Category: Tarrant County Phyician

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

Learning from Taiwan about responding to Covid-19 — and using electronic health records

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

Trump official behind health data rules has a message for privacy critics: Try helping patients, instead of your bottom line

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

There is Some Good News, Too

by Tilden Childs, MD – TCMS President

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


by Tilden Childs, MD – TCMS President

When I was perusing the Wall Street Journal the other day, I ran across an article by one of my favorite writers, Daniel Henninger. He started his article with the following observation, “On Tuesday the New York City sky was clear, blue and filled with sunshine. That’s it for this week’s good news.”  His article was not about COVID-19, but it prompted me to think that yes, there is some good news on COVID-19.

As I suspected early on, the COVID-19 pandemic is not going to be a short-term phenomenon with a “V” shaped medical recovery for the country, unlike the stock market (well at least some stocks). However, some recent developments do appear to be positive and hope for some return to normalcy has not been extinguished. The re-opening of the U.S. economy has been progressing, which is good, but unfortunately the infection rates have also increased. Parts of Texas, particularly in the Valley, are suffering. However, the mantra of “wear a mask or face covering, wash your hands frequently, and maintain physical distancing” seems to be working when rigorously applied. Even President Trump is taking the situation more seriously and now supports the wearing of a mask or facial covering.

The mortality rate from COVID-19 may be lower than was initially thought, but this is a complicated issue. As explained in an article in Nature: “Researchers use a metric called infection fatality rate (IFR) to calculate how deadly a new disease is. It is the proportion of infected people who will die as a result, including those who don’t get tested or show symptoms.” “The IFR is one of the important numbers alongside the herd immunity threshold and has implications for the scale of an epidemic and how seriously we should take a new disease,” says Robert Verity, an epidemiologist at Imperial College London. “Calculating an accurate IFR is challenging in the midst of any outbreak because it relies on knowing the total number of people infected—not just those who are confirmed through testing. But the fatality rate is especially difficult to pin down for COVID-19, the disease caused by the SARS-CoV-2 virus,” says Timothy Russell, a mathematical epidemiologist at the London School of Hygiene and Tropical Medicine. “That’s partly because there are many people with mild or no symptoms, whose infection has gone undetected, and also because the time between infection and death can be as long as two months.”1

Some potential reasons for the apparent recent decrease in the mortality rate were discussed in an article in The Atlantic: “COVID-19 Cases Are Rising, So Why Are Deaths Flatlining?”2

  1. Deaths lag cases—and that might explain almost everything.
  2. Expanded testing finds more cases, milder cases, and earlier cases.
  3. The typical COVID-19 patient is getting younger.
  4. Hospitalized patients are dying less frequently, even without a home-run treatment.
  5. Summer might be helping—but only a little bit.

Let’s hope that #1 above is not correct! I would like to believe that the evolution of our understanding of the virus and the disease it causes, including a better appreciation for its variable severity and multi-organ involvement, has and will continue to result in more and better treatment options which are at least in part improving mortality and morbidity outcomes.

“This is really good news as it now appears that herd immunity may be the key to successfully mitigating the current crisis and controlling the SARS CoV-2 virus.”

Progress on developing a vaccine(s) is moving forward at an accelerated pace. This is the result of  the National Institutes of Health and the Foundation for the NIH (FNIH) forming the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) partnership with the goal of developing “a collaborative framework for prioritizing vaccine and drug candidates, streamlining clinical trials, coordinating regulatory processes and/or leveraging assets among all partners to rapidly respond to the COVID-19 and future pandemics.”3 This represents an unprecedented cooperative alliance between government agencies and private industry to expedite the development of vaccine(s) as well as begin production of potentially successful vaccines in advance of final approval of the vaccine(s). At the time of writing this article, Phase III trials are about to begin for at least one of the vaccines under development. Availability of a vaccine(s) may be as early as late 2020 or early 2021.

This is really good news as it now appears that herd immunity may be the key to successfully mitigating the current crisis and controlling the SARS CoV-2 virus. Recent evidence suggests that immunity following infection is time limited and that significant long-term morbidity is believed to occur after recovery from the acute COVID-19 infection phase. This means that herd immunity generated by vaccinations rather than by community infections looks to be the key to getting the crisis under control and reducing the mortality rate and the long-term sequelae of community acquired infections.

