Texas Family Physician, Q2 2021 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 72 NO. 2 2021

Texas Family Physician Of The Year Adrian Billings, MD, PhD PLUS: Mental Health In The Time Of COVID TAFP Foundation Annual Report

INSIDE

TEXAS FAMILY PHYSICIAN VOL. 72 NO. 2 2021

Building something bigger in the Big Bend

Soft-spoken, humble, and earnestly kind, Adrian Billings, MD, PhD, of Alpine has a vision as big as the Big Bend sky for improving the health and the health care delivery system of Texans in one of the most unforgiving landscapes in the West. Meet the 2020-2021 Texas Family Physician of the Year. By Kate Alfano

Mental health in the time of COVID

The director of behavioral medicine at JPS Hospital Family Medicine Residency provides tips and strategies to help you care for your patients’ mental health.

By Katherine Buck, PhD, LMFT

Beat the heat and the anxiety

Summer has come with its secret schedule of 100-plus-degree days and vacations to arrange, and yet the pressure cooker of COVID still weighs on the minds of those in health care. Our friends at Anticipate Joy are back with more coping tips to keep cool and calm.

By Anticipate Joy

6 FROM YOUR PRESIDENT Keeping up the fight for family medicine 9 AAFP NEWS New report charts future for primary care 10 MEMBER NEWS Local chapter awards grants | Briggs wins TMA award | Members receive state, national appointments 12 IN THE TRENCHES AAFP takes on prior authorization 25 FOUNDATION 2020 TAFP Foundation Annual Report 29 PERSPECTIVE A scribe’s story

NPI 2021 SCHEDULE JULY 15 – 18, 2021 | HOUSTON

DECEMBER 9 – 12, 2021 | HOUSTON

JW Marriott Houston by The Galleria 5150 Westheimer Rd. | Houston, Texas 77056 | (800) 228-9290 $135 per night

JW Marriott Houston by The Galleria 5150 Westheimer Road | Houston, Texas 77056 | (800) 228-9290 $119 per night

Dermatologic Procedures

July 15-16

$1,495

Dermatologic Procedures

Dec. 9-10

$1,495

Colonoscopy

July 15-16

$1,495

Mastering Protocols for Optimization of HRT

Dec. 9-10

$1,295

Joint Exam and Injections

July 15-16

$1,495

Point of Care Ultrasound (POCUS)

Dec. 9-10

$1,495

Mastering Protocols for Optimization of HRT

July 15-16

$1,295

X-Ray Interpretation

Dec. 9

$850

Contraceptive, Women’s Health and Vasectomy Procedures

July 15-16

$1,495

Allergy Testing and Immunotherapy for Primary Care Physicians

Dec. 10

$850

Aesthetic Procedures

Dec. 11-12

$1,295

Hospitalist Procedures

Dec. 11-12

$1,495

Joint Exam and Injections with Ultrasound Guidance Dec. 11-12

$1,495

Suturing

$1,495

SMART Workshop (Sideline Management Assessment Response Techniques)

July 16

EGD (Gastroscopy)

July 17-18

$1,495

Hospitalist Procedures

July 17-18

$1,495

Joint Exam and Injections with Ultrasound Guidance July 17-18

$1,495

Splinting and Casting

July 17-18

$1,495

Wound Care Management and Advanced Suturing July 17-18

$1,495

$395

SEPTEMBER 9 – 12, 2021 | DALLAS

Dec. 11-12

FEBRUARY 17-20, 2022 | PHOENIX

Hyatt Regency Phoenix 122 North Second St. | Phoenix, AZ 85004 | (877) 803-7534 $239 per night — More information coming soon!

Marriott Dallas Las Colinas 223 West Las Colinas Blvd. | Irving, Texas 75039 | (800) 228-9290 $139 per night Dermatologic Procedures

Sept. 9-10

$1,495

Exercise Stress Testing

Sept. 9-10

$1,095

Mastering Protocols for Optimization of HRT

Sept. 9-10

$1,295

Hospitalist Procedures

Sept. 9-10

$1,495

Suturing

Sept. 9-10

$1,495

Aesthetic Procedures

Sept. 11-12

$1,295

Contraceptive, Women’s Health and Vasectomy Procedures

Sept. 11-12

$1,495

Joint Exam and Injections with Ultrasound Guidance Sept. 11-12

$1,495

Wound Care Management and Advanced Suturing Sept. 11-12

$1,495

For complete course information and to register, visit NPI online at www.NPInstitute.com or call (866) NPI-CME1 today.

PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 72 NO. 2 2021 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

Amer Shakil, MD, MBA

president-elect treasurer

Mary Nguyen, MD

Emily Briggs, MD, MPH

parliamentarian immediate past president

Terrance Hines, MD Javier D. “Jake” Margo Jr., 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 cover photo

Audra Conwell

Jonathan L. Nelson

CONTRIBUTING EDITORS Kate Alfano Anticipate Joy Katherine Buck, PhD, LMFT Larry Kravitz, MD Stephanie Quinn Ben Saul Harish Thoppe

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. © 2021 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. 2] 2021

Keeping up the fight for family medicine through the pandemic By Amer Shakil, MD, MBA TAFP President be extremely unusual, to say the least, our greetings members. What a strange year advocacy team aided by the timely efforts and a half its been for all of us. As life is of many family physicians stood strong slowly and cautiously beginning to return to for family medicine and our patients. We something akin to normal, we should take succeeded in passing a set of health care a moment to acknowledge the struggles price transparency measures, including the and the achievements we have experienced, creation of an all-payer claims database for both individually and as a specialty. Over Texas, which will help us understand what these several months, the resilience of drives health care costs and what reforms can family physicians, our physician colleagues, address cost variation across communities. other health care providers, and aides of all We also helped protect sorts has been nothing funding for graduate short of amazing. medical education, helped I have also marveled at the resilience of our If we continue to be increase the duration of coverage for Academy. In February of prudent and patient, Medicaid children and new mothers, 2020, it seemed unimagiwe will emerge from and fought back attempts nable that we would by nonphysician providers cancel April’s C. Frank the pandemic ... to gain independent pracWebber Lectureship and but we’re not out of tice. As a member of many Interim Session. And then the woods yet. This public health and physician it became obvious that we couldn’t possibly hold the pandemic has taken organization coalitions, we make permanent meeting. The Academy a terrible toll on the helped the state’s pandemic emerwould go on to learn to mental health of gency rules that removed produce virtual conferbarriers to telemedicine ences, and that’s how we our colleagues in access and utilization. And would conduct business medicine. we helped pass significant for the rest of the year. regulations on the retail Throughout the sale of e-cigarettes. pandemic, our AcadEven though Texas continues to have emy has remained very active in engaging the highest number of uninsured patients with our members. Despite the hassles of in the nation, the Legislature failed once canceling meetings and figuring out new again to expand Medicaid to working-age ways to complete our usual tasks, TAFP’s impoverished Texans. Doing so would have hard-working staff provided us with much provided access to continuous, comprehenneeded support. Whether by helping memsive care to approximately 1.5 million uninbers obtain personal protective equipment, sured low-wage citizens while bringing an offering counseling support services, or estimated $10 billion in federal funds to the implementing our new online community state each year. We must keep up the fight, platform, the TAFP Exchange, the Academy advocating for a Texas solution to expand was there for us. coverage for those who need it. Consider the work done at the State Aside from advocacy, TAFP’s education Capitol during the recently completed 87th department stayed on track throughout Texas Legislature. Although a succession of unprecedented events caused the session to [cont. on 8]

more control doctors nurses cardiologists family physicians protecting

practice managers

infectious disease specialists internists anesthesiologists

At ProAssurance, we work to protect medical professionals and support their patient safety efforts with custom healthcare professional liability insurance solutions.

nurse practitioners long term care specialists neurosurgeons pulmonologists podiatrists

epidemiologists oncologists

pediatricians general surgeons

If a malpractice claim is made, we listen and provide experienced counsel, bringing clarity and fair treatment to the claims process.

obstetricians & gynecologists allergists hospital administrators

emergency physicians

urologists

geriatricians chiropractors

pathologists immunologists orthopaedists radiologists and more

Healthcare Professional Liability Insurance

ProAssurance.com

COMING SOON ON TAFP’S

CME SCHEDULE TAFP Pulse A Virtual CME Conference August 14, 2021

Annual Session & Primary Care Summit Nov. 5-7, 2021 Nov. 3-4: Business meetings and preconference workshops

