Tarrant County Physician Online

PRESIDENT’S PARAGRAPH

by Stuart Pickell, MD, TCMS President

Why Do We Not Have a Pediatric Residency Program in FORT WORTH?

WHEN I MOVED BACK TO FORT WORTH in 2001, I wondered why we had so few graduate medical education (GME) programs. I came to understand, from those who should know, that Fort Worth simply wasn’t an “academic” city. We had one of the finest osteopathic medical schools in the country, several excellent medical centers, and a fine children’s hospital, but relatively few residency positions for a city our size. In 2011, the Texas Legislature, concerned that the physician workforce would not keep pace with Texas’ rising population, established a goal of 1.1 residency training positions for every Texas medical school graduate. Physicians often remain near where they train, so the reasoning was and continues to be sound. Achieving and maintaining this goal helps to build and sustain the physician workforce.

Fortunately, with no help from Tarrant County, Texas achieved its goal in 2017 (see Table 1). However, the impending graduation of student from new medical schools in the next two years will increase the demand for PGY-1 positions. the Burnett TCU School of Medicine will graduate its first class in May. A year later the Sam Houston University College of Osteopathic Medicine and the University of Houston College of Medicine will graduate their first classes. By 2024, to maintain the minimum 1.1 ratio, Texas will need to increase the number of residency positions by 5 percent, and to maintain its current 1.16 ratio, it will need to increase the number of positions by 10.8 percent.

In the last few years, Tarrant County’s medical community began meeting the challenge by starting several new residency programs. This is a welcome, albeit long overdue, development. Baylor Scott and White and Texas Health Resources have led the way to these recent changes by starting programs in internal medicine, ob-gyn, emergency medicine, and general surgery- this in addition to the programs already established at John Peter Smith and Medical City. The elephant in the room is pediatrics.

Why does Fort Worth, the 13th largest city in the country and home to the 13th largest children’s hospital, not have a pediatric physician residency program? I include the word “physician” because Cook children’s does have a pediatric residency program for nurses. In fact, it has one of the only 34 such programs in the country, but it does not have a program to train physicians- and its the only children’s hospital that has a program for nurses and not physicians. But as the population grows, won’t we need more pediatricians? Regional growth trends suggest we will. For instance, in just the last five years:

• The U.S. population increased by 2.7 percent

• The Texas population increased by 5.8 percent

• The Fort Worth population increased by 9.3 percent

• Fort Worth went from being the 16th to the 13th largest city in the country

• The number of PGY-1 pediatric residency positions in Texas increased from 211 to 213, or 0.95 percent

Looking at the 30 largest cities in the United States, Fort Worth is the only one that doesn’t have a pediatric residency program. Jacksonville, FL, which ranks just ahead of Fort Worth in population, for now, has a pediatric residency program, and it doesn’t even have a medical school. Fort Worth has two medical schools.

Within Texas you will find residency programs in the larger cities – Houston, San Antonio, Dallas, and Austin – but you will also find them in El Paso, Corpus Christi, Lubbock, Temple, Galveston, and Amarillo. The only other cities in Texas that have a medical school and no pediatric residency program are College Station, Edinburgh and Conroe. So, why not Cook Children’s?

I’ve asked this question to more than a few people affiliated with Cook Children’s – some who would like to see a physician GME program and others who would not. While they disagree on the proposition, they generally agree on the historical timeline and current sentiment. Cook Children’s, the result of a merger of Fort Worth’s two children’s hospitals in the 1980s, had a unique vision from its inception. Like many large children’s hospitals, it offered state-of-the-art care for pediatric patients, but it also vowed that patients would only be treated by board-certified pediatricians, i.e., no students or residents. Since most of Fort Worth’s hospitals didn’t have GME programs, Cook Children’s was not an outlier.

What made Cook Children’s particularly unique was its size and resources combined with its lack of GME entanglements. Cook Children’s leveraged this latter feature to recruit physicians who wanted to be clinicians, not educators. A vocal minority of the current medical staff have embraced this feature and do not want it to change. There is also a vocal minority who knew Cook Children’s wasn’t an academic institution when they joined but believe now that it should be. Many others – probably a majority, although no formal vote has been taken – would be fine with a GME program if one existed, but they could go either way.

In recent years, the subject has been revisited several times. About five years ago, Cook Children’s hired Germane Solutions, a GME consulting firm, to examine the viability of a GME program and assist in its development. Their findings are proprietary, but the consensus of the people with whom I talked is that Cook Children’s is positioned to have an outstanding GME program if it wants one. Furthermore, it would enhance the hospital’s national profile and be a financial boon to the local economy. But the success of a GME program hinges on having a medical staff who supports it. One vocal minority does, the other does not. And while the support doesn’t need to be unanimous to make it work, it wasn’t clear that enough of the middle majority supported it to the point it would reach the critical mass needed to make it worth pursuing.

Some theorize that demand for more pediatric residency positions among graduating medical students is lacking, and there is some truth to this claim. In the 2021 match, there were 1.47 pediatric PGY-1 positions for every graduating U.S. medical student who applied for one. But this doesn’t tell the whole story. Between 2016 and 2021, a concerning trend emerged. While nationally the number of pediatrics PGY-1 positions increased by 6 percent there was a 14 percent decrease in the number of U.S. medical graduates applying for them.

Fortunately, foreign medical graduates have filled the void, resulting in a match-fill rate consistently over 98 percent, which makes pediatrics appear both desired and competitive. But shouldn’t the decreased domestic interest in pediatrics provoke more questions? Why are U.S. medical students not considering pediatrics?

