The Last Word

by Shanna Combs, MD, TCMS Publications Committee

This article was originally published in the May/June issue of the Tarrant County Physician. You can read find the full magazine here.

by Shanna Combs, MD, TCMS Publications Committee

I did not get into medical school.

I failed my oral board exams.

I lost my job.

It all sounds like the trailer to an incredibly sad movie.  But the reality of the situation is I am a board-certified obstetrician gynecologist who has the best job ever.  So how did I get here?

“Everything will be okay in the end.  If it’s not okay, it’s not the end.”

These are the words I discovered many years ago when a friend was going through a hard time, and it is still a phrase we shoot back and forth when times are tough and not going the way we planned.  This is the same friend that picked me up after receiving my rejection letter the first time I applied to medical school. I was not allowed to wallow at home alone—a night of dancing was in order.

Once the dust settled on the acute shock of “not getting in,” I had to decide if this is truly what I wanted to do.  I had been a ballet dancer for almost my whole life and was making my income as a dancer, teacher, and rehearsal coach, as well as working at the community college in the physics lab.  Such is the lifestyle of an artist and their multitude of jobs.

Upon not getting into medical school, I initially thought about working in education with the goal of teaching ballet.  Ultimately though, the call to Medicine was too strong, so I re-took my MCAT, took a biochemistry course, and set my path toward reapplication the next year.  I cast a broader net and, in the end, I obtained the privilege of placing “MD” after my name.

Fast forward a few years.  I completed my residency in obstetrics and gynecology, passed my written board exam, and began my career as an attending physician.  I found my way back into teaching as an assistant professor for medical students and residents.  (Guess that career in education was always going to be there.)  During this time, I collected my cases and prepared for the next step in board certification—the oral board exam.

Since you read the opening lines, you already know the outcome.  Let’s just say, I knew I had failed the minute I walked out of the exam.  “Everyone says that” is what I kept being told, but the following week I discovered the truth.  It was a difficult time for me.  I went through some frustration before I got to acceptance, and there were definitely times where I was not the best person I could be.  In the end, I dusted myself off again, pulled up my big girl pants, and began the process for taking the exam again the next year.  After multiple reviews of my case list, many practice exams/pimping/torture sessions, I walked in for my second try at the oral board exam.

I left the exam with a vastly different feeling.  I knew I had passed.  The following week, while driving back from Colorado with my parents, I got the good news that FACOG could also go behind my name.  My mom made me pull over, and somewhere on the side of the road in rural New Mexico we got out of the car to dance and celebrate my success.  

Fast forward a few more years, and we were hit with the global pandemic: COVID-19. The world as we knew it was changed forever.  Little did I know that my personal world was soon to change as well.  A few months into the pandemic, I was notified that the clinic I worked for had terminated my contract without cause.  I lost my job.  How does a busy obstetrician gynecologist lose their job in the midst of a global health crisis?  I will never know—that is the problem with the phrase, “without cause.”

In life there will be successes and there will be failures.  We always talk about the successes but almost never talk about the failures. 

Once again, I found myself wondering what the next phase in my life would entail.  I remembered not getting into medical school and wondering if I even wanted to be a doctor anymore.  I had worked so hard to get to where I was, yet I was questioning it all over again.  Soon after finding out I had lost my job, a friend told me, “You know, you really have not been happy for the past year or two.  Maybe this is just what you needed.”  Harsh words to hear at first, but in the end, she was right.  So, once again I dusted myself off, put on my extra big girl pants, and looked for what I was going to do next.  

I have found true joy in working in the field of women’s health, but I always had a special interest in taking care of kids and adolescents.  Too often this population gets lost in the shuffle.  I am now happy to say I have found a new landing spot in pediatric and adolescent gynecology.  Young ladies go through many changes during their young lives and even more so during the transition of puberty.  I frequently say, “Puberty is hard,” and I am now able to provide the care and support these young ladies need.

In life there will be successes and there will be failures.  We always talk about the successes but almost never talk about the failures.  However, it is within these moments that you learn the most.  So, why not talk about your failures?  I have truly found the honesty of my inner self when I fail.  I never thought I would be where I am today a year ago, five years ago, or 17 years ago.  Yet, I kept rolling with the punches and taking the next step forward always remembering, 

“Everything will be okay in the end.  If it’s not okay, it’s not the end.”

Tarrant County COVID-19 Activity – 06/28/21

COVID-19 Positive cases: 263,335

COVID-19 related deaths: 3566

Recovered COVID-19 cases: 257,757

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Monday, June 28, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Lights in the Dark

by Angela Self, TCMS President

This article was originally published in the May/June issue of the Tarrant County Physician. You can read find the full magazine here.


