I'm going to start on time. You know, according to my two semi-precious stone chronometer with Indiglo, by the way, it's about time to start. So we are going to start. For those of you who don't know me, I am Mike Nelson. For those of you that do know me, I'm still Mike Nelson. I chair the Policy and Advocacy Committee. And to my right are Dr. Katie Sarmiento, who is the Vice Chair, Evan Stepp, who is on our Tobacco and Vaping Work Group, Dr. John Studdard. I don't need to say any more. That's right. Newly minted master Studdard. Yeah, I like that. And we are going to do a little brief update from the standpoint of the Health Policy and Advocacy Committee, meaning each of us is going to talk about our little areas of interest. And we have a number of other experts in the audience, and I would hope that you guys talk as well. This is going to be more of a back-and-forth conversation than it is going to be you guys sitting here and listening to us drone on about what we think is important, because I do coding and billing, and the only person that likes that is Scott Maneker. So, I mean, it's a party of two in here. But let me get started. I have, like, a few slides, so I'll only put on my spectacles. There we are. I'm loading. Okay. You know what the topic's called. All right. That's me. Here's the Learning Objectives. Oh, no, wait. Here's the committee. I've got to figure out what's going on. So these are the people that... Mike, can I give Peter Gay a little credit real quick? We're co-moderators, so when you have to announce your conflicts, Peter Gay had one of the best answers in the history of my history with Zoom over the last three years. It was in a CMS meeting, and they had each speaker introduce himself, and Peter Wise, he's the gentleman in the hat, and they asked Peter, and he says, I have no conflicts, unfortunately, which I thought was a great answer, whether it was true or not. Was that a pardon the interruption? Yes. Okay, just checking. Okay. So here's our group, and advocacy, the actor process of supporting a cause or proposal. Doesn't say what, doesn't say who, doesn't say how. It's just doing it. So for my story, I used to run a practice back in the old days when doctors actually ran practices, and got very interested in doing that in CHEST, and we used to have what was called the Practice Management Committee. A few of us remember that committee quite well. And that got me involved in CPT, so I'm one of the CPT advisors for ATS and CHEST. And that was where my start began, and I like to do editing of things, which is what CPT does. I have found that to be very much an enjoyable thing for me. I've met lots and lots of nice people. I get to go to a lot of fun places through the AMA, and that's what I do specifically in terms of advocacy in the CHEST realm. I do other things too, but that's the thing that I like the most. So why do I keep doing it? Because I like it. Do you advocate for things you don't like? Not really. You tend to just sort of get up and go away. So my advice to you young people is identify your area of interest or expertise, and then act. It doesn't matter what your act is. It needs to be an act that you can do and you have time for. You need to recognize that your time is important for you too. Don't get burned out by your act. You can't do everything. The more friends you have, the better the act works and the better you are to advocate. And don't try to change minds. Try to find compromise. We all learned through COVID that we could not convince those who did not understand the science using science that vaccines were a good thing. So you try to find an area where you can compromise, and once you have found that area, you tend to make more progress than just butting your head up against the wall and try to push people further down. So that is my story. Katie, would you like to give your story? Sure. So I'll just, this is informal, but I wrote down a few notes just to talk a little bit about being maybe one of the younger people involved in advocacy now. I'm not quite gray, but my child is working on that. How I got sucked into advocacy was really kind of a natural process for me. It started by working in the VA and getting involved in a field advisory board for VA for sleep medicine, and I started to learn a lot. The first year, all I did was listen and then take on like a little project to get engaged and start to meet people, and I started to see how many challenges there were in implementing programs at the national level and identifying solutions that would best be solved at a national level rather than a local level. And so for me, that pathway and that journey was really driven by motivation to help my own program succeed, but also through identifying some of these opportunities to get to grow networks, figure out how the system works. I've been part of a coding and billing committee for VA, which is mostly the same as the private sector, but some VA-specific things also exist, and that has been really wonderfully educational for me and involves multiple stakeholders. And as you grow these networks organically, you start to meet new people, learn about new things, get involved and sucked into other parts of the organization, and that's been really, really rewarding for my career. And then I kind of got sucked into this group. I'm not sure how. It started somewhere five years ago, and then I'm here today talking to you, but I am really passionate about trying to get more younger people engaged in advocacy. It doesn't mean going out and changing laws or changing CMS necessarily. It just means figuring out what you're passionate about, figuring out how to respond to no. Often hearing no is more helpful than hearing yes, because it makes you think more creatively about how to navigate the system and how to come up with other solutions. So I'm really excited to see what happens with advocacy and chest and where it goes. Be like water is kind of my mantra. When you hear no, flow around it for better or for worse. Wes? Evan? Good morning. I'm Evan Stepp, national Jewish, Denver. I got into advocacy mainly because I'm a parent that happens to be a lung doctor, I guess. And so my 14-year-old now, but a couple years ago when she was entering middle school, it's when I started to become aware of vaping as a potential problem and nicotine addiction in general. And kind of quickly became kind of angry about that and started to get involved locally just the school. And then was making noise through National Jewish. So it's a bigger place. We have like a