Fall 2010



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The Texas Internist is a publication of the Texas Chapter of the ACP. Articles from the chapter membership are welcome. Send to the Newsletter Editor, Texas Chapter of the ACP Business Office, 401 W. 15th St., Austin, TX 78701, or fax to (512) 370-1635.



Mission Statement

The mission of the Texas Chapter of the ACP is to promote quality health care for all Texans by strengthening the practice of internal medicine.



Governor's Message

Clark R. Gregg, MD, FACP
Governor, Texas Northern District
American College of Physicians

As we enter another autumn season, I want to remind our Texas Chapter of American College of Physicians (TXACP) membership of the wide-ranging activities of your chapter, its volunteer leaders, and its professional staff at the Austin office. I hope this review will reinforce to our members the value of TXACP and inspire recruitment of new members as well. The Chapter dues you pay are a relatively small part of your total ACP dues, but these Chapter dues are well spent for the benefit of our present and future membership.

Clark R. Gregg

TXACP financially supports Internal Medicine Interest Groups (IMIGs) at each of the Texas medical schools. These IMIGs, led by the schools’ faculty, introduce students to Internal Medicine during the years they are forming career decisions. Medical students are also invited to submit abstracts for posters or clinical vignette oral presentation at the annual Chapter Meeting, an experience which will hone their skills and enhance their record in scholarly activity. They may also enter the On Being a Doctor creative writing competition, the winner of which presents at the annual Chapter Meeting.

The major TXACP program which reaches out to medical students and is the most significant Texas state legislative priority for the Chapter is the General Internal Medicine Statewide Preceptor Program (GIMSPP). Students may apply to spend a month during the summer following their freshman year working alongside a practicing internist volunteer preceptor. In this way we nurture the seed corn of the next generation of internists. This program has had deep and lasting value to students and preceptors alike, and many TXACP members have regularly been preceptors over the years. If you are interested in becoming a preceptor, please go to the Preceptorship section on the Texas chapter website or contact Claire-dot-Hogan-at-texmed.org.

Internal Medicine residents may become Associate Members of ACP for nominal dues. Associates in each of the five TXACP districts present oral or poster clinical vignette or research abstracts at annual Associates Day competitions. District winners present their project at the fall TXACP Chapter Meeting, and the winner of this competition receives an expense-paid trip to compete at the National ACP Meeting the following spring. Associate Members also represent each of the statewide districts on the Chapter Board of Directors. Through these avenues, TXACP solidifies Internal Medicine interest and representation at the resident level of training.

Medical students and Associate Members also frequently join other TXACP members in advocacy visits to Austin and to Washington, DC (ACP Leadership Day), where they begin to appreciate the legislative processes which so strongly influence the practice and future of Internal Medicine.

For TXACP Members, in addition to opportunities to encourage and guide the next generation of internists as above, TXACP is very active in continuing education. The Annual Chapter Meeting rotates around Texas and always delivers a diverse and relevant educational content. For several years we have offered SEP modules for preparation for recertification, and recently our Council of Young Physicians has amplified its offerings to the agenda. This year’s Chapter Meeting will be November 13-14, 2010, at the J W Marriott-Galleria in Houston. We have planned a fine scientific program including faculty from both Baylor College of Medicine and UT Medical School at Houston. You have received a meeting brochure, and you can also go to Annual Meeting section on the Texas chapter website.

There are several opportunities for legislative advocacy for Members. In addition to White Coat days in Austin during the legislative session and Leadership Day in Washington, DC, you can become a member of Voter Voice (a web-based legislative issues network). You can also become a Key Contact for legislators whose staff can call when they want your perspective on health policy questions, as well as provide you with a convenient way to contact them on important issues. A TXACP Board member is a representative to the Primary Care Coalition in Texas, and many members sit on TMA boards or committees.

We are ever grateful for our professional Chapter administrative staff members, who work tirelessly and cheerfully with your Board and other Chapter Leadership to coordinate all these activities and enhance value to you, our Members. Please take the opportunity to become more involved in TXACP and its efforts on your behalf.



