"X-Ray Artistry" Cover Art created by Dr. Susan Summerton by Physician Outlook Magazine

ISSUE 10 | VOLUME 1

NOVEMBER/DECEMBER 2020 2020 IS THE YEAR OF CLEAR VISION FOR PHYSICIANS AND PATIENTS ALIKE

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PUBLICATION DEDICATED SOLELY TO PHYSICIANS AND THEIR PATIENTS

Cover Art by Physician Artist Dr. Susan Summerton

CREDIT PHYSICIAN ARTIST DR. DOUNA MONTAZER

F R O M T H E P U B LIS H ER

COVID’s Fourth Trimester

Wri t t en by Ma r l e n e Wu st- S mi t h, M . D.

lmost ten months have elapsed since COVID19 appeared on this planet, and Coronavirus cases in the U.S. continue to soar. We have officially entered “the 1 fourth trimester of COVID19.” In the last issue of Physician Outlook I wrote a piece titled “Pandemic Pregnancy” in which I waxed philosophically about the similarities between an unexpected, complicated pregnancy and the long almost 9 months we had collectively endured as humans after we became unwittingly impregnated with the nasty novel coronavirus. I, for one, was naively looking forward to a quick, easy uncomplicated election-induced delivery come November 4th. 2 | N OV E M B E R / D E C EMBE R 2 020

Unfortunately, it IS 2020, and nothing can or will go as planned. The long-anticipated controversial US election did not yield an unequivocal landslide winner. Joe Biden and Kamala Harris are the President and Vice President-Elect based on electoral college numbers and the popular vote, but the election has yet to be officially certified amidst allegations of voter fraud. With roughly 51% of the votes in favor of Democrats and 47% for Republicans, there is still, unfortunately, continued controversy and division amongst the people of this nation. We are a deeply divided country, with roughly half the country feeling “cheated” and the other half experiencing elation that a new administration will take office on January 20, 2021.

Globally we have embraced contagion control, which involves wearing masks and socially distancing. Some of us wear masks everywhere, even inside of our own homes and vehicles. Some of us wear masks begrudgingly, barely covering our noses. Some of us refuse to wear them at all. Some have continued to work from home, while others (mostly ‘essential workers’) have never stopped going to the workplace, while many of us remain unor under-employed. Many of us are learning to parent in a post-COVID world, which for some means daily in-school attendance (with many stops and starts when a suspected COVID case is identified). Some are home-schooling, and some have children who are learning via a hybrid of in-person and online attendance.

We are ALL anxiously awaiting production and distribution of a COVID19 vaccine, which promises to “open up the world” with >90% efficacy. But a great majority of us are secretly hoping that “someone else” will be first in line to get the shot(s) that will help us all earn our eventual freedom. This virus, like a newborn baby, is not going anywhere soon. It is no secret that we are currently experiencing a surge in symptomatic COVID19 cases. I live in rural Pennsylvania and work in a very rural county in upstate Western NY. Every day I hear about another infected patient, and every few days about another death. Rural areas continue to experience new cases and deaths at a higher rate than metro counties. At our local hospitals we do not have the expertise and capacity to take care of very ill patients. It is difficult to transfer sick patients to higher levels of care. The common ground we all have is that NONE of us, whether Republican or Democrat, wish to have COVID19 seriously affect the health of someone we love. The current ‘sicken in place until ill enough to be hospitalized’ approach that has become the norm over the past 10 months of this pandemic is NOT NORMAL. We do not treat ANY other illness in this way, and I am hoping that the dawn of a new administration will be tolerant of and open to outpatient and early treatment of COVID19 instead of mocking any attempted treatment because of political persuasion or leaning. Politics has played an unprecedented role in this pandemic, partially because of Trump’s frequent rhetoric and style of pitting “the people” against “the establishment,” as well as his early endorsement of hydroxychloroquine as “game-changing.” The vast majority of the 51% of the US citizens who voted for Biden are afflicted by a new tongue-in-cheek diagnosis, aptly termed “Trump Derangement Syndrome.” Most would rather die than consider taking a medication endorsed by “the orange man.” This is an attitude and approach that needs to change. We do not tell patients

with mild angina to wait a few weeks to see if their pain resolves, or instruct them to have crushing chest pain before they seek medical attention. We do not tell patients with cancer to wait two weeks prior to going to an oncologist. Yet, we tell even at-risk COVID19 patients to not present for care until approximately 2 weeks after the onset of symptoms IF they don’t recover. By that time the cytokine storm may have already started brewing in the patient, leading to higher morbidity and mortality. Dr. Peter McCullough and other physicians recently testified before the Senate about the importance of developing and adopting an early treatment initiative. McCullough is a Baylor cardiologist and internal medicine specialist who has treated COVID19 patients and has written extensively about the importance of EARLY outpatient treatment for the SARS-CoV2 virus. In his article titled “Physician Secrets Revealed: Outpatient Treatment for Covid-19” in this month’s Physician Outlook issue he describes the importance of early ambulatory treatment to reduce hospitalization in those patients who are high risk. The three other pillars of pandemic management as proposed by McCullough are contagion control, hospitalization as a safety net for late-stage treatment and prevention through vaccination. I listened to Dr. McCullough and his colleagues’ testimony at a recent Senate Committee hearing with renewed hope that there MAY be light at the end of the tunnel while we await vaccines to be available and distributed to those most at need. Meanwhile I am wearing my mask, but also stocking up on the medications and supplements that could potentially help me and the high-risk members of my family manage COVID19 should we contract it. 1 References 1 The term “fourth trimester” was first coined by Dr. Harvey Karp to describe the three months following the delivery of a baby. I am using the term allegorically to describe the state of the coronavirus epidemic, which is entering its 10th month in existence.

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Table Of Contents

NOV E MBE R | D E C EM B ER 2 0 2 0

FROM T HE PU B LI SHER

COVID’s Fourth Trimester By Marlene Wust-Smith, MD/p.2 VI PP SPOT LI G HT

R.I.P. Notorious R.B.G. By Marlene Wust-Smith, MD and Rosanne Leger, MD/p.6 X-Ray Artiste By Alejandra Suarez/p.8 Physician Secrets Revealed: Outpatient Treatment For Covid-19 By Peter A. McCullough, MD, MPH/p.10 B A B B LI N G S

The Sekhmet Writing Project 7|12: The Unyielding By Megan Babb, DO/p.12 OFFI C E SPAC E

Six Steps To Financial Freedom By Jordan Frey, MD/p.16 Trust Toolbox - Scaling Your Patient Relationship - Individually And Collectively By Nathan Eckel/p.20 A DVOC AC Y I N AC T I ON

Roadmap To Physician Independence By Christina Dewey, MD/p.22 T I ME FOR YOU

Sourdough Bread Recipe By Rebecca Coalson, MD/p.26 IN T ELLI G EN C E ON T HE MOVE

Intentional Inquiry By Amelia Bueche, DO/p.28 T HE LA ST WORD

Pulling Out Of The Nosedive By Craig Wax, DO/p.30 Cover Art (front and back): Susan Summerton, MD WWW.PHYSICIANO U T LOOK . C OM | 5

SKETC H BY P HYSIC IA N A RTIST DR. ROSA N N E LE GE R

V IP P S P OT LIG H T

R.I.P. Notorious R.B.G. Wri t t en by Ma r l e n e Wu st S mi t h, M . D.

About the subject The death of the Honorable Ruth Bader Ginsburg affected many on a personal, guttural level. She was a strong independent woman who championed the rights of ALL women, and NOT just with regards to their reproductive rights. In the wake of RBG’s death I was touched by the art that so many female physician artists created in her honor as they processed their collective grief. The sketch featured here was created by Dr. Rosanne Leger, who clearly espouses two famous RBG quotes in her work life and her artistic outlet. “If you want to be a true professional, do something outside yourself.” “I would like to be remembered as someone who used whatever talent she had to do her work to the very best of her ability.” About the artist Dr. Rosanne Leger was born and raised in Haiti. Her father is Haitian and mother Mexican. She graduated and obtained her Bachelor of Science in biomedical engineering from Rens6 | N OV E M B E R / D E C EMBE R 2 020

selaer Polytechnic Institute in Troy, NY. After graduation, she worked as a design engineer for Alaris Medical Systems in Creedmoor, NC. She later attended medical school at Meharry Medical College in Nashville, TN. She moved with her husband to Florida and did her residency at Halifax Health Medical Center in Daytona Beach. She is a board certified Family Physician and currently works part time as a hospitalist. Dr. Leger enjoys spending time with her family and her other hobbies include running, crossfit and watching movies. Two years ago, Dr. Leger started taking oil painting classes, however, during the COVID-19 pandemic she started sketching on her own. She discovered her new interest in drawing portraits and many of her family members and friends have gladly volunteered to be her subjects. She participated in a project called Women of Color on the Frontlines and Dr. Leger volunteered some of her time to draw women physicians of color wearing their personal protective equipment (PPE) while facing the pandemic.

