Texas Family Physician, Q1 2019 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 70 NO. 1 2019

AAFP’s EveryONE Project Helps You Master Screening For

SOCIAL DETERMINANTS OF HEALTH PLUS: Annual Session Highlights TAFP’s Strategic Plan For 2019 And Beyond

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INSIDE

TEXAS FAMILY PHYSICIAN VOL. 70 NO. 1 2019

Screening for social determinants of health

As family physicians, you know all too well the importance of understanding the social context and environmental realities of your patients, yet these factors are crucial to the provision of good care. Here’s a method that should help. By David T. O’Gurek, MD, and Carla Henke, MD

The EveryONE Project has big plans for 2019

The Academy’s effort to help members address their patients’ social determinants of health had a great year in 2018, but this year holds all new challenges.

By Chris Crawford

Luck be a lady: Family medicine reunion

Friends from across the state gathered in Arlington to learn, network, and rejuvenate. The high rollers were out in force for the Family Medicine Celebration, all styled to a “Guys and Dolls” theme. By Jean Klewitz

6 FROM YOUR PRESIDENT Strong medicine 9 MEMBER NEWS Four members appointed to AAFP committees | Waco FP wins McLennan County Medical Society’s Distinguished Service Award 10 YOUR ACADEMY TAFP in 2019 and beyond 12 STRATEGIC PLAN Check out your Academy’s new strategic plan with all-new mission and vision statements. 26 ASPCS HIGHLIGHTS 27 TAFPPAC DONORS 28 FOUNDATION DONORS 29 PERSPECTIVE The aging physician model

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PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 70 NO. 1 2019 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.

OFFICERS president president-elect treasurer

Rebecca Hart, MD

Javier D. “Jake” Margo, Jr., MD Amer Shakil, MD, MBA

parliamentarian

Mary Nguyen, MD

immediate past president

Janet Hurley, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editor

Jean Klewitz chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell

CONTRIBUTING EDITORS Chris Crawford Carla Henke, MD Larry Kravitz, MD David T. O’Gurek, MD

SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2019 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN [No. 1] 2019

Strong family physicians, strong medicine, strong patients An excerpt from the inaugural speech of the new TAFP President By Rebecca Hart, MD TAFP President i am so humbled, joyful and happy to begin work as your new president. Thank you for electing me and giving me this opportunity to serve you. I hope you join me this year in working harder than ever to keep our profession strong, our physicians inspired, and our workforce increasing. When I began my career as a resident in Family Medicine at Baylor College of Medicine Residency Program in 1988, I was naïve. I knew nothing of the big issues that would face me in my future as a family physician. I knew nothing of CMS, preauthorization, payment reform, physician shortages, mid-levels, MACRA, EHRs, quality incentive programs, or Medicare Advantage plans. Heck, most of these things didn’t even exist back then! I knew only that I loved every rotation back in medical school, so family medicine was right for me. I wanted to be a full-scope family doctor, deliver babies, and work in a small town in Texas to make a difference in people’s lives. In 1991, I joined Dr. Tom Mueller in La Grange where I had my chance to practice full-scope family medicine, doing all the procedures I had been taught. Delivering babies, performing C-sections, flex sigs, dermatologic procedures, minor surgery, and inpatient and outpatient care—the whole nine yards. I was in heaven. But, call was every other night and when I got home from work, I got called back in for admissions or emergencies at the ER.

Very soon I found myself depressed and upset. I was working harder than I ever had before. I had a 2-year-old at home and a supportive husband but I never saw them. I went home and passed out, slept a while, then went back to work. I was burned out and it didn’t take long. We tried to recruit another physician with no luck. No one was interested. Dr. Mueller introduced me to TAFP and I joined the Section on Rural Health and Maternity Care. It was then that I learned of our physician workforce problems in Texas affecting all rural areas. La Grange, 45 minutes from Austin, was in fairly good shape. We had a hospital and five physicians, two who delivered babies. But we could not attract doctors to this small Texas town. Sadly, the problems plaguing our rural communities back then are still true today. Today, 80 of 254 Texas counties have five or fewer doctors, 35 have no doctor at all, and at least 18 rural hospitals have closed since 2013. This lack of access to care has resulted in skyrocketing rates of preventable disease and maternal mortality among rural residents. One solution to this problem would be to reconfigure our physician workforce. According to the Association of American Medical Colleges, nearly two-thirds of medical students pursue subspecialty training instead of primary care, further exacerbating our primary care shortage.

Today, 80 Texas counties have five or fewer doctors, 35 have no doctor at all, and at least 18 rural hospitals have closed since 2013. This lack of access to care has resulted in skyrocketing rates of preventable disease and maternal mortality among rural residents.

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According to the Council on Graduate Medical Education, there is significant evidence that optimal health care outcomes and health system efficiency are demonstrated when at least 40 to 50 percent of the physician workforce is composed of primary care. A new AAMC study reports that Texas will face a shortage of 6,400 primary care physicians by 2030. And currently Texas ranks 47th out of 50 for the number of primary care doctors working in the state per capita. Despite compelling and conclusive evidence calling for a health care system grounded in primary care, academic institutions lag far behind in producing enough primary care physicians to care for a population that is rapidly growing, aging, and presenting worse and more complex health conditions. Perhaps it is time to for our Legislature to incentivize our medical schools to produce more primary care physicians for all of Texas and to hold the schools accountable when they don’t. If we are going to fund medical schools to the level we do, then isn’t it time we hold them responsible for the workforce they produce? I eventually left La Grange with many tears and sadness. After consulting with my mentor Dr. Roland Goertz, I felt the best way I could make a difference was to go into academia, to recruit and train the best and the brightest to family medicine. I spent the next 20 years teaching in and leading residency programs. Now I’ve returned to my first love, private practice, where I have been happily caring for patients for the past six years. And yet we continue to face a great need for more family doctors. We also face a more insidious problem, the moral injury of practicing in a system that prevents us from providing the highest quality care we can — the care we know our patients

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TEXAS FAMILY PHYSICIAN [No. 1] 2019

From left: AAFP Speaker Alan Schwartzstein, MD, of Wisconsin administers the oath of office to incoming TAFP President Rebecca Hart, MD.

[cont. from 7]

need and deserve and that we could deliver if not for the burdensome constraints of our untenable health care system. This moral injury is what burnout is, and we have all felt it in one way or another. You want to give a patient the best antibiotic for their infection but the insurance company requires a pre-authorization form, which takes three days to be approved, so you have to settle for a less effective med and hope it does the job. You feel defeated. You want to send a patient to an orthopedic surgeon right away, but they are on Medicaid and it takes four months to get the next appointment with the only orthopedist that will agree to see them. Again, you feel defeated. You want to admit your elderly patient to the hospital but they don’t meet the strict criteria of Medicare to be admitted, so they sit in the ER for hours, only to be sent home after 24 hours of observation on a hard gurney because they didn’t meet admission criteria. Once again, you feel defeated by the system.

Then you have a ton of paperwork to get your patient home care, phone calls with case managers and medical directors of insurance companies, and you are ready to throw up your hands. After which you spend hours after work typing out the office notes you couldn’t complete during working hours. Maybe you have an hour or two once you’re done to talk to your spouse and kids, but wait—you need to finish your Maintenance of Certification, so you’d better read another article and take a quiz before bed. Help! Yes, doctors today are facing a moral burnout. We can’t do what we were trained to do and that feels wrong. This isn’t what we want to show our fledgling medical students wondering if they want to be a family doctor. But that’s what they see. Hence fewer students are choosing family medicine. More older doctors are leaving right when we need to increase the workforce of well-trained family doctors to serve our aging population.

People ask me if I would do it all again if I had the choice. Without hesitation I would. Was it a hard road? Yep. But I’m proud to be a family physician.

MEMBER NEWS

As you can read 0n page 12 0f this issue of Texas Family Physician, TAFP has adopted a new strategic plan that prioritizes the health of the physician and the practice, the health of our patients and the public, and the health of the specialty and the Academy. Over the next year, we will be laser focused on engaging our members and helping them decrease administrative burdens, understand new and emerging payment models and new models of care, and provide better care for mental and behavioral health problems in their patients and communities. We still have aspiring medical students and residents who are excited to help their patients and to do the right thing for them. I see them all the time. They are our future. People ask me if I would do it all again if I had the choice. Without hesitation I would. Was it a hard road? Yep. But I’m proud to be a family physician. I’m proud of what I have done these past 27 years. I want to keep doing it and keep my relationships with my patients strong. We need to light it up and show people that being a doctor today is as noble a profession now as it ever was. That the Hippocratic oath is not dead. That no one can take away your knowledge. That you can practice as a family doctor anywhere in the world. That the intimacy and trust you establish with each patient is sacred and held to a very high moral standard. That patients want and need that intimacy and trust with their doctor. That the moral standard should be held up and should not be compromised by a constant barrage of payer nonsense, so that we as physicians can do the right thing for our patients. That we can stay cost-effective and continue to give the very best advice based on excellent training in diagnostics and therapeutics. That all this hard work is worth it. As I grow older, I know I want an excellent, excited, hardworking physician workforce, not burned out embers, but glowing flames, enjoying how wonderful it is to be a family physician in this country. Let’s work together to build strong physicians, and with strong medicine, to build strong patients!

