Wednesday, November 15, 2017

Be Antibiotics Aware: Smart Use, Best Care

It’s Antibiotic Awareness Week — Nov. 13-19

Jane D. Siegel, MD
Pediatician/Pediatric Infectious Diseases Specialist
Chair, Texas Medical Association Committee on Infectious Diseases

Editor's Note: November 13-19 is Antibiotic Awareness Week. The following post offers recommendations to limit exposure to antibiotics to only those people who truly need them, in order to avoid development of bacterial infections for which there will be no effective therapy. 

No physician wants to see a patient with a serious infection for which we have no antibiotic to treat it effectively. That is why this week, the Centers for Disease Control and Prevention (CDC) is asking us — physicians and patients — to rededicate ourselves to improving the use of antibiotics. 

For physicians, this means limiting prescriptions for antibiotics to conditions likely to benefit patients, thereby reducing the risk of the emergence of antibiotic-resistant bacteria. If we overuse antibiotics, we run that risk, as treatments for infections from these bacteria stop working because the antibiotics no longer kill the bacteria.

The Texas Medical Association is collaborating with the Texas Department of State Health Services on activities to improve antimicrobial use. Antibiotic Awareness Week, which coincides with similar efforts in Europe, Australia, and Canada, and by the World Health Organization, reminds us to think about how we use antibiotics.
Here are two activities physicians can initiate or emphasize this week, incorporate into our practices, and explain to patients and their families:

1. Antibiotic time out: Right drug, right bug, right duration                                                          
This practice of fine-tuning of physicians’ decision-making involves a few straightforward steps to ensure we use antibiotics only when needed according to established recommendations. 

CDC has some excellent graphics and information for patients and their families so they understand how physicians make treatment decisions and why they might not prescribe an antibiotic in a given situation. This practice is applicable to long-term care facilities (LTCFs) and is a component of the antimicrobial stewardship program that the Centers for Medicare & Medicaid Services will require in all LTCFs in coming years. 

Patients: These are the rules your physician applies to prevent antibiotic overuse when they care for an ill patient:
  • Does this patient have a bacterial infection that requires antibiotics? If the physician believes a patient’s illness could be caused by a bacterial infection, he or she will run appropriate diagnostic tests and prescribe a drug that will be effective against the organisms likely to cause the infection.  The physician might write a prescription for three days with a refill to complete the medication course. If the physician and patient cannot determine whether the patient has a penicillin allergy, the physician may recommend testing the patient to know if drugs containing penicillin are safe to use. Alternatively, the physician may watch and wait without antibiotics and reevaluate later.                      
  • Reevaluate at 48-72 hours. The physician then assesses how the patient is feeling. If any diagnostic test results identify the cause of the infection, the physician may prescribe a more narrow-spectrum antibiotic (a drug that treats only a specific family of bacteria). This helps prevent antibiotic resistance by targeting only the specific bacterium in play and would be effective for the remainder of the patient’s treatment for this illness. If there is more evidence to support a viral infection, the physician will discontinue antibiotic treatment, as antibiotics do not treat viral infections.
  • The physician will determine the necessary duration of the antibiotic course, based on evidence-based clinical pathways, which are clinical guidelines physicians can follow to treat various clinical conditions. Such guidelines are developed by reviews of carefully conducted studies and are endorsed by professional societies. 
2. Buy meat and poultry products that come from animals NOT fed antibiotics as growth factors.   
      The practice of using antibiotics as growth-promoting elements is an important risk factor for antimicrobial resistance. Antibiotics used this way encourage emergence of resistant bacteria in the animals. These resistant bacteria reside on the surface of meat or poultry products and are passed on to humans inadvertently if not handled safely.
Farmers and veterinarians have been educated to stop this practice, and we are making progress in the United States. But there is more work to do. When you go to the supermarket, buy only meat or poultry that says specifically, “No antibiotics used.” Designations such as “organic” or “no growth hormone” do NOT mean the meat or poultry is free of antibiotics. If you do not see this type of packaging in your market, ask the store to start carrying products from antibiotic-free animals. The more demand for these products, the more supply we will find. Both patients and physicians can heed this advice. Visit the CDC website for more information on antibiotic-resistant solutions, food safety challenges, and a U.S. Food and Drug Administration question and answer page

