The Miracles of Music and Medicine

I grew up in the Friday Night Lights of West Texas in the 60s and 70s, where sports – especially Midland Lee and Odessa Permian football – were king. A preemie who remained anemically skinny all through my school years, I also suffered from an uncorrected lazy eye, which resulted in no central vision in one eye and no functional depth perception. I could not catch a baseball or football to save my life. I truly was the proverbial kid who was picked last for every sports team. Luckily, at the age of seven I was already developing a talent for music. I started taking piano lessons in second grade and have been playing ever since.

Though I excelled academically in high school, I started at Rice University as a music major, though not on piano. I was fortunate to study with the principal clarinetist with the Houston Symphony. Thankfully, I came to several realizations my freshman year: 1) Though I was talented, I was not good enough on clarinet to make the big-league symphony orchestras and make a good living at it; 2) I found playing the same music over and over again a bit boring; and 3) I really wanted to go to medical school. I loved music (and continue to love it, just not playing the clarinet). But I did not want to make music my life’s work. Now, I have the best of both worlds – I have a wonderful career and I get to enjoy music on the side.

The other evening, I was sitting at my piano practicing an arrangement of “O Holy Night.” My daughter, a classically trained soprano, will be singing this at Christmastime and I have the great joy of being able to accompany her. As I was playing – glancing between the written music and my fingers on the keys, listening to the sound fill the room – I had the distinct realization of what a miracle music is. At its most fundamental, the concept that various tones and rhythms can be combined in a non-random fashion and be pleasing to the ear both for the performer and the listener is a mirror of creation. Add to that the genius of the development of various musical instruments and the complexity of composition and performance and you arrive at what can only be described as a spiritual experience where the music and the musician combine in a true act of worship. 

As a pianist, it never ceases to amaze me that I can look at a splotchy group of dots on a page and translate that into an elegant motion of arms, hands, and ten fingers to make music. And when I can make music with others, the amazement and joy is amplified even more.

In 2014, Curt Fenley and I had the pleasure of bringing together the choirs and musicians of New Beginnings Baptist Church, under the musical leadership of Gregg Garcia, and our First Baptist Church for a combined Christmas program. We were without a music director at the time. That Christmas celebration demonstrated another miracle of music – the ability to bring a diverse group of people together for common good and purpose. 

These two churches continue to make music and worship together at Christmas! Under the excellent leadership of First Baptist’s John Lassitter and New Beginnings’ Gregg Garcia, we are practicing for our eighth annual Christmas celebration, to be held on Sunday, December 5th at First Baptist at 6 PM. Our weekly practices together, which can really be described as jam sessions, transport us all away from the daily grind to a place of unity and worship. I hope everyone will plan to attend this impressive Christmas celebration! Canned goods will be gathered in support of CISC as well.

On a more somber note, we are now approaching a staggering 1 million excess deaths due to COVID-19. Nearly 100,000 of those deaths are since vaccines have been widely available. As a cancer physician, it is mind-blowing that COVID-19 is killing more people than cancer. I am heartsick when I hear people I know and love continue to refuse vaccination because of an unrelenting campaign of lies and misinformation, both about the seriousness of COVID and the safety and effectiveness of the vaccines. This paper’s obituary page continues to be filled with tragic and preventable COVID deaths.

In the realm of cancer treatment, hardly a day goes by that patients aren’t clamoring for the latest experimental medicine, desperate to try anything they think will help, regardless of unproven effectiveness and potential harm. How ironic (and senseless) that we have a disease that is killing more people than cancer and people refuse to get a proven safe and effective vaccine. 

I am a rational, logical thinker. That does not mean my heart doesn’t ache when so many are dying for a lie or out of misplaced fear. I tell my reluctant terminal cancer patients who are afraid to take pain medication, once I have counseled them on appropriate use, that there is no virtue and no extra stars in their crown for hurting when they don’t have to. I feel the same way about unnecessary COVID illness and death – there is no virtue there. 

Martin Luther wrote, “My heart, which is so full to overflowing, has often been solaced and refreshed by music when sick and weary.” And so, I sit at my piano, calming my spirit and soothing my weary soul. As we enter the holiday season, I urge everyone to appreciate the miracle of music, yes, but also the miracle of modern medicine. Both have the power to heal. Let us thank God for both.

Coronavirus Information and Misinformation

As a physician, I have been fascinated by the rapid acquisition of knowledge about the novel coronavirus and the deadly disease it causes, COVID-19. True, that knowledge may not be coming as fast as we like. But the pace of vaccine development, for example, is remarkable. But along with knowledge come ignorance, misinformation, and deception.

First, a bit of ignorance. At a rally in Phoenix, in June, President Trump fired up his audience with anti-China rhetoric. In doing so, he displayed his lack of understanding of how COVID-19 got its name. “I said, ‘What’s the 19?’” Trump said. “COVID-19, some people can’t explain what the 19, give me, COVID-19, I said, ‘That’s an odd name.’” Trump apparently thought names like kung flu, Wuhan virus, and Chinese flu were more appropriate.

We can all be forgiven for not knowing something like how COVID-19 got its technical (and not intuitively obvious) name. First, the virus that causes COVID-19 is the novel (meaning new) coronavirus SARS-CoV-2, which stands for severe acute respiratory syndrome coronavirus 2. The first coronavirus caused an outbreak of SARS in the early 2000s. This new coronavirus appeared in 2019; hence, the disease it causes, COVID-19 – CO for corona, VI for virus, D for disease – carries the number 19 for the year it started (2019), not because it is the nineteenth disease (it is not). There’s your – and Trump’s – science lesson for the day.

