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Seeing Patients Cradle to Grave on the U.S. Mexico Border: A Profile in Commitment

Adrian Billings MD
I still feel that I am called to do what I am doing and that I am doing the work that I was put on this Earth to do. Hopefully, I am making a difference.
Seeing Patients Cradle to Grave on the U.S. Mexico Border: A Profile in Commitment

Adrian Billings, MD will tell anyone who asks that he loves what he does. Dr. Billings is a family physician practicing in one of the most underserved areas of the United States. He was born and raised in Del Rio, Texas, located on the US/Mexico border. The region’s unique mix of language and culture has always felt comfortable to him and from the time he entered college he knew that he wanted to become a doctor and return to the Texas-Mexico border to practice.

Growing up, Dr. Billings had two important role models. When he was in high school he worked for a dedicated solo-practice veterinarian. In this role, Adrian would assist the veterinarian with house calls for animals in their care. The dedication and care demonstrated in this practice were important examples of how to run a medical practice as well as a veterinary practice. Dr. Billings’ second role model was his family physician, Dr. Garcia, who cared for many of the people in Del Rio. “My family doctor delivered me,” Dr. Billings remembers, “and took care of me all through school including college when I’d come back home. After my freshman year in college I came back and was trained as an anesthesiology technician at the local small hospital in Del Rio. I was able to scrub in on surgeries and assist with patient care. One of my fondest memories is helping deliver babies with Dr. Garcia. I was 19 at the time and I reminded him, ‘you know what happened 19 years ago? You delivered me!’ I knew then that I wanted to be a family doctor who took care of everybody cradle to grave.”

MCN BillingsOPPORTUNITIES ABOUND

That dream was delayed when Dr. Billings was not accepted into medical school out of college. He decided to take a different path and entered into a University of Texas Medical Branch PhD program in Experimental Pathology. After graduation he went to work at the Centers for Disease Control and Prevention (CDC) in the Special Pathogens Branch of the Division of Viral and Rickettsial Diseases. Although it was interesting work, he never lost the drive to attend medical school.

He redoubled his efforts to apply to medical school and was accepted at the University of Texas Medical Branch at Galveston, Texas. While he was working at the CDC a colleague encouraged him to apply to the National Health Service Corps (NHSC) for support during his medical education. Dr. Billings eagerly accepted the financial support in exchange for a commitment to work at least four years in a medically underserved area. He began his residency at John Peter Smith Hospital in Fort Worth, Texas, and served as chief resident from 2005 to 2006. Because his intention was to return to an underserved area of the Texas/Mexico border where there were few practicing OB/GYNs, he decided to take an additional year of training as an OB/GYN Fellow.

Once he finished his residency, he began looking for a place to practice. Since the Del Rio area did not meet the NHSC criteria of an underserved region to qualify for the scholarship repayment, he chose Alpine, Texas, which is relatively close to Del Rio, and, where medical care was desperately needed.

For four years Dr. Billings ran a solo private practice in Alpine. He managed his practice with a strong commitment to the local community and functioned essentially as a community health center (CHC) without the benefits of the resources and services that are afforded to CHCs. When Dr. Billings arrived there had been no full-time family physician providing care. He was one of only two doctors in a 6,000-square-mile area that delivered babies. In those first years of practice Dr. Billings delivered 40 to 70 babies each year. To meet the needs of some of the most debilitated patients, Dr. Billings also made house calls for those who could not make it in to the office. As a solo practice physician he was on call 24 hours a day, seven days a week, for six years.

PRESIDIO COUNTY HEALTH SERVICES

The practice hardships meant that Dr. Billings was unable to recruit a physician partner. At the same time he wanted to expand care to a greater area that included the town of Presidio right on the US/Mexico border. He decided that the best option would be to merge his practice with Presidio County Health Services, a Health Resources and Services Administration (HRSA) Health Center Program grantee.

He became a part of the Presidio County Health Services and saw immediate benefits for his patients. All of Dr. Billings’ private patients were transferred over and now benefit from the community health center’s resources and services. Since all of his patients continue to see Dr. Billings there are few adjustments from the patient perspective. With the support of the overall health center structure, Dr. Billings has been able to recruit a partner who helps to shoulder the patient care load. He is now covered under the health center’s malpractice coverage, which greatly reduces his vulnerability to lawsuits and the costs associated with insurance coverage. Dr. Billings enjoys the support of a HRSA grant that allows the center to provide more enabling and wrap-around services. He is also happy to be able to focus on patients more and worry less about the business side of running a practice.