One perennial concern is low pay relative to other specialties, including pediatric subspecialties. As one of my residency attendings used to quip, “Little people, little money.” This must be on the minds of even the most altruistic of medical students for whom the average student loan debt upon graduation is over $200,000. But perhaps students everywhere are picking up on a trend that Cook Children’s is actively embracing- a hidden curriculum embedded in the cook Children’s philosophy as evidenced by the presence of a residency program for nurses but not physicians, that the future of primary care pediatrics is really nursing.

“Baylor Scott and White and Texas Health Resources have led the way to these recent changes . . . this in addition to the programs already established at John Peter Smith and Medical City. The elephant in the room is pediatrics.”

I hope this is not the case, because while value the contributions that nurses and APPs bring to the clinical care team, their training is qualitatively and quantitatively different from that of a physician. These teams should be supervised by physicians, and those physicians need to be trained… somewhere.

Why no Cook Children’s? Medical staff aside, they have the resources. So, how many attendings does Cook Children’s need to reach the critical mass necessary to start a residency program for physicians as well as nurses. A hospital with their resources could have a large residency program. To make a comparison, Children’s Hospital of Los Angeles is roughly the same size as Cook Children’s could start with eight, the same size as Texas Tech’s program in Lubbock. considering that physicians often practice where they train, could Cook Children’s not do this for the community’s sake?

The Cook Children’s Health Care System and its flagship hospital are. a well-kept secret that will not reach its full potential until It becomes an academic training facility with education and research affiliations. To illustrate this, U.S. News & World Report ranks the top 50 children’s hospitals in 10 different specialties. Most hospitals comparable to Cook Children’s rank in nine or 10 of these specialties, often in the top 30. Cook Children’s ranks in only six, the highest being neurosurgery at 20. The others come in at 38, 41, 43, 48 and 50.

The hospital website states: “As one of the fastest growing areas in the United States, Cook Children’s is continually looking ahead to meet the needs of a very diverse population.” No one will argue with this. Cook Children’s is one of the finest children’s hospitals in the United States. As a city and as a medical community we should be- and are- proud of it. But can it not look further ahead and become home to one of the finest pediatric residency programs as well? Becoming an academic center will enhance its national profile and bolster the pediatric workforce in Texas by exposing students to high-quality pediatric primary care and specialty services early in their training, while providing an exceptional place for them to continue their training and work after they graduate.

Most things worth doing require effort. Starting a new residency program is no exception. Some physicians to me that now is not the right time, that in the wake of COVID-19 they don’t have the bandwidth for it. But will there ever be a “right” time? wll there ever be a time when the stars in heaven align, and there is a unanimous agreement that the time has arrived?

First century rabbi Hillel the Elder once said, “If I am not for myself, who will be for me? If I am only for myself, what am I? If not now, when?” Indeed. Given the need and the benefit to the community, perhaps now is the right time after all.

References:

1. The Texas Hospital Association’s educational series on hospital finance: “Graduate Medical Education, Part 5” – https://www.tha.org/wp- content/uploads/2022/04/Financing_GME_FI- NAL.pdf

2. Data for 2011-2019 may be found in a paper written by the Academic Quality and Workforce of the Texas Higher Education Coordinating Board: “The Graduate Medical Education (GME Report: An Assessment of Opportunities for Graduates of Texas Medical Schools to Enter Residency Programs in Texas.” This was a report to the Texas Legislature per Texas Education Code, Section 61.0661, October 2020, p.x.

3. See: The Kaiser Family Foundation website: https://www.kff.org/other/state-indicator/total-medical-school-graduates/

4. See: https://www.residencyprogramslist.com/ in-texas

5. “The Graduate Medical Education (GME) Report: An Assessment of Opportunities for Graduates of the Texas Medical Schools to Enter Residency Programs in Texas.” October 2020, P. 17

6. Cook Children’s Hospital consistently ranks between the 10th and the 18th largest children’s hospital in the United States depending on whether we are looking at licensed beds, staffed beds, and when the reporting was obtained.

7. See U.S. Census data at: https://www.census. gov/
8. See data from the National Residency Matching nrmp.org/
9. Not surprisingly, every U.S. city with more than one medical school has a pediatric residency program, except Fort Worth.
10. Information obtained for this article synthe- sizes conversations I had with 10 different people, all of whom are knowledgeable of Cook Children’s Medical Center (CCMC) and the movement to develop a physician residency program. Because of the sensitive nature of this topic, I promised that I would not reveal their names or quote them directly but would make a good faith effort to com- municate their understanding of the issue. They did not all agree on whether CCMC should pursue a residency, but they did agree on the major points outlined in the article. Of the 10, eight are or were employed by CCMC, almost all in leadership posi- tions. Three of those have retired and five remain on staff. The other two, both physicians, are lead- ers in the medical community and/or at CCMC and in a position to speak to this topic.
11. See: https://educationdata.org/average-medi- cal-school-debt
12. See https://health.usnews.com/best-hospitals/ pediatric-rankings
13. See: https://www.cookchildrens.org/about/ history/
14. Mishnah Avot 1:14. See: https://www.sefaria. org/Pirkei_Avot.1.14?lang=bi

DEA Proposed Rules Address Telehealth Prescribing Post PHE

by Sean Price

Originally published by Texas Medical Association on March 8, 2023.

Physicians found new flexibility in prescribing controlled substances via telemedicine during the COVID-19 pandemic.

Now that the public health emergency is ending, the Drug Enforcement Administration (DEA) has proposed new rules for prescribers it says could preserve some of those flexibilities “with appropriate safeguards.”

