"Crepuscular Rays of Hope on the Horizon" by Dr. Desmond Bell, DPM, CWS

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P U B L I C A T I O N D E D I C A T E D S O L E LY T O P H Y S I C I A N S A N D T H E I R P A T I E N T S COVER ARTIST: DESMOND BELL, DPM, CWS

F R OM T HE P U BLISH E R

Written by Marlene Wüst-Smith, M.D.

“The heart of man is very much like the sea, it has its storms, it has its tides and in its depths it has its pearls too” - Vincent van Gogh

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he sunbeams emanating from the gentle rolling waves on the cover of Volume 13 of Physician Outlook Magazine’s warm my soul and inspire a sense of awe and admiration for the ocean’s vastness and beauty. I admire and respect the ocean almost as much as I love the practice of medicine.

What we don’t know about BOTH the ocean and the human body is infinite, and these two great mysterious entities provide endless opportunities for humble continuous learning and appreciation of the wonders and dangers that lie within each.

The crests and troughs of the rhythmic ocean tides remind me of the predictable ebbs and flows of human development. Our internal circadian clocks almost magically regulate not only our sleep and wake cycles, but also control our hormones, our behavior and our overall physiology, right down to the cellular level.

We know that it is the gravitational pull of the moon and the sun, combined with our Earth’s rotation on its axis that creates the ocean’s beautiful crashing waves at high tide, and the vast seashell filled sandbars at low tide.

It is equally amazing that for our human bodies it is ALSO because of 2 | 2 022 VOLUME 13

the Earth’s rotation on its axis that we are able to remain wakeful and alert during periods of light, and that it is during darkness (when sleep naturally prevails) that cells are able to rejuvenate and heal themselves.

I am a thalassophile at heart, and this summer I had the opportunity to again be able to “return to my roots” and combine my love of the ocean with a passion for my profession.

For a few glorious weeks during the past several summers I have had the distinct privilege of being able to see patients in one of my favorite places on the planet: the ‘tony’ ocean-lined Hamptons on the East End of New York’s Long Island, which my family and I used to call home. It has been 16 years since we moved away, but I am still drawn to the physical beauty and charm of the region, as well as the crisp, forgiving and cleansing ocean air.

My workdays in the private office that I provide locum coverage in are long and arduous, filled primarily with pediatric patients who are the children of Latino immigrants. In this practice I also see some adult “dreamers” who were born in South America and continue to find comfort in a medical home that treats them with respect and dignity. In addition to the usual ear infections, colds and other infections that can cause high fevers and rashes, my days are filled with treating children and adolescents with obesity, depression, seizure disorders, cancer, autism, ADHD and anxiety, amongst

many other diagnoses (in addition to the usual “bread and butter” well child and adolescent visits). I get the unique opportunity to practice speaking in my native tongue of Spanish, a skill that I do not get to use much near my home in rural Pennsylvania or at the small private rural NY university where I see students during the academic year.

My well-deserved reward at the end of a busy Hamptons workday includes being able to spend my evenings and weekends ocean-side, relaxing with my toes in the sand, going to the many summer festivals (the Greek one in Southampton is my favorite!), seeing old friends, sipping a locally produced “Summer in a Bottle” rosé produced at the local Wolffer vineyard, watching the surfers at “The End” in Montauk, or enjoying a fabulous chef-prepared meal at one of the many fancy restaurants in the area.

The Hamptons has long been known as a “playground” for “rich and famous” Manhattan-ites, with many owning second homes that would usually only be inhabited for the summer months. The demographics of the area changed sharply after the World Trade Center terrorist attacks in 2001 (with a similar phenomenon occurring recently due to the COVID-19 pandemic).

In the wake of 9/11, frightened NYC families (including our own) decided to move their entire households “out East” year-round. My husband and I had purchased a modest 2 story capestyle house in 1998 in a middle-class neighborhood between East Hampton and Sag Harbor. As more and more families moved to the area year-round, the cost of living started to increase exponentially and by 2006 (right before the subprime mortgage crisis created a housing crisis) we made the financially very wise decision to pack up and move away to north-central Pennsylvania.

It makes my heart happy to visit our old stomping grounds once a year to “re-connect” with the sea, but I could never imagine living there fulltime. The traffic has quadrupled, and prices have continued to climb. As a pediatrician, I am blessed with having one of the most rewarding careers in

all of Medicine, but cursed with it remaining as one of the lowest paying specialties that exists.

“For whatever we lose (like a you or a me), it’s always ourselves we find in the sea.”

– E. E. Cummings The cover of this issue of Physician Outlook Magazine boasts a celestial image captured by the very talented and multi-faceted Dr. Desmond Bell, Executive Physician Coach for MDCoaches and amateur photographer. A foot and ankle podiatric surgeon with over 25 years of experience in the Operating Room, Dr. Bell is clearly a man of many talents. He has been blessed with an eye for the beauty in nature and also with a philanthropic heart. He is the Founder and President of the “Save a Leg, Save a Life Foundation,” dedicated to preventing amputations in patients with diabetes, hypertension and other forms of peripheral artery disease.

A highlight of my time in the Hamptons this summer was that I was able to rearrange patients during the third week of July so that I could personally attend Hamptons Tech Week, which was hosted by James Lane Post, Ethereal Global, and Southampton Arts Center. When it comes to technology, I am an experiential learner. I want to be AT the table when discussions are occurring about technology this time around, not ON the menu. I learned my lesson with the clunky EHRs that have ruined the practice of medicine for so many, and I want to understand what is being built for the future of our profession, and for me and my family as patients as we age. I am old enough to remember the slow ear-piercing screechy dial-up AOL tone that first allowed entry on to the World Wide Web, but I didn’t pay attention to how the technology rapidly changed and how it was being deployed. I want things to be different this time around. As vehemently as I am opposed to the CPOM (corporate practice of medicine), so am I at odds with the “Metaverse” version of the internet that Zuckerberg and others are building. An alternative that many in the technology world are embracing is the concept of “Web 3.0,” which is

a “decentralized” or community-owned version.

The Hamptons Tech Week conference educated guests on how Web3 is enhancing and progressing within a variety of industries which included art, real estate, medicine, sports, the environment, and fashion. The conference kicked off with keynote speaker, Emmy and Peabody Award Winner Evan Shapiro, cohost of podcast Cancel Culture, and Professor of Media Studies at NYU) while the panels were hosted

by Julie Lamb, Founder & Executive producer of NFT-vip.io.

The first speaker was Dr. Leah Houston, founder of www.HPEC.io, the Doctors’ DAO. She captured the attention of the largely non-medical audience with the story of HOW and WHY she became interested in creating a physician-founded AND physician-owned Decentralized Autonomous Organization. An Emergency Room physician, Dr. Houston became the inadvertent victim of “identity theft” when a hospital she no longer worked for continued to use her credentials for billing of patients long after she had stopped providing services at that location. The technology that www.HPEC.io is building will allow physicians to truly OWN their credentials and self-sovereign identities in Web 3 and beyond.

Physicians and patients need to retain ownership of their intellectual property and medical records, not insurance companies, hospitals or other third parties.

Dr. Houston was part of a star-studded list of leaders in the fields of technology, cybersecurity, sports, entertainment, Women in Web3, social media, marketing, cryptocurrency, blockchain, NFTs, finance, and the legalities of Web3. Speakers included Erin Franzman (VP content social strategy at CBS), Josh Posner (head of commercialization at StageVerse),

Janet Balis (Partner at EY’s Tech/Media group), Gary Adelman, Sarah Matz (both partners at the Adelman Matz P.C.), Scott Shine, (attorney at Aegon Asset Management), Mark Cianci (legal counsel for Ropes Gray), Elizabeth Nicholas (essayist and author), Amber Allen (founder & CEO of Double A labs), Katia Zaitsev (co-founder & chief business officer of Lexit) , Marisa Sechrest CEO and producer of Altair Entertainment, Nea Simone (founder and CEO of Melanated Studios), Paola Origel Managing Partner & Head Investor Relations at Chainlink Capital), Jaclynn Brennan (Fyli co-founder), Nacera Belal (COO, co-founder of Landng), Kathleen Ross (CMO of SugarBear), Carey Shuffman director of Head of Women’s Segment Strategy at UBS, Tyler Brosious social media manager at New York Islanders/ Adjunct Professor at Iona College, Peter Stein co-founder of Playrs) Nolan Carroll (former NFL player and director of football operations for Jacksonville Academy), Shannon Judd (founder of Transition), Stephen Zimkouski (partner of Celebrity Golf Tournament, Investor & NFT expert), Andy Valmorbida (River Labs founder), Samuel Austin (Chief Technology Officer at Apex Ledger Industries), and other speakers.

Guests enjoyed the Golden Jalapenos food truck as well as bites by Scott’s Protein Balls, juice from Natalie’s, and water from Liquid Death.

I enjoyed meeting all of these fascinating forward-thinking folks, and REALLY happy that I am an early adopter of www.HPEC.io, one of the many tools that is going to help us #TakeMedicineBack.

☤

Dr. Marlene Wüst-Smith Publisher & Founder

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Securities offered through Fortress Private Ledger, LLC. Member FINRA/SIPC. Investing involves risks, and investment decisions should be based on your own goals, time horizon, and tolerance for risk. The return and principal value of investments will fluctuate as market conditions change. When sold, investments may be worth more or less than their original cost.

P HYS IC IAN OUT LOOK M A G A ZINE

CONTENTS 2022 | VOL. 13

FROM THE PUBLISHER

02. THALASSOPHILE 06. YOU ARE MOST DEFINITELY NOT WHAT YOU EAT 08. A LIFESTYLE OF COMMUNICATION THE DESK OF A TEENAGER BORN TO TWO 10. FROM PHYSICIANS - THE COVID-19 DIARY

By Marlene Wüst-Smith, MD

By Wendy Schofer, MD, FAAP, DipABLM and Erin Schofer

By Nonye Tochi Aghanya MSc, RN, FNP-C

By Joseph Shega, MD

By Lauren Yanks

By Chris Gure

By Latino Leaders Magazine

By Michael Andrade

20. PRACTICING GRATITUDE IN A CHAOTIC WORLD 22. THIS. IS. HUGE. 24. IFTHISYOU HAVE BREASTS, YOU NEED TO HEAR

By Diana Londoño, MD

By Natalie Newman, MD

By Joanne Jarrett, MD

26. DEAR PREMED ME 28. ABRAHAM FLEXNER EVOLUTION OF A HEALTH CARE 34. THE ADVOCATE

By Diana Blum, MD

By Linda Rosa, RN

By Mark Lopatin, MD

37. YOU ARE WHAT YOU EAT 38. THE TRUE ART OF MEDICINE MAINSTREAM MEDICINE 40. COMPLEMENTING WITH COACHING

By Trish Craparotta

By Susan J. Baumgaertel, MD

By Wendy Schofer, MD, FAAP, DipABLM and Erin Schofer

CURCUIT BREAKER L ABS

12. PHYSICIANS AND ADVANCE HEALTH CARE PLANNING 14. BRINGING SPIRITUALITY AND MEDICINE TOGETHER 17. WHAT IS A DISABILITY INSURANCE COLA RIDER? 18. MESSAGE OF HOPE WITH DR. DIANA LONDOÑO 19. BE THE CEO OF YOUR OWN HEALTH

ARTIST: AMANDA PRESKE

By Ketan Tamirisa

You Are Most Definitely Not What You Eat “ Y O U A R E W H AT Y O U E AT ” H A S B E C O M E J U D G M E N TA L A S H E L L

IMAG E BY ED G AR S OTO, UN S PL AS H

Written by Wendy Schofer, MD, FAAP, DipABLM and Erin Schofer

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istorical and religious references use “You are what you eat” in the positive and aspirational.

When consuming that which we want to become or ascribe to, we take on traits and aspirations and build ourselves up to be stronger.

Christian Communion also practices the consumption of the figurative blood and body of Christ.

It serves as both a remembrance of His sacrifice for us. Transubstantiation means that as we consume the wine and bread, we are receiving Christ and His divinity.

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Ancient tribes practiced cannibalism with the intent of bolstering their courage or energy. They wanted to be what they ate: full of courage and vigor. They would even eat their enemies to vanquish their energetic spirits before they ascended to the afterlife.