Monday, November 13, 2017

How Overuse of Antibiotics Is Creating Drug-Resistant Bacteria

By John P. Fardal, DO
Austin Family Physician

Editor's Note: November 13-19 is Antibiotic Awareness Week. The following post explains the differences between bacterial infections and viral infections, and how antibiotics can be used to treat bacterial infections but not viral ones. It also explains how overusing antibiotics can be harmful to public health, and urges patients to think twice before automatically asking their physician for antibiotics when they are ill.

Some bacteria split every eight minutes. They can go from a single cell to more than a trillion in less than half a day.

One of the most important advances in health care was the discovery of the antibiotic penicillin. It gave people a very big stick with which to fight bacterial infections. Unfortunately, one of the biggest health threats facing the world is the rise of drug-resistant bacteria, and part of the reason for that rise is the overuse of antibiotics.

How bacteria work:

Bacteria are everywhere, and are mostly beneficial. They help digest food, provide essential vitamins, and compete with bad bacteria. The bad bacteria, however, can make people very sick. Luckily, bacteria are different enough from human cells that scientists have been able to discover or invent chemicals that target them. This is how antibiotics usually work, either disrupting bacterial cell structure or shutting down their molecular workshops.

How viruses work:

Viruses, however, are very different from bacteria. While bacteria stay outside of human cells, viruses invade them and hijack our molecular workshops. Viruses then use their own blueprints to make what they need. They make thousands of copies of themselves in each cell they invade, and then burst out of the cell to invade more cells and repeat the process. Because they hide inside our own cells and use our own workshops, it's hard to shut down their production without shutting down our own normal body processes.

It's not possible to shut down viral workshops, but it is possible to go after the viruses directly. This is where antivirals come into play. They are the viral version of antibiotics, but they are different in an important way ― they generally target one virus strain, while antibiotics usually affect many different bacteria.  There are a lot of viral strains out there. The common cold has more than 200 viral strains all by itself. Antivirals are only effective for a few select viral infections.

How your immune system works:

Our immune system is usually very good at fighting both bacteria and viruses. In rough terms, it first has to notice that something is in our body that doesn't belong there. Once the intruder is noticed, our workshops ramp up production of antibodies that target it so the rest of our immune system can kill it. This can take a few days and is when people usually feel worst.

The problem with antibiotic overuse:

When we use antibiotics, they effectively kill a very large portion of the bacteria, but some bacteria are able to survive through variations of their genetic code ― also known as just being lucky. Usually, our immune system kills off those last few lucky bacteria, but every now and then one slips out with a cough or sneeze, and is able to set up shop in another person. Now there is a strain of the bacteria that can't be killed with that antibiotic, and it can make a trillion copies of itself in half a day. It's ironic, but antibiotics use is the single most important factor in the development of antibiotic-resistant bacteria worldwide.

Drug-resistant bacteria are scary ― really scary. In the days before antibiotics, people died from bacterial infections at a rate we would have a hard time believing today. Last year, about 2 million people in the United States were hospitalized with a drug-resistant bacterial infection. There are a few very strong antibiotics that are kept in reserve just to be used for those resistant bacteria, but eventually, the bacteria will become resistant to them as well. Luckily, it is possible to slow the development of this particular catastrophe by only using antibiotics when fighting a bacterial infection. And that's where the virus comes back into the picture.