Among other things, the new rules – if finalized – would allow physicians and health care professionals to prescribe, without a face-to-face visit, a 30-day supply of Schedule III and Schedule IV non-narcotic controlled drugs, after which an in-person follow-up would be needed for any refill. This class of drugs is the least likely to result in drug abuse, according to DEA. The proposal also would allow for prescribing a 30-day supply of buprenorphine to treat opioid use disorder without an in-person evaluation or referral.

“Improved access to mental health and substance use disorder services through expanded telemedicine flexibilities will save lives,” Department of Health and Human Services Secretary Xavier Becerra said in the announcement. “We still have millions of Americans, particularly those living in rural communities, who face difficulties accessing a doctor or health care provider in person.”

The agency emphasized that the rules do not affect telehealth services that do not involve controlled substance prescriptions. The Texas Medical Association is reviewing how the proposed regulations could interact with other federal and state regulations, says Shannon Vogel, TMA’s associate vice president of health information technology.

DEA has released summaries for both healthcare professionals and patients explaining how the proposed rules would affect prescription practices.

“This is a very good thing that they’re doing and a necessary thing” for access to care, said Mesquite pain management specialist C.M. Schade, MD, a former president of the Texas Pain Society.

Before the pandemic, physicians were limited in their telemedicine prescribing ability by the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, he says. The act requires physicians to conduct at least one in-person medical evaluation of the patient before prescribing a controlled substance by means of the “internet,” which is defined to include telehealth.

“COVID did great things for telehealth, and one of them was breaking through the Ryan Haight Act,” Dr. Schade said.

Some policymakers and behavioral health advocates have expressed concern, however, that patients who need continuous medication therapy may have challenges obtaining an in-person visit within 30 days.

The rules were proposed on Feb. 24 and public comments are due on March 31. The agency has no set timeline for publishing the rules, though it is likely that will come before the PHE ends on May 11.

Physicians with questions and comments about the DEA changes or relevant state regulations can contact Ms. Vogel.

Addressing Conscientious Objection in Healthcare

Insights from the 2023 Healthcare in a Civil Society Forum

by Liz Ramirez

The Tarrant County Academy of Medicine Ethics Consortium, in partnership with Tarrant County Medical Society, hosted Healthcare in a Civil Society on Saturday, February 25, 2023. The annual forum’s central theme focused on “Conscientious Objections in Health Care: Patient Autonomy and Provider Integrity.”

TCMS President Stuart Pickell, MD, joined Steve Brotherton, MD, as HCS moderator and welcomed their keynote speaker, Farr Curlin, MD, at the University of North Texas Health Science Center.

“Dr. Curlin is an internationally known expert on physician conscience and conscientious objection,” said Dr. Pickell. “He is particularly concerned with the moral and spiritual dimensions of medical practice, the doctor-patient relationship, and the moral and professional formation of physicians. His areas of expertise are medicine, medical ethics, doctor-patient relationship, religion and medicine, and conscience.”

On the panel, Dr. Curlin was accompanied by panelists Maxine M. Harrington, JD; Alan Podawiltz, DO; and UNTHSC President, Sylvia Trent-Adams, Ph.D., RN. In the discussion, Preston “Pete” Geren, JD, moderated a panel about educational topics like state intrusion into practice, the effect of providers performing unethical acts, and how medical educators can train students to recognize moral injury.

Participants had the opportunity to interact in small groups and prepare questions for the panelists during the breakout session, where panelists discussed the impact of government and institutional intrusion into medical practice, its effect on healthcare providers, and what providers can do to address it.

“While this event targets medical professionals, anyone who has an interest in the doctor-patient relationship- how it has evolved, where it is heading and implications for the future of healthcare- will find this program helpful,” said Dr. Pickell.

The Tarrant County Academy of Medicine Ethics Consortium believes anyone in the community with an interest to improve healthcare can benefit from this program. The event wouldn’t be possible without the support of Blue Cross Blue Shield, Cook Children’s Medical Center, JPS Health Network, and the University of North Texas Health Science Center.

PRESIDENT’S PARAGRAPH

by Stuart Pickell, MD, TCMS President

This article was originally published in the January/February 2023 issue of the Tarrant County Physician. You can read find the full magazine here.

IT IS AN HONOR AND A PRIVILEGE TO serve as president of the Tarrant County Medical Society for 2023. I aspire to lead as ably as those who have preceded me and to move the ball forward on the many priorities we have as physicians and citizens of Tarrant County. To that end, I posed several questions at the installation event in November that I will follow up on this year, using this space as a launchpad for discussion. At the root of these questions is identity- our identity as physicians and leaders in our community.

For many physicians, and I know this is true for me, there is a sense that, like Harry Potter’s wand, we didn’t choose medicine- it chose us. We have a sense of “calling” to the profession, as if by something external to us or deep within us- either way, something so profound and unknowable that it may defy articulation.

The language of “calling” resonates with nem although for me it was problematic because I had two. When I was five years old, I told my family that when I grew up, I was going to be a minister, a doctor, and a fireman. I have done all three. Firefighting didn’t stick.

What did stick was ministry and medicine. I hoped it would be one or the other, but it never was. In college, I took classical greek and 400-level biology and chemistry courses and majored in history because I liked it. i sought advice from people I respected who were ministers and physicians and they all said the same thing: If you’ve ever thought about doing something besides ministry or medicine, do that instead. As my wife would say, “Hmmmm.”

Years later, and several years into a full-time ministry position, I told a parishioner about my dilemma. He also happened to be a therapist, which only reinforced my commitment to Calvinism. After patiently listening to me explain all the reasons why it wasn’t practical to do both, he looked at me and asked, “Why not?”

Hmmmm.

Ministry and medicine are similar. They are both vocations in the truest sense of the word, a word derived from the Latin vocare, which means “to call.” Both are professions to which the people in them tend to feel a sense of calling that compels and propels them to serve.