On to misinformation and deception. Some misinformation is due to inaccurate information. For example, this paper published that while the number of COVID-19 cases has exploded in Texas nursing homes last month, Angelina County is bucking that trend. That turned out to be based on either inaccurate or delayed information, as local physicians are aware of many local nursing home cases. The paper has updated the story as more information has come available. What is certain, however, is that our case count continues to rise.

Lack of information or incomplete information is different from deception. I have written previously about the importance of wearing masks. But mask wearing took another hit recently when our own Congressman Louie Gohmert (TX-01) not only caught coronavirus, he released a video suggesting it was the mask that gave it to him. In his own self-deception, he believes he wears a mask often, but many eyewitnesses (not to mention ever-present news media) suggest otherwise. Gohmert loves history, but history will not be on his side on this one. Deception to support a false narrative is no different than writing history to support a political agenda. Our country has seen too much of that.

When it comes to treatment, President Trump famously has advocated for unproven therapies, from bleach to the anti-malaria hydroxychloroquine. Regarding hydroxychloroquine, the results are in. With strong data that hydroxychloroquine is not effective either as therapy or as postexposure prophylaxis, the Food and Drug Administration (FDA) recently revoked its Emergency Use Authorization, saying it is “unlikely to be effective in treating COVID-19” and that “in light of ongoing serious cardiac adverse events and other serious side effects, the known and potential benefits … no longer outweigh the known and potential risks” for authorized use. Our national coronavirus guru, Dr. Anthony Fauci, minced no words in saying, "The overwhelming prevailing clinical trials that have looked at the efficacy of hydroxychloroquine have indicated that it is not effective in coronavirus disease.” 

This has not stopped President Trump from practically practicing medicine without a license. 

Trump literally is the most famous and influential person in the world. He is not alone in equating personal or anecdotal experience (I did X and Y didn’t happen; therefore, X prevented Y) with rigorous scientific study. My patients do it all the time. However, they do not have an international bully pulpit. His hubris throughout the pandemic in suggesting treatments (like bleach) is jaw-droppingly astounding. (Bleach works on your countertop, right? Why wouldn’t it work inside your body?) Not only is his medical advice suspect at a minimum, it has been dangerous. And just this last week, Trump had his election campaign Twitter account temporarily blocked and a Facebook post deleted when he posted that children are “almost immune from this disease.” When it comes to your health, listen to the doctors.

But don’t listen to quacks, especially those with pseudo-religious and anti-scientific claims. The bleach treatment claim (touted by a family of swindlers who formed a “church” in Florida) falls into that category. But the icing on the cake – so far – has to go to a true charlatan, Dr. Stella Immanuel, a Houston physician of questionable medical training and even more dubious religious authority. She famously believes in alien DNA, demon sperm and that the government is run in part not by humans but by “reptilians” and other aliens. That didn’t stop Donald Trump Jr. declared a video of hers a “must watch,” while President Trump himself retweeted the video.

Unfortunately, attempts to set the record straight regarding coronavirus misinformation by referencing scientific data are considered by far too many to be “fake news” or viewed as a conspiracy theory. Just look at Facebook for examples. I implore you to use this information for how it is intended. Educate yourself on the facts of coronavirus. There is much we don’t yet know, of course. And the vast majority of us – anti-vaxxers excepted – eagerly await a vaccine. In the meantime, please DO wear your mask – over both your mouth AND nose, please! – and DO social distance. DO use hand sanitizer or soap and water often. Together – caring for each other – we can get through this. 

Achieving Equitable Cancer Care Access in Texas

Much is known about what influences the health of a community, including individual health behaviors as well as social and economic determinants of health.[1] Health equity has been defined to mean that everyone has a fair and just opportunity to be as healthy as possible.[2] Being un- or under-insured puts people at serious disadvantage when it comes to access to healthcare and potential for positive health outcomes.

The Affordable Care Act (ACA, or Obamacare) provides an opportunity for states to expand health coverage to low-income families through the Medicaid program. Multiple recent analyses demonstrate that Medicaid expansion is having an especially positive impact in rural areas in expansion states.[3] Many expansion studies point to improvements across a wide range of measures of access to care.[4] Finally, research shows that Medicaid expansions result in reductions in uninsured hospital or other provider visits and uncompensated care costs, whereas providers in non-expansion states have experienced little or no decline in uninsured visits and uncompensated care.[5]

Texas is one of thirteen states that has chosen not to expand Medicaid. The majority of states not participating in Obamacare expansion are in the Deep South,[6] and these states are also the states in the lowest quintile in overall health as ranked by United Health Foundation.[7] (The State of Texas ranks 37th in overall health in the United States.[8])

That’s not to say the State of Texas doesn’t spend a lot of money on healthcare. According to the Comptroller’s office,[9] healthcare spending represents nearly half the state budget - $42.9 billion in fiscal 2015 – spread across various agencies. Seventy percent, or $30.3 billion, went to spending for Medicaid and CHIP. That spending also includes direct support of various institutions.

For example, the University of Texas MD Anderson Cancer Center, which markets itself heavily as “the nation’s top hospital for cancer care for 14 of the past 17 years”[10] and “one of the nation’s top two hospitals for cancer care every year since the [US News & World Report America’s Best Hospitals] survey began in 1990,”[11] has an operating budget of $5.2 billion and over 20,000 employees.[12] Of that $5.2 billion, 4% - $210.1 million – is general revenue appropriated by the State of Texas.[13]

As a radiation oncologist, I practice in the shadow of MD Anderson, even though I live 120 miles north of the Texas Medical Center. It is a long shadow. That shadow is often comforting, like an old friend. But it is a shadow that discriminates with strict financial barriers and selective insurance contracts. There is a joke in the medical community that the first and most important biopsy you get at MD Anderson is a wallet biopsy – no pay, no play.

