JULY / AUG 2019

A PUBLICATION FOR THE MEMBERS OF THE WASHINGTON STATE MEDICAL ASSOCIATION

Health at Risk Washington see the physical tolls of climate change PAGE 6 Washington Permanente MedicalGroup We are anEqual Employment OpportunityEmployer something special...somethingthat matters. Join usandbecome partofsomethingunique, place to live. elements, andothers,make Washington anexcellent host ofcultural andrecreational opportunities.These destination withbeautifulscenery, friendlypeople, anda Many know thePacific Northwest asanattractive tourist Washington state’s richlydiverse communities. lifetime relationships withpeersandpatients in patient-centered care. We are dedicated to building on prevention, evidence-based practices, and health specialists, osteopaths andoptometrists focused We are nearly1,100 physicians, PAs, midwives, mental multi-specialty group practices inthePacific Northwest. (WPMG) isamongthelargest andmost honored calling to care. Washington Permanente MedicalGroup Permanente Medicineempowers you to harness your about medicinedi erently. From thevery beginning,we have thought Called to care ® please visit:wpmgcareers.org For consideration orto apply, care benefits • Long-term disability, long-term • Continuing medicaleducation • 401(k) &employer-paid contribution • Paid vacation • Medical/dental/vision benefits • Fullmalpractice indemnification the following benefits: shareholder inourpractice andenjoy will have theabilityto become a As aKaiser Permanente clinician,you Washington State OPPORTUNITIES PROVIDER

PHOTO CREDIT COVER: PETE RYAN; THIS PAGE (CLOCKWISE) SAM POSNIK/ISTOCK; RAMON SALINERO ON UNSPLASH. contents Honor your patients'rightto informed decision-making. Protect Against Claims /14 BY PAT CURRY Health care systems address sustainability. Taking aStand /10 BY RITA COLORITO Washington physicians seethephysical tolls ofclimate change. COVER STORY Features July/August 2019 Fax: 360.352.4303 360.352.4848 or800.562.4546 Bldg 7, Suite A,Olympia,WA 98502 1800 Cooper Point Road SW, OLYMPIA OFFICE Fax: 206.441.5863 206.441.9762 or800.552.0612 Seattle, WA 98121 2001 SixthAvenue, Suite 2700 SEATTLE OFFICE Washington State MedicalAssociation. as theofficialpublicationof WSMA Reports ispublishedbimonthly

Health at Risk /6

Katie Howard DIGITAL EDITOR 706.714.2808 [email protected] Pat Curry SENIOR EDITOR Graham Short MANAGING EDITOR Milana McLead EDITORIAL DIRECTOR Jennifer Hanscom DIRECTOR/CEO EXECUTIVE

ADVERTISING Erin Foster AND DESIGN ART DIRECTION Tom Schaaf, MD PRESIDENT Donna Smith,MD CHAIR COMMITTEE: WSMA EXECUTIVE 206.441.9762 [email protected]

Sound the / Sound Alarm Heartbeat sicken moreWashingtonians intheyearsahead. Pollution, extreme heat,badwater, andmorewill Bad for Your Health /16 By theNumbers the news. greenwiththeAMA’scan go toolkit;membersin Meet WSMAmemberAlanMelnick, MD;practices WSMA Huddle communities, andthestate Legislature’s budget. Environmental healthimpactspatients, Climate /2 Consequences Vital Signs climate change. climate change. ofsmoking.It’sdangers timetostart talkingabout ago,A generation physicians spoke upaboutthe Nariman Heshmati,MD TREASURER SECRETARY- ASSISTANT Katina Rue,DO TREASURER SECRETARY- Mika Sinanan,MD, PhD 2ND VICEPRESIDENT Nathan Schlicher, MD, JD 1ST VICEPRESIDENT Bill Hirota, MD PRESIDENT-ELECT 17

BY MARKVOSSLER, MD /3

17

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uring last November’s board meeting, your WSMA trustees were considering the organization’s strategic plan and goals for the coming year. Thoughtful discussion led to one of our leaders posing the question: What should the WSMA be doing around climate change? There ensued a robust debate, which continued in the subsequent days by email. There were a range of views. Many wondered what WSMA’s role could or should be, while some questioned whether the WSMA should be in this space at all. Some shared concern about resources that might be required and others suggested staff Climate lead on the topic with some specific suggestions. No matter what, we know that the health of our environment is closely linked to the health of our communities. Who can forget the smoke from last summer’s Change wildfire season and how that impacted the health of Washingtonians? Already, state officials are predicting another tough fire season for our state. For many practices and hospital emergency rooms, that will mean Stirs Up seeing more patients whose health conditions are worse due to smoke inhalation. The elderly and the very young are the most vulnerable, as always. People with a Perfect asthma or other pulmonary problems are more likely to have their health further compromised by poor air quality. It’s no surprise the medical community is concerned about the impact of Storm climate change on patients and community health. According to a study in the Journal of the American Heart Association, when dense smoke is present, people over the age of 65 are 42 percent more likely to visit the emergency department for heart attacks and their cardiovascular risk is 40 percent higher. In real terms, this means wildfires are creating a crisis that is keeping pace with the increasing frequency and size of these events. Climate change also has an immediate impact on our state’s resources. In this year’s legislative session, state legislators approved $50 million more for wildfire prevention. That’s the largest appropriation in the state’s history, and it puts additional pressure on state dollars. And that pressure puts the squeeze on WSMA’s priority asks, such as increasing Medicaid reimbursements or eliminating a B&O tax increase. Clearly, the impact of climate change on health is a nuanced issue with a multitude of voices and opinions. But at its core, our concern is to help shape a comprehensive approach to environmental challenges so that we can strive to protect the health of patients. A good place to start is getting smart on the topic. Hopefully, this issue of WSMA Reports will prompt more conversation. Have some thoughts on the matter? Write me at [email protected].

