"2020:The Year Of Clear Vision For Physicians & Patients Alike" Cover Created by Dr. Dana Corriel

ISSUE 1 | VOLUME 1

JANUARY/FEBRUARY 2020 2020 IS THE YEAR OF CLEAR VISION FOR PHYSICIANS AND PATIENTS ALIKE

WWW.PHYSICIANOUTLOOK.COM PUBLICATION DEDICATED SOLELY TO PHYSICIANS AND THEIR PATIENTS

Cover art digitally created by Dana Corriel, MD; credits: Perchek Industries & Olga Guryanova

F R O M T H E P U B LISHER

Mad As Hell I'M AS MAD AS HELL... . . . A N D I ' M N O T G O I N G T O TA K E THIS ANYMORE!

The answer is not to leave our profession in droves.

Medicine is Our house, and we are taking it back! without paying much attention to the outside world or cues.

We ignored what happened when HMO’s came into being. We let it go when “Managed Care” started becoming synonymous with health care. We

Wri t t en by D r. M a rl ene Wu st- S mith, M. D.

didn’t push back when insurance companies started to request “prior authorization” and “peer review” at every turn.

W

We turned a blind eye when the Medi-

hen I first sat I down to

curse. Our brains and thoughts have

care fee schedule became the standard

write this column for the

helped us get to where we are today. In

by which all encounters are reimbursed.

inaugural issue of Physician

order to earn the title of a medical doc-

We didn’t speak up when the volume of

Outlook magazine, I was paralyzed by

tor, most of us we had to sacrifice our

patients seen was rewarded over value.

inaction. I knew what I wanted to

childhood, adolescence and our 20’s to

We ignored it when more and more of

say, but was continuously distracted by

early 30’s to an educational tract that

us came under the employ of corporate

rapid fire thoughts that interrupted the

forced us to delay gratification and give

America and left our private practices.

process of putting pen to paper. The

up our autonomy. Many of us go into a

We didn’t understand the Affordable

average human is estimated to have

tremendous amount of debt to finance

Care Act and, like the legislators who

40,000-60,000 independent thoughts

medical school (to the tune of $250,000

signed the Act into law, we never read

while awake every day. If I had the

to $300,000) even though intellectually

the fine print. As a group, with few

attention span to count or record my

we know that this is not a “smart” thing

exceptions, we kept seeing our patients

own thoughts, I would venture to say

to do. We do it because we care. We do

instead of being at the drawing table

that I am more likely to be in the 60-

it because we want to be physicians with

when Electronic Health Records were

80,000 range! I strongly believe that I

every fiber of our being.

being designed. We did not attend the

am not alone. Most physicians are not

So, what has happened? Why are

Town Halls when healthcare legislation

“average” and are likely to be outlier

so many of us finding ourselves so un-

was being crafted. We did not speak up

companions on the far right of that bell

happy with the profession we dreamed

when we witnessed injustices being com-

curve of thoughts per day. The process

about since we were children? I think

mitted. We assumed it was the responsi-

of deciding to become a doctor starts

most of us ignored what was going on

bility of others, thinking that someone

when we are very young, and requires a

around us. In order to be successful

else had the best interest of the patients

vigorous course of studies and tenacious

doctors, many of us have a tendency to

in mind...and if it’s good for patients, we

determination that never lets our minds

bury our heads in the sand, to take on

would comply obediently in the name of

shut down.

the persona of “the absent-minded pro-

“Doing No Harm.”

The ability to produce all of those

fessor.” We put our “nose to the grind-

What we didn’t bank on is the myr-

thoughts is both a super-power and a

stone” and do what needs to be done,

iad of special interest groups who have

2 | J A N UA RY/ F E B RUA RY 2 020

inserted themselves in between the phy-

We are at a crucial time in histo-

“side gigs”). Those who are staying are

sician and our patient. When it takes 32

ry. Physicians are looking for a way out

plagued by issues with addiction, either

clicks to order a single flu vaccine in an

of medicine almost as quickly as they

in themselves, or in their loved ones who

Electronic Health Record, it doesn’t take

finally finish their training to become

are suffering the consequences of having

a rocket scientist to figure out that doc-

attendings. Most of us are trying to

a physician-relative who is burning out

tors are getting fed up. The order that

dissuade our children from following

and feeling powerless to stop the process.

used to take a physician a millisecond

in our footsteps, instead of being proud

Who will take care of US as we

to jot down (granted, in a hieroglyphic

and flattered when they express an inter-

age? Many physicians in the workforce

scribble that only his or her nurse could

est in becoming physicians.

in place today have by and large become

probably decipher) now takes a series

Many of our readers may be too

disengaged. They are passively obeying

of steps and clicks that drives even the

young to remember the movie “Net-

their masters, and clicking and F2’ing

most tech-savvy amongst us to exasper-

work” which came out in 1976, but it’s

their way through long notes that are

ation and burn-out.

high time to open up our windows and

nothing more than billing documents.

shout “I’m mad as hell and I’m not going

We need to collectively put our individ-

to take it anymore!”

ual 40,000-80,000+ thoughts per day to

It’s no wonder that most physicians report frustration because they feel they have been demoted to an overpaid, over-

The reason that I am launching the

good use and pull the rug out from all

worked “data entry clerk” who spends

Physician Outlook magazine is to help

of those who think that they know how

more time charting than they do with

others who are fed up, like me, open that

to best take care of patients and reform

their patients. The “business” of health-

window up in unison. There is strength

health care.

care has taken front seat to patient care

in numbers. We need to--as the young-

delivery. It’s #profitsoverpatients every

er generation would put it--become

place we turn, and it’s not good for

“woke.” We can’t continue to passively

anyone (except maybe the stakeholders

allow our patients and our physician

at the top of the collusive mergers that

colleagues to suffer silently. We are be-

plague our healthcare system today).

ing herded like sheeple by Hospital and

Physicians are being replaced in

Health System Administrators, Insur-

droves throughout the country by less

ance Companies, Pharmaceutical Ben-

educated, often scantily trained alter-

efit Managers, and Group Purchasing

natives. When I get on an airplane, I

Organizations. We are being forced to

expect a fully licensed and experienced

supervise and take the liability for care

pilot in the cockpit, not a flight atten-

provided by non-physicians, and being

dant who has taken a few flying lessons

asked to stay quiet while under-trained

and whose experience is primarily from

and under-prepared replacements are

a simulator. Yet marketing campaigns

being exploited in the name of the al-

for nurse practitioners describe them as

mighty dollar and “access” to care.

having “Brains of a Doctor, Heart of a

It’s time to put a stop to the mad-

Nurse.” There is a movement advocat-

ness and at the very least, spread aware-

ing to change the name of the profes-

ness, and change things where we can.

sion “physician assistant” to “physician

The answer is not to leave our profession

associate,” to appease those who resent

in droves (either by suicide or by leav-

the impression that they are assistants.

ing Medicine for non-clinical jobs or

Medicine is OUR house, and we are taking it back! 1

Dr. Marlene Wüst-Smith Publisher WWW.PHYSICIANO U T LOOK . C OM | 3

Doctors Got Bank

Are you interested in reaching a customer base with high end tastes and money to spend?

Advertise with us Today!

Contact hello@physicianoutlook.com or visit www.PhysicianOutlook.com.

