Aug-Oct 2021 Colorado Medicine

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COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE

COME FLY WITH US 151ST COLORADO MEDICAL SOCIETY ANNUAL MEETING A CELEBRATION OF CMS MEMBERS, LEADERS AND SUPPORTERS

COME FLY WITH U

151ST COLORADO MEDICAL SOCIETY ANNUAL MEETI

C O N T E N T S

A CELEBRATION OF CMS MEMBERS, LEADERS AND SUPPORTERS

COME FLY WITH US You are invited to join the Colorado Medical Society for the 151st Annual Meeting on Friday, Sept. 17, as we gather as a community to celebrate the incredible work of our physician members and the new frontiers that lie ahead.

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F E A T U R E S

D E P A R T M E N T S

7 THE COLORADO OPTION: AN OPPORTUNITY TO SAVE

12 Reflections: Things essential

Colorado Insurance Commissioner Michael Conway discusses the aim of the Colorado Option, to bring meaningful cost reductions in health insurance premiums for Coloradans, and how the plan will affect physicians.

& QA

8 Q&A WITH THE COLORADO MEDICAL BOARD PRESIDENT Colorado Medicine sat down with Donald Lefkowits, MD, to discuss a new board policy ensuring confidentiality in peer assistance and how it came about.

17 LET’S GET VACCINATED Ashok Rambhai Patel, MD, an allergist in Pueblo, Colo., penned a poem about the purpose of COVID-19 vaccinations and the critical need to support vaccination.

20 FINAL WORD: ETHICS IN PHYSICIAN LEADERSHIP Matthew Wynia, MD, dives into ethics in health care and how three topics intersect – health equity, clinician moral injury, and data ethics – plus how these issues played out in the pandemic and what that might mean for the future of health care.

13 Reflections: Lee 14 COPIC Comment: Three ways to “Call COPIC” for guidance 16 Introspections: Showing vulnerabilities allows for connection and learning 18 Medical news • New task forces for employed, independent physician members of CMS in formation • BCMS welcomes members to in-person event • In memoriam: Jerry J. Appelbaum, MD

I N S I D E

C M S

4 President's Letter 11 CMS Education Foundation awards more than $25,000 in student scholarships

CO LOR AD O M E D I CAL SOCI E T Y 7351 Lowry Boulevard, Suite 110 • Denver, Colorado 80230-6902 720.859.1001 • 800.654.5653 • fax 720.859.7509 • www.cms.org

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF 2020-2021 OFFICERS

BOARD OF DIRECTORS

AMA DELEGATES

Sami Diab, MD President

Brittany Carver, DO Rachelle M. Klammer, MD Chris Linares, MD Evan Manning, MD Michael Moore, MD Edward Norman, MD Lynn Parry, MD Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD James Rager, MS Kim Warner, MD Hap Young, MD

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

Mark B. Johnson, MD, MPH President-elect Patrick Pevoto, MD, RPh, MBA Treasurer Bryan Campbell, FAAMSE Chief Executive Officer David Markenson, MD, MBA Immediate Past President

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

AMA PAST PRESIDENT Jeremy Lazarus, MD

COLORADO MEDICAL SOCIETY STAFF Bryan Campbell, FAAMSE Chief Executive Officer Bryan_Campbell@cms.org

Emily Bishop Director of Government Affairs Emily_Bishop@cms.org

Ms. Gene Richer, M Ed, CHCP™ Director of Continuing Medical Education Gene_Richer@cms.org

Kate Alfano Communications Coordinator Kate_Alfano@cms.org

Dianna Fetter Senior Director of Business Development Dianna_Fetter@cms.org

Chet Seward Chief Strategy Officer Chet_Seward@cms.org

Susanna Barnett Membership Coordinator Susanna_Barnett@cms.org

Dean Holzkamp Chief Operating Officer Dean_Holzkamp@cms.org

Marna Steuart, CPA, CFE Director of Finance marna_steuart@cms.org

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

Krystle Medford Senior Director of Membership Krystle_Medford@cms.org

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

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone 720-859-1001; outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colo., and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance.

COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified.

Bryan Campbell, Executive Editor; Kate Alfano, Managing Editor; and Dean Holzkamp, Assistant Editor. Design by Scribner Creative.

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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

Recommitting to joy and our patients Sami Diab, MD, President, Colorado Medical Society

It is hard to believe that my year as your Colorado Medical Society president is coming to a close. As you might remember, I spoke at my inauguration of my desire for myself and all CMS members to find joy in our professional and personal lives, and suggested we do this by generously serving others (patients and our fellow members of CMS), being positive and confident in our ability to connect with others, and seeking connection or support when inevitably we have to recover from adverse situations.

Unfortunately, so many things threaten to rob us of our joy and can make us forget our purpose as physicians: the COVID19 pandemic, political divisiveness, and pressures of the health care system that are often beyond our control. It is easy to yield to these pressures and take a narrow view of our work, which will not serve us or our patients well in the long term.

One movement that resonates with me is the “Charter on Medical Professionalism,” developed nearly 20 years ago by physician leaders of the ABIM Foundation, ACP-ASIM Foundation and the European Federation of Internal Medicine. Dr. David Downs shared the February 2002 article with me that announced the charter.

The charter defines professionalism as the basis of medicine’s contract with society: “It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health.”

The authors wrote – and I agree – that physicians must remain committed to three fundamental principles.

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

•

Patient welfare – being dedicated to serving the interest of the patient.

•

Patient autonomy – empowering patients to make informed decisions about their treatment.