The region of Texas where Dr. Billings practices is home to both migrants who travel part of the year to work in agriculture in the northern states as well as agricultural workers employed seasonally in the Texas border region. The Health Center that Dr. Billings joined, Presidio County Health Services, is one of the 169 health centers across the country that receives funding specifically to provide services to migrant and seasonal agricultural workers. Dr. Billings says that he “feels blessed to be able to take care of this population.”

Dr. Billings is also very positive about his experiences with the HRSA-mandated quality control measures and the data collection system that facilitates the reporting process. From Dr. Billings’ perspective the clinical performance measures and the Uniform Data System provide important quality assurance/improvement screening and peer review processes. He remarks that in a private practice it can be difficult to devote as much attention as is ideal to the outcomes of care. The clinical quality process at the health center offers a snapshot that gives a much better understanding of how the practice is achieving better health care.

Presidio County is in one of the poorest regions of the United States. Dr. Billings’ biggest concern is the overall lack of access to care for many people in the region. He hopes that some of this lack of access will be ameliorated by the Affordable Care Act.

As is true in many isolated areas of the US, lack of access to care is especially challenging when a patient needs specialty care. In Dr. Billings' practice, the greatest need for specialty care is the in the areas of child psychology and psychiatry, cardiology, gastroenterology, orthopedics, and ear/nose/throat. The nearest specialists are located more than 200 miles north in Odessa or west in El Paso, or nearly six hours away in Lubbock. To get some of his sickest patients into care, Dr. Billings has become skilled at negotiating with specialists to see patients who lack insurance or have other challenging circumstances. He is also working to leverage additional resources such as telemedicine to provide on-site specialty care.

Inevitably, Dr. Billings has had to take on more specialty care himself than he would if he were working in a higher resource area because he is the first point of access for most patients. He says that he has seen almost anything and everything.

One example he remembers vividly was several years ago when a young pregnant woman came into the emergency room with vaginal bleeding and abdominal pain. It became quickly apparent that she had an ectopic pregnancy which had already ruptured. The woman’s blood pressure was critically low and she needed emergency surgery. She was too unstable to transfer the long distance to a major medical center. Dr. Billings sat with her and told her what needed to happen. He was very upfront about the fact that he was not as experienced in this procedure as he would have hoped; it had been five years since he had even assisted in this type of surgery. He knew however that he either needed to perform this surgery or she would die. In the end he was able to successfully operate and helped to save her life. “I certainly felt that I had someone working through my hands during this surgery.” This woman is still one of his patients. While this case was extreme, Dr. Billings says that he still gets nervous in these situations. “Even today, just delivering any baby is a miracle, a new experience. I still get nervous. I just hope that my training has been good enough when I am backed into a corner.”

FAMILY MEDICINE RESIDENCY PROGRAM

In addition to providing quality care to the people in Presidio County, Dr. Billings is committed to improving the overall health care system in the region. To this end, five years ago Dr. Billings started talking to Texas Tech University Health Sciences Center-Permian Basin about establishing a formal rural family medicine residency program in the Big Bend region of Texas that includes Alpine, Marfa, and Presidio. The idea has come to fruition; the first resident has been accepted after a competitive process and will begin the residency program later this year. Dr. Billings has also hosted over 60 medical students and more than 12 residents who have come through and spent time learning about frontier practice on the Texas/Mexico border. Dr. Billings says that he initially started to host students and residents when he was in private practice and feeling professionally isolated and lonely. He quickly realized that he became a better physician by helping to teach these medical trainees.

A couple of years ago, Dr. Billings was elected as a Young Physician delegate to the American Medical Association on behalf of the American Academy of Family Physicians. He and his wife attended a reception in Chicago, with many of the other young physician delegates. He was the only family physician and the only person practicing in a rural area. The group was curious about what he did as a rural doctor. One person in particular didn’t understand how it was that he could work in such an isolated area and deliver babies at all times of the night or day. She wondered what it did to his family. Dr. Billings’ wife elbowed him in the ribs and said, “I’ll answer this one. My husband works hard and has to work nights and weekends often. He is a great father to our children when he is there and when he’s not able to be with us, our children are learning about service through him. It is not always about you or about what you want; it’s about helping others when they are in need. We are a team.” Dr. Billings acknowledges that his efforts would not be possible without the support of his family and office staff: “I still feel that I am called to do what I am doing and that I am doing the work that I was put on this Earth to do. Hopefully, I am making a difference.” 

30 CLINICIANS MAKING A DIFFERENCE is a project celebrating Migrant Clinicians Network's 30th anniversary through the life stories of 30 clinicians making a difference in migrant health. Learn more about Migrant Clinicians Network.

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