Vol. 109, Issue 3, 2020
Some leading physicians discuss Georgia’s response to the pandemic
MAG’s president weighs in on social justice & equality The MAG Medical Reserve Corps’ ‘real-life heroes’ How COVID-19 has affected the Georgia Composite Medical Board When and why physicians should apologize
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TABLE OF CONTENTS VOLUME 109, ISSUE 3
8
IN EVERY ISSUE 3 President’s Message
FEATURES 8
MAG members weigh in on the COVID-19 pandemic from A to Z
17
The MAG Medical Reserves Corps credited with saving lives during pandemic
4 Editor’s Message 6 CEO’s Message 14 Medical Ethics 16 GCMB Update: The effects of COVID-19 on the Georgia Composite Medical Board
18 & 24 Health Care Heroes
20 Legal: Sorry seems to be the hardest word 22 Patient Safety 28 County, Member & Specialty News 30 Perspective
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PRESIDENT’S MESSAGE
Righting some wrongs, together Andrew Reisman, M.D.
W
docreisman@gmail.com
atching the images of George Floyd’s death at the hands of a police officer on television in May was nothing less than horrific and sickening and outrageous.
And in July, MAG formed a task force that Dr. Perry-Gilkes chairs that will promote diversity on multiple levels and recommend how to address health care disparities in Georgia’s health care system in permanent and sustainable ways.
And while we shouldn’t paint the police (or anybody else) with any broad brushes – as I appreciate what the vast majority of them do to protect me and my family every day – this man’s senseless death has required everyone to be open-minded and listen and consider the African American and minority experience of living in the United States. It has also forced us, as physicians, to look in the mirror and ask how we can make a difference.
This will, of course be a collaborative process – but some of the actions that I believe that we can take to bring about the change that is needed include…
The first action that the Medical Association of Georgia (MAG) took was to issue a strongly-worded joint statement with the Georgia State Medical Association (which is the leading voice for African American physicians in the state) that stressed that “we will not tolerate inequality, injustice, or racism.”
• Increasing Medicaid payments to ensure that low-income patients have access to the care they need while the physicians who deliver the care do not have to lose money in the process • Allocating more resources to educate Georgians about the crucial need for primary and preventive care
The statement emphasizes that…
• Doing a better job of ensuring that our patients understand and follow physicians’ instructions when it comes to their health care, medications, and appointments – and taking the extra time that is needed to address any language or cultural barriers
MAG and GSMA condemn violence and systemic oppression and will not tolerate inequality, injustice, or racism. MAG and GSMA are greatly saddened by George Floyd’s senseless death. MAG and GSMA condemn senseless acts of violence and systemic oppression, and MAG nor GSMA will tolerate inequality, injustice, or racism.
• Encouraging physicians and allied health care professionals to become more familiar with the obstacles and other social determinants of health that low-income and minority patients face on a day-to-day basis and to formulate strategies to help them overcome those barriers
Given the demonstrable links between violence and racism and poverty and patient health, MAG and GSMA will continue to advocate for health equity for every Georgian – and MAG and GSMA will continue to take steps to mitigate any disparities in the accessibility of medical care, especially when it comes to our most vulnerable or historically oppressed populations.
By the time you read these words, I will be one of MAG’s past presidents. But I am confident that Dr. Perry-Gilkes and the members of the new task force that she is chairing will develop some thoughtful and credible recommendations for ways that MAG can help effect meaningful change within Georgia’s health care system. The task force will address health disparities, cultural competency, and the social determinants of health to “enhance patient care and the health of the public.”
As they have throughout the COVID-19 pandemic, MAG and GSMA and their member physicians will remain focused on ensuring that every Georgian is safe and secure and has access to the medical care they need. MAG and GSMA will also continue to promote diversity within their organizations and our society at large. Shortly after we issued this statement, MAG hosted a virtual ‘Race, Equality & Justice Town Hall’ for MAG member physicians. The goal of this “conversation” – which was moderated by MAG President-elect Lisa Perry-Gilkes, M.D., F.A.C.S., who became the first African American woman to serve as MAG’s president in October – was to listen and discuss ways for MAG to begin to help eliminate societal inequality, injustice, and racism.
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It would be disingenuous to suggest that this challenge is anything less than considerable, but I have seen firsthand what physicians can achieve when they are determined and united – I have seen what we can achieve, together. In addition to Dr. Perry-Gilkes, the MAG Diversity Task Force includes Carl Czuboka, M.D., Emile Pinera, M.D., Fred Flandry, M.D., Julianne Birt, M.D., Keisha Callins, M.D., and Lattisha Bilbrew, M.D. Contact Christiana Craddock at ccraddock@mag.org for details on the MAG Task Force on Diversity. Go to www.gsmanet.org for more information on GSMA.
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EDITOR’S MESSAGE
The Medical Association of Georgia 1849 The Exchange, Suite 200 Atlanta, Georgia 30339 800.282.0224 www.mag.org MAG’s Mission To enhance patient care and the health of the public by advancing the art and science of medicine and by representing physicians and patients in the policy-making process. Editor Stanley W. Sherman, M.D. Executive Director Donald J. Palmisano Jr. Publisher PubMan, Inc. Richard Goldman, rgoldman@pubman.net 770.855.3608 Editorial Board Sara Acree, M.D. John S. Antalis, M.D. Mark G. Hanly, M.D. John S. Harvey, M.D. Frank McDonald, M.D. Mark E. Murphy, M.D. Barry D. Silverman, M.D. Michael Zoller, M.D. MAG Executive Committee Andrew B. Reisman, M.D., President Lisa Perry-Gilkes, M.D., President-elect Rutledge Forney, M.D., Immediate Past President Thekkepat G. Sekhar, M.D., First Vice President James L. Smith Jr., M.D., Second Vice President Frederick C. Flandry, M.D., Chair, Board of Directors Steven M. Huffman, M.D., Vice Chair, Board of Directors Edmund R. Donoghue Jr., M.D., Speaker James W. Barber, M.D., Vice Speaker Debi D. Dalton, M.D., Secretary Thomas Emerson, M.D., Treasurer S. William Clark III, M.D., Chair, AMA Delegation W. Scott Bohlke, M.D., Chair, Council on Legislation Advertising PubMan, Inc. Brian Botkin, bbotkin@pubman.net 678.643.7250 Subscriptions Members $40 per year or non-members $60 per year. Foreign $200 per year (U.S. currency only). The Journal of the Medical Association of Georgia (ISSN 0025-7028) is the quarterly journal of the Medical Association of Georgia, 1849 The Exchange, Suite 200, Atlanta, Georgia 30339. Periodicals postage paid at Atlanta, Georgia, and additional mailing offices. The articles published in the Journal of the Medical Association of Georgia represent the opinions of the authors and do not necessarily reflect the official policy of the Medical Association of Georgia. Publication of an advertisement is not to be considered an endorsement or approval by MAG of the product or service involved. Postmaster Send address changes to the Journal of the Medical Association of Georgia,1849 The Exchange, Suite 200, Atlanta, Georgia 30339. Established in 1911, the Journal of the Medical Association of Georgia is owned and published by the Medical Association of Georgia. © 2017.
The COVID-19 pandemic
A
Stanley W. Sherman, M.D.
s I began to write my editorial, I had just read an article that noted that more than 6,700 people in Georgia have died from COVID-19, including two physicians. One was a 74-year-old family doctor who had helped his old and frail cancer patient who had the virus out to his car in early March, before the widespread use of PPE. Should no good deed go unpunished? The article also reported the death of 98 health care workers in Georgia. Clearly our commitment to our profession and to help our fellow man has not bestowed immunity on us to prevent infection and death – and yet you heroes do your job every day. It certainly makes it easy to devote this issue of the Journal to you.
Spending more time at home during the quarantine, I went through some old files and found that at a 2005 MAG meeting we were given a booklet entitled ‘Personal Preparedness Planning Kit For Georgia’s Healthcare Worker’” from the Georgia Department of Human Resources. This kit – developed after September 11, 2001 – primarily dealt with bioterrorism, but it also addressed a pandemic flu plan. As best as I can tell, the only difference in the two is that bioterrorism is intentionally caused while a pandemic is not. The suspect pandemic organisms were influenzas then; now if you go to the CDC websites noted in the kit, you will be directed to the COVID-19 website. Interestingly, a very valuable section in the booklet was on coping with the emotional effects of a disaster – for us, our families, friends, and patients. The booklet listed such emotional responses as trouble concentrating, forgetfulness, numbness, depression, anxiety, grief, anger, and guilt. The physical symptoms listed were nausea, rapid heart rate, headaches, trouble sleeping or nightmares, and the increased use of alcohol, tobacco, and drugs. It encourages people to talk about their feelings, find healthy ways to relax, take frequent breaks, avoid working long shifts if possible, and seek professional counseling if necessary. It also discusses tips for helping children cope, including encouraging them to talk about the pandemic, allowing them to feel upset or cry, letting them know that their feelings are normal, reassuring them that it is not their fault, and protecting them from repeated exposure to the events they may see on television. Unfortunately, patients are beginning to experience what has been described as “quarantine fatigue.” Instead of complying with the CDC guidelines, they forget masks or remove them in the physician’s office, and they seek more social contact despite the increasing number of cases. CDC’s recommendations for dealing with this are the following: advise only going to trusted Internet sites such as CDC. gov, avoiding constant exposure to the news, focusing on diet , exercise and sleep, and staying connected with loved ones – and when doing so, keeping each other accountable in maintaining infection precautions. Personally, an effective vaccine cannot come soon enough! Our feature article is a Q & A with some fellow members who represent those of us on the front line, those consulting, and those in administration during this pandemic. I hope you will appreciate both the differences and agreements in their views as much as I did. Our ethics article challenges us to deal our patient’s
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emotional health as well as their physical health during this crisis, and in so doing hopefully preventing suicides. Dr. Steven Kitchen chronicles how Phoebe Health system and its physicians dealt with the incredible demands of COVID-19 in a severely infected area. Dr. John Harvey recounts the life-saving activities performed by the MAG Medical Reserve Corps deployed during the peak of the pandemic. Many thanks to him and all of our volunteers. Dr. John Antalis updates us on GCMB’s activities, including those brought on by the pandemic. MagMutual educates us on the liability changes during this crisis. I want to thank MagMutual for their many years of supporting both our Journal and educating our members.Our legal article by Daniel Huff, Esq. covers the importance of an apology in preventing liability claims. MAG President Dr.
Andrew Reisman reports our efforts to encourage diversity and help resolve disparities in health care in Georgia. MAG CEO Donald J. Palmisano Jr. discusses our transition from our endorsement of MagMutual to the new MAG Insurance Agency, which we hope you will find both helpful and economically advantageous to join for your medical malpractice insurance needs. We would also like to welcome Dr. Michelle Au to the Journal, whose many talents include being a fabulous cartoonist. In these trying times we hope her contribution will leave a smile on your face, as it did mine. Please stay well and stay safe. It was a pleasure to be with you virtually at the House of Delegates meeting and I will hopefully see you in person at future meetings!
MAG reminding members to encourage their patients to use Georgia Drug Card to save up to 80 percent on prescriptions The Medical Association of Georgia (MAG) is reminding its members that any patient who has a high-deductible health insurance plan or doesn’t have prescription drug coverage or takes prescription drugs that aren’t covered by their health insurance plan can use the Georgia Drug Card to obtain savings of up to 80 percent off the retail price for brand and generic FDA-approved medications at most retail pharmacies – including every major pharmacy chain. Patients can simply present a card that they can print for free at GeorgiaDrugCard.com to their pharmacist to get the discount.
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Medical practices can order free custom Georgia Drug Cards for their practice by contacting Joy McAdams at jmcadams@ georgiadrugcard.com or 877.233.2146. The Children’s Miracle Network receives a donation every time a patient uses the Georgia Drug Card. Go to www.GeorgiaDrugCard.com for more details.
