Tarrant County Phyician – Tarrant County Physician Online

The Poison, the Clouds, and the Clearing: Mindfulness in Medicine

BY SETU SHIROYA, MS-II TCU , WITH NEHA SOOGOOR, MS-II TCU; EDITED BY JAYESH SHARMA, MS-II TCU

Breathe in. Breathe out.

It is my first day in the clinic. My heart is racing in my white coat that I have little confidence wearing. My anxiety skyrockets, as do my feelings of not belonging.

What if my attending doesn’t like me? What if I make a mistake? What if my patient starts crying? How do I do a lung auscultation again? What does losartan do?

I can’t remember. I can’t think.

Breathe in. Breathe out.

I have been studying the whole day, my career-defining board exam is in one week, my head is throbbing, my eyelids are drooping. I am clicking through flashcards but nothing sticks. The days are merging into one; someone asked me for the day of the week, and I came up blank.

Breathe in. Breathe out. Breathe in. Breathe out.

Only one year into medical school, and everything feels like a dream. I’ve made it so far, yet the future seems so daunting. I love my life but also fear it at the same time. I want to keep going. I’m excited, but I’m nervous. Where am I in my life? Do I even belong here? Am I the only one thinking this?

Breathe in. Breathe out.

I say it to myself over and over again—my thoughts have been spiraling for days. I need to breathe. I need to calm down.

Breathe in. Breathe out.

I do belong here. I’ve made it so far in this journey; the hard work, the endless hours were not in vain. There is so much more to go and I remind myself that I am excited. I just need to take it one step at a time.

Breathe in. Breathe out.

I am going to be present for patients. I will be a doctor. One step at a time.

Breathe in. Breathe out.

The rampaging thoughts settle, my mind clears, and I open my eyes.

It’s going to be okay.

The morning alarm rings, and my first thought is always the same: “Can I sleep for five more minutes and not think about the long day ahead?” I have stressful exams to take and sometimes dread the workload awaiting me. It feels like the only quiet time I get is in the morning, when I am drinking coffee, working out, or just embracing the quietness. I try to find time to relax, but burnout feels like it is always looming over my shoulder. However, mindfulness and meditation have helped me reorient myself and develop a healthy way to process these feelings.

What does it truly mean to be mindful? To me, mindfulness is staying grounded to what is in the present moment. It can be easy to think of the past or try to anticipate the future. However, the only inevitability we hold is this present moment. Not a second before, not a second after.

How can we practice this? Mindfulness comes in many forms; some find relief in running or weightlifting, making it a point to have a constant regimen at the gym. Others find it through meditation, focusing on breathing and relaxing the mind. These share one commonality: a mental space we create where we stop thinking about the past or trying to anticipate the future, focusing instead on what is present within and around us. There isn’t one answer to seeking mindfulness; the greatest difficulty lies in knowing where to begin.

As medical students and future doctors we are expected to quickly calm ourselves after these stressful moments and proceed. Sadhguru, a guru who is the founder of the Isha Foundation, states: “Fear, anger, resentment, and stress are poisons you create in your mind. If you take charge of your mind, you can create a chemistry of blissfulness”.1 It is especially easy in a hectic and high-paced environment or period of life to get lost in our thoughts about the stressors we experience. Our thoughts are like clouds. We can either let them pass, or we can dive into them. Taking control of our mind to let the clouds pass, helping our mind become still and focus on the present, is difficult.

This is where meditation techniques can help train our mind. Meditation techniques often involve bringing awareness to a single action or sound. For example, they can be used to bring awareness to your breathing or the repetition of a few words. One method I use is called “4-7- 8 breathing.” Close your eyes. Breathe in for four seconds through your nose. Hold your breath for seven seconds. Breathe out for eight seconds through your mouth. As you inhale, stay aware of how the air flows through your body, from the tip of your nose to your navel. As you exhale, follow the air out from your navel to your mouth. Repeat this about two to three times.

At TCU Burnett School of Medicine, our Meditation and Mindfulness Student Interest Group aims to educate medical students about techniques such as 4-7-8 breathing and help them stay engaged in healthy mindful practices to avoid burnout. Our goal is to cultivate a supportive student community dedicated to mindfulness, fostering connection through monthly meditation sessions, inspiring physician guest speakers, and meaningful community volunteering.

It is going to be okay.

My mother always told me, “Take it one step at a time, one day at a time.” As medical students, we’re often exposed to patients and situations that can take an emotional toll on our mental well-being; times such as witnessing a patient’s death or delivering a life-shattering diagnosis. Before we can process what we’ve witnessed, we’re often thrown back into a fast-paced environment without a moment to rest. In such a high intensity life, grounding ourselves with activities that bring comfort and ease becomes crucial to our mental well-being. My hope is that we future physicians can practice mindfulness early, so that we can be present for our patients. In turn, we can help our patients be mindful as we work together throughout our most difficult moments to maintain healthy behaviors.

References:

1. Sadhguru Quotes – Fear, anger, resentment, and stress are poisons you create. If you take charge, you can create a chemistry of blissfulness within yourself. Accessed February 13, 2025. https://isha.sadhguru.org/en/wisdom/quotes/date/december-06-2021

PRESIDENT’S PARAGRAPH

Showing Hospitality to the Stranger (and the One with Strange Ideas)

by Stuart Pickell, MD, MDIV, TCMS President

This article was originally published in the July/August issue of the Tarrant County Physician.

