Although there is currently no vaccine to prevent COVID-19, the best way to prevent infection is to take the following precautions:
Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing or sneezing. If soap and water are not available, use an alcohol-based hand sanitizer with at least 60 percent alcohol.
Avoid touching your eyes, nose and mouth with unwashed hands.
Avoid close contact with people who are sick.
Stay home when you are sick.
Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
Where did this disease come from and what happens upon exposure? Scientists believe the current outbreak, COVID-19, is an animal-specific coronavirus transmitted from bats to an armadillo-like creature called a pangolin – which apparently is the animal that can spread this virus to humans. Pangolins are a wild endangered species but used for food and folk medicine in China (they can be found in “wet” markets there). COVID-19 is a new virus to humans, also sometimes referred to as SARS-CoV2. The disease starts like other coronavirus infections. After exposure, the incubation duration (the period before symptoms of a viral infection first appear) is about four to seven days. Then the patient suffers upper respiratory and flu-like illnesses. For some people, it progresses to a “viral” pneumonia. People who are elderly or have underlying diseases seem to be at greatest risk of getting severely sick from COVID-19. There is a great deal that physicians and scientists do not know about this virus and how it might spread among large populations. For example, are people with a mild case of the disease contagious, and if so, for how long? Regular coronavirus infections are seasonal. In North America, they seem to correspond with influenza season, which typically starts in October and can run through May. It remains to be seen whether this will be the case with COVID-19. What’s being done to fight against COVID-19? There are currently no drugs approved for, or that seem to be helpful for, this infection. Drugs are available that appear to have some effectiveness in laboratory studies and might be useful in some people. Scientists continue to study this to see if any drugs are useful. Historically it’s taken decades to produce a vaccine for an individual disease. However, there may be an available vaccine for coronavirus within a year, which would be an incredible feat. The Trump administration also requested $2.5 billion from Congress to combat the virus. What is the coronavirus situation in the U.S.? Right now, as of Feb. 26, there are 15 confirmed cases of COVID-19 in the U.S. across six states1; So far, no one in the U.S. has died from the virus. American public health authorities led by CDC have strongly recommended quarantines and infection-control measures, including isolating hospitalized patients. Hospitals across the state have developed action plans and are training staff in case they must care for patients with COVID-19. This month, CDC confirmed six cases of COVID-19 at the Lackland Air Force Base in San Antonio2, one of the U.S.’ many quarantine stations. There are no reports of secondary cases in the U.S. at the time this was written, so it has not spread in the general population3.
The Texas Department of Health and Human Services (DSHS) is active in tracking and identifying individuals who may have been exposed or infected. Incredibly, CDC already developed a laboratory test for identifying infected people and is distributing that test to designated state and local public health laboratories – including DSHS – U.S. Department of Defense laboratories, and select international laboratories. Standard tests used by physicians to identify “ordinary” coronavirus, will NOT detect COVID-19. So how should Texans respond? First, it would be advisable not to travel to areas of the world where we know there is infection. China and South Korea are on that list. Iran, Italy, Japan, are on alert, meaning certain high risk populations should take precautions. Hong Kong is currently on watch, but the CDC does not recommend canceling or postponing travel there. CDC posts daily travel warnings to avoid COVID-19. People who have been exposed by travel, or other means, need to contact their physician and local health department for evaluation. For perspective, influenza is spreading in Texas right now and is a much greater risk to all Texans. To avoid getting the flu, first have a flu shot, and practice everyday hygiene measures – cover your mouth and nose when coughing and sneezing and wash your hands or use alcohol gel. Fortunately, CDC and our state and local health departments are monitoring the COVID-19 situation, aggressively testing people exposed to the virus, planning for outbreak control, and making recommendations for hospitals, in case the outbreak becomes worse. If this coronavirus acts like SARS and MERS outbreaks, it will most likely be controlled by public health measures including quarantine and isolation. By following CDC’s travel restrictions and taking precautions to avoid exposure like you would do with any other infection, you probably not only will keep yourself from getting sick but also will prevent the spread of such viruses. I would add, this is not 1918 – the year of the deadly Spanish flu – which was the year of a worldwide epidemic that killed millions. Our public health authorities have rapidly identified the cause of the outbreak and distinguished it as a unique and novel (new) virus, and there are ongoing epidemiologic studies to understand how it is spread. In the U.S., travel restrictions and quarantine measures are in place. The state health department has a way to test individuals suspected of being infected. Physicians and hospitals, along with state, local, and federal health departments, are working together to contain the virus. Several potential therapies have been identified, and a vaccine is being studied. If we play our cards right, our society will successfully get through this outbreak.
