May-June 2020 Colorado Medicine

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COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE

COVID-19 CRISIS:

PHYSICIANS MAKING A DIFFERENCE

C O N T E N T S

Physicians respond to COVID-19 In the face of tremendous professional and personal challenges, physicians have quickly pivoted to continue to serve patients and communities during the COVID-19 pandemic.

You are the ones on the front lines; you are the ones keeping our health care system running. A graphic timeline shows how far we have come.

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F E A T U R E S

10 IN THE TRENCHES Miramont Family Medicine CEO John Bender, MD, describes his experience on the front lines of the COVID-19 pandemic figuring out how to secure PPE, establish curbside testing and the painful process of furloughing staff to keep the practice afloat.

14 EPCMS SUPPORTS PHYSICIANS AND THE COMMUNITY As the operator of its community’s medical reserve corps, the El Paso County Medical Society quickly mobilized to respond to COVID-19.

15 TAKING CARE OF YOURSELF Tending to one’s needs now is more important than it was pre-COVID-19 but it can be difficult to prioritize self-care. Martina Schulte, MD, presents a framework for consideration.

16 FINDING BRIGHT SPOTS Mark Wallace, MD, MPH, executive director of the Weld County Department of Public Health and Environment, talks about community providers and health systems rallying to respond to COVID-19.

18 ADAPTING CARE AND PROTOCOLS OB/GYN Brandi Ring, MD, explains how her practice has adapted care, including implementing a cloth mask station for patients.

19 LEADERS EAT LAST Dermatologist Vinh Chung, MD, and many of his practice staff all pitched in to take voluntary pay cuts or cut hours to support members of their team who need their paychecks most.

24 FINAL WORD: PUBLIC HEALTH AND COVID-19 Mark Johnson, MD, MPH, executive director of Jefferson County Public Health, gives a hard look at the dysfunctional relationship between social work and medicine, and their child, public health.

D E P A R T M E N T S

I N S I D E

20 Reflections

4 President’s Letter

21 Legislative update: The coronavirus pandemic upends 2020 legislature

6 Executive Office Update

22 Introspections 23 COPIC Comment

C M S

13 Staff spotlight: Massive mask project

CO LOR AD O M E D I CAL SOCI E T Y CO LOR AD O M E D I CAL SOCI E T Y

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OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF 2019-2020 OFFICERS 2019-2020 OFFICERS David Markenson, MD, MBA David Markenson, MD, MBA President President Sami Diab, MD Sami Diab, MD President-elect President-elect Patrick Pevoto, MD, RPh, MBA Patrick Pevoto, MD, RPh, MBA Treasurer Treasurer Bryan Campbell, FAAMSE Bryan Campbell,Officer FAAMSE Chief Executive Chief Executive Officer Debra J. Parsons, MD, MACP Debra J. Parsons, MD, MACP Immediate Past President Immediate Past President

BOARD OF DIRECTORS BOARD OF DIRECTORS

Curtis Hagedorn, MD Curtis Hagedorn, MD Mark B. Johnson, MD Mark B. Johnson, MD Jason L. Kelly, MD Jason Kelly, MS MD JacobL.Leary, Jacob Leary, MS Evan Manning, MD Evan Manning, MD Edward Norman, MD Edward Norman, MD Patrick Pevoto, MD, RPh, MBA Patrick Pevoto, MD, Leto Quarles, MD RPh, MBA Leto Quarles, MD Brandi Ring, MD Brandi MD MD Brad A.Ring, Roberts, Brad A. Roberts, Kim Warner, MD MD Kim MD HapWarner, Young, MD Hap Young, MD

AMA DELEGATES AMA DELEGATES

A. “Lee” Morgan, MD A. “Lee” Morgan, David Downs, MD,MD FACP David Downs, Jan Kief, MD MD, FACP Jan Kief, Osbourne-Roberts, MD Tamaan MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSc, MD Lynn Parry, MSc, MD

AMA ALTERNATE DELEGATES AMA ALTERNATE DELEGATES Carolynn Francavilla, MD Carolynn Francavilla, MD Rachelle Klammer, MD Rachelle Klammer, MD Katie Lozano, MD, FACR Katie Lozano, MD, FACR Brigitta J. Robinson, MD Brigitta J. Robinson, Michael Volz, MD MD Michael Volz, MD

AMA PAST PRESIDENT AMA PAST PRESIDENT Jeremy Lazarus, MD Jeremy Lazarus, MD

COLORADO MEDICAL SOCIETY STAFF COLORADO MEDICAL SOCIETY STAFF Bryan Campbell, FAAMSE Bryan Campbell,Officer FAAMSE Chief Executive Chief Executive Officer Bryan_Campbell@cms.org Bryan_Campbell@cms.org Kate Alfano Kate Alfano Communications Coordinator Communications Coordinator Kate_Alfano@cms.org Kate_Alfano@cms.org

Emily Bishop Emily Bishop Relations Government Government Relations Program Manager Program Manager Emily_Bishop@cms.org Emily_Bishop@cms.org Dianna Fetter DiannaDirector Fetter of Professional Services Senior Senior Director of Professional Services Dianna_Fetter@cms.org Dianna_Fetter@cms.org

Ms. Gene Richer, M Ed, CHCP™ Ms. GeneofRicher, M Ed, CHCP™ Director Continuing Director of Continuing Medical Education Medical Education Gene_Richer@cms.org Gene_Richer@cms.org Chet Seward Chet Seward Chief Strategy Officer Chief Strategy Officer Chet_Seward@cms.org Chet_Seward@cms.org

Susanna Barnett Susanna Barnett Membership Coordinator Membership Coordinator Susanna_Barnett@cms.org Susanna_Barnett@cms.org

Dean Holzkamp Dean Operating Holzkamp Officer Chief Chief Operating Officer Dean_Holzkamp@cms.org Dean_Holzkamp@cms.org

Tom Wilson Tom Wilson Manager of Accounting Manager of Accounting Tom_Wilson@cms.org Tom_Wilson@cms.org

Amy Berenbaum Goodman, JD, MBE Amy JD, MBE SeniorBerenbaum Director of Goodman, Policy Senior Director of Policy Amy_Goodman@cms.org Amy_Goodman@cms.org

Krystle Medford KrystleDirector Medfordof Membership Senior Senior Director of Membership Krystle_Medford@cms.org Krystle_Medford@cms.org

Tim Yanetta Tim Yanetta Manager of IT/Membership Manager of IT/Membership Tim_Yanetta@cms.org Tim_Yanetta@cms.org

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I N S I D E

C M S P R E S I D E NT ’ S

LE T TE R

Uniting the House of Medicine in the COVID-19 public health crisis David Markenson, MD, MBA, President, Colorado Medical Society

The Colorado Medical Society stands with Colorado physicians during this unprecedented time of the COVID-19 public health emergency and beyond. Following our March 13 CMS Board of Directors meeting, the last in-person meeting of any kind at CMS headquarters, we deployed a host of resources, activities and enhanced communication to help you navigate the crisis.

I hope they have been useful to you. Below is a summary of these actions.

COVID-19 DISCUSSION FORUM The first action CMS took to address the crisis was to launch a discussion forum via the Basecamp platform to promote peer-to peer discussion among the House of Medicine, resource sharing, CMS information and as a source of information regarding barriers to care and pain points experienced by our members and others.

CMS COVID-19 WEBSITE CMS also created and continually updates a COVID-19 micro-website within CMS.org. This is the most comprehensive source of resources geared to physicians.

HOUSE OF MEDICINE COORDINATION The COVID-19 crisis has deeply affected all health care providers, and one early action CMS took was to unite the specialty medical societies and component medical societies in Colorado into one Colorado House of Medicine. Explained more in depth below, this has meant inviting organizations to co-sponsor and promote events, holding regular briefing calls and coordinating advocacy for the benefit of all Colorado physicians.

VIRTUAL PHYSICIANS’ TOWN HALLS These are geared to a broad physician audience. The format is to invite expert panelists to present on hot topics followed by a question-and-answer session. Our panelists have included U.S. Sen. Michael Bennet and U.S. Sen. Cory Gardner; Kim Bimestefer, executive director of the Colorado Department of I am so pleased to see the engagement of CMS members with the Colorado Medical Society. I am also heartened to see how members are posing questions and 4 C O LO R A D O M E D I C I N E

Health Care Policy and Financing; Eric France, MD, MSPH, chief medical officer for the Colorado Department of Public Health and Environment; Lisa Latts, MD, MSPH, chief medical officer of HCPF; and many more. Many component and specialty societies have committed to co-sponsorship of these events to promote a unified House of Medicine.

