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Opinion and Commentary from TMA

Every Word. Every Visit. Every Vote.

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May_Runoff

As part of the Texas Medical Association Leadership College this year, I visited the state Capitol to meet some of my local representatives and their staffers.

Register now for 2019's First Tuesdays at the Capitol.

I hadn’t been to the Capitol probably since I was at Girls State (a government-in-action learning program for young women) nearly 20 years ago. Not much has changed. The grandeur of the architecture. The billiard-green carpet in the Senate chamber. The unimaginable underrepresentation of women and minorities in the old black-and-white photographs of sessions bygone (but that’s for a different blog post…).

Munch_HeadshotAs I was walking up one of the ornately engraved staircases, I commented to my friend about how I almost didn’t feel like I belonged there, like I was a child sneaking into a fancy castle, a place for grown-ups and rich people. And he told me, “This is YOUR house! Just as much as it is anyone else’s.”

How many of us feel like we don’t really belong among “those people?” People who are making decisions that affect health care (and myriad other issues) for everyday Texans? Even as a doctor (perhaps because I am a doctor), I felt horribly out of my element. But the beauty of our democracy is that, at its core, it is still a rule of the people, all people, represented by those we entrust to be our voice in those hallowed chambers. 

You. Anyone. You can be that voice. With every word, with every visit, and with every vote. 

Every word — did you know that every call you make to a representative is logged? Tabulated? And given to the representative? It is!! If you have an opinion on a current legislative issue, or have an idea of your own, reach out! The representative’s staff read, listen, and often respond to your comments. Representatives are trying to poll their constituents to figure out where they should vote on an issue, and what they should stand for. If they don’t hear from you, they can’t represent your ideas!

Every visit — did you know you can walk into the Capitol and visit any office? Meet with the staff or even the representative? You can!! It’s not just for attorneys, or lobbyists, or rich people. Sit down with the staffers, develop a relationship, be their go-to expert on your field of study or interest. Pro-tip: If you're part of a group with some well-thought-out ideas, you’re more likely to score an appointment with the representative personally (photo-op!) Also, remember that the Texas legislative session takes place for 140 days every odd year (like 2017, 2019). So target those visits during downtime, like in even-numbered years (NOW), when elections are on the horizon. Which brings me to …

Every vote — did you know that your vote counts the same as mine? As much as the governor’s? As much as that guy whose political opinions you despise? It does!! Representatives are there because we voted them there. Love what Rep. Jane Doe did for health care? Convince your friends to reelect her! Did Rep. D. Vader not listen to any of your concerns when you called his office? Vote for someone else and tell your friends why you did. Not on Facebook. In real life. 

My visit to the Capitol was an eye-opening opportunity for me to re-engage with the legislative process, one I felt far too removed from for many years. That opportunity is there for you, too. Come walk that staircase with us, in OUR house. We’re ready to go.

Erika Munch, MD, is an obstetrician-gynecologist, reproductive endocrinologist, and infertility specialist in San Antonio.


What Is It Like to be Dying? An Interview With My Dad

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This story was originally published on Sarah Freymann Fontenot’s blog, Fontenotes.

As I mentioned in a recent Fontenotes, my parents both went on hospice in March. In the ensuing months, we have had many talks about dying and all the physical, emotional, and financial needs that surround this last stage of life.

My parents are exceptional. I mean that beyond my view as one of their four kids; from any perspective they are unusual. Mom (93) and dad (96) live independently in a lovely retirement center in Providence, RI, have fully functioning minds if not bodies, and are actively involved with their family and the world. (Negotiating turns with the New York Times is the closest they come to a sport these days.)

They also offer a unique insight into what it is like to be facing death so imminently. Mom is a nurse involved in social justice issues all her life; dad is a retired physician (hematology-oncology) and medical academic (teaching at Harvard [University] and  University of Connecticut medical schools). 

I thought I should interview them about what it feels like to be dying. As mom has stabilized and is significantly the healthier of the two, we have decided to complete her interview down the road. I dedicate this Fontenotes to messages from my dad.