A Publication Dedicated Solely To Physicians And Their Patients.

WWW.PHYSICIANOUTLOOK.COM

JA N UA RY | FEB RUA RY 2020

Table Of Contents FROM T HE PU B LI SHER

Mad As Hell

By Dr. Marlene Wust-Smith / p.2 VI PP SPOT LI G HT

How One Doc Mom Found Her People On A Bike To Nowhere

By Alli Wittbold /p.6 A DVOC AC Y I N AC T I ON

Doctors Vs. "Doctors"

By Dr. Marlene Wust-Smith / p.9 Malpractice Costs Will Soar If NPs Are Deemed On Par With Physicians

By Peter Leone and Craig M. Wax, D.O. / p.10 Patients Beware!

By Estine Wells / p.11 OFFI C E SPAC E

How Telemedicine Intersects With AI, Social Media And Precision Medicine

By Dr. Sherry-Ann Brown / p.12 N EW N EWS

Preventing Addiction In Adolescents

By Alicia Roselli /p.14 Harnessing the Power of the Physician-Patient Relationship

By Rebekah Bernard / p.16 Replacing Doctors With Mid-Levels?

By Dr. Dina Strachan /p.20 IN T ELLI G EN C E ON T HE MOVE

Popular Podcasts

By Pamela Ferman /p.21

How Words Can Heal - Invitation Only

By Dr. Jean Robey /p.22 T I ME FOR YOU

Chicken Marsala Recipe

By Tina Georgopoulos /p.23 Meal Delivery Services - Which Is Right For You?

By Alicia Roselli /p.24

WWW.PHYSICIANO U T LOOK . C OM | 5

V IP P S P OT LIG H T

PHOTO TAKEN ON DR. HAWKIN-HOLT'S IPHONE BY A RANDOM FELLOW PELOTON DOC OR PELOTONIAN

How One Doc Mom Found Her People On A Bike To Nowhere A PHYSICIAN MOTHER SHARES THE WAY PELOTON CHANGED HER LIFE Wr i tte n by A l l i W i t t bo l d

“I

did not expect to get what I’ve gotten. I can guarantee you that,” Dr. Melissa HawkinsHolt, a rheumatologist from outside of Baltimore, explained when I interviewed her about her experience with Peloton since she invested in her bike two years ago. She, and a group of over 500 other mothers in medicine, have found their people in a place they never expected, on a bike to nowhere.

When Dr. Hawkins-Holt purchased her Peloton bike after receiving a work bonus, she thought she was going to get a great workout. She re6 | J A N UA RY/ F E B RUA RY 2 020

marked, “That was the whole point. I was going to get it because I wanted to maintain weight loss and that’s all I expected out of it,” but what she, and her daughter got, was so much more. They found a healthier lifestyle, a supportive community and unexpected friendship.

The Doc Moms Peloton was founded in 2012 as a solution to the dilemma of so many who want to fit fitness into their schedule. According to their website, Peloton provides users with a “world-class indoor cycling studio experience on your

time, and in the comfort of your own home.” Since its start with a stationary bike, Peloton now offers a treadmill and an app that gives members access to a variety of live fitness classes.

The Peloton experience is sweeping the nation and changing the way Americans exercise, and it’s not just because of the incredible workout. Peloton has created an active and supportive community of people within their platform and on social media channels.

The Official Peloton Member Page has more than 200,000 members. From there, users can find their own tribe

that she does. The members of the Doc Moms have become her friends. “That’s it. They’re my friends. I don’t care if I met them on social media, they are my friends in every sense of the word. When bad things happen, they step up; we care about each other.”

The connection Dr. Hawkins-Holt has made with the Doc Moms goes well beyond the bounds of the bike and social media. These women are connecting in real life, in a very real way. The group has organized three “home rider invasions” in New York City, where over 100 members of the group attended a weekend event in New York City to ride in the Peloton studio, see shows, eat and enjoy each other’s company.

She’s met up with friends from the group when they’re traveling through her hometown in the Baltimore metro area, and she’s connected with other members while traveling herself. Dr. Hawkins-Holt even spent Easter weekend with her daughters at a fellow Doc Mom’s family home in Chicago last year.

Dr. Hawkins-Holt’s story doesn’t stop there For Dr. Hawkins-Holt, her own experience with Peloton brought her friendships and a healthy lifestyle she never had before, but it’s what Peloton has done for her daughter that she is forever grateful for. “I am so one thousand percent dedicated to this company because it’s been great for me. I’ve finally found my people. I’ve found friends that I’ve never had in my entire life. But it’s even more important for her [my daughter] because it’s changed her entire world.”

Dr. Hawkins-Holt’s 15-year-old daughter, Lindsey, has always been a highly competitive and athletic girl, but struggled with her weight and self-confidence after puberty started. After Dr. Hawkins-Holt got her Peloton bike in September 2017, Lindsey took a vague interest, she’d done maybe 20 rides and found the trainers inspiring but didn’t really commit. That all changed in June 2018.

“I am so one thousand percent dedicated to this company because it’s been great for me. I’ve finally found my people. I’ve found friends that I’ve never had in my entire life. But it’s even more important for her [my daughter] because it’s changed her entire world.”

—Dr. Hawkins-Holt L i n dse y i s t h e y o un ge st i n h i st o r y t o r e ac h t h e 1000 Pe l o t o n r i de mi l e st o n e .

Co n gr at ul at i o n s!

PHOTO COURTESY OF ALLI WITTBOLD

in other Peloton Facebook groups like Pelowinos, Peloton Teacher Warriors, and groups connected to certain instructors.

For Dr. Hawkins-Holt, that group is the Physician Mom Peloton Group, or as they called themselves for short, the Doc Moms. It’s a group of around 500 physician mothers from all over the country who share a common love for Peloton. After Dr. Hawkins-Holt caught wind of the group and joined, she felt instantly connected.

“Quickly, these became my people,” she shares. “We connected because we could take the classes together, but it just leads to so much more. There will be discussions on our Facebook page about something that happened on a class, and then as people get to know each other more and more it’s about something that happened in our lives. That evolution has been amazing.”

Like so many women in medicine, Dr. Hawkins-Holt put her life on hold to pursue her career. With the years of training and stress involved with becoming a physician, she finished and felt like she had no friends. “Here I am. I’m ready to take on the world and I’m like, I have no one to do anything fun with,” And this experience isn’t unique to Dr. Hawkins-Holt. Physicians everywhere give up their 20s and 30s to complete their education and training, often giving up relationships, accruing significant debt, and enduring what can only be described as burnout.

What’s more, after becoming a mother, it was difficult for Dr. Hawkins-Holt to connect with other moms, creating an even greater sense of isolation when it came to finding friends. “These women don’t get me. I’m working a lot.

When my kids were young, everyone knew my nanny; no one knew me. Because I was never there.”

But Peloton changed that. Because for the first time she feels like she has a real community. A community of other women with her shared experience of being a mother and a physician; women who share the same challenges and joys

WWW.PHYSICIANO U T LOOK . C OM | 7

While visiting her older daughter at a summer ballet intensive in New York City, Dr. Hawkins-Holt invited Lindsey to ride with her in studio, and that one ride was all it took. “I think what happened was she was in studio hearing the milestone shout outs…I remember we left that day and she said, ‘Mom do you think I could get 100 rides by the end of the summer?’ And that became her mission.

