Good morning, everybody. I want to go ahead and begin by paraphrasing a recent op-ed that was written by one of our panelists and his colleagues. So Dr. Boslev and colleagues wrote, recent enthusiasm for legislating medical care has laid bare the fact that physicians have a role and responsibility to be public advocates when evidence-based care comes under attack. Now, it might be that I'm biased because part of my role as a staff person at CHEST is to oversee clinical practice guideline development. So that statement feels pretty uncontroversial to me. Later, the authors substantiate their call to action with a quote from the American Medical Association Code of Ethics, which states, physicians have an ethical responsibility to seek change when they believe the requirements of law or policy are contrary to the best interests of patients. So contrary to the best interests of patients is a much broader and much more progressive framing than evidence-based care. Evidence-based care keeps the scope to clinical practice and things within direct physician control. It aligns with the idea of physician autonomy, which, if we're honest, has been what organizations like the AMA have typically advocated for. Shifting the focus to all things that are not in the best interest of patients represents a widening of the lanes. It opens the door to all social determinants of health that are outside of a clinician's direct professional control. It raises a host of new avenues to explore. The volume is overwhelming. And some of the paths, most of them, are not without controversy. So that's what we're here this morning to explore. I want to thank this panel for agreeing to share their experiences with us this morning. Each of you are people I've had an opportunity to interface with in my role in trust advocacy. And each of you are people from whom I personally draw inspiration when it feels like progress is slow or nonexistent. So really, thank you for being here and for sharing your experience. To get us started, I'm going to start with asking each of you to introduce yourselves. And you can all share whatever details about your professional personal lives feel most relevant to this conversation. And then second, this might be the harder part, but I'm going to ask you to think back to the first moment you remember taking an action on behalf of someone else or speaking out in an issue and think about what was the thing about it that made it impossible for you to stay silent and sort of allowed advocate to be part of who you are today. Good morning. My name is Erica Moseson. I am a pulmonary critical care medicine physician in Portland, Oregon. I'm a full-time clinician, I guess. So I'm working really hard on bringing my whole self to things because I think that makes us better advocates. So I was raised by a Norwegian Lutheran Republican and a Mexican Catholic Democrat who are celebrating 45 years of happily being married this weekend. I am very passionate about air quality and climate change. I host a podcast called Air Health, Our Health about the intersection of climate change, racial inequities, air pollution, kind of for a general audience, but obviously targeted a lot to physicians as well. And I've been very involved in clean air and climate advocacy at the state, local, and federal level. I serve on the ATS Environmental Policy Committee and work with the ALA on clean air and climate change and things like that. I was trying to think back to the first time I remember feeling like an advocate. And the first time I remember being scared, like kind of, as a kid, we'd write letters about saving salmon. And I did some immigration advocacy work with my mom, who's worked a lot with the Hispanic community at our parish and a lot of people who had uncertain immigration status. So that's always been something near and dear to my heart. But I remember being a medical student at Lincoln Hospital in the South Bronx. And I was on my OB rotation and then later my surgery rotation. And just the way Spanish-speaking patients were treated, where I would hear the residents discussing, like, oh, what should we do? Should we do this? Should we do that? I don't know. Let's just do this. And I'd be like, I was told we're supposed to do an informed consent decision, like discussion or whatever. So I would be rapidly trying to explain in Spanish what the doctors were saying so that the patient could potentially participate in this decision. And I literally had one of my friends remind me of this today, who was visiting a resident, look at me, put his hands together and be like, Erica, just stop talking to the patients. And I remember feeling like, I don't think I could do that. And we'd have these scared teenagers who were giving birth and scared about the pain and all these things. And they were often not told about epidurals and them being an option. So I would go around to all of them and explain to them the option, if they didn't have to. And maybe there were some problems with it, but if they wanted it. And I remember one of the anesthesiologists who would show up because suddenly there were more epidural requests. And he'd be like, oh, it's always when you're on. So those were kind of things that scared me because I was a little worried that it was going to negatively affect my reviews. But then I also realize now, residents never fill out reviews because they're too busy. So it worked out fine. So honestly, advocate all you want is everyone's too busy to write a review. Oh, yeah. There you go. OK. And now you go. OK. That's perfect. I'll just take it. OK. Hello? Yeah. OK. Sorry, guys. I'm Haley Gershengorn. I am technologically challenged, apparently. Not surprising. So I'm also a pulmonary critical care physician. I work in the adult world. But probably different for many of you, I work exclusively in the intensive care unit. And so for me, part of what's led me to advocacy actually was more recent, I would say. And I feel like not necessarily as obvious in the outward appearances maybe for some of you guys. So I'm proud to be up here with you guys. I'm at University of Miami right now, originally from New York City. And in the vein that you mentioned, I'll say I come from a very, very privileged and liberal leaning family. And so that was sort of what I was accustomed to. And I moved down to Florida about six years ago now with my husband when his job took us there. And I sort of insisted we live in Miami, because for me, that felt more comfortable than saying I lived in Florida, which felt like it was going to be a very different place to me. But I've realized, of course, over the last several years that things are more broad reaching than maybe I had anticipated from afar. And so that's part of what's made me