TMA Sesquicentennial Article -- January 2003
By Marilyn Baker
From the beginning, Texas doctors have been a scrappy lot. They have to be.
On the rugged Texas frontier in 1853, there had been few, if any, safeguards for the public's health. Quackery was rampant. Without licensing laws, there was no effective way to assure scientific and ethical standards among practitioners. The first medical school known to be attempted was three years from opening. Newspapers were the primary source of medical information; there was no medical library, no medical journal, and no statewide meeting to share new science, case reports, or mutual problems. There was no state board of health. It was in this setting that 35 doctors set out to change things by forming the Texas Medical Association
By 1953, a century later, Texas had more than 8 million people, with two-thirds of the population living in or near cities. Now more than 6,000-strong, TMA had long been a vigilant watchdog on all matters of health care, medical ethics, and medical education; a publisher of a medical journal; an overseer of a clinical library; host to an annual scientific convention; and a source for communities needing a new doctor.
It also had just completed another hallmark of progress, a new home across from an old city park not far from The University of Texas campus and the state Capitol. The new "library and Texas Medical Association headquarters building" offered pleasing views of a tree-shaded creek and sunny meadows in front with a leafy bluff in back. The structure of polished white limestone blocks and granite trim symbolized the attitude physicians wanted to convey: dignity, stability, and permanence. Upstairs were offices for the association and, with nearly all of its members being men, a Woman's Auxiliary. The first floor comprised the library and meeting rooms, and below was a basement for storage, cooling and heating equipment, and a photographic darkroom. N.C. Forrester, the TMA executive secretary, managed a staff of 10.
The 1950s were fertile breeding grounds for dramatic transformations that worried TMA leaders. The beloved system of private practice, reminiscent of the kindly family doctor hovering over a patient's bedside through the night, would evolve as few doctors or patients in 1953 could imagine.
The association marked its first 100 years on Jan. 17, 1953. Four months earlier, then-U.S. Sen. Lyndon B. Johnson had foreshadowed what lay ahead when he spoke at the dedication of the new building. In 1953, the year that James Watson and Francis Crick discovered the double helical structure of DNA, few people beyond those in esoteric laboratories could imagine what an incredible future was in store for medicine. The senator, however, tapped into the desire to cure some of the era's more prominent diseases, foreseeing the day "when all great health movements would be launched . . . the day when programs to fight cancer, tuberculosis, polio, and heart disease will be inaugurated and broadcast from this center."
Aware, however, of the mounting political concerns of physicians, Senator Johnson reviled "socialized medicine," an inflammatory issue in medical circles for most of the 20th century. The subject struck particular fear into the ferociously independent, private practitioners of the 1950s. In the post-World War II era, there was a predominant dread of Soviet-style communism and the worry that it would ride subtly into the American system on the back of socialism. To physicians, this meant one thing: government control of medical practice, as had occurred in England, and medical education. Senator Johnson knew these fears and rebuked the British system of government-managed medical care, characterizing the British doctor as a civil servant who "punches the time clock and dispenses medicine by government regulation."
"In this country," he declared, "we stand no immediate danger of falling into this system. Our people have too much confidence in their doctors. They will look about them and see what their doctors are doing for the community on their own initiative. They will see that the profession is meeting the challenges of the day, that it is taking a positive program to combat the illness of the modern day. It is not for the government, either in this county, state, or national level, to institute a system of medicine for its citizens."
Instead, he called for cooperation between medical associations and individual citizens. "Through that cooperation," he said, "we should strive to make good medical care available to good people regardless of their station in life."
In later years, some listeners would find themselves disagreeing over at least one law he would sign as president. Still, as he had predicted, many great programs, sometimes after heated debate, would be launched through the "center" he was helping to dedicate.
The so-called quiet days of the 1950s were laden with issues that would implode and explode, wax and wane, during the next 50 years. In the mid-20th century, debate in the TMA House of Delegates on matters of public health and various issues bedeviling medicine would be intense, even eloquent, with impromptu speeches lasting into the night. The decisions would be taken to the floor of the American Medical Association House of Delegates, to other medical groups for support, to the public, and to the halls of the state's and nation's capitols.
Health Insurance for the Aging, the Poor
In the nation, there was growing sentiment for greater support of health care costs for the poor and the aging. Physicians feared, however, that some of the mechanisms being considered were misguided and leading toward socialized medicine. In one doctor's words, they must fight "tooth and toenail" to keep the system of medical care they believed was the world's finest. Too, they felt they were doing their part in caring for patients who had little or no means to pay.
