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.

Friday, October 6, 2017

Flu Shots Vital for Moms-to-Be, Babies

By Kimberly Carter, MD, MPP
Austin obstetrician-gynecologist
Fellow, American College of Obstetricians and Gynecologists
Texas Association of Obstetricians and Gynecologists, immediate past president 
Texas Medical Association Be Wise — ImmunizeSM Physician Advisory Panel member

Last week I walked into the hospital and greeted my colleague, who was clearly agitated. He had just finished an urgent cesarean section that resulted in both baby and mom ending up in intensive care. Why? The flu. It’s only early fall, but the flu has arrived and started to claim its victims. As an obstetrician, I want my patients to have a safe delivery and a healthy baby. The flu shot during pregnancy is an important part of achieving that goal.

I sigh when I hear one of my pregnant patients say, “But I’ve never gotten the flu. I don’t need a shot.” I recall a patient I had to put on life support two years ago because the flu severely damaged her lungs. I also remember my patient I had to deliver early because of the flu and how she waited 10 days to meet her baby. I visited her in the intensive care unit as her distraught husband balanced the joy of the newborn, the fear of losing his wife, and the anxiety of doing this alone.

The flu is dangerous to pregnant women, so dangerous that they and children under the age of 5 are prioritized to get the flu shot. Pregnant women lose 30 percent of their lung capacity by 16 weeks. When your lungs lose that much volume, you can’t take the flu’s hit without risking serious consequences.

And the flu’s fever can threaten the developing baby’s life, as happened with my colleague’s patient last week: That baby’s heart rate went from 230 to zero beats in less than five minutes; baby needed chest compressions to revive its heart. Flu affects a fetus early, too; in the first trimester, fever can cause neural tube defects — birth defects of the brain, spine, or spinal cord.

The flu shot a pregnant woman receives protects her and her baby in two important ways. First, it can reduce the risk of getting the flu by as much as 60 percent. And if mom does get the flu, it can be milder. The shot also protects the newborn for those first 6 months when the baby is too young to get the flu shot.

The protection mom gets from the flu shot is transferred to the baby to help build up his or her ability to fight the illness. Then the Centers for Disease Control and Prevention (CDC) recommends flu vaccination for anyone over 6 months of age.

Multiple studies and years of evidence support the safety of flu vaccination in pregnant women. A pregnant woman can get a flu shot anytime during pregnancy, and flu season can last from October through May. No mom-to-be should skip her flu shot.

Knowing these facts, I was dismayed to read a recent controversial study questioning the safety of flu shots during the first trimester of pregnancy. The researchers studied only a small group of women (lessening confidence in accuracy), and this stand-alone research begs more scrutiny. One of the study’s coauthors even acknowledged the outcomes were unexpected and need more investigation.

My colleagues and I are not alone in our continued confidence about vaccinating pregnant women. Recently the American College of Obstetricians and Gynecologists (ACOG) and CDC voiced support for influenza vaccination during pregnancy. ACOG stated: “Influenza vaccination is an essential element of prenatal care,” citing flu’s “increased risk” for illness or death to pregnant women. ACOG reiterated the vaccine’s protection of newborns, too.

For me, flu vaccination during pregnancy is a given. The benefits far outweigh any potential risks. Influenza can kill, and pregnant women — and newborns — are high risk for the disease. Unless proven otherwise, my colleagues and I will continue adamantly to advise the flu vaccine’s protection to our patients. We’re heading into flu season; get vaccinated as soon as possible. If you have any concerns, be sure to talk with your doctor.

Sunday, October 1, 2017

Video: History of the Flu

Influenza, or flu — the perennial illness hospitalizing hundreds of thousands of Americans each year — is set to wreak infectious havoc across the nation yet again. Flu season runs October through May, but health officials say the virus already started circulating in the United States last month — and this flu season promises to be a doozy. To save yourself and your family from influenza’s miserable symptoms and potentially fatal consequences, physicians urge everyone 6 months of age and older get a yearly flu shot.

In light of Influenza Awareness Day today, take a look at The History Channel’s video on the history of the flu — from the Spanish Flu pandemic in 1918, to the creation of a vaccine that plummeted the disease’s death rate, to the flu’s current incarnation as a seasonal health hazard.

Wednesday, September 27, 2017

Medical Considerations Behind Emotional Support Dogs

By James G. Baker, MD
Member, TMA Council on Science and Public Health

If you ask your physician to sign a letter endorsing your use of an emotional support dog, what factors must he or she consider?