•

Social justice – promoting the fair distribution of health care resources regardless of race, gender, socioeconomic status, ethnicity, religion or any other social category.

Dr. Downs has done great work submitting a proposal on Central Line, CMS’s policy development platform, on professionalism that has been referred to the CMS Council on Ethical and Judicial Affairs (CEJA) to study. I am looking forward to CEJA’s recommendations to the Board of Directors so we can consider a CMS policy on professionalism.

It is high ethical standards that set physicians apart from other professionals and makes us worthy of our patients’ trust. I want to encourage each of you to recommit to your mission as a physician to serve patients and communities, and find joy in our profession.

Of all our accomplishments of the past year, I am most proud of our work to secure confidentiality in physician peer assistance. Thousands of CMS members joined us in our advocacy work by signing a petition, writing letters to the Colorado Medical Board and DORA, and testifying in favor of confidentiality. Because of this work, physicians in most cases will be able to get the help they need when they need it most without fear of retribution to their licensure or reputation.

I am also very proud of our streamlined strategic plan that focuses our work

on the most important priorities of our members and utilizes resources in the most effective ways. It paves the way for our work on diversity, equity and inclusion in CMS to make sure all members are welcome in our organization and all voices are heard. And we have launched two new task forces to gain a greater understanding of the needs of employed physician members of CMS and independent physician members. Together we are working together to make a better and stronger society, and CMS is on the right track to represent physicians, grow the membership and put up a good fight in the public affairs arena.

I would like to thank many people for their support during my presidential year. First and foremost, my family – my wife, Liliane and children, Nicholas and Christopher.

The Colorado Medical Society staff may not be great in number but they each bring such great talent and work ethic to our society to keep it running smoothly; thank you to each and every one of you.

I give big thanks to the executive leadership team – the CMS president before me, David Markenson, and my successor, Mark Johnson. I thank Dr. Markenson for his service as he rotates out of CMS leadership and wish Dr. Johnson well in his upcoming year as president.

Also, thanks to the members of the President’s Council, which met nearly every two weeks: Jeremy Lazarus, Dave Downs and Lynn Parry. I greatly appreciate the work of the CMS Board of Directors who thoughtfully led our society through a tumultuous year. And my greatest thanks go to the entire CMS membership for supporting our work and advancing the profession of medicine. ■

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Printed in USA/December 2020

C O V E R

COME FLY WITH US YOU’RE INVITED 151ST COLORADO MEDICAL SOCIETY ANNUAL MEETING A CELEBRATION OF CMS MEMBERS, LEADERS AND SUPPORTERS VIRTUAL EVENT: FRIDAY, SEPT. 17 | 6 - 7:30 P.M. NO COST TO ATTEND Register before Sept. 7 and receive a special gift!

Virtual Grand Rounds: The Latest on the Delta Variant with expert speakers Inauguration of incoming CMS President Mark B. Johnson, MD, MPH Recognition of outgoing CMS President Sami Diab, MD Recognition of leaders and volunteers on CMS committees, councils and task forces Live music, silent auction and raffles

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F E A T U R E

The Colorado Option: A real opportunity to save people money on health care Michael Conway, Colorado Insurance Commissioner

The 2021 Colorado Legislative session was historic – the legislature passed bills that will help us recover from the pandemic, bills that will address climate change by reducing greenhouse gas pollution and encouraging electric vehicles, and bills addressing criminal justice by limiting solitary confinement and reducing punishment for misdemeanors. And it passed at least 15 bills addressing health care.

One of those bills, House Bill 21-1232, better known as the Colorado Option, will bring meaningful improvement to Coloradans with real policies targeting reductions in insurance premiums and mechanisms to ensure those targets are met. Every player in the health care system - the hospitals, the doctors, the insurers, the pharmaceutical industry - all agree that health care costs too much and has to be addressed. This law gives the health care market an opportunity to do just that.

One of the key features of the Colorado Option is the development of a standardized benefit plan. The law prescribes that this plan will be developed by our office, the Division of Insurance, part of the Department of Regulatory Agencies (DORA). This will be a plan that offers the same benefits across insurance carriers, with respect to covered services, co-payments, deductibles and coinsurance.

Standardizing benefits will make it easier for Colorado consumers to shop and compare plans. We will also be able to build in benefits that people will be able to use before meeting their deductibles, such as mental health services, giving them real access to health care and not just an insurance card in their pockets.

And because of the great work of the sponsors of the legislation, in particular

Rep. Iman Jodeh, insurance companies offering the Colorado Option will be required to have networks that are culturally competent to meet the needs of the consumers that purchase the Colorado Option. That will give us a unique opportunity to advance health equity and cultural competency. I look forward to working with the Colorado Medical Society (CMS) and other interested parties to help develop the regulatory framework to achieve those goals.

When it comes to making health insurance more affordable, the law gives the players in Colorado’s health care market the opportunity to meet the premium reduction targets set forth in the legislation. Those premium reductions are tiered over three years: 5 percent per year starting in 2023 for a total of a 15 percent premium reduction by 2025.

Those targets will take into account things like medical inflation and the cost of additional health care mandates passed by the legislature. But meeting those targets will require commitment from the entirety of the health care market.

PREMIUM TARGETS PER YEAR

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STARTING IN 2023

STARTING IN 2025

our mountain communities were paying the highest premiums in the entire country. The Colorado Option combined with the success we’ve already achieved gives us the opportunity to have the lowest premiums in the individual market.