1 According to the World Health Organization (WHO) and Pan American Health Organization (PAHO), 12 of these cases are travel-related; two cases were from person-to-person spread. There are an additional 45 people who tested positive in the U.S. among repatriated persons, including individuals under federal quarantine from Wuhan and the Diamond Princess cruise ship. On Feb. 26, the CDC confirmed a new coronavirus case from a patient who has no relevant travel history and did not contract it from another patient with COVID-19, bringing the total number of COVID-19 cases in the U.S. to 15. 2 One of these cases is from the repatriated group from Wuhan; the other five cases are from the Diamond Princess cruise ship. 3 This is to be determined, after the CDC confirmed on Feb. 26 an individual in California contracted COVID-19 from an unknown source.↩
Last month, the last month of 2019, the last days of the second decade of the third millennium, I talked about change. I was not optimistic at the time about a lot of the changes coming to the way we practice medicine. I don’t believe that many of us are optimistic. I don’t know if any of us have been given reasons to feel optimism. We have become burdened down by the weight of bureaucracy. The bureaucrat rules our every moment of work. I take mine (my work, not my bureaucrats) home with me every night, fulfilling my obligatory paperwork or computer work in my pajamas every evening after putting my daughter to sleep. This work has gotten so commonplace that one of the insurance plans I work with regularly calls this “pajama coding.”
In the New Year, I don’t want to be a pessimist. I want to remember the world through rose-colored glasses. I just needed to find the pair I’ve evidently misplaced. I spent the end of 2019 in Orlando. I took my five-year-old daughter to Disney World for five days. I spent Christmas Eve in the most magical place on Earth. We braved huge crowds of people, long lines at shows and roller coasters, and foul weather as it rained through most of the week. It was there that I had a much-needed realization. It was there with all my childhood friends – Mickey, Minnie, Goofy, Pluto, Donald, and Daisy – that I found those glasses.
To be completely honest, I was somewhat against this whole Disney trip when my wife proposed we go during my daughter’s winter break. I had not been since my own father took me there at the age of seven. I was somewhat afraid of the prices our travel agent was quoting us. At first, I did not remember the trip with my own parents to be worth these exorbitant amounts of money. Then I remembered riding Space Mountain with my father and the Dumbo ride with my mother and younger brother. Those memories are priceless now as my father is not around anymore to make new memories.
My daughter loved this adventure. At her age, everything she saw, everything she experienced, everything we did as a family, was so real. The magic of meeting all of her favorite Disney princesses – Ariel, Jasmine, and of course Anna and Elsa – enchanted my daughter for every moment of those five days. Disney does an excellent job of making sure that every step you take through their resort and parks is more magical than the previous. Yes, I started drinking the Disney “Kool-Aid.” This piece is starting to feel like an infomercial for them.
The moments that stand out the most for me involved our second day there, when we visited an area of the park called Galaxy’s Edge, which is themed around the Star Wars films, now owned by Disney. My daughter has not seen any of the Star Wars films, as I still think she is a bit young to truly enjoy them. She still insisted that she needed to be a Star Wars Princess, so my wife and I dressed her up as “Princess” Rey from the newest trilogy. First thing that morning, she met Rey and Chewbacca working on an X-wing fighter outside the secret Resistance base. Rey paused from her work to embrace her little twin. My daughter hugged her and sheepishly asked, “Who’s that Princess??” We then made our way to the Jedi Temple where my daughter took in Jedi training for younglings. She and her fellow younglings were then marched across the Galaxy’s Edge to participate in the Jedi Trials. She was given a lightsaber and taught the ways of the Force. As her ultimate test, my five-year-old Jedi fought off Kylo Ren and Darth Vader. At the end of the Trials, my youngling proudly exclaimed that she was ready to vanquish the Dark Side and embrace the teachings of Master Yoda. She promptly “Force-pushed” me onto our next ride, piloting the Millennium Falcon across the Galaxy.
And that is the point where everything changed. That is the point where I found my rose-colored glasses and put them back on. My daughter took in a universe she had never seen, stories and names she had only heard from her father (“I am your Father”) and embraced all of this magic in her heart. Her eyes went wide, and the world was beautiful and magical and filled with nothing but adventure, wonder, and delight. I needed that. I need to see the world that way again. And that is the point.
Five days of magic is what Disney gave my daughter, and I was given so much more. I gained perspective. I returned to work in this New Year, in this new decade, invigorated. My optimism stems from the smiles of my baby girl and her beautiful mother. It stems from an understanding that our imaginations power our spirit and our spirit powers our hearts. This year, 2020, will be an amazing year for all of us because I will it to be so. The world is full of magic. We are so blessed to be physicians. I needed a particular princess to remind me of this. Search your feelings, you know it to be true. I hope your year is starting out as well as mine is. I pray that all of us can find perspective and optimism somewhere in this world, so that despite the bureaucrats and the obstacles and the hazards along our journey, we can continue to serve our patients in this, the highest of all callings in the Galaxy. My name is Hujefa Vora, and this is the Last Word.
Hearing Wellness Exposition | by Shirley A. Molenich, MD
Over the last two years I have been writing articles about hearing loss and programs for the general public to better educate them. I became president of Sertoma (Service to Mankind) in 2017, and I realized that hearing disorders really weren’t understood by the public. Sertoma and Hearing Loss Association of America (HLAA) worked together to do our first program in April 2018 and our second program in April 2019. They were both well received.
It is time to talk about our 2020 program, which is scheduled for Saturday, March 28, 2020, at Tarrant County Medical Society building (555 Hemphill St, 76104). The 2020 program will include Jed Grisil, MD (ENT), Terri Jo Edwards, AuD, and Marylyn Koble, MS, CCC-A, Audiology.
