Steven Reames has been the executive director of Ada County Medical Society since 2014. He has served in a variety of non-profit leadership roles in Boise since 2000.

In this monthly blog for ACMS, I share my personal reflections from my seat in the Treasure Valley medical community.

These opinions are mine alone and do not necessarily reflect those of the Ada County Medical Society Board of Directors nor its members.

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  • 07/01/2020 10:10 AM | Anonymous

    By Steven Reames

    Leif Elgethun, CEO of a Sun Valley lighting retrofit software company, wrote an essay on what has transpired so far this year. His thoughts reflect many of my own that I had hoped to write about this month. He gave me permission to reprint a large portion of it.

    "As we approach the halfway mark in 2020, we're confronting two diseases in the US. The first has crippled our economy and resulted in the deaths of far too many of our fellow human beings. And while the pain is severe, it will eventually lift as we build collective immunity and eventually have a vaccine. This disease should be bringing us together as we work together in kindness to protect those most vulnerable which will also protect our economy. I encourage you to think about the sacrifices you made that you will be proud to share with your grandkids and not focus on any short term inconveniences that are no less onerous than wearing shoes and shirts in stores. 

    The second disease is one that America has been fighting since we were founded: Racism. Make no mistake, this disease is alive and well, fostered by apathy just as much as the racist super-spreaders. This disease is similar to the COVID disease in a few regards: 1) it spreads very easily, 2) some people have severe cases and some don't show any symptoms on the outside, and 3) there is no easy cure. The good news is we've been beating this disease since the Civil War and our collective will to eradicate this disease is stronger than ever. The even better news is we each can make a difference in our own lives, at work, and in our communities to ensure we put this dark chapter in our history to bed for good. 

    I am a serial entrepreneur and one thing that I have always done is to respect the differences and beliefs that each of my employees, customers, and partners brings to the table. I have come to the conclusion that this is not enough. I am making significant changes in my personal and business life to do more listening and learning so I can truly understand the systemic racism embedded in our country first. I'm also spending a lot of time looking inward to understand how my beliefs and actions can be improved, including some hard truths I haven't wanted to explore."

    I have been trying to spend more time looking inward as well. Typically, on controversial issues, I stand quiet somewhere in the middle of polar extremes, attempting to be a bridge builder rather than a bridge burner. I have a desire to move progressively in some ways with an anchor of conservatism that often holds me back. I lean revolutionary inside, but due to politeness and not wanting to upset the apple cart, I often lean backward into quiet observation and subtle influencing.

    Unfortunately, I think that would make me part of the complicit silence that allows racism to propagate. In fact, as I read some of Martin Luther King Jr’s quotes, I am even more convicted that trying to walk the fence cannot be justified.

    "In the end, we will remember not the words of our enemies, but the silence of our friends."

    "The ultimate tragedy is not the oppression and cruelty by the bad people but the silence over that by the good people."

    "There comes a time when silence is betrayal."

    ACMS promoted the Idaho Healthcare for Black Lives Matters Rally held on the Capitol steps June 20th, which was collaboratively organized by several ACMS members. Their goal was to hold an event for all in healthcare to promote anti-racism as a core value and stand in solidarity with those who feel most impacted by it. Additionally, they wanted to publicize how health disparities are experienced in the U.S. by people of color.

    As we did so, I was encouraged by some physicians to step very carefully and consider keeping myself and ACMS out of the fray. I heard them as sincere friends, wanting what is best for me and for the viability of the organization they love and the unity it has stood for, and I appreciated their concern. I understood the intent was to "be careful of getting entangled with movements that might have more radical elements or different platforms you can't align with."

    But, when a white male physician says “Steve, even though you and I personally believe that racism is evil and don’t practice it, there are many members who will not appreciate ACMS getting involved in this, but they will never say anything to you,” how am I to interpret that?  Is it not a plea by the "many members" to keep the organization’s capital and influence in the bank to spend another day on issues or in ways that most of its member physicians can agree on? Unfortunately while it may maintain the stature of ACMS, it quietly leaves the bifurcated status of privileged and marginalized groups of people unchallenged. And the status quo goes on.  

    When Ty Waters – a recent African American graduate of FMRI - shares personal anecdotes of coming into an OB ward and being told “we don’t want a black man delivering our grandchild....”