WEEKLY PRESIDENTS’ CALLS We have hosted many calls for the presidents of the component and specialty societies and their executive staf f.

Again, the goal is for a unified House of Medicine and participation has been high. The group has agreed to co-host town halls and webinars and to send joint advocacy letters to government leaders.

FOCUSED TOPIC-SPECIFIC WEBINARS An idea that came from the presidents’ calls was to supplement the town halls with topic-focused educational webinars co-sponsored by individual organizations in the House of Medicine that highlight their specialty or focus.

One example was the wellness webinar co-sponsored with the Colorado Psychiatric Society. Topics are suggested from the Basecamp discussion forum and suggestions from specialty and component society leadership.

VIRTUAL GRAND ROUNDS Similar to the topic-specific webinars but held in the evening, CMS has hosted two Virtual Grand Rounds events, one on Crisis Standards of Care and another on other members are providing solutions.

This is a testament to how peer-to-peer support and continuous learning is core to our profession.

testing. The goal is to make these events eligible for AMA PRA Category 1 Credits™ and COPIC Points.

MENTAL HEALTH CMS has been working in partnership with the Colorado Hospital Association and COPIC to provide mental health support for our practitioners. The first of these initiatives is a Care Line run by the Colorado Physician Health Program.

They will be providing dedicated coping support throughout this public health emergency, with resources from CMS, COPIC and CHA. ENHANCED MEMBER COMMUNICATION CMS staff and leadership send regular communications to our full membership and beyond through email blasts and social media posts highlighting key items of interest for physicians.

ENGAGEMENT AND ADVOCACY As CMS does every day, we are strongly involved in advocating for the needs of our physicians and remaining engaged in all aspects of health care and public health. Our advocacy has led to changes in policies, new programs and modified procedures to assist physicians during this public health emergency and to better support our patients. In addition, we are engaged as the voice of the physicians in Colorado in a multitude of decisions by our governmental leaders and regulators. Letters we have sent urged the expansion of liability protections, support of health care workers and expansion of COVID-19 testing.

I am listening to all the comments and concerns raised through virtual events, the discussion forum and sent directly to president@cms.org, and taking special

note of the pain points and challenges you are all experiencing. My commitment to you is that CMS will continue to raise these issues with the appropriate government leaders, seek solutions that include our input, and communicate to you, our members, the status of these issues and solutions. We will also stress the importance in this time, as every day, that efforts are made to improve the practice of medicine for physicians so we can do what we are uniquely qualified to do: provide high quality care to our patients, educate our patients and their families about their needs and public health, and to continue to be the trusted source of knowledge regarding health care and public health.

I would like to especially call out the leadership of our CEO, Bryan Campbell, and our incredible staff for their exceptional and tireless work during this public health emergency. They have assured that our members have been supported; our communications have been accurate, leading edge and regular; maintained our engagement with government leaders and regulators; and provided both member-wide and individual responses to queries and concerns from the physicians of Colorado. I cannot speak highly enough of their work during these trying times and how their efforts have led to CMS being viewed as the trusted voice of the physicians of Colorado, the unifying force of the House of Medicine and providing the needed support for our members.

Lastly, I want to acknowledge and thank all of you for doing what you do. As physicians, you are doing what physicians have been known for doing for centuries, and still should be recognized for doing today. That is, providing the best care for our patients, advocating for the needs of our patients and the public, educating the public, and being an accurate and reassuring voice in these times of a public health emergency. I salute you, the physicians of Colorado for your caring and leadership today and every day. ■

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C O LO R A D O M E D I C I N E 5

I N S I D E

C M S E X E C UTI V E

O F F I C E

U P DATE

Ant-ball (Or everything I needed to know about public health I learned in U8 Soccer) Bryan Campbell, CMS CEO We are living in strange times.

The last three months have been quite interesting for me, transitioning into the role of the CEO of the Colorado Medical Society. I drove into town just days before the start of the legislative session, jumped right into working with the CMS team, helped to honor a legend as we celebrated the retirement of my predecessor, Alfred Gilchrist…and then, of course, COVID-19 changed everything.

Right about now is the time when a new CEO would start sharing personal information about himself or herself to help the membership get a better understanding of who he is. To get to know me, you need to know about my passion for sports. And right now, that passion is struggling to stay fed with only replays of old sporting events on ESPN. So, I’m going to feed my passion by telling a sports story that I think bears relevance today.

When my daughter Lauren was six, we wanted to get her involved with youth sports. One of our good friends was a soccer coach and invited Lauren to be on his team. I’ve played football, basketball and baseball. I am passionate about all three plus hockey, golf, and even tennis when we get around the major Opens.

That said, I just never got into soccer.

So, while I was excited that Lauren was going to have the opportunity to play for a respected coach and learn team dynamics and get a lot of good exercise, I wasn’t bullish on watching soccer three times a week.

I listened to Coach Eli as he worked with a bunch of six-year-olds, many of whom had never played soccer. A phrase that I quickly learned was “ant-ball.” If you aren’t familiar with this phenomenon, it’s when everyone on the field swarms (like ants) to where the ball is. You see this in youth sports of all ages but it is especially prevalent in soccer.

“Stay in your lane! Stay in your lane!”

I can hear Coach Eli yelling that today, more than 15 years later. He ran drill after drill focused on getting the girls to ignore their instinct and stay in their lane. It’s hard to get six-year-olds to focus. Like all youth sports teams, we had the flower pickers, the goalie who would sit down, and the bull-in-the-china-shop aggressive who went full speed into everything. The first 6 C O LO R A D O M E D I C I N E

few games were what you’d expect … lots of rugby-style scrums on the sidelines and very little scoring.

The first time it happened, it was like magic. The ball careening towards the sideline, the other team and half of our team sprinted towards the ball. “Stay in your lane! STAY IN YOUR LANE!” Coach Eli might have been just as well served to put a prerecorded message out there. It was his only message, and this moment would define why.

As half of the girls peeled back and stayed relatively close to their assigned positions, the ball popped free and into the waiting path of one of ours who’d stayed in her lane. Now with the entire other team in pursuit, she advanced the ball down the pitch to where she made one more great pass to another girl in her lane. Easy pass, easy shot. GOOOOOAAAAALLL! By the middle of the season, Coach Eli’s team was winning games by 20 or more goals. He swapped in every girl in multiple positions. Our leading goal scorer, Kennedy, was so good that he’d end up putting her at goalie for the entire second half so she didn’t score 20 herself. Other teams complained. They said the team was stacked. They actually changed the rules of the league to break up Coach Eli’s team the next season.

It wasn’t that Coach Eli had recruited the most elite six-year-old athletes in northeast Florida (think about the absurdity of that statement anyway), it was that he taught them that working together as a team and by staying in their lanes, everyone could contribute to big wins in meaningful ways. No, not everyone was scoring multiple goals a game, but the wins would not have been possible without the girls on defense staying in position, and the wings keeping their sides on lockdown.

This lesson has served me well throughout my career. In a situation like we are facing right now with COVID-19 and the dramatic impact it’s having on every person in the nation, you can see a lot of ant-ball. I got an email from Sperry, the shoe company, telling me how they are committed to safety in this tumultuous time. That’s not what I need from you right now, Sperry!

I think we’ve all experienced some ant-ball in the health care community around the crisis. As everyone struggles to identify the new normal, you can see a lot of duplication of efforts, which results in a cacophony in one area, and blind spots in another.

At the Colorado Medical Society, our “lane” is helping the physicians of Colorado practice medicine so that they can keep Colorado healthy.

To that extent, we’ve focused on the efforts to assist your practice. Our town hall meetings and virtual grand rounds are designed to provide updates and hear your concerns so our talented staf f can help to provide answers.

We’ve worked with our partners in state specialty and county medical societies to encourage better communication about PPE resources, access to testing for physicians, and reimbursement and education around telehealth. We worked to connect your practice with funds available through the CARES Act and to connect you a bulk PPE order, so that you could continue to provide the care that Coloradans truly need.

We continue to work closely with state agencies like HCPF, CDPHE, CPHP and others who truly have expertise in their specific areas. We provide feedback when necessary but allow them to do what they do best as well.

Here’s a great example of the power of staying in your lane. One of the most

prevalent pieces of feedback that we have experienced at this time is that physicians are feeling burned out. The entire process of going to work when others aren’t, wearing PPE for simple procedures – or, worse, sometimes not having access to needed PPE – all of these contribute to a higher-than-normal level of physician burnout. And that’s saying a lot because physicians already have one of the highest stress and burnout rates of any profession. When we heard this, there was an immediate consideration to create our own resource to provide to physicians. Physician wellness is one of my personal missions, and in my previous role I was part of a group that created the award-winning LifeBridge physician wellness program.