Dr. Jed Grisil has been working with our medical society since last fall to address the need to screen patients for hearing disease, specifically the need for audiograms to better define the problem. He and I have talked about the importance of diagnosing hearing problems earlier, because the longer they go undetected, the more time it will take to see success in therapy. His topic is Treating Hearing Loss in the Modern Age: From Prevention to Treatment and Medicine to Surgery.
Terri Jo Edwards, AuD, will also be a speaker. She did speak at our first program in 2018. Her topic at that time was the brain-ear connection and her talk was excellent. One of her areas of interest and concern is developing a coalition between the audiologist and the physician to help improve patient care. This is an area of major interest in relation to the fact that many chronic diseases play a role as risks for hearing loss, i.e., diabetes, smoking, hypertension, cardiovascular disease, as well as genetic issues. There are also issues about various medications causing hearing loss and certainly important prevention issues, such as noise exposure.
Our third speaker is Marilyn Koble, MS, CCC-A, an audiologist who will speak on tinnitus, which is a difficult problem to diagnose and more so to treat.
We will have discussion about the various technological devices that help patients better manage hearing impairment in addition to hearing aids. I will be doing an additional article as we get closer to the event. Sertoma and HLAA appreciate the Tarrant County Medical Society allowing us to use the facility. We especially appreciate the staff support from Rick Geyer and Allison Howard.
Radiologist Tilden L. Childs III, MD, has always liked to fix things, to understand how they work. At a young age, this led to an interest in electronics. “In those days, electronics kits consisted of individual components which mounted on a chassis and not circuit boards, so with individual resistors, capacitors, and inductors along with various other parts, you followed the instructions to build your own devices. I made a multi-band radio, a voltmeter, and an oscilloscope, among other devices,” says Dr. Childs. He smiles. “I appreciate how much my parents humored me.”
With the encouragement of his father, Dr. Childs decided that he wanted to pursue electrical engineering. “I was planning to go in that direction starting in junior high school; maybe even late elementary school.” When he was accepted to Tulane University’s electrical engineering program, it seemed like it was just the next step in the process, but the experience led to a lot of struggle.
The engineering classes at Tulane were intense and bred a very competitive environment among the students. On top of this, during his junior year, Dr. Childs’ mother was diagnosed with cancer, and the prognosis was not good. He struggled to make the grades he desired but was determined to succeed in his studies. Despite the loss of his mother early in his senior year, Dr. Childs pushed on and graduated from Tulane in 1971. During the summer prior to his senior year, he decided that he wanted to go to medical school. On returning to New Orleans to start his senior year at Tulane, by chance he connected with fellow engineering student Tom Planchard. “God just put him right in my life at the perfect time. He was also an electrical engineering student, and he knew all the things you needed to do to get into medical school. He really helped me along the way; it was like he had this play book. He just took me along with him.”
During his senior year, while planning to go to medical school, Dr. Childs became interested in biomedical engineering, but it was only starting to exist as a field at that time. “I wrote a couple of papers on pacemakers in my senior year, and my interest in biomedical engineering continued to develop,” he says. He decided to attend the University of Texas with the goal of getting his master’s in biomedical engineering and then to apply to medical school.
In many ways it was natural for Dr. Childs to go into medicine. His father was a family practice physician, and his uncles, Dr. Robert P. McDonald and Dr. Burgess Sealy, were an Ob/Gyn and a general surgeon, respectively. It was simply a matter of finding the right field where he could delve into his interest in circuitry and systems.
He began at UT in the Fall of 1971, taking additional prerequisite courses for medical school and for the master’s program. “The classes at UT helped to demonstrate that I could be successful in medical school and confirmed that this was an area of interest that I wanted to pursue,” says Dr. Childs. He did not finish the master’s program, though, because he was accepted into Tulane’s medical school after the fall semester and he decided that he was ready to begin the journey to becoming a physician.
After completing medical school, Dr. Childs began an internal medicine internship at the University of Texas Health Science Center at Houston (UTHealth). He was not set on a specialty at that point but was considering internal medicine. Dr. Childs found it to be an intense and emotionally stressful time. During one of his rotations, he was assigned to the MD Anderson Developmental Therapeutic service in the Hermann Hospital, treating patients who had failed all known therapies. “I can still see their faces,” says Dr. Childs. “It was a very difficult time.”
It was during this time, though, that he discovered his true passion; catheter angiography. He had been considering practicing radiology among other specialties, and when he saw one of his patients get a pulmonary angiogram, he knew he wanted to try performing the procedure. “You could put a catheter anywhere in the body, inject dye and take pictures, and there was no surgery involved. Just a puncture wound, and you put the catheter in the vessel.” He laughs. “I now like to say that it was like one of the earliest video games. The ‘action’ was all on the screen and was all catheter and guidewire manipulation. I loved it; it was the ultimate high,” smiles Dr. Childs. “There was no going back.”
Dr. Childs spent three years in the UTHealth radiology residency, and then stayed for another year to participate in their fellowship program, where he received intensive training in neuroradiology, CT, and ultrasound. At this time, they asked him if he would join the teaching staff at UTHealth as Assistant Professor of Radiology. Dr. Childs did so and stayed in the position for two years. While he enjoyed his time in academia, he knew that he wanted to ultimately be in private practice.