Since June 2018 she’s done 900 rides.”

Lindsey is unique in the Peloton community because she is only 15. Yet, she doesn’t just ride, she gives it her all, consistently beating grown men and women. Her mother shares, “She’s so unique in the Peloton community that she’s gotten a lot of attention because of it. A lot of the instructors know her, they celebrate her, they are happy to see her, have done some special things for her.

And that has set it for her, it’s been really meaningful for her.”

Because of Peloton, Lindsey has become more confident, happier, and so strong. Like her mom, she’s found her tribe of people in a group connected to instructor Jess King, The Jess King Collective. Lindsey and Dr. Hawkins-Holt have attended meet-ups for this group as well. Dr. Hawkins-Holt spoke about the experience, “It’s a bunch of grown people, who love my daughter! They celebrate her. They’re kind and inclusive to her. She walked in there [to the home rider invasion in NYC] and she was surrounded by friends. She found her people.”

How the Doc Moms helped Lindsey better understand her mom It’s not just Lindsey’s group of people and the instructors that have been a source of support to her. The Doc Moms have also embraced, supported and celebrated Lindsey in her journey. Dr. Hawkins-Holt shared about two weekend retreats with a few other Doc Moms where Lindsey was invited to come along.

The experience was meaningful for both mother and daughter because it was the first time Dr. Hawkins-Holt felt like her daughter had been around other women like her.

8 | J A N UA RY/ F E B RUA RY 2 020

Pictured here are many Physician Mom Docs that have met "IRL" (in real life) at "HRIs" (Home Rider Invasions) at the Peloton headquarters in NYC

“It was the first time Lindsey had been exposed to other women that were just like me. And she was absolutely fascinated with it. She just hung onto every word that these women were talking about. I think it was good for her to see that I’m not, like, a freak,” she laughs.

“I’m not alone, I’m not the only one.

There are other women that are just like me.”

When I asked what that meant she said, “We’re stressed; we’re trying to keep it all together. We’re equally fierce and stressed.” She went on to say that this experience wasn’t unique to Lindsey. Many of the Doc Moms’ children have formed friendships themselves and connected on social media. “It’s been good for her [Lindsey], as well as I suspect for the other children of these women, to see what women do. And see how fiercely women live.”

What about her daughter’s future?

With all the changes in medicine today, many physicians are steering their own children away from the stressful realities of working in the field. When I asked Dr. Hawkins-Holt if she’d want her daughter to follow in her physician footsteps, the answer surprised me.

“She’s a smart kid. I think she always thought she would become a physician and I’m okay with that. I think medicine has changed a lot. It’s definitely not what

we got into years ago. There’s so many things that have changed and made it different and somewhat stressful. But I still think that at the heart of it you’re still doing the things you got into it for. We’re still changing lives, saving lives, treating disease. We’re still doing that.”

And at the end of the day, Dr. Hawkins-Holt says she can’t really predict what her daughter will do with her life.

But right now she sees the way she is inspiring and changing people through a fitness platform, and knows that a spark for helping others is there. Peloton has given Lindsey that confidence.

Peloton’s positive impact has changed their lives forever For Dr. Hawkins-Holt, purchasing her bike on somewhat of a whim two years ago changed her life in ways she could have never imagined. For the first time in her life she had a support group of friends that she could relate to, was in better shape, and saw a transformation in her 15-year-old daughter from a self-conscious teen into a confident and strong young lady.

As we ended our conversation Dr. Hawkins-Holt remarked, “There’s been some really amazing things that have come out of this. It’s what I’d really describe as true friendship. And I never had it. Because I was too busy becoming a doctor. And I’m in better shape, too.” 1

A DVO C AC Y IN AC TI ON

tory billing requirements, conditions of participation, supervision requirements, benefit definitions, and all other licensure requirements … that are more stringent than applicable federal or state laws require and that limit professionals from practicing at the top of their profession” Basically, this Order is giving Health and Human Services a one-year deadline to propose a regulation to ensure that services, “whether done by physicians, PAs, or NPs are appropriately reimbursed in accordance with work performed rather than the clinician’s occupation.” So, the “haves” will continue to see “real” board-certified, properly trained physicians, while the “havenots” will be seen by lesser-trained, less-expensive, online-trained “Advanced Practice Providers.”

Let’s be clear. I highly respect nurses, well-trained, experienced NPs and PAs. I fully support my 19-yearold daughter’s career choice to become an orthopedic PA. But that respect doesn’t erase my concerns.

Doctors Vs. “Doctors” T H E D E V I L I S I N T H E D E TA I L S .

Wri t t en by D r. M a rl ene Wü st- S mi t h, M . D.

PHOTO COURTESY OF INGRAM IMAGES

How does the Order define a Doctor?

It matters.

P

resident Donald Trump recently signed an Executive Order in October 2019 (Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors) that proposes lower costs, the ability for patients to fund and use Health Savings Accounts, and the ability to see physicians who don’t accept Medicare. My heart was pounding with joy as I read the Order…until I got to Section 5.

The first paragraph is wonderful, stating that within one year of the date

of the Order, reforms will be made to the Medicare program to enable providers to spend more time with patients.

The devil, however, is in the details: how the Order defines a “Doctor.” The AANP is pushing Nurse Practitioners to get their DNP (Doctorate of Nursing Practice), and now physician assistants can get a DMS (Doctor of Medical Sciences). These degrees can be obtained 100% online within one year.

The Order proposes regulation that would “eliminate burdensome regula-

This is my comment to President Trump: When an individual boards an airplane, the expectation is that the pilot is the “captain” of the aircraft, and that s/he has been through years of rigorous training. We don’t allow online/flight simulator-trained f light attendants dubbed “Advance Practice Pilots” to replace actual pilots. The practice of Medicine is much more complex than flying a plane. It is a team-based physician-led art form that works best when the patient and physician are at the center of the relationship. NPs and PAs are important team members but are not physicians. Insurance companies, hospital administrators and middlemen have hijacked the practice of Medicine for profit. It is time to strip them of their power and expose their dirty tactics. 1 "Originally published in Hispanic Outlook magazine" WWW.PHYSICIANO U T LOOK . C OM | 9

A DVOC AC Y I N AC T I ON

Malpractice Costs Will Soar I F N P S A R E D E E M E D O N PA R WITH PHYSICIANS Writte n b y Pet e r Le one and C raig M. Wax, D. O.

