Virtually Interviewing in the Midst of a Pandemic

by David Lam, OMS-IV

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


The residency application process has changed significantly over the past several decades. I remember a grey-haired attending telling me that when he applied to residency, it consisted of hopping in a car, driving down the freeway, and requesting meetings at hospitals he encountered along the way. A strong handshake later, and the promise of training in the specialty of his choice was secured. Since then, the Match process has been transformed with the stratification of candidates by board examinations which dictate competitiveness for certain specialties. We are under pressure to shine starting on day one, with no assurance that our labors will be rewarded by placement into a residency program.

The class before mine underwent the pomp and circumstance of their Match days at home, sidelined by the COVID-19 pandemic. My class is interviewing for residencies through virtual platforms. We do our best to capture the vibe of a program through an online tour of a hospital recorded on a GoPro camera attached to a resident’s forehead. Our webcams are always on, and we exercise our zygomatic muscles to maintain a soft smile throughout the events of the day. We try our hardest to convey ourselves in the best light possible, both figuratively and literally (many of us have invested in elaborate lighting set-ups). 

This is not an indictment of the residency programs whose attention we are vying for. These are unique times, and residencies face similar obstacles to those encountered by the applicants being interviewed. As we evaluate a place we may call home for the next three to six years, residency programs are navigating how to choose a class of interns without meeting them in person. Then there is the additional challenge of representing the program’s values and culture on a screen. Many have attempted to replicate pre-interview dinners with meal delivery gift cards or virtual resident speed-dating. One residency even sent a care package with personalized memorabilia from their city. 

Although we have lost the ability to explore our future landing spots during the “golden year” of medical school, there are still many silver linings to consider. Instead of having to coordinate plane rides and lodging, applicants can interview from coast to coast in the comfort of a home setting. For students under financial strain, there are fewer restraints on our ability to consider programs that are farther away. Then there’s the benefit that few will admit—wearing shorts or yoga pants out of view of the camera frame during your interview. 

While this certainly is not how I dreamed my fourth year would go, I nevertheless feel grateful. Leaders in graduate medical education are creatively finding ways to help us make informed decisions about the next step of our training. As we interview with leaders in our respective specialties, we reflect on the rollercoaster journey of medical school and the plethora of lessons learned. In the process of making our rank list, we ask ourselves hard questions about what our priorities are. How do we envision our professional identities and who are the people we want to be around during the formative years of residency training? I look forward to the day when I can be the grey-haired attending who wistfully shares stories of virtually interviewing in the midst of a global pandemic. 

Get your Flu Vaccine

by Catherine Colquitt, MD

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

In the midst of the worst pandemic in over a hundred years, it’s easy to overlook vaccine-preventable seasonal influenza. 

According to the Centers for Disease Control and Prevention, as of December 28, 2020, COVID-19 has already accounted for 336,761 deaths and 19,297,396 cases in the U.S. since its first appearance in early 2020. Tarrant County has reported more than 135,793 confirmed cases (TCPH data) and 1,425 deaths so far (https://covid.cdc.gov.covid-data-tracker). The current percent positivity (percent positive tests/all tests performed) for Tarrant County is a staggering 17 percent (also from CDC COVID Data Tracker).1 

For reference, the 1918 influenza pandemic is reported to have killed 21,000,000 people including 549,000 Americans.2

Our most recent prior pandemic, the influenza experience between April 2009 and April 2010, H1N1pdm09, accounted for 60.8 million U.S. cases, 274,304 hospitalizations, and 12,469 U.S. deaths. H1N1 continues to circulate and is still included in the seasonal flu vaccine. A monovalent vaccination produced in response to the H1N1pdm09 pandemic after this strain emerged in 4/2009 wasn’t distributed widely until 11/2009.3

H1N1pdm09 was unique in causing more severe outcomes in younger persons. Approximately 30 percent of persons over 60 in 2009 were thought to have some immunity to H1N1pdm09 conferred by exposure in the past to another H1N1 strain. 

As we make our way through the 2020-2021 flu season while in the throes of the highly politicized COVID-19 pandemic, how will we fare at vaccinating Americans against seasonal flu, and will flu vaccination rates provide some hint at public acceptance of, or enthusiasm for, COVID-19 vaccines? 

According the CDC’s FluVaxView, during the 2019-2020 flu season, 80.6 percent of healthcare personnel received flu vaccines, with 94.4 percent vaccination in healthcare settings which required it and 69.6 percent in healthcare settings which did not make it mandatory.4

In the U.S., for the 2019-2020 flu season, CDC Influenza data are still preliminary but provide a range in numbers of influenza cases from 39,000,000 to 56,000,000, flu medical visits from 18,000,000 to 26,000,000, flu hospitalizations from 410,000 to 740,000, and flu deaths from 24,000 to 62,000. Even using the highest estimate for flu deaths from last season, COVID-19 deaths have already quadrupled the total number of flu deaths last season (https://www.cdc.gov/flu/about/burden/past-seasons.html).5

However, according to Flu Surv-NET (the Influenza Hospitalization Surveillance Network), the number of influenza-associated hospitalizations from 10/01/2020 to 12/05/2020 only totals 61 in the U.S. thus far (compared with prior seasons this is an unseasonably low number).  There is not yet efficacy data for the 2020-2021 seasonal influenza vaccine because of low case counts so far, but most influenza experts expect a mild flu season due to COVID-19 practices of masking, social distancing, hand sanitization, and cough and sneeze hygiene.

As communities struggle to control the catastrophic consequences of COVID-19, getting our flu vaccines and encouraging all of our eligible patients to do the same demonstrates leadership and concern for the most vulnerable among those we serve. Discussing the flu vaccine with our patients also offers context for discussing the COVID-19 vaccines. 

References

1 https://covid.cdc.gov.covid-data-tracker.

2 Epidemiology and Prevention of Vaccine-Preventable Diseases,
13th Edition, p 187

3 https://www.cdc.gov/flu/pandemic-resources/2009-h1n1- pandemic.html

4 https://www.cdc.gov/flu/fluvaxview/hcp- coverage_1920estimates.html.

5 https://www.cdc.gov/flu/about/burden/past-seasons.html

Getting to Know Angela Self, MD – 2021 TCMS President

by Allison Howard

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

Dr. Angela Self always had an independent spirit. At age 17, fresh out of high school, she left her home in Las Vegas to make a life for herself in New York. As she was growing up, Dr. Self did not dream of becoming a doctor, but she never shied away from an adventure. Looking back, she thinks the decision to pursue Medicine shouldn’t have been such a surprise. When she was 14, Dr. Self volunteered as a candy striper at Southern Nevada Memorial Hospital (now University Hospital), and shortly after she moved to New York, she began working as a dental assistant. “Maybe it was a foreshadowing, but I had never even considered that I would go into Medicine,” says Dr. Self. 

The idea to shift directions came suddenly. One day, after assisting with a procedure, Dr. Self began questioning her path. She was filled with a desire to care for patients directly in a capacity where she could serve as their advocate. Medical school came to her as the obvious answer, but she knew it would be a long, winding path. She did not yet have an undergraduate degree so she approached the decision thoughtfully. “Through a process of prayer, and seeking, and volunteering at my ambulance corps, I really felt a strong leading that I was to go to medical school. Once I knew I was going, there was no question in my mind from that moment.” When she felt confident that this was her future, she quickly began making changes to prepare for the long years of study that lay ahead.

Dr. Self realized that she would need a flexible job to support her education, one that would give her freedom to go to classes during the day. She was also hesitant to step away from the clinical interactions she had with patients as a dental assistant. “I thought, it’s going to be eight years before I can do anything,” remembers Dr. Self.  “Here I had been working as an oral surgical assistant, a dental assistant. I had been in ORs with an oral surgeon and had been able to do hands-on things.” Because of this, as she began attending classes at a local community college and continued to work full time, Dr. Self also received training as an EMT and a paramedic. 