marketing department. They, you know, put me in front of the state house to testify for a, you know, flavor ban and that sort of thing. It just kind of grew from there. So then I got, I think how I found my way here is I'm actually, I'm the younger, dumber, Frank Leone, right? So I'm standing in for Frank, but I very much enjoy being on his working group. And I guess I found my way there because I started to submit sessions. And please attend this crackling session tomorrow at 1030, the second time we've done it live. But on just how to stir up general chest membership to get interested in advocacy about tobacco vaping, particularly around youth vaping, even though I'm just a dumb adult lung doctor, you know, that's a 90% clinician or whatever. So yeah, then that's how I found my way to being on Frank's group, which has been wonderful. And I'll be happy to take you through some slides later. I'm just going to sit down since I am the older, smarter Mike Nelson, but my knees are about to give up on me after a few days of chest. I'm John Studdard. My pathway into advocacy and at chest is convoluted. I trained at the Mayo Clinic, and one of my mentors there was a gentleman named Dr. Doug Gracie. Dr. Gracie, at the time, was mainly a critical care physician. And Doug was passionate about policy advocacy and regulatory advocacy related to pulmonary and critical care. And he was, at that point, a one-man public affairs, government affairs committee for chest. It was just Doug Gracie and our attorney from whoever represented us at that point in Washington, D.C. And I trained and had gone home to Jackson, Mississippi, where I was in private practice for 41 years. And I ran into Doug at a meeting like this about two years into my training. And he was on his way to that meeting, and the way things worked there were a little different than they do now 35, 40 years later. And he said, John, you've always been interested in this stuff. Why don't you come with me? You can be on the committee. So it was pretty easy to committee to get on. So I just changed the mechanism of that. Eventually, I became the chair of that committee. My passion was a lot like Evan's at that point in my life. I had two young children who are now grown. I was passionate about tobacco. And most of the committee's work was either around tobacco, which was kind of my interest, or coding, billing, and reimbursement, which was Jim Mather's interest at that point. Jim was a private practice pulmonologist who I had met and got on that committee. And he was from Richmond, Virginia, in a large group. Phil Port became a good friend of mine during those years. And later, I was on the board of the National Association of Medical Direction of Respiratory Care, NAMDARC, but was just too busy raising my family and trying to build a practice to have enough time to do it there. Came back, and really because of Jim Mather's came, I was given an opportunity to be on our foundation board at CHEST, and subsequently was involved in that, involved in leadership at CHEST over the years. And over the last three years, our CEO here, Bob Masacchio, CHEST had stepped out of the advocacy arena, except in coding, billing, and reimbursement space. We felt like that had been a mistake, and we needed to get more involved. We created the health, we acquired NAMDARC, created the Health Policy and Advocacy Committee, and have really been actively back in the space for about three years. Nick Augustin, who just came in, is my boss at CHEST. I may have to give her a big bullwhip, but she's an absolute pleasure to work with. She is got, really had never, she should tell her story before we finish with this and her perspective on advocacy, but really that definition of advocacy was interesting. It would always frustrate me at Board of Regents meetings because advocacy was, because of who our CEO was at that time, was somewhat of a dirty word. And my argument as a private practice doc was, guys, if we're not advocates for our patients, I don't really know why we're practicing medicine. So advocacy is a big word, and as Mike alluded to, it means a lot of different things to different people. Advocacy at CHEST is dynamic. Advocacy in general is dynamic and can be fast-moving. We don't define the schedule, and I'm looking forward to everybody's comments today. And I'm going to be Neil Friedman, who called in sick, as a matter of fact, so. Neil, can you answer that? No, he's not here. Go ahead, John. You've already talked too much. I think I said brief, didn't I? Just kidding. What's the definition of brief? That's a good question. Brief, as is one's gait, as you taught me, is genetically defined. Okay. I'm going to now take over for the time that I can before John starts in again. And Peter, I want to give you the opportunity to stand up and tell us about the NIV things and also why you got involved and what the TEP is and things such as that. But please don't be John, okay? So the last thing we did in terms of regulatory and legislative effort was in 2019, when there was actually a House resolution that was put forth. Phil, go ahead. Hold for a second. People that just came in, this is Dr. Peter Gay. He's at the Mayo Clinic, okay? And Peter was responsible for convening and writing the papers that were the product of the technical expert panel on noninvasive ventilation and delivering oxygen in positive pressured patients. So I'm sorry, Peter. So you give me a two-minute warning, because this is 30 years of work, that ultimately I was part of the 1998 Guideline Committee that came apart basically, or came together because of expenditure of dollars in an area that CMS lights up and says, we got to stop this. So we have to put some sense to this. So as things moved along, we realized we just compromised to get something on the board. And then how much was broke, all of you know, through the years. So finally, when we tried to get together again to get something done, we couldn't get anywhere with CMS. They kept scattering us, meeting with us and scattering us, meeting. We finally went to a regulatory action, and we got a house resolution that says you need a technical expert panel. But of course, that went nowhere. I mean, it never got to CMS. They never organized things. And when we finally did approach them through a committee that CAG had put together, I actually said, well, if you don't have the expertise for this, how about we supply it for you? And with the help of CHEST, we actually developed in the midst of COVID, an October 2020 meeting that put together a technical