SAFE Opioid Prescribing: Strategies. Assessment. Fundamentals. Education
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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.
The mission of the Texas Academy of Internal Medicine is to promote quality health care for all Texans by strengthening the practice of internal medicine.
Steve Urban, MD, FACP
The years to come seemed waste of breath,
A waste of breath the years behind,
In balance with this life, this death.
In June of 2009, Justin Hughes joined the AOA Honor Society at UTMB in Galveston as a junior. Justin was in the intellectual vanguard of his profession; he was also funny, charming and other-directed. His smile was like a light coming on in the room. Less than a month later, swept down with startling violence into the whirlpool of depression, Justin took his own life at the age of 25. The suddenness of his death left hundreds of his family, classmates, faculty members, and friends bereft; thousands of future patients will never know his care, his touch, that smile.
It is admittedly strange to address my first presidential message to the problem of depression among medical students, residents, and practicing physicians. I should be writing about the patient-centered medical home, about the Obama health plan, about the future of internal medicine. But to me the future of medicine still lies in the hands of the individual practitioner caring for the individual patient at a particular point in time. And we lose too many of our fellows to burnout and depression. I’m sure that every one of you can think of a colleague who has taken his life, or slowly destroyed herself through drugs or alcohol, or has left practice due to burnout. Every medical school in Texas has suffered through the loss of its own Justin Hughes.
Several impediments stand in the way of our seeking help for burnout and depression. We’re tough; we can take it. We made it through years of every-third-night call at the Ben Taub, or John Sealy, or at Bexar County, or Parkland, and we can make it through this depression. If we seek care, we have to acknowledge such to our hospitals, our credentialing committees, and our medical boards. We might have to acknowledge our humanity even to ourselves.
Medical schools need to be more proactive in helping students and residents receive help. Students need to be told early and often how to deal with the stresses they will face. Counseling and psychiatric care should be a priority, not an afterthought to be slashed when the budget gets tight; even viewed from a purely economic perspective, it is too costly to lose one student or resident physician. Psychological and psychiatric services should not be channeled through the routine employee health service like a sore throat or low back pain. We need to remind our colleagues and ourselves what we know but sometimes ignore -- that depression is a biochemical disease, not a character flaw. We can make this better.
When he was 10 years old, Justin and his family stopped in Amarillo on their way to Colorado. My wife and I were hosting two Japanese exchange students through our church. The students were shy and uncomfortable; after a few minutes around Justin, they were laughing and at ease. As the Hughes family left, we heard one student whisper to the other: “That Justin, an excellent boy!” This was true. Justin Hughes excelled in every way -- except the ability to ask for help. Let those of us in medical education and medical practice work hard to prevent such tragedies from happening again.
Clark R. Gregg, MD, FACP
Governor, Texas Northern District
American College of Physicians
Really? Observing the current state of what passes for thoughtful debate over health insurance reform, I become more cynical about how legislative business is done. Compared to politics today (and perhaps always), sausage-making appears to be a clean industry. What will evolve with health insurance reform this year remains anyone’s guess, but my growing concern is the stress that the current rancor and political polarization, along with other factors, are having on American Medicine. I think professionalism is at risk.
All of us are witnessing over the past decades that gradually, almost like the proverbial frog placed in a pot of cold water then brought slowly to a boil, the practice and training of Internal Medicine has transformed. It has become increasingly systematized by an array of conformances with well-intentioned practice guidelines and business models, morphed into mandates, measured, sliced, and diced largely by non-physicians and reported to committees, government agencies, business entities, and insurers, who determine how medical care is paid for. Losing visibility in this process is appreciation outside and sometimes within our profession of the value of individual medical judgment: how to care for the patients who by their biology, non-adherence to therapy, polypharmacy, or myriad other reasons, are exceptions to the rules and require more than a fifteen minute visit. Regimentation of “quality care”, economic concerns, and other factors can be demoralizing and risk that physicians might lose our professional rudders.
A close friend and colleague recently prepared and delivered a lecture on Professionalism in Medicine. The keystone inspiration for this lecture was a paper titled, “The moral foundation of medical leadership: the professional virtues of the physician as fiduciary of the patient” (1) in the Ob-Gyn literature from 2001, which remains timely and should resonate with all physicians. In this brief review of some of the historical foundations of modern medical professional ethics, the authors discuss four virtues that have been and should be guideposts for the fiduciary relationship of physician to patient: self-effacement, self-sacrifice, compassion, and integrity. Our exercise of these virtues toward our patients, toward our colleagues, and toward the organizations we lead reinforce the moral value of our profession. Conversely, the vices of unwarranted bias, the primacy of self-interest, hardheartedness, and corruption undermine fiduciary responsibility for our patients and the organizations that serve them. These vices must be recognized and avoided. For a more detailed understanding and appreciation of each of these, I recommend reading this article.