more interested in this. And I would say probably the first thing for me, and it was interesting listening to your stories, because I spent a lot of time actually in the Bronx as well. And so I was thinking, did I do all of those things that you mentioned? And I'm not sure that I did. But the most notable thing to me that I remember, an ex-trainee of ours from New York actually tried to join and has since joined our faculty at University of Miami. And so I knew him 10 years prior when I met him again and he was interviewing for faculty positions. And I learned at the time, because he knew me, he reached out to me that his male domestic partner was not going to be offered health insurance through our institution. And it turned out it was not about the gender of his partner, but about the status of not being married. And I think what I realized was that as a sort of straight married person, it had never dawned on me to look into what our insurance covered. And so myself and a couple of other people tried very hard to advocate for him. Ultimately, he received a bonus from our division to pay for his partner's health insurance because the university did not have and still does not have a way to cover that. But I think that that was sort of a realization of, I can have these thoughts and these beliefs, but if they don't hit me in the face, apparently I don't act on them. And so maybe I will in the future. Great. Thank you. Good morning, everyone. So my name is Gustavo Cortez-Puentes, and I'm originally from Colombia. I was born and raised in Colombia. Both of my parents are from Colombia. I came to the US in 2013 to do training here at the University of Minnesota, initially. And then I moved to Mayo to complete pulmonary and critical care. My practice is mainly critical care adult. And I also do some of the outpatient setting, including cardiopulmonary exercise testing and pulmonary function testing. And I think that advocacy has always been part of my family. So my father was a peace sponsor during the peace process in Colombia. And as a family member, you're always part of that, even if you don't want it. But I think it was a great experience for me growing up. And when I came to the US as a Latino immigrant, I think that I was looking for a lot of opportunities to actually impact my community and also my group practice. So when I joined staff in 2018 at Mayo Clinic, I embraced the role of the share of equity, diversity, and inclusion for critical care since then. And I have a special interest in pulmonary physiology and pulmonary mechanics for many, many years. And I think that most recently, my more active role in both scientific advocacy for inclusion of transgender and gender diverse patients into research came from that specific physiology aspect of my life, which is really trying to determine whether the gender affirming care hormonal therapy is going to change physiologically the function of the lungs and to what extent, et cetera. So that has been kind of my background. And I'm very happy to be here with everybody to discuss more further about this. Thank you. And I'm Gabriel Bocelet. I'm a pulmonary critical care physician at Indiana University. I've been active in chest for a long time since I was a fellow, actually. And wasn't active in advocacy until really the pandemic, if I'm honest. I probably was before that and didn't really realize it. But during the pandemic, and this gets to Nikki's second question about sort of the first time that we found ourselves sort of using our voice for advocacy. During the pandemic in November of 21, things were bad in Indianapolis. Our ICUs were full. They were over full. We were actually, we had a meeting to discuss opening a new ICU that had been shuttered for over a decade to care for patients. And we were seeing a lot of people die. And literally while this was happening, the state legislature in Indiana was debating a bill called HB 1001, which was a bill that would have outlawed the requirement of vaccination for employment, including with hospitals. So it would have basically said that hospitals can't require their employees to be vaccinated. Which truthfully, I just got super pissed off. And they had a public hearing about this bill at the state house in the large house committee room. I had never testified before the state assembly before. And I went. And I wore my white coat and I wore my mask. And it was literally me and three other physicians, one from the ISMA, one from the AAP, and one from the IAFP, there to speak against this bill in a room that was completely full of unmasked people who were there just to burn everything down. Two of the physicians wound up leaving because things got kind of heated and people were asking for our names and where we practiced. And the lobbyist was like, hey, I just kind of want to give you a heads up. So I gave a relatively impassioned speech, three and a half minute speech, on the floor of the house. It didn't matter because I live in a state that has a Republican supermajority and they were uninterested in expert opinions. And I say that it's not that all Republicans are that way. But certainly, if there's one party right now that is not paying attention to scientists, it's a lot of Republicans. And in my state, it's almost all the Republicans. Almost all the Republicans. And being upset about that didn't stop with that. That legislative session, they passed a permitless carry bill that was signed into law weeks after Yuval Day and Buffalo shootings. They heard in committee a bill that would have allowed pharmacists to write ivermectin without a prescription for COVID-19. Just ridiculous stuff. And it sort of opened my eyes to the fact that, holy crap, the decisions that these people are making, almost all non-physicians in the state house, have a really direct bearing on what happens in our hospitals. Like a very direct bearing. And to make a really long story short, I wound up starting a non-profit, 501c4, incorporated nonprofit in Indiana called the Good Trouble Coalition that basically advocates for public health, health equity, and patient-centered care. Because there is no ad, much to my surprise, when I was pissed off and looking around for, OK, where's my tribe of people here that I can work with to make this better? There was none. So I had to create it from the ground up. And so the Good Trouble Coalition has existed in an incorporated fashion for a year now. We've raised enough money to have a lobbyist at the state house during the last legislative session and at this legislative session. And we continue to sort of, I mean, honestly, in a state like Indiana, be a gadfly for the legislature on issues of public health. So now all the rest of you can see why these are people from whom