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TURNING 2021 – STARTING THE YEAR MENTALLY FIT

by Aekta Malhotra, MD, MS

Originally published in the January 2021 issue of the Dallas Medical Journal. Reprinted with permission.

There is a prospective optimism that a new year brings allowing a “start over” positivity that helps our collective need to shed and renew. Yet, before we burst out the Champagne, we should process how we got here as 2020 may well have been the most challenging year of our lives, with enough despair, wounds, and wisdom, such that we are Turning 2021, metaphorically speaking, of course.

We have been in the grips of a worldwide pandemic that has upended our personal and professional lives. Our nation’s soul lays bare amidst a fight for racial equality. As the pandemic rages on, our mental health has continued to take a hit. The chronic exposure to stress is causing a variety of issues. The uncertainty, lack of sense of control, and alteration in our values and routines have given way to anxiety. The successive, unexpected changes brought on by the pandemic have also been underscored by a series of losses—our jobs, how we work, our children’s routines, travel, finances, gathering with family and friends, and simple pleasures like eating out and entertainment. This sense of loss over life as we knew it has been a chief driver of depression. When attempting to suppress severe wildfire, there is a possibility for firefighting crews to be overrun by wildfire, known as entrapment and burnover. There are many metaphors that come to mind when we consider the toll of 2020 on our mental fitness. Move over burnout. We are suffering from burnover.

Turning 2021 might not feel like a moment to see the glass as half full, but a critical step towards restoring mental fitness, and a favorite tool in the psychiatrist’s toolbox, is perspective taking. This is not meant to minimize the harsh reality of an incredibly difficult 2020 with Pollyannaish optimism. Many of us have lost loved ones, friends, and colleagues. We are sad, frustrated, and exhausted. But as we reflect on 2020, taking stock of the losses and triumphs, there were unmissable silver linings:

Creativity
Amidst the suffering, we witnessed heights of human spirit and ingenuity. Rising to the clinical and logistical challenges, we put on our problem-solving caps to make the most of a limited supply of Personal Protective Equipment (PPE), ventilators, and medications. When our hospitals reached capacity, we built makeshift hospitals and converted concert centers into giant negative-pressure rooms. We served our patients to the best of our abilities, embracing the steep learning curve and ever-changing guidelines and information on COVID-19. We held our patients’ hands to give them a dignified sendoff when their loved ones could not be there in their last moments. Our creativity wasn’t just limited to our professional lives; In addition to doctor, we added teacher, caregiver, coach, and other roles to our credit.

Technology
We went virtual. Sure, we went from one online meeting to the next and had to scramble for a bathroom break, but we found a great way to safely connect with our patients, parents, friends, and each other. When we ached for culture, we brought Hamilton, the Metropolitan Opera, and concerts streaming home. We virtually toured cities and world class museums, studying art masterpieces, closely zooming in and out.

We flexed our tech muscles and found other convenient ways to bring the comfort of nourishment and shopping for essentials to our doorsteps. It took a few months to get the hang of it, but we joined online gyms and live workout classes from home.

Our internet bandwidth made it possible to meet the combined needs of work from home, telemedicine, online school, and a dozen devices streaming online platforms simultaneously. We concurrently admired and doom-scrolled the Institutional and governmental COVID-19 data repositories. Most importantly, we had real time information about this pandemic on our fingertips, (at times—perhaps too much information).

Community
We learned that gratitude and grief can coexist. Our circles got smaller by necessity and we became intentional about our connections, out of which came bonus time with family and pets (and plants). Without our usual external outlets and distractions, we turned inwards and made time for introspection. We came upon unexpected opportunities for nourishment—we took up new (and old) hobbies, games, books, podcasts, yoga. We made a commitment to support struggling local and small businesses. Even if the presidential election of 2020 delivered a powerful referendum on how divided we stand, we found ways to unite over popular fads and shows. We developed new coping skills, and when these were not sufficient, we leaned on our colleagues, family, and friends for support. Meanwhile, our scientific community also embraced the challenge of 2020 with a promise of a vaccine, which has been developed in record time.

