November-December 2021-January 2022

VO LU M E 1 1 8 N O . 4 N OV - D E C 2 0 2 1 -J A N 2 0 2 2

COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE

BRINGING PUBLIC HEALTH AND MEDICINE BACK TOGETHER MARK B. JOHNSON, MD, MPH 2021-2022 CMS PRESIDENT

PLUS

IMPROVING CARE FOR PATIENTS WITH PAIN CMS REPRESENTS YOU IN COLORADO OPTION TALKS A LOOK INTO LEGISLATIVE REDISTRICTING

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C O N T E N T S

BRINGING PUBLIC HEALTH AND MEDICINE TOGETHER ONCE AGAIN Newly inaugurated CMS President Mark B. Johnson, MD, MPH, gives his vision for his presidential year, approaching the role with humility and providing a steady hand to keep CMS on course to continue supporting and encouraging Colorado physicians. He wishes to restore public trust in physicians and restore the bond between public health and medicine, for the good of all patients.

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F E A T U R E S

D E P A R T M E N T S

7 A LOOK INTO LEGISLATIVE REDISTRICTING

14 COPIC Comment: What more can COPIC do to support health care?

CMS lobbyists Jerry Johnson and Dan Jablan talk about the redistricting process and why Colorado is one of the few states doing it right…by not making either major party completely happy.

8 DEFINING PHYSICIAN BURNOUT

In part one of a three-part series, Alexander von Hafften, MD, and Jeremy Lazarus, MD, explore physician burnout: what contributes to burnout, how common it is, and a call to action.

11 UCHEALTH CAMPUSES RECEIVE JOY IN MEDICINE AWARD Two Colorado health systems were recognized by the American Medical Association for their work to reduce work-related burnout.

12 IMPROVING CARE FOR PATIENTS WITH PAIN

A new law passed during the 2021 legislature makes it easier and more affordable for physicians to prescribe and patients to access alternatives to opioids.

CMS is on it

13 INFOGRAPHIC: CMS REPRESENTS YOU IN COLORADO OPTION TALKS

Knowing the Colorado Option is a big issue for many CMS members, your medical society has been at the table from the start as the Colorado Option takes shape.

24 FINAL WORD: RE-ESTABLISHING PATIENT TRUST

Kelly McAleese, MD, reflects on the difficult times physicians and patients have faced since the COVID-19 pandemic began and opportunities that abound to recapture the essence of the doctor-patient relationship that is built on trust and confidence.

16 Reflections: It takes a village 18 Introspections: Imposter medicine 20 Partner in Medicine Spotlight: What physicians need to know about Medicare enrollment 22 Reflections: A call to action from an Afghan American medical student

I N S I D E

C M S

6 Annual meeting report

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 2021-2022 OFFICERS

BOARD OF DIRECTORS

AMA DELEGATES

Mark B. Johnson, MD, MPH President

Brittany Carver, DO Enno F. Heuscher, MD, FAAFP, FACS Rachelle M. Klammer, MD Chris Linares, MD Evan Manning, MD Michael Moore, MD Edward Norman, MD Lynn Parry, MD 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

Patrick Pevoto, MD, RPh, MBA President-elect Hap Young, MD Treasurer Bryan Campbell, FAAMSE Chief Executive Officer Sami Diab, MD 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

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

Krystle Medford Senior Director of Membership Krystle_Medford@cms.org

Kate Alfano Director of Communications and Marketing Kate_Alfano@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

Susanna Barnett Membership Coordinator Susanna_Barnett@cms.org

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

Chet Seward Chief Strategy Officer Chet_Seward@cms.org

Paige Brophy Director of Membership Services Paige_Brophy@cms.org

Dean Holzkamp Chief Operating Officer Dean_Holzkamp@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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C OV E R P R E S I D E NT ’ S

LE T TE R

BRINGING PUBLIC HEALTH AND MEDICINE TOGETHER ONCE AGAIN ADAPTED FROM THE INAUGURAL ADDRESS OF THE 151ST COLORADO MEDICAL SOCIETY ANNUAL MEETING Mark B. Johnson, MD, MPH, CMS president

Many folks have asked me what my new initiatives will be during my tenure as the CMS president. I would like to remind all of us that one year ago, the CMS Board identified priorities for CMS and adopted a strategic plan, with one-year, threeyear and five-year goals and objectives. I think it would be the height of arrogance for me to assume I have a better plan.

The board’s highest identified priorities were to create a plan for diversity, equity and inclusion; to protect physicians’ rights to confidential counseling and peer assistance; and to retain, engage and increase CMS membership. CMS committees, councils, task forces, leadership and staff have been working hard this year on those priorities and will continue to do so in the coming year. The strategic goals of the Board were to support members in finding professional satisfaction, to continue to work to provide efficient and effective communication with our members, and to enhance organizational excellence that is recognized with increased membership.

While not directly mentioned, the health and well-being of our patients and communities are the foundation on which all of our activities rest.

These goals and priorities remain in place, and I will do all I can to continue the excellent work that is being done in these arenas by leadership, members and staff. There are two additional areas of personal interest and, I believe, of special importance to the house of medicine at this time, on which I hope to focus the resources of CMS, including the involvement of you, our members.

I’d like to introduce those issues by reminding you of a game we all learned in medical school that we called “morning rounds.”

To be fair, morning rounds are more than just a game. They are an important part of the learning process in becoming a good physician.

They expand your knowledge base, they stretch your critical thinking, they teach you organizational skills, they encourage teamwork and they fine-tune your inner baloney detector. To prepare for morning

View the Colorado Medical Society plan at

cms.org/about/strategic-plan 4 C O LO R A D O M E D I C I N E

Meet Mark Johnson, MD, MPH Mark B. Johnson, MD, MPH, was sworn in as president of the Colorado Medical Society Friday, Sept. 17, during the virtual CMS 151 st Annual Meeting. Johnson has served as a member of the CMS Board of Directors since 2016 and in many other leadership capacities within the medical society – leading committees, councils, workgroups, task forces and acting as a delegate to the former policy-making body of CMS – continually since 1993.

He will bring a focus on public health to his presidency, drawing on three decades of service to Jefferson County Public Health. He retired from the position of executive director of JCPH on Oct. 2, 2020.

Over his professional career, in addition to leading the county through the COVID-19 pandemic, wildfires and floods, he has achieved many other accomplishments: helping write and pass the Colorado Public Health Act in 2008, which helps ensure core public health services are provided effectively and equally to everyone in the state, and helping establish the Colorado School of Public Health, where he still teaches today as an associate professor and assistant clinical professor.

Johnson also advocated for transparency around safety related to the Rocky Flats, led JCPH to receive national accreditation status, and has served and continues to serve on multiple leadership boards and committees in the public health and medical fields. The Colorado Public Health Association presented him the Lifetime Achievement Award in 2019.

Johnson was awarded a Master of Public Health by Johns Hopkins University School of Hygiene and Public Health and his medical degree by Loma Linda University School of Medicine. He received additional training through a preventive medicine residency at Johns Hopkins School of Hygiene and Public Health and a clinical fellowship at Johns Hopkins Hospital Department of Psychiatry. He was a senior assistant surgeon with the United States Public Health Service National Health Service Corps, and achieved the rank of lieutenant colonel in the U.S. Army Medical Corps, U.S. Army Reserves before honorable discharge in 2006. rounds, one must become thoroughly familiar with their patients. You must know each patient’s current symptoms and vital signs, their past medical history, their family history, their occupational history, their current medications, and their lab and diagnostic test results. In addition, you must know the tentative working diagnoses and all of the differential diagnoses that may account for the patient’s current health status.