TMA had been a staunch defender of the private practice of medicine with its fee-for-service approach. In Congress, with pressure to provide relief for the growing number of aging citizens, one idea under consideration was linking health care insurance to the Social Security Act.
Truman C. Terrell, MD, of Fort Worth, outgoing TMA president in 1953, was among many medical leaders warning of the consequences.
"We must be resolute in our defense of American medicine," he warned the TMA House of Delegates, ". . . we must be more vigilant now than ever before. I believe that in the succeeding Congress, much will be done to determine the destiny of American medicine and to lay the foundation for moving forward, or falling back in the care of the health of our people. . . . the next 10 years will see us more concerned with the encroachment of Social Security upon the free and vigorous stream of American enterprise than at any other time. I believe that in the unbridled development of Social Security probably lies the best route to eventual dictatorship in this country. Surely, unless carefully guarded, it represents an easy route to destruction of American medicine as we know it today."
TMA also supported a voluntary health insurance system, primarily an indemnity system, to help defray health care costs, and worked to develop concrete programs. It waged fights against compulsory health insurance proposals in Congress. Nevertheless, in 1956 the association participated in a federal "experiment."
Congress had established the Military Dependents Medical Care Program, then popularly called Medicare, although it preceded the now more familiar one for people 65 and older. State medical societies were asked to administer the program, and Texas was a key state to the government. Still dotted with military bases from World War II, it had nearly one-sixth of the 2 million beneficiaries.
In a special called meeting in September 1956, TMA delegates agreed to coordinate the Medicare program, with Blue Cross and Blue Shield of Texas (BCBS Texas) as the fiscal agent. After some delay and the involvement of 32 specialty groups to review fee schedules, the association entered into a contract with the government on Jan. 1, 1957. From the start, there was uneasiness about the decision.
At the annual session of the House of Delegates in 1957, TMA President Milford O. Rouse, MD, Dallas, observed that, with the statutes on the books, the medical profession had little choice but to cooperate if it could honorably do so. By remaining involved, he said, TMA doctors would have a "right to make suggestions or objections that may result in improving Medicare, particularly in making it more equitable. If we ever decide to withdraw from active participation, our influence as one of the larger groups of doctors in the country will be difficult to be exerted."
BCBS Texas reported that Texas doctors were filing 183 claims daily, averaging $75, and the TMA Board of Trustees recommended that TMA remain involved another year. The delegates, however, were deeply divided and many were in no mood for pragmatism. Their sympathies lay with the minority report of a reference committee, which said, "the subsidization of medical care as now established under the Medicare program is an entering wedge for progressive interference with the private practice of medicine and with the contractual arrangement between physician and patient inherent in the policy and precepts long established by the Texas Medical Association."
Outgoing President Denton Kerr, MD, of Houston, delivered an expressive impromptu speech, calling the program a "conspirator's dream," and citing the potential for red tape, division in the medical profession, loss of freedom, high cost, and confusion.
R.W. Kimbro, MD, of Cleburne, chair of the Board of Trustees, was equally concerned that Social Security would continue to grow unless "we put brakes on it," but added, "we must look at this realistically and not idealistically." Still, the House voted to immediately terminate the 16-month contract.
Later, the Office for Civilian Health and Medical Program of the Uniformed Services oversaw the dependents' program. TMA continued to work for physicians to encourage the concepts of "usual, customary, and reasonable fees" and direct billing to the patient.
Health insurance remained a major issue, and in 1959, Howard O. Smith, MD, of Marlin, declared in his presidential address, "It seems that we are always living in troublous times, however, momentous decisions await this group and other legislative bodies in our country today, and these will have a far-reaching effect on the citizens of the United States and our patients. Something must be done to help solve the problem of those individuals who are unable to pay full amounts for medical and hospital attention and care. We must aid them in being able to select insurance most helpful to them. We do have the support of the insurance companies."
The national consciousness about the problems of the aging was growing. In 1960, Elizabeth C. Thomason, MD, chair of the TMA Committee on Aging, wrote, "Physicians have controlled fetal death and early mortality from infectious conditions so rampant two decades ago, and thus the rate of the aged population has increased rapidly." She called upon Texas physicians to be involved in the issues of aging and disabled persons.