MD Anderson does participate in the Texas Medicaid Program and has a financial assistance program for cancer patients who meet residency and certain financial eligibility requirements.[14] Uncompensated care in fiscal year 2018 at MD Anderson totaled only $170.4 million,[15] certainly less than the $210.1 million appropriated by the State of Texas and less than 3.3% of their operating budget. Modern Healthcare looked at the proportion of charity care provided by the country's 20 biggest not-for-profit hospitals and hospital systems by revenue in 2015 and 2016 and found that the average proportion of operating expenses devoted to charity care was 5.21%.[16]

In fiscal year 2017, MD Anderson provided care to a mere 420 people who primarily had no insurance and who met their financial assistance program requirements.[17] That is barely one unique patient a day at an institution that sees 141,600 patients a year.[18] MD Anderson’s first core value[19] is: “Caring: By our words and actions, we create a caring environment for everyone.” But not everyone gets in.

MD Anderson has a huge and wealthy donor base as well. As just one example, their Moon Shots Program,[20] launched in September 2012, has received $464 million in private philanthropic commitments so far.[21] In 2018 alone, 9.5% of their budget – $498 million – came from restricted grants and contracts and philanthropy.[22]

Let me say, I am in awe of the research that comes out of MD Anderson. They have every right to be proud of their #1 ranking and of having a Nobel Prize-winning scientist on staff.[23] The knowledge that comes out of an institution that sees 141,600 patients a year is staggering. The training of health care providers, including at Harris Health System facilities, is excellent. But I grieve when Texas residents who need the care MD Anderson can provide are prevented from going there.

Ultimately, quality health care is not just about rankings; it must be about access to care as well. As a state-supported institution, MD Anderson needs to loosen its requirements for providing uncompensated care and be willing to negotiate and accept reasonable contracts with insurance providers, especially Medicare Advantage and Obamacare plans. After all, a hospital cannot be “best” if it isn’t best for all. (That is not to let insurance providers off the hook. I have no doubt they shy away from contracting with MD Anderson, knowing less expensive care can be had elsewhere.)

The State of Texas should require minimum levels of charity care and insurance plan participation when hundreds of millions of state dollars are being allocated. State legislators, in view of the substantial economic[24] and health[25] benefits associated with the expansion of Medicaid, should invest in increased health insurance coverage in Texas via the Affordable Care Act. And finally, health care ranking organizations like US News & World Report should include access to care and charity care metrics when ranking hospitals.[26] These are the right – and equitable – things to do.

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[1] https://www.angelinaradiation.com/blog/county-health-where-do-we-begin

[2] https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html accessed 7/5/19

[3] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[4] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[5] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[6] https://familiesusa.org/product/50-state-look-medicaid-expansion accessed 7/4/19

[7] https://www.americashealthrankings.org/learn/reports/2018-annual-report accessed 7/5/19

[8] https://www.americashealthrankings.org/learn/reports/2018-annual-report/findings-state-rankings accessed 7/5/19

[9] https://comptroller.texas.gov/about/media-center/news/2017/170131-health-care-spending.php accessed 7/3/19

[10] https://www.mdanderson.org/newsroom/md-anderson-ranked-no-1-for-cancer-care-in-national-survey.h00-159226512.html accessed 7/1/19

[11] https://www.mdanderson.org/patients-family/becoming-our-patient/why-md-anderson.html accessed 7/1/19

[12] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[13] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[14] https://www.mdanderson.org/about-md-anderson/business-legal/office-of-health-policy/uncompensated-care-program.html accessed 7/5/19

[15] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[16] https://www.modernhealthcare.com/article/20170424/BLOG/170429935/how-much-charity-care-do-not-for-profit-hospitals-provide accessed 7/7/19

[17] https://www.mdanderson.org/about-md-anderson/business-legal/office-of-health-policy/uncompensated-care-program.html accessed 7/4/19 How does MD Anderson serve the low-income population?

MD Anderson has a long tradition of providing quality cancer care for many low-income residents of Texas.

In FY17, MD Anderson provided care to 420 people who primarily had no third-party insurance and who qualified for partial or full financial assistance under MD Anderson’s patient financial assistance program. The estimated unreimbursed cost associated with these patients was $17.5 million.

In addition, MD Anderson provided care to 3,717 people whose primary source of insurance coverage was a state or locally sponsored governmental program such as Medicaid, CHIP, Harris County Hospital District or other Texas county-specific indigent program. The estimated unreimbursed cost associated with these patients was $12.5 million.

MD Anderson’s combined estimated unreimbursed costs for these two categories of patients in FY17 was $30 million.

For the past 23 years, MD Anderson also has provided cancer services at Lyndon B. Johnson General Hospital for low-income Harris County residents. This program is staffed by MD Anderson faculty physicians, nurses and others at an annual cost to MD Anderson of $4 million. The MD Anderson program at LBJ General Hospital more than 1,000 new patients and had more than 12,000 follow-up patient visits in FY13.

[18] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf At MD Anderson, everything we do revolves around our patients. In Fiscal Year 2018, more than 141,600 people sought the superior care that has made MD Anderson so widely respected — 45,000 of whom were new patients.