Those are the professional aspects of morning rounds, but there is another side to them, a game I call roundsmanship. As a game, it is a medical mixture of “Trivial Pursuit” and “Jeopardy!” One must always be ready to immediately and confidently answer any questions that are put to you by the chief resident or attending physician about your patients, their diseases, the recommended treatments, and the current relevant, and sometimes

Dr. Brinegar paused, thought for a

irrelevant, literature. Hesitancy spells disaster. Even if wrong, an moment, and then said, “I don’t know.” immediate and confident answer I almost dropped my clipboard! may buy time or throw the questioner off their game. These are don’t know.” I almost dropped my clipvital lessons to learn because the medical board! I had never heard those words students who are best at playing round- before on morning rounds or from any manship are usually the ones asked to authority in medical school! Could you join the best residencies. even say that? This was not part of the game of roundsmanship!

One of the most memorable events in my medical school career happened more I looked at my fellow students and realthan 40 years ago on morning rounds. ized that I was not alone in my shock Our attending physician at the time was and confusion. The honesty and humility the late Charles Brinegar, an internist exhibited by Dr. Brinegar were breathand diabetologist who had trained at taking! Being the consummate teacher, the prestigious Joslin Diabetes Clinic in however, his next words put both the Boston. During rounds, one of our bright, medical student and the world of medibut cocky, medical students asked Dr. cine back in their proper places. “I’d like Brinegar a question about the meaning you to research that question and be of a rather obscure laboratory finding on prepared to give us a report on your one of our patients. Dr. Brinegar paused, findings tomorrow on morning rounds.”

PAGE 6⊲ thought for a moment, and then said, “I

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

C OV E R P R E S I D E NT ’ S LE T TE R : C O N T

Unfortunately, our medical training has taught many of us physicians to stretch the truth, to obfuscate, or to give complicated and confusing answers to some of the most heartfelt questions put to us because we feel we can never say, "I don’t know." We have paid a price for this hubris. Based on Harris and Gallup polls and data from the National Opinion Research Center, physicians have fallen significantly in both prestige and people’s trust over the last 40 years, and have ranked behind nurses, teachers, engineers and firefighters at various times. In fact, nurses have been the most trusted health care professionals for the past 20 years. Fortunately, we have not scored as poorly as attorneys, who have ranked as the most arrogant professionals for almost 80 years in a row. We must learn, however, how to tell our patients, our elected officials, and our spouses and partners, “I don’t know. Let me research that and get back with you as soon as possible.”

Over the next year I hope to continue and accelerate the work begun by Dr. Diab, the CMS staff and some of the CMS committees to restore public trust in the physicians of Colorado, particularly the members of CMS. This is integrally tied to work already being done by CEJA on defining and disseminating the meaning of professionalism, and the two new taskforces on independent practice and employed physicians in today’s

I N S I D E

Recently, medicine has rediscovered

changing and challenging world of medicine, as well as its role in the marketplace.

public health, finds it intriguing, but is not quite sure how to relate to it.

The other issue that is close to my heart is the role of physicians and organized medicine in the world of public health. As I have written in the past, public health is the illegitimate offspring from a short but passionate affair that medicine had with social work in the late 19th century. Medicine was subsequently seduced away by Mammon, and social work was left with a sometimes obstinate and needy child with a long-lasting distrust of medicine.

Recently, medicine has rediscovered public health, finds it intriguing, but is not quite sure how to relate to it. My conviction is that medicine needs to actively re-engage with public health for the health of the public. After the influenza pandemic of 1918, public health was given great responsibilities but little authority and almost no enforcement capabilities with which to protect the people’s health.

Even that level of authority is now under attack from many quarters, and if lost, will most likely never be regained. As a long-absent parent, I believe medicine needs to once again take up the protection and nurturing of public health.

My first activity with CMS, back in the mid-1990s, was an attempt to protect the integrity and independence of public

health in Colorado. While that battle did not end as I had hoped, it did lead to the formation of the chief medical officer position at CDPHE, who by statute has the authority to directly engage with the governor on health-related issues if they feel the necessity. The chief medical officer, as well as the other state and local public health officials, need the support that only CMS and its members can give them in times of great political and medical distress. During my tenure as president of CMS, I will actively work to rebuild bridges between these two fields of endeavor.

Thank you once again for the honor of leading this great organization at this interesting and disruptive time in health care. From all indications, it appears that there will be numerous battles to face in the year ahead on both the social and political fronts. These cannot be fought by leadership and staff alone. It will call on every ounce of trust, prestige and wisdom stored up in each and every CMS member to successfully face the challenges ahead. From past experience, I know that we can count on all of you to do your part as we move forward. ■

C M S

Report from the 151st CMS Annual Meeting The virtual 151st Colorado Medical Society Annual Meeting was a fun and fast-paced event held on Sept. 17 that featured updates from leadership, education, live music and prizes.

1 Mark Johnson, MD, MPH, thanked Sami Diab, MD, for his service as 2020-2021 CMS president.

1

2

2 Theodore C. Ning, MD, received COPIC’s 2021 Colorado Humanitarian Award.

3 CMS CEO Bryan Campbell, FAAMSE, served as meeting host.

4 Gerald Zarlengo, MD, COPIC CEO, presented an update on COPIC and the liability climate in Colorado.

5 Eric France, MD, MPH, MSPH, gave an informative update on COVID-19 and the Delta variant.

3

4

5

6 Diab gave lighthearted remarks as outgoing president.

7 Johnson was sworn in as 2021-2022 CMS president and gave an inspiring inaugural address.

Thank you to all of the members and guests who joined us for this event.

We look forward to gathering in person in 2022 to celebrate Colorado physicians and rekindle the joy of medicine.

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

6

7

F E ATU R E LE G I S L ATI V E

U P DATE

Location is everything in the redistricting process Jerry Johnson and Dan Jablan, CMS lobbyists The top story of interest to lobbyists and politicos during the current interim between the end of the last legislative session and the start of the next one in January 2022 has been the redistricting process. It takes place every 10 years in Colorado following the release of the new census data. And, to be fair, it holds much more interest to elected officials and those who occupy the legislature’s lobby than it does to the public at large.

The two commissions spent more than 200 hours in meetings during the summer, holding hearings in communities across the state. Nearly 400 individual and group comments were received in a very open and transparent process. The new Colorado system makes it one of fewer than a dozen states using independent citizen commissions to do this work.

Gerrymandering is still the norm across the country.

This redistricting exercise was different than those in preceding decades by virtue of the passage of two referendums by Colorado voters.

The congressional commission’s map created a new Congressional District 8, connecting Adams and Weld Counties along the Front Range, but otherwise seemed to leave the current Congressional districts largely intact after balancing the number of voters in each. The commission passed the congressional

By passing Referendum Y and Z in 2018, the voters overwhelmingly decided that the fairest way to redraw legislative district lines would be by creating independent commissions – one for congressional districts and one for legislative ones – free from the influence of current elected officials or political party leaders. Good government advocates have long proposed independent commissions as the vehicle to end “Gerrymandering,” which we all learned about in our first political science or government class. In 1812, Massachusetts Gov. Elbridge Gerry famously redrew district lines to benefit his party – creating a district that resembled the shape of a salamander. Protecting incumbent elected officials is expressly prohibited in Colorado.