She joined South Orangetown Ambulance Corps in 1987. It was an exciting but hectic time. Dr. Self had three different jobs at that point and picked up extra shifts on the ambulance whenever possible. She worked nights, clocking an average of 60 hours a week while still taking a full load of classes. Despite her long work hours, she was hesitant to slow down. She transferred to Pace University in 1990 and graduated with a BS in Biology in 1992. 

At that point, Dr. Self ran into some barriers. She applied to medical school in New York but ended up being waitlisted. Because of her extreme work hours, she had not been able to maintain a 4.0 GPA. Dr. Self was concerned that this would stop her from going to medical school; it was the first time she began to doubt that she had made the right decision. She considered several alternatives, such as pursuing social work, becoming a pharmacist, or even getting an advanced nursing degree. 

“Dr. Angela Self is an amazing colleague who I have the pleasure to work closely with on many projects. She is compassionate, honest, hardworking, and has everyone’s best interest at heart. I have the utmost confidence that she will represent Tarrant County Medical Society with dignity, compassion, and will be an overall amazing leader.”
Neerja Bhardwaj, MD

Then, a new opportunity arose. “A friend that went to St. George’s in Grenada suggested that I apply there,” says Dr. Self. She knew it would be a big change—Dr. Self hadn’t planned to leave New York for medical school, much less the U.S. Still, she was intrigued. “I had a couple of friends that I really admired that were going to St. George’s,” she shares. They were very positive about the school, so she decided to apply. She was accepted into the program and began classes in 1994. 

Looking back, Dr. Self realizes that she could have applied to other U.S. medical schools, but she has no regrets. Living in Grenada gave her the opportunity to learn hands-on about diseases that are rarely seen in the States, due to Grenada being a developing country. She also gained some wonderful mentors at the school, including Dean of Students Dr. C.V. Rao.  “He taught us, he mentored us, he watched out for us, and remains a friend, I think, to everyone who ever went there.”

While in medical school, she was on call for student emergencies. She also continued picking up shifts as a paramedic whenever she was on breaks. It was difficult to work so much while completing her education, but the benefit of financial security coupled with the valuable patient care experience made it worthwhile. 

Dr. Self moved back to the U.S. in 1996 to complete her clinical rotations, working between New York and Baltimore. She graduated from medical school in 1998 and began an internship in anesthesiology at the Medical College of Virginia in Richmond. Though anesthesia was appealing, she had a passion to care for geriatric and terminal patients, so she believed her future was in oncology. 

At this time, Dr. Self had a big life change—she gave birth to her daughter, Whitney. She took ten months off to care for her young child, until they moved to Texas. At that point, Dr. Self completed her internal medicine residency at St. Paul Hospital in Dallas. It was a difficult time to be going through the intensity of residency.  “It was really hard to go every day because I felt I was robbing my daughter of having a mom,” says Dr. Self. She is grateful to her mother for taking care of Whitney, filling the gap when Dr. Self couldn’t be there.

As she completed her residency, Dr. Self fell in love with primary care. She was also ready to focus on her future. “I needed to commit to motherhood and Medicine, and I felt I could do that by doing internal medicine,” says Dr. Self. When she finished the program, she joined a private practice. Dr. Self worked as an internal medicine physician for 15 years. She was employed at three different clinics throughout that time; at one point, she worked for David Pillow, MD, a well-known pillar of the Tarrant County medical community. “Dr. Pillow taught me that patients will tell you what’s wrong if you just listen,” says Dr. Self. He helped her to avoid developing tunnel vision when treating her patients. “His physical exams were amazing. He taught me so many things that you never learn in medical school.”

Dr. Pillow’s guidance along with an extensive background in emergency care made Dr. Self a strong diagnostician. She was quickly able to discover the root of a problem, especially when critical treatment was required. Twice, she was able to get patients immediate care when they came to appointments mid-heart attack, even though their symptoms were irregular. Because she wanted to serve older patients, whenever she joined a new clinic, the Medicare patients were sent her way. “I got the ones with heart failure, liver disease, lung disease, and cancer, and then I got involved with hospice. That fulfilled that longing in me to work with end-stage patients. I did get to do what I wanted after all.”

Still, there was a downside to private practice; it was difficult to manage financially. “Medicare didn’t pay that much, and geriatric patients take a lot more resources, need a lot more time, so you see fewer in a day and reimbursement is lower, but it was what I was passionate about so I did it as long as I could.”

Eventually, Dr. Self made the move to working in administrative medicine. She has been on the other side of care for about five years now; currently, she is working for an accountable care organization. Though she misses taking care of patients, there are many advantages to her current role. “I can advocate for more people in an administrative role than in a primary care practice, where I might have one to two thousand charts, so I can affect one to two thousand lives in practice,” shares Dr. Self. “Now I can affect many more lives.” One of her focuses is improving the patient experience in post-acute settings.

While the change may seem dramatic, Dr. Self has been involved in organized medicine her whole career and has seen the impact of physicians advocating for their profession. She has been a longtime member of TCMS. In the early 2000s, she helped to review cases for the Public Grievance Committee. Dr. Self became more involved during the 2014 Ebola crisis. She was impressed by the way TCMS, TMA, and the AMA worked together to protect patients and physicians, and she knew that was something she wanted to be a part of. “Ever since then, I’ve made attending TCMS’s monthly board meetings part of my job negotiations!” 

Dr. Self Is an active member of the TCMS Board of Advisors and the Women in Medicine Committee; she also attends TMA and TCMS meetings whenever possible. “(TCMS board member) Gary Floyd says, ‘Good doctors take care of their patients. Great doctors take care of their patients and their profession,’” says Dr. Self. “Being part of organized medicine is helping to take care of your profession. When doctors go down to Austin and speak with lawmakers in their white coats, it changes the way that we are viewed.”

Her fellow physicians look forward to seeing her in this new role as president. “Dr. Angela Self is an amazing colleague who I have the pleasure to work closely with on many projects. She is compassionate, honest, hardworking, and has everyone’s best interest at heart,” says Neerja Bhardwaj, MD, a palliative care physician practicing in Dallas. “I have the utmost confidence that she will represent Tarrant County Medical Society with dignity, compassion, and will be an overall amazing leader.”

In the next year, Dr. Self hopes to grow physician membership and participation in the Medical Society. She believes in the power of banding together to give doctors a voice for their profession and their patients. She also wants to serve as a resource, particularly for independent physicians who are struggling with the fallout from COVID-19. She thinks providing opportunities to connect with other physicians is an important part of this support. “Talking with other doctors who have experienced the same things helps,” shares Dr. Self.  “I’ve been there.” All of this ultimately comes together for one purpose: to serve patients excellently and effectively. 

When advising those who are considering going into Medicine, Dr. Self encourages getting as much exposure as possible before taking the leap. “Make sure you have fully answered the ‘why’ for medical school,” says Dr. Self. “Make sure it is something you are passionate about.” Shadow a physician, work as a scribe—whatever it takes to make sure you have found your calling in life. It isn’t an easy path, but it can be incredibly rewarding. “There is nothing else I would rather do.”

When Dr. Self is not working or attending meetings, you might find her volunteering at the Cornerstone Assistance Network. Even though she doesn’t currently practice in a clinic, Dr. Self still enjoys getting to treat patients, especially those who are struggling to access care. In her free time, Dr. Self loves traveling and going to live concerts. Last year she was able to attend the Eric Clapton Guitar Festival. “It was amazing and made me realize that I love the Blues. I didn’t know I loved the genre before that!” A highlight of her trips is always searching for the best lattes in hole-in-the-wall cafés. Dr. Self loves coffee—she even runs a blog to talk about her caffeinated discoveries (you can read some of her stories at coffeebyangela.com). 

She enjoys going on these trips (when there isn’t a pandemic!) with friends and family. Dr. Self has the most fun when her daughter can come along, but Whitney is pretty busy these days. She is currently working on completing her undergraduate degree with the goal of applying to medical school in the near future. 

We are excited to support Dr. Self as she prepares to lead us as we serve the citizens of Tarrant County and the community of Medicine.