    ...when a patient refuses to believe his black physician's M.D. credentials insisting “no you must mean you’re a physician assistant…”

    …when a physician of color tells me that she has been treated with more disrespect in Boise than she ever experienced on the East Coast, and recalls times she is assumed by patients and staff alike that she is a janitor…

    …when other physicians are told their British-Indian accents are "too hard for patients to understand" and asked "how did they get through medical school anyway?"…

    …and when all these factors together help perpetuate healthcare disparities for people of color…

    …at what point do we – do I - have to say “No, we can’t always try to hold the middle ground”? What is best for me and what is best for ACMS’ historical neutrality on controversial issues probably needs to be set aside to promote what is best for those who have the least power. In fact, our board did just that in 2018, voting to break a decades-long neutral stance on controversial subjects, when it stepped up to support the passage of Proposition 2 to expand Medicaid in Idaho. That issue might be easier to embrace by most physicians who understand that the lack of access to healthcare clearly leads to bad health outcomes, even if they don’t agree with the political solution.

    I am not a physician and I may be naive and uninformed, but I simply do not believe that most ACMS members are split on the issue of race in America, that more change needs to happen urgently. I do suspect, however, many are subversively or unconsciously encouraged not to get too fussy about it or align with radical elements about it. 

    My own attempts to reach across racial lines to do more listening and learning and  always feel awkward, because I am afraid of offending, and so I say nothing. But, I recently messaged an African-American classmate of mine. I apologized to him for offering in third-grade to help him read better if he would just let me touch his 'fro. He replied that his memories of me were positive and friendly. But I also told him how I wish we could somehow return to being more like those young children who were not afraid to reach out and explore our differences because we hadn't yet been trained not to  by our culture and fears.

    So I encourage you - echoing Leif’s sentiments above - to commit to doing more listening, learning, looking inward, and asking ourselves and each other tough questions. Perhaps we could start to dialogue with people who have a different viewpoint with questions like “Can you help me understand how you’ve come to believe or think that way?” When we engage with the experience of others – conservative or liberal, radical or neutral, privileged or marginalized, black, white, brown or otherwise – it is a step towards gaining more compassion, empathy, and respect for those whose lives are different than our own.

    Surely, we can all agree upon that. (But if I am wrong, please help me understand how you've come to feel that way too.)

    And just to be clear, these opinions are mine alone and do not necessarily reflect those of the Ada County Medical Society Board of Directors nor its members.

  • 05/31/2020 10:35 AM | Anonymous

    Over the past 2-3 months, we have witnessed in real-time the tough decisions that government officials, business leaders, and healthcare providers have had to make in the midst of the coronavirus pandemic. And in real-time we have heard, and maybe even voiced, some of the complaints that either not enough or too much is being done in response. This situation highlights the challenges faced by those in positions of responsibility: there will always be double-binds, you can only do your very best with the information you have at hand, and you will always have your armchair quarterback critics who have the luxury of instant replay and a bird’s eye view.

    After hearing one of our member’s prediction in early March that, “It is going to be a poop-show here in no more than 1-2 weeks,” I stopped shaking hands and giving hugs when greeting close friends. Some of them dismissed my concerns saying, “No, that’s not going to happen here in Idaho.” But it was not long before physicians were pelting the Idaho governor’s office with calls to “shut the state down” hoping to slow the spread of COVID-19. They were reading the reports of rapid community transmission in Washington, California, and Italy and wanting to get Idaho ahead of the curve.

    The Catch-22, of course, is that mothballing a HUGE chunk of our economy, delaying elective surgeries and preventive care, and physically and socially distancing ourselves from each other has its own yet-to-be-determined costs. While these decisions seemed to have slowed the spread of the virus in Idaho, we have yet to find out the short and long-term impacts on the physical, mental, and financial health of the greater population.

    I am slowly learning to be less critical of decisions made under such conditions. I remember how, after the 9/11 attacks, Idaho Governor Dirk Kempthorne was criticized for closing Jefferson and State Streets alongside the state capitol building for a few months. There was veiled intelligence pointing to the potential of an attack on a building that looks strikingly like the US Capitol. Kempthorne worried that video footage of a terrorist attack on our local seat of government could easily be edited and retold on a foreign news outlet as a successful strike against Washington DC.

    In retrospect, it seemed like an over-conservative move for our corner of the country that felt so far removed from the epicenter of what had happened in DC, Pennsylvania, and New York City. Nevertheless, when my friend complained about the governor’s decision, I said, “Haven’t you ever had to make decisions as a boss that nobody understood because they didn’t have all the information that you had, but couldn’t share, at the time?” She grudgingly conceded the point.

    Similar types of judgement calls are made frequently by ICU doctors when the oath of “Do No Harm” is balanced with the reality of “but in order to do so, I have to place you into a temporary coma.” It will always be a risk-benefit analysis of which is worse: do little to nothing vs. overtreatment. I also know that many physicians beat themselves up for missing that “one clue” that they should have picked up in their differential diagnosis. Then they redouble their obsessiveness and perfectionism, vowing to never again make such mistakes, which sometimes leads to insomnia and the inability to “be present.”