The redistricting process has been ongoing for the last seven months. The two 12-member commissions began their work in early April and voted on final new district maps this month. The commissions comprised four Democrats, four Republicans and four unaffiliated voters. The maps have been presented to the Colorado Supreme Court for review. Parties can file legal challenges to the maps, but the court’s role is to decide whether the maps meet constitutional muster, a determination that should be available soon after the publication of this issue of Colorado Medicine. The court can approve the maps or send them back to the commissions.

map by a 11-1 vote.

But what to make of the new state House and Senate districts, hence the future balance of the state legislature? The current makeup of the legislature has the Democrats in control, 20-15 in the Senate and 41-24 in the House. The new maps suggest that control of the Senate will be extremely competitive, while the House Democrat majority could narrow substantially. The Democrat and Republican parties seem to be both happy and unhappy with portions of the maps, which points to the process of the independent commission working properly. The commission passed the new state legislative map by a 12-0 vote. The new districts will take effect in time for the 2022 election. ■

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

F E A T U R E

Physician burnout: What is it?

Why is it important?

Jeremy Lazarus, MD Past President, American Medical Association

Alexander von Hafften, MD Physician Health Committee, Alaska State Medical Association

Introduction Health care professional wellbeing is the foundation of health care quality and outcomes.1 Declining nurse, pharmacist, physician, resident, and medical student well-being were well documented prior to the COVID-19 pandemic.1,2,3 The pandemic is increasing distress in the health care workforce and is bringing national attention to health care professional burnout.

This is the first of three articles on physician burnout. This article defines physician burnout and summarizes why it is important. The second article will summarize system and organizational strategies to reduce physician and medical student burnout. The third article will summarize individual physician interventions to improve physician and medical student wellbeing.

Brief history

What is physician burnout?

Physician distress, burnout, anxiety, depression, substance use disorders, and suicide are not new phenomena.

The first JAMA editorial regarding physician suicide was published in 1903.4 For much of the 20th century, physician distress focused on the vulnerabilities of individual physicians. 5 By the 1970s, this perspective was changing. In 1976, Maslach published research on health and social service professional burnout.6 In 1981, Maslach and Jackson published the Maslach Burnout Inventory (MBI).7 The MBI is the first and most commonly used tool for measuring burnout.

Physician burnout encompasses a combination of emotional exhaustion, depersonalization, detachment, cynicism, and sense of low personal achievement.7 Physician burnout evolves over time. It is not a response to a challenging job or long work hours. It is not a personal failing or deficit of resilience. Physician burnout is an individual response to systemic issues and needs a comprehensive and individualized response.2,8,9 Physician burnout is a syndrome, not a medical disorder, mood disorder, or anxiety disorder. However, burnout may precipitate or exacerbate depression,

anxiety, substance misuse, and risk for suicide. A depressive disorder, anxiety disorder, and substance use disorder may be precipitated by burnout and contribute to burnout. An individual physician may experience burnout, a mood disorder, an anxiety disorder, and a substance use disorder. Physician distress, burnout, depression, anxiety, and substance misuse are risk factors for physician suicide.

What are contributors to physician burnout?

Physician burnout has multiple causes including the health care system, health care organizations, physician-patient interactions, and patients. An individual physician’s vulnerability and response to these factors may contribute as well.

Physicians work in high-strain settings with expanding duties and responsibilities, decreasing autonomy and support, and decreasing direct face-to-face time with patients.

The electronic health record (EHR) is a good example. Even though EHRs may contribute to care coordination and patient safety, they have produced unintended adverse consequences. EHRs disrupt physician-patient interactions, contribute to task shifting from non-physicians to physicians, and facilitate everPAGE 10⊲

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

ADVANCED PROSTATE CANCER

Prostate cancer is the most commonly diagnosed cancer in men, other than skin cancer, and the second leading cause of cancer deaths in men in the US.1

2nd in US

leading cause of cancer deaths

1 in 9

*

*Estimated

will be diagnosed with prostate cancer in their lifetime.2

3,650,030

Total estimated number of men who will be affected by prostate cancer living in the US in 2020.3

Advanced Prostate Cancer Types:

• Locally Advanced: Cancer has spread beyond the outer layer of the prostate into nearby tissues.

Locally advanced prostate cancer is considered nonmetastatic.4 • Metastatic: Cancer has spread to other parts of the body, such as the bones, lymph nodes, lungs, or liver.5 • Castration-Sensitive Prostate Cancer (CSPC, also called Hormone-Sensitive Prostate Cancer): A form of prostate cancer that still responds to testosterone suppression therapy. CSPC can be referred to as nmCSPC when there is no detectable metastases upon imaging, and as mCSPC it has advanced to metastatic stage.6 • Castration-Resistant Prostate Cancer (CRPC): Cancer that keeps growing even when the amount of testosterone in the body is reduced to very low levels. Many early-stage prostate cancers need normal levels of testosterone to grow, but castrate-resistant prostate cancers do not. CRPC can be referred to as nmCRPC when there is no detectable metastases upon imaging, and as mCRPC when it has advanced to metastatic stage. CRPC can be referred to as nmCRPC when it has not metastasized.7

Within 5 years of diagnosis, ~10%-20% of men with prostate cancer globally will develop CRPC.8

30%

Estimated 5-Year Survival Rate Men with distant metastatic prostate cancer.9

VS

Patients should work with their doctor to further understand advanced prostate cancer and what they can do to prepare.

Visit www.zerocancer.org for more information.

100%

Men with localized prostate cancer when compared to similar cancer-free individuals.10

Funding and support provided by:

A PATIENT EDUCATION SERIES 1

REFERENCES

American Cancer Society. Cancer facts & figures 2018 (2018). https://www.cancer. org/content/dam/ cancerorg/research/cancer-facts-and-statistics/annual-cancer-factsand-figures/2018/cancer-facts-and-figures-2018.pdf. Accessed May 1, 2020.

2

American Cancer Society. Key statistics for rostate cancer. https://www.cancer.org/cancer/ prostate-cancer/about/key-statistics.html. Accessed May 19, 2020.

3

Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute. ©2019, American Cancer Society, Inc., Surveillance

4

American Cancer Society. Glossary: definitions & phonetic pronunciations: advanced cancer. https://www.cancer.org/content/cancer/en/cancer/glossary.html?term=advanced+cancer. Accessed May 8, 2020.

5

Cancer.Net. ASCO answers prostate cancer. http://www.cancer.net/sites/cancer.net/files/ asco_answers_guide_prostate.pdf. Accessed May 1, 2020.

6

American Society of Clinical Oncology. Prostate cancer: treatment options (01-2017). https://www.cancer.net/cancer-types/prostatecancer/treatment-options. Accessed May 19, 2020.

7

National Cancer Institute. Cancer Stat Facts: Prostate Cancer. https://www.cancer.gov/ publications/dictionaries/cancer-terms/def/castrate-resistant-prostate-cancer. Accessed May 5, 2020.

8

Saad F, Chi KN, Finelli A, et al. The 2015 CUA-CUOG guidelines for the management of castration-resistant prostate cancer (CRPC). Can Urol Assoc J 2015;9(3-4):90-96.

9

Kirby M, Hirst C, Crawford ED. Characterising the castration-resistant prostate cancer population: a systematic review. Int J Clin Pract 2011;65(11):1180-1192.

10

National Cancer Institute. Cancer Stat Facts: Prostate Cancer. https://seer.cancer.gov/ statfacts/html/ prost.html. Accessed May 5, 2020.

PP-XDI-USA-0227, 5/2020

F E ATU R E P H YS I C I A N B U R N O UT: C O N T

increasing reporting requirements by third par ties regarding patient care metrics and regulatory requirements.