The Woodlands Waterway Marriott Hotel and Convention Center The Woodlands, Texas

C. Frank Webber Lectureship & Interim Session April 8-9, 2022 Renaissance Austin Hotel Austin, Texas 8

TEXAS FAMILY PHYSICIAN [No. 2] 2021

Attendees played games and made S’mores on the veranda at TAFP’s Family Fun Fest during the Texas Family Medicine Symposium at La Cantera Hill Country Resort in San Antonio. [cont. from 6]

the pandemic, hosting online CME events and launching a series of virtual Knowledge Self-Assessment workshops to help members meet their maintenance of certification requirements. This spring, the Academy took the first steps toward a return to normal by hosting an in-person CME conference, the 2021 C. Frank Webber Lectureship, and it was a huge success. For many attendees, the Austin conference was their first in-person event in many months. Our conference planners worked diligently with the hotel administration to ensure attendees could learn in the safest possible environment, and the evaluations we collected after the event reflected our attendees’ appreciation. Many comments expressed relief and gratitude for the opportunity to come together once again. Unfortunately, I could not attend. Like many of our colleagues working in various systems and academic settings, a return to in-person conferences was not yet possible. But I was there in spirit! I did attend several committee meetings during Interim Session through video conference. Since then, we hosted the Texas Family Medicine Symposium in San Antonio, and by all accounts, it too was a great success. More than 240 attendees joined us at the luxurious La Cantera Hill Country Resort in June. Many brought their families and attended our first Family Fun Fest on one of the resort’s vast verandas. They played cornhole, giant Jenga and Connect Four, and enjoyed being together in the beautiful setting.

Having these successful although somewhat restricted in-person conferences is yet another sign that if we continue to be prudent and patient, we will emerge from the pandemic. I’m sure all of you are experiencing similar signs, but we’re not out of the woods yet. This pandemic has taken a terrible toll on the mental health of our colleagues in medicine. We must be aware of our own mental well-being and that of those around us. TAFP has partnered with Anticipate Joy, an innovative mental health and wellness company, to provide virtual professional counseling services for our members at a significantly discounted rate. I’m glad to report that our members are taking advantage of this very important resource. I would encourage our membership, if you are feeling really stressed out, you may want to check out this service. See page 23 in this issue of Texas Family Physician or visit TAFP.org for more information. If you know of any of your colleagues who are going through a rough patch, please advise them to try this confidential service. Yes, there are signs everywhere that life is returning to some version of what we know as “normal.” The new “normal” probably won’t be exactly like the days before COVID-19, but I for one look forward to getting back together with you. Our next big opportunity will be the 2021 Annual Session and Primary Care Summit in The Woodlands, November 5 – 7. Until then, let’s take care of one another and let’s take care of ourselves.

AAFP NEWS

NASEM report heralds primary care evolution, urges action Findings chart necessary future for family medicine By AAFP News Staff a comprehensive report published this month by the National Academies of Sciences, Engineering and Medicine strengthens the case for primary care as the foundation of the U.S. health care system. It also makes policy recommendations that reinforce several of the AAFP’s long-standing advocacy positions. “Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes,” concludes the 448-page “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” which reflects some 18 months of research. The Academy was among the 17 cosponsors of the study and plans to participate in stakeholder and lawmaker briefings accompanying its publication. A snapshot of how the authors define “better” and “more equitable” in the context of primary care: Americans, per capita, spend more than twice what citizens in Australia, France, Canada, New Zealand and the United Kingdom pay for health care but experience worse health outcomes than people in those countries, the report notes. These nations, like the United States, are part of the Organization for Economic Cooperation and Development, whose members devote an average of 14% of all health care spending to primary care. In this country, primary care visits account for 35% of health care visits yet make up only about 5% of health care expenditures. The report echoes and extends a 1996 Institute of Medicine report, starting with an updated definition of high-quality primary care as the “provision of wholeperson, integrated, accessible and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained

relationships with patients, families and communities.” That earlier document, “Primary Care: America’s Health in a New Era,” (which the Academy also co-sponsored), made a similar call to prioritize primary care. But it was less definite in establishing accountability methods for its proposals, which went largely unheeded by legislators and policymakers. In the generation since, several of the issues it identified — including the limitations of fee-for-service medicine and the need to buttress the primary care workforce — have grown more acute. NASEM’s study acknowledges that urgency with a five-pronged implementation plan to make high-quality primary care available and accessible nationwide. Specifically, it calls for policies that • pay for primary care teams to care for people, not doctors to deliver services; • ensure that high-quality primary care is available to every individual and family in every community; • train primary care teams where people live and work; • design information technology that serves the patient, the family and the interprofessional care team; and • ensure that high-quality primary care is implemented in the United States. The report’s findings and recommendations support the Academy’s position that the country’s fee-for-service health care design promotes misaligned incentives and prizes “sick care” at the expense of population wellness. This dangerous gap was exposed and exacerbated by the COVID-19 pandemic. AAFP EVP and CEO Shawn Martin said in a May 4 statement, “We look forward to working with policymakers, payers, and our other partners in primary care to make

“We look forward to working with policymakers, payers, and our other partners in primary care to make the study recommendations a reality — the health of our nation depends on it.” — Shawn Martin, AAFP EVP and CEO

the study recommendations a reality — the health of our nation depends on it.” Academy President Ada Stewart, MD, of Columbia, South Carolina, added: “The NASEM report clearly spells out the case for increased investment in our primary care system and ensuring everyone in our country has access to high-quality primary care, something the AAFP has long advocated for. The COVID-19 pandemic further exposed flaws in our current health care system, including those related to many years of underinvestment in primary care.” Source: AAFP News, May 4, 2021. ©2021 American Academy of Family Physicians.

www.nap.edu/catalog/25983/ implementing-high-qualityprimary-care-rebuilding-thefoundation-of-health www.tafp.org

MEMBER NEWS

Awarding grants in the Heart of Texas By Jean Klewitz The TAFP Heart of Texas Chapter started a chapter grant program in early 2020. Supported by family physicians, the grant program fuels local community work. Applicants to the grant program are chapter members supporting the local community or member-nominated community groups within the Heart of Texas’ 12 counties. Leaders of the chapter, Karen Smith, MD, chair, and Katharina Hathaway, MD, vice chair, met while doing some nonprofit work together through the Manor Community Wellness Alliance. Smith was working with others to start the Manor Free Clinic. Their meeting in humanitarian work helped fuel philanthropic community work within their chapter. The Heart of Texas Chapter Grant Program was initiated after an evaluation of the chapter’s finances. Discovering a significant amount of money, the Heart of Texas Chapter started brainstorming what could be done with it. “Many chapters present CME, put on programs, and provide steak dinners for their members,” Hathaway says, “Karen suggested giving away grants instead.” Smith got the idea while working on the Manor Community Wellness Alliance. The alliance struggled to get funds for the free clinic and knew how a small grant could make a big difference. “My husband said, ‘You want to run for president of something that has no agenda but has money? You usually have a huge agenda and no money,’” Smith says. “We wanted to use it well and be good stewards of it and use it for the community. We also wanted to serve our physician population and the causes that are close to their hearts. And those are going to vary and be as diverse as our family doctors are.” The chapter suggested the grants would be from between $500 to $5,000 and would leverage the efforts of community groups and individuals in the area that were making a difference. The board and members loved the idea. “It didn’t seem to be controversial,” Hathaway says, “Everyone was really onboard with it and had great ideas of groups they knew in their communities.” During this inaugural year, the program received five applications, and awarded two grants. The chapter awarded $5,000 to the Texas Physicians for Social Responsibility to produce a report entitled “Environmental Threats to Public Health: Mobilizing for Action Now.” The chapter also awarded Jennifer Pollard Ruiz $875 to train and develop a physician wellness program entitled, “Using Narrative Medicine to Create Resilience: How Can Stories Heal Us?” The TAFP Heart of Texas Chapter, formerly known as the Travis County Chapter, covers 12 counties: Bastrop, Blanco, Burnet, Caldwell, Gillespie, Hays, Lampasas, Lee, Llano, San Saba, Travis, and Williamson. The chapter is looking for innovative leaders within the counties to get involved. “We have money, but we need more people to make it work,” Hathaway says. In observation of the first year of the grant program, the chapter was delighted by the many creative ideas submitted from the community and realized the need for a parttime administrative staff for future grant cycles. The chapter now plans to have two grant cycles per year, one in the spring and one in the fall, and the focus will always be service. “We wanted something that would work across that urban-rural-suburban continuum, and community service is one thing that does,” Smith says. TAFP helps send out notices about these grant cycles, so if you’re interested and are in the Heart of Texas Chapter, be looking for the notice this year. The Heart of Texas Chapter believes the program will help raise the profile of their TAFP chapter and support the members who are involved in community service. “We are challenging family doctors to serve in the community, to let us know where they’re already serving, and to identify other worthy causes that are serving their communities,” Smith says.

