The Last Word – Life Lessons

by Hujefa Vora, MD, Publications Committee Chair

From the Achieves: This Last Word was originally published in the September 2017 issue of the Tarrant County Physician and has been edited for clarity. You can read find the full reprint along with the rest of the content from the July/August 2022 publication here.

He was an amazing businessman.  His acumen, combined with an ability to take the required risks, helped him to build an automobile repair empire.  His smile was infectious.  With it, he instilled a fierce sense of loyalty in his employees and business partners.  And his words.  His Texan twang was musical and fierce.  He could cut a deal in seconds with a “Howdy Y’all” and then a “Sign here . . .”  That’s how he won the heart of his high school sweetheart.  He danced with her from the prom, where he was the King, all the way to the white-washed wedding chapel.  They had four children, each one more beloved than the previous, each with that same smile.  When he first came to me, I could see what they all loved in him.  Despite always being short on time, I would spend the extra few minutes just to laugh at his latest story.  I would adjust his blood pressure medication.  Somewhere along the way, I added a statin.  He did not smoke, and he had no family history.  He was doing well, and so that’s why the stroke came so unexpectedly.  Four years ago, the conditions changed.  The stroke took the entire right side of his body.  He couldn’t walk.  He couldn’t use his right hand and arm.  He was immediately wheelchair-bound.  That was not the worst of it, though.  The worst was when we found out that he had lost his voice.

The stroke hit his speech centers.  He developed an expressive aphasia.  He could understand everything that was said, but he could no longer utter a word.  The damage to Broca’s area was irreparable. His physicians concurred with this assessment.  Perhaps we thought his life was over, or at least the life he had built.  His wife’s love for him was stronger than that, though.  It was stronger than the assault on his brain and body.  She kept him in his business.  She kept him in the game.  She would take him to physical therapy to strengthen his resolve.  She took him to speech therapy and learned his language.  She brought back his smile.

She took him to work every day.  She was his voice in the meetings.  He would smile and grunt, and his empire did not crumble.  Physically, he was weak, but as a partnership, she and her husband held strong.  I remained amazed by all of this whenever I saw them in clinic.  Here was a strong man brought to his knees by a stroke that should have ended him, but instead, he flourished.  He flourished because he had a partner that stood by his side always.  Even as we did not, she understood his every unintelligible utterance, his body language, and above all else, his smile.

I am given the honor of seeing them periodically in the office.  He has had a hospitalization here and there, and she remains his constant companion.  She is his advocate.  She is his voice.  Despite everything we think we know about medical science, she has proven that he is unbreakable.

I often wonder about the intricacies of their relationship.  I wonder at his wife’s ability to understand him.  Most of all, I marvel at their resilience.  Despite overwhelmingly insurmountable odds, they have survived.

Most of all, I marvel at their resilience.  Despite overwhelmingly insurmountable odds, they have survived.

There are so many life lessons I have learned from my patients over the years.  I want to bring only one of these to all of you.  Together, we are stronger.  Despite any of our individual weaknesses, we can always give a voice to one another.  This becomes especially true in our partnerships and relationships outside of our practices.  I am a dinosaur on an island.  I am a solo internist.  How do I ensure that my voice is heard?  I can promise you that the people in Austin and Washington think they know what it is I need and I want.  They think they know what we are saying.  They think that they can fix medicine.  Meanwhile, we think that they are listening to us.  We believe that our intelligence and our charisma will carry the day.  This is in fact our greatest strength and our greatest weakness.  We know we have the answers on how to fix healthcare.  I know this to be a fact.  My fellow physicians, I have heard all of you loud and clear over the past several months.  I have had amazing conversations.  I have gained so much insight into my own difficulties in medical practice, and I have come to a better understanding of so many of the difficulties many of you face in your day to day.  Some of these discussions have led to even deeper insights . . . But there is the rub.  How will we get to action?  Action requires us to understand our greatest weakness.  We help others all day long, and even though we think we have all of the answers, we are unable to really express them.  We too have a form of Broca’s aphasia.  I would assert that we need a partnership to make absolutely certain our voice is heard.  I believe the partner that binds us all together is the Tarrant County Medical Society, in conjunction with the Texas Medical Association.  Many of you have expressed your inability to completely agree with this.  We don’t always agree with our partners 100 percent of the time.  (Don’t tell my wife this!)  Moreover, we need a partner and an advocate that speaks our language and understands us.

