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Choices

The Last Word

By Hujefa Vora, MD, TCMS Publications Committee Chair

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

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

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

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

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

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

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

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

President’s Paragraph

by Shanna Combs, MD, TCMS President

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

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

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

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

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

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

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

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

Let’s Go Mobile!

Public Health Notes

By Catherine Colquitt, Tarrant County Public Health Medical Director

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

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

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

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

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

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

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

References

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

The Delicate Dance of Disseminating Information

By Siri Tummala, MS-II

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

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

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

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

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

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

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

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

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

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

The Last Word

by Hujefa Vora, MD
Chair, Publications Committee

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

Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;

We all had a choice.  We graduated from medical school and then picked a residency along the way.  We knew that this choice had to be lasting.  That was a lot of pressure for those of us who think too deeply or gaze off too far toward the horizon.  And yet, the decision was made, none of us grasping the fact that an even bigger decision lay ahead of us just around the bend, past the undergrowth.

Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,

What did we do next?  Some chose academics, though that was a minority. An even smaller minority chose private practice.  And many chose to join the world of corporate medicine, working for hospitals or insurance conglomerates or large multispecialty groups.  That may be three roads, not two, but you get the gist. 

And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.

At the time, all of these choices looked to be equal.  It felt right, though, that I would start my own business, put out my shingle, a welcome mat of sorts, try my luck, and let the cards fall as they may.  And fall they did.  For 20 years, I have run a business, something I was never trained to do.  I have built a successful practice (knock on wood), successful not because I’ve made a lot of money, something solo primary care physicians rarely do anymore, but because my staff and I have helped a lot of people live better, fuller lives.  Above all else do no harm, but that really means do the best for your patients, their families, our friends, and all of us.

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.

But now, it is so much easier to look back and ponder a new choice.  With the advent of quality measures, ever-changing metrics where the finish line is constantly moving, with the dissolution of the fee-for-service system, it has become infinitely harder to run a small practice. To oversimplify, we don’t always know where or when revenue will come in, and the variability increases with the fact that we never know how much we will be paid for the work we do.  And when my patients remind me that I’m not doing it for the money, I also remember that without the incoming stream of revenue, I would not have a practice that does so much good for my people, my friends, my patients.  Perhaps as I continue to walk this chosen path, I will cross a stream or two, get tangled in the brush, maybe even trip, fall, and get back up again.  No matter what, as all of us who are in small practices are apt to do, I continue forward, not knowing what lies ahead.  Perhaps I will come to another place where two roads diverge in the woods, and I will have to choose again.  For now, I bow to one of the Greats, and let Robert Frost have The Last Word.

Q&A with TMA President Dr. Gary Floyd

By Allison Howard

This article was originally published in the May/June 2022 issue of the Tarrant County Physician.

Photo credit: Texas Medical Association

On April 30, 2022, longtime TCMS member and past president Dr. Gary Floyd was installed as TMA’s 2022/2023 president. A pediatrician who has practiced in Tarrant County for over 40 years, Dr. Floyd sat down with the Tarrant County Physician to talk about everything the led him to this point, and what he anticipates for this next year as he takes the helm of one of the largest medical associations in the country. 

Q  So Dr. Floyd, what would you say, in your opinion, is the best thing about being a doctor?

A  You know, I think the best part or the most amazing part to me is that people, and in my case families, trust you enough to take care of their children. And for adult docs, those patients trust them enough to take care of them. I have always just stood in awe of that. The second part for me has been the collegiality, and that has come both in the workplace and through organized medicine. I have over the years made many acquaintances, many friends, and that’s just not replaceable.

Q  Speaking of the physicians you’ve worked with, how do you think organized medicine – TMA specifically or any of the multiple organizations you’ve worked with over the years – impacts both physicians and patients?

A  I think organized medicine gives us a collective voice for the issues that plague all of us. We can usually come to common consensus, and it gives us a large body of people, a large number of physicians, who will speak out for our issues. And instead of just one person crying in the wilderness alone, you go representing fifty-six thousand members of TMA. People start listening in.

Q  That makes a lot of sense. So, on advocacy: what do you think are some of the most important ways that advocacy has impacted the practice of medicine? I know there’s a pretty long laundry list.

A  There’s a long list, yes. I think for Texas physicians one of our biggest achievements or wins was our liability reform that occurred back in 2003, almost 20 years ago. Thanks to work with the public and literally grassroots in the office in talking to patients, this went before the public in a proposition for a constitutional amendment and passed. So hats off, not only to the physicians who worked so hard on that but to the public who understood the need to bring in more physicians to Texas.