In searching for the best solutions to the health care needs of older people, TMA and AMA supported the Kerr-Mills bill, a federal-state matching program allowing states options to establish the scope of benefits, standards of eligibility, administrative mechanism, and payments for services. The program was put in place in 1962 in Texas, and the state used the matching funds to purchase health insurance from Blue Cross and Blue Shield of Texas for elderly recipients of Old Age Assistance funds. The Kerr-Mills approach reportedly was working well, and though some thought no other amendments to the Social Security Act were necessary, in 1965 Congress approved two more programs. The new Medicare program had limited health care coverage for persons over age 65, and Medicaid provided support for people of lower income who qualified. On July 30, 1965, President Johnson signed the amendments into law, leading to a watershed of change for health care in the United States.
Advocacy to improve the health of Texans had been TMA's focus since the outset, and there had been many results: state licensure of physicians to maintain standards of care, strict ethical requirements for members, excellence in medical education, and stronger public health laws. Now, however, TMA's advocacy role would become more complex, reaching deep into the bureaucracies of government, insurance companies, and other institutions that would affect patient care. The efforts to preserve the unfettered private practice of medicine would continue, but the physicians of the 1950s and their successors would find themselves learning to negotiate their way through myriad regulations that were foreign to their experience.
From Fluoridation to Molecular Science
TMA addressed many other topics in the 1950s: fluoridation of community water supplies; warnings about carcinogens, including chemical additives to food; air pollution; and industrial side effects. It cooperated with the Texas Agricultural Extension Service to provide information to rural residents regarding "economic poisons" and issued a brochure to help physicians treat poison cases. The association reviewed problems of migrant and "bracero" farm workers and sought to help them with an insurance program. It supported efforts to overhaul the mental health system, which eventually led to the development of community mental health care programs.
Under study, too, in the 1950s were maternal and child health care, cancer, heart disease, and the status of tuberculosis sanitariums in the state.
From aerospace medicine to nuclear medicine, TMA members were involved in the transformation of Texas and the world. They were closely associated with activities at the Johnson Space Center in Houston and at Cape Canaveral in Florida. In 1959, the Texas State Journal of Medicine (now Texas Medicine ) carried an article entitled, "Space Medicine, A New Science," a report from Randolph Air Force Base's Division of Space Medicine in San Antonio. In the December 1967 TMA journal, Wernher von Braun, PhD, director of the George C. Marshall Space Flight Center in Huntsville, Ala., detailed how space programs could be used to bring about a richer and fuller life for man on earth.
There remained down-to-earth debates, however, and among those lasting several House of Delegates sessions was one on fluoridating community water supplies. The controversy would continue until 1964, when, without debate, the delegates endorsed fluoridation as a safe public health measure.
TMA from the beginning had focused on the ethical behavior of physicians, and the Board of Councilors in the 1950s played a strong role as an appeals court, conducting trials for physicians appealing grievance decisions of their county medical societies. The board faced many new quandaries. In the 1960s, a little publicized field called molecular biology began accelerating, with results that would lead to the use of new words like biomedical, biotechnical, and bioethics. Issues such as artificial extension of life would become topics of scientific and ethical debate.
Sometimes there would be practical solutions based on science, and, in the late 1970s, for example, TMA supported a definition of brain death that would assist both practitioners and the public in making decisions. Many other areas remained, however, where advances in medicine and science continued to outpace established positions on ethics. All required attention. Social issues spilled over into medicine, and physicians increasingly would have to deal with areas such as child and elder abuse, domestic violence, teen pregnancy, intentional gunshot wounds, and more.
In the 1950s, the United States needed a good supply of physicians for the armed forces in its battle to stop the spread of communism into South Korea and later in Vietnam. A growing fear that the Soviet Union would launch a nuclear attack against the country led to the construction of missile defense systems in Texas. From transportation to medical care and blood supply, TMA prepared for a disaster of any kind that might occur in the state.
Despite the war in Korea, TMA delegates in the 1950s were not happy with the policies of the Veterans Administration, the physician draft, and the scope of services for veterans.
"We must insist that the medical treatment afforded him be for service-connected disability only," said Dr. Terrell, "and we must stand resolute against efforts to place the Veterans Administration in an ever-increasing area of nonservice-connected disability treatment. We must support the sound logic that, where treatment of veterans' dependents is concerned, such treatment should be by contractual arrangements with private physicians and hospitals, rather than by wholesale drafting of doctors into the armed services and unbridled expenditure of taxpayers' money to build a vast network of federal hospitals."