Priorities
There’s nothing quite like a pandemic to make us reevaluate our priorities. As physicians, we (finally) learned to say no as self-care became more critical than ever. We watched a third of the country burn in wildfires and came to appreciate the profound impact of our choices on our environment. A discussion about Turning 2021 would be entirely remiss without acknowledging the pandemic of racial oppression thrust into the forefront in 2020. The intersectionality of COVID-19 pandemic and social determinants of health has been underscored by the disproportionate and devastating impact of the pandemic on black, latinx, and indigenous people of our nation. So, we committed ourselves to the task of self-examination and intentional antiracism. Out of activism came a commitment to change for the better with more progress on equity and justice.

If 2020 was the ultimate exercise in improv, we gave a performance worthy of cheers and ovation. Even so, 2020 was especially stressful for doctors as we were stretched beyond our capacities in all spheres of our life, all at once, and for far too long. Published research on the impact of the pandemic on health care workers in the U.S. is limited at this point, but the data from China, Italy, France, and other countries impacted by COVID-19 earlier on in 2020 are telling. As a volunteer psychiatrist for the Physician Support Line, a free and confidential peer phone support helpline for struggling physicians and medical students, I have heard countless stories of physicians and medical students, I have heard countless stories of physicians who endured a risky, exhausting, and demoralizing milieu for much longer than the human body and mind were meant to tolerate—all the elements of not just burnout, but anxiety, depression, post-traumatic stress disorder (PTSD), substance use, and much more.

In his seminal book on trauma and its effects, The Body Keeps the Score: Brain, Mind, and Body in the Treatment of Trauma, Dr. Bessel van der Kolk discusses how trauma and chronic stress rearrange the brain’s wiring— specifically areas dedicated to pleasure, engagement, control, and trust—in a process known as neuroplasticity. The human response to psychological stress is one of the most important public health problems, and doctors are especially susceptible to it because of the nature of our work and the long hours, only compounded by the pandemic. Many of us are Turning 2021 psychologically wounded, exhausted, and mentally exhausted.

Taking stock of 2020, Turning 2021 mentally fit might seem like a lofty goal. Fortunately, there are evidence-based strategies that can help us ameliorate the impact of chronic stress as we pursue our goal of mental fitness in 2021.

Recalibrate “normal”
We have endured a collective trauma in 2020 that has given way to a crisis of meaning. The chronic stress might make you feel irritated, impatient, angry, sad, and you might experience feelings of disconnection, difficulty concentrating, and a range of other cognitive effects. You might also be navigating anxiety, depression, or fatigue. These are all perfectly human, adaptive responses during such a difficult time.

● Welcome and honor the full spectrum of emotions that make you human, because they are here to teach you important lessons about your triggers, coping skills, and current emotional state.

● Practice Self-compassion – as physicians, we have several personality traits that lead us to pursue careers in medicine, including perfectionism and self-denial. While these traits can serve us well in doing our clinical work, they also give way to unrealistic personal and professional expectations, including denial of personal vulnerability. Some days your best IS enough. You are a doctor, but you’re also human. Acknowledge and accept your vulnerability.

● Seek Help – part of recalibrating normal is to also normalize seeking help. Extraordinary stresses cannot be overcome with ordinary measures. Although we all have the ability within us to heal, we sometimes need support in the journey to self-realization and optimal mental fitness.

Reflect and release
Unprocessed traumatic memories and stress can become sticking points that cause our mental and physical processes to suffer. As such, it is imperative that we reflect inwards and take intentional steps towards improving our mental fitness. The journey to recovery can be slow, intentional, and at times, uncomfortable, yet, immeasurably rewarding. As with any form of recovery, the first step is acceptance.
● Give yourself the permission to grieve the many losses of 2020, including loved ones, colleagues, and even your routines. This isn’t always at our forefront, but in addition to attachments to other people, we also develop powerful attachments to our work, things, and places.

We know that neuroplasticity and trauma go hand in hand. Just as traumatic events can forge neural pathways, so can positive and effective therapeutic experiences that help us cope and heal. The psychiatrist’s toolbox is equipped with evidence-based strategies to help you navigate this journey.

● Psychotherapy – if anxiety is the worst use of the imagination, psychotherapy helps us reestablish psychological safety and dial down the trauma response. There are numerous evidence-based therapies to help address anxiety, depression, and burnover, such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, psychodynamic psychotherapy, and Mindfulness-Based Stress Reduction. The undertaking of knowing oneself might be the most challenging yet rewarding experience of one’s life, with lasting results. In fact, suffering often brings with it the opportunity that drives emotional growth for a more mentally fit self. As with anything worthwhile, this process requires time and commitment.