I think you’d also have to hallmark [that TMA] sued CMS and won in the district court in Tyler and now we’re waiting for their appeal. This had to do with the No Surprise Billing act. Congress got it right in their wording and had a very fair independent dispute resolution process. But in writing, CMS’s rules initially came out very much in favor of insurance companies and detrimental to physicians. So that’s why Texas sued and won. It’ll be interesting to see how this will pan out, and whether the federal government will appeal to a higher court. But we’re ready for that battle. It’s an expensive battle, but it’s well worth fighting for physicians and for patients. 

Q  You’ve talked about some issues that are clearly important to you. Focusing on your leadership roles: a lot of physicians are involved in organized medicine but only so many choose to actually get involved on the leadership level, which allows you to really participate in creating change. What inspired you to do so?  

A  I think every leadership position I’ve ever run for or been elected to, it’s been because others have asked me to do it, so I think it’s been because of the relationships that have been built with colleagues as we went through our normal course of work. Showing up to those meetings and participating in committees. And with respect to TMA, not only committees but councils; apparently people agreed with some of the things that were important to me and with the way that I could express that, and those were the folks that asked me to serve in various positions with TMA. And my wife says it’s because I can’t put my hand down and haven’t learned how to say “no!”

Q  Looking back at some of your leadership roles between TCMS, TMA, AMA, and the different organizations you’ve been with, what have been some of the highlights along the way? 

A  I’ve had the incredible privilege to serve as president of Tarrant County Medical Society, now president-elect for the TMA. I’ve been very honored to serve as president for Texas Pediatric Society and president of the Texas chapter of the American Academy of Pediatrics. One of my most fun jobs was when I got to chair the TMA Council on Legislation. That was really a fun time – there was a lot of interaction at the capital, and I’m looking forward to that as president next year since it’ll be a legislative year starting in January. 

But perhaps one of the most challenging positions was serving as chair of our TMA Board of Trustees during the pandemic when we had to become an emergency disaster board. Thanks to the great teamwork by all members of our Board, we got through it and managed to take care of the TMA business that needed handling.

Q  Going back to the legislative session, what are some of your overarching goals for that? And what are some of the things you hope to accomplish during your presidency? 

A  My agenda is mainly just serving my fellow physicians in the best way I can. You know, I think we’ve really taken it on the chin with COVID. For two years there have been challenges from appropriate equipment shortages to a lot of garbage on the internet that has been very misleading. So my main goal for this year is for us as physicians to reclaim trust, to try to unify better, to try to communicate better, and try to find the common issues that we need to stress and push that really impact our patients. Also, to protect the autonomy of the patient-physician relationship however we can so physicians can address issues comfortably without either [patients or physicians] fearing interference from any of those other entities, be it government, be it insurance, be it hospital – whatever.

Q  That concern is definitely a top issue. So what would you tell someone who is right at the beginning of their career, or the beginning of their involvement with organized medicine?

A  For any physician just starting it’s really important for them to know who they are, so they have to have a support base. And for me that starts with faith, with my faith in the Lord. For them it may be something else, I don’t know, but I think that has really helped ground me. The other part of that is my family; they keep you grounded, and they keep it real. And then joining in with colleagues. Being not just a participant or a member but being and getting involved in organized medicine. 

There’s a lot to be done. We have a lot of committees and councils that are doing excellent work and it’s finding what’s important to you and making the time. You literally have to make the time to get involved. You sacrifice some family time and time working in your practice. So you have to be aware of that; you have to plan. But I just can’t encourage people enough, to know how rewarding and how worthwhile it is to make that time to join with your other colleagues and be involved in organized medicine and join the leadership team.

Q  So looking at this next year, it’s a very exciting time for you. You’ve had a great career; you got to help a lot of people in both practice and in organized medicine, but now you’re starting something new. Do you have anything you’d like the physicians of Tarrant County to keep in mind this next year?

A  One thing I would say, not only to the Tarrant County physicians but those throughout the state, is to stick to issues. State opinions about issues, but insulting public officials is never going to get us anywhere, not even into compromised territory. Call me, call [TCMS CEO] Brian Swift, get it off your chest. But don’t put it out on social media; it rarely achieves anything. 