TEXAS FAMILY PHYSICIAN [No. 2] 2021

New Braunfels family physician receives TMA’s Young at Heart Award new braunfels family physician Emily D. Briggs, MD, MPH is the 2021 Texas Medical Association Young at Heart Award recipient. Doctors from the TMA Young Physician Section announced the award during TexMed, TMA’s annual meeting, held virtually. The YPS, a Emily Briggs, MD, group of TMA phyMPH sicians under age 40 or in their first eight years of medical practice, chose Briggs for her dedication to engaging medical students, resident physicians, fellows, and young physicians in organized medicine. “I have never been so pleasantly acknowledged — and by a wonderful group of future leaders,” said Briggs, a TMA member for 17 years. “Dr. Briggs is a shining example of mentorship,” said Samuel E. Mathis, MD, a Galveston family physician and YPS chair. “She is great at helping promote leadership opportunities for others, while maintaining a solo clinical practice.” Briggs currently serves as TAFP treasurer and has held numerous positions with the Academy. She is a member and past chair of TMA’s Committee on Reproductive, Women’s, and Perinatal Health. She is a 2019 graduate of TMA’s Leadership College and is a member of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured. In practice for nearly 12 years, Briggs cares for patients at her private practice, Briggs Family Medicine. “Dr. Briggs stays involved in organized medicine and is always willing to answer a phone call or email if you have any questions,” Mathis said. “I value her mentorship and insight on organized medicine, patient care, and the intersection of both.” Briggs received her medical degree and a master’s of public health degree at McGovern Medical School at UT Health. She completed her residency at CHRISTUS Santa Rosa Hospital in San Antonio.

TAFP members receive state, national appointments Over the past few months, several Texas family physicians have either won elections or received appointments to important positions in organized medicine. Congratulations to these great TAFP members. At this year’s National Conference of Constituency Leaders, Samuel Mathis, MD, of Galveston, was elected to be the AAFP Board of Directors New Physician Member. Also Rashmi Rode, MD, of Houston, was elected as a 2022 Member Constituency Co-Convener of the IMG constituency. Both are alumni of the TAFP Family Medicine Leadership Experience. The AAFP Foundation Family Leads program selected four of our resident and student members as 2021 Family Medicine Leads Emerging Leader Institute Scholars. The following will receive a $550 scholarship to virtually attend the AAFP National Conference of Family Medicine and Students and participate in the FML Emerging Leader Institute this summer. • • • •

The TAFP 2015 Texas Family Physician of the Year, Antonio Falcon of Rio Grande City, was appointed to the Baylor College of Medicine Board of Trustees. The president, CEO, and executive dean of Baylor College of Medicine acknowledged the significant contributions Dr. Falcon has made in the field of family medicine and his community. “I would like to thank the Baylor College of Medicine Board of Trustees for giving me the opportunity to serve in this capacity.” Falcon said at the Board of Trustees meeting. “I look forward to participating in expanding Baylor’s vision of excellence in medical education and community service.” Tina Philip, DO, of Round Rock was installed as the chair of the Texas Medical Association’s Women Physicians Section Executive Council. She will lead the section toward their goals: offering more opportunities for women physicians and influencing TMA policy through representation in the TMA House of Delegates.

Jasmine Douglas, MD – PGY1, University of Texas HSCTyler Family Medicine Program Alexis Ramos, MD – PGY2, UT Health San Antonio Narmeen Syed, MD – PGY2, DeTar Family Medicine Residency Program Catheryn Teav – M4, University of the Incarnate Word, School of Osteopathic Medicine

KEEP YOUR FINANCIAL HEALTH INTACT WITH RANNSOLVE‘S A/R ANALYSIS AND FOLLOW-UPS. PARTNER WITH US AND ENJOY AN EVEN AND PREDICTABLE CASH FLOW.

CONSTANT LEARNING

DETAILED RADIOLOGY REPORTS

ACCURATE BILLING & DILIGENT FOLLOW-UPS

We are aware that precision in coding and success in claims for all A/R services hinge heavily on keeping pace with the changing regulations. So we continuously train our coding teams on the nuances of current billing codes.

We understand the Billing guidelines’ emphasis on perfect documentation. And so we ensure that our A/R service reports don’t miss any critical information and address all specific clinical questions.

Our highly trained professionals combined with our intensive experience in the A/R domain helps us deliver a high degree of accuracy in our coding and billing solutions.

RCM SERVICE VOUCHER

$995

Claim and get the service voucher for your first service

972-525-1177 info@rannsolve.com www.rannsolve.com

www.tafp.org

AAFP IN THE TRENCHES

Chipping away at the burdens of prior authorization By Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy

ith many Americans thinking about summer vacations, I want to tell you briefly about the Academy’s most recent efforts to lighten your workload.

In May, four members of Congress introduced the Improving Seniors’ Timely Access to Care Act, which would streamline and reduce prior authorization requirements in the Medicare Advantage program. AAFP immediately endorsed the legislation as part of the Regulatory Relief Coalition, 14 specialist societies working as a bloc to reduce Medicare’s administrative complexity. When similar commonsense legislation was introduced in 2019, the bipartisan bill had 280 cosponsors and was endorsed by hundreds of medical, health, and patient-advocacy groups, including the Academy. Little wonder: Its authors prominently cited a 2018 audit by the HHS Office of the Inspector General indicating, among other damning findings, that 75% of Medicare Advantage prior authorization denials over a two-year span (about 216,000 a year) were overturned. During the same period, “independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers,” added the report. The bill did not reach the floor for a vote the last time around. I’m hopeful we’ll see better results during this session, especially because its passage would likely drive welcome and badly needed improvements to prior authorization in commercial insurance plans. Additionally, the legislation’s focus on Medicare Advantage plans would fill a gap in CMS rulemaking that we noted this past December. “By not standardizing prior authorization across all payers governed by CMS, this rule will not meaningfully reduce the administrative burdens with which family physicians are grappling,” the Academy said in a Dec. 23 letter to outgoing HHS and CMS leaders. That rule, “Reducing Provider and Patient Burden by Improving Prior Authorization Processes,” published Dec. 20 in the Federal Register, was finalized but, along with other HHS moves made late in the Trump administration, put on hold by the new White House, pending review. And AAFP, again in tandem with other medical groups, was equally prompt in objecting last April to recent prior authorization expansions by CMS. 12

TEXAS FAMILY PHYSICIAN [No. 2] 2021

“We continue to have serious concerns that beneficiaries will experience significant barriers to access to medically necessary procedures as a direct result of the calendar year 2021 policy,” said our letter to CMS Acting Administrator Elizabeth Richter. “We also worry that future expansions of prior authorization will unnecessarily delay access to care for even more beneficiaries and add administrative and cost burden for providers unless appropriate and transparent regulatory processes are established.” Also in May, the Academy voiced strong approval for the Safe Step Act. That legislation would reduce administrative burden by implementing transparency guidelines to prevent inappropriate use of step therapy in employer-sponsored health plans and create a clear process for patients and physicians to seek reasonable exceptions to step therapy. “The AAFP has long advocated that step therapy should not be mandatory for patients already on a working course of treatment and that generic medications should not require prior authorization,” we told the legislation’s sponsors, Sen. Lisa Murkowski, R-Alaska, and Rep. Raul Ruiz, MD, D-Calif. “Ongoing care should continue while prior authorization approvals or step therapy overrides are obtained. To ensure access, patients should not be required to repeat or retry step therapy.” Finally, Academy member Kisha Davis, MD, MPH, of Gaithersburg, Maryland, appeared before the Senate Finance Committee to deliver detailed counsel on improving telehealth and ensuring health equity in virtual care — advice that included stern words about prior authorization. Among the dozen recommendations AAFP outlined for lawmakers, we told senators in our written testimony: Medicare and Medicaid both waived prior authorization requirements for durable medical equipment and other services early on during the public health emergency. While these requirements have since been reinstated, Congress should permanently reduce the volume of prior authorization requirements across Medicare and Medicaid payers. It should indeed. Source: In the Trenches, May 25, 2021. ©2021 American Academy of Family Physicians.