Antibiotics are for bacterial infections, not viral infections

Most people go to the doctor with upper respiratory symptoms and expect an antibiotic prescription. They believe antibiotics can make their illness go away much faster than just relying on their immune system to do the job. And they are right ― antibiotics can be very helpful when someone has a bacterial infection. However, when they have a viral infection, all the antibiotic will do is kill off good bacteria. This may give the patient diarrhea, and every now and then cause a resistant bacteria to emerge, all without making the patient's infection any better. Nevertheless, some health care providers prescribe antibiotics when it's much more likely that their patients have viral infections, such as the cold, because they want to both keep their patients happy and cover a possible bacterial infection in situations where the diagnosis is not clear cut.

This is where we can all help to save the world in a very literal sense. If your physician thinks you have a viral infection and does not recommend that you use an antibiotic, please consider giving it a few days, to see if your immune system ramps up and fights the virus off on its own. If it doesn't, odds are better that it's bacterial, and a physician will almost always be happy to prescribe antibiotics at that point.  Waiting just a few days can make a really big difference.

Tuesday, November 7, 2017

Doctors Warn of Hurricane Harvey’s Hidden Aftermath

There is a hidden danger beyond the piles of debris and damage left behind by Hurricane Harvey, and it might come as a surprise. Besides mold-related respiratory illnesses, disease from exposure to floodwaters and even mosquito-borne sickness like West Nile and Zika viruses, Texas physicians warn of another, unexpected post-hurricane health concern: Mental and emotional health. Texas physicians warn that stress and grief in the aftermath of the storm may have longer lasting effects on the mental health of some hurricane survivors than storm-related injuries and physical ailments.

After a natural disaster, grief over the loss of homes, jobs, schools, friends, and neighbors takes its toll on a large share of the population. A November Texas Medicine magazine article covering Harvey’s aftermath says some survivors will be diagnosed with varying degrees of post-traumatic stress syndrome (PTSD), experience higher levels of family stress, suffer injuries from domestic abuse, and even see flashback memories of past traumas.

“I think the increase in family stress surprises some people,” said John Mutter, PhD, professor at Columbia University’s Earth Institute, who studies the impact of natural disasters. “It shouldn’t surprise you, but it does. People who live in a [Federal Emergency Management Agency] trailer who used to live in a house get sick of each other quickly, and that leads to trouble. … Post-disaster health issues are as much mental health issues as they are physical health issues.”

Many survivors will endure the five stages of grief: denial, anger, bargaining, depression, and acceptance of loss. As many as one-fifth to one-third (20 percent to 30 percent) of people even go on to meet the full criteria for PTSD. Valerie Rosen, MD, an assistant professor of psychiatry at Dell Medical School at The University of Texas and an expert in PTSD, said most people will have some symptoms consistent with PTSD, but most of these will recover without medical help and not suffer full-blown post-traumatic stress. However, she recommends primary care physicians in Texas, especially those in the coastal areas, screen their patients for signs of emotional distress. “If someone has not recovered on their own, they probably do need to seek treatment to prevent it from being lifelong,” Dr. Rosen said in the Texas Medical Association (TMA) magazine. “But it is something that is very treatable.”

Natural disasters also can kick up memories of past traumas like childhood sexual abuse. A person might function well under normal circumstances but face difficulty after a major storm. Jeffrey Levin, MD, professor of occupational and environmental medicine at The University of Texas Health Northeast in Tyler, said survivors of past traumas deal with stress and loss in their own way. “We’ll be progressing through that, and everyone does that at a different rate,” said Dr. Levin, a former chair of TMA’s Council on Public Health. “There will be a sense of being physically and emotionally drained. People may experience difficulty making decisions, staying focused.”

Dr. Rosen says while there is reason for concern about the mental health of Texans in the aftermath of Hurricane Harvey, not all of the storm’s effects will be harmful or create more problems; some outcomes even could be beneficial.

“There’s also post-traumatic growth, or positive outcomes, where people can really prioritize their lives differently and get a different perspective on things,” she said. “They can also increase their faith in humanity with all the volunteers and increased social connectivity. I think sometimes people are surprised at their own ability to skillfully manage new challenges or adversity.”

