Thursday, March 29, 2018

Don't Politicize Vaccines

Stan Spinner, MD
Lindy McGee, MD
Julie Boom, MD

This article was originally published on TribTalk, a publication of The Texas Tribune.

A patient receives an immunization during a Texas Medical Association conference.

Disease does not care if you are a Democrat or a Republican. Cancer does not care whether you voted for Donald Trump or Hillary Clinton. Influenza has no concern about whether you showed up to vote in the March primary election in Texas. As far as whooping cough is concerned, you can watch whichever cable news you choose and read the web sites of your choice.

The fight to stop disease needs to be non-partisan and non-political, too. People of all political stripes came together to stop polio in its tracks. In the past, Americans understood that critical life-saving tools like vaccines are a part of our national responsibility. Just as our soldiers are fully vaccinated before they go to war, we citizens on the home front have, in the past, done our part to protect the public health and national security.

The life-saving power of vaccines should transcend politics. Unfortunately, vaccines entered the political discourse during the 2018 election season. Attacks on public officials who support vaccines are attacks on a fundamental building block of public health. Just as politicians should support clean drinking water and flood prevention, they should support vaccination as a proven measure to prevent disease.

Vaccines are a victim of their own success. Americans may not appreciate the power of vaccines because fewer and fewer of us have actually seen diseases like polio firsthand. If you do not personally know someone who has suffered or died from a vaccine preventable disease, it might be tempting to say vaccines are unnecessary in order to score easy political points.

Politicians who find political expediency in questioning the need for vaccines are playing a dangerous game. The 2018 Texas primaries demonstrated that voters in the Democratic and Republican primaries support vaccines, as anti-vaccine candidates lost at the polls.

Two strong supporters of vaccines in the Texas Legislature handily defeated anti-vaccine candidates in Republican primaries. In a high-profile Houston race, state Rep. Sarah Davis defeated her anti-vaccine opponent. In rural Texas, a less-heralded race demonstrated the broad base of support for vaccines as state representative, family doctor, and immunization champion Dr. J.D. Sheffield defeated his anti-vaccine opponent. In San Antonio, Democratic incumbent District Attorney Nico LaHood lost his primary – in part because of his anti-vaccine views.

For many reasons, Texas must not allow politicians to smear the life-saving power of vaccines for political gain. In this year’s primary election, Texans spoke loudly and clearly of their support for vaccines. In the months to come, we will learn if our elected officials have heard the voters. Texans must ensure vaccines do not become a political football in the November general election. We are confident that voters will again support science and reject anti-vaccine candidates.

Dr. Spinner is Vice President and Chief Medical Officer at Texas Children's Pediatric Associates. Dr. McGee is Associate Professor of Pediatrics-Academic General at Baylor College of Medicine. Dr. Boom is Director of the Texas Children's Hospital Immunization Project. All three physicians are Houston pediatricians.

The Texas Tribune is a nonprofit, nonpartisan media organization that informs Texans — and engages with them — about public policy, politics, government and statewide issues.  

Tuesday, March 27, 2018

Why Should Texans Care About Bleeding Control? What Can You do to Help?

By Andrew Fisher
Texas A&M University Medical Student
U.S. Army 75th Ranger Regiment Veteran

It’s possible to bleed from an extremity and die within three minutes. The threat is greater since the average response time for an ambulance is seven minutes and law enforcement is eleven minutes. Trauma is the leading cause of death under the age of 46 and the leading cause of productive life years lost under the age of 75. This can have a significant impact on Texans. Most of the potentially survivable deaths in trauma are due to bleeding, some of which can be easily controlled with basic life-saving techniques — techniques you can learn by visiting, or attending a Bleeding Control Basics class during National Stop the Bleed Day on March 31.

The History Behind Stop the Bleed Day: Lessons Learned in Blood

In 1996, Frank K. Butler, MD, and colleagues published an article “Tactical Combat Casualty Care in Special Operations.” This spurred the creation of Tactical Combat Casualty Care (TCCC). It focuses on identifying and treating the three major causes of preventable death and emphasizes early tourniquet application (a device that constricts blood flow to an extremity thereby stopping blood loss). Preventable death happens when an individual’s injuries are not inevitably fatal and could be prevented with optimal medical care. There are three major causes of preventable death in combat — bleeding from an extremity, a collapsed lung that creates tension in the chest, and airway obstruction. The causes of preventable death are multifactorial, but by far massive bleeding is the major cause. One U.S. Army unit was able eliminate preventable death in combat — a feat never before accomplished by any unit in the history of combat. The 75th Ranger Regiment accomplished this feat by teaching every soldier how to identify and treat the three major causes of preventable death. Leadership involvement and following the guidelines published by the Committee on Tactical Combat Casualty Care (CoTCCC) were key to the success of the Rangers.

