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By David Doolittle

In response to Gov. Greg Abbott’s COVID-19 “state of disaster” declaration, the Texas Medical Board (TMB) has taken several steps to help Texas physicians safely and effectively care for patients.

On Thursday, the TMB issued a waiver that allows telephone refills of valid prescriptions for treatment of chronic pain by a physician with an established chronic pain patient. 

“Due to the seriousness of the opioid crisis and the need to ensure there is proper oversight of chronic pain management, this suspension is only in effect until April 10, 2020,” the agency said. “The physician(s) remains responsible for meeting the standard of care and all other laws and rules related to the practice of medicine. The standard of care must still be maintained related to the treatment of chronic pain patients.”

Earlier this week, TMB allowed expanding the use of telemedicine, temporarily waived license and permit renewal requirements, and allowed retired physicians to return to active status (See below).  

“During this critical time, medical providers will need to focus their attention and energy on the health and well-being of our fellow Texans,” said TMB President Sherif Z. Zaafran, MD. “The Texas Medical Board will be doing all that it can to help assist Texas physicians, and other licensees under our authority, in making sure they stand ready and able to treat patients across the state.”

Texas Medical Association President David C. Fleeger praised the TMB action.

“The physicians of Texas greatly appreciate the speed with which the TMB has made these changes to help us better care for our patients in this crisis,” Dr. Fleeger said. “We are committed to working closely with Dr. Zaafran and TMB Executive Director Brint Carlton to identify and recommend additional necessary changes as the situation progresses.”

Expanded Use of Telemedicine

During the disaster period, telemedicine – including the use of telephone only – may be used to establish a physician-patient relationship, TMB said. 

“This expanded use of telemedicine may be used for diagnosis, treatment, ordering of tests, and prescribing for all conditions. The standard of care must be met in all instances.”

Texas laws and regulations on telemedicine have changed considerably to expand access over the past several years. More information on expanding your telemedicine services can be found on the TMA website.

Licensing Requirements

TMB will take into account “extenuating circumstances surrounding the completion of license/permit renewal requirements such as renewal deadlines and completion of continuing education hours” for all license and renewal permit holders regulated by TMB.

Many CME courses, including those offering ethics and professional responsibility credit, are available to TMA members for free on the TMA Education Center thanks to a generous grant from the TMA Insurance Trust.

Retired Physicians Returning to Active Status

Retired physicians whose licenses have been placed on official retired status for less than two years can return to active status during the disaster period, TMB said.

The TMB website includes frequently asked questions (FAQs) on returning to active status, additional requirements, and exemptions for retired physicians to provide voluntary charity care.

Licensing for Out-of-State Physicians 

Out-of-state physicians will be allowed obtain a Texas limited emergency license or hospital-to-hospital credentialing “for no more than thirty (30) days from the date the physician is licensed or until the disaster declaration has been withdrawn or ended, whichever is longer,” TMB said. 

Governor Abbott fast-tracked temporary licensing of out-of-state physicians last week. 

You can also find the latest news, resources, and government guidance on the coronavirus outbreak by visiting TMA’s COVID-19 Resource Center regularly.

Originally published on Texas Medical Association’s website.

If you haven’t already posted a sign on your practice or facility door advising patients what to if they might have been exposed to COVID-19, the Texas Medical Association Covid-19 Task Force has created one for you.

The sign, which you can customize for your practice, asks patients if they have symptoms, if they’ve been exposed to the virus, and if they’ve traveled in the past 14 days. Patients who answer yes are told to call the practice from somewhere away from the entrance and wait for instructions.

It is available on the TMA website in English and Spanish as well as in color and black and white.

The Task Force also has updated its “Frequently Asked Questions” that answer many of the questions you might have about caring for people who have been exposed to the virus while keeping your staff and facility safe.

You can find the latest news, resources, and government guidance on the coronavirus outbreak by visiting TMA’s COVID-19 Resource Center regularly.