MENTAL HEALTH in the time of COVID By Katherine Buck, PhD, LMFT This article is an edited version of a continuing medical education lecture Dr. Buck presented during the 2020 Annual Session and Primary Care Summit.

What is happening to our population? In June 2020, a CDC study showed that a staggering 40% of adults are struggling with mental health issues. Considering we are many months into this pandemic and probably have many more to go, this likely can only get worse over time. Additionally, we are likely to see lasting mental health effects after the pandemic has “concluded.” Who is at highest risk? Racial and ethnic minorities, essential workers, and unpaid caregivers are having the worst mental health outcomes, and younger adults are at a higher risk that normal. Many patients are reporting anxiety or depression, increased substance abuse risk, and have considered suicide. This is occurring across many walks of life and socioeconomic strata. Individuals with pre-existing mental health problems like schizophrenia or bipolar disorder may be hurting even worse from the social isolation of the pandemic, and since there is less access to mental health facilities, and telehealth is not always the best option, they may not be getting the care they need. How about recovering COVID patients? Delirium is one thing we are seeing in hospitalized COVID patients. Those that weren’t even sick enough to need to be in the hospital still describe a COVID fog. We don’t really know the longterm effects, but we’re thinking a third to half could have some kind of lasting neurological psychological effects. Additionally, we are seeing long term effects on anxiety, sleep, and general mood. So how can we help our patients right now? First and foremost, being anxious is normal right now – both for patients and clinicians. It’s about as close to whatever we have for normal. If we all went and did a GAD-7, almost all people could be positive in some manner on that. So it is also important to not over pathologize some of the “normal” levels of anxiety. One of the things you can do with your patients in the exam room is just talk about it, help to name the feeling. You might say something like: “This is really hard. It sounds like you’re worried. This situation feels overwhelming.” Then they feel understood in that moment. That alone can be its own intervention. Generally, when we think about treating patients with anxiety, we think about motivating social support and we think about helping them avoid avoidance. We want them to not avoid a situation that could provide positive reinforcement.

What are things I should look out for in my patients? One thing I would recommend as a resource is the coronavirus workbook from The Wellness Society in the UK — it is really well done and has great patient-friendly resources. Some key ideas that they discuss are below. Threat scanning is something that a lot of people who are anxious do naturally. For instance, worrying that if they coughed it may be coronavirus. If I ask my patients, “How many times do you cough a normal day?” most of us don’t know. It’s pretty normal to cough a few times throughout the day, but because of the increased stimulus value of a cough right now, that immediately becomes scary. Catastrophizing is a similar cognitive distortion where we jump to the absolute worst-case scenarios and those two kind of go handin-hand. We’re scanning for something that feels weird as opposed to, “oh, I just slept wrong and that’s why I’m having this pain.” Hypothetical worry is where we get on that “what if” train. One of the things that can sometimes be helpful with patients who are really engaged in this what-if game is the idea of thought challenging, which I’ll discuss later. Emotional reasoning is hard not to do right now. It’s a real challenge when an emotional experience becomes your reality. “I feel scared, so I must be in danger” could be applied to just about everything happening in our country right now. Another thing to watch out for is the idea of fortune telling. We don’t know what’s going to happen with a lot of things. We have educated guesses, but nobody can predict what’s going to happen tomorrow and if we take scary things that we hear on the news as absolute fact, it’s setting us up for a disappointment as well as this running anxiety. So things I often do with patients when they are involved in this thinking is rather than ask if a thought is wrong, ask is this helpful or unhelpful as a way to think? I will teach patients about the idea of putting a thought on trial. I will ask this patient, “What’s this thought that is scaring you? What is the thought that you keep having?” Then I’ll ask patients to come up with as much evidence as they can for it and as much evidence as they can against it. Sometimes I’ll literally just pull the exam paper down on the table and write it out on the exam paper. I ask them to present this evidence as if they were both the prosecutor and the defense attorney. So who wins? Is there some reasonable doubt? How can I help my patients to have a healthy information diet during these uncertain times? Just like we talk to our patients about having healthy food diet, we should encourage a healthy information diet. Media stories feel really heightened right now, so good questions to ask yourself about a story that you’re reading is “Has the story been covered by multiple outlets or just one?” If it’s only been covered by one media outlet, that’s a pretty good tip off that the story may not be trustworthy. I don’t get into whether something is true or not, but I’m trying to take 100% thoughts down to 50%, because then there’s room for wiggle and there’s less room for the certain anxiety. My general recommendation for keeping a healthy news diet is to be intentional. Instead of losing hours to the television or getting sucked into a doom scroll on Facebook, maybe set aside 30 minutes a day. Be sure to check stories with somebody who’s trusted. This is especially important for some of our elderly patients who may not have the internet literacy that some of our younger folks have. This www.tafp.org

We often see what we’re looking for. If we’re spending all of our time right now looking for danger, the world is an even more dangerous place. is also important for health care workers who may be immersed in COVID at work and then going home and watching more news. If you’re working in health care, you will probably get appropriate safety information in your place of business and can potentially back it down in the evenings. I also recommend the concept of a digital detox day during times of heightened anxiety. How can I talk to my patients about the concept of control? What do we have in our control? What do we have outside of our control? There are a lot of different metaphors that I use with patients about this. A popular one I have used lately is the idea of “pulling the shades.” If you pull the shades, what’s inside your house and what’s outside your house? Right now very few of us have the bandwidth to deal with something that’s outside our house emotionally. The things that are inside our house can be addressed with action-focused coping. I work with patients to make a plan for one or two things they will do about the things that are inside their house before our next session. The things outside of our control really lend themselves well to emotion-focused coping. How can you foster positive emotions within yourself? We get really caught up in trying to control other people, trying to make decisions for other people. That’s just not going to happen, and almost all families in America right now have some level of disagreement. It is important to remember what is inside your house and outside your house. Another activity that I will recommend for managing anxiety is the idea of distraction. It sounds very simple, but there are certainly barriers right now that make it a little more challenging. I typically advise patients to make a list as big as they can on things they like to do and then we figure out a way to make them happen. I remind patients about the importance of planning, the importance of routine and a sense of control. I advise people working from home to get up and make their bed and go into a different room to do all the things that they would normally do at work. There’s something of value to keeping that routine. I also encourage people to come up with daily and weekly plans when feeling sort of lost. The coronavirus workbook has great monthly and daily plans. And these plans don’t have to be huge. You can commit to doing five minutes of a thing. Five minutes of exercise are better than no minutes of exercise. Then slowly over time you can shape that behavior. Another topic I talk about all the time is the importance of gratitude. This works anytime to lift your mood. The Duke Patient Safety Center in North Carolina has done a number of studies looking at the impact of gratitude and researchers have found it to have a larger and longer effect than using an SSRI. It’s also got a great effect on workplace safety as well as workplace culture. I cannot recommend gratitude enough; it tends to retrain our focus. We often see what we’re looking for. If we’re spending all of our time right now looking for danger, the world is an even more dangerous place. 14

TEXAS FAMILY PHYSICIAN [No. 2] 2021

A gratitude practice I recommend is “three good things.” I tell patients to write down three good things that happened during the day before they go to bed. There’s also benefit to sharing gratitude. You could get a big roll of paper, put it on your break room wall and have people write down things they are grateful for that day. The more you train yourself to do it, the more you will have a positive outcome with it. I also recommend to my patients that they keep good social connections. I often talk to patients about how to make friends, because there are many ways to make friends. I ask patients to determine if they have someone they could call at 4 a.m. if there was an emergency, and if that answer is yes, that person meets that requirement for needed social support. One thing I always recommend for mood management is exercise. Almost any exercise will enhance your mood. We’re looking for 30 minutes three to five times a week, but it’s fine to break it into bits and to make a small start to work up from. I also talk to patients who are anxious about diaphragmatic breathing. Most people will tell you, “I tried taking a deep breath and it didn’t work.” Well, there are two keys points that are important to evidence-based diaphragmatic breathing. The first is the rate. I want patients to breathe in for half as long as they breathe out, or out for twice as long as they breathe in. Second is the mechanics, and that’s breathing out and down from the diaphragm. It helps you create a better oxygen exchange It helps send triggers to your body to be calm. Often times when patients tell me, “I did breathing and it didn’t help,” I ask them to show me what they did and usually, it’s all up in the chest. I ask patients to lie down and try belly breathing, so that a deep breath in makes the belly stick out. How do I deal with frustrated colleagues? I think for most people the stress of this waxes and wanes. I know in our practice at any time we usually have a few people having a good day, a few people having a bad day, and then people in the middle, always giving one another some grace. I think that’s pretty valuable when people snap, when people are feeling frustrated. I usually ask, “Hey, what else is going on?” rather than taking the bait of the frustration or the snap. One thing you can encourage folks to do is find ways to take some time to take care of themselves. We’ve talked about the information diet and we’ve talked about all the things that we do for patients, so we can both encourage ourselves and our colleagues to engage in those behaviors. So find a way to incorporate exercise into your life, take up a gratitude practice, and just give yourself and everybody else a little bit of grace.

