President’s Paragraph – December 2019

Giving Thanks

By David Donohue, MD


MY PARTNERS

Texas is growing from, and in, all directions.  A dearth of pediatric neurosurgeons in some regions of our state prompted our pediatric neurosurgical group to help.  We have been affording 24/7 coverage to children’s hospitals in two other cities over the past 18 months.   The arrival of new pediatric neurosurgeons to the afflicted hospitals has finally provided longed-for relief, especially to my partners, who shouldered more than their share of the clinical and administrative load.  It is gratifying to witness my younger colleagues deftly assume the care of pediatric neurosurgical patients in Tarrant County and beyond. My Cook Children’s neurology staff also helped keep the wheels turning this year.


TCMS COLLEAGUES

TCMS officers filled in, and advised, enthusiastically during my absences from TCMS board meetings and special events occasioned by my travels, demonstrating their usual good will and devotion to the organization.  The increasing scope of Project Access testifies to Tarrant County physicians’ altruism.  TCMS members quietly serve on unheralded committees (e.g., Physician Wellness) that do a world of good for physicians.  Any contributions I may have made pale in comparison to theirs. The Tarrant County Physician editorial committee has striven to render my dollops of prose throughout Volume 91 less incoherent, while working to create publications the whole membership can enjoy.


TCMS ALLIANCE MEMBERS

Their dedication to the family of medicine remained evident throughout 2019.  Highlighting important public health concerns, including pediatric head injury (Hard Hats for Little Heads) and immunization efforts sponsoring public education and free vaccination events (Be Wise Immunize)—vital in these days of appalling immunization agnosticism.  Their contributions continue:  community outreach, funding of Allied Health scholarships, and offering solace to families of our deceased or disabled physicians.  Together with TCMS staff, our Alliance is recruiting more young Alliance members and drawing their physician spouses into organized medicine. 


TCMS STAFF

“Things ran smoothly” is a huge understatement.   Especially satisfying is witnessing completion of the TCMS building renovation.  Our staff arranged and executed many TCMS organizational, political, and social events this year.  Beyond the business of running TCMS, our staff facilitates developing working relationships between TCMS physicians and established community players, including City Hall, the DFW Hospital Council, both medical schools, EMS, and the press.  TCMS staff are the operations backbone of Project Access.


MY WIFE

Most of all, I want to thank Angela, who encouraged me to participate in the TCMS years ago.  There is virtually no Alliance duty or position that she has not undertaken at either the state or local level.  As my term expires, she reminds me that the disappointment one senses before the incomplete project or unmet goal betrays not failure, but lofty goals yet to be achieved. 


Let’s continue aiming high.


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Public Health Notes: Influenza 2019

It’s critical, but often lost on patients, that the healthy herd get flu shots to protect the extremely vulnerable few. This includes the very young and old, pregnant women, persons with heart disease (including congenital heart disease), chronic lung, liver, and kidney disease, cancer, diabetes, and other immunocompromising conditions or therapies.

By Catherine Colquitt, MD

Flu season is now upon us, and we are bracing for another memorable year, based on CDC and World Health Organization (WHO) forecasts.  Influenza vaccine was first produced in 1945, but due to constant antigenic shifts and drifts in the hemagglutinins and neuraminidases on the influenza virus lipid envelope, flu vaccine targets, and thus vaccine composition, changes yearly. Constant revision of the vaccine is believed to explain, at least in part, its underutilization by a flu vaccine-weary public.

Flu vaccine strain selection starts in February when WHO experts meet to determine which three or four strains of circulating virus will make the cut for the various upcoming annual flu vaccines. After initial and advanced data analysis, the final flu vaccine strains are set in April, and production, packing, and distribution begin to make ready for orders to be filled each August. Influenza is a transmissible disease, but flu is not as highly infections as, for example, measles, caused by the Rubeola virus. On average, a person with influenza may account for four additional cases of influenza as opposed to 17 additional infections attributable to a single measles case.1 The CDC’s just-released data on the 2018-2019 influenza season and vaccine coverage shows that during the flu season just concluded, 62.6 percent of U.S. children ages six months to 17 years received at least one dose of flu vaccine.2 This is a 4.7 percent increase in coverage over the 2017-2018 flu season. The coverage rate for the same age group in Texas was only slightly lower (61.8 percent). Nationwide the highest flu vaccine coverage was in Massachusetts (81.1 percent) and the lowest was in Wyoming (46 percent).  Among U.S. adults ages 18 to 64, coverage with flu vaccine for 2018-2019 was only 45.3 percent, but represented a significant increase from 37 percent during the 2017-2018 flu season.