For the folks in Tarrant County, I know practice and family and faith life are demanding, but I am an example that you can do organized medicine with all of that. I would encourage you to show up. Just come. The biggest part of getting involved is showing up. We are always looking for people to serve on committees and councils. I didn’t do anything special; I don’t have any special knowledge. The experiences I’ve gained are because I’ve shown up. It’s important to be involved now, because the practice of medicine is being challenged in many ways, and it is your chance to make a difference for your practice and your patients. So show up; you’ll be glad you did.  

In our next issue, you will again hear from Dr. Floyd as he reports on his experience as TMA president and highlights TMA’s top priorities.

TMA Foundation grants tackle public health problems


By Emma Freer

Originally published in Texas Medical Association’s January 2022 issue of Texas Medicine. It was republished with TMA’s permission in the March/April 2022 issue of Tarrant County Physician.

When Trey Moore, MD, started his career as a urologist in Fort Worth 26 years ago, he worked in a busy emergency department and his own private practice. In both settings, many of his patients weren’t covered by insurance and could only access stopgap care. At the same time, he was surprised by the dearth of opportunities for physicians like him to give back to their community by offering their services pro bono.  

So, in 2011 he jumped at the chance to join Project Access Tarrant County, a then-nascent initiative of the Tarrant County Medical Society (CMS) that connects low-income, uninsured residents to specialty and surgical services provided by a network of volunteer physicians and facilities. Since its start, Project Access has served more than 1,700 patients and provided more than $14.5 million in donated health care. 

Dr. Moore especially likes the program’s focus on surgical care, which is unique in the world of health care safety-net programs. Given his specialty, many of his neediest patients – such as those suffering from large kidney stones that cause recurring, and sometimes disabling, infections – require surgery to recover fully. 

“Every [pro bono service] makes a difference, whatever we do, but [Project Access is] particularly helpful because so many of these patients – until they have a surgical resolution – are stuck in a vicious cycle of not being able to go back to work and cycling in and out of emergency rooms,” he said. “It’s a big stress on the patients and their families, and it’s a big stress on the system.”

But relieving that stress would not be possible without ongoing financial support. 

Project Access is one of several long-standing recipients of the Texas Medical Association Foundation’s Medical Community Grant program, which accepts applications from county medical societies and alliance chapters for up to $7,500 in matching funds to support unique community health improvement initiatives. The separate Medical Student Community Leadership Grants program accepts applications from TMA medical student chapters for up to $3,000 thanks to a fund established by Houston pathologist Roberto J. Bayardo, MD. 

For more than two decades, TMAF’s grant programs have helped the Family of Medicine tackle the state’s most pressing health care concerns at the local level. Many grantees, including Project Access, have received funding over successive years, which allows for continuous programming. Physicians like Dr. Moore say this is especially important in Texas, which has the highest rate of uninsured residents in the nation.  

Not only do the grant programs connect patients to life-changing care but also they honor TMA’s mission to stand up for Texas physicians by providing them with resources to create solutions to local health challenges and by reinforcing physicians’ trusted leadership in the community, says TMA Foundation Executive Director Lisa Stark Walsh. 

“Our goal is to remove the obstacle of resources for members to do what they feel is necessary in their communities,” she said. “Medical Community Grants give physicians an opportunity to chip away at long-standing, intractable problems over the long term and to demonstrate their advocacy for the health of all Texans.”  

Originally founded in 1966 as the Texas Medical Education and Research Foundation, TMAF is a separate, nonprofit entity that serves as the philanthropic arm of TMA. Since 1998, the Medical Community Grant and Medical Student Community Leadership Grants programs have disbursed $891,931 across more than 200 such grants to support myriad community health improvement programs all over Texas, ranging from vaccine clinics and border health services to breast cancer screenings and kids’ bicycle helmet giveaway events. 

Houston neonatologist and TMAF Board President Michael E. Speer, MD, is passionate about growing the foundation’s endowment so it can offer even more grants that support Texas physicians and their patients. “If you look at the most successful colleges and charities, the best ones spend very little on themselves and most of their endowment on supporting the organization,” he said.  

This growth mindset has paid off. In recent years, TMAF has fielded increased demand for the grant programs from county medical societies, alliance chapters, and medical student chapters. As a result, the upcoming application cycle will include a new focus area of physician health and wellness. This expansion stems from the success of a recent TMAF initiative, Caring for Physician Healers: Mental Health and Wellness Resources During COVID-19 Fund, which helped seven county medical societies launch or extend physician health and wellness initiatives during the ongoing pandemic. (See “Self-Investment: Physician Wellness Programs Bolster a Beleaguered Workforce,” November 2021 Texas Medicine, pages 22-25, http://www.texmed.org/Self-Investment.) 