I once wrote about my hopes for life after medical school. I would imagine my office decor, my conversations with patients, the time I would spend coordinating their care. The thoughts were all happy and gave me hope when the dark days of medical school cast a shadow over my upbeat mood, when classes took me down the road of insomnia and gave me a near flat affect from studying more than 12 hours a day during exam time. I guess we all looked like zombies immediately before and after our exams, and some even had the fragrance. 

Once a girlfriend came to visit me and she stayed at a hotel on the beach. I discovered the pleasure of sitting and enjoying a piña colada and having zero thoughts of gluconeogenesis or small, slow-conducting fibers (protopathic). Denise, the Coyaba hotel, and a piña colada were all little lights for a med student who was over 2,000 miles from home.

There are times during my professional life that I once again feel like I’m over 2,000 miles from home. Denise is now married and living in Ohio. Piña coladas have way too many calories. The Coyaba hotel would require more PTO than I’m able to take. I’m sitting at my dining room table as I write this because stepping back into the office would make me feel like I’m still at work. I started to take an evening walk but turned around when a close friend told me how much my article sucked (the one you’re not going to read). He didn’t actually say that it sucked; he just pointed out how opposite of uplifting or encouraging it was and said, “It’s not your best work.” Thank you, “D,” for your honesty.
  

Why would I not be the happiest person you could meet? I have a great job. I am happily single and able to go out and meet a girlfriend for coffee any time I want. I see my beautiful daughter on a regular basis (who is working, doing well in school, and enjoying her youth by spending time with her close friends). My mom survived a hospitalization that nearly took her life in 2013 and has never smoked again (I had taken her home on hospice ten days after she was admitted). Heck, I barely have enough bills to qualify as debt. I should be dancing around the whole Grapevine/Colleyville area. But I’m not.

The strange thing about being there for everyone else is that you sometimes forget to keep a little piece of yourself to enjoy—you just give it all away. Yes, this is a “me” problem. I am the one who picks up the phone when I know the person calling is going to vent for the next 30 minutes, but after 20 years of friendship, you make an effort to still “be there” because that’s what friends do. When your very best friend calls and frantically asks for prayer because the vet is coming to put their horse down (which happened two days ago), how do you not take that call? When your mom wants to tell you about a grandkid she’s concerned about and says the stress is overwhelming, are you going to hang up on her? Another friend tells you they are really concerned because they are still having fatigue and shortness of breath since their heart procedure—and this is one of your health-conscious friends. How can you not feel that? Then there is the job that you love doing, but sadly you do it for 12 hours many days. I find myself on long walks, asking, “Am I missing something?” I wonder if there are elderly patients that I could be helping, or if I’m not fulfilling my calling by now being on the “administrative” side of Medicine.

Long walks, good coffee, and two cats have replaced Denise, the Coyaba, and even the piña colada. As I walk along, I play music from the 80s and 90s and look at all of the different trees—I love the long needle pines the best, they look and smell good. I see the cardinals and the other birds flying around and admire how they know the meaning of commitment. On the weekends I spend hours at the coffee shop with the same few people I’ve been meeting there for years (none of us got COVID-19, and almost everyone is getting vaccinated). They give me a special discount at Buon Giorno, just don’t tell anyone. What? They give everyone that same discount for bringing their thermal mug? I look up at the stars and try to find the big dipper, but I live in Grapevine and, you know, light pollution. I run a hot bath and sit there until it’s barely warm. Netflix holds many fond memories from my COVID-19 nights: Shtisel, Sex and the City, The Crown, Girlfriends . . . I really do make the most of each day and try to laugh as much as I can. It’s just been hard to laugh lately, and I wanted to share in case someone else is also having a hard time laughing, or sleeping, or even folding the laundry.

We are the ones who are there for everyone else. Who is there for us? Though my friends and family can drain the very life force from my body, I want you to know that I am here for you. You have sacrificed so much for others, and your colleagues see you. They care even though you thought they didn’t like you. I am struggling a bit these days, as I suspect many of us are after the year we’ve been through. 

Perhaps this is just my COVID-19 carb crash, but I am ready for this season to end. I am praying; I like to pray. I am even going to church on occasion . . . not that I care for going to church. But my faith has always seen me through the most difficult of times, and I once again find myself reading Joshua 1:9, knowing that He will be with me wherever I go. I am going to put that and a few other verses on the wall behind my laptop as a reminder that He is always with me. I have friends who do not share my faith, my politics, or my taste in music, but we do share the need to connect, to laugh, and to be heard. Thank you for reading my article and for being one of the lights in a sometimes dark place. Call me any time at 817-798-8087 (text first if you actually want me to pick up). We’re all walking through this—let’s do it together. 