Dear Administrator Verma, Deeming non-physicians to be essentially equal

there is no return. There is both a patient and phy-

in training and experience to physicians amounts to

sician expense that has not been calculated.

a dangerous experiment on American patients. It is

Likewise it is irrational and counterproductive

improper and unethical for the federal government

to pay a minimally trained person the same as a

to be making such decisions regarding the scope of

highly trained, experienced person. If the reim-

practice of medical professionals.

bursement is the same for poor quality as for good

I have spent over 40 years as a complex litiga-

quality, but the poor quality costs less to provide,

tion specialist, handling over 35,000 malpractice

the entities that degrade quality have a competi-

claims. It seems the law of unintended consequenc-

tive economic advantage. Medicare’s existing price

es is at play. Currently the “Captain of the Ship”

controls are already impeding patient access to

doctrine limits liability to allied health personnel.

high quality care and should not be exacerbated

It also limits professional and legal liability costs.

by additional flawed policies that further disregard

Placing nurse practitioners and physician assistants

important differences between practitioners.

on par will indeed lead to greater claim frequency

The bottom line is that patients’ lives are at

and increased legal costs. Rates for all providers will

risk. The federal government should follow a policy

increase. In fact underwriters will increase offices

of “first do no harm.” It violates this principle to

with PA’s and NP’s. We could see malpractice costs

impose top-down edicts declaring that non-physi-

for internal medicine practices rise from $1-3,000

cians are qualified to practice medicine. I urge the

to $9-12,000 per allied health professional .

federal government to reject such policies. 1

We saw the law of unintended consequences occur with EHR and once down that “rabbit hole”

1 0 | J A N UA RY/ F E B RUARY 2020

Peter Leone President, Edge Professional Liability Services https:// edgepro.net/

A DVO C AC Y IN AC TI ON

I F I T D O E S N ' T F E E L R I G H T, I T L I K E LY I S N ' T R I G H T.

Wri t t en by Est i ne Wel l s

We, as patients and advocates, must become involved in bringing back the "Physician In Charge"

I

ncumbent upon you or your advocate is to listen, question, take copious notes, and keep all records together so your history is well documented and easily accessible to all physicians involved in your care. When making an appointment to see a physician, you are entitled to see the physician of your choice. Many times you are scheduled with a nurse practitioner (NP) or physician assistant (PA), and you are not aware until your appointment.

Confirm who you will be seeing prior to your scheduled appointment, and confirm again when you check in who you are seeing. A frequent tactic is to tell you that the physician has no available

appointments in the near future, but you can schedule with the NP. I understand that NPs and PAs play an integral role in today’s healthcare landscape. It is the lack of transparency that is most disheartening.

In my experience, most physicians and registered nurses (RNs) display their IDs without having to ask. However, sometimes badges of other health professionals are not as prominently displayed or may be confusing. Always, respectfully, request to know the credentials and specific degrees when meeting a new healthcare professional. The training is not equal. Nothing can replace medical or osteopathic school. Physicians learn

how to make complex differential diagnoses. It is the nuances in their training and other factors like having the most extensive clinical exposure and experience that set them apart, making them comprehensively better trained. NP training is more algorithmic which does not take into consideration the more esoteric healthcare issues and individual differences inherent in patients. It amazes me that specialists must complete medical school, then residency, followed by fellowships.

Yet, many hospitals place NPs within a particular department only to transfer them to another department. How do the NPs get the training and knowledge to go from, perhaps, cardiology to orthopedics, or surgery without getting a substantial amount of additional instruction?

A cavalier attitude offends me the most. I have personally witnessed mistakes, bullying and coercive behavior.

Your bill of rights states clearly that you should never feel uncomfortable. If it doesn’t feel right, it likely isn’t right.

Having worked in healthcare most of my life, I respect, admire, and appreciate all it takes to become a board certified physician. Sacrificing so much for the benefit of others, including ongoing financial obligations, should be applauded and rewarded. However, physicians are being marginalized and viewed as commodities in the business world. We, as patients and advocates, must become involved in bringing back the “Physician in Charge.” That I will save for a future article. Be Well!! 1 PHOTO COURTESY OF INGRAM IMAGES

Patients Beware!!

Physicians learn how to make complex, differential diagnoses. It is the nuances in their training and other factors that set them apart.

Estine Wells graduated from Temple University and has served for many years as a managed care coordinator, medical office coordinator, patient advocate, and entrepreneur. She is involved with several healthcare charities.

WWW.PHYSICIANOU T LOOK . C OM | 11

O F F IC E S PAC E

How Telemedicine Intersects WITH AI, SOCIAL MEDIA, AND PRECISION MEDICINE

Wri t t en by Dr. Sherry-A nn B ro wn, M D, P H D

Editor Note: The future of medicine will be based on disruptive technology - will we lead, follow, or be left behind?

T

elemedicine will eventually become a more prominent part of our clinical practice, with the incorporation of artificial intelligence (AI) and social media and networks, and integration with precision medicine in electronic health records. As clinicians and scientists, we should be thinking about where and how these four innovative strategies intersect, so that we can continue to not only contribute to the conversation and direction of these strategies, but also lead them.

Remote monitoring of physiology is an important component of telemedicine or telehealth. If we are to care for our patients remotely in telemedicine, then we must be able to have data on which to make decisions. Some of the data come from remote monitoring, while some may come from information 1 2 | J A N UA RY/ F E B RUARY 2020

we may already have in electronic health records, in addition to the current history during a consultation. The remote monitoring can also be at the time of the consultation, or monitoring can occur outside of the consultation in real-time continuously, or for a discrete portion of time. The remote monitoring may address different areas of physiology, such as blood pressure, blood sugar, heart rate and rhythm, and so on. With this information, the healthcare professional can potentially make adequate recommendations for prevention and management of disease.

Institutions should also embrace the role of AI in remote monitoring of physiology and use of this data in real-time for prediction of disease. Being able to foresee illness or dysfunction with predictive analytics and AI may provide us with

the opportunity to preempt and prevent imminent decrease in quality or quantity of life (within the scope of individuals’ values and goals, of course). Cooperation between AI and mobile health (mHealth) or digital health can maximize potential in remote monitoring. AI algorithms can help guide the performance of echocardiograms, even in the hands of novices or amateurs. This could be particularly useful if an experienced sonographer or echocardiographer is not immediately physically available on site. An individual could have a telemedicine consultation with an experienced cardiologist, while a novice physically on-site with the patient could perform a brief, limited AI-assisted echocardiogram. ECG and other physiological data from smartwatches, smart T-shirts, smart shorts, patches, and other wearables and biosensors, in addition

P HOTO COU RTESY OF IN GRA M IM AGE S

to the typical or routine equipment used for telemedicine, are also over time being coupled with machine learning to alert clinicians to current or future danger in patient health and wellness. The possibilities for the impact of this coupling on morbidity and mortality, particularly in cardiovascular diseases and other chronic conditions, is vast.

The contribution of social media to telehealth will take different forms.

If properly integrated, patients could reach out to their health care professional teams via social media, with indirect or direct connection with or follow-up from vigilant team members assigned to telehealth and social media. Patients are already posting on social media and in social networks about their medical conditions, and are seeking information online to answer their medical ques-

tions. These patients often also are early adopters of wearables and mHealth.

Perhaps social listening and informatics infrastructures could develop pipelines to streamline connection of patients sharing about medical problems and seeking answers on social media with their on-call health care provider team to optimize care. Physiological data from their wearables and mHealth platforms could be interrogated and provided for analysis and interpretation in real-time, along with the telehealth consultation. These data and consolidation should be included in the electronic health records, which will need to be enhanced to handle such disparate sources of data, clinical interaction, and documentation.

Physiological and analytical data from remote monitoring in mHealth or digital health, coupled with AI algo-

One cannot fully think about personalizing care without mentioning “personalized medicine” rithms and pipelines from social media in telemedicine, can help personalize expedient and efficient care for patients.

One cannot fully think about personalizing care without mentioning “personalized medicine” or “precision medicine,” which incorporates other tools such as genomics and a variety of other “omics.”