By harnessing the expertise of medicine to help address a community health problem, the TMAF grant programs complement the work of the association and represent the best of organized medicine, says TMA President-Elect and TMAF board member Gary Floyd, MD.  

“Anyone in practice will find things that need to be changed,” he said. “When you’re alone or in a small group, you’re just a small voice yelling into the wind with very little result. When you join into organized medicine, particularly with TMA, you have [more than] 55,000 voices, and people tend to start listening.” 

Physician-driven results   
Tarrant County Medical Society received its eighth TMAF Medical Community Grant in support of Project Access in 2021. The program’s organizers say it is a prime example of what physicians can accomplish working together to solve an entrenched community health problem. Tarrant CMS was inspired by the Dallas County Medical Society’s now defunct Project Access initiative, which focused on primary care. Given Tarrant County’s robust network of free and income-based primary care clinics, Tarrant CMS decided to gear its own Project Access initiative toward specialty and surgical care since that’s where the need was most acute.  

Tarrant CMS Executive Vice President and CEO Brian Swift says Project Access runs on a shoestring budget that belies its impact. Patients are largely members of the working poor, and many are undocumented immigrants. They don’t qualify for Medicaid but typically don’t earn enough to afford private insurance, leaving them without coverage and beholden to emergency departments for symptom management. Without care that addresses the root cause of their medical problems, however, they are often robbed of their livelihoods – and sometimes their lives. 

By providing specialty and surgical care to eligible Tarrant County residents, the initiative not only helps patients resume healthy lives but also saves area hospitals tens of thousands of dollars in emergency department costs. “These patients don’t have access anywhere else,” said Stuart Pickell, MD, Project Access’ medical director and an internist-pediatrician in Fort Worth.  

Although physician volunteers provide specialty and surgical care, Project Access still requires funding to fulfill its mission. “Free isn’t free,” Mr. Swift said.  

As with previous awards, the county medical society used the TMAF funds to offset the costs of its annual patient database subscription. “Data management does not come cheaply, so we really depend on that [funding] to be able to manage our Project Access database,” Mr. Swift said. 

The grant-funded database – which Dr. Pickell describes as “essential” – allows staff to determine patients’ eligibility, which helps ensure Project Access is distributing its limited resources as judiciously as possible, and to track their care, including the donated value of medical services and administrative costs. In this way, the grant helps Project Access obtain more funding by quantifying its positive impact and cost savings. 

Armed with the database, staff can focus on serving patients – and the broader community. Typical cases include a woman with cervical cancer who would have died without surgery, leaving her young children orphans; a construction worker with a hernia that kept him out of work; and a patient with osteoarthritis that had nearly disabled her until surgery allowed her to resume a productive life. 

The Project Access model not only unburdens its patients and their loved ones from medical crises but also often allows them to return to work. This can be transformative, Dr. Pickell says, because a job offers the possibility of long-term health care access through employer health insurance. 

After a decade of success, staff are now working on growing the program. With more than 500 volunteer physicians across numerous specialties, including ancillary care, their attention is focused on the limiting factor of operating room space and other facility needs. By renting such space, rather than relying on the whims of donors, Project Access can increase its patient volume.  

Physicians would welcome such a change. “It’s such a gracious group of people,” Dr. Moore said. “They’re so grateful to get help. In a selfish way, it’s a great group to treat.”  

Project Access also is keen to expand, both to meet the community need and to highlight the work physicians do every day to serve their patients. It’s supported in this endeavor by TMAF’s Medical Community Grant program, which allows physicians to spearhead solutions to the problems they’re facing on the ground.  

“That’s why it’s so important for the foundation to continue doing what it does,” Mr. Swift said.  

An engine for innovation  
Another repeat recipient, in this case of the TMAF Medical Student Community Leadership Grants program, the annual HOPE Health Fair in Galveston tackles a community health challenge while also providing medical students with the opportunity to fine-tune solutions over the long term. 

The University of Texas Medical Branch (UTMB) TMA Medical Student Section chapter hosted its fifth annual event in November thanks, in part, to its fourth annual TMAF grant award. The fair connects approximately 250 uninsured Galveston residents – around a quarter of whom are homeless – to vaccinations, health care screenings, meals, and educational resources through the St. Vincent’s Student Clinic at UTMB. It also serves as a critical outreach opportunity in Galveston County, where 17.4 percent of residents under age 65 lack health insurance, according to the U.S. Census Bureau. 

