch break, a pee break, any break: our bodies are not meant to run at full steam all the time. We have different gears and we get to use them, when we give ourselves the opportunity to do that.

What does that look like for me?

I take a lunch break. I go pee when I need to, and I enjoy the long walk down the hallway to the bathroom.

I take a deep breath before I go in the next patient’s room - it “centers”

me, but quite honestly it changes my physiology. It calms me and helps me focus upon what’s right in front of me now.

Saying no “Mrs. Schofer was late, can you fit her in over lunch?”

“Oh, by the way, I almost forgot to mention this itchy rash I’ve had for 3 months, what is it?”

“As a part of your institutional service, all physicians serve on a committee which meets after hours. Oh, we didn’t have to include it in your contract. It’s just what we do.”

What is important to you? How do you make sure that you have the

time bandwidth and quite honestly the energy to make it happen without burning out?

These are questions that we do get to ask of ourselves, and start defining how we want to live and practice medicine. And I’ve found that having a very strong set of boundaries helps.

It wasn’t always this way. Dr. Schofer would add on patients and tasks because it was easier to say yes to the patient and the staff, but all the while I was saying no to my needs and my priorities.

I have created boundaries on the amount of time that I spend with patients.

“That’s a great question which we will have to address during your next visit.”

I trained my staff to follow protocols: “Their late arrival unfortunately cannot be accommodated in today’s schedule.” Protocols are brilliant boundary-setting exercises, as well as self-advocacy tools. If this, then that. No emotions, no squabbling. It’s just what it is.

The opportunity that we have as physicians is to see how creating protocols and boundaries are more about saying yes to our needs than saying no to the patient.

Time and chart management Are you an author? Are you writing the next novel in your patient’s note? Patient advocacy does not mean having to fight your case in a note. And self-advocacy means identifying just what needs to be included in the note, and then leaving the creative writing for a different publication.

I realized that I was able to advocate for myself when I identified the basic requirements for a note:

What happened today?

Can I prove it in a court of law?

Is there continuity of care for the next physician seeing the patient?

Niceties about Mrs Schofer’s

dog, her recent trip, or the full blowby-blow differential was taking a toll on me, as I wasn’t able to complete charts in real time.

Leaving work at work This may be a shocker to some: I’m a doctor, and I refuse to be imprisoned by my profession. For the first half of my career, work bled over into my home life. I had notes on my mind, messages to check, and quite honestly work stressors followed me home.

Self-advocacy looked like identifying this as something that didn’t work for me. And that I wanted to change it. I started with charting: not writing the next novel and niceties about the patient’s dog in the note. Templates and judicious copy-forwarding were implemented.

And I declared that when each patient left the room, their note was completed.

The act of focusing on what I

needed: a functioning computer in each exam room, to type during the visit, and to close out each chart from my brain was a tremendous step in self-advocacy. My bandwidth was focused upon this patient, right now, in the office.

And when they departed, so did all my focus upon them.

I could not focus on the next task, or the next patient, or even better yet: leaving the building.

Self-advocacy looks a lot like actually admitting that physicians have needs, that we can prioritize our needs, and take care of them. Taking care of our needs does not compete with taking care of patient or institutional needs.

In fact, taking care of our needs, and advocating for how we can individually work at our best, helps everyone.

Here’s the thing: the professional organizations don’t know what I need in my day-to-day clinic. I’m not waiting for the system and the culture to change from the outside. I get to identify where I can self-advocate for my own needs (like seriously needing 9 hours of sleep every night). That’s my job. ☤

Wendy Schofer, MD is a pediatrician and physician life coach. www.wendyschofermd.com

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Dr. Rachel Roth: Healing Health

by Uniting Physicians INTERVIEW WITH THE CEO AND FOUNDER O F H E A L I S H E A LT H

Dr. Rachel Roth

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ell me a little bit about how you got into medicine and what that process of becoming a doctor looked like for you?

So I am a family medicine doctor. I am a person who was always very passionate about medicine and wanted to go into it from a young age. I am the first doctor in my family. So as I went through that experience, I experienced a lot of disillusionment with the medical system as it is. I think that very much speaks to the experience of a lot of the doctors that are in the group. A lot of that came from the moral injury of working in a system which was pretty toxic for ourselves. One that didn’t actually address the root causes of our pa1 8 | 2022 VO LUME 14

tients problems.

Essentially after residency I needed to heal from that experience so I moved abroad to Israel.

My intention was to stay a few months so I could take some time off. It turned out I needed a lot more time off than I thought and I ended up staying so we have been here almost 8 years.

Working as an ex pat physician I found the positions were very unstable. You didn’t really have a way to negotiate rates and the pay was very low. In general, I didn’t feel empowered to connect with patients and treat them the way they should have been treated. There was always some system dictating how you could practice medicine.

How long you had with the patient,

IMAGES FROM HEALIS HEALTH

Written by Elizabeth Egan

what kind of medicine you could prescribe or what you are allowed to talk about, etc.

