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Weekly Rounds
September 29, 2020

A Beacon of Light in the Darkness

On Saturday at the virtual 2020 Annual Meeting of the WSMA House of Delegates, we inaugurated our incoming president, Nathan Schlicher, MD, JD. For those of you who couldn't be with us, we wanted you to have the opportunity to read an amended version of his speech, so he is our guest columnist this week for Weekly Rounds. You can also watch a video of Dr. Schlicher's speech here.
- Jennifer Hanscom, WSMA CEO

Nathan Schlicher, MD, JD, WSMA 2020-2021 incoming president's speech, Saturday, Sept. 26, 2020.

Good morning colleagues and friends. It is a privilege to serve as your president of the Washington State Medical Association. I am honored to assume the post from my friend Bill Hirota and all the WSMA presidents with whom I’ve worked over the past nine years.

In 2009, when I joined the WSMA as a newly minted emergency medicine physician, we were mired in the Great Recession. It seemed an inhospitable place for a young doctor as there were few jobs, existential threats of governmental regulation, and of the march of corporatization in health care.

Those were uncertain times.

But this year we faced a threat not seen for a hundred years. The coronavirus pandemic upended the practice of medicine and the broader world in unimaginable ways. Where we once happily gathered at concerts and theme parks, we now socially distance. Where we once shared hugs, smiles, and handshakes, now our facial expressions are masked. In a time when Snapchat and text messaging are preferred modes of communication, COVID compounded our isolation, increasing the distance between us, and eroding personal connections. And as COVID took so much away, it left many of us wondering where the light had gone.

When the darkness overwhelmed the nation—it was health care heroes, physicians and nurses who stepped up to care for those in need. We provided care, we held the hands of the dying, we answered the call of our profession, in spite of the risk we faced.

To all of you let me say this: Well done, heroes! In those moments of great challenge, I hope fear was met with hope and a sense of purpose.

Now it’s time to look ahead. I see four key things that will make a difference in our future, and with WSMA’s help, we can make it happen.

First, if we take anything from this pandemic, it’s that physicians must lead our health care system. As Peter Drucker said, “Management is doing things right; leadership is doing the right thing.” We have too much management and not enough leadership in health care today.

Physicians can serve in administration, while also working clinically. We can be both CEO and physician, medical director and doctor, CMO and practitioner. More than 50% of us are now employed by large groups—now is the time for the employed to lead.

Here’s an example—during the early days of COVID, the medical executive committee met to discuss how to face this epidemic. A physician shared the challenges and fears his team faced as they wrestled with caring for their patients, while striving to keep their families safe. He described a plan to open tents, eliminate hallway beds, and encouraged cancelling of surgeries to make the space he needed to combat a pandemic.

But the ever-present business impact of such decisions overrode the innovation. A non-physician leader noted the idea would be taken under consideration, but in that moment the feeling in that room was clear, we were not essential, we were expendable.

That kind of thinking demonstrates perfectly the “iceberg of ignorance.” If you’re not familiar with the concept, it’s a knowledge gap study that reveals the higher up you are on the leadership ladder, the less you know.

Physicians must lead the future and straddle the chasm of ignorance from the front line to the C-suite. Through the WSMA you can make this a reality by attending our Center for Leadership Development programming that promotes leadership development, governance education, and courses to help train the future generation. You are already leaders by being here today with the WSMA, but lets not stop here. Let’s take it to the top!

Second: As we lead, let’s care for those we lead. An emergency physician who survived a near suicide event said: “When we witness trauma and death among the innocent, a little piece of my soul died. We’re never offered counseling and in the end, you get the jaded emergency doctor who struggles to care. My psychologist says it wasn’t just the last girl. It was trauma after trauma after trauma.”

Like you, the patients I have lost remain with me. I can still close my eyes and feel room #12 where Haley died. I was a brand-new attending, three months out of residency, full of confidence, ready to conquer the world in another pandemic, the H1N1 pandemic. I remember intubating her while pulmonary edema filled her lungs and obscured my view, but I managed to sneak the tube in near blind. The cheers of the nurses faded as I saw her heart rate drop from 180 to 60. Her pulse was gone. I well remember those three hours, on and off again coding her, talking to her mom in the hall as she sat motionless in a hard-plastic chair, texting family on her old flip phone. We would get her to Mary Bridge for ECMO, but she would never make it, arresting one last time upon arrival. To this day, 12 years into my practice, it still brings tears to my eyes.

With this pandemic we’ve seen death on a scale not seen in decades. Add its risk to us, to our families, add the moral injury of what we’re facing, and the stress on physicians is profound. Moral injury is the suffering people experience when we are in high-stakes situations, things go wrong, and harm results that challenges our deepest moral codes and ability to trust in others or ourselves. The harm may be something we did, something we witnessed, or something that was done to us. It results in moral emotions such as shame, guilt, self-condemnation, outrage, and sorrow.

It is the type of sorrow and guilt that we know has resulted in the suicide death of colleagues, such as Dr. Lorna Breen, an emergency physician in Manhattan. She was one of the dedicated front-line workers who put her own health at risk, having contracted COVID personally, but going back to work 10 days later to help, once more, caring for those in need. Despite her training, her leadership as a medical director, and her supportive family, she could not reconcile the world in which she worked with the world in which she wanted to live. Her story is tragically not unique.