expert panel of 25 of the nation's finest sleep doctors, and we put this thing together. And we've been beating our heads against the wall for two years. But as of October, as of August 21st, it was submitted as a local coverage determination. And I think finally, one incomplete that's been kicking down the road for three years may come forth. I have no idea what's going to come forth, but something is going to happen before the end of the year. And it may well be we're going to take another incomplete, but I don't know. I've got two quick comments to say that the one thing I think we really need to think about as an organization here is where we're putting our money. Advocacy is incredibly expensive. It costs $10,000 to have a breakfast with a senator. And whether or not anything goes anywhere now is almost impossible to be optimistic about. We don't even have a Congress anymore. So spending money on a regulatory legislative level to me seems insane. So we've got to go back to what Mike is saying. You've got to make friends. You've got to know who's going to make something happen and just hope to make a little inch here. The second thing I've learned looking at all the white guy fossils here, we're terribly undiverse and we haven't mentored young people. And until we do that, then the next generation, as you're saying, how did I get involved with that? And by the end of the year, we're going to all be in a box with nobody at the funeral. So I really think that's the two things we have to do. We need diversity and we need young people to get interested because it is kind of fun and you meet a lot of really cool people. So I encourage you to get involved. Very well said. And thanks, Peter. I appreciate that. John, would you like to give an update on the oxygen problem? Neal Friedman has been our chair of our oxygen work group and basically where we are right now in oxygen is twofold. Number one, template. Presently we used, but prior to the oxygen came out with a new national coverage determination, CMS did about two years ago now. And one thing, there were a lot of improvements in that acute versus chronic. It's not diagnosis driven. The requirements for oxygen is driven by hypoxia or low O2 sets or low PO2s. So it was a real improvement. What was not an improvement was while they did away with what was called the Certificate of Medical Necessity, CNN, and have replaced it with medical record review. Medical record review by, as you all know how medical record reviews work, a large majority I would argue of our oxygen prescriptions are not written in a pulmonologist's office. They're written in the hospital. And the people that have the responsibility of filling, writing the order and knowing what medical records to attach to the order are not always as savvy in the delivery of out of hospital oxygen as a pulmonologist or pulmonologist staff. So medical record review is not in the best interest of patients. And therefore, and it's not in the best interest of providers because a lot of that work ends up in our lap when we're having to clean up what's been initially screwed up. So we worked with, you know, we're real strong believers in if we're going to be effective either on the legislative side or the regulatory side in the respiratory space, industry, manufacturers, suppliers, providers, and patient advocates need to try to work together if you can find a way to agree on things. So in developing the template, Mike Nelson, Rich Branson, who's a respiratory therapist and is an oxygen expert and a respiratory therapist, Rich, introduced us to Kim Wiles from Pittsburgh and myself worked along with the regulatory and compliance people at LendCare to develop jointly a template that was satisfactory both to patients, providers, as well as suppliers. We presented that to CMS. CMS, we've had two meetings with them. First we had a meeting with CMS and then we had a meeting with their contractor. The first meeting was somewhat encouraging compared to the second meeting. The second meeting was not encouraging. Their contractor, I guess CMS is, they never really addressed what we put in the template and what we thought were the necessary clinical data elements to support an oxygen prescription. CMS contractor at this point is looking at creating basically an artificial intelligence mechanism to replace human medical record review with computer medical record review. And it was a frustrating 45-minute presentation. We've just written a letter with all the groups back to CMS asking for a meeting with their contractors to discuss the template that we've shared with them. It would be, I think, a big win for patients and for providers if the template ever became a reality. At the same time, from a legislative perspective in oxygen, American Lung Association, Pulmonary Fibrosis Foundation, American Thoracic Society, and CHESS, but those three are really leading, we are involved with that group in oxygen legislation that is pretty darn comprehensive that we're attempting to get introduced. We have Senate endorsement of the legislation, a sponsor, and they're working on a house sponsor now, but it's removing all of oxygen from competitive bidding. It's liquid oxygen and adequate liquid oxygen reimbursement. It's the role of the respiratory therapist in the home in monitoring oxygen therapy, a patient bill of rights in oxygen, and also a template as part of the legislation, or telling CMS you're going to have to adopt a template. So that's still at the stage of trying to find sponsorships for the bill, but Senator Cassidy, who is the ranking minority member of finance in the Senate, is the Senate-side sponsor, a Republican, and his office is helping to try to gather sponsorship on the House side. So those are the two oxygen issues where CHESS is involved in both. My personal feeling is, and this is John Stutter's opinion, not the opinion of CHESS, which it always is my opinion and not the opinion of CHESS, for whatever that's worth, but that's the disclaimer, is I'm afraid that that legislation, particularly in today's Congress, is too big, all of oxygen, and if we could at least get a little momentum for the big bill, and they call it the community bill, and if we could move back to where it's mainly template and liquid, which I think would be a little easier for members to wrap their heads and hands around, I think it might get some traction. But we'll see. It's still too early to say, I can't imagine it will ever happen in 2023, given the dysfunctionality right now of Congress, and maybe in 24, but