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CEO’S MESSAGE
Introducing the best med-mal solution for physicians in Georgia Donald J. Palmisano Jr. dpalmisano@mag.org
B
ack in the 1980’s, the medical profession in Georgia came face-to-face with a malpractice insurance crisis. Given a shrinking pool of insurers and rising premiums, the Medical Association of Georgia took an active role in founding the professional liability insurer that is known as MagMutual today.
MAG and MagMutual have been great allies since the beginning. But on October 1, MAG’s marketing agreement with MagMutual came to an end – after it became evident that the two organizations were on different strategic paths. I would like to thank everybody at MagMutual, and I would like to wish them well. The trial attorneys have, unfortunately and not unexpectedly, been busy – and another potentially long-term med-mal crisis is in the works. Bolstered by court decisions that neutralized some of the tort reform victories we achieved in 2005, this includes the return of multi-million-dollar “jackpot” verdicts.
·
Best) and AA+ (Standard & Poor’s) Has a pure consent to settle provision that gives physicians the right to refuse to settle a claim
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claims have been closed without payment
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Insurance Agency, LLC
Rather than hope for the best, MAG’s Executive Committee decided to take action and look for a medical liability insurance solution that would be designed for physicians in Georgia and aligned with MAG’s mission and values.
After a considerable amount of time and effort, I am pleased and excited to announce that MAG has collaborated with MedPro – the nation’s largest and highest-rated health care liability insurance carrier – to offer the Medical Association of Georgia Insurance Agency, LLC (MAG Insurance Agency), an industryleading medical malpractice solution. The MAG Insurance Agency’s mission is to provide physicians in Georgia with the long-term security, stability, and peace of mind they need so they can focus on their patients and running a successful practice. You should know that MedPro…
· ·
Is a Berkshire Hathaway Company Offers unsurpassed financial strength ratings of A++ (A.M.
MAG Insurance Agency isn’t going to employ creative marketing, and it’s not going to be built on shortterm savings. We believe that it will, however, deliver stability and long-term price protection – knowing that we face the prospects of a malpractice crisis that I believe could last for 10 to 20 years.
As an added benefit, MAG Insurance Agency will enable MAG to maintain its independence. By taking this strategic action, MAG will control its destiny. We will be able to focus our advocacy efforts on the issues that matter to our dues-paying members, and we will be building equity in a company that has value and that helps to ensure MAG’s financial future. Finally, I would like to emphasize that MAG’s Board of Directors has endorsed MAG Insurance Agency because they believe it’s the right thing to do and because they realize that the success of this endeavor is contingent on MAG members’ widespread participation. We can do this, but we will need to do it together. Go to www.maginsuranceagency.com to get details on the MedPro policy that’s right for you – keeping in mind that MAG members will receive a discount on their premium. Also contact Ryan Larosa at 678.303.9275 or rlarosa@mag.org with questions about MAG Insurance Agency.
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Adam Bressler, M.D.
Shamie Das, M.D.
Thomas E. Bat, M.D.
W. Scott Bohlke, M.D.
Fonda A. Mitchell, M.D.
Rob Schreiner, M.D.
John J. Marshall, M.D.
MAG members weigh in on the COVID-19 pandemic from A to Z
T
he Journal of the Medical Association of Georgia asked a diverse mix of MAG members to weigh in on the COVID-19 pandemic from a number of perspectives, including how it has affected the profession, the economic implications, the biggest challenges they have faced, the steps that their practice or system have taken to protect their patients and their staff, how much support they have (or have not) received from the state and federal government, how MAG and other advocacy organizations have assisted them, and whether the state is prepared for a “second wave.” The MAG members who were asked to participate in this process included (in alphabetical order)… Thomas E. Bat, M.D. – Family Medicine CEO, North Atlanta Primary Care, PC W. Scott Bohlke, M.D. – Family Medicine Bohler Family Practice, Statesboro Adam Bressler, M.D. – Infectious Diseases Partner, Infectious Disease Specialists of Atlanta Shamie Das, M.D. – Emergency Medicine Emory University Hospital, Atlanta John J. Marshall, M.D. – Cardiology Chief, Northside Hospital Cardiovascular Institute & Governor, Georgia Chapter of the American College of Cardiology Fonda A. Mitchell, M.D. – OB-GYN Southeast Permanente Medical Group, Duluth Rob Schreiner, M.D. – Pulmonary Medicine President, Wellstar Medical Group, Wellstar Health System How prepared/unprepared were we for COVID-19? Dr. Bat: Fortunately, our practice recognized that some of the patients we were seeing that had traveled to Asia in January had COVID symptoms – and we started submitting persons under investigation (PUI) forms. However, the government’s response to the pandemic was, on every level, too slow and poorly
coordinated. From testing to public service communications, we lost valuable time and let this virus spread. Having reviewed the U.S. National Influenza Pandemic Handbook for the last 20 years, I believe that we should have collectively responded better than we did. Our failures will be analyzed for decades to come. Dr. Bohlke: I would say average. We have dealt with the flu for years, and we have undergone proper precautions over the years. I do believe that the speed with which virus spread made it very difficult to be completely prepared, and our health system is not set up to handle this type of situation. Dr. Bressler: We were prepared on some level due to previous threats (H1N1 and Ebola), as well as some lead time relative to other parts of the country, but there was simply no way to be totally prepared for the pace and degree of disruption. Dr. Das: Unfortunately, as a country we were unprepared for the COVID-19 pandemic on multiple levels. The pandemic further stressed an already stained health care system. While we have experienced “bad” flu seasons that have pushed our systems to the limit in terms of capacity, the pandemic exacerbated those weaknesses. In terms of the pathophysiology, COVID-19 manifests with a broad symptomatology that is comparable to many respiratory viruses, making it difficult to distinguish (other than the loss of smell and taste, which appears to be somewhat unique). Donning and doffing PPE is another area where we had not practiced enough prior to the pandemic, and we still are not 100 percent sure what level of PPE we really need (e.g., goggles vs. face shields). In terms of a systemic response, we did not learn from other pandemics like SARS, MERS, or the swine flu. Health care systems did not have procedures in place to account for the shift in volumes, the need for isolation, or testing a large cohort of patients. If a mass casualty event had occurred, many hospitals would have been overwhelmed and unable to meet the demands. Dr. Marshall: We were very well prepared. We had lots of PPE, etc.
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Dr. Mitchell: The resource that really stood out at our practice during the early stages of the pandemic was our EMR. It allowed us to contact our patients on a remote basis, which enabled us to divert our resources to the more critically ill patients. Dr. Schreiner: On one hand, “we” – the U.S., the state, my health system, and our industry – were as prepared as possible. For example, we had a national entity charged with preparing for and responding to such events (i.e., the CDC), all health systems are required to have emergency preparedness and HICS infrastructures with discrete communicable disease plans, and we have more health care infrastructure (hospital beds, physicians, nurses, drugs, etc.) than nearly every other country. But on the other hand, the White House administration behaved in ways that diminished the effectiveness of the CDC’s response and the national response. What are the short- and long-term financial implications for your practice? Dr. Bat: We estimate that short-term losses for our practice were in the seven-figure range. It is always hard to make up for income that has not been realized. The long-term losses, such as further shutdowns and the increased prevalence and deaths, are harder to predict. Primary care continues to be at the front line of the COVID response, and we need to grow and strengthen our primary care practices if we hope to defeat this disease. One of the real priorities is increased reimbursement for our frontline physicians. Dr. Bohlke: The loss of revenue in the short- and long-term remains to be seen. A lot will hinge on payments for telehealth services. Dr. Bressler: Fortunately, we have remained busy and able to weather the storm as an infectious diseases practice. Our office/ clinic suffered a significant loss of patient volume early on, but we quickly adopted telemedicine – which helped offset some of those losses. Long term, I suspect telemedicine will remain a part of what we do. With the resurgence of COVID in the summer, after regular hospital activities resumed, we have been busier than ever managing both COVID and our usual ID work. And I think hospitals will further recognize the need for ID services, so I expect that trend to continue. Dr. Das: As a hospital-based physician, our practice has suspended CME funds (other than necessary for recertification) and retirement contributions. The decrease in volumes during the shutdown of elective procedures (and associated complications) has resulted in compensation cuts of 10 percent, and much more for those who are paid on a pure productivity model. The hospital sustained losses in the hundreds of millions of dollars by throttling back elective cases which generate most of the operating margins. Dr. Marshall: None so far. Dr. Mitchell: The biggest impact we saw was the loss of patient volume due to patients’ losing their jobs and, in turn, losing their health insurance. The loss of revenue associated with not being able to bill for remote care (telehealth, video) has been significant. Dr. Schreiner: My medical group shifted from a positive one percent margin to a negative 10 percent margin overnight. And that negative margin will carry over into the first or second
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quarter of next year at least – with cumulative losses that have only been offset by about 50 percent by the CARES Act relief funds. The remainder of the losses had to be accounted for with a combination of pay reductions, furloughs, delayed hiring, and delayed projects. What are the biggest challenges your practice/facility faced (e.g., PPE shortage, testing, capacity, furloughs, employee wellness, other)? Dr. Bat: The lack of leadership at the state and national levels of government remains the biggest challenge. There is no unified plans or messaging, the response time was slow, and there were a lot of mixed signals. Testing failures caused by poor leadership led to an exponential spread of the virus. Staff and physician anxiety nearly paralyzed the delivery system, as more than 80 percent of practices shuttered in March. In Georgia, we never surged past capacity and our health systems took the lead and managed this crisis well. PPE was in the news just about every day – and yet we experienced no shortages. Our masks and gloves protected us, we never closed, we never refused to see a COVID patient, and we began COVID testing as soon as soon as it was clinically available. Employee anxiety surrounding COVID, finances, and job loss are still top-of-mind, but our support systems at our practice have allowed us to excel and perform. Dr. Bohlke: The availability of PPE and testing capacity. We were able to avoid staff furloughs because of federal ‘Paycheck Protection Program.’ Dr. Bressler: We faced some real challenges on several important fronts, including PPE, testing, and employee illness. We also had to deal with furloughs that occurred at the wrong time when things were opening back up and patient volume was increasing. Overall, our hospital and the Emory system has done a very good job of navigating through these issues. Again, as things opened-up and the recurrent COVID wave hit over the summer, we were again strapped to near capacity trying to manage both. Daily, multidisciplinary coordination within our hospitals and the Emory system were critical to navigating those challenges. We have also had to work hard in our practice to maintain momentum and morale and manage staffing concerns and burn out and the like. Dr. Das: We had to contend with a multitude of issues. We had a stockpile of PPE, but we were also asked to re-use PPE that was intended to be used once. Hand sanitizer and disinfectant wipes were rationed. Early on, our hospital system suspended elective cases, freeing up much-needed bed capacity in preparation for the surge of patients – but the timing was a mismatch given the surge of cases that followed the reopening of businesses and as elective cases resumed…we once again saw boarding and issues with nursing resources as the system elected to furlough staff to stem the losses that were related to the shut-down. Dr. Marshall: Our health care system did not have to resort to these measures. Dr. Mitchell: We dealt with an array of challenges, including a shortage of masks and reagent for testing and a physician backlog of surgical cases. Dr. Schreiner: PCR testing capacity was a real issue in the March-April timeframe, as we had about 10 percent of what we needed. We now have 100 percent of the PCR tests we need www.mag.org 9
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on hand, but the highly-variable turnaround time (TAT) for results – from hours for point-of-care testing to many days for send-outs – have impaired our ability to optimally manage the health care workforce, contact investigation, and meet basic customer expectations. The quick turnaround antigen test platforms offer hope. Having enough hospital and office staff (especially RNs) to handle the COVID and non-COVID load has also now become a problem. What unique safeguards/processes did you develop/ employ to ensure patient safety? Dr. Bat: In January, our practice developed protocols to deal with patients who were presenting from Asia. We sourced and used PPE at the onset of the crisis. We developed a COVID task force in March, and we educated our staff and our patients. We joined COVID education groups at our health systems and partnered with them to improve patient care. Our COVID treatment teams were able to keep 95 percent of our COVID patients at home. We continue to improve our COVID care plans, office protocols, and increased testing with same-day results. We have not had any office personnel convert, and we have not lost a single patient to COVID since the onset of the pandemic. We continue to strive to institute best practices and update our protocols – following Georgia DPH and CDC guidelines. Dr. Bohlke: Proper spacing in our exam rooms. We also asked patients to call before they arrived so they could be tested in their cars. Dr. Bressler: We have COVID-specific units. We have extensive isolation and PPE policies and robust testing throughout the Emory system. We also clinically evaluate all PUIs for clearance. Very early on, we started daily multi-disciplinary COVID rounds with ID, hospitalists, nursing, PT, infection prevention, and case management in our hospitals. This has been critical in developing and effective response. Like most places, we have instituted symptom screening and temperature checks. Dr. Das: Our ED implemented a split flow model to isolate patients who have respiratory illness. This created a strain on resources, as we have a duplicated our efforts of triage and work up (labs, imaging, EKGs, etc.) We mandated that everyone, including patients, wear masks to further prevent the spread within the facility and from patients to clinicians.
