Building something bigger in the Big Bend

Many outstanding Texas family physicians provide excellent patient care. Others serve the future of the specialty by nobly teaching medical students and family medicine residents. Still others — certainly many reading this article now — find a niche in organized medicine, advocating for systemic changes to medicine at the Texas Capitol and on Capitol Hill. TAFP Family Physician of the Year Adrian Billings, MD, PhD, takes it a step further, embodying each of these critical roles of a family physician but also expanding his influence on an international level.

Personal practice philosophy: The three A's

Billings' first mentor, before he knew what a mentor was or had the idea to become a physician, was Dr. Ramon Garcia, the family physician who delivered him and cared for him through his childhood and into college. "He was an amazing solo practice community physician who did everything: the hospital, clinic; he was the volunteer football physician for the local high school and I would see him on the sidelines on Friday nights."

Billings worked for a local veterinarian as a teen, thinking at the time that he might pursue that as a career. He regularly assisted the veterinarian with necropsies on animals to find out how sheep, goats, and even cows and horses had died. He also showed lambs at 4-H competitions. One morning Billings went to feed his animals and found a lamb dead. "I figured I'd do my own necropsy," he says. "I rolled up my sleeves, pulled out my pocketknife and, with no gloves, opened up this animal from its neck to its pelvis. After five minutes, I had blood up to my elbows and no idea what had killed this animal or what the animal had died from."

The county extension agent found out about it and suggested sending the head off to the Texas A&M Veterinary Diagnostic Laboratory to make sure it didn't die of rabies. "I'll never forget the following Saturday when the results came in. The county extension agent called me at home and told me that the animal had tested positive for rabies and that I needed to seek medical care now. My mother and father were there … and we all literally thought I was about to die of rabies."

Billings knew he needed to talk to his family doctor, so he found Dr. Ramon Garcia in the White Pages in the Del Rio phonebook. In bold was his office number and, beneath that, not bolded, was his home phone number. Billings didn't hesitate; he called him at home and Dr. Garcia answered the phone. "He was about the age I am now; he had two young kids at home similar to the ages of my kids right now. I knew what he was doing on a Saturday: He was trying to have quiet time with his family. But here I am, one of his patients, calling. He answered the phone, he knew who I was. I very excitedly told him what happened, and he told me, ‘Adrian, you did not have a significant exposure, you're going to be fine. You do not need to seek any medical care.' And he was right. I obviously did not contract rabies and I did not die of rabies.

"But the teaching point that I love to tell trainees about is that he exhibited the three A's to me at that time, as a patient, after-hours on a weekend: He was available to me by printing his home phone number in the Del Rio White Pages. He was accessible to me by answering the phone. And then probably the most important third A is he was affable. He didn't seem put off. It was just the service that he provided for free to his patients. And I'll never forget that."

To honor Dr. Garcia, Billings has listed his home telephone number in the Alpine White Pages for the past 14 years and he also has provided that service to his patients at no cost. "It's something that I just feel as a community physician has been the right thing to do."

And just like Dr. Garcia, he sees patients in clinic and at the hospital. Billings delivers babies and serves as the medical director of Presidio Emergency Medical Services. He serves as the physician for the high school football team and local university football team, is a trustee on the school board, sponsors junior league sports teams, and promotes health education in the local schools. When patients approach him around town, he answers their questions about an issue or lab test, even if it's after-hours and on a weekend.

"Dr. Billings is the most dedicated family medicine physician that I have had the opportunity to work with," wrote Edward Strecker, MD, in Billings' nomination for Texas Family Physician of the Year. "With every patient, he goes above and beyond to provide comprehensive, evidence-based care while always making sure to address the patient's feelings and social situations. For extremely ill patients or those unable to visit the clinic, he is willing to make house call visits."

"He is different from any other family physician in that he truly seems to be inspired to always push forward and improve his community. Everything he does in his life seems to be dedicated to improving himself so that he can better serve his community," Strecker continued. "Dr. Billings is unique in that his passion and focus are infectious and anyone who has the opportunity to work with him is made better by getting to see a physician who is truly called to be a rural family doctor. I know that this has inspired me and impacted my life greatly."

"Dr. Billings is unique in that his passion and focus are infectious and anyone who has the opportunity to work with him is made better by getting to see a physician who is truly called to be a rural family doctor. I know that this has inspired me and impacted my life greatly."