    When we look back and coolly analyze the year the novel coronavirus hit us, there will be glaring blunders, obvious miscalls, over- and under-reaches that can be seen with 2020 vision. We should remind ourselves now that this is the nature of making decisions in the fog of war vs. the clarity of an after-action review. This reality does not absolve anybody from being accountable for making poor judgment when good information was readily at hand. Similarly, pressure cooker decisions almost always expose what we really believe and assume to be true. But ultimately, we may need to destroy the myth that we can make a perfect series of decisions in the heat of any crisis, learning to extend grace towards ourselves and those who lead us.

  • 04/30/2020 8:00 AM | Anonymous

    In the past I have described the physician burnout epidemic as a raging river.  Its features included safety nets designed to catch people before “going over the falls,” the need to teach individual survival skills (e.g. resilience), evaluating your raft and river guide for safety (employers and their leadership), and so on.

    "The "rapid" pace of change in the healthcare industry is so volatile, so uncertain, so complex that it has created Class VI monsters ready to swallow doctors whole. In the past, this river used to have some dangerous places that could be anticipated and planned for, followed by smooth waters to recover in before the next rough patch. But no more – it is just one giant raging tumbler after another."

    I asserted that I saw hope for reshaping the “banks of this riverbed” - that is, the medical culture - precisely because there was an abundance of water in it.

    At least, I thought it was a lot of water at the time.

    Amidst the Novel Coronavirus pandemic, we have all learned just how deluged our healthcare system can become. We are experiencing a worldwide flood of Biblical proportions that has the possibility of reshaping the entire healthcare landscape as we know it. In mid-spring 2020, it seems that the rising flood level has slowed a bit, the waters eventually will recede revealing new topography, and we will return to a post-COVID world where routine medical care can be resumed.

    Hurricane Katrina Flood Waters - Source Wikimedia

    Right now, the public understands that physicians’ fears of catching the virus creates enormous emotional pressures and double-binds. They are reading in news accounts that PTSD is a very real threat for EMS and hospital personnel who are encouraged not to even start resuscitation procedures on anyone without a pulse. And for the first time, a vast swath of the public is experiencing perhaps just a smidgen of what it has felt like to be in medicine over the past decade, including:

    • the necessity of rapid adaptation amidst uncertain times
    • muddled thinking and analysis paralysis because of the blitz of information to ingest and confusion about what the literature indicates
    • mixed messages from public and private administrations
    • a preoccupation with healthcare metrics
    • the disconnection of relationships and reliance on technology to get things done remotely
    • questions about how to care for children at home and parents who want to go out when you do not have time to do so
    • insomnia, grumpiness, suicidality…

    And so, everybody is encouraging everybody to reach and connect with others (while social distancing), to practice self-care, and to access mental health services without feeling like they are “the weakest link.”

    Is this a seminal moment in medical history where we can permanently shed the stigma around physicians being human?

    Alas, it was never “the public” who wagged their fingers at doctors admitting they were frail, imperfect, or struggling. It has always been our own medical culture created out of the uber-competitiveness of medical schools, the crazy work hours of residency in order to get to 10,000 hours of proficiency, and the large scale employers who ended up treating doctors like any other productivity worker. All of this, of course, is built on the foundation of traits that make for a great clinician but often lead doctors to a breaking point when too much is asked of them: conscientiousness, perfectionism, compassion, and the ability to assume life-and-death responsibilities.

    Part of what defines a culture is who and what it rewards, celebrates, castigates, and punishes, whether overtly or discreetly. Admittedly, I can be double minded about this: I applaud the heroic and sacrificial efforts of physicians laying down their lives on the frontlines and at the same time encourage them not to give so much of themselves away that that end up depleted. The paradox of this challenge is maddening for physicians and non-physicians alike: how can you be awesome at your job without being so “extra” that you overdo it?

    I do recognize that this is just the end of the beginning phases of this crisis. Most physicians still do not have the mental or emotional luxury of thinking beyond survival mode right now, and maybe not for a long time. But eventually, we will start picking up the pieces of healthcare in the aftermath of this disaster and decide just what to rebuild together. Right now, nearly every industry is talking about re-imagining a more sustainable pathway going forward and medicine should be no different.

    Emboldened physicians may look at this opportunity to demand better conditions where they do not have to choose between working hard or dying because of their work, physically or psycho-spiritually. It is obvious to all that the lack of physical PPE for healthcare workers is a disgrace. What I hope will also be acknowledged is that “emotional PPE” is a requirement for this job too, so that heroic stoicism is no longer necessary to survive its hardships.

  • 02/27/2020 8:53 AM | Anonymous

    At the 61st Annual Winter Clinics this year, we enjoyed the thoughts and research of a world class physician speaker with an emphasis in the humanities alongside the more clinically focused topics by local and regional specialists. It made for an interesting juxtaposition of left and right brain thinking.