MANY MAJOR RELIGIONS ENCOURAGE adherents to break down barriers between people. The Abrahamic tradition, which includes Judaism, Christianity, and Islam, commends the practice of hospitality, of removing barriers and welcoming the stranger as a guest. The Buddhist tradition takes it a step further, teaching that our connections are real and our divisions are not, so that the very distinction between one group and another- between insider and outsider- is an illusion.

Hospitality is the art of creating community. It is an act- a choice- of welcoming the stranger as a friend, choosing amity over enmity. But encountering the stranger can engender uncertainty. We must decide if the stranger will remain a foreigner whom we keep at a safe distance or become a guest whom we welcome in. Put another way, will we demonstrate hostility or hospitality?

Hostility and hospitality, quite different in meaning, derive from the same reconstructed Proto-Indo-European noun ghóstis, which highlights the ambiguity we experience and the choice we must make. The stranger- or even a strange idea- challenges us. The stranger can be a guest or an enemy but not both at once. The stranger’s presence forces upon us a decision that will require us to examine and assess our relationship to the stranger. As a rule, communities are strengthened when they successfully create room for the stranger to feel welcomed.

On a national level, our ability to find common ground amid diverse viewpoints has been a hallmark of American democracy and the reason it has worked. But something has changed. Historically, healthcare policy has been one topic on which there has been broad bipartisan support. The Medicare and Medicaid Act (1965) is a classic example of bipartisan healthcare legislation. But when congress passed the Affordable Care Act in 2010, not a single Republican voted for it and not a single Democrat voted against it.

Over the last 45 years, tribalism has become ingrained in our political discourse. John Dingell (D-MI), who served in congresses for 60 years, noted that when he began serving in the House in 1955, members saw themselves first as representatives of their state, second as representatives of an institution like the House or Senate, and only third as members of a party. By the time he left Congress in 2015, the order has reversed.

The way state legislatures draw congressional districts illustrates the extent to which parties in power will go to maintain control. One bizarre example is Maryland’s third congressional district, in which I lived until I was 16. It is called by many the most gerrymandered district in the country.

This practice has had toxic downstream effects. It amplifies the voices of those on the political extremes. Candidates in reliable liberal or conservative districts know that elections are won and lost not in the general election but in the primaries. And to win in the primaries they must “play to the base.”

We come by this honestly. We are, after all, a group-based species. But the resulting tribalism pits in-groups against out-groups, where the respective in-groups wield the political issues of the day to define and secure their status. We divide ourselves up as friends and enemies, creating hostility and polarization.

The cleavage that exists between the two tribes no longer cuts across a variety of social and cultural strata as it did 50 years ago. It’s singular and primal, so much so that a 2019 study showed that a significant number of people in each party consider people in the opposing party “evil” and that the country would be better off if members of the opposing party simply died.

The result is two Americas. At their extremes, one tribe would do away with guns altogether while the other would argue that citizens who so desire should be able to arm themselves with an M1A2 Abrams tank (version three, of course, because it’s the best). One tribe argues that abortion should be permissible to the point of birth while the other would criminalize all abortions. When either one of these Americas- right or left- senses they are losing control, they tend to dig in, inconsistencies and cognitive dissonance be damned. Both Americas defend their tribe even when it makes no logical sense to do so and (depending on the tribe) consider adherence to behavioral codes or resistance against them a moral virtue.

To circumvent this impasse, I believe we must cultivate the middle majority, by which I mean the middle 70 percent. I submit that liberal and conservative leaning people who live on either end of that middle 70 percent often have more in common with one another than they do with the extremes of their respective tribes. We must engage those with whom we disagree not on Twitter or in partisan echo chambers but in a non-partisan forum in which all viewpoints may be seriously considered, including those we find objectionable. Perhaps in such a forum we can entertain the possibility that someone who disagrees with us is not evil and does not harbor ill intent. In such a place, hospitality can be both extended and received, a place where the focus is on what unites us, not what devices us.

This may reveal some significant differences in opinion that make us uncomfortable or create uncertainty and ambiguity, but we are strong enough to manage that. To paraphrase Friedrich Nietzsche, what doesn’t kill us makes us stronger, and listening to each other with open minds certainly won’t kills us. We must find the intestinal fortitude to endure the discomfort and consider the possibility that those with whom we disagree may have a valid point; they may teach us something we need to know. Listen more, talk less, or as my wife’s license plate holder puts it, “Wag more, bark less.” When it comes to hospitality, people should be more like dogs.

One thing I’ve learned in my practice is that arguing with a patient who refuses to do what I think is in their best interest never convinces them to change their mind, but if I engage them, if I meet them where they are- not as an enemy but as a friend- if I listen to their concerns and their fears and share with them why I think it would be in their best interest to do something, they may take down the walls and adopt the healthier choice. When that happens, I know that it is not because I have made a convincing argument but because I have treated them with respect, listened to their concerns, and built a trusting relationship.

We must seize the opportunity to move from hostility to hospitality, which means engaging the stranger- and those with “stranger” ideas- not as an enemy but as a friend, a guest, a fellow traveler. We must be able to see those with whom we disagree with new eyes and hear them with new ears, and recognize in all of them that we are member of the same tribe.

Catholic priest and author Henri Nouwen put it this way:

Hospitality is not to change people, but to offer them space where change can take place. It is not to bring men and women over to our side, but to offer freedom not disturbed by dividing lines. It is not to lead our neighbor into a corner where there are no alternatives left, but to open a wide spectrum of options for choice and commitment.

I would like to see TCMS, and the Tarrant County Physician, in particular, utilized by our members as such a space in healthcare. Maybe then we will rediscover- or perhaps learn for the first time- that we have much in common, that what unites us is stronger than what divides us. Maybe then we will make the stranger a guest, if not a friend.