Four TAFP members appointed to AAFP committees Three active members and one resident member of TAFP were named to participate on AAFP committees this year. The three regular members will serve terms of four years while the resident member will serve for one year. Mark Malone, MD, will serve on the AAFP Commission on Continuing Professional Development. Malone is an experienced teacher who taught music education in the public-school system before choosing to pursue medicine. He is a hospitalist at UT Health East Texas Physicians in Tyler. For the past decade he’s served on TAFP’s Commission on Continuing Professional Development and has been active in ensuring the success of many of TAFP’s educational programs. Rita Schindeler-Trachta, DO, will serve on the AAFP Commission on Health of the Public and Science. Schindeler-Trachta started her career of service in the United States Air Force and now serves her community as a family medicine physician, 18 years now and counting. She works full-time with geriatric patients at the Austin State Hospital and part-time providing end-of-life care at the Hospice Austin Christopher House. She dedicates a significant amount of her time educating the public on chronic health issues such as diabetes, heart disease, and intimate partner violence. Schindeler-Trachta became involved with TAFP as a new physician and has continued to show her passion for public health by serving for over 10 years on the TAFP Commission on Public Health, Research, and Clinical Affairs. Richard Young, MD, was appointed to the AAFP Commission on Quality and Practice. Young is the research director for the JPS Family Medicine Program in Fort Worth and an active participant in TAFP’s governance, for more than 15 years. He researches and writes actively about our health care system’s quality and maintains a blog on the subject, www.healthscareonline.com. Young serves on the TAFP Commission on Health Care Services and Managed Care and leads the Tarrant County Chapter of TAFP. Jayaprada “Jaya” Kasaraneni, MD, was appointed to the AAFP Commission on Continuing Professional Development. Kasaraneni is a family medicine resident physician at Texas Tech University Health Sciences Center at the Permian Basin in Odessa. Her education in medicine and healthcare management led her to streamline and improve systems of professional support and development in the various practice settings she worked for along the way. Kasaraneni has been a TAFP member since the start of her residency in 2017.

Goertz receives Distinguished Service Award Roland A. Goertz, MD, MBA, was presented with the McLennan County Medical Society’s fifth annual Presidential Distinguished Service Award at a banquet on Dec. 5 in his hometown of Waco. A past president and board chair of the American Academy of Family Physicians, Goertz has been one of the most influential members of TAFP over the past two decades. In his home community, he has served in numerous capacities both in and out of the field of medicine. Among his most important positions, he has been chief executive officer of the Heart of Texas Community Health Center, Inc., overseeing all operations of the Waco Family Health Center since 1997. Goertz graduated medical school from the University of Texas Health Science Center at San Antonio and completed his residency training at John Peter Smith Hospital in Fort Worth. He completed a clinical teaching fellowship in family medicine in 1986 and received a master’s in business administration from Baylor University in 2003.

www.tafp.org

“When we think about the health of the physician and the practice, we really want to help empower you where you are,” she said.

YOUR ACADEMY IN 2019 AND BEYOND

TAFP’s new strategic plan focuses on helping members care for patients By Jonathan Nelson

ast fall, the TAFP Board of Directors approved a new strategic plan for the Academy designed to strengthen the organization and ensure it works to help members do what they do best: take care of their patients and their communities. The plan is the culmination of a yearlong process led by TAFP’s elected leaders and a select group of other leaders. It will help guide Academy actions and endeavors for the next three to five years. The first order of business for the strategic planning committee was to refine TAFP’s mission and vision statements. The new proposed statements are as follows. Mission Statement: The mission of the Texas Academy of Family Physicians is to promote the health of all Texans by serving the needs of members and advancing the specialty of family medicine. Vision Statement: TAFP empowers family physicians to play a robust role in health care for their patients and their communities. These proposed statements have been approved by the board of directors and will be included as proposed amendments to the TAFP Bylaws, which will be voted on during the Member Assembly at this year’s Annual Session and Primary Care Summit in November. In pursuit of this mission, the committee decided to organize the Academy’s endeavors around a set of structural concepts: the health of the physician and the practice, the health of the patient and the population, and the health of the organization and the specialty. Virtually everything TAFP’s leadership, committees, and staff do can be categorized in one or more of these areas of focus. These three concepts can be expressed as strategic objectives. TAFP’s strategic objectives for 2019 and beyond are: • To support the family physicians of Texas and their practices; • To improve the health of Texans and their communities; and • To advance the specialty of family medicine and strengthen our organization. Under each strategic objective, the committee listed a set of goals determined through a rigorous examination of member survey data and debate. Then the group identified three strategic initiatives for each. TAFP Board Chair Janet Hurley, MD, presented the new strategic plan at the 2018 Member Assembly last November, telling the audience the Academy’s emphasis can be summed up in the unofficial slogan adopted by the strategic planning committee: Strong family physicians, strong medicine, strong patients. 10

TEXAS FAMILY PHYSICIAN [No. 1] 2019

In TAFP’s 2018 member survey, administrative burdens were by far the No. 1 concern of members, with 85.8 percent of respondents saying TAFP should focus “a lot” or “as much as possible” on reducing administrative burdens. Almost 60 percent of respondents listed “administrative burden caused by payers” as one of their top three frustrations. Hence finding ways to reduce those burdens took up much of the committee’s focus when considering the health of the physician and the practice. “We want to continue to work to identify and remove unnecessary administrative burdens throughout the documentation, compliance, claims and billing processes,” Hurley said. “And we recognize our national Academy is working ardently on this as well. Our challenge is to begin to think what are the unique things that our Texas physicians are struggling with. What are some ways we can caucus with our payers to try to reduce administrative burdens for you.” When considering the health of the patient and the population, the committee identified behavioral health as the key problem to address. “I know in the area where I practice, we just simply cannot get people into psychiatry,” Hurley said. I hear some of you have perhaps some better success with that than I do, but it is a definite need and a real frustration for our members. … A lot of times these patients have a lot of unique social needs. We need to begin figuring our how we are going to empower you locally to make a difference with that.” The committee called for the Academy to convene a behavioral health task force comprised of experts across a range of disciplines to identify resources and best practices for integrating behavioral health into family medicine. That task force has already begun its work, so you can expect to hear from them later this year.

“We want to continue to work to identify and remove unnecessary administrative burdens throughout the documentation, compliance, claims and billing processes.” Janet Hurley, MD Chair, TAFP Board of Directors

TAFP Strat 2019 egic Pg Plan

. 12

Finally, the committee recommended a number of initiatives to strengthen TAFP and to support the specialty of family medicine. The Academy will develop a multimedia toolkit members can use to persuade employers, insurers, academic deans, and medical students of the value of family medicine. The Academy will also continue to invest in leadership development for family physicians so members can advance their message across various spheres of influence. So with a new strategic plan in place, the Academy has its focus and its charge for 2019 and beyond. The main theme as Dr. Hurley described it is to help empower our members to succeed. “It became very apparent to us as we continue to push legislation through Austin and as our national Academy pushes legislation through Washington, that we have a very divisive political system,” she said. That divisiveness makes legislative advocacy more difficult and sometimes less effective. “Of course we will continue to stay active in Austin and in Washington, D.C., but we really want to begin empowering you to work locally for the improvement of your patients and your communities.”

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TAFP STRATEGIC PLANNING COMMITTEE

Strategic Plan 2019

Eric Nathan Alford, MD Lindsay Kathryn Botsford, MD, MBA, CMQ

Mission Statement:

Emily Briggs, MD, MPH

The mission of the Texas Academy of Family Physicians is to promote the health of all Texans by serving the needs of members and advancing the specialty of family medicine.

Douglas Curran, MD

Vision Statement:

Troy Fiesinger, MD

TAFP empowers family physicians to play a robust role in health care for their patients and their communities.

Lawrence McLean Gibbs, MD, MEd

Tricia Elliott, MD

Roland Goertz, MD, MBA

Strategic Objectives:

Lesca Hadley, MD

To support the family physicians of Texas and their practices.

Rebecca Hart, MD

• Empower family physicians to achieve professional excellence and personal satisfaction. • Help members succeed in the ever-changing health care marketplace. • Reduce administrative burdens imposed on physicians by public and private payers so physicians can spend more time practicing medicine. • Transform the U.S. health care system so family physicians and their patients can thrive. To improve the health of Texans and their communities. • Advocate for access to high-quality health care for all Texans. • Improve the quality of primary care in Texas by providing continuing medical education and other forms of life-long learning opportunities to physicians. • Support clinical research in family medicine dedicated to improving patient and public health. To advance the specialty of family medicine and strengthen our organization. • Ensure a health care workforce sufficient to provide every Texan access to a personal family physician. • Foster the development of strong family physician leaders. • Host and support a strong, engaged community of family physicians across Texas.