Finding his way home

Billings fully homed in on a path to medicine after spending a summer in college working as an anesthesia technician at the local hospital in Del Rio. "They treated me like a third-year medical student that three months. I got to deliver babies with Dr. Garcia, I got to scrub on C-sections and general surgery cases. I got to intubate patients with the anesthetist," he says. He also worked as a paramedic during his undergrad years and, after graduation, applied to medical school. But he wasn't accepted.

Regrouping, Billings decided to go to graduate school at the University of Texas Medical Branch and earned a doctorate in experimental pathology. He went to the Centers for Disease Control and Prevention in Atlanta, Georgia, his dream job as a PhD, working in a biosafety level 4 lab on a hantavirus project infecting rats. But he felt isolated, not useful, and he didn't feel called to the research. He also really missed the Texas-Mexico border, its people and culture.

Billings took another shot at UTMB, was accepted, and graduated with his medical degree. He completed his family medicine residency at John Peter Smith Hospital in Fort Worth, serving as chief resident his final year, and went on to complete a surgical obstetrics fellowship at JPS. Then, as a National Health Service Corps scholar, he looked for a practice location to complete his four-year service obligation in an underserved area. His hometown of Del Rio didn't qualify as underserved enough, so he chose the town of Alpine, where he had spent time as a medical student in preceptorship, in clerkship as a third-year medical student, and in residency for a rural rotation.

Most National Health Service Corps loan repayers work as employed physicians in federally qualified health centers using grants that support caring for the indigent and Federal Tort Claims Act malpractice insurance that is provided by the federal government. But Alpine did not have an FQHC at the time. Billings agreed to function in private practice as an FQHC but without the grants or federally provided malpractice — a path NHSC advises against. For four years he was a solo private practice physician on call 24/7 with the support of one nurse practitioner providing full-spectrum family medicine with obstetrics and hospital coverage. Though rewarding, when he reached the end of his service period, he merged his private practice with a new FQHC in Marfa, 25 miles west of Alpine, to form Preventative Care Health Services.

"I think for my community and for myself, professionally and personally, it was the best decision that I made," Billings says. "I'm a family physician but my most important job is being a father [to Blake, Zane, and Colt] and husband [to Susan]. Someday I'll be replaced as a physician. I could be replaced as a husband — I don't want to be — but nobody can replace me as a father. So that's the reason I left private practice and 24/7 call is that I needed to balance my professional and personal lives. Because again, my priority is my family and that's the reason I chose family medicine as a specialty."

Currently, PCHS has three locations: Alpine, Marfa and Presidio. They have four family physicians and a nephrologist, behavioral health with several part-time licensed professional counselors, three dentists, and the rural residency program in collaboration with Texas Tech University Health Science Center.

"When I think about the impact of my solo private practice in Alpine without the $2.9 million in federal support that we receive now annually, without the free malpractice that we don't have an expense for now that we can use to direct toward indigent health care, it's a much larger impact and footprint than when I started."

Training and inspiring future rural physicians

Roughly 13 years ago, Billings started hosting medical students and family medicine residents through preceptorships and rural rotations. He keeps a list of medical students and residents who have come through his practice, and the list has grown to more than 300 medical students and 50 residents.

"I benefited as a medical student from a community preceptor, Dr. James Luecke, and he is still a mentor to me; he's still practicing out here. He opened up his private practice to me twice as a medical student and again as a resident. So to honor him, honor other community preceptors and honor the preceptorship program, I wanted to do the same thing." Billings is the current director of the Texas Family Medicine Preceptorship Program.

"It's been a blessing to me, to my practice, and to my community and my patients," Billings said. "I've had preclinical medical students make a diagnosis that wasn't even on my mind. I know that my patients benefit from having these trainees working alongside me. And, really, the teaching is bidirectional. I hope that I'm passing along information to these trainees, but they're also passing along information to me, and making me a better physician and keeping me up to date."

Billings serves a heavily Latinx population and many, particularly in the Presidio location, are Spanish-speaking only or bilingual with Spanish language preferred. He, himself, is bilingual but he recognizes the unique barrier for the patient who is seeing a health care provider who is not fluent or who isn't independent in speaking Spanish. For this reason, spurred by an idea from one of his medical students, he created a Presidio-based Spanish immersion course so students don't have to travel to Central or South America or Spain to have an immersion experience.

And while the Spanish immersion experience is popular with students and will go on to benefit any Spanish-speaking patient the students see later in their careers, the program has a dual purpose of hopefully recruiting a physician to Presidio, a community of 7,000 with no full-time physician or pharmacy.