| covid_long_haulers | COVID Long-Haulers | WSMA_Reports | Shared_Content/News/Latest_News/2021/covid_long_haulers | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/sept-oct-2021-reports-cover-645x425px.jpg" class="pull-right" alt="WSMA September-October 2001 cover image" /></div>
<h5>September 1, 2021</h5>
<h2>COVID Long-Haulers</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>By John Gallagher</p>
<p>
When the coronavirus pandemic first hit, Jason Goldman, MD, MPH, recognized the importance of researching the impact of the virus. An infectious disease physician with Swedish Medical Center in Seattle, Dr. Goldman, who's also a clinical researcher, instituted a study on immune response in COVID-19 patients.
</p>
<p>
"We enrolled the first patients in March 2020," he says. "At the time, we were thinking about COVID as an acute viral infection." So, it was a bit of a shock when patients returned after a few months for follow-up testing and were still exhibiting problems.
</p>
<p>
"It was surprising to find that the immune system had not calmed down in study participants that we tested at one to two months after their acute infection," Dr. Goldman recalls. "The manifestations after COVID persisted a long time and affected many organ systems."
</p>
<p>
What the study was finding were the early signs of what is now known as post-acute COVID-19 syndrome (PACS), or what is commonly called long-haul COVID. More than a year and a half into the pandemic, PACS remains a perplexing problem, frustrating patients and doctors alike, while adding stress to an already overburdened health care system.
</p>
<p>
Sequelae from infectious diseases are hardly surprising; chronic fatigue syndrome, Epstein-Barr virus, and Lyme disease can cause a confusing array of problems. What's different is the sheer volume of PACS patients. Although precise incidence rates don't exist, the number of people who experience significant sequelae for several months after an acute COVID-19 infection has been estimated to be about 10% to 30%.
</p>
<p>
"We have millions of persons in this country now who have had COVID, and even though it's a small percentage with long-haul symptoms, that number is still very large," says Leslie Linares-Hengen, MD, an infectious disease specialist at St. Joseph's Medical Center in Tacoma. "It's much greater than with other post- infectious syndromes."
</p>
<p>
Moreover, because COVID-19 was such a new disease, at the outset, no one had any idea what the long-term effects might be. "We had to live through the epidemic and the care of the patients to understand what was going to happen," says Dr. Linares-Hengen.
</p>
<h3>A tricky diagnosis</h3>
<p>
One major challenge for physicians is that PACS doesn't present as a clear-cut syndrome. "Patients' symptoms seem to be all over the board," says Peter Barkett, MD, an internal medicine physician at Kaiser Permanente Silverdale Medical Center. "It's such a new thing with such variety in presentation that it's really difficult to pin down."
</p>
<p>
Patients with PACS can suffer from pulmonary and cardiovascular problems. They may report brain fog or less ability to taste and smell. They may have intermittent fevers or severe post-exercise fatigue. They may feel anxious or have trouble sleeping. Or they may have some combination of all of these problems. While PACS seems more prevalent in people with severe acute infection from COVID-19, plenty of PACS patients had mild or even asymptomatic infections.
</p>
<p>
"These are complex, multidimensional presentations that are hitting patients," says Aaron Bunnell, MD, a physical medicine and rehabilitation physician with UW Medicine. UW opened a post- COVID clinic in April 2020 at Seattle's Harborview Medical Center, initially targeting those recovering from critical illness, but soon expanded it as the need grew. At present, patients are waiting three months for an appointment.
</p>
<p>
Some patients are putting off treatment in the belief that their symptoms will fade. When they finally do present to a physician, they "are at their wits' end," says Dr. Barkett. "There are a lot of patients who are suffering in silence with long COVID symptoms." Dr. Barkett now makes a point of asking every patient who has had COVID-19 about lingering symptoms and if there are things that they are no longer able to do.
</p>
<p>
Because some patients never tested positive for COVID-19, it's not always clear that their symptoms are related to the disease. Diagnosis can be difficult, particularly for patients who may have been infected early in the pandemic when testing was scarce. Antibody tests are helpful, but not foolproof.
</p>
<p>
Once they do seek help, patients frequently have faced a battery of tests to figure out what's wrong with them. "Because the symptoms are so broad, a lot of these patients are getting a lot of very expensive workups, with largely negative results," says Dr. Bunnell.
</p>
<h3>Time frame for recovery a moving target</h3>
<p>
Treatment is focused on lessening the severity of symptoms. "We don't have any approved therapies for PACS," notes Dr. Goldman. "Mostly it's symptomatic management."
</p>
<p>
Supporting patients and being transparent with them is also important. "When I talk to patients, I tell them we're not going to be able to fix this in one stroke," says Dr. Barkett. "We're going to try some things, check them, and adjust. We will be working on this over the long term."
</p>
<p>
The good news is that for most patients, symptoms seem to resolve over time.
</p>
<p>
"It's comforting for patients to hear that they will get better eventually," Dr. Goldman says.
</p>
<p>
Still, even with that positive news, there are caveats. For some patients, says Dr. Linares-Hengen, "it's a picket-fence recovery: good days and bad days."
</p>
<p>
There is also a subset of patients who don't get better. "For some patients, six months along, they are still having debilitating symptoms," says Dr. Barkett.
</p>
<p>
Moreover, the very definition of "long-haul" keeps moving further out as time goes on. "The longer the studies go post-COVID, the more we see symptoms lingering because of the nature of real- time research," says Dr. Linares-Hengen. "First it was a few months, then six, then eight, and now reports of a year out."
</p>
<p>
Multiple research studies are underway to better understand PACS. One nationwide master cohort study is seeking to enroll 10,000 patients. "If we knew what causes the different manifestations of PACS, we could treat people better," says Dr. Goldman.
</p>
<p>
Meanwhile, the medical system will be faced with how to handle the influx of PACS patients. A lot of the burden may fall on primary care physicians and providers.
</p>
<p>
"It's going to be very taxing to our medical system, probably in a way we haven't seen before," says Dr. Linares-Hengen. "Most of these patients will present in primary care settings. There is not going to be the infrastructure to be managed only by some specialists."
</p>
<p>
Still, says Dr. Barkett, the primary care physician may have a unique advantage in treating PACS patients. "One of the things we can do in reassuring patients is leveraging our existing relationship with them," he notes. "With a lot of things in medicine, the trust and comfort with the clinician making a recommendation makes a big difference. We can be a support system for them."
</p>
<p>
Dr. Linares-Hengen agrees.
</p>
<p>
"Many of these patients are looking for some relief in a world of uncertainty," he says. "We need to be able to listen to them with compassion when it's hard to pinpoint the exact physiological derangement, as well as to help through the uncertainty of treatments. Even though we don't have great answers, they still need our ear."
</p>
<p>
<em>John Gallagher is a freelance writer who specializes in covering health care. He is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the September/October 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 9/1/2021 2:35:03 PM | 9/1/2021 2:30:51 PM | 9/1/2021 12:00:00 AM |
| telehealths_time_has_come | Telehealth's Time Has Come | WSMA_Reports | Shared_Content/News/Latest_News/2021/telehealths_time_has_come | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/sept-oct-2021-reports-cover-645x425px.jpg" class="pull-right" alt="WSMA September-October 2001 cover image" /></div>
<h5>September 1, 2021</h5>
<h2>Telehealth's Time Has Come</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Rita Colorito
</p>
<p>
When Katina Rue, DO, testified via Zoom before state legislators in January, they interrupted to let her know they could no longer see her. As a family physician in rural Yakima, Dr. Rue is used to dropped signals from unreliable, limited broadband. The all-too-common glitch proved her point about needing to pass House Bill 1196, a bill supported by the WSMA on reimbursement parity for audio-only telehealth visits.
</p>
<p>
"It's pretty typical to lose internet connection, and that goes for a lot of the patients around here," says Dr. Rue, who also serves on the WSMA's executive committee, and who at the time worked for Community Health of Central Washington. Many of her patients also lacked internet access, didn't have smartphones, or didn't know how to use Zoom, so they were only able to do phone calls.
</p>
<p>
During the public health emergency, the Washington State Office of the Insurance Commissioner temporarily offered a critical flexibility for physicians like Dr. Rue, requiring state-regulated insurers to reimburse audio-only visits at the same rate as face-to-face encounters. This temporary flexibility greatly improved access to care and provided the impetus for WSMA's advocacy in support of HB 1196, which aimed to make that parity permanent.
</p>
<p>
With advocacy from Dr. Rue, the WSMA, and others, the bill passed and Gov. Jay Inslee signed it into law. "It's a big win for patient access to care," says Jeb Shepard, WSMA's director of policy. However, he cautions that vigilance is still needed. "We're on the lookout for efforts that might encumber a physician's ability to provide audio- only services to their patients." That watchfulness includes being careful not to incent patients to disassociate their care from longitudinal relationships with physicians and care teams.
</p>
<p>
Like many telehealth policy changes in response to COVID-19, audio-only payment parity-and how or when the modality may be utilized-could be reconsidered once the threat of the pandemic is over.
</p>
<h3>The fight continues</h3>
<p>
HB 1196 requires implementation studies of audio-only telemedicine, to be conducted by the Washington State Telehealth Collaborative, also known as the Collaborative for the Advancement of Telemedicine (or simply the Collaborative). The group, which the WSMA helped found, works to develop telemedicine recommendations, including reimbursement, access, best practices, and technical assistance.
</p>
<p>
From these studies, the Office of the Insurance Commissioner must report findings and recommendations to the Legislature by Nov. 15, 2023.
</p>
<p>
One aspect of the law must be studied and recommendations submitted to the Legislature by Dec. 1 of this year. HB 1196 requires that an established relationship, defined as one in-person visit during the last year, is in place before audio-only payment parity is applicable. The WSMA advocated for the requirement. "We heard from WSMA members that audio-only should be supplemental to in-person care, which is the gold standard; not instead of in- person care," Shepard says.
</p>
<p>
Telehealth requires knowing more about a patient up front, which is why an established physician-patient relationship is crucial, says Jessica Schlicher, MD, medical director of Mission Control and the virtual hospital for Virginia Mason Franciscan Health, who testified on behalf of the legislation. "You have to know, 'Can this patient provide me with a good history? Can the patient cognitively give me information that could help me keep them safe?' "
</p>
<p>
With the bill signed and celebrated, the WSMA is already looking at what's next. "Now it's time to engage in these other arenas-with the Telemedicine Collaborative, the Bree Collaborative, the work required by the Office of the Insurance Commissioner-to make sure the physician perspective is considered and we don't lose the progress we made," Shepard says.
</p>
<p>
"As the research comes in, we're really digging down in what's appropriate for care to see if we can come up with some more agreed-to standards because not everything should be telehealth," says State Rep. Marcus Riccelli, D-Spokane, the lead sponsor of HB 1196.
</p>
<p>
To ensure continued improved access, the legislator says it's important not to go backward on telehealth regulations. "We have a lot of folks still struggling to get online, even in our urban areas," he says. "One of the big things we can do to promote access to health care is to increase broadband access, and put forward infrastructure dollars, either state dollars or in combination with the federal level."
</p>
<p>
Where Dr. Rue lives, audio-only telehealth visits proved particularly helpful to low-income and essential workers in the agriculture and service industries. "They could do a telehealth visit in their car ... get their needs taken care of, and then they're back at work. They didn't have to use paid time off."
</p>
<p>
Audio telehealth is a core patient equity issue, says Dr. Schlicher. "Patients should not be denied access to care based on their access to the internet. The standard of care doesn't change whether a patient is in person or via any telemedicine modality," she says. "It's important for people to understand that these audio-only telehealth visits aren't quick phone calls. They're full visits in which a provider performs the normal evaluation and management of health problems."
</p>
<h3>Making temporary changes permanent</h3>
<p>
Along with audio-only telehealth, the pandemic accelerated adoption of telehealth services across providers and patient populations. Even as health care returns to normal, many patients continue to utilize telehealth. Across the UW Medicine health system, telemedicine visits jumped from about 250 in February 2020 to over 31,100 in in just three months, and still average 20,000 to 25,000 visits a month, says John Scott, MD, medical director of UW Digital Health and chair of the Collaborative.
</p>
<p>
"Washington state was already ahead of the curve because we had a lot of telehealth laws on the books that really allowed us to pivot to a lot greater proportion of visits done by telemedicine," says Dr. Scott. State legislation requiring payment parity for audio-visual telehealth visits was passed just prior to the novel coronavirus outbreak. (The first coverage law in Washington was signed in 2016, for Medicaid and private payers.)
</p>
<p>
To facilitate health care's response to the pandemic, state and federal legislatures eased numerous telehealth regulations. WSMA's focus is making sure these temporary changes become permanent, says incoming WSMA president Mika Sinanan, MD, PhD, a general surgeon in charge of value-based care at UW Medical Center.
</p>
<p>
"There are changes in the interstate licensing compact that many states have adopted during COVID that would allow physicians to deliver care across state lines," Dr. Sinanan says. "But those are now being rescinded or changed and that's going to make it more difficult to maintain relationships and take care of patients. We don't see telemedicine going away. It's certainly not going back to where it was pre-pandemic, but there's a concern the regulations will roll back."
</p>
<p>
Patients have several reasons for wanting to access care across state lines, says Dr. Scott. This includes students who attend college out of state; people who come to Washington state for complex procedures and want to follow up with their care team; and retirees and others who split their residency between living in Washington state and elsewhere.
</p>
<p>
Washington state signed onto the Interstate Medical Licensure Compact in 2017 after passage of legislation strongly supported by the WSMA. The compact allows states to streamline the licensing process for physicians who want to practice in multiple states. But the compact is only as good as the states that have joined it, says Shepard. While 26 states now participate, neighboring Oregon has not signed on. (According to Dr. Schlicher, Washington Medical Commission regulations allow specifically for continuity of care for patients who have received in-person care in Washington, even prior to the pandemic.)
</p>
<p>
The hope is to develop federal interstate licensure regulations for telehealth so physicians can continue to practice across state lines as they did early in the pandemic when regulations were relaxed, says Dr. Sinanan.
</p>
<p>
Elsewhere at the federal level, Medicare temporarily relaxed geographic restrictions for telehealth, one of the biggest barriers to providing telemedicine, says Dr. Scott. "Prior to the pandemic, patients had to either be in a rural or medically underserved area. And you couldn't be in your home; you had to go to one of eight approved areas or locations. So, it really wasn't all that convenient. Congress needs to act to make those waivers permanent."
</p>
<p>
To that end, the WSMA supports the reintroduction of the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2021. The legislation would permanently remove Medicare's geographic restrictions on telehealth services and expand originating sites to include the home and other sites, among other provisions. The CONNECT Act has broad bipartisan support, including from key members of Washington's congressional delegation.
</p>
<p>
"For folks living in remote and rural communities especially, access to telehealth can make a world of difference to access quick, convenient care," says U.S. Rep. Jaime Herrera Beutler, R-Battle Ground, who, along with Rep. Suzan DelBene, D-Medina, are among the bill's co-sponsors.
</p>
<h3>Making the case for telehealth</h3>
<p>
For their part, regulators want to make sure that telehealth is held to the same levels of professionalism and HIPAA privacy standards as in-person visits, says Dr. Sinanan. They're also concerned about potential fraud.
</p>
<p>
"The key is reassuring the Legislature that we know what we're doing and that we have rigorous clinical standards in telemedicine," says Dr. Schlicher, who helped write guidelines on the appropriate use of telehealth for Virginia Mason Franciscan Health.
</p>
<p>
"In order for the Legislature to be certain that we're providing an equivalent standard of care, it's important for WSMA members to carefully consider how they will maintain safety within visits using audio only," she says, "and also to create templates and checklists to ensure they're not missing critical pieces of information."
</p>
<p>
Outside of his legislative duties, Rep. Riccelli is a community relations manager for CHAS Health, a federally qualified health clinic in Eastern Washington and Northern Idaho. He saw firsthand the importance of being able to expand telehealth services during COVID-19. "It was a huge shift, but we were grateful to be able to do that with our patients who are some of the most in need of access," says Rep. Riccelli.
</p>
<p>
Physician experiences using telehealth, especially on how it relates to patient access to care, is particularly helpful for legislators to hear, says Rep. Riccelli. "Being able to communicate that to legislators, whether in email communications or in-person communications, when they see relevant policy coming up, will be important."
</p>
<p>
For the WSMA and physicians throughout Washington, advances such as the medical licensure compact and payment parity are significant steps toward greater access to quality, affordable care for more patients.
</p>
<p>
"What we suspected from all our years working on this issue is that telemedicine is a safe and effective way to deliver health care services. And our beliefs were supported during the pandemic," says Shepard. "Our goal now is to take those lessons we learned and really push for improved access to care by keeping some of those flexibilities in place."
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care. She is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the September/October 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 9/1/2021 2:42:40 PM | 9/1/2021 2:35:34 PM | 9/1/2021 12:00:00 AM |
| building_a_new_legacy | Building a New Legacy | WSMA_Reports | Shared_Content/News/Latest_News/2021/building_a_new_legacy | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/latest-news/2021/July/july-aug-2021-reports-cover-article-graphic-645x425.jpg" class="pull-right" alt="WSMA Reports July-August 2021 cover graphic" /></div>
<h5>July 20, 2021</h5>
<h2>Building a New Legacy</h2>
<p>
By Nathan Schlicher, MD, JD, MBA
</p>
<p>
As we guide the activities of the Washington State Medical Association in 2021, we are building on the legacy of forward-thinking physicians stretching back to the late 1800s who were striving to make Washington the best place to practice medicine and receive care.
</p>
<p>
When this was still - quite literally - the wild, wild West, our predecessors acted on a desire to meet the care needs of their communities. In those early meetings, an idealistic few cast a vision for the house of medicine: to encourage the unity and harmony of the profession, to advance its interests, and to promote the advancement of medical science.
</p>
<p>
Today, we continue to build on that legacy and vision. We seek to create a sustainable medical association that reflects the times in which we live and practice medicine. We engage tomorrow's leaders today, as we create an association that reflects the population it serves. We look to the past - and the present - to realize a future that is relevant, nimble, and responsive.
</p>
<p>
As with any undertaking, there are challenges. While the tradition of our House of Delegates remains strong, with passionate advocates driving good policy, attendance and engagement in our policymaking process have sharply declined. Reinvigorating our House is central to the work before us, to ensure our physician-driven strategies reflect engagement and diverse, informed perspectives.
</p>
<p>
On identifying and engaging those diverse voices, our membership has spoken clearly and passionately through recent policy passed by our House. Overcoming systemic bias and institutionalized racism requires all voices at the table if we are to effectively address inequities in health care. Change is needed at all levels, including the makeup of our House and its leadership.
</p>
<p>
Another challenge before our medical association is posed by the rapid changes that are a hallmark of today's health care environment. We must equip our WSMA with streamlined and modernized strategies to remain responsive to the fast-changing needs of our state's physicians and their patients, and to engender a culture of connectedness and trust in governance that is key for any healthy organization.
</p>
<p>
The 2019 House of Delegates recognized these challenges and directed the WSMA to develop strategies that would help improve the value of the House. Since then, your WSMA has been hard at work doing just that.
</p>
<p>
To develop these recommendations, the WSMA engaged an external association strategy consulting firm to explore our organizational directives and concerns and to review today's association best practices and market benchmarking.
</p>
<p>
After stakeholder interviews, the recommendations were reviewed by our board of trustees in September and again in November 2020, then submitted to our bylaws committee for development. The board reviewed drafts in January and May and now the final amendments will be up for a vote during the 2021 House of Delegates meeting in the fall.