● Medications and more – we enter the medical profession with many underlying vulnerabilities, including personal and family medical and psychiatric history, chronic stress from childhood, personality factors, social determinants of health, and much more. Moreover, the stress from medical training is associated with systemic inflammation, telomere shortening, and oxidative stress, findings which have often also been reported in major depression. Antidepressant medications, in particular, are associated with not just mood recovery but also recovery from oxidative stress on a cellular level. There are also several medication and non-medication augmentation strategies that can help you with your mental recovery. Most importantly, a good psychiatrist can blend psychiatric medication management and psychotherapy while empowering you with skills for self-management over time.

If the body keeps the score of chronic stress, then the symbiotic relationship between the mind and body becomes a critical target for recovery.

● Mind-Body strategies – we all know the benefits of exercise as a healthy coping skill to build our mental and physical fitness. However, when we are exhausted, the last thing we might want to do is run laps around the neighborhood with a mask on. Fortunately, recovery from stress does not require us to train like an athlete. In fact, routine, less intense activities, such as walking a pet, doing the laundry and dishes, gardening, and washing your car can be just as effective and give you a sense of accomplishment. One of the best strategies to facilitate traumatic release from the body is to engage in an intentional, slow, and mindful activity like yoga, which you can easily access over the internet from the comfort of your living room.

If you’re suffering from burnover from another discussion about mindfulness, you’re not alone. I had similar skepticism about mindfulness when I first took the eight-week Mindfulness Based Stress Reduction (MBSR) course. In fact, around the third week, I recall being quite frustrated with the process of completing the same body-scan meditation every day for an hour or more, but I stuck with it. Around week six, a sense of calmness came over me. My movements and actions became more intentional and I felt less exhausted, without any change in the rigor of my clinical schedule. My relationship with nourishment also changed as I learned to chew my food instead of my thoughts, which saved me precious mental energy to devote to other aspects of my life. When I wavered from this intentionality, I returned back non-judgmentally to the task at hand. One of the greatest misconceptions about mindfulness is that it helps us fight distressing thoughts. Quite the contrary, mindfulness allows us to change our relationship to the distressing thoughts that are a part of living.

Reimagine “Work”
As physicians, our careers have been shaped by the expectation of conformity married to the assumption that resilience and professionalism are in endless supply, particularly during a pandemic. Fittingly then, 2020 has been the ultimate test of our professional status quo. While the long hours and medical culture might make it seem that your personal identity is inextricable from your professional one, this is a perfect recipe for burnover. Along with recalibrating normal, Turning 2021 mentally fit requires that we reimagine work as an extension of what we do, rather than us as an extension of who we are. You are a person with many gifts, values, dreams, and talents, and one of them just happens to be being a hard-working doctor. This could be a variety of things, including spirituality, advocacy, mentorship, leadership, and other activities outside of your profession. Also, as much as possible, release yourself from the myth and burden of multitasking. Focusing on one task at a time and being mindful of the task at hand will improve your concentration and help you to be more mentally fit. Spreading ourselves thin depletes our battery faster than working on tasks individually. Like any of your devices, the more programs you have running simultaneously, the harder it is on the system. It is the same for our body and mind.

Reclaim Joy
Mental fitness is not merely the capacity to endure, but also the capacity to recharge. Most of us forget the latter. Take the time to slow down and explore other aspects of life that fill your bucket and keep you mentally fit. Recreation, humor, daydreaming, connection with nature, your partner’s touch, and the simple act of doing absolutely nothing at all can all be ways to recharge your mind. Rather than spending your time on passive activities like binge watching shows, find a book or a podcast that teaches you something new. Monitor your screen time and disconnect digitally to give your mind a digital holiday. Be it while on a walk around the neighborhood or on your walk from the parking lot to your office—put down your phone, pull down your mask and stop to smell the roses. New experiences and new ways of doing old things can also set you on the path to mental fitness.

Most of all, remember that mental fitness is not a checkbox, it’s a moving goalpost practiced over time with intentionality. If at first you fail, get up and try again. And again. And again. Join me in the commitment to turn 2021 happy, healthy, and mentally fit!