How would you rate the support/relief you received from state and federal lawmakers and regulators? Dr. Bat: At both the state and national levels, the flow of information was slow and confusing. We also did not get enough help. We missed a window of opportunity in the January/ February timeframe to make a difference. By late March, the government did take some steps that helped – but it was too little and too late. CMS’ decision to loosen the telehealth regulations with private payers was a tremendous success. Let’s hope that government has learned from its failures. Dr. Bohlke: A B-minus. Their response was delayed, but once the scope of the problem was revealed it was appropriate enough to keep the health care system viable and not let it crash and cause more issues for patient care. Dr. Bressler: I was not directly involved in our interactions with the government, but some of the regulatory relief that made a difference were related to lab issues, payment for COVID care, and coverage for telehealth. These were positives. In terms of messaging, guidance, coordination, there has been a vacuum. I also think a much more rapid and extensive system for convalescent care would have helped. Dr. Das: It was non-existent. The lack of centralized, coordinated care and a lack of resources left every entity from private clinics to large safety-net hospitals to compete with one another and the federal government for scarce PPE and life support systems. The expansion of telemedicine was the one saving grace for patients who could no longer access the health system. We were able to innovate and triage the “well” patients from those who needed more urgent medical attention. This also enabled us to allocate our resources to more ill patients. A lot of patients who lacked access – for a variety of reasons – simply deferred their care. We are starting to see more of these patients, some of which have suffered morbidity due to the delay in care. Dr. Marshall: A 10 out of 10. Dr. Mitchell: I would grade them a five on a scale of 10 because they took too long to act on some important fronts, including extending the Good Samaritan Law to inpatient and outpatient care and reimbursing physicians for some virtual care visits.
Dr. Marshall: Flyte suit modification for cardiac catheterization procedures.
Dr. Schreiner: I believe that our state-level government – including GEMA and the governor’s office – was terrific. They expressed a genuine interest in listening to physicians and learning from us and helping us as opposed to dictating to us.
Dr. Mitchell: We established a single-entry point into our building, where we asked screening questions, took temperatures, and distributed face masks and hand sanitizer.
How well do you believe the state has handled the pandemic – and what changes would you have liked to have seen?
Dr. Schreiner: We were highly successful in preventing health care-associated transmission. We only had one patient who was hospitalized who clearly became infected in the health care setting. We followed the evolving CDC and WHO guidelines. So, nothing “unique” – we just followed the prescriptive guidelines (PPE, social distancing, etc.).
Dr. Bat: The state of Georgia took too long to acknowledge the epidemic in a public way (i.e., until it was necessary to “shelter in place”). But behind the scenes, DPH, the governors’ task force, and health system leaders were taking important action that helped to reduce a surge that would have crippled the state’s health care system. That said, we should not have relaxed the mitigation steps that we had in place until our numbers
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were significantly lower. Re-opening the state as early as we did was a mistake. We still are not conducting enough tests, and it is still nearly impossible to conduct a same-day test.
in telehealth use. I believe that people will be more focused on good hygiene practices, including washing their hands on a regular basis and using hand sanitizers.
Dr. Bohlke: This was a very difficult situation for the governor. Close too late and risk peoples’ health or close too early and risk a significant loss for the economy. Georgia is required to balance its budget every year. With a significant loss of income, necessary and vital services that are provided by the state would have to be cut and people/services would have been affected.
Dr. Bressler: We need to increase the use of telehealth, for sure. I think this is now ingrained in our society. Hopefully, public health and preparedness will finally become a greater priority – and I suspect it will. In terms of human and societal behavior, who knows? Maybe, but memories are short.
Dr. Bressler: I think our public health response has been poor. Testing, tracing, treating, quarantining, housing, etc. has been slow and inadequate and inefficient. If not for the monumental efforts of our health systems and private industry, it would have been beyond-belief worse. To me, the need to build a better public health infrastructure and response system is a key lesson. Dr. Das: In a pandemic, systems of care from social services to ambulatory services to acute care must be coordinated to ensure that the right resources are allocated to meet the needs of the community. With the politicization of something simple as wearing a face mask, the government has contributed to the spread of the disease. The fine balance (or imbalance) between supporting commerce and the public health demands to reduce transmission has proven challenging for the current administration to navigate. Again, the lack of coordination at the state level early on contributed to “hot spots.” The lack of timely testing and testing supplies further confounds our ability to contain the virus’ spread. The governor has made some good decisions, including encouraging the use of face coverings. However, his decision to not require people to wear face coverings has placed others’ health at risk and was unfortunate. Dr. Mitchell: The state took too long to close, and we reopened with industries that simply should not have qualified as “essential.” It was ridiculous to suggest that Georgia could host the Republican National Convention. Dr. Schreiner: I think our state handled it well (e.g., the use of the National Guard, mobilizing the MAG Medical Reserve Corps, and daily and weekly conversations with the major health systems to find out what we needed the most and when). I know that the governor has been criticized for “opening the state too soon” to business, but bankruptcy and poverty can destroy families just like the coronavirus. He was caught between a rock and a hard place (i.e., the public health conundrum of ‘death by viral pneumonia’ vs. ‘death by financial catastrophe’). Do you foresee any permanent changes as result of the pandemic? (e.g., increased use of telehealth) Dr. Bat: Let us hope so. Pandemic funding for research, testing, vaccine and therapeutics development, and population health need to become a much higher national priority. Primary care funding should also be expanded, and we need to place a bigger emphasis on technology and telehealth. We need leaders who will stand up and do the right thing. Leadership is about making the right decisions even when it is difficult. Dr. Bohlke: Yes, I believe that we are going to see an increase
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Dr. Das: The lack of adequate reimbursement has historically stifled the growth of the provision of care via telemedicine except in the most progressive health systems. I cannot see the expansion of telemedicine regressing much once the pandemic is under control. Much like 9/11 changed how we fly, this pandemic will no doubt have a lasting effect on how we deliver health care and respond to these kinds of outbreaks. It might take some time, but I am hopeful that this experience will translate into lessons that will result in change – keeping in mind that a lot of the lessons we learned during SARS nearly a decade ago could have significantly improved our response to this pandemic, especially in the area of surveillance, testing, and containment. Dr. Marshall: Yes, I believe we are going to see an increase in telemedicine use and an increase in the telemedicine options that are available. Dr. Mitchell: The pandemic has forced the health care system delivery into the 21st century. We have newfound resources that will help expand care to underserved parts of Georgia. The Georgia Composite Medical Board needs to ensure that health care policy is aligned with the needs of the people. Dr. Schreiner: Telehealth in general – and video visits in particular – are here to stay. The rapid deployment and use of video visits are among the pandemic’s silver-linings. A lot of patients, and especially those with chronic conditions, are going to benefit from more frequent video visits (and fewer inperson visits) by physicians and allied health care professionals. Has any good come out of the pandemic (e.g., changed the way physicians, health systems and hospitals interact and cooperate)? Dr. Bat: Only time will tell if the lessons that we are learning are going to result in any permanent changes. Most physicians went home at the peak of the crisis. The front-line physicians – including primary care, ED, intensive care, pulmonary care, and others – are all heroes. Will the system recognize and reward them? I am not sure. Our health system leaders need to make some hard choices...better care or bigger profits? Dr. Bohlke: Better communications and coordination across the health care system. Dr. Bressler: I do think some good has emerged. There has been an incredible sense of cooperation and camaraderie among the health care workforce. Society also has a greater appreciation for physicians and allied health care professionals and everyone who works at a medical practice or health care facility – at least for now. At the hospital and system level, I have seen a www.mag.org 11
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genuine sense of teamwork and cooperation flourish, which is something I hope continues going forward. Dr. Das: I think it is too soon to know if any of the recent changes in telemedicine and mutual aid transform into lasting change. History does repeat itself, so hopefully we can continue to appreciate the importance of communication and relationships from health systems to individual interactions. Dr. Marshall: Better cooperation and a recognition that we need to be willing to improvise. Dr. Mitchell: The expansion of care delivery options, including face-to-face options and virtual options (e.g., telehealth and video). Dr. Schreiner: I love the way that the physician leaders of health systems from across the state collaborated and cooperated. That never would have happened with non-physician leaders. The video visits proved to be an excellent adjunct to the in-person visits (i.e., from theory to proof ). How did MAG/organized medicine create value for you during the pandemic (e.g., coordination, advocacy, information)? Dr. Bat: As news of the pandemic broke in March, organized medicine was jolted to attention. I was glad to have the help, but the overall response was too reactive. A lot of organizations channeled information from CMS and payers. They attempted to sway the conversation about the need to educate providers, staff, and patients. They attempted to influence lawmakers and other decision makers. Our government made some bold financial moves that helped. Yet there has not been enough of an emphasis on the front line health care responders who continue to put their lives on the line every day. Our practice today is still contending with COVID-19 daily, but we still are not seeing enough assistance with PPE, testing, and supply costs. Dr. Bohlke: MAG created value by providing great and timely information and by being involved with the governor’s task force. MAG represented physicians across the spectrum of specialties and practice settings. Dr. Bressler: I believe that most physicians were focused on patient care and/or keeping their practice afloat. I know that MAG distributed a lot of good information that helped practices deal key issues like telemedicine, HR, office policies, and reimbursement – which allowed me to focus on my job. Dr. Das: Organized medicine helped to create a unified voice for physicians. The #GetUsPPE movement and various town halls have helped to bring awareness to the challenges we face in the trenches. The MAG Medical Reserve Corps helped meet the needs of underserved areas. More than anything, organized medicine helped by disseminating timely information on patient care and practice management. I can lean on MAG to help educate lawmakers and the governor to implement measures to stem the spread of COVID-19. I expect MAG to be a voice for physicians and support those measures that may not be popular but are the right thing to do – such as suspending elective cases and wearing face coverings to prevent the spread.