But this law will also bring much needed relief to small businesses that purchase insurance for their employees in the small group market. Since 2014, premiums for the small group market have increased 34 percent. With this law, we are among the first states in the nation to provide relief of this kind to our small employers.

I cannot thank Reps. Dylan Roberts and Iman Jodeh and Sen. Kerry Donovan enough for having the bold vision that got this done.

If the health care market fails to meet those premium reduction targets, the law directs the Division of Insurance to hold the market accountable for what it has always said it could do: save people money on health care. The Colorado Option requires the Division to hold public hearings to bring transparency to why the market failed, and to take reasonable steps to hold the market accountable.

I also want to thank CMS and its member physicians in their willingness to work on this legislation and be a part of the solution. The various issues around health care are not just complex, but have the potential to negatively impact so many aspects of our lives. Partnering and collaborating with organizations like yours is the key to solving these many issues and helping Coloradans gain access to the health care they deserve.

Over the past few years, the legislature took bold and important steps to make health care more affordable for Coloradans who purchase their health care in the individual market (meaning insurance not from an employer). We all remember the headlines just a few years back that

The Colorado Option continues the drive of the administration of Gov. Jared Polis and Lt. Gov. Dianne Primavera to save people money on health care. And I look forward to working with the Colorado Medical Society as we implement this law to help Coloradans. ■

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

F E A T U R E

New CMB policy ensures confidentiality in peer assistance now and in the future Q&A WITH DONALD LEFKOWITS, MD, PRESIDENT, COLORADO MEDICAL BOARD

& QA

Chet Seward, Colorado Medical Society chief strategy officer, sat down with Donald Lefkowits, MD, Colorado Medical Board president, to talk about a new policy passed by the CMB that ensures confidentiality of peer assistance counseling for Colorado physicians (a top CMS priority), why readers should be aware of the new policy, and what happens next.

Chet Seward: Let’s start by introducing you and framing the issue.

Donald Lefkowits, MD: I joined the Colorado Medical Board in 2015 and began a two-year term as president of the board last year. I first started taking care of patients in Colorado in September of 1980. About a month or two before the pandemic started, after 40 years in the ER, I retired from full-time emergency medicine.

I'm doing a little bit of urgent care work and I'm still in touch with many of my colleagues. In my many years in medicine, I've never seen anything like this, the stress that our providers are under – especially frontline providers, critical care doctors, hospitalists, ER doctors, PAs who do those roles – the loss of life, the fear for their own safety. It has put our providers under a level of strain that has never happened before, at least not in my career. Now more than ever, I think there's a need for many to turn for help.

I have colleagues who suffer right now from post-traumatic stress disorder (PTSD) because of what they've seen and what they've had to deal with these last 18 months. Turning to others for help is not something that comes naturally to physicians; they tend to see it as a sign of weakness, they tend to see it as something that that may hurt their reputation. I hope that the Colorado Medical Board (CMB) can create an atmosphere where licensees feel safe, encouraged and supported to look for help when they need it; that they'll do so early, before concerns rise to a level that may jeopardize patient safety or their own safety; and that they get help so they can return to or stay in the safe practice of medicine, because that's the way we support our citizens in the best way that we can.

Q

Why is ensuring the confidentiality of peer assistance services so important for physicians and the CMB?

A

The goal of the medical board is to keep the public safe, and the best way to do that is to ensure that we have healthy physicians who are supported, educated and able to practice currently competent medicine for all of our Colorado citizens. As is the case with any stressful career, physicians and other professionals we license are apt to run into medical or psychological problems

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that could interfere with their ability to practice. This pandemic has been extraordinarily stressful on physicians. We want them to feel that it's comfortable, safe and appropriate, when they are struggling, to seek help. It's clear in our discussions with our licensees that if a physician turns to a peer assistance provider to seek help, and that leads to a report to the Colorado Medical Board, they're far less likely to seek that help.

Speaking based on my experience on the Board, we're a very pro-active, rehabilitative, board. When physicians are strug-

gling, we do everything we can to protect the public, but to also help physicians get back to safe practice. We recognize our physicians in the state as resources; we want to save careers; we want to allow them to return to practice with the appropriate support. But the perception clearly is that a report to the board jeopardizes their career, and so without confidentiality, they're far less likely to seek help, rather than if they know that seeking help can be treated confidentially.

Q A

What changed regarding the policy that would threaten that confidentiality?

Last year, it was time to renew our contract with our current peer assistance provider. Without knowledge of or consultation with the board, Department of Regulatory Agencies (DORA) staff proceeded to go through a request-forproposal (RFP) process and selected a new vendor, unknown to the board, to become the new peer assistance provider for all of our licensees. It appeared to our licensees that the ability to seek peer assistance confidentially might be lost.

It wasn't discussed with the board, and the medical community was pretty upset that this happened without the Board’s knowledge.

Q A

How was the new policy created?

Colorado Medical Society was one of many, many organizations that raised the alarm about how and why this process was flawed and the urgent need to codify confidentiality protections, especially since Colorado has been held up in the past as a national standard for safe and effective confidential peer assistance.

The board felt like it was important, regardless of who the peer assistance provider would be going forward, that we memorialized in policy the fact that the board believes in confidential peer assistance. We wanted to ensure that peer assistance in a confidential manner would still be available and guaranteed to most licensees seeking help.

The new Colorado Medical Board policy,

10-28 Confidential Assessment and Monitoring of Voluntary Treatment through the Designated Peer Health Provider,

delivers important safeguards for voluntary participants who comply with treatment plans and have not compromised patient safety or caused patient harm, requiring confidential assessment and monitoring by the peer health provider.