These omics can include epigenomics or methylomics, along with other assessments of gene-environment interactions.

Precision medicine is closely related to “systems medicine,” which studies the comprehensive response of the body or parts of the body as dynamic systems that can be perturbed by diverse stimuli, such as the response of the cardiovascular system to administration of therapies for a variety of cancers. Sooner or later, our partnerships in academia, industry, and other facets of society will lead to the creation and use of patient representations in digital systems that synthesize clinical information from patient surveys and visits with physiological, analytical, and precision medicine data.

These are only a small sample of a myriad of reasons why and examples of how telemedicine, remote monitoring, AI, mHealth, digital health, social media, and precision medicine, with integration in electronic health records, might be useful and may become more pervasive in our collaborative multidisciplinary practice of medicine and wellness.

This is indeed the future of medicine.

We will ultimately need to decide whether we will be leading at the forefront or sitting in the back row of this new era of disruptive innovation. 1 Sherry-Ann Brown is a cardiologist.

Source: KevinMD.com, September 6, 2019 WWW.PHYSICIANOU T LOOK . C OM | 13

N EW N EWS

Preventing Addiction in Adolescents A POWERFUL P E R S P E C T I V E T H AT COULD SAVE LIVES. Wri t t en by A l i ci a Ro sel l i

1 4 | J A N UA RY/ F E B RUARY 2020

◊

A

ddiction is a disease, plain and simple. It is not a choice, it is not a moral failure, it is not a lack of will-power. This is an illness that does not discriminate - people of all ages, races, religions, and socioeconomic backgrounds become afflicted.

For a variety of reasons, adolescents and young adults are most vulnerable - some experts claim that substance abuse among adolescents is America's #1 public health problem. There is hope - it can be prevented and it can be treated.

The basis for formulating prevention strategies is understanding how it starts.

So how does it start? How does addiction in adolescents and young adults happen? The devastated parents of an amazing young man who lost his life to an overdose on his 22nd birthday were determined to answer that question, with the goal of helping other parents and Physicians gain a perspective that could save lives. They created a video called "How Addiction Happens." It is short but powerful. In 2018, it was posted by the United Nations Social Development Network. It is being used by schools nationwide in their substance abuse prevention programs, and was chosen for inclusion in the Los Angeles Reel Recovery Film Festival. Can physicians incorporate this into their toolkit as well? 1

The physician community has become the scapegoat for the current opioid crisis in the United States. If one were to believe the headlines without critically thinking about the “big picture,” one might assume that doctors single -handedly caused the epidemic of heroin and painkiller addiction that is currently ravaging communities across America.

We are not without blame, but we were also unknowingly influenced as a profession by powerful lobbyists. Hindsight is 20/20 and we now know that powerful, long-acting narcotics have very limited use in treating chronic, non-cancer pain.

Physician Outlook will be covering different topics monthly as they relate to addiction, as it is a condition that affects ALL of us.

We have close family members who are battling addiction, we take care of patients who are deeply affected, and we ourselves are silently suffering from our own addiction demons (whether it be food, exercise, shopping, work, drugs or alcohol). We need to be at the forefront of these discussions and be open to honest dialogue.

https://www.youtube.com/watch?v=HDfSx_Q7_Yk

WWW.PHYSICIANOU T LOOK . C OM | 15

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Harnessing the Power of the PhysicianPatient Relationship PAT I E N T S U P P O R T I S KEY - DOCTORS CAN'T DO IT ON THEIR OWN. Wri t t en by D r. Re b e k a h B erna rd, M D

I

t is no great secret that physicians are increasingly disillusioned with the health care system, with nearly half of all physicians (The Physicians Foundation, 2018) actively planning to leave the clinical practice of medicine.

The reason that doctors want out of medicine has absolutely nothing to do with patients. In fact, physicians rank patient care as the most meaningful part of their job, and consider patient relationships the greatest source of professional satisfaction (The Physicians Foundation, 2018).

Likewise, patients value their relationship with physicians. 92% of American (The Physicians Foundation, 2018) patients report being happy with 1 6 | J A N UA RY/ F E B RUARY 2020

the care they receive from their primary care physicians, and 80% of Americans (McCarthy, J., 2018) rate the quality of the healthcare they personally receive as "excellent" or "good."

Indeed, patients benefit from a strong relationship with their physician. Studies show that having the same physician over time is associated with lower rates of mortality (Pereira Gray, Sidaway-Lee, White, Thorne & Evans, 2018).

But while Americans value their personal physician, most are dissatisfied (Jones, J. & Reinhart RJ, 2018) with the health care system in general, particularly the cost of health care.

Doctors are also deeply dismayed with the healthcare system, and report

that paperwork, burdensome electronic health systems, and meaningless rules and regulations are driving their exodus out of clinical medicine.

Patients are not oblivious to the toll that the system has placed on physicians.

Many express empathy at seeing their personal physician hunched over a computer keyboard, despite their disappointment at a lack of eye contact during the visit.

Knowing the burden of documentation requirements on doctors, most patients will accept scribes to be present during their office visit, allowing a third party to hear their most frightening symptoms and deepest worries. And increasingly, patients are paying a premium for more personalized medical care outside of the

P HOTO COU RTESY OF IN GRA M IM AGE S

still lose their jobs, with health care organizations increasingly replacing doctors with nurse practitioners and physician assistants as a cost saving measure.

While many patients understand some of the burden being placed on physicians, most do not realize how little power and control the average physician has today.

And very few realize how quickly their doctor can be fired and replaced---often by a lesser trained medical practitioner.

While some physicians are able to escape corporate ownership by turning back to independent practice, many physicians do not have that option. This is a particular problem for doctors who require a hospital setting to work, as a 2010 law banned physicians from owning their own hospitals. Emergency physicians and hospital-based specialists have been hit especially hard by corporate ownership.

These doctors are forced to tow the party line or find themselves out of work.With many doctors unable to practice outside of corporate or government ownership, the only hope for improving the health care system is to harness the power of the physician-patient relationship.

system, including concierge and direct primary care services.

While study after study confirms these root causes of physician burnout, expert recommendations consistently fail to address systemic changes necessary to relieve the burden on physicians.

Instead, doctors are told to manage their time better, delegate more responsibilities to team members like nurses and scribes, and become more resilient to the changes in health care.

With more than 50% of physicians now working as employees of corporations, administrators now call the shots.

These doctors have little choice: get “resilient”—or get fired. And even when physicians play by all the rules, they may

Patient Support is the Key Doctors can’t do it on our own; there are just too few of us, with only 700,000 practicing physicians in the United States.

Moreover, the risks for individual physicians are high, with doctors facing job loss and ostracism for speaking out. But there are far more patients, with about 213 million (Centers for Disease Control and Prevention) Americans being treated by a health care professional in the past year. To make positive change in health care, physicians must engage these patients in our mission. And when patients understand the stakes, they will rally to our cause. I know this is true, because I’ve seen it happen.

In 2018, the small town of Naples, Florida was rocked by controversy when NCH Healthcare, the county’s largest health care system, threatened to eject community physicians from providing in-patient care. The hospital announced a decision to restrict in-patient care to only

Patients benefit from a strong relationship with their physician. Studies show that having the same physician over time is associated with lower rates of mortality. hospital-employed doctors, arguing that the model would improve quality of care, patient satisfaction, and shorten lengthof-stay. Community physicians protested this change, and although the medical staff unanimously voted against the policy, the hospital administration continued to move forward with their plans.