[19] https://www.mdanderson.org/about-md-anderson.html accessed 7/4/19

[20] https://www.mdanderson.org/cancermoonshots.html accessed 7/5/19

[21] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/5/19

[22] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/5/19

[23] https://www.mdanderson.org/newsroom/nobel-prize.html Jim Allison, PhD

[24] https://www.perrymangroup.com/media/uploads/reports/perryman-economic-benefits-of-expanding-health-insurance-coverage-in-texas-03-2019.pdf accessed 7/7/19

[25] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[26] Why did U.S. News adjust for socioeconomic status? In 2014, the National Quality Forum, an influential standard-setting body, recommended considering socioeconomic status in certain evaluations of hospital performance. Since our objective is to enable a patient who is consulting our ratings to make apples-to-apples comparisons among hospitals, it follows that we should adjust for patient attributes such as age, sex and socioeconomic status. https://health.usnews.com/health-care/best-hospitals/articles/faq-how-and-why-we-rank-and-rate-hospitals accessed 7/4/19

Money, Insurance, and Health: An Unfair Relationship

Money doesn't buy happiness, or so they say. But money can buy better health. Add one more difference between the haves and the have nots.

There are many determinants of health. Some behaviors are more under our individual control than others. The Big Three, as I like to call them – smoking, diet, and exercise – would, at first glance, seem to be entirely personal choices. That would be untrue.

Social and economic factors are a major determinant of health. These factors include education level, employment, income, family and social support, and community safety. Each of these factors is correlated with financial well-being. In fact, these social and economic factors as a whole are more important even than individual health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, since health behaviors also correlate strongly with educational level, employment, income, etc. In other words, we cannot address health behaviors in isolation; we must simultaneously address education, jobs, social services, and community safety if we are to improve health.

Another significant determinant of health – the one that gets the most national attention – is access to and quality of healthcare. In the United States, that access is governed primarily by insurance coverage. Every country rations healthcare; in the United States, we just happen to ration it by separating the insured from the uninsured, and that is very much along economic lines. A privileged few are wealthy enough to be able to pay out of pocket for whatever care they need, but they rarely need to. They have insurance. Good insurance. They can afford to pay their deductible, however high it may be. The working poor, however, have some income but little or no savings and often no health insurance coverage at all. They are the ones who get hit with the entire, undiscounted bill for their care. Bankruptcy is an all-too-common result.

Our healthcare system does make some patchwork provision for the truly indigent, but no one should kid themselves that charity care is in any way equivalent – either in breadth of coverage or ease of use – to what we want for ourselves. Even those with insurance are burdened with astronomical deductibles and copays that most simply can’t afford. These persistent financial burdens can force patients to choose less expensive procedures or to go without care altogether.

And then there is Obamacare.

Implementation of the Affordable Care Act, aka Obamacare, started in 2010, when 16% of the US population – more than 40 million people – were uninsured. Healthcare provided since the advent of Obamacare is, as promised, both more affordable and more available. The percentage of people without health insurance has been cut in half.

The dirty little secret is that many healthcare providers don’t take Obamacare plans, funneling patients into inadequate primary care networks and forcing them to drive long distances for more specialized care. In other words, even under Obamacare we continue to ration care with money-related barriers. No question, Obamacare is far from perfect, but it is still better than nothing.

Ray Perryman, considered by many to be the Texas economist par excellence, issued a report in April 2019 titled Economic Benefits of Expanding Health Insurance Coverage in Texas. In this report, Dr. Perryman states, "Health care needs do not simply go away because individuals do not have insurance coverage. Instead, medical issues tend to escalate and lead to higher costs and worse outcomes. Texas would gain over $110 billion in new Federal health spending during the first 10 years." For the callous who are only interested in the economic benefit accrued to the state’s coffers, this report delivers that in spades.

Guess what, though? According to the Perryman Group report, expanding health insurance coverage in Texas also would result in enhanced “health and wellbeing of individuals directly affected by receiving coverage” as well as “reductions in the numbers of uninsured, fewer emergency room visits, improved health outcomes, enhanced employment and productivity, and other desirable developments.” That is a win-win, my friends.

There has been little political appetite to expanding coverage in Texas for fear of “socialized medicine” and an ever-more-intrusive Federal Government. I get it. We can have differences of opinion about whether and how much healthcare is a “right”, how much “responsibility” is required along the way, and the role of government in healthcare. But, leveraging $9.00 in federal resources for every $1.00 in state funding that results in improved health and return on investment is a bet I would make any day of the week.

Our individual and community health depends on many things. Money – or lack thereof – is the most insidious factor. Improving the health of an entire county, as measured by the Robert Wood Johnson County Health Rankings, will require a concerted effort on both the public and private sector fronts and with both large and small scale efforts. Expanding health insurance coverage in Texas via the Affordable Care Act would be an impactful place to start.

There's Something About a Sabbatical

As this column is printed, I will be three weeks into a four week sabbatical. Since I am writing ahead of time, I obviously can’t have predicted how it is going. I can say what I hope it will be, at least to some extent.

I am a Type A personality and part of me – as I write this – wanted to plan out every moment of this break from my daily routine. I even made a list ahead of time of what the sabbatical is and isn’t (for me, mind you). High on that list is that I should not feel guilty if I don’t accomplish certain things that my Type A personality thinks I should. That I should just let it be what it will be. That’s hard for me.

People often ask me – when they find out I am a cancer and hospice physician – how I can do what I do without staying depressed. “Isn’t it hard?” they ask. My pat answer is that I love what I do, so how could it be hard? When I am doing what I believe God has gifted me to do, it is the easiest job in the world!