Many of our patients avoid influenza vaccine due to a commonly held belief that it is not a life-threatening infection or because they have been led to believe that the vaccine itself is unsafe or may transmit influenza. We try to impress upon our patients the importance of taking the yearly flu vaccine in order to prevent flu or mitigate the severity of influenza if they contract it. It’s also critical, but often lost on patients, that the healthy herd get flu shots to protect the extremely vulnerable few. This includes the very young and old, pregnant women, persons with heart disease (including congenital heart disease), chronic lung, liver, and kidney disease, cancer, diabetes, and other immunocompromising conditions or therapies.

When patients stiffen at the suggestion of the annual flu shot, I have also found it helpful to quote the astonishing 2017-2018 U.S. influenza mortality data—79,000 deaths. We also remind patients that use of the vaccine means fewer sick days taken and no household spread, and less out-of-pocket costs for clinic, urgent care, ER, or hospital stays. There are also medication costs, possible treatment of complications, such as post influenza pneumonia, and, appealing to their altruistic impulses, the responsibility of the strong to shield the weak when it comes to flu.

It’s also good to remind patients that they are infectious for 24 hours prior to the onset of flu symptoms and for five to seven days after symptom onset.  The incubation period for influenza ranges from one to four days, with an average of two days.

For the 2018-2019 influenza season, vaccine coverage among healthcare workers was 78.4 percent overall, and physicians now exceed pharmacists in flu vaccine coverage (96.1 percent for physicians versus 92.2 percent for pharmacists per CDC). Nurses had 90.5 percent flu vaccine coverage last season and advanced practice providers were 87.8 percent covered last season. The CDC preliminary estimates are that for the season just ended there were 36,400 to 61,200 U.S. deaths from influenza (AT&T Stadium capacity is 106,681), in addition to 37.4  to 42.9 million cases of flu, 17.3 to 20.1 million medical visits, and 531 to 647 thousand hospital visits.3 For patients who argue that the vaccine is ineffective, experts (not yet published Advisory Committee on Immunization Practices 6/27/19) believe the flu vaccine to be 30 percent effective in preventing  influenza-like illnesses and hospitalizations, which translates to prevention of 40 to 90 thousand hospitalizations.4

But perhaps the most important words for some of our vaccine-hesitant patients to hear is that we, along with our staffs and families, take our own advice and get immunized, too!

References

1.  Influenza and the 2004 Flu Vaccine Shortage, 2005, Tim Brookes

2.  CDC Flu Vaccine Coverage, US 2018-2019 Influenza Season

3.  CDC Preliminary Disease Burden of Influenza 2018-2019

4.  Prevention and Control of Seasonal Influenza with Vaccine, Advisory Committee on Immunization Practices, US 2019-2020 Flu Season

Great Women of Texas – December 2019

By Paul K. Harral

Originally published in the Fort Worth Business Press. Reprinted with permission.

Susan R. Bailey, MD, an allergist/immunologist, has a long history of service in helping guide organized medicine at the local, state and national level. She has served as board chair and president of the Tarrant County Medical Society, and as vice speaker, speaker and president of the Texas Medical Association.

Bailey was elected president-elect of the American Medical Association in June 2019, and will officially take office in June 2020 as the third consecutive woman to hold the position.

Previously, she served as speaker of the AMA House of Delegates for four years and as vice speaker for four years. She has been active in the AMA since medical school when she served as chair of the AMA Medical Student Section.

Bailey has been in practice in Fort Worth for more than 30 years.