Jennifer Hanscom WSMA Executive Director / CEO ANDREA PEER PHOTOGRAPHY; ILLUSTRATION: FREEPIK.COM

2 WSMA Reports July/August 2019 huddle Touching base with need-to-know news for WSMA members

Member Profile Dr. Alan Melnick testifying at the Alan Melnick, MD, 2017 WSMA Annual Meeting. MPH, CPH

Works at: Clark County Public Health

Specialty: Public Health and General Preventive , Family Medicine (double-boarded)

Why WSMA: The WSMA is the voice of Washington physicians, who are essential in protecting and promoting the health of the public. I joined the WSMA knowing that it is a key partner in strengthening ties between the governmental public health system and practicing physicians, and that it takes a leadership role in developing policies to improve the health of all The WSMA is the voice of Washington“ Washington residents. physicians, who are essential Proud moment: Two recently: Working in protecting and promoting the with community partners, including health of the public.” physicians, to control the recent measles outbreak, and working with the WSMA to pass a bill removing the personal medicine because of its upstream, barriers resulting from hierarchical exemption from school requirements for preventive approach in addressing the workplace cultures. the MMR vaccine, thereby helping protect social determinants of health. Washingtonians from future vaccine- “The Status Syndrome,” written by an preventable disease outbreaks. Best advice I ever got: Understanding epidemiologist, analyzes how position in that positional/professional authority can social hierarchy is a determinant of health. Top concerns in medicine: In my be intimidating, and that given the power “The Healing of America” describes how specialty—adequate funding for dynamics, other team members might not industrialized countries achieved universal foundational public health services. In feel safe giving me critical feedback (which access and better health outcomes. health care—health disparities, inequities could adversely affect patient safety), and in access to health care, and the impact “The Ghost Map” tells the story of Dr. that I couldn’t be as effective working alone. of social determinants, such as housing, John Snow, a public health pioneer, who Thus, if I were going to be a successful education, and employment, on health. investigated and determined the cause of physician leader, I needed to learn how cholera outbreaks in mid-19th century. to listen to, honor, and respect my non- What inspires me about being in medicine: “The Immortal Life of Ability to make positive difference in peoples’ physician team members. This is a lesson I continue to learn. Henrietta Lacks” tells the story lives and in the health of communities. of the origin of HeLa cells, Why I became a physician: I began college Pet peeve: Right now, misinformation and raises questions about as an engineering student, but realized I about measles and immunization that research involving human wanted to work with people, that there vaccination opponents are promoting. subjects, including consent, were health disparities, and I wanted to involvement/treatment of Good reads on health care: create positive change. racial and ethnic minorities “Why Hospitals Should Fly” explains as research subjects, and Why I’m drawn to my specialty: I was what hospitals could learn from the airline ownership/profit from human drawn to public health and preventive industry by addressing communication tissues used in research. ANDREA PEER PHOTOGRAPHY

July/August 2019 wsma.org 3 4 huddle the News WSMA Reports Members in vaccination rate athisclinic. in Seattle,was recognized for hiswork increasing thechild April. Dr. Hamling,apediatricianatPacific Medical Centers Immunization Champion Award for Washington state in for DiseaseControl andPrevention’s 2019 Childhood serving thePort Townsend area. officer andaprimarycare physician atJefferson Healthcare, Health Association inApril.Dr. Mattern isthechiefmedical Rural HealthCare Practitioner by theWashington Rural 2019 Dr. JohnAnderson MemorialAward for Outstanding

Alex Hamling,MD, ofSeattlereceived theCenters Joseph Mattern, MD, ofPort Townsend was awarded the

Rehabilitation Institute inSpokane. is thechiefmedicalofficer atSt.Luke’s assistant training program. Dr. Carter the University of Washington’s physician for hiswork asateacher andmentor with ceremony onApril27. Hewas honored Northwest alumnireception and award Preceptor award attheMEDEX presented the2019 MEDEXOutstanding Family Care Network. as president andCEO ofBellingham’s on May 10. Dr. Hipskindrecently retired annual meetinginCoeur d’Alene,Idaho of theYear for 2019 attheacademy’s Family Physicians’ Family Physician was namedtheWashington Academy of Pacific Northwest University in Yakima. to theDeanofCollege ofMedicine currently serves asthephysician advisor d’ Alene,IdahoonMay 10. Dr. Maier academy’s annualmeetinginCoeur Academy ofFamily Physicians atthe elected president oftheWashington