In 2020 I had friends in the states saying they had to get out of here. People were wanting to live near their parents because they worried about them or they needed childcare doctors found that they were totally locked in because their patient panel was there or their job had a non-compete. A lot of people reached out to me to ask how I made becoming an ex pat work and I said, “not very well”.

I said to one of my friends what if we started our own business where we had our own practice that we could control? We could do what all the other telemedicine companies do where we bring in

our own panels and work on those together. I put it on Facebook and suddenly there were 100 of doctors who responded saying they needed that same situation. That is when I realized there was a need and I didn’t want to leave everybody in the same lurch that I have been in for the last 7 years.

I knew that there must be power in this group, in this number of people that are dissatisfied with the way that medicine has become. We decided to form a collaborative company. People will invest money and we will use it for group insurance and to cover all the costs needed allow every doctor to have their own practice. That was how this project got started.

What are the differences with practicing medicine in person vs through telemedicine?

There was recently a survey by the AMA that said 80% of complaints can be addressed through telemedicine. In my experience I would say that is correct.

Most of the decision making process about what to do with a patient has to do with their story.

It also depends on what they tell you is going on and a little bit with how they look. There are subtleties to that that you don’t even realize until you have practiced for a long time. Peoples color or how bright their eyes are or how they hold

themselves. There are just little things that can help to tell you how to diagnose them. You can capture that in telemedicine so the essentials are there to practice good medicine. You have about 20% that you just really need a physical exam for so that is where in person referrals become necessary. Otherwise I think practicing telemedicine is really the same or maybe better. When I sit with someone I can see their home environment.

When you pluck someone out of their home environment and into a sterile clinic you get a different view of them.

People sometimes act when

IMA GE FROM HEA LIS HEALTH

What inspired you to create Healis Health?

I was working for a telemedicine company at the time that I liked; I would have been happy to stay with them. However, they started cutting rates after I had been there for a number of years.

They started filling all the physician held positions with mid-level providers.

It was just a demoralizing moment because you expect loyalty after years of working in a place.

Patients come because of word of mouth or because I am their doctor and they have a relationship with me and they refer their friends to me. I am the one creating value for the company and yet they don’t see that. They just see the bottom line.

It was really at that point that I realized no matter where I am and if I love it, if it is not run by physicians with the patients at the center there is going to be a profit motive that will be forever interfering with my life and the life of the patient.

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they go to the doctor and they try to act as good as they can. At home, you can see what is on their walls, if there are children running around, is their mold? You just get a sense of like how they live and that is a huge piece of information that we miss in the clinic. So yes, I think that practicing telemedicine can be better for a lot of things and then obviously for other things you do just need that physical exam.

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What has been your biggest challenge in creating Healis Health?

What has been really easy is getting doctors. We have not advertised at all and we are very honest and transparent with everyone about where we are in creating the company. Despite it being a young company and not having regularincome flow or stability we have new signups of doctors every day because medicine so needs this transformation. The doctors need to be re-empowered especially after the last couple of years when practicing medicine has become so toxic. I think this is the moment that doctors are ready to come together and create change and that is essentially what we are doing.

The hard part has been reach-

Care for the whole of you.

ing patients because the world is really big and in general, the way that is done is taking on massive investments from corporations and pouring money into advertising.

We have decided not to go the route of taking corporate financing. We have had to build the practices organically which means reaching out to people individually and explaining to them what they can get through the business. That is slow and time consuming and it has gotten us some of the way in the sense that doctors do have small panels of patients. However, it hasn’t been enough to really build the business. We are looking at other ways of reaching big groups of patients that need care and reaching them that way.

What would be your highest goal for the company?

My highest goal for the company is having every doctor have as many patients as they want because that enables us to create freedom for doctors. There are so many who struggle to balance their home and work life. Doctors who struggle with things such as mental health and chronic illness shouldn’t be leaving the workforce entirely because they are great doctors and can expand the pool of people who have access to quality care. In reality of how grueling it is to work in a fast-paced clinic, there are some doctors want to work full time and I would love if their panels become full.

A lot of people just want this as a side project to make money or to be able to work part time to get a better balance in life. I think that is so critical because we have all had doctors who are rushed or don’t listen

or who are just not compassionate with us. I think that has a lot to do with all the other things going on in their head and the burnout and pressure they experience. If we could somehow alleviate that, it will ultimately make for better care.

What is something you would say to a patient to tell them why they should become a part of your practice?

We have talked about that a million times and the challenging thing about that is that each doctor has their own practice and they offer different things. What I would say is I think there is a doctor out there for every patient. There are some people who are very holistic and want more natural solutions but live in a place where they don’t have access to that. Here people can find a doctor who sees eye to eye and will treat them the way they want to be treated.

Similarly, you have patients who have very highly specialized problems and their nearest specialist is booked for months or is far from their home. They can access an incredibly well trained specialist within a week or even in a day through telemedicine. In general, we are trying to break down the barriers between patients and doctors. One of the hard parts has been articulating what barriers we are trying to break because it is different for each person.