TMA’s Disaster Relief Program Awards $83,000 More to Medical Practices Damaged by Hurricane Harvey

Even as physicians anticipate long-term effects of Hurricane Harvey, many of them along the coastal bend are struggling to reopen their own practices and serve their patients — so TMA is offering help. TMA Disaster Relief Program officials recently distributed $83,000 to nine practices damaged by Hurricane Harvey.

This second funds distribution amounts to $424,590 in total that TMA has sent to help physicians with Harvey-damaged or destroyed practices. The funds have assisted 37 medical practices throughout federally designated disaster areas, including Beaumont, Columbus, Houston, Orange, Aransas Pass, and Victoria. The practices employ 116 physicians and 967 nonphysician staff.

The TMA Disaster Relief Program has collected almost $1 million in donations to help physicians whose practices sustained physical Harvey-related damage not covered by insurance or other sources of assistance.

TMA’s Disaster Preparedness & Response Resource Center has guidance on how to donate and for physicians who need assistance for their practice.

Friday, November 3, 2017

Vaccinations Help Ensure Holiday Merriment

Neatly wrapped packages, pies fresh from the oven, and a peck on the cheek make holiday gatherings merry for the youngest to the oldest. Sadly, someone’s cough or sneeze could spread a life-threatening illness to grandma or your new grandbaby whose bodies are less able to fight off infection. That’s why Texas physicians say making sure your family is up to date on vaccinations, including flu, is key to keeping everyone healthy this holiday season.

“Making sure your vaccinations are current protects you and others you’ll be around — from your new niece or nephew to your grandparent in a nursing home,” said Arathi Shah, MD, a pediatrician based in Arlington and member of the Texas Medical Association’s (TMA’s) Be Wise — ImmunizeSM Physician Advisory Panel. “Diseases like flu and whooping cough can’t spread when many people in a community (and family) are vaccinated.”

Infants, pregnant women, and the elderly are among those most likely to get sick and develop a serious complication from a vaccine-preventable illness. Two vaccinations are key to protecting you and others this holiday season:

  • Influenza (or flu): Everyone six months of age and older, including pregnant women, needs a yearly shot.
  • Tdap (protects against tetanus/lockjaw, diphtheria, and pertussis/whooping cough): Pregnant women need this shot in the third trimester of every pregnancy to protect their infant. Other adults need this shot once, then a Td (tetanus/diphtheria) every 10 years. Children and teens receive this shot as part of routine childhood and adolescent vaccinations, so those who are up to date on their vaccinations should have received this.  

Flu season can last from October to May; in most years, it peaks in December through February. Flu can become serious for anyone. The youngest and the oldest are most at risk, as are people with chronic medical problems like asthma or any condition that weakens their body like cancer.

As many as 26,000 U.S. children younger than 5 years of age have landed in the hospital with pneumonia or other flu complications annually in recent years, according to the Centers for Disease Control and Prevention. Most flu-related hospitalizations (nearly 70 percent), as well as flu-related deaths, occur in people over age 65.

Babies can’t be vaccinated for flu until they are at least six months old. That means those around them must protect them from the flu. The flu shot mom gets during pregnancy protects her and baby until the infant can get vaccinated, said Dr. Shah.

Whooping cough, or pertussis, is especially dangerous for infants. The Texas Department of State Health Services says more than half of babies under 1 year of age who get pertussis must be hospitalized. Many will have serious complications, like pneumonia or difficulty breathing, which can be life-threatening.

Pregnant woman are urged to get a pertussis shot during pregnancy to protect their newborn. Family members who will be around an infant also should get vaccinated against pertussis. Infants often catch pertussis from other family members or caregivers who don’t know they have it because their symptoms can be mild.

“Vaccinations are one of the best ways to prevent illness,” said Dr. Shah. “Don’t miss out on a holiday celebration or keep someone else away by getting or passing along sickness that could have been avoided — or worse, unwittingly pass along a potentially deadly illness to a loved one.”

For flu and whooping cough shots, your body needs about two weeks to develop the strongest protection, so doctors urge people to get vaccinated now for protection through the holiday season.

And based on people’s age and health conditions, vaccinations are needed throughout life to protect them from other illnesses like measles, chickenpox, and bacterial pneumonia. Dr. Shah suggests everyone check with their doctor to make sure they have all the shots they need.

Tuesday, October 31, 2017

Medicare & Medicaid: What is the Difference?

By Sarah Fontenot

Earlier this month I watched a prominent U.S. Senator — one who is very vocal about health care — confuse the terms Medicare and Medicaid three times in a five minute interview. If he gets them confused, I thought a quick review might be helpful for non-Senators as well.

Medicare: “We care for our elderly”

Medicare was passed in 1965 and signed by President Lyndon Johnson. The ceremony for the signing happened in Independence, Missouri where President Johnson sat at the table with President Harry Truman, who unsuccessfully fought for insurance for all Americans 20 years earlier. (Truman was not the first President to fight for universal coverage — the idea of a national insurance system can be traced back to Teddy Roosevelt who was President from 1901 to 1909.

President Lyndon B. Johnson signing Medicare into law.
Medicare was more limited than earlier proposals because it only covered Americans 65 years old and older, but for that population it had (and continues to have) a dramatic impact. (If that strikes you as a controversial statement, go here.) Medicare also covers a small number of people who are under 65 because they have certain disabilities.

Medicare is a federal program administered by the Centers for Medicare & Medicaid Services, a part of the U.S Department of Health and Human Services.

Given that the program is run on a country-wide basis, benefits do not differ by region. Medicare for people in Nevada is just like Medicare for people in New Hampshire.

However, the types of coverage an individual may have might vary.

There are four different parts of Medicare:
  • Part A: This is the basic Medicare package. Everyone gets Medicare A (unless you fall under Medicare C). Medicare A is particularly meant to cover hospital bills, but can also include nursing home care (that includes a nursing/care component), Hospice, and possibly home health care. (For more about what Part A covers go here.)

  • Part B: Medicare Part B was part of the original law passed in 1965. This part of Medicare is optional — to have it you need to pay a monthly premium. Medicare Part B covers outpatient care like seeing your doctor at their office, but it also covers the hospital outpatient department, preventive care, drugs that are given to you at your doctor’s office (as opposed to those you take yourself), physical therapy, and other outpatient services. (For more about Part B go here.)

  • (Supplemental Insurance) Although not part of the Medicare plan per se, most Americans with the financial ability to do so purchase Medicare Supplemental insurance from a private company because Medicare Part A and Part B do not cover all expenses a Medicare beneficiary will need."

  • Part C: This is also known as Medicare Advantage or Medicare + Choice. Part C was created in 1997 under President Bill Clinton to bring private insurance companies into Medicare — both to provide coverage beyond what beneficiaries were getting through Parts A and B (a Part C plan cannot offer less than the regular Medicare package) and to (arguably) lower the cost to the Medicare recipient. This attempt to privatize Medicare remains controversial, because it is paid for out of the federal treasury (it is not paid for by the Medicare payroll tax), costs more per beneficiary than regular Medicare, and has been abused by some private payers in the program. (For more on Part C go here, for more on the finances of Part C go here.)

  • Part D: This is the prescription drug benefit passed under President George W. Bush in 2003. The coverage is purchased from private insurance companies to increase the number of Medicare beneficiaries who have insurance to help with drug costs (before Medicare Part D only about 25 percent of the elderly had coverage for drugs). The actual cost of Medicare Part D to taxpayers remains controversial, as does the decision to include in the underlying legislation a provision that does not allow Medicare to negotiate lower prices from pharmaceutical companies.