“We’re just catching ships in the night, people who frequently never have access to health care,” said John W. Davis, one of the event’s organizers and a third-year medical student at UTMB who also is pursuing a PhD. 

The HOPE Health Fair received a $3,000 Medical Student Community Leadership Grant from TMAF in 2021, which covered about 40 percent of the overall cost. Without it, organizers would not have been able to host the event. “It’s very helpful for us to get this grant each year,” said Jenna Reisler, a third-year medical student at UTMB and an event organizer. 

In addition to providing critical funding, the grant also has spurred innovation. Because the organizers are repeat recipients of the grant program, they take pains to improve the event each year. In 2021 they used the award to offer rapid COVID-19 testing and screenings for sexually transmitted infections, including HIV and hepatitis C.  

By offering screenings, the organizers not only help attendees detect any debilitating illnesses they might have contracted but also prompt them to return to the student clinic to get their results and receive treatment. Once attendees have made the jump from the health fair to the student clinic, they can receive treatment for underlying health problems, such as diabetes and hypertension, and start to build patient-physician relationships. 

In this way, the health fair functions as a kind of benevolent Trojan horse, linking Galveston’s most vulnerable residents to health care for years to come. “It’s a way to show people that we care about them,” Mr. Davis said.  

Global reach
Located in a top U.S. county for refugee resettlement, the Baylor College of Medicine (BCM) TMA Medical Student Section chapter and the Houston nonprofit Alliance for Multicultural Community Services have used the TMAF Medical Student Community Leadership Grants program to host the BCM-Alliance Refugee Health Fair. The annual event helps refugees navigate the local health care system – and provides medical students a glimpse at global health in action.  

Like the HOPE Health Fair, the BCM-Alliance Refugee Health Fair aims to serve as a conduit for attendees to long-term health care access. At an upcoming event scheduled for this spring, student volunteers will distribute hygiene kits – including soap, hand sanitizer, masks, and health care resources in multiple languages – via a COVID-19-safe drive-thru. Attendees also will receive basic preventive health screenings and flu vaccines from local free and income-based clinics. 

Although refugees can access Medicaid for up to eight months upon their arrival in the U.S., they are expected to secure private insurance afterward. This is a complicated process that can quickly fall to the bottom of a refugee’s to-do list, overtaken by tasks such as learning a foreign language, securing a job, and familiarizing oneself with the local public transit system. But the BCM-Alliance Refugee Health Fair aims to smooth attendees’ search for health care by introducing them to the Alliance and area clinics.  

“Ultimately, even if these patients don’t stay on with these clinics, they at least have a starting-off point to return to if they develop a medical issue in the future,” said Avery Haugen, a fourth-year medical student at Baylor and one of the event’s organizers. “It really alleviates a lot of the stress of those first steps.” 

The Baylor TMA student chapter will use its latest TMAF grant – its fifth – to print promotional flyers, purchase hygiene kit supplies, and furnish volunteers with personal protective equipment. The grant, which accounts for nearly all of the event’s budget, is critical to its success.  

“This event is really not possible without the help from the TMA Foundation,” said Chris Wong, a fourth-year medical student at BCM and another event organizer. 

In addition to educating refugee attendees about the local health care system, the event also serves as a critical learning experience for the medical students involved. Both Ms. Haugen and Mr. Wong are interested in global health, which is partly what prompted them to get involved with the fair.  

“The event was really my first exposure to the idea of refugee health [and] the very specific health disparities that immigrants face, especially in our very complicated health system,” Mr. Wong said. 

Similarly, Ms. Haugen sees the event as a unique opportunity to learn more about global health while studying medicine in Houston – and largely prohibited from international travel by the ongoing pandemic. 

“For us, the refugee health fair is a really unique example of a way to promote global health on a local scale,” she said.  

The Hidden Costs of COVID-19

Public Health Notes

By Catherine Colquitt, MD

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

In response to soaring overdose deaths across the U.S. during the pandemic, the American Medical Association (AMA) Advocacy Resource Center published a brief on Nov. 21, 2021, cataloging increased overdose deaths state-by-state. They decried decreased access to “evidence-based care for substance use disorder, chronic pain, and harm reduction services.”1

The AMA also sent a letter to the U.S. Centers for Disease Control and Prevention urging requirements for health insurers to eliminate barriers to opioid treatment for patients who would benefit from these therapies (think prior authorizations for prescriptions and faxed referrals for specialists). The letter also supported the Biden Administration’s 2022 National Drug Control Strategy, which highlights increased production of medications for substance use disorders, harm reduction strategies (including needle and syringe exchange programs), access to naloxone without prescription, and elimination of health insurer obstacles which prevent persons with chronic pain from accessing pain management.