A bit about my dad

My dad is a physician (Harvard ’46) who published extensively over the years in the New England Journal of Medicine, JAMA, and many periodicals devoted to medical science, hospital administration, and public health. His 1974 book, The American Health Care System: Its Genesis and Trajectory, served as an academic text at numerous universities for years. Dad was the general director of the two hospitals in Boston that he brought together to ultimately become the “Women’s” part of the Brigham and Women’s Hospital merger. He also was the educational director at Hartford Hospital from 1969 until 1975.

I am telling you all this to illustrate that my dad is a doctor’s doctor. I was raised hearing not only about the importance of medicine to save people and communities, but also the importance of maintaining professionalism to save medicine.

Talking to dad

We want to start with a caveat that pain does not complicate our conversation about dying; although his cancer is advanced, and his bone metastases are multiple, he amazingly, thankfully, is comfortable right now.

Even so, anyone entering a conversation entitled “What’s Is It Like to be Dying?” would undoubtedly anticipate messages both profound as well as sad. Heaven knows my dad is always profound — but he is not, surprisingly, very sad these days. 

His No. 1 complaint is boredom. 

With a sound mind, my dad has a body that will do increasingly less. His level of activity outside of his home is foiled by failing strength, breath, and ability to accommodate all his needs in the outside world. More and more he is a prisoner in his home and in his mind.

If he were a man of faith, he would presumably be having long conversations with his spiritual adviser — but he is not. Death is an intellectual exercise, not a transformational one.

Now sitting, waiting for death is, ultimately, boring. 

He tells stories (with jealousy) of friends who died suddenly or in their sleep. “All I want is a great MI.”

Waiting for his cancer or failing organ systems to ultimately provide him “escape” (and that is his word) is long, tiring, and tedious.

Please call it dying

Amid all that waiting and boredom, dad finds it frustrating that people can’t talk comfortably about death and dying with him. They don’t even use those words.

Mom and dad have extensive conversations about their limited future; more importantly, about their past. In his family, all of us are ready to meet his death, and everything along the way, with him head-on.

But beyond his home? The world has multiple ways to express the sorrow of his “passing,” but not for the dying he is in the process of right now.

“Death and dying are perfectly good Anglo-Saxon words!” he proclaims with a booming voice that would resonate with all who have ever known him. “Don’t use euphemisms — they mean nothing!”

In truth it is not the words per se that bother dad — it is the pervasive discomfort people have to talk about death with him at all. 

Here is the bottom line for my dad. Dying in a world where people won’t talk about death is lonely.

Talking about death with his fellow physicians

Dad’s yearning for people who are open and relaxed talking to him about dying is particularly acute when he talks about his current physicians. None of his doctors will have a frank conversation about dying with him. “I just want to know what it will be like, I just want a doctor I can talk to.” 

Interestingly, his plea is not a complaint that modern doctors should be better at shepherding their patients toward death. Far from it. 

When I asked, “Would it have been better if you were dying back in the days of your training?” “Heavens No!” he thunders. “It was anathema even to mention that your patient might die back then!”

He thinks medicine has come a long way toward increasing its value in end-of-life care since his own glory days.

More to the point — my dad is not sure society’s demands on physicians, or his anger at them, is justified. “Doctors are trained to keep people alive. I am not sure it is fair to now ask them to be experts at helping their patients die.”

Even so — as a physician — he wishes he could get more from his own.

I want to die

Perhaps the most significant puzzlement dad has is, why people don’t understand why he wants to die, sooner (and suddenly) if possible.

Is he depressed? No. 

Does he hate the thought of leaving mom alone after 67 years? Absolutely. Does he get choked up saying farewell to each of us, his loved ones? More than I can describe.

But he wants to distinguish that emotion from being sad about dying. 

Most nights my parents close the day with a cocktail. Every time they do so, for decades now, they greet each other eye-to-eye, hold their glasses up and say “Abbastanza.” 

It is a word they learned on one of the countless trips they took in younger years; this one to Italy. Abbastanza means “enough.” It has been their toast all these years to each other: enough love, enough adventure, enough time to be together and a family. It is a toast of infinite gratitude.

Now that he knows he won’t fully be Jeff Freymann much longer, dad wants to die while all of that is still true, is still the predominant feeling he has about his life.