In 1983, Dr. Childs was offered a position at Radiology Associates of North Texas, where he has remained for the rest of his career. Having been born and raised in Fort Worth, he jumped at the opportunity to come back to the area. Ever the innovator, within his first year, Dr. Childs had volunteered to go to the North Hills location. While there, he developed state-of-the-art programs in neuroradiology, angiography, CT, ultrasound, and nuclear medicine.
It was during this time that he met his wife, Gretchen. “The husband of one of my cousins knew my wife because she worked at TCU as a graphic artist and he sold printing. My cousin called me up one night and asked if they met anybody that I might be interested in, would I like to go out. I said ‘yes,’ and they called me back 30 minutes later and asked, ‘How would you like to go out to dinner tonight?’ So we went out on a blind date.” They dated for about two years, and then got married in 1988. They have two sons, Tyler and Benjamin. Gretchen became a homemaker, but for many years continued to do freelance graphic art and volunteer work.
Their oldest son, Tyler, who is married to Lauren, works in healthcare information technology. Ben, who is married to Chelsey, is a computer programmer. Dr. Childs is proud of his sons for the people they have become and the paths that they have taken. “As a father, it’s great to see your kids having success in their lives and their careers.”
Dr. Childs spent the next 25 years of his own career at the North Hills Hospital location. For the majority of his time there, he served as the radiology program director. Then, 11 years ago, he moved to the Arlington Memorial Hospital location. “Working with the clinicians and the administration at AMH, we were able to build a full-service breast care program. After five years, we achieved national accreditation through the American College of Surgeons National Accreditation Program for Breast Centers (NAPBC). We recently completed our second three-year re-accreditation. We have also been designated an American College of Radiology Breast Imaging Center of Excellence,” says Dr. Childs. “It’s been an awesome experience!” It was also an exciting change because it has given him the chance to have additional significant patient interaction. “I get to interact with patients and help direct their care on a daily basis,” he shares. “It’s very rewarding.”
Outside of his successful practice, Dr. Childs has maintained an active membership in multiple medical organizations. He has held offices or been on committees and delegations in numerous societies, including the American College of Radiology, TCMS, TMA, AMA, and the Texas Radiological Society (TRS). One of his notable highlights was his presidency of TRS in 2014-15. “The acceptance by my peers in the leadership role and participation in the society was very gratifying,” says Dr. Childs.
As he prepares to step into his new role at TCMS, Dr. Childs is looking forward to a year of raising awareness about the importance of organized medicine, especially in relation to advocacy. He especially hopes to reach out to doctors who are just beginning their careers and may not know what steps need to be taken to effect change. “I can’t stress it enough,” he says. “Young physicians need to invest in their future, whether it is their time or money. The things that happen now will affect them exponentially in the long term. You need to be involved because no one else is looking out for you.”
Dr. Childs leads in these areas with his actions. He takes off multiple weeks a year to allow for his very active role in both advocacy and organized medicine. In the Texas legislative session earlier this year, he testified to the state House Insurance Committee about mammography and actively participated in the discussions on balance billing. As a member of both TMA and TCMS’s advocacy committees, he has been an active participant at the TMA First Tuesdays. Between sessions, he has joined with Medical Society leadership to build relationships with politicians and educate them on the issues that are relevant to physicians and patients.
When he began taking an interest in organized medicine, he had no idea it would go this far, but he is grateful that it did. “My involvement in medical organizations has led to some of the best moments in my career,” he shares. “Early on, I decided to just show up to meetings. Listen and then give input. Take the opportunity to help make a change. Over time, I got to the point that I wanted to concentrate primarily on advocacy. My focus now is participating in advocacy in Texas.”
Richard Strax, MD, a fellow radiologist who first met Dr. Childs while they were completing their training in radiology, thinks he will be an ideal leader for TCMS. “Over the past 40 years Ty and I have been close friends and worked together at the Texas Radiological Society and at the Texas Medical Association. Ty’s greatest quality is his ability to bring people together, a direct extension of his natural warmth and caring nature. The Tarrant County Medical Society will be in good hands with Ty in charge.”
Robert Gloyna, MD, a longtime colleague of Dr. Childs’, couldn‘t agree more. “I have had the pleasure of having Ty as my friend, cohort, and partner for many years. We first met on our years in Houston . . . I have utilized his expertise in radiology, particularly early on in radiological special procedures and now in mammography. I have no doubt that Ty will be an outstanding president.”
At TCMS, we are excited to have Dr. Childs lead us as we prepare for a year of impact on the practice of medicine and our community as a whole.
Our state has the highest rate of syphilis cases in the nation, and five of our metropolitan areas are in the top tier in the nation in reporting of syphilis cases. This dubious distinction comes with increasing congenital syphilis (CS) incidence, too. In 2018 (2019 data are still being compiled) Texas reported 367 cases of congenital syphilis (a 64.57 percent increase in CS compared with published 2017 state data), with 21 of them coming from Tarrant County.