We are trying to restore peoples access to doctors they would want to talk to. Someone who you choose and will listen to you. We want to restore that part of medicine where you sit down with your doctor. Ultimately, we want to see patients connected to care in a way they otherwise would not have been able to. ☤

Julia’s Gift IMAG E BY EN G IN AK YURT, UN S PL AS H

Written by Scott Abramson, MD

picked up on this attitude. In her next email equipment request, she concluded with these exact words, “Dr. Abramson, I trust that you will continue to be my advocate.”

And Julia was right.

I should be her advocate.

That is my job.

But sometimes, like many of us, I get overwhelmed by the excruciating details of routine doctor busywork.

I forget.

I forget my job.

I forget that my real job, above all else, is to be my patient’s advocate.

Thank you, Julia, for this reminder.

Thank you for this gift.

I am humbled to receive it.

Respectfully submitted, Scott Abramson, M.D ☤ “Julia’s gift” first appeared in the book written by the author “Bedside Manners for Physicians and everybody else: What they don’t teach in medical school (or any other school)” and is reprinted with permission.

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IMAGE BY ANNIE SP RAT T, UNSPL ASH

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ulia is a fun-loving single gal. She is an avid Oakland A’s fan. She is also my patient. In my two years as her doctor, she has been devastated by the ravages of Multiple Sclerosis. She is now confined to a wheelchair. But Julia is full of spunk and determination. Though she struggles mightily, she still manages to live independently. She combs the internet to find any device that might aid her. I then, dutifully, pursue these requests through our DME (durable medical equipment) department.

Many times, I have had long back and forth conversations with DME personnel to clarify the details of these requests.

I must confess: Some of the intricate, detailed specifics of these equipment orders were getting to be a little annoying. And, truth be told, all this was taking up a lot of my precious doctor time. I was beginning to feel less like a specialist physician and more like a health care butler.

I suspect in one of my email conversations with Julia, she may have

Can Poetry Save Medicine?

Written by Dr. Eve Makoff

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midst the “great resignation” Covid has had health systems scrambling to retain employees. Beyond the burnout that already existed in medicine due to an overemphasis on efficiency and technology, turning doctors into “providers,” and making a calling feel more like a menial job, it’s the moral injury, the traumatic effect of the repetitive witnessing of suffering and death without the power to stop it, compounded by the very hard truth that there are people who refuse to accept the tools science has brought to fight the pandemic, because of politics, that dealt the final blow.

Soothing stress, focusing on spiritual wellness, commiserating with colleagues after devastating clinical encounters, and time away with sand between your toes while nursing fancy pink drinks are crucial to supporting “wellness” - or at least to providing a break from the crush. But do they bring lasting 2 2 | 2022 VO LUME 14

change? Or do we just return, after moments of relief and slip back into the white coat or the blue scrubs, and start all over again at exactly the same unbearable place? Are we accepting a reprieve when what we really need is a whole new path?

After decades of practicing medicine, I had a kind of transformational moment that made me believe one exists.

And it happened through poetry.

In the 1980’s, before medical school, I studied English in college, so it’s no surprise I was drawn to the field of Narrative Medicine. But even with my major, I’d been wary of poetry, questioning my own ability to understand what a poet was trying to convey. I sat silently in those classes, avoiding the professor’s gaze. But in the midst of the pandemic, when I enrolled in the Narrative Medicine program at Columbia, I was forced to confront my fear of verse and granted the opportunity to find its deeper meaning: discomfort with ambiguity.

As physicians we are trained to be certain, confident, and absolute. We speak in statistics, in data. As a student when I’d ask a question like: “The patient re-

ports nausea. She believes it’s from her new medication. Do you think that’s possible?” Time and again I was told by a supervising physician: “Not a chance. That pill never has that side effect.” If a connection wasn’t proven, inexplicable symptoms were dismissed. This kind of disavowal of a patient’s own experience if it strays from the script runs rampant in medicine.

In my first Narrative Medicine class: “Close Reading and Creative Writing,” we read “1994”

by Lucille Clifton. Right away I wondered what was crucial to the poet about that year which happened to be my last year of medical school. But the teacher encouraged us to not dissect the poem, engage in literary analysis, or even question the intention of the writer. We were to submerge ourselves in the text itself and discuss what it evoked for us personally. We were asked to circle lines and phrases that “worked on us,” that made us feel; that connected us in some way to the transcendent undercurrents of our human existence. As I did so, I allowed the lines “you have your own story you know about the fears the tears the scar of disbelief ” to hit me straight in the gut as I thought about my struggle

Coming together that way, spinning words into images and stories, common themes emerged while disparate styles were displayed. We learned how much we had in common despite our differing contexts.

Through this exercise we were also able to see the power and the beauty we generate when we work together.

Since that day, the pandemic still lurks in the shadows – threatening to grow larger again. But something started to shift in what many of us view

as our priorities, at work and beyond. In that moment, through the words of the poem and the community we created, we renewed our sense that our connection as humans is our most important day to day task. And while the structures making medicine feel less personal still exist, we continue to refocus our attention on what matters most – the people in our care, including ourselves. We now recognize that depersonalization and “compassion fatigue,” the hallmarks of burnout, are unable to survive in a milieu that centralizes humanity – and creates poetry together. ☤

IMAGE BY SINCERELY MEDIA, UNSPL ASH

to hold my family steady in the face of the public health crisis.