Medicaid: “We offer aid to our poor”

Medicaid passed in 1965 as part of the same law President Johnson signed to create Medicare — but Medicaid is very different than Medicare.

At its core, Medicaid is the program established to offer health care coverage for low-income children, adults, seniors, and those with disabilities. It covers one in five people in this country, with the majority of funds going to the elderly and disabled, as shown in this graph from the Kaiser Family Foundation:

The biggest difference with Medicaid is it is a federal program run by each state. Federal money is given to the states based on actual needs and costs, matching dollar-for-dollar money spent by a state on their Medicaid population.

Because Medicaid is administered by each state, the level of coverage provided, the medical services covered, and the definition of who is eligible all vary significantly (within limits imposed on the federal level).

The ability of a state to control the specifics of their plan explain why “in 2011, Medicaid spending per full benefit enrollee ranged from $4,010 in Nevada to $11,091 in Massachusetts”.

The original plan under the Affordable Care Act (ACA or Obamacare) was to expand Medicaid to cover all people below 138 percent of the federal poverty level (that’s a family of four living on an annual income of $31,000 or less), which also would expand coverage to non-disabled adults — a major change in many states.

Including all adults on Medicaid would be an enormous difference in several states, such as Texas, where childless adults without disabilities do not qualify for Medicaid between the ages of 18 and 65.)

The ACA plan for expanding Medicaid everywhere was defeated in 2012 by the United States Supreme Court in the pivotal NFIB decision, which said every state had the right to choose whether to expand its Medicaid program under the law.

Initially, 24 states said no to Obamacare; that number has since dwindled to 19. (For more on the reasons these states did not participate in expansion, and why 32 (including Washington DC) went forward with the plan, see Fontenotes # 14.)

That is Medicaid in a nutshell.

Which Costs More?

This summer most of the debate in Congress over the fate of Obamacare really was over the fate of Medicaid.

There are many people who want to change it, especially to curtail spending and increase the state’s ability to dictate the terms of their Medicaid program.

It would be easy to assume that it is Medicaid that is draining our federal coffers — so I will leave you with one more graph (and please note Social Security is the biggest social program in the pie).

That ends a quick tutorial on two enormously complex programs.

I hope you are now ready to speak on a Sunday morning news program without embarrassing yourself!

Want to Know More?

Here is a fun timeline from Kaiser Family Foundation where you can peruse what was happening in American health care in  five year increments, all the way back to the early 1900s.

You might also be interested in this article which addresses whether medicine before Medicare was “The Golden Years” in American health care.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers. Visit her website.

Wednesday, October 25, 2017

Medical Students Assume Huge Debt to Become Physicians

Student Debt Shapes the Future of Medicine

The thought of amassing a half-million dollars in medical school debt, in some cases, is steering some of the best and brightest aspiring physicians to choose certain specialties over others, altering their life plans, or discouraging them from going into medicine altogether. An October Texas Medicine magazine article covering the cost of medical education reports staggering student debt is shaping how new physicians approach medicine.

Nicole Hernandez, DDS, MD, an oral and maxillofacial surgery resident at UT Health San Antonio, said she will have to start paying back her $450,000 in student loans in 2020. Assuming everything goes according to plan, she plans to pay them off within eight to 10 years. However, it is not uncommon for physicians to pay off their medical school debts decades after they began practicing medicine.

Michael Metzner, MD, a second-year general surgery resident at the Joe R. and Teresa Lozano Long University of Texas School of Medicine in San Antonio, said his medical school tried to brace him for the financial impact of his school loans before graduation. “In med school, it’s very easy to think of it as Monopoly money,” Dr. Metzner said. “You see these huge figures, and it’s, like, ‘I’m already $100,000 in debt, and my medical school tuition’s $40,000 [a year].’ It's easy to say, ‘Sign the dotted line.’ But I don’t think it’s until you’re out there working that you realize what that means.”