Katherine Buck, PhD, LMFT, is the Director of Behavioral Medicine at John Peter Smith Hospital Family Medicine Residency, Fort Worth, Texas.

Financial Planning for TEXAS FAMILY PHYSICIANS

HOW IS YOUR

FINANCIAL WELLNESS?

Working With the TAFP for

OVER 25 YEARS

• Do you have enough money to retire? • Have you constructed a Social Security strategy? • Are your investments performing?

www.BenoldFP.com info@benoldfp.com 817-235-6863 Jordan Benold, MBA, CFP®

Dr. Stephen Benold, CFP®

2021 VIRTUAL CONFERENCE

AUGUST 14, 2021 M A XIMUM OF 8 A M A PR A C ATEGORY 1 CREDITS™

F O R M O R E I N F O R M A T I O N A N D T O R E G I S T E R , G O T O W W W.T A F P.O R G

www.tafp.org

Building something bigger in the Big Bend 2020-2021 Texas Family Physician of the Year Adrian Billings, MD, PhD By Kate Alfano Photos by Jonathan Nelson

TEXAS FAMILY PHYSICIAN [No. 2] 2021

www.tafp.org

any outstanding Texas family physicians provide excellent patient care. Others serve the future of the specialty by nobly teaching medical students and family medicine residents. Still others — certainly many reading this article now — find a niche in organized medicine, advocating for systemic changes to medicine at the Texas Capitol and on Capitol Hill. TAFP Family Physician of the Year Adrian Billings, MD, PhD, takes it a step further, embodying each of these critical roles of a family physician but also expanding his influence on an international level.

Personal practice philosophy: The three A’s Billings’ first mentor, before he knew what a mentor was or had the idea to become a physician, was Dr. Ramon Garcia, the family physician who delivered him and cared for him through his childhood and into college. “He was an amazing solo practice community physician who did everything: the hospital, clinic; he was the volunteer football physician for the local high school and I would see him on the sidelines on Friday nights.” Billings worked for a local veterinarian as a teen, thinking at the time that he might pursue that as a career. He regularly assisted the veterinarian with necropsies on animals to find out how sheep, goats, and even cows and horses had died. He also showed lambs at 4-H competitions. One morning Billings went to feed his animals and found a lamb dead. “I figured I’d do my own necropsy,” he says. “I rolled up my sleeves, pulled out my pocketknife and, with no gloves, opened up this animal from its neck to its pelvis. After five minutes, I had blood up to my elbows and no idea what had killed this animal or what the animal had died from.” The county extension agent found out about it and suggested sending the head off to the Texas A&M Veterinary Diagnostic Laboratory to make sure it didn’t die of rabies. “I’ll never forget the following Saturday when the results came in. The county extension agent called me at home and told me that the animal had tested positive for rabies and that I needed to seek medical care now. My mother and father were there … and we all literally thought I was about to die of rabies.” Billings knew he needed to talk to his family doctor, so he found Dr. Ramon Garcia in the White Pages in the Del Rio phonebook. In bold was his office number and, beneath that, not bolded, was his home phone number. Billings didn’t hesitate; he called him at home and Dr. Garcia answered the phone. “He was about the age I am now; he had two young kids at home similar to the ages of my kids right now. I knew what he was doing on a Saturday: He was trying to have quiet time with his family. But here I am, one of his patients, calling. He answered the phone, he knew who I was. I very excitedly told him what happened, and he told me, ‘Adrian, you did not have a significant exposure, you’re going to be fine. You do not need to seek any medical care.’ And he was right. I obviously did not contract rabies and I did not die of rabies. “But the teaching point that I love to tell trainees about is that he exhibited the three A’s to me at that time, as a patient, after-hours on a weekend: He was available to me by printing his home phone number in the Del Rio White Pages. He was accessible to me by answering the phone. And then probably the most important third A is he was affable. He didn’t seem put off. It was just the service that he provided for free to his patients. And I’ll never forget that.” 18

TEXAS FAMILY PHYSICIAN [No. 2] 2021

Adrian Billings, MD, PhD, pets his horses, Shadow and Splash (left to right).

To honor Dr. Garcia, Billings has listed his home telephone number in the Alpine White Pages for the past 14 years and he also has provided that service to his patients at no cost. “It’s something that I just feel as a community physician has been the right thing to do.” And just like Dr. Garcia, he sees patients in clinic and at the hospital. Billings delivers babies and serves as the medical director of Presidio Emergency Medical Services. He serves as the physician for

the high school football team and local university football team, is a trustee on the school board, sponsors junior-league sports teams, and promotes health education in the local schools. When patients approach him around town, he answers their questions about an issue or lab test, even if it’s after-hours and on a weekend. “Dr. Billings is the most dedicated family medicine physician that I have had the opportunity to work with,” wrote Edward Strecker,

MD, in Billings’ nomination for Texas Family Physician of the Year. “With every patient, he goes above and beyond to provide comprehensive, evidence-based care while always making sure to address the patient’s feelings and social situations. For extremely ill patients or those unable to visit the clinic, he is willing to make house call visits.” “He is different from any other family physician in that he truly seems to be inspired to always push forward and improve his www.tafp.org

“Dr. Billings is unique in that his passion and focus are infectious and anyone who has the opportunity to work with him is made better by getting to see a physician who is truly called to be a rural family doctor. I know that this has inspired me and impacted my life greatly.” — Edward Strecker, MD

TEXAS FAMILY PHYSICIAN [No. 2] 2021

community. Everything he does in his life seems to be dedicated to improving himself so that he can better serve his community,” Strecker continued. “Dr. Billings is unique in that his passion and focus are infectious and anyone who has the opportunity to work with him is made better by getting to see a physician who is truly called to be a rural family doctor. I know that this has inspired me and impacted my life greatly.”

Finding his way home Billings fully homed in on a path to medicine after spending a summer in college working as an anesthesia technician at the local hospital in Del Rio. “They treated me like a third-year medical student that three months. I got to deliver babies with Dr. Garcia, I got to scrub on C-sections and general surgery cases. I got to intubate patients with the anesthetist,” he says. He also worked as a paramedic during his undergrad years and, after graduation, applied to medical school. But he wasn’t accepted. Regrouping, Billings decided to go to graduate school at the University of Texas Medical Branch and earned a doctorate in experimental pathology. He went to the Centers for Disease Control and Prevention in Atlanta, Georgia, his dream job as a PhD, working in a biosafety level 4 lab on a hantavirus project infecting rats. But he felt isolated, not useful, and he didn’t feel called to the research. He also really missed the Texas-Mexico border, its people and culture. Billings took another shot at UTMB, was accepted, and graduated with his medical degree. He completed his family medicine residency at John Peter Smith Hospital in Fort Worth, serving as chief resident his final year, and went on to complete a surgical obstetrics fellowship at JPS. Then, as a National Health Service Corps scholar, he looked for a practice location to complete his four-year service obligation in an underserved area. His hometown of Del Rio didn’t qualify as underserved enough, so he chose the town of Alpine, where he had spent time as a medical student in preceptorship, in clerkship as a third-year medical student, and in residency for a rural rotation. Most National Health Service Corps loan repayers work as employed physicians in federally qualified health centers using grants that support caring for the indigent and Federal Tort Claims Act malpractice insurance that is provided by the federal government. But Alpine did not have an FQHC at the time. Billings agreed to function in private practice as an FQHC but without the grants or federally provided malpractice — a path NHSC advises against. For four years he was a solo private practice physician on call 24/7 with the support of one nurse practitioner providing full-spectrum family medicine with obstetrics and hospital coverage. Though rewarding, when he reached the end of his service period, he merged his private practice with a new FQHC in Marfa, 25 miles west of Alpine, to form Preventative Care Health Services. “I think for my community and for myself, professionally and personally, it was the best decision that I made,” Billings says. “I’m a family physician but my most important job is being a father [to Blake, Zane, and Colt] and husband [to Susan]. Someday I’ll be replaced as a physician. I could be replaced as a husband — I don’t want to be — but nobody can replace me as a father. So that’s the reason I left private practice and 24/7 call is that I needed to balance my professional and personal lives. Because again, my priority is my family and that’s the reason I chose family medicine as a specialty.” Currently, PCHS has three locations: Alpine, Marfa and Presidio. They have four family physicians and a nephrologist, behavioral

The clinic staff at Preventative Care Health Services of Alpine, (from left): Christina Aguilar; Iveth Valenzuela; Sarah Ramirez; Jessica Tafoya; Sheby Alexander, MD; Adrian Billings, MD, PhD; and Carol Sternes, RN.

health with several part-time licensed professional counselors, three dentists, and the rural residency program in collaboration with Texas Tech University Health Science Center. “When I think about the impact of my solo private practice in Alpine without the $2.9 million in federal support that we receive now annually, without the free malpractice that we don’t have an expense for now that we can use to direct toward indigent health care, it’s a much larger impact and footprint than when I started.”