Tarrant County COVID-19 Activity – 06/15/21

COVID-19 Positive cases: 261,956

COVID-19 related deaths: 3543

Recovered COVID-19 cases: 256,601

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Tuesday, June 15, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

UNTHSC Medical Students COVID Vaccinate the Public

by Steve Martin, MD, City of Burleson PHA
Sarah Andrade, OMS-I

This article was originally published in the May/June issue of the Tarrant County Physician. You can read find the full magazine here.

Pictured from left to right: Assistant Fire Chief Casey Davis; Melson Mesmin, OMS-II; SarahAndrade, OMS-I; Alexander Nguyen, OMS-II; Salma Omar, OMS-I; Fire Chief K.T. Freeman; Steve Martin, MD     Not pictured: Caleb Reagor, OMS-I and John Griswell, MD

To provide access to COVID-19 vaccines to citizens in our area, the City of Burleson’s Public Health Division established a Vaccination Clinic allowing large-scale vaccinations in a former High School basketball gymnasium called “The Pit” in the heart of Burleson.

Beginning with 100 doses per week of the COVID-19 Moderna vaccine in January of 2021, the clinic has since grown substantially. As of late April 2021, as many as 6,000 doses per week were being provided. This is due to a group effort put forth by the Burleson Fire Department chiefs and firefighters, the City of Burleson manager, mayor, and city council, the Burleson Police Department, Burleson librarians, Burleson Citizens on Patrol, Burleson ISD, THR Huguley nurses, and the City of Burleson Public Health Division. The clinic has vaccinated over 35,000 people since opening, recently averaging 2,000 inoculations per day when the vaccine is available.

Several of the area nursing and medical teaching institutions have expressed a desire to have their students gain the experience of COVID-19 inoculations and community volunteerism. With this in mind, they have begun sending their interested students to the Clinic to participate.

Medical students from the University of North Texas Health Science Center (UNTHSC) in Fort Worth, nursing students from the AdventHealth Nursing School in Keene, and EMT students from Tarrant County College have spent time learning to administer COVID-19 vaccines. They are overseen by active and retired RNs and physicians.

The social interaction with a multitude of extremely grateful vaccine recipients has been a truly rewarding opportunity. Below are specific personal experiences and statements made by volunteers:

“I will never forget the 45-year-old woman who sat in front of me to be vaccinated as she broke down in tears, crying uncontrollably, clutching a picture of her recently deceased husband, a COVID-19 victim.” 

-Donna Martin, RN

“I loved volunteering at the clinic because I get to share in the excitement and gratitude of the community members who are so excited to finally be getting immunized.” 

  -Caleb Reagor, OMS-I 

“Through the Burleson Vaccination Clinic, I administered vaccines to individuals from all walks of life who were impacted by COVID-19 in various ways. While many individuals were eager to help end the pandemic with their vaccination, there were individuals who were uneasy about the vaccine due to the side effects seen in social media and heard through word of mouth. After listening to the reasons for their reluctance, I kindly worked to defuse their anxiety and clarify their questions. Through these discussions, they were much more on board to get vaccinated. These interactions served as a reminder for why I chose to pursue Medicine, and I hope to continue guiding patients towards better health outcomes and improved quality of life as a physician.”

     -Kendrick Lim, OMS-II

“Volunteering at the City of Burleson Vaccination Clinic has been a very rewarding experience because I was able to serve the community and help distribute the vaccine that protects from a very deadly illness. As a future healthcare professional, preventative measures are an important aspect of public health and I am proud to be a part of this program as it continues to grow!”

     -Melson Mesmin, OMS-II

The students have approached this effort with great enthusiasm and interest and have been a big help in vaccinating a large number of persons efficiently. We are so very appreciative of their willingness to join us on this adventure. We hope that there will be many more opportunities in the months to come for our area students to participate at the Burleson COVID-19 Vaccination Clinic and assist in our community’s effort to slow down the pandemic and instill hope.

Medical student Kendrick Lim vaccinating a patient

Medical Student Ashley Broderick vaccinates apatient as Burleson Fire Chief K.T. Freeman looks on. 

Medical students from the Texas College of Osteopathic Medicine (Salma Omar, OMS-I; Melson Mesmin, OMS-II; and Alexander Nguyen, OMS-II) help administer COVID-19 vaccines to the public.

Medical student Maria Nguyen vaccinating a patient.