The challenge right now is that the phrase is being used in the derogatory, “Well, you know, you are what you eat,” as one looks at a person with a body that is not accepted. Modern-day use of the phrase is typically attached to comparing a pudgy body filled with images of

pizza and processed baked goods or the slim body with a rainbow of colorful veggies.

The person saying it may be right. There may be overconsumption of unhealthy foods. There may be an imbalance in the nutrients needed for actually fueling the body, and instead, the body has gone into a continual fat-storage mode.

There is always at least 10% truth on both sides of a discussion.

But here’s the problem: “You are what you eat” does not help the person who is looking to satisfy

We cannot look at a person and wholly guess what they regularly consume. That’s reductionist thinking at work. Even identifying my diet (vegetarian) -what does that mean about me?

I am not a bag of double-cheesy popcorn (the last thing that I ate).

Nor am I unhealthy for having just eaten it. I am not morally superior by any stretch of the imagination by my love of veggies.

The food I eat fuels me, it does not define me.

The same thing goes for my patients and clients who struggle with their weight. They are not defined by what they eat. One of the first steps of helping individuals change habits is to separate identity from actions. If one sees their actions as being a part of their identity, they do not see the ability to disentangle the two. They do not see the option or ability to change. And that is where they are wrong.

We all can change. We all have the option to look at our current actions and ask, “Is this helping or hurting me?” And then we get to decide how we want to proceed.

My double-cheesy popcorn bag: I could have looked at it as hurting me, but I chose to think that at the time, it was helping me.

Because it was what I wanted to en-

You are not defined by what you eat. ☤ This article originally appeared on KevinMD.com and is reprinted with the author’s permission.

IMAGE BY EL EMENT5 DIG ITAL, UNS PL AS H

We are NOT defined by what we eat.

joy. It had nothing to do with who I was as a person. It was nothing more than a bag of popcorn, and nothing less than perfection at the time.

We have an opportunity as physicians, coaches, parents, teachers, and family members to check the “virtuous” way that we talk about food. The rightness or wrongness of a food is defined by the person eating it, who has complete control over changing what they eat over time.

My food is not a moral value, and it does not define me. It fuels me. Food is fuel. While certain foods can be a more effective fuel for physical, mental, and emotional performance, so can certain words.

Shaming and guilt-tripping our family members, selves, patients, does not create a positive “intervention” for change. It creates an unfortunate cycle where we retract, hide, and do not see change as being possible.

We can do better. I propose that we look at what each choice in food does for us: How does it make my body feel? How am I able to sleep and move and focus when I eat this food? How am I giving my body what it needs right now and what will keep it strong over time?

And, how is this food the perfect one that my body needs right now?

Eating the food that fuels aspirations and performance is much better to produce positive change than feeling shame, guilt, and misery. As we practice doing better, we will find ways to help ourselves and our communities create the habit of positive change.

IMAGE BY WENDY SCHOFER, MD, FAAP, DipABLM

hunger at the moment, nor does it show them a healthier way to eat. It does not help them when they just want to tell the speaker of the adage to go pound sand.

What does it do? It shames them for eating and perpetuates a spiral where food (and people) are identified as being good or bad.

That helps no one.

Wendy Schofer, MD, FAAP, DipABLM is the pediatrician-coach who specializes in helping parents raise healthy, whole families without all the food and body drama.

Erin Schofer is a writer, college student, and advocate for a kinder, more inclusive world.

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A Lifestyle of Communication Written by Nonye Tochi Aghanya, MSc, RN, FNP-C

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any years ago, I had a conversation with a patient who angrily said to me “if you don’t know what you’re doing, maybe you should just step down and let someone who knows the job take over.”

This statement was made following the administration of a flu 8 | 2 022 VOLUME 13

vaccine after which the patient experienced a sore spot at the site of the injection. Of course, this patient did not know that there is an up to 64% chance of experiencing soreness at an injection site following the intramuscular administration of a flu vaccine.

As a clinician in such a situa-

tion, what would you do? How do you effectively respond to such a patient attitude?

We find that rising fears and anxieties can manifest as diverse patient behaviors and attitudes, which can create mistrust in the healthcare setting. My lifelong mission is to create awareness of

IMAG E BY N ON YE TOC H I AG H AN YA, MS c, RN , FN P- C

ery remains a revolving quandary.

There are lingering questions that continue to pervade various communities in an era where many are not only dealing with the devastating effects of a pandemic, but also have differing perspectives on the best ways to help stabilize the country’s political, economic, educational, and health structures.

As truths increasingly become as subjective as our diverse per-

IMAGE BY NONYE TOCHI AGH ANYA, M Sc , RN, FNP-C

the factors that contribute to this issue and, more importantly, highlight the solutions that can be implemented to alleviate mistrust in healthcare.

As a healthcare provider for over 30 years, I’ve had contact with patients of various backgrounds and have extensively studied patient behaviors. I’ve also analyzed the effects of various communication styles on behaviors that occur due to underlying anxieties that patients display in healthcare settings. I’ve published various resources for improving communication patterns in healthcare to help alleviate fears and improve a trusting environment for healthcare practitioners and patients. Including online masterclasses that are original, unique, and innovative educational content based on reviews of existing research studies and numerous interactions with diverse groups.

As a population, we must remember that when a pandemic meets protests, our deeds and not our words, demonstrate compassion which leads to societal improvement. A patient’s anxiety is comparable to the environment of fear brought on by feelings of the unknown in the healthcare context, among other things.

In my book “Principles For Overcoming Communication Anxiety and Improving Trust”, I talked about a word that is quite common across many establishments, including the healthcare setting: “adversity”. Such a word is laced with numerous interpretations of its causes, and it notably unfolds with varied emerging ideas of the course of action required to alleviate the agony of its lingering effects. The goal of achieving effective engagements in healthcare practices for efficient care deliv-

sonal perceptions, active attempts to create a common understanding through deliberate interactive means are more important than ever.

Growth occurs when we step out in Faith into the unchartered territory of new forms of intentional interactions to form genuine alliances that are not only restricted to our local communities but within our global communities as well. ☤

A Fellow of American College of Healthcare Trustees, Nonye Tochi Aghanya is married, has four daughters and resides with her family in Virginia.

More information can be found on website: www.nonyetochi.com

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From the Desk of a Teenager Born to Two Physicians

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THE COVID-19 DIARY Written by Ketan Tamirisa

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few months ago we went on our first family vacation for spring break...the first one in 30 months. Sitting by the water, basking under the midafternoon sun, I reminisced how my life went through a roller coaster ride because of the pandemic. Open lands around the water, trees, peace, and tranquility around me brought back a sense of normalcy.

My family had just moved to Texas (so our elderly grandparents could enjoy the warmer weather) from Ohio when the pandemic started. We knew maybe one or two friends in Texas. Social interactions were limited due to physical distance from our dear friends and family back in Ohio. It was during this time that we were trying to find a house, while my brother and I started new schools and my parents found new employment. My parents both worked in the medical field in Ohio and were lucky to find jobs where they could continue the career they had built for years. They soon assimilated into the new hospital environments as physicians once again.

The pandemic added another layer of complexity to our relocation simply because both of my parents are physicians and were taking care of patients –Covid-19 patients too. Born to two physician parents meant close and personal exposure to the destructive wrath of the virus on people during the last few years. Because of frequent out1 0 | 2022 VO LUME 13

breaks at the hospitals they worked at, my parents would often quarantine in our own home (sectioned off in their own rooms). As they were never sure if any sniffles or exposure at work meant the beginning of the infection. This process was necessary since my grandparents were living with us. The quarantine period was extended till they received negative Covid-19 tests.

They would wear masks around the house and stay as far away from the rest of the family as possible.

Isolation in our own home felt stifling. Limited interaction.

This went on for months together without an end in sight. They would change clothes in the garage and clean their keys, cell phones, etc. in the UV cleaning counter near our shoe rack. I vividly remember my parents discussing with my grandparents about paperwork to protect us in case both my parents

became ill at the same time. My brother and I asked them about it at dinner time one night. My parents comforted us saying that they were just being proactive and that there was nothing to worry about.

Their poise during this time made me think about all the physicians out there –they care for those suffering and yet, stay calm and carry the responsibility at home without any complaints of their own struggles or aches and pains.

Our daily schedules were challenging. Even though my brother and I attended online school via Zoom, we still needed someone to take us to our occasional activities. We both wanted to play outdoor tennis or run on the track field which meant we needed transportation. For months, my parents managed busy schedules to make everything work. They would wake up early in the morning to prepare

“Always look at the bright side of things because there’s a rainbow after every storm” -Banteilang Dohling

It’s hard to look at the bright side of this epidemic that has caused worldwide devastation and destruction. However, as a child in a two-physician family, the lessons that the pandemic taught me were different than that of my peers. The pandemic enabled me to improve my work ethic, and responsibility.

To appreciate the sacrifices that my parents (and physicians like my parents) make to keep the equilibrium.

Because my entire freshman year was taught through online

IMAGE BY KE TAN TAMIRIS A

our lunches for the day and coordinated with each other about who was going to get home early. It was as if my parents were stuck in a timeless continuum—a grueling routine they would have to follow day in and day out.

However, what sets my parents apart from others is their resolute determination and steadfast mindset. Even after coming home after a long day of work, they would never hesitate to help my brother and me with homework.

Virtual learning had its pitfalls. We missed the face-to-face interactions with our teachers and friends and couldn’t understand some of the concepts as clearly. When we needed help, they would never complain and were always available.

courses, it was up to me to make decisions that would help me in the future. I had to stay focused, dedicated,and not succumb to distractions. I made sure to be attentive in class, submit my work on time, and be respectful towards teachers, as it was their first-year teaching online as well. Frequent online glitches and crashes were common in the initial months as everyone had to learn a new way of life. Work ethic and responsibility go hand in hand.

When I improved my work ethic, in turn, I also gained more responsibility. Since my parents weren’t home most of the day the responsibility of our new pup, Dexter, fell into the hands of my brother and me.

We coordinated a schedule based on our online school timing. This way each of us would take Dexter out at certain times during the day, as well as feed him. When my parents weren’t home, my brother was also my responsibility. I helped my brother get ready for his online classes every day, made sure he

ate lunch and helped him with his homework. Overall, even though the pandemic affected everyone negatively in one way or another, there were few good things that came out of it. In my case: Self-reliance and helping. ☤

“Many times, there is the unexpected start or end of something......Maybe we had never thought. But such unexpected events are the best. They teach us many life lessons, provide opportunities, make us stronger, wiser....in short, we get the opportunity to know and explore ourselves.”

-Himanshu Chaturvedi

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IMAGE BY ENORASIS (ARTIST BIO ON RIGHT)

Physicians and Advance Care Planning: E M E R G I N G F R O M T H E PA N D E M I C W I T H G R E AT E R A P P R E C I AT I O N F O R E N D - O F - L I F E D I S C U S S I O N Written by Joseph Shega, MD, Executive Vice President and Chief Medical Officer for VITAS Healthcare

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dversity may be one of life’s most powerful teachers.

It can make us more resilient and lead us to take stock of our values, priorities and choices.

The global pandemic has certainly catalyzed a great deal of change for many on a personal level. By forcing us to reckon with the unpredictability and fragility of life, it’s prompted us to think more purposefully about how we want to live our lives – including how we want to finish our life’s final chapter.

The importance of advance care planning cannot be overstated. An advance directive is a written statement of a person’s wishes regarding medical treatment.

These allow patients to make their preferences known early, and knowing a patient’s wishes for end-of-life care helps ensure that their care aligns with their goals and values while also relieving the burden on families to make critical medical decisions on behalf of their loved ones. Yet, as of 2021, a VITAS Healthcare-commissioned survey found that one in five people had a loved one who was seriously ill or died and did not know their wishes for end-of-life care.

Earlier this year, VITAS commissioned another survey to better understand how people’s thoughts and behaviors around advance care planning may be evolving as we be1 2 | 2022 VO LUME 13

gin to emerge from, hopefully, the worst days of the pandemic. Disconcertingly, as restrictions ease and the death toll declines, survey results indicate Americans are still struggling to put a plan into place by documenting their wishes.