However, I was aware of the Colorado CPHP program with a system already in place to provide free and confidential counseling to physicians. I did know that it was not being highly utilized but did not know why.

After ignoring the initial instinct to run to the ball, CMS stayed in our lane and used our membership as a resource to work with CPHP. We found clarity on some

ways to help CPHP improve their service to physicians. Additionally, we are now helping CPHP to spread the word about their new and improved service (Care Line: call 720-810-9131 for immediate counseling) so that we can make sure as many physicians as possible know about the resource and take advantage.

Yes, I miss my sports, but I’m lucky to be working with an amazing team of staff and physicians at the Colorado Medical Society. We continue to search for new and innovative ways through which we can provide the resources you need to keep your practice running as efficiently as possible. Keep those great ideas coming. Some of them will be just like a great crossing pass that we can swing on and score a goal right away. Others will be outside of our lane. That’s OK. If we focus on our members and work with others to guide and enhance what they’re doing, we’ll be positioned to make that winning shot.

And all the time I’ll be hearing Coach Eli in my head. ■

C O LO R A D O M E D I C I N E 7

C O V E R

Physicians respond to COVID-19 Kate Alfano, CMS Communications Coordinator It is difficult to quantify just how much has changed in the two months since COVID-19 was first confirmed in Colorado.

Certainly many measure the vast economic impacts to the travel, restaurant and entertainment industries, and sports fans long for afternoons at the baseball field rooting for the home team. But at the Colorado Medical Society our concerns include practices struggling to stay afloat during the weeks without elective procedures or surgeries, with drastically lower patient visits or with lesser reimbursements from telehealth, plus challenges with testing, supplies of personal protective equipment, and concern for self, family and friends.

What is demonstrated throughout this issue of Colorado Medicine is that Colorado physicians are resilient, collaborative and creative, quickly pivoting to continue to serve patients and communities in this time of public health crisis. Though more time must pass and certain milestones must be achieved before returning to some semblance of normalcy, this timeline serves to show just how far Colorado has come.

Colorado Department of Public Health and Environment (CDPHE) Division of Insurance

MARCH 5, 2020 • CDPHE’s public health laboratory confirmed the first presumptive positive COVID-19 test result from Colorado MARCH 9, 2020 • DOI issued a rule instructing insurance companies not to charge copays or deductibles for medical care related to testing for COVID-19 MARCH 10, 2020 • Gov. Jared Polis declared a disaster emergency due to the presence of coronavirus disease; the corresponding executive order was issued March 11 MARCH 11, 2020 • CDPHE opened the first drive-up testing center at the state lab in Lowry MARCH 12, 2020 • CDPHE issued a public health order restricting visitors at all Colorado skilled nursing facilities, assisted living residencies and intermediate care facilities MARCH 13, 2020 • CDPHE reported the first death from COVID-19 in El Paso County; reopened drive-up testing at Denver Coliseum • CMS Board of Directors met, suspending all in-person meetings and moving the CMS staff to remote work, launching the COVID-19 Basecamp discussion forum and launching the dedicated CMS.org COVID-19 micro website MARCH 14, 2020 • Colorado General Assembly suspended session • Gov. Jared Polis ordered the closure of all downhill ski resorts • Total confirmed cases to date: 109; hospitalizations: 18; deaths: 4 MARCH 15, 2020 • CDPHE recommended canceling or postponing in-person events of 50 people or more

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Milestone statistics

Federal

Colorado Medical Society

Governor / State

MARCH 16, 2020 • CDPHE issued a public health order to close all bars, restaurants, theaters, gyms and casinos MARCH 17, 2020 • CMS sent a letter to Gov. Jared Polis urging action to support health care workers MARCH 18, 2020 • Gov. Jared Polis ordered the suspension of in-person instruction at all public and private elementary and secondary schools in the state of Colorado • CMS hosted the first virtual Physicians’ Town Hall meeting MARCH 19, 2020 • Gov. Jared Polis ordered the temporary cessation of all elective and non-essential surgeries and procedures to preserve PPE and ventilators • DOI issued an emergency regulation opening a special health insurance enrollment period MARCH 21, 2020 • CDPHE amended its statewide public health order on social distancing to limit gatherings to 10 or fewer people MARCH 22, 2020 • Gov. Jared Polis issued an executive order implementing a 50 percent reduction in non-essential business in-person work MARCH 24, 2020 • Total confirmed cases to date: 1,081; hospitalizations: 221; deaths: 48 MARCH 25, 2020 • Gov. Jared Polis issued a statewide stayat-home order effective March 26 • CMS and the Colorado House of Medicine hosted virtual Physicians’ Town Hall • CMS joined the American Medical Association (AMA) in a letter about supporting physician practices with the federal stimulus bill

MARCH 27, 2020 • Congress approved and President Donald Trump signed the $2 trillion COVID-19 relief package • CMS and the Colorado House of Medicine released a statement on the ordering, prescribing and dispensing of COVID-19 medications; updated April 2 • CMS and Foothills Medical Society hosted a webinar on telehealth • Colorado Physician Health Program, with the support of CMS, COPIC and the Colorado Hospital Association (CHA) launched COVID19 Care Line for Physicians: 720-810-9131 APRIL 1, 2020 • CMS and the Colorado House of Medicine hosted virtual Physicians’ Town Hall • CMS sent a letter to CDPHE urging the expansion of COVID-19 testing for health care workers APRIL 3, 2020 • CMS and the Colorado House of Medicine sent a letter to Gov. Jared Polis urging him to expand liability protections for Colorado health care professionals • CMS hosted a webinar on financial assistance • DOI issued emergency regulation requiring insurance carriers to reimburse providers for telehealth services during the COVID-19 emergency APRIL 5, 2020 • The Governor’s Expert Emergency Epidemic Response Committee (GEEERC) approved revised crisis standards of care for Colorado • Total confirmed cases to date: 5,150; hospitalizations: 1,262; deaths: 310

APRIL 13, 2020 • CMS and CHA hosted Virtual Grand Rounds: Crisis Standards of Care APRIL 14, 2020 • CHA and Colorado House of Medicine issued a joint statement in support of crisis standards of care for PPE APRIL 15, 2020 • CMS and the Colorado House of Medicine hosted virtual Physicians’ Town Hall APRIL 18, 2020 • DOI issued an emergency regulation requiring insurance carriers to reimburse providers for emergency services related to COVID19, including out-of-network providers APRIL 20, 2020 • Total confirmed cases to date: 10,106; people tested: 47,466; hospitalizations: 1,880; deaths: 449 APRIL 26, 2020 • Statewide stay-at-home order ended APRIL 27, 2020 • Elective surgeries and procedures allowed to resume MAY 4, 2020 • Total confirmed cases to date: 16,635; people tested: 81,352; hospitalizations: 2,799; deaths: 842 ■

APRIL 6, 2020 • Gov. Jared Polis extended the statewide stay-at-home order through April 26 APRIL 7, 2020 • CDPHE activated crisis standards of care for personal protective equipment • CMS and the Colorado House of Medicine hosted virtual Physicians’ Town Hall • CMS joined the AMA in a letter urging the U.S. Department of Health and Human Services to provide one month of revenue to each physician enrolled in Medicare or Medicaid APRIL 8, 2020 • CDPHE activated crisis standards of care for emergency medical services APRIL 10, 2020 • CMS and the Colorado Psychiatric Society hosted a webinar on physician well-being • CMS and the Colorado House of Medicine sent a letter to Gov. Jared Polis in support of the crisis standards of care plan C O LO R A D O M E D I C I N E 9

F E A T U R E

In the trenches: COVID-19 in a family medicine clinic John L. Bender, MD, MBA, FAAFP The COVID-19 pandemic has brought tremendous stress to the practice of medicine in all settings. As a private practice family physician with clinics in Fort Collins and Parker, and a veteran of the Kosovo War, I feel more than ever that physicians are in the trenches with the sheer number of extraordinary challenges and necessary innovation needed to keep our practices open and keep ourselves, staff and families healthy.

We split our Miramont Family Medicine clinics in the north: a “fever clinic” at our Drake office run by my partner Kelly Lowther, MD, and her team, who have taken on the brunt of the testing, and a “well clinic” at our Snow Mesa office.