The Dead Horse of 2020 (No, not the Election)

By Angela Self, MD – TCMS President

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

Though I vowed not to touch the pandemic as a topic, it seems to be the one thing that’s on my mind. Still crazy after all these months.

I was in Florida when I saw President Trump come on television and announce that we were facing some big changes due to the coronavirus. What I remember most was that his face was white as a sheet and his voice, uncharacteristically, had no dramatic intonation. The serious look on his face and the coming lockdowns scared me much more than the thought of running out of toilet paper. I knew we were headed for a major disaster in this country and it hit me in the gut, hard. I cried easily and often for the next two weeks. I mourned the loss of my country. I knew that many would die, that we would be divided over the handling of the pandemic, and that the pandemic would be highly politicized. I kept changing the channel that March day in 2020. Forgetting Sarah Marshall was needed, and fast. It was an election year and we were already dealing with the polarity of being either a Democrat or a Republican, and now we would be divided over COVID-19 controversy. Let me just say that I have never, ever wanted to get sick from anyone in any public place who was coughing and spewing infectious particles. Masking is about the best idea I’ve ever heard of; I think it’s a great way to decrease disease spread during every cold and flu season, as well as in a pandemic. I once missed Thanksgiving with my family after my sister called and said, “We’re going, but John is sick and he’s running a fever.” I took the next exit off of I-35, turned around, and spent Thanksgiving home alone. It was worth it. 

This past January I was speaking with a girlfriend who was getting over a pretty bad upper respiratory infection. She wasn’t sneezing or coughing, but as we talked a little spit droplet flew out of her mouth and into my eye. When that happens, and it does, I just say, “Whatever they’ve got, you’ve got it now.” I do not get that close, or face to face, to this friend anymore. Some people have to spray it when they say it, and COVID-19 is the last thing you want to have sprayed in your face. Looking back over this year I remember a few of my friends had severe upper respiratory infections. Was it COVID-19? Maybe. It seems like years ago that it was okay to cough or sneeze in public, but not now, and it’s just been a little over nine months. Now when a dust particle brings on an unexpected sneeze, the next thing you hear is, “It’s just allergies, I’m not sick!” I agree with stringent infection control measures in public places. I am saddened, however, by businesses closing, millions losing their jobs, nursing homes not allowing any visitors in a safe, distanced way (meaning little accountability and possibly increased neglect), and healthcare professionals using their credentials to further polarize an already confused society.

“Masking is about the best idea I’ve ever heard of; I think it’s a great way to decrease disease spread during every cold and flu season, as well as in a pandemic.”

So what do we do? How do we move forward? I have a friend who lost his wife to COVID-19 months ago (she was an ER nurse in New Jersey), and I have another good friend who just recovered from COVID-19 pneumonia. This virus is still a public threat. People are still dying. Treatments are helping many, but like the flu and other diseases, there is not a cure. A vaccine will not be 100 percent preventive. It’s the best we’ll be able to do, but it won’t be 100 percent. Do we allow our economy to collapse or do we get back to work in a safe and smart way? It’s easy for those of us who can go to work to say, “Stay home,” as we are able to provide for our families. During this pandemic, I went to a certain coffee shop every day and sat at a table outside with my cousin (it was the only contact that the both of us had with another person during the early days of the pandemic). We would see other coffee friends pull up and have their orders delivered to their car. We watched the mask requirement come in and we complied; we still do. The thing that we mostly did was sit there every morning and act normal while supporting a struggling local business. We were socializing over coffee in a safe manner. If I had to cough (allergies) I would get up and walk around the side of the building. In the spring, if the group ever grew to over the allowed number, someone would leave and let another sit and visit. Our coffee shop owners had to lay off twenty employees and close their shop in Southlake. One of the negative consequences, besides death from illness and job loss, is depression that has been made worse due to social isolation. Though many of us feel we can safely get our groceries, have our coffee, and take care of business, as long as the protective measures are being used, there are still many who are very afraid. That fear has likely served the most vulnerable well, as they’ve had limited exposure to COVID-19, but it has cost others their lives due to depression and suicide. It has cost some child abuse victims their lives, with school being a safe place where they could escape the abuse for at least a few hours. I am grateful that Texas has allowed businesses to reopen and let our citizens get back to work and their kids back to school. This pandemic is not over yet, but hopefully, much of the devastation is behind us as we learn more about this virus and how to best treat it.

 The way I would like to see us move forward is with safety protocols and measures in place, while returning to our livelihoods with moms and dads able to pay the mortgage, keep the lights on, and feed their kids. Talk about “social determinants of health”; can we even measure the food insecurity that’s out there when we’ve taken a meal away from a kid who might not get any meals at home? Let’s move ahead with disease prevention. How many mammograms and colonoscopies were not done this year, leaving cancer undiagnosed and untreated? I’ve seen some “quality” scores and there are many “gaps” that weren’t closed in 2020. The thing about open gaps is that you just don’t know which gap closures would’ve caught a disease process in its early stages.

I wanted to start off the year with an article about avoidable hospitalizations from UTIs gone wild or how medical directors are people too, but instead, I have broken my own rule about avoiding controversy. If you’re a little confused on where I stand on COVID-19, here are my thoughts: 1) respect your fellow man by wearing a mask and keeping a safe distance; 2) consider if you might be putting a high risk person at increased risk (self-quarantine if you’ve been exposed); 3) be kind to each other as many are struggling with the loss of friends, family, personal health, or their job; 4) exercise your rights and freedoms in a safe manner; 5) the virus is very real and very deadly (to some even previously healthy people); and 6) take the vaccine if you get the opportunity—it’s the best we can do to turn the tide on this pandemic. Blessings, and I look forward to an America without COVID-19.

(Re)Building a Culture of Communication in a Changing World

by Stuart Pickell, MD, MDiv, FACP, FAAP

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

How we communicate with patients has changed a lot over the years.  Millennia ago, having little to offer by way of effective medical intervention, healers relied on therapeutic relationships.  What healing occurred was largely due to the relationship itself.  Priests, shamans, witch doctors, medicine men, and the like were important threads in the social fabric of their communities.  Caring for both spiritual and physical needs, they functioned in roles that we recognize today as clergy and physician.

In the second millennia, and especially after the Enlightenment, these twin traditions of healing began to unwind.  As scientific knowledge in general, and medical knowledge in particular, became increasingly robust, the role of the physical healer became distinct from that of the spiritual healer.  

“The Doctor” by Luke Fildes (1891)

While the physician’s library of remedial options increased, it remained limited until the 20th century.  Instead, relationships and trust continued to be the bedrock of the therapeutic encounter.  “Being there”—itself a form of communication—was as important as the intervention.  A beautiful illustration of this is Luke Fildes’ 1891 painting, “The Doctor,” depicting a physician sitting at the bedside of an ill child, the concerned parents in the peripheral shadows.  The physician appears to be doing nothing but sitting there looking concerned, but that’s the point.  “Being there” is doing something and speaks volumes to the parents who simply want to know that someone cares enough to exercise everything in their power, limited as it may be, to effect a cure.

With the Information Age came a breakneck pace of scientific innovation.  In 1900 the definitive textbook of internal medicine was Osler’s The Principles and Practice of Medicine.  It had one author: Sir William Osler.  But by the 1950s the expansion of medical knowledge required that the definitive textbook—the first edition of Harrison’s Principles of Internal Medicine (1951)—had 53 authors.1 The era of specialization had arrived.

Along with it came a gradual dissolution of the longitudinal and relational nature of patient-physician encounters.  Increased specialization meant we could do more to effect a cure, but the more we could do, the more distant physicians became from their patients.  

I trace the origin of this—because it works as a metaphor on multiple levels—to French physician René Laennec’s invention of the stethoscope in 1816.  One day he observed schoolchildren scratching the end of a hollow stick to hear the amplified sound at the other end.  He applied this acoustic principle to solve a problem he was facing regarding the examination of a patient.  As Laennec put it, he had been

“consulted by a young woman laboring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness”2

Given her age (young) and gender (female), direct auscultation was not an acceptable option anyway, so recalling the children’s game he rolled up a piece of paper and listened to her heart.  The stethoscope was born, a technological innovation had occurred, and the physician took the first step away from the patient.  