Sinsky reported that for every hour of direct face-to-face time with patients, physicians spend nearly two additional hours of EHR and desk work within the workday and an additional one to two hours of EHR work at home.10 For physicians, work-life balance has always been a challenge, and technology has made it worse.

Some other major contributors to physician burnout include:9

•

Perceived lack of peer support, lack of professionalism, and disengaged health care organization leadership.

•

Loss of meaning of patient care and in medicine arising from decreased supports, increased responsibility, and decreased autonomy and flexibility.

•

Work compression, work environment intensity, and fatigue.

How common is physician burnout?

Key points

Much of the data regarding physician burnout comes from self-report assessments. Physician distress and burnout are common. The rate of physician burnout is approximately 50 percent among U.S. physicians, residents, and medical students .3,9 Burnout may be 20-60 percent higher among female physicians than male physicians.11 Female physicians may be more likely to describe emotional exhaustion while male physicians more likely to describe depersonalization.11 The rate of burnout among physicians varies by clinical specialty, with specialties on the front lines of access to care being at highest risk.2,9

1. Burnout is a syndrome of emotional ex h a u s t i o n , d e p e r s o n a l iza t i o n , cynicism, and decreased sense of accomplishment.

Does physician distress and burnout impact patient care?

Physician distress and burnout decrease quality of care, patient safety, and patient satisfaction. Physician burnout decreases physician engagement, productivity, and increases turnover and early retirement.

“Patient care quality goes hand in hand with physician wellbeing.” 12,13

Rate of physician burnout

50 percent among U.S. physicians, residents, and medical students

1. Noseworthy J, Madara J, Cosgrove D, et al: Physician burnout is a public health crisis: A message to our fellow health care CEOs. Health Affairs. March 2017.

Available from https://www.healthaffairs. org/do/10.1377/hblog20170328.059397/ full/ 2. Shanafelt TD, Noseworthy JH: Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clinic Proceedings 92(1):129–46, 2017.

3. Dyrbye LN, Shanafelt, CA, Sinsky PF et al: Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives.

Discussion Paper, National Academy of Medicine, Washington, DC, 2017. Available from https://nam.edu/wp-content/ uploads/2017/07/Burnout-Among-HealthCare-Professionals-A-Call-to-Exploreand-Address-This-UnderrecognizedThreat.pdf

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4. JAMA: Suicides of physicians and the reasons. JAMA 41(4):263-264, 1903.

5. Legha RK: A history of physician suicide in America. J Med Humanit 33(4):219-244, 2012.

6. Maslach C: Burned-out. Human Behavior 5 (9):16-22, 1976.

7. Maslach C, Jackson SE: The measurement of experienced burnout. Journal of Occupational Behavior 2:99-113, 1981.

8. Mayer, LE: From burnout to impairment, in combating physician burnout. Edited

by LoboPrabhu S, Summers RF, Moffic, Washington DC, American Psychiatric Association Publishing, 2020, pages 85-100.

9. American Psychiatric Association. APA Wellbeing Ambassador Toolkit. Physician Burnout and Depression: Challenges and Opportunities, Slide 16, January 2018.

10. Sinsky C, Colligan L, Li L, et al: Allocation of physician time in ambulatory practice:

2. Physician burnout is not a deficit of physician resilience.

3. Physician burnout is common and begins in medical school.

4. Physician burnout is associated with substance misuse, anxiety, depression, and suicide.

5. Physician burnout is associated with medical errors, decreased productivity, lower patient satisfaction, and higher physician turnover.

Call to action The American Medical Association (AMA), National Academy of Medicine (NAM), American Association of Medical Colleges (AAMC), Federation of State Medical Boards (FSMB), and many medical societies have published policies, guidelines, and recommendations to promote physician health and wellbeing.

Health care system and organizational interventions will be the focus of the second article in this series. ■

a time and motion study in 4 specialties.

Ann Intern Med 165(11):753-760, 2016.

11. Templeton K, Bernstein, CA, Sukhera J: Gender-based differences in burnout: Issues faced by women physicians. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington DC, 2019.

12. Shanafelt, TD: Enhancing meaning in work: prescriptions for preventing physician burnout and promoting-patient centered care. JAMA 302(12):1338-1340, 2009.

13. Shanafelt TD, Balch CM, Bechamps G, et al: Burnout and medical errors among American surgeons. Ann Surg 251(6):9951000, 2010.

This article was originally published in the Alaska State Medical Association (ASMA) bimonthly newsletter, Heartbeat. It has been reprinted with permission.

F E A T U R E

Two Colorado health systems recognized for efforts to reduce work-related burnout Kate Alfano, CMS Director of Communications and Marketing

Two Colorado health systems joined 42 others around the country in being recognized for their efforts to reduce work-related burnout. UCHealth Southern Region and UCHealth University of Colorado Hospital on the Anschutz Medical Campus were named as recipients of the American Medical Association's 2021 Joy in Medicine™ Health System Recognition Program.

“The Colorado Medical Society applauds these two UCHealth campuses for their work to address burnout at the systems level,” said CMS President Mark B. Johnson, MD, MPH. “Healthy physicians provide better care.

Together we can promote physician professional satisfaction and move the needle on physician burnout, suicide and other crises resulting from the intense pressure and responsibility of medical practice.”

Candidates for the Joy in Medicine Health System Recognition Program were evaluated according to their documented efforts to reduce work-related burnout through system-level drivers.

Scoring criteria was based on demonstrated competencies in commitment, assessment, leadership, efficiency of practice environment, teamwork and support.

“We are thrilled to be alongside so many outstanding organizations as we all progress in our journey to decrease burnout and enhance the inherent Joy in Medicine that brought us all to this field,” said Elizabeth Harry, MD, UCHealth’s senior medical director of well-being.

“We are excited to continue our journey in this space with all of our care team partners as we navigate the ever-changing pressure health care faces.”

Elizabeth Harry, MD, UCHealth senior medical director of well-being

nized that we needed to address the system-based drivers of burnout as well as promote the individual resilience of physicians,” said Robert Lam, MD, director of physician wellness and an emergency medicine physician. “We wanted to make sure we were working to measure the root causes of the burnout epidemic as we continually strive to make the workplace better for our medical staff. This recognition highlights that efforts are aligned with the best practices of creating an optimal working environment to promote the joy of practicing medicine.”

In a news release about the awards, the AMA cited a national study that examined the experiences of physicians and other health care workers who worked in health care systems during the COVID-19 pandemic. The study’s authors found that 38 percent

Robert Lam, MD, UCHealth southern Colorado director of physician wellness

self-reported experiencing anxiety or depression, while 43 percent suffered from work overload and 49 percent had burnout.

“The COVID-19 pandemic has placed extraordinary stress on physicians and other health care professionals,” said AMA President Gerald E. Harmon, MD, in the release. “While it is always important for health systems to focus on the well-being of care teams, the imperative is greater than ever as acute stress from combatting the COVID-19 pandemic has contributed to higher rates of work overload, anxiety and depression. The health systems we recognize are true leaders in promoting an organizational response that makes a difference in the lives of the health care workforce.”

View all recipients here: https://tinyurl.com/ama-joy-in-medicine ■

CMS is pleased to announce Sharkey, Howes & Javer as our newest Partner in Medicine.

Sharkey, Howes & Javer is one of Denver’s oldest wealth management firms, offering comprehensive financial planning and investment strategies to help you thrive at any stage of life. Our team of Certified Financial Planners can help you create a personal financial plan geared towards your specific goals.