Post-Pandemic Shifts in End-of-LifeCare Planning On the positive side, the latest survey showed an uptick in those who reported documenting their end-of-life wishes this year (35.4%) compared to last year(32%). Interest in advance care planning has particularly increased among Black Americans, who have been disproportionately affected by COVID-19. This year, nearly 40% of Black Americans said they were likely to discuss or document their wishes, compared to just 28% who said so in 2021. Black respondents were also far more likely to know someone who has died without having made advance care plans, compared to Hispanic, white, and Asian respondents.

Though the recent upward trend in advance care planning is encouraging, survey results also signal interest may be waning. Last year, 29% of Americans reported that the pandemic increased the likelihood that they would discuss documenting their wishes. This year, that percentage has already

dropped to 22.5%. While younger Americans ages 18-25 were among the most open to end-of-life discussions a year ago, with nearly half (47%) reporting they were likely to have this important conversation, that number has fallento 37.8%.

Even more concerning, there is a persistent gap between those who reported that they value advance care planning and those who have actually begun the process.

While the majority of people (68%) agree that these preparations are important or very important, nearly the same proportion of respondents (64.6%) have not documented their wishes. Meanwhile, just over half (55.5%) have at least discussed their wishes with someone.

The Role of the Physician in Advance Care Planning Here’s another statistic to consider: a striking 71.4% of those surveyed say their healthcare providers have never initiated these important conversations with them.

This is where we as physicians have the opportunity to course-correct and make a difference. After immediate family, the primary care provider was the most common response when asked with whom people would be comfortable discussing advance care planning.

And, these discussions often lead to concrete action. Of those who

Image created by ENORASIS Athens, Greece, used with the permission of the artist.

Shop printable medical art, anatomy, lawyer art on the artist’s ETSY shop:

IMAG E BY VITAS

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reported documenting their advance care directives, 13.2% said their provider had discussed it with them. Those numbers are even higher among Hispanic (24%) and Asian (24.2%) respondents. Many of us were drawn to medicine to save and improve lives. And it’s important to remember that this duty includes helping our patients live their best possible last years, months, and days. That’s why endof-life discussions shouldn’t wait.

We should be having these conversations with our patients early and regularly, while our patients are communicative and alert. Not only can regular advance care planning discussions help destigmatize the topic, but they can also ultimately help our patients feel less anxious about the future and more in control. Of course, these conversations also require resources, support, and practice. At VITAS, we recommend starting with the SPIKES protocol (Explained below):

Additionally, to help physicians and other healthcare professionals feel empowered to effectively discuss advance care planning with their patients, VITAS launched a new preceptorship and certificate program at the National Black Nurses Association Annual Conference in July 2023. This program featured education modules on a variety of topics, including prognostication, hospice basics, and how to communicate with sensitivity, respect, and empathy. It also included practice scenarios where participants can get feedback on actual conversations with patients.

The pandemic has changed the way we view advanced care planning. Physicians can appreciate the importance of end-of-life discussions with new clarity, and ultimately allow more patients to live their final days in a way that honors their wishes and values. It has been a hard-learned lesson, but hopefully, it’s a lasting one. ☤

SPIKES PROTOCOL:

SETTING

Choose a private, comfortable, non-threatening environment to hold the conversation with family/significant others. Ideally, avoid having a desk or computer in between you and the patient –physical barriers can create perceived emotional barriers and inhibit openness.

PERCEPTION

Assess what the patient already understands about their health, diagnosis or prognosis.

Ask them to share their questions and concerns first before providing explanations or steering the conversation.

INVITATION

Obtain the patient’s permission to receive more information about advance care planning.

If they are unwilling to discuss it at that time, respect their wishes – and continue to follow up and invite their permission to have the conversation.

KNOWLEDGE

Offer facts about care options, and meet the patient where they are by tailoring your explanation based on their ability or their family’s ability to receive and understand the information.

EMOTIONS

Notice emotions and respond with empathy. Simply pausing to acknowledge someone’s emotional reaction with kindness and patience can go a long way in building trust.

STRATEGY & SUMMARY

Summarize the news and determine a strategy for how to proceed, based on the patient’s willingness and state of mind.

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Bringing Spirituality and Medicine Together: The Lifelong Healing Quest of Marta Illueca Written by Lauren Yanks, Yale ‘19, M.Div.

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s a child growing up in Panama, Marta Illueca, Yale ’18 M.Div. became accustomed to life in the public eye.

“My father was dedicated to social justice,” she said, “and very active in politics.”

A graduate of Harvard Law, her father held prestigious posts including Ambassador of Panama to the United Nations and President of the 38th United Nations General Assembly. He even became president of Panama during a period of unrest.

“Starting in 1984, my father was president for a year and a half,” Illueca said. “Suddenly, each family member had a bodyguard and code name. But my father was very humble and made sure we all stayed grounded.”

While her father worked on housing for the homeless and other progressive reforms, Illueca’s mother was also busy serving her country. Passionate about health, she was a nurse who founded Panama’s first nursing college.

“My mother really elevated Panama’s nursing education,” said Illueca. “It was her calling. Both my parents were great role models for me and my siblings.”

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quest for herself and others.

“When I was 12 years old, my sister—who was nine years older than me—died suddenly from an undiagnosed heart condition,” Illueca said. “It was extremely traumatic, and it pushed me towards medicine. I wanted to understand why her condition went undiagnosed.”

The death of her sister affected other aspects of Illueca’s life as well.

“Internally, it started my whole spiritual journey,” she said. “I began having intense mystical experiences.”

Illueca describes moments of feeling as if she were outside her body, seeing lights, and having detailed dreams.

“I realized we are more than the physical body,” she said.

“We have a spirit and different layers to our constitution. ”Raised in a traditional Roman Catholic family, Illueca started researching other beliefs, including Eastern spirituality, theosophy, and Jewish mysticism.

“I found beauty and wisdom in everything I studied,” she said. “The mystical experiences stopped when I was around eighteen, but my outlook on life changed forever.”

A life in medicine Illueca would go on to college and medical school, graduating at the top of her class.

“I was valedictorian and accept-

ed to Cornell University Medical College for a pediatrics and gastroenterology residency,” she said.

After her successful training, Illueca continued to practice medicine at Cornell for the next two decades. In 2003, she sought to learn how to develop new medical treatments and moved to Delaware to work for AstraZeneca in the pharmaceutical industry.

“I wanted to be part of therapy research and development, not just limited to prescribing existing treatments,” she said.

Illueca led the company’s Nexium ® pediatric program, helping children who suffered from acid reflux.

“We developed an FDA-approved pediatric treatment that can be used as early as one month of age,” she said.

While immersed in the world of medicine, Illueca never abandoned her spiritual journey. One day, after catching a Broadway show in New York, she stepped outside of the theater and was immediately captivated by a beautiful church.

“Something about that church just drew me in,” she said. “It was during a high church mass and there was lots of incense. As a Roman Catholic, I liked ceremony and ritual. I had no idea it was an Episcopal church. ”Illueca felt connected to this

IMAGES BY L AUREN YANKS, YALE’19, M.Div.

“very sacred space” and went on to find a similar Episcopal church near her home in Delaware.

“I found this beautiful Episcopal church where the rector was a woman, so she became my role model,” said Illueca. “I needed to bein a place where I could see the possibilities for a woman. Before that, I never thought I could become a priest.

That church became my temple.”

Back to school While growing more active in her church, Illueca felt called to delve deeply into the world ofspirit. She

decided to attend Berkeley Divinity School, the Episcopal Seminary at YDS. As Illueca prepared to enter Berkeley, she began her last project at AstraZeneca.

“My final project dealt with chronic pain,” she said. “It was then I saw a presentation by Dr. Daniel Carr, the director and founder of Tufts University’s Pain Research, Education & Policy Master’s program. I was so impressed with his depth of knowledge. ”Carr’s program at Tufts looked more deeply at pain through a variety of disciplines, including ethical,

sociocultural, and spiritual dimensions. Illueca says that watching his presentation and speaking with him afterward felt “like an epiphany.”

“At that moment I realized that my true calling is to bring spirituality and medicine together”, she said. “Carr’s comprehensive pain program appealed to my holistic outlook on medicine, and I wanted to learn more. I began studying at Berkeley and his program at the same time. It just felt right.”

Carr refers to Illueca as “a real standout” and believes her work exemplifies the shift in emphasizing pain “as an experiential thing and not just what happens when you injure tissue.”

“Marta is drawing together different fields of knowledge and helping to further our understanding,” he said. “She is addressing the fundamental question of defining pain, including spiritual pain.”

At YDS, one formative class for Illueca was Theology and Medicine with Dr. Benjamin Doolittle ‘91 B.S., ‘94 M.Div., ’97 M.D. The course explores contemporary medicine from a theological perspective and covers such topics as suffering and healing that resonate in both fields.

Among a number of positions, Doolittle is the Program Director of the Combined Internal Medicine-Pediatrics Residency Program and the Director of the Yale Program for Medicine, Spirituality & Religion. His research interests explore “the intersection of medicine and spirituality, wellness and burnout.” He is also the pastor of Pilgrim Congregational Church in New Haven.

“I pastored as a medical student and as a resident, and I’m still doing it,” Doolittle explained. “I love it.”

Studying with Doolittle was informative for Illueca, and she decided to apply some ideas from class to her master’s thesis at Tufts.

“I wanted to do a formal, systematic review on the clinical research about pain and prayer,” she said.

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A new vocation and a new study Illueca is now an ordained Episcopal priest at Brandywine Collaborative Ministries (www.vcmde. org) in Delaware and spends much of her time giving sermons and providing pastoral care. Although her life looks different now, medicine

still plays an important role. She is a COVID advisor for the country of Panama and is conducting an indepth study on pain and prayer. The ongoing study began last October and is partially funded by the 2020 United Thank Offering grant, a ministry of the Episcopal Church.

“Meints and I are creating what will be the first-ever scientifically validated prayer scale and will ultimately use it to design a bedside prayer tool,” Illueca said.

While not a spiritual person, Meints believes it’s important to research the intersection between science and religion—an area she calls “understudied and often overlooked.”

“Much of our world is religious or spiritual, yet this is often seen in opposition to science and Western medicine,” she said. “We are studying the overlap between these areas to better understand how we can harness the power of prayer in helping folks manage chronic pain.”

The study is unique for Meints, as well as challenging.

“I lean on science and hard data to guide me,” she said. “Marta, however, has been able to blend medicine and religion through the course of her career. I find it inspiring that she is a strong proponent of how these worlds can mesh together quite seamlessly.”

Indeed, Illueca hopes that this study will help strengthen the connection between medicine and religion.

“We are creating a new research model where church and academia collaborate,” she said. “For too long, spirit and medicine have been unnecessarily separated. I want to bring these worlds together in ways that are both scientifically validated and holistically healing.”

Illueca talks about her work with great passion and energy, and she credits her faith for her vitality.

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her thesis director, and he was up for the challenge.

“It was a joyful collaboration,” Doolittle said. “In modern society, we often separate things like pain and prayer. We talk about the body, spirit, and mind, but it seems to me that they’re all part of the same thing. We can’t really separate them because the deepest questions of meaning and life and love are always spiritual questions. What it means to be healthy in body can never be separated from a person’s emotional well being or spiritual health.”

Illueca and Doolittle adhered to the stringent criteria of analyzing over 400 previous study reports, with only nine fitting their standards.

After their analysis, they found that personal prayer—as opposed to group or distant prayer—is more helpful for healing pain. The research also shows greater positive results when a person uses “active prayer,” a term coined by Samantha Meints, Ph.D., a clinical psychologist at Brigham and Women’s Hospital in Boston.

“Active prayer is like asking God to empower you and provide you with the tools needed to overcome the pain,” Illueca said. “It’s a more beneficial coping strategy than just passively asking God to take the pain away.”

During Illueca’s thesis preparation, she contacted Meints and proposed that they develop an instrument or scale dedicated to characterizing prayer used by people with chronic pain. Meints enthusiastically agreed.

“I am inspired by life, and although I’m in my 60’s, I’m just getting started,” she said.