Some sick patients do present at Snow Mesa but we are prepared. Our lobby greeter takes temperatures at the door

and anyone sick is either assessed curbside or in special isolation rooms. We feel strongly that we need to meet the demand of people wanting to see their personal physician for medical attention during the state lockdown. We hastily purchased a telehealth license.

PPE AND N95 MASKS When the COVID-19 pandemic was first diagnosed in Larimer County March 9, I found a 5-year-old N95 mask in my garage from when we built Miramont Family Medicine’s office on Drake Street in Fort Collins in 2015. I have worn it every day since then and, for the week of March 16, shared it with two other medical professionals. I was wearing that mask when I diagnosed three patients who were later confirmed positive for COVID-19.

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Reza Ghafoorian, MD, JD (202) 656 8387 rghafoorian@g2zlaw.com

We almost ran out of masks. That first week one of my employees was able to find 13 masks for 44 people still working in the clinic. Later our church donated more to us, and then one of our four major medical suppliers mercifully sold us another 50 disposable masks. While not as durable, they are better than nothing.

With our N95 mask discipline at Miramont, staff sign for a mask and they must make that durable mask last four weeks before they can be issued a new one.

I now have some N95 masks in reserves for the near future for our staff. I suppose I could wear a new N95 mask, but I think I will just continue to trust the N95 mask that I have been wearing that has protected me from COVID at least three times now.

CURBSIDE TESTING WARRIORS AND TESTING CHALLENGES A recurring theme in news reports for the state of Colorado and the nation is that there are not enough tests or testing capacity to know the full scope of the pandemic and who is infected. Enter Miramont. We did not have access to the free CDC test, but our reference laboratory of 20 years told us early on that they were able to sell us COVID-19 tests for $51 per test. There was just one catch: the laboratory was not willing to actually collect the specimens; they must be collected by a health care provider. And, just as Miramont had donned the N95 masks and PPE without hesitation, our nursing and lab staff began collecting COVID-19 samples on March 13.

Initially we set up isolation rooms, where the first three positive COVID-19 cases were diagnosed. Three weeks later, no staff or other patients who have used those exam rooms have become ill, thanks to increased cleaning and disciplined staff use of N95 masks, gloves and gowns. But nonetheless, we decided early on that any future testing must be moved outside.

My staff accountant’s family retrofitted their invention that was originally meant to allow for up-close

again April 3. Everyone was hoping the furloughs will stop. and mask for collecting the nasal swabs safely.

Especially me. Because now we only had 48 people to do The first challenge for holding clinic in the work of what was once 64. the parking lot was that it was snowing that day. Regardless, we pushed through. My team typically has one or two patients I brought in 10 orange cones that I use cancel per day. On top of this, Monday, to keep people from parking on my lawn March 16 was the first day of Spring Break on the 4th of July, and quickly set up our and that week is always slower in clinic. first curbside station at the Snow Mesa That Monday there were six cancellations clinic. My staff accountant’s family retro- and 20 percent of our visits that day were fitted their invention that was originally converted last minute to remote video meant to allow for up-close observation chat. By Wednesday it was 40 percent of of hummingbirds into a protective helmet the schedule. And by Friday, March 20, and mask for collecting the nasal swabs over half of the patients we cared for would safely. The brave staffers who don the be face-to-face only by a video screen. “hummingbird protection helmet” are paid hazardous duty pay.

Amanda, my aesthetics nurse, was squirming. She had left a skilled nursing Unlike the emergency room and CDC facility to pursue her dream at Miramont “free test,” which were not really available of becoming a master Aesthetics RN. but did produce results almost overnight, But other spas in our neighborhood had our laboratory was not prepared at first. been ordered closed. Suddenly laser We saw four-day turnaround times for hair removal and Botox did not seem like testing rise to almost 12 days, which we a priority. Amanda knew that RNs were knew was agonizing for the patients going to be needed more back in the waiting at home wanting to get back to nursing home to win the war on COVID. work. And then the lockdown hit, so many She was my first labor casualty. could not work anyway. But essential workers were asking every day, “Is my test back yet?” observation of hummingbirds into a protective helmet

The first call from the laboratory came at 3 a.m., which could only mean one thing: Our first COVID-19 test resulted positive on March 23. And it was a health care worker from a nearby hospital system.

She would not be returning to work.

As of April 9 we have tested over 130 people with 12 positive results and counting. All of the other negative tests were diagnosed with things like the common cold, adenovirus, influenza A and B, pertussis and RSV. PAIN FUL STAFF FUR LOUG H S – HEALTH CARE HEROES TAKING ONE FOR THE TEAM It was my decision. I laid them off. All 13.

Sometimes I asked for a volunteer but most were involuntary.

On March 13, we had 64 employees. I diagnosed our company’s first case of COVID on March 23 but the Miramont staff furloughs started before then, on March 20. Then again on March 27. And

Revenues star ted to drop and fast.

Demand for COVID testing was high, but video chat do not pay as well as in-office visits, especially at Miramont where we are often performing labs, X-rays, mammograms and other impor tant primary care services during the same visit. All that really can be done remotely is to charge for time. And the margins in primary care are razor thin. I always tell my staff and patients “being a family physician is like being a family farmer” – we doctor until the money is gone. But I also knew that running out of cash was not going to be an option.

My wife, Teresa, and I started Miramont with one employee and one computer PAGE 12⊲

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C O LO R A D O M E D I C I N E 1 1

We are going to hire them back. back in 2002. We grew big and fast, and the strength of our success was not the high-tech tools we acquired, but the incredible Miramont family of staff who skillfully wielded those tools. We began 2020 with the lowest staff turnover we had seen in years. Nearly 20 percent of our workforce had at one time worked for Miramont, quit and then come back.

The most common reason someone leaves Miramont is actually to pursue their career in health care. They were not quitting because they did not like the medical field. We have had so many staff go on to be psychologists, nurse practitioners, medical doctors, pharmacists and physician assistants.

But our biggest cost has always been labor. Payroll at Miramont is a staggering $3.6 million per year and a 25 percent reduction in revenue must have a 25 percent reduction in overhead, otherwise all is lost. To save the ship, some staff would have to be furloughed.

It was not a simple as across-the-board cuts. First of all, telehealth instantly changed our workflows. We needed medical assistants who could start the visit

remotely just like in the office, but without coming to the office. And with people not coming in, phones had to be answered.

I started with reception team members, moving them to furlough, and then sending medical assistants to staff the phones.

We would no longer have a call center.

We would have a triage call center. Teams no longer needed two medical assistants and a scribe; we would pare each team to one medical assistant and a scribe.

Schools closed. My workforce is 85 percent female, and the burden of having children at home fell disproportionately to young mothers. Anyone we could send home with a company phone and a laptop to keep working we would, but still there was not enough work. I looked ahead.

Some of my physicians who normally would have 80 patients a week on their schedule now had only eight. Others went the other direction. One physician assistant added so many telehealth visits that he saw 39 patients in one day – double his normal volume. Those who were adopting would keep their jobs. I wanted to keep everyone but I could not.

And it was all happening so fast.

Plan for it.

“Do not take their faces off of the website,” I told my operations team. “Do not take their Miramont ID card, do not stop paying their benefits. We are going to hire them back. Plan for it.”

We made payroll this week but cash flow remains a week-to-week challenge as always. I don’t know what it will be like next month. When will we open up mammography and routine colonoscopy?

Will Amanda be back from the nursing home before the summer? And for those on furlough, will they still want to come back to a place that let them go? Will they have enough money for their families this month on unemployment? Will the state of Colorado pay them on time?

We all want our life back. I just want my furloughed staff back. They are no less heroes than my curbside testers in protective face shield helmets. My furloughed staff are my heroes, because they are taking one for the team, to make sure there is a Miramont for all of us to come back to. ■

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Spotlight: CMS senior director sews cloth masks, coordinates meal delivery Kate Alfano, CMS Communications Coordinator

Even before the COVID-19 pandemic, Dianna Fetter, Colorado Medical Society senior director of professional services, was an avid quilter. So when Colorado physicians saw their stores of personal protective equipment running critically low and the FDA approved cloth masks for clinical use, she fired up her sewing machine and started making cloth masks.

She even recruited her husband, Rob, a newly retired engineer, to join the effort.

“He never imagined his first weeks of retirement would be spent making hundreds of masks and losing his fingerprints in the process,” Fetter said.

She coordinated the sewing and distribution with others in the sewing community including a brand-new acquaintance,

Gwen Steele, whom she met in a fabric store; a private, anonymous donor; local sewing group The Thimble Army; and the work of herself and her husband. They donated nearly 1,000 masks to local physicians’ offices for their personal use and to give to their patients during visits, plus many more to nonprofits, friends and neighbors. Four recipients are Mile High OBGYN, Green Mountain Partners for Health, Western Orthopaedics and The Denver Rescue Mission.