Learn more at dpo.colorado.gov/Medical/Laws

We started the process of policy development. It involved taking the Medical Practice Act (MPA) and trying to interpret it in a way that could establish a policy to assure confidential peer assistance, but still maintain the statute and the parameters of the statute in regard to PAGE 10 ⊲

To make a long story short, the RFP awardwas appealed and t p eventually overturned by an administrative law judge and a new selection process, led by the board, was started the first of the year. In the meantime, there has been a significant period of time when it was not at all clear that continued confidentiality would be an option. Appropriately, that really raised the alarm within the medical community. After more than 6 months of meetings and deliberation, a subcommittee of the board recommended, at an emergency meeting on July 20th, that the new contract for peer assistance be awarded to our current provider and that recommendation was accepted, unanimously, at the emergency meeting.

C O LO R A D O M E D I C I N E 9

Q & A : C O N T

monitoring a physician's behavior, placing patient safety as the top priority. We came up with a draft, circulated it, and had a number of stakeholder feedback opportunities, both in writing and in video calls. We made additions, corrections, and a variety of changes based on that feedback, then circulated a second draft.

It was close to a six-month process, but we felt that it was worth our time and effort to try to make this as appropriate a policy as we could, taking into account the needs and the concerns of our stakeholders. The full board adopted the policy – 10-28 Confidential Assessment and Monitoring of Voluntary Treatment through the Designated Peer Health Provider – at our May 19, 2021 meeting.

The goal of the new policy is to make it clear to our licensees that, yes, you can seek help and we encourage you to do it early. If you self-report and seek help from our peer assistance provider, your identity will be kept confidential, and you can get the help that you need without it

needing to be disclosed to the board or any other licensing agency. It also tries to clarify, as specifically as possible, the circumstances when confidentiality might not be available, mostly revolving around if laws have been broken or patients have been harmed. The board feels that in those circumstances, given the requirements of the Medical Practice Act, the board needs to alerted.

Q

So what are the key things about this process and new policy that physicians should know?

A

First, I’ll re-emphasize that even if a licensee is known to the board because of concerns about the safe practice of medicine, the board really tries hard to work with the licensee to create an avenue for return to safe practice. We recognize that the board's primar y responsibility is public safety, as it should

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be, and that one of the ways to keep the public safe is to have access to care. The way that we can ensure access to care is to maintain the ability of our licensees to practice safely. So, when a licensee is struggling, we don't want to punish. We want to create an environment where that licensee maybe needs to step back from practice, but they're able to engage in a program of treatment and monitoring to ensure that they are able, at some point in the future, to return to safe practice.

In general, medical boards around the nation are seen as punitive and strict. It's important that that our licensees know that the Colorado Medical Board will make every effort to rehabilitate, to support and to help a physician return to safe practice, within reason, if we're able to do so.

Finally, I want to publicize the fact that there is now a policy in place ensuring confidential peer assistance and that our licensees should get help when they need it. Regardless of who may be our peer assistance provider in the future, because of this new policy, licensees will understand right from the get-go when they enroll in peer assistance what the conditions are and whether they qualify for confidential peer assistance. If our licensees feel like they are in need of support, whether due to a psychological problem, a medical problem, a substance abuse problem, a relationship problem, if they believe that there's any chance that their ability to practice safely may be in jeopardy, I encourage them to seek assistance through the peer assistance provider, knowing that in most circumstances, they can do so confidentially.

Q

That’s a good way to end this.

Physicians can be patients too. In those instances, taking care of them appropriately, as this new policy provides, is critical so that they can get back to safely caring for their patients. Thank you, Dr. Lefkowits, for your commitment to patient safety, for your dedication to the profession and for your leadership on the board in tackling this issue.

A

Thank you very much for having me. ■

I N S I D E

C M S

CMS Education Foundation awards more than $25,000 in student scholarships INAUGURAL ALFRED D. GILCHRIST STUDENT LEADER SCHOLARS NAMED The CMS Education Foundation awarded more than $25,000 in rural medicine scholarships to medical students who come from rural areas and/or are committed to practicing medicine in rural areas. The Foundation also awarded $7,000 in Alfred Gilchrist student leader scholarships to medical students who have demonstrated outstanding leadership to CMS and/or other membership organizations in the House of Medicine.

Below are the awardees of the rural medicine scholarships; with named scholarships indicated where applicable.

Amelia Barber (CU), Rainer Medical Student Scholarship Originally from Estes Park, Colo., and daughter to an emergency medicine physician and nurse practitioner, Amelia hopes to practice small-town medicine in rural Colorado. She worked as an EMT while an undergraduate at Colorado State University, and is currently a member of the Rural Track Program at CUSOM. Hunter LaCouture (CU) Hunter plans to pursue a career in general surgery in a rural area of Colorado, and advocate for equitable health care, education and awareness to serve the community. He is inspired by his father, who provided dental care to the communities around Elizabeth, Franktown and Kiowa, Colo.

Ashlyn Richie (CU) Inspired by her roots growing up on the plains of eastern Colorado and her father’s battle with multiple sclerosis, Ashlyn will pursue a career in rural primary care. She is currently in the Rural Track Program at CUSOM and has committed to four years in rural Colorado following her training.

Marie Stewart (CU) Though Marie grew up in the metropolitan Bay Area of California, she seeks a career in primary care in a rural area, having felt drawn to the deep sense of community she experienced as a white-water rafting guide in Idaho and an engineer in the coal bed methane fields in Trinidad, Colo.