Although cooperating with the draft, the state's medical schools also felt a sense of hardship regarding the sizable number of teaching physicians being called into military service.
Public Relations and Organizational Growth
Of great concern to the association in the 1950s was the physician's image and public relations. In 1954, C. Lincoln Williston was elevated to executive secretary and sought to enhance public relations through greater liaison with county medical societies and civic groups. He began delivering a speech, "The Best Medical Care for All Texans," throughout the state. He created a more efficient and effective organization, with more active committees and bigger and better programs such as the annual session (nowTexMed), the library , the journal , and good insurance programs for members. The association integrated specialty societies into its annual session and intensified its legislative efforts.
Some doctors were still relocating after returning from the armed forces and postgraduate training. Others, some of whom had served in World War II, were being called into the services to support troops in Korea, and the TMA placement service helped communities and physicians find each other.
The Board of Trustees assured the association's solid financial base by paying off the mortgage on the new building in 1959, setting up building reserves, and increasing income through journal advertising and exhibits at the annual meeting. The scope of TMA programs, however, already had increased and the six-year-old TMA building had to be remodeled for space that summer. The modifications would serve the association until the mid-1970s, when the growth of services would lead to the acquisition of three other nearby buildings.
Another issue of great debate in the 1950s resulted in the establishment of an orientation program for membership, which Mr. Williston said at the time "more than any other single program is introducing purposes and programs of the association to our new and transfer members." The Medical Student Day program was taken to the campuses of Texas medical schools to orient students about the goals of the profession and the association.
Another uneasy internal issue for the association in the 1950s pertained to membership of African-American physicians. In 1952, TMA delegates approved the Lone Star State Medical Association, composed of African-American physicians, as an affiliated organization, and asked AMA to recognize it. The AMA constitution, however, did not permit two organizations from one state, thus African-American physicians wanting to join AMA had to become TMA members. The TMA constitution, on the other hand, stated that its individual members must be "white."
In 1953, Tate Miller, MD, of Dallas, 1948-1949 president and chair of the TMA Committee on Negro Medical Facilities, pled for further action.
"Your chair has been invited to meet with Negro doctors but is disinclined to meet with this group and make a speech telling them that the Texas Medical Association loves them and wishes them well, but refused to do one positive thing for them and may slam in their face the real door of opportunity that leads to the blessings of organized medicine, which door should and so easily could be opened to them."
He asked the delegates whether they wanted his committee to continue its efforts to remove the word "white." "If you vote to continue, I shall proudly carry that message to the Negroes. If you vote that we discontinue, I shall carry that message, but with shame and deep humiliation."
The delegates agreed that the committee should continue its work, and in 1954 concurred with the intent of a resolution to delete the appellation. Constitutional changes required a layover of one year before final action, and in 1955, delegates voted by secret ballot to delete "white" from the association's constitution and bylaws. Of 134 members casting ballots, 102 voted favorably.
Gradually, the delegates also changed their policy regarding osteopathic physicians. In 1967, TMA adopted the position that "Doctors of Osteopathy who practice scientific medicine on an ethical basis are not cultists." In 1971, it voted to allow them to become members, and in 1972 they were eligible to join.
In 1973, the association also added the invigorated medical students of the 1960s to its member roster.
Conquering Disease and Injury
For the practicing physician in the 1950s, antibiotics allowed the healing of more people more quickly. There were advances in laboratory methods, including methods for growing viruses in tissue cultures with subsequent advances in virology. Though not widespread, intravenous therapy would be used to treat dehydration, historically a cause of high death rates in children. In laboratories, where pathologists were seeing large tumors, they gradually would start seeing much smaller ones, and following the routine use of the Papanicolaou smear in practice in the 1950s, cancer of the cervix would begin subsiding and be almost wiped out by the mid-1980s.
Poliomyelitis remained frightening, and patients and physicians saw the consequences firsthand. George Thannisch, MD, of Lufkin, a former member of the TMA Board of Trustees, reported seeing 42 patients in iron lungs in 42 days during his first residency at the Southwest Polio Center in Houston. "When I returned from the Navy -- after Salk vaccine -- the center had been turned into an OB ward because there was no more need for it," he said.