Dr. Marshall: Advocacy. Dr. Mitchell: MAG enabled physicians in the state to have an open line of communications with the governor’s office, the governor’s COVID-19 task force, the General Assembly, and other key stakeholders. MAG also went to bat for physicians on some key issues – including reimbursement. Dr. Schreiner: MAG – and Donald Palmisano and Ryan Larosa, in particular – organized and facilitated weekly calls with physician leaders. And MAG’s Government relations team (i.e., Derek Norton and Bethany Sherrer) did great work resolving some important telehealth issues with the Georgia Composite Medical Board. Are we prepared for a “second wave”? Dr. Bat: A second wave is months away, and we still need to survive this ongoing current surge. The administration’s COVID task force has gone into hiding. States are being forced to re-open for the wellbeing of the economy. Physician leadership is needed to guide these decisions, but there is not a lot of dialogue taking place. More testing is desperately needed – though I would add that our practice can now do up to 2,000 same-day COVID tests per month, and we hope to double that capability in the next month. We should be building our stockpile of PPE, but that is not occurring. I am confident that our medical scientists will develop therapeutics and vaccines by the end of the year. Our physicians, nurses, and first responders are heroes – and they will always be ready to serve our patients. The American Academy of Family Physicians is proposing new funding and payment methodologies to ensure the availability of primary care to meet the needs of our population. The successful primary care practices have become adept at delivering virtual care (e.g., telehealth, telephone, remote patient monitoring). COVID care plans allowed primary care physicians to keep 95 percent of COVID patients at home, monitoring their vitals, oxygen saturation, and admission into and out of ERs and hospitals. Being able to conduct COVID testing at primary care offices will help as society learns to safely return to work and school. Primary care practices must also get ready for the flu season, increased viral testing, developing treatment protocols, and developing immunization programs. Dr. Bohlke: I do not feel that there will be a second wave per se, but rather an ongoing pandemic. So far, it has not turned out to be a seasonal virus and not affected by the change of season. I believe that we will need to continue to be prepared every day until vaccinations are available plus a proven medication is available for the virus. Dr. Bressler: We essentially have just come through one. It was difficult to manage the COVID-19 epidemic and the rest of our health care needs at the same time, but it may no longer possible or even desirable to focus exclusively on COVID. Moving forward, I think we have at least learned enough to navigate both. How well we are truly prepared depends on how big that wave ultimately gets and what metrics are used to determine success. Dr. Das: We saw a lull in May, and I think we have already
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crested the second wave. So many of the interventions that were taken early on have been abandoned, and the public is now so weary of isolation that I believe things are going to get worse before they get better. We are doing better in terms of PPE, but testing has proven to be a real challenge. I think the real challenge will be the coming flu season. Some have speculated that increased hygiene and social distancing might mitigate any summative impact, but only time will tell. Given the rate at which guidance was being provided and data published, the American College of Emergency Physicians (ACEP) created a clearinghouse web page. Getting guidance on how to obtain personal protective equipment was challenging and confusing given the lack of studies related to efficacy and supply chain issues. ACEP supported the #GetMePPE initiative, which was founded by an EM physician and continues to work to address supply chain issues. Shut downs in many communities and health systems strained emergency departments in other ways, including subsequent staff furloughs and lost revenue to creating new patient care pathways and split flow models of care delivery for patients suspected of being infected with COVID-19 and those presenting with other symptoms. Finally, ACEP has continued to advocate for addressing the psychological and social impacts of health care workers’ morbidity and mortality due to COVID-19 exposure. ACEP has been actively engaged on all these issues and the subsequent expansion of telemedicine resulting from CMS reforms. As emergency physicians, we continue to serve as the safety net of our health care system and rely on the tools and training necessary to serve our communities 24/7/365.
hospitalists, critical care, nursing, allied health, RT, PT, laboratorians, case managers…everybody who plays a role in our health care system that may not always get recognized. They have all played a vital role during the COVID-19 epidemic. Dr. Das: Given the limited information and lack of coordinated government efforts, most health systems were left to fill the void with whatever information and guidance they could obtain. We are in uncharted territory, due the scale of the pandemic, in the modern era of medicine. When one examines health systems around the world that were successful in mitigating the effects of the pandemic, there are common themes, such as centralized coordination of care, including public health interventions and testing strategies, that aided in getting the outbreak under control. The U.S. is different in many ways to other countries who lack the geographic and cultural diversity that defines our country, but we need to really understand the shortcomings of our private, for-profit, decentralized health system. Yes, we get blockbuster drugs and other technologies – but we are abysmally bad at population health. We need to start becoming more intentional about how we deliver care and ensure equitable access and humanistic end-of-life care. Technology cannot solve all of society’s problems. We are all in this together. Hopefully, the current crisis has made that more apparent. I am hopeful that we will come out of this better than when it began.
COVID-19 Resources
Dr. Bat: We are at the beginning of a process. Let us hope that we do better in the future, but hope is not a plan. We need to keep the conversation going, and we need to continue to serve the people we are trained to help. God bless America’s health care workforce!
American Academy of Family Physicians www.aafp.org/patient-care/emergency/2019-coronavirus.html American College of Cardiology www.acc.org/latest-in-cardiology/features/accs-coronavirusdisease-2019-covid-19-hub American College of Chest Physicians www.chestnet.org/Guidelines-and-Resources/COVID-19/ Resource-Center American College of Emergency Physicians www.acep.org/corona/covid-19-Main American College of Obstetricians and Gynecologists www.acog.org/en/Topics/COVID-19 American Thoracic Society www.thoracic.org/covid/index.php Centers for Disease Control and Prevention www.cdc.gov/coronavirus/2019-ncov/index.html Georgia Department of Public Health dph.georgia.gov/health-topics/coronavirus-covid-19 Infectious Diseases Society of America www.idsociety.org/public-health/COVID-19-Resource-Center/ MAG COVID-19 Resources Center www.mag.org/covid19 Pediatrics Pediatric Infectious Diseases Society www.pids.org/resources/covid-19.html
Dr. Bressler: The pandemic has highlighted the crucial need for our health care providers, including infectious diseases,
PPE Clearinghouse www.projectn95.org
Dr. Marshall: According to the American College of Cardiology, clinicians and researchers have documented significant cardiovascular sequelae in association with the infection since the earliest published clinical reports on COVID-19. Examples of this include elevated cardiac biomarkers, myocardial infarction, acute cardiomyopathy, myocarditis, and proarrhythmic and prothrombotic effects. Most cardiovascular interventions remain supportive, with biomarker and rhythm monitoring and standard prophylactic anticoagulation as indicated. We will be more prepared for a second wave than we were for the first one, for sure. Dr. Mitchell: No, but we do need more capacity for testing and screening symptomatic patients. We also need better contact tracing to stop the spread of the COVID-19 virus. Dr. Schreiner: We better be, because it is something that we are going to have to contend with for the foreseeable future. Are there any other key takeaway points that you would like to make?
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MEDICAL ETHICS
COVID-19 and suicide: Trading one pandemic for another By Sarah Kathryn Chambley, MS-4, with input from J. David Baxter, M.D., FACP, Interim Associate Dean Savannah Campus and Associate Professor of Medicine, Mercer University School of Medicine
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n times of crisis, communities historically come together to support one another, a phenomenon called the “pulling-together effect.”1 A sense of belongingness, such as being one community member of many experiencing a crisis, is protective against adverse mental health.2 The nation pulled together on September 11, 2001, and suicide rates decreased after the terrorist attacks.1 However, the coronavirus pandemic is a new and unprecedented kind of crisis. In the midst of a time when human instinct is to come together in support of one another, humans are faced with the fear that the community is the very real threat to health. Efforts to remain socially distant (i.e., the six-foot rule) to contain COVID-19 and protect our physical health have been implemented. Large gatherings have been prohibited. Visitation has been limited in hospitals, even when death is imminent. And at least early on, all non-essential businesses had to close their doors to the public. All these efforts, while valid, raise concerns that in attempt to contain the virus the government has incidentally put the nation at risk for another kind of pandemic; a suicide pandemic. Mental health may be put at risk while intending to protect physical health. The coronavirus pandemic has affected more than the nation’s physical health. The direct and indirect effects of the shutdown have increased the risk of suicide – keeping in mind that school and childcare closings have forced parents to take time off from work or to work from home, businesses have shut their doors or laid off employees in order to follow social distancing protocols, and more than 22 million Americans applied for unemployment insurance in April 2020.3 Times of economic hardships are associated with higher suicide rates. For every one percent increase in unemployment, there is a one percent increase in suicide deaths and a greater than three percent increase in deaths related to opioids.4 Additionally, the shutdown itself and the media’s portrayal of it has built up barriers to mental health care services. The media has implied that mental health services are not a priority by exaggerating the fact that health care systems are overwhelmed with critically ill COVID-19 patients. Many Americans falsely believe that mental health services fall into the category of non-essential medical care.1 Additionally,
Sarah Kathryn Chambley
news coverage regarding the knowns and unknowns about coronavirus can cause great worry, stress, and anxiety for a consumer – especially the ones who are at greatest risk of contracting the virus. Physical and mental health problems alone can trigger suicidal behavior, compounding the anxiety of being at greater risk of coronavirus infection. Prevention efforts, such as social distancing, have inadvertently put our nation at greater risk of suicidal thoughts and behaviors. Social connectivity, which typically increases during times of crisis, decreases suicide risk. Weekly attendance at religions services is associated with a five-fold lower suicide risk.5 However, these gatherings have been prohibited under the social distancing guidelines. Restrictions to visitation in health care facilities, such as hospitals and nursing homes, have remained in place during the pandemic. Stay-at-home orders have increased social isolation and loneliness, both which are associated with suicidal thoughts and behaviors. There is an additional factor that makes this situation all the more concerning. In March 2020, more than 2.5 million firearms were sold in the U.S. This is an 85 percent increase in sales compared to March 2019, and it marks the highest sales in U.S. history.3 Ownership, access, and unsafe storage increase the risk of suicidal behaviors for not only the owner, but for all members of the household. Handgun ownership puts the owner at a 22-fold greater risk. The presence of a gun in the home is associated with a two- to 10-times greater risk for every member of the household.3 Firearms are the most common method of suicide. The reason for the increase in sales remains unclear, but the increase is relevant and frightening regardless of the reason. Concerns about continuing the social distancing and stay-athome orders are growing throughout the medical community. Economic instability, lack of access to mental health services, heightened stress and anxiety, social isolation, and a rise in firearm purchases create the perfect scenario for negative health outcomes. More than 600 physicians signed a “A doctor a day” letter that was sent to President Donald Trump in May that urged him to end the national shutdown. They said that they are concerned about the already apparent negative effects of the
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shutdown on our country’s wellbeing, including missed health checks, financial instability, and an increase in substance abuse and mental health problems.6 The letter highlighted several patients who had experienced negative health effects as a result of the government shutdown. The first example was a man and woman with two children. His job was furloughed and hers was reduced to part-time. The man began drinking heavily and the woman was diagnosed with depression, worsening her preexisting diabetes mellitus type two. Another patient, unable to see her therapist, relapsed into depression and died of a fentanyl overdose several weeks into the pandemic. The letter stated that, “The millions of casualties of a continued shutdown will be hiding in plain sight, but they will be called alcoholism, homelessness, suicide, heart attack, stroke, or kidney failure.”6 Concerns regarding potential negative outcomes of the government’s COVID-19 prevention efforts are not suggesting that no action should be taken to control the spread of disease. My assessment is that they are underscoring the need for individualized precautions and patient care. Social connectivity is essential for the patient who is at high risk of mental illness, while an immunocompromised patient might benefit more in isolation. A dilemma arises because those with heightened risk of experiencing a trauma, such as an immunocompromised patient, are the ones most likely to experience adverse mental health – like anxiety, depression and suicide – during and after the trauma.7 When this dilemma does arise, health care providers should educate the patient on the virus while attempting to understand what the patient values most, whether that’s their mental or physical health. Are health care providers practicing beneficence and non-maleficence when counseling a patient with pre-existing depression and anxiety to follow stay-at-home orders? Are hospital facilities really respecting patient autonomy by denying visitors, especially at during end-of-life care? Social distancing does not have to equal social isolation. During this time of crisis, social support can be maintained via telephone and video chat, such as Zoom or FaceTime. Virtual religious services can still take place, with both live stream and pre-recorded options. The media can help by distributing suicide hotline information and showing advertisements that prompt viewers to check in on their own mental health. Physicians should utilize the already established resources to combat negative health outcomes during the pandemic, such as telehealth services. Every patient encounter, not just one’s with a psychiatrist, can serve as an opportunity to monitor a patient’s mental health status. Online resources that are designed to detect and provide care for basic mental health conditions are available. Now is the time for primary care physicians to ensure that a referral pathway to mental health specialists is in place at their
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practice. It is undoubtedly difficult to tell whether the benefits of self-isolation to physical health outweigh the harm to mental health, but the medical community has and must continue to raise red flags that the fight against one pandemic might be creating several others. MAG members are encouraged to submit their ethics articles and comments and questions to David Baxter, M.D., FACP, at baxter_jd@mercer.edu.