For a canine to be designated as someone’s emotional support dog, the person seeking such an animal must have a note from a physician or other medical professional stating that (1) the patient does have a psychiatric disability, and (2) the emotional support animal provides a benefit for the patient beyond the simple need for companionship. The most common reason for the letter request is that emotional support dogs legally are viewed as a “reasonable accommodation” in apartments that have a “no pets” rule.

The idea of using a dog as emotional support would seem to make perfect sense. After all, who wouldn't benefit from having a four-legged friend at his or her side? Here are a couple of considerations doctors make when assessing the benefit of an emotional support dog for patients with mental health challenges.  

Peaberry, Dr. Baker's current
assistance pup-in-training.
First, while there is good research showing the benefits of service assistance dogs for people with physical disabilities, there is little evidence for the use of service assistance dogs, let alone emotional support dogs, in mental illness. How are service dogs and emotional support dogs different? Service dogs are trained intensively by professionals for many months to perform specific tasks for people with disabilities. For example, trainers teach service dogs to open doors and turn on lights for people with physical disabilities. The dogs might serve as ears for hearing-impaired people or as eyes for someone who is visually impaired. Service dogs also can be trained as skilled companions for people with intellectual disabilities or mental illness. By contrast, an emotional support dog is not trained to do any specific tasks related to a disability, but rather provides a therapeutic benefit to its owner through companionship.    

Second, the lack of specific training requirements for an emotional support dog is problematic. Hopefully the patient’s dog is friendly, calm, and without unexpected behaviors, especially in public. But due to the lack of training, an emotional support dog may bark, act aggressively if it feels threatened, or be intrusive of others in public. By contrast, a service dog is trained to ignore distractions and cause minimal imposition to its surroundings. At the very least, an emotional support dog should have formal obedience training sufficient to obtain a canine good-citizen certificate, but longer-term obedience training would be even better. Ideally, the dog would be a skilled-companion service dog, trained in skills and tasks to help mitigate the patient’s specific disability.

Hopefully in the not-too-distant future there will be an evidence basis for physicians to recommend emotional support dogs for people living with mental health challenges. For example, the Department of Veterans Affairs is participating in a three-year study to compare service dogs and emotional support dogs in the management of post-traumatic stress disorders. But until there is evidence to support the use of these dogs, most physicians will and should continue to steer patients towards treatments that show evidence-based benefit for their specific challenges.  

Dr. Baker and his wife, Janet, serve as volunteer puppy-raisers for Canine Companions for Independence, a nonprofit organization that enhances the lives of people with disabilities by providing highly trained assistance dogs at no charge to the recipient. Dr. Baker also is associate chair of clinical integration and services in the Department of Psychiatry at Dell Medical School and systems chief medical officer at Integral Care, the public mental health authority for Travis County.

Thursday, September 21, 2017

Preventing Flu in Long-Term Care Facilities

Clare Gentry, MD, a Houston infectious disease physician
Member, TMA Committee on Infectious Diseases

We’re just past the dog days of summer, longing for cooler weather and welcoming the start of football season. By now, the flu vaccine is already on its way to local communities, getting ready for the kickoff of seasonal influenza (flu) vaccination efforts. Some specific groups of people — including our elderly family, friends, neighbors, and others living in long-term care facilities (and the people around them) — should plan now to get vaccinated against this disease.

While flu season officially runs from October through May, the flu virus doesn’t always follow calendar rules. The highest rates of infection during the past decade have occurred as early as September/October and as late as January/February. In recent years, Texas’ flu season has peaked in December and January.

Though experts debate the best time people should get a flu shot, the Centers for Disease Control and Prevention (CDC) and the Texas Department of State Health Services (DSHS) continue to recommend all eligible people receive flu vaccine as soon as it becomes available in the community. An annual flu vaccination is recommended for anyone 6 months of age and older. 

While it may be difficult to predict exactly when flu season will strike, two things hold true each year:  
  1. Residents of long-term care facilities (LTCFs), such as nursing homes and assisted living centers, are consistently at higher risk of complications from influenza, such as pneumonia and bronchitis.
  2. Flu vaccine can decrease rates of hospitalization and death in these people. Nearly 70 percent of hospitalizations from flu-related illness are in people who are over age 65. And most (up to 85 percent) flu-related deaths are among the elderly.
Residents of LTCFs can contract influenza from new residents, health care workers (HCWs), and visitors. These people should get vaccinated against flu to provide greater protection to residents. Protecting those we care about and care for in LCTFs truly is a community effort. 

Residents of LTCFs

It should go without saying that residents of LCTFs should be vaccinated to protect against flu each year. Even in years when vaccine has been less effective, vaccinated individuals had lower rates of hospitalization and death than nonvaccinated adults. 