Maybe I’m just preaching to the choir.  In the end, we will all need to continue to work together, not individually . . . We must come together and make sure that our voice is heard loud and clear . . . They will hear us.  Kumbaya.  My name is Hujefa Vora, and this is our Last Word.

Medicine on the Road

by Sebastian Meza, OMS-I

This article was originally published in the July/August 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

Texas is suffering a healthcare crisis from a lack of practicing physicians. This fact is even graver in rural communities, where the nearest hospital might be a couple of hours away. It is time that we take medical care closer to these vulnerable patients, and that is where mobile healthcare clinics can offer an efficient solution.

As a first-year medical student at the Texas College of Osteopathic medicine, I was fortunate enough to serve with the Pediatric Mobile Clinic at the Health Science Center. To picture this mobile clinic, you must imagine a bus or RV that has been transformed into a fully functional pediatric clinic. It might seem like there would not be much space in the mobile unit, but it is fully equipped to perform many medical services. The unit carries out vaccination drives, full screen wellness check-ups, sports physicals, and much more. It is a small glimpse into the future of medicine.

Looking back at my very first day serving as a student doctor, I did not know the extent of what the pediatric mobile clinic could do. My first patient came in and presented with learning difficulties, café au lait spots, and some vision problems. It was an enormous surprise to find myself examining a possible case of neurofibromatosis, a rare disease that we had covered just a few days prior. I left that day thinking about how this child would not have been able to receive care or be referred to a specialist if the Pediatric Mobile Clinic had not shown up at his school. I felt grateful and fortunate to have been there to serve the children of our Fort Worth community.

It was not until I had a chance to serve in this mobile unit that I realized that this concept was a great solution for Texas’ rural communities. Mobile clinics bring medical services to areas that are hours away from major cities with large medical centers. These clinics are easily adaptable and can be transformed to house many different kinds of practices. They operate much like a regular clinic; patients can look up when the mobile clinic will be near them and then schedule appointments online. Primary care practices can take full advantage of transforming and adapting the mobile units to serve a specific patient population. 

For example, mobile clinics can directly help many underserved communities by being closer to patients, which saves time and transportation costs that can often be barriers to seeking treatment. Mobile health clinics do require an initial capital expense for institutions and hospitals. However, they bring in enough revenue to cover their own costs, they draw patients into the sphere of the base clinic or the hospital, and they help keep our community healthier. 

I did not expect to feel so strongly about the concept of mobile healthcare clinics when I first set foot onto that crowded bus, but it is impossible not to recognize how efficient it is to have mobile clinics at our major schools and hospital institutions, as well as in rural communities. These mobile clinics should be part of our vision for the future of healthcare. It is time to advocate for more mobile clinics on our Fort Worth roads!

Behavioral Health to Combat Physician Burnout

By Sofia Olsson, MS-I, and Anand Singh, MS-I

This article was originally published in the July/August 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

Burnout is not a new term for physicians. In fact, prior to the pandemic, an online survey conducted by the American Medical Association in January 2020 found that there was an overall physician burnout rate of 46 percent.1 Unfortunately, the pandemic has exacerbated burnout for physicians due to a multitude of unprecedented factors. Burnout can be defined by three main symptoms: exhaustion, depersonalization, and lack of efficacy.2 Physicians may exhibit harmful behaviors as coping methods in response to burnout, so it is important to acknowledge behavioral health as it addresses how individuals’ daily habits and actions impact their mental and physical health. As two medical students, we founded Behaviors Supporting Mental Health (BSMH) to raise awareness surrounding behavioral health for all individuals. For our current campaign, we are focusing on physicians’ response to burnout. Through BSMH, we hope to provide resources for physicians to address their behavioral health and reduce or prevent burnout.

Continuous refinement of our daily habits, actions, and behaviors leads to better
mental and physical health. 

First, though, we want to acknowledge the prevalence of burnout and what factors are contributing to this phenomenon. According to research conducted by the Agency for Healthcare Research and Quality, the cause of physician burnout is multifactorial.3 The study found that some of the main causes of physician burnout are tied to physicians having to balance family responsibilities, work under time pressure, deal with a chaotic work environment, have a low control of pace, and implement electronic health records.3 Unfortunately, physician burnout has been linked to consequences such as lower quality of patient satisfaction and care, physician alcohol and drug abuse, and even physician suicide.2 Therefore, addressing physician burnout and combatting unhealthy behaviors are critical for physicians themselves as well as for the patients they serve.