</p>
<p>
In this issue, you'll find the proposed amendments to the WSMA bylaws (printed in the insert), which reflect the recommended restructuring of our governing bodies. We urge all members to review them prior to the September meeting of the 2021 House of Delegates, when they will be considered for adoption. Your feedback will be solicited via our secure and private online discussion forums.
</p>
<p>
The changes proposed do not alter the policymaking process of the House of Delegates. Instead, the proposal seeks to make the House of Delegates stronger, giving all WSMA members an opportunity to have their voices heard during our policymaking process.
</p>
<p>
These recommendations reflect a transformed path that builds on the best of our traditions, achieves a greater sense of community, ensures a diverse and equitable board of trustees and House of Delegates, and yields a sustainable and relevant association for the next 100 years.
</p>
<p>
Our path forward is in view. Standing together, we can take a bold step into a future we have built that honors the best of who were yesterday, and who we are today.
</p>
<p>
<em>Dr. Schlicher is president of the WSMA.</em>
</p>
</div> | 7/20/2021 3:06:36 PM | 7/20/2021 1:10:37 PM | 7/20/2021 12:00:00 AM |
| by_the_numbers_getting_comfortable_with_discomfort | By the Numbers: Getting Comfortable With Discomfort | WSMA_Reports | Shared_Content/News/Latest_News/2021/by_the_numbers_getting_comfortable_with_discomfort | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img alt="WSMA Reports July-August 2021 cover graphic" src="/images/Newsletters/latest-news/2021/July/july-aug-2021-reports-cover-article-graphic-645x425.jpg" class="pull-right" /></div>
<h5>July 20, 2021</h5>
<h2>By the Numbers: Getting Comfortable With Discomfort</h2>
<p>
During the 2021 WSMA Leadership Development Conference, keynote speaker Bill Eckstrom had this to say about change: “What makes you comfortable can ruin you, and only in a state of discomfort can we continually grow.†His talk about getting comfortable with discomfort rang true for attendees and speaks to us today as we consider a transformation of our House of Delegates. As these attendance numbers from recent House of Delegates meetings show, a reinvigorated House is needed to better position your WSMA for the future. To learn more about this transformation effort, read the “<a href="[@]Shared_Content/News/Latest_News/2021/building_a_new_legacy.aspx">Building a New Legacy</a>†column.</p>
<p>
<a href="javascript://[Uploaded files/News and Publications/Newsletters/2021/by-the-numbers-wsma-july-aug-2021.pdf]">Click here to see the numbers</a>.
</p>
</div> | 7/20/2021 3:27:09 PM | 7/20/2021 1:10:34 PM | 7/20/2021 12:00:00 AM |
| facing_the_demands_of_change | Facing the Demands of Change | WSMA_Reports | Shared_Content/News/Latest_News/2021/facing_the_demands_of_change | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/latest-news/2021/July/july-aug-2021-reports-cover-article-graphic-645x425.jpg" class="pull-right" alt="WSMA Reports July-August 2021 cover graphic" /></div>
<h5>July 20, 2021</h5>
<h2>Facing the Demands of Change</h2>
<p>Jennifer Hanscom, Executive Director/CEO</p>
<p>
In the early days of the COVID-19 pandemic, WSMA's executive committee gathered weekly to strategize the association's response to the crisis. With Washington's "Stay Home, Stay Healthy" mandate in place, it wasn't long before we started hearing comments like "It's quiet, like on a Sunday," from a
member describing his medical facility at the time. Another chimed in saying, "Same here, our hospital has the lowest census we've ever had in 20 years." Someone else noted that their emergency department had open beds and no waiting.
</p>
<p>
We marveled at the slowdown of the pace at our members' practices and ambulatory settings. We collectively crossed our fingers, hoping this meant we did enough to have the capacity to care for COVID-19 patients. However, no one anticipated that our chronic or urgent care patients might delay care or necessary procedures. A member at Overlake was the first one to flag for us that the volume of stroke patients had plummeted at his stroke center. It was a harrowing harbinger of things to come, as we knew without a doubt that it wasn't because people weren't having strokes. It was because they weren't seeking care. Soon after, among other disturbing stories, we learned about a heart attack patient who delayed care so long that he died in the emergency clinic's parking lot before he could receive care.
</p>
<p>
For all of us, the pandemic has taken so much. For some patients it took away the will to seek care or it caused critical care to be delayed. For some medical practices, it stole their financial viability, causing reductions in staff or worse, closures.
</p>
<p>
The pandemic was a perfect storm for disastrously compromising the health of patients and practices. It may yet be years until we can assess the full extent of its impact. What we know for now is that the unforeseen consequences will be with us, much as long-haul COVID-19 will be as well.
</p>
<p>
As we emerge on the other side of a pandemic, as well as a racial awakening, among the lessons learned is that we must recognize and face the demands of change head on. I've been reflecting on that lesson as your WSMA leadership contemplates how best to ensure a sustainable organization that reflects the times in which we live, all the people we represent, and the practice of medicine. It's time to look forward and create an opportunity for all voices to be at the table, now and into the future.
</p>
<p>
I urge you to review the insert within this magazine, which outlines the bylaws updates that will be voted on at the annual meeting of our House of Delegates this September. Be sure to also read "<a href="@/Shared_Content/News/Latest_News/2021/building_a_new_legacy.aspx" name="Building a New Legacy"><a href="[@]Shared_Content/News/Latest_News/2021/building_a_new_legacy.aspx">Building a New Legacy</a></a>" for background into the transformational changes these bylaws amendments represent.
</p>
<p>
I'm grateful to the bylaws committee for their diligence and thoughtfulness as they prepared these proposed amendments. Their work captures several months of debate at the WSMA board of trustees. To learn more or to share your thoughts, visit the virtual reference committee discussion forum at <a href="https://wsma.org/vrc">wsma.org/vrc</a>.
</p>
</div> | 7/20/2021 3:05:47 PM | 7/20/2021 1:09:15 PM | 7/20/2021 12:00:00 AM |
| proposed_bylaws_amendments_for_2021 | Proposed Bylaws Amendments For 2021 | WSMA_Reports | Shared_Content/News/Latest_News/2021/proposed_bylaws_amendments_for_2021 | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/latest-news/2021/July/july-aug-2021-reports-cover-article-graphic-645x425.jpg" class="pull-right" alt="WSMA Reports July-August 2021 cover graphic" /></div>
<h5>July 20, 2021</h5>
<h2>Proposed Bylaws Amendments For 2021</h2>
<p>
Your state medical association - its governance and regulation of affairs - is defined by a set of bylaws. And each year a committee, consisting of volunteer WSMA members, convenes to consider changes to these bylaws. Those proposed amendments are then put before the WSMA House of Delegates for consideration.
</p>
<p>
At the 2021 WSMA Annual Meeting this September, delegates will be asked to weigh in on five separate amendments to the bylaws. These proposed amendments reflect discussions at the WSMA board of trustees on restructuring our governing bodies in response to a resolution passed by the 2019 House of Delegates (see "<a href="[@]Shared_Content/News/Latest_News/2021/building_a_new_legacy.aspx">Building a New Legacy</a>" for details). WSMA Reports provides notice of these proposed amendments to members as required by Article XIX of the bylaws.
</p>
<h3>Summary of amendments</h3>
<p>
The proposed bylaws amendments would:
</p>
<ul>
<li>Restructure the board of trustees
<ul>
<li>Remove the AMA alternates from the board of trustees;</li>
<li>Reduce the number of the trustees-at-large from twenty-one (21) to fourteen (14); and</li>
<li>Remove the finance committee chair and designate the secretary-treasurer to be the finance committee liaison to the board of trustees.</li>
</ul>
</li>
<li>
Restructure the House of Delegates
<ul>
<li>Require component county societies to be "functioning component county societies" when apportioning delegates to the Houses of Delegates;</li>
<li>Define "functioning component county society;"</li>
<li>Reduce the number of special sections that receive delegates (removes senior section and osteopathic section);</li>
<li>Create "delegates-at-large" to the House of Delegates;</li>
<li>Require all proposed resolutions be sponsored by two (2) members of the House of Delegates.</li>
<li>Amend the number of days the secretary-treasurer must furnish each member of the House of Delegates and the secretary of each component society and section with a copy of each such resolution from thirty (30) days before the next meeting of the House of Delegates to twenty (20) days (to allow adequate time to process resolutions); and</li>
<li>Add clarification to board of trustees composition regarding the AMA delegation.</li>
</ul>
</li>
<li>
Establish a diversity, equity, and inclusion committee, with responsibilities that include reviewing candidates for delegates-at-large to the House of Delegates.
</li>
</ul>
<p>
In the proposed amendments relating to the items listed above, those portions of the bylaws that are struck out are to be deleted and those colored and underlined are to be added. Bylaws text that remains unchanged and that has been omitted from this document in the interest of brevity is represented by an ellipsis [...]. A complete set of the current bylaws can be downloaded from the WSMA website at <a href="https://wsma.org/policies">wsma.org/policies</a>.
</p>
<p><a href="javascript://[Uploaded files/News and Publications/Newsletters/2021/wsma-julyaug-2021-bylaws-final-amendments-only.pdf]">Download a PDF of all proposed amendments for 2021</a>.
</p>
</div> | 7/20/2021 3:16:35 PM | 7/20/2021 1:10:39 PM | 7/20/2021 12:00:00 AM |
| covid_19s_unforeseen_consequences | COVID-19's Unforeseen Consequences | WSMA_Reports | Shared_Content/News/Latest_News/2021/covid_19s_unforeseen_consequences | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2021/july-aug-2021-reports-cover-article-graphic-645x425.jpg" class="pull-right" /></div>
<h5>June 25, 2021</h5>
<h2>COVID-19's Unforeseen Consequences</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Rita Colorito
</p>
<p>
It's been more than 18 months since Washington state reported its first case of COVID-19. During that time, and still today, the pandemic has had far-reaching effects on Washingtonians' health. Beyond those who battled the disease, countless others faced health consequences because the pandemic made them reluctant or unable to receive the care they needed.
</p>
<p>
With the pandemic still not over, the true downstream effects on health care won't be evident for years to come. But preliminary tallies by public health agencies are sobering.
</p>
<p>
Health care avoidance and delay may have contributed to excess deaths outside of COVID-19, according to a February 2021 report from Public Health - Seattle &amp; King County. Age- adjusted death rates in King County were 12% higher in 2020 compared to the previous three years, including a 23% increase for both diabetes-related deaths and overdose deaths, and a 7% increase in cardiovascular deaths.
</p>
<p>
<em>WSMA Reports</em> spoke with doctors from four specialties-pediatrics, general surgery, radiation oncology, and addiction medicine-to find out the impact of the pandemic on their patients.
</p>
<h3>Pediatrics</h3>
<p>
Of all the age groups, children have largely been spared from the devastating health effects of COVID-19. But they've been impacted in other ways, says Amy Carter, MD, chief medical officer for Allegro Pediatrics, which serves families in the eastern Seattle metropolitan area.
</p>
<p>
In the early days of the pandemic, Allegro saw its total visits drop by 70%, says Dr. Carter. "Parents were very worried, so [they] did not want to come in."
</p>
<p>
Data from the Washington State Department of Health show some children may be missing needed vaccinations. From the start of the pandemic through September 2020, DOH data show overall pediatric vaccinations down nearly 19%.
</p>
<p>
Pre-pandemic, same-day appointments made up half of Allegro's daily schedule, with 30% of those dedicated to sick-child visits. Today, Allegro is still only at 80% of pre- pandemic volume. In a parent survey, 10% to 15% said they still don't feel comfortable bringing their children in for any reason.
</p>
<p>
On the plus side, sick-child visits are nearly non-existent, says Dr. Carter. "The vast majority of normal kids would have colds in the winter, or get the flu, or have an ear infection. Those stopped happening because social distancing and masks work," she says. "While it was positive for kids that so few got sick this past year, it was hard for our outpatient pediatric business model to compensate for such a decrease in patient demand."
</p>
<p>
In the pediatric population, the biggest impact was on mental health. "We've never had a higher volume and higher acuity for mental health issues," says Dr. Carter. "(We saw) every mental health diagnosis you can think of-more suicides and suicide attempts, more kids where it's impacting their functioning, or kids who need to go on medication."
</p>
<p>
Parental mental health during the pandemic also affected children. As schools start to open back up, Dr. Carter says she's seen a spike in reports to child protective services-abuse hidden during the pandemic.
</p>
<p>
The developmental fallout for newborns remains to be seen, says Dr. Carter. "We have children who haven't seen anyone outside their immediate family, or left their house, in a year. ...We don't really know long-term what it will do."
</p>
<p>
The pandemic affected childhood physical growth. "Normally children follow their predicted growth line year over year. But this last year was remarkable because we saw a huge increase in weight gain," she says.
</p>
<p>
The percentage of children ages 2 to 17 who are obese increased to 15.4% from June to December 2020, up from 13.7% in the year-earlier period, according to a May 2021 study in Pediatrics.
</p>
<p>
Allegro also saw an increase in children with eating disorders. "This surprised us a little at first, but it shouldn't, in retrospect. For an anxious temperament, with no control over life, in general, eating is one of the few things that you can have control over," says Dr. Carter.
</p>
<h3>General surgery</h3>
<p>
Elective surgery was on the government- mandated cutting block early in the pandemic. As a result, total elective surgery dropped by about 60% to 70%, says Mika Sinanan, MD, PhD, medical director of contracting and value-based care for the general surgery clinic at the UW Medical Center - Montlake.
</p>
<p>
Once those surgeries resumed, some patients further delayed surgery out of COVID-19 fear. Others delayed because of visitor restrictions, says Dr. Sinanan. "It made it harder for patients and their families to support each other. For many patients, that was unacceptable."
</p>
<p>
In some cases, delaying surgery has caused disease conditions to worsen, says Dr. Sinanan, a board member of the Washington Chapter of the American College of Surgeons and president- elect of the WSMA. "I deal a lot with inflammatory bowel disease. And there were some people who were in pretty good shape a year ago who are more malnourished and more ill now. It will take more work to get them better and it will take them longer to recover."
</p>
<p>
UW's general surgery clinic is now operating at full capacity, and then some-continuing to affect elective surgery in a different way. "We had a couple of days where we actually had to cancel or delay elective surgery for up to five days because we didn't have enough hospital beds for our staff to actually offer them surgery," says Dr. Sinanan.
</p>
<p>
Those hoping to schedule their surgery have been frustrated by wait times caused by a backlog, says Dr. Sinanan. "By the time they get to the clinic, they want to have their surgery the next day or as quickly as possible. And sometimes it's not possible to get them scheduled in the time frame they want."
</p>
<h3>Radiation oncology</h3>
<p>
When you're facing cancer, time is often of the essence.
</p>
<p>
"Cancer care is not really elective. We had to rapidly figure out how to safely treat our patients," says Edward Kim, MD, medical director for radiation oncology at the UW Medical Center and a physician at the Seattle Cancer Care Alliance.
</p>
<p>
While current cancer patients continued to receive care, oncologists saw fewer people undergoing preventive screenings. Delayed screening and diagnosis remain the biggest concern for oncologists, says Dr. Kim, treasurer of the Washington State Radiological Society.
</p>
<p>
"I'm starting to see in my practice patients that developed symptoms concerning for cancer last year, but for whatever reason-hesitancy or difficulty getting access to care-they didn't come in. Some of these patients ended up having later diagnoses, or more advanced disease by the time they were actually diagnosed," says Dr. Kim.
</p>
<p>
Nationwide, screening for breast, prostate, and colorectal cancers dropped sharply from March through May of 2020, according to a study published in JAMA Oncology. And while screenings for breast and prostate cancer rebounded in July, the overall estimated COVID-19-associated screening deficit across those three cancers was 9.4 million in 2020 compared to 2019.
</p>
<p>
Dr. Kim and his colleagues have observed a drop in patients presenting with early-stage breast and prostate cancers. "Those are cancers that are often diagnosed with screening. ... I think it's possible they will eventually be diagnosed. And the concern is that those patients may have more advanced disease," he says.
</p>
<p>
More advanced disease means a longer treatment road ahead. "Even if we are able to cure a patient with a more locally advanced tumor, they still may have to go through more treatment and have different side effects than if the cancer been caught earlier," says Dr. Kim.
</p>
<p>
The focus now is to convince people to resume cancer screenings, says Dr. Kim. "We have to reinforce the message that we have protocols to keep patients safe to deliver the care they need."
</p>
<h3>Addiction medicine</h3>
<p>
Pandemic mitigation measures exacerbated the social determinants of stability and recovery that many with substance use disorders contend with on a daily basis, including mental health issues, homelessness, and joblessness, says Lucinda Grande, MD, a family medicine physician with Pioneer Family Practice in Lacey.
</p>
<p>
As a result, those with such disorders were especially hard hit. Not only was this already vulnerable population at 8.7 times higher risk of COVID-19 infection and at a higher risk of hospitalization and death, they also fared worse indirectly.
</p>
<p>
More people died in Washington of drug overdoses in 2020 than any year in the last decade, according to preliminary data from the Department of Health. Overdose deaths from all drugs skyrocketed, up 38% during the first half of 2020 compared to the first half of 2019.
</p>
<p>
"That's up from an average 3% increase over the previous four years," says Dr. Grande.
</p>
<p>
Opioid overdose deaths also increased 36%, with the greatest increase among people of color and tribal communities, says Dr. Grande. If it weren't for previous measures in the state to ensure the availability of naloxone, overdose deaths may have been even higher, she says.
</p>
<p>
The primary reasons for higher rates of substance use are increased social isolation and other stresses, says Dr. Grande. "It's a well-known saying that the opposite of addiction is connection."
</p>
<p>
Though Pioneer never closed its facilities-early in the pandemic, its staff conducted patient visits outdoors- it saw a nearly 30% reduction in patient volume in mid-March, says Dr. Grande. "The most rapid acceleration in overdose deaths occurred between March and May of 2020, coinciding with the implementation of the mitigation measures," she says.
</p>
<p>
Overdose deaths are the tip of the iceberg, says Dr. Grande. Among people who had previously been stable or in a fragile recovery state, she's has seen a significant increase in recurrence of substance use.
</p>
<p>
"A patient stable on Suboxone lost his construction job due to the pandemic and was stuck at home, where long- brewing conflicts exploded," Dr. Grande says. "He turned to alcohol and ultimately, back to heroin to numb the emotional pain. After he got a new job, he finally developed the impetus to return to care."
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care. She is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the July/August 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 6/25/2021 4:35:48 PM | 6/25/2021 10:16:48 AM | 6/25/2021 12:00:00 AM |
| financial_fallout | Financial Fallout | WSMA_Reports | Shared_Content/News/Latest_News/2021/financial_fallout | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2021/july-aug-2021-reports-cover-article-graphic-645x425.jpg" class="pull-right" /></div>
<h5>June 25, 2021</h5>
<h2>Financial Fallout</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By John Gallagher
</p>
<p>
On March 19, 2020, with Washington state on the front lines of the surging COVID-19 pandemic, Gov. Jay Inslee took the drastic step of halting all elective surgery. That effectively closed the practice of Seattle-based ophthalmologist Aaron Weingeist, MD. Almost all ophthalmic surgeries, including most cataract surgeries, were sidelined under the governor's initial guidelines. Dr. Weingeist's 18,000-square-foot office building, which includes a surgical center, was suddenly quiet.
</p>
<p>
"It was pretty scary for a few months," says Dr. Weingeist, legislative affairs director for the Washington Academy of Eye Physicians and Surgeons. "We shut everything down and sent 30 employees home," while still keeping the employees on payroll.