Within class discussions, the poem’s meaning blossomed, expanding beyond my own emotions and reflections to include the various other perspectives in the virtual room. We all came from different backgrounds and places. In this iterative process, we learned there was no one meaning in those words, and that every text is incomplete without the input of us, its receivers. Our thoughts, our feelings, were all valid regardless of what the poet intended. And in the process of sharing our perspectives, we got to know each other, and ourselves, better.

In the fall of 2021, as the pandemic roared on, I was asked to find a team building exercise to address the theme of “engagement” at my job where I was a medical director. The need was to stop the bleeding – to repair the detachment, the sense of depersonalization, that was now a national problem in medicine.

So I looked for a poem.

It couldn’t be too metaphoric, or too long, or overly lavish with imagery. I searched for a simple provocative set of stanzas intended to retrieve the connections between us that were lost in the stress of the pandemic. I chose a short, simple poem about love.

That day, hundreds of healthcare workers read the poem together. And as prescribed by the Narrative Medicine exercise, groups of staff co-created their own poems, all starting with the line “Most importantly love.” Each individual would add whatever sentence or phrase came into their minds after hearing the words of the person who spoke before them.

By the end of the day, dozens of new poems were formed and shared with excitement by people who never thought they were creative. Many of whom, like me, had been similarly put off by the obscurity of poetry.

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Dealership Doctor LAKELAND EMPLOYEES OPTED FOR “DOCTOR VISITS” AT A C A R D E A L E R S H I P

IMAGE BY FELIX FUC HS , UN S PL AS H

Written by Liz Antaya, M-HBD, Employee Benefits Advisor, Mitigate Partners

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akeland, FL –The owner of a locally owned car dealership and his employees in Southwest Florida took matters into their own hands when it came time to renew their health insurance provider. Instead, they dropped the big-name insurance company and created their own employer-funded plan. The result: a double digit drop in their health premiums and doctor visits on location at the car dealership. There’s no error. Family Medicine Physician of Persona 2 4 | 2022 VO LUME 14

Healthcare Direct, Dr. Christopher Salud, sees employees at the car dealership every other week. Employees sign up for appointments, in advance, selecting from 30 –60 minute appointments. An office on the second floor of Lakeland Auto Mall’s showroom has been re-purposed for their “dealership doctor”. Employee Mike Kuykendall is thrilled. He’s one of the 62 employees –among more than 50% of the entire dealership staff on the health plan–participating in this program.

“I’ve seen the doctor several times and he’s been very helpful to me and my wife,” explains the salesman. “You can schedule your appointment during your workday and when the time comes, you take your lunch break, see the doctor and go back to work.” The family-owned business, owned and operated by Greg Balasco, was among my first clients when I switched over to Stahl & Associates Insurance, one of the largest privately owned, independent insurance agencies in

In the end the employees received better access to high quality healthcare for less money!

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The on-site doctor visits have helped with employee retention and recruitment, but that’s not the only thing. Under its employer-built health plan, employees also have access to a Nurse Navigator. A registered nurse is available to help employees find medical specialists when needed. A 1-800 telephone line was created for easy access to a Nurse Navigator and the service is free to the employee if they select from the recommended high-quality specialist, meaning deductibles and coinsurance is waived entirely for the member doing the right thing. Employees also have direct access to their

DEALERSHIP DOCTOR

“dealership doctor” 24/7. Dr. Salud is available via cellphone. Asked by the local ABC affiliate what it’s like to be this accessible, he said “It gets back to practicing medicine the way I envisioned it when I became a doctor. It’s getting to know people, spending time with people and really helping them.” Salud is paid directly by the employer a specific monthly fee, per employee.

Employer-built and funded health plans like the one at the Lakeland Auto Mall dealership have changed the way he practices medicine too.

He now sees 400–600 patients per year instead of 4,000. That gives him more time to address mental health issues, as well as the prevention and management of chronic diseases. It’s a win-win-win. The savings to the employer are significant, so are the improved health outcomes of employees and the doctor-patient experience. ☤ Reprinted with permission from the author (versions of this article have appeared in Automotive News and featured by ABC News).

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year on a Cigna level-funded plan and 30% or $368,000 less than the offered renewal, and these savings include the additional cost of adding the Direct Primary Care Doctor and removing barriers to care like high deductibles and coinsurance.

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Florida and joined the national network of employee benefits advisors of Mitigate Partners, LLC. Prior to that I had been immersed in the “BUCAH” world-the largest health insurance companies in the U.S. including Blue Cross & Blue Shield, United, Cigna, Aetna, and Humana.

Every year at renewal time, the dealership kept getting increases. We were playing that BUCAH dance.

You get an increase, then have to take away benefits to minimize the increase, or you switch to another one of the BUCAHs for a lower rate only to see a 35% increase in the first renewal. That’s what happened after the dealership switched from Florida Blue to Humana. It happened again when the dealership changed from Humana to Cigna trying to spare employees from a 35% hike in health premiums. A year later, at the first renewal, Cigna came back with a 25% increase.