We know tourniquets and hemorrhage (bleeding) control are effective in saving lives. In Iraq and Afghanistan, up to 2006 when tourniquets were just starting to be used, extremity bleeding caused nearly one in ten (7.8 percent) of total fatalities. From 2006 to 2011 however, just 2.6 percent of people died from extremity bleeding. That’s a 67 percent decrease in fatalities from extremity bleeding.

How Does This Relate to the Public (Civilian Sector)? 

The Hartford Consensus, published in the wake of the Sandy Hook shooting, provides guidelines for people in active shooter situations. The concept is easy: early and definitive control of external bleeding through tourniquets and hemostatic dressings (bandages designed to quickly stop bleeding) would save lives and decrease preventable deaths.

In 2016, a report titled  “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury” helped identify the number of preventable deaths in the U.S. The report listed eleven recommendations aimed at better coordination efforts between the military and civilian experts in order to reach zero preventable deaths in the U.S. The report identified, of the 147,000 trauma deaths in the U.S. in 2014, 20 percent (or 30,000 people) could have survived with aggressive bleeding control and optimal care.

Events like the ones that happened in Parkland, Sandy Hook, Boston, and Orlando show that an active shooter incident, or acts of terrorism, can happen anywhere and anytime. While a terrorist event catches everyone off guard, bystanders can be better prepared to save lives with a Bleeding Control Basics course.

It’s very unlikely you will be in an active shooter or terrorist event, but it is more likely you will be present at a traumatic event caused by an accident. It could be a motor vehicle accident, a home accident, or at a place of employment. Regardless of where, proper training and preparation enables you to react and respond.

You can prepare yourself by taking a Bleeding Control Basics course. This is an effort by the Stop the Bleed initiative, which has mutual involvement from the White House, the Department of Homeland Security, the American College of Surgeons, and the American College of Emergency Physicians. Everyone has the power to stop life-threatening bleeding caused by injuries in the home, industrial settings, or even mass casualty events. State and local government, medical groups, healthcare organizations, and local first responders share a mutual interest to inform the public that this training is available.

This Saturday, hundreds of free Bleeding Control Basics courses will take place across for National Stop the Bleed Day. Click for information about taking a course. This initiative was started in September 2017 by current and former members of the U.S. Army and law enforcement. They recognized the need for civilian or bystander hemorrhage control in many situations before EMS arrives.

If you are interested in serving your community as a Bleeding Control Instructor on March 31 or any other time, please contact The National Stop the Bleed coordinators in your area at or visit to register.

Monday, March 26, 2018

Hard Hats Save Little (And Big) Heads

Dr. Barker fits a helmet on a child during a
Hard Hats for Little Heads helmet giveaway event.
By Charles O. Barker, MD, Dallas
TMA Hard Hats for Little Heads Physician Advisory Panel member

I have been involved with the Texas Medical Association’s (TMA’s) Hard Hats for Little Heads program for a number of years. St. Barnabas Presbyterian Church in Richardson will conduct its 13th Annual Health Fair just before school starts in August, and again, I plan to be there with friends to fit about 100 heads with bike helmets. I do this because it is the right thing to do, the compassionate thing to do, and certainly the family doc thing to do. 

I also have personal reasons for wanting to put hard hats on all our little or not-so-little heads. Those riding bikes, skateboards, and other fast-moving platforms with “naked” heads are especially vulnerable to injury.

During the late 1980s, I trained hard and competed in triathlons. Back then, bike training could be dangerous because much of it was on open roads — some busy — and some on backroads. Today, bike training is even more dangerous, with motor vehicle drivers using electronic devices while driving. Over the years, several of my good bike training buddies lost their lives in this way.

I remember the day I was riding on White Rock Lake Trail, a safe, well-designed trail that runs along Dallas’ White Rock Lake. Frequent locator markers tell you exactly where you are on the trail. If you have a problem, you just call 911 and give the locator number, and help will be on the way. I thought, “How great, if I get into trouble! Thank you, Dallas.” 

I never had to use this safety net, but got really close once. I was bike-riding by myself (shouldn’t have done that!), had my helmet on (thank goodness!), and was on my way back to my car. I rounded a corner a little too fast on the paved trail when my racing tire slipped off the edge of the path into that “not-so-sweet” grass-pavement zone. My attempt to return to the pavement was met with going head over heels onto the concrete. 

The first thing that hit was my “little” head, which was saved only by that “very sweet” helmet. I had never heard that sound before — helmet hitting concrete. If I had not been wearing that helmet, I’m pretty sure I would have been knocked unconscious — or worse. And the location markers would not have done me any good; I was alone and would have been at the mercy of the next passerby.

My experiences have taught me several things can prevent or mitigate brain injuries: 
  1. Bike ride and train only on protected roads or designated biking trails; 
  2. Train with others of equal ability — and stay together; 
  3. Wear a well-fitted helmet; and 
  4. Make sure your bike, its parts, and tires are in good shape. 
Simple. And yet we all fall short of following the good advice. We can do better, right?  Thank goodness I am here to tell the story … and very motivated to put those hard hats on little heads.

Wednesday, March 21, 2018

Mental Health: Not Just Something to Think About

By Maria Monge, MD
Austin adolescent medicine physician

It is Global Teen Health Week and today we are focusing on Mental Health. Research shows that a healthy mind helps keep bodies healthy. Adolescents and young adults are significantly impacted by mental health issues. In the United States, almost one in seven teens is currently dealing or has dealt with depression. What’s more, one in three has current or past anxiety. Globally, suicide is the second leading cause of death in adolescents and young adults.

As an adolescent specialist, I routinely discuss mental health concerns with my patients and their families, as I firmly believe that good physical health is linked to good mental health. I often give my patients these five tips to improve their mental health.

Five Tips for Improving Mental Health

  1. Sleep. According to the National Sleep Foundation, adolescents and young adults require 8-10 hours of sleep per night for optimal functioning throughout the day. Unfortunately, very few teens are able to achieve this. Strategies such as consistent bed time and wake times, trying not to nap during the day, using filters to block blue light filters from electronic devices (blue light can disturb your sleep cycle) and avoiding all electronics one hour prior to bedtime can all be helpful to promote better sleep quality.
  2. Eat. Teens need consistent meals throughout the day as well as enough food to fuel their bodies, brains, and activities. Skipping meals and nutrition can lead to increased anxiety, feelings of sadness, and inability to think clearly. Some teens like to eat multiple times per day such as three smaller meals and three snacks, while others find that eating three full meals is a better option. Either way, nutrition fuels a healthy and happy brain.
  3. Drink water. Setting a goal of 64 ounces (8 cups) of water per day not only helps with overall health, but also with mental health. Even mild dehydration can have an effect on mood. A way to judge how much water Is consumed in a day is to fill up a 64-ounce container with water and place it in the refrigerator and only drink water from that container during the day. People are often surprised how little they are drinking! It is a good visual reminder of just how much fluid we need to stay healthy.
  4. Exercise. Experts recommend 60 minutes of physical activity every day for children and young teens, and at least 60 minutes 3-5 times per week for older teens and young adults. The physical activity should be of moderate intensity and include some strength training, such as body weight squats or resistance band training. Often it is helpful to set small goals for exercise and work up from there. Additionally, scheduling a time to exercise helps to make it part of a routine.
  5. Practice Mindfulness. Teenagers and young adults often feel stress and anxiety about their lives. Mindfulness is a mental state that occurs when an individual acknowledges and accepts his or her present emotional and physical feelings. It is a powerful way to deal with stress in the moment and is a way to approach life without judgement. Using mindfulness has been shown to decrease stress, anxiety, and symptoms of depressed mood. It is sometimes not easy to be mindful, especially when faced with a stressful situation, but practicing skills over time can really help with this. There are multiple websites and free mobile applications that are available to guide teens. (The Journal of Medical Internet Research, a peer-reviewed journal for digital medicine and health care, published their findings on the best mindfulness mobile apps — you can view their results here.)

If you or your family member are experiencing signs of depressed mood, anxiety, or overwhelming stress, please call your doctor for an evaluation. If you or a family member does not feel safe or is experiencing thoughts of suicide, immediately call 911, go to your local emergency room, or contact the National Suicide Prevention Lifeline at 1-800-273-8255. 

Monday, March 19, 2018

“But I feel fine!” Why Teenagers Need Regular Preventive Health Visits

By Maria Monge, MD, Austin
TMA Be Wise — ImmunizeSM Physician Advisory Panel

It is Global Teen Health Week, and today we are focusing on the importance of prevention in adolescent health. As an adolescent medicine specialist, I see teenagers and young adults for a number of concerns, but one concern I hear often from both patients and their families is that they feel great and they don’t understand why they would need to see a doctor just to check in.

Let’s review many reasons why preventive health and screening are critical for adolescent health. The top two leading causes of death in teenagers living in the United States are accidents (including motor vehicle accidents) and suicide, both of which may be prevented with timely screening and intervention.

One of the most critical pieces of a routine adolescent health visit is that the patient be allowed to have time alone with the doctor. The doctor should explain that the conversation will be confidential unless the patient agrees to discuss the topics with the family or the teen is a threat to themselves or someone else. The confidential part of the visit allows the teenager to express concerns openly without fear of judgement.

Here is a list of some what happens at an adolescent and young adult preventative health visit.

  1. Vaccinations. Teenagers should receive recommended shots to protect against vaccine-preventable illnesses. Some of these vaccines are a continuation of those given in childhood; others are unique to the teen years.  These include vaccinations to prevent tetanus, diphtheria, pertussis (whooping cough), human papillomavirus (HPV, a virus that causes cancer), meningitis, hepatitis A, hepatitis B, and influenza. Staying current with immunizations is critical to health and can be a requirement for some jobs and colleges. Teens should keep a record of the vaccines they have had to ensure they are staying up to date even if changing doctors.  An easy way to do this is by signing up for ImmTrac2, Texas’ vaccine registry. ImmTrac2 is a free and secure immunization registry that allows physicians and schools to verify an individual’s vaccination history. Parental consent is required to enroll children and teens under the age of 18. Note: These records are deleted from ImmTrac2 once the individual reaches adulthood, so teenagers and adults 18 years and older must opt back in to ImmTrac2 to keep their records in the registry.

  2. Mental health screening. Mental health and physical health are linked. As adolescents and young adults grow older, often they face increasing stress, which can lead to symptoms of depression and anxiety. In the United States, one in three adolescents has symptoms of anxiety and one in seven has symptoms of depression. Doctors play a crucial role in linking adolescents to professionals who can help improve a patient’s mental health and also provide tips for better emotional and mental health. The American Academy of Pediatrics now recommends yearly mental health screening for all teenagers.

  3. Review of growth and development. A visit to the doctor’s office is an opportunity to review height, weight, and puberty changes for younger adolescents. It is a time when the patient and his or her doctor can look together at goals for nutrition and exercise and also ensure that current numbers are in a healthy range and appropriate for that teen’s body. It also allows time to discuss expected physical changes that occur in adolescence. In adolescent females, it is an opportunity for a discussion about menstrual periods and their symptoms.

  4. Screening for high blood pressure.  A recent study estimates that 3.5 percent of all teens have high blood pressure though many do not realize it, because it is typically without symptoms. Teenagers rarely check their blood pressure, so a health visit is a great opportunity for this.

  5. Screening for sexually transmitted infections and discussion of sexual health. By the time teenagers graduate from high school, almost 50 percent have had sex. Preventive visits give doctors an opportunity to discuss safer sex practices and screen for sexually transmitted infections including chlamydia, gonorrhea, and HIV. Often these infections are present but there are no symptoms. Screening for syphilis, hepatitis B, and hepatitis C also is recommended in certain high-risk teens. ALL teens 13 years of age and older should have at least one HIV screening, even if they are not sexually active. Additionally, the adolescent preventive visit allows an opportunity for teens to discuss birth control if needed.

  6. Screening for substance use and abuse. Adolescent substance use is an ongoing problem. For the first time in U.S. history, regular marijuana use is more common than cigarette use in adolescents, and rates of alcohol use remain concerning. Approximately 25 percent of fatal motor vehicle accidents in teenagers involve alcohol. Doctors can screen for substance use and refer patients to treatment as needed.

  7. Sports participation clearance. Most school athletic teams require some type of medical clearance for participation. This examination is best done in the medical home by a teenager’s regular doctor who has knowledge of the patient’s history. Typically, these exams can be performed at the same time as a regular yearly visit.

  8. Recognition of resilience and accomplishments. Teenagers are unique, talented, and resilient. Building resilience is one of the most important defenses against adolescent adversity. A regular health visit gives a doctor the opportunity to recognize and support teens for their accomplishments and strengths. 

Adolescents and young adults are generally very healthy and rarely need medical attention; however, a yearly preventive visit can ensure continued health for teens well into the future.

Thursday, March 15, 2018

Your Primary Care Practice: Where Everybody Knows Your Name

By Sue S. Bornstein, MD
Dallas Internist
Member, Texas Medical Association Board of Trustees

Some of you may remember the TV series “Cheers.” While it was essentially a sitcom, I believe that the show had something important to offer. I am referring to the theme song. The song goes: “Sometimes you want to go/ Where everybody knows your name/ And they're always glad you came.”

What does this have to do with primary care medical practice? A lot! Primary care specialties are family medicine, internal medicine, and pediatrics. Although not always counted in the definition, obstetrics and gynecology practices provide primary care to many women, especially during their child-bearing years.

Primary care is the first place you should think to visit when you are ill. These physicians and their teams are highly trained to deal with problems that come up quickly and also take care of health issues that tend to be longer term, like diabetes and heart failure. Your primary care team will get to know you as a person, learn what health concerns and issues you may have, and find out what is important to you and your family. Think of your primary care physician as the quarterback of your health care team.

Why is it important to have a dedicated primary care team? People who have regular contact with their primary care physician are likely to live longer and be healthier.

As medical care becomes more complex with greater use of specialists and sophisticated testing and technology, having a primary care team committed to your health is more important than ever before.  A new model of primary care — the patient-centered medical home — was designed to make sure that the patient is always at the center of the care team.

The patient-centered medical home increases patients’ access to the doctor’s office through various means including longer hours, telephone consults, electronic visits, and even group visits. The model emphasizes better care coordination among health care team members and seeks to avoid unnecessary or redundant testing. It also focuses on helping patients better manage their chronic conditions like diabetes.

Your primary care patient-centered medical home will remind you when it’s time for a life-saving health screening such as a mammogram or colonoscopy and when it’s time for you to come in for a follow-up of your medical issues.

This new model requires that physicians and their teams hone skills such as:

  • How to create an effective care team; 
  • How to better engage patients in their care; 
  • How to identify and track patients who are at high risk for health problems; 
  • How to improve transitioning patients from the office to the hospital or hospital to rehab or other setting; and 
  • How primary care can improve care for people with depression and other behavioral health issues.

Primary care physicians strive to enhance the care they deliver, which is why many will attend the upcoming Texas Primary Care and Health Home Summit. TMA is a founding sponsor of the sixth annual summit dedicated to helping clinicians and their staff incorporate new tools and methods to improve the care they deliver to their patients.

The summit will be held April 5-6 at the Renaissance Hotel at the Arboretum in Austin.  Physicians and other members of the primary care team interested in attending can learn more at

Wednesday, March 14, 2018

Influenza 2017-2018: A review of the flu virus and vaccine effectiveness

By Jasmeet Kaur, MD
Austin family physician

Have you had your flu vaccine yet?

It’s a simple yet essential part of your annual doctor visit. The influenza virus causes the flu. Flu symptoms include upper/lower respiratory tract symptoms, runny nose, cough, headache, fever, chills, and body aches. By vaccinating against the flu, you can significantly decrease your chance of getting the illness, or lessen the severity of the illness. Other ways to minimize chances of getting the flu are washing hands frequently, avoiding touching your nose/mouth/eyes, cleaning commonly touched surfaces frequently, and avoiding shaking hands with or coming in close contact with others who are ill. To prevent spreading germs, cover coughs and sneezes, and stay home if sick.

Flu season in the United States peaks from December to February; however, the virus circulates year-round. Influenza is responsible for millions of illnesses, hundreds of thousands of hospitalizations, and tens of thousands of deaths yearly.

The flu is spread through droplets from coughing, sneezing, or talking, which land in the mouths, noses, or lungs of nearby individuals up to six feet away, or directly when someone touches a surface or object with flu virus on it. The flu starts being contagious one day before symptoms develop and lasts up to five to seven days after the person becomes sick. This means people can spread the illness before realizing they are sick.

Most individuals with mild illness recover in less than two weeks and do not need medical care or antiviral drugs. Flu-related complications include pneumonia, bronchitis, or sinus infections. These groups of people have the highest risk for flu-related complications: children younger than 5 years old (particularly children under 2 years old), adults over 65 years old, pregnant women to two weeks postpartum, nursing home/long-term facility residents, and Native Americans. People with particular medical conditions such as chronic diseases, diabetes, and weakened immune systems also may be more susceptible to flu-related complications. In the current flu season, during the last week of December, 8.2 percent of the people in the United States suffering from influenza and pneumonia died from it. The Centers for Disease Control and Prevention (CDC) calls that epidemic. In previous years, as many as 7.1 percent of patients died.

You might have heard about “type A flu,” or “H1N1.” What do these names mean? Scientists divide the influenza virus into types A, B, and C, and subtypes H1, H2, H3, N1, and N2 based on differences in the virus’ makeup. Influenza A leads to annual local outbreaks, epidemics every two to three years, and even occasional pandemics. In comparison, influenza B causes milder disease, with outbreaks occurring every four years. Seasonal influenza C usually causes mild disease and is generally not responsible for epidemics or pandemics. (A disease outbreak means more people are sick than expected in a community or region or during a season; an epidemic means the disease spreads rapidly to many people; and a pandemic is worst of all because it means a worldwide disease outbreak.)

Influenza viruses are constantly changing and mutating. Small mutations are responsible for seasonal influenza viruses and require a new vaccine with each annual influenza season. Larger mutations can result in pandemics.

CDC analyzes and monitors nearly 2,000 influenza viruses every year to help determine which strains should be included in the upcoming season’s influenza vaccine. Despite the close monitoring, there are limitations to the vaccine’s creation. One reason is there is a lag of six to eight months between when current influenza strains are identified and when influenza vaccines are manufactured in large amounts; during that lag the virus can further mutate, resulting in a poor vaccine match for the current circulating strain.

By mid-January, CDC pointed to the influenza A (H3N2) virus subtype as this season’s most common culprit. By then, the season’s vaccine had been mass-produced and distributed, and even given to millions of people. Unfortunately, it was not a perfect match for this year’s virus. Early predictions give this year’s flu vaccine a 33-percent overall effectiveness against influenza and a 10-percent effectiveness against the H3N2 strain. Regardless of the limitations of the vaccine, it remains one of the best ways to reduce one’s chances of getting the disease, or reduce the severity of the disease. And for those who do get sick from the flu, antiviral medications such as oseltamivir, zanamivir and peramivir (better known by brand names like Tamiflu) can make the illness less severe and shorter.

Bottom line: Make sure next time you go to your doctor you are able to say, “Yes, I received my flu shot this year!”

Tuesday, March 13, 2018

Quicker Physician Exams of Foster Children Could Save Young Lives

Texas children suddenly thrust into the state’s foster care system will receive a necessary health check by a physician sooner, potentially addressing life-threatening issues. Senate Bill 11, one of four child welfare reform bills the Texas Legislature passed during the 2017 session, requires foster kids to see a physician within three business days of placement in foster care. Texas’ Child Protective Services (CPS) is expanding “community-based” foster care throughout the state as part of the change.

Before the law went into effect September 1, 2017, new foster children waited as long as 30 days to see a doctor for a physical exam. For many children that meant delays before they received help for medical problems tied to hunger, poor hygiene, and general lack of medical care. James Lukefahr, MD, a pediatrician who works at the Division of Child Abuse at The University of Texas Health Science Center at San Antonio, says the initial three-day exam is for the child’s safety. “It's going to be more of a screening exam to make sure they don't have any significant needs,” says Dr. Lukefahr. “We're looking for previously unrecognized injuries and anything that needs to be treated and — especially for older kids — looking at mental health screenings.”

For some children, the need is urgent — even a matter of life and death. The March issue of Texas Medicine magazine reports that between 2010 and 2014, 144 Texas children died while CPS investigated claims of abuse in their cases. Many other children in state custody had to sleep temporarily in CPS offices for lack of suitable homes. Meanwhile, problems such as low pay and high turnover among CPS workers created instability. The new law standardizes child abuse and neglect investigations, covers the cost of daycare services for foster children, and requires CPS to notify a physician when the agency moves a child to a new home.

San Antonio pediatrician Ryan Van Ramshorst, MD, a member of the Texas Medical Association Committee on Child and Adolescent Health, says the reform allows a “warm handoff” between physicians. "Now I can call the new pediatrician or the new family physician and let him or her know what's been going on with the care of that child to make that transition a little bit more seamless," Dr. Van Ramshorst said.

It is unclear if the new three-day rule will increase the number of foster children seen by pediatricians and family practitioners. Texas covers foster kids under STAR Health, a Medicaid program, so only physicians who accept Medicaid are likely to see children in foster care. According to TMA's 2016 Physician Survey, only 41 percent of Texas physicians accept new Medicaid patients, and just one in five accept some new Medicaid patients (21 percent). Foster care children in some areas like rural counties with physician shortages have greater difficulties seeing a physician.

The move to a three-day deadline was successfully implemented in Dallas and Lubbock after the law went into effect in September. For example, all of the newly placed foster care children in Lubbock saw a physician within the three-day window. Statewide, the transition to a three-day deadline will happen in stages. The entire state should be in compliance by Jan. 1, 2019.

"It's really rewarding to do something that makes you feel like you're going to have an impact on [health care] systems," says Valerie Borum Smith, MD, a Tyler pediatrician. "I think at the end of the day what we all want for children in foster care is for them to be safe, for them to be healthy, and for them to have the best outcomes possible.”

Friday, March 9, 2018

Why Hospice?

By Sarah Fontenot


When I was in my mid-20s, I was a nurse in a service offering hospice care to many of our patients. That experience left me with a life-long appreciation for the patient-focused, family-centered, personalized, and attentive care that is possible at the end of life.

My connection to hospice got even more personal last week as both my father (age 95) and mother (93) became hospice patients.

My family is in a time of introspection, caring, and questions. I thought I would address our concerns here to satisfy my parents, my three siblings, myself, and ultimately any of you facing a similar situation.


Please read on.

 — Sarah

The Why of Hospice

There are many misunderstandings about hospice — and that is unfortunate. Unfortunate because hospice offers an approach and resources that could benefit so many more people than it currently does.

We are all aware of — and celebrate — the enormous advances in medical treatment options for people with severe illness and/or injuries; we celebrate victories over what were once terminal conditions. But medical science has its limits — death will not always be delayed.

Is aggressive treatment the best way to transition towards what will be, inevitably, a death? More importantly, in each case when treatment is bordering on futile, is that the patient’s decision — or is the patient’s choice muted by age, weakness, resignation, or incompetence?

When what matters is not the length of life but the quality of the living that is left — and hospice may be the answer.

What Makes Hospice Unlike Traditional Medical Care?

Hospice offers a different way to die — in your own home or in a designated hospice facility (and in some cases in a nursing home or hospital). Hospice is not a place — it is an ideology.
Traditional treatment is cure-oriented. Interventions, surgeries, medications, therapies — all of these are either to eradicate disease, fix an organ or bodily function or broken part, or at least modify the implications of any of the above. Of course, any treatment regime must also consider pain and discomfort or obstacles to daily living — but the trajectory of treatment is toward making things better.

In contrast, hospice focuses on comfort: physical, emotional, psychological, and spiritual welfare. Treatment for a cure is stopped,* and attention on well-being is paramount.

*Treatment for other problems a patient may have can continue; treatment for the terminal condition will not.

Who Is Eligible for Hospice Care?

As we are all too aware, death is not exclusive to the elderly. When younger adults or children are dying, they can turn to their private insurance company and/or state and local payment programs to discover available hospice treatments and coverage.

But most people requesting hospice care will be over the age of 65, and therefore, Medicare beneficiaries. 

Medicare eligibility for the hospice benefit requires that your regular doctor* and the hospice medical director both certify that you have a life expectancy of six months or less, should your illness or condition run its “normal course.”

That certification must be repeated by a hospice physician again in 90 days, and then every 60 days for as long as you live.

*Involvement of your physician (if you have one) is only necessary at intake, but entering hospice does not mean you must abandon your physician — his or her continuing involvement in your care is at your discretion and between you, your physician, and your hospice team.

Is Hospice Limited to Cancer?

Heavens, no. The history of hospice in our country springs from cancer care, but cancer is not a requirement for eligibility — in fact, only a minority of hospice patients (only 31.1 percent in 2008) have cancer.

Since 2006, the most common diagnosis for hospice admission is non-Alzheimer’s dementia; in recent years there has also been an increase of patients with neurologic-based diagnoses, and nonspecific conditions such as “adult failure to thrive.” (For more)

What is critical to eligibility is the patient’s life expectancy, not the medical condition that is causing the patient to die.

What Is a Family’s Role in Hospice?

As with all medical treatment, if a patient is competent, he or she decides to enter hospice as the last phase of life. If the patient is not competent, the decision rests with a legally recognized representative (subject to state law).

But regardless of legalities — hopefully, the decision to enter hospice comes with full support of the patient’s family. That will surely be better for the patient — but the family will benefit from hospice as well.

Hospice is a family-centered concept of care. Not because the family will be required to provide the physical, intimate care of their loved one (another misperception about hospice) but because the family and patient will want to make plans together whenever possible. 

At the end (as well as along the way), a hospice team can support the grieving family as they say goodbye and ultimately lose their loved one to death. The family’s well-being is core to the hospice mission.

As described by the American Hospice Foundation:

The gift of hospice is its capacity to help families see how much can be shared at the end of life through personal and spiritual connections often left behind. It is no
wonder that many family members can look back upon their hospice experience with gratitude, and with the knowledge that everything possible was done towards a peaceful death.

What Does Medicare Cover?

Meeting the physical, emotional, psychological, and spiritual needs of hospice patients and their family requires a multidisciplinary team. Depending on the plan of care determined by the hospice provider, patient, and family, that team could consist of (but is not limited to):

  • Doctors,
  • Nurses and nurse practitioners,
  • Home health aides,
  • Counselors and social workers,
  • Pharmacists,
  • Physical and/or occupational therapists, and
  • Volunteers

Perhaps most importantly to those at home, hospice includes 24/7 availability of nurses and doctors to provide the patient and family with the support and care they need.

The Medicare hospice benefit covers virtually all expenses related to care received, whether that care occurs in the patient’s home or in a hospice facility (and with some limitations in a nursing home or hospital).

Is Hospice for Everyone?

Not all people want to relax into death; there are plenty among us who want to fight until the end. If that characterizes you or your loved one, I want to remind you that hospice is a choice.
My concern is that people who would appreciate the approach of hospice either do not know enough about it or have been scared off by persistent myths that make this critical decision more difficult.

If those of you who might be interested in pursuing this path find out more now and add this option to your end-of-life planning (and feel that you can better encourage your loved ones to consider hospice as their own choice) — I am gratified.

But my greatest hope is that my family is assured that Mom and Dad are entering the last phase of their life — but not the worst.

Want to Know More?

What is palliative care? The difference between palliative care and hospice causes a lot of confusion. Care that focuses on comfort and function is called palliative care, and a person on hospice will receive this type of attention. There is, however, an entire specialty in medicine known as palliative care, which is not restricted to terminally ill patients. A palliative care doctor is often an addition to a traditional medical team of specialists all working to help a patient toward a cure or the best possible outcome of treatment. Palliative care is part of a treatment plan; hospice is the plan for moving a patient toward dying with optimal comfort. For a short (1:34) film on the difference, go here.

The history of hospice (and the law regarding physician-assisted suicide and other topics related to end-of-life care) is reviewed in meticulous detail here.

Thursday, March 8, 2018

After Raising Age For Tobacco Purchases, State Sees Decreased Sales To Minors

By Jocelyn Wiener
California Healthline

This article was originally published on California Healthline.

In June 2016, California became the second state in the country, after Hawaii, to increase the minimum tobacco sales age from 18 to 21.

A report published last month in the journal Tobacco Control suggests the new law is already working. Seven months after it took effect, preliminary data show, the percentage of state retailers selling tobacco to kids under age 18 dropped significantly — from 10.3 percent before the law took effect, to 5.7 percent afterward. The rates are based on surveys in which teenaged decoys attempted to purchase tobacco from retailers.

By raising the minimum age to 21, experts had predicted teenagers would no longer have such easy access to tobacco through their slightly older friends.

Survey data also showed that almost 99 percent of tobacco retailers were aware of the new law, and that the majority supported it.

April Roeseler, chief of the California Tobacco Control Program and co-author of the report, said she was “pleasantly surprised” at how well tobacco retailers had responded to the increased age of purchase.

“We know that they’re the front line in helping make this law be successful,” she said. “I think we expected that this would be a tough law to implement and get compliance with, but I think it’s just indicative of the groundwork we’ve been doing in California for nearly three decades.”

Larry Cohen, executive director of the Oakland-based Prevention Institute, said he, too, was surprised that most retailers support the law.

“It’s a sign that there’s real momentum over the past couple of decades in recognizing that tobacco is harmful and that protections are appropriate,” he said.

Sen. Ed Hernandez (D-West Covina), chair of the Senate Health Committee, said he first proposed legislation to increase the state’s minimum tobacco sales age after reading a magazine article about teen smoking in 2015. Soon after, the Institute of Medicine published a report saying that 90 percent of adults who became daily smokers first used tobacco by the time they were 19.

The following year, Hernandez introduced the law, and his colleagues in the California legislature passed it. The law does permit active-duty military members to purchase tobacco even if they are not yet 21, a concession Hernandez said he made in order to get needed votes. He said he received pushback from people in the military who believed “if you are old enough to go to war, you are old enough to smoke.” Hernandez notes that the law still requires members of the military to be 21 to buy alcohol.

The new report shows that how well retailers comply with the new age limits also varies geographically: Retailers in Los Angeles sold to underage buyers much more frequently than did those in the Bay Area.

“There are always kids that come around,” said an employee of Sana Market and Liquor on Telegraph Avenue in Oakland, who did not want his name published so he could speak freely.

He said the market — which carries snacks and alcohol in addition to cigarettes — is very strict about checking IDs.

They also refuse to sell to adults when it is clear they are trying to buy for someone under legal purchasing age. So-called shoulder-tap buys continue to be a problem, according to the study.
Still, said the employee, there is only so much the law can do: “Whoever is going to smoke is going to smoke.”

Nearby, just off upscale Piedmont Avenue, Stephen Richman, the longtime owner of The Piedmont Tobacconist, said he supports the increased age of sale. Even before the new law, he said, teenagers rarely tried to buy from his shop, with its wood-paneled walls, leather lounge chairs and background jazz.

He pointed to a big, yellow sticker on the cash register that read: “The Sale of Tobacco Products to Persons Under 21 Years of Age is Prohibited by Law and Subject to Penalties.”

“This discourages them,” he said.

Occasionally, he said, a young person comes in hoping to buy a cigar to hollow out and fill with marijuana. When they hear the price, he added, they usually leave.

Monday, March 5, 2018

Cancer Prevention? I’ll have a dose of that!

By Maria Monge, MD, Austin
TMA Be Wise — ImmunizeSM Physician Advisory Panel

In my job as an adolescent medicine doctor, I talk to many patients and their families about human papillomavirus (HPV) vaccination. Because teenagers are generally healthy, my visits with them typically focus on ways to stay healthy throughout their lifetimes. The HPV vaccine is an important part of this.

I regularly share this important information with my patients and their families about HPV infection and HPV vaccination:

  1. HPV is very common. At least 80 percent of people living in the United States will become infected with HPV in their lifetimes. It is almost impossible to avoid infection, and HPV is spread through skin-to-skin contact. Fortunately, most people’s bodies can fight off the infection, so they do not develop any long-lasting effects. Some are not so lucky.
  2. HPV infection can cause cancer. Each year in the United States, more than 30,000 people are diagnosed with cancer caused by HPV infection. These cancers include cervical, head and neck, vulvar, vaginal, penile, and anal.
  3. The HPV vaccine prevents cancer. The HPV vaccine prevents more than 97 percent of the virus’ infectious strains. Because of this, in only a little more than a decade of HPV vaccine use, worldwide rates of precancer cells of the cervix have decreased by more than 50 percent. It is estimated that with increased HPV vaccine rates, almost all —more than 90 percent — of cancers caused by HPV could be prevented.
  4. The HPV vaccine is safe. Multiple studies in millions of teenagers worldwide who have received the HPV vaccine have shown the HPV vaccine is safe and effective.
  5. Early HPV vaccination is best and strongly recommended. The HPV vaccine is recommended for all girls and boys at age 11 or 12 years. If the vaccine is started before someone turns 15, they only need 2 doses of the vaccine because the response is better at a younger age. Receiving the vaccination early — before exposure to HPV — also increases protection.

My passion is to help teenagers and young adults live happy, healthy lives. Toward that end, I recommend the HPV vaccine to all my patients.  

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