As medical specialization grew so did that distance.  Now we don’t even need to be on the same continent.  Physicians, as masters of applied science, assumed the role of the expert who diagnosed a condition and recommended a course of action to a patient. The patient then largely deferred to the physician’s judgment and expertise, reinforcing the benevolent paternalism that had been implicit in patient-physician encounters for generations, only now it had a name.  

Popular culture was replete with examples of benevolent paternalism, perhaps best embodied by actor Robert Young who played the lead role in both Father Knows Best (1954-1960) and Marcus Welby, MD (1969-1976).  His character was similar in both series.  He was the trusted expert, and those in his charge did what he told them to do.  

Or did they?  Patients actually doing what they are advised to do is every bit as important as the advice itself.  We came to realize what the priests, shamans, witch doctors, and medicine men knew millennia ago: personal relationships built on a foundation of trust and effective communication are important.  If the primary endpoint is healing the patient, we must be able to communicate the pathway that gets them there, which means we must understand and help them navigate around the roadblocks they will encounter along the way.  These could be social, cultural, linguistic, ethnic, racial, intellectual, and/or economic, to name a few.  Dr. Welby may have arrived at the correct diagnosis and recommended an appropriate evidence-based course of treatment, but what good is that if the patient won’t—or can’t—follow through with it?

Twenty-five years ago, the correlation between effective physician-patient communication and improved health outcomes was already obvious.3  The body of evidence has only grown, demonstrating that providers who are good communicators obtain more complete information, arrive at more accurate diagnoses, and facilitate more appropriate counseling, all of which increase the likelihood that patients will adhere to the plan.4  And if that doesn’t get our attention, good communication has also been shown to reduce the likelihood of a lawsuit.5

Locally, the importance of effective communication has been underscored by the creation of a dean level position at the UNTHSC-TCU School of Medicine, the highest position ever dedicated to this important aspect of patient health at an American medical school.  We should be proud that this occurred in our county, but it’s just a beginning.  There are many layers to this onion, and it will take more than an emphasis at a medical school to peel it.  For those of us who are already in practice—many for decades—we are learning to communicate in new ways.  A year ago, telemedicine consults were not on my radar at all.  Now I have several every day.  These newer forms of communication and patient interaction, coupled with a better understanding of what effective communication actually is, introduce additional challenges to the patient-provider relationship.

Recognizing the timeliness and rapid evolution of this topic, Healthcare in a Civil Society, the annual CME hosted by TCMS’s Ethics Consortium, will dedicate its 2021 symposium to effective patient communication.  As the era of shared decision-making has moved forward, so has our need to communicate with our patients in meaningful and relevant ways.  This program will explore how communication between providers and their patients has changed, and the ethical implications this change has had in a variety of areas.  

AMA President, Dr. Sue Bailey, will keynote this Zoom event which has been generously supported by UNTHSC and the Cook Children’s Medical Center Foundation.  The Hon. Pete Geren will moderate an expert panel who will address topics such as:

  • Shared Decision-Making – How can we know that a medical decision is truly “shared” and the consent obtained truly “informed”?
  • Truth-Telling and Apology – How do we communicate with patients about difficult topics, especially when something goes wrong, or we make a mistake that results in patient harm?
  • High-Stress Conversations – How does our communication with patients change when providers are in a high-stress situation, and how can providers self-regulate and/or de-escalate a contentious conversation?    
  • Patient Communication (in general) – What can we all do that will engage patients and foster relationships in which information can be shared in a meaningful way?

The event includes a breakout session to allow participants to explore the topic more deeply in small groups.

Effective patient communication has come a long way in recent years, but we have a long way still to go.  All are welcome to join us for this informative and interactive session. You can view a flyer with registration information here.

Sir William Osler (1849-1919)


References

1The exponential growth of medical knowledge can be illustrated by tracking the number of authors for the definitive textbooks.  As noted, by 1951 Harrison’s Principle of Internal Medicine had 53 authors.  By the time I was in medical school it had 273 authors.  Today  it has over 600.  Plot it on a curve.  It’s exponential.  

2From René Laennec’s De l’Auscultation Médiate, quoted in Laënnec and the Stethoscope. JAMA. 2019;322(5):472. doi:10.1001/jama.2018.15451

 Stewart MA.  Effective Physician-patient Communication and Health Outcomes: A Review.  Canadian Medical Association Journal.  1995; 152(9):1423-1433.

3Effective patient–physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:389–93.

4Virshup BB, Oppenberg AA, Coleman MM. Strategic Risk Management: Reducing Malpractice Claims Through More Effective Patient-Doctor Communication. American Journal of Medical Quality. 1999;14(4):153-159.

“Thank You”

by Teresa Godbey, MD
2020 Gold-Headed Cane Recipient

This piece was originally published in the November/December issue of the Tarrant County Physician. You can read find the full magazine here.

Let me start and finish by saying “thank you.” Receiving the Gold-Headed Cane is a humbling experience for me, because I am not really a scientist, nor procedurally gifted, not an expert in any particular field of Medicine, have never published a scholarly article, and am not even currently on the front line of the SARS-CoV-2 pandemic. It’s been several years since I got out of bed to come to the hospital in the middle of the night, and even then it was often to call in the person who would do the procedure or make the decision that would be critical for our patients. 

With a B.A. in English literature and a lot of courses in languages, I came late to the realization that I needed to apply to medical school. And I would not have done so had I not had a mother who was willing to keep an infant son so I could start all those math and science prerequisites, and a father who’d made it possible for her to be a stay-at-home mother and grandmother. So thanks to my wonderful parents. This decision to go into Medicine seemed to some like an abrupt change of pursuit, but for me, the unifying theme between my undergraduate studies and the practice of Medicine has been the privilege of learning people’s stories.  In practicing Medicine, one can even help to bring about a plot twist or be a minor character in the story . . . but to hear what came before from disparate walks of life, then facilitate the ability of the patient to make their story unfold has been my motivation. 

Some of those stories still make me smile years later.  The patient who volunteered to run a small cemetery in a tiny town was at the cemetery when the grave for her mother, who had died at 103, was freshly dug. She met a young couple visiting in search of ancestral lore. In the process of helping them find a headstone of interest, she managed to back up and fall into her mother’s grave, sustaining a tib-fib fracture. Somehow, she managed to laugh at and see the mythic overtones of that painful experience.  So many patients have shared their triumphs in life with me, with luck as well as gumption helping us all along the way. Sometimes luck is better than gumption. There was the decision to call a surgeon to see a middle-aged man, to remove a large obstructive right colon mass even though this mass, surely a malignancy, must have metastasized given its dimensions.  The surgery was going to be diagnostic and palliative but proved curative when a plastic cocktail sword was found at the center of a large inflammatory mass. 

Then there are the gut-wrenching stories of loss and the staggering abilities of some people to keep putting one foot in front of the other . . . the woman who witnessed one of her sons shoot and kill another. How she managed to grieve the loss of one of her boys, while still being a mother to the one who went to prison astounds me to this day.  I can only hope that allowing her to relate this to me was in some way beneficial to her, but her strength and grace were such that I’m not sure I was needed.

It can be discouraging now to practice in an environment of corporate intrusion, such as to be told on which shelf the lubricant must be kept in the exam room, or to be coached to attest to diagnoses based on flimsy or inaccurate data. There are those of you who are gifted with a scalpel, a scope, a cath; those who can calm the chaos of the ER for a quiet moment to see a diagnosis coalesce.  I suspect those abilities make it easier to keep a sense of purpose, so for those of us who are PCPs, let this be my plea. Hear the patient. Hear their story. See them. Feel them. There are times that I hear from a patient, “That doctor just came to the door, and never even examined me.” So yes, I know that current guidelines put ever less emphasis on certain parts of the physical exam, but please, keep honing your skills. The time spent on physical exam may not all be of value statistically. But when the unnecessary oral exam or rectal exam turns up a cancer, it changes your story as well as the patient’s. Plus, the patient who gets a rectal exam won’t tell someone else that you just came to the door. For those of us in primary care, using our senses is the only way we can, so to speak, change the ending. 