“I want to thank Dianna Fetter, the Colorado mask project and the Colorado Medical Society for helping my office get 50 cloth masks,” said Carolynn Francavilla, MD, a family physician with Green Mountain Partners for Health. “We have

a shortage of surgical masks in our clinic and this will help ensure our patients have masks to wear during encounters and our staff has protection should we run out of surgical masks. I am so grateful to have one less thing on my plate right now – thank you for stepping up to help my clinic.”

Fetter has also arranged for food delivery. One delivery, donated by Qdoba in Lone Tree, went to SkyRidge Hospital.

Another delivery, donated by Chick-fil-A - Alameda Avenue in Aurora, went to the emergency department staff at the Medical Center of Aurora.

“It turned out to be a welcome surprise for our nurses and technicians as it was a very busy and stressful night,” said Rachelle Klammer, MD, an emergency room physician at Medical Center of Aurora.

“Everyone from the housekeepers to the pharmacists got to enjoy a moment of relaxation, and they are so thankful for everything that CMS and the community are doing to thank first responders and health care professionals.” ■

Left, Dianna Fetter models one of her cloth masks. Right, the emergency department staff at Medical Center of Aurora thanks CMS and Chick-fil-A for the donation of food.

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F E A T U R E

Best practices in supporting physicians and the community EPCMS RUNS COLORADO SPRINGS’ MEDICAL RESERVE CORPS Mike Ware, CEO, El Paso County Medical Society

It’s rare as medical societies to get involved in direct patient care, but we’re a rare breed in Colorado Springs.

Our city was founded by people who saw opportunity in the unmined rock in the mountains. Our organization, the El Paso County Medical Society, was founded in 1879 to support physicians who saw an opportunity to improve the treatment of consumption. And in the anthrax attacks that followed 9/11, we saw another opportunity. Physicians and their care teams would integrate during natural disasters to support their local community.

It started as DR HELP, and in 2003 it would become the Medical Reserve Corps of El Paso County (MRC) after joining with the national network of MRC’s operated under the U.S. Department of Homeland Security.

Most MRCs are operated by local health departments. We, on the other hand, are one of only four medical societies in the country that operate a medical reserve corps. In our case, it’s a program run by the EPCMS Foundation.

Canyon Fire and 2013’s Black Forest Fire – the call came early on a Saturday morning. Almost literally, no one had prepared for this, ourselves included.

In fact, only one group had envisioned this.

Collectively, the Bill and Melinda Gates Foundation, Johns Hopkins University Bloomberg School of Public Health – Center for Global Health Security, and the World Economic Forum had prepared with an Oct. 18, 2019 tabletop exercise anticipating a global pandemic. In that exercise, a novel coronavirus, similar to the 2003 SARS coronavirus, jumped from bats to humans and spread worldwide over 18 months. Sixty-five million perished before a vaccine could be created.

We all had a role in preventing this outcome.

SCALING THE TEAM

COVID THREW US FOR A CURVE

The biggest challenge came in the first week as everyone was ramping up. MRC operates on a shoestring budget. The small leadership team of Jodi Landair, MA, EPCMS’s members care manager who serves as MRC’s program director; Barb Bridgmon, RN, MRC’s program coordinator; and two medical directors, Sean Keenan, MD, and Paul Wall, MD, would need a larger team.

There’s something about 5 a.m. on a Saturday that says, “drop what you’re doing, we’re mobilizing!” And like both other times we mobilized – 2012’s Waldo

In prior mobilizations, we operated with two individuals alternating shifts. In this case, we needed eight people focused on the mobilization every day, so we added

functional roles for clinical operations, administrative support and media relations – all of which were needed immediately. In fact, MRC was on local TV, radio and in the newspaper within 72 hours of mobilizing.

The initial plan foresaw us staffing two alternate care sites, one community testing location and embedding personnel in long term care facilities with COVID-positive residents. This plan still holds, though fortunately it does not appear we’ll need the alternate care sites.

Fortunately, too, both EPCMS and MRC are fully integrated components of our community’s emergency response plan, and are specifically referenced in the documents. The plan was in place, and with a larger management team we were ready.

WHAT DOES THE FUTURE HOLD? As of this writing, our credentialed volunteer count has grown to 212 and we’ve already contributed 523 hours of support, a number we expect to grow as we prepare for the “long slog” over the summer. Our personnel are embedded in many of the long term care facilities in our area, staffing the county’s 24-hour telehealth call line, and with plans to support Teller and Pueblo Counties if needed.

This all comes on top of our regular EPCMS activities supporting physicians and their medical practices. Along with PracticeBeat, a leading patient acquisition software platform, and our partners at the Pueblo County and Denver Medical Societies, we launched the COVID Survival Webinar Series focused on helping practices survive the short term, launch telehealth and get their operations back to normal once the stay-at-home order is lifted.

My prediction: In six months we’ll look back on everything that has transpired and be proud. We’ll have learned a lot to share with our community, and be inspired by a grand awakening of the American spirit.

Serving others is life’s greatest reward. ■

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F E A T U R E

Taking care of yourself during the coronavirus pandemic Martina Schulte, MD Chair of the CMS Committee on Physician Well-being and President of Community Physician Consulting In the early days of the pandemic, many physicians and other health care professionals were reaching out to colleagues, friends, and online sources in search of answers and guidance to the many questions immediately germane to their lives and practices: • Could I be bringing the virus home to my family?

• What protective equipment should I, and my staff, be using in our routine work?

• What changes do I need to make to my practice and how I see patients?

• Is my primary responsibility to my patients or my family, or both, and how do I navigate this?

Now, there is an abundance, or even overabundance, of information sources and sites for managing one’s practice, transitioning to telehealth (and getting compensated for it), mitigating exposure risks to family and significant others, and caring for oneself. It may feel like too much to sift through and figure out, especially when time is limited and self-care may be taking a back seat to everything else.

But, tending to oneself and one’s needs is even more impor tant than it was pre- COVID -19, given the additional stresses and challenges of the pandemic.

So, figuring out how to prioritize selfcare and practically make it a reality can become the issue. To the right is a framework familiar to physicians, Maslow’s Hierarchy of Needs, that offers a simplified guide to approaching one’s self care.

This framework provides a graphic depiction of our needs as human beings, demonstrating the foundational needs at the bottom of the pyramid and our fulfillment and actualization needs at the top.

The pyramid structure also illustrates the requirement to meet the base of the pyramid needs first in order to have the capacity to meet the needs at the top.

While many physicians have not had to spend conscious time and energy thinking about the needs at the base of the pyramid, this virus and the pandemic have dictated a refocus on basic/physiologic, safety and connection needs.

The time and emotional and cognitive energy that many physicians are now spending on personal and loved ones’ safety is absorbing the space that used to go into addressing other needs. Putting on and removing personal protective equipment multiple times during working hours consumes personal reserve. And after working, many physicians are then spending time upon returning home, changing, cleaning up, and trying to be safe for their families and loved ones.

This newly consuming physical and cognitive load that has accompanied the pandemic and what it means to do physician work now replaces emotional and intellectual space that used to be available for pursuing and investing in the other needs on the hierarchy pyramid. For physicians not in the hospital but experiencing huge disruption to their practices, emotional and cognitive energy might be going into practice survival.

This is another example of energy being expended for more basic needs, leaving little to none for other needs.

The challenge now is recognizing and allowing this new allocation of energy to basic/physiologic, safety and relationship needs, without self-criticism or judgment.

Now is the time in many physicians’ lives when the situation and reality demand that one’s personal and professional focus is on survival, caring for one’s own basic needs, attending to one’s personal safety and the safety of family and community, and staying connected. Now may be the time to acknowledge, allow, and accept that it is necessary and important to spend time and energy in a focused way that does not include the top of the pyramid. Living in this extraordinary time means adapting to one’s own and others’ needs in ways that fit the time. When survival and safety and relationships are again secured, that may be the time to explore and pursue other needs. ■

Self-actualization: achieving one’s full potential, including creative activities

Self-fulfillment needs

Esteem needs: prestige and feeling of accomplishment Belongingness and love needs: intimate relationships, friends Safety needs: security, safety Physiological needs: food, water, warmth, rest

Physiological needs

Basic needs

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F E A T U R E

Finding bright spots – and a way out – of this pandemic Mark Wallace, MD, MPH Executive Director of the Weld County Department of Public Health and Environment

For me, as with nearly every one of us, life has changed very dramatically. While many of us in this profession work long hours, I think for many of us – especially for people my age who are mid-career – this is recalling for us the days back when we were interns and residents working 110 hours a week and struggling to find that time to rest and regroup. It’s a good thing that a kind of muscle memory remains, that you can put yourself into a place where you are working hours that are out of your control and that are often filled with uncertainty, and be able to adapt, maneuver, innovate and respond in ways that are very similar to our training years. I don’t do hospital medicine anymore but it is a good thing that I was trained that way so I could be prepared for this.