It makes sense that medicine, as a profession, would be hardwired toward serving others. After all, our calling first had to be validated by a medical school that saw in us what we saw in ourselves. We had to be chosen by someone else to become part of a tribe. Do you remember how you learned that you had been accepted to a medical school? I do. I got a letter. I think it’s fitting, however, that student admitted to TCU’s Anne Burnett School of Medicine literally get a call- by telephone- telling them the good news. And admissions committees seek candidates who have integrity and demonstrate empathy; people who are team players and servant leaders. This is and always has been at the core of our identity as physicians.

How we grow into that identity, and how our call to serve becomes manifest, will be as unique as each one of us. People who are called are called not just to be but to do- to apply their knowledge and expertise in a unique and meaningful way. In a way, physicians don’t have a career so much as a mission- which, at the risk of sounding pedantic, comes from the Latin word mitterre, which means “to send.” The English word is rooted in medieval Christianity, but today’s “mission” is more likely to describe the driving principles of an individual, or a business, or a non-profit group or a healthcare institution. it speaks to their identity, their raison dêtre. We are called, and we are sent, sent on a mission to serve the people in our charge- our patients- and the community in which we all live.

So, how are we doing? Are we fulfilling our mission? In many ways, we are doing quite well. We have excellent physicians in just about every specialty. We have fine institutions for adults and children and one of the best county health systems in the country. But we still have pressure points. How does the execution of our mission, individually and corporately, impact the larger community- not just us or our practices or our institutions but the people we have been called to serve?

Throughout the year I will use this space to explore this question, examining our individual and corporate roles and responsibilities as physicians in the hope that doing so will promote a constructive dialogue that furthers our mission to serve the larger community. Some of the pressure points I see and hope to explore include:

- The inadequacy of Graduate Medical Education in Fort Worth, and especially at Cook Children’s Health System. The Cook Children’s Health System and its flagship hospital are among the finest in the country. It has excellent leadership and medical and support staff. But would the community not be better served if it leveraged this prestige and became an academic center as well, training physicians and pediatric specialists who, by the way, often practice near where they train?

- Lack of access to the county healthcare system for undocumented county residents. Undocumented residents can receive emergency care at a reduced rate (which is often still too expensive for most) but are ineligible for the preventive care that might have averted the need for emergency services in the first place. Even Project Access can’t access county health facilities for use by our member physicians who are willing to donate their time and expertise to do necessary but non-emergent procedures.

- Lack of physician input in the assessment, planning and implementation of strategies to address community healthcare needs and crises. Such planning should start with physicians, the people in the community who know the patients personally and who, because of these relationships, the patients trust to act in their best interest. COVID – a crisis made worse by its politicization – quickly devolved into divisive rhetoric that led to a profound mistrust of medical authorities, especially at the national level. Our member physicians voluntarily stepped into this nightmare. We partnered with neighboring county medical societies and aided the local health authorities with its media information operations, providing an honest assessment of available information to inform and educate physicians and the public. And yet, when it came to planning and implementation, the local authorities turned to non-clinical hospital leadership for input and direction.

Working together to address challenges and overcome obstacles is the center of our mission, a mission that emanates from a calling, a calling that forges our identity as physicians. What makes our calling and its ensuing mission so important, and our profession so rewarding, is the relationship we share with each patient – one that is founded on empathy, trust, and mutual respect. It’s the one thing that remains constant in the chaos, because when our patients don’t trust anyone else, they still trust us.

Our mission is not about us – it’s about our patients and our community. And if our mission is to improve their health and safety, we must be willing to take an honest look at ourselves, to understand where we have been, assess where we are, and anticipate where we are headed. And if we discover that our mission is no longer serving our patients or our community, we must have the courage to change it.

Organized medicine helps us identify challenges, assess the adequacy of our mission, and if needed, adjust it. I am honored to be a part of that process and look forward to continuing our conversation.

TMA Pleased by U.S. District Court Ruling Granting Summary Judgment Motion

Court Agrees With Physicians’ Argument
in Federal No Surprises Act Rule Case

Statement by Gary W. Floyd, MD, Texas Medical Association (TMA) president, in response to the U.S. District Court for the Eastern District of Texas ruling on TMA’s motion for summary judgment in its lawsuit opposing certain components of federal regulatory agencies’ final rules regarding dispute resolution under the No Surprises Act. TMA argued the case in the U.S. District Court in December, addressing the second of four TMA lawsuits against federal agencies related to rulemaking under the surprise-billing arbitration law.

“TMA is pleased the court granted its motion for summary judgment in its lawsuit challenging certain components of the federal agencies’ final rules relating to the federal independent dispute resolution (IDR) process under the No Surprises Act. This is an important next step after TMA successfully challenged an interim final rule that similarly skewed the IDR process in health plans’ favor.

“This decision is a major victory for patients and physicians. It also is a reminder that federal agencies must adopt regulations in accordance with the law.

“The decision will promote patients’ access to quality care when they need it most and help guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices.”

TMA is the largest state medical society in the nation, representing more than 57,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.

Feds to End COVID-19 Public Health Emergency in Mid-May

by Emma Freer

Originally published by Texas Medical Association on February 7, 2023.

After nearly three years and 11 extensions, the Biden administration recently announced the COVID-19 public health emergency (PHE) will finally expire May 11, fulfilling its commitment to give states at least 60 days’ notice of its expiration.

“If the PHE were suddenly terminated, it would sow confusion and chaos into this critical wind-down,” the Executive Office of the President wrote in a Jan. 30 statement.

Still, the end of the PHE has significant consequences for Texas physicians and their patients.

The federal Families First Coronavirus Response Act temporarily increased federal Medicaid matching dollars by 6.2% for states that agreed to maintain Medicaid coverage for anyone enrolled in the program from March 2020 through the end of the PHE.

That included Texas, where more than 2.5 million residents, predominantly postpartum women, and children, benefited from continuous Medicaid coverage.

These matching dollars will phase out between April and December, according to a provision in the Consolidated Appropriations Act of 2023, a $1.7 trillion spending package that President Joe Biden signed into law on Dec. 29, 2022.

To continue to receive these funds through the end of the year, states must comply with certain federal requirements, including agreeing not to terminate enrollment based on returned mail due to an incorrect address.

In the meantime, state Medicaid officials have a plan for unwinding this coverage, but it requires redetermining millions of patients’ Medicaid eligibility in just eight months. The Texas Health and Human Services Commission (HHSC) will begin sending notices in March reminding patients to update their information.

The Texas Medical Association has met regularly with HHSC over the past year to provide input on the state’s plan with the goal of achieving as smooth a transition as possible. Despite progress, such as streamlining the ways in which Medicaid patients can complete their eligibility applications, TMA remains very concerned about a looming coverage cliff.

Fortunately, the end of the PHE coincides with some recent policy developments, including increased federal funding for navigators – community organizations that connect eligible consumers to federal marketplace health plans – and extended subsidies for the same plans. TMA experts say these changes could help some Texans who lose Medicaid coverage enroll in a different plan.

The Consolidated Appropriations Act also makes permanent an option for states to provide 12 months of continuous Medicaid coverage to postpartum women.

TMA would like to see the Texas Legislature take advantage of this option, one of the association’s top priorities this session.

Moreover, the law requires states to provide 12 months of continuous Medicaid coverage to children, beginning Jan. 1, 2024. TMA is urging HHSC to align this provision with its redetermination process to minimize the burden on families and to prevent gaps in care.

In addition, the Consolidated Appropriations Act extended certain pandemic-era telehealth flexibilities for Medicare patients through 2024, disentangling them from the status of the PHE. These flexibilities include:

Waiving geographic site restrictions, which allow patients to access care from their homes; and

Allowing physicians to use audio-only telehealth services.

TMA and others in organized medicine recently wrote a letter to the Centers for Medicare & Medicaid Services (CMS), requesting the agency issue an interim final rule to align its telehealth policies and timeline (to expire 151 days after the end of the PHE) with those in the Consolidated Appropriations Act. Not doing so, they wrote, could create “an unintended barrier to vital health care services, as well as potential confusion” among clinicians and patients.

Prior to the act’s passage, CMS made permanent the same telehealth flexibilities for Medicare patients accessing mental and behavioral health services as well as coverage of video-based mental health visits at federal qualified and rural health centers.

Finally, the PHE’s end means physicians not using a HIPAA-compliant platform for telehealth will need to switch to one by May 12.

Physicians can refer to CMS’ fact sheet regarding PHE waivers and flexibilities for more information.

For more detailed coverage on how the end of the PHE will affect Texas physicians and patients, check out the January/February issue of Texas Medicine magazine.

Meet Stuart Pickell, MD, Our 2023 TCMS President

By Allison Howard

This article was originally published in the January/February 2023 issue of the Tarrant County Physician.

“IN MANY WAYS, MEDICINE IS A FORM OF MINISTRY,” SAYS DR. STUART PICKELL.

HIS PERSPECTIVE ISN’T SURPRISING. When you get to know Dr. Pickell, one thing quickly becomes clear – if he is interested in a project or an organization, it is because it involves serving the community. It is his desire to help others that threads his varied passions together – including his careers as both a Presbyterian minister and a physician.

“When I was five, I told my family I was going to be a minister, a doctor, and a fireman,” says Dr. Pickell. “And I did all three.”

While his stint as a fireman was limited to volunteering during high school, the experience impacted his future. During that time, Dr. Pickell became an EMT and worked for both firefighting and ambulance services. This early introduction to medicine helped to cement an interest in patient care that would continue to influence him in the years ahead.

Still, Dr. Pickell did not take a direct route to healthcare. When he attended the College of William and Mary, he was undecided between medicine and ministry. Instead of picking a degree that would only fit one or the other career path, he decided to study history and use his elective courses to take prerequisites for both seminary and medical school.

“I was in Williamsburg going to William and Mary, which is in a town where it’s always 1773,” explains Dr. Pickell. “So I was living there, with a lot of primary sources around me, and it made researching and the study of history more interesting, and it came to life more. And I knew that for ministry or medicine, it didn’t really matter what I majored in.”

Dr. Pickell was still unsure of his future path when he graduated, so he worked at a community hospital and church for two years before he decided to pursue a career in ministry, following in his father’s footsteps.

He received his Master of Divinity at Princeton Theological Seminary, and shortly after graduating, began working as the associate minister for youth and families at First Presbyterian Church in Fort Worth.

While he was enthusiastic about the job itself, leaving the East Coast to move to Texas was not originally appealing to Dr. Pickell. His interactions with some colorful Texans he met at Princeton did not leave a favorable impression. This, combined with sports rivalries imprinted since childhood, made the move less than ideal . . . so much so that it inspired some literary liberties.

“I actually rewrote the story of Jonah in the Bible; recasting it with Jonah as me and Nineveh as Fort Worth,” he says, laughing. “It was sort of therapeutic for me.”

Looking back, though, Dr. Pickell has no regrets about making the move. Texas was his future and is a place he now is grateful to call home.

“It was the second-best decision I’ve ever made – after marrying my wife,” he says.

Dr. Pickell enjoyed serving in the Church, but he still carried the desire to heal bodies alongside souls.