Benefit to CMS members: Mention CMS to recieve a waiver of the initial financial planning fee (value starting at $2,000+ depending on complexity of plan) Email: info@shwj.com | Phone: 303.639.5100 www.shwj.com

“When we created the Physician Wellness Program in UCHealth’s southern Colorado region, we recog-

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

F E A T U R E

Improving options for effective pain treatment FIRST-OF-ITS-KIND LAW MANDATES COVERAGE AND REMOVES PRIOR AUTHORIZATION FOR ALTERNATIVES TO OPIOIDS (ALTOS) Kate Alfano, CMS Director of Communications and Marketing “The COVID-19 pandemic had an unprecedented impact on substance use and on access to treatment and support options. Social isolation, the pandemic-induced recession, and changes to care delivery brought about by shut-downs contributed to the most significant one-year increase in drug overdose deaths in recent memory.”

This bleak statement from the Colorado Health Institute provides context to some stark facts.

•

Opioid overdoses rose by 54 percent in 2020, accounting for nearly two in three overdose deaths in Colorado.

•

1,477 Coloradans died of drug overdoses in 2020 – the most overdose deaths ever recorded in the state, and a 38 percent increase from 2019.

•

Fentanyl overdoses became m o re c o m m o n , m o re t h a n doubling between 2019 and 2020 and increasing by 10 times since 2016.

•

E xis ting inequities and the COVID -19 pandemic exacerbated the increase in overdose deaths in communities of color.

•

O p i o i d p re s c r i p t i o n s h a ve decreased by 4 4.4 percent nationwide between 2011 and 2020, including a 6.9 percent decrease from 2019 and 2020.

In essence, as the world turned its attention to the novel COVID-19 pandemic in 2020, the not-novel opioid epidemic worsened. In response, and at the urging of the Colorado Medical Society, Colorado Consortium for Prescription Drug Abuse Prevention (Consortium), Colorado Pain Society (CPS) and others, the 2021 Colorado General Assembly passed legislation to provide help to patients struggling with pain and the physicians who help them manage it, which evidence suggests will help prevent patients from developing a substance use disorder.

Measures in House Bill 21-1276 – sponsored by Rep. Chris Kennedy, Rep. Leslie Herod, Sen. Brittany Pettersen and Sen. Kevin Priola – that CMS strongly supports increase access to alternatives to opioids (ALTOs) by requiring health plans to provide affordable coverage for nonpharmacological pain treatment (six physical therapy, occupational therapy, chiropractic, and acupuncture visits with a cost-sharing amount no more than for a primary care visit) and requiring health plans to provide coverage for at least one atypical opioid at the lowest cost-sharing tier of the plan’s formulary with no requirement for step therapy or prior authorization. In addition, a plan cannot require step therapy for any additional atypical opioids.

CMS expressed strong opposition to provisions in the bill that will continue indefinitely a limit on prescribing opioids to a seven-day supply (with existing exceptions fought for by CMS), direct boards of prescribers to set limits on benzodiazepine prescriptions (with exceptions for which CMS fought), and require prescribers to query the Prescription Drug Monitoring Program each time before prescribing an opioid or a benzodiazepine (again, with exceptions).

“This law is the first of its kind in the country to limit cumbersome and time-consuming prior authorizations, and to make it easier and more affordable to access ALTOs,” said Jonathan Clapp, MD, CPS president and chair of the CMS Substance Use Disorder Committee. “Eliminating prior authorizations in any capacity is a huge victory for physicians who too often feel powerless against payers and their tactics to dictate patient care.”

Clapp encourages physicians to consider using ALTOs first and to take advantage of continuing medical education provided by the Consor tium and accredited

by CMS. View educational oppor tunities on the Consor tium’s website, www.corxconsortium.org.

CMS will continue to advocate for ways to make it easier for members to treat pain and substance use disorder in patients. ■

STATE AUDITOR RECOMMENDS IMPROVEMENTS TO PDMP, USE BY PHYSICIANS Colorado’s Prescription Drug Monitoring Program (PDMP) was created in 2008 to electronically track and monitor prescriptions for controlled substances to help prevent their misuse, allow prescribers to review patients’ prescription histories, and help law enforcement and regulatory boards investigate potentially harmful prescribers.

A March 2021 report by State Auditor Kerri L. Hunter, CPA, identified potential areas to improve the effectiveness of the PDMP: • • • •

Require prescribers to query the PDMP before prescribing each opioid (achieved by HB 21-1276).

Enforce the requirements that prescribers and pharmacists register to use and query the PDMP. Enforce statutory limits on opioid prescriptions and develop enforcement mechanisms for noncompliant prescribers.

Ensure pharmacies comply with rules to submit data on prescriptions in a timely fashion.

While outside the state audit, for years CMS has strongly recommended improving interoperability with electronic health records (EHRs) and the PDMP, which would aid query functionality for physicians and their practices and reduce the administrative burden for compliance.

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F E ATU R E LE G I S L ATI V E

U P DATE

Colorado Option update:

CMS is on it

Rulemaking nearly complete

CMS advocating for you

T he bot tom line

The Colorado Division of Insurance is speeding toward the Nov. 30 deadline to submit the 1332 State Innovation Waiver request to the federal government, which will outline the framework for the standardized plan for the Colorado Option, and the Jan. 1 deadline to finalize rulemaking.

The Colorado Medical Societ y has vigorously advocated for physicians and patients at all stakeholder meetings and has submitted multiple letters with written comments, including an Oct. 20 letter on the draft benefit design regulation and an Oct. 26 letter on the draft network adequacy regulation. Our comments to date have emphasized the need for evidence-based benefit design to help incentivize high-value care and control costs through additional support for prevention and chronic disease management.

CMS believes the Colorado Option should be designed to include innovative, evidence-based mechanisms to control costs and reduce health disparities so the plan drives better value in health care, increases competition, and enables broad provider participation. Physicians should not be held responsible for cost cuts in a product that may be flawed from the start.

Need a refresher?

The Colorado Option will be available starting in 2023 for Coloradans who buy health insurance on the individual and small group markets.

Revisit CMS's Colorado Option Primer

https://cms.org/uploads/HB21-1232_for-physicians.pdf ■

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

What more can COPIC do to support health care?

Gerald Zarlengo, MD, Chairman & CEO COPIC Insurance Company At COPIC, there is one question that we consistently ask ourselves – what more can we do? It’s a question that reminds us to think in new and different ways about how we live out our mission of “improving medicine in the communities we serve.” It’s also a process that starts with listening to our insureds and the challenges they are facing while being actively engaged in health care, from one-on-one conversations with a pediatrician on the Western Slope to closely following health care policy issues at the Capitol.

We know that our insureds look to us for coverage that offers value and protection, but we also know that they deserve more than just a standard insurance policy. COPIC recognizes that the ideas that emerge out of the “what more can we

do” discussions need to be shaped into support that provides meaningful benefits. The last two years have emphasized the increased complexity of medicine, the sizable demands placed on physicians, and the importance of providing trusted support to them.

The following examples highlight ways that COPIC is looking forward to offering more support and doing what we can to help the health care community.

More support with specialty-specific education While we see some similar issues across medical specialties, we know that each specialty has its own unique challenges.

A key aspect in the development of our educational resources is looking at how we provide specialty-specific knowledge.

CMS is pleased to announce Panacea Financial as our newest Partner in Medicine.

Panacea Financial is a nationwide digital bank built for doctors by doctors. Panacea provides financial services designed specifically for physicians throughout their career: from medical school, through residency or fellowship, and into practice. Panacea’s products cover the full suite of banking needs including free checking and savings accounts, PRN personal loans, student loan refinancing, and any loans you may need to start, build, or grow your practice.