President's Message

Modern Medicine and the 900 Pound Hillbilly

Steve Urban, MD, FACP
Amarillo, Texas

The cost of modern medicine, like the universe, expands at an ever increasing pace. It’s like Billy Bob, the 900 pound man of the tabloids. No matter how much he consumes, there’s always room for more. This won’t end well, but we practitioners can’t help ourselves either. We stand in line, bucket of Extra Crispy in hand, feeding the beast and just hoping to get out of the way when the inevitable crash comes.

Steve Urban

A few of the reasons for medicine’s voracious appetite are so obvious that even cousin Ned, who struggled in the sixth grade, can figure them out: (1) If patients don’t really pay, they don’t care how much something costs.(2) On the other hand, if insurers pay doctors by the procedure, they’re liable to get more procedures than the patients really need. (3) If patients sue doctors for doing too little, doctors will do too much.

But partly this is Billy Bob’s own damn fault.

The medical model has expanded to include conditions that William Osler would never have recognized as diseases. We can probably all agree that tuberculosis and squamous cell carcinoma of the lung are diseases. Diabetes is a real disease, albeit an arbitrarily defined one. How about alcoholism and drug addiction? Clearly, there are biochemical aspects to these conditions, but dissatisfaction of the spirit is in there somewhere. Diseases defined purely by their symptoms (fibromyalgia, chronic fatigue syndrome) are more problematic still. Don’t even get me started on the grab-bag of unpleasant character traits that make up personality disorders and other “diseases” in the house of psychiatry. Have we helped these people get well by defining their malaise or awkwardness as a disease? Is there any human ache or dissatisfaction too nebulous to be squeezed into a diagnostic group?

When it comes to testing, too, modern medicine threatens to pop out of its trousers. When the LE prep and subsequently the ANA were developed, they helped to define a disease (systemic lupus) that could be maddeningly difficult to diagnose. Now, everybody with rosacea and a sore knee gets an ANA, and we have a proliferation of new “diseases” like the ANA positive arthralgia syndrome. Sad to say, I am old enough to remember when they got the first CT scanner at the Methodist Hospital in Houston. It was as big as Nacodoches, and each scan took an hour to complete. It was better than an exploratory craniotomy, but just barely. You only got one if you REALLY needed it. Now, you get a CT scan if you cough twice or feel a twinge in your side. Before us spread whole new diagnostic vistas (e.g. adrenal incidentalomas) to help pay for radiologists’ second homes. Just wait till everybody gets his medicare-qualified PET scan!

Medical treatments too continue to expand. Even really useful treatments like L-dopa, antibiotics, and statins are now sprinkled around like Lowry’s seasoning salt at a fish fry. Got a fever? Take this antibiotic. LDL above 70? Take this statin, just to make sure that you’ll die of Alzheimer disease rather than something quick.

And then, we have the growth industry of marginally useful therapeutics. Alzheimer patients are consigned to eternal treatment with cholinergic enhancers on the basis of the flimsiest evidence. Again, we just can’t help ourselves. Woe betide anyone who denies a woman her right to treatment for the imaginary “disease” of osteopenia.

So, here we watch, helpless, as car number 2010, driven by B. Obama, scrapes the wall. We showed up just in time; this is going to be some crash. If it wasn’t for Billy Bob in the passenger seat for ballast, he might have made that turn.



On Being a Doctor

Medicine as a Calling

Ilana Bragin, MD

Code 411, Airway team, airway team! I was in the middle of making the crucial decision of whether to lie down and attempt sleep, or give up on the idea of rest entirely and refuel with coffee, when I heard the announcement.

Ilana Bragin, MD

As usual, I bolted upright, feeling a little like Batman just saw the batman signal, and started to sprint in the direction of the code.

For those not in the medical field, or who haven’t trained at Bellevue Hospital in NYC, a “Code 411” is a call for the Airway Team, basically meaning someone is in cardiac arrest. I think it used to be called a Code Blue, but between Code Red (fire) Code Purple (nuclear), and Code Brown (you guessed it), people were getting confused, so this most crucial of codes got its own area code.