For reference, in 1998, syphilis rates in the US dropped to historic lows and the CDC and other partners wrote of eradicating syphilis in the U.S., but by 2012, syphilis rates had begun to climb rapidly and are soaring today. In 2017, the CDC issued a call to action entitled “Let’s Work Together to Stem the Tide of Rising Syphilis in the United States.” This 12-page document suggested roles for patients, clinicians, public health entities, state health departments, community leaders, biomedical science, universities, and industry partners, among others, in curbing the incidence of syphilis.
However, syphilis rates continue to climb, and Texas is reporting marked year-on-year increases in CS as well. In 2015, the Texas Legislature amended Texas Health and Safety Code, Section 81.090, which mandates syphilis testing of all pregnant women at their first prenatal visit and in the third trimester (2015 CDC Sexually Transmitted Disease Guidelines recommend that the third trimester syphilis screening occur between 28 and 32 weeks of pregnancy). This requires the Texas Department of State Health Services (TxDSHS) to present a biennial CS report to the legislature by January 1 of odd-numbered years for its review and consideration.
The current TxDSHS Congenital Syphilis Report (January 2019) states that “in 2017 nationally, Texas ranked fourth (case rate). There were 166 cases of congenital syphilis reported to DSHS. The rate was 41.7 cases per 100,000 births. Texas accounted for 18.1 percent or nearly one-fifth of the total congenital syphilis cases reported in the United States.”
The CDC estimates that 40 percent of infants born to women with untreated syphilis are stillborn or die as newborns. Usually syphilis is transmitted to the fetus when the mother has primary or secondary syphilis while pregnant, but women with untreated or inadequately treated syphilis, early latent or late latent syphilis, still have a 23 percent chance of an adverse syphilis-related pregnancy outcome. In order to prevent CS, maternal treatment must occur at least 30 days before delivery of the infant (if the mother is treated more than one month prior to delivery, her treatment will address the infection in both mother and fetus).
CS is classified based on the timing of symptoms and signs in the affected child. Early CS presents with vision or hearing impairment, runny nose (“snuffles”), anemia, hepatitis, splenomegaly, long bone abnormalities, developmental delay, and rash manifest before the child’s second birthday. Late CS (from second birthday onward) signs and symptoms include dental and bony abnormalities (remember Hutchinson’s incisors and saber shins?), hearing and vision deficits, and central nervous system manifestations such as gummas and encephalitis, and (rarely) cardiovascular pathologic effects.
TxDSHS has piloted adding CS to regional Fetal Infant Morbidity Reviews in two areas hardest hit by the recent and ongoing rise in CS cases, Harris and Bexar Counties, and is developing an enhanced surveillance system to ensure more complete reporting. The agency is also facilitating improved pregnancy assessments of women with or exposed to syphilis, working to expedite prenatal care referrals for syphilis infected pregnant women, and is partnering with hospitals to provide assessment and management of syphilis in antepartum, intrapartum, and postpartum settings.
Even in the late 1990s and early 2000s with U.S. syphilis rates at historic lows, wide racial and socioeconomic disparities in syphilis rates were observed. Women at highest risk for syphilis during pregnancy include those without insurance (and therefore with late or no access to prenatal care), in poverty, involved in sex work, using illegal drugs, infected with another STD, and in communities with high syphilis rates.
We are still using the same medication to treat syphilis that were transformative in the 1930s and 1940s, and we still rely on syphilis diagnosis and response to treatment which measure antibody titers, having no gold standard for directly establishing active infection (except dark field exam of clinical specimen, rarely done these days).
We need a vaccine against syphilis and new medications to treat it, especially in penicillin-allergic pregnant women with an absolute contraindication to desensitization (such as Stevens-Johnson syndrome). In the meantime, we can use the tools we have to better serve our patients and prevent tragic vertical transmission of an infection we once thought was on its way out.
As a result of early twentieth century atrocities, respect for the individual’s autonomy correctly became a foundational principle of medical ethics. But has our desire to honor patient autonomy resulted in the subjugation of other foundational principles and competing values?
From our founding as a nation we have valued personal liberty and freedom. While we have been inconsistent in our implementation of these values – civil rights come readily to mind – they remain at the core of what it means to be an American.
Ethical codes encompass more than American values and ideals, of course. Western nations united around the barbarity of unethical experiments conducted by Nazi Germany before and during World War II. Determining that this should never happen again, the international community reached a consensus resulting in landmark ethical codes, declarations and reports. These included:
The Nuremberg Code – 1947 – in response to Nazi experimentation on Jews;
The Declaration of Helsinki – 1964 – written for the World Medical Association regarding research on humans;
The Belmont Report – 1979 – drafted, in part, in response to the Tuskegee Syphilis experiments.
All three of these initiatives focused on the individual’s right to decide what can and cannot be done to their bodies. The Belmont Report, drafted by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, a committee that included Tom Beauchamp (yes, that Beauchamp), codified this as the “respect for persons.” Beauchamp and James Childress further developed this concept in their seminal tome, Principles of Biomedical Ethics (Beauchamp & Childress, 1979). Referring to it as “respect for autonomy” it was the first of three ethical principles or “pillars” along with “beneficence” and “justice.”
Today we live in an era of shared decision making, a byproduct of the patient autonomy movement. We are rightfully expected to explain risks and benefits and to obtain informed consent regarding recommended courses of action – all to make certain that the patient’s autonomy is respected. The generation of “doctor knows best” is no more as physicians have become the resident experts who provide information regarding diagnoses and treatment options without prejudice, allowing patients to decide for themselves what they want to do. This movement has and should be celebrated. But what if what the patient wants to do runs up against competing community interests, values, and ethical principles?