References:

“Hospes or Hostis.”Accessed May 27, 2023. https://biblonia.com/2020/08/13/hospes-or-hostis/
Seib, Gerald. “Gerrymandering Puts Partisanship in Overdrive; Can California Slow it?” Wall Street Journal. November 29, 2021. https://www.wsj.com/articles/gerrymandering-puts-partisanship-in-overdrive-can-california-reverse-it-11638198550
Edsall, Thomas B. “No Hate Left Behind: Lethal partisanship is taking us into dangerous territory.” New York Times. March 13, 2019. https://ww.newyorktimes.com/2019/03/13/opinion/hate-politics.html
Kalmoe, Nathan and Lillian Mason. “Lethal Mass Partisanship: Prevalence, Correlates, & Electoral Contingencies.” Prepared for presentation at the January 2019 NCAPSA American Politics: 17, https://www.dannyhayes.org/uploads/6/9/8/5/69858539/kalmoe___mason_ncapsa_2019_-_lethal_partisanship_-_final_lmedit.pdf
Nouwen, H. “Reaching Out: The Three Movements of the Spiritual Life.” Penguin Books. 1986

PRESIDENT’S PARAGRAPH

How Much Does It Cost NOT to Provide Healthcare Services to the Undocumented?

by Stuart Pickell, MD, TCMS President

This article was originally published in the May/June issue of the Tarrant County Physician.

Note from the author: Although I have sourced much of the content in this article, some of the information comes from off-the-record conversations I have had with people who are or have been in leadership positions within the hospital district. In exchange for their honest assessment, I promised not to quote them.

I SUSPECT THAT, IF ASKED, THE average Tarrant County taxpayer would oppose spending tax dollars to fund healthcare for undocumented residents. I suspect also that they have at best a partial understanding of the issue borne out of media mischaracterizations and confirmation biases- on both ends of the political spectrum. Would that we could focus our attention on the information we need- as opposed to the information we want- when we make policy decisions that impact the community.

Harvard psychologist William James, in his presidential address to the American Philosophical Association, stated, “We are making use of only a small part of our possible mental and physical resources.”¹ From this case the notion that we use only 10 percent of our brains, a myth so perpetuated by self-help books throughout the 20th century that by 2014, a survey revealed that roughly 50 percent of teachers around the world believed the myth to be true. ² But James was not asserting that we use only a small part of our brain; he contended that we do not engage it fully. What he described is consistent with what we now know about attention and flow states. To solve problems, our brains work best when we focus our attention. This is also true for communities. If we want to address community concerns seriously, we must focus our attention not just to what we see on the surface, but on the currents that run underneath it. However, when it comes to healthcare and undocumented residents, you can’t finish the question before the knives come out and the war paint goes on. But this question is more nuanced than a soundbite debate regarding immigration. Let me provide some context and propose a path forward.

The County Health System

JPS is the “safety net” facility for those who “fall through the cracks” in our healthcare system. The county health system traces its origin to 1877 when the then-future mayor Jogn Peter Smith donated five acres of land south of town to provide medical care to city and county residents.³

The first public hospital opened in 1906. Associated with the Fort Worth Medical College, it was called the City-County Hospital and was free to all accident victims and others by agreement.⁴ In 1914, a new hospital was built across the alley from the medical college which, by this time, was affiliated with TCU. This building, at 4th and Jones, still stands and is now the Maddox-Muse Center. By the 1930s, the city had outgrown this facility and a new City-County Hospital was built on the land originally donated by John Peter Smith. In 1954, the hospital changed its name to honor the land donor.

Until the 1950s, faith-based healthcare institutions managed many of the hospitals and health networks in Texas. Fort Worth’s first hospital was St. Joseph (1885).⁵ The demand for reliable access to healthcare services for the indigent drove initiatives to create a taxing mechanism to improve healthcare resources in growing Texas communities. This resulted in a Texas state constitutional amendment in 1954 permitting the creation of county-wide hospital districts in counties with a population of at least 900,000 to better serve those communities. ⁶ Tarrant County formed its hospital district in 1959, centered around JPS. As needs increased, the facility grew, and in 2008, it acquired St. Joseph Hospital, which was torn down in 2012 to create space for ongoing expansion.

Because the hospital districts fall along county lines, they come under county jurisdiction and are overseen and managed by the county commissioners court. By statute, every Texas county must have a county judge and four county commissioners, each representing a district consisting of one-fourth of the county’s population. Every county, from Harris County’s 4.7 million residents to Loving County’s 83 residents, has four commissioners and a county judge. The commissioners courts are responsible for setting policy and determining budgets, many of which are dedicated to roads and bridges, law enforcement, and the hospital districts. ^7,8 According to the Texas Health & Safety Code, the county must “provide health care assistance… to each of its eligible county residents.” ⁹ But who is “eligible”?

JPS has enjoyed excellent executive leadership, as evidenced by their ranking in Washington Monthly as the best teaching hospital in the county. ¹⁰ Yet while the executive team has significant authority to create a vision, establish priorities, and execute the network’s mission, it’s the Board of Managers- the JPS governing authority- that funds it and determines eligibility criteria. This board consists of representatives appointed to two-year terms by the commissioners court.