I was the Medical Consult. This is at once a rewarding and somewhat abusive position: it means holding responsibilities that range from doing 24 hour internal medicine consults for other specialties, accepting patient admissions from the Emergency Room and delegating levels of care, supervising interns and other residents, and feeling generally responsible for the large and overwhelmed Internal Medicine service. The responsibilities also include running the codes.

Running a code is supposed to be easy. It’s as formulaic as medicine gets, an algorithm that boils down to only a few medicines, and often 360 joules.

Sounds easy? It’s not.

At this most critical moment in a patient’s life, literally on the cusp between death and life, the responsibility on the doctor, especially a doctor in training, often feels overwhelming. Recognizing a correctable problem, like a tension pneumothorax, could be the difference between recovery and triumph, or rapid decline and death.

I arrived at the scene and orders started flying out of my mouth.

Get a backboard! Start compressions! Call anesthesia! Start bagging!

And then, because it was the middle of the night, I realized grimly that there was almost no one in the room to heed my orders, and suddenly I was everywhere at once. I was rolling the patient on his side to slide a backboard underneath; I was sticking pads on his chest and connecting the defibrillator. I was on top of him, using all the strength I had to give him chest compressions, cringing when I heard his ribs crunch underneath.

And then, seemingly hours later, the room filled to the brim, pulsing with the energy of people working together to try and save a life. There was a floor nurse, an ICU nurse and an anesthesiology resident. There were interns, respiratory therapists, and a patient from the next room over who came in to watch the commotion and had to be shooed away.

More minutes passed, but it felt like hours. The patient’s chart was pulled and suddenly he became a person with a name, a family, a life story.

We’d been attempting resuscitation for longer than probably necessary, but I found it hard to give up, hard to accept the fact that the patient was dead. Dead dead, as opposed to the slightly-dead which he was when I first entered the room thirty minutes ago. Death, which in most people’s mind is an instantaneous occurrence, in the hospital can be dragged out for minutes, hours, days.

The code ended anticlimactically, with a slow pouring out of the room of defeated doctors, nurses, techs, humbled by their inability to cheat death and give this patient another attempt at life, resorting to the comforting thought used so often in life, as in medicine, “it wasn’t meant to be.”

It’s at moments like this that medicine feels like more than a typical career choice with tough hours and a history of “hazing” its entry level workers. This is not just a job, although sometimes it can be just that. Medicine at its best is much more—it is a calling. Making critical decisions, whether it be on the 28th hour of a thirty hour shift or the seemingly more mundane decisions encountered in an outpatient office, is not just following algorithms and filling out paperwork. Medicine, the art and the science, is a passion for life, for health, and for the human body and the miracles within. It is a calling that infuses us with the energy to stay up for those long shifts during residency, and it is a calling that haunts us with those nagging thoughts long after the doors to your office close, interrupting dinner with your family, or keeping you up at night, “Did I do the right thing, did I make the right decision?” With people placing their trust, their health in your hands, medicine is a responsibility as well as a means to make ends meet.

Now, one year later from the intense, all consuming experience that was residency, I am practicing primary care in a small group setting. I may not be experiencing the high drama of overnight codes in the hospital, but every day I put on a white coat and hang a stethoscope around my neck, and walk into a patient’s room and try to earn the trust that my career commands and requires. It is this feeling that medicine is a calling that drives me to read medical journals with my morning coffee when I might rather enjoy more light entertainment, so that I can be my best to help patients and heal people, making good on that Hippocratic Oath, and make decisions that hopefully prevent those hospitalizations and possible codes from happening.



Nominations Slate Announced

W. Mark Armstrong, MD, FACP, Nominations Committee Chair
Sue S. Bornstein, MD, FACP, TXACP President-elect

The TXACP Nominations Committee is pleased to announce an outstanding slate of candidates for election to the TXACP Board of Directors. On behalf of the committee, I would like to express our appreciation to those who submitted nominations. Our Chapter is fortunate to have members who are willing to devote time and energy in a volunteer leadership role on behalf of our profession and our patients.