Originally published on Texas Medical Association’s website.

Internet scammers are trying to cash in on the widespread anxiety over COVID-19, and awareness is the best defense, according to the U.S. Cybersecurity and Infrastructure Security Agency (CISA). 

Likewise, the Texas Attorney General’s Office has issued a warning about outbreak-related scams. 

Scammers frequently send emails with malicious attachments or links to fraudulent websites, CISA says. These trick unwary people into revealing sensitive information or donating to phony causes. 

“Exercise caution in handling any email with a COVID-19-related subject line, attachment, or hyperlink, and be wary of social media pleas, texts, or calls related to COVID-19,” the agency said in a statement. 

CISA advises people to:

• Avoid clicking on links in unsolicited emails;
• Be wary of email attachments and social engineering or phishing scams;
• Use trusted sources – such as government websites – for fact-based information about COVID-19;
• Avoid revealing personal or financial information in email, and do not respond to emails asking for that information; and
• Verify a charity’s authenticity before making donations. Review the Federal Trade Commission’s page on charity scams for more information. 

The Texas attorney general’s office website details the different types of internet scams and ways to spot scammers.  

Physicians and practice managers are encouraged to review CISA’s Risk Management for COVID-19. 

You can also find the latest news, resources, and government guidance on the coronavirus outbreak by visiting TMA’s COVID-19 Resource Center regularly.

Originally published on Texas Medical Association’s website.

By David Doolittle

Originally published on Texas Medical Association’s website.

As the number of COVID-19 cases in Texas and around the country grows, what steps should your clinic take to ensure the safety of your staff and patients?

The Texas Medical Association COVID-19 Task Force has published a “Frequently Asked Questions” that answers many of the questions you might have about caring for people who have been exposed to the virus.

Among the questions answered:

• What do you tell your patients when they call?
• What steps should your clinic take to prevent COVID-19 exposure?
• How should your staff safely care for a patient who has a potential case of COVID-19?
• Should you tell a patient with a potential case of COVID-19 not to come to your clinic?

The FAQ is based on guidance from the Centers for Disease Control and Prevention (CDC), the Department of State Health Services (DSHS), and other health organizations.

As of Friday, 39 cases have been confirmed in Texas, mostly in the state’s largest metropolitan areas, according to the DSHS tracker for Texas COVID-19 cases.

You can find the latest news, resources, and government guidance on the coronavirus outbreak by visiting TMA’s COVID-19 Resource Center regularly.

The Texas Medical Association, in conjunction with the Texas Department of State Health Services, has scheduled a critical conference call with Texas physicians next week. Answer your home phone at 7 pm CT, Tuesday, March 10, to take part in TMA’s Tele-Town Hall Meeting on COVID-19.

This is an opportunity get information to proactively protect your practice as COVID-19 continues to spread throughout Texas. Key discussion topics will include working with local/regional health department and how to counsel your patients. TMA President David Fleeger, MD, will moderate the hour-long event, and a number of specialists will participate in the discussion.

Potential speakers include the following:

• John Hellerstedt, MD, DSHS commissioner

• Wendy Chung MD, chief epidemiologist, Dallas County Department of Health and Human Services, and current chair of TMA’s Council on Science and Public Health

• Jennifer Shuford, MD, DSHS infectious disease medical officer

• E. Linda Villarreal, MD, chair of the TMA Board of Trustees

• TMA staff experts

Not only is this an opportunity to learn more about a critical topic, but participants also have the opportunity to earn one hour of CME credit for education in medical ethics and/or professional responsibility.

Click here to find out more information about this event.

Click here to access TMA’s online COVID-19 Resource Center.

“For every thousand hacking at the leaves of evil, there is one striking at the root.” –Henry David Thoreau

by Tom Black, MD

Publications Committee Chair Dr. Hujefa Vora will be taking a temporary break from his committee duties. In his stead, members of the committee will continue to contribute to the Last Word. Dr. Robert Bunata will serve as Interim Chair.