This business owner was fed up and desperate to avoid the usual benefits meeting with his 220+ employees. “Every single year we had to fight with the increase in premiums,” said Balasco. The fight had made the dealership open to the idea of ‘unbundling’ and actively managing their own employer-built health plan. My time in graduate school at the University of Lynchburg for Health Benefits Design provided the tools I needed to help businesses save money and take better care of their employees and had prepared me for this moment.

The car dealership became the first in Polk County to create its own actively managed, employer-built health plan with DPC at the foundation. The savings from a traditional or commercial health plan to an actively managed, employer-funded plan can be substantial, sometimes between 20%-60%.

The first year the plan spent 12% or $121,000 less than the previous

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Self-Advocating for Patients Written by Stephen Daniel, Health Rosetta Associate Advisor, Insurance Office of America (IOA)

2 6 | 2022 VO LUME 14

the outcome have been without family advocacy?

My point is simple:

If something does not feel right, or you are uncertain, ask and keep asking until you feel an appropriate treatment is being rendered. The key is being able to manage your illnesses more proactively.

“Recent studies have estimated medical errors may account for as many as 251,000 deaths annually in the United States, making medical errors the third leading cause of death.”* Without question, the need to self-advocate and ask great questions can save your life. I am proud to be counted among the growing number of innovative advisors, led by organizations such as Mitigate Partners, who recommend resources to empower clients and their employees to advocate for themselves. Medical professionals are managing ever-increasing caseloads with incredible demands placed upon them by growing government policies, administrations, and continued changes in best practices. Healthcare workers need you to speak up and ask sound questions for both yourself and the people you love. Fortunately, some tools can help.

One such tool is from the company, Quizzify**, which decrees, “Wiser people make better healthcare decisions.” Further declaring, “Just because it’s healthcare, doesn’t mean it’s good for you,” they provide sample questions you need to ask your healthcare providers when faced with a new diagnosis and treatment plan.

Below is a sample: -Why do I need this test or procedure?

-What is the difference between a test and a procedure?

-What are the risks? Could there be side effects?

-What are the chances of getting inaccurate test results? Could the possibility of inaccurate or inconclusive results lead to more testing or another procedure?

-Are there simpler, safer options?

-Regarding any heart procedure, ask if lifestyle changes, such as healthier eating and exercise could generate the same results.

-What happens if I don’t do anything?

-Ask if your condition might get worse –or better –if you don’t do the procedure right away.

-How much does it cost? Is it a cheaper test or procedure? Find out what your insurance coverers and determine whether all the providers involved are in your network. For prescriptions, ask if there are generic alternatives.

You are your best advocate!

Make certain you are a wise, healthcare consumer, and remember, “Just because it’s healthcare, doesn’t mean it’s good for you.” ☤ IMAGE BY STEPH EN DA NIEL, HEALTH R OSE T TA ASSOCIATE ADV ISOR, IOA

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y mission in this article is to introduce you to the idea of self-advocating for quality medical care. I aim to provide you with the ability to engage in productive conversations with your healthcare providers.

Professionally, I have 20 years of experience as an Employee Benefits Advisor, helping my client’s members navigate medical encounters and negotiate complex interactions with insurance companies.

I have just lost my father due to congestive heart failure, he received his diagnosis 10 years before his death. In that time, my family and I have had several encounters with hospital staff, physicians of numerous specialties, nurses, CNAs, physical therapists, and the list goes on.

Let me share one life and death encounter to highlight the critical nature of Self-advocating. My father was in the hospital, and thankfully a lightened Covid policy allowed me to stay with him overnight. Around 3:30 am, Dad began to complain that his leg felt “heavy.” As I was trying to understand what he meant, I contacted the nurse’s station. Thirty minutes later, they determined that he had no distal pulse in his leg, which was likely due to a blood clot. They said they would advise the hospitalist. Having served in the Marine Corps, I had basic training in life-saving procedures.

I knew Dad could not go long without blood circulation in his leg so I began to rub it, in an attempt to increase circulation. I persistently asked for a doctor’s consultation. Ten hours later, Dad’s cardiologist finally came into the room. He immediately requested an OR. He was angry that he had not been notified sooner and warned my mother that Dad may lose his leg, or even survive the surgery.

Thankfully, my father survived with his leg intact. But, why did we get so close to losing him? What would

*As cited in Anderson JG, Abrahamson K. Your Health Care May Kill You: Medical Errors. Stud Health Technol Inform.

2017;234:13-17. PMID: 28186008. **Visit https://2go.quizzify.com/ for a complete list of questions.

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The Doctor in Pajamas Written by Dr. Robyn Alley-Haley

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he mood hung in the air like a clenched jaw and slumped shoulders. I watched a fellow patient shuffle by the nurses’ station with his little paper cup. You know, the ones that are an inch or two tall and wide with a slight lip; the kind you see strictly in hospitals. I knew it was brimmed with multiple meds, probably the colors of the rainbow. The purple antidepressant, the yellow mood stabilizer, the blue antipsychotic, and the light green with the middle stamped out with the shape of a heart benzodiazepine. And, of course, there had to be the red ones - the laxative that we all were prescribed because our medications were so constipating. It was a beautiful and sunny day outside with birds calling their mates or just to hear themselves, who knows. The lazy summer breeze was moving the tree limbs and looked like they were dancing.