I draw inspiration, right? What I think is so fascinating about hearing each of you share your experiences is you're all advocating at a different level, right? You're talking, it's the way you practice. It's within your institution. It's what you choose to study. And it's going to the state legislature. And I think people think of advocacy so often as just that piece, as the legislative. And what can we do? But Dr. Bosslet, you raised a really important point about polarization. And I said evidence-based medicine wasn't controversial, but that's sort of wrong, right? Because there are aspects of what I think most physicians would consider evidence-based medicine that are really controversial. Dr. Cortez-Prentice, you touched on transgender issues. Haley, I know you've been active in abortion issues. And I'm curious how you navigate bringing these issues forward to people you know have ingrained beliefs that are different from yours. So that's whoever wants to take that first. Yeah, thank you. Thank you very much, Nikki. That's a great question. So I think from the perspective of pulmonary medicine in critical care in the work that we have been starting with our group at Mayo Clinic, we have a very unique institution in the sense that we have branches in three different states with very different legislatures and very different laws about this specific issue. So whenever we try to approach this, not only to proceed with the research aspect of the transgender health, we also needed to create an environment that was conducive to actually perform research in this patient population. And this is kind of the beauty of this specific topic is that it requires really a change in the practice, a change in how the dynamics work in the clinic. And that required a lot of networking and emphasizing basically on the human aspect of the transgender and gender diverse individuals and how they deserve the same care that everybody else. So that required changes at the level of, for example, education in all the clinical areas, ICU and pulmonary and critical care, starting from, in pulmonary clinic, starting from the desk check-in process, in communication that is affirmative, in communication that respect the identity of our patients. And of course, you have to create a front that has to be supported by leadership to be able to actually move forward to implement this way of communication in our clinical scenarios. But not only that, it's important that we are going actually against the standard of practice, as you said, right? Normally, and this is what triggered us, which is nowadays cardiopulmonary exercise testing and pulmonary function testing are analyzed and interpret based on the sex assigned at birth. Thinking that sex is a variable that basically doesn't move or doesn't modify at all throughout the lifespan. So entering to debate that standard of care is very important, trying to stick to the facts and show the evidence of what we know so far that could potentially change that aspect, and then continue to emphasize a lot in improvement of delivery of care. So instead of moving from, you know, we need to alter what you do today for your standard of care, it's just more moving to personalized care. So we kind of emphasize that. Instead of thinking of the consequences of gender affirming care or the negative aspects of gender affirming care, we speak about physiology of adaptation to gender affirming therapies. So I think it's important, it's an aspect that humanize the population we're working with and also emphasize on delivery of care, improvement in delivery of care. So I think when that is the spectrum of your, the scope of your practice and your research is easy to get people in different states within the same institution that are subject to different laws to actually work together in one aspect. And I think that I would say that, so I think that research and data acquisition is important in changing minds, but it never wins the day. I mean, we saw this during the pandemic, it doesn't ever win the day. From my perspective, the way hearts and minds are changed around stuff like this is with storytelling, frankly. We give, so as the president of the Good Trouble Coalition, so it's continued engagement and storytelling, that's it. So the Good Trouble Coalition is a nonpartisan group. So I get invited as a president of Good Trouble to go on podcasts and things like that. And I was invited to be the chair of a statewide campaign committee for a candidate that I really support, but I'm not willing to do that because I would alienate the people that I need to talk to the most. And so part of it is understanding that, number one, you have to engage the people who disagree with you more than those who agree with you, which is uncomfortable for a lot of us. And second, you have to sort of use stories to illustrate the data that you come up with because that's the only thing that people listen to. And preferably, if you're gonna go to a state house and talk to a legislator, which if you haven't, you should, you should go with a story from that legislator's district. Let me tell you about a patient that I took care of from your district. And be granular, as granular as you can. And this is kind of the hard part about it is because with granularity, we are sort of handcuffed by HIPAA. I mean, we saw this with Caitlin Bernard in Indiana. I mean, that op-ed that you read from, Nikki, was written at three in the morning after the state medical licensing board slapped Caitlin on the hand for telling a story, a very powerful story, clearly, about a patient. So I can't undersell the importance of leaning into talking to those folks who disagree with you in a very respectful way. And also doing it, giving them a sheet with sort of data on it is unhelpful. You have to tell a story about a human being that something affected that they're gonna make a decision on. I'm just gonna add one thing to that. I think both of those pieces, to me, have worked in different settings, right? But I also think the part of the idea, and I think this is true in any negotiation, discussion you have with people. How do you negotiate? You figure out where the common ground is and you start there, right? And I think it may be difficult depending on what arena you're in. So certainly in the state legislature where there's a supermajority that you may not agree with, it's probably even harder. Some of the things that I've had the privilege of working particularly actually with Gabe with, right, at some of our professional organizations about how do we respond to issues like this. We sort of start from a base, probably, right, that all of us agree on some very basic things. We care about healthcare for our population, right? We care