“I’d sit in my office, and I’d look out the window and think, ‘I don’t know if my calling to ministry is actually inside the church,’” he remembers. “‘I think maybe my ministry should be a ministry of presence, of being in the community.’”

He was hesitant, though. At that time, Dr. Pickell was still paying off student loans from his seminary and college degrees, and, perhaps more importantly, he was raised to believe that one was supposed to pick one career and stick with it.

It was the late Gordon VanAmburgh, a beloved counselor and First Presbyterian church member, who asked Dr. Pickell an important question that set him on a new trajectory.

“It was just two words, but in many ways, they changed my life,” Dr. Pickell says. “I said to him, ‘You know, I just don’t know that it’s feasible to have two careers.’ And he looked me in the eye and said, ‘Why not?’”

Dr. Pickell didn’t have an answer to that, and it led to decisions that would completely reshape his life. He applied to medical school and was accepted to
UT Southwestern, where he pursued his medical education.

Though Dr. Pickell was grateful that his prerequisites were completed, it was challenging to jump into his classes after taking an extensive break from the hard sciences.

“I wasn’t sure I was going to stay,” he says. “I liked the idea of being a doctor, but the first year was pretty rough for me. They were talking in biochemistry about discoveries five years earlier as if they were ancient history. It had been 10 years since I had taken biochemistry, so I was like, ‘I am totally lost here.’”

Though it was challenging, Dr. Rob- ert Sloane applauds him for taking the plunge to practice medicine.

“Knowing the time commitment required, it took courage on his part to train in medicine in addition to ministry,” says Dr. Sloane, who wrote a letter recommending Dr. Pickell’s acceptance into UT Southwestern. “[H]e is always caring and compassionate in his endeavors. He is committed to his work and careful in its

performance.” During his time at UT Southwestern, Dr. Pickell met his wife, Emily, while serving as an interim pastor for two small churches in and around Clifton, Texas, during a summer break. They married in the middle of his third year. Dr. Pickell completed medical school followed by a residency in internal medicine and pediatrics (Med-Peds) at the University of Mississippi Medical

Center. After completing his residency, Dr. Pickell joined an all-Med-Peds practice in Nashville but decided to return to Texas a year later. He has worked as a Med-Peds physician in Fort Worth ever since. Currently, he is a member of Texas Health Physicians Group.

For over 20 years, Dr. Pickell has thrived in building long-term relationships with patients and guiding them through complex ailments.

“Medicine is an applied science,” he says. “I like to apply principles to people to help them, whether it’s spiritually or physically, emotionally – whatever.”

Though his patients have remained at the center of his career, Dr. Pickell has maintained active participation in professional groups and committees throughout his work as a physician – including a great deal of work in ethics.

He has served on several ethics committees, including the Tarrant County Academy of Medicine’s (TCAM) Ethics Consortium, which he has chaired
for many years. And in 2016, Dr. Stuart Flynn, dean of the Anne Burnett School of Medicine at TCU, appointed Dr. Pickell to lead in the development of the medical school’s ethics curriculum.

While Dr. Pickell continues to lead the ethics curriculum, he has also expanded the reach of TCAM’s Ethics Consortium through the development of Healthcare in a Civil Society, an annual forum that has typically featured content experts from the Tarrant County community. Dr. Kendra Belfi, Dr. Pickell’s predecessor in chairing the TCAM Ethics Consortium, is grateful for his contributions to ethics in medicine.

“Dr. Pickell is a deep thinker and an articulate leader, who brings professionalism to everything he works on,” she says. “When I was about to retire and needed to find someone willing to take over chairmanship of the Consortium, I asked him to consider it – and he did. He has now been chair of the Consortium for longer than I was and has taken us to new heights.”

Throughout his years of practice, Dr. Pickell has concluded that successful leaders inspire others more through ac- actions than words.

“The biggest part of being a leader is leading by example; being willing to do what you’re asking other people to do,” says Dr. Pickell.

He speaks from experience. In addition to his work in ethics, Dr. Pickell is Project Access Tarrant County’s medical director, has served on over a dozen TCMS and TMA committees, and has worked in executive leadership positions in organizations as diverse as a health in- formation exchange company, a pioneer ACO, and an innovative primary care practice model.

“Leadership is now more about building effective teams, which is why articulating the vision is so important,” he says. “It’s not just that you have a vision and expect everyone to follow you like the Pied Piper. You must communicate it to the team, sell it to them, invite them to own it.”

Sharing a vision is key as a doctor, and it is something that Dr. Pickell believes is fostered by organized medicine. He likes to compare the relationship that physicians have with TMA and TCMS to those he shares with his own patients, many of whom he has treated for decades.

“You develop relationships and leverage them to get things done,” says Dr. Pickell. “And I think that TMA and the county medical societies are in some ways like that. They are relational, and they provide an organizational force or impetus that amplifies the message we are trying to communicate individually within our practices, broadcasting it to a larger audience than any of us can reach individually.”

As he both leads and provides support on varied projects, Dr. Pickell does it with the vision of supporting the future of medicine. In addition to his work on the ethics curriculum at the Burnett School of Medicine, Dr. Pickell has served as a preceptor to advance medical students’ hands-on education since 2002 and as an associate professor for the Department of

Internal Medicine at the Burnett School of Medicine since its inception.

Dr. Pickell’s passion for education is no surprise to those who know him; he has long desired to foster young minds in his work for both the body and the spirit. And it is a passion that extends beyond the students under his direction to the patients he cares for.

“Perhaps the most succinct statement
I could make is that I have entrusted my three children to him twice,” says Dr. Steve Brotherton, a friend, and patient of Dr. Pickell’s. “First as the youth pastor at our church, then again as their personal physician, just as I have entrusted my own health.”