References Reger, M.A., Stanley, I.H., & Joiner, T.E. (2020). Suicide mortality and coronavirus disease 2019 – a perfect storm? JAMA Psychiatry. https://doi:10.1001/jamapsychiatry.2020.1060 Joiner, T.E., Van Order, K.A., Witte, T.K., Selby, E.A., Ribeiro, J.D., Lewis, R., Rudd, M.D. (2009, July 31). Main predictions of the interpersonal-psychological theory of suicidal behavior: empirical tests in two samples of young adults. Europe PMC. 118(3):634-646 . doi:10.1037/a0016500. 3. Mannix, R., Lee, L.K., & Fleegler, E.W. (2020). Coronavirus disease 2019 (COVID-19) and firearms in the united states: will an epidemic of suicide follow? Annals of Internal Medicine. https://doi.org/10.7326/M20-1678 4. Azar, A.M. (2020, May 21). We have to reopen – for our health. The Washington Post. https://www.washingtonpost.com/opinions/reopening-isnt-a-question-ofhealth-vs-economy-when-a-bad-economy-kills-too/2020/05/21/c126deb6-9b7d11ea-ad09-8da7ec214672_story.html?fbclid=IwAR3WXJ14eeKqzOPeRddGmN_ jOlqZTAP9DqoBWoIfKJIfbEhkSONhgEU4HlM 5. VanderWeele, T.J., Li, S., Tsai, A.C., & Kawachi, I. Association between religious service attendance and lower suicide rates among US women. JAMA Psychiatry. 2016;73(8):845851. doi:10.1001/jamapsychiatry.2016.1243 6. Olsen, T. (2020, May 20). Doctors raise alarm about health effects of continued coronavirus shutdown: ‘Mass casualty incident’. Fox News. https://www.foxnews.com/politics/doctors-raisealarm-about-health-effects-of-continued-coronavirus-shutdown?fbclid=IwAR0rEvY3eEMlqZ HE2KcZVgPrw1YMLq4oQLq_yByDvLk1EV8sVqApGWXad3w 7. Centers for Disease Control and Prevention. (2020, May 14). If you are immunocompromised, protect yourself from COVID-19. CDC. https://www.cdc.gov/ coronavirus/2019-ncov/need-extra-precautions/immunocompromised.html 1. 2.
Find out how MAG’s health insurance and 401(k) plans can help your practice The Medical Association of Georgia (MAG) is reminding its members to take advantage of two exclusive benefits, including the MAG Healthcare Solutions Plan and the MAG 401(k) Plan. The MAG Healthcare Solutions Plan – which has already delivered savings of more than 25 percent for one practice – is available to MAG member practices that enroll five or more full-time physicians and practice staff, keeping in mind that every physician at the practice must be a MAG member for the practice to qualify for the plan. It features medical, dental, and vision plans from Humana. The plan’s administrator also offers “competitive prices [for health, dental and vision insurance plans] from Aetna and Cigna for practices with two to four employees.” Meanwhile, the MAG 401(k) Plan can help member practices save time, reduce expenses, and avoid administrative headaches – and it offers the advantages and flexibility of a stand-alone plan. It now has $85 million-plus in assets and more than 500 participants, including more than 150 physicians. Contact Ryan Larosa at 678.303.9275 or rlarosa@mag.org for details on these plans.
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GCMB UPDATE
The effects of COVID-19 on the Georgia Composite Medical Board By John S. Antalis, M.D., past chair and member, Georgia Composite Medical Board John S. Antalis, M.D.
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ho would have thought that an obscure virus that originated in China in November 2019 would consume our lives as physicians in 2020? Health care workers on front lines who have battled this pandemic, many of whom have lost their lives, deserve our deepest thanks and appreciation. COVID-19 has affected the work of the Georgia Composite Medical Board (GCMB). However, the work has nonetheless continued thanks to the dedication of its executive director, staff, and my fellow colleagues on the board. GCMB has held virtual interviews and committee meetings since April. It appears that this will continue for the foreseeable future. The Georgia General Assembly postponed its session for two months, finally coming to an end in late June. GCMB will develop rules for the following bills that have been signed into law by Georgia Gov. Brian Kemp... H.B. 752: Update on Georgia’s participation in the ‘Interstate Compact’ This added language authorizing the GBI to conduct background checks, as required by the compact, on physicians who use Georgia as their “home state.” S.B. 321: PA & APRN updates This allows physicians in ANY practice to supervise up to four PAs. It also allows APRNs to order radiographic imaging in non-lifethreatening situations if the procedure is covered by their protocol agreement and has been approved by GCMB. S.B. 313/H.B. 946: Change in PBM practices This will make pharmacy benefit managers (PBMs) more accountable to physicians and patients. It will prevent them from requiring patients to use PBM-owned pharmacies and receiving additional pharmaceutical manufacturer rebates by limiting drugs on the formularies to those who have given rebates, and it requires PBMs to utilize physicians who have been actively practicing within the last five years in the same specialty area for providing advisement in connection with a prior authorization or step therapy appeal or determination review. H.B. 888: Out-of-network payment reform This was one of MAG’s legislative priorities for 2020. GCMB will only have a role in enforcing this law if the insurance commissioner finds a physician has either displayed a pattern of acting of violating the law or has failed to comply with a lawful order of the commissioner or an arbitrator. S.B. 359: COVID-19 liability protections This will protect all health care providers and health care facilities against COVD-19 liability claims that involve injury or death, unforeseen delivery of health care due to the virus, or unintentional infection or exposure to a patient. Gross negligence, willful
and wanton misconduct, the reckless infliction of harm, or the intentional infliction of harm is not protected. H.B. 1125: Improved compiling and reporting of high-risk breast cancer patients As a result of this bill, the Georgia Department of Community Health and GCMB will compile pertinent breast cancer data that is based on history and risk factors, GCMB will disseminate the data on a yearly basis to Georgia physicians, and the State Health Benefit Plan will be required to cover breast cancer screening for patients who are at high risk and over 30 years old. H.B. 914: Approval of medical license by endorsement for military spouses This allows a military spouse to obtain a Georgia medical license “by endorsement” (i.e., transfer) if they possess an active out-ofstate license and are in good standing without any infractions in any state. Also note that GCMB has established three committees to respond to issues affecting Georgia physicians and patients. Sexual Boundary Committee This began as an ad-hoc committee in 2016. In 2017, the Federation of State Medical Boards (FSMB) created a work group of physicians – including one from Georgia – and other interested organizations to create a white paper on sexual misconduct, which was completed in 2020. This FSMB work group white paper addressed licensing boards’ actions in the areas of discipline, reporting barriers, and expanding sexual boundary/harassment education training to undergraduate/ graduate students. The GCMB committee will review the white paper and develop recommendations for GCMB’s consideration. Telemedicine Committee This group will review all of the applicable Georgia statutes and rules, including OCGA Section 33-24-56.4 and Rules 360-3-.07 and 360-3-0.17 and the COVID-19 Emergency Rule 360-3-0.100.08. Telemedicine has become a mainstay in medical practice. The emergency provisions are scheduled to remain in effect until Gov. Kemp ends them. Following physician and public comments, GCMB will submit its recommendations to the General Assembly for consideration. Community Outreach Committee This group will establish greater transparency of GCMB’s actions. This includes an improved patient complaint form and updating GCMB’s website. Please contact GCMB Executive Director LaSharn Hughes at lhughes@dch.ga.gov with comments or suggestions related to these committees. Dr. Antalis is a member of the Whitfield-Murray County Medical Society, and he was MAG’s president in 2004-2005.
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MAG MEDICAL RESERVE CORPS
MAG MRC credited with saving lives during pandemic By John S. Harvey, M.D., FACS, medical director, MAG Medical Reserve Corps John S. Harvey, M.D., FACS
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nowing that the state’s health care system could be pushed to its limits by the COVID-19 virus by the middle of April, Georgia Adjutant General (TAG) Maj. Gen. Thomas Carden contacted the Medical Association of Georgia Medical Reserve Corps (MAG MRC) on March 23. Georgia Gov. Brian Kemp’s COVID-19 Task Force had asked Maj. Gen. Carden to “expand the availability of medical manpower in the state, to develop mechanisms to respond with medical care provision, and create management structure to novel virus response.” Having been activated by the Georgia Department of Defense (i.e., Maj. Gen. Carden) and Georgia Department of Public Health Commissioner Kathleen Toomey, M.D., on March 24, the MAG MRC leadership team immediately convened and developed an action plan. The MAG MRC increased its ranks from 75 trained and deployable members to more than 250 available medical professionals – with a reserve capacity of 300 more responders – in a matter of several weeks. These volunteers were available to serve in a variety of capacities and settings, from erecting mobile “surge” hospitals to working at COVID-19 test centers to caring for patients via telehealth/telemedicine. With the help of the Medical Association of Georgia, MAG MRC members received expanded professional liability protections under the governor’s emergency declarations and under the authorizations of the Georgia Department of Public Health. The state also authorized providing MAG MRC volunteers with workers compensation protections. Since its formation in 2014, the MAG MRC has trained to respond to declared emergencies for two- to three-day periods. But in the case of the COVID-19 outbreak, we were deployed for more than two months. It is also worth noting that based on the mission’s total manpower-days, and using a conservative professional compensation rate, the MAG MRC has created more than $1 million in value for the state during the pandemic. “As the COVID-19 pandemic started to challenge the state’s hospital capacity while simultaneously infecting medical staff, it became clear to me that we needed to generate some additional options for Governor Kemp and his staff,” Maj. Gen. Carden
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said. “Fortunately, I was familiar with the Medical Association of Georgia’s Medical Reserve Corps – so I reached out to Dr. John Harvey. The MAG MRC took immediate action, increasing our medical capacity in critical areas.” Maj. Gen. Carden also pointed out that, “In addition to augmenting our staff in medical facilities and COVID testing sites, medical screening at hospitals, nursing home decontamination sites, and foodbank distribution centers, the MAG MRC leadership team provided key inputs and advice as we worked to build our response capacity.” And Maj. Gen. Carden said that he is convinced that the MAG MRC “saved many lives.” In addition to practicing physicians, the MAG MRC’s ‘COVID-19 Response Team’ included retired physicians, PAs, APRNs, nurses, dentists, EMTs, pharmacists, medical students, and fourth-year pharmacy students. The MAG MRC was deployed to health care sites across the state, including the state’s operation and virtual operations centers – as well as sites in Thomasville, Valdosta, Bibb County, Clark County, Fulton County, Mitchell County, Randolph County, and Tift County. Whether you were a MAG MRC member who was deployed to the field or not, MAG and the MAG MRC are immeasurably grateful to every individual who stepped forward during the state’s hour of need. Moreover, the MAG MRC stands ready to respond to future calls for assistance from the State of Georgia, whether that involves a “second wave” or some other kind of emergency. MAG members who are interested in joining the MAG MRC can go to www.magmrc.org/get-involved or contact Fred Jones at fjones@mag.org. The MAG MRC is a group of citizen volunteers who respond to natural disasters and disease outbreaks that threaten to overwhelm a community’s health care system. It complements the official medical and public health and emergency services resources in the state. The MAG MRC is part of a state and national network of MRC. There are nearly 1,000 community-based MRC units and 200,000 MRC volunteers in the U.S. Dr. Harvey served as MAG’s president in 2015-2016, and he is a colonel in the Georgia State Defense Force. www.mag.org 17
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HEALTH CARE HEROES
MAG MRC Leadership Team John Harvey, M.D. Paul Hildreth Paul Purcell W. Hayes Wilson, M.D.