“Abbastanza” and “I want to die” are synonymous for my dad.

Messages

Dad and I did not set out with a specific purpose or thought about what any reader would glean from this very personal Fontenotes.

However, we hope it leaves you with a thought, some solace, or a view of death different from — an addition to — your own concepts or concerns about dying.

Most of all, we thought when the time arises it might be a stepping stone to have your own conversations with your loved ones in your own way.

If that is you — start talking. Being open is the hard part, it will get easier along the way. We promise.

In closing, I want to thank my dad for once again so generously sharing his thoughts, as he always has and will until his last breath.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers. Visit her website.


The Best Mother’s Day Gift

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This story was originally published on www.tribtalk.org

What better Mother’s Day present could Texas give than a commitment to making motherhood safer? And that’s just what Texas physicians are doing.

Despite some recent disagreement over the exact numbers, there is no question that pregnancy, delivery, and the first year after giving birth are much too unhealthy for Texas women – especially Texas women of color.

We talk about “maternal mortality and morbidity.” But remember this: “mortality and morbidity” are just high-sounding words for “death and disease.” And as physicians, we oppose death and disease. We fight it every day – for children, for car crash victims, for the elderly, and for the millions of Texans who live with chronic ailments like diabetes and heart disease.

And we fight death and disease for our mothers.

That’s why the Texas Medical Association (TMA) convened our Maternal Health Congress. It comprised the state’s leading experts on the problems – and the potential solutions. The congress heard 36 proposals in committee and adopted a seven-point plan to make motherhood safer in Texas. It calls on all of us – physicians, state officials and lawmakers, and you – to help deliver this Mother’s Day present.

Here are the high points:  

  • Ask Texas to request a federal waiver so we can build a tailored health benefits program for uninsured women of childbearing age. This program will provide the kinds of health care – including primary care, behavioral health care, preventive care, and specialty care – to keep Texas women healthy before, during, and after pregnancy.
  • Have TMA develop a formal education program to help Texas physicians better recognize and find treatment for women with substance abuse disorders. This must be a priority as drug overdoses are the leading cause of maternal death in Texas.
  • Pass legislation to make long-acting reversible contraceptives much more easily available to Texas women. As the Maternal Health Congress report states, “Increasing women’s ability to plan and space their pregnancies leads to lower abortion rates, improved infant and maternal health, educational and economic opportunities for women and their families, and cost savings for the state.”
  • Have TMA develop a formal education program for physicians, nurses, and hospitals on the best practices proven to prevent death and disease among women during and after pregnancy.
  • Have TMA develop a campaign to educate the public on how women can make motherhood safer by taking better care of themselves before they get pregnant, getting early and timely care when they become pregnant, and knowing where to find help after their babies are born.  

This plan goes before the TMA House of Delegates meeting next week in San Antonio. I am confident it will pass.

If you are lucky enough to still have your mother with you, please give her the flowers, our chocolates, or dinner out that you had planned to give. And then tell her you are joining with Texas physicians to give the Best Mother’s Day Gift ever.

Carlos J. Cardenas, MD, is a gastroenterologist from Edinburg and president of the Texas Medical Association


LARCs and the Burden of History

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Editor’s note: This article was originally published in the May 2018 edition of the Texas Health Journal, published by The University of Texas System Population Health Initiative. Reprinted with permission. It focuses on the work of Edinburg obstetrician-gynecologist Tony Ogburn, MD, to expand women’s use of long-acting reversible contraceptives (LARCs). Women who are better able to plan and space their pregnancies have lower health risks before and after their babies are born. That’s why expanding the availability and use of LARCs is a key recommendation that came out of the 2018 Texas Medical Association Maternal Health Congress. The TMA House of Delegates will consider those recommendations when it convenes in San Antonio on May 18 and 19. 

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Dr. Tony Ogburn, founding chair of the Department of Obstetrics and Gynecology at the University of Texas Rio Grande Valley (UTRGV) School of Medicine, has spent much of his career in women’s health trying to close the gap between two realities. 