Training and inspiring future rural physicians Roughly 13 years ago, Billings started hosting medical students and family medicine residents through preceptorships and rural rotations. He keeps a list of medical students and residents who have come through his practice, and the list has grown to more than 300 medical students and 50 residents. “I benefited as a medical student from a community preceptor, Dr. James Luecke, and he is still a mentor to me; he’s still practicing out here. He opened up his private practice to me twice as a medical student and again as a resident. So to honor him, honor other community preceptors and honor the preceptorship program, I wanted to do the same thing.” Billings is the current director of the Texas Family Medicine Preceptorship Program. “It’s been a blessing to me, to my practice, and to my community and my patients,” Billings said. “I’ve had preclinical medical students make a diagnosis that wasn’t even on my mind. I know that my patients benefit from having these trainees working alongside me. And, really, the teach

ing is bidirectional. I hope that I’m passing along information to these trainees, but they’re also passing along information to me, and making me a better physician and keeping me up to date.” Billings serves a heavily Latinx population and many, particularly in the Presidio location, are Spanish-speaking only or bilingual with Spanish language preferred. He, himself, is bilingual but he recognizes the unique barrier for the patient who is seeing a health care provider who is not fluent or who isn’t independent in speaking Spanish. For this reason, spurred by an idea from one of his medical students, he created a Presidio-based Spanish immersion course so students don’t have to travel to Central or South America or Spain to have an immersion experience. And while the Spanish immersion experience is popular with students and will go on to benefit any Spanish-speaking patient the students see later in their careers, the program has a dual purpose of hopefully recruiting a physician to Presidio, a community of 7,000 with no full-time physician or pharmacy. “Hosting these trainings has been just an incredible boost to our workforce out here. They have provided an incredible recruiting opportunity for our area, which is typically a very difficult-to-recruit-to underserved area.” John Ray, MD, who first met Billings in Alpine as a medical student, kept in touch after his training and eventually chose to go work with him, wrote of Billings’ extraordinary commitment to education. “Having been a student of his, and seen the countless other students come though, it’s obvious that he shines when teaching. www.tafp.org

“I’ve had preclinical medical students make a diagnosis that wasn’t even on my mind. I know that my patients benefit from having these trainees working alongside me. And, really, the teaching is bidirectional. I hope that I’m passing along information to these trainees, but they’re also passing along information to me, and making me a better physician and keeping me up to date.”

— Adrian Billings, MD, PhD

“The capstone of this commitment was bringing a rural residency program to the hospital in Alpine in collaboration with the family medicine residency at Texas Tech in Odessa,” Ray continued. They finished their first year with a resident in May 2020, welcomed another in June, and matched their first-choice resident starting in 2021. “This has been Dr. Billings’ project and brainchild, and is fundamental in recruiting providers for our underserved area.”

Practicing outside the exam room Billings has an incredible ability to see short-term and long-term needs and solutions, which is served well by what he calls his practice outside of the exam room. “It means advocacy outside of the walls of my federally qualified health center and outside the walls of the critical access hospital that I practice in. It’s being able to be involved in professional organizations, having discussions with elected policymakers and state and federal leaders, and telling my patients’ stories. I think that’s where, if I feel like I’ve made a contribution and the reason that I’ve been recognized for certain things, it’s been because of the advocacy.” He credits TAFP as one of the places he has developed his leadership skills, that by serving on committees, sections, and councils, he has learned how to be an advocate, how to run a meeting, how to respectfully disagree with someone and get your point across to try to bring them on your team and on your side. “This involvement and this leadership that I’ve been afforded really helps enable, sustain, and validate that the work I’m doing for my communities, for my patients, for my practice, for my colleagues is really important.” In 2014, he was invited by Kathleen Sebelius, then-secretary of the U.S. Department of Health and Human Services, to be part of the U.S. federal delegation as a private sector health care disparity adviser 22

TEXAS FAMILY PHYSICIAN [No. 2] 2021

to the annual World Health Assembly in Geneva, Switzerland. He testified on behalf of the U.S. government in support of a resolution working its way through the World Health Organization in support of the training of generalist physicians, primarily in developing countries, in 11 life-saving surgeries. And in 2017, he was invited to testify before the U.S. House Energy and Commerce Subcommittee on Health as the expert witness on the National Health Service Corps, for the reauthorization of the $310 million budget. Since 2015 Billings has served as co-president of the PresidioOjinaga Binational Health Council supported by the Texas Department of State Health Services Office of Border Health, which brings together a multidisciplinary group of health care officials from Texas and the U.S. and from the state of Chihuahua and Mexico to have a discussion about the challenges and issues each are facing on their respective sides of the border. “More often than not, we find that we’re facing the same challenges on each side of our borders that the other is, so it really has helped to foster collaboration and kind of understanding,” Billings says. Further expanding his education and knowledge of global health care, in 2019 he participated in a one-year fellowship with Atlantic Fellows for Health Equity at George Washington University in Washington, D.C. Twenty fellows were chosen that year, 10 domestic and 10 international, and they met several times in person, had biweekly remote online learning, and a project to work on throughout the year. In the summer of 2019, Billings and his cohort traveled to Rwanda 25 years after the genocide that decimated the country and its physician health care workforce. “It’s a remarkable health equity story about how Rwanda has recovered 25 years later and developed an equitable multidisciplinary health care workforce in the wake of such a tragedy.” The fellows spent a week on the rural RwandaUgandan border at the University of Global Health Equity, developed primarily by U.S. nongovernmental nonprofits like Partners in Health, the Bill and Melinda Gates Foundation, and others. Billings says he would love to replicate the school in the rural U.S. “The institution’s goal is to train a diverse, culturally competent workforce for rural Africa,” Billings says. “It is on the wall of this school that I found a quote from Dr. Paul Farmer, who helped found Partners in Health when he was a medical student at Harvard. And this quote really speaks to why I’ve been so active with advocacy and collaboration outside our exam room and outside of the Big Bend area. The quote says, ‘Our most significant accomplishments in life will be done in partnership, as a team.’” “I know that under-resourced health care workforce programs like mine, and like many inner-city, urban health care workforce programs, we don’t have all the knowledge nor all the resources nor all the workforce that our patients deserve and need. So that’s been the reason I’ve been so active with academic training institutions to host medical students, residents, and now a rural family medicine residency program here is to try and improve our services to try and tell our patients’ stories, so that these more developed urban health care academic training institutions can hopefully share some of their resources to improve our population and public health out in these rural areas.” Billings will tell you he is not the best doctor out there and that it is his patients and family who inspire him to be a better person by looking out for the needs of others. But he is certainly an exemplary family physician, teacher, and community leader with the ability to build something bigger than himself, identifying needs from the micro to the macro, and working to form teams to improve health care for all now and far into the future.

Beat the heat (and the anxiety it may bring) By Anticipate Joy

he sun is out, the school year has ended, and Texas is embarking upon absolutely balmy 100+ degree weather. Summer is officially here. While the summer season is always depicted as a chance to relax and unwind, it can be a very stressful time. Trying to plan vacations, enduring an influx of clients rushing to get appointments before school starts back up in August, and missing out on time with loved ones who might be home while you’re at work can all be stressors impacting your mental health. Combine that with all the challenges this year has brought with the pandemic — specifically impacting your industry — and you get a great deal of built-up anxiety going into the summer months.