What inspired her to draw RBG Supreme Court Justice Ruth Bader Ginsburg (RBG) has inspired so many, including women physicians. She has been a leading voice for race and gender equality, women’s interests to name a few. When she passed away, Dr. Leger felt the need to draw her. A group of physician artists got together and through their art, paid her a tribute. While searching the internet, one picture caught Dr. Leger’s attention and she knew she had to at least attempt it, not knowing how it would come out. The portrait of Supreme Court Justice RBG was inspired by Sebatian Kim’s photography from Time Magazine “The 100 Most Influential People” 2015. 1

PADPCA is a non-profit organization of Independent Direct Primary Care physicians in Pennsylvania.

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P HOTO C REDIT BY (SUSA N SU M M E RTON , M .D.

V IP P S P OT LIG H T

X-Ray Artiste

Wri t t en by A l ej a ndra S u a rez

usan Summerton, M.D. is an accomplished doctor, educator, public speaker, and artist, who has transformed science into art by digitally recreating images from the human body into unique pieces of art. Dr. Summerton graduated from Temple Medical School in Philadelphia and then did a residency in diagnostic radiology at Albert Einstein Medical Center. Currently she is an Associate Professor of diagnostic radiology at Penn Medicine in Philadelphia where she teaches and specializes in breast and body imaging. Susan’s artistic career began serendipitously several years ago and has escalated in the last few years. Over 20 years ago, inspired by a poster she had in her home called the Butterfly Alphabet (the letters A-Z had been collected 8 | N OV E M B E R / D E C EMBE R 2 020

from close up photographs of patterns on butterfly wings,) she started collecting letters, shapes and symbols she discovered embedded in x-ray images with the goal of creating her own Human Body Alphabet for a poster for her office. Then in 2014, for the Centennial Meeting of the Radiological Society of North America in Chicago, she entered a contest where radiologists were asked to submit their most interesting case or a piece of art and for the first time she realized she had all the letters of the alphabet and created a piece that said: RSNA 100: A century of Transforming Medicine. This first piece she ever made received Honorable mention and was displayed in the Centennial Pavilion in Chicago during the week of the meeting. Since then she has won the First Prize, Photography category, at Frank H. Netter Symposium on Arts and

Health, Thomas Jefferson University in 2017, among other mentions and awards. Now she exhibits her art at medical shows and art shows and her pieces are available for viewing and purchase at the world famous Mutter museum in Philadelphia. Mostly she enjoys creating commissioned personalized pieces of art often given as gifts and finds that both the recipient and the giver of her artistic gifts seem to find great joy in her art. Her favorite piece, which graces the cover of this month’s Physician Outlook, perfectly captures her view of her art and her profession: The Human Body is the Finest Work of Art. After all, as people say: “her x-ray art helps connect them to a shared humanity, regardless of age, gender or nationality, because inside our bodies we’re all the same.” 1

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V IP P S P OT LIG H T

Physician Secrets Revealed: Outpatient Treatment For Covid-19 EARLY AMBULATORY MULTIDRUG THERAPY FOR SARS-COV-2 (COVID-19) INFECTION Wri t t en by Pete r A. Mc Cu ll o u gh, M D, M P H

he SARS-CO-V2 (COVID-19) globa l crisis has driven considerable efforts on pandemic response (Figure 1) which can be viewed as having four pillars: 1) contagion control, 2) early ambulatory treatment to reduce hospitalization and death, 3) hospitalization as a safety net to save lives at the critical stage, and 4) herd immunity through vaccination and prior COVID-19 illness. Unfortunately efforts at contagion control have failed, hospitalization is not an adequate safety net, and vaccination is not currently 1 available. Across the globe we must turn our attention to the least emphasized 2 pillar of early ambulatory treatment. There are a wide range of responses on early treatment to multi-drug home treatment in deployed in countries such as India, Brazil, Guatemala, and Salvador to near complete prohibition of ambulatory treatment in the U.S., Canada, United Kingdom, Western 1 0 | N OV E M B E R / D E C EMBE R 2 020

Figure 1- Four pillars of pandemic response 3

European Union, and Australia. Penalties for an Australian physician who attempts to prescribe a therapy such as hydroxychloroquine in an acutely ill COVID-19 patient can include 4 imprisonment. Never has modern medicine witnessed such disparate courses of action for doctors and patients. After approximately ~50,000 publications on COVID-19 cited in the National Library of Medicine, a U.S.-Italian Collaboration published the first guidance on the scientific rationale for early ambulatory treatment of COVID-19 as the only hope to reduce the chances of hospitalization or 5 death once COVID-19 is contracted. These guidelines have been updated and adapted as shown in the Figure 2 and largely apply to adults over age 50 and those with medical comorbidities. The principles include using off target antiviral treatment (hydroxychloroquine, ivermectin,

favipiravir, combined with an antibiotic [azithromycin, doxycycline] to provide synergism and coverage for bacterial super infection as soon as possible even before confirmatory 67 testing is completed. By day five or if any pulmonary symptoms develop, treatment of cytokine storm with 8 corticosteroids is the next step. Finally, given the disastrous risk of microand macro-thromboembolism with activation of thromboxane A2 and the development of antiphospholipid antibodies, full dose aspirin and intensification of treatment to include low-molecular weight heparin or novel 9 10 oral anticoagulants is advised. The shortest course of treatment with full resolution of symptoms is five days, average is 10 days, and for older individuals with multiple comorbidities or senior facility residents, a full 30 days of treatment is advised. The COVID-19 pandemic has called for

Figure 2. Protocol treatment of early COVID-19 like and confirmed COVID-19 syndrome in patients at home or non-hospital facilities in self-quarantine. Yr=year, BMI=body mass index, Dz=disease, DM=diabetes mellitus, CVD=cardiovascular disease, chronic kidney disease, AZM=azithromycin, Doxy=doxycycline, HCQ=hydroxychloroquine, IVM=ivermectin, Mgt=management, Ox=oximetry

superior discernment of an evolving yet imperfect universe of scientific information forged with clinical judgement and the art of medicine as the only immediate path to stem the tide of hospitalizations and death. The second pillar of pandemic response deserves the highest attention by public health officials and the U.S.-Italian treatment algorithm should be front and center in 3 the COVID-19 global crisis. 1 References 1- Vahidy FS, Drews AL, Masud FN, et al. Characteristics and Outcomes of COVID-19 Patients During Initial Peak and Resurgence in the Houston Metropolitan Area [published online ahead of print, 2020 Aug 13]. JAMA. 2020;324(10):9981000. doi:10.1001/jama.2020.15301 2- McCullough PA, Arunthamakun J. Disconnect between community testing and hospitalization for SARS-CoV-2 (COVID-19) infection. Proc (Bayl Univ Med Cent). 2020 May 14;33(3):481. doi: 10.1080/08998280.2020.1762439. PMID: 32675999; PMCID: PMC7340440.