And now, a few more people to thank: Dr. Stephen Eppstein, for driving from Fort Worth to Dallas on the one day of the week he could have relaxed a little, to be the town attending for my Internal Medicine rotation in 1984 . The town attending is the one you can ask the questions you might be embarrassed to ask your regular attending, like: Why aren’t there viral UTIs when there’s viral everything else?  Dr. Kendra Belfi, the first female internist I really got to know, and who took such good care of my mother and my aunt.  All the wonderful doctors in the Texas Club of Internists with whom I’ve enjoyed education and recreation over the years: thanks for waiting until the old guard died off so you could finally change the bylaws and let women in—in 1997. My son, Noah Boydston, for turning out mostly OK, and loving me even though I was away so much when he was little.  Oh, and if you have to wait until age 48 to meet the love of your life, Leighton Clark was worth the wait. Thank you all. 

The Doctor’s Doctor

Gold-Headed Cane Award Recipient Teresa Godbey, MD

By Allison Howard

This piece was originally published in the November/December issue of the Tarrant County Physician. You can read find the full magazine here.

If Teresa Godbey, MD, has one piece of advice for physicians early in their careers, it is to develop relationships with their colleagues. “Find at least one group where you want to go to meetings. You need other people. It’s fine to read and educate yourself on your own, but you need at least one regularly attended organized group.” 

Dr. Godbey, TCMS’ 2020 Gold-Headed Cane Award recipient, is speaking from experience. In October, she retired after 33 years of practicing Internal Medicine in Fort Worth. Throughout her career, she has been a member of the Texas Club of Internists, the Texas Medical Association, and the Tarrant County Medical Society. “I don’t know what I would do without them.”

Though Dr. Godbey has long been involved in the medical community, becoming a physician was not her original plan. She got her undergraduate degree in English, but when she finished college, Dr. Godbey was unsure of her future career. She worked at Xerox for a year but soon realized that she wanted to go a completely different direction. Dr. Godbey was a new mother at the time, and she wanted stability and independence—and to do something that she loved. When she realized her interest and abilities converged at Medicine, she started down that path and never looked back. She began attending classes at UTA to get the necessary prerequisites to apply to medical school.

While the decision was sudden, the inspiration was not. Many people from her past influenced Dr. Godbey—from her beloved childhood pediatrician, Dr. Frank Cohen, to a favorite high school teacher, Valda “Frau C.” Carroll, who suffered from multiple sclerosis—these important individuals planted seeds that would impact her future. When the opportunity arose for Dr. Godbey to go back to school, her vision was clear: she was going to become a physician.

“Dr. Godbey has always been the type of physician I aspire to be myself.  She has remained passionate about and fiercely committed to her patients, even in these times of increasingly heavy burden of clerical activities which constantly seek to burn us out and pull us away from the joy of direct patient care.”

Not everyone shared her enthusiasm. Between her young son and her English degree, Dr. Godbey’s academic counselor did not think she was a serious candidate for medical school. Dr. Godbey was told that she had to make A’s in all of her classes. “Thankfully, I was very confident then!” laughs Dr. Godbey. “That didn’t worry me.” No, she was not concerned about her math or science classes—it was PE that made her nervous. “PE was the class that really scared me. I intentionally got my undergraduate degree at a college that didn’t require it, but UTA was making me take PE. The only thing that would fit between the math and science courses and labs was racquetball. Racquetball!” Dr. Godbey remembers in dismay. Though racquetball was not her strong suit, her coach was fortunately more focused on dedication than ability. She completed all of her classes—even racquetball—with excellent grades and was accepted into medical school at UT Southwestern in 1980.

Dr. Godbey emphasizes that she did not go on this journey alone; she believes she never would have become a physician without the support of her mother. “She watched my son, Noah, for me. She loved it and made it possible for me to go back to school,” says Dr. Godbey. “I never could have done this without her.” 

Once in medical school, Dr. Godbey began to consider the different specialties she could pursue. Everything came into focus during the beginning of her third-year rotations when she realized that she wanted to practice Internal Medicine. Dr. Godbey was originally considering a career as an OB/GYN, but when she recognized her love of interactions with patients during her medicine rotation and saw the appeal of building decades-spanning relationships with her patients, she shifted her focus, deciding to apply for a residency in Internal Medicine. She was accepted into Parkland Hospital’s residency program in 1984 and was hired by Internal Medicine Associates in 1987. She stayed with the group through mergers and acquisitions her entire career.

During her years in practice, Dr. Godbey developed the longstanding relationships she had hoped for with many of her patients. “My patients have aged with me for the most part,” she says. She also enjoyed the fact that primary care treats an expansive range of healthcare needs. While numerous patients and cases were significant throughout her career, one success comes to mind as a win she will never forget. A woman diagnosed with hyperemesis gravidarum had been sick in the hospital for weeks. She had been put on IVs and TPN, but as time went on, her condition continued to deteriorate. Numerous physicians had seen her, but they could not determine the root of the problem. When Dr. Godbey was called in, she looked at the chart and immediately saw something concerning. “I remembered Dr. Leonard Madison talking about beriberi when I was in medical school, which is thiamin deficiency. It was just there, on her chart. No thiamin.” At that time, there was a shortage of thiamin nationally, so it was not included in TPN. Since patients were generally not on TPN for an extended period of time it was not an issue, but because this woman had been using it for weeks, the deficiency was causing her significant distress. They quickly added an additional thiamin supplement to her IV, and within a day she had recovered and was on her way home. As much as it was an exciting experience for Dr. Godbey, she defers the credit to her medical school professor: “She got better thanks to Dr. Madison and his lecture on beriberi!” 

“I don’t know of any doctor who deserves this award more. She is the most caring doctor I have ever known, always putting her patients’ needs and well-being above all else.”

Dr. Godbey’s colleagues emphasize that it is her complete dedication to patient care that characterizes her as a physician. Jennifer Arnouville, MD, says, “Dr. Godbey has always been the type of physician I aspire to be myself.  She has remained passionate about and fiercely committed to her patients, even in these times of increasingly heavy burden of clerical activities which constantly seek to burn us out and pull us away from the joy of direct patient care.”

Over the years, Dr. Godbey certainly saw the practice of Medicine change, much as her own practice developed. What was once a group of seven or eight physicians has grown into what is now USMD, which is part of the even larger OptumCare. Though there were many adjustments, some things stayed the same. Ed Nelson, MD, one of the physicians who hired Dr. Godbey 33 years ago, continued with the practice alongside her. Dr. Nelson, Lee Forshay, MD, and Tom Davis, MD, were the partners at Internal Medicine Associates when Dr. Godbey joined the practice. She is grateful to have had the opportunity to work with these physicians; they helped shape who she is as a physician and her approach to patient care. 

Reflecting back on when Dr. Godbey was hired, Dr. Nelson says the group could not have made a better choice. “What we couldn’t know then is what a great doctor she would be for the next 33 years. She and I have been associates, colleagues, and friends that whole time. I don’t know of any doctor who deserves this award more. She is the most caring doctor I have ever known, always putting her patients’ needs and well-being above all else.”

A number of physicians have supported Dr. Godbey throughout her career, including Stephen Eppstein, MD, and Roger Eppstein, MD; this father and son pair impacted Dr. Godbey in different but significant ways. Dr. Stephen Eppstein was her town attending in medical school, the person she could go to if she ever had a question or needed direction. “He was the safe one to ask for help,” she shares. He was also the one who directed her to Internal Medicine Associates. Dr. Roger Eppstein was one of her longtime partners at USMD. Dr. Nelson and Dr. Roger Eppstein were in her “pod” at the clinic and were often the physicians Dr. Godbey turned to for advice on difficult cases and to discuss new regulations or the state of Medicine. Even though she was in a large practice, the longstanding relationships she developed over time helped her overcome the isolation that can be a struggle in corporate medicine.