In 1996, Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act deeming undocumented residents ineligible for many federal, state, and local public benefits, but it allowed states to expand benefits if they wanted to. ¹¹ This created some uncertainty at the state level. In September 2003, a Texas law went into effect that deemed undocumented immigrants eligible for non-emergency care subsidized with local funds. According to the Fort Worth Star-Telegram, the JPS Board of Managers interpreted this law to be a mandate and voted to allow undocumented immigrants to enroll in JPS Connection starting in January of 2004. ¹² The following month, Senator Jane Nelson wrote a letter to then Attorney General Greg Abbott seeking clarification regarding the statute. ¹³ Five months later, the Attorney General rendered his opinion that the code “permits, but does not require, a hospital district to provide nonemergency public health services to undocumented persons who are otherwise ineligible for those benefits under federal law.”¹⁴ A few weeks later, the JPS Board of Managers rescinded their expansion policy, although those who had already enrolled were permitted to remain in the system.

Cracks in the System

Texas has the ignominious distinction of leading the nation in uninsured residents. At 18 percent, our uninsured rate is over twice the national average. ¹⁵ There are many factors, including Texas’ decision not to accept federal funding for Medicaid expansion (as of July, Texas will be one of only 11 states that has not accepted it) and a knowledge gap on the part of currently eligible people who don’t know how to enroll.^16,17 But another driving factor is undocumented residents, the number of whom living in Texas is anyone’s guess.

Castigating immigrants, documented or not, as “the problem” obfuscates the bigger picture. We live in a transportation hub that provides ready access to much of the world. Immigration is considered a good thing. People come here because our expanding economy offers them jobs. Immigrants constitute 23 percent of the Texas workforce. A 2019 DFW survey revealed that immigrants made up 46 percent of our workforce in construction, 30 percent in manufacturing, and 26 percent in restaurant and food services. They contributed $119 billion to the Texas economy in personal income. Furthermore, 71 percent speak English, about 59 percent own homes, and 79 percent have lived in Texas for at least 10 years. ¹⁸ A recent national study focused on the experiences of undocumented immigrants revealed that immigrants typically pay more into the health system through taxes and premiums than they use in the form of healthcare services. ¹⁹ They do the same for the Social Security trust fund, something the Social Security Administration has known for years.²⁰

And yet, at least in Tarrant County, undocumented immigrants struggle to access healthcare. they go to JPS at a discounted rate (typically 40-80 percent), but because of their legal status they often forego routine care even if they can swing a hammer of lift a beam or scrub a floor- they keep working for fear of losing their jobs. For the undocumented, the fear of discovery and deportation is real. They don’t just fall through the cracks; they hide in them. This works until a chronic problem becomes and urgent one, and they can no longer work and must seek care. With the average three-day hospitalization costing $30,000, the patient will still owe $6,000-$12,000 after discounts, which most cannot afford.²¹ Since they cannot enroll in federal programs, JPS will end out absorbing the cost.

JPS probably provides a lot of uncompensated care that we don’t know about. It would be illegal not to provide care in an urgent/emergent situations- not to mention unethical- so why don’t we focus our attention on the cost of NOT taking care of undocumented residents?

The fact is, no one wants to talk about this because its political kryptonite. State legislators say this is a county issue. The county commissioners say it’s the Board of Managers’ decision, but the Board of Managers is appointed by and serves at the pleasure of the county court. Everyone says it’s a federal issue, and yet when Medicaid expansion comes up the state turns it down. Geez.

I attended First Tuesdays at the capitol on March 6th, where I had the opportunity to sit down with the legislative aid for a Republican senator. When Medicaid expansion came up, she admitted, of the record, that Texas should accept it, but that this issue is a non-starter for her senator. Why? As Robert Frost put it,

Before I built a wall I’d ask to know what I was walling in, or walling out. ²²

Likewise, before we say we’re not going to provide basic healthcare services, shouldn’t we want to know all the facts? The JPS Health Network’s report regarding healthcare planning for Tarrant county states that its critical for the system to “continue to shift the emphasis from hospital care- for medical and behavioral health issues- to ambulatory care to decrease the need for preventable and costly inpatient care.” ²³ But our current policy creates a Gordian Knot in which a sizeable number of Tarrant County residents are forced to do the opposite. So, they wait until they can no longer work, at which point the problem may require a hospitalization and a more expensive “fix.”

A Proposal

What we need is to get past the political campaign slogans and focus our attention on the actual problem. Immigration reform is a valid concern and should be addressed, but it’s not the issue here. Our issue is local, and it impacts the people with whom. we live and work, and those we hire to work for us. The undocumented residents in Tarrant County aren’t leaving anytime soon. Furthermore, they contribute to the economy and pay taxes. What we need, then, is a task force to examine seriously and assess honestly all the issues that contribute to the problem. They should focus their attention not on the surface concerns that we find in a political campaign ad but on the underlying currents, the factors that make this problem more nuanced than can be contained in a soundbite. This task force should be apolitical by intention (to the extent that anything can be) and include people who care about the community, economic development, fiscal responsibility, and, of course, healthcare. TCMS is well positioned to help lead this initiative. We represent a variety of political viewpoints, but we share a common concern for taking care of our patients individually and collectively.

Factors this task force should consider include:

How Harris, Bexar, Dallas, and Travis Counties are managing this issue.
The number of people living in Tarrant County who are barred from county healthcare services.
The impact undocumented residents have on the community, including:
- Their contribution to the economy
- How much they pay in taxes
- How much we are spending urgently treating preventable conditions.

Money is a finite commodity, so it, too, must be included in the conversation. Tax dollars should be spent wisely. County Judge Time O’Hare pledged to do this during his campaign, especially regarding the hospital district.²⁴ He also promised to cut taxes, fund law enforcement, and eliminate waste, fraud, and abuse. ²⁵ This alignment of priorities suggests that hospital district funding may be in peril.