But that simple answer obscures that fact that burnout is a real possibility, even for me. Even though I love my job, frustrations arise. Not every patient is pleasant or easy to work with. Stress happens. We all need a break sometimes.

There are different ways to get away, and how we go about it may depend on where we are in life. During the routine work year, breaks can come in all shapes and sizes, from the afternoon off to a three day weekend or a more substantial week or more off for a vacation. These standard breaks rejuvenate us and help us stay focused when we are back at work.

A sabbatical is something altogether different.

The word sabbatical has at its root what we recognize as Sabbath – rest – which has a deeply spiritual meaning of both rest and worship in Judeo-Christian theology. The idea of an extended rest from work has a long history in the academic setting, where professors are given time off from teaching to travel, write a book, or study. But I never hear of doctors taking a sabbatical.

Doctors need it. Physician burnout is, according to some, is at epidemic levels. Others call it a crisis. Whatever. Let’s just say, burnout among physicians is far too common. The specialty of emergency medicine reportedly has rates of burnout at nearly 60% with many other specialties at 50% or higher. Burnout is basically severe, chronic stress characterized by emotional exhaustion and lack of empathy for patients along with a cynical or negative attitude and a sense that you are spinning your wheels in your career and not getting anywhere. Does that describe any physician(s) you know? I guarantee it does. I don’t want it to describe me.

Why physician burnout exists (and is increasing) is not the subject of this essay. But if you talk to doctors, government bureaucracy, electronic health records, insurance companies, and declining reimbursement despite longer work hours are almost always going to come up.
Doctors need a break. More than just a scheduled afternoon off or periodic vacation. I would argue that at some point in a physician’s career – if they want to stay the course for the long haul – they need to take a sabbatical.

What does a sabbatical look like? It depends on the person. My advice for those considering a sabbatical is to keep in mind three key components: time, distance, and purpose.

Time is important in order to distinguish a sabbatical from a vacation. Two weeks, for example, is not long enough to truly get away from work. You spend the first week just beginning to unwind and the second week worrying about the hell you are going to pay when you get back to the office. Four weeks is a minimum for a true sabbatical.

Distance is important as well – certainly physical distance, in that you want to avoid the temptation to check in on work. Get out of town. Out of the country, even. In this digital age, electronic distance is also important. Are you still going to be tied to Facebook? Instagram? Twitter? Or worse, to your electronic health record? Emotional distance is key as well. Let go of the thought that only you can do what you do.

Finally, consider if there are things you’ve always wanted to do – books to read (or write), goals to accomplish – but you’ve never had the time to do them. Be creative; think outside the box.

Avoid the temptation simply to travel, where you feel obligated to visit every cathedral and museum from A to Z. That’s a vacation. A sabbatical is about you. Be careful, though, that you don’t set unrealistic goals for your sabbatical, and that you don’t come back feeling guilty that you didn’t accomplish all that you set out to do. Remember, the definition of sabbatical is rest. Be still. Listen. Be open. Don’t just “do”! Find out more about who you are apart from medicine.

Personally, I’m taking my cue from two Biblical imperatives that guide my thinking about life in general. The first, Romans 12:2 (NIV), states, “Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing and perfect will.” And the second is from Philippians 4:8 (NIV): “Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things.” I will be reading German theologian Dietrich Bonhoeffer’s profound book, The Cost of Discipleship. But I am not going to feel guilty if I don’t finish it. I’m resting, after all.

The Anti-Vaccination Movement is Fake – and Dangerous – News

Most vaccine-preventable diseases of childhood are at or near record lows. Vaccines prevent the deaths of about 2.5 million children worldwide every year. Yet some highly contagious diseases like measles and whooping cough still pop up where enough people are unvaccinated.

In the United States, compliance with childhood vaccinations remains quite high overall. At least 90 percent of children are getting the recommended vaccinations on time for many diseases – but not all, and not in all locales. Maintaining a high percentage of children vaccinated is important. Herd immunity occurs when a certain threshold percent of a community (such as a school) is vaccinated, reducing the probability that those who are not immune will come into contact with an infectious individual. For highly infectious diseases like measles, 90 to 95 percent of a community needs to be vaccinated to provide herd immunity. That is why vaccinations are required for our schoolchildren.

According to the Texas Department of State Health Services, students are required to have seven vaccinations in order to attend a public or private elementary or secondary school in Texas: Diphtheria/Tetanus/Pertussis (DTaP/DTP/DT/Td/Tdap), Polio, Measles, Mumps, and Rubella (MMR), Hepatitis B, Varicella (chicken pox), Meningococcal (MCV4), and Hepatitis A. Texas law allows physicians to write medical exemptions if they feel the vaccine(s) would be “medically harmful or injurious to the health and well-being of the child or household member.” All well and good.  Texas law also allows – ill-advisedly – “parents/guardians to choose an exemption from immunization requirements for reasons of conscience, including a religious belief.” The “belief” of the anti-vaccination movement is based on lies and is only “religious” in its cult-like following of a dangerous (and discredited) Pied Piper, Andrew Wakefield.

A 2017 Washington Post article states, “A leading conspiracy theorist is Andrew Wakefield, author of the 1998 study that needlessly triggered the first fears. (The medical journal BMJ, in a 2011 review of the debacle, described the paper as “fatally flawed both scientifically and ethically.”) Wakefield’s Twitter handle identifies him as a doctor, but his medical license has been revoked. The British native now lives in Austin, where he is active in the state and national anti-vaccine movement.”