She completed her residency in general pediatrics and a fellowship in allergy/immunology at the Mayo Graduate School of Medicine in Rochester, Minnesota, and is board certified in allergy and immunology, and pediatrics and has been awarded the title of Distinguished Fellow of the American College of Allergy, Asthma, and Immunology.

Bailey received her medical degree with honors from the Texas A&M University College of Medicine as a member of its charter class, and was later appointed to the Texas A&M System Board of Regents by then Gov. George W. Bush, the first female former student to become a regent.

She has been named a Distinguished Alumnus of Texas A&M University and of Texas A&M University College of Medicine.

“With her leadership and tenacity, she has fought for patients and physicians at all levels to get the best care possible,” said nominator Kathryn Narumiya of the Tarrant County Medical Society. “In addition to running a practice, Dr. Bailey is passionate about creating policies that benefit our citizens and make our communities healthier. Bailey has received nationwide recognition for her efforts and is truly a Great Woman of Texas.”

Bailey is married to W. Douglas Bailey, has two sons and one grandson, and is an elder and longtime choir member of University Christian Church.


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The Last Word – December 2019

By Hujefa Vora

I want to close out this year talking about change.  How much have your practices changed in the past year?  How much have your lives changed over the past year?  You’ll notice that I use the terms practice and life interchangeably.  Unbeknownst to our patients, our clients, our friends, and sometimes even our own families, these terms are equivalents.  One cannot achieve the title of physician without accepting this fact.  Our work defines us as human beings.  There is no other way to make an accounting of all the time we spend caring for others while neglecting our personal responsibilities.  This year, I missed my daughter’s first gymnastics meet because I had a patient attempting to code in the hospital.  Life changes.  Practices change.  When the government rolls out new regulations governing how we practice medicine, it changes not only our interactions with our patients and their insurance companies, but also the relationships we have nurtured over the years.

So how has my practice changed?  I recall a time just 10 years ago when I could easily see 20 patients a day in my office.  Comfortably.  I remember being able to do my documentation while I sat in front of the patient.  Prescriptions were sent off with a click or two of my mouse.  Follow ups were scheduled and the patient was satisfied. I started my practice 13 years ago with the exact same electronic medical records system that I am using today.  That has not changed, though there have been many updates to the system over the years.  What has changed quite dramatically now is how I use this system.  Practice with the same system for more than a decade, and users build a higher level of proficiency and efficiency.  It would make sense that I would be faster with the system, that my proficiency would make it easier to navigate the windows and the electronic maze of my patient’s chart.  Changes over the years in the rules behind coding and documentation have not made us more efficient though.  Let me give you my most cumbersome example of change in my practice pattern brought on by changes in rules and regulations brought about Medicare.  I am an internist by trade, but the vast majority of my patients are diabetics, so I fancy myself a closet endocrinologist most days.  When I first started practicing, I routinely ordered glycosylated hemoglobin (a1C) levels to gauge the degree of control my patients had over their diabetes.  My staff would order the test for the patient to have drawn at a local lab.  We would get the results back and I would call the patient a week later, provided the patient went to get their blood work in the first place.  Based on the results of that test and the discussion with the patient, I would call in any medication changes.  Then, we would follow up with the patient in a month or two and see if the medication adjustment worked by rechecking the levels.  This worked for a few years, until Medicare and the insurance companies decided that a1C levels would only be paid for if they were drawn three months apart.  Patients would get angry at me and my staff when they started getting bills for the a1Cs I was ordering.  We were forced to move away from this really good method of tracking diabetic

Patients would get angry at me and my staff when they started getting bills for the a1Cs I was ordering.

