Category: The Last Word

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.

By Hujefa Vora, MD – Chair, Publications Committee

This piece was originally published in the January/February 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

The medical students were sent into hiding.  We chose not to risk their bodies to the unknown illness.  Instead, most of them sat alone at home in front of computer screens.  They attended lectures virtually.  Physical contact became taboo.  Learning turned into rote memorization of presented facts, with little opportunity for the hands-on training of our time.  

In our clinics, we went into hiding as well.  Our appointments became virtual.  We too hid behind these computer screens.  Physical contact became taboo.  To start a visit note, we would write that the patient had consented in an informed fashion to participate in a virtual visit, utilizing a platform with audio and visual capabilities.  Patients would take their own blood pressures using their automatic home monitors.  Often, they would not only create their own objective findings, but also their own interpretations of their subjective history.  When we no longer touch our patients, when we can no longer hold their hands, we become severed.  The patient-physician relationship is powered by the force of our connection to our patients.  

A story that needs to be told.  I had a patient who smoked incessantly.  He was referred to my office by his cardiologist, who explained his worsening shortness of breath by saying it is not his heart.  He came into my office for the first and last time in March of 2020 just prior to the lockdown.  We spoke of his three packs a day habit.  We talked about how for the last month, he was unable to walk across his living room without becoming short of breath and coughing until it felt like his heart would pop out of his chest.  Fearing the worst, I sent him out to get a chest x-ray.  Those fears were confirmed with the finding of a complete white out of the right lung.  A CT scan confirmed the presence of malignancy in the setting of emphysema.  We couldn’t get a biopsy right away because the lockdown happened.  Many of you will remember that elective surgeries were put on hold.  Biopsy of a mass which I was sure was cancer was not necessarily elective, but getting the procedure done became nearly impossible.  I had to present the case to our surgical review board at the hospital in a Zoom meeting.  They authorized my procedure and scheduled the next available interventional radiologist.  As the day of the biopsy approached, we were informed that the patient would not be admitted without a negative COVID PCR result.  In the early days of the pandemic, PCR results took sometimes one or two weeks.  We had 72 hours, and it took about that long to actually get the test done.  Upon finding that we were not going to get the biopsy done, I spoke to the patient and his family over the telemedicine platform my office had just installed.  If we admitted him to the hospital, we might be able to get things done more efficiently.  The patient’s daughter refused this option.  We will be surrounded by COVID.  I can’t risk that.  The patient continued smoking his cigarette pensively, deliberately.  The patient was offered a pulmonary consult instead and possible bronchoscopy.  It took another three weeks to get the patient in front of the computer screen of the pulmonologist, and then another two weeks after that to get the bronchoscopy done.  Ten days later, a pathologist called me to let me know that the patient had waited too long to quit his smoking habit and now had squamous cell carcinoma of the lung.  This is the kind of news that needs to be conveyed in person, not something to be said over the phone.  The patient refused to break his lockdown, so that meant the phone was how this would happen.  Unfortunately, the patient’s daughter was unavailable, so we were unable to establish the video component of the virtual visit.  I told my patient he had cancer over the phone, unable to reach out and make any physical contact, not even something as simple as a handshake or a pat on the shoulder.  I couldn’t see his face to read his thoughts, get some signal of the inner turmoil he might be experiencing.  I did my best to follow his verbal cues.  We talked about the plan.  He wanted to know our next steps.  Well, it took another month to get the patient onto a Zoom call with an oncologist.  Another three weeks got us into the virtual room of a cardiothoracic surgeon.  The surgeon agreed that the patient would need surgery to remove the tumor and at the very least improve his quality of life by making it so he could breathe.  The patient was referred back to our original cardiologist for cardiac clearance prior to surgery.   In order to get his stress test, he was subjected to another PCR test for COVID-19.  This came back a little quicker than expected, negative as was expected.  The patient underwent his stress test and was negative for inducible ischemia.  He was cleared for surgery.  At his preoperative evaluation for his scheduled surgery, the patient was told he would need another COVID-19 test.  He refused, as he had the PCR just two weeks prior at his stress test, and he was tired of the runaround.  Unfortunately, this assertion of control, this blatant attempt by the patient to avert further procrastination, further delays of his surgery, backfired.  In the meanwhile, I had been following the patient’s progress for the past six months with monthly phone visits or Zoom calls.  And so, I tried to take control of the situation.  I spoke to the surgeon, questioning why it had been necessary to delay surgery for a cardiac clearance in a patient with known cancer.  We would not have delayed the procedure for CABG had this been necessary.  So we had lost more time.  I produced the records of three COVID testing results over the past few months.  I again met with the hospital’s surgical review board.  We worked out a plan of care.  I brokered a deal.  The patient would go for surgery as soon as the surgeon scheduled.  We had one last meeting before surgery.  It was now September.  The patient asked me if he would be recovered by November 4th, election day.  I told him that I was not sure.  He informed me that he would not schedule his surgery until after election day, because he needed to vote in the election.  The surgeon reluctantly agreed to schedule him for surgery on November 5th.  The oncologist interceded and demanded that another PET CT be done prior to scheduling the surgery.  Another PCR was ordered and refused.  Another deal was struck.  The patient’s PET CT showed progression of the disease – not a surprise.  On November 5^th, the patient finally went for his surgery, 249 days after our opening salvo. Ten days in the ICU.  I didn’t see him because we were in the heart of COVID at this point.  You know this patient though.  He was too stubborn to let this cancer beat him, too tough and thick-skinned to allow even COVID to get through.  He survived all of this.  The oncologists offered him chemotherapy and radiation treatments, but he refused.  He went back home to his couch and his cigarettes.  Behind the scenes, I continued to coordinate his care with the surgeons, his oncologists, the cardiologist, and the pulmonologist.  To him though, I was just another voice over the phone, a talking head disrupting his existence.  Molasses.  Quicksand.  COVID testing.