    Some physicians may remember the name Dr. Salvatore Mangione because of his well-known book Physical Diagnosis Secrets.  In fact, one physician commented that she kept the book close to her all the way through residency. Trained in pulmonology, Dr. Mangione is currently an Associate Professor of Medicine at Thomas Jefferson University. In part because of his Italian upbringing and education, he has a strong interest in the historic, poetic, and artistic as it relates to medicine.

    Leading off with “The Art of Observation and the Observation of Art,” Dr. Mangione underscored the importance of a skill that astute physicians use every day to make effective clinical diagnoses: the Zadig Method. It was first pioneered by Italian physician Giovanni Morelli, practiced and taught by Dr. William Osler, and epitomized by Sherlock Holmes, a character modeled in part on Edinburgh surgeon Joseph Bell.

    Mangione illustrated it by exploring the painting “A Portrait of a Lady,” which hangs in the Philadelphia Museum of Art in his home city. If you did not know any better, one might think it would be more aptly titled “A Portrait of a Somewhat Homely Lady.” But with a deeper knowledge of 15th century Venice, Renaissance portraiture styles, and close examination of her physical features, one can actually deduce quite a bit.

    Dr. Mangione observed:

    • Based on the color and style of her clothing, her lack of jewelry, and her headscarf, she is most likely one of the 11,000+ tax-paying prostitutes in Venice at the time.
    • Although the color of her face could indicate the use of rouge or perhaps even indicate secondary syphilis, knowledge of how and when make-up was used and when the STD appeared in Italy disfavors that conclusion.
    • More likely, the skin-rash, her receding hairline, and wispy red hair supports the possibility of lupus. This is further evidenced by a swollen right eyelid and a noticeable goiter.

    The accurate rendering of these features, Mangione pointed out, predates Cazenave’s report of lupus érythémateux by almost 400 years. Does art have something to teach doctors about the importance of being more observant? You bet.

    In another talk, Dr. Mangione explored 11 different archetypes which physicians have fit into over the centuries. He explained that to have the greatest impact in our communities and societies we must not think of the profession as a one-dimensional technician of science. He did a deep dive into some of the roles by profiling three physicians:

    • The Physician as Poet – Canadian Col. John McRae, whose “In Flanders Fields” is the iconic WWI poem written as a plea by the dead to the living to not let them die in vain.
    • The Physician as Humanist – William Osler, who revolutionized medical teaching in North America, wrote before his death, that grievous damage “has been done by regarding the humanities and science as anything but ’twin berries on one stem’”
    • The Physician as Philosopher - Rita Levi-Montalcini, one of 12 female physicians to receive the Nobel Prize in Medicine, hers for the discovery of Nerve Growth Factor. Her career included not just medicine, but also as a Senator for Life appointee in Italy and an outspoken advocate on human rights.

    In his banquet keynote speech, “Leonardo at 500,” Dr. Mangione pulled nine lessons in creativity from the life of Da Vinci, on whom he has clearly done extensive research. In fact, he has published a few articles on the man considered to be the most creative to have ever lived. In a 2019 American Journal of Medicine article, he makes the case for how Da Vinci’s likely dyslexia led to him being such a great visual thinker.

    Once again, the talk emphasized the need as physicians to balance the best of scientific advances with some seemingly non-scientific principles such as humor, ambiguity, and idleness. He argued it is out of these qualities that Leonardo’s great creativity sprung. Combined together, Dr. Mangione’s wide ranging talks resonated with what many physicians are feeling today: the practice of just pure medical science as a widget in the cog of healthcare without the time or permission to feel and be human is deleterious to a calling as healers.

    If anything, Winter Clinics punctuated the need for physicians to reclaim medicine from owners, managers, and governments who may not share the same deep humanistic impulses that led many to medical school. It was important for attendees to explore innovations in cardiology, point of care ultrasound, cancer, and internal medicine; to talk about using tele-health to deliver care to rural areas; and to think about the possibilities that genetic testing holds. But my overwhelming takeaway was that science will not help us answer the ethical questions that arise in the practice of medicine. Those dilemmas, Mangione said, can only be addressed by looking backward at the rich history of poetry, literature, art, and philosophy expressed over the past few millennia.

  • 01/01/2020 12:00 AM | Anonymous

    Up until 1960, Boise area physicians were members of the SW Idaho Medical Society(SWIMS), a territory that started at the Nevada/Oregon border going north to New Meadows and east to Glenns Ferry. An evening dinner was held monthly in the Owyhee Hotel. The highly collegial meetings – always preceded by a cocktail hour – allowed for doctors to discuss patient cases, meet specialists for referrals, and routinely ignore the objections from more conservative members about the use of dues to pay for drinks.