“The first thing I do every morning is to thank God for a new day. I try to see God in everyone I see and in everything I do. I believe I am being guided, and I am deeply grateful for everything in my life—past, present, and future. I feel very blessed.”

Reprinted with permission from author and Yale Divinity School.

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What Is a Disability Insurance COLA Rider?

Written by Chris Gure

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nflation is an unavoidable part of life and is something we can all plan for—sometimes decades in advance. In our physician oriented inflation series, we are addressing how doctors can get a head start on inflation so they don’t feel its affects as strongly in the future.

No matter what plans we lay, life may have a different idea about what’s in store for us. There may come a time where a physician— who spent a lot of money on tuition and a lot of time in school— finds they are unable to work due to an injury or illness. This is when disability insurance can step in to help policyholders maintain their standard of living even if they can’t work for a temporary or extended period of time.

When someone goes to purchase disability insurance, they may choose to add a cost of living adjustment (COLA) rider. This rider can help policyholders fight the effects of inflation.

Keep reading for more insight into what a COLA rider is and why you may choose to buy one.

What Is the COLA Rider?

A COLA rider can help ensure that disability insurance benefits

you’re paying for keep up with inflation. Adding a COLA rider to your disability insurance rider can be expensive, but you’ll find that you can easily recoup the costs if you do ever need to use your policy’s benefits as a COLA rider can greatly increase that benefit amount. You’ll especially get your money’s worth if you end up needing to utilize your policy benefits early in your career.

The way this works is the COLA rider adjusts your policy’s monthly benefit on an annual basis. This increase can be based on a fixed percentage or may be linked to the consumer price index.

Is the COLA Rider Worth Purchasing?

A COLA rider can be very well worth it if you end up needing to tap into your disability insurance benefits one day. That being said, not everyone may find this extra cost worth it. It can be helpful to first make sure you have the maximum amount of coverage you qualify for based on your income before you consider purchasing a COLA rider. That way, you can make sure you’re gaining access to as large of a benefit amount as possible before you worry about inflation.

Your age can also help you de-

termine if this is the right move to make. When someone is young, and has limited assets, adding a COLA rider to their disability policy can help secure their financial future. If someone is inching closer to the end of their career, they likely don’t need to worry about inflation affecting their benefits too harshly.

It’s also worth noting that COLA riders only increase monthly benefits after someone has already been disabled for 12 months, so only those filing longer term claims can really benefit from this rider.

The Takeaway In short—COLA riders help disability insurance policies keep pace with inflation. If someone is already maxing out their potential coverage, they may find that a COLA rider gives them some extra peace of mind that they’ll have ample financial protection if one day they become unable to work. ☤ Go to Chris Gure’s Fortress Financial Substack to learn more financial strategies. (https://fortressphysicians.substack.com)

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Message of Hope with Dr. Diana Londoño City of Hope’s Dr. Diana Londoño’s interest in urology comes from seeing her father struggle with this condition.

Since then she has aimed to connect with the Latino community to provide top health care and prevention.

Having suffered a life-altering loss in her family, Urology Specialist, Dr. Diana Londoño is helping spread a message of hope to patients with similar ailments.

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IMAGE BY. DIANA LONDOÑO, MD

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n the Latino community we have become accustomed to how easily one’s life can suddenly be uprooted and destiny changed from one day to the next. Dr. Diana Londoño underwent such a life-altering experience during a visit to her father in Mexico. Born in Mexico City, Londoño moved to the U.S. when her parents separated at the age of 12. During her formative years she was involved in the student council and took on many leadership roles. Her undergrad education was focused on government and she planned a career in politics.

On an annual trip visiting her father back in Mexico, however, she noticed a dramatic change in his health that would impact her perspective and career purpose.

While he would usually be in in peak physical condition, proud and almost “vainly”eager to express the stereotypical Latino attitude, he was now in a wheelchair barely able to attend to his daughter and even a bit ashamed at his own condition like any typical father. Unfortunately, his prostate cancer quickly metastasized in a

way that is “rare nowadays with early screening”and which people can easily avoid and live well over their 60’s. Londoño decided to seek a career in medicine focusing on similar diseases to prevent this from happening to others.

Dr. Londoño is currently a part of the City of Hope’s research initiative to educate local Latino communities and potential medical students in the field. She feels there “is a lot of miseducation and taboos”that people develop due to language barriers. For example, earlier in her career she

worked in Miami’s Little Havana where 90% of the patients were Spanish-speaking. The number of Spanish-speaking doctors here and abroad is limited and so it is difficult to translate important health information. Overall, Londoño’s goal at City of Hope is to help enhance people’s quality of life through compassion and communication maintaining their dignity despite cultural differences.

(Originally published by Latino Leaders Magazine in September of 2018, reprinted with permission)

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Be the CEO of Your Own Health Written by Mr. Michael Andrade, Partner at Mitigate Partners, LLC

We found that telling a doctor “no”, “no thank you”, “what else do you have?”empowered these experts to be even more resourceful.

We believe her life has been extended because of finding the right doctors. If we would have listened to her first and second doctors her health may be worse. If she didn’t change her approach and coach her

IMAGE BY TRAC Y WALK ER

“

Ms. Walker, it appears the cancer has metastasized in your pancreas and liver.” Words that forever changed our lives. You’re overcome with emotion, disbelief, and uncertainty. Is this curable? How long do I have? You don’t know what to do, don’t know where to turn, and don’t even comprehend your reality until many, many, months later.

Through her journey Tracy had some unpleasant experiences and along her journey something changed. She changed. Tracy became empowered by respectfully telling her doctor NO. She became the CEO of her health. Her role was to find the best team of doctors possible and be her advisors on her journey. Through research she was able to find five of the foremost authorities on her cancer in the US. We talked with three. Each of these three were consistent in the treatment, every doctor had a different interpretation for where she is with the progression of her disease. The most important lesson we learned was that Tracy had to advocate for herself.

doctors to be her advisors, she may not be with us today.

As traumatic as the diagnosis is, Tracy and I are both grateful for the impact we’ve been able to create. Her diagnosis absolutely transformed both of us personally and professionally. She empowers others and has started her own movement #wedefytheodds.

As a benefits advisor I had to change everything I knew about purchasing healthcare and have become part of a transformational ecosystem of support. I now positively impact lives by helping people avoid many of the mistakes made early on. Helping patients find ex-

pert physicians using quality first, saves lives, eliminates unnecessary suffering, and saves a lot of money.

If you’re a physician reading this, consider how you’re referring your patients now. My experience with physicians is that they refer the same way everyone else does to people they know and like. If this is you, please consider whether or not you have enough quality information to truly know if you are sending to best doctor for this person or just the best doctor you know. Your trust and guidance saves lives and eliminates suffering and is the foundation for solving healthcare. ☤

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WHY WOULD THIS BENEFIT ME? Written by Diana Londoño, MD

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hen people talk about practicing gratitude, we may think it is a nice concept, but what does that have to do with me? Or how can there be any benefit? What does it really mean to “practice gratitude?”

The definition of neuroplasticity describes what researchers have found and proven that neurons that fire together make new connections and real changes in the brain. The more we practice anything in life, the better we become at it. Repetition leads to mastery.

However, before you do anything, a thought and an emotion will precede that action or goal.

For example, if you want to run a 5K, a helpful thought can be that your health is important. You will feel motivated, therefore you will practice daily to achieve your goal.

It will be both a daily practice of the thoughts that fuel you and the actions taken to allow you to reach that goal. If you think it’s impossible, you will feel overwhelmed and defeated and you will not do it.

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on, and the results will follow. You will not run a 5K if you think it’s impossible. It is our thoughts which create our results.

So, if we make a point to practice daily gratitude, we then put our attention on thoughts which will begin to change our brain.

Thoughts of gratitude will cause neurons to fire and cause connections changing our neurochemistry and leading to neuroplasticity. When we practice gratitude, hormones like dopamine and serotonin are secreted in our brain and we begin to feel different. Remember, dopamine and serotonin are our happy hormones, and they are depleted in conditions like depression.

Having the opposite thoughts filled with negativity instead of gratitude has been associated with anxiety and depression. Therefore, exercising our brain “muscle” to strengthen thoughts that cause the release of neurotransmitters that will cause positive effects in our brain and body is not just new age woo-woo, it’s science.

The challenge lies that in our iPhone world where everything is

instantly gratifying, we want the results to occur overnight. We practice this for 2 days and we do not see a change and we give up.

Again. It is a practice. Running for two days will not get you to finish a 5K race. Mastery will take a lifetime, but anything worthwhile takes effort. If you have kids, they didn’t start speaking and saying thank you every time by themselves. They practiced it with your guidance and repetition, over months and years it led to building that neuroplasticity or changes that became automatic to say “thank you” after something was given to them.

So how does this really work?

How do you do it? How long will it take? It does not have to be something that takes more than a few minutes and an easy way to start a new habit is, like James Clear wrote in “Atomic Habits,” to stack it to something you already do. That means add it at the end of something you already do as a daily habit.

For me, before I go to sleep, I keep a notebook by my nightstand, and I write down things I am grate-

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Practicing Gratitude in a Chaotic World:

ful for right before I close my eyes.

I do this as well when I wake up.

I also write a thought of what I want to focus on for the day such as patience, kindness or being less reactive and more deliberate in my answers.

I definitely fail in my attempt to carry those goals throughout the day, but I want to train my brain to focus on positivity and gratitude because my efficient brain will start scanning the world for other evidence of things to be grateful for the remainder of the day.

Our brain is very efficient, so if you have paved the neural road map, it does not have to make new connections that take more effort.

Make it easy for your brain to master these connections and thought patterns.

Research has shown that by incoporating the practice of gratitude, affects will be noticeable in 8 weeks. Others may notice you are less reactive, in a better mood and they may ask you

what has changed. The answer is you trained your brain to practice something underrated yet powerful: gratitude.

Dr. Diana Londoño is one of the few female Urologic Surgeons in the United States. Passionate about her patients’ medical needs, feelings and their privacy, she approaches ALL of her patients as if they were family. Understanding that urological problems can be difficult to discuss, she believes “we must strive to keep a patient’s dignity intact during difficult times of illness, stress or anxiety.” Dr. Londoño sees patients at City of Hope at their Glendora, California location.

Born in Mexico City, Dr. Londoño was educated in Southern California, graduating with honors from Claremont McKenna Collegeand earning her medical degree at UCLA. She completed her surgical internship and urology residency at Kaiser Permanente, where she trained in open, endoscopic, lap-

aroscopic and robotic-assisted procedures.

Dr. Londoño is fluent in both Spanish and English, and appears frequently on Spanish language television as a medical expert.

Sheis a prolific writer and speaker, as well as a physician coach.

She is passionate about Physician Wellness, and founded the confidential FREE Physician Coach Support Line to help combat physician burnout. It is estimated that 65% of some medical specialists are burned out. Burnout affects 56% of all female physicians. 25% of all physicians are depressed and 13% report having suicidal ideations. 400 physicians or more per year complete suicide.

This is a crisis in healthcare.

We are all patients.

Physician wellness affects us all. ☤

Physician Coach Support

provides compassionate peer support using coaching skills (free of charge) for any physician who may be struggling with a situation or a thought they need support with.

Their mission is to increase awareness to help physicians live a more conscious life.

Learn more about the free support services for physicians, make an appointment or provide a donation to support their efforts by going to https://physiciancoachsupport.com/.

☤

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S T U D Y P R OV ES NON- PHYSIC IA N C AR E IS MOR E COSTLY

This. Is. Huge.

Written by Natalie Newman, MD

“Targeting Value-based Care with Physician-led Care Teams: An important study debunks the myth that NPs and PAs are able to deliver a level of care similar to that of physicians.”

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he Hattiesburg Clinic is a large multi-specialty group with dozens of locations and practices across southern Mississippi. In January of 2022 a study was published in the Mississippi Medical Society’s journal which refuted the commonly held misconception that APPs provide a level of care similar to that of physicians.

The retrospective study, titled “Targeting Value-Based Care With Physician-led Care Teams” collected

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and analyzed almost a decade’s worth of data from the large Mississippi clinic’s electronic medical record.