In addition, a letter from AMA’s Dr. James Madara, MD, to Regina M. LaBelle, the acting director of the Office of National Drug Control Policy, on July 9, 2021, stated that healthcare inequities and social determinants of health fueling the overdose epidemic and disproportionately affecting the “marginalized and minoritized” must be addressed.2

The National Vital Statistics System recently released its “Provisional Drug Overdose Death Counts” for 2021 for the fifty states and the District of Columbia.4 The total overdoses will likely be revised upwards as case compilations for 2021 are completed and reports verified, but the provisional death toll is staggering. Over the 12-month period which ended in June 2021, overdose deaths rose from 47,523 to 98,022, and in Tarrant County, our overdose deaths mirror the national trend with 350 overdose deaths for the 12-month period ending March 2021, compared with 185 overdose deaths for the 12-month period ending January 2021. (Tarrant County data are not yet available for April – December 2021 on the NVSS dashboard.) 

Overdose deaths provide one measure of the toll of COVID-19 in the U.S. and expose need for redress of healthcare inequities, access to medication for opiate use disorders, substance use disorder treatment, mental healthcare access, and access to pain management. Another way the impact of COVID-19 is being assessed is through peer-reviewed publications exploring the hidden costs and benefits of conventional in-person (commuter) work versus work from home. 

“Over the 12-month period which ended in June 2021, overdose deaths rose from 47,523 to 98,022, and in Tarrant County, our overdose deaths mirror the national trend with 350 overdose deaths for the 12-month period ending March 2021, compared with 185 overdose deaths for the 12-month period ending January 2021.”

The results of such studies are uneven and the responses necessarily somewhat subjective when subjects are questioned regarding their feelings about in-person versus telework; in general, workers viewed telework more favorably when they volunteered for it and when their schedules included a combination of both in-person and telework. When mandatory, some teleworkers experienced increased “work-family conflict” as the lines between work and domestic life blurred during telework. Teleworkers and conventional in-person workers reported variable effects on depression, exhaustion, fatigue, and energy level.5

Using data from the American Time Use Survey, authors asked workers to record in a diary where they worked (whether they commuted or not) and noted that male teleworkers in this study reported lower pain, stress, and tiredness levels, but that there was no difference in these measures among female commuters versus non-commuters.6

In another study based on the American Time Use Survey, the designers compared pain in working-at-home versus conventional workers and found no difference in pain reporting between the two groups. However, working-at-home fathers reported increased stress and working-at-home mothers reported decreased happiness.7

COVID-19 is, at the very least, an engine powering academic inquiry, which may have unexpected future benefits for the way healthcare is delivered and work is done.  In the meantime, we must continue the important work of educating, advocating, and caring for our communities.

References
1. AMA Advocacy  Resource Center:  Issue brief: Nation’s drug-related overdose and death epidemic continues to worsen, Updated 11/12/2021 

2. AMA letter to Regina M. LaBelle, Acting Director of Office of National Drug Control Policy, 7/9/2021

3. AMA letter to the U.S. Centers for Disease Control and Prevention, June 2020

4. National Vital Statistics System Provisional Drug Overdose Death Counts – NVSS dashboard for current data, with final data when available from https://www.cdc.gov/nchc/nvss/mortality_public_use_data.htm

5. Oakman J et al. A rapid review of mental and physical health effects of working at home: how do we optimize health? BMC Public Health (2020) 20:1825

6. Song Y, Gao J. Does telework stress employees out? A study on working at home and subjective well-being for wage/salary workers J Happiness Stud 2019;21(7):2648-68

7.   Gimenez-Nadal JI, Molina JA, Velilla J. Work time and well-being for workers at home: evidence from the American Time Use Survey. Int J Manpow 2020; 41(2): 184-206

I’ve Done My Research

President’s Paragraph

by Shanna Combs, MD

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

“I’ve done my research.”

These can be some of the most dreaded words to hear as a physician from our patients and their families.  We can spend seven-plus years in medical school, residency, and sometimes fellowship, studying our field before we embark on our journey to practice medicine.  We also hone our craft through continued learning throughout our careers.  Yet, we are often confronted with the above phrase.  Since when did Dr. Google become such an expert that it can supersede our years of training and practice?

This became ever more apparent as the COVID-19 pandemic started over two years ago. (Yes, we have crossed over the two-year mark and are still counting).  With a lack of information and understanding of this novel virus as well as increased access to information on the internet, we in science and medicine saw people seeking out answers from all the resources they had access to.  This unfortunately led to propagation of numerous pieces of misinformation, distortions, and half-truths.  Add to this the politicization of our nation and the polarization regarding best measures on how to handle the COVID-19 pandemic, and unfortunately, we in science and medicine are left as the ones not to be trusted.

As a women’s health physician, I am confronted with this on an almost daily basis.  While the internet can be a valuable resource of information, it can also be a not so valuable resource of misinformation, lies, and myths.  Misinformation was commonly passed along in relation to women’s reproductive health even before the advent of the internet.  Unfortunately, nowadays it has a much wider reach with the “expertise” of Dr. Google to further spread these untruths.

What are we to do in this constant back and forth of the internet versus the doctor?

For me, I try to meet my patients and their families where they are.  I work with them to better understand where they are coming from as well as who or what their source of information is.  I cannot undo the vastness that is the internet and Dr. Google, but I can work to build a relationship with my patients and their families to come to shared decision making to provide the best care for them.  

For me, I try to meet my patients and their families where they are.  I work with them to better understand where they are coming from as well as who or what their source of information is.  I cannot undue the vastness that is the internet and Dr. Google, but I can work to build a relationship with my patients and their families to come to shared decision making to provide the best care for them. 

While this is helpful in individual encounters of patient care, I also feel that it is important for us as physicians to be out in the public arena as well. Because of this, I never turn down an opportunity to speak when asked, and I am always happy to provide my expertise for those in the media.  As physicians, we have a duty to educate. This is a responsibility not only to the individual patients we take care of, but also to the public. By offering education that is based in science and grounded in our years of continued study and experience, we can work to counteract the vast amount of distorted information that is out there.  I, for one, will continue in my efforts to dispel myth and spread truth.

A Texas Trailblazer – May Owen, MD, a Medical Pioneer and TMA’s First Female President

By Sean Price


Originally published in Texas Medical Association’s December 2021 issue of Texas Medicine. It was republished with TMA’s permission in the March/April 2022 issue of Tarrant County Physician.

On May 27, 1936, May Owen, MD, answered a scientific riddle in a speech before the Texas Medical Association, explaining research that would soon make her a statewide celebrity. 

The name of the paper she read that day, “Peritoneal Response to Glove Powder,” sounded vague to nonexperts. But the other clinical pathologists who gathered to listen understood that Dr. Owen had uncovered that a common medical practice posed a threat to patients.  

The mystery started nearly 16 months earlier when a fellow Fort Worth physician alerted Dr. Owen to the case of a 19-year-old woman with unexplained fibrous membranes and tumorous nodules growing in her abdomen. The woman had had her appendix removed two years previously, and something about that operation had gone wrong.  

After months of research, Dr. Owen proved that the unusual growths plaguing the woman had been caused by the talcum powder used at the time to coat surgical gloves. Human tissue couldn’t absorb the powder, so if just a little bit inadvertently fell into a wound during an operation, it caused infection, scar tissue, and other problems.  

Dr. Owen read her paper before a mostly appreciative audience that gave her a standing ovation, according to her biography, May Owen, MD, by Ted Stafford, which is the source for most of this article. But when most of the crowd sat down, one man remained standing and began to shout. 

“I have been sitting here listening to this woman spout off about the dangers of glove powder,” he said. “I don’t believe a word she has said.” 

He continued ranting until the meeting’s chair ruled him out of order and told him to be quiet. Later that day, Dr. Owen won an award from the Texas Society of Pathologists, just one of many she would earn, including an honorary doctor of science degree from her alma mater, Texas Christian University (TCU). 

The man’s outburst rattled Dr. Owen, reminding her of just how far she had come as a woman in medicine – and how far women like her still had to go to win acceptance. But she never lost confidence in herself or her findings. 

“I knew if I lived to be 100, that [discovery] would be my most important contribution to humanity,” she recalled.  

The research forced surgical glove makers to switch to a starch-based powder the human body could absorb. Texas newspapers clamored to interview this “woman doctor” – partly because her work had caused such an uproar and partly because so few women physicians existed anywhere at the time. 

Dr. Owen’s pioneering work continued in the decades to come, making her the first female president of the Texas Society of Pathologists in 1946, the first female president of the Tarrant County Medical Society in 1947, and the first female president of TMA in 1960. 

