As the COVID-19 pandemic continues to drastically affect the health center workforce, the second season of the STAR² Center Talks Workforce Success dives deeper into the immediate and long-term effects of this crisis on health centers. In this episode, ACU’s Michelle Fernández Gabilondo interviews Dr. Adrian Billings, Chief Medical Officer, at Preventative Care Health Services in Alpine, TX and Madeline Dixon, a 3rd year medical student at Texas Tech, to discuss the unique workforce challenges of serving underserved populations in rural communities and border towns during the COVID pandemic and vaccine rollout.

Transcript by Rev.com

Introduction: Welcome to the COVID-19 installment of STAR² Center Talks Workforce Success, which features the voices of workforce leaders from health centers and primary care associations around the nation. We know this invaluable information will help in your journey to advance the workforce initiatives of your organization.

Michelle Fernández Gabilondo: Welcome, everyone. My name is Michelle Fernández. I am the senior training specialist at the Association of Clinicians for the Underserved. We are very excited to have Dr. Adrian Billings, chief medical officer at Preventative Care Health Services in Alpine, Texas, and Madeline Dixon, a third-year medical student at Texas Tech in El Paso, Texas, here with us today to talk about the impact of COVID on the health center workforce. Welcome to both of you.

Dr. Adrian Billings: Good morning, and buenos días (good morning) and saludos (greetings) from the Southwestern Texas-Mexico border. Thank you for having us.

Michelle Fernández Gabilondo: Absolutely. And yes, saludos a todos. Gracias por estar aquí. (Greetings to all. Thanks for being here.)

Dr. Adrian Billings: [inaudible].

Michelle Fernández Gabilondo: So to get started, Dr. Billings, we always ask about the health center that you work in. So, could you really just tell me a little bit more about your health center, where it’s located, and the patients you serve? Because I know you work in a very rural area, so for our listeners to learn a little bit more.

Dr. Adrian Billings: Yeah, of course. So, I work for Preventative Care Health Services. We are a federally qualified health center, located in a frontier health professional shortage area and with three locations in Alpine, Marfa, and Presidio, Texas, a very frontier rural area. We are located about 210 miles southeast of El Paso, and about 160 miles southwest of Midland-Odessa, and Alpine is located about 90 miles north of Big Bend National Park. Our health centers are located kind of 90 miles from each other. The Presidio is 90 miles from Alpine, and Marfa lies in between.

Michelle Fernández Gabilondo: Wonderful. Thank you for sharing that. And then, just like everybody we bring on, we always also want to know about your specific professional journey, but because we also have Madeline here today, I am going to ask both of you that question. So first, Dr. Billings, if you could tell us about your professional journey, how you got to your current role and how long you have been in that role. And then for Madeline, being a third-year medical student, what drove you to go into medicine and where do you see yourself in the future?

Dr. Adrian Billings: I guess my story really started in Del Rio, Texas. It’s a community about 200 miles to the southeast of Alpine, and it’s the community where I was born and raised. I’m a product of the Texas-Mexico border, and very begrudgingly left to go to college. I didn’t want to leave the border, and I went to college and medical school with the hopes of trying to get back as soon as possible to the border. But I was delivered and cared for by a family physician into college, really, all throughout my youth and into college, and he was a very strong role model for me of what a community physician is in a very rural area. And I went to medical school with the idea of becoming a family physician and returning to the Texas-Mexico border.

Dr. Adrian Billings: And I accepted a National Health Service Corps scholarship to go to medical school from the federal government. So, many of you who are US federal taxpayers paid for my medical school, so I want to say thank you. And I returned to the nearest community that I could, to my hometown of Del Rio, that qualified for the scholarship repayment. But also on my journey, just as Madeline came out here as a medical student, I came to Alpine for two separate months as a medical student, and then I came again as a resident physician in my final month of residency, and rotated out here. I went on and did a family medicine residency, followed by a surgical obstetrics fellowship at John Peter Smith Hospital in Fort Worth, Texas. And I came out to Alpine in private practice, which is a private practice option to repay my National Service Corps obligation. At that time, there was not a community health center in Alpine.

Dr. Adrian Billings: And after four years of being on call 24/7 and delivering a lot of babies in the middle of the night, working a lot of weekends and learning more about the benefits of a federally qualified health center, I merged my private practice with this federally qualified health center, Preventative Care Health Services. And by and large, that was the best action that I could have done for my community because now we’re receiving about $2.9 million in federal support from the Health Resource Services Administration to support indigent care. And we’re also covered under the Federal Tort Claims Act for our malpractice. So, that’s a cost that we no longer have to bore.

Dr. Adrian Billings: And we’ve also expanded from just my private practice with one nurse practitioner and myself to three locations, four family physicians, a nephrologist, dental care with three dentists and behavioral health care with several part-time licensed professional counselors. So, when I think of the impact and the footprint of my small private practice in one location to what we’ve grown to today, certainly I think we’re doing a better job at attempting to impact population health and serving more underserved patients and providing a safety net for patients who otherwise might not receive health care.

Michelle Fernández Gabilondo: Thank you so much. And as a taxpayer I want to say, it was definitely money well spent because you really exemplify the best of the medical community. So, thank you for that. And Madeline, would you like to share?

Madeline Dixon: Absolutely. So, I’m a third year medical student in El Paso. I’m from a suburb north of Houston and my mom is a dietician, so I’ve always been surrounded by the medical community. She works at MD Anderson, so I have absolutely seen the impact of ancillary care on health. So, that was very formative in wanting to serve in the healthcare community. I went to college at Texas A&M and I very quickly realized I want to be a doctor when I was in a couple of women’s organizations and I learned that I really enjoy taking care of women. I really enjoy public health. So, I am definitely going to be applying to OB-GYN residency at the end of this year. And I decided to go to El Paso for medical school because, not only was it the most welcoming city that I interviewed in, but it also provides a lot of opportunities that larger cities don’t offer. I get to see internal medicine and family medicine physicians within the city provide a larger scope of practice than what they do in Houston, and I also get the opportunity to take medical Spanish courses.

Madeline Dixon: I believe we are one of the few, if not the only medical school, that offers medical Spanish as part of the formal curriculum. So, I came in knowing no Spanish and I now know enough to communicate, and I’m still learning. So, I decided to also pursue a master’s in public health concurrently with my medical degree. So, I’m also getting my masters of public health from the University of Texas at Houston and I will be graduating with that in August with a certificate in maternal child health. So, I’m hoping to use that to better serve my patients in the OB-GYN realm, because there’s a lot of women’s health that’s also very much impacted by public policy and public health. So, I want to be able to have a more well-rounded perspective on my patients, and I hope to go to residency in Texas and continue to serve the community that has educated me.

Madeline Dixon: And I chose to come to Alpine for elective rotation because while I see physicians in El Paso certainly perform to a larger public practice than in Houston, I believe that the physicians here, like Dr. Billings, really have a large responsibility for their community that is very unique to this sort of practice. And I would love to have this experience because I don’t know where I’m going to end up following residency, if I’m going to be in a large city, or if I’m going to be in an underserved community like this, and having the perspective of every physician in this area will make me a better rural physician, if that’s what I choose. But if I also choose to work in a city, when I’ll have an understanding of what my colleagues in more rural communities experience on a day-to-day basis.

Michelle Fernández Gabilondo: Wonderful. Thank you so much for sharing that. And you’re also going to be such an invaluable asset to the medical community and as a Latina myself, I just want to say to both of you, muchas gracias por todo lo que están haciendo. (Thank you very much for everything you are doing.) So, as both of you mentioned, right now, Dr. Billings, you work in a rural community and Madeline, you’re training doing this elective rotation in a rural community. So the next question that we want to ask is really, as a provider in these rural communities, what are the biggest workforce challenges that your health center faces and then with that, now that the COVID pandemic is happening, what is that toll that it has taken on your staff?

Dr. Adrian Billings: Yeah. Thank you for that question. I think the challenges that we’re facing out here in the Big Bend region, in Alpine, Marfa and Presidio, Texas along the Texas-Mexico border are not necessarily unique to our area, but are very common in most rural, small workforce areas, as well as some inner-city underserved health centers as well, in the sense that, pre-pandemic, we were an under-resourced, small healthcare organization. And I think the best analogy is to think of a small football team or a small soccer team and not having anybody on the bench to give somebody a breather if they’re tired or if someone gets injured, being able to substitute. I think that’s the best analogy for these under-resourced under-developed or developing rural healthcare workforces, even such as our health workforce out here in the Big Bend area.

Dr. Adrian Billings: Pre-pandemic, we were already under-resourced and doing the best that we could to provide medical, dental and behavioral health care, as well as, at the same time, doing hospital care. Our physicians still provide hospital care at our local hospital, a critical access 25 bed hospital, and we’re still delivering babies and providing maternity care as family physicians out here. But when the pandemic hit, we were then tasked with beginning COVID testing in our area, and that put a strain upon our healthcare workforce out here. And most recently in December, December 23rd is when we received our first COVID vaccine, we then had the added responsibility of not only providing COVID testing, but also providing the significantly important COVID vaccination process. And so that has further strained our workforce. And I think that the majority of our early testing has been done by the National Guard very early on in the process, where they would come in on a weekly or every other week and do just a full day of nothing except COVID testing.

Dr. Adrian Billings: And that allowed us to continue doing the medical care, the dental care, the behavioral health care, and then the hospital care that we do, and it really allowed our communities to have access to COVID testing. And then that transition to private entities that were hired by the Texas Department of State Health Services, and so we were really hopeful when the COVID vaccine came out that that same process would be duplicated for COVID vaccination. And unfortunately that hasn’t. The majority of the COVID vaccination that has been done out in the Big Bend has been done with local resources, our local workforce with our organization and/or our hospital. And so that doesn’t come without consequences to our patients because when we provide a COVID vaccine clinic, we’re trying to do a mass vaccination clinic, and we don’t have the workforce to remain operational at the same time as the medical or dental clinic, or provide behavioral health care.

Dr. Adrian Billings: We’re really pulling that workforce to staff and provide the vaccine clinic. And so what that means to our patients is that perhaps they can’t get in for an urgent care visit. Perhaps there’s somewhat of a delay in getting them their lab results or refilling their prescription medicines. And perhaps unfortunately some of them go directly to the emergency room for an urgent care issue that could have been served within the clinic had we had the workforce to provide it. I’m very proud of our organization and our staff, from our receptionist to our providers to our nurses to our administrative staff. They have really risen to the task of responding to the pandemic with testing as well as vaccination, and we’ve had many Saturday clinic and many after-hours clinics to provide these services. And certainly this has been a strain professionally, and I’m sure personally on all of our staff, but I think that we feel that we’re rising up to try and meet the needs of our communities that we serve to the best that we can with the workforce and the resources that we have.

Michelle Fernández Gabilondo: Thank you so much for sharing that. And yes, that is very much what we’re hearing across the board with all types of health centers, regardless of the area they’re located in, is that strain on the workforce of first the testing, now the vaccines, but needing to put some things to the side of what they would be offering patients in order to make up for that workforce in order to have the vaccinations, the testing, all of those things in place. So, absolutely what we’re also hearing from other health centers, so thank you for sharing that. And one of the things that I want to expand on a little bit is specifically vaccines. Because as you mentioned, first came the testing and now it’s the vaccines and in the area where you live, you recently spoke about the problem of pharmacy deserts. So, could you explain what is a pharmacy desert and then how that then affects your workforce ability to distribute those COVID vaccines to the patients? And I’m sure then that also interplays with everything else that you just talked about, the ability to offer all of the other care.

Dr. Adrian Billings: Sure. Yeah. So, pharmacy deserts really tie into what we were discussing of an under-resourced healthcare system. So, pharmacy deserts are areas, whether they’re communities such as Presidio, that does not have a pharmacy located in the community of 7,000 patients. The nearest pharmacy from Presidio is 60 miles away in Marfa, and they’re currently not offering COVID vaccinations. So, the nearest pharmacy where patients from Presidio can get access to pharmacies providing COVID vaccinations are 90 miles away in Alpine. So, we really know that the most efficient way to arrive at herd immunity is to have multiple organizations teaming together to offer COVID vaccines. And I’ll back up a little bit. The nearest corporate pharmacy to Presidio is in Midland and Odessa, and that is 250 miles away where there is a corporate pharmacy that could offer COVID vaccination to these patients.

Dr. Adrian Billings: The three pharmacies that are located in Alpine and the one pharmacy that is located in Marfa are small, privately-owned, locally-owned pharmacies without the large resources of a corporate organization such as these corporate pharmacies. So, what this does is this is an access to care issue, especially for our Presidio patients, whether it be COVID vaccination or just getting their prescriptions filled in a timely manner. The process that we do to get prescriptions filled in Presidio is, we send an electronic prescription in, usually to the Alpine pharmacies, and hopefully the next day the prescription arrives on the daily bus that drives between Midland-Odessa, stops in Alpine, Marfa, and then ends at Presidio. However, some of our patients access the Mexican pharmacy healthcare system because it’s only two miles away from Presidio, and certainly it’s a same-day service that they can get that.

Dr. Adrian Billings: And I like to paint the picture of thinking as, perhaps, if I’m a father and if I were living in Presidio and I took my infant or toddler child in and the provider diagnosed an otitis media, and I knew that the best treatment to relieve the pain and the infection so that it didn’t get worse is to get amoxicillin into my child as soon as possible. And can you just imagine being that parent in that situation and being told, “Well, I sent the prescription and I hope that it will arrive tomorrow on the bus”? To me, that’s just unjust. We need to do better for our country and for our population and provide equitable, culturally competent access to healthcare, including pharmacy care.

Michelle Fernández Gabilondo: Absolutely. Thank you so much for all of the points that you made with that. And that’s one of the things that’s so amazing with health centers and the providers and the staff who work in health centers, is you not only provide the care, but also the advocacy of equitable care that is culturally competent, as you mentioned. And seeing those inequities also takes a very strong toll in and of itself on the workforce, because all of you are doing so much to ensure that the underserved have what they need and working within these limitations, but still making things happen.

Michelle Fernández Gabilondo: So, it really is just wonderful to see and all of the effort that goes into ensuring that this is something that everybody has the right to the healthcare that they deserve. So, thank you so much for sharing that. As I begin to wrap up today, I did want to just open it up to both of you and really have you share, what is one of the most important things that you want listeners to know about what it means to be a provider or a health center staff member, or potentially a future provider in a rural community health center during the COVID crisis?

Dr. Adrian Billings: If it’s okay, I’ll start off. First, I consider it an incredible privilege to practice and serve the patients and the communities that I serve. Our staff, we have this difficult job in an under-resourced frontier area, and it is just an incredible privilege to be able to serve in this capacity. And getting back to the advocacy, it’s so important. Madeline and I had this discussion yesterday, and I have this discussion with every trainee who rotates with me, that it’s not only important for us to be active and involved and care for our patients within the walls of our clinics, within the walls of the hospitals that we may serve, but we have to be active practicing medicine outside the exam room. And by that, I don’t mean just doing home visits, which we still provide to our patients out here that have challenges accessing us within the clinic.

Dr. Adrian Billings: I mean speaking to people like you, doing podcasts, speaking to the press, answering their calls, returning their calls, having a discussion with the elected state and federal policy-makers to tell our patients’ stories. About 75% of my patients in my practice down in Presidio are Spanish-speaking only. Many of our elected policy-makers do not speak Spanish. And so that creates a barrier for my patients to speak to elected policy-makers that impact, really, the care that I and Madeline provide within the walls of our clinics and hospitals. And as physicians, as medical students, we need to use our privilege, the privilege of our medical degrees, to advocate for our patients and tell their stories to try and impact policy, to make health care disparities go away or decrease. We have to be active practicing medicine outside the exam room. And certainly these efforts are what really sustain me in doing what I’m doing of practicing in a frontier under-resourced area.

Madeline Dixon: And then from my perspective, like I said, I’m from Houston and I train in El Paso. This is my first experience in a very rural community and I’ve only been here for a short period of time so I don’t have much perspective, but I’m learning. But I would say, talking to my fellow trainees that have never had this experience and might be from a similar background as I am, just having an understanding of the disparities that the population here faces, that is very, very different from what an individual would experience in an urban or suburban environment. And I think that perspective can also help us, especially in El Paso, because we receive a lot of the patients from these rural communities.

Madeline Dixon: And then we give them our treatment and we send them home, not understanding that these patients come back to their rural communities and have this un-access to the pharmacies, to their physicians. So, simply raising awareness for the medical trainees, that we need to not only address their medical issues, but also those social determinants of health. And when we discharge them, when we counsel them, really take into account their living situations and their geography so that we can best serve them.

Dr. Adrian Billings: And I’m reminded of one of my favorite quotes from Dr. Paul Farmer, who created Partners in Health as the medical student at Harvard. And this quote really exemplifies what I think these rural and under-resourced healthcare programs want and realize. And the quote goes, “Our most significant accomplishments in life will be done in partnership as a team.” And I think what that means to me and my ask of larger healthcare organizations, perhaps in urban areas, is that, please collaborate with healthcare organizations like mine. We need your knowledge, we need your workforce, and we need your help. Most importantly, our patients need your help and need your knowledge and need the resources that you can provide in a rural area. And that is so, so important. We know that the best care is one in a multidisciplinary nature, not just with a physician, not just with an advanced practice clinician, but having a behavioral healthcare provider, having a pharmacist, having a robust nursing staff and having a robust administrative staff in addition to a large healthcare training institution such as Texas Tech University Health Science Center, El Paso.

Michelle Fernández Gabilondo: Thank you so much to both of you. It was really such a privilege to have both of you share your knowledge and your expertise, but also, I just want to say, hearing both of you talk, it was also just, on a personal level, very emotional for me being a Latina woman. Every Latina and Hispanic culture is different, but there’s this unifying factor with all of us, and to see a workforce in a community that cares so much for these patients, individuals who do have these language barriers and many other barriers that they face, it’s just very emotional to me to see how much you care for our community. So, I just want to say a personal thank you for that.

Michelle Fernández Gabilondo: And then of course, just the knowledge that you bring, the expertise and how you speak about the workforce and being in a rural community, just all of it is a great privilege to have you here, I know. A great thank you from all of us here at ACU. And again, this is Michelle Fernández Gabilondo, senior training specialist at ACU, and today we were talking with Dr. Adrian Billings, the chief medical officer at Preventive Care Health Services in Alpine, Texas, and Madeline Dixon, third-year medical student at Texas Tech in El Paso. Thank you so much to both of you.

Dr. Adrian Billings: Michelle, muchísimas gracias y que le vaya bien. (Thank you very much and I hope things go well for you.)

 Michelle Fernández Gabilondo: Gracias. (Thank you.)

Closing: Thank you very much for joining us today. We hope today’s conversation provided you with ideas, suggestions, and insights into ways you can approach, adjust to, and mitigate the immediate and long-term changes COVID-19 brought to your health center. Also, check out all of our free workforce tools and resources found at chcworkforce.org.