3- https://www.covid19treatmentguidelines.nih. gov/ (accessed November 8, 2020) 4- https://www.health.qld.gov.au/system-governance/legislation/cho-public-health-directionsunder-expanded-public-health-act-powers/ prescribing-dispensing-or-supply-of-hydroxychloroquine-direction (accessed November 8, 2020) 5- McCullough PA, Kelly RJ, Ruocco G, Lerma E, Tumlin J, Wheelan KR, Katz N, Lepor NE, Vijay K, Carter H, Singh B, McCullough SP, Bhambi BK, Palazzuoli A, De Ferrari GM, Milligan GP, Safder T, Tecson KM, Wang DD, McKinnon JE, O’Neill WW, Zervos M, Risch HA. Pathophysiological Basis and Rationale for Early Outpatient Treatment of SARS-CoV-2 (COVID-19) Infection. Am J Med. 2020 Aug 7:S0002-9343(20)306732. doi: 10.1016/j.amjmed.2020.07.003. Epub ahead of print. PMID: 32771461; PMCID: PMC7410805. 6- Ladapo JA, McKinnon JE, McCullough PA, Risch H. Randomized Controlled Trials of Early Ambulatory Hydroxychloroquine in the Prevention of COVID-19 Infection, Hospitalization, and Death: Meta-Analysis. medRxiv 2020.09.30.20204693; doi: https://doi. org/10.1101/2020.09.30

7- McCullough PA. Favipiravir and the Need for Early Ambulatory Treatment of SARS-CoV2 Infection (COVID-19). Antimicrob Agents Chemother. 2020 Sep 23:AAC.02017-20. doi: 10.1128/ AAC.02017-20. Epub ahead of print. PMID: 32967849. 8- Cano EJ, Fuentes XF, Campioli CC, O’Horo JC, Saleh OA, Odeyemi Y, Yadav H, Temesgen Z. “Impact of Corticosteroids in COVID-19 Outcomes: Systematic Review and Meta-Analysis”. Chest. 2020 Oct 28:S0012-3692(20)35107-2. doi: 10.1016/j.chest.2020.10.054. Epub ahead of print. PMID: 33129791. 9- Mahajan P, Dass B, Radhakrishnan N, McCullough PA. COVID-19-Associated Systemic Thromboembolism: A Case Report and Review of the Literature. Cardiorenal Med. 2020 Oct 22:1-8. doi: 10.1159/000511800. Epub ahead of print. PMID: 33091905. 10- Singhania N, Bansal S, Nimmatoori DP, Ejaz AA, McCullough PA, Singhania G. Current Overview on Hypercoagulability in COVID-19. Am J Cardiovasc Drugs. 2020 Oct;20(5):393403. doi: 10.1007/s40256-020-00431-z. PMID: 32748336; PMCID: PMC7398761.

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B A B B LIN G S

The Sekhmet Writing Project 7/12 THE UNYIELDING

Wri t t en by D r. M ega n B a bb

s the second wave of COVID-19 sweeps across the nation, physicians are once again being put in impossible positions. Even though women make up nearly 40% of the active physician workforce in America today, they have been disproportionately affected by COVID in their roles as physicians as well as their roles as parents and spouses. Because female physicians are often tasked with the responsibilities of being a caregiver for their own family on top of the one responsible for coordinating child-care needs, COVID has placed an even greater burden on them. It must not be understated that those who are able continue to give voice to the female physicians doing so much for our country during this very unique time. 1 2 | N OV E M B E R / D E C EMBE R 2 020

The Unyielding Dr. A. Bouden: I have a sixteen-yearold daughter. For the past year, we had envisioned a beautiful sweet-sixteen party for her. However, with a heavy heart, my husband and I decided that this was not an appropriate time given what our country has been going through with COVID. While our daughter was saddened by this news, she understood it to be the right thing to do. A friend of hers did not make the same decision and proceeded with a large celebration. I am now taking care of her father in the ICU after he contracted COVID from a party attendant. If only we could all realize the difference between what we want from what we need.

Dr. S. DeWalt: I am the only physician in my family. Everyone is relying on my guidance on how to proceed with family get-togethers and holiday plans and have been incredibly respectful of my guidance. However, when my daughter saw that a large “back-to-school” party was happening next door, she didn’t understand why she couldn’t attend. Two weeks later, two of her classmates tested positive for COVID and her entire class was shut down. I, too, am exhausted with COVID but when will people realize that until we all make sacrifices and better choices, we will remain stuck in this situation. Dr. K. Reynolds: Our hospital lost a nurse to COVID in August. A friend of

S e v e n | T w e lv e: T h e U nyie ld i n g

mine who did not believe that COVID was harmful as I tried explaining to her, refused to acknowledge her ignorance towards the situation. Three weeks ago she buried her husband after he contracted COVID and suffered from multiple complications from it. She said, “I wish you had done more to warn me of the dangers of COVID.” Hindsight is always twenty-twenty, however until America learns to listen to what they do not want to hear, we will continue to lose our loved ones to this virus. Dr. E. Kay: My sister was diagnosed with pancreatic cancer in September. Six weeks after her diagnosis, she died. Her only request of us was to forgo

her funeral. “My life was a celebration each day I lived. I will not let my death be the cause of another’s.” She was a physician as well. We are all making sacrifices. Dr. M. Kohl: The second wave of COVID has hit our town just an hour outside the state’s capitol. I had my daughter three weeks ago: however I ended my maternity leave early because our system was struck so hard, I was needed. Three of my colleagues are hospitalized and the others in my practice are working nearly a hundred hours a week because we are so short-handed. I understand that times are tough for everyone, however, if we all sacrificed a little, physicians and other healthcare

workers wouldn’t have to sacrifice more than their fair share. Dr. S. Gant: I work in a large community hospital. Our hospital has lost at least one patient to COVID for the past twenty-two days in a row. The amount of work is so great that I have slept at the hospital for the past nine nights and have only seen my children via Facetime during this time. The hardest part is watching friends and family exist as though everything is back to normal - all the while I and so many others are sacrificing everything to keep our communities healthy. Dr. L. Gnatt: Healthcare workers are sacrificing so much of themselves right WWW.PHYSICIANOU T LOOK . C OM | 13

P HOTO C RE DIT BY DR. SA IRA RA H M A N

now by working longer hours and extra days to care for patients as COVID numbers soar. I am struggling due to the deep disappointment I feel from many in my community for being so cavalier about our COVID situation. Many are denying its existence while others are actively dying. Dr. P. Walker: The school district my children attend has worked tirelessly to get them ready for in-person learning. I and three other physicians helped speed the process. However, a group consisting of thirty moms decided it was a good idea to throw a Kids-AreGoing-Back-To-In-Class-Instruction party without social distancing or mask-wearing. Four of them became ill with COVID and subsequently so did their children. Unfortunately, the school officials decided to push back in-class instruction until after Decem1 4 | N OV E M B E R / D E C EMBE R 2 020

ber as a result. The amount of work that went in to make this a possibility went down the drain because of a selfish few. Dr. D. Lee: Tomorrow will be my children’s ninth month in a row of quarantine. My husband and I are intensivists and have not seen each other for more than two days in a row in the past three months. I wish we could pretend that COVID isn’t real but if we did that would lead to more people dying. If only America could realize that we are all sacrificing during this time. Dr. T. Mandelburg: Currently I am seeing patients after hours who are struggling due to losing a loved one from COVID by ensuring they are getting access to the help they need during this very difficult time. I wish America could see that our services as physicians

are finite and there is only so much we can do. We cannot do this alone and if we continue to see numbers rise, we will not be able to keep up with the demand. Then where will we be? In an effort to provide recognition to the female physicians of America, it is incumbent that we continue to support their efforts and needs. For it is their sacrifices that are likely responsible for our country’s head to remain above water during this incredibly difficult time. If we all continue to choose community over self, we may find ourselves minimizing the number of lives lost to this very deadly pandemic. Let us all strive to be like those female physicians who are UNYIELDING. If you would like to learn how you can help women in healthcare, please visit AMA.org and visit their COVID-19 Resource Guide: Women in Medicine, to find out more. 1

P HOTO C REDIT BY IN GRA M IM AGE S

O F F IC E S PAC E

6 Steps To Financial Freedom DECREASE BURNOUT AND BECOME A BETTER DOCTOR TODAY! Wri t t en by Jo rda n Frey, M D T h e Pr u d e n t P l a st i c S u rgeo n

hysicians are some of the worst accumulators of wealth despite being highly compensated. This contributes to financial strain, burn out, and diminished overall well-being. How do I know this? Well, until just recently, that was me. Now, I’m on the path to financial freedom and have dedicated myself to helping other physicians in similar financial straits to achieve financial well-being. How did this gigantic turn around happen? And how can you do it? That’s what I want to share! For those who are not familiar with my story, I’ll give a brief review. I am a plastic surgeon in Buffalo, NY and just completed my 7 year training in plastic surgery and microsurgery in New York City as of June 2020. Before my training, I obviously had 4 years of undergraduate school and 4 years of medical school. I paid for all of that education 1 6 | N OV E M B E R / D E C EMBE R 2 020