Gregory Carter, MD, ofCentralia was Marcy Hipskind,MD, ofBellingham Russell Maier, MD, ofYakima was people definetheirlane.” because they refused to letother millions oflives are owed to them not speakup. Imaginehow many and publichealthleaders did world would benow ifmedical cigarettes. Butimaginewhere our in talking aboutthedangers of regulation, inautomobile safety, no role to play inenvironmental and publichealththatthey have my predecessors inmedicine There are peoplethathave told Overheard download ontheWSMA website. The WSMA Delegate Handbookwillbe available for AUG. 30 WSMA’s “Listening Tour” arrives inVancouver. AUG. 29 WSMA’s “Listening Tour” arrives inSpokane. AUG. 22 WSMA Delegate Handbook. at theWSMA Seattle office forpublicationinthe Deadline for reports andresolutions to bereceived AUG. 16 Washington state primaryelection. AUG. 6 legislative session. Effective date for billspassed during2019 state JULY 28 August primaryelection18-day voting period begins. JULY 19 Hold theDate —LEANA WEN,PRESIDENT, PLANNEDPARENTHOOD IN ANEWYORK TIMESINTERVIEW, MAY 5,2019 July/August 2019

ILLUSTRATION: FREEPIK.COM ILLUSTRATION: FREEPIK.COM July/August 2019 local county society orstate specialty society. the 2019 WSMA AnnualMeeting,pleasecontact your of trustees. Ifyou would like to serve asadelegate at well asrepresentatives ofspecialsectionsandtheboard their respective county society orspecialty society, as WSMA members whorepresent, andare designated by, for details). The HouseofDelegates iscomposed of Oct. 12and13inSeattle(see inthisissue meetinginsert Delegates, WSMA's premier policy-making event, is The 2019 AnnualMeetingoftheWSMA House of How to Serve asaWSMA Delegate totally preventable diseasessuchasthese. right thingto ensure ourstate hashopefor afuture free of legislators whostood onthesideofscience anddidthe devastated thelives ofchildren. Here’s ashout-out to the of atimewhenpolioepidemicsrocked thecountry and to cure. that vaccines save lives andthatprevention ispreferable vaccine, WSMA memberphysicians reminded legislators exemption for theMMR(measles,mumps,andrubella) Bill 1638,whichremoves thepersonal andphilosophical During thebattlethislegislative session to pass House Vintage WSMA This photo from theWSMA archives isasoberreminder started today!started practices. Get and thepublicongreen to helpeducate theirpatients promoting sustainability and serve asrole modelsfor encourages physicians to bit.ly/amatoolkit. The AMA guide to doingjustthatat The AMAoffers asimple footprint intheirpractices. by reducing thecarbon and helptheenvironment Physicians canlower costs Here’s how Want to go green? huddle the physical tolls ofclimate change Washington physicians see at Risk Health BY RITA COLORITO

PHOTO CREDIT PHOTO CREDIT

PETE RYAN Every spring and summer, Tony Natural Resources predicts 2019 will 2019 will predicts Resources Natural safe shelter. and food, sufficient water, and air health—clean of public determinants societal and environmental the impact that insects disease-carrying of spread and level rise sea as well as flooding, and drought, events, heat severe and frequent of increasingly acascade to led have gases, greenhouse by skyrocketing driven worldwide, Assessment, temperatures rising Climate National 4th the to According smoke wildfire of dangers The more severe.” much be also but can frequent, more much not only are exacerbations “Those Dr. air,” says Butruille. the in allergens smoke more and and conditions drier you when have spike all allergies and smoke. avoid to the try they as patients of Dr. Butruille’s for many air. of unhealthy days consecutive several experiencing Seattle with world, the in worst the was Washington in quality air the August, last times At office. Northwest Pacific Forest Service U.S. the to according state’s greatest to exposure wildfires, the has Mountains, Cascade of the east foothills the in people of some 2,000 of fires on record in 2018. concern, with the highest number wildfires are the front-and-center Throughout Washington state, the 21st century”—climate change. “greatest public health threat in Health Organization says is the the impact of what the World in Leavenworth, deals with Butruille, MD, afamily physician “Respiratory issues, asthma, COPD, issues,“Respiratory asthma, ashut-in period become has August city aBavarian-style Leavenworth, Washington’s Department of Department Washington’s than adults because their metabolism metabolism their because adults than weight of body pound per air more breathe who children, smoke on wildfire of effects long-term and developmental other second.” every heart the through filtered of what’s percent get 20 kidneys the and heart, the to circulates is absorbed through the bloodstream, tissue, lung deeply into very penetrates micrometers, 2.5 under matter, particulate Dr.says Dooley. “Small Bellevue. in nephrologist Dooley, a MD, Annemarie says problems, County. &King Seattle – Health Public officer for health and MD, a physician Duchin, Jeffrey says see,” to expect can we diseases pulmonary and cerebrovascular, cardiovascular, more the environment, our in have we problems. lung and heart and allergies, asthma, elderly, with those and the women, pregnant children, young to west of struck the March, Cascades. the end of by occurred that wildfires unseasonal 50 49 andof fires, 1,850 year’s of last percent 40 Some state. the of half eastern drier the it’s not just and season— longer fire and earlier an and temperatures drier hotter, experience Researchers are still determining determining still are Researchers sieve,” agiant as act “Your kidneys kidney with those are impacted Also pollution air smoke more and “The risk greatest the poses smoke Wildfire wsma.org 7 runs faster, says Chris Covert-Bowlds, SEATTLE • TACOMA MD, a family physician in Seattle. TOP CLIMATE HAZARDS “The concern is that their lung HAZARD INTENSITY: CURRENT 2050 development may never reach its full potential,” he says.