The committee worked diligently to select members and Fellows of the ACP who represent the diversity of our Chapter membership. See links below for candidate bios. Directors serve a three-year term. The president-elect advances to president in November 2011.

The slate will be presented to the Chapter membership for a vote during the annual business meeting and awards luncheon on Saturday, Nov. 13, in Houston. In accordance with the bylaws, members may make additional nominations from the floor.

Please congratulate and thank these physicians for their willingness to serve in a leadership capacity for our chapter:



Felicia L. Austin-Tolliver, MD, FACP, Sugar Land

view bio


Northeast Director

Laura DeMoya, MD, Dallas

view bio


Northwest Director

Maureen Francis, MD, FACP, El Paso

view bio


Southeast Director

LeChauncy Woodard, MD, MPH, Pearland

view bio


Southwest Director

Edward Sargent, MD, FACP, San Antonio

view bio

  At-Large Director Robert Goldsteen, DO, FACP, Dallas view bio



Associates, Students Energize Chapter Annual Meeting

Each year the Texas Chapter is fortunate to have large contingents of Associates and medical students attend the annual meeting. These younger members bring energy and excitement to the gathering, and their vignette and poster competitions generate great interest among all attendees. Doctor’s Dilemma™ attracts a large, enthusiastic crowd.

The 2010 annual meeting will be held Saturday and Sunday, Nov. 13-14 at the JW Marriott at the Galleria in Houston. Registration for Associates and students is free, but advance registration is required.

Students and Associates may attend any of the educational offerings at the meeting plus the Texas Chapter Annual Business Meeting and Awards Luncheon. The Cocktail Reception and Awards Presentations will take place on Saturday and we encourage you to attend these events to greet old friends and make new ones.

There are four competitions for these members. During the Saturday morning Plenary Session, five regional Associate clinical vignette winners will vie for first place to advance to ACP’s Internal Medicine 2011 poster competition in San Diego, CA in April.

Also on Saturday morning, medical students chosen at each school will compete with clinical vignettes for cash prizes and an expense-paid trip to ACP’s poster competition. On Saturday afternoon, Associates will present their research and case-study posters to judges, and medical students will compete in a separate case-study poster event. First- and second-place winners will be selected in each category.

An always-lively, highly competitive Doctor’s Dilemma™ contest wraps up the meeting on Sunday. Want to test your knowledge before the big competition? Click here for information on the new online version and iPhone App!

For more information, please visit the TXACP Annual Meeting page to learn more about events planned especially for medical students and residents. Are you ready to register? Click here!

We look forward to seeing you in November!




Presentation of GIMSPP Decade of Service Award to Preceptors

The distinctive General Internal Medicine Statewide Preceptorship Program (GIMSPP) Decade of Service award will be presented to eight highly dedicated and devoted volunteer preceptors at the Texas Chapter of the ACP annual meeting during the Awards Luncheon on Saturday, Nov. 13. These physicians joined the program in 2001 and since that time have taught and mentored young medical students for at least seven of those years. Without the selfless fidelity of our committed preceptors, the preceptorship program could not exist. We owe them enormous gratitude for teaching the future physicians of Texas.

W. Mark Armstrong, MD, FACP
W. Mark Armstrong, MD, FACP
Dr. Armstrong works in Dallas and has taught eight GIMSPP students since joining the program in 2001. One of his students wrote that, “Dr. Armstrong was readily available to answer my questions and provided extra resources through which I could learn.”
N. Perryman Collins, Jr., MD
N. Perryman Collins, Jr., MD
Dr. Collins works in Sugar Land and has taught sixteen students since joining the program in 2001. A student wrote this about Dr. Collins, “The best attributes of my preceptor were his knowledge and insight into social issues in medicine. I was able to get a taste of the real issue that physicians have to face once they finish medical school.”
Frood Eelani, DO
Frood Eelani, DO
Dr. Eelani works in Ft. Worth and served as dedicated mentor to nine students since 2000. Dr. Eelani’s students wrote of him: “Dr. Eelani was patient and understanding throughout my preceptorship. I am very serious when I say the student that gets Dr. Eelani as a preceptor in future years will be lucky. They will be the ones to return to school with the good stories.”