(except for some scholarships and work study) with loans. Every dollar. Every cent. As you can imagine, I built up a pretty nice bit of debt. And what did I do in training? I… deferred…all…of…it. Why in the world would I do this? The answer is quite simple. I was financially clueless. My strategy could best be summed up as sticking my head as far in the sand as I could and hoping for the best. I knew I was messing up but was scared to see just how bad things were and was intimidated to start my financial education. But then a funny thing happened. I picked up a financial book for physicians and read the first chapter. I had owned the book for about a year but had just let it collect dust until now. After the first chapter, I just kept reading and learning…and reading and

learning. And I haven’t stopped since. The weird thing was that once I committed myself to my financial education and set a goal of achieving financial well-being, I wasn’t scared of my mistakes anymore. By looking them in the face, I finally had power over them and could start climbing out of the hole instead of digging it further. I also found that my overall well-being improved along with my financial well-being. I became a better doctor. But if I could go back, I would do things differently I’m firmly focused on my future. I know that I can’t change the past so there’s no point in wishing that I had handled my financial life better…or at all for that matter. What I would like to do, however, is to look back at my missed opportunities, emphasizing what I could have done. If you are in

a situation similar to what mine was, learn from me! Start your financial education. Look any financial faux pas in the face. Make positive changes in your life. If I can do it from the huge hole that I dug for myself, so can you! Here are 6 steps that you can start doing TODAY to get you on the path to financial freedom, to decreasing burn out, and to becoming a better doctor and person! Step #1 – Start tracking your net worth to increase it Net worth is the score card of wealth. You need to know how to keep score to play the game. So, this is a very easy first step. There are innumerable online calculators that will compute your net worth, walking you through the whole process. If you are like me, there will likely be a sense of dread upon doing this. I was embarrassed by my mistakes and intimidated by the answers that I was going to find. Fight through this. Confronting any mistakes gives you power to finally overcome them. And usually, the answer isn’t nearly as bad as you expected. And finally, chances are that I dug myself a deeper hole than you. If I can start digging out of my hole, so can you! Like I said earlier, once you know your net worth, you know how to keep score. Now you can start to play the game the right way. This is a huge first step. Do this and you are financially ahead of most of your peers. I guarantee it. Step #2 – Create a budget (or an anti-budget!) with a 20% savings rate (no anti-savings rate though) My wife and I like budgeting (OK, maybe that is a stretch). But we definitely tolerate it and look forward to it. I see a budget not as a limiting thing that stops you from living your life. In fact, I see it as an empowering tool that is helping me achieve my financial goals so that I can live the life

I want. This comes from adopting an abundance, rather than a scarcity, mindset with money. With this change in mindset, my wife and I sat together one night a few months ago and created a monthly budget incorporating every dollar that we would make on a monthly basis. We first budgeted out our “needs,” such as food, healthcare, and taxes (yes, make sure you include taxes). Next, we set aside our savings. Notice that we budgeted this before budgeting out “wants,” like entertainment and such. This is called paying yourself first. If you budget everything but your savings, you will invariably have nothing left. It’s human nature. We tend to spend up to our budget. Break this cycle! Set a savings rate of at least 20% and then budget the rest as you see fit. You need to make sure you have enough to retire! All of this is incorporated in our written financial plan. (https:// prudentplasticsurgeon.com/budgeting-made-simple/) Hate the budget? Try the anti-budget! Ok, ok I know that there are people reading this and saying, “I hate to budget” or “If I have to budget, I’m not living.” Fine, then use an anti-budget. Rather than having no budget, spend your monthly earnings, and hoping you have enough left over for some savings, set a savings rate up front. Make it at least 20%. When you get your paycheck, take 20% out and place it into a different account to be invested according to your plan. Then, spend the rest as you please. Boom…you just (anti) budgeted. Whether you budget or anti-budget, just by creating that savings rate, your net worth will increase by that exact amount in the coming month. Invest that money wisely and your net worth will increase exponentially through the magic of compound interest. Step 3 – Increase your debt paydown

“..your net worth will increase exponentially through the magic of compound interest.” For 7 long years after I graduated medical school, I didn’t pay down a single one of my loans. Uninformed people told me that loans would take care of themselves after I became an attending. I’ll burst your bubble – that is not true. Loans don’t take care of themselves; you have to have a loan and debt plan. That’s what takes care of the loans. Now that you’ve completed step #2 and created a budget with at least a 20% savings rate, some or all of that savings rate should go towards paying down any outstanding debt in the following order: • Commercial debt (credit cards, etc.) • Loans with rates >8% • Loans with rates between 3-8% • Loans with interest rates <3% Since you’ve also completed step #1 and calculated your net worth, you know that all of your debt is in the liability column. This means that every $1 you use to pay off your debt increases your net worth by $1. That is a 1:1 net worth increase. Nothing else, repeat nothing else, will give you that immediate return. Factor in the interest rate causing your debt to grow by the second when it’s not paid and debt paydown is the best investment you can make. My student loan debt of >$400,000 is by far the biggest weight on my net worth. My written financial plan calls for me to pay that down aggressively. I highly recommend that you take the same mindset. Whatever you are currently paying towards your debt, increase it. Even if it’s by $20. That’s a $20 increase in your net worth. Ordering takeout for one night won’t do that to your net worth. Join me online at www.physicianoutlook.com to read the rest of this article, and also visit my website https:// prudentplasticsurgeon.com to start YOUR journey to financial freedom. 1 WWW.PHYSICIANOU T LOOK . C OM | 17

O F F IC E S PAC E

Trust Tools

SCALING YOUR PATIENT RELATIONSHIP INDIVIDUALLY AND COLLECTIVELY Wri t t en by Na th a n E c k e l , p hy si c i a n spo u se

ast month I asked, what would you do to get a few minutes of breathing room in your day? With today’s post-COVID health landscape, many solo physicians find that it’s not enough to go about business as usual. They are realizing that they need to think ahead of the rest. And that kind of creative thinking takes time and energy. The good news is that in the last six months we’ve seen something that never happened before. We’ve seen medical norms change in response to COVID-19. If you’re interested in a simple way to utilize this shift to benefit your patients as well as yourself - and get the extra bandwidth you’d never have otherwise, keep reading… because the an2 0 | N OV E M B E R / D E C EMBE R 2 020

swer is so much more straightforward than you might realize. In last month’s article, I talked about how to protect your staff’s time simply by pre recording your FAQs and sending your patients to that content instead. This month I want to dig deeper into why this strategy might just work for you - whether you are a solo physician, group partner, specialist, direct care, fellow, or hospitalist. No matter what role you play, some variant of this principle will absolutely have the potential to save you energy, time, and margin in a clutch situation. Have you ever become frustrated by patients who listen to celebrity doctors? Today’s tip will show you how to turn the tables on illegitimate health voices that often exploit the vacuum.

The Power of 1:Many:1 Communication Pre-COVID, all of traditional medicine was about the 1:1 and only 1:1. The result? A lot of repeating yourself to different patients who had a similar problem and needed to do a similar thing. Here’s an alternative - take a look at last month’s article about creating your own FAQ Library to save you time and empower your patients. You don’t need to keep doing things the same way. You have time to reinvent yourself now before the “suits” learn of these tips. I don’t know about you, but I always prefer “get-to” instead of inside. This approach is the best of both worlds. If you’re like a lot of doctors, you paid the price and learned the ropes not for money or prestige but to serve your

...patients will likely pay less attentionto physician celebrities or “influencers” once they know you are also able to communicate on media... out could we lessen or even entirely avoid when we use crisis-management thinking to preemptively relieve it. Perhaps the best thing about 1:Many:1 is the last part. You might not particularly enjoy pivoting to all your patients as a collective. That’s OK - because you will pivot right back to 1:1 the next time they show up for their appointment. But you might notice a difference in the way that patient shows up: how they listen to you, how readily they might comply. The reality is that we live in a media-saturated culture - for better or for worse. Once you choose to step into unfamiliar waters not only to build a “personal brand” but to scale your impact through recorded media, you might be surprised to see how differently your patients respond.

patients. You went through that gauntlet for the sake of the physician-patient relationship - 1:1. I’m suggesting that you have more options to do this than you ever imagined especially if you’ve been feeling secretly overwhelmed by new pressures and regulations in this post-COVID world. 1:Many communication doesn’t mean you become fake or cheesy like some TV physician experts. You don’t have to trade in any of your values or authenticity because these are already your patients, and they are already listening to you. Instead, 1:Many communications simply means that you begin to think of all of your patients instead of individual patients. Again, whether you are a specialist, hospitalist, solo physician, or otherwise,

there is an angle you can make a part or most of this work for you. Where would you like your patients to be in their health ten years from now? Ten months from now? When you think of your patients as a group, it becomes easier to position yourself to help them proactively meet their goals. Direct care physicians could easily differentiate themselves by doing this. Do you have recurring issues in your practice that are draining you or your staff? Maybe it’s an unpopular payment policy or a regulation that is never fun to talk about in the moment. One way to lessen the negative impact of something like that - is to preemptively address it via a recorded message that goes to all your patients or a segment of them that would likely be impacted. How much staff burn-

In summary: • You don’t need to be limited to 1:1 any longer • You can scale to 1:Many with targeted, relevant messages • You reconnect 1:1 at their next visit • Your advice when recorded can address some, many, most or even all your patients who share a given condition • Your patients will likely pay less attention to physician celebrities or “influencers” once they know you are also able to communicate on media I hope this brief look into the power of 1:Many:1 fills you with hope and energy for your patients. PS - the change has already begun. I am already working with forward-thinking physicians who want to seize these tools - despite not being entirely familiar with them. You can find out more at patient-proof.com 1 WWW.PHYSICIANOU T LOOK . C OM | 21

ADVO C AC Y IN AC TIO N

Roadmap To Physician Independence

Wri t t en by Ch r i st i na D ew ey, M D

ver the past 25 years I’ve witnessed the birth of “Healthcare.” When younger, I was often asked, “Do you want to be a doctor when you grow up?” I’d answer, “No, I don’t want to take care of sick people for the rest of my life!” But I loved science, math, puzzles, people, learning, anatomy, figuring out how things worked, a challenge, and I matriculated into medical school in 1992. It was a time of collaborative engagement, new friendships, discovery. We challenged each other to do better, be better, and the whole class supported each other. Our goals were all the same: learn as much as possible in order to care for patients to the best of our abilities. We were challenged and expected to help each other, study together, quiz each other, and work together. We had all worked 2 2 | N OV E M B E R / D E C EMBE R 2 020

incredibly hard to be accepted into medical school and now was the time for each of us to learn to excel, depend upon, and work together. A medical hierarchy exists, and mastery is expected, and required, prior to being advanced to the next level, because patient lives are at stake. We had already proven ourselves as capable leaders, and now was the time for us to be molded and taught both the art and science of medicine. In addition to science, we learned principles of medical ethics: respect for autonomy, beneficence, nonmaleficence, and justice, and the importance of heeding these guiding principles as we entered into the practice of our age old learned profession. For at its core, medicine is the practice of honoring the Hippocratic oath: to first do no harm, and to help and to heal our patients to the best

of our abilities, bounded by the code of medical ethics and humanity. It is this time honored tradition of medicine that creates physicians: caring, capable, driven, resilient human beings that strive, self sacrifice, and give their hearts and minds to what drives them most: their patients. I’m reminded of a saying, “physicians are not made, they are chosen.” In concert with this saying, I‘d theorize the majority of physicians, and the driving force behind all that we do, is the relationship we form with our patients. For the physician-patient relationship is sacred, cultivated over time, and cherished by both parties. Our patients are not numbers, units or items on an assembly line. Our patients are mothers, fathers, husbands, wives, sons, daughters, sisters, brothers, friends, colleagues. Our

Moreover the Medical Industrial Complex has created additional obstacles and for profit entities that further impede access to physician-led medical care, including but not limited to: • • • • • • • • •

IMAGE CREDIT DAVID MOSBORG

•

patients are family. To me, Medicine = Physician + Patient, and I practice as I was trained: honoring my oath to do no harm, and taking the time necessary to appropriately care for, and put my patients first, always. Enter Healthcare. Over the past 25+ years, non-physician middlemen have inserted themselves into, between, and in every crevice of our sacred bonded relationships. Patients have become commodities, and physicians have become replaceable pawns in an ever growing corrupt game of increasing prices: the for-profit business called Healthcare. Physicians, nurses, and patients are no longer in control of medical care and patients often no longer have a choice in who they see when they seek medical

care. Hospitals, insurance companies, PBMs, and GPOs have all colluded together, creating monopolized, incentivized networks. These corporate entities OWN healthcare and restrict patient choice regarding physicians, hospitals, prescription medications - be in network or else. Script not on our formulary too bad! Primary physician, Consultant, ER, or hospital out of network - sorry we won’t cover that bill! Insurance reviewer feels the test/procedure ordered by your doctor isn’t indicated - we won’t approve/pay for it! These corporate giants lobby and control the legislators. This corporatization of healthcare has led to the rise of mid-level “providers.” Healthcare is a business whose only concern is money and making more money. Corporate control is why physicians are being fired & replaced by mid-levels.

Malpractice Scope of practice Insurance scandals Sham peer review EHR/surveillance capitalism on the pain and suffering of our patients PBM/GPO issue - 1987 Safe Harbor law causing ever increasing drug prices/ shortages 1997 freeze on SGR - and its effect on GME & lack of residency spots for those graduating medical school Tort reform PHP programs - speak your mind/ contradict the “norm”/ be labeled as disruptive - and be forced into “treatment” or lose your license MOC - extorting physicians to pay for their product or lose hospital privileges & insurance reimbursement

Until we - the physician community - acknowledge that all of these issues have a symbiotic parasitic relationship with each other, and that these issues must be recognized and addressed, corporate healthcare will continue to engulf, consume, and disempower the physician community. Luckily, we physicians have identified and realized the root cause of our problems, and we’ve had enough! In Dr. Hyder’s first two installments of how to “Flip the Script,” the parasitic infection of middlemen intrusion into medicine is well delineated and described. Additionally, an article I wrote last fall, (published on KevinMD.com), To extinguish burnout, bring back physician autonomy, further outlines how third party middlemen have created systemic changes that have led to diminished physician control and the creation of for-profit healthcare. The rise of easily accessible social media platforms have allowed physicians to reconnect with each other, eliminating WWW.PHYSICIANOU T LOOK . C OM | 23

IMAGE C REDIT DOU N A M ON TAZE R, M .D.

the silos erected by corporate healthcare giants. Our connections are key to creating change. For we alone, as physicians, hold the power, the knowledge, and thus, the control over our house of medicine and our future. Physician value and power comes from our identities and the very data we create during each and every patient encounter. As physicians, only we are licensed, trained, and credentialed to practice the science and art of medicine. Without us, our knowledge, our skills, our expertise, our training, OUR DATA, there is no medicine, and without medicine, healthcare will collapse. Grassroots physician organizations have formed and grown over the past 2 4 | N OV E M B E R / D E C EMBE R 2 020

several years. We physicians are leaders, innovators, and resilient, driven individuals. We fix, help, and heal, and we’ve used our collective strengths to develop new ways of connecting with our patients in order to regain our autonomy and practice medicine as we were trained. As physicians, we have the innovative capabilities, the knowledge, training, and drive to collectively create our very own roadmap to independence, free of middleman intrusion and roadblocks. DPC (Direct Primary Care) Physicians are breaking up with the corporate healthcare monopolies and starting their own private, self-owned and run practices again. Direct Primary