Reimagining the Future of Medicine in a Post-COVID World

by Susan Bailey, MD – AMA President

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

Dr. Bailey presented this speech at the AMA’s House of Delegates on November 13, 2020.

In my inaugural address to the AMA House of Delegates in June, I talked about how a hero’s journey is symbolic of the journey we walk as physicians.

Our journey starts with a moment of inspiration to pursue Medicine. We find a mentor to show us the way. We encounter struggles and hardships before emerging stronger and more resilient . . . forever changed by the experience.

Few times in history have we embodied the hero’s journey like we have in this past year. In June I talked about Harry Potter, Star Wars, and The Wizard of Oz . . . but much of the last few months have felt more like the dystopian world of The Hunger Games.

COVID-19 has brought immense challenges and pain for so many—including our physician community. We have struggled mightily at times. Many of us know a colleague who lost their life to COVID-19. Many of us have fallen ill, or we have watched a family member or loved one battle the virus.

We have done things in 2020 that we could not have imagined . . . shining a spotlight in an uncomfortable place—on ourselves—as we repeatedly cried out for more protective equipment to keep us and our patients safe.

For the financial aid to keep our struggling practices afloat.

For the information and resources to make sense of it all. To provide counsel for our patients. To better understand what we were up against.

As we greet the new year 2021, the pandemic feels a little different now.

We don’t know if it is the end of the beginning . . . or the beginning of the end. But we are a bit wiser and a bit tougher than before.

“As with every hero’s story, we must learn from the trying times we have experienced. We must grow and move forward because that is what a hero is asked to do. “

We don’t know everything about the journey ahead, but there is plenty we do know.

This year has shown us the best in physicians and our health care community—the nurses, assistants and staff personnel who are always by our side.

Who are in the trenches with us even in the most difficult of times . . . and that understand the importance of physician-led teams.

But this year also has revealed how politics can be corrosive . . . how misinformation and anti-science rhetoric can impede our ability to respond in a health emergency and can magnify the cracks and inequities in our health system.

Nine months into our fight against COVID-19, the pandemic is as dangerous as ever. We have reached record highs and surges continue across the country.

We have learned in this most difficult year that no person and no community is safe from this virus. It reaches everyone . . . no matter their background, their income, or their politics.

And yet, in face of this pandemic—perhaps the greatest threat to public health in our lifetimes—physicians have heroically answered the call.

Time and again, through surges and plateaus, working under intense pressure and at great personal risk, our physician community has risen to the challenge of this moment.

We have done this with courage and with selflessness because of our singular dedication to our patients’ health.

And now, with a new year ahead and possible vaccines on the horizon . . . we are about to make a fresh start. Change is in the air.

Never again can we allow the politics of division to undermine our ability to deliver the very best care to our patients.

Never again can we allow anti-science bias and rhetoric to undermine our public health institutions . . . and discredit the work of physicians, scientists, and researchers.

Never again can we allow a campaign of misinformation and disinformation to co-opt conversations around public health . . . and sow divisions that only serve to prolong the suffering of so many.

Never again can we allow public health officials to feel the pressure of threats and intimidation simply for doing their jobs.

And especially when lives are at stake, never again should physicians have to fight a war on two fronts—caring for severely ill patients in a raging pandemic . . . while at the same time battling a public relations war that questions the legitimacy of our work and our motives.

This is unacceptable . . . and we will not and cannot continue to work in this atmosphere.

While we have seen the best of physicians in 2020 . . . we were reminded again of the power of the AMA, the TMA, the TCMS, and of the entire Federation community working on our behalf and being our voice when it mattered most.

Our organizations created tools and resources—all grounded in credible science and evidence—to help us respond to this historic crisis.

We pushed the administration to accelerate production for testing and PPE. TMA and TCMS kept our practices supplied with life-saving equipment.

Our medical organizations helped establish a financial lifeline for struggling physician practices, securing tens of billions of dollars in financial support, grants, and interest-free loans to infuse practices with much-needed capital to survive this pandemic.

Organized medicine was a leading national voice in support of science, evidence, and data as the surest path through this pandemic, launching a major public health campaign to encourage everyone, everywhere to “Mask Up.”

All of us should be proud of how organized medicine has stood up for physicians this year.

As with every hero’s story, we must learn from the trying times we have experienced. We must grow and move forward because that is what a hero is asked to do.

That is what physicians are expected to do.