They concluded what so many of us already know: NPs and PAs are important parts of a physician-led healthcare team but SHOULD not practice independently or without supervision. There is a reason medical school and residency are long and arduous. The Johns Hopkins model of medical education has withstood over 100 years of challenges and growth in medicine. The model works.

The Hattiesburg Clinic set up their own similar FPA-like model with “collaborating” physicians and enabled nurse practitioners (NPs) to have their own patient panels. They then did what no state legislature, regulatory or licensing body has ever done in any state with FPA . . . they followed up—10 years later. You know, to see if what they instituted was actually working. Mad respect for this institution.

There is no doubt in my mind that everything they did was in the best interest of their patients. That’s why they have the reputation they do and it is well-deserved. If every FPA state and academic center were to do the same, I predict the results would be similar. With all due respect, I think the one mistake the authors made was in believing that there was “”mounting evidence nationally that APPs could provide levels of care similar to that of physicians”.

“We allowed APPs to function with separate primary care panels, side by side with their collaborating physicians.

Although necessity initially drove our decision to allow APPs to function in the primary care provider (PCP) role, we felt comfortable with this decision over the following years as there was mounting evidence nationally that APPs could provide levels of care similar to that of physicians.”

The reality is there was no mounting evidence. It didn’t exist and still doesn’t. Physicians for Patient Protection (PPP) stated this years ago and no one listened. Then PPP documented and debunked the studies in their

“The practice of medicine is the gold standard by which all other disciplines of health provision are measured.

The onus is on others to prove, with VALID evidence of sound quality and unquestionable standards and methodology, that their discipline measures up.”

—Yv Newman.

In other words, if one wants to practice medicine, the responsibility lies with one to prove he/she can do so effectively and competently.

That didn’t happen with FPA. The one exam specifically developed for nurse

IMAGE BY NATALIE NEWMAN, MD

book, “Patients At Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare”. That information was then shared in the “Patients At Risk” podcast (https://youtu. be/yGeFGndEiwA) in three episodes.

Bottom line, the studies the American Association of Nurse Practitioners (AANP) uses to push FPA are outdated poorly done studies. I’ve often said, if docs took the time to review even one study, the shoddy methodology would be evident.

Unfortunately, when fiction is repeated often enough, it becomes fact. And no one checks the “facts”, they just believe. That is how FPA has progressed successfully- -that and exceptional lobbying by the AANP. My perspective of the entire FPA movement is that it doesn’t make sense. I’m a chick with a lot of common sense.

In my opinion, some things are so evident as to not require a study.

Nurses are not physicians, so how could they possibly have similar outcomes as physicians? Who would believe that s**t? Turns out, a lot of people do. And instead of asking NPs to prove what they claim with actual, respectable evidence, physicians are asked to prove a negative–that NPs are not qualified. Absurd.

practitioners with Doctors of Nursing Practice (DNP) degrees to prove their competency failed, after 5 years of being administered. Nothing has replaced it since.

I believe every state with FPA has a responsibility to do what the Hattiesburg Clinic did (which I view as a microcosm of the enactment of FPA).

FOLLOW UP.

It is essential that someone take the time to evaluate and assess if FPA is working as purported. Oregon has had FPA the longest, why hasn’t a review been done there? Or in Arizona where FPA has been in existence since 1996? The Hattiesburg Clinic is probably one of the best examples of a MD/ DO-NPP collaborative model. Yet, the results of their study was an eye-open-

“10 year review of Hattiesburg clinic shows decreased healthcare quality & patient experience, increased cost & resource utilization with ‘independent’ NPs.” — @HalstedMD er for them. Makes me wonder what we might see in less exemplary models...In any case, true to form, the Hattiesburg Clinic is changing its practice based on the results of their study. I would expect nothing less from such a clinic. Every institution should be as responsible and discerning. Kudos to them again.

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If You Have Breasts, You Need to Hear This!

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Written by Joanne Jarrett, MD

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s glad as I am that I havebreasts, they are often a problem for me. They get in my way. They are subject to gravity, they often make me or others uncomfortable when they aren’t adequately clothed, and there aren’t many comfortable solutions.

Am I alone here?

I don’t know a single woman who doesn’t want to rip off her bra the minute she walks through her door. But I also don’t know many who are totally comfortable hanging around flapping in the breeze with NO support and cov2 4 | 2022 VO LUME 13

erage. I had discovered shelf-bra camis and began wearing them as loungewear and pajamas. I could never figure out why this concept wasn’t expanded into other pieces like tees, sweatshirts, and pajamas. I envisioned something that feels and looks great to wear at home but is also fit for public consumption should the need arise.

After years of googling “shelf bra pajamas” and “shelf bra loungewear” and coming up with nothing but slinky lingerie (please!!! Who wants to do dishes and laundry in lingerie? Ridiculous!), I had no

choice but to take matters in my own hands.

In 2017, I designed and made my first prototype of shelf bra pajamas in my home sewing room. I took cues from my favorite shelf bra cami (perfectly soft but flattering shelf that has just enough thickness for coverage and separation to avoid that loaf-of-bread look) and looked at the fabric contents of my coziest clothes to help find the ideal fabric. It occurred to me that if this was something I wanted and couldn’t find, maybe others would like them too. I de-

10 REASONS “LADY-DOCS” NEED SHELFIES cided to try to manufacture and sell them, and Shelfies were born!

I drew up the six pieces I wanted in my at-home wardrobe and then set about to learn how to make my vision come to life. Inspired by a story I heard on the podcast, Side Hustle School, I took several online and in person classes to learn the business of fashion design, manufacturing, and marketing.

Product development is a slow and expensive process. Moving from my drawings and homemade prototype to technical drawings to patterns to samples took about a year. And none of the first samples were spot on. Perfecting the patterns requires sample fittings and then fit and pattern corrections followed by new samples. Once my patterns were perfected (and the pattern maker and sample sewist had been paid for umpteen expensive hours of work), we had used all of the money my husband and I had designated for this endeavor. And we hadn’t yet purchased fabric, cups, elastic, tags, etc. So, in May of 2018, Shelfie Shoppe launched a Kickstarter campaign to collect pre-orders that would finance the first actual factory run of Shelfies. The Kickstarter campaign was successful, and we moved on to the manufacturing phase. It was so exciting! Raw materials were collected and the first batch of Shelfies were hand made in a sew shop in the bay area of California. They are now sold at www.shelfieshoppe.com and at local markets, and new pieces are being developed.

In case you aren’t quite convinced that shelf bras are life changing, here are ten considerations to help drive home the point:

•The doorbell. Sometimes, it rings.

Don’t you hate it when your just milling about at home in your cozy clothes and no bra, minding your own business, and someone has the GAUL to ring your doorbell?

You look down and think, “Well, someone is about to get an eyeful!” If your pajamas had shelf bras, doorbell dread could be less of a thing!

•School drop-off. I KNOW I’m not the only one who sometimes thinks,”Well, if we leave now, we may actually not be late. But I’m still in my pajamas. Oh, I’m sure I won’t have to get out of the car...”

Eventually, you get caught.

•Ice cream. Sometimes we have a sudden need for ice cream and have already ditched the bra for the day. Just because you want ice cream doesn’t mean you have the spark to re-don your real clothes.

•Hormonal breast tenderness. When I was pregnant, my breasts HURT! Especially when I rolled over in bed. I would have slept SO much better with a shelf bra! I wore an actual bra to bed. It was a bummer.

•Sleepovers/House guests. I LOVE when my kids have friends sleep

over. They have so much fun! The laughter. The SNACKS! But I used to dread not being able to change into my cozy clothes until they went to bed. I wanted to ditch the jeans and underwire bra, but I didn’t want to make the kids feel uncomfortable. Now that my pajamas have shelf bras, I can RELAX even with guests in the house.

•Sons. I don’t have any, but many do. I have a girlfriend who tells me that at a certain stage, they stare.

•Mirrors. I just look better with a little coverage, support, and separation. And I do catch a glimpse of myself from time to time. Because, mirrors.

•Containment. I’m just going to say it. Bra free, sometimes a boob finds its way into my armpit in the night. It pinches! Shelf bras prevent that awkward phenomenon.

•The mailbox. It’s waaaaay out there on the street. And chances are, you have a few neighbors.

•The step goal. Sometimes I look at my fitbit and realize that despite the fact that I’ve changed into my pajamas, there’s no way the step goal is getting reached without going for a walk. The shelf bra takes away one of my 67 excuses.

The process of going from idea to product has been so enriching to my life. If you have something you need and can’t find, consider trying to make it come to life! ☤ Use the code “PO15 PO15” for 15% off your Shelfie Shop order! www.shelfieshoppe.com W W W. P HYS I C I A N O UTLOOK.C OM | 25

IMAG E BY PAT T Y B RITO, UN S PL AS H

Dear PreMed Me Written by Diana Blum, MD

2 6 | 2022 VO LUME 13

Dear PreMed me,

Please take a deep breath before reading this letter from the year 2022.

The unfortunate reality is that practicing Hippocratic Oath Medicine has become near obsolete since you applied to medical school in 1999; in fact, defending the oath itself has become a tremendous challenge, and the resultant moral injury has caused a mass exodus of physician colleagues from clinical practice.

You will wonder why you gave up your 20’s and early 30’s to study and train as hard as you did only to accrue hundreds of thousands of dollars of debt and to learn that much of the public has very little appreciation, much less value for, your rigorous education, training, or experience. These days, an online degree with barely any clinical prep gets you the title “doctor” and a government sanctioned license to kill.

The humble mentality you were once taught in medical school - “First do no harm because You don’t know what you still don’t know” is long gone. “Confidence” has replaced “Competence” because in today’s “Healthcare” purgatory, ALL “Providers” appear to be interchangeable. Critical thinking skills are now a liability for employers, who prefer that patient care be delivered based on productivity optimization algorithms and that pesky oath physicians took just keeps getting in the way.

You will witness government sanctioned corporatization of your once sacred profession destroy the doctor-patient relationship by creating bureaucratic barrier after barrier. You will report examples of patient harm caused by the prioritization of profits over patient care only to realize those with power could care less about human suffering.

And just when you didn’t think things could get worse, you will

discover that in the 2020s, scientific method principles and informed consent are no longer respected, instead, the “lived experience” mantra and “end justify the means” attitude make open and honest debate impossible. Physician self-censoring has become the norm if you want to keep your paycheck and increasingly, your medical license.

I don’t mean to be a downer, but the house of medicine is sadly divided at this critical moment in history, while ideological political agendas ensure that the crony status quo remains, and physician dissidents are silenced.

On a more personal note, you will lose close friends to long battles with cancer, and empathy for their inhumane journeys through the medical industrial complex will motivate you to speak up and demand meaningful change.

You will proudly join a grassroots movement that calls for #Transparency and #Accountability for the conflict of interests which have captured and destroyed our once trusted institutions. You will be fortunate to meet other inspiring Hippocratic Oath advocates, and many of these fellow Mama Bear Warriors will become some of your closest friends.

The learned helplessness you once felt being a cog in a broken system will be replaced by empowerment growing your own Direct Specialty Care practice. The appreciation regularly expressed by your patients for the individualized care you provide will fill up your bucket with joy and strengthen your resolve to #takebackthehouseofmedicine. One day, you may even be invited to share your story and the wisdom you discovered while pursuing this calling.

May the following words of advice help you navigate the inevitable challenges you will face embarking on this arduous but extremely rewarding adventure.

1.Have a daily self-compassion & gratitude practice. This will make the darkest days feel a bit brighter.

2.Know your worth.

3.Be kind.

4.Don’t let your kindness and compassion be mistaken for weakness.

5.Breathe. No really, pause and focus on your breathing at least a few times a day for 1 minute; your nervous system will thank you.

6.Recognize that you may not cure many diseases, but you can comfort all patients.

7.Default to assuming good faith intent but understand how conflict of interests drive decisions and behaviors; this is especially important when evaluating the “Business of Medicine”.

8.Allow yourself to be vulnerable, understanding we are all a work in progress and that is a necessary step toward growth.

9.Admit when you are wrong, admit when you don’t know something; you can’t build trust any other way and this is critical for healthy relationships, especially ones between doctor & patient.