Well before this crisis, we were a profes- critically injured, how many people came sion in an extreme state of burnout. But in last night, where are you with your for me personally this is one of the situa- personal protective equipment (PPE), tions where you see what physicians and what do you need? I am fortunate to be our colleagues can bring to an unprece- in a community that, while we are a hot dented challenge: The unceasing giving spot, has partnerships that we have built of themselves to care for others – taking over years of caring about our mission, personal risks that leave them with deci- of being disciplined in how we built our sions about whether they can go home trusted relationships, so in moments of to their families and questioning whether stress like this we don’t have to worry they have the right equipment that they if we can rely on each other. It’s always need to protect themselves while they’re a yes. at work – but they show up every day and they are at the top of their game.

We’re really fortunate to They tell you that this is what have s trong health they prepared for, this is who care s y s tems up we are, and it’s our time to here, and we’re step up and do it over and really fortunate to In moments of over and over again. have incredible stress like this clinical people we don’t have to For me there’s an energy – the doc tors worry if we can behind that. As difficult w h o a re p a r t rely on each other. as it is some days to hear of the Northern It’s always a yes. the stories and see what my Colorado Medical colleagues in the hospital are Society – but also facing, it also highlights this critithe nurses and first cal connection between community responders. I sit on calls and hospital. This response that we’re every day with the city managers trying to do, this war we’re waging, won’t and with those leading first response. be successful if it isn’t connected all the We built the right foundation for us and way from public preventive health through that has made it possible to keep going this emergency response into the hospi- at this pace. tal and then back out into the community.

One of these examples of a little place I frequently start my day with connec- where you can take control is PPE. It is tions to my Weld and Larimer county such a critical part of this fight to save the colleagues who are on the front lines in people who are out there on the front the hospitals, the chief medical officers lines. When you’re in the environment and chief executive officers of Banner where all of these resources are scarce, Health and UCHealth, as well as Sunrise it’s easy to get discouraged and start to Community Health Center. Where are wonder whether you’ll need to change we, how are we doing, how many vents the calculus about how many people are do you have, how many people are that going to get infected and potentially die.

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Then people come together. Our health department organized a PPE drive and had all sorts of people bring in supplies, from painters to construction companies to those in other science-based fields, and they gave generously in recognition that we have to protect the people on the front line. Again, it gives you a boost. We realize we can make it for a little longer.

Even when it comes down to some of the more controversial things, where we finally got to the stage where cloth masks were being recommended, even though at the beginning we were not recommending them, again we saw a tremendous outpouring from the community; folks who I don’t think had sewn in 25 years pulled sewing machines out of their basement and got to work. I walked into my office one day and there were three gorgeous masks on my desk that had been given to me. There are lots of those bright points where we see what communities will do.

They tell you that this is what they prepared for, this is who we are, and it’s our time to step up and do it over and over and over again.

The hardest part of this is the ongoing uncertainty, and it’s the area where I spend most of my day: how do we look at the prevention of the spread of this disease when we can’t pursue our normal way of aggressively managing something like this. We have to constantly innovate and work without evidence, which is a difficult place for evidence-driven physicians! I urge caution. We could end up doing harm and that’s the last thing we want to do in our need to innovate quickly.

There are lots of those bright points where we see what communities will do.

Rising above the current situation to the 30,000-foot view, there are some things we’re going to have to wrestle with. One is that we are in a cycle of these unknown emerging infectious diseases. We’ve had them in different ways, some of them easier than others: H1N1, SARS, MERS and now coronavirus. My hope is that we exit this pandemic with a sense that it will happen again – not to depress us but to say we are going to be better when the next one comes We built the right around. There’s foundation for us a resilience in and that has made human beings. it possible to keep This has going at this pace. been dramatic enough that w e’r e g o i n g t o figure this out. We are going to have a long-term view of the world that says we can’t ever let ourselves get in the position in which we don’t have PPE, in which we are not prepared to immediately respond.

How does community engage again so that we also have muscle memory on social distancing? How do we get back to all those things we love but be prepared so that if we have to come back around to it quickly we can do it? We’ll be able to acknowledge all the things we did before and be ready to do them again. I’m hopeful we’ll learn some things out of this and not have a short memory. ■

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F E A T U R E

Adapting care and protocols during the pandemic Brandi N. Ring, MD, FACOG, FAWM, Obstetrician and Gynecologist, Mile High OB/GYN This is an interesting time to be practicing medicine – on one hand everything is different but on the other hand it is all still the same. We are more cautious about some things, but the basics of our everyday care is the same: we treat the whole person, physically, mentally and emotionally.

Everyone is doing their part

In my specialty of obstetrics-gynecology, even in the midst of a pandemic, babies need to be born and they

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won’t wait for this to all be over. We have talked a lot about how much in medicine we don’t know yet and it highlights how dependent we are on science to guide our everyday practice. I’ve had many discussions in the last month about the risks and the benefits of all of the monitoring and visits we do, and a lot of educating about the importance of our routine tests and which ones we can shift earlier or later to decrease in-person visits. We have had to learn how to do visits without facial cues and body language, both through the barriers of masks while in person and the limitations of technology-assisted virtual visits. We try to minimize touch, missing out on important social connections and rapport building.

The power of simple connection has never been so obvious as when it is not there. It is truly an exercise in adaptability.

The response from patients has been overwhelmingly positive. They are adapting with us and understand the need for changes to protect everyone. They bear the bumps and bruises of new procedures and technology and ever-changing information with us. We are also seeing an unprecedented amount of support from the community. From delivery of food to the nurses and staff working on Labor and Delivery, to the 8 p.m. “Howl” of support that brings me to tears nearly every night, the sense of community in Denver has never been more palpable.

My office in particular has been the gracious recipient of hundreds of homemade masks of all patterns both for staff to use over our medical masks to conserve our PPE and for our patients to wear during their visit to help protect us all. With the generosity of volunteers from the Colorado Medical Society sewing at home, we have been able to build a “Colorado Mask Project” station in our waiting room to allow all of our patients and visitors equal ability to use a mask for their visit. Every time a mask gets utilized it is a little reminder of all the people out there helping our community where they can – from the essential workers, to the stay-athomers, to the at-home crafters. Everyone is doing their part to get through this tough time as a community so that we can all be together again soon. ■

F E A T U R E

Leaders eat last Vinh Chung, MD Board-certified Dermatologist and Fellowship-trained Mohs Surgeon, Vanguard Skin Specialists The patient-doctor relat ionship has been ingrained through our long medical training and remains at the center of our decisions in daily practice. Based upon trust, this relationship demands that we make decisions that are always in the best interest of the patient. The coronavirus pandemic has brought to the forefront another type of critical relationship – the staff-doctor relationship. While antagonistic staff-doctor relationships are notoriously common and can drive physicians to burnout, they do not have to be this way. When healthy, the doctor’s relationship with staff can be an incredible source of pride and joy.

After executive orders suddenly limited medical services and procedures, the revenues of our medical practice dipped by 90 percent. This unsustainable situation had no end in sight. The cash reserves in our practice were bleeding out and would be depleted if changes were not made immediately. Even before any federal loans or financial assistance became available, our leadership team took action.

Watching our team members care for each other is an incredibly beautiful moment that I’ll never forget. I’ve always been proud of our staff because of their excellent work.

This time I’ve been humbled by their character. Generosity, selflessness, and the desire to protect one another flourished and became so much more contagious than fear or self-preservation.

Our practice has since received the Medicare stimulus payment and funding from the Paycheck Protection Program, which will buy us more time as we ride out the pandemic. While we had to accelerate departures for team members who were already transitioning out, we have not had to lay anyone off. Two-thirds of our tribe volunteered to furlough, cut pay or reduce hours. There are glimpses of light at the end of the tunnel, and we really do believe we can make it through this crisis with our entire team intact. When we make it to the other side, we plan to restore everyone’s pay and hours in the reverse order from bottom to top. The leaders will eat last.

Similar to the patient-doctor relationship, the physician’s relationship with staff is based upon trust that must be earned.