The activities physicians partake in can impact their risk for burnout, so assessment of one’s behavioral health is important regardless of current mental health. Several coping strategies, such as making an action plan, taking a time out, or having discussions with colleagues, have been correlated with a lower frequency of emotional exhaustion in physicians.4 On the other hand, keeping stress to oneself has been associated with a greater frequency of emotional exhaustion.4 After making note of behaviors and identifying their purpose, one can decide whether these actions should be eliminated, continued, or supplemented.5 Changing behaviors, however, is easier said than done. Since useful coping skills are not “one size fits all,” BSMH aims to provide resources that help physicians build a toolkit of ways to improve their behavioral health. For example, the app Provider Resilience, designed by the Defense Health Agency, functions as a method to keep physicians motivated and hold them accountable in their behavioral health.6 The QR code shown is a link to the BSMH website (https://tinyurl.com/bsmhproject), which includes further resources tailored to prevent or relieve burnout in physicians. Our contact information can also be found here for anyone with questions or a desire to collaborate.

Continuous refinement of our daily habits, actions, and behaviors leads to better mental and physical health. Regardless of the extent of a physician’s burnout, addressing behavioral health is always a necessity. Intentional actions impact one’s identity as a physician and any other role they have outside the clinic. Transitioning one’s behavioral health from passive to intentional can improve one’s ability to balance familial responsibilities, work under pressure, and deal with a chaotic work environment.2 This puts physicians in control of their behaviors and decreases their risk for substance abuse and suicide while improving the quality of patient care.7,8 Meaningful reflection and continuous behavioral health improvement creates a healthier mindset that allows physicians to better care for their patients and themselves.  

References

1. Berg S. Physician burnout: Which medical specialties feel the most stress. American Medical Association. https://www.ama-assn.org/practice-management/physician-health/physician-burnout-which-medical-specialties-feel-most-stress. Published January 21, 2020. Accessed May 18, 2022. 

2. Drummond D. Physician Burnout: Its Origin, Symptoms, and Five Main Causes. Fam Pract Manag. 2015;22(5):42-47.

3. Physician Burnout. Content last reviewed July 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html      

4. Lemaire JB, Wallace JE. Not all coping strategies are created equal: a mixed methods study exploring physicians’ self reported coping strategies. BMC Health Serv Res. 2010;10:208. Published 2010 Jul 14. doi:10.1186/1472-6963-10-208

5. Hem, Marit Helene, et al. “The Significance of Ethics Reflection Groups in Mental Health Care: A FOCUS Group Study among Health Care Professionals.” BMC Medical Ethics, vol. 19, no. 1, 2018, https://doi.org/10.1186/s12910-018-0297-y. 

6. Provider Resilience. Version 2.0.1. National Center for Telehealth & Technology. 2021.

7. Harvey, Samuel B, et al. “Mental Illness and Suicide among Physicians.” The Lancet, vol. 398, no. 10303, 2021, pp. 920–930., https://doi.org/10.1016/s0140-6736(21)01596-8. 

8. Panagioti M, Geraghty K, Johnson J, et al. Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis. JAMA Intern Med. 2018;178(10):1317–1331. doi:10.1001/jamainternmed.2018.3713

CALL FOR MUSICAL PHYSICIANS: Join Fort Worth’s First Medical Orchestra

by Allison Howard

This article was originally published in the July/August 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

Physicians, dust off your instruments—Fort Worth’s first medical orchestra is looking for healthcare workers who have a dual passion for music and medicine.

The group, which is being organized by retired physical therapist and flautist Susan Fain, is expected to begin rehearsing this fall.  While the details are still being ironed out, Susan says that everything is falling into place.

“We are collaborating and negotiating for a space, conductors, and music,” she says.  “And it looks really good.”

Susan, who holds doctoral degrees in both physical therapy and flute performance, was first inspired about 10 years ago when she heard the Doctors Orchestral Society of New York. She soon discovered there were over 30 such orchestras throughout the U.S., and she saw it as the perfect opportunity to marry her passions.

“In medicine you’re helping people, and in music, you really are helping people,” she says. “You’re helping yourself, learning to create, and all of that discipline is across both professions.”

