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by Hujefa Vora, MD, Publications Committee Chair

From the Achieves: This Last Word was originally published in the September 2017 issue of the Tarrant County Physician and has been edited for clarity. You can read find the full reprint along with the rest of the content from the July/August 2022 publication here.

He was an amazing businessman.  His acumen, combined with an ability to take the required risks, helped him to build an automobile repair empire.  His smile was infectious.  With it, he instilled a fierce sense of loyalty in his employees and business partners.  And his words.  His Texan twang was musical and fierce.  He could cut a deal in seconds with a “Howdy Y’all” and then a “Sign here . . .”  That’s how he won the heart of his high school sweetheart.  He danced with her from the prom, where he was the King, all the way to the white-washed wedding chapel.  They had four children, each one more beloved than the previous, each with that same smile.  When he first came to me, I could see what they all loved in him.  Despite always being short on time, I would spend the extra few minutes just to laugh at his latest story.  I would adjust his blood pressure medication.  Somewhere along the way, I added a statin.  He did not smoke, and he had no family history.  He was doing well, and so that’s why the stroke came so unexpectedly.  Four years ago, the conditions changed.  The stroke took the entire right side of his body.  He couldn’t walk.  He couldn’t use his right hand and arm.  He was immediately wheelchair-bound.  That was not the worst of it, though.  The worst was when we found out that he had lost his voice.

The stroke hit his speech centers.  He developed an expressive aphasia.  He could understand everything that was said, but he could no longer utter a word.  The damage to Broca’s area was irreparable. His physicians concurred with this assessment.  Perhaps we thought his life was over, or at least the life he had built.  His wife’s love for him was stronger than that, though.  It was stronger than the assault on his brain and body.  She kept him in his business.  She kept him in the game.  She would take him to physical therapy to strengthen his resolve.  She took him to speech therapy and learned his language.  She brought back his smile.

She took him to work every day.  She was his voice in the meetings.  He would smile and grunt, and his empire did not crumble.  Physically, he was weak, but as a partnership, she and her husband held strong.  I remained amazed by all of this whenever I saw them in clinic.  Here was a strong man brought to his knees by a stroke that should have ended him, but instead, he flourished.  He flourished because he had a partner that stood by his side always.  Even as we did not, she understood his every unintelligible utterance, his body language, and above all else, his smile.

I am given the honor of seeing them periodically in the office.  He has had a hospitalization here and there, and she remains his constant companion.  She is his advocate.  She is his voice.  Despite everything we think we know about medical science, she has proven that he is unbreakable.

I often wonder about the intricacies of their relationship.  I wonder at his wife’s ability to understand him.  Most of all, I marvel at their resilience.  Despite overwhelmingly insurmountable odds, they have survived.

Most of all, I marvel at their resilience.  Despite overwhelmingly insurmountable odds, they have survived.

There are so many life lessons I have learned from my patients over the years.  I want to bring only one of these to all of you.  Together, we are stronger.  Despite any of our individual weaknesses, we can always give a voice to one another.  This becomes especially true in our partnerships and relationships outside of our practices.  I am a dinosaur on an island.  I am a solo internist.  How do I ensure that my voice is heard?  I can promise you that the people in Austin and Washington think they know what it is I need and I want.  They think they know what we are saying.  They think that they can fix medicine.  Meanwhile, we think that they are listening to us.  We believe that our intelligence and our charisma will carry the day.  This is in fact our greatest strength and our greatest weakness.  We know we have the answers on how to fix healthcare.  I know this to be a fact.  My fellow physicians, I have heard all of you loud and clear over the past several months.  I have had amazing conversations.  I have gained so much insight into my own difficulties in medical practice, and I have come to a better understanding of so many of the difficulties many of you face in your day to day.  Some of these discussions have led to even deeper insights . . . But there is the rub.  How will we get to action?  Action requires us to understand our greatest weakness.  We help others all day long, and even though we think we have all of the answers, we are unable to really express them.  We too have a form of Broca’s aphasia.  I would assert that we need a partnership to make absolutely certain our voice is heard.  I believe the partner that binds us all together is the Tarrant County Medical Society, in conjunction with the Texas Medical Association.  Many of you have expressed your inability to completely agree with this.  We don’t always agree with our partners 100 percent of the time.  (Don’t tell my wife this!)  Moreover, we need a partner and an advocate that speaks our language and understands us.

Maybe I’m just preaching to the choir.  In the end, we will all need to continue to work together, not individually . . . We must come together and make sure that our voice is heard loud and clear . . . They will hear us.  Kumbaya.  My name is Hujefa Vora, and this is our Last Word.

by Hujefa Vora, MD
Chair, Publications Committee

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

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

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

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

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

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

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

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

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