This is not a hypothetical question. Tarrant County is the epicenter of the tension between patient autonomy and the common good. A national survey of kindergartners recently revealed that Tarrant County has one of the highest rates of kindergartners with non-medical exemptions for vaccinations. (Olive and Hotez 2018) Now we are seeing the downstream effects of this behavior in the form of preventable diseases like measles, a development that places the greater community in danger. At some point we must ask where the line between the patient’s autonomy and the public good must be drawn.
This issue has broad public implication. Case in point. On December 16th, the U.S. Supreme Court refused to hear an appeal of a 2018 decision made by the 9th U.S. Circuit Court of Appeals. The case in question centered on two Boise city ordinances that prohibit camping or “disorderly conduct” by people sleeping in public places. Those who violated the ordinances were given a nominal fine or briefly jailed. Six homeless residents sued the city in federal court in 2009, itself a testament to judicial efficiency, claiming that the practice violated their constitutional rights under the 8th amendment which prohibits “cruel and unusual punishment.” (Chung 2019). The 9th Circuit sided with the plaintiffs.
This case, like most, is nuanced. The ordinances are predicated on there being temporary shelter options for the homeless. Two Boise shelters have policies to never turn away anyone for lack of space, so the city ordinances had been continually enforced. However, these shelters, run by Christian organizations that have mandatory religious programming and enforce limits on the number of days a person can stay, raised the question as to whether or not the homeless truly have viable options. This factored heavily in the 9th Circuit’s decision. Still, does this decision not undercut a municipality’s ability to maintain public health and safety? Again, where do we draw the line?
The adage “Your right to swing your fist ends where my nose begins” – which originated in the nineteenth century temperance movement – is often cited in arguments regarding personal freedom and the exercise of one’s liberty. Prohibitionists, seeking to restrict the sale and consumption of alcohol, which they considered to be a public nuisance and societal ill, sought to impose their will on the larger community. That particular issue has long been settled, but the underlying sentiment continues to raise its head as we consider the ways in which the exercise of perceived individual rights and autonomy have crept into the national dialog. For instance:
In an era of limited resources and escalating costs, how do we manage the expectations of patients who want “everything done” when the interventions they seek will not improve their outcome, may be harmful and divert resources from places where they might be better utilized.
Are physicians obligated to provide services even if they consider them to be unethical or fiscally irresponsible?
How do we address those in our community who opt out of public health initiatives, like vaccination, when their failure to participate puts others in the community at risk?
How should the community manage the health consequences emanating from patients exercising their rights to engage in at-risk behaviors? Should government impose public smoking bans? Should patients who engage in high-risk behaviors that result in chronic illness or injuries that utilize limited resources be managed differently within the system? If so, how?
How should we address hot-button political topics like gun control and firearm safety, especially in the current political climate?
Should a discussion of the public good become part of all ethics consultations?
Recognizing the importance of our respect for patient autonomy while also honoring our commitment to the public good, the Tarrant County Academy of Medicine’s Ethics Consortium will devote its annual symposium, Healthcare in a Civil Society, to this topic. The program, which will be February 1st (see related information on page 18), will feature healthcare leaders representing public health, the law, clinical ethics, and public policy. While we don’t expect to solve all of the problems, we do plan to take some first steps toward finding local solutions to this important healthcare issues. You are welcome and encouraged to join us for this engaging CME event.
It was my surgery rotation. I was still adapting to the rotation life, attempting to appear confident while trying to recall minute details from first year anatomy to impress my attending. As we rounded on patients, my attending informed me that one of our patients had an extremely poor prognosis as surgery was unable to completely resect a tumor. When we approached the patient’s room to break the unfortunate news to her and her family, my heart was pounding, and I clumsily grasped my clammy hands in front of me. Thoughts were racing through my head – how were we going to break the news? Will I be able to keep my cool? What was the right thing to say in this situation? Where did one even start when talking to a patient about dying?
As a child, my first impression of doctors was akin to that of superheroes. I saw them as healers whose profession was dedicated to helping patients lead quality lives against adversity. To my simple mind, I found it astounding as doctors worked with their team to do the impossible from putting broken bones back together or performing delicate surgeries to remove a malignant tumor. The doctors with their team were Avengers donning white coats, always there to help save the day. While I shed my idealistic perspective as I grew older, I continued to hold on to the essence of my initial view of doctors as healers who worked diligently to do everything they could for their patients.
When I began volunteering with a hospice, I realized I had yet to uncover and consider a vital concept in the patient-provider relationship – death. It was an obvious and inevitable experience within the healthcare field, but somehow, I had never given pause to what it meant. In my classroom years of medical school, I was constantly focused on the treatment. The end goal was “what can I do to help this patient get better?” or “how can I get this patient discharged?” But here, I was faced with patients who were terminally ill and had accepted their outcome in life. These patients were not necessarily looking to get better but instead wanted to comfortably live out their remaining days. The care team was doing their utmost to ensure the patient felt no pain and helped empower the patient in the face of death. They worked alongside the patient to ensure their wishes were clearly expressed and would be fulfilled upon their death. As I spent time with the patients, listening to their life stories and dreams, I started to refocus my understanding of medicine and what it meant to be a doctor.