</p>
<p>
According to the American Medical Association, ophthalmology saw the biggest reduction in Medicare physician spending in the first half of 2020, with a 29% drop in payments. Without revenue, Dr. Weingeist's fixed costs loomed large.
</p>
<p>
"We have a very large loan, which was a huge stressor," he says. Fortunately, the practice, Clearview Eye &amp; Laser, was able to work out an interest-only payment plan with its bank. Still, he says, "it's a shockingly large amount of overhead when you don't have any revenue coming in."
</p>
<p>
Dr. Weingeist's experience is far from unusual; the pandemic caused havoc for specialists across the state. A Commonwealth Fund study from February found "a substantial cumulative reduction in visits across all specialties over the course of the pandemic in 2020."
</p>
<p>
The governor "definitely did the right thing" shutting down elective surgery, says Arooj Simmonds, MD, executive medical director of surgical services- anesthesia at Swedish Health Services, which serves the Seattle metropolitan area. Yet patient and provider safety came at a high cost.
</p>
<p>
"There was a financial fallout," Dr. Simmonds notes. "You could talk to some surgical groups and they would say they were not paid for months." She notes that physicians tied to hospital groups were less likely to have been impacted.
</p>
<p>
Anesthesiology practices saw "a lot of partners at home, working one day a week, getting a significantly smaller paycheck," she says. "Some practices laid off non-partner physicians."
</p>
<p>
In addition to the elective surgery ban, many patients postponed care to avoid risking exposure to COVID-19. Samuel Lien, MD, president of the Washington State Society of Plastic Surgeons, says that more than half of his practice's business vanished overnight.
</p>
<p>
"If a normal week was 50-60 hours, it was cut back to half or three-quarters of a day in clinic and the same for surgeries," says Dr. Lien, who practices at Providence Mill Creek Plastic and Reconstructive Surgery in Everett. Self- pay cosmetic surgery came to a halt.
</p>
<h3>A return to normalcy-somewhat</h3>
<p>
By the second half of the year, practices had adapted to the new reality and saw patients returning to pre-pandemic levels. "From a surgical perspective, things are getting back to normal," says Dr. Simmonds. "I'd say the same for anesthesiology."
</p>
<p>
For some specialties, the return to normal was even more robust.
</p>
<p>
"We saw a big uptick in elective surgery," says Dr. Lien. "People fortunate enough not to have lost their job were not vacationing and were having a relatively low cost of living, so they suddenly had money. If you can Zoom from home, then it's pretty easy to recover from cosmetic surgery while still performing your work duties. People saw that as a great opportunity."
</p>
<p>
In other cases, however, the rebound is taking longer. "We've gradually ramped back up, but we're still at 75% to 80% of our normal volume," says Dr. Weingeist.
</p>
<h3>Reimbursement challenges ahead</h3>
<p>
This year, as specialty practices recover from the acute impacts caused by the pandemic, they face being squeezed by Medicare and well-meaning initiatives that threaten to divert resources away from them toward primary care.
</p>
<p>
"Our state needs to adequately invest in primary care, that's for certain," says Jennifer Hanscom, executive director/ CEO of WSMA. "Yet we can't further compromise patients' access to care by reducing specialist payments to fund better primary care reimbursement. That's not in anyone's interests-not patients', not the profession's, not the community's."
</p>
<p>
The tumult of the past year has brought those concerns into bright relief. Specialties that are still recovering are now faced with the prospect of a significant reduction in payments as legislators and government agencies look to redistribute money within health care.
</p>
<p>
The pandemic paused many of those initiatives as attention was diverted to the public health response. Chief among the changes put on hold was a revision to the Medicare fee schedule that would have had an outsized impact on specialties. Now that the pandemic is fading, those initiatives will be returning to the fore.
</p>
<p>
As the impact of the pandemic on specialties still lingers, efforts continue to reduce the total cost of health care in Washington state and at the federal level.
</p>
<p>
"There are still a lot of headwinds for the practices, including reimbursement changes at the federal level," says Nathan Schlicher, MD, WSMA president. "It's the challenge of trying to maintain a practice while you're experiencing death by a thousand cuts."
</p>
<p>
Those cuts include the 2021 Medicare fee schedule released late last year. The proposed schedule would have instituted payment cuts to specialties to increase primary care reimbursement. Organized medicine, including the AMA and the WSMA, successfully opposed the move, but the cuts have only been temporarily avoided.
</p>
<p>
"Everyone breathed a huge sigh of relief this year," says Hanscom. "But we're in a situation where if and when the Medicare fee schedule does go into effect, it will be devastating to specialties. On average, the specialty community will be negatively impacted by at least 11%."
</p>
<p>
Then there are Washington state initiatives that aim to bolster primary care. The Health Care Authority's primary care transformation project could be massively consequential as it seeks to reimagine primary care, including financing and how care is delivered, across all payers. Yet details are lacking on how the state intends to pay for that effort.
</p>
<p>
"I'd say at the WSMA, we are feeling a little anxious and uneasy about this effort," Hanscom says. "They are working on a very rapid timeline and we don't know how HCA intends to pay for the transformation. Without a significant and stable long-term infusion of cash, which we are not counting on, then that leads me to believe they will be looking to shift costs. It's not clear if they are looking more broadly than physician reimbursement. I hope so, but if they follow Medicare's playbook, that's when things will get contentious. To date, we don't have these details."
</p>
<p>
Specialists emphasize that they believe that primary care does deserve to be paid better. "Everybody thinks primary care should get more," notes Dr. Weingeist.
</p>
<p>
Hanscom notes that many cost- control efforts focus solely on physicians. These include Cascade Care, which the state describes as a "higher value" health insurance option designed to increase access to care. However, its reimbursement structure often pencils out to be below the cost of delivering services.
</p>
<p>
"I support things like Cascade Care," say Dr. Simmonds. "But we just need to make sure it pays physicians the appropriate rate for what they do."
</p>
<p>
Recently, the governor appointed members to the state's new health care cost transparency board. One of its roles: setting a health care cost growth benchmark for providers and payers.
</p>
<p>
"When we're looking at driving down the cost of care, we should really be looking at the total cost of care, not just physicians," adds Hanscom. "Policymakers can't ask physicians to unilaterally bear responsibility for cutting costs in the system. Our concern is they will try to force physician payments down without addressing any of the underlying cost drivers and overhead, like regulatory and other burdens, and significantly threaten practice viability."
</p>
<p>
Ultimately, says Hanscom, it's the patient who suffers.
</p>
<p>
"If a patient can't get access to specialty care in their community, where does the patient end up? Either the hospital emergency department or in worse condition in a hospital bed," she says. "That's not better, higher- value care. Preventative care is not only delivered by primary care physicians, but specialists as well."
</p>
<p>
<em>John Gallagher is a freelance writer who specializes in covering health care. He is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the July/August 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 6/25/2021 4:35:54 PM | 6/25/2021 10:04:20 AM | 6/25/2021 12:00:00 AM |
| q_and_a_with_melanie_de_leon_jd_mpa | Q&A with Melanie de Leon, JD, MPA | WSMA_Reports | Shared_Content/News/Latest_News/2021/q_and_a_with_melanie_de_leon_jd_mpa | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" alt="WSMA Reports Extra logo" /></div>
<h5>June 16, 2021</h5>
<h2>Q&amp;A with Melanie de Leon, JD, MPA</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
Washington Medical Commission Executive Director Melanie de Leon, JD, MPA, began her involvement with the commission starting in 2003, when, as an assistant attorney general, she litigated cases for several state Department of Health boards and commissions. Through that work, she became "enamored of the medical commission," as she puts it, eventually becoming the commission's executive director. De Leon is directing a dramatic overhaul of the commission's disciplinary and licensing functions, both to bring them up to date and to bring greater transparency and clarity to processes that act as guardrails for the practice of medicine in Washington state.
</p>
<p>
<em>WSMA Reports</em> sat down with de Leon to update WSMA members on these important changes.
</p>
<p>
<strong><em>WSMA Reports</em>: What improvements has the commission made to the disciplinary process? </strong>
</p>
<p>
De Leon: The commission moved to all-electronic case files, decreasing the time to process investigations and the case disposition. We initiated a new classification for health care investigators who complete our standard of care investigations; as such, we now have a clinical health care investigator who must be an MD, DO, PA, ARNP, or RN to qualify. This classification ensures the investigator understands the issues involved in this type of matter.
</p>
<p>
We overhauled the way we conduct our cases involving sexual misconduct. Now each case is assigned two reviewing commissioners, one female and one male; one is a clinician and one is a public member and both must have completed a training regarding a trauma-informed approach to sexual assault/misconduct cases.
</p>
<p>
All the investigators and staff attorneys have completed training regarding a trauma-informed approach to sexual assault/misconduct (which is two-day course).
</p>
<p>
We redesigned the respondent notification letter [read more about the letter below].
</p>
<p>
We are currently developing performance metrics for different steps within the investigative process instead of one overarching measure.
</p>
<p>
We have begun offering settlement conferences for stipulations to informal disposition). This change has led to the commission closing cases and finding that no action was necessary in several instances. While this step for STIDs is voluntary, many commissioners use it.
</p>
<p>
We revamped the compliance process to add an initial phone meeting (now virtual) with a licensee who has a new STID, or order, to explain next steps and to help them through this process.
</p>
<p>
We are researching how to track and manage the cost of disciplinary cases to better manage our litigation costs going forward.
</p>
<p>
<strong>Tell WSMA members about the commission's new notification letter. What is a notification letter? </strong>
</p>
<p>
A letter is sent out to the physician or PA notifying them that the commission has opened an investigation into allegations made against them via a complaint filed with us. In the past, this was a form letter devoid of any information regarding the nature of the allegations. Commission staff met and rewrote the letter to make it customer-oriented and to include, in all cases except those regarding allegations of sexual misconduct, a copy of the redacted complaint. This provides the respondent an opportunity to read the allegations and understand the issues. The respondent also has the opportunity to respond to the allegations later in the investigative process.
</p>
<p>
<strong>Why did you decide to make those changes? </strong>
</p>
<p>
It is important for the person against whom the complaint is filed to know what the complaint is about, so they are not left speculating. While most of our investigations are closed without taking any action, it is still a very stressful time for the respondent, especially if they have no idea what the complaint is about.
</p>
<p>
<strong>When did you roll this out? </strong>
</p>
<p>
The new letter went into practice on Feb. 1.
</p>
<p>
<strong>What steps has the commission taken during your tenure to improve the licensure process? </strong>
</p>
<p>
We have done many things to improve and streamline the licensing process for both initial applications and renewals. We worked very hard to get the Interstate Medical Licensure Compact legislation passed. Our team has created new procedures to process licenses requested through the compact.
</p>
<p>
In 2017, we restructured the personal data questions in our licensing application. We redefined the term "current" regarding medical conditions that might impair the licensee's ability to practice safely by reducing the timeline from two years to six months. We inserted a "safe harbor" option so that a licensee may answer "no" if the behavior or condition is already "known" to the Washington Physicians Health Program. We define "known to WPHP" as "the practitioner has informed WPHP of the behavior or conditions and are complying with all WPHP's requirements for evaluation, treatment, or monitoring."
</p>
<p>
Starting In 2019, we entirely revamped the initial licensing application and did the following:
</p>
<ul>
<li>Changed NPI number requirement (now optional).</li>
<li>Gender "X" option is being added.</li>
<li>Removed fax number requirement (outdated technology).</li>
<li>Education: In most cases, we use information contained in the AMA Physician Masterfile that meets selected primary source verification requirements of the Joint Commission, the Accreditation Association for Ambulatory Health Care, the American Accreditation Health Care Commission, and the AAHCC Utilization Review Accreditation Commission. The AMA Physician Masterfile is a National Committee for Quality Assurance-approved source for verification of medical school, post-graduate training, ABMS board certification, and federal DEA registration. In rare instances, we may request transcripts.</li>
<li>Professional experience: Applicants only need to detail seven years of history, with a requirement to explain any gaps of 90 days or more.</li>
<li>Hospital privileges: Instead of applicant-provided answers, we use the National Practitioner Data Bank.</li>
<li>Licenses in other states: Instead of applicant-provided answers, we use the AMA Physical Profile, FSMB Practitioner Profile, and NPDB report.</li>
<li>AIDS education and training attestation are no longer needed.</li>
<li>A photograph is no longer requested.</li>
</ul>
<p>
In spring 2020, all the licensing processes were mapped and moved to an all-electronic file system. Due to the pandemic, staff were not able to access paper files, so this change enabled them to work remotely.
</p>
<p>
In January 2021, we analyzed the licensing unit workload and developed performance measures for each step of the licensing process, as well as developed reports to track the measures. We reviewed and updated staffing levels to meet new performance expectations. This review resulted in the creation of three new positions:
</p>
<ul>
<li>to process Interstate Medical Licensure Compact applications </li>
<li>entirely dedicated to e-mail and phone call response </li>
<li>and an administrative position to process all the paperwork the unit still receives.</li>
</ul>
<p>
With our new hires, licensers will be free to focus specifically on reviewing applications and moving them forward. Two of these positions are in recruitment and we hope to have them filled by May 1, 2021.
</p>
<p>
Renewals are done online at the present time, other than a few instances when the pandemic fee waiver expired, creating technical systems issues and some limited applications where providers are unable to use this capability. We are still working to get late and retired active renewals online.
</p>
<p>
As of March 2021, we have implemented a process change that will notify applicants that the licensing unit has begun working on their application. The notification provides them with resources to follow up before we do a formal review.
</p>
<p>
Starting January 2021, the licensing manager and licensing lead have conducted several "Coffee with the Commission" live virtual presentations and an FSMB webinar to help provide information and helpful tips to help improve the application process and experience for the applicants.
</p>
<p>
<strong>What is the best way for licensees to provide feedback or ask questions to the commission? </strong>
</p>
<p>
Our <a href="https://wmc.wa.gov/">website</a> has a "contact us" tab that provides a list of topics licensees can select and provide their feedback or pose a question. Based upon the issue, the contact form gets routed to the unit who can respond.
</p>
<p>
<strong>Anything you want our members to know about yourself or the commission? </strong>
</p>
<p>
We do much more than process complaints. We promulgate rules that implement statutes and work closely with stakeholders in developing those rules and to mitigate any adverse impact on licensees. We stand up for physicians and physician assistants regarding scope of practice, the practice of telemedicine, and in all issues that affect the Medical Practice Act. We provide interpretive statements and guidance regarding issues not covered in rule or law. We provide a robust website for licensees to gather information or make inquiries. We develop and provide free educational seminars, webinars, and podcasts to licensees on a myriad of topics, many that also provide free CME credits. While the WMC is a regulatory body, we are unique in our thoughtful and innovative approach.
</p>
<p>
<em>This WSMA Reports Extra is exclusive to the WSMA website. An edited version of this interview is featured in the July/August 2021 issue of WSMA Reports.</em>
</p>
</div> | 6/16/2021 3:42:20 PM | 6/16/2021 3:37:40 PM | 6/16/2021 12:00:00 AM |
| meet_dr_umair_a_shah | Meet Dr. Umair A. Shah | WSMA_Reports | Shared_Content/News/Latest_News/2021/meet_dr_umair_a_shah | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/may-june-reports-article-graphic-645x425.jpg" class="pull-right" alt="May/June 2021 cover of WSMA Reports" /></div>
<h5>April 29, 2021</h5>
<h2>Meet Dr. Umair A. Shah</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Rita Colorito
</p>
<p>
The power of medicine to impact society has been the defining thread in the life and career of Umair A. Shah, MD, MPH, Washington state's new secretary of health.
</p>
<p>
That seed was planted in Dr. Shah's life before he was even born. His parents emigrated from Pakistan to Cincinnati in 1960. The son of immigrants, Dr. Shah grew up watching his father cope with serious health challenges.
</p>
<p>
"One time, I remember he was in an incredible amount of pain and had to be taken into emergency surgery. I saw him going behind some doors ... and then a few hours later, the surgery was over, and he wasn't in pain. As a young boy, I attributed that to the doctors and nursesand health care professionals who took care of him," he says.
</p>
<p>
Despite those early experiences, Dr. Shah almost didn't go into medicine. He kept thinking about pursuing law. He nearly set on that path as an undergraduate at Vanderbilt. And then his mother had a devastating stroke.
</p>
<p>
That's when he made the mental shift to a career in medicine. "I felt so strongly that I wanted to help people through difficult times," he says. "I also started to recognize the absolute critical importance of not just medicine, but also public health."
</p>
<p>
In medical school, the history of smallpox eradication caught his interest and he began his foray into global public health. He traveled for a two- month internship at the World Health Organization in Geneva, Switzerland. Global health's symbiotic relationship with domestic health is something Dr. Shah hopes to highlight in Washington state.
</p>
<p>
Getting the public through health crises is something Dr. Shah has been doing throughout his 22-year career. Before taking the public health helm in Washington state in December 2020, Dr. Shah served as executive director for Harris County Public Health in Texas for seven years, managing a $100 million budget and 700 public health professionals, which grew to more than 1,500 staff during COVID-19. He not only led the community through numerous public health emergencies, he and his family (his wife and three children) have survived them, too.
</p>
<p>
As Houston residents, they've been through dozens of natural and man-made emergencies, including hurricanes, flooding, chemical incidents, novel H1N1, Ebola, Zika, and now COVID -19. Dr. Shah spent the bulk of 2020 fighting on the front lines of the pandemic, both as a physician and leading the public health response.
</p>
<p>
In late February, his family—including his wife (an accomplished dentist) and kids, all of whom stayed in Houston to see the school year through—saw so many people impacted during Texas' devastating winter storm. Even that couldn't disrupt Dr. Shah's whirlwind schedule as Washington's top doctor. Since late December, he's crisscrossed Washington state virtually and in person to meet with a wide net of public health and community stakeholders.
</p>
<p>
"I believe strongly that I am the secretary of health for the entire state of Washington," he says. "That's why it is so important for me to go to different parts of the state, whether it's Spokane, or Tri-Cities, Yakima, Mason [County], the Jamestown Tribe, Port Angeles, or the Puget Sound area. At the end of the day, it is important for me to understand and recognize what is happening in those communities."
</p>
<p>
Dr. Shah's lived experience is something he includes when given the opportunity to testify before local, state, and national legislators. In February, Dr. Shah testified in a virtual hearing of the U.S. House Appropriations Subcommittee on public health response capabilities, and the following month, he appeared before the U.S. Senate Health, Education, Labor, and Pensions (HELP) Committee. His overarching message: Public health should be invested in and a fully funded, ongoing priority, not a line item.
</p>
<p>
Public health at the state level can't work as well as it should without committed and sizable federal funding and initiatives, says Dr. Shah. "Chronic underinvestment in public health, not just in Washington, but across the country, is a real issue," he says. "We're seeing it play out in the middle of COVID-19."
</p>
<p>
A big sports fan, Dr. Shah likes to use sports analogies when discussing public health needs. "Public health is the offensive line of the football team, yet everybody focuses on the quarterback, which is health care," he says.
</p>
<p>
His emergency department experience also deeply informed his view of theimportance of prevention. "I realized you could continue to just treat the trauma, or you could go out into the neighborhood and community and try to prevent it in the first place," he says. His other takeaway: Health happens outside of the four walls of a health care setting.
</p>
<p>
"I could tell Mrs. Johnson to exercise. And if Mrs. Johnson goes back into a neighborhood where there aren't parks, or it's not safe for her to walk, or if she has to take two buses to get her around town so time is short, how likely is it she is going to be able to exercise and come back losing weight the next visit?" he says.