When trust is absent, any relationship can become a thorn in our side or an obstacle we must work around. These unhealthy relationships with staff and administrators are often the root cause of physician burnout. They must be addressed if physicians want to have fulfilling careers.

There is no better way to earn trust than to walk with our staff through a crisis. When our staff know that we are willing to protect them, they will do the same for us. And I believe wholeheartedly that in the long run, our patients will be better cared for as a result. ■ Vinh Chung, MD, works for Vanguard Skin Specialists in Colorado Springs, Colo. He has a passion for instilling meaning and purpose into the workplace. He can be reached at vchung@vanguardskin.com

We committed to follow our motto that “leaders eat last.” Financial setbacks are scary for everyone, but we recognized that our hourly employees have it much worse. They need their paychecks to buy groceries and to pay rent, so we committed to protect them. Starting from the top down, our executive team took an 80-100 percent cut in our salaries. The rest of the medical providers also voluntarily took significant pay cuts. After we announced our decision, other staff members stepped up and followed suit. Our managers asked to “work more and get paid less.” Some staff members even volunteered to work for free. Across our medical practice, team members who earned the most sacrificed in order to protect those who earned the least.

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Dear newly minted third-year Catherine Waymel

Catherine Waymel is a native Coloradan and member of the University of Colorado School of Medicine class of 2020. Having grown up with experience caring for her grandmother and younger sister with Down Syndrome, she is looking forward to a career in MedPeds, where she will be able to care for patients of all ages and abilities. She is excited to begin her residency at the University of Chicago where she also hopes to continue working in medical education to support students through their own medical school journeys.

Dear newly minted third-year, Congratulations!!! You should feel incredibly proud of completing the first half of medical school. It is no small feat, and you deserve recognition for this remarkable accomplishment.

If you are like me, you may be feeling more than a little nervous about starting the next phase of your training. You might be wondering if your test-taking skills will translate to successful patient care, if the dreaded pimping is as terrible as it sounds, or how you will prepare for these “shelf” exams. You may even be wondering if you will measure up to the challenges of caring for patients in a post-pandemic world. So, what advice can I give you?

• Be curious. I think that curiosity is the greatest asset of students and physicians alike. Be curious about medicine, and be curious about your patients. If you are curious, you may discover that your patient is depressed, and you are the first person he has told. You may discover that your brother went to high school with your patient’s grandson. Or through hand signals, a letter board, and random guessing, you’ll discover that your newly aphasic patient is dying for her mouth to be swabbed with a bit of coffee (and two sugars, if you please).

If curiosity guides you, knowledge and fulfillment will follow; your enthusiasm to work with your team and take care of your patients will be evident, and more importantly, genuine.

• Learn to accept positive feedback.

You have learned so much over the last two years, and yet in the realm of clinical medicine it will feel like a drop in the ocean. You will spend much of your time wondering how you will learn everything your attending knows, and if your internal dialogue is like mine, you will constantly repeat a list of everything you need to learn or work on. So, when your patient, resident or attending commends you for something, take a moment and let it sink in.

You are worthy.

• Put yourself in your patients’ shoes. The more different their lives are from yours, the more important it is to do so. Speak well of them, always. You are here to care for them, and they are trusting you with the most intimate and fragile moments of their lives. Do everything you can to never betray this trust.

• Don’t be afraid to answer questions. You will learn more if you attempt to answer a question and get it wrong, than if you stay silent out of fear of sounding dumb. You will suggest things that are nowhere near best practice – I once suggested starting an 89-year-old on a statin. And that’s okay, because it’s part of the process. You will learn to love the questions – they are a crucial element of learning and you’ll miss them if you hit a rotation where they don’t ask you anything.

• Know that everyone’s got your back.

Who is ever yone? The entiret y of CUSOM. Your classmates, Hidden Curriculum facilitators, ACP faculty advisors, all our Deans, myself – we all know you will be an amazing physician and want you to have the best year possible. If you need support, whether academic or emotional, know that everyone above sought out a position to help see you through this journey. If someone mistreats you or makes you feel unsafe, we want to know so we can help change the culture in which you learn. And if you rock a rotation you thought would be your undoing, we want to know so we can celebrate your success!

I think that these are the most important things to carry into third year. Other random advice: eat well but drink sparingly before surgeries. Always carry more than one pen, and if you lend it, make sure it’s one you won’t miss. Help your team as much as you can, but leave when dismissed. Uworld has varying applicability for each rotation, so you have to find your studying groove and take all shelf preparation advice with a grain of salt.

So, go celebrate! Spend time with friends and family, and sleep in this weekend.

Come Monday put on your white coat, and throw yourself wholeheartedly into this next year. You’ll be great out there.

Best wishes, Catherine Waymel ■

Reflective writing is an important component of the CU School of Medicine curriculum. Beginning in the first semester, medical students write essays, stories or poetry that reflect what they have seen, heard and felt. Reflections is edited by Steven Lowenstein, MD, MPH, and Tess Jones, PhD. It is dedicated to the memory of Henry Claman, MD, Distinguished Professor of the University of Colorado, founder of the Arts and Humanities in Healthcare Program, and original co-editor of this column.

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Interrupted session: The coronavirus pandemic upends 2020 legislature Emily Bishop, Program Manager, CMS Division of Government Relations The Colorado General Assembly met for a special Saturday session on March 14 to temporarily adjourn in response to coronavirus. The unprecedented move was made to encourage social distancing and prevent the spread of COVID-19.

Much has happened since then, including an economic downturn, a landmark Colorado Supreme Court decision, and the pandemic’s increasing impact on every aspect of life for Coloradans.

One of the biggest questions when the legislature began their extended recess was whether the 120-day general assembly session had to be consecutive or could extend beyond the original sine die date of May 6. The Colorado Supreme Court ruled in a close 4-3 decision that it could be extended, but whether the legislature will use all of the residual 53 days remains unclear.

Currently, the legislature is scheduled to reconvene May 18 but even this is tentative and the adjournment could be further extended. One thing is clear, however: the legislature’s priorities when they reconvene will look a whole lot different than they did pre-pandemic. For one thing, the budget for new legislation has been slashed with the economic downturn over the last two months. Senate President Leroy Garcia (D-Pueblo) has indicated the focus will be on supporting health care and front-line workers, as well as passing the budget for FY 2020-21, school finance bill, and any outstanding sunsets for practice acts that are set to expire on July 1. Outstanding bills from before the pandemic will be assessed by their potential cost, their contribution to the state’s current needs, and their potential contention.

One possible bill introduced when the legislature reconvenes is a direct response to COVID-19 and the unique needs of physicians. Spearheaded by COPIC and supported by the Colorado Medical Society, the issue of expanded liabilit y protec tions for physicians responding to the pandemic has been raised multiple times with the Polis administration as a potential executive order.

The administration has responded with concern that this falls outside of the emergency powers of the governor. COPIC, CMS and our partners are currently exploring immediate action through other avenues; however, if need be, a new bill retroactively expanding liability protections will be a priority of CMS during this truncated session. ■

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Finding comfort in a “village” through the pandemic Dellvin Nguonly Critical reflective writing holds a prominent place in the Medical Humanities curriculum at Rocky Vista University, College of Osteopathic Medicine. Beginning in the first semester of Medical Ethics, students engage in critical reflection to explore their own assumptions and biases and how their values impact their practice. This submission is selected and edited by Nicole Michels, PhD, chair of the Department of Medical Humanities; and Alexis Horst, MA, writing center instructor.

Dellvin Nguonly was born in Gaithersburg, Md., and moved to southern California as a teenager to complete high school. After obtaining his Bachelor of Science in Biochemistry from the University of California Los Angeles, he is now a current first year Osteopathic Medical Student at Rocky Vista University in Parker, Colo. In his free time, he enjoys cooking, playing video games and any waterbased sport.

I was always told that “it takes a village to raise a child” and I’ve always believed that to be true, especially in the Cambodian community. During the Khmer Rouge, millions were killed, and many families were separated or lost. Because of that, a family-centric culture developed, wherever and whomever that was. As such, my family found our own “village”: a community of other Cambodian families who became my aunts, uncles and cousins, and helped raise me as their own. I was brought up to believe that I could be anything and was told to work hard for a better life that they didn’t get the chance to have; of course, I wanted to do right by them and fulfill the dreams they couldn’t chase.

I didn’t know them and although confused at first, I quickly realized what was going on. It wasn’t about who they were to me, but it was who they represented; I was one of their own and they were like my uncles and aunts who raised me.

who desperately need it, to manufacturing companies shifting their production to combat the scarcity of ventilators, we as our own sort of village have come together to support each other in our greatest time of need.

