North Dakota Governor's Newsletter December 2020

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Fadel Nammour, MD, FACP, ACP Governor

Fadel Nammour, MD, FACP, ACP Governor


Message from the Governor

Dear Colleagues,

I hope this month of December will bring the joy and happiness of the season to your lives.

Again thank you all for the commitment to your patients and dedication to their well-being despite a raging pandemic.

I would like to share Dr. Gaba's insight on physician wellness. Dr. Gaba is an anesthesiologist at Sanford and has made Yoga one of his hobbies and tools to get through life struggles and to maintain good health - both of mind and body.



Physician Wellness during the COVID-19 Pandemic with Dr. Vijay Gaba

Towards the end of World War II, Sir Winston Churchill rightly said, “Never let a good crisis go to waste.”

Even before the COVID-19 pandemic, healthcare workers were suffering from an under diagnosed epidemic: ‘burnout’. It has been compared to Post Traumatic Stress Disorder seen in soldiers after a war. It has been described as “an experience of emotional exhaustion, depersonalization, and feelings of low achievement and decreased effectiveness.”

We have all had to change our daily routine because of this pandemic. Some of us are working the frontlines, others are facing decreased staff availability, nervous patients, visit cancellations, and decreased income. On top of all this, we are concerned about our own parents, siblings, spouses, and children at home.

We still do not know how long this COVID-19 pandemic will last and there is so much uncertainty about treatment and vaccination. The current political climate in this country is only adding to the uncertainty with the management of the pandemic and vaccine distribution strategies. Social distancing has led to isolation, loss of our daily routines, and less access to some coping strategies.

In the time of pandemic, what can we do to manage stress?

It is extremely important for us to think positive, even during the bad days.

Yoga is one stress management tool that we can do from our homes. Unlike some other activities, we can practice yoga in a small space with little to no equipment. it can be done on our own or with guidance. There are now many virtual live sessions that allow the potential for connection with others, a valuable offering in this time of isolation.

There is good evidence to support that yoga can relieve stress. People who practice yoga are more calm, experience less anxiety and less symptoms of post-traumatic stress disorder. Yoga also improves wellbeing, including increased gratitude, compassion, relatedness, acceptance, centeredness, empowerment, self-esteem, compassion and self-awareness.

Yoga and meditation can also help to reduce the severity of COVD-19 by helping the immune system and improving lung health. There are potential benefits for a patient's neuroimmune system as yoga helps replace the fight or flight response with a “relaxation response.”

Yoga has three components

  1. ‘Asana’ – practice of physical postures.
  2. ‘Pranayama’ - practice of breath control.
  3. ‘Dhyana’- practice of meditation.

When we incorporate all three forms, while practicing yoga, it is called ‘balanced yoga’.

I will elaborate on one pranayama practice.

Pranayama, the practice of breath control in yoga, is considered as one of the best exercises for your lungs. Practicing pranayama regularly during the time of COVID-19 can help increase our lung capacity and lung efficiency and make us stronger and more able to deal with COVID-19 in case we are infected. One such pranayama is ‘Kapalabhati’ or ‘skull shining breath’.

How to do Kapalabhati Pranayama

Start by sitting in a comfortable position.

Keep your spine straight and close your eyes.

Place your palms on your knees, facing up.

Exhale completely.

Inhale normally through the nostrils and exhale sharply, pulling your navel in toward your spine and allowing your belly to forcefully expel all the air from the diaphragm and lungs by compressing it.

As you relax the navel and abdomen, your breath will flow into your lungs automatically.

Try taking 20 such breaths to complete one round, relax without opening your eyes, and feel the sensations in your body.

You may do two more rounds of Kapalabhati Pranayama.

Beginners may start with just 2 minutes a day and gradually increase the practice with time.

Thank you,

Dr. Vijay Gaba


1. Can Yoga and Meditation Help with Coronavirus Treatment? Hannah C.Jul 14, 2020 12:41 AM EDT

2. A Perspective on Yoga as a Preventive Strategy for Coronavirus Disease 2019. R Nagarathna,1 HR Nagendra,2 and Vijaya Majumdar Int J Yoga. 2020 May-Aug; 13(2): 89–98. Published online 2020 May 1. doi: 10.4103/ijoy.IJOY_22_20





For all ACP priorities and achievement, current and past years, I refer you to the ACP webpage on Advocacy

Related to COVID 19, ACP is urging HHS to allocate funds to primary care physicians and others to help them weather the COVID-19 pandemic.#SavePrimarycare

Also ACP is advocating for immediate steps the administration, congress, state governments and private sector stakeholders can take to help address this pandemic


The North Dakota legislative assembly convenes every 2 years. The 67th legislative assembly consists of 47 senators and 94 representatives. The regular session will start on January 5, 2021. The session is limited to 80 legislatives days. For your information this is the link to the 2021 legislative deadlines If you have any issues or concerns or would like to send a bill to the ND legislature do not hesitate to reach out.