</p>
<p>
"It's these social factors of equity—all the housing, transportation, education, and everything else ... that really drive health. And yet we spend so much of our precious dollars in this country on health care delivery, and not on prevention and public health," he says.
</p>
<p>
Equity, in fact, is the first of three core values, followed by innovation and engagement, that Dr. Shah says he will champion as Washington's public health leader. During WSMA's virtual Legislative Summit in February, he presented his big-picture priorities, which also include partnership, capacity building, and global-domestic health.
</p>
<p>
In a coronavirus-free world, Dr. Shah says he would have started his first 100 days focused on listening sessions to get at these core values—he pushed that down the road so he could focus on COVID-19. For now, pandemic response and vaccine rollout remain his top priorities. "The immediate goals are to protect Washingtonians and get us out of this horrific pandemic," he says.
</p>
<p>
Dr. Shah says he accepted Gov. Jay Inslee's appointment for several reasons. "Washington has always championed equity, championed taking care of its fellow Washingtonians," he says. The numerous opportunities for public- private partnerships in both domestic and global health also drew Dr. Shah to swap the sunny confines of Texas for the warmth of Washington's people, if not exactly its cold, rainy days—something he's still getting used to.
</p>
<p>
And then there's the innovation piece— the potential to tap some of the brightestminds at the intersection of technology and health located in Washington, particularly to create state-of-the-art public health data and response systems. "There's a real important opportunity for public-private partnership here," he says.
</p>
<p>
As Washington state's first secretary of health who is also a medical doctor, Dr. Shah wants WSMA members to know they've got a colleague in the public health sector.
</p>
<p>
"I'm somebody who has talked to patients, who has understood the challenges on the ground, in a health care setting, who knows what it's like to be in the middle of a code situation," he says. "Oftentimes public health and health care are in opposition to each other, but they're so intertwined. If we can really bring ourselves together, not because of a crisis, but because it really makes common sense, we have the opportunity to achieve the goal for everyone, which is optimizing their health."
</p>
<p>
He also knows firsthand the overwhelming exhaustion public health and health care professionals have felt throughout the pandemic. "My team had to force me to take a day away, around maybe September, I think, after about eight months of responding to the crisis," he says.
</p>
<p>
In the long term, Dr. Shah aims to transform public health "... to really think about how we can work together, not just in a traditional way, but in an innovative way with equity leading our efforts and engaging all partners and doing everything we can to champion health."
</p>
<p>
As Gov. Inslee rolls out his public health restructuring plan, Dr. Shah views his role and that of the Department of Health as supportive. "We want to provide information. We want to do what we can to explain where we think there are vulnerabilities in the system. We want to be good stewards of public funds. And we want to be subject matter experts providing what the data show," he says. "At the end of the day, our role is to champion the fact that public health must be prioritized."
</p>
<p>
The politicization and vilification of public health is another reason Dr. Shah believes in the power of positive engagement and communication. "We all know that COVID-19 has been politicized. And we've seen in this last year how horrific that can be. More than 500,000 Americans have died, and we have 5,000 Washingtonians who have died," he says.
</p>
<p>
One of his first retweets as the state's top doctor was on COVID-19 vaccine equity. "COVID-19 didn't start public health inequities, but it certainly has unearthed [them] and made them markedly worse," he says.
</p>
<p>
Dr. Shah is adept at social media and uses it often to overcome what he calls public health's "invisibility crisis." From his parents, he learned one shouldn't just call out a problem but work toward a solution. And his solution to this problem requires visibility, value, and validation.
</p>
<p>
"We must raise the visibility of public health. When there is visibility, people seevalue. When people value something, they tend to want to validate it with pro-health policies and/or pro-health resources," he says. "The problem is I never thought public health would see its visibility raised with the fourth 'v', which was virus. COVID-19 has raised the visibility of public health not in a way that's systematic or methodical ... So I really hope COVID-19 is an inflection point for allofusasanationandasaglobeaswe think about transforming health."
</p>
<p>
He offers this assessment of the past year: "2020 was like the first half of the football game and we didn't do so well. We were behind. We came back at halftime, which was right around the holidays, and with the new administration coming in, we have come out of halftime with new strategies and reenergized. Now we're in the second half. And we're hoping we don't see a further surge and continue to move in the right direction."
</p>
<p>
While we don't know yet how the pandemic will end, there is the one certainty in public health. "There will be another emergency lurking around the corner, and we have to be ready for it," Dr. Shah says.
</p>
<p>
For his part, Dr. Shah is committed to investing in the public health offensive line, so the next time, public health isn't stuck scrambling for the next crisis.
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care. She is a regular contributor to WSMA Reports.</em>
</p>
<p><em>This article was featured in the May/June 2021 issue of WSMA Reports, WSMA's print newsletter.</em></p>
</div> | 6/3/2021 4:39:22 PM | 4/29/2021 1:22:27 PM | 4/29/2021 12:00:00 AM |
| supporting_washingtons_safety_net | Supporting Washington's Safety Net | WSMA_Reports | Shared_Content/News/Latest_News/2021/supporting_washingtons_safety_net | <div class="col-md-12">
<div class="col-sm-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/may-june-reports-article-graphic-645x425.jpg" class="pull-right" alt="May/June 2021 cover of WSMA Reports" /></div>
<h5>April 29, 2021</h5>
<h2>Supporting Washington's Safety Net</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By John Gallagher
</p>
<p>
For years, public health in Washington functioned largely beneath the radar. Occasionally, issues such as a 2019 measles outbreak in Clark County would raise the visibility of public health departments, only to have them fade into the background once the immediate crisis passed.
</p>
<p>
Then came COVID-19.
</p>
<p>
For more than a year, public health has been front and center in addressing the pandemic. What quickly became apparent was that years of underfunding left public health departments ill- equipped to handle the overwhelming volume of work that the pandemic triggered.
</p>
<p>
"Would we have been more prepared if we had invested in public health infrastructure?" asks Scott Lindquist, MD, Washington state's acting public health officer. "The answer is absolutely yes."
</p>
<p>
Under the state's last two-year budget cycle, foundational public health services received $28 million. A 2018 assessment by the state Department of Health, state Board of Health, local health jurisdictions, sovereign tribal nations, and Indian health programs estimated that fully funding foundational public health services would cost $450 million per biennium budget.
</p>
<p>
In fact, public health in Washington state has been underfunded for nearly two decades. In the 1990s, the state created a dedicated funding source for public health through the motor vehicle excise tax. A 1999 ballot initiative removed that funding, and another ballot initiative shortly afterward limited property tax increases that would have funded public health initiatives. (The WSMA has been calling for a dedicated funding source for public health since 2002.)
</p>
<p>
"I love the analogy that public health is a house that is 100-plus years old, but the foundation is crumbling and the infrastructure is showing signs of wear," says Dr. Lindquist. "But we keep having events like H1N1 where we get streams of funding, which is like getting a curtain for the third story of the house."
</p>
<p>
The failure to adequately resource public health infrastructure meant that a crisis was inevitable. Like the 100-year-old house where maintenance had been deferred for years, at some point the infrastructure for public health was bound to buckle under stress.
</p>
<p>
"COVID-19 just illustrates some of the outcomes you get" from underfunding public health, says Alan Melnick, MD, public health director and Clark County health officer. "I'm not blaming lack of public health funding for COVID, but in terms of having preparation early on and being able to respond quickly, we were challenged because of the way we've been underfunded and understaffed for many years."
</p>
<h3>An all-encompassing mandate</h3>
<p>
While the coronavirus has focused attention on communicable diseases, public health encompasses far more than that. Its portfolio covers everything from chronic disease and injury prevention to environmental health and maternal, child, and family health—from tobacco cessation to septic systems.
</p>
<p>
"It's not just infectious disease we're worried about," says Jeff Duchin, MD, health officer for Public Health — Seattle &amp; King County. "I'm increasingly concerned about climate change and [its] impact, and all of our chronic disease influenced by social determinants of health. These are chronically neglected areas of work that have never been adequately funded, yet are responsible for the largest portion of morbidity and mortality."
</p>
<p>
Indeed, public health is a critical component of patient care.
</p>
<p>
"It's easy to get lost in the day-to-day as an individual physician caring for patients," says Andrea Carter, MD, chief medical officer for Samaritan Health Care in Moses Lake. "But we don't reach the whole community."
</p>
<p>
By contrast, says Dr. Carter, public health can collaborate with all the clinics in the district on a coordinated response to local challenges. "When we do a gun safety event, it's spearheaded by the health district and all the clinics work together," she says. "It's a community- wide initiative. Those are big issues that can be addressed, and we can gain a lot more ground doing it that way." While individual providers may be addressing the same problems in one-on-one settings or even through an institutional effort, the impact can't be as great.
</p>
<p>
Dr. Carter says the pandemic brought home just how vital public health is for all patient care. "There has been a unified command and weekly public health briefings," she says. "We were able to have a common goal and the same message for patients. We learned to appreciate the important role of public health through COVID."
</p>
<p>
Dr. Lindquist notes that despite its limitations, the public health system and the people working within it performed heroically in the face of the pandemic.
</p>
<p>
"COVID did not break the public health system in Washington state," he says. "We identified the first case in the country. We got this person tested, got results the next day, and got him hospitalized, all seamlessly because the system was in place. COVID probably wasn't in Washington first, but our system was intact enough to detect it."
</p>
<p>
Still, the pandemic revealed cracks in the system that are undeniably deep. Long-standing problems with data systems, lab capacity, and staffing became abundantly and painfully clear.
</p>
<p>
"One of the big things the pandemic pointed out was how fragmented our data systems are, in terms of providing real- time access to data," says Amy Person, MD, the health officer for the Benton- Franklin Health District. "We still get a lot of our info from labs and hospitals by fax. It's one thing when in a normal year you have at most 1,500 to 2,000 cases, and it's another when at the high point you have hundreds of cases a day. Then people couldn't even fax to us."
</p>
<p>
Dr. Duchin notes that states had to scramble to create a large-scale immunization system. "We had to scale one up cobbling together new data- management technology," he notes.
</p>
<p>
Limited lab capacity constrained testing at the start of the epidemic. Staffing problems were inevitable after years of budget cuts.
</p>
<p>
"During the pandemic, it was all hands on deck," says Jaime Bodden, managing director of the Washington State Association of Local Public Health Officials. "You had environmental public health staff who normally work with restaurants or permitting septic systems working on the pandemic."
</p>
<h3>A lack of advocacy</h3>
<p>
All of these challenges were the result of a long and steady decline in public health funding.
</p>
<p>
"We have woefully underfunded public health," says Rep. Marcus Riccelli, D-Spokane, the House sponsor of Senate Bill 5149, which would strengthen public health funding. Riccelli is also the sponsor of House Bill 1152. That measure, which passed the House by a 56-41 vote in March, would create four regional centers to coordinate shared services across local health jurisdictions and the state.
</p>
<p>
"We talk about public health as the front line of defense, and we see what happens when we don't fund it," he says. "Everyone everywhere should be able to get some standardized level of public health that is reliable. We know that a strong public health system is possible with intentional investments."
</p>
<p>
Part of the challenge for public health is that its work is easily overlooked. "There's no advocacy group for people who don't get sick," says Dr. Melnick.
</p>
<p>
"You can't point to a road and say, 'This was brought to you by public health,'" Bodden says. "When public health does its job, nothing happens, and that's not a good selling point."
</p>
<p>
Since the loss of a dedicated revenue source, "our funding has become very destabilized, very piecemeal and stagnant," Bodden says. "It's been the same amount for the past 20 years." Over that period of time, the population in the state has grown by more than 1.7 million.
</p>
<p>
The lack of funding may make sense to legislators in the short term, but in the long term, the costs are simply deferred, not eliminated. Dr. Duchin notes that there are thousands of undetected cases of latent tuberculosis in King County alone. Treating latent tuberculosis costs about $500. Treating active tuberculosis costs about $17,000.
</p>
<h3>Chasing dollars</h3>
<p>
To make up for the revenue shortfall, health districts end up chasing dollars from other sources. Unfortunately, the funding that is available is often structured in a way that limits its impact.
</p>
<p>
"There are programs that come and go," says Dr. Duchin, citing chronic disease and injury prevention as examples. "The funding is episodic and not stable, and it requires competition. It's a significant investment in time and energy just applying for grant funding."
</p>
<p>
"The funding tends to be very project- based and very specific, which is a challenge because in public health things aren't separated," agrees Dr. Person.
</p>
<p>
The project-specific grants also create other problems. "You have funding to work on tobacco-related things, so you build up a network of community partners and start moving things forward," says Dr. Person. "Then tobacco is not a big issue, but diabetes is. Suddenly, the work you've done with tobacco is done, and you can't just shift that over to diabetes."
</p>
<p>
The emphasis on projects and deliverables rubs against the long-term emphasis that public health should have. However, desperate for some funding sources to help their communities, health districts feel the need to pursue them, despite the downside.
</p>
<h3>Politics over science</h3>
<p>
Simply increasing funding for public health will not solve all its problems. Like all too many institutions, the system and its leadership have become targets of intense politicization. Last November, the Spokane health board fired health commissioner Bob Lutz, MD. Dr. Lutz was a focus of attention from Spokane Mayor Nadine Woodward, who complained that the county was not moving forward rapidly enough toward reopening. She also criticized Dr. Lutz for talking about what she termed "controversial" topics, such as climate change, without the board's consent.
</p>
<p>
Such episodes highlight the delicate role that public health plays.
</p>
<p>
"Public health officers are sometimes forced to implement policy that will have a significant negative impact on some individuals and their livelihood," says William Hirota, MD, a gastroenterologist at Virginia Mason Franciscan Health and a member of the Tacoma-Pierce County Board of Health. The Tacoma-Pierce County Health Department faced its own political firestorm in November, when several Pierce County Council members proposed to dissolve the joint city and county department. "You end up with some animosity."
</p>
<p>
In retrospect, some of the problem could have been alleviated with closer ties to community stakeholders, he says.
</p>
<p>
"Part of the problem of not being completely prepared is a lack of relationship building," says Dr. Hirota, who is the immediate past president of the WSMA. "One of the lessons learned is that in order to build an effective public health foundation, we're going to need to have a clear reassessment of our needs, develop policies that are going to be timeless, build these plans out, and be accountable for them. That means we need to be very engaged in public-private partnerships."
</p>
<p>
Even with improved funding and structural change, other challenges will remain. "Our workforce is diminishing" as a result of funding cutbacks over time, says Dr. Melnick. "We have to train a workforce to do this work, and we need to have a more diverse workforce."
</p>
<p>
Ultimately, says Dr. Lindquist, the goal should be to provide enough unrestricted funding so that every public health district in the state can provide the same level of services.
</p>
<p>
"When I look at rabies, am I going to get the same level of protection in Seattle as I will in Othello?" he asks. "No matter where you are a resident of Washington state, you should have the same level of public health protection."
</p>
<p>
Dr. Lindquist is cautiously optimistic that such a goal is attainable as a result of the pandemic. "I have been in public health since 2001," he says. "We have never had as much attention paid to the need to fund the infrastructure for public health as we are seeing now."
</p>
<p>
<em>John Gallagher is a freelance journalist who specializes in covering health and the health care system. He is a regular contributor to WSMA Reports.</em>
</p>
<p><em>This article was featured in the May/June 2021 issue of WSMA Reports, WSMA's print newsletter.</em></p>
</div> | 6/3/2021 4:39:36 PM | 4/29/2021 10:36:59 AM | 4/29/2021 12:00:00 AM |
| health_equity_101_class_is_in_session | Health Equity 101: Class Is in Session | WSMA_Reports | Shared_Content/News/Latest_News/2021/health_equity_101_class_is_in_session | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/march-april-cover-645x425.jpg" class="pull-right" alt="WSMA Reports March/April 2021 cover image" /></div>
<h5>March 22, 2021</h5>
<h2>Health Equity 101: Class Is in Session</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Pat Curry
</p>
<p>
After working as a street medic and having extensive involvement in the anti-war movement in New York, Luis Manriquez, MD, decided to go to medical school to gain "the technical skills to address social justice."
</p>
<p>
As a student at the University of Washington School of Medicine, he founded the Health Equity Circle, an interprofessional group that equips students to take action on health equity using the tools of community organizing.
</p>
<p>
"When I started medical school, people knew about social determinants of health and thought it was cool, but it wasn't expected to be part of your medical training," says Dr. Manriquez, who now is an assistant clinical professor at Spokane's Washington State University Elson S. Floyd College of Medicine, where he also leads health equity development efforts. "Now, it's an expectation when students come in, and I think that's great. The mindset of students is that this is part of being a doctor."
</p>
<p>
Indeed, health equity has become part of the fabric of medical training in Washington state. All three of the state's medical schools have extensive ongoing efforts to incorporate equity into their curriculum, and they are working to address systemic implicit bias and expand the diversity of their student bodies.
</p>
<p>
There's no better time than during medical school to plant the seeds, says Michael Lawler, MSW, PhD, president of Pacific Northwest University of Health Sciences in Yakima.
</p>
<p>
"If you train people to work with each other, they'll do that when they go out in the field," Lawler says. "It's an aspirational vision, but when we think about COVID, the two issues facing us are health and equity. They're both apparent."
</p>
<h3>Creating an inclusive environment</h3>
<p>
At PNWU, equity and inclusion are being integrated across the university's strategic five-year plan. That includes organizing an office dedicated to equity, diversity, and inclusion. Workshops on bias and microaggression have been held for students, faculty, staff, and the board of trustees "at their request," says Mirna Ramos-Diaz, MD, MA, FAAP, who recently was named PNWU's first chief diversity officer. The university also is creating a restorative justice model, which emphasizes repairing harm through collaboration.
</p>
<p>
In 2020, the University of Washington School of Medicine created the Office of Healthcare Equity. The office has been hard at work to make addressing equity and implicit bias central to how the school runs. Almost all of UWSOM's 32 clinical teams currently have an equity team and a bias reporting tool is making it easier for members of the community to speak up.
</p>
<p>
"After the events of the summer— the killing of George Floyd and others and the protests—our leadership took the strong stance to require equity, diversity, and antiracist training for all members of our community," says Paula Houston, EdD, chief equity officer for UW Medicine, the parent health care system for UWSOM. "The fact that people are having the conversation has really built awareness and the realization they need to change behavior."
</p>
<p>
The office also has created an equity impact review tool so that policies and procedures can be viewed through an equity lens. The goal is to make it as easy as possible to say who a policy will benefit, who it will burden, and how to mitigate that burden.
</p>
<p>
Houston says that when she presented it at a leadership meeting, she thought one or two people might be interested in piloting it.
</p>
<p>
"Nine departments wanted to do it immediately," she says. "People want to do the right thing; they just didn't know how to do it. They want to make this a better environment."
</p>
<p>
David Garcia, MEd, WSU's assistant dean for health equity and inclusion, says the work being done today on health equity and implicit bias is much like it was with technology in the early 1990s, when organizations had to develop the infrastructure to embrace the digital world.
</p>
<p>
"At some point, we all had to get email," Garcia explains. "With inclusion, we are at a point where we need to develop the infrastructure and become healthier as organizations. We want to be able to look back in 10-15 years and say we're doing our part. Our communities depend on it. The rationale has never been clearer to me on why we need to be doing this work."
</p>
<h3>Weaving equity into curriculum</h3>
<p>
How do medical schools ensure the educational experience doesn't perpetuate stereotypes?
</p>
<p>
"That is the million-dollar question," Garcia says. "We do case-based learning and a lot of small-group learning. When we introduce a case at the beginning of the week, how are we ensuring cases are reflective of the state of Washington?"