She believes this could be a step toward work-life balance for those who love sharing music with others but have set their instruments aside due to lack of opportunity. Now, she is ready to create that opportunity, and she is thrilled to do so in a city that is rife with a passion for the arts.

Susan, whose career was divided between practicing physical therapy, pursuing music, and raising her five children, has played flute in both civic and professional orchestras. And her experience organizing events and groups is extensive, ranging from planning classical concerts to putting together a small orchestra (where she served as the conductor!). Now, retired from physical therapy and ready to devote herself fully to her love of music, she is thrilled to start this next endeavor.  

“I want to be like Esther – ‘You might have been born for such a time as this,’” Susan says. “To bring the two halves of my life together and make them both count.”

It seems she isn’t the only one that feels that way. As the word spreads there has been a lot of interest; so far, 10 instrumentalists have committed to the orchestra, and more have expressed a desire to get involved. 

Ultimately, Susan’s goal is to form a full orchestra that will perform a handful of concerts each year to raise support for local charities. She believes it will enrich the community and be a chance to cut through much of the noise created by the constant challenges in the practice of medicine.

“Performing is like creating an oasis for the audience,” she says. “This is a moment where you can forget the outside world, and all the things going on in society that we struggle with, and we can sit for a moment and just stop and reflect on truth and beauty. That, to me, is what it’s all about.”

For more information about the Fort Worth Medical Orchestra, contact Susan Fain at sdfain1@gmail.com or 405-830-2107. 

President’s Paragraph

July 1st

by Shanna Combs, TCMS President

This article was originally published in the July/August 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

As I write this, we are amidst graduation season for kindergarten, high school, college, and medical school; it is a time to celebrate the culmination of one of many of life’s journeys.  By the time you read this, it will be another magical time of year that all medical professionals know . . . July 1.  The time of year when medical students are starting their journey into medical school, or starting their clerkships and entering the clinical learning environment.  It is also the time when newly minted doctors put on their crisp, long white coats and try out what it sounds like to say, “Hi, I’m Doctor So-and-so.”  It is the time of year when the cycle of medical education continues to turn, and for those of us in practice, it is a time to reflect on our own journey in medicine.  Below are some words of wisdom I have for the next generation of physicians.

First year medical students

Welcome to the profession! You have started the journey into the best career you can ever have.  The path ahead will not be easy, and there will be many highs and lows.  Always keep in mind the reason you chose medicine and enjoy the ride.

Clerkship students

You finally made it . . .  you are out of the classroom and getting to do what you wanted to do when you started medical school – learn how to take care of patients.  The hours will be long, and your brain will hurt from all the new knowledge, but you are finally starting the work that you signed up for.  The best piece of advice I have is the same thing I was told at the beginning of my clerkship year: “You are paying for the privilege to be here . . . get your money’s worth.”  There will be no other time in your career where the whole world of medicine is open to you.  

Decisions you make are no longer about a, b, c, or d choices; there is now a human life attached to your decisions.  There is a whole lot of grey in medicine and not every patient “reads the book.”  Keep an open mind and learn as much as you can.  

Residents

You are now a doctor . . . listen to the nurses.  They can teach you many things and help you in times when you do not know what you are doing, or they can make your life a living hell.

You, too, were a medical student once and were taught by a resident who took you under their wing – or were dismissed by a resident who forgot where they came from.  What type of resident do you want your medical student to see you as?

You now have the privilege to sign orders, write prescriptions, and perform procedures.  All of this has an impact on a human life.  Never forget that.

Attendings

The doctor who is not willing to say “I don’t know” or “I need help” is the most dangerous doctor out there.  When another doctor asks for help, realize that they have reached the end of their knowledge base and are asking for your expertise.

It is called the practice of medicine, not perfection.  You may have completed medical school, residency, and possibly even fellowship, but there is always something more to learn.  When you do this, it is no longer just for your own education or to pass the test, but so you can provide the best care for your patients.  They are the reason we do what we do.

Happy July 1 everyone!

Medicine Has No Borders

by Aiyana Ponce, OMS-I

This article was originally published in the May/June 2022 issue of the Tarrant County Physician. You can read find the full magazine here.