Tarrant County COVID-19 Activity – 06/11/21

COVID-19 Positive cases: 261,719

COVID-19 related deaths: 3538

Recovered COVID-19 cases: 256,226

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Friday, June 11, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Healthcare Compliance Check

by Cheryl Coon
Healthcare Attorney

This article was originally published in the May/June issue of the Tarrant County Physician. You can read find the full magazine here.

As we start a new year, health care providers should consider a compliance check.  Health care laws change, new regulations are promulgated, and advisory opinions1 are issued on a frequent basis.  Healthcare policies and procedures need to be reviewed to make sure they are up to date, and organizations may need to undertake certain necessary actions, e.g., updating their HIPAA security policy.  Compliance checks are ideally performed at least once a year.  

In the past year, for example, the federal Stark anti-referral regulations were amended.2  The Stark amendments made significant changes to the rules, including revising the definitions of “fair market value” and “commercial reasonableness.”  In addition, amendments to the HIPAA regulations have been proposed,3  and the Office of the National Coordinator for Health Information Technology (ONC) finalized rules for electronic records that include provisions relating to patients’ access to their medical records.4 

For a compliance review, HIPAA issues to consider include, but are not limited to:

  • Review employee training to confirm it is up to date, including necessary or desirable written documentation;
  • Review Notice of Privacy Practices provided to patients – is everything current; do new areas need to be added or sections deleted? Are the explanations of possible uses of patient data correct?
  • Review the security risk assessment, particularly given the increase in cyberattacks. Review any changes to technology, new equipment such as computers or servers, new software, and what third parties and employees have access to medical records.  Has your location changed?  Is your security contingency plan still accurate?  
  • Review to verify patient access to their records complies with the new ONC rules and HIPAA;
  • Determine if there are new business associates to add, business associates that need to be deleted, or agreements amended;
  • Verify that the named HIPAA privacy and/or security officer is still in that position;
  • Review the breach reporting policy and make necessary or desirable changes;
  • Determine if any third-party agreements or business associate agreements have been revised or added, and if so, if the agreements in writing include any amendments;
  • Assess compliance with state privacy/medical record laws, which often have different provisions than HIPAA.6

    In other areas, things to consider include, but are not limited to:
  • Perform an inventory of third party agreements and verify, for new or amended relationships, as applicable, that an appropriate Stark referral analysis was performed and is up to date and that an anti-kickback analysis also was performed and is up to date, i.e., is remuneration fair market value?7 
  • Update policies and practices to conform to the new Stark rules and any other applicable new or amended federal and state laws;
  • Review continued compliance with any safe harbors relied on under the Stark rules and/or anti-kickback rules, if applicable, e.g., equipment or real estate leases, personnel service and/or management agreements;
  • Confirm employee background checks are up to date;
  • Confirm federal health care exclusion screening is up to date;
  • Confirm licensed employees have completed continuing education requirements and any other conditions to maintain licensure;
  • Inventory leases and any amendments and make sure appropriate documentation is in place, including, if applicable, a fair market value analysis;
  • Verify record retention policies still comply with current laws and that the procedures are being followed;
  • Consider whether an audit of the use of appropriate billing codes is necessary;
  • Verify required licenses are up to date for personnel and any equipment;
  • Verify compliance with federal and state telehealth laws, if applicable, including any provisions related to COVID-19;
  • Verify that patient record request policies are up to date and that personnel are complying with the policies;
  • Verify appropriate due diligence is being performed for applicable laws when new vendors or contractors are engaged.

Your organization should also consult in-house or outside counsel to verify any changes to federal and state laws before beginning the compliance review process.  Furthermore, there is value in engaging an attorney and seeking legal advice on the review in order to invoke the attorney-client privilege where possible.  The privilege will not protect all documents or all communications, but it provides significant protection during the process for covered communications.9   

Again, this “list” is not comprehensive, particularly given the plethora of health care laws that could apply and the complexity of such laws.  As an example, this list does not focus on Medicare or Medicaid compliance.   Nonetheless, it should provide a reminder for the key areas to cover when conduct a general healthcare compliance check.

References:

1. This article is not intended to be a comprehensive summary of all final or proposed changes to federal and state health laws and regulations.  Additionally, given the many types of healthcare providers, the article does not address all possible federal and state laws but is intended to provide an example of the type of questions they should ask.

2. See, e.g., OIG Advisory Opinion No. 20-08 (Dec. 20, 2020) ((regarding a federally qualified health center’s proposal to offer gift cards to incentivize certain pediatric patients to attend rescheduled preventive and early intervention care appointments).

3. 85 Fed. Reg. 77,492 (Dec. 20, 2020).