As she mentioned in her message to young physicians, Dr. Godbey believes that participating in organized medicine is an important part of connecting with fellow doctors and staying up to date on changes in the profession. “It’s a critical way to build relationships and meet people that can support you in your career that you can also support,” says Dr. Godbey. “I always know that TMA and TCMS are there for me—I would feel completely out of touch if I didn’t have the bulletins from TMA and Tarrant County Medical Society. New rules, new regulations, what’s happening currently with the pandemic. They keep me informed.”

Organized medicine also provides leadership opportunities and chances to break barriers, as Dr. Godbey experienced firsthand. When she was first considered for membership by the Texas Club of Internists, they required a 100 percent vote to add new members; because of this, a number of Internists, including minorities and females, were not accepted. Finally, in 1997, the Club amended their bylaws to fight these exclusionary practices. Dr. Godbey was the first female physician to attend a Club meeting, become a regular participant of the group, and ultimately, become the president; she served in that role in 2014. “It was amazing to see the how things changed—they barely let me in, and not 20 years later I was their president,” shares Dr. Godbey. She has seen other positive shifts over the years, such as rising numbers of female medical students. “It was 20 percent women when I went to medical school—now it is over 50 percent.” 

While encouraged by the developments she has seen, Dr. Godbey believes that it is critical to continue advocating for minority and female physicians and any other groups that are not given full access to opportunities. Not just because doing so is best for individuals—it is also best for the practice of Medicine.  

While advocacy and involvement are important, Dr. Godbey cautions young physicians to maintain work/life balance. Overall, she is encouraged by what she sees. “Younger doctors are better at prioritizing their homelife than we used to be,” she admits. “Don’t let go of that balance. Keep your interests outside of Medicine—reading, gardening, exercise. Whatever it is, it helps you keep your purpose in focus.”

When she in not busy Dr. Godbey enjoys hiking, cooking, and reading. Most of all, she loves to spend time with her family, including her husband, Leighton Clark, and their children. They have a blended family, which has added many blessings to Dr. Godbey’s life. “I had one son and I ended up with two sons and three daughters,” she shares. Between the two of them they have Noah, Philip, and Meredith; daughters-in-law Ashley and Mary; and granddaughters Marianne, Elinor, and Prudence. Dr. Godbey also shares a close relationship with her sister, Susan Pantle. Whenever possible, she and Leighton enjoy spending time with Susan and her husband, Mark. 

Some things have come full circle; now that she is retired, Dr. Godbey and her husband will help watch their youngest grandchild, much as Dr. Godbey’s mother took care of Noah all those years ago when she was in medical school. “I’m excited to have the chance to give back,” says Dr. Godbey. “And to get to spend more time with Prue. I love taking care of my granddaughters.” 

Dr. Godbey’s colleagues view her career as one hallmarked by commitment to her patients; her passion for excellence and empathy in providing care is something well known throughout Tarrant County’s medical community. “Dr. Godbey has been a role-model and mentor for me throughout the years that I’ve been in practice,” says Dr. Roger Eppstein. “Always a ‘doctor’s doctor,’ she has practiced evidence-based, compassionate Medicine throughout her career.  It is no wonder why her patients have been so loyal to her.  She has been practicing thoughtful ‘value-based medicine’ even before anyone coined this term.”

In acknowledgment of Dr. Godbey’s outstanding career, the Tarrant County Medical Society is proud to congratulate her as the 2020 Gold-Headed Cane Award recipient.

President’s Paragraph – “Reflections”

by Tilden Childs, MD – TCMS President

This piece was originally published in the November/December issue of the Tarrant County Physician. You can read find the full magazine here.

by Tilden Childs, MD – TCMS President

This is my last article as president, and as I think upon the past year, my mind drifts to reflections upon my life, my family, my friends, my associates, my teachers, and my profession—especially to the many patients for whom I have worked and strived for excellence in care over the last four decades. The seasons of life pass before our eyes in slow motion, but when the fall of our life arrives, we wonder how it all went so fast. I am thankful for the time that I have had on this earth and for the exposure to the many various facets of our world, both directly and vicariously, and particularly in what I consider to be the most intense and rewarding profession, the practice of Medicine. It is a privilege, indeed a calling, to be part of this greatest of professions.  Thank you for the opportunity to serve as your TCMS president this year.

One of the interesting and entertaining friends who appeared ever so briefly in my life is Dr. Charles D. Williams. Charlie is a radiologist in Tallahassee, Florida. I met him through my participation at the American College of Radiology on the AMA Delegation. Charlie was awarded the ACR Gold Medal a couple of years ago. He wrote two books called Simpler Times (1993) and More Simpler Times (2008), where he reflected on his life growing up in Moultrie, Georgia, as the son of a Colquitt County sharecropper during the 1940s, “during the time when life was less complicated—the time when people had to make over, make do, or do without.” Believing that laughter is the best medicine, Dr. Williams’ books are collections of stories written through the eyes and innocence of a young boy nicknamed Pedro at birth by his grandmother. The short stories reflect on the wisdom and humor of his grandma and her three boys—Millard, Dillard, and Willard. As he states in the introduction to his second book, “we need to understand and appreciate where we came from so that we can recognize where we are.” Or as his grandma used to say, “The main thang is to keep the main thang the main thang.” Charlie is a dear friend!

“The seasons of life pass before our eyes in slow motion, but when the fall of our life arrives, we wonder how it all went so fast.”

In my own life, when summer comes to an end and the fall begins, I always reflect on my time at the former boys’ camp in Hays County known as Friday Mountain Boys Camp. I first went there in the early 1960s when I was eleven years old after failed strenuous resistance to my parents unwavering determination to deliver me to the hands of unknown strangers in a foreign land. But what a magical place it was! I went there for four summers as a camper, two summers as kitchen help, and a total of six summers as a counselor during college and medical school. The daily routines and weekend programs offered at the camp seem remarkable now. In one place, a kid could learn about nature (I tried hard to learn to like snakes), horseback riding, swimming, scuba diving, and handicrafts. They had various opportunities to learn and participate in sports in a relatively non-competitive and friendly environment, as well as learn how to safely handle and shoot a rifle and throw horseshoes. Hiking over the several hundred acres of the camp, and particularly up and down Friday Mountain, gave everyone a wonderful exposure to nature and an appreciation of the land. There was even an educational day trip into town to see parts of Austin (it was my one and only time to go to the top of the UT Tower), and a three-day overnight trip to Lake Travis with swimming, water skiing, and sailing. As a counselor, I had the opportunity to learn and then teach sailing on Lake Travis. Yes, I got paid to go swimming and sailing on Lake Travis! And many kids and a few of us young adults learned some of life’s lessons as well as a number of Baptist hymns.  Sunday morning services on the wooded, shaded banks of Bear Creek were special. 

But as is true of life in general, times have changed, and the former camp is now the oldest Hindu Temple in Texas and the largest in North America, Radha Madhav Dham (formerly called Barsana Dham). For an interesting and insightful reflection on the history of the camp and its subsequent transformation, I refer you to the article by David Gaines in The Wall Street Journal issue dated September 12, 2020, entitled “I Climbed Up Friday Mountain and Down Barsana Hill.” Some of us former campers and counselors still remember the way it was and are sad that it is no longer, but in some small way, this article helps to provide me with at least a measure of closure. To quote the final sentence of the article, “Land uses change, but the land abides. And the characters just keep rolling through.” 

How true, how true! And that is one of the things I have come to realize about life in general—“the characters just keep rolling through.”