The political noise made by these charlatan zealots has been difficult for legislators to ignore. This disturbing movement has been gaining traction especially in certain private schools in Texas. In one such school, the Austin Waldorf School, reportedly more than 40 percent of the school’s 158 students are unvaccinated. This is mindboggling ignorance in a “school” where tuition ranges from $11,450 to $17,147 a year.

Baylor College of Medicine professor Peter J. Hotez, MD, PhD, Founding Dean of the National School of Tropical Medicine and Director of the Texas Children's Hospital Center for Vaccine Development is truly on the front lines of the battle being waged by the anti-vaccination movement. The fact that Dr. Hotez is both a world authority on infectious disease and a parent of an autistic child hasn’t stopped the anti-vaccination movement from attacking him. It does, however, make their attacks even more sad; they have no facts to back up their case, so they just get mean (for example, saying he is in denial that vaccination caused his daughter’s autism).

This insidious – and disproven – idea that vaccines are linked to autism continues to rear its ugly, dangerous head, despite what Dr. Hotez calls “rock-solid proof” to the contrary published in peer-review journals like the New England Journal of Medicine, JAMA (the Journal of the American Medical Association), the British Medical Journal, and by organizations like the Institute of Medicine and the American Academy of Pediatrics. The data that originally was claimed to show a link between vaccines and autism was later found to be falsified. In other words, the anti-vaccine crowd is fueled by conspiracy theories and truly fake news. (Though not known with certainty, it is believed genetics and environmental exposure during early pregnancy may play a role in development of autism.)

The problem with conspiracy theories is that facts don’t matter. Those who try to argue based on facts are automatically considered part of the conspiracy. Unfortunately, President Trump was rumored early in his presidency to favor a proponent of this ‘vaccines cause autism’ theory to chair a new commission on vaccines, lending credence to the lies. Thankfully, those commission efforts appear to have stalled.

Some argue against vaccinations on the basis of parental rights. I’m so sorry, but you do not have the “right” to endanger others’ children. It is a time-honored role of government to provide a safe, healthy environment for its citizens. Just look at the public health disaster in Flint, Michigan, where the government abdicated its responsibility.

Texas needs to stop allowing nonmedical “conscientious” exemptions in our schools. Your “right” to ignorantly and dangerously keep your child from receiving vaccinations stops at the schoolhouse door. California made it tougher for parents to opt out of vaccination compliance and vaccination rates increased. Texas should do the same.

In this New Year and upcoming legislative session, may the Texas Legislature resolve to pass legislation limiting nonmedical exemptions. Here’s hoping they can ignore the cacophony of lies and claims of “rights” of those who try to stop them. Those liars endanger all our children, and that is not a right they should have.

The Crockett Hospital’s Painful Demise

June 30, 2017 was a sad day for Crockett, Texas, our neighbor just 47 miles to the west. Little River Healthcare ended its management affiliation with the Houston County Hospital District that Friday, effectively shuttering the Crockett hospital. Nearly 200 employees are affected by the closure.

The simple sign taped on the front door said, “HOSPITAL CLOSED” and directed people to either call 911 in an emergency or to go to Palestine Regional Medical Center, the closest hospital 39 miles away.*

Though this seemed like a sudden event, in many ways it was a slow death over many years. The 49-bed Crockett hospital – most recently known as Timberlands Healthcare, under the management of Little River Healthcare since April 18, 2016 – had danced with several management partners over the last several years. Little River Healthcare didn’t even last 15 months. 

Prior to Little River Healthcare, CHC (Community Hospital Corporation) was brought in June 1, 2015 to run the Crockett hospital for an interim period after the hospital’s messy divorce from East Texas Medical Center (ETMC) in Tyler. ETMC ran the hospital for 10 years. ETMC claimed to have invested $27 million in facility and technology upgrades in Crockett, but for a hospital in the 21st century, that was a paltry amount when spread out over 10 years. 

So why didn’t Little River Healthcare succeed?

According to published news reports, Little River Healthcare blamed Blue Cross and Blue Shield for not paying $32 million it was owed; BCBS would not comment. Little River stated that when it took over the Crockett hospital, the hospital had been “cash flow negative for a long time,” but that they thought they could turn it around.

It was a helluva lot to turn around. Payroll alone was $1.5 million per month. To keep the hospital running in its current state would have cost $2.7 million per month. The Houston County Hospital District board had already increased property taxes to the max amount and even borrowed money in an attempt to keep the hospital afloat. 

LRH Co-Owner Ryan Downton was quoted as saying, “We came to the conclusion the patient volume just isn’t there in the town anymore.” The problem was not volume; it was reimbursement. You can double or triple the number of patients you see, but if you don’t get paid adequately, you are just digging a deeper hole.

Crockett is a dying town. According to the Census Bureau, its population is around 6,500 and shrinking. 39% of the population is living in poverty. Only half of those 16 years of age and older are employed. A mere 17.2% of the population 25 years and older has a bachelor’s degree or higher (and 22.4% don’t even have a high school diploma). 27.4% of the population under the age of 65 has no health insurance. In today’s medical climate, no hospital can survive with this demographic. No hospital district can squeeze enough taxes and reimbursement out of an uneducated, poverty-stricken, unemployed, and under- or un-insured demographic to keep a hospital afloat.

What happened in Crockett is, unfortunately, not unusual. At least 15 rural hospitals have closed across Texas over the last several years. Dozens of counties in Texas have just a single physician – or none at all.