The drone of the cicadas that only hatch every 10 years provided the melodramatic theme song of the movie I seemed to be watching.

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Was it a movie? No, I reminded myself. I am here. This is real. I am in my body. I sometimes forget the difference between the world within and the world without. My gaze goes back to my fellow patient. He was tall with a hollow absent look on his pale face. He was wearing light blue pajamas that were slightly wrinkled and brown sheepskin-lined slippers that shuffled with a noise of swish, swish. If he was going faster, he might have looked like he was on ice skates.

No, that is too smooth and gliding for what I see. He looks more like he is trying to walk on ice. The difference was that his arms were lax at his side with none of the animations it took to stay upright on the ice. It was slow and his feet barely left the tiled floor. My view of him is blurry as I look through the screened window. I am outside on the smoking porch, feet up and slouched in my over-stuffed rattan chair, feeling rather like poured concrete. I shouldn’t smoke, but it is better than killing myself right now. Someone told me my fellow

patient was a doctor at one time.

He came here every few weeks for Electroconvulsive Therapy. He often didn’t know where he was or where he was going. They said he couldn’t remember his own family sometimes. The therapy erased his memory. He was once a doctor? It was hard to believe this shell of a man who now just shuffled around the day room was once a surgeon with a busy practice. He must have been smart and quick and steady to get through medical school and training. How far down in life could one go? Pretty far, I guess. I remind myself that I was once full of life and a busy, busy Obstetrician Gynecologist. That seemed so far away now. I held my head in my hands moving my forehead up and down and then took the last drag

ing my head on my neck seemed unbearable at times. Right, I am here and I am feeling better. At least the empty blackness is gone most of the time. I light another cigarette. It’s better than crying.

Dr. Rathburn, you haunt me still. I was so close. It could have been me. *Note: Dr Rathburn is a fabricated name and I went through the experience of being suicidal over 20 years ago. A long and successful career followed. I am now a retired Ob/Gyn and coach physicians full-time. I know coaching would have made a difference in my burnout – before I became clinically depressed. At the time I felt alone and suffered in silence. I do not want even one of my colleagues to feel that terrible pain and advocate peer support programs and access to mental health resources that includes coaching for those with burnout and psychiatric care and counseling for those who are clinically depressed. from my cigarette and attempted to extinguish it in the disgusting over-full ash tray. Disgusting. How far had I gone away, I thought? Was I coming or going? How far down would I go? I couldn’t tell.

I had been at the hospital for several weeks at the point of meeting my fellow shuffling doctor patient. We eventually got the news that Dr. Rathburn had hung himself from one of those beautiful trees that the wind made dance.

How sad. It adds to my own grief.

Who had found him? How did he look? Babies that are born with a nuchal cord have the cord wrapped around their neck. That’s the closest I have seen to a hanging. I once delivered a baby who had it wrapped around 3 times and by the time he was born, his face looked

bloated and bruised, tongue swollen and sticking out and he had petechiae (small dots of microscopic veins that burst) on his face. I wonder if he looked similar. Did he have petechiae? How would he even do that? I wish I knew. I wish I had said goodbye. I wish the image of him shuffling by me would leave my head. Would every warm and beautiful summer afternoon with the tree limbs dancing remind me of him; of this place; of this horrible feeling? That was something to look forward to. At least I was thinking of a future. That had not been possible just a few short weeks ago. When it’s dark, it is bleak, like black silence and extraordinary effort to move and operate the body. The pain of the empty feeling heart and just hold-

Let’s change the conversation about burnout and depression.

A cultural shift to being human with human psyches is in order. The sooner the better. ☤

Dr. Alley-Hay is a retired Ob/Gyn and Certified Physician Development Coach. She has a blog and can be found for coaching at dralley-hay.com This article was originally published on KevinMD.com and printed with permission of the author.

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Doctors On Social Media Speakers Bureau B E A PA R T O F T H E H E A LT H C A R E R E V O L U T I O N

Speaker: The Intense MD (Dr. Megan Gooch, MD) Critical Care physician who speaks about life support, advance directives, end of life and physician burnout.

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Speaker: Louis M. Profeta MD Dr. Profeta channels three decades of Level 1 Emergency Medicine to bring an openbook rawness to audiences that are desperately hungry for an honest and open discussion of some of the most important issues of our time.

He can make you laugh, cry, and shake your fist in anger… often within a few minutes of time.

Speaker: Dana Corriel, MD I bring enthusiasm & passion to speaking events that focus around innovation, creativity, digital building, and career impact using the online tools of today.

Speaker: Kim Yu, MD, FAAFP Highly sought after inspirational physician leader, expert in advocacy, health equity, leadership, health IT, value-based care, global health, wellbeing, mission-driven philanthropy, and social media. #InspireCreateLead

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Speaker: Cecilia Cruz, MD, MPH, CPCC, ACC

Speaker: Dawn L Baker MD, MS

Speaker: Basma S. Faris, MD, FACOG, CCMS

Dr. Cruz’s strength lies in her ability to genuinely connect with those around her. She is a dynamic and engaging speaker who is lead by her heart- her desire to serve and improve the lives of all whom she touches.