We can’t simply yoga our way out of this problem. The WSMA is working hard to combat the epidemic of burnout and moral injury. We are pushing for real change by looking at the drivers of the problem. Administrative simplification and easing the work of running a practice remains a high priority of our Olympia team. The WSMA Foundation is leading a wellness initiative with PDSA cycles to improve the practice of medicine. And when we take our rightful place as the leaders of our health system, we will be the drivers of change that builds a robust and holistic system that cares for its doctors as well as its patients.

Third: As we lead our way into a healthier future, we must reinvigorate passion for professionalism. When I started law school, our civil law professor, standing in the deep well of the auditorium of new 1L students, spoke in the deep baritone of professors past about the three learned professions: religion, law, and medicine. He noted how each held an important role not just because of the job they did, but because of their leadership in the community and the example they set through their actions.

Each of the professions cared about the forgotten before themselves, seeking to serve rather than be served. They cared for parts of the human condition: the body (medicine), the soul (religion), and society (law). I believe that medicine has the power, and obligation, to work on body, soul, and society.

I’m disillusioned with many in our profession when I see what they write on social media or how they speak to a colleague with whom they disagree. Civil discourse has gotten lost. We’ve become subject to the echo chamber effect of politics, religion, and science denialism.

As the learned profession of medicine, we should be able to discuss the challenges of racism and acknowledge the differential experience of our African American colleagues, patients, and citizens, while respecting that most police officers are good people doing hard work in a challenging environment, as are we. As physicians we should be willing to speak about the increasing economic disparity in our communities and the risk it poses to our patients if they cannot afford care even while working two jobs.

The WSMA is a beacon of civility in an uncivil world. Our Olympia efforts are not flashy, making threats or big burns in testimony. We do not rage or tweet against a bill, no matter how much it upsets us (can you say: naturopath scope of practice?).

We will continue that standard of educated dialogue and reflect well on our profession. We will advocate to address the social determinants of health including racial disparities this year by supporting a Health Equity Continuing Medical Education Program. We will, with your approval today, start a Latinx Section in the WSMA to increase the representation of Latinx members and give a new conduit to their voice.

If we are going to heal a divided nation that is far too isolated, we must lead through our actions together. I hope today as we discuss some of these challenging resolutions we will rise to that occasion as the first step on building a better future.

Fourth: As we advocate for a more civil world, we must be scientists first. The American author Jim Butcher once wrote “The human mind isn't a terribly logical or consistent place. Most people, given the choice to face a hideous or terrifying truth or to conveniently avoid it, choose the convenience and peace of normality. That doesn’t make them strong or weak people, or good or bad people. It just makes them people.”

In these times of COVID, it seems easier to accept illogical truths. I’ve been shocked to see physicians argue against masks, ignoring observational studies and mountains of historical evidence from other diseases. We’ve seen physicians trying to profiteer by minimizing the risk. Now there’s a neuroradiologist pushing debunked theories over the objection of the world class expert Dr. Anthony Fauci. Others on the front lines have given in to fatalism, believing that there is nothing we can do to prevent the disease, so why even try?

Physicians must help lead a course correction. We understand the scientific method that guides trial and error, the ethical standards that limit our ability to certain types of studies, and how to review the quality of source materials. The WSMA provides Continuing Medical Education and promotes valid science. We advocate for sound public policy like the elimination of the personal exemption from the MMR vaccine and support DOH rules on mandatory masking in schools. We continue to advocate for the health and welfare impacts of climate change and the social determinants of health. But it is imperative that we lead these conversations with our patients, organizations, and colleagues in an honest, respectful way.

If we do not confront the half-truths and mistruths with compassionate advocacy, we give them room to grow and breed.

So this… my mentor in life was a wily old Methodist preacher whom I met when he was 77 and I was 11. He never shied away from controversial topics, choosing to lead with compassion and respect. When he gave a controversial sermon at Seattle’s First United Methodist Church in the ’80s and received hundreds of letters from “Christians” who wrote some of the most vile language you could imagine, he responded to each of them with compassion and love. When I gave my first homily at 13 and upset a church member who demanded a swift rebuke of this young man, Big David graciously said all were welcome in the church and when they threatened to leave, he wished them luck on their journey.

He led by example, giving generously to those in need and challenging his privileged congregation to host Seattle’s Tent City on their church grounds. When the neighbors complained, at the age of 85 he limped around in his Ultrasuede jacket and bicycle socks, knocking on their doors, inviting them to sit in the pews with those they had condemned. And when he died at the age of 94, his closing lines on his life were simple, “I love you, thank you, I love you.”

Like David, we must step forward to lead our health system, with professionalism and compassion, seeking the wellness of those we serve, and encouraging the pursuit of knowledge. I believe when we rise to this calling and become the beacon of light and embrace our professionalism, we give our life’s work purpose.

It is not easy, it is not simple. We must choose to care for our neighbors and go the extra mile. We must choose to lean into leadership rather than be led. I believe that our future is bright if we stand together, defend our trade, and reinvigorate our profession.

This is my pledge because I love what I do as a physician and I love you for what you do to care for our neighbors.

Thank you.

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