Facing the possibility of having their hospital privileges summarily restricted, the independent physicians brought their concerns to the Collier County Medical Society, which represents 600 of the county’s 800 practicing physicians.

When the hospital ignored recommendations from the Medical Society, the group decided to take the issue directly to the community. Medical society leaders met with a marketing agency to plan a public relations campaign to oppose the NCH hospital admissions policy.

In just weeks, thousands of dollars were raised by community physicians and concerned citizens, allowing the group to begin a strategic multi-media assault.

The campaign focused heavily on educating the community about the NCH admissions policy and the impact of this decision on patient choice.

The message was repeated in television, internet, and newspaper ads, as well as printed brochures available in physician offices. Physicians added their names to a full-page newspaper ad and wrote individual letters to the editor. Several doctors appeared on television news to discuss physician concerns.

But most importantly, physicians were able to engage patients and convince influential community members to add their voices. The mayor of Naples, WWW.PHYSICIANOU T LOOK . C OM | 17

Engaging Patients In order to gain support from our patients, physicians must work together.

First, we must create a clear and consistent message. We can do this by working with organized medicine groups, specialty societies, or grassroots physician groups. Next, we must communicate our message directly to patients. We can do this by personal conversations with 1 8 | J A N UA RY/ F E B RUARY 2020

P HOTO COU RTE SY OF IN GRA M IM AGE S

the Collier County Commission, and the Naples City Council wrote letters (Freeman, L., 2018) to the NCH Board of Trustees asking the hospital to reconsider their stance. Yard signs (Freeman, L., 2018) decrying “NCH Denying Patient/Physician Choice” were posted in front of multi-million-dollar homes across Collier County. Large hospital donors pulled funds earmarked to the organization in protest, resulting in the cancellation of a $1 million biannual fundraiser event (Reye, A., 2019). Patients made themselves heard by writing letters to the editor and showing up at meetings and rallies, and fifteen thousand signed an online petition in protest of the policy.

The campaign continued throughout the months of November and December, with no call for compromise

by NCH. In fact, the hospital doubled down on its original plan, responding with its own public relations campaign, as well as holding two town halls (Freeman, L., 2018) to explain why the self-contained hospitalist system would be better for patients.

Community physicians kept up the pressure, and patients continued to support the doctors. On January 21, a rally in downtown Naples was held to support community physicians. And on January 23, the NCH Board of Trustees asked for, and received, the resignations (NBC2 News, 2019) of the hospital’s top leaders. Community physicians, thanks to widespread support from patients, had won. This unlikely miracle occurred not by luck or accident, but from a coordinated, organized effort by community physicians and engaged patients.

our patients in the exam room, through social media postings, writing letters to the editor, op-eds, and through public relations and marketing campaigns.

One example of this is the group Physicians for Patient Protection, a group dedicated to promoting physician-led care and truth and transparency in health care advertising. Starting out as a secret Facebook group for like-minded physicians, the organization gained official corporate status in 2018 and created bylaws and a mission statement. In 2019, using membership dues and donations, the group hired a public relations company to bring their message directly to patients through media sources.

While most mainstream media sources did not immediately respond

to the group’s pitches, through consistent effort and focusing on patient testimonials, interest began to grow.

In December 2019, the group began to receive queries from reporters with large media outlets like FOX News and USA Today.

As physicians, we often feel very alone when confronting large health care organizations and government policies. Effecting change seems downright impossible. But by working together with patients for a common goal, we can make a difference. 1 Rebekah Bernard MD is a physician in Fort Myers, Florida and the author of How to Be a Rock Star Doctor and Physician Wellness: The Rock Star Doctor’s Guide.

References: The Physicians Foundation (2018). 2018 Survey of America’s Physicians Practice Patterns and Perspectives. Retrieved from https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf McCarthy, J. (2018). Most Americans Still Rate Their Healthcare Quite Positively. Retrieved from https://news.gallup.com/ poll/245195/americans-rate-healthcare-quite-positively.aspx Pereira Gray, Sidaway-Lee, White, Thorne & Evans (2018). Continuity of care with doctors - a matter of life and death? A systematic review of continuity of care and mortality. Retrieved from https://bmjopen.bmj.com/content/8/6/e021161.info Jones, J. & Reinhart, RJ (2018). Americans Remain Dissatisfied With Healthcare Costs. Retrieved from https://news.gallup. com/poll/245054/americans-remain-dissatisfied-healthcare-costs.aspx Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/nchs/fastats/physician-visits.htm Freeman, Liz (2018). Residents urge Naples Council to send message to NCH about hospital admissions. Retrieved from https:// www.naplesnews.com/story/news/health/2018/12/05/naples-city-council-hear-angered-residents-over-nch-admissionspolicy/2213736002/ Freeman, Liz (2018). Yard signs spread in Naples area vs. HCH plan to limit doctors’ hospital admission privileges. Retrieved from https://www.naplesnews.com/story/news/health/2018/12/02/yard-signs-spread-naples-area-vs-nch-limits-doctors-hospitaluse/2154905002/ Reye, A. (2019). Florida hospital cancels fundraiser amid criticism for admission policy. Retrieved from https://www. beckershospitalreview.com/hospital-management-administration/florida-hospital-cancels-fundraiser-amid-criticism-for-admissionspolicy.html Freeman, L. (2018). NCH Healthcare System to hold community forums on admission policy. Retrieved from https://www.naplesnews. com/story/news/health/2018/12/17/public-can-ask-nch-leaders-admissions-policy-forums-wednesday/2339897002/ NBC2 News (2019). NCH CEO resigns after unanimous vote of ‘no confidence’. Retrieved from https://www.nbc-2.com/ story/39841635/nch-ceo-resigns-after-unanimous-vote-of-no-conficence-naples-community-hospital

PERFECTING THE IDEAL

New Job Board Coming Soon Physician Outlook is the place to find medical professionals who are passionate about their profession and oath to Do No Harm.

If you are

the type of hospital or health system that values patients over profits, post your jobs with us.

Contact hello@physicianoutlook.com.

Physician Outlook Magazine A Publication Dedicated Solely To Physicians And Their Patients.

WWW.PHYSICIANOUTLOOK.COM

WWW.PHYSICIANOU LOOK NTO M A .DC OM I C | | 192 4

N EW N EWS

Replacing Doctors With Midlevels?

SOMETIMES "BEING CHEAP IS VERY EXPENSIVE."

PHOTO COURTESY OF INGRAM IMAGES

Wri t t en by D r. D i na S t rachan, MD

Editor Note: If you are lucky, being “cheap” might cost you time and money. If you are unlucky, it might cost you your life.

T

he use of midlevel providers, physician assistants and nurse practitioners, as replacements for actual doctors, was once again in the news last week. Edward- Elmhurst Hospital, a Chicago area health institution, fired 15 physicians stating in an e-mail that "Patients have made it very clear that they want less costly care and convenient access for lower-acuity issues (sore throats, rashes, earaches), which are the vast majority of cases we treat in our Immediate Cares.”