1. OCEAN The cascading effects of heat Climate change means another new 2. DROUGHT normal for Washington—increased temperatures and extreme heat events. A report from the University of 3. WARMING Washington Climate Impacts Group (CIG) finds climate change is likely to 4. PRECIPITAITON increase heat-related illness, including heat exhaustion and stroke. Nationwide, extreme heat kills more Americans than 5. SEA LEVEL any other form of severe weather. Between 1990 and 2010, King County saw a 10 percent increase in deaths on “extreme heat days,” according to the National Climate Assessment. Recent SPOKANE heat waves have seen a significant TOP CLIMATE HAZARDS increase in hospitalizations, especially for HAZARD INTENSITY: CURRENT 2050 the elderly, says Dr. Duchin. Increased temperatures play a major role in ground-level and 1. DROUGHT fine particulate matter (PM2.5), both widespread air pollutants in Washington 2. WARMING that increase the risk of cardiovascular disease and death, including death from 3. WATER DEFICIT lung cancer. With high concentrations of these pollutants, Yakima and the greater Spokane area received failing grades from 4. PRECIPITAITON the American Lung Association’s most recent air quality report. 5. FIRES Renal health also should be on everyone’s radar, says Dr. Dooley. Heat stress can impact those with existing renal injury or at an increased renal risk, such as those with diabetes, as well as people YAKIMA whose kidneys are otherwise healthy. TOP CLIMATE HAZARDS “You can form kidney stones just by HAZARD INTENSITY: CURRENT 2050 being dehydrated without having any kidney injury, by working or even playing out in hot weather,” she says. 1. DROUGHT Carbon dioxide in the atmosphere not only makes the trees produce more pollen, but the warmer weather and 2. WARMING reduced rainfall is causing the pollen season to start earlier, last longer, and 3. PRECIPITATION become more severe. “People are having asthma symptoms earlier and worse than ever before,” says Dr. Covert- 4. WATER DEFICIT Bowlds, whose son has asthma. The result is also more severe allergy 5. FIRES flares, says Markus Boos, MD, a pediatric dermatologist with Seattle Children’s. “We have clinics where it’s wall-to-wall Source: Climate Central kids with atopic dermatitis,” he says.

8 WSMA Reports July/August 2019 Vector-borne and infectious diseases Warmer year-round temperatures “Polar bears dying is sad, but worldwide are also driving the population of disease-carrying mosquitoes and ticks. kids in South Seattle struggling In the United States, vector-borne disease cases tripled from 2004 to 2016, according to breathe is the current face of to the Centers for Disease Control and Prevention. Washington state is home to climate change and .” more than 40 species of mosquitoes, many of them capable of spreading disease. —DR. COVERT-BOWLDS Higher temperatures have led to an earlier onset of the potentially fatal West Nile virus-carrying mosquitoes, according Vulnerable communities and their ability to live in a clean home to the Washington State Department of Communities of color, those with lower absent mold and contaminated drinking Health’s vector surveillance program. incomes, and indigenous people face water,” she says. Since the first three human cases of West the greatest and disproportionate The impact of climate change goes Nile reported in Washington in 2006, climate risks, a CIG study found. These beyond the physical. Mental health there have been an additional 92 endemic marginalized communities often lack the issues are often not discussed, but are cases. King County had its first reported resources needed to manage their health a significant burden of climate change, case of West Nile last summer. or get the medical help they need, says says Dr. Duchin. “Extreme weather The few reported cases of Zika virus Heidi Roop, a CIG climate change and events, like heat waves and floods and were acquired elsewhere. The fear equity researcher. windstorms all have significant mental nationwide is that it’s only a matter of In Washington’s agricultural sector, health effects, particularly post- time before the two types of mosquitoes some 79 percent of outdoor farm workers traumatic stress disorder, anxiety, and that cause Zika move northward. experience a heat-related illness during depression.” Warming sea temperatures and summertime harvest. Those workers are increasing ocean acidity fuel harmful vulnerable to heat-stress nephropathy, Physicians must speak out algal blooms that can contaminate says Dr. Dooley. It’s the leading killer of Physicians are in a unique position to recreational water and shellfish. men under age 45 in Central America, advance the dialogue on climate change, Warming waters are also becoming more where the majority of the population but public health systems face a steep hospitable to disease-causing pathogens works outdoors. hurdle when it comes to addressing such as vibrio, says Dr. Duchin. “Vibrio Exacerbating the health of many climate change. cases have risen dramatically in recent outdoor workers during periods of high “We don’t have the resources in years; it’s a disease that grows where heat or wildfire smoke is that they often place to adequately track the health a lot of our shellfish are farmed,” he don’t seek medical help for fear of losing consequences of climate change,” says said. “People get nasty gastroenteritis— their job, says Russell Maier, MD, a family Dr. Duchin. “It lends to this complacency vomiting, diarrhea—from vibrio. And it physician in Yakima, and physician and helps people to minimize the fact also has a real economic impact.” advisor to the dean of Pacific Northwest that this is the single largest health threat University of Health Sciences. “If they facing us and will be for centuries unless do come in, what we’re seeing is more we get our act together quickly.” Quoted advanced respiratory illness. It’s hitting “Sometimes doctors get too focused them when they can least afford it.” on treating the disease without asking, In Seattle, and other highly populated ‘What are people going to do to solve the cities, the air quality is always worse in causes?’” Dr. Dooley says. “We should be lower-income communities, which often screaming red [alert] in the summer to sit near major highways, says Dr. Covert- get vehicles off the road. The problem is Bowlds. These communities often lack air not only particulate matter from wildfire conditioning necessary to deal with heat smoke, but from diesel emissions.” waves or times of wildfire smoke. Every physician has a responsibility Jeffrey Duchin, MD Annemarie Dooley, “Polar bears dying is sad, but kids in to get involved, Dr. Butruille says. “We MD South Seattle struggling to breathe is are seeing the public health effects of the current face of climate change and climate change now,” he says. “We’re air pollution,” he says. “That human going to see more of them in the future suffering is what drives us to keep at it.” and shame on us if we don’t do what Smoke and air quality aren’t the only we can to both prepare for and mitigate climate change-related health concerns, the results.” says Roop. “If people live in flood plains Chris Covert- Markus Boos, MD and in coastal areas with sea level rise, Rita Colorito is a freelance journalist who Bowlds, MD those all have impacts on people’s health specializes in writing about health care.