I hope this Good News gives you reason to Keep up the fight and Keep the faith.

Thank you and stay safe!

References
1. https://www.nature.com/articles/d41586-020-01738-2

2. https://www.theatlantic.com/ideas/archive/2020/07/why-covid-death-rate-down/613945/

3. https://www.nih.gov/news-events/news-releases/nih-launch-public-private-partnership-speed-covid-19-vaccine-treatment-options

Thank You, Telemedicine

By Susan Bailey, MD – AMA President

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

It happened twice in the same morning.

I saw two women for checkups that morning—their stories were so similar.  Both older but not elderly, living alone, physically impaired needing a walker or motorized scooter, and always very crabby at their appointments.  A litany of chronic non-specific complaints—fatigue, aching, headachey, etc.  Honestly, I was not looking forward to their visits. They never seemed satisfied, and I never felt like I had helped them much.  When I saw them both on the schedule that morning, I confess that I grimaced a bit.  

But their telemedicine visits were just the opposite of their usual in-person visits.  They both were happy, smiling, and relaxed.   The conversations were easy and their questions were few.  I anticipated much COVID-19 anxiety but found little; they were used to staying at home and hadn’t had to change their way of life much.  They both just needed refills—I would have liked to have done a physical exam, but I really didn’t need to.  

At the end of the morning, I wondered to myself what was different, and then it hit me.  They didn’t have to physically come to see me, which so many of us take for granted but for them was likely a physically draining, frustrating, expensive, humiliating, and even painful experience. Wow. Was I humbled.  

Telemedicine is a gift to some of our patients, such as parents stuck without childcare who have to bring multiple children along with them, people who lack reliable transportation, or elderly people who don’t like driving anymore but are embarrassed to ask for a ride. It can help someone two hours away who just needs a refill or a patient who can’t afford to miss work.  I could go on and on; I’ve seen cases like every example I’ve given and I’m sure many of you have, too.

The coronavirus pandemic has added a new layer of urgency to the implementation of telemedicine.  Physical distancing and shutdowns have made it extremely difficult, if not impossible, to see our patients safely face to face (especially when PPE is still hard to find).  Telemedicine enables routine care to continue without the risk of exposure to the virus.  It keeps medical offices safe and in business.  

The AMA, along with many other organizations, has been developing telemedicine policy and recommendations for years.  The AMA House of Delegates approved a report from the Council on Medical Services laying out principles for coverage and payment in June 2014.  

An AMA survey in 2016 showed that 15 percent of physicians worked in a practice that utilized telemedicine in some way.1 But a far smaller percentage of actual patient encounters were done via telemedicine. 

When COVID-19 struck and communities were shutting down all over the country, the telemedicine guidelines, reimbursement policies, and the work we had already done with CMS helped the organization be ready with their new guidelines for coverage and payment, which were initially released on March 17, 2020.  

AMA had been working with the Physicians Foundation, the Texas Medical Association, the Florida Medical Association, and the Massachusetts Medical Society to create the Telehealth Initiative to provide a wide array of assistance for physicians to implement telemedicine in their practices.2  The launch of the program was not scheduled until later in the year but instead was moved up to March 19, 2020, just two days after the CMS announcement.  

Virtually every medical society in the country now has guidance available for physicians on using telemedicine. 

However, the current telemedicine coverage and payment program will only stay in effect as long as there is a national emergency, which has now been extended to the end of October 2020.  Of course, we all know that COVID-19 will not be gone then, so AMA is working with state and specialty societies to lobby Congress for permanent solutions.  

I believe that every specialty will develop its own guidelines for the appropriate use of telemedicine going forward, and every practice will utilize telemedicine to some degree.  

The genie is out of the bottle. Let’s hope it stays that way. We deserve to be compensated fairly for services regardless of location, and our patients deserve the ease of access.   