She had help from friends and relatives during her difficult rise from poor farm girl to honored Fort Worth physician, and that made her a conscientious mentor to hundreds of young physicians and people interested in medical careers. 

One of them was Margie Peschel, MD, who started her career in Fort Worth as a resident in 1959, when women were still rare in the medical profession. She later became a pathologist who ran what is now Carter BloodCare from 1976 to 1997. 

“I always felt lucky to be in Tarrant County because Dr. Owen set the example that women are welcomed,” she said in an interview with Texas Medicine.  

From farm to medical school 
Dr. Owen was born in 1892 in Falls County, just southeast of Waco, the sixth of eight children. She grew up doing hard work on the family cotton farm, and her parents, Jack and Lilli Owen, allowed her to go to school only after her morning chores were done.  

Dr. Owen’s mother died when she was nine years old, and her father – whom she describes in her biography as autocratic and demanding – became even more so. He put more chores on his daughter and scoffed when she told him she intended to be a doctor.  

“Get that silly idea out of your head right now,” she recounted him saying, according to her biography. “Your place is here on the farm. We will not discuss this matter anymore. Do you understand?” 

Dr. Owen’s father tolerated her finishing school up to seventh grade, but only the intervention – and financial assistance – of an older brother allowed her to go first to high school and then to college at TCU in Fort Worth, graduating in 1917. In 1921, she became the first woman to graduate from what is now the University of Louisville School of Medicine in Kentucky. 

Dr. Owen’s father did not actively prevent his daughter’s education, but he also never helped it and never acknowledged her accomplishments. Nor did he answer the many letters she sent after she became a physician.  

“Her father never honored her,” Dr. Peschel told Texas Medicine. “It was sad. We would drive from Fort Worth to Austin for TMA meetings, and she shared things like that – that her daddy never did recognize her.” 

During the 1920s and 1930s, Dr. Owen worked mostly as a pathologist for Terrell’s Laboratories in Fort Worth, and the owner – Truman Terrell, MD – was her friend and mentor. He loaned her the money to attend medical school. She also did advanced study at the Mayo Clinic in Rochester, Minn., and Bellevue Hospital in New York.  

Despite her intense training, some fellow physicians – frequently older doctors – still refused to accept her medical opinions. In one case, when a surgeon argued that she was wrong, Dr. Owen found a clever way to win him over. 

“I split the specimen in half and did my examination on one section and reported my findings to the surgeon,” she told her biographer. “The other half was sent to the pathologist at Massachusetts General Hospital in Boston. When his report came back, it agreed precisely with what I had reported. After a while the people who had doubted my ability and competence began to accept my work without question.” 

Dr. Owen also earned the respect of veterinarians early in her career because her rural background gave her an understanding of animals and farming. In 1931, a vet at the Fort Worth Stockyards asked for her help in identifying a mystery disease that was killing sheep. Some suspected anthrax. But Dr. Owen discovered that the molasses cake being fed to the sheep to fatten them up was giving the animals diabetes. This discovery changed the way sheep were raised worldwide. 

Despite what coworkers recount as a crushing work schedule, she remained active in all levels of organized medicine, and she encouraged medical students and young physicians to join organizations like TMA. By the time Dr. Peschel became a pathologist in 1964, Dr. Owen knew just who to talk to to get her colleague assigned to committees in TMA and other medical organizations. 

“She was so active,” Dr. Peschel said. “She introduced me to everybody at TMA and the pathologists in the state. She just knew all these people. She was an excellent mentor.” 

Dr. Owen expressed a deep debt to the people who helped her get a start in medicine. 

“I know I could never have done it alone,” she said in her book. 

As TMA president, Dr. Owen established TMA’s Physicians Benevolent Fund to help physicians in times of distress. She led the charge with a $2,500 contribution of her own, and since 1961, the fund has distributed more than $4.38 million in financial assistance.  

“We all know of cases where our colleagues have suffered illness, death, or other misfortunes,” Dr. Owen said to TMA board members when requesting the fund’s creation.  

She contributed money to students individually and also helped establish the May Owen Irrevocable Trust through TMA to provide low-interest loans to medical students. When Texas Tech University Health Sciences Center in Lubbock opened in 1973, Dr. Owen helped provide the library’s first 20,000 volumes and established the school’s first endowed chair. 

In old age, Dr. Owen continued to work hard until her health failed. She died on April 12, 1988, at age 96.  

“She said, ‘We should all be so lucky to work at something we love until the day we die,’” Dr. Peschel said. “She did that.”