That day at the market reminded me of my own family, the community that raised me, and where I come from. Furthermore, it showed me that as a medical student now, my situation is by no means any different. I found the same collectivist mentality I was raised in here in medical school; I found my own village of friends, colleagues and professors. They are what keep me grounded and are how I have survived medical school thus far.

Although right now the future may be uncertain, this crisis has given me time to reminisce on the past, my journey so far and contemplate my future. I realize now that it truly does take a village to raise not only a child but also a physician through the trials and tribulations that each journey entails. I am a product of the sacrifices my villages have made for me and I am forever thankful to them and the privileges I have because of their support.

When I was recently visiting home, I went back to a local Cambodian grocery store I frequented within the heart of “Cambodia Town” in Long Beach, Calif. While my family made small talk with the owner, they mentioned that I was in medical school and was going to be a physician one day. I felt like a celebrity; random ‘yeays’ and ‘thas’ (the Khmer words loosely translating to grandmother and grandfather, respectively) I had never met came up to me simply to say how proud they were of me.

Even now, amidst the ever-changing state of the COVID-19 pandemic, the one thing that has remained constant is this notion of the village. Despite the calls for quarantines and social distancing due to the issues of general public safety, medical school moves on and so do we. I find comfort in my own village; from simply checking in on one another through the virtual community, there is an unspoken bond of togetherness in spite of the isolation. From seamstresses sewing face masks for the health care professionals

As a future physician, I will one day repay this debt to those in need. It is a responsibility I am proud to take on, because after all, it is the duty of the physician to take care of the village, whomever that may be. ■

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Doing what needs to be done in this crisis Gerald Zarlengo, MD Chairman & CEO, COPIC Insurance Company

It’s difficult to comprehend what has happened during the last several months. From the drastic change in daily routines to the unprecedented burden placed upon our health care system, all aspects of our lives have changed. For those in health care, their days often involve a mix of struggles – the struggle to understand where we are headed, the struggle to allocate finite resources, or the struggle against physical exhaustion to name a few. However, the one area in which I have not seen any struggle is the willingness of physicians and medical providers to step up and do what needs to be done.

I continue to be amazed at the dedication and resilience of those in the medical community. Their selfless actions and dedication are what will lead us out of this pandemic. Every week, they face difficult decisions that often carry heavy burdens. While many physicians are strong and capable of making these decisions, we need to do what we can, so they don’t carry all of the weight on their shoulders. They need our support and we need to step up for those on the front lines of this crisis.

In addition to the difficult clinical challenges of COVID-19, physicians are trying to understand the ever-changing guidelines and how to best care for their patients and staff, along with having to wade through stressful ethical dilemmas. They have also been thrown into new environments where there is uncertainty and questions about practice standards. These are areas where COPIC has drawn upon our expertise to help.

COPIC is working closely with our partners to review liability issues that apply to COVID-19 situations. We are monitoring federal and state guidelines, analyzing how they impact physicians, and ultimately providing clarity about what is legally permitted when responding, sometimes with limited resources, to potential COVID-19 patients as well as other patients impacted by the COVID-19 emergency. These efforts included advocating for health care providers so that government authorities recognize that providers must be provided various liability protections given this unprecedented crisis. The federal government and the overwhelming majority of states have issued or passed orders, regulations, guidelines or legislation that provide a number of protections.

We’ve also offered our support for physicians thrust into the telehealth environment. While some are familiar with this setting, many others are learning quickly to adjust. COPIC’s team is providing guidance and resources so physicians feel comfortable in their ability to provide care through telemedicine in a way that is compliant with both federal and state law.

To help ease the strain on medical practices and facilities, COPIC established a COVID-19 Physician Program. The program provides temporary liability coverage for physicians who do not have other available insurance coverage, who are not currently a covered physician under a COPIC policy, and who will be providing professional services to a COPIC-insured practice or facility to assist with addressing COVID-19.

As we have heard, there is also great concern with how we are ensuring our providers are protected from acquiring the virus.

The COPIC Medical Foundation has pledged $250,000 to the State of Colorado for the purchase of personal protective equipment (PPE) and medical supplies in partnership with the Polis administration’s Innovation Response Team Task Force.

While discussions are often focused on the clinical aspects of treating patients and flattening the curve, we cannot forget the personal emotional toll this is taking on medical providers.

In addition to the open-access support services, such as the Care Line being offered through the Colorado Physician Health Program, COPIC is identifying and contracting with resources in each of our markets to provide confidential, no-cost access to psychologists and psychiatrists who understand the pressure health care providers are under.

As peers, we recognize the importance of being there for each other, and most importantly, being able to listen when providers need someone they can turn to during this turbulent time.

We continue to have staff available to answer the increasingly complex questions arising from this crisis, and have Legal and HR Helplines, as well as our 24/7 Risk Management Hotline where a physician risk manager is available.

I don’t know what things will look like when we emerge from this nor how this will change the future of health care. I do know that I have faith in the minds and spirits of my fellow physicians, and that this has rekindled what drove me to become a doctor.

As medical providers deliver compassion and care to patients affected by COVID-19, they deserve the same from us. It is our responsibility and is what needs to be done.

COPIC has posted an open-access COVID-19 Information and Resources page on our website at www.callcopic.com/ covid-19-information-and-resources. We will continue to update this information on a regular basis. ■

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Public health and COVID-19 Mark Johnson, MD, MPH Public health is the illegitimate offspring from a short romance between medicine and social work in the late 1800s. I say illegitimate because medicine promptly abandoned its lover and child, chasing after the tempting siren calls of technology and pharmacology. Social work, feeling used and exploited, regretted having ever been involved with medicine in the first place. The outcome of this union is a wayward ward of the state, begrudgingly nursed along whenever it cries loud enough or when it is found to be useful.

From such a pedigree, one should not be surprised to find that public health’s main field of interest is promoting health in groups of people. Its basic sciences are epidemiology – the study of how diseases and conditions move through populations – and biostatistics, the essential analytical tools necessary to study the large amounts of data collected on how living organisms are being impacted by these movements. Unfortunately, public health’s most effective tools are prevention and regulation, neither of which are very popular in a libertarian and individualistic free-market society.

As public health has aged, however, some of its children have attracted the attention of the grandparents. Medicine has recently been smitten with the promise of population health, and social work has found itself captivated by the idea of the social determinants of health.

Together, however, they have lately discovered a new appreciation for one of their oldest grandchildren, community epidemic response.

The COVID-19 pandemic has impacted medicine and social work in ways that will change them both for the foreseeable future. Medicine, I believe, will be the one most greatly changed by the epidemic.

The entrepreneurial spirit and economic forces t hat have been stealthily pushing medicine out of the professions and into the realm

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We will survive this pandemic, just as we did the of business will need to be reassessed. Just-ininfluenza pandemic of 1918, but the new normal time inventories, global s u p p l y c h a i n s , p ro f for medicine will not be the old normal. it-based decision-making and limited access to services by miologic tracing, isolation of the ill and large portions of the most vulnerable in the quarantining of close contacts. our society have put the health of our entire nation at risk. While the scandal- We will survive this pandemic, just as we ous shortage of personal protective did the influenza pandemic of 1918, but equipment (PPE) calls more for lessons the new normal for medicine will not be to be learned than for investigations the old normal. Patients will most likely into persons to be blamed, the resulting mandate many changes: washing hands loss of health care workers, emergency before and after every examination; wearresponders and law enforcement agents ing masks during all close interactions; is a tragedy of unspeakable proportions. no handshakes or hugs; and probably a more professional appearance. Health Although technology has dramatically care workers will demand adequate improved our abilities to test, track and stocks of PPE at all times. Global phartreat patients, much of our technical maceutical and equipment supply chains expertise has been forced to sit idly by, will be suspect. More research into and pharmacology has played little, if any, antiviral medications, antibiotics and role in the response to COVID-19 thus immunizations will be requested, even if far. Temperature scanners, applications the federal government must subsidize for smartphones, rapid antibody tests the developments. and the creative cloud-based sharing of scientific data and innovative ideas have We have become complacent in mediall played helpful roles, but we have been cine and we are paying the price. Nature forced by the novelty of this disease to fall has a way of collecting what it is due. If we back onto late 19th- and early 20th-cen- learn anything from this pandemic it must tury means of prevention and control: be that Mammon is a seductive but cruel public health stay-at-home orders, home- and demanding god, and that science, made masks, social distancing, epide- while frustratingly ambiguous at times, must be practiced carefully and honestly, and then trusted above the wishes of the populace or the whims of the politicians. ■

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