The “Monopoly money” reference is common among medical students. Christina Thorngren, MD, a third-year emergency medicine resident at the Dell Seton Medical Center at The University of Texas, used the term in discussing her $485,000 in medical school debt from the out-of-state private school she attended. While she has no regrets about her career choice, she knows people who shied away from medicine over the price tag. She suspects a potentially huge debt load affects whether talented students will consider medicine as a career. “I’ve known people who thought about going into medicine and who would’ve been really good doctors, who chose not to go into it and chose to do something else…because they were afraid of the debt,” she said.

Texas Medicine cites a study by the Association of American Medical Colleges, showing three-quarters (76 percent) of all medical school, graduates have education debt averaging $190,000 per person. That is up from an inflation-adjusted $125,372 in 2000. As a result, medical school debt hangs over every aspect of a new physician’s life.

Debt is reshaping the field of medicine, as more students choose certain medical specialties over others to pay off their debts. Gary Ventolini, MD, regional dean of the medical school at the Texas Tech University Health Sciences Center’s Permian Basin campus, said some students are considering more lucrative specialties, instead of traditional primary care. He said the choice of career and debt concerns often spill over into personal life choices. “[Debt] influences their decisions about whether to marry or not, or to have a family,” Dr. Ventolini said. “Many are afraid of losing a girlfriend or boyfriend [if they wait].”

James Dahle, MD, a Utah emergency physician who also runs the financial website, said medical students’ best strategy for coping with debt is to learn the basics of personal finance, live frugally, and do everything possible to cut expenses and avoid adding more debt ― both during school and while they’re paying back their student loans. “It’s the basics of personal finance ― it’s just math,” he said. “You don’t get a pass on math because you’re a doctor and you decided to do something good with your life.”

Dr. Thorngren anticipates paying off her medical school loans in her 40s or 50s. And despite the cost, Dr. Hernandez said she has no regrets about her dual-degree career choice. “I've always said, ‘Do what you want because you’re passionate about what you want to do,’ ” she said. “Consider the amount it will cost you, but don’t choose something just because of how many dollar signs there are.”

Monday, October 16, 2017

Student Leaders

TMA’s Minority Scholarship Program is about more than just money. 

Growing up in El Paso, Amanda Arreola always perceived medical care as a luxury.

Her family didn’t have much money. Both of her parents had only high school degrees; both of their parents were immigrants. “So going to the doctor was not a thing, unless it was an emergency. And if you were to go see a doctor, El Paso was too expensive so you went across the border to seek medical attention in Mexico.”

It wasn’t until she arrived at Baylor University in Waco that she realized the average person doesn’t do that. “There’s no border in the middle of Texas. The disparities were very apparent once I moved. That had a lot to do with why I chose medicine.”

However, excitement over her acceptance into the inaugural class at The University of Texas Rio Grande Valley (UTRGV) School of Medicine in 2016 soon turned to worry over how she could afford it. She remembers reading the Texas Medical Association (TMA) email announcing she had won TMA’s $10,000 Minority Scholarship. “It was the first step for me that this was actually going to happen. It’s an amazing feeling, and I am so grateful to TMA for that.”

When TMA started the Minority Scholarship Program in 1999, physician pioneers envisioned cultivating a generation of diverse doctors to meet the health needs of Texas’ diverse population. The program — made possible since 2004 with grant funding from Texas Medical Association Foundation (TMAF, TMA’s philanthropic arm) — has since encouraged nearly 200 minority students under-represented in Texas medical schools to enter the profession by lightening their financial load.

Less expected, perhaps, was the cultivation of a generation of budding physician leaders.