But it doesn’t need to be. A serious study may reveal that we are “wasting money” by NOT providing these services, especially when we factor in the cost of uncompensated urgent and emergent care and the loss of worker productivity. We won’t know unless we ask. Furthermore, the surge in property values, and therefore property taxes, has afforded the state a $32.7 billion surplus. ²⁶ Many constituencies are vying for that money- the taxpayers themselves, law enforcement, teachers- and all should be given serious consideration. But could we not give serious consideration also to addressing the healthcare needs of some of the most vulnerable individuals in our community by allowing undocumented residents to access the county healthcare network?

Once we know what we’re dealing with, we can begin to chart a course forward, riding the underlying currents rather than fighting them until we arrive at a destination that demonstrates hospitality, compassion, and fiscal responsibility. We may even find that the most fiscally responsible thing we could do is to offer basic primary care to these populations through a creative collaboration between JPS and other community resources. But we won’t know unless we ask.

References:

James W. The Energies of Men. Science. 1907; (Vol. 25, No 635 (March 1, 1907)): 332-323.
Howard-Jones PA. Neurosciences and education: myths and messages. Nature reviews Neuroscience. 2014; 15 (12):817-824. doi:10.1038/nrn3817
History of JPS. Accessed March 25, 2023, https://www.jpshealthnet.org/about-jps/history
Site of the Fort Worth Medical College. Historical Marker for the Fort Worth Medical College. https://www.hmdb.org/m.asp?m=53215
Park KB. St. Joseph Hospital. Texas State Historical Association. Accessed March 25, 2023, https://www.tshaonline.org/handbook/entris/st-joseph-hospital
McKinley RD. Texas Hospital Districts: Past, Present, and Future. Affairs DoP; 2019. August 2019.
What Is a County Commissioner? Texas Association of Counties. Accessed March 19, 2023. https://www.county.org/About-Texas-Counties/About-Texas-County-Officials/Texas-County-Commisioner
What Does a County Commissioner Do in Texas? Texas Association of Counties. Accessed March 19, 2023. https://www.county.org/About-Texas-Counties/About-Texas-County-Officials/Texas-County-Commissioner
Health and Safety Code, Texas State Legislature §61.022 (2023). https://statutes.capitol.texas.gov/ Docs/SDocs/HEALTHANDSAFETYCODE.pdf
Editors T. Introducing the Best Hospitals for America. Washington Monthly 2020.
Personal Responsibility and Work Opportunity Reconciliation Act of 1996. 1996.
Allison A. Local, state policies may contribute to higher cervical cancer death rate for Hispanic women in Tarrant County. Fort Worth Report. November 22, 2021. https://fortworthreport. org/2021/11/22/local-state-policies-may-contribute- to-higher-cervical-cancer-death-rate-for-hispanic- women-in-tarrant-county/
Nelson J. Senator Jane Nelson to Attorney General Greg Abbott, February 4, 2004. In: Abbott AGG, editor. Letter from Senator Jane Nelson to Attorney General Greg Abbott seeking a clarifying opinion regarding the eligibility of undocumented residents for health care services under the Health and Safety Code Section 285.201 as added by Chapter 198, Acts of the 78th Legislature, Regular Session, 2003. ed 2004.
Abbott G. Opinion No. GA-0219. 2004.
Percentage of Population Without Health Insurance Coverage by State: 2019 and 2021. United States Census Bureau. Accessed March 25, 2023, https://www.census.gov/library/visualizations/ interactive/population-without-health-insurance- coverage-2019-and-2021.html
Status of State Medicaid Expansion Decisions: Interactive Map. Kaiser Family Foundation. Updated February 16, 2023. Accessed March 25, 2023, https:// www.kff.org/medicaid/issue-brief/status-of-state- medicaid-expansion-decisions-interactive-map/
Barton K. Tarrant County residents have access to free health care, but some say awareness is a barrier. Fort Worth Report. October 11, 2021. Accessed March 19, 2023. https://fortworthreport.org/2021/10/11/ tarrant-county-residents-have-access-to-free-health- care-but-some-say-awareness-is-a-barrier/
Garcia Z. Immigrants are crucial to Texas’ economy. FWD.us. Updated February 23, 2022. Accessed March 19, 2023. https://www.fwd.us/news/ texas-immigrants/
Ku L. Who Pays for Immigrants’ Health Care in the US? JAMA Netw Open. Nov 1 2022;5(11):e2241171. doi:10.1001/ jamanetworkopen.2022.41171
Goss S, Wade A, Skirvin JP, Morris M, Bye KM, Huston D. Effects of Unauthorized Immigration on the Actuarial Status of the Social Security Trust Funds. Actuarial Note. April 2013. Accessed April 2, 2023. https://www.ssa.gov/oact/NOTES/pdf_notes/ note151.pdf
Why health insurance is important: Protection from high medical costs. Accessed March 27, 2023, https://www.healthcare.gov/why-coverage-is- important/protection-from-high-medical-costs/
Frost R. Mending Wall. North of Boston. 1914;
Health Care Planning for Tarrant County and the Role of JPS Health Network. 2018. February 27, 2018. https://www.tarrantcountytx.gov/ content/dam/main/administration/JPS/CBRC%20 Report%20FINAL%20%202%2021%2018.pdf
Allison A. Commissioners court elections could shift priorities of JPS Health Network during pandemic. Fort Worth Report. February 2, 2022.
Judge Tim O’Hare website. https://www. electtimohare.com/
Harper KB, Schumacher Y, Fort A. How could Texas spend its record $32.7 billion surplus? The Texas Tribune. March 13, 2023. Accessed March 27, 2023. https://www.texastribune.org/2023/03/13/ texas-budget-surplus/

ALLIED HEALTH SCHOLARSHIP PRESENTED TO 17 STUDENTS

The Tarrant County Scholarship Committee grants scholarships for allied health students.