More than I can recall in my career, there is growing and disquieting polarization among physicians in many career specialties, seemingly reflective of the public and political atmosphere, that tugs at the fabric of our professionalism. I remain confident, however, that if physicians constantly reexamine our core individual motives, keep our fiduciary responsibilities foremost, and guide our collegial relationships and organizations on the right path, we can maintain and nurture the professionalism that our patients, our society, and we ourselves value so highly.
A spirit of camaraderie and excitement was palpable throughout the many activities planned specifically for the eighty medical students and Associates who attended the TXACP Annual Meeting in November 2009.
The medical student clinical vignette contest was highly competitive, providing a challenge for the judges to select a single first-place winner. Vanessa Gray, TAMHSC, won with her presentation, “Duct, Duct, Loose.” Coming in a close second was Elizabeth Bowhay, UTHSCSA. Third place went to Julia Meade, TAMHSC. The top three received cash prizes. Gray will advance to the national competition with an all-expense paid trip to Toronto, compliments of the Texas Chapter. Co-chair of the TXACP Medical Students Committee, Karen Szauter, MD, FACP, Galveston, once again devoted many hours to planning and hosting the student activities.
The Associates clinical vignette competition featured five residents who were selected in their regional competitions to compete at the statewide meeting: Tarek Alhamad, MD, Texas Tech El Paso; Jenny Duewall, MD, Baylor University Medical Center; Stephen Harder, MD, UT Houston; Capt. Bryant McNeill, MD, Wilford Hall; and Saba Radhi, MD, Texas Tech Lubbock. Dr. Harder won the competition with his vignette, “Crystalline Man,” and will receive an all-expense paid trip to Toronto to represent the Texas Chapter at the national level competition during the ACP Annual Session in April.
In a dramatic conclusion to the annual Doctor's Dilemma competition, the team from Baylor College of Medicine at Houston emerged as champions. Team captain Stacey Rose, MD, led her team members to victory: Danish Siddiq, MD, and Fawad Aslam, MD. The Houston team will represent the Texas Chapter in the Doctor's Dilemma competition at the ACP Annual Session in Toronto this April.
Congratulations are also due to the Baylor University Medical Center team that took second place and to the Texas Tech University Health Science Center in Amarillo team that took third place. This competition could not have been possible without the help of Drs. Suma Pokala, FACP, Temple, and George Crawford, FACP, San Antonio, for organizing this event and to Drs. Hari Raja, FACP, Dallas and Jose Perez, Jr., FACP, Houston, for their assistance with the competition.
During the fourth competitive year in the annual poster competition, twenty six abstracts were submitted from medical students and Associates. The submissions came from seven Texas medical schools and nine residency programs. Attendees were allowed to view and discuss the research and case presentations at Saturday evening’s reception.
Thanks to the work of dedicated TXACP volunteers who judged the posters. The competition would not be possible without your help. The following winners were announced during the reception:
Clinical Poster Winners:
Clinical Poster Winners:
The 2009 annual meeting would not be possible without the help of the companies that continue to support our organization. The Texas Chapter of the ACP would like to thank the Harris Methodist Health Foundation for their generous educational grant at this year’s meeting.
The following companies provided financial support as well for the meeting. Our chapter is extremely grateful for all of their assistance and for every company that contributed to this year’s meetings success!
Silver Level Exhibitors
The Doctors Company
Bronze Level Exhibitors
American College of Physicians
DARS (Department of Assistive and Rehabilitative Services)
Greenway Medical Technologies
IPC-The Hospitalist Company
McKesson Health Solutions
Morgan Stanley Smith Barney
Scott & White Physician Recruitment
Sound Inpatient Physicians
South Texas Veterans Health Care System
Spectracell Laboratories, Inc.
SysInformation, Inc. Healthcare Management
TMLT (Texas Medical Liability Trust)
The Delta Companies
Visiting Physicians Association
Internal Medicine departments at four Texas medical schools have provided sponsorships so that more of their students can be matched for preceptorships through the GIMSPP.
Alejandro C. Arroliga, MD, FACP, Chair of Internal Medicine at the Texas A&M University System Health Science Center, has again provided a sponsorship of $2,100 so two additional students from his school can participate in GIMSPP rotations next summer.
Cynthia Jumper, MD, MPH, FACP, Chair of Internal Medicine at Texas Tech University Health Sciences Center, has given $2,000 so that more students from the Lubbock school can benefit from preceptorships.