The North Dakota Medical Association has set some priorities for 2021, and ACP ND chapter advocacy and council will be monitoring and participating in some of those bills at the state level.

The following is a brief summary of those priorities:

Medicaid Expansion: Medicaid Expansion, approved by the North Dakota Legislature in 2013, covers 20,000 North Dakota lives under the age of 65 with incomes below 138 percent of the federal poverty level. It provides access to affordable care for working North Dakotans who make too much to qualify for traditional Medicaid, but not enough to qualify for health insurance subsidies. Without the state investment in Medicaid Expansion, North Dakota loses this economic generator with trickle-down impacts to communities, businesses, and individuals. Unless reauthorized, it will expire on July 31, 2021. The budgeted amount for the 2019-2021 biennium was $633 million {$586 million in Federal Funds), which represents a huge impact on North Dakota's healthcare infrastructure.

Medicaid Reimbursement: Health care operates on a fixed reimbursement system, meaning providers cannot increase charges to offset increasing labor costs. Reimbursement rates must be equitable to the cost of care. NDMA supports sustainable payments to providers. In 2019, the ND Legislature authorized a 2% and 2.5% raise for 2019 and 2020.

UND School of Medicine and Health Sciences: In the last five sessions, the North Dakota Legislature adopted the School's Health Care Workforce Initiative (HWI) to address the health care provider needs of North Dakota now and in the future. The legislature granted 16 new residency slots, 16 more medical students, and 30 additional health science students and a new medical school building to house all health science students. To maintain this good work, the Medical School needs adequate funding. NDMA will continue to support UND SMHS in its pursuit of greater retention of graduates and increasing the number of physicians in the state.

Other Issues

Telemedicine: In the 2017 session, the Legislature passed a bill requiring health insurers to provide coverage of health services delivered by means of telehealth and NDMA has since worked with North Dakota Medicaid to update its telehealth policies. Right now North Dakota has coverage parity and not payment parity. NDMA will continue to support consistent payment structures across payers that will foster telemedicine services to help patients who would otherwise lack adequate access to providers or services.

Maternal Mortality Review Committee: North Dakota's maternal mortality review committee has been conducted by the ND Society OBGYN since 1954. For better communication with CDC, other states, and immunity protections, MMRC is going into statute and housed with the UNDSMHS OB/GYN department.

Behavioral Health: North Dakota's behavioral health system has critical gaps including a lack of early identification and intervention services, difficulty in accessing services, a lack of consistent screenings for at risk populations, and a lack of, or barriers to, accessing community-based recovery supports. Every dollar in prevention efforts can yield ten dollars of savings in health costs, educational costs, criminal justice costs, and lost productivity. NDMA supports efforts to close the gaps and allow better access to services.

Other NDMA Priorities:

  • Support patient safety issues
  • Support independent Judgment of physicians
  • Support public health initiatives
  • Support physician scope of practice and oppose inappropriate challenges to scope of practice.



ACP Statements Supporting Science and Expertise

● On September 27, ACP joined close to 100 other organization representing physicians and other clinicians, public health experts, scientists, patients, and other advocates, urging FDA Commissioner Hahn and Director Marks of the Center for Biologics Evaluation and Research to ensure that a COVID-19 vaccine is only authorized or licensed when it meets the Food and Drug Administration's (FDA's) existing high standards of safety and efficacy

● On August 27, ACP again expressed public support for the use of science, based on the best available evidence, in the fight against COVID-19 and emphasized that public health agencies should not be subjected to pressure or be influenced to issue policies that are not based on evidence and expert recommendations of their own scientists

● On July 14, ACP issued a statement supporting the use of scientific expertise, based on the best available evidence, in the fight against COVID-19 and urging national, state and local officials to heed the advice and information from leading experts. This statement included explicit support for Dr. Anthony Fauci, who received a Mastership from ACP, in his effort to help stop the spread of COVID-19