References
1. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05077

2. https://www.ama-assn.org/press-center/press-releases/ama-supports-telehealth-initiative-improve-health-care-access

The Summer Our Lives Stood Still

By Cassidy Lane, OMS-II

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


I was 13 years old the last time that I experienced a summer break, because it was that summer that I decided that I wanted to be a physician. I spent every summer after that through high school at the Volunteer Department of the nearest Level I Trauma Center in East Texas. If I wasn’t volunteering I was shadowing, and if I wasn’t shadowing I was scribing or taking classes that would prepare me for medical school. It became a constant cycle, month in and month out for 11 years. Every one of my spring breaks, winter breaks, and summer breaks was jam-packed with exciting new medical adventures, classes, or some other activity that was someday going to get me into medical school and ultimately help me become a physician. As crazy as it sounds, my story is not unique. This is the path for many students, former, current, and future, who pursue a career as physicians. This is a way of life that we gladly accept, because for many of us the idea of doing anything else is much more depressing than spending every break of our youth working towards our future career. 

I was all geared up to spend the summer after my first year of medical school the same way. I had two in-hospital research projects lined up, was interviewing for a pediatric research program to review case studies and publish reports on the cases, and I was already looking for a summer job to bring in a little extra income during what I considered my “slow” month between the two academic years. Then, in an instant, a global pandemic hit, all my plans fell apart, and I was left with a very empty calendar during a period that was supposed to be a time for me to check all of the boxes that residency programs would want to see completed by the time I apply just three short years from now. When the initial shock wore off that a virus was capable of shutting down medical programs created and run by very people who live to combat these same types of diseases every day, it was like I had stepped  into the sunshine for the first time in 11 years. As I began to read about the attempts of countries all over the world to contain and combat the virus, I was struck by an unexpected common theme in the rest of the world that I felt within myself: rejuvenation. 

There were stories about nature being able to cleanse itself once people were no longer allowed to pour waste into it every day. Families were spending more time with one another at home, and smiles were being shared through technology all across the world because people were no longer able to go, go, go. Self-care began to emerge at the forefront of peoples’ minds, and I began to understand what it meant to take a step back and soak in the moments.  I started cooking dinner every night, I read books on history and got outside every day. At a time when uncertainty was the norm and we were all scared, I spoke with colleagues and friends who were learning and growing personally outside the realm of medicine into better spouses, friends, and students. With this fresh new start that we received, we have been able to go back to school refreshed and ready to learn about medicine and people instead of being burned out and emotionally exhausted. During the time that our medical lives stood still, our mental and emotional health was able to re-blossom into excitement about life, medicine, and being the physicians that we are destined to become. 

And Then There Were Two

By Shanna Combs, MD

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

As is tradition, despite what may be going on in the world (global pandemic, public demonstrations, etc.) every year, sometime in late June or early July, the wheel of medical education continues to turn.  The TCU and UNTHSC School of Medicine continued this cycle on July 6, 2020. And just like that, our school went from one class to two, officially welcoming its second class of 60 medical students. The students in the Class of 2024 are from 18 states within the U.S., with 38 percent of them from Texas. Fifty-five percent are male and 45 percent are female. The new students come from 45 different undergraduate higher education institutions.

And just like that, there were two, and we continue our journey of developing a new medical school.

Similarly to our now second-year medical students, our first-year medical students are having to discover the brave new world of virtual medical education due to COVID-19.  Despite this distance, our new students show the same enthusiasm for diving in that is always present in a brand-new class.  This enthusiasm helps to invigorate those of us involved in medical education, and it helps us to continue to appreciate the honor it is to be a physician as well as an educator.  

I was fortunate to participate in an interprofessional education event with our new first years as well as senior nursing students from TCU, held virtually of course.  Our students were able to work through the concepts of communication in the clinical environment with the nursing students.  They were also able to gain insight from the nursing students who have already been working in the clinical environment.  It reminds me how important it is that our learners start working together while training.  We highlight the concept that medicine is a team sport, and we must work together to obtain optimal outcomes for our patients.

The medical education wheel continues to turn.  

By the time you read this, our second-year students will have completed the first of three phases of our curriculum, which is traditionally considered the basic science content.  After years of planning and a global pandemic occurring more than halfway through our first year, it is hard to believe that this milestone has already occurred.  Our students will now begin the transition to the clinical learning environment (barring any changes that may occur due to COVID-19). They will have the opportunity to step away from the computer screen and step back onto the campus for their Transition to the LIC course.  