you know 24 is an election year, which you know how that changes everything also. It's not a huge issue to anybody but to our patients and their caregivers and providers in this space, but it is a huge issue for that group of people. Thanks John. Cassie Kennedy just came in the room, Cassie will be our last person from the committee to speak, and she's a member of the staff doing lung transplant. Oh, I didn't talk about Evan yet? For God's sakes. He's introduced himself, but he hadn't presented. I need some Aricept if anybody has some in the audience, please. So Cassie and Evan will speak, and then we really want to hear from you guys and gals, because ultimately, as has been pointed out by Peter, some of us are getting long in the tooth, and we're not going to be doing this much longer, although we'll try to help, and we really need the younger people of the world to get involved, because you're going to be the change makers of the future, not us. So Cassie, why don't you step up and you can talk, and then Evan, I apologize for getting you. Hi, thank you everybody for coming today. My name is Cassie Kennedy, I'm from the Mayo Clinic, and I was asked to lead the pulmonary rehab working group, and there is a pulmonary rehab group in our sister society that is doing a lot of work on reimbursement, and so we do have a connection there and co-representation in both directions, but when we looked at pulmonary rehab, what really came to the forefront for us is that there is a niche for us in that we can advocate towards health disparities in the pulmonary rehab space. So if you look at the literature, there have been a decreasing number of physical pulmonary rehab centers, and a lot of patients do not have access to a physical pulmonary rehab center. However, the literature in alternatives to a physical pulmonary rehab center are not robust. So we do not know, for example, if tele-rehab is equivalent to an in-center pulmonary rehab, or if physical therapy or home-directed pulmonary rehab would be equivalent to an in-center pulmonary rehab. Our suspicion is probably not, but I think we don't have any direct trials comparing tele-rehab to in-center rehab. However, it's very unlikely that we can advocate for the building of hundreds upon hundreds of physical pulmonary rehab space. So what we're trying to do is look at where would we best serve our patient population. Would it be to advocate for more research in the pulmonary rehab space so we understand what we're getting if we pursue tele-rehab or some of these alternatives? And would it serve the community? We think it would to, with that research, then move towards professional standards for some of these alternatives. And then the committee really has awareness of the fact that not everybody has broadband access either. And if you overlap the places that have a disparity of physical pulmonary rehab with the places that have a disparity in broadband access, unfortunately, you know, you address some of the spaces with tele-rehab, but not all of the spaces. And so we really want to make sure that we're not, the profession is not advocating for an alternative that is just going to create an additional disparity. You know, we were reflecting yesterday on the fact that, okay, even if you have broadband access, not everybody has the privacy and physical space within their living space, you know, or they may not even have stable housing to do an in-home pulmonary rehab. So those are the kind of things that we're dealing with on our committee. And our working group is working on putting together a white paper that evaluates all of these things comprehensively. And this can be iteratively revised as the research improves. And we can, you know, try to work towards that goal of how do we get everybody access to pulmonary rehab. So that's really where we've decided our niche is, is advocating for more access and less disparity in pulmonary rehab completion. Okay. Thank you, Cassie. Evan? Sure. Yeah. My two remaining slides. Okay. Good. So wherever you went through, I advocate, those are my kids, they're probably just like your kids or your nieces or nephews or whatever, but that's who I think needs a voice here in my own, what drew me in personally anyway. So two whole slides, just fasten your seatbelts. This is the Tobacco Unvaping Working Group. You know, a diverse group here. Our top, I won't take you through everybody, but just to kind of run through briefly. Our fearless leader, top left there, Frank Leone, trapped in Pennsylvania, I guess, for this meeting. But we've got representatives from Campaign for Tobacco-Free Kids, a health policy lobbying group that keeps us, keeps our finger on the pulse of Washington, kind of right up to the second. I've got an Army pharmacist who actually won the ATS service award, I think it was last year or the year before. Former thoracic surgeon who's also worked at CTP, the guy with the best picture there near the bottom right, works with FDNY and has innovated a lot of ways to make sense of tobacco cessation. I'm sure John would object to be put on the roster here, but honestly, I can't imagine our group without your voice, the John Studdard's opinion, as it were. And not, oh, and then let's see, our ATS Tobacco Action Committee Chair is on our committee, too, which is a great way to kind of cross-pollinate, as it were. And me at the top right there, I'm just, like I said, kind of an angry parent that happens to be a lung doctor. You know, I'm mainly a clinician, but I think that's, at least for the younger folks here, because everybody else pretty much, I think everybody besides me on that slide has basically made a career out of tobacco or nicotine cessation or prevention or something. And here I am, just the last couple of years, kind of finding my way here with this voice. So that's certainly, you know, if you've, as Mike was pointing out before, if you've got an advocacy itch, you know, let CHEST help you, so. Brief update on what we've done, more or less, over the last, I guess, year or so. Main current project is we're reviewing a bunch of literature now to help draft a formal research statement to share with the Center for Tobacco Products to help guide or support research in areas that will help us kind of shape policies. I think that's one place that at least Brian King is the relatively new head of CTP has indicated is, you know, hey man, I get it, this all sounds good, but can you show me some data to help us guide this policy? So that's one thing that we're working on actively now. We provide responses