As a high schooler attending a medical magnet school, my first patient interaction came early, but the lesson I learned that day has influenced the type of physician I hope to become. Nervously, I greeted my first patient, Laura, and informed her that I would be assisting the nurse that day. I helped with her bath and brushed her hair with care, just as I brushed my own mother’s hair when she was hospitalized. Laura was blind and her tracheostomy tube prevented her from speaking, but despite that initial disconnected feeling, I was told, “The goal should be to take care of the patient as if she were your own family member.” That goal was to serve with compassion and empathy. These words have remained with me each time I have interacted with a patient. I took lessons such as this one with me after graduating and made it my mission to maximize my impact on others while serving my community.

Over spring break this year, I participated in a medical mission trip to Guatemala with 35 of my peers. Over the course of five days, we traveled by air, sea, and land to visit Santa Maria de Jesus, Magdalena Milpas Atlas, Monterrico, and San Juan, where we saw over 600 patients. Upon arrival at the pop-up clinic locations that were normally schools or church community rooms, there was often an impressively long line that formed before doors opened. Patients waited hours to be seen each day, and that was a humbling sight. 

As a first-generation American raised in the U.S.-Mexico border region and a native Spanish speaker, I served as a link between patients, physicians, and medical students. My responsibilities were to initially take patient’s vital signs and blood glucose readings and then discuss their medical history and chief complaints so I could give the information to the attending physicians volunteering with us. Other days, I had the opportunity to work with a student partner and conduct full patient interviews. We would present our differential diagnoses to one of the attending physicians and work alongside the patient to create the best plan of care. On one of these days, I noticed that a patient came in particular distress. Upon my initial analysis, I noticed that he had what I call “working hands.” Large, dry, and calloused, they resembled the hands of my construction laborer father. As soon as I introduced myself by saying, “Buenos días, mi nombre es Aiyana,” his demeanor changed entirely. One moment he was shyly nodding and following the motions, and the next he looked up, seemingly comforted by familiar words. He, like many others, opened up and provided critical information necessary for his recovery. This change in demeanor occurred patient after patient, and I began realizing how incredible it was to contribute to the enhancement of patient care that would otherwise be limited by communication barriers. I am proud of my work as a translator, but I learned that there is far more that goes into quality of care than a shared language. Though some physicians and students were limited by language, I witnessed spectacular uses of eye contact, hand motions, diagrams, and body language – all of which portrayed a genuine desire to connect with and educate patients. Everyone seemed to have an impeccable awareness of their patients’ needs and feelings, despite their differences.

 As soon as I introduced myself by saying, “Buenos días, mi nombre es Aiyana,” his demeanor changed entirely. One moment he was shyly nodding and following the motions, and the next he looked up, seemingly comforted by familiar words.

It is a privilege to be entrusted to care for the life of another human being and I do not plan on taking such a responsibility lightly. It is important to acknowledge that one does not need to travel to faraway lands to serve those in need, as many underserved individuals are likely residing minutes away from us right now. In the future, I will continue to participate in mission trips abroad in addition to serving the local community, wherever I go! 

Choices

The Last Word

By Hujefa Vora, MD, TCMS Publications Committee Chair

Last month, I wrote about choices.  We all seem to encounter hundreds, if not thousands, of choices every day.  And who really knows how the slightest choice affects the next set of choices that present themselves before us.  Our choices at times can appear meaningless to us.  As I prepare for my day, I choose my scrubs from my closet.  Unconsciously, I make the decision to wear the blue ones.  I decide to just grab a granola bar for breakfast as a matter of convenience on my way out the door rather than to sit down with my wife at the dining table for the coffee and omelet and communion I am truly craving.  On my way to work, I decide to stop and fill up some gas, though my truck still has a quarter tank.  The floor nurse messages me that my patient’s family has decided to try and meet with me around lunchtime today rather than meet me for my morning rounds.  I let her know that I am not sure that this will work, as there are likely to be another few hundred choices that I have to make before I get there.  I will try.  That seems to be all I can do in any given situation.  At any rate, I decide to go by and see the patient first this morning.  This will give me a moment of clarity without the interference that sometimes follows families into a room.  I make the choice to turn left rather than right—I will start my day in the ICU and make my way back to the orthopedic facility later.  I know that I will make it to all of the patients before the end of my day.  My choices thus far have been mundane rather than the life and death decisions which we are glorified with when others speak of our profession.

The choices I made that morning were not anything but ordinary.  And yet, as we find sometimes, they guided me exactly to the place where I was needed most.  