Tarrant County Medical Society (TCMS) and TCMS Alliance Foundation’s Scholarship Committee awarded 17 estimable students a total of $36,250.

Every year, the Scholarship Committee meets to review Allied Health Scholarship applications. As the final selection process, the Committee interviewed finalists to learn more about each individual’s story and why they are pursuing a career in allied health. Its aim is to award qualifying students in financial need to aid them in their educational and professional careers.

“Making the road easier for even one person has many rewards, but to be able to provide scholarships to several people is beyond gratifying,” said TCMS Alliance Foundation President and Scholarship Committee member Debbie Massingill. “Many students come from non-medical backgrounds. You are giving them a ‘you’re doing great’ when many have heard ‘you can’t do that.’”

The Allied Health Scholarship Committee is comprised of TCMS physicians and Alliance members. Since 1972, the Committee has awarded allied health students to help aid their education. “The desire, dedication, and hard work of so many students who wish to become healthcare providers give me hope for the future of medicine,” said Massingill.

All applicants must attend colleges in Tarrant, Parker, or Johnson counties, such as Tarrant County Community (TCC), University of Texas at Arlington (UTA), Texas Christian University (TCU), Weatherford College, Southwestern Adventist University, Hill College, Tarleton State University, or Texas Wesleyan University.

2023 Allied Health Scholars:

Tolani Adebowale of Weatherford College; Victoria Alexander of Weatherford College; Makenzee Benson of TCU; Sarah Broder of TCU; Leah DeLeon of UTA; Peyton Elvington of Weatherford College; Carolina Flores of TCC; Megan Harmon of UTA; LaToya L. Jones of UTA; Ruby Le of TCC; Courtney Lemons of Weatherford College; Kayla Robinson of UTA; Alexandria Snider of UTA; Alexandra Sonsini-Hornick of TCU; Emily Tanner of Weatherford College; Erin Tanner of Weatherford College; Ashley Wheeler of TCU.

The Tarrant County Medical Society is a professional organization dedicated to improving the art and science of medicine for the residents of Tarrant County since 1903. TCMS serves over 4,000 physicians, residents, medical students, and Alliance members and is a component society of the Texas Medical Association. To learn more, visit here.

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Media Contact:
Elizabeth Ramirez, Communications Coordinator;

eramirez@tcms.org / (817) 632-7519

Student Article: Representation in Medicine

by Lindsey Thomas, OMS-II

I chose to practice medicine because of my love for science, personal family connections in the field, and even the embellished view of Medicine in the media. However, the most impactful factor was that I had a female African American physician during a time of vulnerability and academic transition. I was balancing health challenges while also deciding what I was going to do in college, and it was my hematologist who provided the example of what I wanted a future for myself to look like. Seeing her success in a field that was dominated by a different demographic propelled my passion to be a physician. She showed me that I could also strive for greatness among the barriers set by society. Throughout my work as a medical assistant and now as a medical student, I have seen firsthand the disparities faced by physicians of color compared to other physicians, and I want to be part of the movement to change the narrative.

One way I knew I could make my aspirations a reality was by joining TCOM’s chapter of Student National Medical Association, or SNMA. On the national level, SNMA strives to serve underrepresented communities as well as produce physicians with cultural humility. One of the ways I’ve been able to further the organization’s mission is by my participation in the Mini Medical School events. We have partnered with the Fort Worth ISD’s after school program to give age-appropriate presentations on a medical topic at the elementary schools in the district. The students have particularly liked our superhero-themed presentation on the lobes of the brain and our introduction to the organs. Some of the elementary schools have already started to incorporate this basic anatomy instruction into the curriculum, so many of these students are able to answer questions during the presentation. The students are predominantly from underserved areas, and it is our hope that having medical students that are from similar backgrounds will inspire them to dream big. Additionally, we speak with high school and undergraduate students interested in joining the medical profession and advise them on achieving their goals. Through SNMA, I can reach students in a personable way and be a figure of possibility to young students that look like me.

As I continue through medical school, I aspire to use the knowledge I gained from student organizations like SNMA to give back to my community and to be a voice of advocacy in the need for diversity in medicine. The practice of medicine is constantly evolving and the people who are delivering healthcare should be evolving as well.

Physician Wellness

Tarrant County Physician Wellness Program: Addressing Burnout and Promoting Resiliency

by Casey Green, MD

THE TARRANT COUNTY MEDICAL SOCIETY IS launching a new wellness initiative available to medical society members and their families. We recognize the challenges associated with an ever-changing landscape in healthcare exacerbated by the COVID-19 pandemic that contribute to stress, burnout, and job dissatisfaction.

Modeled on the successful program at Travis County Medical Society, the Tarrant County Medical Society Wellness Program seeks to proactively address those among us who may be struggling. We have a mission to enhance the health of physicians, their families, and the communities in which we all live and work.