to requests for information from CMS and FDA and other government organizations, all with the same kind of idea in mind. Some of our members, either in person or by telephone calls, have met with Brian King and also the FDA Commissioner, Robert Califf, to discuss these matters. And then Frank was even invited to the White House to participate in the Cancer Moonshot Smoking Cessation Forum, I understand that he left under his own power and didn't get thrown out either, which is, you know, which is a good win for everybody, I guess. As one example, how we coordinate among other societies, they have recently been working with the American Heart Association just on a strategy around menthol and flavor ban ideas, policies, and then just in general, with these monthly meetings, we just have lots of lively discussions on terminology or goals or whatever we kind of kicked up from the last month. And Frank just does a masterful job of kind of guiding us into a productive space and it really is a fun group to work with. So that is my little update. Mike, can I throw, add one thing before you turn to the audience? I think it's important for the group to understand that happens to be here this morning is while we have policy priorities that are defined by the Board of Regents, which is our leadership group, there are other areas of advocacy that work their way to the top of prioritization. We try to look at things through the lens of equitable patient access to care in everything that we're doing and led by the values that have recently been kind of redefined by our Board of Regents. A couple of issues that kind of fall into that category are issues related to lung cancer and lung cancer screening where we've been, Nikki and I have been doing a good bit of work as far as making friends and establishing relationships in that space and I'm not sure exactly where that will go, but the other big area is that I'm personally really excited about and I think Nikki is too, is in the climate space because I like Erica Mosasson back there who really is a national leader in the environmental space. We've had two, three, maybe three presentations at CHESS. They've been excellent and there is a lot of younger energy around those issues and we feel like it's a responsibility of CHESS to have a presence in that space. Thank you, Evan, thank you, John. Dan, I'm gonna put you on the spot. How about standing up to the microphone and just saying who you are and what your interests are because I think you might be the youngest person in here. Maybe, maybe not. Oh geez, okay. Don't worry, nobody will get mad at you. Fair enough, obviously not as long of a tooth, I guess. Good answer. Thanks, I'm Dan Feifley. I'm a second year pulmonary critical care fellow at Indiana University. I have been involved actually in the advocacy space as a medical student predominantly through my work with the American Medical Association. Personal interests for me include the intersection of healthcare policy and medical education in terms of how educational policy gets enacted in the ways that ends up affecting how we end up teaching people. And so as a fellow, I'm really interested in the development and growth within graduate medical education specifically. Okay, thank you. See, that wasn't so bad, was it? Now you've got all these new friends. Okay, so now it's the question and answer time. We actually talked longer than I thought we were gonna talk. And we will try to answer your questions. We will try to do our best to help motivate you as we can. Recognize that John has made it clear we have things that we do that are set by the Board of Regents, but that doesn't mean that we can't help you or facilitate your efforts if you have efforts in a particular area that you're interested in. Can we throw a lot of money at you? Probably not, but again, we can introduce you to other people that become your friends who can help motivate the powers that you need to help motivate to make change. So questions from anybody? Yes, sir. Come to the microphone, please. It's just probably a good discipline for everybody because I can't hear. My biggest fear. My name is Samir. I'm from New York, sort of like Dr. Stepp. We have a big vaping problem and tobacco problem in our community. And prior to COVID, we had sessions with Senator Schumer, who's our Senator, and trying to get vaping flavor bans, which was a big issue, ultimately passed through our state Senate, but there was a lot of backlash. And I'm a clinician. I'm a father to a six-year-old, back then it was two, three. How do you guys deal with that, particularly as things have gotten so politicized? I mean, my name was on forums from pro-tobacco sites, and how can this doctor do that? How do you deal with that? How do you sort of reconcile that with the work you wanna do? Because obviously we want people to get better. We want things to be nice, and whether it's tobacco or climate, there's a lot of people who are on the other side of these things. So I just wanted to get your opinion. Yeah, good question. I think it came up recently. I'm on the Tobacco Action Committee, the ATS2, and we wrote a letter after one of the UK, Britain, did their kind of passing out of vapes to quash the combustible cigarette addiction. And on the surface, you can kind of see where it comes from, but we thought it was a totally dumb idea. And we acknowledged that our lead author, who was actually the pharmacist on the slide that I showed, was gonna be kind of probably a target for that, because there are a lot of voices and dollars that support nicotine addiction, basically, right? So I don't know. I have not personally yet come up where I'm actually kind of a dead person on social media. Maybe that partly helps, but I haven't found myself in the crosshairs. But I think increasingly with an issue like that, as opposed to say, I was thinking this, John, when you were talking, the oxygen thing as far as an uphill battle at is, at least there's, I don't know what lobby would be kind of pushing you down. It's just like, hey, you gotta knock heads together and get somebody to be interested in it. You know, it's a different type of barrier, but you're not gonna end up black or targeted on social media for that. So I don't know. I mean, I think you just have to find yourself on the right side of the argument and check yourself and make sure that you're okay trying to be that voice. But it's important, I think, to acknowledge that at least depending upon what conversation you're trying to be a part of, that there might be