As a recent session of the American College of Surgeons was ending, the words of Ray Magliozzi came to my mind, “Well, it’s happened again—you’ve squandered another perfectly good hour . . .” The subject of the session had been “Firearm Injuries,” and the take-away message was, of course, the need for gun control. As I waited to file out of the auditorium, Thoreau’s words rang in my ears, and I wondered how many more fruitless discussions we must endure, hacking at the leaves of the issue, before someone begins striking at the root?

When a question arises that can’t easily be answered, it’s often because the wrong question is being asked. Maybe that’s why we have repeatedly and consistently failed to resolve the conundrum of firearm injuries. 

In the well-known parable of the six blind men and the elephant, each of the men describes the elephant differently. Although none of the men were incorrect, none had defined the entirety of the elephant itself. Similarly, there are so many aspects to the problem of firearm injuries that until we begin discussing them as disparate entities with different causes and remedies, we will continue to be enticed into advocating only the lowest common denominator—the supernatural disappearance of all firearms.

In this era of frenetic 24-hour news, consumers expect the “quick fix” and the “one size fits all” solution so they can move their attention expeditiously onward to the next crisis. In the world of reality, within which some—perhaps even most—of us live, the usually reliable Occam’s law of parsimony is simply unrealistic when applied to this multi-faceted issue. It’s simply so much easier to demand the confiscation of all firearms than it is to analyze the root causes of firearm violence and address them as the distinct and unique issues that they are. 

I would be among the last to suggest looking to Hollywood as a moral North Star, but occasionally a pearl of wisdom is unexpectedly heard from the silver screen. In the 1953 movie “Shane,” the heroic title character expresses the following: 

“A gun is a tool, Marian; no better or no worse than any other tool: an axe, a shovel or anything. A gun is as good or as bad as the man using it.”

These are words from a by-gone era that would never be heard today in the same medium, but are they not true?

Let’s analyze the problem of firearm violence as if it were a medical condition. All rashes are not treated in the same manner, nor are all cases of shock or of diarrhea or of headache. Does treating a fever address the cause of the illness? I submit that firearm violence is a symptom or expression of societal disease, not a disease itself, and treating it without addressing the root cause makes as little sense as treating pneumonia with acetaminophen alone.  

Viewing firearm violence as a symptom of disease, the list of differential diagnoses would include the following:

• Suicide:
• genetic or acquired mental disorders; drug abuse; acute                       psychological states such as trauma or loss; cultural, familial, and social situations.

• Homicide:
• hate, greed, lust, desire for control, mental disorders, emotional                        agitation, impaired judgment due to substance abuse. 

• Unintentional injuries:
• inadequate gun education, carelessness, improper storage.

Would anyone suggest, aside from the impractical proposition of decreeing the disappearance of all firearms, that the solution to each of these issues is anywhere near the same? In some cases, controlling access to firearms is indeed the best solution, but to mandate it as a panacea is as inappropriate as treating every case of arterial hypotension with epinephrine alone.

Assume for a moment that all guns vanished instantaneously into thin air. Would the despair and depression that leads one to commit suicide be simultaneously cured? Would the hatred and greed that result in homicide abruptly disappear? Would everyone prone to foolish and reckless behavior suddenly become wise? 

Factors contributing to intentional violence are numerous, pervasive, and so entrenched in our culture that it is not hard to see why we have chosen to focus our attention on the utopian and inherently impossible objective of eliminating guns. Such factors must certainly include the ubiquitous and desensitizing violence portrayed in movies, television shows, video games, music lyrics, and music videos; illegal drugs; rampant materialism; the lack of self-esteem due to a hedonistic obsession with personal appearance; the rise of secularism and the decline of religion; and the general decline of ethical behavior toward others. Regarding unintentional injuries. Ah—there’s an area in which we might actually be able to make some inroads, such as mandating trigger locks and education regarding the handling of firearms. But in the overall incidence of gun violence, unintentional injuries are but a drop in the bucket.