Ruth Bain, MD, 1982-1983 TMA president and an Austin family physician, recalled the daily terror of parents and also watched helplessly as her niece died of bulbar polio. Then she had the experience of thinking she, too, had come down with the illness. From her hospital bed, she could hear the pumping of the iron lungs across the hall where her niece had died. Fortunately, Dr. Bain recovered and wondered years later whether she had contracted a Cocksackie virus instead of polio.
In 1954, Jonas E. Salk, MD, began inoculating schoolchildren with his antipolio injectable killed virus, and in 1956, Albert Sabin, MD, developed his more effective attenuated live virus vaccine. Soon, Texas physicians began inoculating patients, participating in many local drives to stop the dreaded virus. In 1959, an article in the Texas State Journal of Medicine reported an 85-percent decline of polio incidence in the country during the three-year period ending in 1957, but also noted that paralytic polio was increasing among preschool-age children.
By 1961, a poll of deans of medical schools cited more medical progress, including "a unifying concept" on the cause of cancer emerging late that year. "Cancer, no matter what," the report said, "is the result of a change in the chromosomal nucleic acid (DNA) of the affected cells. The arrangement of subcomponents of DNA forms a code in which all of the heritable information needed by the cell is stored. Apparently, cancer is caused by a particular, though as yet undefined, change in DNA structure which alters this information code."
Cited also were medical genetics, new pharmaceuticals, such as those for polio (especially the live-attenuated) and measles, and synthetic penicillin. In addition, the deans noted progress in the application of electronics and computers to medicine, and tests under way on mumps vaccine, plus the isolation of the hepatitis virus.
Smallpox, the scourge of early-day Texas, would be declared eradicated by the World Health Organization in 1980. Regardless, new public health challenges such as AIDS would emerge, and old diseases would return. In 1989, TMA mounted a major campaign to heighten awareness of poor health conditions along the 1,254-mile Texas-Mexico border.
Texas doctors in the 1950s adopted positions on industrial, environmental, and lifestyle impacts on health. In 1955, alcohol advertising was eliminated from the Texas State Journal of Medicine . Smoking had been a rite of passage for many, a social and leisure activity, and encouraged in the military services. Routine instructions to staff for committee meetings in the 1960s were to set out "pencils, writing pads, and ash trays" as a courtesy to doctors during the meetings. The dangers of tobacco, however, became a greater issue in the United States after 1964 when Surgeon General Luther Terry released a major report on the consequences.
In 1977, the House of Delegates forbade smoking during TMA functions, and in 1989, smoking was prohibited in TMA buildings. The association strengthened its efforts on behalf of the health of Texans, supporting a number of measures that would discourage smoking, including an antismoking campaign in 1989.
Political and Legislative Matters
Virtually every topic in medicine at one time or another involves state or federal legislation, and in this arena TMA has been considered a leader. The association would develop policy on narcotics, drug addiction, medical aspects of automobiles including the use of seatbelts, bicycle safety and the use of helmets, school bus safety, cancer, heart disease, stroke, sexually transmitted diseases, and organ donations. A variety of federal promulgations had the attention of Texas doctors and the association. In 1959, Sen. Estes Kefauver began scrutinizing the pharmaceutical industry, and hearings ensued in the 1960s, which caused drug companies to provide detailed disclosure regarding their products in advertising and patient information.
After passage of Medicare and Medicaid in the 1960s, there was an onslaught of federal regulations to address. The new regulations would bring an array of acronyms to both governmental and private medical programs, and each time, physicians would have to adapt to the confusing array. This meant TMA would play an ever-greater role in helping physicians through the mazes, serving as advocate for patients and physicians alike as different proposals and formulas for cost control and even rationing of health care were put forth. More than 100 amendments to the Medicare law, for example, were passed in 1972, including the establishment of professional standards review organizations (PSROs) to review Medicare services.
TMA sought to assure that governmental programs were run fairly and appropriately through physician peer review rather than governmental review. When there was an effort to divide the state into nine different PSROs in the early 1970s, TMA fought valiantly for a single statewide organization while also working for repeal of the law establishing PSROs. In 1973, the House of Delegates also formed the Texas Medical Foundation "to preserve the physician-patient relationship, perpetuate freedom of choice for the patient and physician, promote distribution of medical and health services for the people of Texas, and protect the public health." The "sole guiding principle" of TMF was "to insure the continuing improvement of quality of care in this state as Texas physicians have always done."