Panacea Financial is a division of Primis, Member FDIC. www.panaceafinancial.com

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These efforts include analyzing and sharing data about claims trends by medical specialty, virtual meetings that bring together peer physicians for interactive discussions, podcast episodes geared toward specific specialties, and courses/ seminars informed by our faculty advisors who represent different specialties and practice settings.

More support during a lawsuit There are two key programs that we continuously highlight to insureds who are facing a lawsuit. The first is COPIC’s Care for the Caregiver® program which helps insured providers deal with the emotional stress of a lawsuit. The program pairs the provider with a specially trained “peer” practitioner who has personally gone through the legal process. These peers offer a shared perspective to address difficult feelings, and more importantly, their responsibility is to listen with a comforting sense of support. The second program is our PR/Reputation Support.

We know that a lawsuit often comes with negative media coverage and attempts to disparage a physician’s character. To address these situations, COPIC has partnered with a strategic communications firm that can help manage how to proactively address these situations and protect your reputation.

More support through legislative advocacy Some of COPIC’s work to improve medicine happens in collaboration with our colleagues at the Colorado Medical Society and Colorado Hospital Association.

COPIC believes that taking an active role in advocating on legislative issues allows the health care community to devote its resources to quality improvement and patient care. Our year-round, state-level legislative advocacy efforts center on monitoring initiatives that may impact the tort environment, change regulatory oversight, create unreasonable burdens on health care delivery, or reduce access to quality health care. Our goal is to provide our insureds a sense of assur-

ance in knowing that COPIC is keeping an eye on legislative issues so they can focus on their patients.

More support through grant funding The COPIC Medical Foundation works to improve health care outcomes through grant funding. Each year, organizations can apply for grant funding for initiatives that align with the goals of the foundation.

The focus area of our 2022 funding cycle is reducing fragmentation across care settings. The foundation is accepting applications Nov. 1, 2021 through Jan. 14, 2022. View more information and download the grant requirements and application at www.callcopic.com/aboutcopic/copic-medical-foundation. ■

All Medical Answering Service

Owned and operated by the Colorado Medical Society, and backed by history of physician ownership, MTC is uniquely focused on the needs of its clients. Serving medical professionals is all we do.

Season Two: Within Normal Limits Podcast Our podcas t , Within Normal Limits: Navigating Medical Risks, is back for its second season. Eric Zacharias, MD, COPIC’s director of medical education, continues to host the podcast and engage in interesting conversations with other physicians and exper ts about timely issues. Each episode is 20 -30 minutes and focuses on a topic informed by COPIC’s experience and trends we are seeing in health care. Some of the episode topics featured this season include:

•

Informed refusal with patients who disagree with care recommendations

•

Handling unsolicited tests

•

Terminating a patient relationship

Within Normal Limits is available on popular platforms such as Apple Podcasts, Google Podcasts, Spotify, and Amazon. You can also go to www.callcopic.com/ wnlpodcast for more information.

MTC’s management team has over 50 years of combined experience in medical answering services. Our operators are professional, friendly, and expertly trained to handle any client situation. We offer a full range of customizable services to ensure your patients enjoy personal, timely communication while you stay on top of your busy schedule.

MTC is committed to providing the highest level of customer service.

MTC is a member of the Association of TeleServices Int’l (ASTI) and a proud recipient of the prestigious ASTI Award of Excellence for service quality. MTC continually upgrades its technology and our servers and your data are kept in a secured state-of-the art data center with redundant internet and power supply.

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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 R E F LE C TI O N S

It takes a village Jeremy Ansah-Twum

Jeremy Ansah-Twum is a third-year medical student at the University of Colorado School of Medicine. He is an African American of Ghanian descent; he was born in Los Angeles but has spent most of his life in Colorado.

Jeremy attended college at the Colorado School of Mines and majored in Petroleum Engineering with a minor in Biomedical Engineering. He has always been heavily involved in football, track and other sports, as well as playing the guitar. Raised by his parents, who are both ministers, he also developed a strong Christian faith which has fueled his burning desire to help others, now through medicine. While he is still keeping an open mind, he is interested in orthopedic surgery and sports medicine as possible career choices.

Not long ago, I admitted a new patient to the adolescent inpatient psychiatric unit. LS was admitted following a suicide attempt, and we watched her improve steadily over her nine- day hospital course. When she initially arrived, she was guarded and unwilling to cooperate.

She had been hospitalized before – in fact, more than 20 times – for chronic suicidal ideation, and was branded with the diagnosis of borderline personality disorder in addition to major depressive disorder and unspecified anxiety. LS felt that nothing would come from this hospitalization besides a premature discharge, because that is all she had experienced in the past. Her hopelessness, coupled with an extensive history of self-harming behaviors, yielded a rather tumultuous start to her admission.

It was very rewarding to see this patient gradually open up during her time on the unit and really commit to her treatment regimen. Each day we engaged in intensive therapy work, including cognitive behavioral therapy, safety planning and mindfulness training through guided meditation practices. LS showed the strongest response to a form of therapy centered around patient values, known as acceptance and commitment therapy or ACT. This treatment allowed her to identify the values, people and things that she held most important. She learned to distinguish the thoughts, emotions and actions that would move her further away from those values from the behaviors that would drive her closer. By the end of her stay, LS had completely bought in to working actively toward getting better and making positive changes in her life.

She garnered a heightened awareness of how her thoughts, emotions and actions were linked, and how they could be channeled to coincide with her values.

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The challenge came with finding a place to discharge this young patient. She had been staying at a residential facility, but we learned that she would no longer be welcome there due to her erratic behavior. Her family was a primary source of conflict in her life and was unable to provide the stable home environment that she so desperately needed. They had ver y limited resources and had already abandoned her. Her mom never returned the hospital staff’s calls, and no family member ever contacted us on her behalf. LS had no resources and no familial support, and she now was effectively homeless. A multidisciplinary team – yes, a true village – of medical personnel, social workers and a case worker, worked together to help her navigate her difficult situation, reaching out to other residential programs and special needs supporting organizations.

One new housing opportunity was identified, and I was excited to share this prospect with her. She seemed thrilled by this new housing possibility, by the opportunity to get her life back on track. But then, this residential program never called back. They had never even evaluated her for admission. Instead, they superficially determined that she would not be a good fit, and they denied her acceptance. The only option left was temporary housing at a hotel for one night, while the team continued to search for openings. Upon informing LS of these latest developments, I could see the disappointment in her eyes. She knew that she would likely end up in a homeless shelter, where she would easily fall into her old habits of self-harming, where suicidal thoughts might return, and where her thoughts, emotions and actions would again move her further away from her values.

It was hard for me to witness how this patient’s low socioeconomic status, her lack of family support, and her complex psychiatric history were hindering her ability to receive ongoing care following discharge. I was afraid she would never be able to utilize the coping skills we had worked so hard to develop. The endless lectures and nonstop reminders about the social determinants of health sprinkled throughout my medical school curriculum suddenly had no bearing and could not soften the blow of now witnessing the human impact firsthand. LS confided in me how much she feared being left alone in a hotel room while waiting to find out if she would be homeless. We had made so much progress throughout her admission, and now my sense of accomplishment and optimism had been challenged. All I could do was believe in the work we had done, and trust that she would stay committed, strong and safe. I knew I had to stay hopeful.