Randall J. Urban, MD, FACP, Chair of IM at University of Texas Medical Branch, and Marc Shabot, MD, FACP, UTMB Alumni Association, have funded the James C. Guckian, MD internist-in-training sponsorship with $1,300 so a student from their school can participate in a rural preceptorship.
L. David Hillis, MD, FACP, Chair of IM at UT Health Science Center at San Antonio Department of Medicine, has again provided funding of $2,000 in order for two additional students to be matched with a GIMSPP preceptor.
These vital sponsorships demonstrate the importance the chairs place on academic Internal Medicine departments taking the lead in supporting students’ introduction to this exciting field of medicine.
Eugene W. Stokes, MD, FACP and Karen Szauter, MD, FACP, Co-Chairs of the Medical Students Committee, Govs. Andrew K. Diehl and Clark R. Gregg and the GIMSPP staff thank Dr. Arroliga, Dr. Jumper, Dr. Urban, Dr. Shabot and Dr. Hillis, the A&M University System, Texas Tech University Health Sciences Center, University of Texas Medical Branch and UT Health Science Center at San Antonio for the continued support of this crucial program.
"To most physicians,
my illness is a routine incident in their rounds,
while for me it’s the crisis of my life.
I would feel better if I had a doctor
who at least perceived this incongruity."
Speed walking through the lobby, I was trying to grab some lunch when my phone rang. It was my intern. “We have a patient in the ER.” Disgruntled and hungry I put on my eager medical student voice, “I’ll be right there.”
On arrival to the emergency room I was met by the ED physician, “Are you here to see room 8? She was sent from her nephrologist to be admitted. She has cancer and the oncologist sent her for dialysis prior to starting chemo, but the nephrologist sent her back to get chemo before dialysis. Since you all are the primaries I’ll let you sort this out.” I was instantly annoyed. Did room 8 really need one more doctor in this ping pong match?
On entering her room my attitude was instantly transformed. “Buenas tardes, como esta?” she greeted me with a large smile and cheery voice. This was the most pleasant “sick person” I had ever encountered. Her spirit was contagious.
On talking with her I learned that she had been diagnosed with ovarian cancer two years ago at the age of forty eight. She underwent resection, but was told that they were unable to remove the entire tumor. She subsequently had metastasis to her liver, three quarters of which was resected, and underwent a year and a half of chemo which was interrupted by Hurricane Ike. She was prescribed a large dose of ibuprofen for abdominal pain last year, subsequently went into renal failure, and now needed dialysis in addition to chemotherapy. And she was still able to smile…
My shoulders felt heavy after taking her history. I moved on to the physical exam and sunk even lower as she winced when I palpated multiple masses in her left lower abdomen. By the time I elicited a fluid wave in her protuberant, jaundiced belly I was trying extremely hard not to let the dismay leak across my face. “I’m going to speak with the other doctors and we’ll be back to talk with you.”
We admitted her to the medical floor with orders to consult nephrology and oncology. Her kidney functions were worsening, she was anemic, and her liver function tests were abnormal. I knocked on her door and she instantly saw the concern on my face. “It’s not looking good is it,” she said, tears welling up in her eyes. “I know. I can tell. You can feel it, you know?” I didn’t have a response. I just shook my head in silence. She reached out, hand trembling. I took her hand.
“I’m ok with it. But the hardest part is leaving my daughter. She’s only fourteen. I don’t want to leave her.” Tears began to roll down her cheeks. Somehow she was still smiling as she was speaking to me. I felt my throat get tight. My vision began to blur and I realized that my eyes were filling with tears. As I stood over her I felt so small, so humbled. I sat on the side of her bed as I silently began to cry. I decided to stop analyzing. I quieted my mind and sat in silence, brushing tears off of my cheeks as she explained that she knew this day would come. “I’m ok with it,” she repeated. “I have to be strong for her. We don’t have a lot of time left. I have to be strong for her.”
When I left her room that morning I felt broken down and vulnerable but also guiltily relieved. I was still able to feel. I knew that our experience would be lost in translation to anyone I told. I could only say “my patient made me cry.”
Over the next couple of days we found out that she had failed the first and second line chemotherapy treatments. She was going to be discharged with hospice care. The last day I saw her she was just as cheerful as when we first met. She had told her daughter about her prognosis and was excited about going home to be with her family. “Hospitals are lonely. Even if no one is at home with me, I’m still home,” she explained. She reached out her arms to give me a hug. I leaned in and let her hug me. I hugged back.
As I was pulling away she held my face between her hands, looked me in the eyes and said, “You are wonderfully compassionate. Don’t lose that.” I looked her in the eyes and promised that I wouldn’t. I was leaving the room when I realized I had genuinely looked at her and made a promise. I didn’t look through her, I didn’t look over her at the blood pressure cuff on the wall, and I didn’t avert my eyes. I looked at her. I saw her. I promised.