Paulyna Schultz (RVU), Jack and Maribeth Berry Medical Student Scholarship Paulyna was deeply affected by the death of her brother and the resulting support and comfort her family received from her community in Wray, Colo. She has a master’s degree in clinical psychology and seeks to become a psychiatrist in a shortage area such as northeastern Colorado.

Tori Weingarten (RVU) Tori grew up in the agricultural town of Fort Morgan, Colo., and witnessed numerous obstacles to accessing the health care system that meant many rural residents could not achieve optimal health. She desires to practice in a rural Colorado area and internationally.

Below are the inaugural awardees of the Alfred D. Gilchrist Student Leader Scholarship.

Pratibha Anand (CU) Pratibha has extensive experience in teaching, leadership, advocacy and clinical work that she applies to her medical education. She has two master’s degrees in business administration and health care administration. She will benefit from all of her training, relationships and life experiences in her future medical career.

Danielle Coleman (RVU) Danielle’s first experience with the Colorado Medical Society was attending Medical Student Day at the Capitol, which led her to become RVU’s Policy and Advocacy Chair. Later she became a leader within the larger Medical Student Component of CMS and a member of the CMS Board of Directors. She plans to join a CMS committee and be involved in her specialty society during residency and beyond.

Sofiya Diurba (CU) Leadership has been a core part of her medical education through four years of medical school and continues to be a passion and priority. Former CMS CEO Alfred Gilchrist, the namesake of the scholarship, served as a mentor to her in advocacy and lobbying and she, in turn, mentored other medical students. She helped organize to two Medical Student Days at the Capitol and the inaugural White Coat Wisdom event.

Alysa Edwards (CU) Alysa has been involved in the Colorado Medical Society and American Medical Association, and has mentored other students on paths to involvement. She hopes to continue educating herself about the issues affecting her community, mentoring students and using her voice to influence change. She also hopes to complete a Spanish-speaking medical

elective to support her growth as a young physician and will continue her leadership roles in CMS and AMA. Ross Tanick (RVU) Ross has been involved in organized medicine since his first year of medical school as part of the American Medical Association student section at the National Advocacy Conference. He has also served as community service and outreach chair of the RVU Chapter of the Colorado Medical Society, on the RVU Chapter’s board of directors and on the Colorado Academy of Family Physicians Board of Directors. He intends to stay in Colorado and practice family medicine.

Congratulations to all of these outstanding students.

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D E PA R TM E NT S R E F LE C TI O N S

Things essential Pauline Hoosepian-Mer, MS Pauline Hoosepian-Mer, MS, is a fourth-year medical student at the University of Colorado School of Medicine and plans to pursue internal medicine with interests in global health and infectious disease. As a refugee American, Pauline realizes the distinct social empowerment inherent in health advocacy and aspires to work with underserved populations to that end. After obtaining her Master of Science in Global Medicine, she aspires to apply the global reach of health care to communities locally and abroad. Through poetry and creative writing, Pauline aims to learn more about herself and connect better with others.

Dear Phase III Student, I read Tim O’ Brien’s short story, “The Things They Carried” in the Strauss Health Sciences Library one afternoon during second year. He describes a company of foot soldiers in Vietnam and the literal things they carried.

Here’s what I carried (or wished to carry) during my third-year rotations. Consider it a guide as you wish.

A few good pens – gel, smooth. At least something will go smoothly. Let your team members forget to return them. Now they have something that once belonged to you. You are connected.

A couple of sheets of blank paper. Fold them into quarters and tuck them into a pocket. Jot it down.

Gum. Jerky.

There’s this hype about nuts. I prefer chips.

A few bills of cash, to repay someone who buys you coffee, or at least offer.

Get a reflex hammer. It swings better than a stethoscope.

Keep your meds on hand: Tylenol, Zyrtec, Zofran.

Print out Direct Observation Forms in advance. Keep them in your bag.

Should you lose your bearings, go to your gratitude journal. Reread, remind.

3.0 silk ties for tying around chair arms, drawer pulls.

And when you witness a fellow student connect with a patient, deftly maneuver a tricky conversation, deliver a spot-on presentation – let them know. You are, after all, a platoon. Then it’s easier to carry.

Alcohol pads for sanitizing stetho scope earbuds.

Yours.

Pauline Hoosepian-Mer ■

Have the translator's phone number saved on your phone.

Memorize a really funny joke. Whether patient-prompted or brilliantly timed, it lightens the load.

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D E PA R TM E NT S R E F LE C TI O N S

Lee Derek Mason

Derek Mason is a fourth-year medical student at the University of Colorado School of Medicine. Born and raised in Colorado, Derek received a Bachelor of Science in neuroscience from Regis University and a Master of Public Health from the Colorado School of Public Health. He plans to apply for residency training in psychiatry. He enjoys playing video games, voice acting, writing, exercising, and spending time with his partner, Jameson.

Out of all the patients I have interacted with in my third year, Lee, you are probably the person who comes to mind first. I remember meeting you for the first time.

Your body was swollen with pain. Redness stained the canvas of your body you had embroidered with ink. Engorged and moist, you concealed the color of your eyes from me. Your back would not give you the grace of steadfastness, either.

Instead, it was crooked and demanded metal as payment for stability. Nonetheless, it was your body. It has been with you through every laugh, shout, wallow and sigh. It belonged to you as much as you belonged to it, and the journey you two shared had brought you to me.

it was congenial. You taught me pieces of your story. I was most interested in the works you had on display. From them, I discovered you had a mother you loved beyond words. How she was the constellation foretelling your destiny. She had inspired your trade, and you adored her for that. This resonated within me as my own mother has etched part of my horoscope in the stars that govern my life, too.