just a unhinged, well-funded, you know, kind of backlash that's sort of not personal in a way, but it feels very personal when your name shows up on like a list or something. So I think it's just one more barrier to advocacy in a way, but it's also kind of part of living in our current world. So I don't know if I answered your question, but I think it's a very thoughtful and important point to consider. Yeah, I think the tobacco industry is and always has been a formidable folk. They've gotten a little bit more subtle in how they spend money, and they'll create these foundations or this wellness group or this, I can't remember what it was. It was some caucus that was trying to be created in Congress but if you just follow the money, it was apparent that the money funding a lot of this is from the industry. So I appreciate your concern. I would urge you to keep those children, beautiful children or child, I can't remember how many there were, in the forefront of your mind and continue to do the right thing because you are doing the right thing. I would add one thing to that, and this is something that Nikki and John and I and our legal people in Washington frequently come into or get into, not in terms of what you talked about, but we'll get letters asking us to sign on to things that may be out of our purview or may be looking at them very closely. We probably shouldn't be signing on them for a number of reasons, but my philosophy with what happens with people such as yourself when it does happen is to ignore the heck out of it because if you respond to it, you just add more fuel to the fire. And I think, I hope anyway, that good will always rise to the top, but I think what happens often is it becomes a shouting match and then you're gonna lose that 100 times over because they've got a lot of money and you don't. But you've got right on your side and so I'm with John, just keep working at it, especially where vaping goes because it is a big health problem. Other questions from other folks? I do have a laser pointer and I will pick you out if you don't ask a question, just so you know. Bert. So I've got a comment and then a question if I may. A comment for the gentleman who spoke just recently about being a target of being an activist. One thing is that most of us are now employed by hospital systems that are very careful about their reputations in the community and when we speak, we can go through our hospital system if it is in their interest and that can defray some of the backlash a little bit. If you choose to go outside your hospital system in a way that they don't support, you have to leave their name off of whatever you're doing. Gabe Boslett has formed a nonprofit to do what he's doing and that is really taking it to the extreme, but something that is certainly an option for advocates. The question that I have is regarding if we choose to act on a state level, would CHESS be interested in putting together toolkits so that those members who want to be advocates at a state level would have something that they can refer to, facts, figures, et cetera, then supported by the national organization? I would respond to that by saying CHESS staff, would you like to address that? That was so easy for me. This is Nikki Augustine. She is the policy and advocacy queen of CHESS. Yeah, so CHESS doesn't currently have a state level infrastructure. What we recommend and part of the reason why we partner, I'm not sure how in depth we went into some of the organizations that we partner with, but for example, if I look at the list, the legislative effort in oxygen is being led by the American Lung Association. So they're an organization who does have a really functional state infrastructure. Campaign for Tobacco-Free Kids does a huge amount of work at the local level and they still keep us informed of that, but we don't really have, we're sort of still new. The advocacy team is this, plus Liz Stigler, who I'm gonna call out. Liz is our head of diversity, equity, inclusion, and belonging. And she joined CHESS just over a year ago and has really helped us bring a lens of health equity and DEIBE and helped us form a whole new category of relationships. So I don't know that we are the direct support for that kind of activity, but as the group has mentioned already, if that's something you have an interest in, acting locally, tell us what state you're from. We might have some friends that do have those state-level statistics and resources available. I'm gonna comment on the last question because you gave me the microphone now, which is silly of you. Oh my God, stuttered and a gussy. I know, right? So, Samir. I'm gonna sit down now. You sit down. The other, one of the other areas I oversee is our public relations department. And so when it comes to, like part of my responsibility is to figure out if CHESS is gonna go on the record, what that public profile should be, and sort of recognize what the risk of backlash is and ensure that we prepare for that. And I think these guys, maybe because you're not active on social media, underestimate how awful people can really be, right? So I just, I wanted to return to that because it's a real thing, especially when you have a six-year-old, right? Like you're sticking your neck out there. And so you also, I would say, do what you're comfortable with. But sometimes part of stemming that backlash is to work with organizations like us, right? Because on things like tobacco, on things like climate change, we're happy to carry the water, and we're getting our board more comfortable with that idea. And this is a board member here, this guy. So we're getting our board more comfortable with the fact that we're gonna have to face criticism. But if we're standing behind those values, that's like one of the benefits that you can have in working with us. Now you can go ahead. Oh, thanks, I appreciate that. Yeah. Oh yeah, Erica, please. Hi, Erica Moseson from Portland, Oregon. So I have been very active in flavor bands at our county level, and I've encountered exactly what you're talking about. And so one of the things I think, like so in terms of different options, I completely agree that the American Lung Association as a local state partner can be really helpful. But I think if you have like a local chapter of like your thoracic society, like the thoracic society sometimes do it. So one of the ways I'd gone through it is I helped get our Oregon Thoracic Society to be willing to like just submit testimony. And so one thing that could be helpful, I don't know if Chester would