</p>
<p>
Dr. Manriquez says a health equity thread is woven through all four years of training at the WSU medical school.
</p>
<p>
"My approach is that medical school doesn't make you an expert in anything; you get an introduction," he says. "If that's true of the liver and the heart and the kidneys, it's also true of health equity. We want to develop a foundation to understand the concept. So, in the first two years, we have foundational sessions; in the session on bias, we explain the science of bias, how it works, and antibias tools. We do the same thing with racism, sexism, disabilities, health literacy, and making use of an interpreter."
</p>
<p>
In the third year's longitudinal integrated curriculum, there's more content in understanding bias and equity in a clinical setting. "Why do you see this difference in health outcomes by race or status? Some are assumptions on the part of the provider or the patient; some are actual barriers to access. ... These inequities in health are a huge deal; the differences in black and white life expectancies are tremendous."
</p>
<p>
UWSOM went through a curriculum renewal in 2015 that added eight themes that go across all four years of study, says Suzanne Allen, MD, MPH, vice dean for academic, rural, and regional affairs for the medical school. Those themes are communication, diversity, ethics, health equity, inter- professionalism, lifelong learning, quality and safety, and professionalism.
</p>
<p>
The school also recommends that all students read a common book each year on a social justice issue. For 2020-2021, the book is the thought-provoking "How to Be an Antiracist" by Ibram X. Kendi.
</p>
<p>
Through its Pathways programs, students can focus on serving a marginalized population.
</p>
<p>
"The idea is they do an elective course in the first year or two of medical school and do a summer clinical experience with that population," Dr. Allen says. "We then ask them to do one of their required third-year rotations with a clinic or facility where they'll see a large number of those patients."
</p>
<p>
Standardized patient encounters provide a great opportunity for faculty to make students think about their own bias and whether it is creating blind spots in care, says Thomas Scandalis, DO, dean of the College of Osteopathic Medicine at PNWU.
</p>
<p>
Sometimes, it's as simple, and as crucial, as making students aware that assumptions can lead them astray.
</p>
<p>
"A student sees a mom with a child and says, 'Where's the dad? Tell me about your husband,' " says PNWU's Dr. Ramos-Diaz. "They're assuming the other parent is a man."
</p>
<p>
Students also need to be prepared "for working with [older] people like me who aren't current on how to address people," Dr. Scandalis says. "Our students are very comfortable in their own skin. Some get a little freaked out, though, when they get on rotation and hear that bias."
</p>
<p>
"That is why we have training at the beginning of the year," Dr. Ramos-Diaz says. "Their eyes are opened."
</p>
<h3>Recruitment</h3>
<p>
Perhaps the most exciting and potentially impactful effort at the medical schools is in recruiting future classes of medical students. All three schools are looking closely at the methods used to select applicants.
</p>
<p>
Both the WSU Elson S. Floyd College of Medicine and PNWU take a holistic approach to the admissions process and avoid making decisions solely on grades and MCAT scores. "An overreliance on GPA and MCATs can really eliminate diverse populations you want to enroll," says Leila Harrison, PhD, MA, MEd, senior associate dean for admissions and student affairs at the WSU medical school. "It can be a barrier; we focus on the mission."
</p>
<p>
The school also recruits at rural colleges and community colleges. "That's not common for medical schools," Harrison says.
</p>
<p>
But efforts go far beyond that, even to connecting with children as young as elementary school age to spark an interest in becoming a doctor. PNWU's communications staff has produced a children's book, "I Want to Be a Doctor! A Day at Medical School." The book also has been translated into Spanish.
</p>
<p>
A year-long peer mentoring program called Roots to Wings pairs Native American and Mexican American middle and high school students with PNWU students.
</p>
<p>
"We use cultural values and traditions as a conduit to teach sciences," Dr. Ramos-Diaz says. "When you bring cultural values and science together, students have a greater desire to participate and that science has meaning. Then, they're excited. I remember a student saying to a med student, 'So does that mean as a Native, I can be a doctor?' Of course, yes! It was like an awakening."
</p>
<p>
Students who are particularly interested are invited to participate in a two-month summer internship at the National Institutes of Health in Bethesda, Maryland, where they are paired with scientists from their own background when possible.
</p>
<p>
LeeAnna Irvine Muzquiz, MD, associate dean for admissions at UWSOM, is a member of the Confederated Salish and Kootenai Tribes and grew up on the Flathead Reservation in Montana. She says the admissions office has moved away from the concept of creating "pipelines" of applicants to more of an "ecosystem" approach.
</p>
<p>
"When we think about pipelines, they tend to break and leak," Dr. Muzquiz explains. "A pipeline seemed to work for me, but it was the mentoring and the surrounding ecosystem that helped me make it through [medical school]. All of us have a role to play in nurturing the next generation; we can all have an influence on what the ecosystem looks like."
</p>
<p>
UWSOM's efforts include Doctor for a Day. The vision of the program, which is organized by medical students, is to bring a hands-on, educational day of activities to students of color, featuring volunteer doctors, physical therapists, nurses, and dental students who look like them.
</p>
<p>
At that age, having someone believe in and encourage you can have a tremendous impact, says UWSOM's Dr. Allen. She was planning to be a nurse until a visit to her family physician for a school physical. On hearing her plans for nursing, "He asked me, 'Why don't you want to be a doctor?' and he let me follow him around," Dr. Allen says. "I can trace five women from the same era who became physicians because of him."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the March/April 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 3/22/2021 1:01:53 PM | 3/22/2021 1:00:41 PM | 3/22/2021 12:00:00 AM |
| trial_by_covid_19 | Trial by COVID-19 | WSMA_Reports | Shared_Content/News/Latest_News/2021/trial_by_covid_19 | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/march-april-cover-645x425.jpg" class="pull-right" alt="WSMA Reports March/April 2021 cover image" /></div>
<h5>March 18, 2021</h5>
<h2>Trial by COVID-19</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Rita Colorito
</p>
<p>
Vera Schulte had two weeks left in her third year of medical school when the University of Washington School of Medicine locked down due to COVID-19. Because UWSOM has a condensed pre-clinical curriculum, Schulte finished almost on time. Friends in other medical schools, she says, weren't so lucky.
</p>
<p>
"They were delayed in finishing their third year, which makes applying for residency quite a bit more difficult. If
you haven't rotated in pediatrics, family medicine, or general surgery, etc., it's hard to realize that's the kind of doctor you want to be," says Schulte, whose chosen specialty is obstetrics and gynecology.
</p>
<p>
Much of clinical training is trial by fire. Being in the room where health care happens is critical to medical education and residency. Under normal circumstances, that means long hours
interacting directly with faculty and patients in a team-based approach.
</p>
<h3>Starting from scratch</h3>
<p>
COVID-19 burned medical-education- as-usual to the ground—at least in the short term. As the pandemic surged, medical schools and residency programs grappled with staying safe. Personal protective equipment was running low. Preceptors manning the pandemic front lines couldn't oversee usual rotations. Statewide clinical training and rotations ceased mid-March, going virtual over risking the unknowns. Most wouldn't resume in-person training until July.
</p>
<p>
Nationwide, the American College of Surgeons shut down clinics and operating rooms to fellows and residents. "[It was] very frightening because this had never been done in the history of the ACS," says Byron Joyner, MD, MPA, UWSOM's vice dean of graduate medical education, who sent residents and fellows home to ensure their safety.
</p>
<p>
"We didn't know how our trainees should be involved in a pandemic and we didn't have enough PPE at the time," says Dr. Joyner. He spent the first weeks of lockdown fielding calls from anxious students and calling the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties for guidance.
</p>
<p>
"Residents and fellows were afraid that they might not be able to take their boards after graduation without having done enough rotations," says Dr. Joyner. "The most subtle and nerve-wracking concern was just the uncertainty and the ambiguity. What was next? When would this be over?"
</p>
<p>
The response to the shutdown from students was a mixed bag, says Suzanne Allen, MD, MPH, UWSOM's vice dean for academic, rural, and regional affairs. Some didn't feel safe on their clerkships, while others expressed frustration at missing a once-in-a-lifetime opportunity to care for patients during a pandemic.
</p>
<p>
The solution to both: a virtual course in pandemics the first half of spring
quarter, followed by virtual rotations the second half. These proved very popular, says Dr. Allen.
</p>
<p>
Being honest about what they knew and didn't know helped Washington State University's Spokane-based Elson S. Floyd College of Medicine quell anxiety, forge forward safely, and build institutional resilience, says Judith Bowen, MD, PhD, its associate dean for curriculum.
</p>
<p>
"In this way, we are able to help students understand our obligation to keeping them, their family members, and our faculty (and staff) safe, and to avoid having any of us inadvertently contribute to ongoing viral transmission," says Dr. Bowen.
</p>
<h3>Embracing opportunity, virtually</h3>
<p>
WSU College of Medicine's longitudinal integrated clerkship design allowed students pulled from clerkship to continue learning through a virtual, case-based curriculum, says Dr. Bowen. The longitudinal design meant that all students had completed some direct patient care experience in all of the clerkship disciplines before moving to the virtual curriculum. As the clinical environment settled and more PPE became available, in-person training resumed in June. "Although we planned for future disruptions, third- and fourth- year students have been fully engaged as part of the clinical workforce since then," says Dr. Bowen.
</p>
<p>
Despite initial drastic measures, medical schools not only adapted, but also strengthened the way they teach thanks to the pandemic, says Anita Showalter, DO, associate dean for clinical education at Pacific Northwest University of Health Sciences in Yakima.
</p>
<p>
Used only sporadically pre-COVID-19, medical schools and residencies fully embraced Zoom and other online platforms for town halls, webinars, team meetings, and to provide eyes-on patient care. Within a week of the shutdown, all PNWU core rotations were online. To replicate the in-clinic experience, PNWU used standardized patient simulations via teleconferencing (one example: working through videos of a vaginal birth).
</p>
<p>
"The goal was to make them work through analyzing patients and clinical decision-making as they would have if they had been in the clinic with their preceptors," says Dr. Showalter. As students have returned to rotations, PNWU has maintained the online curriculum to accommodate students and preceptors testing positive for COVID-19 or needing to quarantine.
</p>
<p>
Even though rotations have resumed, they still look different. To reduce the risk of transmission and to be sensitive to patients, rotations have limited team size. "It didn't seem right to let medical students participate when the patient's own family couldn't come in," says Dr. Showalter.
</p>
<p>
Wherever medical schools can go virtual, they have. At UWSOM, that includes clerkship orientations and lectures. "We don't want large groups of people congregating in the same place," says Dr. Allen. The benefit to that, she says, is all clerkship students, regardless of where they are across UWSOM's six regional campuses and 200 clinical sites, can now attend all lectures.
</p>
<p>
Amid the chaos, the goal remains to give students enough experiential learning to graduate, says Dr. Showalter. That's where newfound teleconferencing skills have come in. "We had one situation where the doctor contracted COVID. The student went into the clinic and via teleconferencing, connected the patient with the doctor. [The student] could be the hands for the doctor who was not able to be on site," she says.
</p>
<p>
The pandemic has also affected residents who aren't patient-facing, says Elizabeth (Libby) Parker, MD, a third- year UW resident in anatomic pathology last spring. As elective procedures were cancelled or delayed, Dr. Parker saw a shift in the kinds of specimens she received.
</p>
<p>
"We're very closely linked to what our clinical and surgical colleagues are able to perform, procedure-wise. What they're able to do really impacts our clinical work," she says. As elective procedures have increased, Dr. Parker is now seeing the full spectrum of cases.
</p>
<h3>Silver linings</h3>
<p>
While students are required to complete yearly infection control reviews, the hyper-awareness surrounding COVID-19 has had a measurable impact. "It's already led to a decrease in other kinds of hospital infection rates," says Dr. Allen; it's something she sees continuing.
</p>
<p>
"Students who are in medical school right now, who are 'growing up' during a pandemic, are going to be so much better at infection control, because that's what they've known from the start," she says.
</p>
<p>
Resident research and scholarly activity also increased because of the pandemic, says Dr. Parker, who co- published medical education literature on her experience teaching remotely. "There's been a bolus of research on COVID-19. It's been exciting to have so many minds working on the same problem from so many different specialties," she says.
</p>
<p>
Dr. Parker has also welcomed the didactic creativity offered by online platforms. She still uses Path Presenter, a virtual platform where pathologists worldwide can share digital slides. "We're able to use it to teach and still be interactive and simulate our day-to-day work," she explains.
</p>
<p>
COVID-19 also highlighted inequities in health care—and the need for clinical training to address those concerns head on. Graduating doctors with more robust telemedicine experience is one downstream effect of the increase in virtual clinical training and a real benefit for rural patients, says J. Miguel Lee, MD, residency program director for Providence St. Peter Family Medicine's Chehalis Rural Training Program (CRTP). "It was actually one of the silver linings, if you will, of this catastrophe," he says.
</p>
<p>
A small residency program and clinic, CRTP gathered its faculty and nine residents to develop a plan for patients who couldn't get to the clinic or were too wary of coming. "We went from no virtual care to 100% virtual care in a matter of two days," says Dr. Lee.
</p>
<p>
In the neighboring communities, telemedicine has been embraced, he says. "We had 95-year-olds with their grandkids holding their phone up for virtual care and it's really worked quite well."
</p>
<p>
Even though residents have seen patients virtually, it hasn't taken away from their experience serving rural communities. "It's just an added tool
in our toolbox," Dr. Lee says, "and, you know, potentially, it will increase access to people who can't drive for two hours for an appointment but can turn on the computer at home."
</p>
<h3>From health care to human care</h3>
<p>
Amid the winter surge, many of the same trainee concerns around safety, education, and patient care remain, says Dr. Joyner from UWSOM. "They're worried about getting sick and getting others sick," he says. "They're worried about not having enough education to graduate, not enough competence and confidence. It strikes at their very core of being a doctor."
</p>
<p>
The availability of vaccinations for themselves and their families also worries residents, says Dr. Joyner, adding that most of UWSOM's 1,400 trainees have already received their first dose.
</p>
<p>
One year after the first COVID-19 cases, Dr. Showalter says her biggest concern is students' mental health and well-being. "Medical school tends to be a very alone time, with students working very hard but isolated from other social supports," she says. "With all the COVID restrictions, that was doubly bad. So, we're really watching our students to make sure they're staying in a good place mentally," she says.
</p>
<p>
Dr. Lee echoes her concerns. "Wearing masks all the time and not being able to gather, I think that is taking away one of our tools for wellness—the activities we normally did together," he says. "Despite the fact we can't do those things, I think we still feel very, very united with our group."
</p>
<p>
"In some ways we are missing out on human connection," Dr. Parker says. "But I think that hopefully time will show we're still able to do a lot of good and we're still able to have enthusiastic engagement."
</p>
<p>
To keep students engaged and feeling connected during isolation, medical schools encouraged service and research projects. "When vaccine supplies began to arrive, our clinical partners reached out to invite student volunteers to assist with administration," says WSU's Dr. Bowen.
</p>
<p>
UWSOM created many opportunities for COVID-19-related service learning. Many, like Schulte, volunteered for the Seattle Coronavirus Assessment Network to assist with screening and testing. In her spare time, Schulte also babysat for health care workers. Academically, she participated in a research project on COVID-19's impact on pregnant women in Washington state.
</p>
<p>
"Although being pulled from clinical duties was difficult, I was tremendously grateful for the plentiful opportunities during this time to continue supporting the community and continue my medical education, even if it was outside of the hospital," Schulte says.
</p>
<p>
Residents and faculty have shown incredible resilience throughout the pandemic, says Dr. Joyner. Many trainees have repeatedly asked to be redeployed to the COVID-19-dedicated ICUs. "They have contributed enormously to our effort to keep our community safe and to care for our sickest patients," he says.
</p>
<p>
Last fall, Schulte's six-days-a-week clinical training schedule returned to pre-COVID-19 levels. During her gynecologic oncology sub-internship, she started pre-rounds by 5:45 a.m. and signed out at 6 p.m. After a quick dinner, she reviewed medical student projects and worked on her own research, finally getting to bed by 11 p.m. The more things change, the more they stay the same.
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care. She is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the March/April 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 3/18/2021 4:11:48 PM | 3/18/2021 4:02:28 PM | 3/18/2021 12:00:00 AM |
| stormy_seas | Stormy Seas | WSMA_Reports | Shared_Content/News/Latest_News/2021/stormy_seas | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2021/Jan-Feb-2021-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>January 19, 2021</h5>
<h2>Stormy Seas</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>By John Gallagher</p>
<p>
When the COVID-19 pandemic exploded in early March, Ki Shin, MD, was on
vacation in Hawaii with his wife, also a physician, taking a break from
their practice in the small town of Montesano. "We got there on Monday
and then the governor's restriction happened," Dr. Shin recalls. "All
of a sudden, we were out of town and my staff was freaking out. It was
an immediate crisis. Not a lot of information was available to us, and
we had a lot of scared people, staff and patients included."
</p>
<p>
Upon their return home, the Shins immediately set about trying to
stabilize their practice. Faced with a 40% drop in appointments, the
couple took a 50% pay cut so that they could keep their staff on
payroll.
</p>
<p>
"For us not to get paid for a couple of months was totally doable, but
that was not true for the staff," says Dr. Shin.
</p>
<p>
After a rough few months, some of the financial pressures eased. The
Shins obtained a loan under the Paycheck Protection Program (PPP), the
part of the federal Coronavirus Aid, Relief, and Economic Security Act
designed to help small businesses. They also received $30,000 from
Medicare, which covered the practice's overhead for a month.
</p>
<p>
Eventually, patients started returning, and Dr. Shin's practice is
stable again, but still not entirely recovered. "The [patient] volume
is coming up, but it's not back to normal," he says. "It's about 90% of
what it was previous to COVID."
</p>
<h3>Survey answers detail challenges</h3>
<p>
The recovery of Dr. Shin's practice, and other practices around
Washington, is a hopeful sign. However, the new normal falls short of
the old one. Moreover, the ever-changing course of the pandemic,
including the potential for another lockdown, makes the outlook for
practices in Washington uncertain at best.
</p>
<p>
"Physicians are doing okay right now, but they are still so
vulnerable," says Jennifer Hanscom, executive director and CEO of the
WSMA. "The ground they're standing on is shaky. There might be an
earthquake brewing underneath."
</p>
<p>
Shawn Andrews, primary care medical director at Summit Pacific Medical
Center in Elma, says that the effects of the pandemic seem to vary by
type of practice.
</p>
<p>
"In terms of finances, the larger practices will survive," she says.
"Our budgets are not pretty but we're viable, and that's not a given
for everyone this year. We're not in the same boat as folks in private
practice or even some other critical access hospitals."
</p>
<p>
A fall 2020 survey of WSMA members found that the pandemic has taken a
significant toll on practices, making their financial viability a real
concern. Of 69 members from a range of practices and specialties who
responded to the survey, more than half reported a temporary reduction
in compensation because of the pandemic. Nearly half the survey
respondents said that they had to lay off or furlough staff, including
physicians.
</p>
<p>
Almost a quarter of the respondents said that the financial impact of
the pandemic on their practice is between $500,000 and $1 million.
Those figures echo a national survey of 3,500 physicians conducted by
the AMA last summer, which found practice revenue dropped by roughly
one-third.
</p>
<p>
While the worst of the pandemic appears to be over, the ripple effects
continue. The vast majority of the physicians who responded to the WSMA
survey said that their patient volume was down compared to before the
pandemic, with more than a third saying it was down between 25% and
75%. Even more troubling was that fact that more than 40% reported
having a month or less of cash on hand to pay operating expenses. The
WSMA benchmark is 18 weeks.