The first reality is that almost half of pregnancies in the United States are unintended, which may increase the risk that women will suffer postpartum depression and fail to receive early prenatal care, among other risks. Even the risk of severe outcomes, like infant and maternal mortality, may go up when pregnancies are unintended.

The second reality is that unintended pregnancies are easier than ever to prevent. There are a range of contraceptive methods that are effective, easy to use, and inexpensive. In particular, for Ogburn, there are long-acting reversible contraceptives, or LARCs.

LARCs, which include intrauterine devices (IUDs) and implants like Nexplanon, are highly effective in preventing pregnancy, last for an extended period of time and, once inserted, work without user action. The combination of these elements, in fact, make them the single most effective method of contraception. They are also, however, one of the most distrusted by the public, and one of the hardest to access even for women who are interested. 

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When LARCs were first introduced in the 1950s, the devices worked at preventing most patients from getting pregnant. However, an early version of the IUD, called the Dalkon Shield, was difficult to insert and had high incidence of infection, infertility and Pelvic Inflammatory Disease. In 1974, when the Department of Health, Education and Welfare ordered family-planning clinics to stop prescribing it, roughly 3 million people were using the Dalkon Shield IUD. The devices were pulled from the shelves, many women had their IUDs removed, and the manufacturer filed for bankruptcy.

Although IUDs used in the U.S. today are dramatically safer, misconceptions over the method’s safety persist from decades ago. 

“It's not uncommon that a patient will come in for a LARC consultation and their mom or aunt says, ‘Oh no, those are dangerous’ or ‘They don’t keep you from getting pregnant’ or ‘They can cause an infection’. So there's still a generation of women that have very negative attitude about LARCs,” Ogburn said.

It’s getting better, though, said Ogburn. He’s seen a shift in the public perception of these birth control methods, over the last decade, as more information emerges, and misconceptions are corrected. OBGYNs and other organizations used to only recommend LARCs as a last resort. Now, they’re the preferred primary birth control method for most providers, and for many women. 

“When I first started really getting involved in family planning, the usage rate of LARCs around the country was about 1 to 2 percent of women who were using contraception,” Ogburn said. “Now, depending on the patient’s age and the area of the country, that rate’s somewhere around 10 or 11 percent. It's been a dramatic increase.”

But outdated misconceptions and unfounded fears aren’t the only barriers to LARC use. Access to clinics and clinicians trained to insert long-acting reversible contraception remains a serious problem for many patients In the Rio Grande Valley, as well as in many other underserved areas. To help combat this, the UTRGV School of Medicine has started residency programs in Ob/Gyn and Family Medicine that provide comprehensive training in contraception, including in the use of LARCs. 

“We're the first medical school based in the region,” Ogburn said. “Before UTRGV opened, there was a gap in the community in terms of LARC training, both for IUDs and implants. So myself, as well as several of my faculty, have held numerous trainings with clinicians, community groups, hospitals and the nurse-family partnership.”

The opening of the medical school represents one of the biggest steps forward for the region’s ability to provide healthcare for women, Ogburn said. The school’s physicians are now able to spread the word about LARCs, provide training to more providers, and help allay misconceptions. The medical school has only been open for two years, but there is tremendous optimism that many of the future physicians who train in the Valley will stay in the region after completing medical school. 

That will be one of the most beneficial aspects for women and maternal health, according to Ogburn. 

“The new physicians will be familiar with the community, they will be newly trained in evidence-based practices, and they will incorporate them in the community,” Ogburn said.

The ability to plan your pregnancy is a vital component to healthy pregnancies, healthy moms and a healthy family, Ogburn said, and women's health really is one of the keys to the overall health of a community.

“Nationally, the unintended pregnancy rates have gone down by about five percent over the last 25 years — from 50 percent to 45 percent. I think there's very little question that the increased use of LARCs have definitely influenced that,” Ogburn said. 

“To keep from getting pregnant is critical for the issues that we have, not only in Texas but nationally, in terms of maternal mortality and morbidity and neonatal health,” he added. By helping women control if and when they become pregnant, LARCs can help strengthen the overall health of Texas communities.

Shelby Knowles, is pursuing a master’s degree in journalism through The University of Texas System’s Population Health Scholar program