In retrospect, I take solace in having seen the vigorous efforts of this patient’s case worker, social worker and the team of health care providers who fought to find solutions to her dynamic struggles. As a medical student, I have seen how our health care system often fails patients with unfavorable social determinants, especially those with complex mental illnesses, due to the intricacy of their unique circumstances. But now, I am reminded how we must also take notice of the committed individuals who stand within those gaps. In caring for LS, I saw firsthand the power of teams of health care professionals cooperating and was encouraged by the tremendous display of genuine care for this patient, no matter the outcome of her housing dilemma. ■

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

Imposter medicine Michael Dea 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.

Michael Dea is a second-year medical student aspiring to become a surgeon. Michael was born in San Francisco, Calif., but spent the majority of his life living in various countries in Africa including Botswana, South Africa and Uganda. He moved back to Southern California where he completed his bachelor’s and master’s degrees.

Although he does not consider any one place his home, he loves living in the beautiful state of Colorado! This piece is dedicated to his parents, Monica and Randall Dea, for their continued love and support.

Scalpels are sharp. They’re precise.

They’re nimble. They help save lives.

They’re reliable servants to our health and prosperity. They were forged into this world with a clear mission. They simply use their sharp edges, their symmetry and their levity to do their best and engage with the moment as it comes. They accept their calling with grace, humility and precision. They don’t doubt themselves or wake up with the fear of failing like I do.

They are not afraid of blood, old age or cancer. They are tools from the world that break into the vast and complex worlds of our patients’ bodies, an extra finger on an already trained hand to carve out the threat of disease. Death can’t hide from them. I respect scalpels, the work one must put in to even hold it, the years of study and practice, and their representation of how far we’ve come in medicine. At the same time, I am constantly reminded that they are only a miniscule part of the equation. In the spirit of that old adage, a tool is only as good as the surgeon wielding it.

I recall a time when a trained surgeon used this tool to make that difference in someone else’s life. During a surgical service at the International Hospital of Kampala, I met John, a young man from

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South Sudan who was medevacked to us with an infected gunshot wound to the abdomen. That’s when the utter reality of this profession struck me like a lightning bolt. The questions I asked myself revealed my insecurities, as they became more grounded in self-doubt and fear, instead of just mere medical curiosity. Questions like: when the time comes, would I be reliable, like a scalpel is, to make confident and quick decisions?

Could I ever carry the responsibility of helping save someone like John, and put aside my self-doubt and vulnerability?

Witnessing the attending physician interact with John humbled me. It reminded me that every decision I would make as a doctor could heavily impact someone else’s life. It lit a fire within my chest to become the best physician that I can be, which first means being more confident in myself and removing my doubt.

This inspiration and magic of medicine was immediately conflicted when I started medical school, where I was greeted by a mountain of challenging emotions. This included my old friend self-doubt, and a new friend, imposter syndrome. My first days of school as a first year were plagued with thoughts and feelings of not being good enough. Would I be able to

get through these next four years without failing? Would I be able to perform high enough on board exams to be competitive for residency applications? I allowed these haunting questions to infiltrate my mind, like a parasite making its way into the human body to wreak havoc.

Whereas I initially envisioned a hands-on and humanitarian approach to my learning, I was greeted with the prospect of having to spend most of my time at home in front of a Zoom chat room on my computer due to the pandemic. It seemed to me like the big picture was gone, or at least missing, while we memorized details like the Krebs Cycle. In my mind, patient care was put in the backseat, the reasons why I decided to go to medical school became clouded, as grades suddenly became the most important aspect. The old saying, “fake it till you make it” never felt more true.

Here’s what I’ve come to realize: We will never learn everything in medicine, and who wants to be perfect anyway? And it’s okay to feel like an imposter. It offers me humility; I acknowledge my shortcomings and that fear of not being good enough sharpens me, like a scalpel, to tailor my learning to my weak points, while building

my strengths. In lecture, I push myself out of my comfort zone and ask those seemingly foolish questions despite the embarrassment that I imagine I might feel.

I’m learning to become comfortable being uncomfortable because ultimately, that’s how I will grow as a competent physician, but also as a human being, friend, brother, son and one day, father.

The path I’m on isn’t smooth or straight.

It’s not easy or short but struggling with something is the best way to learn. Last summer, as I rounded on patients at a local hospital in Nairobi, Kenya, the attending asked me what I thought should be done with a patient’s gangrene diabetic foot.

I stumbled over my words, awkwardly finding a way to find a way to answer.

He then turned to another student who answered as if he rehearsed the night before. His quick and concise response made me feel small, like I didn’t belong in that room – perhaps even in this field.

It's only by being honest with our imperfections and finding time to understand them and reflect on them are we able to overcome doubt. The point is that the moment you stop comparing yourself to others is the moment you can become true to yourself. Imposter syndrome will never really go away, but our ability to cope with it will increase. Though this may take a lifetime to accomplish, I will take each day at a time.

Relieving a patient toward the road of recovery is a notion as old as time, and in moments of doubt and fear through the years of study, I can remind myself that at its core, medicine is about making patients feel safe during their most vulnerable states. To be true to them means being true to myself. I may not be the “smartest” doctor, but I won’t let this take away my empathy, or my ability to connect with my patients. In this profession of lifelong learning, the daily

practice of empathy in pursuit of holistic, greater, more rewarding work has to be at the core of my pursuit as an aspiring physician.

Last week, I used my 11 blade and practiced on my suture kit, the way my future self might perform an appendectomy, breathing in deeply to keep my hand steady, doing everything in my power to make one straight line across. A scalpel is reliable and consistent. It doesn’t think for itself or struggle with the burden of emotion and self-doubt. It doesn’t act differently; it only does what we want it to do. But perhaps that’s a quality not seen in humans. In contrast, I am constantly changing and growing in my medical training. The rollercoaster of emotions has not ended…but until then, I’ll enjoy the ride. It’s comforting to know that my confidence, too, can be built and that maybe one day, be worthy enough to wield a scalpel. ■

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D E PA R TM E NT S PA R TN E R

I N

M E D I C I N E

S P OTLI G HT

Heading toward 65 WHAT PHYSICIANS NEED TO KNOW ABOUT MEDICARE ENROLLMENT

By Mary Jo Heins, independent Medicare insurance agent and former medical practice manager Physicians are Medicare insiders when it comes to the workings of Medicare billing, coding and coverages. All practice staff want to become well-versed in Medicare idiosyncrasies via education and research, not billing denials.

1 Size of the employer group If an individual is on an employer group health insurance plan with 19 or fewer employees on the plan, Medicare is primary and the employer plan is secondary.

Likewise, being educated regarding Medicare enrollment will save us from denials of coverage. As I’ve guided hundreds of people on their Medicare journey, I’ve found several recurring Medicare idiosyncrasies to be central to the conversation with physicians and other high-income individuals, as well as billing departments.

 Relevant link: https://tinyurl.com/2v4etbhr Let’s flesh this out. A 65-year-old sole practitioner (only six people on the health insurance plan) could have their health insurance carrier say “Due to the size of your practice, we are secondary. Medicare is primary. Oh, you don’t have Medicare? Well then, we are secondary to you as a self-pay.” This is the letter of the law, though I do not know of specific instances where insurance carriers have taken this hard line. In any case, why risk the possibility? Also, Medicare could impose a 10 percent late enrollment penalty.

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2 RMAA (income-related monthly adjustment amount) – Medicare premiums vary by income Medicare Part B and Part D premiums are tied to your adjusted gross income (AGI).