That is what we expect of ourselves.

All of us are eager to see an end to this pandemic. And with encouraging new reports about vaccines nearing approval, there is tremendous excitement about what the new year will bring.

But we are not there yet. All of us need to continue to do our parts. We need to constantly remind everyone to wear masks, wash hands, and physically distance. We need to remain steadfast and focused until the very end.

We should not underestimate the fight in our opponent. Every time we feel like we have COVID-19 on the ropes, here and abroad, we see it roaring back.

We have to remain strong and follow where the science leads us.

The next few months will be buzzing with anticipation about the post-COVID world that will emerge.

Regardless of when that day arrives . . . and when normalcy returns, whatever that will look like . . . our AMA, specialty, state, and county societies will play a critical role in shaping the health system of the future.

A system that ensures that everyone has access to the affordable and meaningful coverage they need.

A system that relies on science, evidence, and data to guide our approach to public health and prevention.

A system free of the historic barriers to care . . . and ensures that all patients stand on equal footing.

A system that supports and integrates a revitalized public health infrastructure.

A system that protects the patient-physician relationship from outside influence at all costs.

And a system that prioritizes physician health and wellness . . . and eases administrative burdens that take us away from what we do best . . . caring for our patients.

Despite the challenges of this past year, and they have been extraordinary, I continue to believe in the power of organized medicine to fix the persistent problems in our health system.

I believe in science and evidence to light our way.

And I believe in the strength and resolve of physicians to take on any challenge . . . and rise to any moment.

The hero’s journey is our journey. And we are exactly where we are meant to be.

The Evolution of Medical Education

by Monte Troutman, DO – Publications Committee

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

I can brag on myself as I have been involved with medical education for over 40 years now. Thirty-seven of those years were spent working as an assistant and then an associate professor of medicine at the Texas College of Osteopathic Medicine (TCOM) within the University of North Texas Health Science Center. I was the first full-time gastroenterologist there. I left private practice in Dayton, Ohio, where I was adjunct faculty at the Ohio University College of Osteopathic Medicine. I wanted to be more involved in medical education than that position offered. So why am I telling you all this? So you know that I have been around a long time and have seen a lot of changes, including monumental ones in medical education, from the classroom to clinical bedside clerkships.

UNTHSC developed an Academy of Medical Educators where physicians, other health care providers, and basic scientists at TCOM have learned and discussed the theories and principles of medical education including Bloom’s educational approach and Miller’s framework for assessing clinical competence.

After we learned the fundamentals, we now concentrate on other aspects of medical education. One of the of most significant changes that has transformed how we educate is that we no longer “lecture.” Indeed, it is now considered a four-letter word—lecturing is seen as passive learning. Also gone are reading assignments from textbooks. Other forms of education now rule the roost. This includes online education and interactive forms of learning.

So, what is so wrong with textbooks? About 10 years ago, I read a letter to the editor in the New England Journal of Medicine, where two second-year UCLA medical students calculated the total number of pages assigned by instructors for one semester. A staggering 10,000 pages were assigned and were fair game when testing occurred at the end of the semester. Too much? Yes!

A recent Google search stated the doubling of medical technology in 1950 was 50 years, in 1980 seven years, in 2010 three and a half years, and in 2019 one and a half years. Now in 2020 it is 73 days; not even three months. I recently told this to a fourth-year medical student on my service and as his eyes widened, he exclaimed, “That’s scary!” So, to revisit what is wrong with textbooks, here it is: The editors work with other experts to write a designated chapter, all work is edited and corrected, it is then published, printed, distributed, and purchased, etc., etc. This whole process takes years. So how many times has medical technology doubled in that time frame? Educators still refer to textbooks, but as references, not as primary education material.

A man walks into a bar in New Orleans and asks for a Corona and three hurricanes. The bartender hands him the bill—$20.20. Yes, the COVID-19 pandemic has changed things, possibly permanently. Virtual medical education is the current modus operandi. Zoom, WebEx, Skype, and Join.me, to name a few, are the classrooms today. Right now, learning clinical skills is generally virtual. Inconceivable but true—not hands on but virtual patients. Not entirely new, just brought to the forefront due to the pandemic.