10.And lastly, learn how to genuinely forgive. Forgiveness is a helpful life lesson for physicians to teach and model for their patients. It eases much suffering, and this has a healing effect on thebody. Imagine our society if more people were able to truly forgive. ☤

From, Me

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Abraham Flexner A C A D E M I C M E D I C I N E ’ S FA V O R I T E S C A P E G O AT

Written by Linda Rosa, RN

I

t’s not surprising that quack practitioners having long blamed Abraham Flexner for closing “alternative medicine” schools in the early 20th century because of “prejudice” against non-science-based health care. But it came as something of a shock to hear that no less than the Association of American Medical Colleges (AAMC) recently scrubbed his name from their most prestigious award for “Distinguished Service to Medical Education” for having “racist and sexist views.”

(Redford) While not denying Flexner’s positive impact on modern medical eduction, this demotion was done in service to AAMC’s commitment to “becoming anti-racist, diverse, equitable, and inclusive.” AAMC also sees Flexner’s celebrated 1910 Report (“Medical Education in the United States and Canada”), based on first-hand inspections of all 155 US and Canadian medical schools, as “contributing” to the closure of five of seven Black medical schools existing at that time.

Because AAMC gives scant evidence for its accusations, skepticism is warranted.

RACIST? AAMC gives two examples for Flexner’s allegedly “racist” and “pejo2 8 | 2022 VO LUME 13

rative language” in his Report. First, it charges: “…Flexner asserted that African American/Black individuals were better suited to serve as sanitarians rather than surgeons…” [emphasis added] But Flexner’s actually statement in context was: “A well-taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an M.D. degree is dangerous… The negro needs good schools rather than many schools — schools to which the more promising of the race can be sent to receive a substantial education in which hygiene rather than surgery, for example, is strongly accentuated.” [emphasis added; Report, p.180] What AAMC failed to acknowledge was that ‘sanitarians’ in the 19th and early 20th Centuries were medical doctors and researchers specializing in public health (Freedman), not ‘sanitation workers’ or ‘health inspectors’ – not what The Washington Post (and others) would interpret as a “menial role” when editorializing on the defenestration of Flexner. (Cohen, 2021) At the time of Flexner’s Report, sanitarian physicians were afforded considerable status for researching and combatting the spread of dread diseases, such as

cholera, typhoid, smallpox, and tuberculosis which were leading causes of death. Because of poor nutrition and hardships, Blacks were dying at a higher rate. Moreover, specializing in public health didn’t exempt Black schools from the high standards expected of all medical schools.

Note AAMC’s straw man: Flexner’s Report nowhere claims Blacks to be “better suited” as sanitarians, but rather as such would be “immensely useful.”

Flexner actually was restating the primary mission of the two surviving Black medical schools that he worked to save – Meharry (Tennessee) and Howard (Washington, DC). Both schools had emphasized public health as offering the greatest need of Black communities.

As for writing, “an essentially untrained negro wearing an M.D. degree is dangerous,” Flexner was not saying anything about Blacks having inferior intellectual abilities. He believed public had much to fear from all untrained physicians: “…a nostrum containing dangerous drugs is doubly dangerous if introduced into the household by the prescription of a physician who knows nothing of its composition and is misled as to its effect.” (Report, p. 65) Flexner regarded osteopaths so

poorly trained that he opposed legislation that would give them the privilege to sign death certificates. (Flexner, 1960, p.86) Second, AAMC charges Flexner with believing the primary role of Black physicians “should be to protect White people from disease.” Again, in actual context, he wrote: “Not only does the negro himself suffer from hookworm and tuberculosis; he communicates them to his white neighbors, precisely as the ignorant and unfortunate white contaminates him.” [emphasis added; Report p.180] Whenever Flexner is accused of racism – even in the AMA Journal of Ethics – this same quote appears, but invariably it ends with the word “neighbors.” (Laws) A fair-minded interpretation of Flexner’s position might well be, we’re all in this together when it comes to terrible diseases.

The Report expressed Flexner’s personal respect for Blacks, as with, “He has his rights and due and value as an individual.” (Report, p.180) Medical historian Thomas Neville Bonner cites other instances, such as: “In the history of the world, he wondered, had any race done “what the Negroes were doing with their meager resources.” He deplored the distortions of the black role in the post-Civil War South in the pioneering film The Birth of a Nation…he said, historically it was “utterly worthless trash.” (Bonner, 2002) SEXIST? AAMC’s charge that Flexner was “sexist” is likewise utterly unsupportable: [T]he Flexner report also contained gender-oppressive … ideas. … In his report, Flexner wrote that while women were not barred from applying to medical school, they ‘show a decreasing inclination to enter it’ — and that those who did had ‘obvious limitations.’ (emphasis added; AAMC FAQ, 2020) Yet again, in actual context: “[Women are] so assured a place in general medicine under some obvious limitations that the struggle for wider educational opportunities for the sex

was predestined to an early success in medicine. It is singular to observe the use to which the victory has been put….interne [sic] privileges must be granted to women graduates on the same terms as to men.” [Report, p. 178] Regarding the assertion about the “decreasing inclination” of women entering medicine: Flexner cited the number of female medical students and graduates for the years 1904 to 1909 (in both co-ed and women’s medical schools). The total number of schools matriculating women had indeed decreased from 100 to 94, and the total number of women students had steadily decreased from 1,129 to 921. The drop in enrollments seemed genuinely to concern and perplex him: “their enrolment [sic] should have augmented.”

(Report, p. 179) Scholars have since suggested the drop in enrollment may have resulted from stiffer enrollment requirements, the closure of some co-ed medical schools, increased competition from men for fewer openings, and states enacting laws restricting women from doing internships. (Moehling) As for his remark about “obvious limitations,” what those were to a reader of that age are not so obvious today.

The context, however, does not disclose any prejudicial attitude, nor does AAMC offer any clarity.

Flexner’s biographers have related how ahead of their time his whole family had been in championing women’s rights and education. Flexner put his sister through college, and later, with his wife, Anne Crawford Flexner, financed the higher education of their two daughters: Jean would help set up the US Division of Labor Standards; and Eleanor, educated at Oxford, became a “pioneer of women’s studies,” focusing on the struggles of Black and working women. Eleanor spoke often with her father about her book, an enduring classic entitled, Century of Struggle: The Woman’s Rights

Movement in the United States.

From his position on the Rockefeller Institute’s General Education Board, Flexner worked for equal rights and educational opportunities for women, as well as for Blacks. He pressed schools like Harvard to admit women to their medical schools. (Bonner, 2002) Both Abraham and his wife have been described as “feminists,” walking along with 25,000 women down 5th Avenue in New York City during the historic 1915 parade for women’s suffrage.

(SNAC Obituary, Eleanor Flexner) MEDICAL SCHOOL CLOSURES, GENERALLY While many credit Flexner with spearheading modernization of medical education, he played a part in a process that began years before his Report. With revolutionary scientific progress, eminent physicians had convinced both the American Medical Association (AMA) and AAMC of the need for reforms in medical education, in face of a multitude of schools turning out poorly trained doctors.

By 1904, the AMA had set up a Council of Medical Education (CME).

Four years later, CME reported on their two-year inspection of all the country’s medical schools, then numbering 162,

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finding half to be inadequate. The AMA began rating medical schools accordingly, and state medical boards beefed up licensure requirements, in part by using these ratings.

Notably, CME didn’t publish its findings. With aggressive competition between many medical schools – and this being the era of “trust-busting” – AMA contracted with the Carnegie Foundation for the Advancement of Teaching to take the expected heat for telling the country’s medical schools to sink-orswim.

Enter then Abraham Flexner who recently had impressed Carnegie’s director with a critique of America’s colleges. Flexner proved a quick study on best medical education practices from Johns Hopkins and went out on an 18-month investigative trek around the continent. At the time, medical schools were already feeling the pinch to modernize for several years. Some were already preparing to close, some were merging or becoming a university department, and many were scrambling for scarce funds.

Flexner found two-thirds of 155 medical schools to be “utterly hopeless,” including all three women’s schools and five of the seven Black schools. Many medical schools were small, private, cash cows for lecturers who rented rooms and offered little in the way of laboratory facilities, library, or experience with actual patients.

Some were outright diploma mills.

Flexner saw ‘sectarian’ schools as particularly disturbing, where homeopathy, osteopathy, allopathy (still using four humors), and spiritualism were the focus. His opinion of chiropractors was so low, he didn’t consider their schools “medical’: “…unconscionable quacks, whose printed advertisements are tissues of exaggeration, pretense, and misrepresentation of the most unqualifiedly mercenary character. The public prosecutor and the grand jury are the proper agencies for dealing with them.” [Report, p.158] Flexner’s published Report had exposed the reality, in bleak terms, that the vast majority of medical schools were turning loose hordes of poorly prepared practitioners onto an unsus3 0 | 2022 VO LUME 13

pecting public. His Report informed state licensing boards which medical schools were outright fibbing about their facilities.

In another decade, half as many physicians would be graduating from half as many medical schools, with health care improving, as Flexner hoped. It was a true revolution in medicine – coming like the showdown at the OK Corral. Science rode into town with more effective, reliable medicine, demanding high training standards and adequate funding.

CLOSURES OF WOMEN’S SCHOOLS After the Civil War, 14 medical schools for women had been created, but there were only three left by the time Flexner made his rounds, and oddly enough, only the more homeopathic of the three survived after that.

Flexner predicted that none of the three women’s schools could make significant improvements “without an enormous outlay” of funds. Noting that 80% of female students already attended co-ed medical schools, he recommended that “large sums” would “accomplish the most if used to develop coeducation institutions.” (Report, p.179). As with Black schools, he recommended leniency towards co-ed schools willing to modernize.

CLOSURES OF BLACK SCHOOLS Neglecting the realities of medical education and regulation over a century ago, the 21st Century AAMC has pronounced: “[Flexner’s] work contributed to the closure of five out of seven historically Black medical schools. Our action today recognizes the long-standing negative impact of the Flexner report on the training of Black physicians and the health of the Black community in the United States.” (Redford) Several biographers see Flexner not as the person who closed five Black medical schools but rather as the person who saved two.

“His support for Howard and Meharry—despite their having funding levels and licensing exam pass rates that were far below those of the predominantly white schools he endorsed—likely helped ensure their

survival against the forces that pressured comparable white schools to close. His support extended beyond his report’s endorsement…” (Miller and Weiss, p.240) In the decades before Flexner’s Report, seven Black medical schools had closed. Flexner visited the remaining seven. Out of those, he pronounced only Meharry and Howard “deserve liberal support,” despite their students’ low scores on licensing exams.

Further, he wrote that the other five schools were “in no position to make any contribution of value” and would require immense infusions of resources to survive. Much better, he thought, to concentrate scarce resources on Meharry and Howard.

The five schools that would close together produced less than 20% of Black medical graduates, and only about half of those passed their licensing exam. Enrollment in three of these schools (Flint, Louisville National, and Knoxville) plummeted starting in 1906, suggesting their focus switched to graduating the remaining students.

(Miller and Weiss) In 2005, AMA would denounce Flexner for not supporting more Black schools, though medical historians claim his Report had little impact compared to AMA’s rating system. Flexner encouraged leniency towards Black schools – certainly more than shown by the segregationist AMA, which admitted no Black physicians to its ranks and gave “A” ratings to 38 white medical schools that Flexner recommended for closure. (Miller and Weiss) Arguably more serious obstacles for Black medical schools, were poverty and poor secondary education.

In 1900, AAMC required a minimum four-year high school education for enrollment in medical schools, but in the South at that time, as few as 3% of Black children had access to a high school.

Many black medical students needed a job and preferred night classes, but schools offering night classes could be denied an “A” rating.

Post-Report, Flexner went to bat for both Meharry and Howard, requesting that licensing boards give these schools time to make improvements.

IMAG E BY S AS UN B UG H D ARYAN , UN S PL AS H

While Howard would continue to get federal funding, Flexner worked the next 30 years to secure large private grants for both schools. He would be elected to Howard’s board of trustees, and eventually became chair.