And finally, whatever your belief, I hope that you can appreciate what my friend Dr. Doug Cecil has shared, as gleaned from an old benediction from a circa 1850 Anglican Prayer Book:

Now go into the world in peace,
Have courage,
Hold on to what is good.
Honor all men,
Strengthen the fainthearted,
Support the weak,
Help the suffering,
And share the Gospel.
Love and serve the Lord in the power of the Holy Spirit.

You Play the Way You Practice: Training Up the Healthcare Team

By David Farmer, PhD, LPC, LMFT, FNAP

This piece was originally published in the November/December issue of the Tarrant County Physician. You can read find the full magazine here.


This article was sponsored TCMS Publication Committee member Monte Troutman, DO.

In a recent Wednesday afternoon, first year Texas College of Osteopathic Medicine (TCOM) medical students met for the first time with interprofessional student colleagues encompassing eleven health professions. Sequestered at home due to the COVID-19 pandemic, students meet in a ZOOM virtual meeting room. Together they participate in a modified version of the reality show “What Would You Do,” identifying and correcting disrespectful communication and behavior to foster value and respect among interprofessional teammates. Students from Medicine, Pharmacy, Physician Assistant, Physical Therapy, Public Health and Health Administration, Nursing, Social Work, Speech Language Pathology, Athletic Training, and Dietetics from the University of North Texas Health Science Center (UNTHSC), TCU, Texas Woman’s University, Texas Wesleyan, and The University of Texas Arlington, practiced competency development in interprofessional teaming to  improve patient and population health outcomes. 

Had it not been for social distancing in response to COVID-19, these students would be meeting in person, in small interprofessional teams on the UNTHSC campus in Fort Worth. These interprofessional student workshops are part of a national initiative to integrate interprofessional education (IPE) into each health profession’s curriculum. IPE is the collaboration among students from two or more healthcare professions to promote teamwork and improve outcomes.1

The purpose of IPE is to prepare health profession students for interprofessional practice by teaching collaborative practice competencies within the context of interprofessional teams. What are those competencies? In 2009, six national education associations of schools of health professions: The American Association of Colleges of Osteopathic Medicine, The American Association of Medical Colleges (AAMC), The American Association of Colleges of Nurses, The American Association of Colleges of Pharmacy, The American Dental Education Association, and The Schools and Programs of Public Health, formed the Interprofessional Education Collaborative (IPEC) to promote IPE. The IPEC released a report of an expert panel in 2011 recommending four core interprofessional collaborative practice competency domains be integrated into health profession education: Values and Ethics for Interprofessional Practice; Interprofessional Practice Roles and Responsibilities; Interprofessional Communication and Teams; and Teamwork for Interprofessional Collaboration.2 IPEC now includes twenty-one national associations. 

At TCOM, the knowledge, skills, and attitudes necessary for effective collaborative practice are being integrated into both the preclinical and clinical years of training in a variety of contexts. 

Integration of these core IPE competencies has been woven into the accreditation standards of the health professions. For Osteopathic Medicine, the American Osteopathic Association’s Commission on Osteopathic College Accreditation introduced Standard 6.8: Interprofessional Education for Collaborative Practice, which states that the curriculum of a College of Osteopathic Medicine must prepare osteopathic medical students to function collaboratively on interprofessional health care teams, calling out adherence to the IPEC core IPE competencies.3 For Allopathic Medicine, the AAMC Liaison Committee on Medical Education (LCME) introduced Standard 7.9: Interprofessional Collaborative Skills, which states that the core curriculum must prepare allopathic medical students to function collaboratively on interprofessional health care teams.4 

It is important that IPE occurs across the continuum of undergraduate and graduate pre-clinical and clinical training. A focus on interprofessional teaming is now included in residency training. The Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review (CLER) Program provides formative feedback to institutions sponsoring graduate medical education on the effectiveness of resident and fellow engagement in six focused areas for continuous institutional improvement. CLER was established to learn how best to optimize patient safety and clinical quality in clinical environments of teaching institutions and to learn how to best prepare physicians-in-training to meet the needs of a changing health care system.5 In 2019, the CLER Version 2.0 introduced a new focus area—teaming. The new Teaming Pathway requires that the clinical learning environment provides continual interprofessional educational programming on teaming that engages residents, fellows, and faculty members across the continuum of patient care and at all care delivery sites.6 

So why is effective teaming so important? Some health care needs are adequately and efficiently handled by individual practitioners. Not all patients need an interprofessional healthcare team; however, the needs of many patients and populations can be better met by the use of teams.7 Effective collaboration among health profession teams has been found to be a factor in improved quality and safety in patient care.8 An added bonus is that participation in an effective team can be a protective factor for health care providers in reducing burnout.9 The purpose of the team approach is to optimize the special and shared contributions in skills and knowledge of team members, leading to patient needs being met more efficiently.

At TCOM, the knowledge, skills, and attitudes necessary for effective collaborative practice are being integrated into both the preclinical and clinical years of training in a variety of contexts. UNTHSC adopted IPE as an institutional initiative in 2012 with the development of the Department of Interprofessional Education and Practice to lead IPE initiatives. An IPE Curriculum Committee was formed with representation from each of UNTHSC’s colleges and schools along with representation from partnering institutions participating in IPE with UNTHSC. Through this committee, faculty across health professions model effective interprofessional collaboration, working together to create meaningful opportunities for students to learn and practice the competencies necessary for collaborative practice. 

Though COVID has presented new challenges in medical education, innovative learning strategies are being utilized to keep TCOM students engaged in the development of their collaborative practice competencies. Third year TCOM students preparing to enter clinical rotations recently trained in a team development system utilizing Zoom and the virtual game Minecraft to demonstrate process improvement in teamwork, across three virtual simulations. Medical students commented, “This was an engaging and fun way to practice teamwork! Can we have more opportunities to utilize Minecraft?”

IPE has gained momentum across the nation; however, concern has been raised at the absence of authentic models of interprofessional collaboration within the clinical learning environment. The National Collaborative for Improving the Clinical Learning Environment (NCICLE) sponsored a symposium in 2017 to better understand issues related to enhancing the interprofessional clinical learning environment. Symposium attendees were invited by NCICLE and represented education, practice, and leadership across the spectrum of health care. An outcome of the symposium was the expressed concern that interprofessional values taught through IPE at the undergraduate and preprofessional levels are at risk of being lost as new clinicians enter clinical learning environments that reflect traditional approaches to health care delivery that remain siloed and hierarchical in nature.10

Emphasis is being placed nationally on enhancing the clinical learning environment through interprofessional learning to support the continuum of learning between academic and patient care settings.

How can you help? A clear understanding of IPE initiatives within undergraduate and graduate medical education can help clinicians reinforce collaborative practice competencies with students and trainees in the clinical learning environment. We know that the competencies necessary for effective collaborative interprofessional practice must be explicitly taught and modeled. The UNTHSC Department of Interprofessional Education and Practice has created faculty IPE development programs and is piloting an interprofessional collaborative development program for preceptors. Let us know how we can help you and your teams enhance the clinical learning environment. 

References
1 World Health Organization. (2010). Framework for Action on Interprofessional Education and Collaborative Practice. Geneva: WHO Press.

2 Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

3 Commission on Osteopathic College Accreditation. (2019). Accreditation of Colleges of Osteopathic Medicine: COM Continuing Accreditation Standards. Chicago: American Osteopathic Association.

4 Liaison Committee on Medical Education. (2019). Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree. Chicago: Association of American Medical Colleges and American Medical Association.