The award also introduced Ms. Arreola to organized medicine, since she received it at TMA’s annual policy-making meeting, TexMed. She has since spearheaded the launch of a TMA medical student chapter at UTRGV. As chapter president and reporter on the executive board of TMA’s Medical Student Section (TMA-MSS), Ms. Arreola has recruited more than a dozen students to TexMed and TMA’s First Tuesdays at the Capitol lobbying event in Austin to advocate for issues important to aspiring physicians. She also volunteered at this year’s TMAF gala held during TMA’s annual meeting in Houston.

Now in her second year, her goal is to practice primary care in Texas, “because that’s where the need is.” And in the Valley along the southern tip of Texas in particular, “I would love to do more community outreach. We want people to know they have a school they can go to, do their residency, and stay and practice and keep physicians here. That’s really the goal of the school, to create access.” (Watch this video to see Ms. Arreola and fellow UTRGV students and residents practicing outreach care in Texas’ medically underserved colonias.)

Since 1999, TMA has awarded the annual scholarships to first-year Hispanic, African-American, and Native American students at each of the now 12 Texas medical schools. TMAF grants have helped the program keep pace with school growth and enhance the award amount from $5,000 to $10,000.

“We have so many brilliant minority students who may not have the opportunity if they didn’t have scholarship funding or access to loans. TMAF has been very fortunate with its donors to not only sustain that program, but to grow it,” said TMAF board member and donor E. Linda Villarreal, MD.

The Edinburg internist vividly recalls walking into the bank to borrow money every semester for four years of medical school, even into residency. Dr. Villarreal earned her medical degree from Universidad del Noreste in Tampico, Mexico, before completing residency at Texas Tech University Health Sciences Center in El Paso.

“The banker got to know when I would be walking into the bank, and I sometimes felt like he thought, ‘Oh no, here she comes again.’ I did not have financial support from anybody,” she said.

Nowadays, students can leave medical school with debt loads reaching as high as $200,000, or more.

“It’s pressure enough dealing with medical school, regardless of where you go. The last thing you need is to worry about money,” Dr. Villarreal said. The Minority Scholarship Program “is an investment in TMA because [students] are going to know TMA helped them and they are going to come back, and that’s paying it forward.”

Matthew Edwards, MD, saw that investment come full circle: He, too, was introduced to TMA through TMAF as a 2012 scholarship awardee, which eventually opened his path to residency at Stanford University. Before he left Texas this summer — where he hopes to return one day to practice — The University of Texas Medical Branch at Galveston graduate helped grow the scholarship program as a member of the TMAF board and the TMA-MSS executive council.

“It expands the opportunity for more individuals from unique backgrounds that may be under represented in medicine to also get involved in organized medicine and help advance those issues and causes and perspectives. And that’s another very important prong in [TMA’s] mission to improve the health care of all Texans,” Dr. Edwards said. “It’s a reminder the buck doesn’t stop with you. The mission will keep going, and it highlights the importance of leadership and mentorship.”

Like Ms. Arreola, Dr. Edwards didn’t notice the health care disparities growing up in his low income African-American community in Dallas until he left for Princeton University. Also the first in his family to go to college, he remembers his initial thoughts. “Coming from an underserved background, there can be a little culture shock and hesitancy to put yourself out there,” he said. Beyond the monetary value of the scholarship, “having an organization that has faith in your goals and your contribution to medicine has symbolic meaning I can always look back on.”

Dr. Edwards sees his experiences in medical school, organized medicine, and public health coming full circle as he pursues a career in academic psychiatry.

“Most academic centers are smack in the middle of major areas that pull from different communities and almost always see disparities,” he said. “Being a doctor is more than learning how to practice medicine. It’s learning to empathize with people similar to and different from you.”

Nearly 500 physicians, as well as many county medical societies and corporations, have supported the TMA Minority Scholarship Program with a tax-deductible gift to TMAF — and it’s an investment that pays.

“This is an investment in our children. This is an investment in your mother having a doctor,” Dr. Villarreal said.

To support the scholarship fund and explore TMAF’s many other philanthropic initiatives, visit the TMAF website.

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