about, at least in theory, diversity, equity, and inclusion. So how do we start from that and work from that to the things that we want to advocate for? And I think if we can identify where our areas of commonality are to start with, we do better to then make the steps to try to align our differing views with that. Yeah, I completely agree. So one thing I love about hosting a podcast is I didn't learn any of this stuff in medical school, residency, or fellowship, and maybe you guys want to, you know, better ones than I did or paid more attention, and maybe there was a talk and I just missed it. So I had, you know, I felt obligated as someone, you know, hosting a podcast on the air that can kill you to cover the importance of COVID vaccination, but I felt, like, nauseated doing it. And I was talking to an amazing, you know, like, national security virology expert from Johns Hopkins, and I was like, this has, like, been done. Like, everybody has, like, this is ridiculous, right? So, but I, so I also brought in a behavioral scientist who is a member of a, you know, a gender minority who grew up in, like, Northern California and wildfire country, and was, like, trying to convince people to, you know, make their house safe from wildfires, and they hated it because it was the government literally trying to save their house. Like, they just didn't want to do anything because they didn't want anyone to tell them. And so she got into behavioral science, and she does, like, had a PhD in behavioral science. So I brought her on the podcast, too, and by the end of it, I was just talking to her because she was blowing my mind on everything. She was like, it's very nice of you scientists to, like, talk science, and you guys are all weird because you will change your mind based on data. You will be presented with new information and be like, huh, let me incorporate that and change your mind. That's weird, it's a weird thing, nobody does it. Everybody is like, this is the right thing, it's how I was raised, and that's what's right. And if you change your mind, you're a flip-flopper. And I was like, huh. And so she was like, you have to connect on the values, and you have to make, she's like, if you're trying to get your uncle vaccinated and to get him vaccinated, he has to decide that the pharmaceutical industry and the government wants to help him, it'll never happen. You have to find out what he cares about and show how you want to change the behavior, not the belief, right? And so that's the thing. So it's like, how does a stable climate align with this person's values? And you connect on that. So for example, national security. Electric vehicles get us off dependence on foreign oil. Right, you know what I mean? Like, you just find out what the value is because we all actually share it, right? Like, I mean, it's like, I guarantee we all share the value, and so it's just like, I'm just kind of connecting around that. And I agree, like, the partisan blind, like, the longer you can put off a conversation about whether it's Democrat or Republican or whatever, like, the better you are. And just the human story element, if you can do that before the tribe comes in, whatever the, like, anyway. So that was a change in my mind. It's like, she's like, don't change anyone's mind. You just like, just think about the behavior that needs to change to help the shared values. And that was, I thought, very helpful. So it's really changed the way I talk to patients. It's changed the way I talk to everybody. Not everybody, but like, I still pop off on all sorts of things. But I mean, like, it's changed the way I've approached these things, where I'm like, you know, I'm really worried that, like, we might lose our, your town in a wildfire, just like town in Oregon. Like, I'm really worried about that. And like, so are the super conservative mayors of the town. Like, they're super worried about it. And you're like, hey, here, this is what they tried, and this is what it happened, you know? So I think that's the value connection, I thought, was really helpful. So I think what's interesting about hearing where all of your minds went is, you went to interactions with largely non-physicians. And I think we like to believe, as you said, that physicians are all on the same page, because you all come from a place of evidence-based practice and decisions are clear. But certainly one of the lessons for me, as CHEST has gotten into advocacy, is that that is not true. And we are at a conference that is designed to educate pulmonary critical care and sleep clinicians. And a lot of the tension that CHEST has already gotten, you know, we have a great team who monitors social media and monitors what people are saying about us. And, you know, sometimes we're woke, sometimes we're not doing enough. So we certainly don't calibrate to everything we hear. But the interpretation of what should a PCCM sleep physician spend their time advocating for is vastly different. And I'm curious how you engage with colleagues who sort of view advocacy as, you know, the more traditional, whether it's reimbursement or kind of going back to that autonomy of the profession. And, you know, if you're not in obstetrics and gynecology, why would we talk about abortion? How do you navigate those? I mean, everybody, every individual and every society, professional society has to realize that not taking a position on these things is taking a position on these things, which is fine. But let me just start by saying that's not a value judgment on my part as to sort of whether or not that's the right thing to do or not. But, you know, the reason that I have done the work that I've done in this area and the reason that I feel strongly the way that I do is because I look inside myself at the values that I hold and realize that not being involved in this is not consistent with my values. And there are parts of my brain that probably understand that I may be alienating some people and there are parts of my brain that definitively knows that, I'll be honest, my job is at risk at times. I have had discussions with people at the institution at which I work as to whether or not I can use their name in interviews. I don't anymore, which is part of the reason why I created Good Trouble, so I could use that name. But it's not without risk, internal risk for my own self. So from the standpoint of an organization, from my perspective, the organization has to do its own values biopsy, personal values biopsy, and decide what those values are. To me, it is hard to understand how an altruistic medical society doesn't fall on the side of patient-centered care and patient-physician decisions. It is extremely hard for me to understand how that is not a no-brainer. Even if the end result of