4. See 85 Fed. Reg. 6,446 (Jan. 21, 2021).  The proposed changes largely relate to the new ONC rules regarding access to patient records.

5. See 85 Fed. Reg. 25,642 (May 1, 2020).

6. According to many experts, training should be performed at least annually.

7. For example, the Texas Medical Record Privacy Act has a much broader definition of “covered entity” than HIPAA, being any person who engages in the practice of assembling, collecting, analyzing, using, evaluating, storing, or transmitting protected health information and including any person who obtains or stores protected health information.  See also 15 Tex. Admin. Code § 390.2 which lists various statutes that could be applicable to Texas covered entities.

8. The definitions of “fair market value” and “commercial reasonableness” have changed under the new Stark rules that were effective January 19, 2021 (with limited exceptions).

9. The new Stark rules also made changes in these areas. 

10. Generally, the elements of attorney client-privilege are: (1) the person asserting the privilege must be a client or someone attempting to establish a relationship as a client; (2) the person with whom the client communicated must be an attorney and acting in the capacity as an attorney at the time of the communication; (3) the communication must be between the attorney and client exclusively; (4) the communication must be for the purpose of securing a legal opinion, legal services, or assistance in some legal proceeding, and not for the purpose of committing a crime or fraud; and (5) the privilege may be claimed or waived by the client only.

Tarrant County COVID-19 Activity – 06/03/21

COVID-19 Positive cases: 260,993

COVID-19 related deaths: 3515

Recovered COVID-19 cases: 255,235

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Thursday, June 3, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Mentorship Matters

by Shanna Combs, MD

This article was originally published in the May/June issue of the Tarrant County Physician. You can read find the full magazine here.


One of my favorite roles as a physician and medical educator is the opportunity to be a mentor.   At the TCU and UNTHSC School of Medicine we recently kicked off our 2021 Diversity and Inclusion Mentoring Network Series.  As with everything in life, our mentoring network had been put on the back burner due to the COVID-19 pandemic.  It was so refreshing to get back into the mentoring groove again with our latest event, even if it was virtual.

Mentoring is a critical piece to the development of aspiring physicians, not just at the medical training level but also at the college, high school, and school age level.  Unfortunately, over the past few decades the decision to become a physician has all too often been met with negativity…

. . . too much schooling, too much debt, no time for a family or a life, medical-legal concerns, too much paperwork, financial concerns, and ultimately, physician burnout.   

I still remember telling physicians that I wanted to be a doctor when I grew up and immediately hearing how that was not a good career choice, and if they had to do it all over again, they would choose another field.  Thankfully, I occasionally met a doctor or two who showed me how much they loved their work and encouraged me in my pursuits.  This is why mentorship matters.

During this crazy year of a global pandemic, we have truly seen the importance of our healthcare team members and have even named them heroes.  I only hope that this will continue.  While our path as physicians is not always easy, I feel that it is an extremely rewarding one, and I want to help others see how amazing it is to be a doctor.  Mentorship comes in all forms, and one just needs to be willing to share their guidance and expertise to become a mentor.  Mentoring can be formal, peer-to-peer, developmental, instructional, or informal.  No matter the form, mentorship is extremely important and provides benefits to the mentor as well as the mentee.

At our recent mentoring event, not only was I able to provide guidance and nurture our up-and-coming physicians, but I was also able to learn a lot about our community.  Some of the amazing features of the TCU and UNTHSC School of Medicine Diversity and Inclusion Mentoring Network are that it crosses multiple areas in Medicine, includes mentors from a variety of backgrounds and journeys in life, and is made up of physicians, researchers, administrators, and leaders in the community.  In addition, due to the need to meet virtually, it now includes mentors from across the country who have a connection to our school.  It was exciting to hear about others’ successes, failures, and varied experiences in Medicine as well as to hear about their “why” for pursuing it as a vocation.  It was also refreshing to see the joy on the students’ faces as they were able to interact in small groups with mentors and hear the various pearls of wisdom each one had to share.  

By mentoring medical students, you can provide opportunities for growth and professional development, demonstrate the various careers and specialties in Medicine, and give career advice and counseling.  Most importantly, though, you can see the enthusiasm for your chosen profession. So, if you need a little more joy in your life, I highly recommend finding a way to be a mentor to those in need of guidance and encouragement.  Please feel free to join our Diversity and Inclusion Mentoring Network at the TCU and UNTHSC School of Medicine.  As with everything in life, a village can only make you stronger.

To join the TCU and UNTHSC School of Medicine Diversity and Inclusion Mentoring Network, please go to https://tcu.co1.qualtrics.com/jfe/form/SV_eA8Gugmvl5wg69w.