As I arrive at the hospital, the cafeteria’s coffee machine calls my name.  The granola bar wasn’t quite enough.  I chose a decaf vanilla latte.  Now the coffee machine is not that place, but it is certainly the place I needed most.  Caffeine would make it better, but that goes without saying.  My coffee and I meander onto the unit.  The nurses are busy at their bedsides, assessing the patients at the start of their morning.  As I walk toward the central nurses’ station, I note the rhythms of the telemetry monitors. Muffled underneath is the low hum of air flowing through endotracheal tubes.  The aroma of the coffee hides the scent of hand sanitizer and bleach.  Just the granola bar was a poor choice, but the choice of coffee from the cafeteria more than compensates for that.  It is all entrancing, calming, and yet chaotic.  The ICU has its own music.  Occasionally, the better choice of words is controlled chaos.  My moment is broken by a flourish from the room 20 feet in front of me.  The rhythm is broken as a woman flies out of the room, hurtles towards me, and demands her nurse.  For a moment, I hesitate.  I then realize that the blue scrubs I chose this morning happen to be the same blues worn by our ICU nurses.  I follow her into the room.  The patient is bucking the ventilator.  In his bed, he is strapped down, but from the spasms in his shoulders and neck, his arms look like they will try and pry loose.  I hit the Code button on the hospital bed.  The ICU machine is awakened by a cacophony of deafening alarm bells.  Three nurses barrel into the room with a crash cart.  A few simple, unplanned choices have guided me to this moment.  

“The choices I made this morning were not anything but ordinary.  And yet, as we find sometimes, they guided me exactly to the place where I was needed most.”

There were no decisions this morning prior to this moment that required my four years of college, four years of medical school, or three years of residency.  And yet, they were a doctor’s decisions and choices.  The next few choices were those of a seasoned physician with more than 20 years of working in hospitals and ICUs.  

I don’t have any history, as this is not the room of the patient I have yet to visit this morning.  All I have is the information the nurses start barraging me with.  The patient is seizing, so IV benzodiazepines are administered. Another choice.  The patient starts to calm, spasming muscles relaxing.  Calm washes over the scene for a moment.  Everyone, including the patient, pauses to breathe.  The momentary silence is broken by the sobbing of the patient’s wife, I presume.  She asks if the doctor has been called.  Without skipping a beat, I reassure her that the intensivist is on his way.  The wife stutters out a prayer, then thanks me for my actions.  My choice in that moment is not to correct her, but rather affirm to her that we will take good care of her husband until the intensivist arrives.  I remain in the room for several more minutes until the intensivist comes in to relieve me.  He assesses the situation, thanks me for intervening while he was indisposed with another patient situation, and then allows me to walk back out of the room.  As I leave, he pokes his head out of the glass door and shoves a cup into my hand.  “Don’t forget your coffee.”

Every choice we make in our days is governed by several principles.  I am about to speak in generalities, a choice I am making in this moment.  We are physicians.  Our lives revolve around this choice.  Being a physician is not just a job, not simply some way to make money, but rather a life choice, because being a physician is not my job, but it is my Life.  We are called upon, above all else, to do no harm—our choice is to take this oath and live by it.  No matter the moment, the situation, the patient comes first, above all else.  We apply our knowledge, our skills, and our hearts to every patient individually, understanding that it is our oath and the choices that have followed thereafter that define our most noble profession at its core.  As a physician, it should always be my choices, and my patients’ choices, which guide me to those moments and through those moments when I am needed most.   One might say that I am pro-choice.  I choose to agree.  My name is Hujefa Vora, and I choose the word “choice” as this, The Last Word.

“If you are not at the table, then you are on the menu.”

President’s Paragraph

by Shanna Combs, MD, TCMS President

This article was originally published in the May/June 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

While the origin of this quote is debated, I find that it sets the scene perfectly.  The point is that you need to be engaged to have a say in the process.  I frequently use this phrase when discussing issues related to women’s health and LGBTQ care when government officials or other people in power try to dictate how I practice medicine.  In less than a year, various entities in the Texas government have tried to dictate this at least three different times.  There just is not enough space in my exam room for all of us.  And sadly, I feel that they are only just getting started.