that are personal decisions between a patient and their physician that others feel are morally repugnant. It's hard for me to understand that. So just like I have to understand that there are, that this decision about this internal discussion about my values may ultimately betray parts of me, frankly, because it puts my job at risk. It makes my wife uncomfortable at times. There are hard conversations that have to be had because of sort of some of the things that I've chosen to do. The society needs to do the same thing. And I'm not talking just about CHESS, let me be clear. I'm talking about all of the pulmonary and critical care societies. I'm talking about the AMA and every medical society that's out there. These are political organizations, period. They like to think that they're not, but they are. And they're seen as political organizations. When CHESS speaks, CHESS speaking has massive political value for the way that we handle values-based determinations about what is medical care and what isn't. So you know, I think it's just inherent upon societies to do the hard work of exploring its values and being explicit about where that calculus leads them. And I think, you know, if I'm honest, there have been many of us who have been frustrated about multiple of the pulmonary and critical care societies. And part of that frustration is that either those societies have said nothing, okay, which is tacitly giving a nod to the status quo, or have made statements that have been completely vapid and empty and sound more like just trying to appease people than anything else. So yeah, that was a really long-winded answer, but... I'm just going to sort of tag on to that. I think your question of how do you engage with people and advocate with them and convince them it's what they want to do, I think there are different levels to that, right? And so I think the first is my colleagues, right? I think that we all prioritize what we spend our time doing. There are a million things we can all do, and you know, I love taking care of patients, but I take less care of patients than I would if I didn't also do research, which I like, right? So I think we all have to balance things. And so I think choosing to be an outspoken advocate, and particularly what things you advocate for, are not something that I think we should impose upon anybody else. You can have opinions. It doesn't mean you need to be an advocate for those things. But I happen, I think to piggyback on what you had said, Gabe, I think the position of organizations to me is slightly different, and obviously the organization is made up of people, but the organization sort of has a sort of an implicit sort of, if I don't say something, it means I agree with the status quo, or I'm not. And so I think there's sort of more, one has to accept that there is that honesty to making a statement or not. And I think to me there are, you know, this is not our lane, or this is our lane. I think one part of it, which I fully agree with, Gabe, of the everything that is interjecting itself between the clinician-patient interaction to me is something that clinical organizations should be angry about. I think that is absolutely true. But I think the other question, too, and we've talked about this a bit, both with regard to CHEST and other pulmonary critical care societies as well, is some of these things impact the members, if not the patients. And I think that the organizations are obviously, our primary concern is our patients, no question. But realistically, in addition to being clinicians, we are also somebody's patient. And when it comes to the organizations, when we show up at a meeting like this, we are also important stakeholders for CHEST. And I think that that is important. And other organizations, not just CHEST, right? And I think that that is an important part. It is our lane if it impacts our patients, but it is also our lane if it impacts our members. And I think that that we need to sort of refigure a bit. Yeah. And I would say, you know, the curse of whataboutism, if you get into advocacy, is just, and I don't have a perfect answer for it, but I kind of, I never did improv, but I was surrounded, I went to college, and improv happened all over the place. And so I did learn that people say yes, and a lot. And so I think it's yes, and, right? So they, so it's like, it is vital that physicians be financially secure, independent, able to practice independently. Because I think we've all worked for organizations where you're like, you're being shady, right? So it's like, and I think, so we need the people who are advocating for physicians to be well reimbursed, to have it not be super complicated, to not be on the phone with prior ops for, I mean, I'm a full-time clinician for like gajillions of hours for a patient to get an inhaler. That is very, very important, right? You like, sacrifice all your 20s, right? You need to like, be able to fund a retirement account, pay off the loans, like, it is vital. So I think yes, and, to be like, oh my gosh, yes, we are advocating for you to be financially independent. We are advocating for you to get paid what you deserve. We are advocating to get these insurance companies out from between you and the patients. Yes, because we know that it's so important, this is where you connect on the values. For you to be able to practice the way you want, and for you to be making the best decisions for your patient. And if your patient is someone who's struggling with this and that, and the other thing, we want to make sure that those patients are supported. And that you're not their social worker, right? Like, we should clean up the air pollution in their area so that you're not having to be the one trying to figure out if their, you know, like, insurance company will buy them a HEPA filter, right? We should help them get their gas stove out of their house so they quit having asthma exacerbation. So it's like a, this is why we're caring about like, you know, clean air and climate, because like, we don't have enough pulmonary critical care doctors. So like, we can either make more, we can clean up the air and stabilize the climate. So it's just like, kind of a, I think a yes and approach, whenever people are yelling at you about whatever. That's what I do. I'm like, yeah, that would make me mad too. Also, wildfires make me mad. Let me just say one other thing. Yes and. I mean, let me yes and that a little bit. So the other thing to sort of keep in mind with, in regards to societies and their approach to this, is that seven years ago, this was not on anyone's radar. Right? I mean, seven years ago, I didn't, I wasn't the president of a nonprofit. And if you told me that I would be, and that I'd be at the state house with a