Was this why I remember you? The twine that sewed us together was stitched by our mothers? Possibly. Or, perhaps, it was only a piece. If that is true then the other piece would be…

was mad at you for it. Things my sister never was able to have were begotten unto you. In your weakness, I uncovered a part of myself that was judging you. In this judgment, though, was a vision of my sister. Together for a moment in time in a distant space, immersed in each other.

She whispered to me her gospel of grace, and it brought me back to you.

Damn it.

We were both roughly the same age; I cannot recall now if you were older or younger than me. Regardless, you reminded me that illness and disease do not always care how old you are. No one is safe. Lupus had scoured your body and it had introduced you to me. What a lovely acquaintance.

Yup. There it is. A part of you reminded me of my sister. It was something that made me care for you, and envy you.

Your tears rippled memories from when my sister cried, and a part of me wished I could steal those tears for her. When you cried, the compassion my sister taught me overflowed to you. In those waters, though, existed a current of bitterness.

While you had pain and you knew suffering, I could not help but think that my sister suffered more. For your own reasons, you could not bear to be in the hospital any longer and you wanted to leave. You still could walk, though. You could feed yourself. You had a husband and children.

Truthfully, I both envied that of you and

In this moment, I was grateful that you were healing, and that I, too, was healing.

I think that in the way that a part of you told the story of your mother to me, a part of me told you a story of my sister. That when I helped take care of you, my body served as a conduit to the spirit of my sister, as she had always taken care of me. A legacy of Lee. ■

“Lee, meet Derek.” Lupus snarled through grinding teeth, “Derek, meet Lee.” You and I, though, had a more pleasant relationship than you and Lupus. What did we talk about? Was it even pleasant?

Or was it just the idea of something better than the disease you bore? No, some of

Over time the smoldering embers beneath your skin faded, from them emerging the pink of cherry blossoms.

Health was a welcome guest in the house in which Lupus resided.

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.

C O LO R A D O M E D I C I N E 1 3

D E P A R T M E N T S C O M M E NT

Three ways to “Call COPIC” for guidance Gerald Zarlengo, MD, Chairman & CEO COPIC Insurance Company Navigating the complexities of health care can be a daunting task. In addition to the medial aspects of patient care, physicians and practice administrators have to manage ever-changing legal, regulatory, and business environments.

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C O LO R A D O M E D I C I N E 1 5

D E PA R TM E NT S I NTR O S P E C TI O N S

Showing vulnerabilities allows for connection and learning 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.

Hojin Seo is a first-year medical student at Rocky Vista University. She is from Phoenix, Ariz. and graduated from the University of Arizona with degrees in physiology and molecular/cellular biology. Outside of school, she enjoys long-distance running and is currently working towards completing a half-marathon in every state.

If I had a dollar for every time someone said, “medical school is the most fun you’ll ever have,” I’d have a dollar. Instead, most people like to say the same few phrases we students have heard from the moment we were pre-meds researching interview questions on Student Doctor Network.

“Medical school is like trying to drink out of a fire hose!” “It’s a marathon not a sprint!” “The days are long, but the years are short!” “It’ll all be worth it in the end!”

These statements aren’t wrong. In fact, I’m assuming it’s their steadfast truth that makes them so trite. For a semester during this pandemic, I was a first-year medical student. Or as I like to say, a member of Zoom University’s College of Medicine.

What I wasn't told when I started medical school during a pandemic was how the insane amount of new information would be accompanied by an overwhelming sense of loneliness. I felt like the only one drinking out of a fire hose, running this marathon in isolation. My school days consisted of me talking to the four walls in my bedroom in feeble attempts to study.

During live-streamed anatomy lab, when someone would say, “That’s the femoral artery,” all I could see were some different shades of gray and beige. When the GroupMe would flood with motivational GIFs before exams, I’d think, “What’s the point when we have to do this all over again, week after week?” Eventually, it all settled down to one thought: Why should I care?

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This thought process landed me at the bottom of a spiral — a place that I frankly don’t want to revisit. I felt my motivation and desire to learn slowly fade, and after a string of poor grades, I was asked to repeat my first year. Immediately, I felt as if I was given a scarlet letter: a branding that would forever haunt me as that one student who failed her first semester.

Afterward, I felt lonely. I avoided anyone who asked me how school was going and gave some vague responses if I felt pressured to say something. I was afraid to reach out to anyone because I didn’t want to explain myself. I was consumed in my guilt and shame.

Eventually, I needed something to do, so I decided to re-study the subjects I failed.

The logical part of me felt that it was better to be productive than to wake up every morning without a clue of how my day was going to go. I reviewed old slides, re-made Anki decks, and forced myself into a routine. Slowly, this routine gave me a sense of purpose. I started to appreciate the subjects I was learning and took time to research concepts I didn’t understand. Before, I felt as if I never had the time. Now, everything was at my speed. I welcomed this refreshing change of pace.

I even started to tell a few classmates about what happened and was surprised when they shared their struggles with me.

One student had a breakdown in a vet’s office because she was caring for her sick puppy while her partner was hospitalized.

Some were sneaking anti-depressants after family dinners. Others were studying while waiting in the pick-up lane of their children’s school, questioning if they were being good parents. In short, by being open about my failure, I started to feel less alone.

We feel more comfortable opening up when others share their imperfections.

However, most of us tout our accomplishments and hide our vulnerabilities.

Our CVs are filled with our successes; our social media feeds are a curation of only our finest moments. Yet, none of that is ever enough to know anyone.

There’s a reason that medical school acceptances aren’t solely based on applications. There’s a reason that our most meaningful moments aren’t accompanied by an edited Instagram post. It’s ironic that in a field that promotes connection with patients, we as students don’t feel comfortable sharing ourselves. From this view, our medical education experience needs to be improved. We students need to admit that none of us truly has it all together. Behind the perfect white coat headshots are the missed weddings and funerals. We’re spending our healthiest years for our future patients, whom we don’t yet know. It can be grueling, miserable, and enough to overwhelm anyone. As doctors, we’re obligated to be with people at some of their most vulnerable and lowest moments. How are we supposed to do that when we’re not

honest with our peers who, of all people, know what it’s like to be us?

These past months I searched for my reason on why I chose this field. I found some of it again but truthfully, I’ve yet to fully rediscover why I want to be a physician. This experience has shaken my own beliefs about what I thought it meant to become a doctor. The girl who went in as a fresh-faced and doe-eyed first-year student came out the other end as a battered, repeat first-year student now with a Zoom subscription. I’ve lost the dream of what I thought my medical school experience would be and the plan I had for myself. Becoming a doctor was the first and greatest thing I've wanted,

and to have failed at something that has been a monumental part of who I am will undoubtedly leave me with a scar.

Our grief isn’t linear. We don’t cleanly move on from stage to stage, nor do we compartmentalize our grieving into distinct emotions with strict borders.

Instead, our emotions bleed into one another, and we feel the grief come at us in waves. Some days I feel hopeful.

Other days I’m crying on my bedroom floor while polishing off a sleeve of Ritz crackers, wishing that I was going into my second year. What I want more than anything is to package this experience into a pretty box and thank it for the lessons it taught me. But I can’t; the hurt

is still too present. However, between these lows I’ve experienced some good through the people who stood by me, sent me flowers when I was feeling sorry for myself, and treated me to lunches and dinners. I’ve always known that no one goes through life alone, but in this period of my life, I felt it. I lived it. To all those who believed in me then and believe in me now, especially to my peers who were vulnerable with me, it is because of you that I attempt to move forward. And while that step forward might be small, it's better than not moving at all. ■

F E A T U R E

Let’s get vaccinated Ashok Rambhai Patel, MD, Pueblo, Colo.

Let’s get vaccinated To prevent trips to ICU Not to get buried six feet under or cremated Not to suffer from Lilliputian or Long COVID Let’s get vaccinated We brace ourselves for Pain and swelling at the injection site Possibly fever, chills and headaches Let’s get vaccinated Allergic reaction may cause itching, hives, shock But the reaction can be treated effectively Adrenaline shot works like a charm Let’s get vaccinated Sensational reports of side effects scare us When a tree falls after a crow sits on a branch Would we blame the crow?

Let’s get vaccinated Do we die from COVID or from worries about the side effects?

Millions got vaccinated so far satisfactorily So many lives saved Let’s get vaccinated With whichever vaccine we can get All approved vaccines prevent hospitalizations and deaths Decrease COVID-19 spread in the community

Let’s get vaccinated Hurry to induce herd immunity To dine at our favorite eateries To scream at sports events Let’s get vaccinated Before variants get toehold Mass vaccination corners the virus Shrinks fertile ground for virus to mutate Vaccine helps us and others, whole community Love thy neighbor Tikkun Olam, Vasudev Kutumbakam Help the whole world get vaccinated The world is one family, Vasudev Kutumbakam Love thy neighbor Heal the world, Tikkun Olam

C O LO R A D O M E D I C I N E 1 7

D E PA R TM E NT S M E D I C A L

N E W S

Join newly formed task forces for employed physicians, independent physicians The Colorado Medical Society Board of Directors recently formed two task forces that may become permanent entities within the society: the Employed Physicians Task Force or the Independent Physicians Task Force. The two task forces will meet three or four times beginning later this summer or early fall, with all work finalized by the end of this calendar year. Virtual participation will always be available for meetings.

EMPLOYED PHYSICIANS TASK FORCE Chair: Alwin Steinmann, MD Contact CMS staff for more information: Paige Brophy; paige_brophy@cms.org

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CMS aims to have all of the large employers of Colorado represented.

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Task Force members will represent their fellow physician colleagues on behalf of their employer during task force meetings.

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Task force members will help construct a survey that will be sent to all CMS employed physician members and analyze results.

Task force members will help construct a survey that will be sent to all CMS independent physician members and analyze results.

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Task force members will give a formal recommendation to the CMS Board of Directors as to whether permanent entity for independent physicians is viable and should be created. ■

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D E PA R TM E NT S M E D I C A L

Task force members will give a formal recommendation to the CMS Board of Directors as to whether a permanent entity (such as a committee, section etc.) is viable and should be created.

INDEPENDENT PHYSICIANS TASK FORCE Chair: Omar Mubarak, MD Contact CMS staff for more information: Krys Medford; krystle_medford@cms.org

N E W S

BCMS welcomes members to in-person Meet and Greet The Boulder County Medical Society held its first in-person Meet and Greet of 2021 on July 22. Judy Ladd, BCMS executive director, said the event was very well received by physician members and their guests, who were thrilled to socialize with their colleagues in person once again. ■

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D E PA R TM E NT S M E D I C A L

N E W S

In memoriam: Jerry J. Appelbaum, MD JUNE 20, 1927 - MAY 24, 2020 Jerry J. Appelbaum, MD – a pioneer in occupational medicine, and a longtime leader in organized medicine and admissions committee member at the University of Colorado School of Medicine – died May 24, 2020. A celebration of life was held June 18, 2021.