Physician burnout, the apparent catalyst to this situation, is considered a psychological response that may be experienced by doctors exposed to chronic situational stressors in the healthcare practice environment. It is often characterized by overwhelming exhaustion, feelings of cynicism and detachment from work, and a sense of ineffectiveness and lack of accomplishment.1

Physicians experiencing burnout, according to the medical literature, exhibit a wide array of signs, symptoms, and related conditions, including fatigue, loss of empathy, detachment, depression, and suicidal ideation. Nearly 25 percent of physicians surveyed last year were experiencing clinical depression. There were also significantly increased rates of depression among their family members.2

The most cited reasons for burnout include too many bureaucratic tasks, decreasing autonomy, increased work hours, and recent additional contributing factors related to COVID-19. Of those physicians experiencing burnout, more than half report it is strongly affecting their daily life and more than two thirds acknowledge impairments in relationships.2

Physicians often have to deal with difficult and tragic situations and losses. This continued exposure to human suffering can have a significant impact on mental and emotional wellbeing over time that often goes unrecognized.

Burnout is not always related to stressors arising in a work environment or to an individual’s character traits. Family issues, personal and professional relationships, financial pressures, insufficient work-life balance, or other external stressors may also contribute. Efforts aimed at the identification, treatment, or prevention of burnout must, therefore, approach the issue from a broad enough perspective to take all of these factors into account.

Too many physicians are reluctant to seek help for fear that they will be perceived as weak or unfit to practice medicine by their colleagues or employers, or because they assume that seeking such care may have a detrimental effect on their ability to renew or retain their state medical license.

The TCMS Wellness Program has developed relationships with community therapists who work with physicians or their family members to help them back on the path to wellness. These services will be confidential and paid for by this program for the first four sessions for any members or their families.

The goal of this new initiative is to provide information and resources to support physicians and their families in order to encourage and inspire each other to practice physical, mental, emotional, spiritual, and social wellness. The program is in its final formation steps, and we hope to meet these needs with workshops, mentorship, education, and other activities to promote healing, growth, and resiliency. We are excited about the future and will share more details as the program grows.

You can find more information about how to access the program at www.tcms.org/TMAiMis/Tarrant/Wellness or call 972-449-0762.

References

1. Maslach, C., Jackson, S.E. (1981). The Measurement of Experienced Burnout. Journal of Occupational Behavior, 2(2):99-113. See also, Maslach C, Jackson SE, Leiter MP. (1996). Maslach Burnout Inventory Manual. 3rded. and Maslach C, et al. (2001). Job Burnout. Annu Rev Psychol, 52:397–422

2. Kane L. ‘I Cry but No One Cares’: Physician Burnout & Depression Report 2023. Medscape. Published January 27, 2023. Available at: https://www.medscape.com/slideshow/2023-lifestyle-burnout-6016058.

Public Health Notes

Health Equity Through a Public Health Lens

by Catherine Colquitt, MD, Tarrant County Public Health Medical Director, and Yvette M. Windgate, ED.D.

This article was originally published in the March/April issue of the Tarrant County Physician.

As we turn the page on 2022 and our “tripledemic” surge recedes, let’s take a moment to reflect on health equity and disparities through the crucible of COVID-19.

Healthy People 2030 defines health disparities as “a particular type of health difference closely linked to social economic, and/or environmental disadvantage.” It further asserts that health disparities “adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive, sensory, physical disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to discrimination or exclusion.”1 Our collective goal is health equity, described by Healthy People 2030 as “the attainment of the highest level of health for all people.” Achieving health equity requires valuing everyone equally, with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”1

In the early 2000s, U.S. Surgeons General began to issue reports on disparities in tobacco use and access to mental health care based on racial and ethnic demographics. Since those ground-breaking reports, issues including infant mortality, pregnancy-related seats, chronic disease prevalence, and overall measures of physical and mental health have been examined through the prism of health equity. Part of the impetus of the Affordable Care Act (ACA) was to provide strategies for securing access to healthcare for traditionally underserved groups. Impactful gains were made in numbers of persons insured and access to higher quality care. However, those gains were somewhat eroded in the former presidential administration by cuts to funding for AVA navigators and outreach efforts, and the authorization of state waivers, which allowed some states to decline Medicaid expansion by instead offering their own wavers.

COVID-19 further impacted healthcare coverage losses through lost jobs and wages, resulting in increasing economic hardships, housing difficulty, and food insecurity, disproportionately affecting Black and Hispanic workers, especially those in essential in-person jobs (i.e., transportation, manufacturing, grocery, pharmacy, retail, warehouse, food processing, and healthcare). Due to healthcare workforce shortages and operational changes (e.g., video clinic visits requiring patients to have internet access), these same groups also experienced challenges to healthcare access.

During COVID-19, certain groups (i.e., Alaskan Native, American Indian, Black, and Hispanic individuals) experienced higher death and illness rates than their White or Asian counterparts, likely due in part to their work in essential jobs, higher prevalence of preexisting comorbidities for poor COVID-19 outcomes, use of public transportation, and crowding at work or home.

Additionally, according to the Kaiser Family Foundation’s survey data (The Undefeated), Black adults are more likely than White adults to report certain negative healthcare experiences, such as a provider not believing them, or refusing a test, treatment, or pain medicine the patient believed he or she needed. the Undefeated survey data revealed that Black and Hispanic individuals were less likely to have been vaccinated against COVID-19 as of April 2021. While vaccination rates against COVID-19 have risen on all ground, the gaps between White, Asian, Black, and Hispanic demographic groups have not narrowed. The effect of the health disparities laid bare by COVID-19 has been profound and predated the pandemic. For example, in 2018, the average life expectancy was four years lower in Black individuals than in White individuals, with the lowest life expectancy in Black men. That unfortunate trend continues today. In Tarrant County, the 76109 zip code in Fort Worth, a majority White neighborhood, holds a life expectancy of 82.4 years. Nearby 76104, host to historically Black neighborhoods, like Morningside, has a life expectancy of 66.7, and it is even lower for Black men at 64 years.