Care (DPC) is a reimagined type of private practice, with an affordable monthly subscription fee, that gives patients access to their doctors and puts physicians back in control. DPC physicians are free of corporate oversight, rules, regulations, government mandates, MOC, insurance regulations, EHR mandates, and reporting measures that do nothing to enhance the patient’s care and only profit the middlemen. DPC is physician autonomy reestablished. HPEC (Humanitarian Physicians Empowerment Community) As physicians our credentials are our identity. Our diplomas, our medical licenses, our board certifications verify our education, training, experience, and our credentials are what allow us to practice medicine and be reimbursed for our services. Healthcare middlemen have been using OUR credentials in their for-profit game. Currently, the healthcare players require physicians to pay them to verify OUR credentials through a process that, on average, takes 4-6 months to complete, and costs over $5 billion per year. Physicians lose up to $150,000 in revenue for each credentialing event, and it costs healthcare systems over $1Million per physician, per credentialing event. Using blockchain technology, HPEC is creating a censorship free collaborative network of physicians, wherein each physician has their own secure, digital self sovereign identity (SSI) with verifiable credentials. Once your SSI is verified, you alone own and control your digital identity, allowing for direct secure communication without middlemen interference. By leveraging this new technology, physicians will once again own and control their identities and any and all generated data: patient notes/ charts, referrals, prescribing patterns, tendencies to order certain tests, insurance trends, billing/coding, your patient’s private medical records. To date, we have been unknowingly participating and giving up our patients’ private health information. Corporate healthcare middlemen

have taken advantage of this easily accessible generated data, and exploited and used our data to increase their profits, to the detriment of both patients and physicians. With HPEC, we will own our data, and own our right to work. The digital documentation and sharing of our patient’s information with third parties will no longer be necessary. HPEC allows for secure direct confidential communications between both physicians and their patients, free from third party oversight or influence. Additionally, by digitally owning our credentials, our SSI gives us power, as we are the only source of truth regarding the validity of our credentials, granting us portability and leverage when negotiating contracts, and empowering us to choose with whom we work, and share our knowledge, experience, abilities and professional connections. SSI will also allow for peer to peer collaboration and communication around shared interests and common goals. Physicians will be able to collaborate with their colleagues and vote on issues that concern them in a truly democratic way. Once every physician has their own self sovereign digital identity, they will also be able communicate with their patients in a direct private manner. Because HPEC is decentralized, it eliminates the risk of privacy infringing surveillance models or distant and bloated bureaucracies influencing the practice of medicine. Built by physicians for physicians, HPEC is a secure, trusted, censorship resistant physician only network which will preserve the sanctity, privacy, and trust of the physician patient relationship, and empower us to regain control over our learned profession, and, once again, own our house of medicine. myDoqter With the rise of social media, online interactions and searches are now the “go to” for finding and discovering information. The younger generation has likely never heard of the yellow pages. Word of mouth recommendations still happen, but most occur virtually via

social media connections and online reviews. And anyone can post anything on the internet. Online reviews have increased exponentially. Websites pop up claiming “doctor,” “board certified,” “specialist in,” and the public is none the wiser. Even professional sites - once physician only - are now intermingled with non-physician providers, many of which claim to be doctors or are listed as having attended medical school! Transparency in training and actual credentials are often difficult for us to determine, yet alone the public. This is why myDoqter was created. By physicians, for physicians, myDoqter has created a physician only network. Physicians on the site must be licensed, and their credentials verified (which will become instantaneous once SSI’s by HPEC are utilized!) Physicians then attest their colleagues’ capabilities and specialty through peer review. Think of it as an online physician referral network. The physicians you’d refer your patients to are now in one place: myDoqter. The best part? The public - as patients - uses the site to find qualified physicians with verifiable transparent credentials approved by their own private physician. myDoqter is on its way to becoming the referral network for BOTH physicians and patients. Reconnecting patients with trusted physicians and reestablishing the private physician:patient relationship. Transparency in training, verified by practicing physician peers, available to the public, reconnecting patients with physicians: myDoqter. A powerful combination DPC, HPEC, and myDoqter all embrace the same underlying principle, which I believe both physicians and patients alike currently seek: the reconnection and reestablishment of the direct physician:patient relationship, free of third party middlemen interference. Medicine is both a science and an art, and physicians make up its heart and soul. For it’s the time we spend with our patients, the relationships we form, and

Medicine is both a science and an art,and physicians make up its heart and soul. our connections to each other, that fill our sacred house, and put the human back into medicine. Now is the time for physicians to realize our significance and value, to overcome the perception of compliance and learned helplessness, and to activate, align and use our innate resilience to take back our house. By leveraging our credentials, training, education, and our connections, we are in the driver’s seat, and in control of our future. For without us, there is no medicine, and without medicine the entire for-profit healthcare conglomerate no longer exists. Together we are powerful, and if enough of us believe we can change the current system, we will. Dr. Sam Shem recently said, “Power arises in a good connection and a good connection is good medicine.” Let’s reconnect together, harness our potential, unite in our power, reestablish physician autonomy, and follow this roadmap back to the ethical practice of medicine, putting our patients first, above profits, as we were trained. 1 ~ Christina Dewey, MD, FAAP @PedsMamaDoc drchristinadeweymd.com References/websites: https://www.physicianoutlook.com/articles/doctors-its-time-to-flip-the-script https://www.physicianoutlook.com/articles/ how-guide-physicians-reclaiming-credentials-identi?fbclid=IwAR1pIWu9Pj8nEp4QM3 l 0 X J T l M M _ H G h C f V H m Z Vc 5 R T f s 2 r i EGo7T9Aim7Sls https://www.kevinmd.com/blog/2019/09/ to-extinguish-burnout-bring-back-physician-autonomy.html https://www.dpcare.org/about https://hpec.io/ https://youtu.be/i-cRg_FuMVc https://www.mydoqter.com/ https://doctorsonsocialmedia.com/conversations-with-shem-episode-three/ http://www.samuelshem.com/v2/

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TIM E F O R YO U

Sourdough Bread Recipe Wri t t en by Re b ec c a C o a l so n, M D

Sourdough Bread Recipe - 1/4c active sourdough starter (King Arthur Flour recipe) - approx. 1 and 1/3c. warm water - approx 4c unbleached flour - 1 and 1/2 tsp salt Mix the ingredients in a stand mixer with the dough hook until a stiff dough forms. Knead by hand 2 minutes more. Place a clean disposable shower cap (yes you read that right) over the bowl and let rest for about 30 minutes. Work the dough into a smooth ball by lifting the outer edge and folding it toward the center, doing this all the way around. Cover the bowl again with the shower cap and let dough rise at room temp (at least 70 degrees) for about 8-10 2 6 | N OV E M B E R / D E C EMBE R 2 020

hours until it has doubled in size. (Overnight works well). Remove the dough gently from the bowl and place on a floured surface. Shape it into a round ball by using the same technique as before, pulling the edge and folding it toward the center of the dough, working all the way around. Let the dough rest for about 5-10 minutes. Generously flour a cup towel and place in a proofing basket. After the 10 minutes, pull the dough toward yourself with a cupping motion to tighten its shape and then place the dough in the proofing basket seam side up. Cover and let rise for about another hour until the dough has almost doubled in size. Preheat the oven to 450.

Place parchment paper in a dutch oven and then place the dough (seam side down) on the parchment paper. Score the bread - for the loaf pictured, use thread to divide the loaf into 4 sections by gently running it over the bread but not breaking the “skin.” Use a razor blade to make a leaf like pattern. Get creative! Anything goes. Bake the dough for 15 minutes covered in the dutch oven, then remove the lid and bake for another 20 minutes. Carefully remove the loaf from the pot and bake directly on the oven rack for about another 10 minutes. Please note that baking times may vary. When finished, transfer to a wire rack and let cool for at least 30 minutes. Enjoy! 1

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IMAG E CRED IT DR. REB ECCA COALS ON

IMAGE CREDIT DR. REBECCA COALSON

IMAGE C REDIT DR. REBECC A COA LSON

P HOTO C REDIT BY SA IRA RA HMA N H A N DS

I NT E L L I GE NC E O N TH E M OV E

Intentional Inquiry Wri t t en by Am el i a B u ec he, D. O.