July/August 2019 wsma.org 9 10 a Stand Taking Colleen Groll WSMA Reports BY PAT CURRY sustainability systems address Health care Quoted John Leigh Tony Garcia Jonathan Cogen, MD

Several Washington state hospital “We areinthe businessofhuman of sustainability forVirginiaMason. industry,” says John Leigh,director efforts achieved a48percentrate. andcompostingthe hospital'srecycling 40 percentlocallyorsustainably, and nutrition departmentpurchasesnearly water annually. Thehospital'sfoodand have saved around7milliongallonsof year, andwater conservationefforts than 4.5millionkilowatt hoursper conservation effortshave saved more Since 2011, VirginiaMason’s energy Virginia MasonMedicalCenter have taken and asked them to suggest care organizations about the steps they change. efforts to reduce their effect onclimate small steps individual physicians can take. sustainability managers at three health systems have been recognized for their “Our footprint isgiantasan talked to the to talked WSMA Reports will—and itshould.” waste generation,” hesays. “Italways items forinfectioncontrol. waste throughsingle-useordisposable so much because hospitalsgenerate bins.recycling Every effortisimportant at ways toimprove andlocate signage looking Mason focusesonrecycling, about itassoonpossible.” unconscionable tonot doingsomething health ofhumanbeings, itwouldbe will have negative effects onthe well-being. Knowing climatechange “Patient safety willalways trump An adhocgreenteamatVirginia July/August 2019

MHJ/ISTOCK The health care industry is “Sometimes, as physicians, we are afraid responsible for 10 percent of the nation’s total emissions in greenhouse gases, including the use of anesthetic of talking about controversial issues. gases. One of the biggest impacts of the efforts at Virginia Mason is a radical There’s nothing controversial about this; reduction in the use of desflurane. The available options are more sustainable the world is getting warmer. We should and less expensive. “One doctor got behind this work care about the children in front of us.” ­ here with my predecessor,” Leigh says. “It just takes one champion to start —DR. MARKUS BOOS asking questions in their department and pushing those who are reluctant to give it a try and see it can be done. ... That was one thing we could do without a lot of technology, waste management, and “Your space changes all the time; an difficulty or fanfare.” water conservation. A sustainability office could have once been a storage Leigh says his “grand plan” is for committee of senior leaders steers the room or a waiting room,” he says. “What Virginia Mason to achieve carbon direction of the program. often gets overlooked is the HVAC neutrality, which means taking action The big wins in sustainability occur system that supports that space. … In to remove as much carbon dioxide when senior executives see saving some cases, spaces need to be adjusted from the atmosphere as you put into energy, water, and solid waste as a for more or less air flow.” it. That means spending money on revenue stream, Garcia says. If physicians lease a building, upgrading equipment. Justifying the “If you save costs on utilities, it’s they should “be the squeaky wheel,” expense can be tough at a health care the same as generating revenue,” he Fues says. “If you see that things are facility, he says. explained. “Cost cutting is nothing new automatically on at weird hours, put “This is an industry with not a lot of in health care; this is a painless way to in a work order. That’s an easy fix. If surplus capital to perform important cut costs because you’re not affecting you own your own building, the EPA facility upgrades like this,” he says. “We your service level, you’re reducing what has a utility bill benchmarking tool tend to lose out on internal competition you spend on a utility.” (portfoliomanager.energystar.gov). You for capital improvements. It’s hard to The easiest way to reduce energy should be benchmarking your building compete against an MRI or another and water consumption, he says, is to see how your building compares on important piece of equipment.” through technology and automation. a per square foot basis versus other A quick win for individual physicians “Sometimes the hardest part is getting similar buildings.” is to “green up” the supplies; use less authorization to invest in technologies, in the first place wherever possible, but there is a lot of proven technology out Seattle Children’s Hospital and then challenge manufacturers and there we can leverage,” he says. A 2019 winner of the Practice suppliers to find ways to move toward For example, sensors help reduce Greenhealth Environmental Excellence environmentally preferable products energy use because they “don’t require Award, Seattle Children’s Hospital set and packaging. someone to turn something on or off, several environmental goals in 2017 and They can also look at whether any so there’s no training required,” Garcia achieved them within a year. Water use items in their clinics expire before they says. Software ensures air handlers for irrigation was reduced by about a are used. work efficiently, filters are clean, and million gallons. “Focusing on reducing waste can the system is sequenced accurately and The hospital also increased a daily have a lot of environmental benefit,” calibrated for the use of each space. pay incentive to $4.50 to employees he says. “Reducing 5 percent is pretty Small changes can add up as well. to carpool, bike, walk, or take public doable from my observation.” LED lights use less energy, require far transit. Staff members who carpool or less maintenance, and provide better vanpool can park on campus. A shuttle is MultiCare Health Systems light quality than incandescent or provided from the Link light rail station MultiCare has been focused on fluorescent bulbs. Ultra-low-flow toilets to the hospital. sustainability for at least a decade, and is reduce the water usage rate per fixture; “Asthma is always in our top 5 in the parent company to Washington state’s if automatic flush vales are used, careful admissions,” says Colleen Groll, manager first green hospital, Good Samaritan calibration could reduce the amount of of Seattle Children’s sustainability Hospital Dally Tower in Puyallup. The false flushes. program. “When we get more staff out system recently hired Tony Garcia, who One area that can make a big of their cars, we’re reducing pollution ran the sustainability program at the difference is space management, says Ron because in Seattle, transportation is the Disneyland Resort for 10 years. Fues, project director with construction Number 1 emission.” His early efforts are focusing on engineering firm McKinstry, which works Pulmonologist Jonathan Cogen, MD, establishing task forces looking at with MultiCare. noted that many of his patients drive