It is a two-year look back on AGI, which is line 11 of your 1040 income tax return. AGI includes wages, capital gains and rental income and is significantly higher than taxable income.

Every November, Social Security sends notification of the new year’s premium based on the AGI from your income tax return two years prior.  Relevant links: https://tinyurl.com/yxr76tbs https://tinyurl.com/yuwzuf5z What does this look for high-income individuals? If your AGI for 2019 was more than $500,000 on an individual return or more than $750,000 on a joint return, your Part B premium would be $504.90 per month. This may be lower than what you are paying for the health insurance premium through your practice if your expenses are allocated against your draw from the practice.

The kicker is Part D, Rx coverage. The Part D IRMAA for the individual referenced above is $77.10 per month. So, in addition to the Part D insurance premium, which may be only $15-$20 per month, you pay Medicare $77.10, bringing your total Part D “premium” payment to roughly $100 per month.

For individuals on no chronic medications or a few generics, this premium price tag is disconcerting and calls for discussion of alternative strategies.

3 Enrolling in Medicare – age 65 v. when employment ends Medicare spells out three enrollment periods to enter Medicare:

•

Initial Enrollment Period (IEP) – seven months around your 65th birthday

•

Special Enrollment Period (SEP) – when your employer health insurance ends

•

General Enrollment Period (1/1 – 3/31 with an effective date of 7/1)

I also include two others:

•

•

IEP when drawing Social Security retirement benefits (you get your enrollment /card automatically and must actively DECLINE if appropriate for your circumstance).

24 months following receipt of Social Securit y disabilit y benef its (thus accounting for individuals younger than 65 being on Medicare. Timeframe is shorter for some medical conditions).

 Relevant link: https://tinyurl.com/m9y6y8wm FAQ – Do you have to enroll in Medicare at age 65? NO. Presently, more people are continuing their employer coverage and entering Medicare later via a SEP. Conversely, if an employee has a chronic medical condition, is on an employer’s high-deductible health plan and is experiencing significant out-ofpocket costs, leaving their employer plan and moving to Medicare while still employed may lower their total out-ofpocket expenses.

4 COBRA Medicare does not view COBRA as employer health insurance; thus it does not qualif y for a Special Enrollment Period. You can be misinformed regarding COBRA when it comes to dependents and their ability to opt into COBRA independent of you as the retiring employee.

For example, if you are 67 and your spouse is 64 and not yet eligible for Medicare, you should enroll in Medicare via a

Special Enrollment Period. Your younger spouse may obtain health insurance coverage by: 1. Opting into COBRA coverage from your employer, 2. An individual health insurance plan or, 3. If working, their own employer’s health insurance coverage.

If you mistakenly choose COBRA coverage and wait to enter Medicare when your spouse turns 65, your only valid enrollment period will be the General Enrollment Period, delaying your effective date until July 1 and incurring a 10 percent penalty.

Mary Jo Heins is an Independent Medicare Insurance Agent and former medical practice manager. For 10 years, she has assisted individuals in understanding and enrolling in all aspects of Medicare. ■

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

Flying kites of hope: A call to action from an Afghan American Medical Student Jessica Saifee

Jessica Saifee is a third-year medical student at the University of Colorado School of Medicine. She graduated from Wellesley College in 2016 with a degree in Neuroscience and South Asian studies. She is currently in the global health track at her medical school, where she focuses her interests and research on refugee health.

My name is Jessica Farangaiz Saifee. I am a third-year medical student at the University of Colorado School of Medicine, and I’m the daughter of an Afghan refugee. My family fled Afghanistan when the Soviet Union first invaded in the 1980s. First, I have to say that I represent one voice of the many displaced children of Afghanistan.

My medical school advisor once told me that grief is the loss of an imagined future. Over the last two months, we have witnessed that loss. Twenty years of progress shattered in 10 days. The future of Afghan women and children unknown.

My motherland sent into a state of panic.

Sights of my people clutching onto planes to escape the Taliban. We also witnessed how the nations of the world closed their eyes to the situation and left us abandoned.

My people have felt grief as we watched our beloved family members relive their trauma. Growing up, I heard stories from my family members recounting the trauma, but I also fondly remember the stories of the motherland. My father would often tell me stories about flying kites or picking pomegranates from the trees. He would recite poems for me at a moment’s notice, sharing pieces of our culture. I could only experience these fragments of my culture with my family in the United States. Living here while my heart was in Afghanistan. A deep longing to step foot on the motherland.

I am a medical student because of my family’s sacrifices. I am safe. I have the privilege of studying medicine and advocating for my community. During my third year, I have had the honor of caring for immigrants and refugees at the Denver Health Refugee Clinic. I am humbled that I can participate in their care. Soon, when I graduate, I will take an oath to serve and protect people, to support and empower those who are vulnerable and to do no harm. I ask that everyone, from my fellow medical students to world leaders, stand with me now to do no harm and to help the Afghan people.

Now, all we can do is sign petitions.

Protest. Scream. Donate. Tell people to pay attention to what is happening. We feel helpless. Look up the word “diaspora.” That is who we are. As children of the diaspora, we feel survivor’s guilt. This could have happened to us.

When I need a light, a reason for hope, I remember what many Afghans were told as children: We were never a defeated people. ■

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F E ATU R E F I N A L

WO R D

Re-establishing patient trust Kelly McAleese, MD

You trusted us before; we are Reflecting over the last 18 months, these have been hard times for all of us. Medical students were recruited to serve as fullfledged health care providers overnight.

Anesthesiologists saw nurse practitioners being offered their jobs. We saw our country become divided on multiple issues. Physicians have been stewards for our patients’ care, and we have sacrificed so much during this time to maintain this strong bond.

However, times have changed in how patients see the medical community.

Our country has witnessed patients’ decreased confidence in the health care system as a whole, and we have subsequently seen the doctor-patient relationship deteriorate. In this age of widespread

access to information, patients may now rely on “Dr. Google,” local TV news, or a friend over the advice of their physician.

In this way, patients are re-interpreting the doctor-patient relationship.

While patients previously depended on us for education on a particular topic, we may now spend much of the patient visit debating with them and re-educating them. We even see our most agreeable patients opt for non-immunization with little scientific evidence to back up their beliefs. Patients aren’t as dependent on us and feel they don’t need us as much as they once did. We have sunk into the background and are lower on the list of trusted people in their lives. We can’t just blame political division and the prepon-

here for you now; and we will be there for you in the future. derance of conflicting digital data. What are the larger reasons for this change?

There are more barriers between physicians and our patients than ever before.

We have more demands with less time, and we are expected to accomplish them within an expanded workday. The holding of a patient’s hand, the comforting touch on the shoulder, or sitting down to lend a listening empathetic ear have been replaced by social distancing, telemedicine and frenetic EHR documenting demands.

We know that our patients’ lives have also been disrupted. They have been purposeful targets of false information.

They have lost loved ones and have not been able to grieve appropriately.

They have become socially isolated from contact with grandchildren and other family members.

We have an opportunity now as the pandemic becomes endemic. Mark this point in time where the past 18 months end and our future responsibility begins.

Physicians will need to recapture the essence of the doctor-patient relationship and regain trust and confidence. We need to re-establish this bond when we are able to, by getting back to face-toface communication, offering the human touch, and taking the time to listen.

Whether it is a patient dealing with end-oflife issues or with a new diagnosis, the essence of these meetings begins with redeveloping and re-establishing “trust.”

But we physicians can only reverse this trend if we are united on the same front and if we maintain the same positive message for our patients. “You trusted us before; we are here for you now; and we will be there for you in the future.” ■

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