A cancer and infertility survivor, Dr. Baker emphasizes the importance of physician wellness by infusing current data on her subject with personal stories as a physician navigating the intersection of work, home, community, and self.

Dr. Faris is one of a select few physicians who have also trained as a Registered Dietitian. She is one of fewer OBGYNs with a background in nutrition and can speak on any topic where nutrition and Women’s health intersect.

Speaker: Dael Waxman, MD

Speaker: Matthew Mintz, MD

Speaker: Robert Saul, MD

Dr. Waxman has received training in and has been integrating family therapy, clinical hypnosis, mind/body medicine, mindfulness and leadership coaching into teaching, practice, and faculty development for over 25 years.

Dr. Mintz is a veteran speaker with expertise on a variety medical conditions (including medical cannabis and CBD), medical education, and helping physicians start their own practice.

Dr. Saul deeply cares for all children. We all need constant reminders about the optimal nurturing of children, and his work provides a multi-dimensional approach to parenting that is refreshingly new.

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A Case of the Curious Physician Y O U R S Y M P T O M S I N D I C AT E A C A S E O F C O A C H I N G CURIOSITY Written by Teresa Malcolm, MD, FACOG, MBA, CPE, CPXP, ACC

Y

ou’ve heard your colleagues talk about it. You’ve Googled it. Maybe you’ve even visited a couple of websites, tried a complimentary session or two, but you haven’t committed.

Do you have a case of the coaching queries?

Well, leader friend, by all appearances, you do. Your investigation is a sign of interest that something is rumbling inside and I’d like to offer some information to soothe your curiosity like a cup of mentholated tea soothes a scratchy throat. I’m a coach and a physician who overcame my ‘queries’ and have helped hundreds of other physicians remedy their cases of curiosity about coaching.

Here are seven reasons why physician coaching is what the doctor ordered for the inquisitive: 1. Clarity about what matters most. In every coach’s doctor bag is the mantra to coach the client, not the problem. This means coaching provides time to focus on YOU and your agenda. Designated time to focus on what you want is rare and coaching is 100% client-focused.

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your values and your core motivations to help you gain clarity about what matters to you and then identify what steps to take next.

2. Understand what’s in your way. You’ve figured out what you want but an obstacle is blocking your path. What is it and why can’t you pass it by? Coaching explores your roadblocks - jaundiced assumptions that you have about yourself, a situation, and others. It disrupts base beliefs that stop your success and helps you move away from a binary model of right vs. wrong. By reframing the internal,

negative story that is holding you back with an empowering story full of potential, you can tell the saboteur to move aside and get out of your way.

3. Real, honest conversations. When was the last time you shared a challenge with someone who could quickly get to the heart of the matter without knowing all the details? A physician coach is trained to zoom in and help you see yourself by asking thought-provoking questions. We speak physician speak, share in the physician experience, and know your struggle

5. Opportunity to strategize with a trusted partner. Strategy is about decision making and two minds are better than one when you have a decision to make. A coach is in your corner and is someone you can trust to deeply listen as you brainstorm or express “think alouds” without judgment. Coaches excel in pointing out blind spots and shifting your focus from impossibility to possibility. Aha moments fuel strategic thinking. Ultimately you are responsible for your actions and success, but a coach partners with you in deciding when to say yes and when to say no.

on a personal level. That saves time explaining extemporaneous particulars because a physician coach is “on-call” for you. We are free of outside distraction during a session and exclusively focused on your goals. The entire conversation is confidential, so you can openly express emotions in a safe space and say what is on your mind. A physician coach will, in turn, validate your emotions and respond with empathy.

4. Inspires actions to further your goals. We’ve all received a suggestion or a piece of advice prefaced with, “Here’s what you

6. Unstick from your area of struggle. A common theme expressed by my clients is not knowing exactly how to handle a problem or an issue. They have been unable to handle it themselves and feel stuck. For a super smart, high-performing, problem-solving physician like yourself, being stuck is frustrating. Getting unstuck and moving forward is the intention of coaching. It helps you draw from your past experiences and expertise while incorporating inner wisdom so you can take powerful action. Your coach assumes that you possess the resources necessary to address your area of struggle

and helps you view it from a different perspective to find a solution.

7. Start with a fresh perspective. When was the last time you tried something for the first time?

How did your inner narrative change from maneuvering around a learning curve? Coaching encourages you to imagine problems from a different perspective and to experiment with new ways of thinking.

Dr. Wayne Dyer said, “If you change the way you look at things, the things you look at change.” Coaching gives you access to a broader set of perspectives to change how you see the problems and people around you.

I hope this recommended treatment plan solved your case of the queries.

How will you treat your case of curiosity? ☤

IM AGE BY TERESA DEAN MALCOLM, MD, FACOG, MBA, CPE, CPXP, PCC, LINKEDIN

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should do to succeed.” Afterward, you think to yourself, “Mmhmm, that does not work for me.” Rather than telling you what to do, coaches invite you to explore multiple possibilities and choose a well-designed action that motivates you.