be willing to do this, but if it's, and our rule is like, people can't just like go off on whatever passion project they have and say they're there for the Oregon Thoracic Society. Like, so our rule is very simple. Our executive committee said, if it's in line with an ATS statement that's already been submitted. So for example, the ATS Tobacco Control Committee recommends that we do not have flavored tobacco products. We can just show up and be like, hi, I'm Oregon Thoracic Society. Because everything in the local area, being local is important, right? And so, but then you can just be like, you know, and then they would just be authorized to speak for them. So I don't know if Chester, like if something's totally in line with like, we recommend flavor bans everywhere. Like if that's just Chester's policy, you know, if there's someone that people could just reach out to and just say, hi, like I'm here for Chester, you know what I mean? To say that, you know, I always don't light things on fire and breathe them into your lungs, right? And that's what we recommend. And then just kind of having it be having that. I actually didn't make a nonprofit. I technically made my thing in LLC after talking to a lawyer just to kind of try to wall it off a little bit. But then, and also once you do that, you can have a baton. So it's not you every time, you know what I mean? Like you can have your buddies in the mix. But I think if Chester could do something like that, even like, these are our principles, like our values are our big things. It's like we want everyone to be able to get oxygen. We want there to be no flavored vapes. And then you can show up as, in wherever you're at, your county or whatever, that you're authorized to just show up and say, you know, and even if you're, the other thing that could happen is even if you're not specifically pro-common, whatever the policy specifically is, you can just say, as a representative of Chester, we recommend that every community make sure that its kids are safe from flavored tobacco products. And then it's like, just as like a statement, that might be like a helpful thing for people to have, to have like a little bit of a shield. Yes, thank you, Erica. And I guess I would turn to Nikki again and say, you know, or not say to Nikki, but say to you people, before you do that, as a board member, I kind of have to say this, we want to make sure that you're not doing something that you mistakenly think that we are supporting, because sometimes that backlash actually makes things much worse rather than much better. But it's just an email, a text, or one of those old things called phone calls to Nikki to say, hey, listen, I think I'd like to say this. Is this something that Chester would stand behind or have an opinion about? And if she says, yes, by golly, have at it. If she says, well, we need to run this through, then don't use Chester's name. Just like what Bert said, when your institution, if you belong to a university, does not want you to comment using their name, don't comment using their name. That's a fireball offense. Okay, other questions, other comments? We've got nine minutes. Yes, sir. Go, Dan, go. All right, perfect. I guess I have, ends up being two questions, but they're somewhat related. One is, how do you, what's your, what's Chester's kind of process for kind of establishing more formal working relationships with either sister societies or other working groups in terms of your decisions about who takes a lead versus Chester's involvement? And somewhat related to that, then, is to say, like, when you're establishing those groups in terms of what's making, you know, as you said, the Board of Regents establishes priorities, but is there a way or a mechanism for membership of Chester to say, you know, at this point in time, we think that there's a stronger priority that we need to be in an advocacy space for? If you know Nikki Augustine, you will know that there's always a procedure that you follow. How do you get your coffee in the morning? Nikki, would you like to reply to that? I'm not sure if it's the coffee time, or? No, no, no. I do have a kind of hypnosis about coffee when it's not Starbucks. Okay, so the process for establishing new priorities doesn't really exist yet, actually, but. Oh yes, it does in her head. In my head. So what we're doing in the next year, and we're kind of doing this, when the Board of Regents adopted our policy agenda, they adopted the things that you see here, and they said, and health equity, right? Like, let's sprinkle it on top, because that's what you do with health equity, right? And so we have health equity emerges in some of these areas, right? Menthol in the flavored tobacco plans, clearly targeting, looking at how do we help the black community who's been disproportionately targeted with these products. But we really, we cover, as a society, pulmonary critical care and sleep medicine. So this certainly isn't all there is in health equity. So over the next year, we're gonna put together, we're putting together a task force early in 2024, and we're gonna do an open call. So that's different than what we've done to date in the way that we've populated our groups, because we don't wanna start from an assumption that we know who the people are who are both interested and have expertise. And so we're gonna put together an open call for people who wanna participate on this task force. The work of the task force is really sort of designing a needs assessment and landscape analysis. So I have some, as Mike pointed out, some assumptions about what this will look like. We have seven network groups. So we imagine we're gonna wanna engage those networks and understand from the critical care perspective, where do you see barriers to care? Where do you see disparities that you think CHESS should be addressing? So we almost liken it to like a listening tour. So that's one component. But we also, I also oversee the guidelines area. So we wanna take an evidence-based approach as well, and we wanna understand what's emerging in the literature. John referenced lung cancer screening disparities, right? Like that's all over the place. And so we wanna put all of these pieces together, right? Part evidence, part opinion, and kind of look at the whole landscape, and then use that as our jumping off point to say, where can CHESS really lead? Then we start to filter. Where do we need to make friends? Where are people? This is part of how we'll use our DC council is really to understand, where are there people already doing good