What can we do to address these disparities and improve the health of our county and county? The Biden administration has prioritized initiatives aimed at addressing health disparities at the federal level through several executive orders and proclamations. Locally, Tarrant county Public Health (TCPH) has created a Community Health Equity and Inclusion (CHEI) division to promote health literacy and address health equity issues concerning county residents, with the greater goal of decreasing health disparities and inequities in Tarrant County. The CHEI division educates residents and public health professionals regarding health disparity and inequity issues and engages community partners (i.e., Fatherhood Coalition of Tarrant County, Mental Health Connection of Tarrant County, My Health My Resources of Tarrant County, United Way of Tarrant County, and Brave/R Together) to find solutions that promote diversity and health equity.

TCPH continues to collaborate with community partners on annual events, such as the African American Health Expo, the North Texas Wellness Fair, and the Senior Synergy Expo. We are also participating in community celebrations, school events, and COVID-19 testing and vaccination pop-up clinics. Recently, TCPH and fifty-sic agencies- including hospital systems, institutions of higher education, city and county governmental entities, charitable organizations, and faith-based organizations- have joined forces as the Tarrant County Unity Council. This council’s purposes are:

To identify and address health equity challenges for those disproportionately affected.
To build, leverage, and expand fair resource allocation to safe, affordable, and accessible health, housing, transportation, and communication that advance racial equity and address other inequitable social conditions, with the purpose of reducing or eliminating health disparities and health inequities.

References:

Health Equity in Healthy People 2030, https://health.gov/healthypeople/priority-areas/health-equity-healthy-people-2030
L Hamel et al, Kaiser Family Foundation: Key Findings from the KFF/Undefeated Survey on Race and Health 10/2020
Life Expectancy by ZIP code in Texas, https://www.texashealthmaps.com/lfex
Tarrant County Public Health, Family Health Services, Community Health Equity and Inclusion, Community Involvement, https://www.tarrantcounty.com/en/public-health/family-health-services/health-equity–community-outreach/previoud-activities.html?linklocation=Button%20List&linkname=Community%20Involvement
Tarrant County Unity Council, https://www.tarrantcounty.com/en/public-health/family-health-services/health-equity–community-ooutreach/tarrant-county-unity-council.html

STUDENT ARTICLE: ADVOCACY FOR PATIENTS’ MENTAL HEALTH

by AIYANA PONCE, OMS-II

This article was originally published in the March/April issue of the Tarrant County Physician.

HISTORICALLY, STIGMA AGAINST MENTAL HEALTH, ACCESS to care, and discrimination contribute to worsened health outcomes. This is especially true for certain racial or ethnic groups such as those made up of Black and Hispanic individuals, as there are culturally negative views on mental health symptoms and/or treatment, a fear of mistrust of the medical community due to historical discrimination or mistreatments, or lack of access to mental health services.

To help address this, the Lay Mental Health Advocates (LMHA) program was created. This free, virtual training program is designed to teach laypersons the fundamentals needed to advocate for someone who is dealing with mental illness. LMHA focuses on teaching mental health advocacy by understanding how social determinants worse mental health and play key roles in overall health outcomes for marginalized communities. The social determinants of health are defined by the U.S. Department of Health and Human Services as “the conditions in the environments where people are born, love, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

LMHA began as a volunteer project during my time as a research trainee at the National Institute of Allergy and Infectious Diseases before beginning medical school. In addition to conducting experiments in a traditional laboratory setting, I was a fellow of the National Institutes of Health Academy. This program allowed me to meet other trainee scientists equally as passionate about patient advocacy. Ultimately, the goal of this program was to implement a volunteer project that addresses health disparities in the local community.

We saw a need for interventional programs to fill the mental health gap that is particularly prevalent among marginalized communities. Our program consists of a weekly online workshop led by psychiatry residents or attendings from Duke University Hospital and local community leaders. they include interactive role-playing advocacy practice, case study reviews, and other informative components. Our eight-week-long program was modeled after the Johns Hopkins Medicine Lay Health Advocate Program and the Mental Health Allyship Program. Through LMHA, advocates can identify several different mental health conditions, gain a greater understanding of the factors that exacerbate health disparities, understand how to provide effective emotional support, and gain confidence in the role they can play in the lives of their community members by BEING mental health advocates.

The pilot program took place during Spring of 2021, and we had 100 participants whose ages ranged from 18-58. We are now on track to our third workshop series, with participants from across the county. In addition to that, we are currently expanding our team, working on our non-profit application, and establishing a volunteer program to work with the Duke Behavioral Health Inpatient Unit.

Watching this program grow beyond anything my team had imagined has been very rewarding. I wanted to share this journey with those of you reading to encourage you to continue advocating for yourself, your patients, and your community. If you ever see a problem that needs to be addressed or a gap that needs to be filled, just go for it- you never know what may come of it.

References:

1. https://www.psychiatry.org/patients-families/stigma-and-discrimination

2.https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020–08964-3#ref-CR28

3 . https://health.choc.org/understanding-the-role-of-cultural-stigma-on-seeking-mental-health-services/

4.https://health.gov/healthypeople/priority-areas/social-determinants-health

PRESIDENT’S PARAGRAPH

by Stuart Pickell, MD, TCMS President

This article was originally published in the March/April issue of the Tarrant County Physician.

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

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.