Several flu vaccines are available for people over age 65, including a high-dose vaccination. Ask your doctor about which one is right for you. And be sure you’re up to date on all vaccinations recommended for adults, including a shot to prevent pneumococcal disease

Residents also can contribute to the spread of flu. Residents entering a LTCF for the first time or returning after hospitalization might have been exposed to flu without knowing it. Facilities can help prevent the spread of flu by:
  • Screening new or returning residents for signs and symptoms of flu,
  • Documenting residents’ vaccination status, and
  • Offering (and encouraging) flu vaccination at admission. 
Staff should be aware of atypical symptoms in elderly or chronically ill patients. Older patients may not exhibit typical signs of fever, cough, or nasal congestion with flu. Instead, changes in appetite or energy levels or increased sleepiness can be some of the first signs of infection. Families of LTCF residents can help ensure relatives get their annual flu vaccine and maintain accurate vaccination records.

Health Care Workers in LTCFs

Vaccination of health care workers is a critical part of any effort to prevent flu and its complications in LTCF residents. In fact, many facilities now mandate flu vaccine for all health care workers. Why? Multiple studies have shown that vaccination of health care workers in LTCFs can decrease the number and severity of flu cases in the facilities’ residents. 

Facilities should make every effort to vaccinate workers and document employees’ vaccination status. If a HCW shows signs or symptoms of flu, he or she should be tested for flu and stay home from work until symptoms resolve. Families of LTCF residents should inquire about vaccination rates of workers and be aware CDC has set a goal of 90-percent vaccination coverage for HCWs across the country by the year 2020.

The Society for Healthcare Epidemiology of America (SHEA) has long advocated for mandatory influenza vaccination of all HCWs. In their most recent position paper, SHEA experts classified influenza vaccination as “a core patient and health care provider safety practice” that should be “a condition of both initial and continued employment.” The Texas Medical Association also urges 100 percent flu vaccination for health care workers. 

In addition to flu, HCWs should stay current on all recommended vaccinations to protect themselves and the people they care for. 

Family and Friends of LTCF Residents 

Visitors to LCTFs should take action to prevent unknowingly passing the flu on to their loved one living there. Though CDC recommends flu vaccination for everyone over the age of 6 months, flu vaccination rates in Texas typically are less than 50 percent. Adults with relatives living in LTCFs should get flu shots to protect their loved ones. During peak flu season, facilities may elect to limit the number of visitors and may prohibit residents from gathering in common areas. 

As flu season approaches, it is important to remember that flu prevention, especially with regard to LTCF residents, is a community effort. Why not take the step to protect yourself and your loved ones this flu season? 

Tuesday, September 19, 2017

TMA Establishes Relief Program to Assist Hurricane-Devastated Medical Practices

When staff of a Houston-area children’s urgent care clinic saw security-camera images of brown, murky Hurricane Harvey floodwater submerging the waiting room, they knew it was bad. Quickly, the physicians and other clinic workers jumped into action. They also consulted the Texas Medical Association (TMA) for help, and learned about the TMA Disaster Relief Program.

Pediatrician Anastasia L. Gentles, MD, said help was needed because Harvey flooded their NightLight Pediatric Urgent Care clinic in Humble. “Our x-ray equipment, our nebulizers, all of our inventory except the few things in the upper cabinets – was destroyed,” she said. “Our whole crash cart had water in it… it was awful.”

Floodwaters inundated the typically busy medical practice. Staff helplessly watched the destruction on security cameras. “At first it was just water on the floor,” said Dr. Gentles. “Then a couple of hours later you couldn’t see the chairs. It was a little lake in there.”

After the water receded, photos documented the damage: Unopened packages of supplies to treat patients were crumpled and waterlogged, including child-sized bandages, tongue depressors, boxes of stickers  — Sponge Bob, Paw Patrol, Mickey Mouse — and stethoscopes in water-lined drawers. The cabinets and drawers were all warped and splitting. In the lobby, a nest of furniture — a colorful child-size plastic table and little chairs tangled with adult-size waiting-room chairs, tilted askew — all sat covered in a beige filmy slime. Mold was quickly growing, so all internal walls would have to be removed.

Dr. Gentles outside NightLight Pediatric Urgent
Care Clinic during cleanup after Hurricane Harvey.
They salvaged what they could and raced to schedule a demolition crew and contractor to rebuild the facility. They also started searching for a temporary home in which to care for patients.

“We feel the loss from a community standpoint. Everybody keeps calling us — people were coming up to the door even the day after the storm to get their children seen,” said Dr. Gentles. “So we know they’re missing us from that standpoint.” They also want to reopen quickly to help their staff — many of whom lost their home or cars in the flood – get back to work.