The assumption is that midlevel providers provide the same service as board-certified doctors for a reduced cost to the system--but it that true? Salaries offered to midlevel providers may be lower than that of physicians, but are they able to provide the same quality of healthcare at a lower cost to patients? Is convenient access to a midlevel provider, rather than an actual doctor, really what the public is looking for?

2 0 | J A N UA RY/ F E B RUARY 2020

As a board-certified dermatologist in the competitive Manhattan marketplace, I’ve observed a number of examples of lower quality, less efficient and more expensive care for patients who finally make their way to my office after making choices based on ostensible “conveniences,” and cost savings alone, or thinking that something is just being “a rash” that anyone could treat. What is ironic about this is that in a crowded marketplace the consumer is expected to be able to get better service because of competition. It appears that that theory is not true. That is the problem when patients are thought of as "consumers" and not patients.

A few weeks ago, a long-time patient of mine came back to see me. “You’re gonna be mad at me,” she confessed. “Why would you think that?” I asked. She had developed a rash on her face over a month prior. In fact, it was a condition I had treated her for in the past. She says she

didn’t come to me because there were “no appointments” (not true) so she went to an urgent care near her. She saw a primary care doctor who wasn’t sure what she had, but who gave her an oral antibiotic in case it was an infection. This was not the right diagnosis. The medication didn’t work.

Next, she went to a private-equity backed dermatology practice mostly staffed by physician assistants. The diagnosis she was given was, oddly, even less accurate, despite this being a specialty office. The physician assistant treated her for the incorrect diagnosis, shingles, with the correct medication but at the wrong dose. The dose is super standard and easily available on the internet—so this was odd. Again, this oral medication didn’t work. So she found herself returning to someone who might have been a little less convenient to see, but who had the expertise to correctly diagnose her in a few minutes.

Was going to someone other than an actual specialist more convenient and cheaper? No. She had to go to three visits when she could have gone to one.

She had to pay three consultation copays when she could have paid one. The insurance provider had to pay out more, too.

She paid for three prescriptions when she could have paid for one. Let us not forget that she also ingested 3 drugs that could have caused a side effects or antibiotic resistance—a public health problem—and that two of them provided no benefit to her.

Once travelling in Mexico I heard a local person comment about street food, “sometimes being cheap is very expensive.” The cheap meal gets you sick. You miss work. You have to buy medicine.

And none of this is convenient.

It will be interesting to see for whom replacing doctors with people with lesser training is cheaper and more convenient.

From what I can tell, it won’t be cheaper for the patients. 1 Dr. Dina Strachan is an internationally recognized, Harvard and Yale educated, board-certified dermatologist, entrepreneur, consultant, speaker and best-selling author of Moxie Mindset: Secrets of Building a Profitable, Independent Physicians Practice in a Competitive Market. Learn more at www.drdinamd.com.

Follow her @drdinamd

IN TELLI G EN C E ON T HE MOVE

Popular Podcasts BELOW ARE THE PODCASTS WE ARE LISTENING TO AT P H Y S I C I A N O U T L O O K :

PODCAST OF THE MONTH

Weight Loss for Busy Physicians Busy physicians looking to lose weight and improve their mindset find great success by applying what they learn on Dr. Katrina Ubell's podcast.

Dr. Ubell combines science, life coaching principles, and a sprinkle of humor to help listeners lose weight permanently. Many physicians also recommend this podcast to their patients.

Dr. Death “We are at our most vulnerable when we go to our doctors.” Dr. Christopher Duntsch was a practicing neurosurgeon in Dallas, whose charisma and confidence drew in patients. He promised to take away the pain and complete surgeries that others would not dare. After a number of complications were reported, patients looked to the hospitals and the medical board for answers - and left with more questions. https:// wondery.com/shows/dr-death/

Armchair Expert

The idiom “Armchair Expert” refers to a person that knows a lot about a topic but has no real experience to back it up. Hosted by Dax Shepard, a recovering addict with a degree in Anthropology, it highlights the struggles and shortcomings that make us human. From superstars to actual experts, this podcast is a mix of personal development and pop culture. https://armchairexpertpod.com/

Skimm This

Growing in popularity, SkimmTHIS is the podcast version of the website, TheSkimm.

What we like about it: SkimmTHIS is a rundown of all the days top stories in just 10 minutes. Since this runs every evening, your commute home can also work as a quick brief on what happened throughout the day. https://www.theskimm.com/news/ skimm-this WWW.PHYSICIANOU T LOOK . C OM | 21

IN TELLIG EN C E O N T HE MOVE

How Words Can Heal I N V I T A T I O N O N LY

Wri t t en by D r. J ea n Ro bey, MD

The clearer vision of the new year, and the role of love lost, rose like the sun over the dewy drops.

I

watched her follow the assistant down the hall into an exam room.

I am positive the glow from her purple and blue hair came around the corner first and awoke me from my filing and signing to look up and see her pass my office door. Her presence was heavier than usual and I was curious why in particular.

I entered the room and complimented the vibrant colors of her otherwise snow white hair. She told me how her husband loved her audacity and punk hair so to honor him and send a message up “should he ever look down onto the Earth” she made sure to be “something he couldn’t miss” and dyed it outrageous colors.

“How are you?” I asked as I opened the electronic medical record to begin my documentation. The standard question, meant to invite unapologetic disclosures, rustled the wet leaves.

“Well, I hated to sell the house. I really hated the move. I think I cursed Andrew every time I needed to lift a box. I have family all around now and I like my new house but I hated leaving the old one. It’s been a long time since I have moved into a new house and well, I did it all without Andrew,” she shared.

The old house in the higher altitudes of Prescott had been a respite away from the city for decades for the couple. Once her husband Andrew fell 2 2 | J A N UA RY/ F E B RUARY 2020

ill and muddled through the throws of cancer and the corruptions of a hunger never felt and a dwindling reserve only to die one December morning, she weathered “one more winter”. Then last January she remodeled the kitchen with a modern marbled concrete with gold threading and redid the counters to give them nearly Vegas snazz. She put the house reluctantly on the market and sold it all too fast in a week’s time. She was not really ready for the rapid sell and wanted to break the contract. Andrew tapped her shoulder one day and whispered in her ear that she needed to head into the bigger, safer city, so she packed the last box cursing his absence as she lifted the box herself and drove away.

Grief met her at the driveway of the new house, the first night there, the first weekend there, the first box opened to unpack, the first thing that broke that left her to fix it herself and on and on. Grief met her New Year’s Eve. “Here we are Andrew,” she toasted.

“I think the strangest thing about grieving,” I pondered, “is there seems to be no end to it. Grief comes in a new reiteration and package and we find ourselves grieving yet another “first” and another “new” thing without that person in our lives.”

She nodded her head so full of acute thoughts of quiet nights in a home Andrew has never been in.

“You know,” I offered, “I have studied grieving. I have studied it and seen it come around and around to seemingly no end. I have studied memory. I have seen the mind and soul choose what to recall and why. Do you know my father must have driven me to school a thousand times and though I know that, I remember clearly only twice? I am sure you don’t ever think of a boy from grade school when you go to do new things. Yet,” I challenged, “the memory of your late husband and his absence returns to you over and over again.”

She shifted her posture in the chair, intrigued by the notion that grief could be more than just a burden, and that repeated presence collectively over a lifetime could sear the mind poignantly far beyond things we too often forget and care nothing of.