lobbyist two months out of the year, I would tell you that you were crazy, but things have dramatically changed. I mean, things have dramatically changed. You know, physicians are now the teachers of the 1980s. And people don't like to hear me say this, but it's true. In states like Indiana, the legislature is up in the business of teachers, 150%. And that didn't, that wasn't the case before, but it is now. And they're, and they're very much micromanaging what the teachers can do and say. And for us as physicians, we were left alone before. We are no longer left alone. And so the fact that I'm wrestling with this internally, and that societies are wrestling with, well, how do we, how in the world do we do this, is, isn't, you know, is a natural sort of response to the fact that the world has fundamentally changed since the pandemic. Thank you. This is something you've touched on in your 3 a.m. op-ed as well, that, that sort of part of what's happened in this moment is that physicians have moved from a place of privilege to being a little more like everybody else, right? You were on a pedestal in a lot of ways in society, right? Trust in physicians. That was unquestioned. That is no longer true. You had autonomy. You owned your practices. That is no longer true. And so there's this leveling of the playing field that's happened. And I think for societies and individuals, we're sort of in this position that we have to care about all of the things now, and that's uncomfortable sometimes. And you think, how do I resource it? You, none of you have any time, right? You have a lack of time. You have families. You have other interests and things to do, but you invest anyway. I want to leave time for audience questions. So we'll play like, let's do a rapid fire game. This will be the, is it our lane game? I'm going to ask the audience to participate too. This just needs to be like a nod of the head or a shake of the head. You don't even have to like put your hand way up in the air and call yourself out. But let's say, should pulmonary critical care and sleep clinicians advocate around, let's say conflict is real in Palestine today. So war. Is war in our lane? God, that's a hard question. That's a really hard question. But this is the whataboutism sort of thing that, I mean, this is the whataboutism. Where do you draw the line? I mean, and so when we've had these conversations with societies, this question comes up, well, where do we draw the line? Like, are we going to, you know, okay, you talk about gun safety, well, what about drug policies? Okay, great. I think that's a very valid point. And my response to that is, if you're concerned about that, then from my perspective, I'm comfortable with having a discussion about drawing the line around defending the doctor patient relationship, right? Because most of the things that I care about and have advocated about have been things in which legislatures or government has started to insert themselves into the exam room. And so if we want to draw that line, I'm comfortable drawing it there. So then if I'm going to take that stand, then my answer to your question is no. And I saw, and I think it's, like, this is part of the exercise, because I think there were a fair number of people nodding, right? You could say something like, health care coverage, right, is that in our lane. And I think that is the root cause of so much of what you see. Go ahead, Haley, I'm sorry. No, no. I was, I like that, and I was thinking about your comment, Gabe, about sort of the doctor patient relationship, and I agree that that's one sort of line we can draw. I think another one could be back to this idea of where are the shared values, right? Our value is that when people are, we try not to injure people, that's against health. When people are injured, they have access to care. And that can be in a variety of different ways, right? We probably advocate against war. We don't advocate for one side of a war, because people get injured, and that's against health. We don't necessarily advocate for this type of health insurance coverage, but we advocate for the fact that people should have access to health insurance. And I think that to me, those are still within clear clinical health care areas, and maybe shared values, maybe not entirely, but are closer than we advocate for universal health care coverage by the government. We advocate for private, right? Those to me are, I think, a little bit more difficult. Yeah, I would agree. So one of my, one of the first seasons of my podcast was during the racial justice protests in the wake of the murder of George Floyd. And Portland, Oregon was just inundated with tear gas. Our police were rioting, and the federal officers that were sent by the Trump administration were also rioting, and spraying tear gas widely in our population. And it was so interesting watching the news, the national news, and the way they were portraying our city, which was not the experience. I had friends who were pulmonary critical care doctors, who were part of the wall of moms. I had friends who were pulmonary critical care doctors, like mothers, who were like, this is bananas. And they actually went down to the things, and joined arms, and were at 95s, and were just like, hey, leave the kids alone. They were literally dancing over there with like, you know, not that there was a lot of riot, there was a lot of violence, there was all sorts of, things degenerated, it was terrible, right? But they got just tear gassed, literally, wearing a t-shirt, being like, I'm a mom, I'm just standing here. I'm not over there with the people who are throwing Molotov cocktails, I'm just saying that these people over here who are just waving signs, and shouting for equality, shouldn't get tear gassed. And they got tear gassed, in the face. And I had patients who had tear gassed, coming into their, like, houses. And so I did a podcast on the evidence, there's not much on it, on the respiratory health impacts of tear gas, because again, just hoping the data will change the minds. And the Oregon Justice Resource Center ended up using it, as part of an amicus brief, to put a 14 day moratorium on the use of tear gas, which of course, people blew through, because then the feds came in. But it's one of those things where I think, like, defining the circle is helpful. Saying things like, you know, war, we know, like, is destructive. But again, picking a side of a conflict is impossible. But saying things like, the use of tear gas. The use of these weapons. You know, like, this, you know, because it's hard, because it's like, or the things that drive, my line is mostly like, the things that turn people into patients, is what I worry about. Which is like, climate change, wildfires, air