The TMA Disaster Relief Program aims to help the countless medical practices across south and coastal bend Texas facing a similar fate return to caring for patients as quickly as possible — and the need is great. A new TMA survey finds nearly two-thirds (65 percent) of physicians in Texas’ official disaster area counties were forced to close their practice temporarily, and one-third (35 percent) had to reduce their hours or services.

“People need their doctor, but so many of our physicians suffered total, devastating losses to their medical practices as a result of Hurricane Harvey,” said TMA President Carlos J. Cardenas, MD. “We wanted to jump in and help them rebuild or relocate as quickly as possible, because their patients need them.”

Funds the Disaster Relief Program distributes will help physicians pay for storm loss expenses their insurance or other sources will not cover.

The program has raised a substantial amount already. The California, Colorado, Massachusetts, and Rhode Island state medical associations have pledged or sent generous donations. This past Saturday at TMA’s Fall Conference, the American Medical Association and the Physicians Foundation presented checks for $150,000 and $500,000, respectively, pushing the total raised to nearly $1 million. To donate to the program, click here.

“Doctors understand the call to care for their patients, and empathize with colleagues stripped of the ability to help their people, their community,” said Dr. Cardenas. “So we’re thrilled — but not really surprised — that these physicians and their organizations are opening their wallets to help Texas doctors help Texas patients. This storm was a monster, and communities across the south are hurting; they need to get back to normal, and they have basic needs like food, shelter, and health care. We want them to regain that access to their hometown doctor as quickly as possible.”

TMA created similar fund drives after hurricanes Rita and Ike in 2005 and 2008, donating between $5,000 and $8,000 to each medical practice in need. TMA received $700,000 in contributions to the fund in 2008. TMA’s philanthropic arm, TMA Foundation, is overseeing fundraising, and The Physicians Benevolent Fund is administering the TMA Disaster Relief Program. Physicians: To apply for assistance through the TMA Disaster Relief Program, visit or email”

Wednesday, September 13, 2017

Houston Stadium Becomes Makeshift Hospital During Harvey Recovery

Hurricane Harvey has been a disaster for the Houston area by any definition, but the medical response at major shelters has been anything but.

Lisa L. Ehrlich, MD, is codirector of medical operations at Houston’s NRG Stadium shelter and president of the Harris County Medical Society. She volunteered in the wake of previous hurricanes, including Andrew and Katrina.

Dr. Ehrlich, who has earned the nickname “Power Ponytail,” has run the NRG shelter with emergency physicians Beau Briese, MD, and Aaron Schwartz, MD. Numerous volunteers did a great job of screening people as they entered, Dr. Ehrlich told the Texas Medical Association late last week.

Anyone older than 70 or younger than 1 was automatically evaluated by the medical team.

Lisa L. Ehrlich, MD, with Brian Reed, MD,
director of public health at the NRG shelter.
Many of the people in the shelter were homeless, so physicians also screened aggressively for tuberculosis patients and those with behavioral problems, she said.

In both cases, patients tend to underreport their illnesses, so after the shelter staff asked, “Do you have any medical problem?” they would follow up with a second question.

“[The patients would] say, ‘I don’t have any medical problems,’ and we’d [follow up and] say, ‘How long’s it been since you had your medicine?’ ‘It’s been five days,’ ” Dr. Ehrlich said. “We caught a lot of people who needed care that way.”

Physicians also walked among shelter residents to look for signs of drug withdrawal or psychological problems.

“We kind of routed those out early,” she said.

As of late last week, the shelter has seen a variety of predictable illnesses, including type A flu, scabies, bed bug bites, and conjunctivitis, Dr. Ehrlich said. All of those ailments are under much better control than they were in the wake of Hurricane Katrina, Dr. Ehrlich said.

“It’s a totally different place,” she said. “We’re actually isolating people with medical problems.”

During Katrina, people sheltered at the old Astrodome had so many different medical conditions that doctors put the well people — not the sick people — in medical isolation, Dr. Ehrlich said.

“We had a small number of healthy people, and there was just so much pestilence,” she said. “It was the inverse of how it should be if you’re running a shelter.”

The greatest long-term medical problem facing the Houston area after Harvey will be treating behavioral disorders. Like the rest of the country, Houston already has a shortage of psychiatrists.

“Now we have an overwhelming number of people in need, and we’re in a huge stress situation, so things like anxiety disorders, depression, schizophrenia, and other mental needs are going to be higher when we already don’t have enough psychiatrists in the first place,” she said. “And now they have a backlog to just see their own patients because they’ve been displaced and shut down for two weeks. … We already weren’t great to begin with, and [Hurricane Harvey is] going to just put huge stress on the system.”
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