Targeted Initiatives for 2019 and Beyond The strategic planning committee identified three initiatives to address each of the strategic objectives. The health of the physician and the practice • Provide education and resources on practice enhancement and models of care. • Identify and remove unnecessary administrative burdens throughout the documentation, compliance, claims, and billing processes. • Create a wellness CME structure that includes family friendly options, learning, and movement. The health of the patient and the population • Address the struggle family physicians have in treating mental and behavioral health in patients. • Implement a narrow scope of health literacy patient information relevant to patients, payers, employers, and physicians. • Create a behavioral health task force with the goal of educating and empowering members to act locally to meet the needs of their community. The health of the specialty and the organization • Increase member engagement and membership. • Improve leadership development of family physicians across spheres of influence. • Create a multimedia toolkit to help persuade employers, insurers, deans, and students of the value of family medicine.

TEXAS FAMILY PHYSICIAN [No. 1] 2019

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THE EVERYONE PROJECT BUILDS ON SUCCESSFUL YEAR FOR 2019 By Chris Crawford

he EveryONE Project from the AAFP had a busy 2018 creating a comprehensive toolkit and other resources family physicians can use to address social determinants of health, or SDOH, in their practices and communities throughout 2019 and beyond.

Danielle Jones, MPH, manager of the AAFP’s Center for Diversity and Health Equity, said the Academy also launched its inaugural Health Equity Fellowship program last year, with three family physicians from throughout the country rounding out the first class. “This new program is designed to cultivate a cohort of family medicine physicians who will be considered subject matter experts on the social, institutional and cultural influences that impact health,” Jones told AAFP News. “At the completion of the fellowship, participants will be called upon to act as family medicine leaders capable of impacting change in their local communities and primary care roles by sharing their experience and demonstrating their leadership.”

TOOLKIT UNPACKED The EveryONE Project toolkit consists of three parts. The first of these, Practice Leadership for Health Equity, focuses on enabling medical practices to create an organizational culture that values health equity and develop team-based approaches for addressing patients’ social determinants of health. Resources in the section focus on building a culture of health equity at the practice level and address learning about patients’ communities, uncovering practice staff’s unstated assumptions and potential biases, and adopting a practice-wide approach to improve health equity. Additional tools in this section include links to county health rankings, a health department directory from the National Association of County and City Health Officials, and the AAFP’s Health Landscape Population Health Profiler. The report “Addressing Social Determinants of Health in Primary Care: A Team-based Approach for Advancing Health Equity,” which The EveryONE Project released back in April, also is included in this area. The second part of the toolkit, Assessment and Action, offers tools to help with the screening and referral processes that are outlined in the first part of the toolkit. This includes validated screening questions for a variety of social determinants, tools to work with patients and the Neighborhood Navigator to help identify community services. 14

TEXAS FAMILY PHYSICIAN [No. 1] 2019

Finally, since health inequities are primarily caused by social and cultural issues, the third part of the toolkit, Community Collaboration and Advocacy, provides information and resources to help family physicians engage with their community and advocate policies that have been shown to reduce health inequities. Included in this section is “The Physician Advocate” guide, which is intended to help family physicians facilitate in-service presentations and lunch-and-learn sessions to help foster a culture of health equity in the family medicine practice. This area also includes issue briefs on health in all policies and food insecurity, which are intended to be used by family physicians as they engage with local elected officials and other decision-makers. Jones said the toolkit’s value lies in its ability to arm family physicians and their organizations with a process and the necessary tools to address SDOH and health equity both upstream and downstream — all in a single resource. “Plus, knowing it’s from a trusted source such as the AAFP provides members and their organizations with much needed confidence that this is work they can not only do effectively, but with the support of the AAFP,” she said. “It’s our hope that family physicians continue to use the resources for ongoing education for themselves and members of their practice team. We plan to continuously update the existing resources and develop new ones so that the toolkit remains current as the evidence on this topic continues to advance.” Kevin Kovach, DrPH, MSc, population health manager in the AAFP Health of the Public and Science Division, added that The EveryONE Project team encourages members to use the Academy’s health equity issue briefs to work with their organizational leaders and elected officials to ensure good decisions are made that support health equity and community health.

COMING IN 2019 As for what’s to come in 2019, Jones said members can expect The EveryONE Project to provide additional resources on topics such as implicit bias — specifically, curriculum for those in residency and training for those in practice that will be of significant value to family physicians in delivering culturally proficient care aimed at reducing health inequities. Additionally, The EveryONE Project expects to post a plan from the AAFP on how it aims to diversify the medical workforce and will create more issue briefs members can use to communicate complex health equity topics to stakeholders. Kovach said the AAFP also will work collaboratively with chapters to develop plans for building capacity to advance health equity by addressing SDOH. Finally, in October, Jones said the AAFP will convene a Health Equity Summit to bring together a diverse group of global thought leaders. “The summit will be designed to promote the building of collaborative partnerships among family medicine organizations, other primary care clinicians and their organizations, public health experts, educators, researchers, trainees, advocates, policy experts, social service organizations, patients, and community members,” Jones said. During the summit, participants will develop collective action plans and identify ways these collaborations can make reducing health disparities and achieving health equity a strategic priority within and across all participating organizations and partnerships, Jones concluded. Source: AAFP News, Jan. 2, 2019. © 2019 American Academy of Family Physicians.

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A practical approach to screening for social determinants of health Screening patients to understand their social context is the gateway to addressing barriers and improving health. David T. O’Gurek, MD, and Carla Henke, MD

ecades ago, the historic Whitehall studies demonstrated the impact that social context can have on individuals’ health and wellbeing.1,2 Family physicians understand this well because they see firsthand how social needs (or “social determinants of health”) create access, adherence, or performance barriers, often impeding their efforts to provide evidencebased clinical care that improves overall health.3,4 For example, a patient who lacks safe housing, reliable transportation, or adequate food resources may struggle with medication adherence or getting to visits on time. The ecology of medical care5 and the current financing system, which tend to focus on health care as opposed to health, may limit physicians’ ability to address social context. Nevertheless, family physicians can take practical steps to address social determinants of health in their practices. This article will discuss the concerns and challenges related to screening for social determinants of health and offer several tools and recommendations.

TO SCREEN OR NOT TO SCREEN Despite studies demonstrating the impact of socioeconomic factors on health, there is no evidence-based screening recommen-

dation for social determinants of health from an organization such as the U.S. Preventive Services Task Force. Even without a formal recommendation, several policy statements support such screening,6,7 and a current national initiative through the Centers for Medicare and Medicaid Services (CMS), the Accountable Health Communities Model,8 may soon shed evidence on the impact of screening. Additionally, community health centers have been screening for social determinants of health and coordinating related services for years. Their experiences have suggested some best practices for developing “medical neighborhoods,” particularly in underserved and diverse communities. Concerns about the limited research for screening for social determinants of health are understandable, but they reveal our implicit bias against information from sources other than randomized controlled trials (RCTs).9 Although RCTs rely on standardization, consistency, and fidelity of the intervention, community-based research on community-level health interventions must rely on variation to deliver interventions in the field to tailor to community needs, often requiring longer study times and costlier studies.10 Due to the challenge of controlling for multiple social variables, research in this field tends to be observational. For this reason, the Community Preven-

This article originally appeared in the 2018 May-June edition of Family Practice Management.

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tive Services Task Force, an independent, nonfederal panel of public health and prevention experts that provides evidence-based findings and recommendations, developed a guide for assessing evidence regarding health impacts of social interventions.11 In addition to being aware of concerns about research, physicians should note that screening for social determinants is intrinsically different from traditional screening for medical problems. Both, however, require that screening occur in a setting where appropriate referral or linkage to resources to address an identified need can take place. To do otherwise would be ineffective and unethical.12 Discovering a need and being ill-equipped to address that need creates potential harm for the patient, and frustration and burnout for the physician. To avoid these unintended consequences and make screening an invaluable part of the clinical process, practices need to ensure that screening is patient- and family-centered, integrated with referrals to community-based resources, comprehensive across all patient populations, and focused on leveraging the strengths of patients, families, and communities.13

SCREENING TOOLS There is no single preferred screening tool recommended for social determinants of health; however, the National Association of Community Health Centers and several other organizations use the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). The PRAPARE tool collects demographic information and assesses a patient for a host of social needs including housing, employment, education, security, transportation, social integration, and stress with optional measures of incarceration history, domestic violence, and refugee status (15 core questions and 5 supplemental questions). The data can be directly uploaded into many electronic health records (EHRs) as structured data. It is generally administered by clinical or nonclinical staff at the time of the visit, but a paper version can be given to the patient to self-administer. The American Academy of Family Physicians also offers a social determinants of health screening tool, available in short and long form in English and Spanish, as part of The EveryONE Project. The short form includes 11 questions about housing, food, transportation, utilities, personal safety, and the need for assistance. It can be selfadministered or administered by clinical or nonclinical staff. Additionally, CMS’s Accountable Health Communities project developed a 10-question Health-Related Social Needs screening tool (the AHC-HRSN) that addresses housing instability, food insecurity, transportation needs, utility needs, and interpersonal safety.14 This tool is meant to be self-administered. It draws on evidence from other validated assessments that address specific unmet social and material needs (see “Screening tools for social determinants of health”).

WORKFLOW CONSIDERATIONS Because physicians can become easily overwhelmed and stretched when asked to incorporate “just one more thing” to their daily practice flow, social determinants screening and follow up must not be the sole responsibility of the physician. Instead, it should be a team-based effort integrated into the practice’s care management workflows. Large practices may have care coordinators, patient navigators, health coaches, or community health workers who can assist in streamlining and directing screening processes as well as coordination of care. In small practices, nurses, medical assistants, and other support staff will be critical. In addition to deciding who on the care team will perform the screening, practices also need to decide how often the screening will occur, where the screening data will be stored, how results will be communicated to all care team members, how the patient’s need will be prioritized, and how the follow-up strategy will be documented. For example, a practice may decide that the medical assistant is responsible for administering an annual screening after rooming the patient and entering the results in real-time as social history in the EHR for the physician to review. If a patient is currently experiencing housing instability, food insecurity, and domestic violence, the physician would decide which issue to address first, document the care plan and follow-up plan in the EHR, and instruct the medical assistant to handle the referral details with the patient. Other workflow options would be to use nonclinical staff to conduct the screening either before or after the visit, or have patients complete a self-assessment while they wait. Although having a standardized work-flow is important, that workflow may not always be sufficient; therefore, in screening for social determinants of health, clear communication among all team members is critical. Community of Hope, a community health center in the District of Columbia, has found that when a consistent framework for communication among care team members does not exist, either nothing is accomplished in regard to care management or duplicate and parallel processes occur, creating more work for the

Discovering a need and being illequipped to address that need creates potential harm for the patient, and frustration and burnout for the physician.

www.tafp.org

Family physicians have long understood the importance of social factors and their impact on the health of patients and communities. team and no change in the patient’s health. The center uses a daily team huddle, appropriate routing of messages, and a process for consistent documentation within EHR notes, telephone encounters, and the problem list to improve communication and care coordination when it comes to addressing the social determinants of health. For any workflow to succeed, practices will need to develop a list of referral resources to connect patients to needed services in the community, such as meal programs or utility assistance programs. While not comprehensive, the list of “Community resources for addressing social determinants of health” can assist practices in identifying resources. Practices can also develop partnerships with local agencies to address the needs most prevalent in their population and begin to build a medical neighborhood.

CODING AND PAYMENT Physicians can include supplemental ICD-10 “Z” codes in the patient’s diagnosis section and problem list, such as codes Z55–Z65, “Persons with potential health hazards related to socioeconomic and psychosocial circumstances.” Although Z codes are not generally reimbursable, including these codes in the medical record can help

with population health, panel management, and quality improvement initiatives.15 Data collected may also eventually factor into value-based payment systems that will reimburse family physicians for this critical work to improve health. The data can also be useful in developing innovative solutions and partnerships to address the social determinants that most directly affect a population. For example, Community of Hope created partnerships with a mobile farmer’s market as well as a bike-share program to promote healthy eating and exercise not only to the health center patients but also to the community in which the clinic is located.

PULLING TOGETHER AND MOVING FORWARD Family physicians have long understood the importance of social factors and their impact on the health of patients and communities. Transforming medical practice to have a larger impact on prevention and health as well as meeting the goals of national initiatives such as Healthy People 2020 will require screening for social determinants of health and development of coordinated care systems that meet social needs. The nation’s community health centers have built a model for screening and care coordination; however, opportunities exist for developing best practices in other settings to improve the health of communities. While this process can be daunting, resources are available. Furthermore, screening and coordinating services to meet social needs is an opportunity to reduce physician and staff burnout related to the inertia of improving health in communities where social and policy barriers prevent us from doing so. This opportunity can also improve the system as a whole, encouraging payment reform that values the factors that most significantly affect health. Reprinted with permission from Fam Pract Manag. 2018 May-June;25(3):7-12.

REFERENCES 1. Marmot MG, Rose G, Shipley M, Hamilton PJ. Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health. 1978;32(4):244–249. 2. Marmot MG, Smith GD, Stansfeld S, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991;337(8754):1387–1393. 3. Lasser KE, Hummelstein DU, Woolhandler S. Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey. Am J Public Health. 2006;96(7):1300–1307. 4. Schoen C, Doty MM. Inequities in access to medical care in five countries: findings from the 2001 Commonwealth Fund International Health Policy Survey. Health Policy. 2004;67(3):309–322. 5. Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001;344(26):2021–2025. 6. Committee on the Recommended Social and Behavioral Domains and Measures for Electronic Health Records, Board on Population Health and Public Health Practice, Institute of Medicine. Capturing Social and Behavioral Domains and Measures in Electronic Health Records. Washington, DC: National Academy of Medicine; 2014. http://www.nap.edu/catalog/18709/capturing-social-andbehavioral-domains-in-electronic-health-records-phase. Accessed March 8, 2018. 7. Council on Community Pediatrics, American Academy of Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339. 18

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8. Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Accountable health communities – addressing social needs through Medicare and Medicaid. N Engl J Med. 2016;374(1):8–11. 9. Newman TB, Kohn MA. Evidence-Based Diagnosis. New York, NY: Cambridge University Press, 2009. 10. Braveman PA, Egerter SA, Woolf SH, Marks JS. When do we know enough to recommend action on the social determinants of health? Am J Prev Med. 2011;40(1):S58–S66. 11. Briss PA, Brownson RC, Fielding JE, Zaza S. Developing and using the Guide to Community Preventive Services: lessons learned about evidence-based public health. Annu Rev Public Health. 2004;25:281–302. 12. Perrin EC. Ethical questions about screening. J Dev Behav Pediatr. 1998;19(5):350–352. 13. Garg A, Boynton-Jarrett R, Dworkin PH. Avoiding the unintended consequences of screening for social determinants of health. JAMA. 2016;316(8):813–814. 14. Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. Washington, DC: National Academy of Medicine; 2017. https://nam.edu/wpcontent/uploads/2017/05/Standardized-Screening-for-HealthRelated-Social-Needs-in-Clinical-Settings.pdf. Accessed March 8, 2018. 15. Gottlieb L, Tobey R, Cantor J, Hessler D, Adler NE. Integrating social and medical data to improve population health: opportunities and barriers. Health Aff (Millwood). 2016;35(11):2116–2123.

SCREENING TOOLS FOR SOCIAL DETERMINANTS OF HEALTH Three screening tools can aid physicians in addressing multiple social determinants of health in a primary care setting. SCREENING TOOL

NUMBER OF QUESTIONS

SOURCE

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

15 core, 5 supplemental

http://www.nachc.org/research-and-data/ prapare/toolkit/

The American Academy of Family Physicians 11 (short form) Short: https://www.aafp.org/dam/AAFP/ Social Needs Screening Tool 15 (long form) documents/patient_care/everyone_project/ patient-short-print.pdf Long: https://www.aafp.org/dam/AAFP/ documents/patient_care/everyone_project/ patient-long-print.pdf The Accountable Health Communities Health-Related Social Needs (AHC-HRSN) Screening Tool

10 core, 13 supplemental

https://innovation.cms.gov/Files/worksheets/ ahcm-screeningtool.pdf

The AHC-HRSN tool draws on evidence from several need-specific assessments, below, which can provide valuable background. SOCIAL DETERMINANT ASSESSMENT

VALIDATED POPULATION BACKGROUND

Food insecurity Hunger Vital Sign

Low-income families with young children

http://childrenshealthwatch.org/ public-policy/hunger-vital-sign/

U.S. Department of Agriculture U.S. Household Food Security Survey

Households with reported annual incomes below 185 percent of the federal poverty level

https://ssrn.com/abstract=2504067

Housing instability

District of Columbia Department of Health & Human Services Temporary Assistance for Needy Families Comp- rehensive Assessment Housing Domain

Families at risk of or experiencing homelessness

https://www.acf.hhs.gov/sites/default/files/ ofa/enhancing_family_stability.pdf

National Center on Homelessness Veteran population Among Veterans Homelessness Screening Clinical Reminder

https://www.va.gov/homeless/nchav/ research/assessment-tools/hscr.asp

Interpersonal Hurt, Insulted, Threatened Men and women safety With Harm and Screamed Domestic Violence Screening Tool

https://www.baylorhealth.com/ PhysiciansLocations/Dallas/SpecialtiesServices/ EmergencyCare/Documents/ BUMCD-262_2010_HITS%20survey.pdf

http://www.fpnotebook.com/prevent/ Exam/WstScrnFrIntmtPrtnrVlnc.htm

Women Abuse Screening Tool – Women Short Form

Partner Violence Screen Women http://www.fpnotebook.com/Prevent/ Exam/PrtnrVlncScrn.htm Abuse Assessment Screen Women https://www.acog.org/About-ACOG/ ACOG-Departments/Women-with-Disabilities/ Abuse-Assessment-Screen Utility needs Children’s Sentinel Nutrition Assessment Program

Families with children younger than 3 years old

http://pediatrics.aappublications.org/ content/pediatrics/122/4/e867.full.pdf

COMMUNITY RESOURCES FOR ADDRESSING SOCIAL DETERMINANTS OF HEALTH GENERAL RESOURCES

FOOD INSECURITY

Feeding America 211 http://www.211.org Aunt Bertha

http://www.auntbertha.com

Cap4Kids http://cap4kids.org

Supplemental Nutrition Assistance Program

http://www.feedingamerica.org http://www.fns.usda.gov/snap

Special Supplemental http://www.fns.usda.gov/wic Nutrition Program for Women, Infants, and Children (WIC)

HOUSING

LEGAL ISSUES

Public Housing and Voucher http://www.hud.gov/topics/ Program rental_assistance

Medical-Legal Partnerships

http://medical-legalpartnership.org

www.tafp.org

PHOTO: VICTORIA VAN WINKLE

Report from the TAFP 2018 Annual Session and Primary Care Summit in Arlington By Jean Klewitz

family physicians and other health professionals from around the state gathered in Arlington, Nov. 9-11, for TAFP’s Annual Session and Primary Care Summit. A total of 481 registrants gathered to network, earn CME, shape TAFP policy at committee meetings, and celebrate the specialty of family medicine. Attendees learned about a variety of topics during the CME portion of the conference and earn up to 20 AMA PRA Category 1 Credits™. Participants attended three Knowledge Self-Assessment workshops Wednesday, Friday, and Sunday, on 20

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hypertension, care of the vulnerable elderly, and mental health in the community. The National Procedures Institute also offered their popular course on suturing. The TAFP Foundation held an exclusive dinner at the Sheraton Arlington Hotel with proceeds going to benefit the Nancy W. Dickey, MD, Medical Student Scholarship. Friday morning’s opening keynote speaker was, Sam Cullison, MD, vice president for graduate medical education at Methodist Health System, who spoke on mental health. The rest of the weekend’s CME included topics on osteoarthritis,

TAFP’s 2018 award recipients Saturday’s annual TAFP Business and Awards Lunch began with members voting to adopt the TAFP Bylaws changes. Next, TAFP’s top honors were announced. Here’s a list of the 2018 winners. Physician of the Year: Rodney Young, MD Rodney B. Young, MD, is chair of the Department of Family and Community Medicine at Texas Tech University Health Sciences Center School of Medicine in

PHOTOS: VICTORIA VAN WINKLE AND JONATHAN NELSON

FAMILY DOC REUNION

cardiomyopathy, gout, sleep apnea, COPD, wrist and hand injuries, and much more. AAFP Speaker Alan Schwartzstein, MD, of Wisconsin, provided an update on the national academy on Sunday morning. Rebecca Hart, MD, gave a TAFP update during Friday’s Member Assembly Luncheon. Delegates from TAFP’s local chapters elected Lane Aiena, MD, to serve as new physician director, and Ike Okwuwa, MD, and Gerald Banks, MD, to serve as atlarge directors on the board.

Opposite page, top: Justin Bartos, MD, and Sheryl Bartos try their luck at the Family Medicine Celebration. Bottom: Nancy Dickey, MD, celebrates the new TAFP Foundation medical student scholarship in her name with Lloyd Van Winkle, MD. Right: Rodney Young, MD, accepts the TAFP Physician of the Year Award from TAFP Board Chair Janet Hurley, MD. This page, top left: Charmaine Martin, MD, wins the Exemplary Teaching Award. Center: Carlos Jaén, MD, PhD, wins the Public Health Award. Bottom left: Erica Swegler, MD, accepts the TAFPPAC Award. Bottom right: Charles Ted Mettetal, MD, wins the TAFP Humanitarian Award.

Amarillo. Throughout his distinguished career, he has earned numerous honors and awards, including the Texas Medical Association’s Award for Excellence in Academic Medicine and the Distinguished Alumnus from Texas Tech School of Medicine. “Dr. Young’s personal and professional career defines that of a servant leader,” TAFP President Janet Hurley, MD, said at the awards ceremony. “He has an exceptional record of community service and understands how being involved in the community can effect positive change in people’s health. He combines his love of teaching with his love of medicine to serve people in his community who are displaced and disadvantaged.” In addition to his academic responsibilities, Young maintains a busy clinical practice, spending half of his time in direct patient care. In his community, Young serves on the board of directors for Heal the City, a free clinic that provides primary care, chronic disease management, and other preventive and wellness services for Amarillo’s unin

sured patients. He also serves on the board of directors for the Harrington Cancer and Health Foundation, which provides patients access to high-quality cancer care, detection, supportive care, and survivorship services. Presidential Award of Merit: Christopher Crow, MD; Lance Spivey; and Jeff Lawrence of StratiFi Health and the Catalyst Health Network Christopher Crow, MD, a family physician and nationally recognized health care innovator, has spent the past 20 years focusing on helping communities thrive through improving the delivery of health care. Lance Spivey is a health care executive with more than 22 years of experience in strategic, operational, and financial management. Jeff Lawrence is responsible for driving operational excellence and has spent the past 28 years serving the health care community. “This group of family doctors learned how to manage patients well, got key members on the team, and now are directly reshaping care in their community consistent with their goal

of helping communities thrive,” Hurley said. “These family physicians, empowered locally, have made a difference in the health care of their community.” Catalyst Health Network is a nonprofit health corporation that is committed to transforming the health and well-being of North Texas communities through the power of relationships. StratiFi Health, a population health and physician practice services organization, provides the management services needed to operate the Catalyst Health Network. Humanitarian Award: Charles Ted Mettetal, MD Charles Ted Mettetal, MD, practices full scope family medicine with obstetrics and hospital work at Lakeland Medical Associates in Athens. In 2010 he started Hope Springs Water, following a trip to the developing world as part of a medical team. “There he saw suffering due to a lack of clean water,” Hurley said. “Noticing how much bottled water fills the shelves at the grocery store, he saw a way to connect the www.tafp.org

I.L. Balkcom, MD, and Lee Schreiber, MD, enjoy the games at the Family Medicine Celebration.

Top: Janet Hurley, MD, and AAFP Speaker Alan Schwartzstein, MD, show off their new Hi-Roller hats with newly inducted TAFP President Rebecca Hart, MD. And the band played on! Great music made the night’s “Guys and Dolls” theme come alive at the Family Medicine Celebration.

TEXAS FAMILY PHYSICIAN [No. 1] 2019

Physician Emeritus: Walter Wilkerson, Jr., MD Walter D. Wilkerson, Jr., MD, has had a long and distinguished career in Montgomery County. He served as an assistant clinical professor with Baylor College of Medicine and the University of Texas Health Science Center in Houston, where he shared his experience and knowledge with medical students. He also served as chair of the board of trustees for Doctors Hospital and Conroe Regional Medical Center for many years. In addition to his clinical responsibilities, Wilkerson held a variety of volunteer appointments for the state of Texas, including a six-year term as chairman of the Texas Board of Health. Throughout his long career, he has been active in both TAFP and the Texas Medical Association.

Wilkerson retired from clinical practice in 1997 to focus his time and energy on another one of his passions — politics. “Nicknamed ‘King Wally’ by Karl Rove, Wilkerson has served as chair of the Montgomery County Republican Party since 1964,” Hurley said. Patient Advocacy Award: Rep. Four Price Rep. Four Price is serving in his fifth term in the Texas House of Representatives where he advocates for constituents residing in five Texas Panhandle counties. “In the Legislature, Representative Price is known as an effective problem solver with common-sense solutions,” Hurley said. “He carefully studies issues, reads the bills, listens to all proposed solutions, and votes in the best interest of his constituents.”

PHOTOS: JEAN KLEWITZ AND JONATHAN NELSON

water we buy with the water needed around the world. He began selling Hope Springs bottled water, with a hundred percent of the profits going to service around the world.” In addition to selling bottled water, Hope Springs Water sends out volunteer teams several times a year to drill wells, build latrines, and teach good hygiene practices. His earliest projects with Hope Springs Water were in Nicaragua and Belize, where they reclaimed 150 abandoned wells. In 2011, they began working in Africa, funding wells, rainwater catchment and storage systems, and a water treatment project in Sierra Leone, which helped ward off an impending cholera epidemic. Hope Springs Water’s mission is simple yet powerful: to bring hope to the world through clean water, reliable sanitation, and hygiene education.

PHOTO: JEAN KLEWITZ

Clockwise from top left: From left, Jeff Lawrence, Christopher Crow, MD, and Lance Spivey of StratiFi Health and the Catalyst Health Network accept the Presidential Award of Merit. From left: Javier “Jake” Margo, Jr., MD; Janet Hurley, MD; Stella Winters, MD; and Terrance Hines, MD, at the Family Medicine Celebration.

Rep. Price is chairman of the House Calendars Committee and he serves on the House Public Health Committee. He is co-chair of the Health and Human Services Transition Legislative Oversight Committee and serves on the House Redistricting Committee and on the House Committee on Natural Resources. Public Health Award: Carlos Roberto Jaén, MD, PhD Carlos Roberto Jaén, MD, PhD, serves as the chair of the Department of Family and Community Medicine at UT Health San Antonio and he was the co-director of AAFP’s Center for Research in Family Medicine and Primary Care for more than a decade. He served on the panel that published the U.S. Public Health Service guidelines for smoking cessation

Nineteen of TAFP’s most treasured members attended the Past Presidents’ Breakfast this year. TAFP President Rebecca Hart, MD, sports a money boa in the spirit of “Guys and Dolls” at the Family Medicine Celebration.

in 1996 and 2000, and he was the co-chair of the panel in 2008. His research has been recognized nationally and in 2013 he was elected to the National Academy of Medicine. “In his role as an educator and leader, he shares his passion for family medicine and public health with medical students, residents, and faculty,” Hurley said. Exemplary Teaching Award (Full-Time): Charmaine Martin, MD Charmaine Martin, MD, is Associate Professor and Assistant Dean of Student Affairs at the Paul L. Foster School of Medicine in El Paso where she has taught for more than a decade. She has an impressive resume filled with awards, community service, and research. She is recognized for her ability to challenge, inspire, and moti-

vate her students in the clinic. With the compassionate care she provides, she sets an example they want to live up to. “One student referenced his first encounter with Dr. Martin at his white coat ceremony where she spoke about social justice and how it relates to the journey of becoming a physician. The student wrote: ‘I didn’t know what type of doctor she was, but she immediately became a role model,’” Hurley said. Exemplary Teaching Award (Part-Time): Mary Anne Snyder, DO Mary Anne C. Snyder, DO, is a part-time assistant professor at the University of the Incarnate Word School of Osteopathic Medicine and a clinician at the Toyota Family Health Center. In both locations, she precepts medical students. www.tafp.org

JONATHAN NELSON

TAFP’s 2018-2019 officers from left: Parliamentarian Mary Nguyen, MD; President-elect Javier “Jake” Margo, Jr., MD; Treasurer Amer Shakil, MD; President Rebecca Hart, MD; and Immediate Past President Janet Hurley, MD.

“Students commented not only on her ability to teach in a way they understand but also on her enthusiasm and the joy she exhibits on a daily basis,” Hurley said. Exemplary Teaching Award (Volunteer): Chrisette M. Dharma, MD Chrisette M. Dharma, MD, precepts medical students at her practice, Southwest Family Medicine Associates Clinic, and as a clinical assistant professor at UT Southwestern. Those she has precepted say she has a strong ability to identify strengths and weaknesses and that she challenges them. “One even compared her to Mr. Miyagi from The Karate Kid,” Hurley said. “One student put it best when he said, ‘great teachers help students recognize their full potential and then help them cultivate that potential.’” TAFP Foundation Philanthropist of the Year: Dale Moquist, MD Dale Moquist, MD, has received numerous awards for his work as a professor, physician, and scholar. He is an instructor with National 24

TEXAS FAMILY PHYSICIAN [No. 1] 2019

Procedures Institute and former faculty at the Memorial Family Practice Residency Program, and he served as director for the Wichita Falls Family Practice Residency Program and faculty at the Family Practice Residency Program of the Brazos Valley. “When I became president of the Foundation two years ago, l succeeded Dr. Moquist, who had held the office for 10 years,” said TAFP Foundation Board of Trustees President Linda Siy, MD. “It’s remarkable what the Foundation was able to accomplish in those 10 years due to his leadership, his passion for family medicine, and his vision.” During his tenure, the Foundation created several new scholarships, began its research endowment, doubled its research budget, and doubled its income from monthly donors. TAFP Political Action Committee Award: Erica W. Swegler, MD Erica W. Swegler, MD, served as the president of TAFP and went on to represent Texas in AAFP’s Congress of Delegates. In 2017 she was elected to the AAFP Board of

Directors where she continues her work on behalf of the specialty. “She has long understood the power of the PAC,” Hurley said. “She has tirelessly championed both TAFPPAC and AAFP’s FamMedPAC — not only as a continuous donor, but by challenging her friends and colleagues to do the same.” Installation of officers Following the presentation of awards, Dr. Schwartzstein installed the TAFP 2018-2019 officers. They are President Rebecca Hart, MD; President-elect Javier “Jake” Margo, Jr., MD; Treasurer Amer Shakil, MD; and Parliamentarian Mary Nguyen, MD. “I am so humbled, joyful and happy to begin work as your new president,” Hart said in her inaugural address at the awards ceremony. “Thank you for electing me and giving me this opportunity to serve you. I hope you join me this year in working harder than ever to keep our profession strong, our physicians inspired, and our workforce increasing.”

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MEMBER NEWS

Highlights from TAFP’s Annual Session • November 8-10, 2018 The committees, commissions and sections of the Texas Academy of Family Physicians met in Arlington and deliberated on many important matters. Thanks to all the members who participated. Most commissions, committees, and all sections are open to guests and meet twice a year at TAFP’s Interim and Annual Sessions. You can also request an appointment by submitting a “Make Your Mark” involvement form. Contact Juleah Williams at jwilliams@tafp.org with any questions. Here are a few of the highlights from the recent meeting. All recommendations mentioned will be presented to the TAFP Board of Directors.

ADVOCATING FOR YOU AND YOUR PATIENTS The Texas legislative session was a topic of conversation throughout the meeting. The Commission on Legislative and Public Affairs discussed TAFP’s priorities regarding state appropriations for the Family Medicine Preceptorship Program, Physician Loan Repayment Program, Family Practice Residency Program, Texas Healthy Women’s Program, and Medicaid payment rates. They also discussed opioid prescribing initiatives including mandatory e-prescribing, integration of the Prescription Drug Monitoring Program with electronic health record software, and a limit on the number of days opioids can be prescribed for acute problems. The commission also discussed potential legislation to allow physicians to dispense pharmaceuticals in their practices. WORKFORCE DEVELOPMENT The Commission on Academic Affairs discussed the Texas Family Medicine Preceptorship Program. TAFP administers the state-funded program and saw a great increase in student participation this past year. In 2018 the program had 143 preclinical medical students complete a family medicine preceptorship, up from 80 in 2017. Increased marketing and higher stipends for students were two factors that led to the dramatic increase. The program needs volunteer preceptors to ensure continued suc26

cess. The goal of the program is to provide an opportunity for first- and second-year medical students to experience family medicine outside the academic health center. More than 50 medical students and residents attended ASPCS and most participated in the Resident and Student Track held on November 10 to learn about the legal and ethical issues in medicine, autism, the upcoming legislative session and more. Students participated in a resident-led procedure workshop on suturing and residents had their own suturing workshop taught by faculty from National Procedures Institute on November 9. MEMBER SERVICES AND RESOURCES IN DEVELOPMENT ABFM’s announcement to pilot an alternative to the exam beginning in 2019 was a topic of conversation throughout the meeting. Several leaders attended a meeting with ABFM leadership just before Annual Session and discussed their efforts to align the Maintenance of Certification Part IV requirements with institutional quality improvement initiatives regularly carried out by physician groups and health systems. The Commission on Core Delegation asked staff to continue sharing this information and resources through the various communications channels and in our CME to assist members with MOC. The Section on Maternity Care and Rural Physicians discussed their new scholarship program.

TEXAS FAMILY PHYSICIAN [No. 1] 2019

TAFP awarded scholarships to three members – a medical student, resident, and a practicing physician to attend AAFP’s 2018 Family-Centered Maternity Care Live Course. They were all asked to share what they learned with others. It’s important to have the voice of family medicine heard wherever decisions are being made about health care and that certainly includes the Texas Medical Association. The Nominating Committee asked the staff to plan an information meeting during the next C. Frank Webber Lectureship and Interim Session for members interested in getting more involved with TMA. Current and past TMA leaders will be available to answer questions and share their experience. The Leadership Development Committee met to review the Family Medicine Leadership Experience and shape the curriculum for the 2019 class. They also discussed ways to keep the alumni involved in TAFP. The new class will have their first session during TAFP’s Interim Session in April. TAFP is an ACCME-accredited provider of continuing medical education. Staff and volunteers collaborate to plan and produce education for members and ensure compliance with all requirements. At Annual Session, the Commission on Continuing Professional Development and the CME planning committee worked on future educational offerings and discussed how to integrate more physician wellness and burnout prevention initiatives and content into TAFP’s continuing professional development. They also discussed behavioral health integration into practice and how our education can support efforts by members to address mental and behavioral health issues in their practice and community.

PUBLIC HEALTH AND RESEARCH The Commission on Public Health, Clinical Affairs and Research had presentations and discussed a variety of issues. Dr. Russell Kohl from TMF Health Quality Institute and Elizabeth Montgomery from the National Kidney Foundation gave a presentation about their Campaign for Kidney Health. The commission discussed corporal punishment with Dr. David Schneider and Dr. George Holden and agreed to draft a resolution to AAFP on the topic. Dr. Sherri Onyiego is TAFP’s representative to a Hepatitis C advisory group and she provided an update on their work. Claudia Rodas with the Campaign for Tobacco Free Kids presented legislative efforts to prevent youth tobacco use, specifically advocating Tobacco 21, an initiative to raise the legal age to purchase tobacco products from 18 to 21. TAFP is an active member of the T21 initiative. The commission also discussed parental incarceration and legislative efforts to give judges flexibility to allow families to stay together. The Section on Maternity Care and Rural Physicians had a presentation from Dr. Nancy Dickey, the Executive Director of the A&M Rural and Community Health Institute on the changing face of rural health care. The Section on Research had a presentation on toxicantinduced loss of tolerance. They also discussed their monthly conference calls and invited members to participate. To join these calls and interact with fellow researchers across the state, contact Jean Klewitz at jklewitz@tafp.org. TAFP meetings are an opportunity to gather and participate in discussion on a variety of topics. Section meetings are held during TAFP’s Interim and Annual Sessions and are

Thank you, 2018 TAFPPAC donors! intended for any interested member to participate. ORGANIZATIONAL ISSUES Dr. Janet Hurley unveiled TAFP’s new Strategic Plan during the TAFP Member Assembly on Friday, November 9. The voting representatives to the Member Assembly elected these 2018-19 leaders: President-elect: Javier D. Margo, Jr., MD Treasurer: Amer Shakil, MD Parliamentarian: Mary S. Nguyen, MD Delegate to AAFP: Douglas Curran, MD Alternate Delegate to AAFP: Troy Fiesinger, MD New Physician Director: Lane Aiena, MD At-large Directors: Gerald Banks, MD and Ike Okwuwa, MD

Lane Aiena, MD Kelly Alberda, MD Maureen Alvarado, MD Adanna Amechi-Obigwe, MD Maryanne Arienmughare, MD IL Balkcom, MD Justin Bartos, MD Lee Bar-Eli, MD Nathan Baumer, MD Joane Baumer, MD Stephen Benold, MD Henry Boehm, MD Lindsay Botsford, MD, MBA, CMQ Emily Briggs, MD, MPH Matthew Brimberry, MD Chinglin Lillian Chan, MD C. Mark Chassay, MD Maria Coimbra, MD Antonio Falcon, MD Troy Fiesinger, MD Triwanna Fisher, MD Lewis Foxhall, MD Kelly Gabler, MD Lisa Glenn, MD Roland Goertz, MD, MBA T. David Greer, MD

Ajay Gupta, MD Natalia Gutierrez, MD Lesca Hadley, MD Suhaib Haq, MD Rebecca Hart, MD Clare Hawkins, MD, MSC Farron Hunt, MD Janet Hurley, MD Brian D. Jones, MD Kimberly Kone, MD Kaparaboyna Kumar, MD, FRCS James Lackey, MD C. Tim Lambert, MD Loren Lasater, MD Don Lawrence, DO Eric Lee, MD Leah Raye Mabry, MD Javier Margo, MD Kathy McCarthy, CAE Alyssa Molina, MD Dale Moquist, MD Maria Munoz, MD Nancy Naghavi, DO Mary Nguyen, MD Uzoamaka Obinabo, MD Jessica Osizugbo, MD

Katie Ray, MD John Ray, MD Rashmi Rode, MD David Schneider, MD Puja Sehgal, MD Dan Sepdham, MD Nihita Shah, MD Amer Shakil, MD, MBA Linda Siy, MD Mary Anne Snyder, DO Mary Spalding, MD Joshua Splinter, MD Dana Sprute, MD, MPH Richard Stuntz, MD Irvin Sulapas, MD Sheri Talley, MD Elizabeth Tran, MD Hanh Trinh, MD Lloyd Van Winkle, MD Christopher Vera, DO, MPH Andrew Weary, MD Walter Wilkerson, MD Keith Wilkerson, MD Khalida Yasmin, MD Richard Young, MD

Special Constituencies Director: Stuti Nagpal, MD Resident Director: Janie Gibson, MD Medical Student Director: Justin Fu At the annual Business and Awards lunch, the membership approved bylaws amendments recommended and published in Texas Family Physician last year. These changes bring TAFP’s bylaws in line with AAFP’s bylaws. MEMBER HIGHLIGHTS Several members completed terms as committee chair and they were thanked for their years of service: Terrance Hines, MD – Bylaws Committee Linda Siy, MD – Nominating Committee Ron Cook, MD – Commission on Academic Affairs Adanna Amechi-Obigwe, MD – Commission on Public Health, Clinical Affairs and Research

The Texas Academy of Family Physicians presents:

2019 Texas family medicine symposium JUNE 7– 9, 2019

LA CANTERA HILL COUNTRY RESORT SAN ANTONIO, TEXAS Maximum of 24 AMA PRA Category 1 Credits™

2019 TEXAS FAMILY MEDICINE

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FOUNDATION FOCUS

James A. Murphy, MD ★ Mary S. Nguyen, MD

2018 TAFP Foundation donors

Thank you to these 2018 TAFP Foundation donors, whose contributions fund scholarships for Texas medical students, family medicine research grants, and travel scholarships for residents to attend continuing professional development activities.

★ = TAFP Foundation monthly donor

Donald R. Niño, MD ★ Paul B. Oliver, MD Olusesan Oluseun Olotu, MD Sidney C. Ontai, MD James Michael Orms, MD Derrick Chase Owens, MD James Andrew Paskow, MD Barbara Pierce, MD Didier F. Piot, MD Anne Marie Ponce de Leon, MD ★ Henry David Pope, MD Fanny Elena Ramirez, MD Horacio R. Ramirez, MD ★ John R. Richmond, MD ★ Shelley Poe Roaten, MD

Abbvie

★ C. Mark Chassay, MD

★ James Michael Henderson, MD

Leon Rochen

Austin Regional Clinic

Victor Chavez, MD

★ Terrance S. Hines, MD

Porfirio Rodriguez, MD

Horizon Pharma USA

Dallas Coate, MD

James Holly, MD

Sam Edwin Rolon, DO

Iora Health

Samuel T. Coleridge, DO

Robert A. Howard, MD

Stephanie Roth, MD

PhRMA

Maria Colon-Gonzalez, MD

James J. Hrachovy, MD

Kristi Salinas, MD, CPE

Kelsey-Seybold Clinic

★ Seth B. Cowan, MD

H. Chung-tai Hu, MD

★ Sarah Samreen, MD

Medencentive

★ Douglas W. Curran, MD

Charles V.O. Hughes, MD

Maxwell Scarlett, MD

Texas Health Resources

Phillip H. Disraeli, MD

★ Farron C. Hunt, MD

★ David Schneider, MD

Teladoc Health, Inc.

★ Chrisette Dharmagunaratne, MD

★ Janet L. Hurley, MD

Lee R. Schreiber, MD

Texas Association of Health Plans

★ Jorge Duchicela, MD

★ Jamal Islam, MD, MS

★ M. Sandra Scurria, MD

Texas Medical Association

Roberto A. Duran, MD

Melissa Jacaman, MD

★ Dan Sepdham, MD

Texas Medical Liability Trust

Carolyn Eaton, MD

Lee Janson, MD

★ Amer Shakil, MD, MBA

Triple Aim Consulting

★ Bruce Alan Echols, MD

★ Brian D. Jones, MD, CPE

★ Linda Siy, MD

Village Family Practice

Sheridan Scott Evans, MD

★ David Katerndahl, MD

★ Mary Spalding, MD

Lane J. Aiena, MD

★ Tricia C. Elliott, MD

Kara L. Kern, MD

Joshua Splinter, MD

Marian C. Allen, MD

★ Christopher S. Ewin, MD

★ Shelley Kohlleppel, MD

★ Charles Stern, MD

Victor Lee Allen, MD

★ Robert Floyd Ezell, MD

★ Sharon Stern, MD

★ Adanna Amechi-Obigwe, MD

★ Antonio Falcon, MD

★ Kaparaboyna Ashok Kumar, MD, FRCS

★ Charles Anderson, MD

★ Troy T. Fiesinger, MD

★ C. Timothy Lambert, MD

Irvin Sulapas, MD

Nalini Balachandran, MD

★ Aimee Lyn Flournoy, MD

W. Ross Lawler, MD

Erica Williams Swegler, MD

★ Ichabod L. Balkcom, MD

Linda Whidden Flower, MD

★ Don A. Lawrence, DO

★ Sheri J. Talley, MD

★ Maria Diana Ballesteros, MD

★ Lewis E. Foxhall, MD

Sarah Lay, MD

James R. Terry, MD

★ Madhumita Banga, MD

Edwin R. Franks, MD

★ Eric Lee, MD

Todd A. Thames, MD, MHA

Gerald Clifford Banks, MD, MS

Gregory Fuller, MD

Jennifer Liedtke, MD

Isnardo E. Tremor, MD

★ Tom Banning

★ Kelly A. Gabler, MD

Donald E. Lovering, MD

Thuy Hanh Thi Trinh, MD, MBA

★ Lynda Jayne Barry, MD

Oscar Garza, MD

★ Leah Raye Mabry, MD

Garth Olstein Vaz, MD

★ Justin V. Bartos, MD

★ Lawrence Gibbs, MD, MEd

Joseph Robert Mansen, MD

Miguel A. Vazquez, MD

Melissa A. Benavides, MD

★ Lisa Biry Glenn, MD

★ Javier D. Margo, MD

Hsin-Yi Janey Wang, MD

★ Stephen Benold, MD

★ Roland Goertz, MD, MBA

James Charles Martin, MD

Samuel C. Wang, MD

Adrian Billings, MD, PhD

★ John Edward Green, III, MD

Samuel Eli Mathis, MD

★ Sally Pyle Weaver, MD

★ Henry Julius Boehm, MD

★ Thomas David Greer, MD

★ Kathy McCarthy, CAE

★ Jim White

★ Teddy Boehm

Rosa Guevara-Montes, MD

★ William Mike McCrady, MD

Walter D. Wilkerson, MD

★ Lindsay Botsford, MD, MBA, CMQ

★ Ajay Kumar Gupta, MD

Paul McLean, MD

★ Hugh H. Wilson, MD

★ Emily D. Briggs, MD, MPH

★ Natalia Gutierrez, MD

★ Susan Clymer McMullen, MD

★ Lloyd Van Winkle, MD

Maria Blahey, MD

★ Lesca C. Hadley, MD

Fred L. Merian, MD

Keith Allen Wixtrom, MD

Joseph S. Burch, MD

★ Suhaib W. Haq, MD

★ Jessica Miley

★ Khalida Yasmin, MD

Raul Niduaza Calvo, MD

★ Rebecca Hart, MD

Tasaduq Hussain Mir, MD

★ Robert Youens, MD, MMM

Rebecca Lee Campos, MD

Richard B. Hartin, MD

Marta Maria Molina, MD

★ Richard A. Young, MD

Chris Casso, MD

★ Clare A. Hawkins, MD, MSC

★ Dale C. Moquist, MD

Luis E. Zepeda, MD

★ Chinglin Lillian Chan, MD

Guoxiang He, MD

★ Maria De Jesus Muñoz, MD

Yanqiu Zhao, MD

TEXAS FAMILY PHYSICIAN [No. 1] 2019

★ Donald E. Stillwagon, MD

PERSPECTIVE

movie, “The Purge.” So many of my older colleagues just threw up their had a retirement role model once. A secret role model, who arms in horror and screamed, “I’m outta here.” In the Darwinian new didn’t retire. In the moment, I never told him of my admiration. I changes of medicine, you either adapt or die ... or retire. was just passing through his clinic, 40 years ago, and never knew In 2014 there were about 78,000 clinically active primary care how long his impact would remain within me. physicians between ages 55 and 80 years in the United States. The As a fourth-year medical student at George Washington median age of retirement from clinical activity of all primary care University, I had signed up for a tropical medicine elective at the physicians who retired in the period from 2010 to 2014 was 64.9 Gorgas Institute in Panama, one of the top infectious disease research years, but as many as 40 percent of 75-year-old physicians were still institutes in the Western Hemisphere. Gorgas was created in 1921, practicing in some format. The number of physicians in the U.S. over named for Dr. William Crawford Gorgas, who eradicated yellow fever 65 years of age more than quadrupled between 1975 and 2013. in Panama, thus facilitating the construction of the Panama Canal. What of these aging physicians? A 2017 article in BMJ caused Interspersed with the daily lectures, we rounded in the hospitals and controversy in concluding, saw florid cases of tetanus, “Patients treated by older measles, and typhoid. We physicians had higher morwent on field trips includtality than patients cared ing visiting a leper colony, for by younger physicians.” a living museum of medical I am an aging teacher of history. medical students. I used to I was also invited to worry whether I was losing join an investigation of my edge. Was I keeping up? an equine encephalitis In my advancing years, was outbreak (no thank you; I ingraining my own insidiI decided I was too young ous errors in my students’ to die as a medical martyr medical repertoires? succumbing to the disease In 2016, a working I was cataloging). So group within the American instead, on most days, I was Medical Association supassigned to the cutaneous ported the idea that with leishmaniasis lab. That age come declining skills: or the micro lab, looking “Comprehensive assessthrough slides of poop for ment approaches show hookworms and roundthat increasing physician worms. I worked under age and longer time since the world’s top expert in graduation predict overall leishmaniasis. He was a poorer performance.” thin, quiet 75-year-old man By Larry Kravitz, MD But surveys show older with a delicate touch for physicians have a higher scraping sample slides from level of job satisfaction, open, festering skin ulcers. lower sense of stress levels, He would teach me how to and lower rates of malpraclook under the microscope tice claims settlements. Also, age is not the only factor that affects for trypanosoma cruzi, the parasite from blood-sucking reduviid bugs competence and it might not even be the most important one. “Solo that dropped on the sleeping Panamanians from the straw roofs of practice, international training, lack of board certification, general their primitive domiciles. My revered doctor showed up everyday to practice, and incongruence between training and scope of practice the clinic, always on time, wearing his bow tie and Panama straw hat. predict an increased likelihood of poor outcomes on performance And sometimes after work, I would see him, jogging home, 5 miles, assessments,” the AMA authors noted. out along the jetty at the western edge of the Panama Canal along the It’s not written in stone that we will be worse physicians when Pacific Ocean, with the waning sun leading his way. we are older. It’s just another challenge in yet another day. Beware At 25 years of age, I thought, “That’s who I want to be.” I can’t of stagnation. Know that you are at risk for erosion of your skills. imagine still being able to do all of that at 75, but if I did, that would Constantly reassess. Constantly adapt and rejuvenate your aging be a good medical life. practices, whether you are 35 or 75. And it’s not just knowing the Now I am 65, and have been a practicing family physician for 40 newest pharmaceutical. So much of the real professional recertificayears, and people keep asking if I am going to retire? tion is keeping up with technology and bureaucracy: EMR, HIPAA My first immersion in physician retirement came when my medical secure texting, streaming CME podcasts (at two times speed if you group had to let go of our paper charts and switch to EMR. That culled want mental exercise), macros (and MACRA), Dragon dictation, the herd of my older physician peers. It was the medical version of the

THE

AGING

PHYSICIAN MODEL

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patient portals, electronic prescribing, POCUS, and ICD-10. Adapting to our realistic world. That’s a form of recertification, and there really is some intellectual stimulation in some of those cursed administrative burdens like the EMR. They really can improve quality of care, despite the price of your documentation burnout. My personal way to adapt is to teach. To teach is too learn. Now I have made peace with the quality of skills I am sharing. Of course, I am teaching them both the wrong and the right. Becoming a teacher means being imperfect but having the fortitude to stand up in front of the student and be present for their learning as well as your own. We selected this new generation of medical students to be mature beyond their years. They will embrace our humanity and imperfection. They will embrace my knowledge and accept the risk of my ingrained errors and outdated training. Being a good student means being discriminating about the knowledge you accept. We live both in an Information Age and a Disinformation Age. Our young followers are more facile in processing data than we will ever be. And so I tell them at the start of every rotation, “You are here for two things. To learn things that help you be a better doctor, and to learn what things you never want to be as a doctor. I am sure by the end of the month, I will embody them both.” As long as I continue to step up to the plate and accept them into my world, I will grow as a better doctor alongside them. Keeping students in my practice forces me to keep up to date, and I don’t think I make any more mistakes teaching students now than I did 20 years ago, probably less. Aging has just made me more honest and transparent about the process. Neuroplasticity is the ability of the brain to change throughout an individual’s life. We know now that the aging brain is not just decaying. Some areas are growing new connections. And we can help our brains learn. We have control over our brain changes. But to quote Somerset Maugham, an author who always speaks to the physician’s heart, “the path to salvation is narrow and as difficult to walk as on a razor’s edge.” There is no retirement from our lives. There is no retirement for our minds. To quote a Nike ad that speaks to my runner’s heart, “there is no finish line.” My company’s CEO and founder has a role for me now. He says my multispecialty group needs “gray beards.” Those older physi-

cians who mentor and steady the new partners — the young bucks of medicine, with their unbridled healing passions. We watch over them. It doesn’t take much. It’s an immediate collegial pat on the shoulder rather than the looming knuckle rapping of the Peer Review Committee. Peer review is the stick and I am the carrot. The living enticement that they can make it. I’m just an average guy and I’ve made it all these years. So can you. I look down the office hallway full of toiling young physicians and I feel the value of multigenerational providers. I look over to my young scribe, putting in her gap year before she joins our ranks at medical school. Next to her is the latest iteration of third-year medical student on rotation with me. I teach his awkward fingers to be sensing instruments of liver spans and swollen spleens, and thyroid nodules and knee effusions. I show him how to gently scrape away scaling skin to view fungal hyphae under the microscope. And as I again walk the two miles home from my clinic, with the evening sun sinking over the Texas llano, I find that I, too, am an iteration, that of my distant Panamanian role model. And I now understand that 40 years ago, I had a role in that role modeling. It dawns on me that the old Panamanian secretly needed me in his life to become the role model to whom I gazed upward. Without a student to regularly rekindle his medical passion, would he have stayed the beacon that he was? As I incorporated all his wizened medical acumen, were my questions quietly piquing a renewal of his research vigor? Does it really take all of us together to create an enlightened milieu that we can all find inspiring? I choose to answer “yes,” and I hope to affirm that even more so when I’ve walked a further 50 years down this medical path.

It’s not written in stone that we will be worse physicians when we are older. It’s just another challenge in yet another day. Beware of stagnation. Know that you are at risk for erosion of your skills. Constantly reassess. Constantly adapt and rejuvenate your aging practices, whether you are 35 or 75.

TEXAS FAMILY PHYSICIAN [No. 1] 2019

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By volunteering to precept a Texas medical student, you can open a door to a new world for the next generation of family doctors. QUESTIONS? Give us a call at (512) 329-8666 or send an email to Juleah Williams, jwilliams@tafp.org.

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