“How are you?” This is a loaded question that often garners an empty response. We may not want to share. We often do not know what to say. We can feel uncertain if the inquirer actually wants to know the truth…or if we are willing to speak it fully. How should we be? What is an answer to this question? How is it received? How is it addressed? When you are asking, consider your intention. Why are you asking? Are you inviting a dialogue? Do you have a preconceived expectation of reply? What will you do with the response that is given? Particularly in an era of limited and modified interaction, having an expanded awareness of the impact of inquiry can be essential. Listening for feedback, rec2 8 | N OV E M B E R / D E C EMBE R 2 020

ognizing lack of an authentic or complete response. Hesitation, pause, exceptionally concise or the use of “fine” can offer opportunity to consider the experience of the other. Entirely acceptable to recognize and allow the response given just as it is. If asked in passing, that may be the full extent of the engagement. If launched for a more significant interaction, perhaps a pause in return, with follow up, can be helpful. Staying in a space of curiosity can invite expansion of sharing. Consider: • Would you like to share more? • Is there any support you need? • What were the biggest challenges this week?

•

What were your greatest successes? Normalizing the experience of challenge and possibility for success can be a helpful method for engagement that encourages without expectation. Noticing if you are listening or fixing – and if this aligns with what they are seeking. When you are being asked, consider your reaction. Do you question their intention? Are you up for a dialogue? Are you willing/ready/able to answer without concern of their expectation of your response? Do you have an expectation of their reaction to your response? Taking an inventory of your energetic and emotional reserve can be helpful in guiding the depth of your engagement. Perhaps a short and surface answer is sufficient in the moment.

If you have more to say, consider how you would extend a response that invites further dialogue rather than a monosyllabic reply. Checking in to verify readiness of the inquirer can be a helpful step to ensure all are engaged willingly in the discussion. Body language and eye contact can help to guide this assessment. If you’re looking to expand sharing, consider how you might stay in an open space as you offer a response, potentially adding: I’m not doing very well – do you have time to hear more? I’ve had an amazing week – I’d love to tell you about it if you have time! Thanks for asking – I’m not totally sure, but I’d appreciate a moment to consider and respond. I am actually doing fine – how are you? Normalizing the experience of taking up space for oneself encourages others to do the same when they have the need. Notice if you are seeking listening, reflection or solutions and be clear on your needs if they are not matched by the response. Loneliness is an epidemic, increasing with the on-going modifications to socialization and physical interaction over the past year. Connection is a key antidote and can be found in meaningful communication. Bringing intention to inquiry and reflection to response can turn a quick quip into a caring conversation, supporting both participants. Unloading expectations and applying empathy strengthens the ask. Shifting reaction to reflective reply enriches the response. Thoughtful dialogue weaves a tapestry of connection that covers the participants and warms the collective spirit. 1 Join us online at www.PhysicianOutlook.com to read Dr. Bueche’s next article “Never One Thing.” It explores osteopathic philosophy as foundational to the experience of inclusion across humanity. All aspects of mind, body and spirit must be well, and to be well means the freedom to be authentic across all dimensions of the whole person, the whole physician.

LIVE. LIFE. FULL.

DR. MARCEA WHITAKER

LIFE COACH AND PHYSICIAN

Feeling stuck in the life you are living? There is more. Find out how to break free and finally live

INFULLBLOOMHEALTHANDLIFECOACHING.COM

410-705-4850

WWW.PHYSICIANOU T LOOK . C OM | 29

T H E LA S T WO RD

Pulling Out Of The Nosedive

PHOTO CREDIT INGRAM IMAGES

GOVERNMENT DESTROYED HEALTH INSURANCE (AND MANY RELATED COLLATERAL INDUSTRIES) Wri t t en by C ra i g M . Wa x D O

very time government gets involved in an industry, it plants and nurtures the seeds of its destruction. It has been said many times, in many ways, “Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies,” said Groucho Marx. “If you put the federal government in charge of the Sahara Desert, in 5 years, there’d be a shortage of sand,” said Milton Friedman. “Asking government to fix government is like asking cancer to cure cancer,” anonymous. “A government big enough to give you everything you want, is strong enough to take everything you have. I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them,” said Thomas Jefferson. 3 0 | N OV E M B E R / D E C EMBE R 2 020

And, that is exactly what the US federal government had done over the last century. Originally, in 1912, soon to be President Teddy Roosevelt called for a national health insurance program during his campaign. From the War Powers Act of 1941, that enabled employer sponsored health insurance, to the so-called Patient Protection Affordable Care Act (ACA) of 2010 that destroyed employer sponsored health insurance, government actions, witting or unwitting, are our undoing. Take Medicare 1965 legislation for example. It was passed to provide the aged and infirmed seniors of 65 years and older with health insurance. Bear in mind, in 1965, very few survived to 65 years old and there were many in the working class to pay for each senior. Now, the demographics are reversed and there are many more seniors who are liv-

ing to 65 years old (60.6 million Americans covered by Medicare in 2019) and relatively many less working to support them. The original promise was that you would invest in Medicare taxes all your working life and it would accrue and compound to buy you Medicare insurance when you retire at 65. Problem was, Medicare was a Ponzi scheme that offered immediate benefits to 65-yearold retirees, who hadn’t paid in one thin dime. In fact, former President Harry Truman was given the first ceremonial Medicare card at the program’s inception in 1965, because of his goals for a national health insurance fund in 1945. He hadn’t contributed, just benefitted. The HMO act of 1972 warped health insurance by creating “health maintenance organizations or HMOs,” that redefined health insurance. Instead of being a per incident charge to patient

and insurance, patients either paid nothing or a small nominal fee at incident of care. Physicians and hospitals were paid a low, monthly “maintenance” fee per person, or capitation payment and all care was included and expected by all parties. This transferred the risk from the insurance company, a traditional risk-taking entity, to the physician or hospital, not traditionally a risk-taking entity. Translate that into less pay, more responsibility and more risk for physicians and hospitals. More pay, less responsibility and less risk for insurance companies. “In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests it, an appropriate transfer should be implemented.” (https://www.cms. gov/Regulations-and-Guidance/Legislation/EMTALA) In other words, yet another unfunded mandate on physicians and hospitals. By the 1990s, between the HMOs proliferating and mandated EMTALA care without payment, both care and insurance skyrocketed, while government crony insurance companies laughed all the way to the bank. HIPAA, the Health Insurance Portability and Accountability Act of 1996, provided for the digitization of analog medical charts. Lobbyists had succeeded in planning a digital takeover of medicine for the coming decade via EHR, Electronic Health Records. And, it was all in the name of privacy, at least that’s how it was sold to the American public.

In reality HIPAA was not a privacy act at all, but a disclosure act. It specified that government and insurance entities could get access to your, until now, private medical records, while others, like physicians, had to go through hoops just to get information on their own patients. “The American Reinvestment & Recovery Act (ARRA) was enacted on February 17, 2009. ARRA included many measures to modernize our nation’s infrastructure, one of which was the “Health Information Technology for Economic and Clinical Health (HITECH) Act.” The HITECH Act included the concept of electronic health records – meaningful use [EHR-MU], an effort led by Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health IT (ONC). HITECH proposed the meaningful use of interoperable electronic health records throughout the United States health care delivery system as a critical national goal. “Meaningful use” was defined as the use of certified EHR technology in a meaningful manner (for example, electronic prescribing); ensuring that the certified EHR technology connects

in a manner that provides for the electronic exchange of health information to improve the quality of care. By using certified EHR technology, the provider must submit to the Secretary of Health & Human Services (HHS) information on the quality of care and other measures.” https://www.cdc.gov/ehrmeaningfuluse/introduction.html Although the stated goals were improving care and exchanging health information, the act did the opposite. Care worsened as physicians and others took their eyes and attention off the patients. This frustrated patients too. The act also made information exchange more difficult as the systems had no standards for exchange and had lots of red tape, complete with HHS-threatened monetary penalties for non-compliance. The final ax in the back of health insurance was the Patient Protection and Affordable Care Act of 2010, that was unilaterally passed by Democrats on Christmas weekend. The act completely redefined health insurance into three narrow bands of coverage, instead of the hundreds of different options that were previously available. It resulted in insurance costs skyrocketing, and patients