    Eventually, a group of doctors elected Dr. Loy T. Swinehart as the president of the unofficial “Boise Physicians Club.” A group in name only, they distributed triangular shaped windshield stickers for physician cars to keep them from getting towed if parked in unauthorized places or doctors only stalls. Soon, it became obvious that the Boise area needed its own officers and local organzation, although it made the rest of SWIMS members nervous about them breaking away.

    A petition was carried to the IMA Annual Meeting in Sun Valley and passed by the Officers and Councilors there, granting a charter to ACMS on January 30, 1960. Ada and Elmore Counties were designated as its own component society of the Idaho Medical Association and Dr. James J. Coughlin became the first president of the Society.

    In its first meeting that month, a long list of reasons was recorded as raison d'etre for ACMS. They provide an interesting perspective on the issues of the era for the medical community, some remaining quite relevant even to today. Among them:

    • Marriage Counseling
    • School physicians – football exams
    • Mental Health Clinic
    • Indigent Care
    • Physician-Hospital Relationship
    • Polio Foundation
    • Booth Memorial

    One of the major roles that ACMS played late into the 20th century was a grievance committee to examine malpractice and patient complaints. This consumed much of the organization’s time adjudicating issues to protect the practice of medicine through local peer review. As this process was increasingly assumed by the Idaho Board of Medicine – and amidst anti-trust lawsuits against membership associations in other states - medical societies have happily shed this responsibility to agencies with more authority.

    A 1963 County Fair Display showing diseases that had been laid to rest by immunizations. If only!

    Over the years, ACMS has had a strong hand in various community health efforts including:

    • Since the early 1970's, helping launch at least 4-5 community clinics for the uninsured. More recently, ACMS stood in the gap for the uninsured when it mattered most just last year, by helping raise funds to pass Proposition 2 to expand Medicaid in Idaho in a historic ballot initiative vote.
    • Supporting the establishment of the Family Medicine Residency of Idaho in the 1970’s and helping promote the expansion of it and other residency programs in Boise.
    • In 1975, ACMS and IMA helped bring the California-based Medical Insurance Exchange Carrier (MIEC) to Idaho to provide liability coverage amidst a statewide malpractice crisis when several carriers fled the state.
    • Helping charter Ada Canyon Medical Education Consortium (ACMEC) to provide ongoing medical education opportunities.
    • Providing financial and medical support for organizations like the Booth Memorial Home for Pregnant Teens, the March of Dimes, and NAMI.
    • Helping promote various public health issues including immunizations, anti-smoking statutes, suicide prevention, and mental health.
    • Coming alongside area high school physicals screening since around 1980.
    • Launching three Boise State University scholarship funds (through the ACMS Auxiliary, which has its own article length legacy since the 1930s) for nursing, medical technology, and respiratory therapy.

    Some say that 60 is the new 40 and if that is the case, this medical society is nowhere near retirement. Whereas nationally, many local medical societies are having existential crises when big employers of physicians no longer feel a need to pay association dues, ACMS is continuing to grow. In the past six years alone, our membership has jumped from 1229 to over 2300. Our market saturation of physician members among all those licensed in Ada County is 72%. These facts owe to continued strong relationships and mutual esteem with hospitals and large groups, a city that is bursting at its seams, and relevant modern programming.

    Nowhere is this more evident than in the way ACMS has led the way on issues surrounding physician well-being. We were an early adopter of providing confidential physician counseling as a membership benefit. We have subseuqently helped rapidly spread this kind of program to over 20 county medical societies through collaborative publication of an award-winning toolkit. Our efforts at fanning the flames for institutional and cultural change has been pivotal and inspirational. It is not only ACMS as an institution, but its individual members who have caught this vision and are adamant about stemming burnout in the profession.

    This year we are celebrating our 60th anniversary with a weekly spotlight on an ACMS physician each month. You can see our first eight honored here and we will get to 52 over the next 12 months. We want all members to nominate those who deserve to get more attention than they are used to.

    As ACMS looks beyond our own careers and lifetimes to the next 60 years of medicine, we face an ever-changing landscape of regulations, societal and consumer expectations, and technological market disrupters. Now more than ever physicians must fight to stay connected to each other and to their patients to provide the very best care. As your local medical society, we aim to build a foundation of leadership excellence and relationships that will embrace the challenges of the future while holding onto the historical fundamentals of medicine. Thank you for joining us for the ride.

  • 11/29/2019 8:00 AM | Anonymous

    Last month, I hung out on the sides of a memorial service for Dr. James Valentine that was hosted by the St. Luke’s Medical Staff Office. Dr. Valentine passed away in a self-piloted helicopter crash in October near the Owyhees; his daughter who was riding with him survived. For those who do not know him, Dr. Valentine was a highly skilled bariatric surgeon who has been part of our medical community for 26 years. His surgical colleagues admitted that he was twice as productive as them because of his honed giftedness in the operating room.

    There was, of course, a lot of grief and tears expressed, the quiet and solemn sense of loss, not just of a prominent surgeon in our community but also of a giant among human beings. On and off the field, he had a ravenous appetite for adventure and various hobbies. He taught one of his daughters how to fly a prop plan on a trip through Canada and the next week he turned around to go hiking in the Himalayas. He owned a Hummer, sports car, a dump truck and a smart car, the last of which apparently was especially fun to pull his six and-a-half foot frame out of. But beyond his technical skills, and maybe a little eccentricity, what was spoken about most was his genuine interest in every person that he encountered.

    From the janitor to the nurses and M.A.s, physicians and patients, everybody shared how intensely interested Dr. Valentine was in their lives. In the middle of a fast-paced clinic, he would slow down to inquire with people how were things going. When finished with the patient’s health care needs, he would extend the appointment just to get to know them a little more, often asking patients, “What do you do for fun?” He loved making people laugh. As one doctor put it, “He was the only surgeon I’ve known to bring a fart machine into the operating room.”

    And as I watched people laugh, cry, console and comfort each other, I believe that I witnessed a microcosm of the entire medical community we live in. The fact is that in healthcare, there is going to be pain. Sometimes it will revolve around patient care: bad outcomes, a malpractice suit, family that feels let down by our efforts. Other times, pain is initiated by the systems in which we work: bureaucratic hurdles to get good care to patients, credentialing issues, peer review, coding, and EMRs. We live in a world that no matter how hard we work at it to iron out all the kinks, there are always going to be kinks.

    So, in this moment I felt honored to witness, I saw the true picture of how see our medical community operating under the most trying of times. It doesn’t matter the color of your scrubs, pedigree or degree, we can still connect with each other on the very basis of our society: human to human, heart to heart, people just being people.

    Dr. Valentine’s friendship and warmth clearly inspired many people to live richer relational lives. At one point, Dr. Josh Barton, who provided one of the eulogies, said that he is done putting work ahead of everything else. “I’m not waiting any longer to build my friendships deeper. I’m starting now.”

    That is something we can all take to heart.

  • 10/31/2019 4:24 PM | Anonymous

    Boise VA Medical Center’s Dr. William Weppner recently gave a presentation titled “How Innovation Takes Hold: The Structure of Medical Revolutions.” He described how scientific paradigm shifts occur when a theory that no longer adequately explains what we can observe is replaced by one that does.

    This process, originally described in Thomas Kuhn’s seminal 1962 work, is usually initiated by those “very young or very new to the field whose paradigm they change.” Such new ideas are often initially rejected by insiders who defend existing models for a variety of reasons before eventual adoption. Case in point: when Ignaz Semmelweis’ proposed and demonstrated effectiveness in hand sanitation to prevent childbirth infections due to “cadaveric contamination,” his ideas were rejected by the medical community for many years.

    Dr. Weppner finished by exploring game-changing medical revolutions that are already in process: gene editing, targeted immunotherapies, and of course artificial intelligence. This set me to wondering how A.I. might affect the way we educate medical students.

    Let me back up and start by sharing how one local public charter school is openly asking some big questions about the way they teach. Administrators recently shared this video with parents and teachers which should leave educators everywhere scrambling to answer this question: If 40% of the jobs that our kids will fill in just 20 years do not yet even exist, what skills will we teach them to succeed? This is going to require completely different educational methods than the outdated 19th-century ones we currently use, such as standardized multiple-choice test-taking.

    What is true in elementary school is certainly true in medical school. Even Dr. Weppner shared, to knowing chuckles and nodding heads in his audience, how medical school instructors will say that half of what is being taught is not accurate: they just didn’t know which half. The tongue-in-cheek admission is borne out by physician researchers Adam Cifu & Vinayak Prasad, authors of Ending Medical Reversals.  They performed a study indicating that 40% of “practice changing” publications from a decade of a prominent medical journal articles were found to be either wrong, or actually harmful. A study by IBM in 2013 reported that clinical knowledge is doubling every 18 months.

    If the acquisition of so much medical knowledge is so quickly outdated and A.I. is going to come alongside physicians to help make better medical decisions, this begs the question: how might medical education change to create better doctors for the future? Let’s look at some examples.

    The exponential growth rate of the body of specialized biomedical knowledge is only going to continue to increase. And yet, medical schools continue to try to stuff all of this into the emotionally healthy brains of brilliant and uber competitive medical students in a short window of time. We know what this does to them based on research: just two years in, their mental health plummets below that of their non-medical peers. They simply can’t keep up without major mental distress.

    Indeed, where I have seen the most distress in physicians is those who are unwilling or unable to roll with the punches that rapid industry change has brought over the past 15 years. I can cite local examples of physicians bow out of the game early because of ICD-10 or Epic adoption. I would submit that at a minimum, medical institutions need to continue to integrate “non-clinical” skills like stronger lifetime adaptive learning and team-based interpersonal abilities.

    There are promising examples being proposed: AMA has just published The Master Adaptive Learner in their MedEd Innovation Series based on research led by William B Cutrer, MD, M.Ed. He describes the four critical personal characteristics that support this process are curiosity, motivation, growth mindset and resilience. In this model there is a learned balance between routine clinical expertise (where efficiency is high and innovation is low) and creative exploration (where the innovation and efficiency trade off is reversed.) The target of the “optimal adaptability corridor” is what they call “adaptive expertise,” where a wide range of conceptual understanding is applied and both innovation and efficiency are high.

    This brings us full circle to Kuhn’s citation of Albert Einstein when he wrote about the wave-particle duality: “It seems as though we must use sometimes the one theory and sometimes the other, while at times we may use either.” Medical schools, health institutions and physicians who can hold this tension in balance will probably be the ones who can thrive in whatever the future brings. Teaching this skill might just help bring about another revolution in the practice of medicine.

  • 09/30/2019 6:00 AM | Anonymous

    This summer, the Ada County Medical Society (ACMS) Foundation provided suicide prevention training to more than 370 local medical students, physicians, advanced practice providers, and hospital administrators. So far, a grant from the St. Luke's Community Health Improvement Fund (CHIF) and partnership with The Speedy Foundation has made possible five different trainings.

    Suicide rates for U.S. physicians are estimated to be up to 230% higher than the rate for the general population. Our goal is to equip our local medical professionals to help themselves, distressed colleagues, and their own families. We provided QPR training, an evidence-based suicide gate-keeper process with three steps: Question, Persuade and Refer. QPR is like CPR: both professionals and lay-people can be trained in it and should apply it immediately when they think someone they know might be suicidal.

    I am glad to have received this training myself and have used it three times in the past year alone. For instance, I spoke with a physician this month who was struggling with something that most certainly would bring professional and personal shame. Not knowing her well, I took the risk of asking, "Has this made you consider harming yourself or taking your own life?" She answered, "Well, I think I've worked through those issues and have moved beyond them." My interpretation is that in her mind, that option was actually on the table.

    The unique skillsets that help physicians make it through the rigor of medical school and residency, and make them good doc-tors – for example, being obsessive, autonomous, and able to turn their emotions off and just do their job – can be a recipe for suicidality when things go wrong.

    And in medicine, things often go wrong.

    St. Luke's Elmore and Treasure Valley medical staffs hosted two of the training sessions and we were very gratified when the Idaho College of Osteopathic Medicine (ICOM) opened its doors as well. We provided focused training to faculty and staff, as well as both first and second-year classes. Over time, I believe today's trainees have a strong role to play in reshaping the culture and systems of medicine, and helping bend the curve down toward zero physician suicides.

    September was National Suicide Prevention Month and September 17th highlight-ed the second annual National Physician Suicide Awareness Day, organized by the Council of Residency Directors in Emergency Medicine. This day commemorates physician lives lost to suicide and strives to raise awareness about this issue.

    I encourage you to program the Idaho Suicide Prevention hotline into your phone for calls or text: (208) 398-4357. You can also text 741741 or call 1-800-273-8255 for the national hotline. You do not have to wait until there is an imminent threat - you can use these lines to identify referral re-sources or get comfortable with asking the difficult question.

  • 08/30/2019 6:00 AM | Anonymous

    I just finished reading “Things Fall Apart” by Chinua Achebe. It is the 1958 archetypal modern African novel, one of the first to reach global critical acclaim and on many lists of the most influential novels of the 20th century. While it is a relatively simple read by length and content, it is not an easy read as a Westerner and left me squirming in my seat and thinking about its parallels to medicine.

    The protagonist, Okonkwo, is a warrior tribesman in pre-colonial Nigeria. He is an overcomer against enemies, droughts and deluges, a champion wrestler, and strives to show no weakness. He judges other men to be “women” because of their inability to do hard things, whether it is work their own land or be willing to go to war. The novel follows his personal journey through ascendancy in his clan as well as a shameful temporary exile for a manslaughter accident.

    His story climaxes as colonial and religious forces threaten to upend the way his people have lived for generations, leaving him bereft of his identity in a world that is evolving too quickly. SPOILER ALERT: The book is a tragedy. I won’t say just how it ends, but it concludes abruptly in the patronizing words of the British District Commissioner who is musing about the book he’ll write someday: “The Pacification of the Primitive Tribes of the Lower Niger.”

    As I closed the book, my mind went quickly to the many physicians who I suspect may feel a bit like Okonkwo. In their own time, they were legendary, self-reliant warriors who did whatever was necessary for the tribe of medicine, revered heroes, maybe even a bit intimidating at times, holding influence over their clans as demi-gods.

    In time, however, capital imperialists moved into their realm, offering assurances of salvation from everyday hassles and access to new markets. The younger warriors took the bait and the older ones suddenly found themselves trying to make sense of this new world order and where they fit in it. They moan about the “wussification” of medicine, don’t understand this whole burnout epidemic, and wonder what will become of their traditions. They ache for the days when their cultural identity and hard work provided them with influence, status, and security. Whether they like it or not, the world is coming to their front door and telling them how medicine is going to work (and how they’re going to work for medicine.)

    In the end, will this warrior class of physicians become just a footnote in the annals of how medicine progressed towards some soulless ideal of care? Will they rise up against “The Man” and say, “you can go here, but only so far”? Will they remember the obstacles they overcame to get into medicine and use their fortitude to stay engaged in it? Or will they finish their careers or lives feeling the futility of fighting against a foe that views them as expendable widgets in the standardization of medicine?

    It is too early to say if things will fall apart for physicians the same way they did for Okonkwo. There is still plenty of opportunity to fight for how medicine is delivered. The ideals that are worth “unsheathing machetes” for must revolve around what is best for the patient and what allows doctors to maintain their sense of purpose over the course of their career. This will require both resistance to and adoption of new ways. To have influence, doctors will have to learn the language and motivations of new administrations to keep them from destroying what is sacred in medicine.

    Anything less than that will truly be a curse on the land.

  • 07/29/2019 7:08 PM | Anonymous

    Remember two, three, four years ago when all the construction along Myrtle Street was going on? The JUMP building was finally being finished, two new hotels were going up at Capitol Blvd, followed quickly by the Fowler Street apartments. And as soon as that was done, lanes were shut off on Front Street to host the new parking garage and hotel across from Simplot. It was like a vaso-construction of major arterials. Is it possible for a city to have a myocardial infarction in the heart of downtown?

    By the end of 2017 it seemed that quality of life in Boise had been noticeably reduced for the first time in the 18 years I’d lived here. I had convinced myself that “someday we will get our lanes back that have been used for construction.” Perhaps I could recoup a third of my commute time that had been added. Eventually, I came to grips that there was probably never going to be any going backwards unless I wanted to move to Twin Falls, Pocatello or Moscow. This was the new normal.

    I sometimes wonder if doctors feel the same way about their practice of medicine. Everyday it seems like there is more traffic added to your work: more boxes to check, more questions to ask, more paperwork to fill out. Suddenly, new lane restrictions arise that don’t allow you to use all the space or time or energy previously available to you when things seemed to flow so smoothly. Where there used to be a good “stopping distance” between patients, everything is crammed a little tighter now and patients expect more out of you in less time you’re provided to give it. Collisions between patient time blocks occur more frequently. 

    You tell yourself that someday EHRs, and AI, and ACOs you help you recoup your lost bandwidth and you’ll get your hands off the keyboards and onto patients during exams. 

    We’ll see.

    I have shifted my expectations and come to accept the reality that our streets will be as crowded as they are for a long time to come (or at least until artificial driving intelligence takes over and radically affects the number of cars on the road). In the meantime, here’s a few ways I’m responding that help me on my drive home:

    1. Gratitude - First, my commute is only between 15 and 30 minutes, at worst. Compare this with our peers in Seattle or Portland or anywhere in urban California, let alone a third-world county. When I was driving a pastor from Kenya around Boise some time he said, “You have the most beautiful roads. I pray that someday my own people will have access to roads such as these.” Hearing that perspective made me appreciate all we do have.

    2. Be Creative - it is too easy to always use the same proven paths over and over, and if you’re commuting from Boise to Meridian every day, you don’t have that many options. But there is something to be said about taking an entirely different way from time to time. It may be faster or slower or about the same, but seeing some different scenery can help a lot.

    3. Travel as a Team - I have the privilege of carpooling with at least two of my kids during the school year. This summer, it’s been a real privilege to carpool with my college-age son, commenting about news stories with each other or just debriefing each others’ days.

    4. Speak up when you see something wrong - over the years, I have provided DOZENS of suggestions to the very responsive Ada County Highway District, several of them being addressed and implemented. I am positive they roll their eyes every time they see another email. But they are responsive and I can take credit for the Federal Way speed limit south of Amity going up to 45 after they introduced five lanes there years ago. (My kids also credit me with the introduction of flashing yellow left-turn signals to the city, but it was probably coming anyway.)

    I don’t know how my driving lessons might translate for you in regards to medical practice; that’s a journey for you to take on your own. I do know that by the time I get home I am ready to greet my family with a little more peace and understanding then if I bellyache the entire way.

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