Frances Purcell, Ph.D. Leonard Goodelman Fred Jones
Medical Association of Georgia
Other Incident Command Team Tony Bagdonis, Ph.D. Travis Bailey, D.O. James W. Barber, M.D. Tameka Bowden Blaire Burton Maya Crawford Capt. Julien Edner Deputy TAG Joe Ferraro
Charles Ford Eric Fouad Thomas Godwin Hannah Gold Mike Greene, M.D. Tom Haltom, M.D. Saundra Harvey Miki Hayashi
Luz Heaton, M.D. Ankita Kanwar Sen. Kay Kirkpatrick, M.D. John Knopf, M.D. Ian McCullough, M.D. Donald J. Palmisano Jr. Carlos Parrado, M.D. Isabella Tondi Resta
Col. Tim Romine Chris Rustin Manoj Shah, M.D. Lisa Sward, M.D. Max Tarica Demetri Vacalis, Ph.D. LaKieva Williams Jay Zaisim
John S. Gerguis, M.D. Angela S. Gerguis, M.D. Wendy H. Greenberg, M.D. Kristin N. Hake, RN Luz M. Heaton, M.D. Mohammad A. Helala, M.D. Joel E. Higgins, M.D. Teresa Hollingsworth Nancy R. Jackson-Patterson, RN
Ankita Kanwar Rila Kim-Tummala, M.D. Maranda F. Lumsden, RN Olivia R. Norris, EMT Walesha K. Oglesby, RN Katherine J. Purdy, PA Cassandra Riley Jose F. Rodriguez-Curras, M.D. Lisa A. Sward, M.D.
Amanda R. Tong, RN Stella I. Tsai, M.D. Gurshawn S. Tuteja Laurie K. VanMeter, LPN Spencer D. Wenzel, PA Taylor G. Wilson, EMT Mark J. Yanta, M.D.
Cynthia J. Brown, RN Donald G. Browning Jr., M.D. Mark T. Brulte, M.D. Terry N. Bryant Joseph D. Bush Jeffrey D. Callaway Oscar T. Cassity Jr., M.D. Michael Chaliff, M.D. Katherine E. Chapman, RN Meenakshi Chugh Michelle M. Cipriani, M.D. Mariana M. Claghorn, DC
Dwayne L. Clay, M.D. Aris Cochon, M.D. Sarah L. Codrea, D.O. Hiram D. Coffey Jr. Howard J. Cohen, M.D. Lori S. Corley, M.D. Matthew Cornelison Maya N. Crawford, M.D. Teodoro F. Dagi, M.D. Gordon A. Dale Alexa V. Dantzler Rebecca DeCarlo, M.D.
Field Deployed Amena Y. Abbas, EMT Lisa Angel, RN Mason T. Bennett Steven E. Bernard, EMT Natalie M. Bertrand Donna B. Burton, EMT Joy B. Chastain, M.D. Kathryn S. Cozonac, RN Bryan J. DeMarco, M.D.
Available for Deployment Benjamin H. Adams, M.D. Dare A. Adewumi, M.D. Sharon C. Amaya, M.D. Marc G. Amaya, M.D. Michael G. Anderson, M.D. Christopher J. Apostol, M.D. Michael I. Appel, M.D. Zoe G. Athens Michelle Au, M.D. Summera Aziz, M.D. Susan J. Baker, DMD Angie M. Barco, NP
Jack A. Bell, DDS Adam E. Berman, M.D. Richard R. Besaw William F. Bina III, M.D. Samantha H. Bishop, RN Travis W. Blalock, M.D. Melissa M. Bock, RN Sarah E. Boswell, M.D. Gwendolyn M. Boyce Jeffrey A. Bradley, M.D. Kenneth M. Braunstein, M.D. Holly Brode
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Gwendolyn A. Delaney, M.D. Carmel S. Doolan, RN Anne L. Dunlop, M.D. Kelly L. Dyar, RN Melissa M. Easley Stanley B. Eaton, M.D. Michelle Egeolu, M.D. Jared C. Eggleston Christina R. Ekstrom, NP Richard S. Ellin, M.D. Dylan B. Elliott Jeffrey B. English, M.D. Christopher Everett, M.D. Ginny R. Everton, RN Allen B. Filstein, M.D. Kathryn M. Fitton Charles L. Ford IV, M.D. Sheri A. Forman George W. Garriss III, M.D. Shahzad S. Ghori, M.D. Jeffrey E. Goldberg, M.D. Bradley G. Goldberg, M.D. Gayle L. Goldstein, M.D. Michael J. Grady, D.O. Michael Greenwald, M.D. Evan M. Greller, DC Saumya Gurbani Giang Ha
Timothy S. Hanes, M.D. Caryn Hanrahan Abdul Mateen M. Hasan Caryn S. Hatcher, RN Benjamin Hayes, M.D. Thomas C. Henris, M.D. Robert Hirsch, M.D. Wayne K. Hoffman, M.D. Gregory Hopkins, M.D. Maggie L. Hopkins, M.D. Sharon Howard Mary K. Humphries, D.O. Suraayah R. Hunter, RN Meredith Ingram, PA Lara M. Jacobson, M.D. Stephen W. Jarrard, M.D. Kelley B. Jimison, NP Albert Johary, M.D.
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Ryan P. Johnson, D.O. Laroice R. Johnson, RN Alisha M. Kavouklis Shannon D. Keely, RN Leah Kim Kimberly Klaus, PA Claudia S. Kretzschmar, M.D. Keren Landman, M.D. Donald K. Lane Joash T. Lazarus, M.D. Brian A. Lee Sr., EMT Ella Leung, M.D. Tina M. Lewis, EMT Bradford C. Lipman, M.D. Debra Lister, M.D. Sarah A. Long, RN Sarah S. Lopienski, RN Robert S. Lykens, M.D. James R. Malcolm, M.D. Steven I. Marlowe, M.D. Tara N. Massarelli Susan M. Massey-Connolly Alfred Mazur, M.D. John P. McCaskey, M.D. Tammy L. McClenny, RN Frank McDonald Jr., M.D. Flavia E. Mercado, M.D. Rebecca B. Mietling, RN W. Charles Miller, M.D. Debra L. Miller, LPN Tanya L. Mims, APRN Mary Alice N. Mina, M.D. Nan R. Monahan, M.D. Mark D. Moncino, M.D. Ralph Morales, M.D. Elena Morgan, M.D. Darla J. Morgan, M.D. Charlie D. Morgan-Seeley, RN Lauren S. NagashimaWhalen, M.D. Patrick Narh-Martey, M.D. Romulo Navarro, M.D. Michal J. Nesnick, DC Danny A. Newman Jr., M.D. Amanda A. Newton, RN Ceana Nezhat, M.D.
Steve A. Nickisch, M.D. Sherwin Niles, EMT Michael A. Norman, M.D. Abidemi O. Ogunbode Omoyele A. Oluwa Claudia J. Ordonez, LPN Gary S. Orris, M.D. Ehizele Osehobo, M.D. Cheryl W. Owens Kiran Patel, M.D. Sarah G. Pearson, RN Jessica M. Peeler, NP Haoran Peng, M.D. Carla Perry, NP Mariko S. Peterson, M.D. Dee W. Pettigrew III, M.D. Annie Phung Caroline Pilgrim, PA Alexander M. Pishal Pamela K. Platt Carmen R. Prater, RN Tami M. Prince-Clarke, M.D. Robin R. Pyburn, M.D. Alyse M. Ragauskas Vandana Ramaswamy, NP Sophia S. Rashid Taylor Rathel, EMT Challori Reddy, M.D. Jada Reese, M.D. Patrick D. Retterbush, M.D. Matthew C. Revilla, PA Monica V. Rhymes, NP Eddie Richardson Jr., M.D. Jonathan L. Riley Misty R. Roach, LPN Nichon D. Roberson Barbara E. Robertson, M.D. Bruce E. Rudisch, M.D. Joseph A. Ruiz MarQuenda Sanders James T. Sandwich, M.D. Ebony R. Sankey, RN Barbara L. Schuster, M.D. Rachel E. Schwartz, PA Jennifer Seagle John R. Simpson, M.D.
Susan E. Smith Carla B. Smith, RN Christopher C. Smith, EMT Jessica Stewart, RN Michael Sundell Renee M. Swaim, RN Katharine C. Templeton, PA Laura Tharp, M.D. James E. Thomas Williams F. Thorneloe, M.D. Martin L. Throne, M.D. Raymond E. Tidman, M.D. Tisha M. Titus, M.D. Jeff A. Traub, M.D. Pamela C. Traya, PA Thomas S. Upshaw, M.D. Christopher P. Vakkur, EMT Rabia Vaughns, PA Jo Veal Michelle M. Venn, RN Joshua L. Vickers, M.D. Cynthia L. von Hohenleiten, RN Catherine E. Wallace Marshall Waller Steven Walsh, M.D. Jen Warfield, RN Catherine Warner, M.D. Thomas Wehmann, M.D. Christopher C. Whalen, M.D. Emily K. Willis Carol M. Wolff, DDS Christine L. Woodall, RN Sheila Woodhouse, M.D. Susan E. Yandel, NP Amy E. Yarbrough, RN Ginger L. Yrabedra, NP Alison K. Zavadny, M.D. Rim B. Zecarias, RN Joanne Zhu, M.D.
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LEGAL
Sorry seems to be the hardest word By Daniel J. Huff, Huff, Powell & Bailey, LLC
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aying that you are sorry is a regular part of everyday life. Being sorry is a common expression for minor events as well as significant life-changing events. There is a place for physician apologies to patients and patient families, particularly when there is been a bad outcome. Recent research suggests that such an apology is beneficial to both patients and physicians. In my practice representing physicians and hospitals in medical malpractice cases, I have seen apologies transform attitudes towards health care providers who are involved in a bad outcome. I’ve seen health care providers and plaintiffs who have been in litigation for years embrace and sob following this simple exchange: “I’m sorry” and “I know.” I’ll bring this up early to acknowledge and move past the fact that apologies are good for patients and good for health care providers. It allows both to share honesty and respect that promotes healing.
Physician apologies Physician apologies have been touted as one way to avoid medical malpractice litigation. Conventional wisdom is that apologizing to a patient or a patient’s family after a bad outcome prevents them from consulting with a lawyer to pursue a legal action. There is a dearth of empirical evidence to support this conventional wisdom, but it is a widespread belief. Anecdotally, many plaintiffs pursue legal action because they did not know what happened to them or their loved one and a lawsuit was initiated to answer their questions. I personally believe that some patients will pursue legal action regardless of an apology. At the same time, there are some patients who considered legal action but chose not to file a lawsuit after an apology. In the aggregate, apologies are beneficial for physicians both personally and legally. Saying that you are sorry does more good than harm for you and your patients. The drawback to physician apologies has traditionally been that the apology would cause the patient to realize a mistake was made and seek legal counsel. Additionally, physicians are afraid that any apology could be used against them in a legal proceeding as evidence that they made a mistake.