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being dropped by their insurance plans, employers dropping coverage, patients forced to either buy bloated, expensive plans via PPACA individual mandate and shared responsibility payment or be fined/taxed by IRS, or be forced on to Medicaid government taxpayer sponsored insurance for the poor. Literally, we spent billions to save millions of dollars; a ridiculous proposition. For all these reasons I called ACA “the Unaffordable Careless Act.” Regarding Medicare, Congress passed MACRA with MIPS, Medicare Access and CHIP Reauthorization Act with Medicare Incentive Payment System - Quality Payment Program, in 2015. Now, instead of Medicare paying physicians and hospitals a set fee (one price fixed by Medicare) for care and services, Medicare was going to grade physicians and hospitals based on arbitrary criteria and outcomes for payment. This was indeed the last straw. Insurance was destroyed and Medicare was no longer true insurance either. See above illustration. All this despite the original 18 page Medicare legislation of 1965 declaration, “Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice 3 2 | N OV E M B E R / D E C EMBE R 2 020

of medicine…” yet, every rule by HHS, CMS’ unelected bureaucrats, not to mention Congress, has violated original Medicare law. In summary: The US federal government changed established natural norms and motivated and facilitated the creation of employer sponsored health insurance. Then, they ruined it with the creation of HMOs. When that went bad, because it was a bad idea and went naturally sour, they forced the digitization of healthcare through Medicare and Medicaid to have more government control and the ability to sell out to lobbyists. Of course, that failed miserably too, so they launched a more complete takeover with ACA. This doubled and tripled costs, while eliminating individual personal choice, and created over 100 new government entities for control. Now this too is failing, and some are calling for complete government control of all healthcare entities through single-payer healthcare, like Medicare and Medicaid, or socialized medicine - complete government ownership and management. Is there a way out of this utter chaos caused by government destruction of healthcare? Yes! Repeal or disable all government healthcare legislation

and allow free market competition and innovation to proliferate naturally. We must support the success of DPC, direct primary care and other forms of direct care where physicians and healthcare facilities compete for patient “business,” and patients pay directly at the time of service, with no intermediaries to drown them in red tape or excessive cost overruns. Payment models include direct pay, whether through membership models or fee for service arrangements. Let’s pull out of this government piloted nosedive before we hit the ground. After all this, the US federal government must not be permitted to overtake any industry. Politics, presidents, and Congress have utterly torn apart and redefined healthcare to serve itself and its cronyism lobbyists. To save the best healthcare in the world, we must repeal all the industry warping and redefining legislations with fancy confident names which are not reflective of the permanent damage they inflict on all parties. Free market capitalism, entrepreneurial innovation and competition would yield consumer choice, quality and best price. 1 References: A Plan for Health Freedom and Individual Choice - The Case for Full Repeal; (PPACA/MACRA/MU Audits); Craig M. Wax, DO, Family Medicine; Kristin Held, MD, Ophthalmology; Presented at National Physicians’ Council for Healthcare Policy; December 4, 2016; Washington, D.C. A brief history of Medicare in America https:// www.medicareresources.org/basic-medicare-information/brief-history-of-medicare/ President Johnson signs Medicare into Law https://www.history.com/this-day-in-history/ johnson-signs-medicare-into-law Emergency Medical Treatment & Labor Act (EMTALA) https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA Public Health and Promoting Interoperability Programs (formerly, known as Electronic Health Records Meaningful Use) https://www.cdc.gov/ehrmeaningfuluse/introduction.html Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/ MACRA-MIPS-and-APMs

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Al-Agba and Bernard tell a frightening story that insiders know all too well. As mega corporations push for efficiency and tout consumer focused retail services, American healthcare is being dumbed down to the point of no return. It’s a story that many media outlets are missing and one that puts you and your family’s health at real risk. JOHN IRVINE, DEDUCTIBLE MEDIA

Laced with actual patient cases, the book’s data and patterns of large corporations replacing physicians with non-physician practitioners, despite the vast difference in training is enlightening and astounding. The authors’ extensively researched book methodically lays out the problems of our changing medical care landscape and solutions to ensure quality care. MARILYN M. SINGLETON, MD, JD

A must read for patients attempting to navigate today's healthcare marketplace. BRIAN WILHELMI MD, JD, FASA

This book is a warning of what is to come if we ignore training and education. Share this book or tell others to buy it. We cannot wait to act on this.” DOUGLAS FARRAGO MD AUTHENTICMEDICINE.COM

This book exposes one of the best kept secrets in our current healthcare jungle created through the corporatization of medicine. Filled with relevant examples and anecdotes to help the reader understand the issues being addressed, this book captivated and held my interest from beginning to end. AINEL SEWELL MD

Inspiring, inciteful, and eye-opening! An in-depth and thought-provoking examination of important decisions affecting modern healthcare in America. This work should be mandatory reading for all administrators and policymakers influencing the US healthcare industry. KEVIN LASAGNA, LTC, US ARMY

A masterful job of bringing to light a rapidly growing issue of what should be great concern to all of us: the proliferation of non-physician practitioners that work predominantly inside algorithms rather than applying years of training, clinical knowledge, and experience. Instead of a patient-first mentality, we are increasingly met with the sad statement of Profits Over Patients, echoed by hospitals and health insurance companies. JOHN M. CHAMBERLAIN, MHA, LFACHE, BOARD CHAIRMAN, CITIZEN HEALTH

HIRING TWO PHYSICIANS! PMR/Sports Med/Pain/Neurology/Rheumatology/OMM/NMM

P.R.I.S.M. Spine and Joint is a thriving multidisciplinary practice specializing in complex musculoskeletal and neuromuscular care with a particular focus on hypermobility. We work closely and are co-located with a Neurosurgical Practice specializing in Ehlers-Danlos Syndrome/Chiari/Spine instability/Tethered Cord. Located in Silver Spring, MD just 0.5 miles from Washington, D.C., our area offers impressive schools, culture, and national parks as well as the Chesapeake Bay. The public school system is renowned, offering French/Spanish/Chinese Immersion programs and tech magnet programs starting in elementary school. Our practice currently has a six month wait for new patient appointments, and continues to grow each week! Contact: Adam@prismsj.com Position Summary Practice in an environment which combines NMM/OMT, Sports Medicine, PMR, and Neurology to care for complex patients with spine and joint instability and injury as well as athletes and weekend warriors. Many of our patients have Ehlers-Danlos Syndromes, and within a few months you will be an expert in heritable connective tissue disorders and the accompanying variety of injuries, autonomic nervous system dysfunction, and care needs of these patients. Lots of research opportunities/collaborations in place. Average of 36 clinical hours per week, minimal home call. 3 weeks PTO in year one, 4 weeks thereafter. Competitive salary, performance incentives, and benefits package including Health/Dental/Vision/Disability Insurances. Minimum Qualifications •MD/DO, BC/BE. Eligible for state licensure. •Life-long learner with commitment to patient care

Publisher: Marlene Wüst-Smith, MD Editor in Chief: Alicia Roselli Managing Editor: Alejandra Suarez VP of Advertising: Pamela Ferman Director of Art and Production: Ricardo Castillo Marketing/Social Media Intern: Allison Easton, Pennsylvania State University Contributing Authors: Megan Babb, DO; Amelia Bueche, DO; Rebecca Coalson, MD; Christina Dewey, MD; Nathan Eckel; Jordan Frey, MD; Rosanne Leger, MD; Peter A. McCullough, MD, MPH; Craig Wax, DO Cover Art: Susan Summerton, MD (front & back); Other Art: Douna Montazer, MD; Saira Rahman, MD and Steven Mosborg - Mosborg Exposures LLC Published By “Physician Outlook Publishing” Editorial Policy Physician Outlook Magazine is a national magazine dedicated to empowering physicians and their patients to improve the world of medicine together. Editorial decisions are based on the editor’s judgement of the quality of the writing, the timeliness of the content and the potential interest to the readers of The Physician Outlook Magazine. The magazine may publish articles dealing with controversial issues. The views expressed herein are those of the authors and/or those interviewed and might not reflect the official policy of the magazine. Physician Outlook neither agrees nor disagrees with those ideas expressed, and no endorsement of those views should be inferred unless specifically identified as officially endorsed by the magazine. Letters to the Editor Email: aroselli@physicianoutlook.com Information on Advertising, Subscriptions, Job Board Email: hello@ physicianoutlook.com “Physician Outlook is a registered trademark” WWW.PHYSICIANOU T LOOK . C OM | 35