“You know, I’ve always been a generalist,” says Dr. Pickell. “I like to do a lot of different things. Some people will focus on one thing and really excel at that one thing. I’ve never been wired like that.”

In many areas – ministry to medicine, education to private practice, ethics theory to hands-on application – Dr. Pickell has spent his career striking a balance between a mixed set of interests. But this extends beyond work and professional organizations.

“Husband, father, healer of bodies and souls – most know these plain facts about Stuart Pickell,” says his longtime friend Robert Johnson, who Dr. Pickell met during his time at seminary. “But there

is so much more to him: musician, actor, closeted NASCAR fan . . . and good and generous friend. For the nearly forty years I have been friends with Stuart, I have found him to be a man of great intellect, compassion, humor, and faith.”

He enjoys playing the guitar and piano, as well as writing music and essays when

he has the chance. In one particularly rewarding venture, one of the songs he wrote for a youth event in the 90s was recorded by a friend and got air time on a Denver radio station.

Dr. Pickell grins. “Yeah, that was a pretty neat experience.”

But his favorite pastime is being with his wife and their two sons, Jonathan and Will. If the family is able to spend time
at their weekend house in Clifton, even better.

“I love going down to Clifton and just being in the country,” says Dr. Pickell. “People in small towns have a strong sense of place, of community. They are grounded. I didn’t experience that growing up; maybe that’s why I like it.”

As he begins his term as TCMS president, Dr. Pickell is looking forward to using the “President’s Paragraph” to share his top concerns about medicine, such as the need to increase GME slots and funding for Project Access.

More than anything, he wants to start conversations since they are the first
step toward making tangible changes. He wants the message from TCMS to be very clear so those we interact with, such as hospital leaders and local politicians, understand the medical society’s purpose and the perspective of physicians throughout Tarrant County.

“It’s important to stay centered on why you’re doing what you’re doing,” he says. “When it comes to a ‘mission,’ I think the ‘why’ is really important. For me, this goes back to my faith. I do what I do because I believe that a loving God – who loves everyone else as much as me – has called me to serve in this way.”

We are excited to have Dr. Pickell lead us as we move forward with TCMS’s mission of advocating for the physicians and patients of Tarrant County.

New TMA Lawsuit Challenges Big Fee Hike in “No Surprises Act” Arbitration

Fourth Lawsuit Disputes 600% Fee Hike Demanded of Doctors

The Texas Medical Association (TMA) is challenging a 600% hike in administrative fees for seeking federal dispute resolution in No Surprises Act (NSA) situations. TMA seeks relief by filing a fourth lawsuit in the U.S. District Court for the Eastern District of Texas.

This TMA lawsuit against federal agencies challenges a steep administrative fee hike that will strip many physicians and healthcare providers of the arbitration process that Congress enacted. TMA calls the fees “arbitrary and capricious,” contrary to the law, and in violation of notice and comment requirements.

The U.S. departments of Health and Human Services, Labor, and the Treasury, and the U.S. Office of Personnel Management collectively adopted interim final rules implementing the federal surprise-billing law. The rules include establishing the nonrefundable administrative fee all parties must pay to enter the federal independent dispute resolution (IDR) process in the event of a payment disagreement between an out-of-network physician or provider and a health plan in circumstances covered by the law. The situations could occur when emergency services are provided by a doctor or health care provider outside of the patient’s insurance network or when out-of-network services are provided at an in-network facility.

The federal agencies set the initial administrative fee at $50 and announced in October 2022 it would remain at $50 for 2023. Two months later the agencies announced a 600% hike in the fee to $350 beginning in January 2023, “due to supplemental data analysis and increasing expenditures in carrying out the Federal IDR process since the development of the prior 2023 guidance.”

The steep jump in fees will dramatically curtail many physicians’ ability to seek arbitration when a health plan offers insufficient payment for care.

“The problem is that many payment disputes in these cases amount to less than the fees physicians would have to pay to dispute the unfair payments,” said TMA President Gary W. Floyd, MD. “Why would doctors and providers pay the $350 nonrefundable administrative fee to arbitrate a $200 or so payment dispute with a health insurer? The fees deny physicians the ability to formally seek fair payment for taking care of our patients, and that’s just wrong.”

TMA argues the administrative fee hike is difficult for all physician specialties to bear, but especially those specialties that have more small-dollar claims, such as radiology.

The non-refundable administrative fee is in addition to the separate fee that each party must pay the IDR entity for its services, though that fee is refundable to the party that wins the arbitration dispute.

TMA also disputes the rules’ narrowing of the law’s provisions on “batching” claims for arbitration, which Congress authorized to encourage efficiency and minimize costs in the IDR process.

TMA’s first lawsuit – filed in 2021, and which TMA won at the district court level – alleged that in the interim final rules governing arbitrations between insurers and physicians, the agencies unlawfully required arbitrators to “rebuttably presume” the offer closest to the qualifying payment amount (QPA) was the appropriate out-of-network rate. TMA filed its second lawsuit in September 2022 challenging the NSA’s August 2022 final rules published by the federal agencies, alleging the final rules unfairly advantage health insurers by requiring arbitrators to give outsized weight or consideration to the QPA. The court’s ruling on that suit’s December 2022 hearing is anticipated at any time. TMA filed its third lawsuit in November 2022 challenging certain portions of the July 2021 interim final rules implementing the federal NSA. No hearing date has been set for that case, which challenges certain parts of the rules that artificially deflate the QPA.