They will first get acquainted with the new normal of wearing a mask while trying to interact and gain rapport with simulated patients.  They will also practice and hone clinical skills that were not able to be taught virtually.  They will learn new procedures and have opportunities to practice.  They will discover different medical environments, such as the operating room, labor and delivery, the inpatient setting, the emergency room, and outpatient clinic, and how they will play a role in those settings.  They will also learn about the appropriate donning and doffing of personal protection equipment as well as telehealth that is now more commonplace due to the COVID-19 pandemic. 

Once they complete their transitions course, the students will move into the hospital setting to continue their education.  We are grateful to our physician and hospital partners in the community who have worked with us to bring our students into their clinical practice and hospital settings.  To quote Sir William Osler, “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”1

And just like that, the medical education wheel continues to turn.

References
1. Boston Medical and Surgical Journal, January 17, 1901, page 60.

A Masking Primer for COVID-19: Public Health Notes

By Catherine Colquitt, MD, Tarrant County Public Health Medical Director

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

There is still much controversy regarding efficacy of masking during the COVID-19 pandemic, so I reviewed some of the thousands of peer-reviewed scientific articles addressing this topic since SARS exploded onto the world stage in 2003.  Epidemiologists, infection perfectionists, and most if not all practicing physicians field questions from patients, friends, health care workers, and first responders about masking, and, while a comprehensive literature survey is beyond my scope, I came away from my reading heartened by evidence which clearly supports masks as a source control measure (a means of preventing transmission of infection from a source to others) AND endorses the use of masks, especially respirator and surgical masks, to PROTECT the wearer as well.

Masks, along with social (or physical) distancing, and hygiene (hand and surface disinfection, and cough and sneeze control) are the mainstays of control of droplet-spread pathogens and are critically important when COVID-19 hospital resources are strained, when treatments are reserved only for the sickest of those hospitalized, and in the absence of a vaccine or treatment for outpatients with COVID-19.

The science of evaluating masks is very complicated and typically involves at least three parameters: filtration efficacy (percentage of particles prevented from escaping the wearer’s mask), the pressure gradient across the mask (affects filtration efficacy and the comfort of the wearer), and fit, or face seal, of the mask on the wearer (droplets can escape more easily around looser edges of the mask on the wearer’s face).

The National Institute of Occupational Safety and Health (NIOSH) is responsible for conducting research and making recommendations for the prevention of work-related injury and illness and is a resource for information regarding healthcare and occupational PPE in setting on COVID-19.  NIOSH also assesses important PPE to confirm efficacy and develops crisis strategies for coping with PPE shortages. NIOSH is responsible for the “N95” label on the mask you have likely been fit-tested to wear.  The “95” generally indicates filtration efficacy of 95 percent of particles in the challenge aerosol (usually 0.1 micron diameter latex sphere aerosol) from the nose and mouth of the wearer. The “N” indicates that the respirator is NOT resistant to oil, “R” is somewhat resistant to oil, and “P” is oil-proof.  (The oil resistance matters in some industrial settings in which the oils to which the respirator filters are exposed can remove the electrostatic charges from the filter media and thereby compromise filter efficacy.)

Fig. 1. Pictures of face masks under investigation.  
We tested 14 different face masks or alternatives and one mask (not shown).  
Photo Credit: Emma Fischer, Duke University.


In 2008, VanderSande et al. evaluated professional and homemade masks (made from tea cloth) for their efficacy in reducing respiratory infections in the general population and found that cloth masks provided a “modest degree” of protection to the wearer, while surgical masks were 25 times more effective and respirator masks were 50 times more effective at protecting the wearer than homemade cloth masks.1

S. Rengasamy et al., writing in Annals of Occupational Hygiene in 2010, analyzed filtration performance of cloth masks for particles 20-1000 nanometers in diameter and found instantaneous penetration level of 40 percent to 90 percent across the range of fabrics they tested.1

Fischer et al presented a low-cost technique for assessing filtration efficacy through various mask fabrics during speech and confirmed excellent filtration efficacy of respirator and surgical masks (figure 1), fair efficacy of some  multilayered cotton, polyester, and mixed fabric masks, poor filtration efficacy with some cotton weaves as well as knitted masks and bandanas, and, somewhat remarkably, very poor filtration efficacy for fleece face coverings (often used in gaiters or “neck tubes”).  (See figure 2) Fleece performed worse than no face covering at all, presumably by dispersing larger droplets into several smaller ones, thereby increasing the droplet count.