5 Weiss, K. B., Wagner, R., Bagian, J. P., Newton, R. C., Patow, C. A., & Nasca, T. J. (2013). Advances in the ACGME Clinical Learning Environment Review (CLER) Program. Journal of Graduate Medical Education, 5(4), 718–721. https://doi.org/10.4300/jgme-05-04-44

6 CLER Evaluation Committee. CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, Version 2.0. Chicago, IL: Accreditation Council for Graduate Medical Education; 2019. doi:10.35425/ACGME.0003

7 Institute of Medicine. (1972).

8 TeamSTEPPS®: (2015). TeamSTEPPS: Evidence Based Research. Rockville: Agency for Healthcare Research and Quality. Retrieved April 12, 2020, (Available at:) https://www.ahrq.gov/teamstepps/evidence-base/index.html

9 Willard-Grace, R., Hessler, D., Rogers, E., Dube, K., Bodenheimer, T., & Grumbach, K. (2014). Team Structure and Culture Are Associated With Lower Burnout in Primary Care. The Journal of the American Board of Family Medicine, 27(2), 229–238. https://doi.org/10.3122/jabfm.2014.02.130215

10 Weiss KB, Passiment M, Riordan L, Wagner R for the National Collaborative for Improving the Clinical Learning Environment IP-CLE Report Work Group. Achieving the Optimal Interprofessional Clinical Learning Environment: Proceedings From an NCICLE Symposium. http://ncicle.org. Published January 18, 2019. doi:10.33385/NCICLE.0002

The Last Word

by Robert Bunata, MD – Publications Committee Interim Chair

This piece was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.


After our first year of college, my little group of high school friends had a summer reunion.  Ed was pursuing literature and publishing, Steve accounting, and Roger a business degree.  We had the following conversation after Roger said, “I have a great idea. You be the doctor and I’ll run the business.”

To that I replied, “Why would I do that?  I’ve watched my father and mother run their business just fine for years. I think I can do it myself with a little help and I’d have control like my dad.” 

“But with smart business practices you could make more money and I’d handle the stress of the paperwork.”

“Granted,” I said, “I might make more money, but that’s not what I want. I want freedom, control, and to do what I’ll be trained for, to take care of patients.  I want to make sure my business runs like I want. And, besides, I’d have to pay your salary as well as mine, meaning I’d have to take home less or charge the patients more.” At that time I failed to add: “Besides, Roger, if I approach my patients with a bill collector they would think I was only interested in making money and not in them.”  

Over the next decade or two, due to the mix of new health insurance companies, specialization, technical development, and lots of greed, medical costs got out of hand and the specter of Roger came back in the form of big business and managed care.  

About 25 years ago, as our autonomy was being eroded, I wrote an article for The Physician advocating that doctors stand up for their rights.  I went so far as to recommend we form a union even though it was illegal.  But I did not have a plan or even an idea of what to actually do.  Business and politics won and they set the agenda for the practice of medicine, and we followed like sheep to the slaughter—literally to the slaughter in the form of burn-out, depression, retirement, and suicide.  

“We should admit that we gave up control of our profession too easily, and let politicians and businesspeople define who we are.”

Two recent articles I read express the same exasperation. Richard Byyny, MD, and George E. Thibault, MD, have recently published a monograph entitled, “Burnout and resilience in our profession.”1 Since I am unable to paraphrase the article satisfactorily, I will quote the part I found most interesting, shortening where possible. 

Our current problems with burnout were anticipated by sociologists who posed that bureaucratic and professional forms of organizing work are fundamentally antagonistic. Medical schools do not yet prepare graduates as practitioners who can best resist the bureaucratic and market forces shaping health care and the care of the patient. 

Physicians experience conflict between what they …should do, and what they have been educated and socialized to do. They have been professionalized for acquiescence, docility, and orthodoxy. They are taught to be more like sheep than cats—ultra-obedient following the rules. They are not taught to be cats—independent activists – … advocating for medical values.

We have prepared physicians to follow the rules; however, whose rules? The rules generated by … (our own) … profession?  Or the rules generated by the organization with different values and objectives?

As a result, physicians see professionalism more about conformity. This creates a conflict in the current health care system and organizations. Physicians seem to be perverting core principles of the profession to a just-follow-the-rules … practice of medical professionalism. We are essentially responsible for the problems we now encounter, especially when the care of the patient is often not the focus.

We need cats who will resist conformity in service of extra-professional forces. The mission … (should be) about saving health care for patients and society and enabling (us) … to care for patients and not experience burnout.

That article was sitting in my mind when I came across another— “After the storm”—by Siddhartha Mukherjee, MD, subtitled, “The pandemic has revealed dire flaws in American medicine. Can we fix them?”2 Mukherjee is an oncologist who won a Pulitzer Prize for his book, The Emperor of All Maladies: A Biography of Cancer. He says he wrote this article to use this tragedy to improve American medicine.  First he discusses the points of failures in the organization and implementation of the medical distribution system, and the tendency to buy the cheapest foreign products (masks, gowns, pharmaceuticals), shunning our local providers. He especially criticizes the underfunding of medical research and public health.   

Then he reaches the most interesting part of the article, an anecdotal story about how he contacted doctors in different parts of the country on Twitter and Facebook to share ideas on treating COVID-19 patients.  In their informal transmissions they shared minute by minute discussions like the cause and treatment of thrombi, or how to best position patients to breathe. That improvised social media exchange drew his attention to the fact our balky, billion-dollar electronic medical record (EMR) system doesn’t provide a medical, but rather a financial database.   

These articles tell us that we need some housekeeping, some specific and some general changes.  By “we” I must emphasize that means every doctor, not just a few with an interest in politics.  This involves not just every doctor’s practice or earnings, but our whole life.  If we don’t work together and improve this, burnout will spread like COVID-19.   

There are many things that need improvement (to my mind too, especially the underfunding of medical research), but I’d like to look at two specific changes to consider.  

The first specific change is improving our EMR system to make it more medically useful. Mukherjee’s anecdote tells our story.  If we compare our EMR to the system in Taiwan— which may or may not be fair given such factors as their size and homogeneity—their electronic health records system made a swift targeted response to COVID-19 possible.3 Although the system was not designed to stop a pandemic, it was nimble enough to be reoriented toward one. The government merged the health card database with information from immigration and customs to send physicians alerts about patients at higher risk for having COVID-19 based on their travel records.  

While the U.S. has come a long way with its use of electronic records, thanks in part to the financial incentives built into the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the sharing of data—so called interoperability between different electronic health record vendors—has lagged. It’s expensive, but shoring up the U.S.’s digital health infrastructure will help improve routine care while empowering us to better respond to future infectious disease outbreaks.4,5,6 

Next specific change, the topic of EOBs, is one of my pet peeves.  Whenever I get an EOB for services I’ve received, the doctor’s charge is high compared to the payment received.  This is especially obvious dealing with Medicare EOBs with approved payments from Medicare being about a third of what the doctor charges.  When physicians see an EOB, we think how we’re being underpaid, but many patients have told me they think it shows the doctor is overcharging.  When I see this, I think this is exactly what “Roger” would have done, and it paints a bad image of doctors.  It makes us look like we’re only interested in making money and not in them.

As you can imagine, the list of improvements we could make can go on forever. But the point is we have to work together to improve the practice of medicine and the lives of doctors. 

Now for the general changes to consider. They are more vague and difficult to enumerate.  In my opinion, we should admit that we gave up control of our profession too easily, and let politicians and businesspeople define who we are. For instance, we should stop ridiculous requirements like having our payments reduced if a patient doesn’t take his medicine. We should take back what is rightfully ours—control of our profession, our practices, and our lives.  A big part of burnout is the feeling of not being in control; the best way to feel like we’re in control is to actually be in control. While I don’t have a detailed plan to do this, identifying the objective is a start. This should be a prime issue on the agenda of the AMA, AOA, TMA, TOMA, and of every doctor.  

Another general change concerns professionalism.  We all know what professionalism means on an individual level: put the patient’s interests ahead of our self-interests. We have all done that at one time or another—missed a Thanksgiving dinner or a child’s soccer game.  But what does professionalism look like on a national level?  What does it mean to put the nation’s patients’ interests ahead of our collective own?  While I have a few ideas I would rather not reveal them now. I am asking each of you to consider the question and write a letter to the editor or send an email with your observations and ideas. You can email us at editor@tcms.org, or mail us at 555 Hemphill St, Fort Worth, 76104.

References
1. http://alphaomegaalpha.org/medprof2015.html

2. After the storm. New Yorker, May 4, 2020

3. https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation

4. https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation