Monthly Archives: July 2012

They Won’t Live Past 21

These words still echo twenty years after I heard them in a first year medical school lecture on congenital genetic disorders.

At the time, patients with Down’s Syndrome (Trisomy 21) were not expected to live far into adulthood. While we needed to learn how to treat them as children and teens, we paid no attention to their possible lives as adults.

Experience has taught me otherwise. I have cared for teenagers and young adults with Down’s Syndrome, completed many medical clearance forms for Special Olympics, and discussed how elderly parents should plan for their children’s continued care after they die.  I have delivered children with Down’s when the prenatal testing said the risk was normal.  I remember the chill we felt when my wife’s 16 week ultrasound showed cysts in our daughter’s brain that suggested Trisomy 18, a lethal genetic defect. As we drove to the amniocentesis appointment, we wondered what we would do if the answer was  yes.  She turned eleven recently.  Thankfully, the answer was no.

As the youngest of eight, the odds were not in my aunt’s favor.  The prenatal testing we have today did not exist in the 1960’s.

She turned fifty last week.

I’m glad you proved them wrong.

Happy Birthday

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Family Medicine Is …

Family medicine is:
1) Learning via Facebook that the preteen girl you took care of ten years ago just finished a veterinary medicine fellowship and has started her own practice.
2) Being invited to the Bastille Day celebration hosted by the French Consulate by two patients who are Holocaust survivors.
3) Telling medical students and residents that their stories about their desire to be family doctors resonate as much with politicians as reams of policy papers.

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Time To Swing For The Fences – 2012 Texas Academy of Family Physicians Presidential Address

“OMG, this is wicked cool, I can’t believe I’m president.”

Oh, sorry.  That was my daughter’s version of my speech.  Here’s mine.

Good afternoon, and welcome.

Whether we practice in Houston or Henderson, Wichita Falls or Weimar, El Paso or Del Rio, Alpine or Austin; we are all Texas family physicians.  We bring different perspectives to the Academy based on where we live and where we’re from.  I know what it’s like to work in a large integrated healthcare system, run a community health center, and teach our future family physicians, but I don’t know how to run your practice.  I want to hear from each of you about how we can strengthen family medicine and take care of our patients.

Our health care system is in the midst of a painful rebirth.  The insurers, the government, and the hospitals are pulling us in different directions.  We stand with our patients at the middle of this storm of abbreviations and acronyms:  ACA, ACO, PCMH, EHR, and Medicaid 1115 waiver.

Now, we can ride off into the sunset like the cowboy in the old Western, resigned to obsolescence as the specialists, large hospital systems, and insurers take over healthcare.  Or we can choose to pull up our britches and get to work.  “If you don’t like change, you’re going to like irrelevance even less.”  President Lyndon B. Johnson said there are two kinds of people in the world:  “can-do people” and “can’t-do people.”  I think family doctors are can-do people.

When Bobby Youens and Jorge Duchicella of Weimar grew frustrated at the lack of family physicians in rural Texas, they got together with Tricia Elliott of UTMB to organize a rural residency track.  Instead of resigning himself to complaining about changes in health care, Lloyd Van Winkle of Castroville organized primary care docs into an IPA – and ran for the board of the American Academy of Family Physicians.  When Melissa Gerdes and Mike McCready grew concerned about how family docs would fit into large healthcare systems, they became physician leaders who could advocate for their patients from the inside.  Instead of getting mad, Roland Goertz got even – and headed off to Washington, DC as our academy president to bend the ear of every congressperson and Senator he could find about the value of family physicians.  While other specialties complain about “the government doing this” or “insurers doing that,” family doctors come up with a plan and get to work.

It is easy to get frustrated by the changes hitting us daily, but I urge you to channel your anger into action.  We understand better than most the reality on the ground – and what our patients need.  When patients ask me if I think all the frustrations are worth it, I think of a 1991 CNN interview with an old redneck from Boots and Coots.  Now Boots and Coots is who they send in when the world is going to hell – and someone needs to put the fire out.  Behind him, the burning Kuwaiti oil wells spewed smoke and flames into the sky.  When the reporter asked him why someone would do something so dangerous, he answered in his best Texas drawl:  “Hell, there’s nothin’ I’d rather be doin’ than fightin’ oil fires.”  I don’t push each day to get my patients the healthcare they deserve to quit now.  They deserve my best.  And there’s “nothin’ I’d rather be doin’.”