</p>
<h3>
Extra costs, curtailed services drive need for more financial help
</h3>
<p>
As it did for Dr. Shin's practice, the federal PPP loan provided a
financial lifeline for many practices.
</p>
<p>
"Luckily we got one of the PPP loans," says Juliette Erickson, MD, a
physician in a private practice in Grays Harbor. "That helped us
tremendously and got us over the hump. We stopped having weekly
meetings on how to pay the next paycheck and started focusing on
medicine again."
</p>
<p>
However, as much as the loans helped, their benefit was limited. More
than 80% of the physicians in the WSMA survey said that additional
financial support would be helpful. In part, that's because new safety
protocols have also meant more expenses.
</p>
<p>
Chelsea Unruh, MD, a physician at Yelm Family Medicine, says that the
expenses related to COVID-19 requirements have added up. Like other
clinics, Yelm Family Medicine does initial screenings of patients in
its parking lot, but the costs don't stop there.
</p>
<p>
"We have had to rebuild our back parking lot for these car visits,"
says Dr. Unruh. "We have had to outfit our front desk with shields. We
are investing in rapid testing and signing contracts for long-term use
of specific machines."
</p>
<p>
Then there is the extra expense of additional personal protective
equipment. "The cost of PPE went up," notes Hanscom. Now practices are
having to bear the costs of full PPE, masks, and sanitizers that
previously were used much more sparingly.
</p>
<p>
Like Dr. Unruh, Dr. Erickson also sees clients with COVID-19 symptoms
in the clinic parking lot. "I'm dressed in full PPE," she says. "It's
not the best way to see an ill person, but it's the best we can do and
still protect our staff and patients."
</p>
<p>
The need to sanitize exam rooms thoroughly between patient visits can
also have a direct impact on patient volume. "We decreased the number
of patients we're seeing per hour," says Dr. Shin. "I was able to see
four patients an hour, but with the cleaning between visits, we chose
to limit it to three patients per hour."
</p>
<p>
Even with such precautions in place, some staff still have to
quarantine because they were exposed to the virus outside of work.
</p>
<p>
"The other income challenge has been the loss of time from our staff,
from exposures or from being ill themselves," says Dr. Unruh. "None of
those exposures happened at work, but we don't get to control the
private lives of our staff. To exclude someone for 14 days because they
made a poor choice has been rough on morale and staffing."
</p>
<p>
To protect staff and patients, some practices have curbed services,
including Dr. Shin's. "In Montesano, there are no blood draw labs, so
lots of patients were coming into our clinic even though [the labs]
were for someone else," Dr. Shin says. The practice eliminated that
service, forcing patients in the area to travel farther for it. Dr.
Erickson says that she is referring more patients to the ER because her
clinic lacks the proper PPE to treat suspected COVID-19 patients.
</p>
<p>
But Dr. Andrews says that patient volume at her hospital's ER, as well
as its urgent care clinics, is still down significantly. "Many people
wait until they are very ill to seek services, and often suffer much
worse outcomes," she says. Nonetheless, she says that larger practices
have been better positioned to withstand the pressures from the
pandemic for a variety of reasons, including business plans less
impacted by long term drops in volumes, better PPE availability, and
space to separate well patients from symptomatic ones.
</p>
<h3>Telehealth use soars</h3>
<p>
The pandemic accelerated several trends that were already underway.
Chief among these has been the growth of telehealth. Three-quarters of
the physicians in the WSMA survey said that they implemented telehealth
as a result of the pandemic.
</p>
<p>
"We had never done telehealth before," says Dr. Unruh. "Then suddenly
we had half a day per provider devoted to telehealth visits."
</p>
<p>
As helpful as telehealth has proven, it has its drawbacks. In rural
areas, internet connections can be spotty, if patients have broadband
service at all.
</p>
<p>
"It's hard to do telehealth where people don't have iPads or iPhones,"
says Dr. Erickson.
</p>
<p>
For Dr. Erickson, telehealth has also inadvertently caused a staffing
problem. One of the three doctors in her practice began doing
telehealth at the start of the coronavirus outbreak as a way of
bringing income into the practice and fell in love with it. She has
accepted a full-time job as a telehealth physician and will be leaving
the practice.
</p>
<p>
"This is her way of moving with her career, but she would never have
found that job if we were not financially struggling in the first
place," says Dr. Erickson.
</p>
<p>
Moreover, as useful as telehealth has proven, its long-term future as a
viable option is still in doubt. "CMS holds the key for that," says Dr.
Andrews. "CMS will decide what we can and can't get paid to do." If
telehealth is not reimbursed or not reimbursed at a reasonable rate,
practices will not be able to sustain it. Accordingly, the WSMA has
made telehealth reimbursement a priority for its advocacy efforts in
the 2021 state legislative session.
</p>
<h3>Independent practices face tough challenges</h3>
<p>
Among the other changes hastened were retirement decisions. "We have a
group of anesthesiologists who are in their late 50s to late 60s," says
Brian Nyquist, MD, a partner at Olympic Anesthesia in Bremerton. "We
had several people who were close to retirement that retired. We knew
it was coming, but it's not like you can hire people before you need
them."
</p>
<p>
The flip side of the retirements, says Dr. Nyquist, is that the
"business kerfuffle of COVID" has made recruiting easier. While
previous attempts to recruit were uphill battles, he says that there
are more physicians applying for open positions at his practice. He
believes that because of COVID-19, "a lot of corporate owners,
management services, and practices have clamped down on people and
contracts," leading physicians to look for new opportunities.
</p>
<p>
Whether that applies to rural practices is an open question.
"Recruiting is incredibly challenging, but more physicians are
realizing that independent practices are a joy to work in because you
are more autonomous," says Dr. Erickson.
</p>
<p>
However, the financial pressures of the past year may make it harder
for independent practices to survive. "There's been a nationwide trend
away from private groups," says Dr. Nyquist. "We are privileged to
continue to be a private group. For now we're positioned pretty well,
but there are lots of pressures—most of them financial, some
societal—that want to drive physicians to work for hospitals. I
fear that this is probably going to exacerbate that."
</p>
<p>
Even when a vaccine is available, the effects of the pandemic will
still be felt. "For the next year, I don't see how we don't do things
we're doing now, like not have a waiting room," says Dr. Shin. "I don't
think we're going to change the number of patients we serve per hour. I
think we're looking at this as a long- term issue."
</p>
<p>
While the financial situation for Washington physicians had stabilized
by year's end, the specter of another spike in coronavirus cases still
haunts practices. "If we went back to a dark winter where we couldn't
even see patients in the office, we would absolutely struggle again,"
says Dr. Erickson. "It keeps you up at night."
</p>
<p>
Still, she remains committed to keeping the clinic afloat. "We've been
here 35 years, and there are literally not many options in town," she
says. "The most important thing is how we continue to do our work."
</p>
<p>
<em>John Gallagher is a freelance journalist specializing in covering
health care.</em>
</p>
<p>
<em>This article was featured in the January/February 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 1/19/2021 12:13:40 PM | 1/19/2021 11:57:02 AM | 1/19/2021 12:00:00 AM |
| virtual_advocacy | Virtual Advocacy | WSMA_Reports | Shared_Content/News/Latest_News/2021/virtual_advocacy | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="WSMA Reports Jan-Feb 2021 cover art" src="/images/Newsletters/Reports/2021/Jan-Feb-2021-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>January 19, 2021</h5>
<h2>Virtual Advocacy</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>By Pat Curry</p>
<p>
As with so many other institutions, the 2021 session of the Washington State Legislature has been fundamentally changed by the coronavirus pandemic. No one thinks it’s a good idea to put hundreds of people together in a room for hours a day over several weeks.
</p>
<p>
So, the structure of this year’s session will be quite different. It will be conducted largely—or entirely—remotely, and the Capitol campus will be closed to the public.
</p>
<p>
Due to the remote nature of the session, fewer bills will likely be considered, with a focus on the state budget and responding to the pandemic. Given the public’s outpouring of support for health care workers, it might seem that this would be the year to shoot for the moon in terms of asking the legislature for health care funding.
</p>
<p>
That would absolutely be true if there was a surplus of cash.
</p>
<p>
“The state’s budget outlook has improved somewhat from the nadir in the spring, but there remains a revenue shortfall,†says WSMA Government Affairs Director Sean Graham. “Actions will need to be taken to keep the budget in balance in the short term and the longer outlook our top priority in the budget realm is staving off any cuts that would impact access to care for the state’s patients.â€
</p>
<p>
“I’m grateful we represent the individual physician because we can put a human face on the situation and speak for people who were racing in to solve the problem,†says WSMA Executive Director/CEO Jennifer Hanscom. “That’s an added benefit.â€
</p>
<p>
Even with the sympathy that physicians and other health care providers have garnered from policymakers, any number of tax increases are likely to be proposed in the 2021 session and some will impact physicians. Among WSMA’s legislative priorities this year is ensuring the financial viability of practices, including opposing tax increases that will unduly impact the physician community.
</p>
<p>
“We know that virtually all our state’s businesses have been impacted by the pandemic, but that’s particularly true of physician practices and medical groups,†Graham says. “Most physician practices have had a substantial loss of patient volume and some are teetering on the brink financially.â€
</p>
<h3>Advancing telemedicine</h3>
<p>
The top policy issue for the WSMA this year relates to increasing the availability of telemedicine. Washington state has been a leader in telemedicine policy, but more can be done. For example, the state’s telemedicine coverage is limited to services that require a patient to have internet access.
</p>
<p>
“A lot of our state doesn’t have access to reliable broadband,†Graham explains. “We need insurance coverage for services offered over the phone. We also need to make sure there’s reliable broadband; it’s a health equity and education issue. The pandemic has made it clear that access to the internet isn’t a luxury; it’s a necessity.â€
</p>
<p>
In the regulatory realm, the WSMA will be working to address telemedicine reimbursement inequities.
</p>
<p>
“We found out that some of the insurers are trying to play games with the reimbursement parity requirement passed by the Legislature last year,†he says. “We’ll be working to ensure that payment parity means just that—services are reimbursed the same whether they’re delivered in person or via telemedicine.â€
</p>
<h3>Monitoring scope of practice</h3>
<p>
The WSMA also will be paying close attention this year to attempts to promote inappropriate scope of practice increases.
</p>
<p>
“Just about every provider advocacy group with a presence in Olympia will be
bringing a scope of practice increase in 2021, most of which will have ostensible ties to the pandemic,†Graham explains. “As an example, we know of several provider groups that will look to be granted prescriptive authority or to have their prescriptive authority increased.
</p>
<p> “They have wanted it for years,†Graham says. “They’ll come in 2021 and say, ‘There’s this need for access to care. Physicians are overwhelmed. Let us take this off their hands.’ When the WSMA looks at those proposals, our lens is balancing access to care with patient safety. We want to make sure any scope of practice increase would include sufficient training to ensure quality of care.†</p>
<p>
WSMA President Nathan Schlicher, MD, JD, MBA, is more pointed in his position on the issue.
</p>
<p>
“We believe that if you want to be a doctor, you should go to medical school,†says Dr. Schlicher, who also is a former Washington state senator. “We value all our fellow professionals and we want them to be an incredibly important part of the team, but physicians should lead the team and people should practice within their scopes.â€
</p>
<h3>Facing structural racism</h3>
<p>
In light of the global protests against racism, the WSMA is taking a strong stand in this year’s legislative session to promote health equity and racial justice. To that end, the association is taking the rare stance to advocate for having professional boards develop continuing medical education for physicians and other health care providers to address structural racism and health disparities within the medical community.
</p>
<p>
“This is so outside our box,†says Hanscom. “At the WSMA we have traditionally opposed mandating clinical education. How do you make sure the content, especially clinical content, you’re mandating is accurate? Medicine is ever evolving.
</p>
<p>
“But with this topic, the Legislature wouldn’t be mandating the content and it’s not clinical in nature,†she says. “I think it’s well recognized that we need to look deep in medicine’s history and develop content that addresses what has led to disparities in health care, particularly in the areas of race and culture. It’s a first step to overcoming larger societal issues. You have to start at home first.â€
</p>
<p>
And while it might seem like improving cell phone and broadband access is off topic for WSMA’s advocacy efforts, telemedicine has made it important for the WSMA to join with other groups to support those efforts.
</p>
<p>
“With this new way of delivering care, we find it particularly beneficial to physicians to get to know patients in their own environment,†Hanscom says. “Imagine what you can pick up. You’re seeing things that might give you clues to why their chronic conditions aren’t well managed.â€
</p>
<p>
In an example the WSMA used in a newspaper op-ed, a physician had a patient who was a cellist and was struggling with her wrists.
</p>
<p>
“She’ll never bring her cello into the clinic,†she says. “In telemedicine, the physician saw her play her cello. Seeing her movements helped the physician develop a course of treatment for her.â€
</p>
<p>
Telemedicine visits delivered over the phone are also helping physicians connect with chronic disease patients who aren’t able to take time off from work for a clinic appointment. But they might take a break from work and talk to their doctor on the phone.
</p>
<p>
“That’s just better patient care,†Dr. Schlicher says.
</p>
<h3>New opportunities for physician advocacy</h3>
<p>
If there is a silver lining to the elimination of in-person lobbying in the Legislature this year, it's that it exponentially increases the opportunities for WSMA members to serve as advocates. Committee testimony won’t be limited to individuals on the Capitol campus; anyone in the state could testify, Graham says.
</p>
<p>
“People in more rural areas that often feel left out have the same opportunity to participate,†he says. “Those are the areas often with the most dire need for access to care. They have unique needs in their areas; it’s a good opportunity to highlight those disparities.â€
</p>
<p>
Plus, the WSMA has been a vital source of information for the state’s elected officials during the pandemic, making them aware of the issues facing physicians. Legislators already know what the medical community is facing and they’re willing to listen.
</p>
<p>
“No one will be surprised by what we have to say,†Hanscom says.
</p>
<p>
Even better, WSMA members can advocate from their own offices.
</p>
<p>
“We need people to send emails and letters and set up virtual meetings, which we’re all getting more familiar with,†Dr. Schlicher says. “It takes a little more planning, but it’s a lot easier on your schedule.â€
</p>
<p>
With many of the traditional avenues for advocacy closed in terms of lobbyist access, it will be imperative that the physician community is fully engaged, he says. The 2021 Legislature is still going to be dealing with the pandemic and how to control it, and it’s vital that physicians are there to guide the discussions.
</p>
<p>
“Social determinants of health, access to education, food, internet—all those things impact the health of our community,†he says. “All those issues need our voice.â€
</p>
<p>
In addition to the issues affecting patients, Dr. Schlicher notes, the WSMA needs members to remind legislators that the same physicians risking their lives on the front lines of the pandemic are struggling financially. They need and deserve help to be able to keep their doors open and keep serving their patients.
</p>
<p>
“If we’re not involved and we’re not at the table, then we’re on the menu; the Legislature will look at us as a source of revenue,†he says. “Practices are facing significantly higher costs, fewer patients, and impending CMS cuts. Small practices risking their lives shouldn’t be the source of revenue for the budget.â€
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the January/February 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 1/19/2021 12:12:56 PM | 1/19/2021 12:10:27 PM | 1/19/2021 12:00:00 AM |
| answering_the_call | Answering the Call | WSMA_Reports | Shared_Content/News/Latest_News/2020/November/answering_the_call | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2020/Nov-Dec-2020-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>November 6, 2020</h5>
<h2>Answering the Call</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Pat Curry
</p>
<p>
At times, 2020 has broken our hearts and our spirits. The global pandemic of the novel coronavirus SARS-CoV-2 made its American landfall in Washington state, slamming into our health care system with a vengeance that spared no one. An extremely efficient predator, the virus attacked the most vulnerable first and made the connection points that humans value most - a touch, a hug, a kiss, a song - potentially lethal.
</p>
<p>
The pandemic required an unprecedented response from our health care community, who accepted the challenge without hesitation. In this issue of WSMA Reports, we recognize the efforts of just some of the physicians who exemplified the best that health care has to offer.
</p>
<p>
It would be impossible to fully capture the extraordinary sacrifice and exemplary service demonstrated by WSMA members during this difficult year. As you read these profiles, consider each of them as representative of the thousands of physicians and medical professionals who faithfully served our communities during these past months, often at great risk to their own health. To each of you, we are grateful.
</p>
<h3>Policy</h3>
<p>
<strong>Kathy Lofy, MD</strong>. As the state health officer and chief science officer at the Washington State Department of Health, Dr. Lofy is one of a handful of people at the helm of the state's response to the COVID-19 pandemic. Dr. Lofy has
been a frequent participant at Gov. Jay Inslee's press conferences sharing information about the pandemic, using her medical training and calm demeanor to deliver critical updates on the latest science, data, and state policy. Dr. Lofy received WSMA's 2020 President's Unsung Hero Award for her extraordinary service.
</p>
<p>
<em>Ed. note: As this issue of WSMA Reports went to press, Dr. Lofy announced she will step down from her position as the state's top health officer at year's end. She will be missed and we wish her the very best.</em>
</p>
<p>
<strong>John Lynch, MD</strong>. As medical director of infection control and prevention at Harborview Medical Center/ UW in Seattle, Dr. Lynch has had a significant impact on national health care policy as it relates to the pandemic. He served on the panel to develop and write the guidelines for infection prevention in patients with suspected or known COVID-19 for the Infectious Diseases Society of America, of which he is a board member. "John is kind of the scientific cheerleader for this," said Chris Baliga, MD, medical director for infection prevention at Virginia Mason in Seattle. "He's a full-time academician. They're the ones who ponder the big questions, working nationally to advance the science, trying to keep the guidelines and opinions and position pieces in line with what we know. He heavily influenced the state and CDC policy in the early days from King County. That was work very much appreciated by all of us."
</p>
<h3>Public Health</h3>
<p>
Throughout the state, our public health officers have worked nonstop to provide up-to-date, evidence-based information to the health care community and the public to help reduce the spread of the highly contagious virus. Faced with ever-changing guidance, these health care guardians also have been forced to address everything from health inequity to conspiracy theorists insisting the virus is a hoax and that mask requirements are unconstitutional.
</p>
<p>
With King County the first epicenter of virus spread in the state, two public health heroes came to the fore:
</p>
<p>
<strong>Jeff Duchin, MD</strong>. In his role as health officer for Public Health - Seattle &amp; King County, Dr. Duchin has risen to national prominence. An epidemiologist and an infectious disease physician, Dr. Duchin used his position not only to provide the public with clear, science- based information, but also to shine a light on health inequities exacerbated by the pandemic. Dr. Duchin is a winner of WSMA's 2020 Grassroots Advocate Award for his informed, articulate, and committed advocacy work.
</p>
<p>
<strong>Scott Lindquist, MD</strong>. The former health officer for the Kitsap Public Health District and the current state epidemiologist for communicable diseases, Dr. Lindquist has helped lead multiple facets of the COVID-19 public health response, including testing, treatment, coordinating with local health officers, tribal health centers, and health care. Dr. Lindquist has also led surge activities by assisting local public health in testing, case contact investigation, and health care response.
</p>
<p>
Other counties soon saw their own struggles with COVID-19 and the emergence of their own public health heroes. Those include <strong>Anthony Chen, MD</strong>, director of health at Tacoma-Pierce County Health Department and chief health strategist for Pierce County; <strong>Teresa Everson, MD</strong>, public health officer for Yakima County, the state's second hotbed for COVID-19 cases; and <strong>Amy Person, MD</strong>, health officer for the Benton-Franklin Health District and the Klickitat County Health Department and immediate past president of the Washington State Public Health Association.
</p>
<p>
During an exceedingly challenging public health crisis, all of our public health officers across the state are heroes. Thank you for your service to keeping Washington's communities healthy.
</p>
<h3>Advocacy</h3>
<p>
<strong>Donna Smith, MD</strong>. Past president of the WSMA and medical director at Virginia Mason in Seattle, Dr. Smith is well known and respected, which helped facilitate her ability to jump into the political fray on behalf of the WSMA during discussions on issues such as the state's non-urgent procedure delay order and appropriate use of personal protective equipment. Her help in persuading the Legislature to extend the COVID-19 proclamations was key to WSMA's success in providing the state's health care professionals with the support they needed during the crisis. For her tireless work on behalf of the state's physicians, Dr. Smith is a winner of WSMA's 2020 Grassroots Advocate Award.
</p>
<h3>Telehealth</h3>
<p>
<strong>John Scott, MD</strong>. Officially the medical director for digital health at UW Medicine in Seattle, Dr. Scott is unofficially the Washington state telehealth czar. After participating in years of legislative negotiations that helped establish Washington as a leader in telehealth policy, Dr. Scott chairs the Washington State Telehealth Collaborative, which is charged with advancing excellence and innovation in telehealth for all Washington communities. During the pandemic, he worked tirelessly to support physicians who were transitioning care to telehealth, helping them stay connected with their patients and helping their practices stay afloat. For his own staff, Dr. Scott guided UW Medicine through its explosive growth in the use of telemedicine during the pandemic, from training physicians in all 45 specialties to establishing home monitoring for patients recovering from COVID-19. Dr. Scott is a winner of WSMA's 2020 Grassroots Advocate Award for his advocacy work in telehealth.
</p>
<h3>Trailblazers</h3>
<p>
<strong>George Diaz, MD</strong>. Chief for infectious diseases at Providence Regional Medical Center in Everett, Dr. Diaz treated the nation's first confirmed COVID-19 case, a Seattle-area man who had recently returned from China, alerting the medical community to the reality that COVID-19 was spreading globally. Dr. Diaz had guided the hospital through a pandemic drill just three weeks earlier and oversaw admitting the patient to an isolation unit within two hours after the CDC confirmed that he had the virus.
</p>
<p>
<strong>Francis Riedo, MD</strong>. An infectious disease specialist at EvergreenHealth in Kirkland, Dr. Riedo had the wisdom to do the first test for the COVID-19 virus in a hospitalized patient in Washington state. He had to scramble to contain the virus in his ICU, hospital, and community. He was responsible for reverse airflow rooms, PPE, screening protocols for 5,000 employees, employee testing, rotating shifts, daily communication to staff, press statements, and now is conducting one of the first trials for a COVID-19 vaccine. "Frank was living a nightmare scenario with the exposure and staff and number of patients," Dr. Baliga said. "He was the voice of pragmatism. He was having to navigate the reality of it early on in a horrific, dramatic way. [The Evergreen leadership] rose to the challenge and are a great example of what can be done."
</p>
<h3>Logistics</h3>
<p>
<strong>Michael Myint, MD</strong>. As physician executive for population health at MultiCare in Seattle, Dr. Myint has provided thoughtful guidance on hospital efforts to provide personal protective equipment. He set up a PPE inventory and sharing program that would allow hospitals to access and to share PPE. Health care systems received many donations, but sometimes only small numbers. By aggregating the available inventory, one institution would be able to have enough supply of that mask to adequately fit, test, and protect that cohort of staff.
</p>
<h3>Mental Health</h3>
<p>
<strong>Avanti Bergquist, MD, MS, FAPA</strong>. A child and adolescent psychiatrist with the Eating Recovery Center of Washington in Bellevue, Dr. Bergquist has been a constant and consistent source of information for physicians and parents to help children deal with difficulties related to the pandemic. A distinguished fellow of the American Academy of Child and Adolescent Psychiatry, Dr. Bergquist also is vice president of the Renton School Board and has been an advocate for schools providing mental health support to students as they return to the classroom.
</p>
<h3>Volunteerism</h3>
<p>
<strong>Lucas Hansen, MD</strong>, emergency room physician at Providence St. Peter Hospital in Olympia. Early in the pandemic, Dr. Hansen responded to New York Gov. Andrew Cuomo's plea for health care workers from across the country to go to New York to help. He spent two weeks treating patients at Elmhurst Hospital in Queens, a hospital described by The New York Times as "the epicenter of the epicenter" of the COVID-19 epidemic in New York City. On his return to Washington state, he shared lessons learned with fellow physicians. Dr. Hansen's example of commitment and caring is echoed by the thousands of health care professionals in Washington state and across the nation who have put their own health at risk to care for COVID-19 patients.
</p>
<h3>Research</h3>
<p>
<strong>Lisa Jackson, MD</strong>, Kaiser Permanente Washington Health Research Institute in Seattle. Dr. Jackson is the principal investigator for a National Institutes of Health- funded investigational vaccine for SARS- CoV-2. Their Phase 1, dose-escalation, open- label trial of the mRNA-1273 vaccine was held in March; it included 45 healthy adults who received two doses 28 days apart. It was successful in producing an immune response in all participants evaluated. In July, Dr. Jackson and her team reported on the results of their trial in the New England Journal of Medicine. Following the report, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told the Associated Press, "No matter how you slice this, this is good news." The study has now moved forward to a 30,000-person trial to determine if the vaccine is effective.
</p>
<p>
<strong>Alison Roxby, MD</strong>. An assistant professor of global health and medicine at the University of Washington in Seattle, Dr. Roxby received national attention on how a study team prevented a COVID-19 outbreak in an assisted living community by testing and surveying all the staff and residents and implementing stringent social distancing, sanitation, and other prevention measures. The CDC's Morbidity and Mortality Weekly covered Dr. Roxby's study; she spoke with Rachel Maddow on MSNBC on the importance of the research findings, as a high percentage of coronavirus deaths have been associated with community spread in senior living facilities.
</p>
<h3>Infectious disease physician "superheroes"</h3>
<p>
In the last days of February, a group of King County infectious disease physicians began a furious email string about the guidance coming from the Centers for Disease Control and Prevention and what they were facing in their respective hospitals. It quickly became an unofficial peer support group of physicians. But it was much more than that, Dr. Baliga said.
</p>
<p>
"Our entire infection prevention plan - precautions we were using for people with COVID, deciding who gets the respirators, what to do as you run out of various parts of PPE, what to do when your staff is exposed - is based off this group, especially early on when the guidance was very vague or didn't work. ... In the first few months, we had this scenario where we were really the front-line team trying to help navigate the CDC and public health guidance and directing it back. This group was instrumental in that."
</p>
<p>
Together, they were selected as winners of WSMA's William O. Robertson, MD, Patient Safety Award, which recognizes patient safety initiatives in the ambulatory care setting. They are:
</p>
<p>
<strong>Chris Baliga, MD</strong>, medical director for infection prevention, Virginia Mason in Seattle.
</p>
<p>
<strong>Peter Hashisaki, MD</strong>, infectious disease specialist, Overlake Medical Center &amp; Clinics in Bellevue.
</p>
<p>
<strong>John Lynch, MD</strong>, medical director of infection control and prevention, Harborview Medical Center/University of Washington in Seattle.
</p>
<p>
<strong>John Pauk, MD, MPH</strong>, infectious disease specialist, Swedish Center for Comprehensive Care in Seattle.
</p>
<p>
<strong>Francis Riedo, MD</strong>, infectious disease specialist, EvergreenHealth in Kirkland. Olympia Tachopoulou Stafford, MD, infectious disease specialist, Franciscan Infectious Disease Associates at St. Joseph in Tacoma.
</p>
<p>
<strong>Danielle Zerr, MD, MPH</strong>, infectious disease specialist, Seattle Children's; division chief of pediatric infectious diseases at the University of Washington in Seattle.
</p>
<p>
Dr. Baliga was quick to point out that the King County ID doctors are far from being alone in their efforts to fight the virus. Dr. Riedo cited the work of <strong>Mark Johnson, MD</strong>, an infectious disease specialist with Confluence Health in Wenatchee. Dr. Johnson "has been instrumental working with health care providers in Central Washington to provide both clinical care and the public health messaging needed to stem the tide of new patients," Dr. Riedo said.
</p>
<p>
Indeed, physicians are working together at unprecedented speed to bring the virus under control.
</p>
<p>
"Part of the messaging," Dr. Baliga said, "is that this group is part of a much larger group of people trying to deal with this."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Nov./Dec. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 11/6/2020 11:17:51 AM | 11/6/2020 11:16:33 AM | 11/6/2020 12:00:00 AM |
| doctors_making_a_difference_yuan_po_tu_md | Doctors Making a Difference: Yuan-Po Tu, MD | WSMA_Reports | Shared_Content/News/Latest_News/2020/November/doctors_making_a_difference_yuan_po_tu_md | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2020/Nov-Dec-2020-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>November 2, 2020</h5>
<h2>Doctors Making a Difference: Yuan-Po Tu, MD</h2>
<h5><em>Members only; sign-in required.</em></h5>
<p>
<em>Ed. Note: The November/December issue of WSMA Reports featured an edited interview with Dr. Tu. Read the full-length version below. </em>
</p>
<p>
After the first community-acquired U.S. case of COVID-19 was identified in late January at The Everett Clinic, Yuan-Po, Tu, MD, and his colleagues at The Everett Clinic, part of Optum, reacted quickly. Drawing on their experience with the H1N1 pandemic in 2009, clinic leaders knew that securing personal protective equipment for health care workers would be vital. Despite having a stockpile of PPE and orders placed for more, by the first week of March, the clinic was burning through PPE at an alarming and unsustainable rate.
</p>
<p>
In January, Dr. Tu, an internal medicine physician who works at the urgent care walk-in clinics at The Everett Clinic, had been awarded a United HealthCare clinical research fellowship to study the impact of clinical decision support in the electronic medical record system on antibiotic stewardship. With the impact of the emerging pandemic in March, he shifted the study focus to what he thought could help alleviate the strain on PPE supplies by designing and executing a study to examine the sensitivity of patient-collected specimens for COVID-19 testing.
</p>
<p>
<strong><em>WSMA Reports:</em> What brought about the idea to study patients self-administering nasal swabs for testing?</strong>
</p>
<p>
In the early days following identification of the first COVID-19 patient, we could see that we were consuming surgical masks and PPE at an alarming rate. In the first three days of the response, the warehouse had issued nearly 10,000 surgical masks. We calculated that we were using 2.2 sets of PPE with N-95 respirators to test each patient for COVID-19. This was a huge amount of PPE and represented a non-sustainable burn rate.
</p>
<p>
Nasopharyngeal sampling has been the tried-and-true method for testing for upper respiratory viruses. I knew that we could recover influenza virus from nasal samples, as we have been using nasal samples to test for influenza for years.
</p>
<p>
One of the basic principles of occupational health is to remove the danger from workers. I hypothesized that we would be able to recover the SARS-CoV-2 virus from nasal samples and that we could remove the risk to the health care workers by having the patient self-collect the samples.
</p>
<p>
<strong>What advantages do nasal swabs self-collected by the patient have over testing done by a health care worker?</strong>
</p>
<p>
Nasal collection saves PPE by decreasing the potential for aerosolization and, hence, the risk of exposure to health care workers. Nasal sampling is a lot faster than nasopharyngeal sampling and is much more comfortable for the patient compared to NP swabs.
</p>
<p>
<strong>How do you see the pandemic playing out this fall and winter? </strong>
</p>
<p>
I anticipate that the number of COVID cases will increase, as we always see more upper respiratory illness in the fall and winter months. Congregation of people in close quarters indoors can results in rapid outbreaks, as we have seen with the opening of colleges.
</p>
<p>
Testing continues to evolve. Since March, clinical innovation has changed testing for COVID. We have evolved from nasopharyngeal sampling to self-collected nasal swabs. Other studies have shown that foam polyester swabs are equivalent to flocked nylon swabs. Other transport media, including 0.9% saline and phosphate-buffered saline, have been shown to be equivalent to viral transport media.
</p>
<p>
We now know that dry swabs used to collect nasal specimens are stable for three days and are equivalent to swabs transported in liquid media. This has facilitated home collection and shipping the specimen to a central testing lab.
</p>
<p>
<strong>What complications do you anticipate with COVID-19 colliding with flu season?</strong>
</p>
<p>
The winter season will increase the challenge of identifying patients with COVID-19, as any person with upper respiratory viral symptoms will have COVID-19 in the differential and will need to be tested. In a normal flu season, patient census is often close to capacity of hospitals. Adding COVID-19 patients will put additional strain on hospital systems.
</p>
<p>
Every effort should be made to maximize influenza vaccinations this fall to try to decrease the burden of influenza in our community.
</p>
<p>
<strong>In an ideal world, how would testing look for the remainder of the pandemic?</strong>
</p>
<p>
Ideal testing would be inexpensive, fast, accurate, simple to perform, and widely available. Ideal testing would be a test that could be performed at home without the need for medical supervision, with the results available in minutes without a reader or instrument.
</p>
<p>
<strong>What is the biggest barrier standing in the way of achieving that?</strong>
</p>
<p>
Just like nasal testing changed how we collect specimens for testing, we will need a fundamental change in how testing is performed. Molecular testing for COVID-19 currently is expensive, complicated, and requires complex equipment.
</p>
<p>
Multiple antigen tests have been approved by the FDA, with EUA for symptomatic individuals. Depending on the sensitivity and specify, antigen testing may be able to be used to test a wider number of individuals.
</p>
<p>
Other technologies are in development that have potential for changing how we test. But they are much further from commercial release.
</p>
<p>
<strong>What has the pandemic response so far revealed in terms of what systems we should have in place to better respond to future crises?</strong>
</p>
<p>
Severe pandemics cause unprecedented medical, social, and economic impacts. Pandemic infections affect the entire world. Effective political leadership, coupled with medical and social guidance, is key to responding effectively. There will be a next time. Analysis of how we respond will be key to learning how to respond better to the next pandemic. No single individual or single system will be able to succeed alone. To do better, we need our entire political, public health, and medical systems to be better as a team.
</p>
<p>
<em>This article was featured in the Nov./Dec. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 11/2/2020 3:36:18 PM | 11/2/2020 12:32:27 PM | 11/2/2020 12:00:00 AM |
| wsma_responds_to_covid_19 | WSMA Responds to COVID-19 | WSMA_Reports | Shared_Content/News/Latest_News/2020/November/wsma_responds_to_covid_19 | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2020/Nov-Dec-2020-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>November 2, 2020</h5>
<h2>WSMA Responds to COVID-19</h2>
<h5><em>Members only; sign-in required.</em></h5>
<p>
By Rita Colorito
</p>
<p>
Shortly after the Centers for Disease Control and Prevention confirmed the first U.S. coronavirus case in Snohomish County on Jan. 20, officials from the Washington State Department of Health reached out to the WSMA. At the time, the DOH had minimal information to share.
</p>
<p>
Jennifer Hanscom, WSMA's executive director/CEO says she appreciated the heads up. "I remember thinking, 'Oh, that's good that they're informing us, but it sounds like it's well controlled,'" she says.
</p>
<p>
In late February, Hanscom received another call from DOH, this time more urgent. Coronavirus was racing through the Life Care Center in Kirkland. "They told us they were mobilizing an information center to deal with COVID-19," says Hanscom. "That's when I knew, 'Wow. This is it. This is going to be big.'"
</p>
<p>
Within weeks, Washington state had become the U.S. coronavirus epicenter. On March 11, the World Health Organization formally declared COVID-19 a global pandemic. The WSMA found itself on the front lines of helping its members manage a novel coronavirus with little understanding at the time of how the virus spread or how to contain it.
</p>
<p>
"We quickly realized that we have to be the eyes and ears for our physician members," Hanscom says. "We also had to make sure patients felt informed and safe. We wanted to be a trusted voice for them as well."
</p>
<h3>Getting the word out</h3>
<p>
The WSMA's first order of business was keeping members and the public informed in real time. That meant sifting through an overload of constantly changing—and often conflicting—medical information. Most of this was done virtually, as the association encouraged its staff to work remotely beginning on March 10.
</p>
<p>
"We realized we needed a physician lens on this, so that we could understand the clinical implications," says Hanscom. To accomplish this, WSMA's executive committee met virtually at 7 a.m. every Wednesday. Consensus was then shared with WSMA members and other public health stakeholders.
</p>
<p>
Armed with clear, science-based information from the state's physician leaders, Hanscom managed a response she described as "fast and furious." Association staff often worked late into the night and on weekends. "I was counting on my team to be available 24/7, to make sure we were getting accurate information," she says.
</p>
<p>
"Fast and furious" is an appropriate way to describe the level of activity, says Jessica Martinson, WSMA's director for continuing professional development.
</p>
<p>
"I remember having four concurrent meetings on my calendar and trying to be at one of them on my cell phone and one on my computer simultaneously," she recalls. "It was this huge flurry of activity."
</p>
<p>
Email blasts were sent to every physician and physician assistant in the state, regardless of membership, as well as to county and specialty medical societies, and to the CEOs and CMOs of clinics, hospitals, and hospital-based medical groups. The WSMA also updated its website with the latest information and conducted outreach through press releases, contacting reporters, and using social media, particularly Twitter.
</p>
<p>
To reinforce emerging best practices and tackle misinformation, the association coordinated messaging with the Public Health - Seattle &amp; King County, the University of Washington, and Virginia Mason. "From a public health perspective, it was important we were all saying the same things," says Hanscom.
</p>
<h3>Managing public health</h3>
<p>
That coordination was critical; in the early days of the pandemic, COVID-19 mitigation efforts were scattershot. Lacking guidance from the federal government, Washington state and the WSMA were left to figure things out on their own.
</p>
<p>
On March 6, Martinson went to EvergreenHealth in Kirkland to teach a scheduled course to certify advance care planning facilitators. (Health care systems would come to rely on such planning to help elderly patients navigate end-of-life decisions precipitated by COVID-19). This was before the now- standard practice of wearing masks.
</p>
<p>
"We wrestled with whether we had any business being there," says Martinson. EvergreenHealth had registered the state's first COVID-19 death on Feb. 28. Most of the Life Care Center cases had been taken there. The hospital was quickly becoming ground zero for COVID-19 deaths.
</p>
<p>
Martinson focused on making the class as safe as possible, ensuring social distancing, and providing hand sanitizer. "Everyone was cool-headed, but you could tell they were under intense pressure," she says. "But we weren't talking about rationing ventilators yet. We weren't in that mindset at all. It wasn't part of the national conversation," says Martinson.
</p>
<p>
By mid-March, WSMA's executive committee had reached a stunning conclusion: The state could run out of ventilators, beds, and personal protective equipment. The WSMA sent an urgent letter to Gov. Jay Inslee advocating for the shutdown of non-urgent medical procedures—a step that the University of Washington Medical Center and Swedish Health Services had already taken.
</p>
<p>
The governor quickly followed the medical community's advice. On March 19, he announced restrictions on non- urgent medical and dental procedures, which remained in effect until May 18.
</p>
<p>
WSMA members also began raising the alarm that "business as usual" was a threat to public health. They were adamant the state shut down non-essential businesses and gatherings, says Hanscom.
</p>
<p>
In response, the association submitted another letter to Gov. Inslee. WSMA's members were part of the catalyst for Inslee's "Stay Home, Stay Healthy" orders, which went into effect on March 25 and include a four-phase, county-by-county "Safe Start" reopening plan.