However, another potential anxiety inducer not as frequently discussed is the heat that summer brings. The same physiological effects caused by heat — sweating, shortness of breath, lightheadedness, etc. — can resemble the symptoms of a panic attack, triggering higher sensations of anxiety. In addition, the long-lasting summer sun can throw off your circadian rhythms and impact sleep time, which in turn can affect mental health by bringing about more anxious experiences. Humidity too has been shown to negatively impact concentration levels, leading to apprehension and anxiety over working ability. To prevent the stress the sweltering summer sun can bring, here are some tips to make sure you are taken care of. [cont. on 24] www.tafp.org

[cont. from 23]

5 EASY STEPS TO GET STARTED

1. 2. 3. 4. 5.

Get access. Use the customized scan code or bit.ly/3d3853e to access your organization’s mental health benefits. Complete a brief intake. Answer a few questions about yourself. Purchase session(s). Take advantage of the low TAFP member rate. Purchase up to four sessions. Select a therapist. Review available therapists using filters and request a therapist that best fits your needs.

• Spend some time indoors. While summer might seem like a time to be outside as much as possible, in Texas the temperatures can make being outdoors unbearable and anxiety-inducing. Seek out cooler, indoor activities to engage in with loved ones to keep out of the sun. • Eat a healthy diet. As physicians, you’re fully aware of how important eating habits can be. However, a healthy diet can help you withstand the hotter temperatures, lessening the anxiety-mirroring symptoms heat may bring. Additionally, making sure you aren’t missing meals helps mental health as well, as it minimizes jittery sensations from low blood sugar and ensures the 95% of serotonin receptors located in the gut lining are being fueled. • Stay properly hydrated. Each of you knows how important hydration is, particularly so during the hot, humid summer months in Texas. It is essential to make sure you are following your own advice given to clients and drinking water at home and at work, not only for your physical health but your mental state. • Build-in extra time for sleep. With the heat, falling asleep can be far more difficult than usual. It’s important that you try and allocate extra time to give yourself a chance to fall asleep and get your full rest. Additionally, anxiety can bring racing thoughts that increase difficulty in getting to bed. Giving yourself enough time to gently and slowly fall asleep will help keep those anxious thoughts from stealing hours of rest. We at Anticipate Joy hope these tips help you to stay cool and calm over the next few hot months. However, we also want you to know that you are not alone if you are experiencing anxiety, and that you are worthy of further assistance if you need it. TAFP cares about you and your mental health and therefore offers a discounted rate with our licensed mental health providers here at Anticipate Joy.

Pick a time.

WHAT IS ANTICIPATE JOY?

After the therapist approves your request, select an appointment time that works for you and your therapist.

Anticipate Joy is an innovative mental health treatment and wellness company that supports healing and personal growth through a HIPAA-compliant online professional counseling platform. Anticipate Joy creates an introduction between the client and the therapist, along with the technology that enables the client to have therapy sessions with a licensed mental health provider within the convenience of their own home.

YOUR BENEFITS TAFP has purchased a number of sessions making online therapy available to you at a significantly reduced rate of $35 per session when you use the TAFP access. These sessions are available for all members.

SCAN HERE TO BEGIN

TEXAS FAMILY PHYSICIAN [No. 2] 2021

THE REALITY OF PHYSICIAN BURNOUT Not all heroes wear capes, especially during a pandemic. Medical providers all over the state of Texas have stepped into the role of unsung hero as they have worked in the trenches. There is no doubt that you have worked long hours and have taken the brunt of the mental and physical burnout associated with COVID-19. Anticipate Joy is so excited to partner with TAFP to assist you in overcoming some of the emotional and psychological stress that you have had to endure.

TEXAS ACADEMY of FAMILY PHYSICIANS FOUNDATION ANNUAL REPORT 2020

Mission: The Texas Academy of Family Physicians Foundation is the philanthropic arm of the Texas Academy of Family Physicians and is organized for scientific and educational purposes in support of the medical specialty of family medicine and for the advancement of the health and well-being of patients.

www.tafp.org

The TAFP Foundation focuses its work on two strategic areas — practice-based primary care research and supporting the next generation of family physicians. Through the generous support of individual donors and TAFP, we are able to provide scholarships, travel funding, research grants, funding for family medicine interest groups, and research poster competition prizes. If you are a donor, thank you for being part of our success. As with other organizations, 2020 was a very different year for the TAFP Foundation. Travel stopped, live meetings with fundraising opportunities transitioned to virtual, and our donors experienced an incredibly stressful year in their lives and practices. We still managed to find ways to support medical students and residents, our volunteers did their work virtually, and our monthly donors continued to provide the support we need. As we transition back to live meetings and opportunities to be together, we thank our donors and look forward to starting the next chapter with you.

Practice-based primary care research The research grant program through the TAFP Foundation began in 1988 and continues to grow. Twice a year, proposals for research grants are accepted and many are funded. More than $600,000 has been awarded in small grants and many of the projects go on to be published or expanded into larger studies. In 2020, research on home blood pressure monitoring, the impact of interpreted language of the physician-patient relationship, and determining the capacity necessary to designate a surrogate for dementia patients were approved for funding. Grant recipients are encouraged to share their research at TAFP CME events in didactic lectures and poster presentations. The TAFP Foundation also supports the prizes for the annual research poster competition held at TAFP’s Annual Session and Primary Care Summit. In 2020, the poster competition was virtual, allowing attendees and others to view posters online.

Family medicine residents The Foundation recognizes residents as the future leaders in family medicine and provides funding to help them attend family medicine meetings. There are also scholarships for residents to present research at national meetings, an advocacy scholarship, and a few that recognize excellence at individual residency programs. In 2020, the TAFP Foundation launched a new program for residents — Texas Family Medicine Scholars. Dr. Kendra Williams from the Texas Tech Health Sciences Center of the Permian Basin Family Medicine Residency Program was selected as the first recipient. The multi-year scholarship

program provides generous financial support and leadership development to one resident each year to build the next generation of leaders for family medicine. Dr. Williams is off to a great start navigating the pandemic and developing a project to bring cancer screening to her rural community.

Medical students: The core of our work Most of the funds expended each year are devoted to medical students. Supporting and encouraging their interest in family medicine has always been a fundamental part of the TAFP Foundation’s work. As the state’s population swells at both ends of the age spectrum, the need for primary care physicians has never been greater. Much of our funding involves in-person activities, including travel funding to attend conferences and funding for family medicine interest groups at each of the medical schools. After the pandemic began, FMIGs were no longer able to plan lunch meetings, and TAFP and AAFP meetings were either canceled or became virtual. We had to adjust. With no actual travel to fund, the TAFP Foundation provided support for the registration fee for AAFP’s Virtual National Conference. With 124 medical students and residents funded, we tripled our normal reach. In the early 1990s, the TAFP Foundation embarked on a quest to build scholarships for medical students interested in family medicine. Since then, student debt levels have dramatically increased, and our total scholarship dollars awarded is now more than $400,000. The scholarships are all fully endowed so that they will continue in perpetuity to be a method of supporting future family physicians.

These fantastic programs are only possible through the support of members like you. As the TAFP Foundation continues to support and encourage the next generation of family physicians, we remain clear and focused on why we do what we do.

TEXAS FAMILY PHYSICIAN [No. 2] 2021

Highlights from 2020 • More than $35,000 in scholarships were awarded to students and residents across the state. • Research grant funding was awarded to a variety of projects on timely topics such as home blood pressure monitoring, use of interpreters for patient visits, and care for patients with dementia. • The TAFP Foundation collected over $30,000 in monthly donations from TAFP members, staff, and friends in 2020. • The TAFP Foundation funded 124 medical students and residents to attend AAFP’s Virtual National Conference.

FINANCES

The TAFP Foundation’s monetary support was crucial to my participation while I was a student and resident leader. After seeing firsthand the fantastic work of the Foundation, there was never a doubt in my mind that I needed to do my part to support and empower the next generation’s leaders. — Jake Margo, Jr., MD, TAFP Board Chair and monthly donor since 2005

Statement of financial Position (as of 8/31/2020)

CURRENT ASSETS Cash $195,543 Investments $3,025,407 Other receivables

$3,335

Total assets

revenues

$3,224,085 $60,000

LIABILITIES AND NET ASSETS Accounts payable

$15,127

$40,000

Net assets

Without donor restrictions

With donor restrictions

$903,971 $2,304,987

Total liabilities and net assets STATEMENT OF ACTIVITIES

$50,000

$3,224,085

$30,000

Donations TAFP Grant Investment Return Fundraising Event Miscellaneous Income

$20,000 $10,000 $0

Revenues Donations

$48,364

TAFP grant

Investment return

$46,144

Fundraising event

$16,950

Miscellaneous income

Total revenues

$60,000

Scholarships

$173,057

$50,000

Management, General Expenses

$40,000

$32,704

$30,000

$29,550

$20,000

Scholarships

$35,346

$38,552

Fundraising, management and general

Total expenses

Travel, Student Interest Groups

$60,000

Research Travel and student interest groups

Research

$1,599

Expenses

expenses

$136,152

$10,000 $0

www.tafp.org

Experienced & Confidential L E G A L R E P R E S E N TAT I O N F O R T E X A S P H YS I C I A N S Statewide representation with more than 2000 cases and over 110 years collective experience.