I grieve for Crockett. My brother and his wife live there. I have had the privilege of treating many dear patients from Crockett over the years. We share a compassionate state representative, Trent Ashby, whose rural upbringing cannot be far from his mind in a situation like this. Trent has said he is “committed to working with all of the involved stakeholders to mitigate the loss of existing jobs and help move forward with a plan to increase access to healthcare in our area of the state.” I don’t doubt it one bit. But to be honest, there’s not much he can do. CHI St. Luke’s Health Memorial Lufkin leadership was over in Crockett even before the closing to assist some with employment, but even they can’t come close to softening the impact of nearly 200 jobs lost.

Ultimately, this falls far too heavily on the shoulders of the local Houston County Hospital District board to find a solution. They can’t pull money out of thin air or tax property any higher. And they certainly can’t get paid for healthcare when no insurance coverage or safety net exists. I hope the hospital district board can reassess and reallocate resources to focus on providing comprehensive primary care and prevention services to the citizens of Houston County, at a minimum. They also need to strengthen relationships with surrounding regional hospitals to provide higher level of care services where needed. 

Those of us outside Houston County need to open our eyes. Without a much deeper, systemic and national change in how we allocate and pay for healthcare in this country, what just happened in Crockett is going to be replicated in more and more communities around the country. Let’s help Crockett, but don’t think it can’t happen to us.

*Will Johnson, Senior Reporter for the Messenger News in Grapeland, and Caleb Beames with KTRE-TV have done an excellent job reporting on the hospital closure, and I am indebted to them for some of the details and quotes in this column.

What I Learned in Medical School That Was Wrong

I recently attended my 30th medical school reunion at Baylor College of Medicine in Houston. It was a grand time of reminiscing and reconnecting with war buddies from the trenches of medical school. Part of our reunion weekend included lectures on current hot topics, such as the absurdity and danger of the anti-vaccine movement. But the lecture most of us were anticipating was on what we were taught in medical school that turned out to be wrong.

The topic itself was quite an admission from one of the most prestigious academic institutions in the world. I mean, everything science tells us is true, factual, indisputable, and remains so forever, right?

One example where the teaching of the time was wrong was peptic ulcer disease. When we started medical school, surgery for ulcers was common. Ulcers were thought to be caused by stress-induced excessive secretion of acid in the stomach. The surgical procedure known as antrectomy (removal of the distal end of the stomach) and vagotomy (cutting the nerves that lead to acid secretion) was performed basically to stop acid production. But this was not a small operation. Patients were often left with really unpleasant gastrointestinal issues such nausea, vomiting after eating, and dumping syndrome (abdominal cramps and diarrhea after eating).

What we now know is that ulcers quite often are caused by a bacterium known as H. pylori, which can be easily treated with an antibiotic – to kill the infection – and antacids. Not only was this revolutionary (and simple), but the medical establishment refused to believe it at first. There were many reasons, but it just didn’t fit what they thought they knew. It was, so they thought, a psychosomatic illness. And bacteria weren’t thought to be able to live in the stomach. The Australian doctor who co-led the discovery was so desperate to prove his theory that he even drank a cocktail of the bacteria to prove his point. History shows he was vindicated. The whole bacteria/ulcer connection was a radical idea at the time. Yet it was right, and the two who discovered it were awarded the Nobel Prize in 2005.

In my own field of oncology, there has been significant progress over the last 30 years. We now cure 70% of cancer patients compared with just 50% a generation ago. It was still a fairly paternalistic time in medicine. You didn’t question what the doctor told you to do. Physicians were taught – wrongly – that we should treat all patients aggressively all the way up to the end of life; otherwise, we would be taking away hope and devastating our patients.

In retrospect, it seems obvious that was a ridiculous and cruel assumption. Informed consent demands honesty. Hope cannot be reduced simply to wanting to live one more day at all cost, especially when ravaged by an incurable disease. What about hope for reconciliation with estranged family members? Hope for a pain and symptom-free death? Hope to die at home surrounded by family and friends, not alone in an ICU? Of course, now we have an entire field of comfort care/palliative medicine – including hospice care – to help with end-of-life symptoms and care.

Another example is less about what we were taught that was wrong than with what we just didn’t know. My class of 1987 started medical school in 1983. The AIDS epidemic was so new at that time that we didn’t even know caused it. The human immunodeficiency virus (HIV) – originally called HTLV-III, or human T-cell leukemia virus – wasn’t even called HIV until 1986. Fear and judgmentalism drove much of the public and academic response to this novel epidemic. We even had a classmate die of AIDS before the identification of the virus was made. These were scary times. With HIV/AIDS, we were living in and experiencing a time when urgent research and rapid discovery were needed to fight a terrible (and terribly misunderstood) disease. Our own fear and prejudice slowed that effort down.

I am curious what we will admit to being wrong about when the current medical school graduates have their thirty year reunion in 2047. Perhaps a brilliant discovery about Alzheimer’s, for example, will turn the medical world upside down. That is an illness where everyone would rejoice in acknowledging what we either got wrong or just didn’t know. Of course, more or unique discoveries in the field of cancer prevention and treatment would be welcome. In any case, we must be willing to admit that we don’t know everything there is to know today, and that we just might be wrong about some things. However, in today’s political climate I am not holding my breath to hear a mea culpa from the scientific community any more than when H. pylori was discovered. Maybe I’m wrong…

The Grass is Greener in Lufkin!

Sometimes our medical community gets a bad rap. In any community, there can be a tendency to think the grass is always greener somewhere else. This is true whether we talk about education, retail, quality of life, or in my case, medical care.