Student Article: Continuing the Passion for Science in Medicine

This article was originally published in the January/February 2023 issue of the Tarrant County Physician.

by Homero Coss, OMS-II

OFTEN ONE OF THE FIRST QUESTIONS I AM ASKED WHEN I mention that I am in medical school is, “How did you know you wanted to become a doctor?” Sometimes I scramble to find the most inspirational and motivating answer, as there were many reasons why I chose the career path that I did, However, at the core of every underlying reason was first, my love for science, and second, the desire to put that love into good use. Throughout my undergraduate years, I made sure to put scientific research at the forefront of my priorities. I took additional classes to help develop my skills as a researcher and participated in local symposiums whenever I could. Going into medical school, I kept research and the scientific process in mind as I learned about each body system. Given my medical education, I could delve further into the pathologies and the application of their respective treatments, and, if there were any developing treatments, I could keep an open mind about them and seek an opportunity to participate in the field research (if my busy school schedule let me). Thankfully, this past summer, my school presented the perfect chance to participate in the Pediatric Research Program (PRP) with Cook Children’s Hospital.

The PRP selects a group of second year medical students to take part in research “that aligns with their specialty interest.” There are also additional benefits such as being provided a mentor who guides you along the way and opportunities to present work at local/regional/national conferences. I chose neurology as y number one field of interest, so I was assigned a case study with a pediatric neurologist as my research mentor. I was excited and eager at the prospect of beginning work, especially since I had been assigned to Cook Children’s. The idea of being in an environment that was dedicated to helping children with challenging diseases brought a sense of fulfillment to my foundational goal of helping people heal.

Writing a case study was a novel experience, but I was fortunate to have a dedicated mentor who aided me through the process and helped me understand clinical information that my then year-one-medical-student mind could not comprehend. My mentor further allowed me to shadow her periodically throughout the summer, which was a nourishing experience to my medical education. I was able to interact with many pediatric patients who were affected by a variety of neurological disorders, especially congenital ones. This provided me with an appreciation for specialist physicians since they offer a great sense of hope and security to their patients- something I had associated more with primary care. What was even more admirable was my own mentor pursuing her research and developing case studies to help spread awareness of the pathologies that affect her patients.

Regarding my own project, I was able to learn more about the neurovascular complications of Marfan syndrome and the importance of considering it as a possible cause of stroke. I thoroughly enjoyed the process of gathering information and researching literature since it showed me how physicians from different parts of the country can come together and use their scientific nature to bring light to issues and possibly come to solutions. I look forward to working on more case studies and research projects as a medical student because it reaffirms my belief in using scientific methods and research to better the lives of patients and reach new heights in treatments.

A Thankful and Healthy New Year for Public Health

This article was originally published in the January/February 2023 issue of the Tarrant County Physician.

by Catherine Colquitt, MD, AAHIVS
Medical Director and Local Health Authority
Kenton K. Murthy, DO, MD, MPH, AAHIVS
Assistant Medical Director and Deputy Local Health Authority

During the holiday season, many were reunited in person to celebrate with loved ones after almost three years of relative seclusion.

There was much to be grateful for this season. While COVID-19 case counts and hospitalizations are rising in Texas and in Tarrant County, our present COVID rates pale in comparison to December 2020 or January 2021.1 And though influenza and Respiratory Syncytial Virus (RSV) infections are strikingly and unseasonably high, and the perils of a tridemic (COVID-19, influenza, and RSV) are on our minds, many of us and our patients and neighbors are fully vaccinated against COVID-19 and have already had the bivalent mRNA vaccines (for protection from the Wuhan and Omicron COVID-19 strains) as well as the current seasonal influenza vaccine.

As we shift gears from the COVID-19 pandemic to COVID-19 endemic,
we hope that our next iteration of COVID-19 vaccines will roll out side
by side with next season’s influenza vaccine. However, if new versions of COVID-19 vaccines are required to mitigate the spread of COVID-19 between now and then, our scientists and vaccine manufacturers, our distribution networks, the FDA, the Advisory Committee on Immunization Practices, the CDC, and state and local partners will work together to respond to future challenges.

It seems fitting to consider what we have to be thankful for, and gratitude in healthcare is a very active field of study at present. A meta-review in Qualitative Health Research by Day et al reviewed recent works and referenced pioneering works on gratitude research dating to the early twentieth century and organized this vast body of work into six “meta- narratives: gratitude as social capital, gifts, care ethics, benefits of gratitude, gratitude and staff well-being, and gratitude as an indicator of quality of care.”2

Given the ubiquitous articles reporting on healthcare worker
burnout and the mental and physical consequences of COVID-19 on our workforce, Day et al suggested in their conclusion that more research is needed on “gratitude as a component of civility in care settings” and that further study might help researchers to understand the intersection of gratitude “with issues of esteem, community cohesion, and the languages of valorization that often accompany expressions of gratitude.”2

Individually, we might all take a moment to self-assess using a simple exercise such as the Gratitude Questionnaire – Six Item Form (GQ-6), or we might dig more deeply into the bibliography of “Gratitude in Health Care: A Meta-narrative Review” to study our own complicated relationship with gratitude more closely.2,3 Those in healthcare have been under great strain since COVID-19 first appeared on the scene, and perhaps a gratitude practice is just what the doctor ordered to help us to reboot and revive the sense of wonderment with which we began our careers.

References
1. Texas Department of State Health Services COVID -19 Dashboard.
2. Giskin Day, Glenn Robert, Anne Marie Rafferty. 2020 Gratitude in Health Care: A Meta-narrative Review. Qualitative Health Research. 2020 Dec; 30(14): 2303-2315
3. Gratitude Questionnaire – Six Item Form (GQ-6), taken from Nurturing Wellness by Dr. Kathy Anderson.