Davies et al., in Disaster Medicine and Public Health, tested the efficacy of homemade masks as protection in an influenza pandemic and offered that homemade masks should be used only “as a last resort” to prevent droplet transmission from infected individuals, but a homemade mask would be “better than no protection.”4

Scientists continue to study how and when and whom to mask since SARS and H1N1, and aerosol science will continue to evolve and to refine our use of PPE during and after the COVID-19 pandemic, but the overwhelming published scientific opinion supports the use of masks and, the better the mask, the better the protection for the wearer and those he or she faces.

Ready! Set! Mask!

References
1. VanderSande et al. 2008. PLOS ONE 3 (7) e2118.

2. S. Rengasamy et al. Annals of Occupational Hygiene, 2010. Vol 54, No 7, pp 789-798.

3. Fischer et al. Science Advances. SciAdv.10.1126/sciadv.abh3083, 2020.

4. Davies et al. Disaster Medicine and Public Health Preparedness. 2013 August: 7 (4) 413-418.

Alliance Update – Immunize 2020

By Terri Andrews and Linda Kennedy

BeeWise-Immunize Test Site – Ridgmar Mall

It has long been our fear to have community spread of an illness that potentially overwhelms our healthcare system capacity and results in the illness and/or death of tens or even hundreds of thousands of people.  Many years ago, the TCMS Alliance and Foundation joined other concerned organizations, both public and private, to form the Immunization Collaboration of Tarrant County (ICTC) to help promote and provide immunizations in our community.  In this year of COVID-19, we know that our fears were well founded and what the world looks like with a virus and no vaccine.  Our community is opening from the quarantine that was needed to control the initial spread of COVID-19.  Schools are opening and thousands of children need required vaccines to move from virtual to in person classes. Many of our local children missed scheduled vaccines when the pandemic hit North Texas.

Every August, the ICTC has hosted immunization clinics which Tarrant County Public Health provides the vaccines for at five different community health fairs and back to school events over four weeks. This model in five locations over a shorter time is not possible in this time of COVID-19. Fortunately, ICTC was able to react to the new circumstances hosting the Be Wise—ImmunizeTM Low Cost Back to School Vaccine Event July 20 through September 11, 2020 at Ridgmar Mall in Fort Worth. The site provides plenty of social distancing space for families and students receiving the needed vaccines.  Immunizations are low cost for families who are uninsured or are covered by CHIP or Medicaid.  

In 2005, TCMS Alliance brought Be Wise—ImmunizeTM to Immunization Collaboration of Tarrant County. ICTC is a volunteer driven, nonprofit organization dedicated to the systematic eradication of vaccine preventable diseases in Tarrant County. ICTC projects directly improve the health and well-being of children, teens and adults through low cost vaccine events, community education on the importance of childhood and adult immunizations, and advocacy for better vaccine systems and policy since 1991. Over 40 agencies are members of ICTC.

TMA Foundation and TCMS Alliance support for ICTC programs is ongoing.  The Be Wise—Immunize logo, leadership, funding, and volunteers from across Tarrant County keep ICTC going strong. ICTC Vaccine events 2019 provided 9412 clients with 24,057 doses of vaccine. To learn more or to be an ICTC volunteer visit http://www.icthome.org or http://www.tcmsalliance.org.

Growing Together

by Veer Vithalani, MD, MAEMSA System Medical Director

Note from the editor:
Dr. Vithalani is an active member of the TCMS Board of Advisors. As he officially moves into the role of our local EMS Medical Director, TCMS wanted to provide him the opportunity to speak directly with members about his background and goals for our EMS System.


“After successfully completing an EM residency, I plan to undertake an EMS fellowship and hope to one day serve as a Medical Director for an ambulance company while working in an academic emergency department.”

These words concluded my personal statement as I applied to residency programs in 2010. One of the reasons I was so excited when I matched into the inaugural class at the JPS Health Network in Fort Worth was the opportunity to develop the program’s experience with a world-renowned EMS system, MedStar.