Flexner also nagged the AMA to upgrade Meharry’s rating from “B” to “A,” which was necessary for its graduates to be licensed. He pointed out less deserving white schools that had been given “A” ratings. (Bonner, 2002) Some commentators have suggested Flexner could have consider saving Leonard Medical School (Raleigh, NC), the nation’s first 4-year medical school. In 1910, Leonard had an AMA rating of “B,” and its graduates had higher exam scores than Meharry. But with few resources – and membership in the AAMC rejected – Leonard became a 2-year medical school in 1914, with students finishing their training at either Meharry or Howard. It closed in 1919. (Murray, 2006) It is likely there were not enough Blacks with a high school education to support another medical school at this time. (Miller and Weiss, p.241) One can only speculate what Flexner, a man with progressive and outspoken views, thought in passing up the opportunity to recommend desegregated medical schools while his Report held the industry’s attention.

QUANTIFYING RACISM IN MEDICAL EDUCATION AAMC blames Flexner’s Report for “exacerbated systemic racism in medicine,” relying, in part, on a paper appearing in JAMA Network Open which dubiously extrapolates that had not five of the seven Black medical schools that closed in the Flexner era (Flint, Leonard, Louisville National, Knoxville, and the University of West Tennessee), an additional 35,315 Black physicians would have entered the workforce between 1911 and 2018. (Campbell, 2020) Statistical models, as reported by this paper, need to be meticulous in their methods and assumptions to avoid “garbage-in/garbage-out” pitfalls.

It was good that the authors honestly admitted that their use of linear regression was sub-optimal because “variable and incomplete data on year-specific enrollment and graduation rates” for three of the five closed schools.

(That alleged “missing data,” is readily available in JAMA’s archived “Medical Colleges of the United States” annual reports. Researchers such as Miller and Weiss have used this data in their analyses.)

If there had been peer reviewers, they probably would have taken note of the authors apparently turning one school (University of West Tennessee) into two schools (Table 1). And they surely would have questioned the “con-

servative assumptions” underlying the modeling in the Campbell study – not all that conservative, as it turns out, because the authors put a “cap” on the annual output of graduates, suggesting the modeling results beggared belief.

This sort of “modeling” seems little better than picking numbers out of a hat. Moreover, as an “economic” study, it failed to consider the stress on these five medical schools had they survived, such as discrimination in scoring licensing exams, poor secondary schooling for Blacks, the Great Depression, two world wars, inflation, the Black migration to the North and competing desegregated medical schools.

Referring to the Campbell study – lauded as “innovative” (Laraque-Arena) – JAMA editors later indulged in some historic revisionism that ignored the contributions of the two surviving Black medical schools, Meharry and Howard: “Black men and women were nearly completely expunged from medicine. The consequence of those closures substantially reduced any meaningful capacity to educate Black men and women as physicians…” (Yancy & Bauchner) But according to Miller and Weiss the Black medical schools that closed were not the whole story: “With the exception of Leonard … the schools that closed between 1910 and 1923 were small operations that W W W. P HYS I C I A N O UTLOOK.C OM | 31

CONCLUSION What can be done to counter the actual legacy of racism in medical education?

Perhaps honesty about its history would be a good start. It was certainly tragic that there were not more medical schools and hospitals with adequate resources serving Blacks. There is no denial of the injustice of Jim Crow and so many segregated medical schools.

AAMC would have done better recognizing Flexner’s example of promoting medical education for Blacks and women, and owning up to its organizational failure to follow that example. Just as the AMA needed a fall guy back in 1910, today’s AAMC has found it most convenient to slander the stellar legacy of a man who did much to promote racial and sexual equality while hewing to excellence in education.

For an accurate history of Flexner, AAMC needed only to look under its own nose – at its own journal. In 1998, Thomas Neville Bonner, PhD, published “Searching for Abraham Flexner” in Academic Medicine. The journal’s editor referred to Bonner as a “distinguished historian of medicine,” and indeed, he soon published the definitive biography of Flexner (Iconoclast: Abraham Flexner and a Life in Learning). Bonner surely would have challenged AAMC’s indefensible historical revisionism had he not died in 2003, perhaps even by repeating this as a poignant retort: “In December 1940, Flexner made ‘a hemispheric broadcast’ by radio on the American way of life, in which he expressed regret ‘that Democracy [had] not come to prevail in the relations between the colored man and the white man [nor] in the relations between men and women.’ He called for a ‘militant’ extension of freedom.”

(Bonner, 2002) For a man with his achievements, who said that at the height of Jim Crow, and now be called a racist and sexist

by an institution which owes him much – and should know better – reflects more on AAMC than on Flexner. It actually may be a good thing that AAMC has dissociated itself from Abraham Flexner, particularly with its award, previously ‘distinguished’ by using his name. With its action, AAMC has presently shown itself less worthy of a connection to him than he to it.

☤

Acknowledgement: The author’s gratitude to Larry Sarner for his editorial assistance and review of the Campbell study mentioned in this paper.

Bibliography: Thomas Neville Bonner, Iconoclast: Abraham Flexner and a Life in Learning, (Johns Hopkins University Press, 2002) Thomas Neville Bonner, “Searching for Abraham Flexner,” Academic Medicine, Feb 1998, 73(2):160-166.

Kendall M. Campbell, et al, “Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools,” JAMA Network Open, 20 Aug 2020.

Noam Cohen, “Sure, erase the names of history’s racists. That won’t undo their messes,” The Washington Post, 26 Mar 2021.

Abraham Flexner, Abraham Flexner: An Autobiography, Simon & Schuster, NY, 1960) p. 86 Abraham Flexner, “Medical Education in the United States and Canada,” Report to the Carnegie Foundation for the Advancement of Teaching, 1910.

Eleanor Flexner, Century of Struggle: The Woman’s Rights Movement in the United States, Harvard University Press, 1959.

Eleanor Flexner, 1908-1995. Social Networks and Archival Context (SNAC).

Ben Freedman, “The History of the Sanitarian,” The Sanitarian, Sep-Oct 1954; 17(2):67-79 E Hoover, “Did Flexner’s Report condemn black medical schools? Not so, in my opinion,” J of the National Medical Association, Sep 2006; 98(9):1432-1434.

JAMA, “Medical Colleges of the United States: Annual Presentation of Educational Data by the Council on Medical Education,” 1910, 1911, 1912, 1913, 1914.

Danielle Laraque-Arena, “Historically Black Universities and Medical Colleges – Responding to the Call for Justice,” JAMA Network Open, 20 Aug 2020.

Terri Laws, “How Should We Respond to Racist Legacies in Health Professions Education Originating in the Flexner Report?” AMA J of Ethics, Mar 2021.

Lynn E Miller, Richard M Weiss, “Revisiting Black Medical School Extinctions in the Flexner Era,” Invited Commentary, J of the History of Medicine and Allied Sciences, 2 Feb 2011; 67(2):217-243.

Carolyn M Moehling, et al, “Shut Down and Shut Out: Women Physicians in the Era of Medical Education Reform,” Social Science History Association presentation, Apr 2019.

Elizabeth Reid Murray, “Leonard Medical School,” 2006, NCPEDIA. Garbrielle Redford, AAMC Managing Editor, “AAMC renames prestigious Abraham Flexner award in light of racist and sexist writings,” 17 Nov 2020.

AAMC, “Frequently Asked Questions: AAMC Award for Excellence in Medical Education, formerly the Abraham Flexner Award for Distinguished Service to Medical Education,” (date presumed Nov 2020) Todd Savitt, “Abraham Flexner and the Black Medical Schools,” J of the National Medical Association, Sep 2006, 98(9): 1415-1424.

Clyde W. Yancy and Howard Bauchner, “Diversity in Medical Schools – Need for a New Bold Approach,” Editorial, JAMA Network, 2 Jan 2021; 325(1):31-32.

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IMAGE BY BENJAMI N LEHMAN, UNS PL AS H

together produced fewer than a fifth of the black doctors who graduated in any given year.” (pp.240-241)

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The Evolution of a Health-Care Advocate EXCERPT FROM “RHEUM FOR IMPROVEMENT” Written by Mark Lopatin, MD

L

et’s look at how documentation has exceeded actual patient care in level of importance.

Documenting what you have done as a physician is essential, but it has gotten entirely out of hand. I have jokingly commented that my degree should be changed from an MD to a DEO, as I have become a glorified data entry operator. Getting the right answer no longer matters. Instead the focus is on whether a physician has shown their work and appropriately justified the reasoning for a particular diagnostic test or treatment to a third party.

Documentation that is unsatisfactory

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to a third party may mean denial of a particular test or treatment or result in in a dequate reimbursement. The electronic health record (EHR) has become nothing more than a billing tool. The price we pay is that the more time physicians spend documenting, the less time we spend engaging patients.

Documentation should be focused on explaining a physician’s thought processes, but instead the emphasis has been placed on quantifying data. For example, as a rheumatologist, one of the key things I must assess is pain. Pain is subjective and

cannot be quantified using a 1-10 numerical scale. Physicians, however, are forced to use such a scale to satisfy one of the insurer’s criteria for reimbursement. The problem is that one person’s “8” is another person’s “2”. Furthermore, pain levels are different at different times, in different places, and for different conditions.

Physicians are expected to provide one number at each visit to quantify a patient’s pain experience.

Physicians are also routinely required by insurers to not only provide a number to define a patient’s pain level but also to document if a

This excessive need for documentation detracts from physicians’ ability to care for patients properly.

The key word here is “excessive.”

Documentation is important, but not to this degree. As noted by one physician, “Dr.Mom,” on the medical blog “Sermo,” Am I the only doctor who is sick and tired of being told how much my time is worth? I have to justify my time and substance of visits for each payment. I am spending more time documenting my visits than I am seeing my patients. If I see a pa-

tient for 30 minutes, I have to document for 30 minutes why I spent that time. I get the distinct honor of coding the assessments and then I get to code quality measures. AND LORD FORBID I DON’T — then I don’t meet the standard of care. Just whose standard is that?

Furthermore, much of the documentation is required for billing purposes, rather than patient care.

Doctors Christopher Notte and Neil Skolnick have noted, “The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient no matter how mundane or trivial.” The demand for documentation results in long computer-generated notes that contain little practical information. It is not uncommon for a 16-page progress note to contain only one paragraph of useful information.

We have seen tremendous advances in science and technology, but the take-home message needs to be that being a physician and caring for patients is inherently a human experience. This is where we need to be placing our focus, not on documentation for documentation’s sake. How a physician relates to their patient may well be the most critical aspect of easing the patient’s suffering and is not something that can be quantified.

The corporate takeover of medicine is extracting the humanity out of health care at an alarming rate, resulting in unprecedented levels of physician burnout. I assert that the best doctors are the ones who genuinely care about their patients as opposed to the ones who know the most. Medicine needs to be filled with “H”s: Helping, Humor, and Humility as corollaries to Healing, but Humanity remains the most important “H.” Hopefully this message will come through in this book. The need for documentation is just one example of how humanity, and therefore health care, is being compromised. ☤

Reviews from Amazon: “This book gives patients and the medical profession an honest and personal account of a journey in Health Care advocacy.

You will not only learn why your healthcare is so expensive and complicated, You will be inspired to do something about it!!

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Wendy Stahler AVAILABLE ON AMAZON

IM AGE FR OM SOMEDOCS

patient’s pain is better or worse. The question is, since when? Since the initial diagnosis? Since their last office visit? Since last week? Since yesterday? How do I record the pain level for a given condition, if it is better than it was last week, worse than it was yesterday, and about the same as it was at her last office visit a month ago?

How should I document improvement when the pain in one joint is better, but pain in another joint is worse?

What if the pain from her rheumatoid arthritis is worse, but her pain from fibromyalgia is better? Am I expected to document the pain at each visit, in each location, in each time frame, and for each condition? The amount of time it would take for me to document all of that would preclude me from actually providing medical care.

Time spent documenting measures such as this is time not spent truly caring for patients.

Even documenting the diagnosis has become difficult. Physicians must use an alpha-numeric code for each diagnosis, and the number of codes expanded from 13,000 to 68,000 in 2015. These diagnostic codes often must be specified based on factors such as onset of the problem, an underlying cause to the problem, chronic versus acute, with or without complication, left versus right, initial versus subsequent visit, and so on.

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You Are What You Eat A NUTRITIONIST’S PERSPECTIVE

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he truth behind the phrase ”Your are what you eat” is the simple notion that in order to be healthier you need to eat healthier food, but is it as simple as that?