I consider practicing medicine to be a profound privilege, and it is one that is only obtained after many years of hard work, study, and usually a huge financial commitment. For those who do not know, I did not come to medicine straight out of college.  I chose to pursue studies in ballet and pre-medical course work while getting my undergraduate degree, then followed my passion to an opportunity to teach and dance professionally.  After a few years, I decided it was time to go back to the pursuit of a career in medicine.  However, I did not get there the first try and had to make a further commitment to improve my application to get into medical school the second time.  Having studied ballet in college, I definitely felt a little out of my element in medical school.  I still recall a time when a professor in a small group learning session referred to me as the “lowest common denominator” due to my nontraditional background.  Despite this, I continued in my studies to obtain the title of Doctor of Medicine.  To practice medicine, however, you do not stop there; you must take the next road in the journey of medical education, and I went on to study obstetrics and gynecology in residency for another four years of training.  So, in total, I have spent 12 years in education to become the doctor that I am today.  That does not include the hundreds of hours of study that one must continue after residency to maintain the privilege of being a doctor as well as to provide the best and most up-to-date care to one’s patients.  Despite all of that, for obstetricians and gynecologists, our field is continually under the microscope for various areas of the care we provide, and outside influences are always trying to tell us how to do our job.

As mentioned earlier, there have been three times when the government of Texas has tried to dictate how I can practice medicine.  On September 1, 2021, Senate Bill 8, prohibition of doing an abortion after a heartbeat is detectable, was implemented.  This has led to many far-reaching consequences that do not have anything to do with abortion, such as concerns regarding management of ectopic pregnancy, management of premature rupture of membranes before viability, and lethal fetal anomalies not identified until 18–20 weeks.

“I consider practicing medicine to be a profound privilege, and it is one that is only obtained after many years of hard work, study, and usually a huge financial commitment.”

On December 2, 2021, Senate Bill 4 became effective, further placing non-evidence based restrictions on medication abortions as well as requiring physicians and healthcare facilities to report complications that occur from medically induced abortions. This essentially forces physicians and healthcare facilities to report our patients who are already going through a challenging time.  In addition, we must justify the use of the same medications used for abortion when used for other medical reasons and sometimes delay the care for patients in the process.  

On February 18, 2022, the attorney general of Texas wrote an opinion letter equating transgender care with child abuse.  This was followed by a letter from the governor on February 22, 2022, to the Texas Department of Family and Protective Services, asking them  to “conduct a prompt and thorough investigation of any reported instances of these abusive procedures in the state of Texas.”  While these are officially opinions only, they have led the transgender community to fear seeking evidence-based care. Furthermore, some physicians and healthcare entities who provide this care have shut down or halted the care of these patients.  These opinions have further isolated an already at-risk population from the care they need and deserve. 

We have all trained, studied, and worked too hard to let those who have not done the same dictate the care we provide.  Would we allow outside influences to decide who gets cancer treatment or cardiac care based on the opinion of a person without proper medical education and training?  The truth is, no, we would not accept that.  Unfortunately, when it comes to the issues of reproductive health and LGBTQ care, an attitude of “that does not affect my practice, so I do not need to say anything” is taken.  Yet, there are far-reaching implications that we must consider.  No matter your opinion on any of these issues, we as physicians need to fight back on these interferences in the patient-physician relationship.  I will continue to provide the evidence-based and compassionate care that my patients deserve.  I will also continue to bring myself to the table of advocacy, so that neither my practice nor my patients end up on the menu.  

Let’s Go Mobile!

Public Health Notes

By Catherine Colquitt, Tarrant County Public Health Medical Director

This article was originally published in the May/June 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

Tarrant County Public Health (TCPH), with its long history of providing vaccinations and testing in response to outbreaks and exposures, is rapidly expanding mobile operations to meet more testing, vaccination, treatment, screening, surveillance, contact tracing, and risk reduction education needs in our rapidly growing county. 

TCPH staff and leadership have learned much during the COVID-19 response about taking services “local.” We have benefitted greatly from working with such partners as county, regional, state, and federal government agencies, as well as first responders, municipalities, the Tarrant County Medical Society, school districts, colleges and universities, primary and secondary private schools, preschools, childcare facilities, places of worship, and municipal and state emergency management and preparedness experts. 

Responding to the need for mobile services with COVID-19 has reshaped healthcare delivery and has redefined preventive risk reduction and early/expedited treatment strategies for communicable diseases. It may also help us to move closer to the health equity we wish to achieve in our county and beyond. The COVID-19 pandemic has exposed disparities in access to vaccines, testing, accurate COVID-19 information, and expert advice regarding COVID-19 risk reduction strategies (masking, social distancing, practicing cough and hand hygiene, self-isolating when ill, quarantining after COVID-19 exposure, and vaccination). 

As of March 24, 2022, some 2,894,773 COVID-19 vaccinations have been administered in Tarrant County, with 1,338,110 people (66.24 percent of eligible Tarrant County residents) having received one dose, and 1,179,080 people (58.37 percent of eligible Tarrant County residents) being considered fully vaccinated with one Johnson and Johnson vaccine or two doses of mRNA vaccines.1

Essential clinical services offered by TCPH include immunizations; HIV testing, prevention, and treatment; STD screening and treatment; tuberculosis treatment; screening and contact investigations; drug treatment for latent tuberculosis infection; travel medicine clinics for advice; and vaccinations essential for safe international travel. We believe that a hybrid approach to the delivery of these services is vital to addressing health equity and access issues that could otherwise interfere with our objective of safeguarding the public’s health. We continue to operate our brick and mortar clinics across the county, but we must be nimble to serve communities which can’t easily access services in our fixed locations. We have a highly visible VaxMobile (an articulated city bus provided by our Fort Worth Transportation Authority partners), and we have purchased five mobile immunization trailers customized for the purpose. We have also purchased a 26-foot-long mobile van in which we can see clients for education, testing, and treatment.

We are ready, willing, and coming soon to your neighborhood. Remember, “Public Health is Where You Are”!

References

1.Data from Texas Dept of State health Services COVID-19 Dashboard
https://dshs.texas.gov/coronavirus/AdditionalData.aspx

The Delicate Dance of Disseminating Information

By Siri Tummala, MS-II

This article was originally published in the May/June 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

“Cranial nerves two through twelve intact. Sensation is absent to light touch in right C5 and C6. Strength five out of five in bilateral upper and lower extremities. Bilateral hyperreflexia noted in patellar reflexes. No gait abnormalities,” I recite to my neurology preceptor. I quickly tap my right foot in nervous anticipation of disseminating the physical examination findings and their implications to the patient. 

Context is everything. One year ago, abnormal neurological findings on an Objective Structured Clinical Examination (OSCE) would excite me. It was a free space to explore various pathologies in depth without fear of harming the patient. But this is not an OSCE. Gone are the days when hired actors pretended to be patients with medical cases. This is the real world with patients experiencing debilitating symptoms presenting to clinics. Now, abnormalities are not just an opportunity to see topics I learned in class or in a textbook last year come to life. Rather, abnormal physical exam findings in the real world can have devastating effects on individuals’ lives and on their overall wellbeing. 

Informing patients about abnormal findings that warrant further imaging is not an easy task. I take a deep breath and knock on the door. I calmly deliver the news that his neck pain, hyperreflexia, as well as his numbness and pain in the middle and pinky fingers necessitates an MRI of the cervical spine for evaluation of possible cervical degenerative disc disease. 

“So, I won’t know if I have that disease until I get the MRI?” asks the patient.

“Yes, that’s correct. Imaging is a tool we can use to confirm our clinical findings,” I reply. 

The patient’s body starts to reflect the stress he feels from this information. Sweat beads form on his forehead. His brows furrow. His lips quiver. 

“But it won’t be until a couple of weeks that I can get the MRI and have the results back,” he worriedly says. 

I sense his uncertainty, and I spend twenty extra minutes with him. I calmly explain that it is normal to feel anxious about the unknown. I further explain that imaging is a helpful tool we can use to confirm our clinical findings. I reassure him that physical exam findings and imaging results together will allow us to formulate an efficacious treatment plan to fulfill his goal of improving his symptoms. 

Our job as healthcare professionals transcends purely applying medical knowledge to real-life settings. The quality of the medical information we give patients is valuable only if it is delivered in an understandable manner that takes into consideration how that information affects their daily lives. If the pathology is prioritized over the patient, medical care will not suffer, but the patient will. Given that our primary duty is to ensure the wellbeing of patients, patient encounters are more fruitful when extra time is spent explaining the importance and relevance of the information. It takes years to fully master medical topics for medical students who spend all day studying and are constantly immersed in the material. It is not a fair expectation to assume that patients will recognize the significance of and be able to apply health recommendations without a clear and thorough explanation by the caregiver. Patients are real people, and this recent encounter reminded me that entering medical settings is a vulnerable situation that requires physicians to acknowledge their experiences with care and compassion.

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