Franciso Fuentes, MD
Franciso Fuentes, MD
Dr. Fuentes works in Houston and has served as a preceptor to ten students since joining the program in 2001. Quotes from his student’s state: “Dr. Fuentes is a great preceptor. He took the time to show and teach me about various aspects of cardiology and of general medicine. He was very willing to explain and answer any questions I had. I learned so much from him and it was a valuable experience.”
Brooke Jimma, MD
Brooke Jimma, MD
Dr. Jimma is in private practice in San Antonio and has taught eight students since joining the GIMSPP in 2001. Dr. Jimma’s students said the following about her as a preceptor: “Dr. Jimma made this a wonderful experience. She gave me plenty of independence to see patients on my own, but at the same time, would point out interesting cases for me to research more about throughout the day. I would highly recommend her to anyone who is interested in this program.”
Gus W. Krucke, MD
Gus W. Krucke, MD
Dr. Krucke works in Houston and has served as preceptor to twelve students since 2001. One of his students wrote the following comment about him as a preceptor: “Dr. Krucke is a tremendous asset to the GIMSPP program. He does everything in his power to make certain that the student learns and has a good time doing it. I’ll have memories of Dr. Krucke taking the time everyday to go to lunch with me and discuss the triumphs and tribulations of his profession as well as life in general.”


Lynn Lester, MD
Lynn Lester, MD
Dr. Lester works in Ft. Worth and has been a mentor to eight students since joining the GIMSPP in 2001. One quote from her student reads: “Dr. Lester was an amazing preceptor. Her humor, sincerity and passion were inspiring and I learned a lot. You can really tell that she loves her job and that her patients love her!”
Ana Y. Perez, MD
Ana Y. Perez, MD
Dr. Perez is in private practice in San Antonio and has taught thirteen students in the past nine years. Some of her students wrote in their evaluations of her: “Dr. Perez was a fantastic preceptor! I have gained so much confidence in talking to patients and examining them. I highly recommend Dr. Perez to all future applicants.”




If a Frog had a Back Pocket ... It’s Time for a Political Reality Check

Tom Banning
TXACP Legislative Consultant

The unwritten laws of politics are as immutable as the laws of nature. As Voltaire put it perhaps more eloquently, “hawks have always eaten pigeons when they have found them.” Understanding these three, albeit cynical, rules will help you break the code to why some bills survive the legislative process and some die before ever being filed.

Tom Banning

Politics drives process that sets policy
You’ve heard us preach this before, but this is the holy trinity of how things really work. Who we help elect and how strong our relationship is with them determines the rules of the legislative process—whether or not a bill will get filed, set for hearing, debated on the floor, signed by the Governor, etc. In turn, this means our policy options are limited by political and legislative opportunity. In other words, policy objectives—no matter how well-meaning—may only see the light of day if our politics are in proper order.

Legislative reforms are reactive, not proactive
Legislative policy changes occur after the proverbial train wreck, plane crash, biblical plague, financial meltdown, oil rig explosion—you get the picture.

A politician’s first duty is to get re-elected
Every legislative idea and every vote that is cast passes through a political filter that measures the potential electoral consequences of supporting or opposing one set of constituents while antagonizing another. A legislator may not always be influenced by the politics, but they will invariably weigh the political consequences (a potential career-ending vote) against the policy implications (passing a tax bill to fund indigent health care).

Most physicians are understandably frustrated by the legislative process and think it is a fixed, insider game. I’ve heard it expressed many times from many different physicians: “If only they listened to me and supported my idea on how to fix health care, all would be right with the world.”

In a perfect world, our elected officials would make decisions based solely in the best interests of patients, but we don’t live in a perfect world and you can’t pass wishes. Politics and other considerations ultimately come into play. That’s how it works in the real world of practical politics and health care policy.