“I think, “ I continued, “grief becomes an invitation to realize you were so very touched by a person that you cannot move into first, last, new or otherwise situations without conjuring their company. I think it is an invitation to be in awe of love.”

The clearer vision of the new year and the role of love lost rose like the sun over the dewy drops. The light glistened in the air and all felt crisp and airy. The heaviness left her chest and she energized the strands of hair on her head like a beckon up to Andrew.

“I never thought I would be grateful to be sad at times. I wish he was here, and not just to move boxes,” she grinned. “I always think of him and at times I think of him non stop, feeling so sad I am missing out on US.” She navigated the land minds of sad pitfalls and concluded, “That I have anyone to wish was here to share life’s moments is certainly a wonderful thing to have.”

Dearest Punky Martha, By invitation only, might you share a moment, even if in grief, with my love for you?

Love, Andrew 1

Chow Time

CHICKEN MARSALA RECIPE

Prep time: 5 min Cooktime: 20 min Ingredients: 4 pre-cooked chicken breasts or 2 lbs rotisserie chicken 2 tablespoons olive oil 1 shallot sliced 2 ½ cups sliced mushrooms of choice 1 tablespoon garlic 1 cup Marsala wine 1 cup chicken stock 1 ½ cup heavy cream 1 tablespoon Dijon mustard Salt and pepper to taste Fresh chopped Italian flat leaf parsley for garnish Side of choice - Goes great with: Rice pilaf, potatoes, egg noodles/pasta, or broccoli.

Directions: In a large skillet, over medium heat, add 1 tablespoon of olive oil, shallots, and mushrooms until brown (approx. 2 min), then add garlic and cook for another minute.

Supper in a Snap Wr i tte n b y T i n a G eo rgo po u l o s

H

i. I’m Tina-Marie, an Armenian French American, mother of 4.

I teach belly dancing and I’m married to a busy gastroenterologist.

About 15 years ago, I wrote a “go-to” cookbook that I sold in local, small gourmet markets for busy moms like myself utilizing rotisserie chicken and prepared grilled chicken breasts.

I’m a home taught chef who grew up with a French mother and Armenian

P HOTOS COU RTE SY OF IN GRA M IM AGE S

T I ME FOR YOU

father whom both love to cook. With their influence, cooking became one of my greatest loves, a true passion in my life, but with 4 babies in 8 years, I either had to make shortcuts or not cook.

So my recipes will show anyone with 30 min or less that they can still make amazing dishes, for themselves, especially for their growing families, that they can serve stress-free and with a smile every time. Bon Appétit! 1

Add Marsala wine, bring to boil on medium heat for 1-2 minutes.

Reduce to simmer.

Add chicken stock, heavy cream, and Dijon mustard. Cook on medium heat for 2 minutes.

Add chicken breasts, cut in thirds, to the skillet. Bring to boil, then reduce heat and simmer for 10 minutes until thickens. Garnish with parsley.

WWW.PHYSICIANOU T LOOK . C OM | 23

Chow Time MEAL DELIVERY

Wr i tte n b y A l i ci a Ro sel l i

PHOTOS OBTA IN ED F ROM HTTPS://P RESS.BLU EA P RON .COM /M E DIA -A SSE TS

T I ME F O R YO U

A re y o u sh o r t o n t i m e fo r pl an n i n g, sho p p i n g an d pr e p?

T

here are so many options for food and meal delivery services these days, how do you know which one is right for you? The answer depends on your priorities, why you're interested in the first place. Are you short on time for planning, shopping and prep? Are you wanting to incorporate healthy, clean foods into your diet? Are you bored and looking for new and easy ways to try new recipes with minimal effort and without investing in ingredients you may never use again? If you're a selfproclaimed foodie like me, you may be skeptical that any of the options could satisfy your discerning palate.

In my search for information on the options, I found several articles and reviews that proved quite helpful. Many were comparisons of the most popular services where various options were evaluated for nutrition, convenience, cost and innovation, among other criteria. The services that consistently stood out were Blue Apron, Hello Fresh and Plated. Hello Fresh was highlighted for convenience, eco-friendly packaging and meal variety. Plated received kudos for 2 4 | J A N UA RY/ F E B RUARY 2020

being straight forward, a good choice for those less experienced in the kitchen. Blue Apron was recognized for its unique and high-quality recipes.

Having a clan of fairly adventurous eaters and being quite confident in my cooking skills, I wanted an option that would introduce us to new foods and flavors. With this objective in mind, I chose to give Blue Apron a try. After several months of consistent and reliable deliveries, my family and I have been pleased with almost every aspect of the service. On the rare occasion that a shipment arrives damaged or missing an ingredient, an email to their customer service department results in a prompt and fair refund. The quantity of food is plentiful, and we often have an extra serving which is great for lunch later in the week.

Our favorite aspect of the service is the international emphasis in their recipes. Despite our already diverse culinary experiences having been raised on Cuban, Italian and American cuisine, we discovered a whole new world was waiting for us. We are now regularly

Blue Apron is a great choice for physicians and patients alike - it is convenient, healthy, and will satisfy the foodie in you. exposed to Asian, Middle-Eastern, and Moroccan recipes, to name a few. Who knew that kumquats were so delicious?

Or that spice blends like Za'atar and Ras el Hanout even existed? I am pleased to say that my spice cabinet has taken on a more eclectic profile.

When it comes to meal delivery services, it seems no matter your motivations, options exist for every one of them. You may need to try several, or rotate among them, before you find your groove. You may even find that after a while, you are so inspired by what you've learned and added to your repertoire that you don’t need them at all. 1 Visit us online for an affiliate discount

CONTINUING MEDICAL EDUCATION (CME)

MALIBU MICROBIOME MEETING

PROGRAM HIGHLIGHTS Understanding Microbiome Standards and Research Nutrition and the Microbiome Update on C. difficile

DR. THOMAS BORODY CDD AUSTRALIA

DR. NEIL STOLLMAN

DR. COLLEEN KELLY BROWN

UCSF/

EAST BAY CENTER FOR DIGESTIVE HEALTH

DR. SAHIL KHANNA MAYO CLINIC

DR. YINGHONG WANG MD ANDERSON

UNIV. OF MINNESOTA

DR. JAMES B. ADAMS ARIZONA STATE

DR. ALEX KHORUTS

DR. PAUL FEUERSTADT YALE

DR. JESSICA ALLEGRETTI HARVARD

DR. SABINE HAZAN

PROGENABIOME

DR. HOWARD YOUNG NIH

DR. SCOTT JACKSON

Other applications of FMT Manufactured microbial therapies

NIST

Regulating the human gut

DR. FAMING ZHANG

NANJING MEDICAL, CHINA

DR. MAZEN NOUREDDIN CEDARSSINAI

DR. ZAIN KASSAM FINCH

★ ★ ★ ★

microbiome Up to 6 hours of CME Panel discussions / Q&A Hootenanny Party at Malibu Ranch with live entertainment (special surprise band TBA) Catering by Malibu Farm

REGISTER at www.MalibuMicrobiomeMeeting.com Organized by Progenabiome, a genetic sequencing laboratory of the gut flora.

CME activities jointly provided by MRA, Inc. and AKH Inc., Advancing Knowledge in Healthcare. See website for details.

#MALIBUMM2020

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