July/August 2019 wsma.org 11 long distances to see him. He could help minimum and then hand me whatever “Sometimes, as physicians, we are with that. else is needed.” afraid of talking about controversial “[One] morning, four of my five Physicians can help the environment issues,” he says. “There’s nothing patients came over from Yakima for a and save money for their practices by controversial about this; the world is half-hour visit,” he says. “If I went out properly disposing of medical waste. getting warmer. We should care about there, it would have cut those drives.” “Some people think a piece of gauze the children in front of us. That is a Reducing waste reduces carbon with a little blood on it needs to go in the way to talk about it without getting on emissions, so dermatologist Markus red waste bag,” he says. “Those bags are our high horse or use terms that are Boos, MD, changed the way he has his actually for things that are soaked with off putting. When I hear about climate staff set up his trays for skin biopsies. waste that can be expressed. Those items change, it can feel overwhelming. What “The nurses are great and they would are a lot more involved to dispose of.” can I do as one person? As a society, set up these beautiful trays,” he says. Whether physicians have their own prac- everybody’s voice matters.” “I would use half of it and the rest was tices or work in a group or a hospital system, thrown away. I had them put on the bare they can make a difference by speaking up. Pat Curry is WSMA Reports’ senior editor.

Conference was the largest ever, with healthier work systems, identifying 2019 Leadership some 200 physicians and physician the keys to team wellness, making Development Conference assistants in attendance. Clearly, the business case for wellness to participants agreed with one attendee the C-suite, and rediscovering joy Leading Change who noted: “I believe the topic of this in practice. Attendees also learned Conference focused on strategies meeting is extremely important, for it about volunteering opportunities with to improve wellness impacts the future of medicine.” Medical Reserves Corps, Shared Hope, Sessions included how to create an Operation Smile, and Medical Teams With an emphasis on wellness, this extraordinary workplace, how to lead International, in addition to taking time year’s WSMA Leadership Development while living out your values, building to relax, socialize, and network.

The WSMA Leadership Development Conference not only provides opportunities for learning and networking, but also for family time and relaxation at Campbell's Resort at Lake Chelan. Photographs: Cindy Sharpe

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PHOTO CREDIT A Real Foundation. Real People. throughout your entireclaim, It’s sonicetohaveoneperson It’s amazingtobetreated likethis. and itsimpactonyouthroughout theprocess. who knowsyourstory-- yourpersonalstory– Kirkland, WA Obstetrics &Gynecology Angela Chien,MD