control.  I started bringing my diabetics into the office every three or four months.  My supply salesman introduced me to a machine that we could use in the office to check a1C levels. The catch here was that regulations dictated that because I was not

running a certified lab, the insurance companies would not always pay for the a1Cs we drew in the office.  Thus, only some of my patients got everything done at the point of care.  It was easily noticeable with my patients that those who had their a1Cs checked at the time of visit had better overall long-term outcomes in relation to their diabetic care.  Medicare eventually took notice of the importance of measuring glycosylated hemoglobin levels and started asking us to track these levels more routinely.  With the advent of Medicare’s quality initiatives several years ago, tracking a1C levels became a key quality indicator for diabetes control.  It is only recently that they started paying for this test if it was done in the office.  Reporting of quality metrics has been the ultimate gamechanger.  As every insurance company begins to incorporate the reporting of these quality metrics, the process has become even more cumbersome.  I decided that the easiest way to tackle this issue was to measure all a1Cs in-house.  If the insurance company would not pay, then my practice would eat the cost, not pass it along to the patient.  Every company we have worked with on this particular metric has a different way that they want these values reported to them.  Medicare has codes for the different ranges of the a1C that have to be coded into the note at the time of care, so whether or not they paid for the test became irrelevant.  A patient with no reported glycosylated hemoglobin level was just as bad as an uncontrolled diabetic in terms of the scoring of the quality of care being provided by the physician.  Ultimately, a lower quality score means a significant drop in revenue.  Most insurance companies would not allow us to simply document the level in the chart.  Medicare would not allow an a1C to be reported without proper documentation that the test was done in-house.  We are now required to document the value of the test, followed by phrases stating that the test was “drawn, collected, and performed in office, in-house, today <today’s date>, at <time>.”

My patient volume has not increased substantially, but the amount of time required to see each patient has made it impossible to continue to do this on my own.

Understand that Medicare has primary care physicians tracking over 30 different quality metrics for every patient we see.  Also understand that what Medicare does in terms of regulations trickles down to every commercial insurance plan eventually.  So how has my practice changed?  I am a five-star rated doctor for Medicare.  That means that because I am truly obsessive-compulsive about most of these details and metrics, my staff and I keep track of all of these metrics for all of our patients at all of their visits all of the time.  First and foremost, we do our best to provide the ultimate in good service and care to our patients.  Then, we spend the rest of our time buffing and polishing the patients’ charts so that we can stay in business and continue to serve our patients.  A typical visit of 10 minutes of face-to-face time with the patient requires about 20 minutes of documentation, insurance processing, and quality reporting.  A simple follow-up visit takes a minimum of 30 minutes.  A new patient may have taken 30 minutes when I first started my practice, but we typically give an hour of my time for these visits now.  And I had to hire a second nurse practitioner to keep up with the flow of patients.  My patient volume has not increased substantially, but the amount of time required to see each patient has made it impossible to continue to do this on my own.

And so, the practice of medicine continues to change.  Our lives continue to change.  I hate to be a pessimist, but not much of the change feels positive right now.  The optimist in me says the next year will be better.  I just hope that I don’t miss too many more gymnastics meets.  No one twirls quite so beautifully, or awkwardly, as my little girl.  That too will change.  My name is Hujefa Vora, and this is the Last Word.


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Student Article – December 2019

The Economics of Being a Medical Student

By Justin Salman, OMS-III

By most objective measures, medical school education has become more competitive, more expensive, and more mentally taxing than ever. Compared to even twenty years ago, medical students and residents find themselves more debt-ridden and “burned out.” Nevertheless, we seem to casually accept these conditions as inherent to the medical school experience, going so far as to glorify them as rites of passage and necessary to becoming a good doctor. For most of us, getting into medical school was met with such relief and deference that anything that followed was just a corollary to being inducted into such a small and prestigious group. Every medical student is grateful for the opportunity to realize his or her dream of becoming a physician and helping others, but the narrative that accompanies what it means to be a medical student must be recalibrated to better reflect the real-world conditions.

Let’s begin with cost. In 1989, the cost of attending a public and private medical school was roughly $6,600 and $18,300 per year, respectively. Today, according to the Association of American Medical Colleges (AAMC), the average cost at those same schools is $36,755 and over $60,000 annually. That’s an increase of over 550 percent for public schools and 327 percent for private schools over a span of thirty years. For reference, the inflation rate over that same time period was 107 percent. Moreover, the median student debt for students in 1989 was around $50,000 and $28,000 for public and private schools, respectively.1  In 2018, the average medical school debt across all institutions rose to $196,520.2  Highlight the point further, the average debt incurred by the 2018 graduating class at Rocky Mountain Vista College of Osteopathic Medicine was $364,000! Despite these substantial increases in tuition costs and overall cost of living expenses over time, resident physician salaries have remained stagnant for the last forty years.1 By any metric standard it is clear that medical students today are starting behind the curve financially compared to a generation ago.

Despite these substantial increases in tuition costs and overall cost of living expenses over time, resident physician salaries have remained stagnant for the last forty years

In addition to the increased financial burdens, medical students face an increasingly rigorous and competitive residency application process that emphasizes elite performance on standardized exams. The United States Medical Licensing Examination (USMLE) Step 1 is the first standardized exam medical students take in their second year and is considered the single most important academic benchmark when applying for residency. In fact, it is cited by the AAMC as the most important scoring criterion when considering applicants by program directors across all specialties. Unsurprisingly, the USMLE Step 1 average has increased dramatically in direct response to the emphasis placed on it by program directors. In 1993, the minimum score to pass was 176; that number increased to 194 in 2017. The mean score in 1992 was 200; today the mean score is 231, and at the current trend the average will be 250 in 2030.3 The term “Step 1 Mania” has gained traction among medical academic communities due to the noticeable and dramatic psychosocial effect that Step 1 performance has on students. These effects include increased risk of burnout, depression, and suicide, all despite the fact that little correlation has been established between Step 1 scores and physician competency.4 That is not to mention the massive revenue streams generated by the National Board of Medical Examiners (NBME) in administering the exam and selling practice exams to students. In fact, this year represents the first year that the NBME generated more revenue selling practice exams than they did on Step 1 exam fees.5 The over-emphasis on Step 1 scores along with the continually increasing averages translates to a hyper-competitive residency application process and reflects the current trend of students going into higher paying specialties in place of primary care fields to pay off their increasing debt.

As future physicians, we are trained to gather as much data from the patient as possible in order to make an accurate diagnosis and treatment plan. Likewise, in order to fix the current system, it’s important we start gathering accurate data. This article is not meant to be prescriptive. It is meant to provide insight into the trends and patterns that govern the current environment of medical and post-graduate education. We can continue down the path of treating the symptoms of the current system with an endless stream of wellness lectures, or we can try to implement systemic changes that address the underlying pathology. Whether it’s mitigating the cost of school tuition, increasing resident physician wages, or re-evaluating the residency application process to put less emphasis on a single exam score, we need to start confronting the foundational issues of our medical education system for the well-being of its constituents.

References

1. U.S. Department of Education, National Center for Education Statistics, 1988-89 through 2009-10 Integrated Postsecondary Education Data System, “Fall Enrollment Survey” (IPEDS-EF:88-99); “Completions Survey” (IPEDS-C:89-99); “Institutional Characteristics Survey” (IPEDS-IC:88-99); Fall 2000 through Fall 2009; and Spring 2001 through Spring 2010. (This table was prepared October 2010.)

2.  Medical Student Education: Debt, Cost, and Loan Repayment Fact Card. (2018). Medical Student Education: Debt, Cost, and Loan Repayment Fact Card. Retrieved from https://store.aamc.org/downloadable/download/sample/sample_id/240/

3.  Carmody, J. B., Sarkany, D., & Heitkamp, D. E. (2019). The USMLE Step 1 Pass/Fail Reporting Proposal: Another View. Academic Radiology, 26(10), 1403–1406. doi: 10.1016/j.acra.2019.06.002

4.  Carmody, B. (2019, January 20). Raising the bar: encouraging trends in USMLE Step 1 performance, 1997-2017. Retrieved from https://thesheriffofsodium.com/2019/01/17/raising-the-bar-encouraging-trends-in-usmle-step-1-performance-1997-2017/.

5.  Carmody, B. (2019, January 20). Raising the bar: encouraging trends in USMLE Step 1 performance, 1997-2017. Retrieved from https://thesheriffofsodium.com/2019/01/17/raising-the-bar-encouraging-trends-in-usmle-step-1-performance-1997-2017/.


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