By Jonathan Nelson
The House Public Health Committee of the Texas Legislature held a hearing this week focused on addressing health care access for communities along the Texas-Mexico border. TAFP’s Family Physician of the Year, Adrian Billings, MD, PhD, made the drive from his home in Alpine to Austin to provide his perspective on the great need for primary care investment in rural Texas.
“My work, although rewarding in so many ways, has been both exhausting and challenging because of the incredible need for care in my communities,” Billings told the committee. “Rural health care organizations such as critical access hospitals and rural clinics are like small football teams. We have very few, if any, additional staff on reserve sitting on the bench for relief. For example, our Alpine clinic today does not have a provider because I am here testifying.”
As the chief medical officer for Preventative Care Health Services, a federally qualified health center with clinics in Alpine, Marfa, and Presidio, Billings described how the COVID-19 pandemic has exacerbated the workforce shortage the Big Bend region has always faced. Since February, five family physicians, a family nurse practitioner, and a physician assistant have left the area, along with one of two sonogram technicians, and several nurses.
“This loss of nurses has been significant and most acute in our labor and delivery unit at the hospital,” Billings said, referring to Big Bend Regional Medical Center. “On July 5th, our hospital had to close the only labor and delivery unit between El Paso and Del Rio, which are over 400 miles apart, due to the shortage of labor and delivery nurses. From July to September, our labor and delivery unit was only able to be open Monday morning through Thursday morning. During the time of diversion, pregnant women in labor had to be diverted or transferred to the next available labor and delivery units in Fort Stockton or even further to El Paso and Midland-Odessa. Those women whose labor was too far advanced for transport had to be delivered in the emergency room without labor-and-delivery-trained nurses.”
That diversion increased the possibility of poor maternal and neonatal outcomes because of the time spent in transport, but it also put everyone else in the region in jeopardy. While the area's only ambulance was in use transporting a woman in labor to an adequately staffed labor and delivery unit, any patient in the area experiencing a health emergency had no access to medical transport.
Born and raised on the border and having completed multiple rural rotations as a medical student and resident in training, Billings believes recruiting potential physicians and other health care providers from rural areas and training them in rural practice settings is key to building the primary care workforce rural communities need. Before the committee, he proposed the creation of a Texas Center for Rural Health Care Workforce based on a similar program in Illinois, the Rural Medical Education Program at the National Center for Rural Health Professions at the University of Illinois Health Sciences Campus at Rockford. That program has been funded by the Illinois State Legislature since 1992.
“I firmly believe from my own experiences as a medical student rotating in Alpine and other rural Texas communities as a medical student and resident physician that we need to enable more rural students or students interested in rural practice to spend significant periods of their training in vulnerable communities like Alpine, Marfa, and Presidio so they can graduate and return to serve these communities,” Billings said.
Committee member Rep. Nicole Collier, D-Fort Worth, asked Billings what changes could be made to encourage health care providers along the border and in other rural communities to remain in practice. “If we gave more pay, do you think that’s going to offset the location?” she asked.
It’s more than the pay, Billings responded. It’s providing the resources.
“It’s really about robustly building the rural health care team.… Having a hospital that is able to manage the majority of what walks in the door and to not have to worry about the sonogram technician being gone and not being able to do an emergent or urgent sonogram, and practicing in the dark, the ambiguity that rural medicine can be. That is an incredible stress as a physician that I experience almost on a daily basis. That has been a large reason for many of these physicians and health care providers that have left the area, just the challenge of providing the standard of care in an under-resourced setting.
“My colleagues and me, we deserve more, we deserve better. More importantly, our patients deserve better. And that is not going to happen without commitment from government entities to bolster the rural health care team and rural health care resources. It will only get worse if nothing is done.”