There were frequent mutations in mechanisms for government health insurance programs, and in 1984, TMF contracted to manage the government-established peer review organizations and began reviewing treatment of Medicare beneficiaries.
The recurring issue of professional liability, peaking at times, may be seen throughout the history of the past 50 years of medicine in Texas. In the 1950s, the association's Council on Medical Defense addressed the medicolegal problems confronting individual physicians, providing data and brochures such as "Facts to Protect You and Your Patient" that were mailed to members. A crisis in professional liability insurance occurred in the 1970s, and, though partially solved by a number of association-supported-and-sponsored tort reforms, again became acute in the early 21st century.
In early 1980, the Texas State Board of Medical Examiners (TSBME) was up for evaluation under the state's new Sunset Act, and that meant that the entire Medical Practice Act would be opened for review, including the definition of the practice of medicine. TMA studied all existing laws and relevant information and established a key principle: that the current system, which had evolved over a period of 70 years, was sound and workable and should be continued to protect the public health. It also developed 12 other principles, among them greater reporting from medical peer review committees by insuring legal protection, confidentiality of patient information, and expansion of the TSBME to include three public members.
The "sunset" process was repeated in 1993 and is scheduled again for 2005.
Advocacy remained a major TMA thrust, but there were many new fronts. In the latter 1980s, the association developed a campaign to improve the fairness and quality of the Texas Supreme Court, garnering grassroots support throughout the state. The "Clean Slate in '88" campaign mounted by TEXPAC , TMA's political arm, changed the face of the Texas Supreme Court and made it less friendly to trial lawyers.
TMA further enhanced tort reform legislation and, in addition, developed the Hassle Factor Log in the early 1990s to gather complaints. The log documents payment and other problems doctors have with insurers and is used by TMA's Health Care Financing Department staff in meetings with carriers and by the Legislative Affairs Department to develop legislation to correct problems. TMA also increased the number of practice management seminars presented around the state.
In 1986, Mr. Williston retired. Robert G. Mickey, who had been the first executive director of TEXPAC on a part-time basis, became executive vice president of TMA in 1987, and during his tenure the association underwent more expansion of services.
TMA constructed a new 10-story building at 401 West 15th Street. The view from the building offered a broader horizon than the 1952 structure and included the Capitol, The University of Texas area, downtown Austin, and a panorama of the city's western hills.
The new executive director reorganized staff to meet the needs of a changing membership and saw the expansion of the role of the Board of Trustees, the enhancement of the TMA insurance program, an integrated planning and budget for the association, development of a new corporate identity with the theme "Physicians Caring for Texans," and an invigoration of the association's public health role as well as greater advocacy in the realms of public affairs and socioeconomics. During this era, also, the association developed a major campaign to fund the TMA Foundation and created the first science teachers award to encourage and support the advancement of science in the state.
Medical Education and Physician Supply
A perennial TMA focus has been the supply and distribution of physicians, and much work was under way in the 1950s on the needs of a growing population. The association endorsed the concept of a third medical school in The University of Texas System, leading to the establishment of a school in San Antonio. John Smith, MD, 1977-1978 TMA president, was devoted to the establishment of the school and recalled that one disadvantage his city found was a shortage of hospital beds. Consequently, in the mid-1950s, he called on TMA and others for help in supporting a new state law providing for hospital districts in Texas.
The dominant bloc of membership in the House of Delegates belonged to physicians in general practice, but a hot topic was the number of specialists. Family doctors, said the chair of the Committee on Rural Health and Doctor Distribution, were increasing proportionately after a lull brought on by World War II, "which created a preponderance of specialists in 1940." According to the committee, 71 percent of the doctors were general practitioners in 1940, whereas in 1950 that figure had dropped to 47 percent. The committee also sought to induce physicians from overcrowded areas to move to more sparsely settled areas. It concluded further that there were a sufficient number of specialists to meet the state's needs.
AMA had established the American Fund for Medical Education (AMEF) to assist medical schools that were operating with deficits, and in 1960, May Owen, MD, the first woman president of TMA, called for donations to AMEF. "We are faced with two grave dangers -- possible deterioration of the quality of our medical schools and possible complete socialization if federal aid is accepted," she said. Federal funding of medical education, however, would become a reality. TMA nevertheless would continue to assist medical students in the state through funds donated by Sam Thompson, MD, of Kerrville, and his wife, and by Dr. Owen and others.