www.phyins.com (800)962-1399

3/20/18 9:10 AM 14 physicians insurance physicians WSMA Reports decision-making right to informed Honor your patients’ Against Claims Protect caused the harm to the plaintiff, but vigorously contestedcaused theharm totheplaintiff,butvigorously thenotion thatnegli had and bloodmonitoringinadequate. Thedefenseconcededthatgentamicin dosageswereexcessive thatgentamicin of standard ofcare,thesuitalleged thepatientnamedphysician One yearafterdischarge, inalawsuit. Onissues evaluationCase tothe structuresof permanentdamage ofthefoot. a canetosteady hergait.Therewerenosignsofinfection,norany indication vestibular labyrinth. from thehospital,patientrequired Whendischarged determined toxicity thatgentamicin tothe hadresultedinirreversible damage discontinuing gentamicin. Thephysician ofantibiotic,therapeutic range. immediatelyorderedachange ty, thoughserumlevels hadremainedwithin,orvery closeto, thedesired to walk. Her physician toxici immediatelysuspectedgentamicin-related - A nursingassistant hadtohelpherbackbed.Thephysician was notified. tient experienceddifficulty walking,reportingasenseof“feelinguncoordinated.” within24 to48hourswascharge anticipated.However, laterthatevening, thepa vestibular toxicity, thelatter ofwhichcanresultinataxiaandoscillopsia. had potential serious adverse effects, includingnephrotoxicity, otoxicity, and toring ofserumlevels toavoid toxicity. Thephysician was aware thatthedrug mg/kg (apotent ofgentamicin antibiotic) every eighthours, withclosemoni- involving herleftfoot. Her attending physician orderedIVadministration of5 of whether thestandard ofcareismet. failure toobtain informed consentcanresultinphysician liabilityregardless Asanentirelydistinctare coupledwithallegationsofnegligence. legaltheory, on issuesofinformedconsentarerare;commonly, informed-consentclaims basedsolely afailuretoobtainand lawsuitsallege informedconsent.Actions National dataindicates The patient’s problemswithmusclecoordination persisted. Itwas later The following morning,thepatienthadsimilardifficulties attempting On the11thday ofhospitalization,thepatienthadimproved markedly. Dis- A 26-year-old femaleathlete was hospitalizedforasevere staph infection thatmorethanone-thirdofallmalpracticeclaims July/August 2019 - -

RUSSELLCREATIVE/ISTOCK The defendant physician recalled mentioning to the patient that he had selected the potent antibiotic because of its proven track record. He was uncertain if he had mentioned possible side effects, but “might well have.” Partnering gence had been involved. Despite the pa- hearing loss, and ataxia. If the defendant with network tient outcome, plaintiff experts floundered had done this, a “decent discussion” in their efforts to provide convincing about alternatives might have followed. providers to evidence that the defendant had deviated Medical experts on both sides provided from acceptable standards of practice. testimony concerning the statistical make healthcare The plaintiff’s second legal theory was probability of the harm that had befallen that the defendant had failed to obtain the patient and information about the work better. informed consent. She testified that her likely severity of such injuries. physician had told her nothing of the The defendant physician recalled risks of gentamicin therapy, nor had he mentioning to the patient that he had se- mentioned any alternatives. lected gentamicin because it was a potent She recalled that he had told her that antibiotic with a proven record against gentamicin was a “heavy-duty” antibi- staph infections. He was uncertain if he otic, necessary because of the severity had mentioned possible side effects, but and type of the infection. However, “might well have.” “heavy-duty” did not suggest to her that He was forced to admit that nothing in the drug carried any special risks. The the medical records indicated the patient plaintiff said she trusted her doctor, and was told anything specific about gentami- it had never occurred to her to ask ques- cin. When the questioning turned to thera- tions about the antibiotic. She merely peutic alternatives, the physician acknowl- asked the defendant if her foot would be edged that he “probably didn’t go into that Get CME OK and how long she would have to stay …” He would have had a discussion with in the hospital. the patient about other antibiotics had for Your Activity! Her physician offered general reas- it appeared that gentamicin was proving surance, which she appreciated at the ineffective, but that was not the case. time, but no specific information. She After weeks of testimony and lengthy CompleteCME® is a joint provider program that offers a full said he seemed “very caring.” She had felt deliberation, the jury returned its ver- complement of services to meet your that if there were something she needed dict: The defendant had not violated the continuing medical1/6 education needs. to know, her doctor or the nurses would standard of care, but had failed to obtain have told her. The plaintiff testified that the plaintiff’s informed consent. The jury CompleteCME®House Services Ad include full she “devoutly” wished the defendant found that information concerning risks of event coordination and CME oversight. had told her that there were “less risky” gentamicin and treatment alternatives was antibiotics that might have worked. She “material” and should have been disclosed. Contact us if you would like to said she would have told her doctor to try If the required disclosure had taken provide CME credit or MOC points something other than gentamicin. place, the jury found that a reasonable for live activities, regularly scheduled series, enduring materials, etc. Plaintiff experts agreed, under cross patient would have, more probably than examination, that gentamicin was not not, elected one of the options. Had Find out more at bit.ly/CompleteCME, contraindicated or inappropriate—“it one of the alternative antibiotics been email [email protected] or call worked”—but were firm on the point that chosen, the plaintiff would have avoided 206.956.3639 today! it was not the sole antibiotic suitable to the damage to her vestibular system and combat this infection. “There are other would not have suffered from ataxia. weapons in the arsenal,” they said, and As noted, informed-consent claims the patient should have been told. are most often paired with allegations of These same experts told the jury that, negligence. However, failure to obtain in their opinion, the defendant had a informed consent can result in liability “clear duty” to tell the patient about the action, regardless of whether the stan- “considerable risks” of kidney damage, dard of care is met.