All the nutrients from all the foods we eat help to support the foundation of our structure, and the function and wholeness of every living cell in our body, from our skin and hair to our muscles, bones, digestive and immune systems.

We may not feel it, but our bodies are in a constant state of repairing, healing and rebuilding.

Each of the cells in our body has a “shelf life”, a stomach cell lives about a day or two, a skin cell about a month, and a red blood cell about four months.

So, every day, our body is busy making new cells to replace those that have “expired.” And how healthy those new cells are and how well they function are directly determined by the food choices we make.

A daily diet filled with highly processed food that’s low on nutrients doesn’t give our body much to work with, however a nutrient rich, whole food diet can help our bodies build cells that work better and are less susceptible to premature aging and disease.

Whole foods are not processed, are as close to nature as possible and they’re free of additives, colorings, flavorings, sweeteners, and hormones and as a rule, the closer to nature you eat, the fewer calories it will take for you to feel satisfied.

The reason for this is processed foods often have low amounts of fiber and water, a high ratio of calories to nutrients and a mix of tastes from added sugar, salt, and artificial flavorings that overly stimulates the appetite center in the hypothalamus -(an important area located deep in your brain between the pituitary gland and the thalamus that acts as your body’s smart control coordinating center) Whole foods are the exact opposite with lots of natural fiber and fluid, a high ratio of nutrients to calories, and free of added sugars, salts and artificial flavors which send signals of satisfaction to our brain quicker which means we also consume less calories.

As an example, think of how many raw almonds you can eat before feeling full, then compare that to eating chips that have added salt and artificial flavouring which keeps triggering us to eat more.

So by eating more whole foods we tend to eat less without feeling deprived or hungry and have little to no cravings.

Some of the whole foods you can start including in your daily diet are:

Vegetables Fruits Nuts and seeds Whole grains And for you carnivores choose leaner sources of protein like fish, chicken, and turkey.

IMAGE BY TRISH CRAPAROT TA, NUTRITIONIST AND HEALTH C OAC H

Written by Trish Craparotta, Nutritionist and Health Coach

The key is to not change everything at once and start incorporating more vegetables to one of your meals each day and then build from there.

For a snack try eating a handful of nuts instead of potato chips or try choosing a snack that is more protein dense.

For your meals try preparing your breakfast, lunch, or dinner at home with fresh ingredients instead of prepackaged or eating out and build from there.

Remember YOU ARE WHAT YOU EAT and this will reflect negatively or positively on the outside so fuel your body with healthier foods and snacks and it will reward you for making better choices by reducing excess body fat, improving skin conditions, digestive issues and help to build a healthier gut and immune system.Healthier food leads to a healthier body, which, in turn prevents illness and disease and increases your odds of a longer, happier life... and who doesn’t want that? ☤

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The True Art of Medicine Written by Susan J. Baumgaertel, MD

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here have been countless references over the years to the “art and science” of medicine. I, for one, certainly have embraced both in my long career as a physician in internal medicine.

However, I have always had a special connection to the art part.

My late mother was an artist and so I grew up with art everywhere.

This influence also percolated into my pre-med college education as my undergraduate degree was in architecture and urban planning.

Before recently starting my own business, I worked for the same organization for 25 years. I had at least a dozen or so of my mother’s paintings in my office suite, with some of the special ones in my exam rooms. Every time my office would move over the years, the paintings moved with me.

Each of my two exam rooms had a “tasteful” nude painting from the mid 1980s when my mother was inspired by a series of life drawing classes she was taking.

My two rooms also had a more ab3 8 | 2022 VO LUME 13

stract painting to balance out the optics.

There were quite a few of her paintings in the immediate hallways. I enjoyed the fact that every day while taking care of patients I was surrounded by art.

Many times my patients would strike up a conversation about a particular painting and it was always fascinating to me that they –sometimes unexpectedly so– would have such a deep appreciation for the artwork.

One such experience I shall never forget occurred in 2017.

One of my lovely patients in her mid-seventies lived two states away in Montana, but would travel to my office in Seattle WA for her annual exam.

On that particular day in early March I had entered the exam room to start her physical and noticed that she was standing up looking intently at one of the paintings, as if in an art gallery. My entrance seemed to have startled her just a little as her gaze had been so intense.

She recovered quickly, we chatted about other subjects, and then moved forward with our medical discussion and physical exam.

Imagine my surprise when justdays later I received a beautiful letter in the mail from her, including a photograph. It was a story about that day and about that particular painting.

She has been kind to let me share this experience publicly, including her letter verbatim.

1. Migration, 1987, Pastel; Helen Rawl ings Baumgaertel (1934-2009)

“Hi Dr.B,

This is an explanation of my experience with the painting in your exam room on March 7th. The painting elicited very strong feelings in me and, since I am committed to celebra ting ‘moments’, I thought I’d tell you about my moment with this painting.

In the 1970s we had a cabin at Ocean Park on the Long Beach peninsula.

We would go there on the weekends.

For my daughter, who was about 8 years old, it was a magical place where she was able to experience the ocean in all types of weather. She is 45 now, and living in Montana, but she and her husband spend a week every year on the coast so they can experience being near the ocean.

One of the things I loved about the beach was the way the seabirds flocked together and flew in what seemed to be some sort of pattern –swooping round and around as though in some choreographed manner over the water.

That is what I instantly saw in your painting, and it brought back happy memories of our time at the beach. I was a bit startled, in a good way, at how the painting affected me. I don’t often react to paintings in that way.

I have enclosed a copy of a photo taken of my daughter and her dad at Long Beach in about 1978. I think you can see from my daughter’s body language that she is in awe of the ocean before her. That has never subsided. And when I looked at your painting I also saw, in my mind’s eye, my daughter and her love of the beach and felt –for a moment –the wonder of the birds in flight.

In appreciation of experiencing your painting, Susan in Montana”

I have read this letter many times over the years and each time it brings a beautiful tear to my eye.

Perhaps it is just the wondrous human connection, especially over art and nature. My mother passed away in 2009, so it is also lovely to connect this special memory to her.

The title of my mother’s painting? Migration. And yes, although quite abstract, it was created in the context of experiencing the vibrant beauty of seabirds flocking along the ocean shore.

2. Ocean Park, Long Beach Peninsula, c. 1978 (photo

courtesy of SM)

Art is everywhere all around us and in nature.

It connects us.

It is part of medicine and part of caring for people.

It is my truth.

This article originally appeared on KevinMD.com and Doctors on Social Media. It was republished with the author’s permission☤ W W W. P HYS I C I A N O UTLOOK.C OM | 39

Complementing Mainstream Medicine with Coaching Written by Wendy Schofer, MD, FAAP, DipABLM and Erin Schofer

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ow does life and health coaching benefit mainstream medicine?

The expansion of the coaching industry over the past decade offers physicians and patients alike an opportunity to create a new medical paradigm, transforming the current deficiency model of mainstream medicine to include a holistic and empowering view of the human experience. Coaching complements medical practice and offers patients and medical professionals a new healing paradigm.

As an allopathic physician practicing conventional medicine, I learned to evaluate and diagnose ailments, leading to treatment and cure. After 20 years of practice, I have found the ultimate alternative to mainstream medicine is actually embracing the totality of the precious human before me. That means acknowledging what is working even more so than what is not working in regard to the health of the physical body, as well as mental, emotional, and spiritual health.

The opportunity to look at health in this multi-dimensional way is best served through the lens of capacity, growth, and fulfillment, instead of the mainstream medicine approach of deficiency or prevention of harm.

As a pediatrician, I remember doing well visits where I would ask questions until I settled on “it,” the problem that needed to be addressed. Ironically, these patients were coming in for routine physicals and to make sure everything was growing and going well.

I was on the hunt to find something that was wrong. I meant no harm with this; it was actually something that I looked at as a mystery: what was there that I could fix and help this patient? This is the standard medical mindset: search for the problem, find the source, and eradicate it.

As I was introduced to the concepts of life and health coaching, I was offered a new perspective. With coaching, we believe that every client is whole and complete, and has the answers for their own unique body and situation. I was educated on appreciative inquiry, which means searching for the good, and shining a

light upon it as what our brains focus upon grows.

With my new perspective, I started focusing upon what was going right for my patients in the office. I started celebrating their victories, and their perceived failures. My patients were perplexed by the focus on their failures, but we explored more. Failures are opportunities to learn, and the more that we learn from what doesn’t go as we anticipated, the more we become resistant to failure.

That opens us up to become more capable of doing and enduring.

I had made a complete shift in my approach to medical care, simply because I stopped looking for things to fix. My patients, just like my coaching clients, are whole. The alternative that I offer to them is a different perspective. It is still medicine. It is holistic, and empowering.

Recently, I welcomed a mother and child for an urgent visit. The child had fallen from a couch and the mother was terrified that there was a deeper injury. On the surface, the question was whether there was anything to fix about the child. He did not meet clinical criteria for significant risk or evidence of injury: that part was easy.

The mother was palpably upset: her child had been hurt on her watch, while she was right there, but could not stop the injury. As I evaluated the child, I asked her to tell me about how she had been supportive of her child that day. She had been playing with him on the couch, seated right next to him when he fell, she addressed his needs right away, she was comforting him in the office. She reflected that her anxiety decreased because she saw how she had been there with her child all day. Instead of continuing to hurt herself more with judgment and accusation, she let herself heal from the trauma of the day, as the child clearly would as well.

DISCOVER ANATOMY-INSPIRED FINE ART AT LYONROADART.COM

Life coaches do add to the value of mainstream medicine, with some caveats. Life coaching is not the practice of medicine. And to be honest, that’s the good part. Because mainstream medicine is built upon a deficiency model of finding what’s broken and fixing it. But together, coaching complements mainstream medicine.

Using coaching tools, physicians can help their patients view their health as an investment that they make every day, instead of a bar to achieve.

If you’re not familiar with life and health coaching, seek a physician coach online. When we as physicians are familiar with the options to help ourselves and our patients, doors open for a new type of healing.

Coaching tools integrate nicely into modern medical practice. ☤

Wendy Schofer, MD, FAAP, DipABLM is a pediatrician, lifestyle physician and certified life and health coach.

She is the founder of Family in Focus, and Weight Coach for Your Whole Family. Erin Schofer is a college student and editorial guru.

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Publisher: Marlene Wüst-Smith, MD Editor in Chief: Alicia Roselli Managing Editors: Hannah Bushery, Marlene Wust-Smith, Jill Labecki VP of Advertising: Pamela Ferman Director of Art and Production: Hannah Bushery Marketing/Copyright Editor/Journalism/Social Media Interns: Hannah Bushery, Dana Bushery, Madison M. Smith Contributing Authors: Marlene Wüst-Smith, Wendy Schofer, MD, FAAP, DipABLM, Erin Schofer, Nonye Tochi Aghanya MSc, RN, FNP-C, Ketan Tamirisa, Joseph Shega, MD, Lauren Yanks, Chris Gure, Diana Londoño, MD, Mr. Michael Andrade, Natalie Newman, MD, Joanne Jarrett, Diana Blum, MD, Linda Rosa, RN, Mark Lopatin, MD, Trish Craparotta, Susan J. Baumgaertel, MD Cover Art: Desmond Bell, DPM, CWS 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 of the authors and/or those interviewed, and may 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: hello@physicianoutlook.com Information on advertising, subscriptions, and job board email: hello@physicianoutlook.com “Physician Outlook” is a registered trademark.

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Cover Artist: Desmond Bell, DPM, CWS In addition to being a talented amateur photographer, Dr. Desmond Bell brings more than 25 years of dedicated bedside practice as a doctor of podiatric medicine in Jacksonville, Florida. A highly regarded and well-respected clinician, educator, and organizational leader, Desmond is a Board Certified Wound Specialist and is the Founder and President of the “Save A Leg, Save A Life Foundation,” a multi-disciplinary non-profit organization dedicated to the reduction in lower extremity amputations and improving wound healing outcomes.

In his role as Executive Physician Coach, Desmond is uniquely positioned to coach today’s healthcare professionals to a greater level of career progression and satisfaction in their chosen fields.