work? You guys have heard the American Thoracic Society referenced a lot of times here, right? Because we're doing the same thing in a lot of ways, slightly nuanced differences in some cases. And so bringing those things together, I think if we can join with our sister societies, we can ultimately support a broader agenda for the community. So that's really, we'll be putting out, when we put out the call, we tend to do a couple of avenues. We have a newsletter that comes out every day called CHESS Today. We'll do an article in CHESS Physicians. So we'll try to put it out on our social channels. I know you guys are so very busy that a lot of communications just have to wash past you, but keep an eye out for that because we really want, if people don't make it on the task force, we wanna at least talk to you. We're envisioning we'll have focus groups and other things. Hi, can I throw out one other point, not to add to Nikki's point, but something to be aware of if you aren't already. We have a publication, online publication of CHESS called CHESS Advocates that has just been rolled out by Nikki's team in the last year. The editor is Drew Harris at the University of Virginia. And it really tries to capture the why of advocacy on a lot of stories. And it really is, if you hadn't seen it, I think there've been two editions of it so far. It's great. And it's different than what you would normally see from the societal publication space of advocacy. Question? Nice young person. Yes. Thank you for calling me young. I'm Val Griffith, I'm from Chicago, Illinois. I have a almost two year old daughter and I like to think about how I wanna represent her voice since she doesn't yet have one. And one of the things I think about and to follow up on our conversation yesterday, one of the things I'm very interested in is air quality. I was very happy to meet Erica. And so I also see this very much as a healthcare disparity and health equity issue. And so I'm wondering, will this be addressed in these working groups and how can I get involved? Yes. Yes. Great. And the get involved part just means to continue your conversations with Nikki. And when the call comes out, please all of you, when the call comes out, put your name in. I mean, you need to get rid of old people like me and I'm looking to ride off into the sunset. So if somebody needs to take my place, obviously somebody needs to take John's place because he's just, oh my gosh. But you're the people that are gonna do it. So no, we would strongly encourage and appreciate you guys putting your names in the hat when the call comes out. And Liz will help you with the DEIB part because that's a part that we all think that we do, but we probably miss what we should be doing because we don't understand that we're not doing it. I don't think anybody, I shouldn't say that, I think most people don't willfully act that way. I think that comes from some biases that they have internalized and they're not aware of themselves. So please ask Liz because she can direct you very well in terms of the DEIB implications of that problem. Other questions? We very much agree and understand that environmental sustainability climate has a huge facing in the space of racial inequities of care. Right. One last comment, anybody? If not, you're gonna get three minutes of your life back and you can go stand in line at Starbucks. Okay, then I think, how about the panel? Panel, any last comments? John, I won't ask you again, so. No. Erica, please do. Erica's gonna take away your three minutes. Erica can say 45 minutes and I can say in a week and a half. I know, so people who listen to my podcast tell me I'm one of the few podcasts they don't listen to on 1.5 speed. I believe that. Because I'm like, here's 45 minutes of content in 20 minutes because we're all busy. So I had a question, I think one thing in terms of like ads and I don't know, so I've been working in Oregon, we're trying to, there's an organization there that's very kind and they're maybe trying to build a zip code level, as in legislative, county, whatever level, database of people who would be interested in speaking on clean air and climate and air pollution and that sort of thing. But that's very nice for Oregon. And I love Oregon and I'm very proud of it. But there's like our whole country and eventually globe and stuff and I don't know, but I am a full-time clinician who doesn't have any like academic time or anything like that. I don't know about chest potentially if they have the bandwidth. Since you guys have all these members and actually have our zip codes and where we live and also have a lot of clinicians who are probably, who are actually in smaller communities and areas of zip codes where they might, their representatives may benefit from hearing about the importance of like clean air or tobacco and that sort of thing. That would be a value add to give, like in terms of a place where we could partner with our sisters. Because ATS may have more people highly located in like urban centers and stuff just at big university centers versus the like clinician network that chest has. So that could be a very good value add to offer the sister societies of like an ALA. Like what do you need? Do you need a doctor in like this tiny little area to go talk to their person? Like we can get you that. Like I think that would be a good symbiosis I would say. No, I think that's an excellent idea. And I would also say that we are, we're trying very hard to engage the sister societies but there's these political problems of who's gonna make the money issue. But I think in terms of advocacy. There isn't any money. Good point. I think in terms of advocacy, we're all on the same page. I will also say, yeah, you live in Oregon, I live in Kansas. And in Kansas you can burn your fields when you want to put them up for the next year's planting. And so it really is a state dependent phenomenon. And unless we all get together as an organization and as a nation as a whole, it's probably not gonna change. Correct. Right. Yeah. I take every little positive as a positive. And I sort of just ignore the negatives because again, you're gonna make small steps. This will not happen overnight. Other comments or questions? If not, you've lost 30 seconds of your Starbucks time. Thank you all for showing up. We really appreciate it. Please get involved. And I hope to see you in the future.

meeting

Mike Nelson

Policy and Advocacy Committee

health policy

advocacy

coding and billing

areas of interest

Evan Stepp

vaping

Dr. Cassie Kennedy