From early in my residency, I began learning the basics of EMS medical direction under the mentorship of Dr. Jeff Beeson. He would stress the importance of working collaboratively with the local medical community and would take me with him to the monthly board meetings of the Tarrant County Medical Society (TCMS). The TCMS played a fundamental role in the creation of the EMS system in Fort Worth, and through its designated positions on the Emergency Physicians Advisory Board, has been influential in shaping the structure of the EMS system through numerous challenges. Drs. Gary Floyd and Steve Martin have served since the early days of the Emergency Physicians Advisory Board (EPAB) and have been a tremendous source of counsel and guidance for my predecessors and me.

I was able to join the Office of the Medical Director (OMD), first as an EMS Fellow, then Associate Medical Director, and finally Interim Medical Director. Throughout this time, I’ve witnessed incredible growth in this system. This progress is evident in every aspect: tighter integration between EMS and first responders; increased standardization of credentialing and quality assurance; closer working relationships between the OMD and agency leaders; and increased resource sharing, such as unified dispatch centers, dispatch integration, and shared capital. All of these actions keep us centered on patient-focused goals. Patients call 911 in their time of need, and the system is there for them, regardless of race, gender, or creed.

I am honored to accept the position of Medical Director for the Metropolitan Area EMS Authority (MAEMSA) system. My goal moving forward is simple; we will continue to guide our commitment to clinical excellence throughout this system. Accomplishing this mission takes continued passion and dedication from all involved—from front-line field providers, dispatchers, support services, educators, administrators, Chiefs, City leaders, OMD, and beyond. My philosophy is that this is our practice of medicine, and we are all in it together. We will help our patients together, make mistakes together, learn together, and grow together. 

Moreover, in the difficult times of the COVID-19 pandemic, my goal remains the same. The OMD is responsible for the daily management of the Tarrant Medical Operations Center, functioning as the coordinating body for mitigation of medical and healthcare effects of disasters. With active participation from all key stakeholders, from hospital leaders to local physicians, public health officials to emergency managers, and elected officials to public safety, everyone is doing their part to mount a coordinated and consistent response for the safety and well-being of our community.

I would not have reached this position without my mentors and predecessors, Drs. Jeff Beeson, Steven Q. Davis, and Neal Richmond; leaders from JPS and IES, Drs. Robinson, Zenarosa, and Kirk, who brought me to Fort Worth and trained me in Emergency Medicine, and my wife and kids, to whom I owe all of my life’s successes; to all, a heartfelt thanks.

I do not take lightly the trust and responsibility placed in me by the MAEMSA Board, First Responder Advisory Board, and EPAB. I hope to live up to the high expectations we have all set. This system has long been a shining star in the world of EMS; I look forward to playing my part to continue that into the years to come.

Integrated Pharmacist Services in Medical Practices

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

By Jennifer Fix, PharmD, MBA, BCGP, BCACP
Steven Hauf, B.A., CPhT, PharmD Candidate (2020)

Introduction by Monte Troutman, DO, TCMS Publications Committee:

Hello colleagues. Although I have been a member of the Tarrant County Medical Society (TCMS) for many years, this is my first time to submit any writings to the Tarrant County Physician publication.  TCMS asked for a member of the Texas College of Osteopathic Medicine (TCOM) and a member of the TCU School of Medicine at UNTHSC to join their Publications Committee (PC). I don’t know how to say no, so I joined. 

The PC wanted an insight into changes in medical education and how these changes impact the current state of healthcare. I felt that I could contribute since I have been a full-time faculty member at TCOM for over thirty-five years. Yes, I have seen dramatic changes in how our medical students are taught. I hope that I can contribute in a way that shows these dramatic changes will have a positive impact. 

One of the changes in medical education is the emphasis on the team approach concept. Physicians and students in training are now taught to be a member of a team that cares for patients. One of the members of the team are our pharmacists. I chose a new friend and colleague to write the first of I hope many articles that provide insight into the team approach. Dr. Jennifer Fix is a valuable member of the faculty of the School of Pharmacy. She is now embedded in our clinical practice of gastroenterology at the Health Science Center. I didn’t realize the service and help that she and the pharmacy students could offer our practice. Not only helping our gastroenterologists but also our clinical staff. I believe “invaluable” is the term that best describes their contribution to the team. The best part of their presence is that our medical students get to see the pharmacist in action. Yes, this is new concept and our students learn the value of teamwork with our pharmacist colleagues. Please read and enjoy and learn!     

“Put me in coach!”  It was at the American Association of Colleges of Pharmacy (AACP) Annual Meeting that clinical pharmacist and professor, Dr. Jennifer Fix, most recently heard this line from one of the keynote speakers as he talked about the ability, desire, and willingness of pharmacists to serve alongside physicians in integrated medical practices.  The CDC says that, “pharmacists have long been identified as an underutilized public health resource. Pharmacists are well positioned to help out with improving chronic disease management and make a difference when they are actively engaged as part of a team-based care approach.”1,2 

Pharmacists working in accordance with a physician’s referral in providing face-to-face, in-office services for chronic health condition management, education, and medication optimization is likely to be something you would hear most pharmacists express as a short-term goal for the profession and something pharmacy schools have implemented into their curriculum.  Todd Sorenson, PharmD, President of the American Association of Colleges of Pharmacy has declared his bold aim which is “that by 2025, fifty percent of primary care medical practices will have integrated comprehensive medication management (CMM) services into their care model; and those services will be delivered in collaboration with pharmacists.”  

The Health Science Center (HSC) in Fort Worth, part of the University of North Texas System, is widely recognized for its work in Inter-professional Education (IPE) – and is already ahead of this 2025 goal laid out by Dr. Sorenson. HSC has pharmacists integrated into several of their medical practice sites.  Through collaborations with health-related programs at Texas Wesleyan University, Texas Christian University, Texas Women’s University, and University of Texas at Arlington, HSC medical students from both the Texas College of Osteopathic Medicine and The Texas Christian University/UNTHSC School of Medicine participate in IPE events alongside pharmacy, nurse practitioner, physical therapy, nursing, nutrition, and social work students.3  Graduates of the School of Pharmacy located at the HSC in Fort Worth, receive a Doctor of Pharmacy degree (PharmD). Prior to graduation, though, these student pharmacist interns must complete three years of coursework followed by experiential rotations. Among these rotations are opportunities for the pharmacist intern to experience an ambulatory care setting in which they can put their education into practice in managing patients with common chronic diseases alongside their preceptor, a clinical pharmacist with collaborative agreements with physicians to enhance patient care. Most pharmacists working in medical practices have completed one to two years of post-graduate residency to develop their skills and many have also completed Board Certification in Ambulatory Care Pharmacy recognized by the Board of Pharmaceutical Specialties.4

One example of this collaborative practice between physician and pharmacist includes patients referred by a physician for a clinical pharmacist comprehensive medication therapy consult where pharmacists are engaged to identify, address, and solve drug therapy problems. In a 2018 study titled “Drug Therapy Problem Identification and Resolution by Clinical Pharmacists in a Family Medicine Residency Clinic,” the researchers conducted a retrospective chart review and found that half of the drug related problems (DRPs) found were resolved the same day.  The most common DTP category identified in this study was the need for additional drug therapy (41.6%), followed by the need for additional monitoring (14.5%), suboptimal adherence (9.9%) dose too low (9.4%), adverse drug reaction (7.3%), unnecessary therapy (6.7%), ineffective drug therapy (5.5%), and dose too high (5.1%).5 While physicians are capable of handling such issues, pharmacists are extensively trained to identify and respond to these specific problems and their expertise should offer peace of mind to the physicians they work with, who will know that the medications have been evaluated by these medication experts. 

Pharmacists can enhance outcomes and enhance quality of care as well as the overall patient experience.

While pharmacists used to be found only in corner drug stores or hospital basements, this is no longer the case.  Pioneering physicians who have already integrated pharmacists into their medical practices have done so by establishing the scope of practice for the clinical pharmacist that they oversee by defining the details of a Collaborative Practice Agreement (CPA) and agreeing on a list of disease states and drug classes that they would permit the pharmacist to initiate, stop, or modify. The CPA is submitted to the State Board of Pharmacy for review and acceptance. In Texas, pharmacists are authorized to sign non-controlled substance prescription drug orders established through a CPA.6  The National Alliance of State Pharmacy Associations show that CPAs can “decrease the number of phone calls required to authorize refills or modify prescriptions, thus allowing each member of the health care team to complement the skills and knowledge of the other member(s), effectively facilitate patient care, and improve patient outcomes.”7  In addition to medication reconciliation, clinic-based pharmacists, upon collaboration with the physician, are also able to provide disease state specific modifications in existing treatment regimens, provide drug therapy education, process refills, assist with navigating insurance challenges, obtain medical, surgical, social, and vaccine histories, and much more.  Given the opportunity, pharmacists can enhance outcomes and enhance quality of care as well as the overall patient experience. 

Through physician acceptance and implementation of pharmacist integration, medical practices continue to equip themselves for evolving payer regulations and their ability to meet patient care benchmarks. For instance, the Centers for Medicare and Medicaid Services (CMS) have a new “Meaningful Measures” framework initiative to identify the highest priorities for quality measurement and improvement.8 This initiative outlines quality topics for the core issues related to the highest quality of care and better patient outcomes that are directly related to CMS strategic goals, every one of which pharmacists are educated on and are well-suited for assisting the practice in meeting these goals. These measures include quality priorities such as; reducing harm caused in the delivery of care, strengthening family engagement as partners in care, promoting effective communication and coordination of care, collaborating with communities to promote best practices of healthy living, and making care affordable. 

Billing models for clinic pharmacists continue to evolve, but the baseline billing codes are recognized for Medication Therapy Management.  According to the American Society for Hospital Pharmacist Billing Guide, 99605 is recognized for Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, with assessment, and intervention if provided; initial encounter; 99606 is used for a subsequent encounter; and  99607 can be used to bill for each additional 15 minutes.9 

In summary, we believe that the integration of pharmacist services into medical practices is important and could potentially be an essential key to meeting quality measures that enhance overall practice reimbursement while offering physicians a partner to assist them in meeting the needs and improving the care of patients with common chronic disease states.

References
1. Advancing Team-Based Care Through Collaborative Practice Agreements. A Resource and Implementation Guide for Adding Pharmacists to the Care Team. Center for Disease Control and Prevention (CDC). https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf. Accessed July 30, 2019.

2. CDC releases practical guide for pharmacists to establish collaborative practice agreements. American Pharmacists Association (APhA). https://www.pharmacist.com/article/cdc-releases-practical-guide-pharmacists-establish-collaborative-practice-agreements. Published 2017. Accessed July 27, 2019.

3. Interprofessional Collaborations. Interprofessional Education and Practice. https://www.unthsc.edu/interprofessional-education/interprofessional-collaborations-ipe/. Accessed April 8, 2020.

4. Ambulatory Care Pharmacy. Board of Pharmacy Specialties. https://www.bpsweb.org/bps-specialties/ambulatory-care/#1517761118361-6c02bae3-f5a01517779729021. Accessed April 10, 2020.

5. Macdonald, D., Chang, H., Wei, Y., & Hager, K. D. (2018). Drug Therapy Problem Identification and Resolution by Clinical Pharmacists in a Family Medicine Residency Clinic. INNOVATIONS in Pharmacy, 9(2), 4. doi: 10.24926/iip.v9i2.971.

6. TexasStateBoardofPharmacy.PharmacistsAuthorizedtoSignPrescription Drug Orders for Dangerous Drugs Under a Drug Therapy Management Protocol of a Physician. Texas State Board of Pharmacy Web site. http://www.tsbp.state.tx.us/ files_pdf/DTM.pdf. Accessed July 27, 2019.

7. Collaborative Practice Agreements: Resources and More. National Alliance of State Pharmacy Associations https://naspa.us/resource/cpa/. Published 2017. Updated June 8, 2017. Accessed July 27, 2019.

8. Meaningful Measures Framework. Center for Medicare and Medicaid Services (CMS). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html. Published 2019. Updated July 22, 2019. Accessed July 30, 2019.

9. Ambulatory Care. ASHP. https://www.ashp.org/-/media/assets/ambulatory-care-practitioner/docs/sacp-pharmacist-billing-for-ambulatory-pharmacy-patient-care-services.pdf. Accessed April 10, 2020.

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