July/August 2019 wsma.org 15 Makes People Sick Climate Change by the numbers Source: University ofWashington Climate Impacts Group those numbers are sure to increase intheyears ahead. associated healthimpacts,andresearchers report that in vector ecology. Washingtonians are experiencing the weather, impactonwater andfood supply, andchanges increasing allergens, environmental degradation, severe through airpollution,extreme heat,water quality, We’re seeingtheeffects ofclimate change in our state

by V. parahaemolyticus, abacterium associated after 2012after North-Central Washington wildfires. The projected increase ofozone-related deaths Number ofWashingtonians sickened annually respiratory diseases(respectively) duringand 516k with eatingshellfishthatincreases markedly individuals over 45intheSeattlearea dueto (respectively) whohave asthma,whichmay Number ofWashington adultsandchildren 28% department visitsfordepartment cardiovascular and Projected numberofdeathsperyear of Percent ofincreased localemergency worsen withalonger allergyseason. when ocean temperatures increase. in Spokane County by mid-century. 6,000+ extreme heatevents. 17% 100

& &

102k 18%

PHOTO CREDITBY SGT. JECCA GEFFRE, ARMY NATIONAL GUARD (PUBLIC DOMAIN) RAMON SALINERO ON UNSPLASH says it’s talkingaboutclimate change. timeto start dangers ofsmoking.Cardiologist MarkVossler, MD, A generation ago, physicians spoke upaboutthe theSound Alarm Visit wsma.org/reports to read Reports online. articles climate change” tothatlist.climate change” every day, getvaccinated.” It’s timetoadd“acton lose weight,exercise, take yourbloodpressuremeds words oftentake timetosinkin:“Stop smoking, state ofmedicalscienceandourbest judgment.Our best interests, delivering advicebasedonthecurrent real. Asphysicians, westrive toactinourpatients’ attack was causedby heatstress. was identical toonefromsixmonthsprior. Hisheart myocardial infarction, buthiscoronaryangiogram room. HisEKG andlabtests wereconsistent with a called 911,andwas rushedbacktoouremergency While waiting forhelp, hedeveloped chest pain, during rushhouronI-405, hiscarbroke down. clinic afteraroutinevisit.Ashewas drivinghome On thehottest day last summer, Clearly, are thehealthimpactsofclimate change It’s criticalthatwe helps prevent the a warming world. worst impacts of deliver ahealth message that a patientleftmy and tomorrow. place forourpatientsandcommunitiestoday toward makingtheworld abetter, safer, healthier and preventing newpollutingfossilfuelprojects. in additiontopromoting clean,renewable energy health. Thatincludeskeeping ourpatientshealthy, should, betrusted advocates forpolicies thatprotect experience asphysicians We isaprivilege. can,and dirty, pollutingenergy. time totake thesame strong stance toward reducing about theadverse effectsoftobaccothen.Now it’s were firminourresolve andunitedinourmessage of smokingwereclear, andphysicians spoke up. We today’s therealhazards threatsofclimatechange, as thetobaccoindustry ago. did a generation Butlike and itssupporterssow doubt aboutthescience,just indisputably ahealthissue.Thefossilfuelindustry take action,orspeakout. are fearfultoprofessionallycomment,beinvolved, reasons, many physicians feelitisinappropriateor medical communityintoaction.Yet foravariety of asthma-related patientvisits, shouldgalvanizethe increasing incidencelocallyofheat,smoke, and the healthimpactsofburningfossilfuels, andthe pollutants areimmediate. torealize,thebenefitsofreducing longer other air the benefitsofreducingcarbonemissionsmay take cancers, andabnormalfetal development. While COPD, atherosclerotic heartdisease,stroke, several serious risks, includingexacerbation ofasthma and matter, nitricoxide, andsulfurdioxide, alsopose warming. Co-pollutants, suchassmallparticulate not limitedtocarbonemissionsandatmospheric and diseasethatclimatedisruption willbring. patients tocopewiththechangingpatterns ofinjury the worst impactsofawarming worldandprepares that wedeliver ahealthmessage thathelpsprevent to beinadequate.Now morethanever, it’s critical about prevention whentreatmentaloneislikely make recommendationsabouttreatment,and patients aboutissuesthataffecttheirhealth,to of theWSMA HouseofDelegates. of Washington Physicians for SocialResponsibility, andamember chairman ofthecardiology sectionatEvergreenHealth, president Mark Vossler, MD, isapracticing cardiologist inKirkland, your story (less than500words) [email protected]. Are you passionate aboutthisoranothertopic? Sendus Let’s doourparttolearnmoreandwork The uniquecredibilityandtrustworthiness we But thereshouldbenodivideaboutwhatis The growing body ofmedicalliteratureon The healthimpactsofburningfossilfuelsare It isevery physician’s responsibility toinform heartbeat wsma.org 17 At the End of Life: Agency, Role, and Responsibilities of the Physician/Advanced Practitioner

SEPTEMBER 13-14, 2019 University of Washington | Seattle, WA

National experts explore the complexities that arise when physicians/advanced practitioners are asked to stop machines (ventilators, cardiac devices, dialysis), prescribe medications that may result in death (physician aid-in-dying, palliative sedation), and support patients who choose to stop eating and drinking (VSED).

Join the conversation.

REGISTER AT: UW.CLOUD-CME.COM/AEOL

This activity has been approved for AMA PRA Category 1 Credit™.