pollution, and stuff. You know what I mean? So it's like, the things that are driving people into our exam room, and into relationship with us. I think, you know, trying to push those back upstream. So, you know, I think it's hard, but that's where we can advocate. Yeah, I know. I think, I totally agree. I think everything that becomes a social determinant of health, either immediate or long term, is our lane. That's everything. I mean, truthfully, like, that is everything. And that probably determines 70 to 80% of health outcomes anyway. There's a book by a public health sociologist at the University of Michigan called Weathering. Has anyone read of Weathering? It's a wonderful book, actually, about just the role that basically being disadvantaged in a society with the inequality that we have here, the effects that they had on health. It's a really great thing, actually. This lady's coming to Indianapolis later this month. I can't wait to see her speak. But it's everything. And so this is the hard part. I mean, Nikki, your rapid fire's devolved into... So, but I mean, this is the hard part about trying to draw a circle around it. And that's why, you know, people just have to, you know, you have to draw the line somewhere. If you advocate everywhere, you're sort of advocating nowhere. So the hard part is doing the sort of values introspection and figuring out where that line is. Yeah, I think that I agree with you, Gabe. So just limiting the advocacy to whatever happens in the exam room is probably limited, in my opinion. So I think that looking at whatever happens in the society that may affect the way patients are going to implement or have access to things they need to actually make those recommendations possible are part of our lane as well. So looking at perhaps not all social determinants of health, but perhaps the most important determinants of health that may have an immediate or long-term impact on the health of our patients is probably the best way to filter what our lane is. But I think it needs to also embark and include things that happen outside the exam room. I think looking at access to health, how patients are going to implement those recommendations, do they have limitation to, you know, look for help, engaging in the community. I mean, when you look, for example, just at the simple fact of pulmonary rehabilitation, we may advocate for things that are just inside the facilities, access to appointments, et cetera. But if we don't look at access to transportation, community networks, or if you go further, for example, determining what is actually success of pulmonary rehabilitation, right? If you think of modifying what we consider good outcomes depending on the culture of the patients, right? For your grandma, being successful at pulmonary rehabilitation may be, you know, be able to go to the store. For a Latino grandma, it might be just being able to enjoy dinner with their family, right, et cetera, et cetera. So there are so many differences that I feel that also be included in our advocacy framework. I mean, I think we'd all say we want just to say that the tobacco industry should cease to exist. And I've never had a tobacco exe that could walk into my exam room. But I definitely want them to stop driving patients in there. So I think of cleaner climate change and all that sort of thing as part of the things that, like, the social determinants. And so I think this is where it matters. I think it's so important to have, like, to make sure if one thing CHEST works for is, like, just making sure that we have a lot of diverse voices, right? Like, if the percent representation of CHEST in every single which way you measure it matches our population, then what we'll have is all the voices who can speak to those things, right? So you can have the people who, you know, can speak to, like, what's driving people in. I think one of the things that's hard is a lot of times it feels weird because you have a historically very privileged profession kind of reaching out into places where they're not. And so they feel like they're not in their lane. But if our whole community is filled with people who came from that lane, then it makes it, I think it makes our advocacy much more natural and organic, I guess I would say. I agree with all that and at the same time would say that as someone who has interfaced with multiple of the societies to sort of advocate for them to advocate, okay, it's very scary for them to hear this sort of wide circle advocacy argument that we should be involved in everything. And I don't blame them for that. And part of the reason why that's hard for them to sort of get their heads around for very good reason is that we are a society of heterogeneous humans who all have different sort of values and thoughts about all of this stuff. So the reason why I sort of put the patient-centered care, the patient-focused care thing around it is that is tangible for a group like CHEST or ATS or SCCM to get their head around and agree, okay, because even us asking them to go that far makes some of the people uncomfortable. So it's a sort of negotiated, it's a negotiated step forward. Does that make sense? I fully agree with you. I fully agree with you. It's just operationalizing that becomes almost impossible. So I think you've all been very kind in not at least in the context of the session and perhaps you're waiting until after saying like, Nikki, what is CHEST going to do about? So thank you. But here's what I will say. So I oversee advocacy for CHEST, but obviously it is not Nikki's policy agenda. It has to be CHEST's agenda. I'm fine with it being Nikki's policy agenda. So you know where Nikki stands on most things, so sure. But part of what I think about is your point about my sense is that targeted efforts make a bigger difference than diffuse efforts. And so it's this resource question for me. And so when I think about what is a filter, aside from I think the very good points you have all raised about values and kind of where we're all connected as humans that comprise the organization, the question for me becomes where do CHEST is really our membership, right? So where does our membership have the authority? And to the very good point you've all raised in different ways, where does CHEST have direct access to the stories? Because that is like the stories of what is being impacted that we're trying to achieve. So if you could tell the story of the lack of care in a wartime situation, right, CHEST should be an avenue to help communicate that. And I think part of launching a new publication called CHEST Advocates that's a quarterly newsletter that was the brainchild of this woman, Susan Rice, over here, was really to be a venue for stories. And in some ways it's