As doctors, it is an unfortunate truth that we cannot save each and every patient. It is a difficult and bitter fact, especially considering the motivation for many of us entering the healthcare field stems from a want to help people. At first, I felt insecure, scared, and anxious when approach the topic. I was afraid I would somehow offend the patient, or they would be angry with me thinking that I had failed them. However, as I watched my surgery attending, I realized talking about death while an unfortunate topic, could be liberating. My attending quietly sat next to our patient, held her hand, and talked with her honestly. He assured her that while we would be doing as much as we could to help her, we wanted her to start considering her end-of-life wishes. The patient turned to my attending with tears in her eyes and told him she was thankful for his honesty. She appreciated that instead of leaving her in the dark to incessantly worry and question her future, his guidance allowed her to maintain her autonomy in death.
As I continue my own journey in medical school, I hope to continue to face my own insecurities regarding the topic of death so I can be a better doctor for my patients. Rather than superheroes who go around fixing and saving everyone, I now see doctors as companions who guide a patient on their journey of healing and empowerment through emotions of joy, relief, and grief… even in death.
As I begin this year, please let me say “Thank you!” for the opportunity to serve as the president of the Tarrant County Medical Society. It is truly an honor and a privilege to be allowed to serve my peers in this capacity. Indeed, participating in organized medicine has become my passion and is an integral part of my professional life. My medical “family” extends from coast to coast. At the Interim AMA meeting in late November, for example, I enjoyed visiting with and collaborating with friends from the TCMS, the Texas Medical Association, the American College of Radiology, and from the other state medical and specialty societies from around the country while working on the myriad issues facing the medical profession today. It is through my participation in organized medicine that I have come to realize and appreciate the diversity of our profession, both in the range and breadth of our opinions and approaches to the practice of medicine as well as the diverse, and sometimes divisive, internal and external pressures and issues facing the House of Medicine. However, I am more than ever convinced that the goal of service to and care of our patients remains the number one priority. The House of Medicine needs to remain unified in this mission. I encourage all of us, no matter what our employment or practice situation, to maintain unity by participation in organized medicine.
From time to time people ask me how to become involved in or how to further their participation in organized medicine. As I reflect on the many opportunities that abound for one to serve in this capacity, I wish to share with you some of the things I have learned and observed on my journey in this complex and exciting world of organized medicine. This is not an all-inclusive listing of opportunities and venues but rather a “how to” guide based on some of my experiences and thoughts.
Participation “The action of taking part in something”
So, first and foremost, show up! Be present! Within the overall context, start by recognizing that there are local, state, and national general medical organizations/associations (TCMS, TMA, and AMA, for example) as well as numerous specialty colleges and societies (local, state, and national). So, join the appropriate organizations. Then, get involved in the activities of your society. Make the effort to attend meetings. Within each organization, there are committees, councils, commissions, and/or delegations pertaining to the various issues and aspects of medicine. So, find an area of interest and help by attending the meetings and getting involved with a committee, council, commission, and/or delegation. Also, understand that colleges, societies, and associations are interconnected, to some extent, such that participation in one can result in participation in others. So, for example, consider becoming an alternate delegate and then a delegate representing your organization at other societies. This could include helping to represent the TCMS at the TMA. Also follow the same steps in your specialty college and sub-specialty societies. Importantly, consider finding a mentor to help advise and guide you as your participation increases and as you ascend to new levels of leadership.
Another parallel path, particularly for those with a bent for politics, and not exclusive to the discussion above, is to be involved in the political process through advocacy, which has become a primary function of organized medicine.
Advocacy (from Wikipedia) “Is an activity by an individual or group that aims to influence decisions within political, economic, and social systems and institutions. Advocacy includes activities and publicationsto influence public policy, laws, and budgets by using facts, their relationships, the media, and messaging to educate government officials and the public. Advocacy can include many activities that a person or organization undertakes including media campaigns, public speaking, commissioning, and publishing research. Lobbying (often by lobby groups) is a form of advocacywhere a direct approach is made to legislators on a specific issue or specific piece of legislation.”
The first and quickest way to start your advocacy effort is to join the Political Action Committees (PACs) associated with your organizations. PACs are integral to advocacy (and lobbying), providing structured organizations which provide you the opportunity to help in the selection and support of candidates and issues relevant to medicine. Next, take an active role in the political process as afforded by the various organizations and PACs. Begin to establish a relationship with your representatives and senators (state and national). This seems difficult to most people, but the TCMS and the TMA can help facilitate this. An excellent venue to begin the dialogue at the state level is to attend the TMA First Tuesdays during the biennial legislative session by accompanying the TCMS to the Texas Capitol. This immersive exercise is a great first step. This will “break the ice” to help you become comfortable talking with your elected officials and their staff. You can then explore additional ways to become more effective in advocating for your causes. However, rather than wait for the next legislative session (January 2021), consider meeting with your elected officials or their appropriate staff in their district offices to introduce yourself and then to offer to give help and insight on issues and policies being developed during the “interim” year (2020) prior to the next session. During the session, follow the action at the Capitol online through the Texas Legislature Online link which includes live and recorded access to committee meetings and sessions of the House and the Senate. (We are fortunate to have such robust access to our Texas political process.) Even more, consider going to Austin to testify in committee hearings on issues of importance to you. For those with higher level commitment ambitions, service opportunities exist through participation in state agencies. And finally, consider running for public office! (Or, at least actively support those who do.)