Tony Cobos*

Michael Sharp*

Courtney Newton

Chris Sharp

Medical and Physician Assistant Board Actions Probation Modification/Termination Peer Review • Licensure • Reinstatement Medicare-Medicaid Appeals/TMF DEA/DPS Registration/Investigation Actions Medico-legal issues • Managed Care Exclusions Personal Counsel in Medical Liability Cases

4705 Spicewood Springs Rd, Suite 100 | Austin, Tx 78759

p 512 473 2265 f 512 473 8525

www.sharpcobos.com

*Board certified in Administrative Law by the Texas Board of Legal Specialization.

12-SC-0101-1.indd 1

5/10/12 10:40 AM

Achieve healthier outcomes—for everyone. In its first major development for The EveryONE Project, the AAFP compiled a validated, intuitive, action-oriented, and free toolkit to help physicians recognize and respond to social factors that impact the health of their patients. Utilize The EveryONE Project toolkit to: • Raise awareness about the effects of social determinants of health. • Discover specific health risks in patients of all backgrounds. • Understand and manage potential biases that may exist. • Connect patients with essential resources in their area. Reveal and address the unseen health hurdles your patients face every day. Start using The EveryONE Project toolkit now. aafp.org/EveryONE/tools

The EveryONE Project Advancing health equity in every community

PERSPECTIVE

A SCRIBE’S STORY By Ben Saul, Harish Thoppe, and Larry Kravitz, MD

It is hard to lay bare your personal medical practice to the eyes of another professional. As I have told every medical student on rotation with me, “You will learn from me how to practice medicine right, but you will also quietly learn how to practice medicine wrong, seeing things you will know you never want to repeat.” We are imperfect. When we are teaching medical students, we showcase our successes, but we relinquish any hope of hiding our professional flaws. You must make your own peace with that in order to teach. You must trust in the benevolence of students to see that you stepped up to the plate and volunteered to try to raise their medical skills. Medical students shadow and practice, practice and shadow. They come and go, usually for four short weeks within a family medicine rotation. But scribes come and stay; they are the ultimate shadows. Muted by the nature of their mission. Silent witness to the inner clinical sanctum. We take them on to share the exhausting intensity of our trusting patients with their challenging mortal illnesses and aging. A

IN THEIR WORDS: It is true that the bond between scribe and physician is undeniably strong. As a scribe, I gained a physician mentor and a good friend. I often felt that when we entered an exam room our brains merged so I could think and understand as he did. Family medicine can be arduous, but it makes up for this by its deeply personal qualities. I was perpetually amazed by the scope and breadth of knowledge family physicians were able to provide to their patients, possessing the ability to change the hat they wore to meet the needs of the patient at hand. While now I am only in my first year of medical school, I understand the importance of developing the skill and understanding to diagnose and manage a patient. However, after working with a physician for more than a year as a medical scribe, I now under-

bond develops with your scribe, often unspoken, yet undeniably strong. I have had scribes in my family practice for six years now, each one for about a year. Four are currently in medical school, and for one deserving scribe, we are hopefully waiting on his acceptance. Most scribes are in a gap year awaiting medical school, and hiring one is more than hiring an employee; you are entrusted with hiring an apprentice. In the year you have these future doctors, in a sense, you are grooming them for medical school; and you are imprinting on them a path, a template, for their entire physician career. They are the unassigned medical students, but the ones whose future careers you may influence more than any of the students you ever see on family medicine rotations. I want to tell their story, because scribes in family medicine are different than ER scribes, surgical scribes, or orthopedic scribes. Because family medicine is not just clinical, it’s personal. But I cannot tell their story. They have to tell it themselves.

stand medical education is much more about intangible skills. These are the things that cannot be taught from “UpToDate” or “Gray’s Anatomy.” How we understand and connect with patients is what makes a great physician, and I am grateful for beginning that education with a family physician. Young and budding physicians are undifferentiated, and I believe any physician who takes a scribe will contribute much more to medicine than they anticipated. As pre-med and medical students, we often focus too much on one thing; what do I want to be? Perhaps it’s a cardiologist, a general internist, a family medicine physician, or an orthopedic surgeon. While these thoughts are certainly important to ponder, they could never paint the whole picture. I believe the more important and meaningful question to ask oneself when considering a career as a physician is

www.tafp.org

I always wondered what it took to be a good physician. While I learned about lab and imaging interpretations, medical terminology, and what to look for when treating various medical conditions, this is not what will help me the most as a doctor in the future. It was learning about myself, my strengths and weaknesses, by comparing myself to a role model and understanding that I didn’t need to be perfect to be a good doctor.

who do you want to be rather than what. As we witness physicians’ entire practice with all the victories and failures unsheltered from our eyes, scribing with a family physician sets the scaffold to make these discoveries on one’s own. I often believed my heart was too big to bear the weight of medicine, but I now understand I can master this trait and use it to connect on a deep level with patients, and foster better quality, patient-centered health care. I always wondered what it took to be a good physician. While I learned about lab and imaging interpretations, medical terminology, and what to look for when treating various medical conditions, this is not what will help me the most as a doctor in the future. It was learning about myself, my strengths and weaknesses, by comparing myself to a role model and understanding that I didn’t need to be perfect to be a good doctor. Pursuing a career as a physician is a life-long journey of learning and commitment to those for whom you care. My time as a scribe in family medicine both helped me understand just how fulfilling being a doctor can be and strengthened my passion for it. After reflecting on my experience as a scribe in family medicine, I know my family physician mentor will continue to be one of the most influential figures in my medical career. In fact, even now I think about

POSTSCRIPT: Having a scribe shortens a physician’s workday by an estimated 2.5 hours, an average physician work product equal to $450, exceeding the average scribe cost of $200 per day. That’s 2.5 hours a physician could spend with their spouse, their family, their exercise, and restoring their spirit. It can lengthen

TEXAS FAMILY PHYSICIAN [No. 2] 2021

our patients often as I undergo my didactic medical school education. I remember how he spoke to patients in dire need. I remember how he spoke to patients who received terminal diagnoses. I remember how he spoke to patients who felt like they couldn’t live another day. And I know he isn’t perfect, but I do know he was devoted to his patients and that is what matters most of all. Whether they know it or not, when a physician begins taking scribes, they make a lasting impact on the medical profession with all those who work alongside them. In a sense, pre-med and medical students are a chimera of all their mentors along the way to completing their medical education. A physician with a scribe has the opportunity to play an enormous role in the way students envision themselves as future physicians. I believe leaving a legacy for the future of medicine should always be part of any good physician’s career aspirations. While I think the training of medical students may be more tangible in the world of medical education, investing time into a scribe may have more impact than anyone could imagine. It did for me. When I become a licensed physician, I know I will always carry a piece of what I learned while working in family medicine. My advice: consider taking a scribe because you might just change the course of someone’s medical career without even realizing it.

careers by unburdening the physician at the twilight of their practice when they have the most wisdom to role model for eager students. In some medical schools, former scribes make up as much as 35% of the class. Behind the eyes of a scribe is a future physician soaking up the inner essence of medicine. Unleash their future.

THE AAFP POWERS ME, SO I CAN POWER MY PATIENTS. LaTasha Seliby Perkins, MD AAFP New Physician Board Member Washington, DC

Discover how membership can power you.

aafp.org/powering-you

Presorted Standard U.S. Postage

PAID

Austin, TX Permit No. 1450

ture u f e h t e p help sha edicine m y il m a f of

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. This work was supported in whole or in part by a grant from the Texas Higher Education Coordinating Board (THECB). The opinions and conclusions expressed in this document are those of the author(s) and do not necessarily represent the opinions or policy of the THECB.

! r o t p e c e r be a p

Texas Family Physician, Q2 2021

Articles inside

MEMBER NEWS

PERSPECTIVE

AAFP NEWS