Over the past several years, the lecture (that four-letter word again) hall has been sparsely filled unless attendance is mandatory, as some medical schools still do require, or if an in-person quiz is on the schedule. Before attendance began to drop, medical educators made the classroom an interactive session and the iClicker was used to respond to questions. However, with Power Point presentations now online before the lecture is given, and voice over with the Power Point, why go to the lecture hall? Pull up the Power Point whenever you want, play it at 1.5 to 1.8 speed, and listen to it twice. The thought is that the classroom is wasted time, and you avoid being called on in class.

There is still in-person training. I teach in the second year, which includes small group sessions called Clinical Reasoning Modules (CRMs). In the CRMs, about eight to 10 students are presented with clinical cases by a moderator who leads the discussion on history, physical, labs, imaging, etc. The model used is a version of clinical reasoning called a “mind map,” and it stresses differentials and necessary testing and imaging. Grading is based on participation. As the “clinical expert,” I rotate to all the small groups and answer questions. This is where I get to meet students I have never seen before.

So, if there are no textbooks or lectures, what do the students do to prepare or to learn? Good question! Instead of scheduled lecture time, regular time is scheduled during their day to “study.” Faculty prepares Directed Student Activities (DSAs). The DSAs include society guidelines, videos, online sites like Up To Date and more. Here textbooks are listed, usually as reference rather than test material. As you can imagine, the students are very resourceful and tell me about sites they find on their own that support their learning process. The list I have been informed about and use to refine my DSAs are Baby Robbins, Pathoma, First Aide, Sketchy Medicine, Get Body Smart, Picnomics, and Hardin MD. As you can imagine, the time spent by faculty to screen all these sites is overwhelming. Since our curriculum is problem-based, symptoms or problems are the topics of our DSAs. Since I am a gastroenterologist, my topics are abnormal liver chemistries (not called LFTs anymore), nausea and vomiting, dysphagia, GI bleeding, constipation, diarrhea, and so forth. Can you imagine the time needed to condense these topics into DSAs that are current and learnable using this format?

I have been around a long time and seen a lot of changes, including monumental ones in medical education, from the classroom to clinical bedside clerkships.

To worsen the situation, clinical clerkships have been adversely affected by the pandemic. Many institutions banned medical students from direct patient contact, and in some instances, from entry into hospitals or surgery centers. Virtual patients were used to teach clinical skills devoid of in-person contact or interviewing. When will they get to see patients in person and learn bedside and in-office clinical skills? Who knows with the recent COVID-19 surge. Some have learned telehealth clinical care, which in some cases may be here to stay. Recent legal issues about student participation in clinical care have also started to cloud the problem. How will all this impact future clinical skills?

So, all these issues in medical education will indeed have an impact on health care. Medical educators have their work cut out for them in the new learning environment compounded by a seemingly never-ending pandemic. Not only are medical students educated to pass boards and clinical competencies, but to become lifelong learners. They must learn without DSAs and with doubling of medical technology every several months. When do they learn cost restraints, physical exam, and other competencies?

I know that this essay is called the Last Word, but this is hardly the last word on this topic. Hold on to your hats—this is a new world. Who knows what the new normal will be? As for me, the Last Word is that knowledge can be communicated, but not wisdom.

Virtually Interviewing in the Midst of a Pandemic

by David Lam, OMS-IV

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

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

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

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

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

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

Get your Flu Vaccine

by Catherine Colquitt, MD

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

Getting to Know Angela Self, MD – 2021 TCMS President

by Allison Howard

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By Angela Self, MD – TCMS President

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

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

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

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

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

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

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

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

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

by Stuart Pickell, MD, MDiv, FACP, FAAP

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shared Decision-Making – How can we know that a medical decision is truly “shared” and the consent obtained truly “informed”?

Truth-Telling and Apology – How do we communicate with patients about difficult topics, especially when something goes wrong, or we make a mistake that results in patient harm?

High-Stress Conversations – How does our communication with patients change when providers are in a high-stress situation, and how can providers self-regulate and/or de-escalate a contentious conversation?

Patient Communication (in general) – What can we all do that will engage patients and foster relationships in which information can be shared in a meaningful way?

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

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

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

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

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

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

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

“Thank You”

by Teresa Godbey, MD
2020 Gold-Headed Cane Recipient

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

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

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

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

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

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

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

The Doctor’s Doctor

Gold-Headed Cane Award Recipient Teresa Godbey, MD

By Allison Howard

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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