Participation in organized medicine has become my avocation as well as my current passion, and I hope others (many others) will come to see the wisdom and necessity of this stance. The future of medical practice always has and always will evolve, both in what we do and how we do it. It is our responsibility, as it always has been, to be on the forefront of this change and to guide this process along the path that will best benefit our patients and society as a whole, without leaving any individual patient unaccounted for. We have been fortunate to have such active participation with so many excellent leaders in Tarrant County. We can and should all work together to continue to grow the atmosphere of collegiality and cooperation by supporting the House of Medicine. As physicians, we are all leaders and we should, we must, recognize and accept this challenge and responsibility.
In my next article, I plan to give longitudinal examples of how an individual’s participation in medical organizations can help to guide and facilitate medical policy development and implementation. Again, thank you for this opportunity to serve!
This is a letter to the Editor at the Fort Worth Star-Telegram from the Tarrant County Ethics Consortium. Reprinted with permission.
We have monitored the scenario surrounding Tinslee Lewis at Cook Children’s for the last two months as it has moved the issue of the Texas Advance Directives Act (Texas ADA, 1999) in general and the 10-day rule in particular, back onto the front burner. While we agree with the Fort Worth Star-Telegram’s assertion that the Texas ADA is imperfect, we do not agree that extending the 10-day period that hospitals have to find an alternative facility is the solution (“Don’t paint Cook Children’s as a villain in tragic Tinslee Lewis life support case,” January 04, 2020).
As technology has advanced, so have the options available to treat critically ill patients. Many people facing acute life-threatening events find aggressive medical intervention a life-saving bridge until their bodies can recover. But there is a point past which no amount of medical intervention will help. In fact, it may hurt.
For the last 40 years healthcare facilities have increasingly relied upon ethics committees to aid them with the unenviable task of examining clinical situations in which medical technology contributes to a moral conundrum in which there are no good options. The typical ethics committee consists of an interdisciplinary team of healthcare workers, often employees of the institution, and also community members who have no official relationship with the facility. In the rare instance when a family insists on aggressive treatment that the medical team believes is non-beneficial or even harmful, either party may request a formal hearing before the ethics committee. The committee’s objective is to hear the concerns of both the family and the medical team and discern the ethical thing to do for the patient. If the committee decides to withdraw aggressive interventions that the family wants continued, the facility may invoke the Texas ADA.
The Texas ADA leverages the expertise of healthcare and ethics professionals to promote a deliberative process at the bedside, carefully considering the family’s desires for treatment in light of the medical realities to discern the best treatment options available for the patient. As medical professionals, we have an imperative to honor our patients’ treatment desires. While we sympathize with the Lewis family, their desire to continue aggressive interventions does not give them – or anyone – the right to demand treatment that violates the norms of the medical profession, the caregivers’ moral integrity or the long-standing ethical precept of “do no harm.”
Much of the criticism of the Texas ADA focuses on the section that allows a health care facility caring for a patient to discontinue life-sustaining treatment ten days after giving written notice. During this time the treating facility and the family seek to identify another facility willing to assume care. Opponents claim that ten days is not long enough to do this. We disagree.
First, every case that gets to the point of invoking the Texas ADA has been thoroughly vetted by the medical team in consultation with the family. When it becomes clear that an impasse is imminent the search for an alternative facility begins, usually weeks if not months before any formal hearing of the ethics committee.
Second, the law allows a judge to grant an extension if, given more time, there is a reasonable likelihood that another facility would be willing to accept the patient. Finding a willing facility usually does not happen since a situation deemed futile by a medical team in Fort Worth would be considered no less futile anywhere else. Even so, judges often grant extensions, especially in high profile cases.
Third, many families have not dealt with the gravity of their loved one’s condition, a reality they can no longer ignore once the 10-day rule is invoked. Extending the 10-day period will not make their grief any less and will not increase the likelihood of finding a facility willing to assume the patient’s care.
We understand that the Texas Advance Directives Act is imperfect, but this law, including the 10-day rule, are better than what we had before when actively dying patients with no hope of recovery were subjected to indefinite pain and suffering because well-meaning loved ones were unwilling to let them go. A longer waiting period will not bring hope to a hopeless situation; it will only prolong suffering. So, while we strongly advocate for initiatives that will improve the health and wellbeing of Texans, we believe that extending the 10-day rule is not one of them.
The Tarrant County Academy of Medicine Ethics Consortium is a diverse, non-partisan group of people interested in health care and ethics in Tarrant County. We are physicians, lawyers, educators, nurses, chaplains, administrators and other interested citizens who seek to improve the health and well-being of the diverse communities that make up North Texas by sharing the application of ethical principles to current healthcare issues through education, advocacy, and collaboration, and by encouraging civil conversation and dialogue.