Meanwhile, TMA was expanding its efforts to encourage students to take up health careers and supported the increasing enrollments at the three existing schools in The University of Texas System; the establishment of The University of Texas Medical School at Houston, which would open in 1971; state support for undergraduate medical students who were Texas residents at Baylor College of Medicine, Houston; and the authorization of a new medical school in West Texas under the Texas Tech University System, which would open in Lubbock in 1972. Texas would also see the development of other schools, including the Texas College of Osteopathic Medicine, later the University of North Texas Health Science Center at Fort Worth, which first accepted students in 1970, and Texas A&M College of Medicine, which opened in 1977.
In all, Texas saw the addition of five medical schools and a tripling of enrollment between 1966 and 1977. The association supported full funding of the state's medical schools and, to encourage physicians to remain in the state and serve in needed areas, developed legislation to expand primary care residencies. By the turn of the century, the eight medical schools in Texas were graduating more than 15,000 physicians yearly.
TMA also continued its support of lifelong continuing education for physicians. Historically, it had favored voluntary continuing medical education (CME), focusing on program excellence and member needs spanning formal and informal studies and even telemedicine. Since the 1970s, the association has served as an accrediting agency for intrastate programs in Texas. In 1995, CME hours became a prerequisite for the annual registration of a physician's license in Texas, and physicians must now maintain 24 hours of CME each year, including 1 hour of study in medical ethics or professional responsibility.
For Texas medicine, it had been an incredible journey since 35 doctors traveled by horseback to establish TMA in 1853, and perhaps more amazing since the 1950s, when medicine was barely on the cusp of space medicine and the new discoveries in molecular biology. By the beginning of the 21st century, Texas had nearly 21 million inhabitants, and instead of 35, TMA had more than 37,000 members. The state had developed world-renowned medical centers and medical schools, and in 1985, medical researchers in Texas began receiving Nobel prizes. The changes were startling, coming out of a century that had seen the first private pathology laboratories with crude equipment and a menu of slightly more than 20 analytes transform into sterile rooms lined with computers and more than 1,000 analytes.
But there were new worries, and diseases rarely seen in laboratories of modern-day America had the potential to return. The nation's tragedy on Sept. 11, 2001, exacerbated fears of terrorist activity, including bioterrorism. With the dispersal of anthrax agents through the mail service following the air attacks on New York and Washington, there was greater concern about intentional spread of disease. To help physicians recognize, diagnose, and treat unfamiliar biological, chemical, and viral agents, TMA established the Bioterrorism Task Force and produced a tool kit, "Physician Protocols and Patient Information on Biological Agents." Published as a supplement to the January 2002 issue of Texas Medicine and made available on the TMA Web site, the kit focused on the four most likely weapons of terrorists: anthrax, botulism, plague, and smallpox.
TMA's quick responses on behalf of members and the public perhaps led MedicalEconomics magazine on Aug. 6, 2001, to pose a question, "America's Best Medical Society?" With that as a headline, the article cited recent advocacy successes, and declared that TMA was "flexing political muscle with stunning success."
Among the examples cited was the association's campaign to effect change in the Texas Supreme Court. Medical Economics observed that back in the 1980s, "many Texas physicians believed that the top court's malpractice decisions were tilting disproportionately against them. Starting in 1987, TMA launched a multifront campaign to unseat what it viewed as plaintiff-friendly justices. By rallying the grassroots and backing doctor-friendly candidates (Texas justices are elected), the campaign succeeded beyond anyone's expectation. During this same period, the TMA joined forces with other groups to assure passage of some of the hardest-hitting tort reforms in a decade. . . . In the years since, the TMA has flexed its political muscle with stunning success -- pushing through measures in the areas of patient protection, HMO liability, and physician collective bargaining. It was also a key player in brokering a voluntary agreement between Aetna and the Texas attorney general that addressed a range of physician complaints."
Over the years, TMA has filed other suits against groups that it felt were not properly treating physicians and patients. For example, in the 1980s it filed a suit that led to preferred provider plan rules designed to permit patient freedom of choice in indemnity plans, and stopped federal recoupment of $15 million from 5,000 physicians and 200,000 patients. It sued Aetna and Humana for deselection without cause, resulting in many physicians being "reselected."
Then in 2001, with other state medical societies, the association sued several HMOs that physicians believed were guilty of abuse by denying care and making late payments. TMA also asked the Texas commissioner of insurance to better enforce the state's "prompt pay" laws.