Our patients went into hiding.  Their trust of the medical establishment is broken.  Our relationship with them, though we looked out for their best interests, is broken.  We have socially distanced ourselves into a corner.  It is time to come out of hiding.  It is not taboo to touch our patients’ lives.  It is what they expect.  With this new year, we must wake up.  We must remind our patients that we will always fight for them, whether we are fighting against cancer, against COVID, against politicians, against ignorance, against fear.  Never against them, but always with them.  My patient survived, thrived, but I have never seen him again.  This is the Last Word.

by Hujefa Vora, MD

A note from our committee meeting seemed to resonate with me. One of our editors asked the group to describe the tone of this edition of the Physician. They were asked to clarify the rhetorical question. The point made was that this edition of the magazine read more like a collection of biographies than a medical journal.  Are we physicians compiling and writing a medical journal?  For over a decade now, I have worked with this committee to help produce this magazine.  I don’t know if I’ve ever really thought of it like I do perhaps the New England Journal of Medicine or JAMA.  Such magazines are usually filled with double-blinded studies, research into this and that, and critical analyses of the science of the day.  Our journal seems a bit different.

The President’s Paragraph tells of a rocky childhood and challenges overcome. In reading this, we are reminded that as physicians, we all have stories that define not only who we are personally, but also the lives we lead professionally. We are not automatons or angels with all the answers. We are humans who aspire to be more for the betterment of all of humanity.  We are not brilliant white sheets flowing in the wind.  Rather, we are tapestries with amazing, intricate stories.  The beauty of these tapestries is reflected in the practice of our trade.  Because of our own complexities, our patients connect with us, and so bonded we weave the physician-patient relationship.  Through the experiences of our own pain, we are able to relieve their pain, alleviate their suffering, and embrace our collective humanity.

The student article also speaks to fighting through stigmas and strife to achieve a goal, an almost unattainable dream. Humble beginnings define the immigrant and minority community biographies. The idea that a poor student from a third world country with nothing more than the shirt on his or her back could somehow immigrate to this country and then in a generation that individual’s progeny are successful professionals and entrepreneurs, physicians even. This idea would sound impossible back in their homelands.  Like our student though, many physicians have lived through this dream. We were told that the obstacles were insurmountable. We may not have been recognized as being able to be something more than our station, our family’s station. We may have been told that we don’t belong.  We may not have had the means to support ourselves and our families.  And yet, we endeavored to persevere.  Some students may have been discounted.  Despite this, we fight on.  We work harder.  Become stronger, wiser.  We work so that we can achieve this solitary goal of the betterment of the lives of our patients.

The feature article speaks to our connections. They are not always palpable, but they remain very real. For some of us, the physician-patient relationship comes easy. We are able to effortlessly bond with our patients.  We acknowledge our collective humanity, forging solid connections.  The relationships we have with our families and our friends often remain more evasive.  And so when these relationships cross into our professional lives, we often celebrate them.  The article celebrates the human connection, the love and respect we have for our fellow man, and then the love we have for our friends and family.  Every day in our practices, we celebrate the physician-patient relationship.  Inevitably, we celebrate our patients and the love we have for them.  Many of us agree that medicine is an art, not a pure science.  We weave our tapestries together with our patients.  We often speak of professional distance, but this really does not apply well to medicine.  We often cross our patients with loved ones, and vice versa.  We take care of our patients just as we would our own families and flesh and blood, to the point that our patients often become our family in their own right.

 We take care of our patients just as we would our own families and flesh and blood, to the point that our patients often become our family in their own right.

These are the issues which are woven into this month’s edition of the Tarrant County Physician.  If you read back, you will readily recall that these are the issues that are found throughout every edition of the journal of the Tarrant County Medical Society.  In every sense, the articles that are published for your perusal are our collective biographies.  They are the words of our TCMS Family.  These are the stories of the physicians of Tarrant County.  We have always asked our membership to contribute to the magazine, and we have never been disappointed.  All of you have beautiful tapestries to share with all of us.  I continue to encourage you to share your stories with our committee.  After all, in answering the initial question, this is not a medical journal.  We always appreciate and publish any scientific contributions by our member physicians and will continue to look forward to doing so.  If you have any articles or studies or research that you have done which you would like us to consider publishing, please send them in.  And if you think your story, your biography, your words can be shared, then please send these in as well.  The Tarrant County Physician is a direct reflection of our membership.  All of us have amazing, interesting, intricate, and beautiful stories.  Every time you read my own articles, I share my own biography with you.  I hope that y’all will continue to share your stories with me and all of us in your TCMS Family (you can do so by sending them to editor@tcms.org).  My name is Hujefa Vora, and this is Our Last Word.

by Tom Black, MD – Publications Committee

This piece was originally published in the November/December 2020 issue of the Tarrant County Physician. You can read find the full magazine here.

“I can only wait for the final amnesia, the one that can erase an entire life.”
—Luis Buñuel

There is little doubt that my wife will outlive me, likely by decades. Her father lived to the age of 100, and we celebrated her mother’s 101st birthday last month. There is no substitute for good genes. Her father’s memory remained sharp until he laid down one afternoon for a nap and didn’t awaken. He had been quite a baseball enthusiast as a young man—his grandsons loved to hear him tell about the time he met Babe Ruth. In his final years, he avidly watched any and every sport on television and knew every player and their current statistics in several of the major sports. His wife, however, has followed the more familiar scenario of progressive dementia with increasingly poor short-term memory over the past three years. At this moment, she is sitting across the room from me, and she just asked for the third time in five minutes what the temperature is outside. It is sad for me to see this happening to one of the three most wonderful women I know.

I am all too familiar with dementia from my own father’s last few years. He had been a brilliant chemical engineer and remains one of the most accomplished people I have ever known. It was painful to witness his decline. I once watched him read and reread a typed letter on a well-worn piece of paper. Each time he did so, his smile faded and his eyes filled with tears before he sadly put the letter down. Within a few moments he had regained his usual happy demeanor and was about his business until he noticed the letter lying where he had placed it. He picked it back up and reread it with the same sad results. After observing this cycle several times, I peeked at the letter and saw that it was from his primary care physician. It read, “Dear Mr. Black, you have been diagnosed with dementia . . . . .” I disposed of that letter very quickly, and my father never realized it was gone. His memory loss progressed inexorably from short-term to include even long-term during his final year, resulting in a peaceful but oblivious state of total amnesia. It was no longer possible to pursue a meaningful relationship with him because we shared no common ground and could discuss only the environment around us at that moment. We could no longer revel in family memories. He recognized no photographs and could not even recall personal food preferences. Toward the end, we visited him—not for his sake, for we realized our visit would have no significance to him after we left—but for our sake, because it would be of significance to us. 

In his 1985 book, The Man Who Mistook His Wife for a Hat,  the late neurologist, Dr. Oliver Sacks, recounted the story of “The Lost Mariner.” Jimmie G. had developed amnesia due to Korsakoff syndrome. He could remember nothing of his life since the end of World War II, including all events that had taken place more than a few minutes earlier. He believed it still to be 1945, and although he behaved as a normal 19-year-old, Jimmie was, in reality, nearly 50. He was completely incapable of accomplishing anything noteworthy because he could not build one memory upon another to form a progressive narrative. His life had been frozen in time, in 1945. It was a living death.

Is there a better explanation of what makes life meaningful than Memory? Without memory, life cannot possibly be more than a moment-to-moment existence. In his memoirs, the film director, Luis Buñuel, wrote, “You have to begin to lose your memory, if only in bits and pieces, to realize that memory is what makes our lives. Life without memory is no life at all. Our memory is our coherence, our reason, our feeling, even our action. Without it, we are nothing. I can only wait for the final amnesia, the one that can erase an entire life.”  

“Generations from now, their descendants will know about them, but they won’t know them.” 

I am noticing that my forgetfulness is slowly increasing. Doorways have become amnestic devices; as I pass though one into the next room, I find I have suddenly forgotten the reason I came. I am on the hunt for ways to stave off memory loss.

Which brings me finally to the point of this essay. 

The movable printing press was invented in China around 1040 AD using porcelain type, but Gutenberg had the immense advantage of an alphabetic language when he introduced the metal movable-type printing press in Europe around 1450. Suddenly information could be much more easily recorded than ever before, and the past could now be remembered by means other than oral or hand-written accounts. Within 50 years, over 9 million books had been printed, accelerating the dissemination of ideas in the early Renaissance. What defines the Modern Age if not the ability to more thoroughly record and recall past actions and discoveries? And how much greater of an invention is digital storage, which can “remember” and make instantly available entire libraries of information. 

My father lived out west, and I was able to visit him about three times a year. At the time we celebrated his 90th birthday, my mother had recently passed away, and my father had plenty of free time. I asked him if he would do me a big favor, and he agreed. Knowing he had led a very interesting and eventful life, I asked him if he would please write his autobiography so his children, grandchildren, and future descendants could always know what a great man they had as an ancestor. He agreed to have at least one chapter completed by each time I visited, and while I was there, I typed what had he had written into his computer. After the 16th chapter, he declared that he was done. I had the book printed and bound, along with the diary that my mother had kept the last two decades of her life, and each of their living descendants received a copy. This book has become a priceless remembrance of two noteworthy lives, more meaningful to me than to my children, because I knew both of my parents so well that I seem to hear them speaking the words as I read them. For the next several years, my father spent much of his time reading and rereading his autobiography, reliving in his mind, I am sure, the halcyon days of his youth and productive adult life that he would otherwise have been slowly forgetting. 

About that time, I was talking with a friend and former college roommate. His 100-year-old father, a former physician, was living with my friend and his wife at the time, and I asked my friend what his father was doing with his time. “Oh,” he replied, “most of the time he just sits and reads the autobiography he wrote 10 years ago.” With the brain, as with a digital storage device, sometimes a hard copy is helpful to have on hand for when the primary device begins to fail.

Although a written autobiography won’t assure you of immortality in an eternal sense, it will give you an opportunity to achieve immortality in this life and assure that the memory of your existence will long outlast you. Begin writing it now while your experiences are fresh in your mind; small bits of your personal history may be eroding away even as you are reading this. It was labor intensive for my father to write the words by hand and then to type them into the word processor. It is so much easier these days with recording devices everywhere; my iPhone will even transcribe voice-to-text while I am driving, and I can edit later. I can’t imagine the process getting any easier than that, since thought-to-text technology, to my knowledge, is not just around the corner. 

Throughout their last years, my wife and I interviewed her aged parents. We quizzed them about what life was like as they were growing up during the ‘20s and the years of the Great Depression. We learned of their lives as newlyweds during World War II and as they raised their children during the mid-twentieth century. We added to what we already knew of them as empty nesters. We compiled our notes into biographies of them before and after they became a couple. A century from now my father-in-law’s descendants might still read about him growing up in a town with no paved roads and few automobiles, about his visit with Babe Ruth and his stint in the Army during WWII. They will read about his wife’s parents, who were immigrants from the Ukraine; her reputation as the best golfing, bowling, and tennis partner in the area; and how she and her future husband met on a blind date. But it just isn’t the same as my parents’ accounts; they are altogether too brief for such long and noteworthy lives. Most importantly, they lack a personal touch. I don’t hear their voices when I read their second-hand stories. Generations from now, their descendants will know about them, but they won’t know them. Don’t allow that to happen to you. For a future reader to hear your voice rather than that of your biographer, you must write your story yourself. It is your opportunity to have The Last Word.

 ¹Oliver Sacks, The Man Who Mistook His Wife for a Hat, [New York: Simon & Schuster, 1970]

²Luis Buñuel, My Last Breath, [London: Virgin Books, 1983], p. 4-5.

by Shanna Combs, MD, TCMS Publications Committee

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

I did not get into medical school.

I failed my oral board exams.

I lost my job.

It all sounds like the trailer to an incredibly sad movie.  But the reality of the situation is I am a board-certified obstetrician gynecologist who has the best job ever.  So how did I get here?

“Everything will be okay in the end.  If it’s not okay, it’s not the end.”

These are the words I discovered many years ago when a friend was going through a hard time, and it is still a phrase we shoot back and forth when times are tough and not going the way we planned.  This is the same friend that picked me up after receiving my rejection letter the first time I applied to medical school. I was not allowed to wallow at home alone—a night of dancing was in order.

Once the dust settled on the acute shock of “not getting in,” I had to decide if this is truly what I wanted to do.  I had been a ballet dancer for almost my whole life and was making my income as a dancer, teacher, and rehearsal coach, as well as working at the community college in the physics lab.  Such is the lifestyle of an artist and their multitude of jobs.

Upon not getting into medical school, I initially thought about working in education with the goal of teaching ballet.  Ultimately though, the call to Medicine was too strong, so I re-took my MCAT, took a biochemistry course, and set my path toward reapplication the next year.  I cast a broader net and, in the end, I obtained the privilege of placing “MD” after my name.

Fast forward a few years.  I completed my residency in obstetrics and gynecology, passed my written board exam, and began my career as an attending physician.  I found my way back into teaching as an assistant professor for medical students and residents.  (Guess that career in education was always going to be there.)  During this time, I collected my cases and prepared for the next step in board certification—the oral board exam.

Since you read the opening lines, you already know the outcome.  Let’s just say, I knew I had failed the minute I walked out of the exam.  “Everyone says that” is what I kept being told, but the following week I discovered the truth.  It was a difficult time for me.  I went through some frustration before I got to acceptance, and there were definitely times where I was not the best person I could be.  In the end, I dusted myself off again, pulled up my big girl pants, and began the process for taking the exam again the next year.  After multiple reviews of my case list, many practice exams/pimping/torture sessions, I walked in for my second try at the oral board exam.

I left the exam with a vastly different feeling.  I knew I had passed.  The following week, while driving back from Colorado with my parents, I got the good news that FACOG could also go behind my name.  My mom made me pull over, and somewhere on the side of the road in rural New Mexico we got out of the car to dance and celebrate my success.  

Fast forward a few more years, and we were hit with the global pandemic: COVID-19. The world as we knew it was changed forever.  Little did I know that my personal world was soon to change as well.  A few months into the pandemic, I was notified that the clinic I worked for had terminated my contract without cause.  I lost my job.  How does a busy obstetrician gynecologist lose their job in the midst of a global health crisis?  I will never know—that is the problem with the phrase, “without cause.”

In life there will be successes and there will be failures.  We always talk about the successes but almost never talk about the failures. 

Once again, I found myself wondering what the next phase in my life would entail.  I remembered not getting into medical school and wondering if I even wanted to be a doctor anymore.  I had worked so hard to get to where I was, yet I was questioning it all over again.  Soon after finding out I had lost my job, a friend told me, “You know, you really have not been happy for the past year or two.  Maybe this is just what you needed.”  Harsh words to hear at first, but in the end, she was right.  So, once again I dusted myself off, put on my extra big girl pants, and looked for what I was going to do next.  

I have found true joy in working in the field of women’s health, but I always had a special interest in taking care of kids and adolescents.  Too often this population gets lost in the shuffle.  I am now happy to say I have found a new landing spot in pediatric and adolescent gynecology.  Young ladies go through many changes during their young lives and even more so during the transition of puberty.  I frequently say, “Puberty is hard,” and I am now able to provide the care and support these young ladies need.

In life there will be successes and there will be failures.  We always talk about the successes but almost never talk about the failures.  However, it is within these moments that you learn the most.  So, why not talk about your failures?  I have truly found the honesty of my inner self when I fail.  I never thought I would be where I am today a year ago, five years ago, or 17 years ago.  Yet, I kept rolling with the punches and taking the next step forward always remembering, 

“Everything will be okay in the end.  If it’s not okay, it’s not the end.”

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.

by Robert Bunata, MD – Publications Committee Interim Chair

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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