It was this hospital admission that she would associate with the day they told her there was nothing more that could be done, that she would remember her daughter crying as she told her that she wouldn’t be around to see her get her driver’s license, graduate from high school, get married. She wouldn’t be around to read to her grandchildren or tell them stories of how different everything was when she was their age. As I walked down the hall I realized that I hoped this was the admission that she would remember someone sitting down with her, holding her hand, and crying with her as she accepted her fate. She started off as the cancer patient in room 8 and left as Sara Garza*, the patient who reminded me you can make it through the third year of medical school without becoming jaded, and the patient to whom I vowed never to lose my compassion.
Two distinguished members were honored with the Texas Chapter highest awards during November 2009 Annual Chapter Scientific Meeting in San Antonio.
Texas Chapter Laureates for 2009 are Don W. Powell, MD, MACP, Galveston; Eugene W. Stokes, MD, FACP, San Angelo.
The Laureate Award honors those Fellows and Masters of the College who have demonstrated a life of commitment to excellence in medical care, education, or research and in service to their community, the Chapter, and the ACP.
Mohamed M. Haq, MD, FACP, Houston was honored with the Chapter Volunteerism and Community Service Award.
The Volunteerism and Community Service Award honors Texas Chapter members who have demonstrated an abiding commitment to excellence in medical care, education, research, and dedicated service to their community, the Chapter, and the ACP.
The Texas Chapter of the ACP Services Chumley/SynderAdvocate of the Year award was presented to F. David Winter, MD, MS, FACP, Dallas for his outstanding leadershi in legislative advocacy and grassroots activism on behalf of medicine and the patients of Texas.
The Awards committee welcomes and accepts nominations from the membership year round. Nominations from the chapter should include a detailed letter of recommendations and curriculum vitae (CV). Additional letters of support are welcome and may strengthen the nomination.
Send nominations, CVs, and letters of support to: Texas Chapter of the American College of Physicians, Awards and Recognitions Committee, 401 W. 15th St., Austin, Texas 78701; or email to Gena-dot-Girardeau-at-texmed.org.
Officers and board members for Texas Chapter of the ACP and Texas Chapter of the ACP Services, the Texas Chapter’s advocacy arm, were elected during the annual awards and business meeting luncheon November 14, 2009, in San Antonio.
R. Steven Urban, MD, FACP, Amarillo
Sue S. Bornstein, MD, FACP, Dallas
Stephen J. Sibbitt, MD, FACP, Temple
TXACP Services President
Victor A. Simms, MD, FACP, Pasadena
TXACP Services President-Elect
Roger S. Khetan, MD, FACP, Dallas
TXACP Services Secretary-Treasurer
W. Gary Reed, MD, FACP, Dallas
M. Keith Schrader, MD, Plano – Northeast Director
John D. “Jack” Myers, MD, FACP, Temple – Northwest Director
Ami D. Sen, MD, FACP, Houston – Southeast Director
Alejandro Moreno, MD, FACP, Austin – Southwest Director
Pete Yunyongying, MD, Dallas – At-Large Director
If you are interested in serving on the TXACP or TXACP Services board of directors in the future, e-mail Gena Girardeau, TXACP executive director, at Gena-dot-Girardeau-at-texmed.org. Be sure to include your curriculum vitae.
J. Richard Downs, MD, FACP, San Antonio, received the ACP Laureate Award from the Air Force Chapter at its annual chapter meeting in November 2009
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.
Fellowship recognizes personal integrity, superior competence in internal medicine, professional accomplishment, and demonstrated scholarship.
Charles R Cervantes, Jr, San Antonio
Carol L Croft, Dallas
Peter F Davis, Dallas
Michael B Fallon, Houston
Devabrata Ganguly, Bogata
Ronald O Gibbons, Odessa
Elizabeth J Glazier, San Antonio
Charles M Godo, Killeen
Colonel Jamie B Grimes, San Antonio
Dale J Hamilton, Houston
Roy S Herbst, Houston
David B Huang, Missouri City
Michael M Johnson, Boerne
Kristen H Lampe, Dallas
Avi B Markowitz, Galveston
John D Myers, Temple
Rajeev Narang, Corpus Christi
Bernard S Ng, Houston
Ofobuike N Okani, Waco
David Rosenstock, Dallas
Navid Sadeghi, Houston
Sunil K Sahai, Houston
Amit A Shah, Dallas
Advancement to Fellowship applications are available:
Texas Chapter Annual Scientific Meeting
October 25-27, 2019, JW Marriott San Antonio