</p>
<h3>Tackling legislative issues</h3>
<p>
The state's legislative session, which ended on March 12, was in its waning weeks as the virus became the top priority. The Legislature scrambled to appropriate $200 million in state budget reserves to fund the pandemic response. WSMA negotiations on other issues took a back seat as it grappled with a host of shutdown-related issues, says Sean Graham, WSMA's director of government affairs.
</p>
<p>
"We had calls with each member of our state's congressional delegation to update them on what was happening in our physician community," says Graham. Legislative priorities included ensuring sufficient personal protective equipment for physician clinics, creating flexibility around the state certificate of need laws and physician licensure law, and ensuring appropriate liability protections for care that was delivered or delayed during the pandemic. The WSMA focused on how members could keep patient care front and center.
</p>
<p>
Ensuring payment parity for telemedicine, long a WSMA priority, became even more essential, says Jeb Shepard, WSMA's director of policy. In fact, the legislative session ended with WSMA achieving long-fought success in the creation of the Washington State Telehealth Collaborative. It requires insurance carriers to pay for telehealth services if they reimburse providers for face-to-face service.
</p>
<p>
"That piece of legislation was signed by the governor in early April, but the issue was it wasn't effective until January 2021," says Shepard. With the legislative session over, the WSMA had to get creative to get telehealth covered in 2020.
</p>
<p>
"We urged the Office of the Insurance Commissioner and the governor's office to take whatever action was in their emergency authority to implement payment parity," says Shepard. In Washington state, the governor can strike out portions of a legislative code, but can't add to them, explains Shepard. To get telehealth payment parity immediately, Gov. Inslee struck out the effective date of the law that had just passed.
</p>
<p>
"That unleashed a proliferation of telemedicine and we saw a rapid transition to telehealth among smaller and mid-sized practices," says Shepard.
</p>
<p>
By May, the medical community had a better understanding of COVID-19 and how to mitigate spread of the virus. The WSMA began hearing from members that the shutdown of non-urgent procedures was hurting their economic viability.
</p>
<p>
It was also taking an emotional toll, as physicians had to furlough personnel to keep their practices solvent.
</p>
<p>
The WSMA worked with the Washington State Hospital Association, Washington State Nurses Association, and the Ambulatory Surgery Center Association to help clarify Gov. Inslee's proclamation on non-urgent procedures so that physicians could use their clinical judgment without fear they were breaking the law.
</p>
<h3>Going forward</h3>
<p>
With a handle on the logistics of COVID-19, the WSMA began shifting its focus to physician well-being. In April, Martinson conducted a five-part webinar series to help members discuss what it means for patients with serious underlying conditions who develop COVID-19. "These are really hard conversations for physicians to have, but they're necessary," says Martinson. More than 500 members participated. The association also conducted webinars on telehealth and communicating under stress and hosts the COVID-19 Grand Rounds series.
</p>
<p>
"We were hearing from our members that they were under enormous pressure and that they were not getting the support they needed," says Martinson.
</p>
<p>
The WSMA reached out to several employee/physician assistance programs in the state. "We wanted to make sure our members had access to professionally trained mental health experts," says Martinson. The association also connected members to resources that could facilitate group debrief sessions. This was separate from WSMA's work on physician burnout.
</p>
<p>
"Everyone's grappling with COVID-19; some were more directly impacted than others," Martinson says. "Front-line physicians may experience trauma and are susceptible to PTSD. So, it's not just a matter of being resilient and having good workflow."
</p>
<p>
The WSMA also facilitated weekly Zoom meetings for ICU and critical care physicians to share their experiences. About 30 regularly attend these now- monthly virtual meetings.
</p>
<p>
Both the WSMA and Washington state are preparing for the uncertainty of the fall and winter months, and the association's work to promote an evidence-based approach to the pandemic is far from over. In September, in a necessary, but previously unfathomable move, WSMA corrected CDC misinformation.
</p>
<p>
"We had to explain to our members that Washington state isn't following CDC guidelines on COVID testing because those guidelines don't follow the science," says Hanscom.*
</p>
<p>
Retired Navy Vice Adm. Raquel Bono, MD, state director for COVID-19 Health System Response Management, has convened a series of pandemic-focused working groups. WSMA's secretary- treasurer, Nariman Heshmati, MD, has participated in working groups on personal protective equipment and contact tracing.
</p>
<p>
"Our work is still continuing," Hanscom says. "It's just happening in a more organized, less frantic fashion."
</p>
<p>
<em>* On Sept. 18, the CDC reversed its guidance and recommended that people without symptoms who have been in close contact with an infected person need to be tested.</em>
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in covering medicine and health care. She is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Nov./Dec. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 11/2/2020 3:37:13 PM | 11/2/2020 3:31:55 PM | 11/2/2020 12:00:00 AM |
| equity_in_medicine | Equity in Medicine | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/equity_in_medicine | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>Equity in Medicine</h2>
<p>
By John Gallagher
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
An estimated 10,000 health care professionals and students, wearing white coats and scrubs, walked from Harborview Medical Center to Seattle City Hall on June 6 in a Doctors for Justice event to protest racial violence. They had responded to a call to action from Estell Williams, MD, an acute care surgeon at the University of Washington Medical Center and an assistant professor of surgery at the UW School of Medicine, who asked her colleagues to "show the full strength of Medicine that seeks justice for the most marginalized of our community."
</p>
<p>
Motivated in part by the experiences of her own family, Dr. Williams organized the march with her husband, Edwin Lindo, JD, a lecturer at the UW School of Medicine. "I have experienced police violence, racism, and mortality as a result of disparate outcomes experienced by the Black community within my family," Dr. Williams says.
</p>
<p>
In a letter announcing the march, she recalled a childhood event seared in her memory. Her father was pulled over by police while they drove home through a predominantly white neighborhood. As the officers searched their car, "I cried in fear and terror in the backseat, thinking of what they had done to others who looked like my dad," she wrote. "They handcuffed him, took him to the police station and forced him to stay there, while I had to wait in the street for my mother to pick me up. They released him two days later without a charge or valid reason for arresting him. To be clear, my father never committed a crime in his life, and the pain and fear I felt for the days he sat in the jail never leaves my mind. I knew there was a possibility that I would never see him again."
</p>
<p>
Just as importantly, she believes doctors should use their position of privilege to call out all the issues that harm the health of their patients, from overrepresentation in the justice system to poverty, housing, and employment.
</p>
<p>
"All of these things interconnect," Dr. Williams says, "and we as health care workers have to recognize it and speak out because the true health of our communities exists outside the walls of the hospitals and clinics."
</p>
<p>
The renewed awareness about racism has led to a fresh look at health equity issues. For decades, physicians have known that the race or ethnicity of patients or the language that they speak can have an effect—often negative—on their health. According to the Kaiser Family Foundation, Blacks, Hispanics, and Native Americans/Alaska Natives had higher infant mortality rates, die from diabetes at a higher rate than whites, and are in general more likely than whites to report fair or poor health status. Asian Americans/Pacific Islanders overall often fare better than whites, but with wide variation among subgroups.
</p>
<p>
Health equity has always been a complex issue.
</p>
<p>
"Defining 'equity' depends on who you are," says Michael Schaffrinna, MD, chief medical officer at Community Health of Central Washington, which operates federally qualified health centers (FQHCs) in underserved areas. "For some, it's access to care. But there's much more to health care than just getting an appointment or, for that matter, having good clinical care."
</p>
<p>
The COVID-19 pandemic has thrown into sharp relief the issue of health disparities, with much higher rates of infection and death among Blacks and Hispanics. But another event this spring has also affected the discussion about health equity: the killing of George Floyd by police officers in Minneapolis and the subsequent demonstrations about racial injustice.
</p>
<p>
The extent to which racism has affected medicine's ability to eliminate health disparities is now part of the conversation in a way that it never has been in the past. "Racism is a public health emergency of global concern," a recent editorial in The Lancet said. "It is the root cause of continued disparities in death and disease between Black and white people in the USA."
</p>
<p>
"It feels that the normalization of the conversation is much more universal," says Benjamin Danielson, MD, chair of the Governor's Interagency Council on Health Disparities and clinic chief at Seattle Children's Odessa Brown Children's Clinic. "I spent a lot more time preaching to the choir before. Now perhaps the sense of importance and maybe the less compromising nature of the situation does put some emphasis behind real conversations about health equity."
</p>
<p>
Certainly, medical systems have been working hard for years to reduce health disparities. Dale Reisner, MD, medical director (OB-GYN Quality &amp; Safety) at Swedish Health Services and a past president of WSMA, notes that her health system started working to address the issues well before the latest focus on racism.
</p>
<p>
"Even before George Floyd, we have really been trying to enhance our abilities to address health disparities with trainings, information sessions, and respectful treatment of all patients," she says. Reisner has had a particular focus on reducing Black maternal mortality, which in Washington state is twice the rate than for white women, even with the state's mandate for access during pregnancy. (The mortality rate for Black mothers nationally is threefold higher than for white women.)
</p>
<p>
Suicide and postpartum overdoses are major contributors to Black maternal mortality. "Women with mental health and substance use disorders often are not respected, so we've had a very innovative addiction recovery program at Swedish with compassionate care basically as the core of the model," Dr. Reisner says. She adds that the fact that such an approach is even necessary is "sad, when you think about it."
</p>
<p>
Swedish has a program that includes doulas, trained professionals who serve as support for women during pregnancy, birth, and the postpartum period. "Many of them have come from disenfranchised communities, so [they] can relate to the patients," Dr. Reisner notes. "As an advocate with white skin, I can do my best, but someone with brown skin is not going to trust me as much because I don't share their same experience."
</p>
<p>
But as Dr. Reisner and other physicians point out, the progress to date still leaves a lot to be desired, Dr. Williams says.
</p>
<p>
"Even though medicine is getting better, we're still seeing the same disparities," she says. "You can make the argument that people are not only not getting the same level of care but are getting a worse level care."
</p>
<p>
The real challenge with addressing health disparities is that many of the factors that drive it happen outside the clinic. "We give this prescription in the clinic, but we don't then try in a meaningful way to address the ways patients experience the world when they leave the clinic," Dr. Williams says. "We need to recognize that there are certain diseases that need to be treated in a hospital setting, but a lot of problems are directly related to systemic racism."
</p>
<p>
Researchers have long documented the impact that social determinants of health—the conditions in which people are born, live, and work—have on outcomes. Now, the urgency of that work is gaining more recognition and acceptance. "There is greater regard for social determinants of health in embracing health equity in a systematic way," says Dr. Danielson. "Health care systems getting involved in social determinants is a health equity act."
</p>
<p>
Dr. Schaffrinna says that for those kinds of discussions to be successful, "we have to approach it not with blame, but 'How do we change?' " That means acknowledging up front that racism is a problem.
</p>
<p>
"Is there discrimination? Absolutely," he says. "We must confront it."
</p>
<p>
But he believes that medicine should also focus on how poverty is a driver of disparities.
</p>
<p>
"When you look at Americans suffering from the effects of poverty, it appears that all of them suffer," he says.
</p>
<p>
Even within the confines of the system, barriers exist, notably the chronic challenge of financing. Addressing health disparities costs money, such as Swedish's investment in doulas. Investing in such efforts is especially difficult when practices and medical systems are facing huge drops in revenue as a result of the pandemic.
</p>
<p>
"Everybody is recognizing that it's an issue, but no one is willing do anything," says Dr. Schaffrinna. "Most of the FQHCs are trying to begin the process of addressing social determinants, but there's no revenue coming in for that expense."
</p>
<p>
Moreover, some solutions have the potential to shift money away from the medical system altogether. "As a nation we spend an enormous amount of money on health care, and it's not giving us the biggest bang for buck," adds Dr. Schaffrinna. "We should put some of that money into addressing social determinant factors. Our country can't afford to do it all, and the only way to do it is to reallocate resources to other areas, similar to what people are saying about police departments." (Activists have been pushing for cities to invest in mental health workers as front-line respondents to individuals in crisis, instead of the police.)
</p>
<p>
The respect that society places on physicians offers them a special opportunity to play a role in tackling the problem of health equity. "Because we have by nature and profession a caring tendency and because we're interacting with patients who manifest all the effects of this social injustice, it positions us in a unique way to be the ones who also can bring awareness and advocacy for the need to make change," says Okechukwu Ojogho, MD, a transplant surgeon at Providence Medical Group in Spokane.
</p>
<p>
The really thorny question is the extent to which medicine is willing to broaden the conversation about health equity to racism, including institutional racism in medicine. The profession is starting to recognize, as the New England Journal of Medicine said in a recent editorial, that "slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to present, and that legacy infects medicine as it does all social institutions."
</p>
<p>
Dr. Williams says that the current conversation about racism reveals some long-standing assumptions about medicine. "We've done a disservice to medicine as an entity by attempting to exist as an apolitical, neutral entity," she says. "We have for a long time felt that we're altruistic human beings who are neutral and somehow colorblind, and in doing so, we have blinded ourselves to the root causes that perpetuate the health outcomes we see."
</p>
<p>
Ultimately, the profession has to have a painful conversation about racism if it is going to conquer health disparities, Dr. Danielson says.
</p>
<p>
"I'm hoping a health equity conver- sation is not a substitute for a conversation about racism," he says. "You can do a whole lot toward health equity without changing any power paradigm. You can still hold all the strings and be in a position of power and do more things to promote health equity. An anti-racism perspective has built into it a pretty strong power shift."
</p>
<p>
How much change happens depends on doctors themselves, says Dr. Danielson.
</p>
<p>
"I would imagine a lot of us are on the edge of our seats right now," he says. "Will this really be a transformational time? It would be too bad if people sit on their seats and wait for something external to show them it's time to move forward. Moving forward is the thing we need to do, not the thing we wait for someone else to do."
</p>
<p>
Dr. Williams says that just a year ago, something like the march would have been impossible to imagine. But one conversation with another doctor that she had at the event stood out. In her speech at the march, Dr. Williams noted that "we scrutinize all our actions in the hospital to minimize harm to patients, but we don't consider actions in our greater community with the same scrutiny." The physician that Dr. Williams spoke to had never considered this.
</p>
<p>
"Hearing that physician declare that their eyes were opened showed me that we did something good that day," Dr. Williams says. "And if we opened just a few more eyes, we can do something good for many more lifetimes to come."
</p>
<p>
<em>John Gallagher is a freelance journalist who specializes in health care issues. He is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 10:32:10 AM | 8/31/2020 10:22:40 AM | 8/31/2020 12:00:00 AM |
| faith_through_action | Faith Through Action | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/faith_through_action | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>Faith Through Action</h2>
<p>
By Milana McLead
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
If you ask what he was like as a child, Nathan Schlicher, MD, answers with a smile, and says, "I was probably a precocious kid."</p>
<p>
That might be an understatement, considering he skipped first, fourth, seventh, and ninth grades, graduated from high school at 14, skipped a year of college, completed law school a year early, and started medical school at 19. “It was normal to me, as crazy as that sounds,†he says.
</p>
<p>
Perhaps that was because a strong, bright family grounded him and kept him humble. “My grandfather was a brilliant physician,†Schlicher says. “He taught me early on: ‘You may be very successful, but there’s probably somebody who’s done it faster, younger, smarter. Don’t get hung up on yourself. Be happy with who you are and try not to make anyone feel any different.’ â€
</p>
<p>
His father, Peter, was a hospital administrator and his mother, Carol, a nurse, so medicine was ever-present in the household. “We grew up talking about medicine and enjoying stories around the dinner table,†he says. “Since my dad wasn’t clinical, my mom would try to gross him out. We all had a great time with that.â€
</p>
<p>
While Dr. Schlicher’s intellect and relative youth are front and center, one quickly learns that a strong faith and a deep passion for service are at his core.
</p>
<p>
An early mentor and Methodist minister known as “Big David†solidly influenced his teen years. “Big David was a good man who lived the message and cared for the people. He was open, loving, and kind, and very much believed in faith through actions,†Dr. Schlicher says. “I try to live as he did in terms of doing what I can for the community; remembering that faith is not words, but actions; and the importance of caring for others.â€
</p>
<p>
A career in medicine was the perfect companion for that framework for life. “I grew up volunteering and always knew that medicine would be part of my life. And emergency medicine—to be able to make a difference, to be there at some of the most challenging times of people’s lives—I love being there in the moments when it matters so much,†he says.
</p>
<p>
If anything keeps him awake at night—at least on the nights he’s not working in the ER at CHI Franciscan’s St. Joseph Medical Center—it’s unsolvable problems. “If I feel like I missed an opportunity to make a difference, to solve a problem I could have had an impact on—my mind churns on ‘What should I have done differently? What could we have done differently?’ We do the best we can, we plan ahead, and think through every scenario to get the right answer. Sometimes it works, sometimes you fail, but you learn and try not to repeat those mistakes.â€
</p>
<p>
Problem-solving comes naturally to Dr. Schlicher, as does taking the lead in finding solutions. Observe that your patients need a voice in the Legislature? Solution: Seek and win appointment to an open seat in the Washington State Senate, and serve as a state senator advocating for effective health care policy. See a need to reduce preventable emergency room visits? Solution: Create an “ER is for Emergencies†campaign that shifted behavior and perceptions about seeking care in the ER.
</p>
<p>
Need to encourage better opioid prescribing behaviors while protecting patients from highly addictive medications? Solution: Design “Better Prescribing, Better Treatment†program as a peer-to-peer, non-punitive initiative that has reduced opioid prescribing
in Washington state, with more than 20,000 prescribers in 50+ health systems participating in the program.
</p>
<p>
Impatient with inaction—a side effect of his life in emergency medicine—Dr. Schlicher’s inner drive to make things better compels him to lead and to step up where needed. “I very much try to live the philosophy that we are going to do things,†he says. “I think that’s what we need to work on in medicine—it’s not just showing up, it’s leading.â€
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His leadership philosophy serves him well in the ER, in advocacy, and in the WSMA. “It’s important that you listen to the people you’re working with—a leader is a team member. It’s not just leading the team, it’s inspiring them, working to hear their thoughts, and building relationships,†he says. “That comes through listening and having a vision of where you’re going and communicating that vision well.â€
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He steps into his role as president of the WSMA at an unprecedented time. The impact of COVID-19 has shaken the house of medicine especially hard; Dr. Schlicher sees that as one of the big issues ahead. “COVID is a window into all the dysfunctions in medicine,†he notes. “It’s a lens into the systemic structural problems of health care. That strain on the system is challenging, but it offers us an opportunity to bring positive change for better access to health care, better health systems, and better environments for clinicians to practice in.â€
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He sees a connection between the issues uncovered by the pandemic and an associated opportunity to improve physician wellness. “The things likely to drive us to burnout are the systemic structural problems, poorly designed EMRs, lack of backup and support, and being asked to do things outside of our scope or abilities,†he says. “We need to build a better work environment to help people be happier in all parts of their lives. If you do it right, people are happy.â€
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As he leads the work of the WSMA in the year ahead, his focus will be on improving access to health care, physician wellness, and driving quality. And he sees the WSMA as the conduit to making positive change happen. “Physicians need to lead health care because we see it through a clinician’s lens. If you don’t have that, there’s a knowledge deficit in leadership. We need to grow the next generation of trailblazers so that physicians are leading the health systems, regulatory entities, and in Olympia. Physicians need to be at the tables where decisions are made so our voice is heard, and that’s what you support when you join the WSMA.â€
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<em>Milana McLead is WSMA senior director, strategic communications and growth, and editorial director of WSMA Reports.</em>
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<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
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</div> | 8/31/2020 11:14:07 AM | 8/31/2020 10:29:46 AM | 8/31/2020 12:00:00 AM |