I have been accused of being critical of our local healthcare community. Perhaps my commentaries on healthcare in general, and the very real problems we all face, have been taken by some to mean I am not supportive of our local healthcare. Nothing could be further from the truth! 

Those who work with me know that I strive for excellence in all I do, and I expect the same from those who work with me. I have considered it an honor and a privilege to be part of this medical community for almost 25 years now, and had I not found this community to be welcoming, supportive, and high quality, I would not have stayed.

Think about it. We are a town of barely 35,000 people, and we have access to everything from neonatal intensive care to neurosurgery and open heart surgery. (Oh, and excellent cancer treatment as well!) These services are rarely seen in a town our size, and it happened for a number of reasons.

First of all, we are a destination for healthcare for patients coming from many surrounding counties. That give us an effective population of several hundred thousand - enough to support sophisticated specialties. Second, we have had visionary leadership from key physicians over the years. I won't try to mention all who have made a difference - there are many - but I do want to highlight just a few for what I see as having provided a significant and long lasting contribution to local healthcare.

Anyone's list would include Dr. Ravinder Bachireddy, a world-class cardiologist whose incessant focus on quality brought credibility and excellence to local cardiac care at a time when everyone in the state (indeed, the nation and the world) was headed to Houston. Along the same lines, Dr. Bill Shelton and Dr. Kavitha Pinnamaneni, in their respective radiation and medical oncology fields, made it possible for cancer patients to stay at home for outstanding cancer care, unifying many different physicians and surgeons involved in cancer treatment into a nationally accredited cancer program.

Dr. George Fidone's energy, intensity, vision, and incredible skill has brought pediatric care to virtually every child in the area. Our kids are healthier for it. Neurosurgery, neurology and stroke care are as good here as can be found in big cities, thanks not only to local medical leadership but also to philanthropic support. Robotic surgery has been embraced and mastered by our local surgeons and gynecologists to a far greater extent than our neighbor to the north or, frankly, most communities.

An early family practice pioneer, Dr. Anna Beth Connell led the way early on for women physicians to be not only allowed into the good ole boy network but also respected as colleagues. Women now make up the majority of medical school graduates and are coming to Lufkin in record numbers and in all specialties.

Finally, I cannot even begin to talk about healthcare without considering the incredible support of local foundations, especially the TLL Temple Foundation and the Kurth Foundation. Their contributions can hardly be totaled or their impact measured. We struggle at a national level to figure out how to care for all people, but that burden has been significantly lowered at the local level by the incredible generosity of our foundations. For that, I am eternally grateful.

Sometimes we all need a reminder of how green the grass is right here in Lufkin and Angelina County, and what a privilege it is to have the healthcare community and resources we have. Next time you see a local doctor, nurse, or other healthcare professional, thank them for living and working here!

Support Raising the Smoking Age to 21

The 85th Texas Legislative Session is in full swing. On Wednesday, February 15, a bill was filed in the House by Representative (and physician) John Zerwas (R) to raise the smoking age in Texas to 21 (so-called Tobacco 21, or T21 for short). A companion bill has been filed in the Senate. This is truly a bipartisan effort and is a great idea. For decades now, the legal drinking age has been 21. Tobacco kills far more people than alcohol, and almost all long-term smokers start smoking before they reach the age of 21.

Deep East Texas contains the lowest ranked counties in Texas for health outcomes, and part of that is due to our higher smoking rates. Nearly 90 percent of adults who smoke started smoking before the age of 18 and nearly 100 percent started by age 26. 18- and 19-year-old smokers are a major supplier of cigarettes for younger kids, who rely on friends and classmates to buy them. Raising the smoking age to 21 can help decrease our smoking rates as well as save tax dollars on future healthcare spending related to tobacco use.

Speaking of tax dollars, annual Texas health care expenditures directly caused by tobacco use amount to a whopping $8.85 billion, and we taxpayers bear part of that cost. The State Medicaid program’s total health spend as a result of tobacco use is $1.96 billion. No, we can’t save all of that, unfortunately, unless no one smokes. However, Jeffrey Fellows, PhD, in a Center for Health research report wrote, “Increasing the smoking age to 21 [in Texas] would result in 30,500 fewer smokers after three years, and lead to $185 million in reduced healthcare expenditures and productivity costs over five years. Lower cigarette excise tax revenue of $3.4 million would reduce the 5-year net savings; however the state would still generate a net financial savings of just under $182 million.”

It isn’t just about dollars; it’s about lives, too.

The Institute of Medicine predicts that smoking prevalence would decline by 12 percent if the national minimum age of sale was raised to 21. One of their models also predicted that raising the national minimum age of sale to 21 would result in approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those individuals born between 2000 and 2019. Smoking kills.

In case you wonder if the tobacco companies think this will work, here’s a quote from a 1986 Philip Morris report (one of the largest suppliers of tobacco products worldwide): “Raising the legal minimum age for cigarette purchaser to 21 could gut our key young adult market (17-20) where we sell about 25 billion cigarettes and enjoy a 70 percent market share.” To the tobacco industry, it is always and only about market share and profit.

Raising the smoking age to 21 isn’t the only answer to our smoking and poor health epidemic. Many cities and even entire states have gone smoke-free. Texas needs to. Dietary and exercise components of good health also need to be emphasized. But if we can lessen the number of the next generation who start to smoke simply by increasing the smoking age of to 21, why wouldn’t we? That’s right… there is no good answer. For a healthier Texas and Angelina County, support Tobacco 21.