MEMBER VOICES: Family medicine — caring for patients in and out of the exam room

The inaugural address of TAFP’s newly inducted president, Terrance Hines, MD

By Terrance Hines, MD
November 17, 2023

My fellow Texans and esteemed members of the Texas Academy of Family Physicians, it is my honor to address you today to discuss the future of family medicine. As we look ahead, we are confronted with challenges and opportunities that require us to adapt and innovate to meet the needs of our patients and communities.

Recently, Academy leaders gathered in Austin for a strategic planning retreat. We had a wonderful meeting, full of lively discussion and ideas about how we can best serve our members. Throughout the strategic planning process, a few themes came to the forefront — one was the plasticity of family medicine, and the other was the power of storytelling.

So let me tell you a story. As I began my career, my identity as a gay man — in part — shaped the patient panel I built. I was committed to creating a space that was overtly and intentionally inclusive. Over time, gay men seeking welcoming care expanded to include those in need of pre-exposure prophylaxis for HIV prevention, and those patients invited their lesbian and transgender friends.

When I talk about plasticity, I worked in the largest not-for-profit health system in the state of Texas. But PrEP wasn’t done locally by specialists in infectious disease, and gender care wasn’t done by our gynecologists, urologists, or endocrinologists. However, I’m a family physician, which means I’m a specialist too. I didn’t learn about these critically important interventions in medical school or even in residency. But I learned translatable skills. I knew how to prescribe estrogen to cisgender women and testosterone to cis men. Which means I was by extension taught how to prescribe it to trans patients as well. I was taught that the value of a family physician lies in our ability to innovate and adapt to meet the needs of the person in front of us.

Fast forward to just a few months ago. I was walking through my clinic when a colleague stopped me. She brought up a photo on her phone of a man dressed in firefighter gear. She said, “This is my son; you used to be his doctor.” She then went on to tell me that several years ago, he was a “she.” She was depressed, suicidal, and her lived experience was tearing their family apart. My colleague said, “You started my son on hormones, and he is surviving and thriving, and is a firefighter and is training to be a paramedic, and our family is whole again.”

My reaction was that it was my honor and my duty to help him become himself and the hero he was always meant to be. It's a testament to the resilience of the human spirit and the transformative power of medicine. It's also a reminder of why I have the privilege to be in the exam room, and an example of why politicians should not. We as physicians have earned our place, we are experts, and we've been invited to make a difference in the lives of our patients.

If advocacy is one of our pillars, then we must be prepared to use our power and privilege as physicians to stand up for those who can't. This often involves doing the hard stuff, the uncomfortable work. Our patients depend on us. … We must be the voice for the voiceless. Caring for the patient must extend beyond our four walls.

This year, the John Peter Smith Family Medicine Residency Program, where I trained, celebrates its 50th anniversary. I want to recognize the incredible colleagues and mentors at JPS who have been instrumental in shaping my practice and worldview. They've taught me not just how to be a good doctor, but more importantly and more than any other life experience, how to be a better person.

The lessons I learned during those 80-hour weeks, Q3 call, and that infamous week of OB nights gave me a glimpse into the lives of our patients who are barely keeping it together, of those who work multiple jobs just to make ends meet or must make hard choices in life every day. When one is broken to their physical and emotional core, it is then that they can finally see through the veil of power and privilege that many of us as physicians hold, and when we can truly see into the lives of our patients. It's vital for us to understand the systemic barriers and challenges our patients face.

Putting ourselves in the shoes of our patients, experiencing true empathy with them, that is the heart of what it means to be a family physician. We know that and we feel that in the exam room. But we also know that care — that duty — has to extend beyond the clinic.

Texas is the state with both the largest number and highest percentage of uninsured residents in the country. We have the most uninsured children in the country. Yet we still refuse to expand Medicaid. We should do better.

Maternal mortality continues to be a major problem in Texas, and abortion care is virtually impossible to receive here, even for those who need it due to severe or life-threatening conditions. Regarding women’s reproductive health care, we must do better.

Supporting transgender minors is also crucial. According to a recent survey by the Trevor Project, more than half of transgender and nonbinary youth report seriously considering suicide. We know that providing gender-affirming care can reduce suicide rates by a staggering 70%. We can do better.

According to the Texas Health and Human Services Commission, the state is likely to need about 2,000 more family physicians in 2032 than we are projected to have. I’m happy to report that on this front, we actually are doing better. With increases in state funding for graduate medical education including a much-needed infusion of funding for family medicine residency programs, we see new residency programs opening across the state. But we can’t rest on our laurels; we must continue to support and encourage the recruitment and training of the family medicine workforce for the future.

I know that my policy views don’t necessarily represent those of every member of the Academy — and I should probably add my employer — and that’s okay. We must be able to engage in tough conversations and be able to disagree with one another. At the same time, advocacy is at the heart of our profession. We must champion bodily autonomy and physician autonomy. But those arguments cannot be our lukewarm, milquetoast fallback position when we don’t want to confront the hard challenges of homophobia, transphobia, misogyny, classism, and institutional racism that are pervasive in our state government. If advocacy is one of our pillars, then we must be prepared to use our power and privilege as physicians to stand up for those who can't.

This often involves doing the hard stuff, the uncomfortable work. Our patients depend on us. And sometimes that means we expend political capital. Sometimes we lose. But we must play the long game. We must be the voice for the voiceless. Caring for the patient must extend beyond our four walls.

In a recent article, AMA President Jesse Ehrenfeld emphasized the importance of following the science and being willing to lose in the pursuit of doing what's right. It's our duty as physicians to advocate for our patients and work toward a more just and equitable health care system.

I'm humbled and honored to serve as president of the Texas Academy of Family Physicians. Together, we can make a real difference in the lives of our patients and in the future of health care. Thank you for being a part of this journey, and I look forward to all that we can achieve together.