Legal protections In the last 20 years, 39 states have enacted apology laws. These laws generally make health care apologies inadmissible in a medical malpractice lawsuit. These laws were enacted to 1) encourage physicians to apologize and 2) reform the tort system by excluding evidence that might increase physician liability. Georgia enacted a physician apology statute in 2005. It is codified O.C.G.A. § 24-4-416 and provides as follows… In any claim or civil proceeding brought by or on behalf of the patient allegedly experiencing an unanticipated outcome
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of medical care, any and all statements, affirmations, gestures, activities, or conduct expressing regret, apology, sympathy, commiseration, condolence, compassion, mistake, error, or a general sense of benevolence which is made by a health care provider or an employee or agent of a health care provider to the patient, a relative of the patient, or representative of the patient and which relates to the unanticipated outcome shall be inadmissible as evidence and shall not constitute an admission of liability or an admission against interest. Georgia’s apology statute is broad, and it covers more than apologies. Most statements after an unanticipated outcome are subject to being excluded under this statute. To the extent that you don’t think that this is a true “tort reform” statute, remember that a comparable statement by a patient or patient’s family member would be admissible under the same circumstances. For example, if a patient said after an unanticipated outcome that, “I’m sorry, I should have come to the hospital much sooner when I first felt sick” it would be admissible to prove the patient’s contributory negligence. Since the adoption of George’s apology statute, statements made after a bad outcome are regularly excluded by trial courts and are affirmed on appeal.
Apology techniques Georgia physicians should be comfortable giving a candid apology to a patient or patient’s family after an unanticipated outcome. Candor and sincerity are critical to a successful apology. The apology should be delivered in person with an open dialogue to allow questions and answers. Remember that an apology cannot change the past; it’s about the future. Saying that you’re sorry does not mean that you were wrong, but it does mean that you value the relationship you have with your patient and your patient’s family. In the context of answering questions about the unanticipated outcome, be factual. Do not provide opinions about information that is not available to you. It is not the time to blame others for the outcome. It is a time to acknowledge responsibility for your role in the outcome and to promote healing. We have all seen plenty of scripted apologies on television that do more harm than good. Don’t butcher a good apology with an excuse. You may want to have someone with you when you apologize to your patient or patient’s family. You may also want to do it alone. Create an environment that is most comfortable for you and your patient. Documentation of the conversation is always beneficial and can be described generally in the patient’s medical record. Here is a simple example of a way to document an apology… Discussed patient’s unfortunate outcome with his wife today. Explained medical care and prognosis, all questions were answered. The bottom line is that candor, sincerity, and heartfelt apologies (continued on page 23)
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PATIENT SAFETY
COVID-19 immunity protections for health care organizations in Georgia By Lisa Hwang, risk intern, and Raj Shah, senior regulatory attorney, The Institute at MagMutual
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eorgia has enacted a series of executive and legislative decisions to combat the spread and impact of COVID-19 or coronavirus.1 Given the magnitude of COVID-19 and rising concerns of accessing health care services during these unprecedented times, health care organizations and physicians are faced with the profuse burden of having to balance providing medical treatment with the potential legal complications. In response to these concerns, Georgia Gov. Brian Kemp issued an executive order on April 14, 2020 (“Executive Order 04.14.20.01”) and the Georgia legislature passed the ‘Georgia COVID-19 Pandemic Business Safety Act’ (S.B. 359)2, which provides health care organizations with heightened legal protections during the COVID-19 pandemic. Gov. Kemp’s executive order 04.14.20.01 protects providers from medical malpractice claims Gov. Kemp issued an executive order titled ‘Designation of Auxiliary Emergency Management Workers and Emergency Management Activities.’ The order is important because it 1) redefines the services that are provided or performed by health care organizations as “emergency management activities”3 and it provides health care organizations with medical malpractice immunity and 2) extends these medical malpractice immunity protections to “employees, staff, and contractors” of health care organizations.4 By expanding the definition of “auxiliary emergency management workers,”5 the order gives health care organizations and physicians greater protection from medical malpractice liability claims for the services they provide during the COVID-19 Public Health State of Emergency. Patients who wish to pursue a medical malpractice liability claim for treatment sought and received during the “COVID-19 Public Health State of Emergency” will have to prove a heightened standard of negligence including willful misconduct, gross negligence, or bad faith. The executive order applies to all patients, and it is not limited to patients diagnosed with COVID-19. Executive Order 04.14.20.01 became effective on April 14, 2020, and the protections will continue throughout the “public health state of emergency.” Georgia COVID-19 ‘Pandemic Business Safety Act’ (S.B. 359) civil liability protections S.B. 3596 provides protection to health care organizations from lawsuits by patients or visitors claiming they contracted COVID-19 at their health care facility by establishing a heightened standard of gross negligence for claims of
transmission and infection of COVID-19. Patients or visitors who wish to pursue claims that they contracted COVID-19 at a health care facility will have to prove a heightened standard of negligence, including willful misconduct, gross negligence, reckless infliction of harm, or intentional infliction of harm. S.B. 359 provides an automatic assumption of the risk defense for health care organizations and medical facilities against allegations of transmission, infection, or exposure of COVID-19 as long as an adequate disclaimer is provided to the patient or visitor. The following provides a rebuttable presumption of assumption of the risk by patients or visitors… Any receipt (or an appointment confirmation) given to the patient to enter the premises that is in at least 10-point Arial font and placed apart from any text that states… Any person entering the premises waives all civil liability against this premise’s owner and operator for any injuries caused by the inherent risk associated with contracting COVID-19 at public gatherings, except for gross negligence, willful and wanton misconduct, reckless infliction of harm, or intentional infliction of harm, by the individual or entity of the premises. Or A signage posted at a point-of-entry with at least one-inch Arial font placed apart from any other text that states… “Under Georgia law, there is no liability for an injury or death of an individual entering these premises if such injury or death results from the inherent risks of contracting COVID-19. You are assuming the risk by entering these premises.” The intention of these disclaimers is to notify patients of the health care organization’s immunity against claims of contracting COVID-19 at the health care facility. If an adequate disclaimer is provided to the patient prior to entry or appropriate signage is displayed at the point-of-entry, in accordance with the font and placement requirements, a health care organization is shielded from a COVID-19 liability claim. COVID-19 immunity best practices While Executive Order 04.14.20.01 and S.B. 359 support health care organizations by providing liability immunities during the COVID-19 Public Health Emergency, it is important for health care organizations to document the steps that are taken to comply with infection control guidelines to prevent the spread and transmission of COVID-19. Additionally, health care organizations need to continue communicating with their patients and offering routine medical care to prevent any allegations about delaying a patient’s
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diagnosis or care. Patients have the right to make informed decisions about obtaining medical care and may choose to delay or forgo recommended care during the COVID-19 pandemic. If this occurs, health care organizations should take steps to ensure that those patients understand the risks, benefits, and alternatives before making an informed refusal. Those conversations and any variation in care should be explicitly documented in the applicable medical records.
(legal ‘apologies’ article continued from page 20) are good for patients and patients’ families after bad outcomes. They are also good for physicians and other health care providers. It is unclear whether they truly prevent patients or their families from pursuing a legal action.
In some cases, it probably doesn’t matter whether an apology is given or not. Regardless, Georgia law encourages these discussions by preventing them from being used against you in any legal action pursued after a bad outcome. Like many other medical-legal issues, effective communication and documentation are critical to both the medical and the legal
References Executive Order 03.20.20.02 authorized telemedicine licenses to out-of-state physicians pursuant to O.C.G.A. § 43-34-31.1 and granted temporary Georgia licenses for pharmacists who are currently licensed in good standing in another state; Executive Order 03.23.20.02 authorized unlicensed nursing school graduates and providers with licenses expired in the past five years to provide health care services during the COVID-19 Public Health State of Emergency in Georgia. 2. Georgia COVID-19 Pandemic Business Safety Act, Georgia General Assembly, 2019-2020 Reg. Sess., SB 359 (Ga. 2020). 3. O.C.G.A. § 38-3-35. 4. Exec. Order 04.14.20.01. 5. Auxiliary management workers include air ambulance services, ambulance providers, emergency medical services systems, EMSC programs, local coordinating entities, cardiac technicians, emergency medical technicians, paramedics, and paramedic clinical preceptors. 6. Effective August 7, 2020. 1.
outcome. Consultation with risk management and legal counsel is recommended when considering these conversations. Huff is a founding partner in the law firm of Huff, Powell & Bailey, LLC. He represents physicians, hospitals and other health care professionals throughout Georgia in professional negligence lawsuits. Huff is a regular contributor to the Journal. Contact Huff at dhuff@ huffpowellbailey.com or 404.892.4022. Paid editorial content.
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HEALTH CARE HEROES
Phoebe Health: At the unlikely center of the COVID-19 storm By Steven Kitchen, M.D.
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Steven Kitchen, M.D.
ike many community-based hospitals, in late 2019 and early 2020 Phoebe Health was carefully monitoring the progress of the novel Coronavirus outbreak via communications from the Centers for Disease Control and Prevention (CDC), Georgia Department of Public Health, and the Johns Hopkins Center for Systems Science and Engineering COVID-19 Global Dashboard. We had activated our emergency preparedness team, updated our infection prevention policies to align with CDC guidelines, and assessed our inventories and vendor allotments of PPE. We felt reasonably well positioned to respond to the emerging viral pandemic based on the projections at that time. However, we never envisioned the fury and magnitude of the gathering storm clouds that were soon to descend upon Albany and the Phoebe Health system.
The old adage that heroes run towards a fire rather than away from one was embodied when I observed two of our critical care nurse practitioners and one of our intensivists walking into the MICU (which was “Ground Zero” for COVID) to assist their colleagues when all hell was breaking loose. I vividly recall many instances of nurses, physicians, respiratory therapists, and other personnel garbed in full PPE and staying in patients’ rooms for hours without interruption to provide care under the most demanding of circumstances. I recall late one Friday afternoon touring two floors of our medical office building that were being used to sew and assemble cloth masks and becoming overcome with emotion when I observed dozens of our Phoebe family working away on an ad-hoc assembly line with the singular purpose of making a difference and keeping our workforce safe.
Tuesday, March 10 proved to be a seminal day. One of our critical care physicians informed me that he had been notified that a patient who had been treated in one of our ICUs and later transferred to an Atlanta area hospital had tested positive for COVID-19. The patient’s spouse, hospitalized at the same facility, had also tested positive. The patient had traveled from Atlanta to Albany to attend a funeral, unknowingly serving as one source that resulted in widespread community transmission. Later that afternoon, Phoebe admitted its first confirmed case of COVID-19. Within 24 hours, four additional patients suspected of COVID were admitted.
Any attempt on my part to recognize the legions of Phoebe employees and medical staff, both clinical and non-clinical, who worked tirelessly to serve our community during this crisis, would be woefully inadequate. However, there are some individuals whose presence, service, and leadership were truly extraordinary and deserve special recognition.
At the directive of our system CEO, Scott Steiner, we activated our emergency preparedness response plan and converted our boardroom into a central command center. We designated a 36-bed general medical unit on the 8th floor and our 12-bed MICU on the 8th floor to cohort COVID patients. Within 48 hours, both units were full and we began converting additional general medical units and ICU beds into COVID units. We soon found ourselves with more than 100 medical beds and all 38 ICU beds occupied with COVID-19 patients. Scrambling to stay ahead of the tidal wave of affected patients, we converted an 11-bed medical unit into an additional COVID ICU, and we converted our PACU into a makeshift ICU for non-COVID patients. Our emergency rooms continued to be inundated with patients presenting in acute respiratory failure, exceeding our bed capacity, and severely taxing our staffing resources. At the peak of the surge, our COVID census exceeded 160 and 30 COVID admissions per day. Our system clearly needed help, and our sister facilities across the state answered the call – accepting patients and lending a much-needed hand to Phoebe in our hour of need. Martin Luther King Jr. once stated that “a measure of a man is not where he stands in moments of comfort and convenience, but where he stands in times of challenge and controversy.” Likewise, I believe that the true character of an institution or enterprise is not revealed in easy times, but rather during adversity, hardship and crisis. I will be forever inspired by the images and memories of the countless and selfless acts of courage and heroism I witnessed during the height of the COVID crisis at Phoebe.
Medical Director of Critical Care Jyotir Mehta, M.D., was a permanent fixture in our ICUs for many weeks, and he provided steady leadership and remarkable adaptability in the face of unprecedented tumult and uncertainty. Director of Chaplaincy Will Runyon also had a constant presence in our ICUs, bringing immeasurable comfort and support to both patients and staff in the midst of untold suffering. He valiantly assumed the difficult task of FaceTiming family members during end-of-life situations, and many times was the sole person in the room with the patient when the family said their last goodbyes from an iPad. CFO Brian Church and Vice President of Supply Chain Trey French literally sourced the globe to obtain the necessary PPE and other essential supplies that we needed to meet our patients’ care needs and ensure the safety of our workforce. However, the Phoebe response to the immense burden of COVID-19 in our communities ultimately emanated from the exceptional leadership that was provided by Phoebe Health System President and CEO Scott Steiner. From the most nascent days of COVID-19 at Phoebe, Scott embraced the challenge at hand, and he guided our institution through the crisis with unparalleled poise, courage, and grace – a source of unwavering inspiration for all. The countless acts of heroism that were displayed by physicians and other health care personnel throughout the COVID-19 pandemic are a powerful testament to the professional ethos that has endured for centuries. Despite the many intrusions into the practice of medicine, physicians and other health care professionals remain steadfast in answering the call, responding to the crisis, looking beyond themselves to a higher purpose, and ensuring that patients receive compassionate care – even under the most difficult of circumstances. I am honored and humbled to serve at their side.
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CMS & SPECIALTY NEWS
COUNTY MEDICAL SOCIETY NEWS Bibb County Medical Society
by Dale Mathews, Executive Director The Bibb County Medical Society (BCMS) has not been able to hold in-person society meetings in the spring or summer due to the COVID-19 pandemic. BCMS has been encouraging citizens in Central Georgia to wear face coverings. BCMS sent letters to Georgia Gov. Brian Kemp and Macon-Bibb County Mayor Robert Reichert to address the medical importance of wearing masks during a pandemic. BCMS also distributed a news release addressing the urgent need to wear face coverings and for patients to take other precautions, and BCMS President Zach Lopater, M.D., was interviewed by a local TV station on the topic. DeKalb Medical Society
by Melissa Connor, Executive Director A free ‘Medical Cannabis in Georgia’ dinner meeting that the DeKalb Medical Society (DMS) was scheduled to host for its members in the fall will be rescheduled in the first quarter of 2021. The event is being sponsored by Curaleaf (curaleaf.com), which is a medical cannabis company. DMS will distribute details once the event has been rescheduled. Contact Melissa Connor at mconnor@pami.org with questions or to join DMS.
Muscogee Medical Society
by Dan Walton, Executive Director The Muscogee County Medical Society’s (MCMS) Board of Directors is monitoring the COVID-19 outbreak and will resume the society’s monthly meetings once it determines it is safe to do so. Go to www. muscogeemedical.org for details about MCMS and call Dan Walton at 706.733.1561 with questions. Richmond Medical Society
by Dan Walton, Executive Director The Richmond County Medical Society’s (RCMS) Board of Directors is monitoring the COVID-19 outbreak and will resume the society’s monthly meetings once it determines it is safe to do so. Go to www. richmondcountymedicalsociety. org for details about RCMS and call Dan Walton at 706.733.1561 with questions.
MEMBER NEWS Anurag Sahu, M.D., and Kenneth Taylor, M.D., are members of the 2021 ‘Leadership Atlanta’ class. Dr. Sahu is an associate professor of medicine with Emory Healthcare and a member of the MAG Foundation’s Board of Trustees, while Dr. Taylor is a cardiologist with Piedmont Healthcare. Sudhakar Jonnalagadda, M.D., was recently installed as the 37th president of the American Association of Physicians of Indian Origin (AAPI) – which is the “largest ethnic medical body in the U.S.”
Dr. Jonnalagadda is a boardcertified gastroenterologist/ transplant hepatologist in Douglas and a graduate of the MAG Foundation’s Georgia Physicians Leadership Academy.
SPECIALTY MEDICAL SOCIETY NEWS Georgia Academy of Family Physicians
by Tenesha Wallace Hood, Director of Communications and Public Health The Georgia Academy of Family Physicians (GAFP) is scheduled to honor five of its members with awards during the organization’s virtual 2020 ‘Annual CME Meeting’ on November 13-14. This includes Beulette Hooks, M.D., FAAFP, of Midland (Family Physician of the Year), Julie Dahl-Smith, D.O., FAAFP, of Augusta (Family Medicine Educator of the Year), Mike Busman, M.D., FAAFP, of Americus and Eddie Richardson Jr., M.D., FAAFP, of Eatonton (Community & Volunteer Services Awards), Chivon Stubbs, M.D., of Atlanta (Resident of the Year), and Ryan Smith, M.D., of Atlanta (Keith Ellis Resident Award). Visit www.gafp.org or call Tenesha Wallace Hood at 800.392.3841 for information on GAFP. Georgia Chapter of the American Academy of Pediatrics
by Kasha Askew, Director of Membership & Education The Chapter has sent weekly email updates that featured resources and tools to its members and non-members since the beginning of the pandemic. The Chapter also
offered free virtual learning via webinars on telehealth, COVID-19, immunization, breastfeeding, and more. These were recorded and are available at www.gaaap. org. The Chapter’s fall CME meeting, ‘Pediatrics on the Parkway,’ will be held virtually on Saturday, October 31 and Sunday, November 1. Rebecca Reamy, M.D., from Columbus is this year’s program chair. The program will feature presentations on dermatology, adolescent OB-GYN, headaches and seizures, and a ‘Martin Michaels Advocacy Lecture’ by American Academy of Pediatrics President Sally Goza, M.D., who is from Fayetteville. Participants will also have access to on-demand, preconference seminars on pediatric orthopedics and sports medicine; coding and practice management; hospital medicine; and office emergencies and disaster preparedness. The program will also feature a virtual exhibit hall and a virtual poster hall. Go to www.gaaap.org to register. Having thanked its outgoing president Terri McFadden, M.D., for her leadership and hard work, the Chapter installed Hugo Scornik, M.D., of Conyers as its president on July 1. Georgia Chapter of the American College of Cardiology
by Melissa Connor, Executive Director The Georgia Chapter of the American College of Cardiology’s 2020 Annual Meeting is scheduled to take place at The Ritz-Carlton Reynolds, Lake Oconee in Greensboro on November 20-22. The event will include
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sessions on CV risk and prevention, the diagnosis and treatment of ischemic heart disease, case-based viewpoints, congenital heart disease, cardiovascular imaging, diversity and inclusion, and instructive cases. It will also feature fellow poster presentations and an alwayspopular ‘Jeopardy’ competition. Contact Melissa Connor at mconnor@pami.org with questions or to join GA-ACC. Georgia College of Emergency Physicians
The Georgia College of Emergency Physicians will host the ‘Georgia Emergency Medicine Leadership and Advocacy Conference’ (GEMLAC) at
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The Ritz-Carlton Reynolds, Lake Oconee in Greensboro on December 3-4. Go to www.gcep.org or contact Karrie Kirwan at karrie@ theassociationcompany.com for details. Georgia Gastroenterologic and Endoscopic Society
by Dan Walton, Executive Director The Georgia Gastroenterologic and Endoscopic Society’s (GGES) annual meeting that was scheduled to take place in September has been cancelled because of the COVID-19 pandemic. Go to www.ggesonline.org for more information or to join GGES.
Georgia Neurosurgical Society
The Georgia Neurosurgical Society’s (GNS) ‘Fall Meeting’ is scheduled to take place at The Ritz-Carlton Reynolds, Lake Oconee in Greensboro on December 5-6. In addition to the in-person meeting, a virtual component is available. Go to www.ganeurosurgical. org or contact Karrie Kirwan at karrie@theassociationcompany. com with questions or to join GNS. Georgia Society of Otolaryngology/Head & Neck Surgery
The Georgia Society of Otolaryngology/Head & Neck Surgery’s ‘Fall Meeting’ will take place at The Ritz-Carlton
Reynolds, Lake Oconee in Greensboro on December 5-6. Go to www.gsohns.org or contact Karrie Kirwan at karrie@theassociationcompany. com with questions. Submit your county medical society, member or specialty society news to Tom Kornegay at tkornegay@mag.org. Also contact Kornegay with any corrections, which will run in the next edition of the Journal. The Journal reserves the right to edit submissions for length and clarity. Bolding recognizes the physicians who are active MAG members at the time the Journal was prepared. Go to www.mag. org/membership to renew your MAG membership.
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PERSPECTIVE
Life, death & the in-between Mark Murphy, M.D.
I
t all started with a chest x-ray. Before the chest x-ray, I’d harbored some vague notions of invincibility. My mother and father-in-law both died young, which should have been enough to dissipate any illusions. Despite this, I was living my dream life in those days. I had married Daphne, my childhood sweetheart, and we were the parents of two beautiful children. I was in training to be a gastroenterologist in Chapel Hill, North Carolina. Things just seemed right. But Daphne had developed a persistent cough, so I ordered a chest x-ray for her as a precaution. That examination revealed another reality: A cancerous mass the size of a bowling ball filling her chest, encasing her aorta, and crushing her trachea. To make matters worse, I looked at the films myself, even before the radiologist. Daphne stood right behind me while I struggled to describe what I was seeing. I’ll be honest: When I first saw the tumor, I thought Daphne was going to die. And I could not tell her that. We held hands in silence that day on the way home, the terrible gravity of our new reality hanging unspoken between us. When the tears came at last, they came in a torrent so intense that we had to pull over to the edge of Highway 15-501. “The kids won’t remember me,” Daphne said. That blunt statement crushed me. The eventual diagnosis was Hodgkin’s lymphoma, advanced but eminently treatable. After six months of surgery, chemotherapy, and radiation therapy we had our lives back. A few years later, at age 42, Daphne was found to have breast cancer – a consequence of radiation therapy she had received for the lymphoma. But she had a bilateral mastectomy and survived that, too. I’m 58 years old now. Daphne and I have now lived long enough to see our children marry. We even have a granddaughter. As a physician, I have intimate experience with people at the extremes of their lives. Having witnessed both the beginning of life and the end of it, I have come to realize that there is the potential for profound beauty in what lies in between. The COVID-19 pandemic has brought me a fresh perspective. We’ve all had to contend with the “new normal” of social distancing, mask-wearing, and the very real potential risk of
contracting COVID ourselves. I’ve had colleagues, friends, coworkers and relatives become infected with it. I’ve watched several COVID patients die, alone and isolated from their families. Our society has hit the pause button on many of the things that define the milestones in our lives, from weddings to funerals and everything in between. Today’s world has become a cavalcade of the strange, from riots, earthquakes, and hurricanes to comets, dust storms and plagues of locusts – creating a pervasive aura of impending apocalypse. But life goes on – adulterated, but persistent. And despite the stress of the pandemic, we should all take a moment or two to reflect upon what this all means. First of all, we are not immortal. At some point, we are all going to die. And that makes every second of our lives precious, every memory vital, and every experience something worth cherishing. Second, we should all try to make a difference in the world – not for ourselves, but for others. The late John Lewis once said, “If you see something that is not right, not fair, not just, you have a moral obligation to do something about it.” Our lives should not be driven by selfishness, or by the base needs of material acquisition, but by the desire to do the right thing, driven by courage of our convictions. Finally, we should all learn to appreciate the fundamental power of love. Love is the most powerful of human emotions – and yet we all too frequently squander it, failing to appreciate how truly important it is until the people we love are gone forever. Recently, Daphne developed yet another dry cough. She didn’t feel ill, and she had no fever, but the cough persisted for weeks. Last week, Daphne got another chest x-ray. It was all clear. You see, age has its negatives: Our waistlines expand, our skin wrinkles, and our hair turns gray. But with age also comes wisdom – and with wisdom comes the ability to count your blessings while you have them. That’s the intrinsic beauty of the in-between. Count me among the blessed. You should count yourselves, as well. Dr. Murphy is a Savannah gastroenterologist, a longtime MAG member, and a former president of the Georgia Medical Society.
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