Firearm violence is a symptom, not a disease. It’s a common pathway by which various deeply rooted maladies of society are expressed. Only when we begin seeing firearm violence as a symptom can we begin the arduous task of diagnosing and appropriately treating underlying societal diseases. Meanwhile we must halt the irrational, perpetually unproductive, and divisive demand to cure a variety of diseases by treating their common symptom. 

We seem to have three choices: continue the Sisyphean efforts to eliminate all firearms; begin tackling the overwhelming issues that contribute to firearm violence; or resign ourselves to the future we have created.

The real question is, does society have the resolve to identify and remedy the roots of societal disease, or would we prefer to continue hacking at the leaves?

“When a question arises that can’t easily be answered, it’s often because the wrong question is being asked.”

Hearing Wellness Exposition – 2nd Edition   |   by Shirley A. Molenich, MD

As you are probably aware, Sertoma and Hearing Loss Association of America have joined together to do a series of programs on hearing loss for the general public for the past two years. Our third program will be on March 28, 2020, at the Tarrant County Medical Society from 9am to 1pm, with registration beginning at 8:30am.

In my last article I mentioned three of our speakers – Jed Grisel, MD (ENT), Terri Jo Edwards, AuD, and Marylyn Koler, MS, CCCA, AuD. At this event, we will discuss how the brain and ear work together, give new information on prevention/treatment, and review modern research. We are also going to discuss tinnitus, which is a difficult disease both in terms of cause and treatment. 

There is a great deal of research going on in the area of hearing disorders. More information is becoming available about many chronic health issues that play a role in hearing loss. There is significant new knowledge about genetic causes of hearing loss with over 140 related gene mutations identified. With these gene mutilations identified, basic scientific research has discovered the specific biological changes that occur, yielding information which may open up the avenue for treating hearing loss. There also continues to be increasing development of technical assistance.

There is a clear need for audiologists and physicians to work together to care for patients by identifying hearing loss issues earlier, which can lead to better results for patients. Basically, when auditory hair cells are damaged, neurons in the brain will atrophy axons along with the synapses, leading to hearing loss. This means that if a person gets hearing aids, they will require regeneration of the axons with new synapses. There are areas of research now on the theories of cognitive function and hearing.

We will discuss opportunities to help the hearing impaired with school, education, and vocational rehabilitation of hearing impairment, and new technology. 

“There is a clear need for audiologists and physicians to work together to care for patients by identifying hearing loss issues earlier.”

This will be our first program in which tinnitus is discussed. There has been research conducted by the National Center for Rehabilitative Auditory Research at the V.A. Portland Health Care System in Oregon, which was founded in 1997. Tinnitus has been one of their major areas of research. Basically, tinnitus is the experience of hearing sound (such as ringing or buzzing) without an external source. Part of the problem has been that tinnitus is a chronic condition without an existing reliable treatment. There are many protocols that have been tried, i.e. nutritional, pharmacological, surgical, deep brain transcranial electrical stimulation, sound, and transcranial magnetic stimulation, among others. The one treatment concept using sound therapy is Tinnitus Retraining Therapy, which has been the gold standard in coping with but not curing tinnitus. This technology works because the brain becomes habituated to it, so the tinnitus is no longer perceived as a negative and disruptive experience.  

We want to continue to educate the public about hearing disease and to reinforce new ideas and treatment options that are coming soon. We appreciate the help of the Tarrant County Medical Society in this endeavor. 

Sources 
Reviewing Tinnitus Research as an Educator, Veteran and Parent.
Oman Rodriguez – Hearing Health Foundation. Fall 2019, pp.26-28.
Tackling Tinnitus
James A. Henry, Ph.D – Hearing Health Foundation. Fall 2018, pp. 10-12.