Let’s be honest, though.  We took some lumps in the 2011 legislative session:  the primary care preceptorship was eliminated, state GME funding for residencies like mine was cut to within an inch of its life, and the loan repayment program which placed family docs in needy communities was slashed so badly it’s on life support.  Medicaid rates weren’t cut, but in typical legislative fashion, Medicaid will run out of money on December 31st.  Your physician leaders and academy staff have drafted a policy manifesto for the 2013 legislative session:  the Primary Care Rescue Act.  This plan shows our legislators how they can improve the health of their constituents – our patients – by investing in training new family doctors and getting those doctors to where our patients need them.

To improve health care in Texas, we need to:

  1. Train more primary care doctors by restoring funding to our residency programs
  2. Push our tax payer funded medical schools to train more residents  and make sure the medical students they educate  go where the taxpayers need them
  3. Encourage medical students to pursue primary care by funding the primary care preceptorship program
  4. Consolidate Texas’ two loan repayment programs and restore their funding
  5. Encourage doctors to adopt health information technology by offering loan programs and business tax credits
  6. Reward quality improvement by requiring health plans which receive state general funds to increase the fees paid to physicians who achieve national quality certifications from the NCQA and others.

These areas will be the focus of our legislative efforts for the next session.

Now we could trot off to Austin in January with this list in hand to ask for more money – just like the school teachers, the universities, and everyone else whose programs were cut last time around.  Too often, doctors approach politics like a disease to be cured. We come up with a sound policy, then we wait for our leaders to respond to the rightness of our cause.  But being right doesn’t get us votes.

Politicians follow a different logic.  Our most important issue may not be theirs.  We must get to know them, learn what motivates them, and understand what issues matter to their constituents.  Next year, the legislature will make decisions that will have a major impact on healthcare in this state.  Now is the time to lay the groundwork for 2013.

Everyone in this room can contribute.  You each have a state representative and a senator.  Call them.  Remind them you are a constituent – and so are your patients.  “My patients have trouble getting the healthcare they need, they live in your district, and they vote.”

I am honored and humbled to be chosen as your president.  It is time to swing for the fences.  As I look forward to the next 12 months, I think of a slogan from college:  “Lead, follow, or get out of the way.” I am proud to be president of an academy which chooses to lead.

Thank you.

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Swimming, Biking, and Running: What Could Go Wrong?

My goals were simple:  try not to drown, try not to crash, and try not to break anything.

As a kid, my parents enrolled me into every sport our town had.  I swam, played soccer, basketball, and baseball, and even tried gymnastics.  I was never particularly good, but I loved to play.  I figured out quickly that hand-eye coordination was not my strong suit.  Opening your eyes when you’re trying to hit a baseball helps a lot.  As the shortest male in a family of 6 ft plus men, basketball quickly fell by the wayside.  I did well in soccer mainly because I could run around all day without getting tired.  In high school, I decided to put running to use and joined the cross-country and track team.  On weekends I took my 10 speed and rode all over town.

After years of marathons, running had become a grind.  I was looking for something new.  I thought buying a new bike would help me make exercise exciting again, but a few unfortunate incidents got in the way.  In March 2010, on a fast training ride, I crashed into a city bus shelter while trying to avoid another cyclist. I needed 4 ½ hours of surgery, six days in the hospital, and six months of rehab to get my left hand to work again.  In January 2012, I broke my right foot while running through my neighborhood.  For two months, I had to get around on crutches.

For rehabilitation, and for the sake of my wife’s sanity, I took up swimming.  Learning proper stroke technique decades after leaving the neighborhood eight and under swim team was harder than I thought.  I have swallowed enough pool water to fill a bath tub, but have not drowned yet.

My struggles with swimming made me nervous before the start of the race.  I entered a slow swim time because I was afraid of getting run over by faster swimmers.  Once I jumped in the water, my fears eased.  “All I have to do is swim 300 meters without drowning.”  Three laps later, I gladly accepted the hand that lifted me out of the water. “Now comes the fun part,” I thought.  My bike leg went smoothly as practicing on the race course the weekend before helped.  The second transition was slow as I struggled with my socks and could not get my visor to fit.  I even forgot to put my race number around my waist.  My wife’s cheering was really her attempt to tell me what I had forgotten.  I just smiled and waved.  I was able to run about the pace I thought I could from training and crossed the finish line in just over 53 minutes.  Starting at the back after the swim left me with no idea of how I had done.  I was simply proud to finish feeling good.

When I saw that I had won my age group, I was shocked.  No way. The high fives from the other triathletes felt great.  I went home, joined USA Triathlon, and signed up for my next race.

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