Appelbaum shaped the occupational medicine industry through over 25 years of service to Mountain Bell and Gates Corporation, and over 50 years of professional and educational leadership at the national, state and local levels.

He served as president of organizations such as the Colorado Society of Internal Medicine, the Rocky Mountain Academy of Occupational Medicine and the Denver Medical Society, and in leadership roles for numerous other organizations in Colorado and nationally. He was recognized for his ongoing service and contributions to the practice of medicine as a fellow of the American College of Physicians and the American Academy of Occupational

Medicine, among many others, and he was certified by the American Board of Preventive Medicine. He served as a medical and occupational health consultant until age 91.

Appelbaum was devoted to the University of Colorado School of Medicine as associate clinical professor of medicine/ preventive medicine and, most enduringly, a 30-plus year member of the Admissions Committee, valued for his advocacy for access and equity in education.

He attended New York City's public Stuyvesant High School, Washington & Jefferson College (bachelor of arts), Columbia (master of arts), and New York Medical College (doctor of medicine).

Jerry fulfilled his duty to his country by serving in the United States Army, which brought him to Fitzsimons Army Medical Center and to Denver, where he returned some 10 years later to practice medicine and raise his family.

Known for his infectious enthusiasm for life and deep-felt compassion for his patients, family members and friends, there were no strangers in his life, only friends he had yet to meet. He is survived by children Dale, Leslie and John, six grandchildren, and his partner Nancy.

A celebration of life honoring Appelbaum was held Friday, June 18. Donations in Jerry's honor can be made (attn. Tribute) to Denver Dumb Friends League (303751-5772) or U.S. Holocaust Memorial Museum (866-998-7466). Jerry is interred at Fort Logan National Cemetery. ■

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C O LO R A D O M E D I C I N E 1 9

F E ATU R E F I N A L

WO R D

Time for reflection – and action – on the moral challenges facing health system leaders Matthew Wynia, MD, MPH, FACP

Matthew Wynia, MD, MPH, FACP, directs the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus. He co-directs the Aspen Ethical Leadership Program, a selective-admission program for exploring and developing skills for managing ethical challenges facing health system leaders. The next cohort of leaders meets Oct. 3-6, 2021; more information is at: bit.ly/AELP2021

It’s become a truism that the pandemic has elevated public awareness of ethical issues in medicine and public health. Triage of scarce resources in disasters, the ethics of quarantine and isolation, the legal and ethical legitimacy of mask and vaccination mandates – these are no longer just public health ethics classroom exercises, they are topics of dinner-table conversations worldwide and the subjects of wrenching real-world decisions by leaders.

Longs tanding racial, ethnic and geographic health disparities have also been exacerbated by the pandemic, leading to heightened public awareness of historical and structural injustices in U.S. health care. The racial justice protests of 2020 didn’t focus much on excess deaths among minorities in the US health care system, but they could have. And more people now recognize systemic injustices as intertwined, with health disparities intersecting with structural injustices in policing, education, transportation and other domains of American life.

For many health system leaders, this recognition has prompted a difficult a c k n ow l e d g e m e n t : r a c ia l , et h n i c , geographic and disability-related health disparities cannot be solved by “cultural competence” initiatives aimed at individual clinicians. Just as frontline clinicians have long struggled to help their patients facing various barriers to good

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health – over which individual clinicians have little or no control – many leaders are now struggling to figure out their roles in remedying structural problems in payment, geographic distribution of resources, transportation, employment and other barriers to the wellbeing of historically disadvantaged communities, because these factors lie outside the traditional purview of the health care systems they lead.

In the meantime, the fact that professional ethics calls on frontline clinicians to put patients’ interests ahead of our own was probably already widely known, but it was also mostly theoretical for many patients.

The pandemic changed that too, as the news filled with stories and images of doctors and nurses, often haggard and broken but labeled as “heroic.” But this dynamic also poses a challenge for health system leaders, with many predicting a mass exodus of clinicians in the coming months and years.

Similar to the complex challenge of addressing health inequities, many leaders are coming to realize that addressing the challenge of rising moral distress and burnout among clinicians cannot be solved using an approach focused on bolstering individual resilience. Clinicians being ground down by packed schedules, resource shortages, and EMRs tailored to billing rather than patient care might not find enough solace in free yoga classes at noon on Wednesdays. But do

individual health system leaders really have the leverage to change the core functionality of available EMRs, or the rates at which their communities choose to be vaccinated, or payment models that reward volume over value?

With the complex challenges confronting health system leaders, it’s no surprise that they are experiencing moral distress and burnout, too. Moral distress arises when someone knows the right thing to do, but is constrained by external forces and can’t do it. It arises most often from power dynamics – and while moral distress can be alleviated by naming it and recognizing its effects, it is solved only by effective advocacy to improve underlying conditions.

As I write this, I can almost hear frontline clinicians muttering that their system leaders are paid quite well for bearing these burdens. But so are many clinicians who burn out nevertheless. In health care, remarkably, there is little relationship between one’s level of remuneration and the experience of burnout.

The bottom line is that health system leaders, like clinicians, need to learn how to recognize, analyze and act on the ethical challenges they face. Today more than ever, they need to create safe spaces for talking about the painful experiences of the last year, to share creative practical interventions, and to practice the skills of ethical leadership. ■

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