As mentioned earlier, coaching is client-focused, so providing you with the space to design steps aligned with your values and move you closer toward achieving your goals is the coach’s aim. A coach helps you discover your inspiring and intrinsic motivations.

Teresa Malcolm, MD, FACOG, MBA, CPXP, CPE, ACC, is a physician executive coach who partners with healthcare organizations to transform their physician community by empowering them as leaders. She is the Founder and CEO of Master Physician Leaders, a coaching firm committed to cultivating inclusivity, compassion, and excellence in physicians.

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This article first appeared in The Patriot, the Fisher House Foundation semiannual magazine and was reprinted with the author’s permission.

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First Loves and Second Hand Lives A POEM ON PERSPECTIVES OF IMMIGRANT PROFESSIONALS Written by Ayushi Chugh, MD

We bring First Loves On Pearl strings of skill and art Of fixing brains and forging hearts On One-way tickets Set sail to foreign shores With gifts of parental memories Waiting to exhale borrowed smiles Share minds with other worlds Driftwood soaked in knowledge Stories etched in sweat Prime years yearning to be acknowledged Cost of priceless debt

All is not lost as you own these roads Find common ground You never knew existed On the map

Endless queues, eternal toil Of worship lit in midnight oil Life in shadows beckons our duty A Calling, service or indemnity

See a new world Through my offspring’s colored iris Re-learn as he speaks my tongue In strange accents

Fly across seven seas Build a home beneath bleeding feet One day at a time uplifts like breeze Beneath sanguineous severed wings

Tapestry of life threads Historic Intertwines Continuum of genetic knits And futuristic knots

Everyday, re-attempt to rhyme In imperfect sync Unravel maze of new streets Puzzles and imperfect fits

This world is but an oyster For Diaspora on foreign shores Enrich nations with embrace Nuptials of Strength with tremendous Grace

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IMAGE BY KERW IN ELIAS, UNSPL A SH

So take that hand That appears so different Yet heart beats the same inside Of First Loves and second hand lives….

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Publisher: Marlene Wüst-Smith, MD Editor in Chief: Alicia Roselli Managing Editors: Hannah Bushery, Marlene Wust-Smith, Jill Labecki VP of Advertising: Pamela Ferman Digital Media Manager: David Ramirez Director of Art and Production: Hannah Bushery Marketing Manager: Ashley Baranello Marketing/ Copyright Editor/Journalism/Social Media Interns: Hannah Bushery, Dana Bushery, Madison M. Smith Contributing Authors: Marlene Wüst-Smith, Jerry Ashton, Amruti Borad, DO, Mark Lopatin, MD, Maria Simbra, MD, MPH, Eliza Humphreys, MD, MPH, Wendy Schofer, MD, Elizabeth Egan, Scott Abramson, MD, Eve Makoff, MD, Liz Antaya, Stephen Daniel, Robyn Alley-Hay, MD, Dana Corriel, MD, Teresa Malcolm, MD, FACOG, MBA, Christy Wilcox, Ayushi Chugh, MD Cover Art: Vic Guiza Published by “Physician Outlook Publishing” Editorial policy: Physician Outlook magazine is a national magazine dedicated to empowering physicians and their patients to improve the world of medicine together. Editorial decisions are based on the editor’s judgement of the quality of the writing, the timeliness of the content, and the potential interest to the readers of the Physician Outlook magazine. The magazine may publish articles dealing with controversial issues. The views expressed herein are of the authors and/or those interviewed, and may not reflect the official policy of the magazine. Physician Outlook neither agrees, nor disagrees with those ideas expressed, and no endorsement of those views should be inferred, unless specifically identified as officially endorsed by the magazine.

“Letters to the Editor” email: hello@physicianoutlook.com Information on advertising, subscriptions, and job board email: hello@physicianoutlook.com “Physician Outlook” is a registered trademark.

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IMAG E BY VIC G UIZ A, LIN K E D IN E D IN , LI N K G U IZ A B Y V IC IM A G E

Cover Artist: Vic Guiza Vic Guiza is an award winning Creative Development Designer, has a BS in Communications, with over 36 years of combined experience in Comics, Mobile App Development, Children’s Books, Advertising, Illustration, Design, Animation, Licensing and Toy development. He thrives in administrative, managerial, and creative positions, has a burning passion for all things design, and is supported by a unique ability to create and motivate through positive relationships. He is able to communicate easily and effectively with clients.

Guiza is always working with one single goal in mind “appeal”, the link between the concept and the target.

He has been involved with top companies, brands and Ad Agencies from 17 countries. Some of his clients include Disney, The Simpsons (Bongo Comics), Marvel Comics/Upper Deck, Teenage Mutant Ninja Turtles, OutskirtsPress.com. TheXTails.com, Televisa, Sabritas, PromoWorld, Kellogg´s, Danone, Exim Licensing, Sinolink Holdings Ltd., Roof Top Content Group, Dr. Collins, Ogilvy & Mather, etc.