Of TMA's prompt pay efforts, Medical Economics said, "TMA took a double-barreled approach to the issue of prompt pay by insurers: First, it lobbied Insurance Commissioner José Montemayor to do a better job of enforcing prompt-pay laws already on the books. Responding to a TMA invitation to visit county medical societies, Montemayor barnstormed the state. He learned that insurers were routinely flouting the rules he'd issued only months before, and that Texas doctors were steaming. 'There were places where a couple of hundred doctors and their staffs had come together, and it was really like an angry mob,' says Kim Ross, TMA's charismatic vice president for public policy, who accompanied the commissioner on his tour."
The insurance commissioner subsequently appointed an ombudsman to handle slow-pay complaints.
No one can say that the journey through medicine in Texas has not been fascinating. And as in the days when doctors rode horseback to the state capital to form the Texas Medical Association, the individual physician drives today's association activities. As Medical Economics quoted Louis J. Goodman, PhD, TMA's current executive vice president, "Everything the association does is grounded on what's actually happening out there in all parts of the state and the grassroots."
Communication changed dramatically over the years. The TMA journal evolved from a peer-reviewed publication to a magazine. TMA established a newsletter, TMA Action , and electronic communication media to reach members and the public. As the Internet became a more dominant source of information, TMA developed a strong Web site accessible by members and the public. Physicians had almost unlimited access to information. They could readily access more than 15,000 peer-reviewed journals worldwide or they could obtainonline searches through the National Library of Medicine, which reported that more than 400 million searches are conducted through its MEDLINE each year.
Along with its zeniths, though, physicians had seen many disappointments and frustrations with the evolving health care delivery system. Texas had experienced deep tragedies and disasters during the 50-year journey. Texas physicians were there to look after the victims of events such as the assassination of President John F. Kennedy and the wounding of Governor John B. Connally in 1963; the Whitman shooting in 1966 at The University of Texas campus in Austin; hurricanes, tornadoes, and floods; and the Branch Davidian siege near Waco in 1993.
Within TMA, there had been a significant increase in the number of women and growing ethnic diversity. Many more physicians were graduating from the state's schools and undertaking residencies in Texas. The number and type of specialties practiced by physicians boggled the mind. As of Dec. 31, 2001, TMA membership had reached more than 37,000, including 31,017 physicians and 4,159 medical students; 77 percent were men and 23 percent women.
Of the 1,225 degrees conferred by Texas medical schools in 2001, 774 were to white graduates, 40 to black graduates, 141 to Hispanic graduates, and 258 to Asian graduates. Six were listed as Indian, 3 as international, and 3 as unknown. The division by gender showed that 738 were male and 487 female. Of 1,311 entering students in medical schools in the fall of 2001, the numbers of women were reaching that of men: 605 to 706. There were 55 blacks, 173 Hispanics, 259 Asians, and 5 Indians; 9 were listed as international and 30 as unknown.
The 35 doctors back in 1853 and those 6,000-plus physicians in 1953 would marvel at a very different Texas Medical Association at its sesquicentennial celebration. Backed by a strong staff, there had been many great contributors to its growth: the officers and board, council, and committee chairs; delegates from county medical societies and specialty societies; and delegates to the AMA. There had been physicians who worked quietly in the trenches to accomplish medicine's goals and an array of prominent leaders (and sometimes mavericks) who inspired action. Some great old faces had disappeared and some eager medical students who had been added to the roster in the 1970s would become dynamic leaders, rising to prominent posts in AMA as well. The Woman's Auxiliary had become the TMA Alliance and comprised both men and women.
In 1996, Dr. Goodman was named TMA executive vice president and chief executive officer and is guiding a highly trained and knowledge-based staff in an ever-greater advocacy role, including more specialized and personal services for physicians and their patients.
The number of programs to manage, issues to analyze, and legislative and public affairs matters to oversee are beyond listing. But the work of the association goes on, the dreams remain big and maybe even bolder. And Texas physicians remain intent on delivering the best medical care to all Texans.
Marilyn M. Baker, CAE, is the author of two books, Caring for the Children: The History of Pediatrics in Texas and The History of Pathology in Texas . She is coauthor with Ruth M. Bain, MD, of Doors Will Open for You: Memorable Experiences in My Life as a Doctor . She also was director of the TMA Division of Medical Information, which comprised several departments, and the Office of Strategic Planning, and is a former editor of Texas Medicine .
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