stories for our membership, it's an outlet, but it's also to help leaders within CHEST see the momentum that's building and see really what's important. And part of our, you know, you've made this point to me before, our future relevance sort of depends on our ability to reflect member values. And so I think that's something that's not easy, but conversations like this are so important. You've all heard a lot here. I do want to make sure we save some time for questions in case anybody in the audience also has questions. So I'll sit silently for 30 seconds and see what emerges here. Yeah, do you want to come up to the mic? I could play like Vanna White. It's Donahue. Yeah, Donahue, full Donahue. Yeah, now Vanna White would just be waving at you. I said I was presenting her song. I don't know if it's on. Oh, I learned. There's a switch. Which apparently you have to switch like four times. There you go, there you go. Okay. Hi, everybody. My name's Olivia Rizzo. I'm an internal medicine resident at Case Western University Hospitals in Cleveland. I'm a PGY3, and I'm working on an advocacy curriculum for a residency. So I was wondering, do you guys work with trainees, and how do you teach them about advocacy? And if not, what would you like to learn in training about advocacy? They all just got very excited looking. I just saw all their faces go, oh, this is great. So I have three kids, 11, 10, and 8, and I'm increasingly just trying to bring them to whatever I'm already doing. I think one thing going to your thing a little bit about it's okay to talk about bandwidth, and I think it's just okay to be honest about that. And there's this phrase that I'm doing a session on clean air and advocacy that I think is very important to know. I do not currently have the bandwidth to give this project the attention it deserves. Everyone should know that phrase and memorize it. So with the advocacy thing, what I do is if I'm on consults and I'm supposed to go testify about wood smoke or something, I just take them with me. I'm like, today on the rotation, you're coming with me to the Multnomah County. And then I also think asynchronous learning is really helpful. I learn a lot with podcasts, which is why I decided to host one. So trying to make resources, recognizing that everyone, especially trainees, they also may be parents. They also may be doing other things. And so the extent to which you can say, here are some resources for you, bam, bam, bam, bam, whenever you have time, you can kind of fit it in. I remember sitting in med school and being forced to sit through lecture after lecture after lecture, what we called the fuzzy stuff. And you were just falling asleep. And it was slide shows. And I think we also know a lot about adult learning, and they don't learn that way. So I think, especially for things where you're trying to hook someone's passion, I think stories and on the ground and a specific problem. I wouldn't have them have lecture. I mean, maybe some stuff on the ethics of advocacy and don't be a white savior and all that sort of stuff. But I think some background ethics on it is probably the most important thing of the ethics of this. Don't be doing selfies of you with whatever. And then just experiential. So there's so much low-hanging fruit. Pick a project, let them work on it, and see how frustrating it is and learn about these things. So that would be what I would say is do it by doing it, not by teaching it in front of a PowerPoint presentation. And I think part of that is to say, I think another way to say that, I think, and you can correct me if I'm wrong, is that this is a very nonlinear process. It is not like here's step one, here's step two, here's step three, here's step four. It is, you know, so when I'm asked to speak about advocacy, I basically tell my story and the things that I've done. But to think that that's going to be what's going to work for you in whatever project you're passionate about is kind of a fool's errand. But I am in development of a GME track for advocacy at our institution and getting buy-in, because I do think that there are some skills that people can learn to sort of prepare them for if and when opportunities arise for them to be advocates. And then I also think that there is value in doing some direct action, so sort of some homeless care, which is sort of another type of advocacy we haven't talked about today, which is direct to consumer, sort of making people's lives better. And also going to the statehouse and seeing how this whole thing works. What is it like to sit down with a legislator? Like there's some value in that. And so it's a very nonlinear process, but I do think there are skills you can garner. But it is a messy, I like the word messy, it's a very messy sort of educational process in order to be able to learn how to do this. Yeah, I think that's a great question. I think it's a great opportunity with trainees to kind of try to emphasize the importance of both passion and the availability of resources for advocacy. So I think a good strategy is to put together all the resources that exist in your institution, if any, any interest group, and kind of generate a menu of opportunity for engagement. And then trying to emphasize on what the impact of those projects or initiatives for advocacy have taken on patient care. So, for example, in the case of in our institution for pulmonary function and transgender health and cardiopulmonary exercise testing, just really raising the point of the differences between pulmonary function and sex, and the importance of these variations in the interpretation and the long-term impact of that. So they not only see the fact that you're just working with a group of people that share the same interest, but actually has a very significant impact down the road. So emphasizing on resources, passion, but also in the effectiveness of that advocacy is very important. I think Gabe warned me that the only thing I had to be worried about with this session was time management, and that has turned out to be true. So I want to thank this panel for your willingness to be vulnerable and to share your experiences. In a lot of ways, there's an element of advocacy that is inherently about conflict, and I think we've used that word a couple of times. And leaning into conflict isn't always any of our comfort zones. So I think you have done a tremendous job sort of demonstrating positive conflict, if that could be a new phrase today. Good trouble. Good trouble. Good trouble. There we go again. Good trouble. So thank you. I'm sure we'll hang out again for a few minutes if anybody has questions.

physicians

advocacy

healthcare

evidence-based care

values

stories

medical societies

social determinants of health

patient outcomes