A veteran legislator, who to this day is still handing out one-liners and hard-earned wisdom to his less experienced colleagues on the House floor, is fond of reminding them that “if a frog had a back pocket he’d carry a pistol and shoot snakes.”

What he means, in my words, not his, is that good ideas will be devoured by the reptiles in the legislative swamp every time unless you can defend those ideas with more than mere words and good intentions. Or as Al Capone famously said, “you get more with kind words and a gun than kind words alone.”

Consider this: If all 6,000 plus members of TXACP gave $100 per year, to Texas ACP Services, we would be able to match and even exceed the political muscle of other influential professions and businesses. If only one-tenth of our members developed personal relationships with their elected officials, our grassroots presence would be transcendent. A legislator couldn’t swing a dead cat without hitting an involved internist in his or her district armed and ready to work.

In the synergistic combination of activism and money, political action puts the pistol in the frog’s back pocket.



TXACP Welcomes New Staff Member

Jenny Holkesvik

TXACP is pleased to introduce Jenny Holkesvik as the new Exhibits and Associates Program Coordinator. She manages the annual meeting exhibit sales and trade show, provides staff support to the TXACP Associates committee and provides administrative support for many chapter activities. Jenny comes to us from the Texas Association of Counties, where she was employed for nearly 6 years.

Please give Jenny a call to welcome her to TXACP. She can be reached at (512) 370-1508 or Jenny-dot-Holkesvik-at-texmed.org.



Preceptorship Program Manager Retires

Pat Maples

Pat Maples, Preceptorship Program Manager, retired effective on July 26. Pat has worked with GIMSPP since Nov. 1, 2002 and has been vital to the success of the program. Everyone who has had the pleasure of knowing Pat is very aware of her passion and dedication to GIMSPP. Over the years, Pat has seen the GIMSPP funds flourish and diminish and she adapted quickly to the changing needs of the program. She is a natural advocate and has an enthusiasm for this program that will be hard to match.

It is a great loss for TXACP and GIMSPP. Over the last eight years Pat has touched the lives of many medical students and contributed to the future of internal medicine in a way that she should be proud of and we should all be thankful for.

Pat did say that this has been the best, most fulfilling and rewarding work of her career. She is looking forward to exploring new interests and spending more time with her grandchildren.



TXACP promotes Staff Member to Preceptorship Program Manager

Claire Hogan

TXACP is pleased to announce that our very own Claire Hogan has been promoted to the position of Preceptorship Program Manager. Claire has been working with TXACP half-time for almost three years (during this time she also worked half-time with the Texas Urology Society) as the Exhibits and Associates Program Coordinator. We are excited to have Claire working full-time with our chapter.

Please join me in congratulating Claire. She can be reached at (512) 370-1523 or Claire-dot-Hogan-at-texmed.org.



Member Kudos

Robert Kimbrough, MD, FACP, Lubbock received the Dean’s Distinguished Faculty Service Award for the Lubbock campus.

Felicia Austin-Tolliver, MD, FACP, Sugar Land received a 2010 LEAD certificate from ACP. The Leadership Enhancement and Development (LEAD) Program targets internists early in their careers and offers a variety of activities designed to provide participants with the skills, resources, and experiences necessary to become effective leaders in any setting.

Pete Yunyongying, MD, FACP, Dallas has qualified for LEAD program.

Send news of your accomplishments, or that of a colleague, to: Gena Girardeau, TAIM Executive Director, 401 W. 15th St., Austin, TX 78701; fax to (512) 370-1635; or e-mail to Gena-dot-Girardeau-at-texmed.org.



Congratulations to our Newest Fellows

Fellowship recognizes personal integrity, superior competence in internal medicine, professional accomplishment, and demonstrated scholarship.

Lisa Y Armitige, MD, FACP, San Antonio
Jennifer L Gonzales, MD, FACP, Cuero
Sunil Krishnan, MBBS, FACP, Houston
Randeep Suneja, MD FACP, Katy
Maurice N Ugwuibe, MBBS, FACP, Corpus Christi

Advancement to Fellowship applications are available: