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SOCIAL DETERMINANTS OF HEALTH Social Determinants of Health By Carlos Roberto Jaén, MD, PhD, FAAFP....................12 Access to Healthcare: Threats & Opportunities Requiring Physician Action By Lyssa Ochoa, MD.....................................................16 Location, Location, Location: Associating Physical Environment with Health Outcomes By Teresa Samson, OMS-III at UIWSOM .......................19 Food Insecurity in a Post-COVID Bexar County By Olivia Chen and Dirk Wristers ...................................22 Health Literacy Improves Women’s Health Care By Kalli R. Davis, OMS-II, Matthew D. Parker, MD Ariana Lewis, MD, Kent Rohweder, MD .........................24 Underutilization of Total Knee Arthroplasty By Katelyn Franck, Margaret Jonas, MS, Jaydee Foster, MA, Matthew Morrey, MD, Roberto Fajardo, PhD ..........26 COVID-19 & Education: The GAP Year By Leah H. Jacobson, MD, FAAP ..............................................................................................................28 Centers for Disease Control: Implications of the Emerging SARS-CoV-2 Variant VOC 202012/01 Last Updated Dec. 22, 2020 Content source: National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases ............................................................................30 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10 On Becoming a Physician By Abeer Chohan .........................................................................................................31 Interdependence and Positive Psychology: Using Our Shared Experiences to Flourish in Challenging Times By Jon Courand, MD ..........................................................................................................................................32 BCMS Circle of Friends Physicians Purchasing Directory........................................................................................34 Recommended Auto Dealers .................................................................................................................................39 Auto Review: 2021 Chrysler Pacifica Hybrid By Steve Schutz ...............................................................................40 PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com

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SAN ANTONIO MEDICINE • January 2021

JANUARY 2021

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VOLUME 74 NO. 1

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS. EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

For advertising rates and information Call (210) 410-0014 Email: louis@travelingblender.com SAN ANTONIO MEDICINE is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, its members, or its staff. SAN ANTONIO MEDICINE the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS

Rodolfo “Rudy” Molina, MD, President John Joseph Nava, MD, Vice President Brent W. Sanderlin, DO, Treasurer Gerardo Ortega, MD, Secretary Rajeev Suri, MD, President-elect Gerald Q. Greenfield, Jr., MD, Immediate Past President

DIRECTORS

Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member David Anthony Hnatow, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member John Shepherd, MD, Member Ezequiel “Zeke” Silva III, MD, Member Amar Sunkari, MD, Member Col. Charles Mahakian, MD, Military Representative Kristi G. Clark, MD, Board of Ethics Chair George Rick Evans, General Counsel Jayesh B. Shah, MD, TMA Board of Trustees Stephen C. Fitzer, CEO/Executive Director Nichole Eckmann, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Katelyn Jane Franck, Student Nichole Christiane Henkes, Student

BCMS SENIOR STAFF

Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Yvonne Nino, Controller August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member Antonio J. Webb, MD, Member David Schulz, Community Member Donald Bryan Egan, Student Member Teresa Samson, Student Member Alexis A. Wiesenthal, MD, Member Stephen C. Fitzer, Editor 6

SAN ANTONIO MEDICINE • January 2021

PRESIDENT’S MESSAGE

Health Literacy:

A Social Determinant of Health By Rodolfo Molina, MD, 2021 BCMS President

Part 1. Historical Perspective and Definition Greetings all. This opening article, proposed in two parts, marks the beginning of my stewardship of the Bexar County Medical Society as your President. I feel it’s the duty of our Board to remain mindful of our mission and statements: …. “the organization that serves and represents the member physicians of Bexar County in providing quality health care for their patients and the public. Vision: To make Bexar County a healthier community.” With that being stated, I plan to humbly steer a course that does not lose sight of our mission and vision and at all times is ready to accept critique, ideas, and worthy complements on how I’m doing. This two-part article deals primarily with our Vision statement; making Bexar County a healthier community. The first part will ground us with a historical perspective on health literacy and the second part takes us into actionable ideas on how to proceed in making our community healthier. Let me begin by telling you this true story. In the winter of 1847-48, a typhus epidemic broke out in a northern area of Prussia inhabited mainly by a largely poor Polish population. Fearing a scandal as the situation in this minority community grew more dire, the Prussian government sent, as was tradition, an outsider to assess the situation. A young, junior pathology lecturer at the Charite Hospital in Berlin, Rudolf Virchow, arrived at the province known as Upper Silesia on February 20th. The 26-year-old left three weeks later on March 10th, 1848. He later proclaimed that these were the most important three weeks of his career for they had been “decisive” in shaping his ideas of his life’s work.1 The first part of his report dealt primarily with geographical, anthropological, and social characteristics of the province. He went on to describe housing conditions, level of education, diets, drinking patterns as well as popular medical beliefs and practices of the population. He certainly wrote about typhoid, but he made a point of writing about the epidemic as it related to other endemic diseases such as pulmonary tuberculosis, measles, and dysentery. He refers to these diseases of the indigent as “crowd” or “artificial” diseases, caused by bacteria, but spread by individual susceptibilities and social determinants such as poor housing, sanitation, diet, and working conditions. Does this sound familiar? Virchow believed in social reformation within medicine as a necessity for better health: treating a pathology without context was and remains insufficient. He used the term “Social Medicine” to describe his ideas on how best to address disease. Virchow’s observations remain relevant to our discussion of health 170 years later. Broadly speaking, when discussing social factors that influence health today, there are many. However, one that has carried multiple definitions in the past and becomes of paramount importance in the time of a pandemic when information is scarce and always

SAN ANTONIO MEDICINE • January 2021

in question, is known as “health literacy.” What is health literacy, principally, and how do we measure it? In a 2010 review, Berkman et al. acknowledged that the definition of health literacy has had its own evolutionary track, meaning different things to different groups. When defined more broadly as the constellation of numerical and reading skills needed for interfacing with health care structures as a patient, low literacy has had a clear relationship with poorer health outcomes in the last few decades.2 The definition continues to evolve as technology provides greater access to health information, and we become more focused on access and less appreciative of the skills needed for interpretation of that information. We must therefore also embrace a more environmentally framed conceptual model that takes into account the role of language, culture, education, and social capital. Nevertheless, its measurement relies on using tools and questionnaires for literacy that remain a work in progress. For our purpose, we will use the following accepted definition for health literacy from the Institute of Medicine (IOM): “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”3 If you are seeing patients like mine, you understand that for a chronically ill patient to achieve those metrics as defined by the IOM is very difficult. Virchow in his final analysis stated, “Education, freedom and welfare can never be fully attained from the outside, in the manner of a present, but from the people’s realization of their needs.” Virchow was underscoring the importance of a public education policy that promotes a desire for a healthy society. Achieving strong health literacy across the general public requires both a top down approach (politicians, policies, caregivers) and bottom up grassroots (our patients) approach if we wish to prioritize and succeed in this effort. To be continued. Rodolfo (Rudy) Molina MD MACR FACP is a Practicing Rheumatologist and 2021 President of the Bexar County Medical Society. References 1. Taylor, R., Rieger, A,. Medicine as Social Science: Rudolf Virchow On The Typhus Epidemic in Upper Silesia. International Journal of Health Services, Vol. 15, No. 4, 1985. 2. Berkman, N. D., DeWalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N., Lux, L. et al. (2004). Literacy and health outcomes: Summary. In AHRQ evidence report summaries. Agency for Healthcare Research and Quality (US). 3. Kindig, D. A., Panzer, A. M., & Nielsen-Bohlman, L. (Eds.). (2004). Health literacy: a prescription to end confusion. National Academies Press.

BCMS ALLIANCE

Staying Connected During the Pandemic By Nichole Eckmann, 2021 BCMS Alliance President

2020 is a year that we will never forget! It’s a year that has been filled with so many challenges. It all began in the month of March when many of us, including myself, were on vacation and enjoying Spring Break, when news of the COVID-19 virus and the possible lockdowns began. Kids began virtual learning, more adults started working from home, the shelves in the grocery stores were increasingly bare, we had to start wearing masks, and we began social distancing, staying 6 feet apart. The reality was that no one really knew what to expect long term. We were all whisked into a new way of living and we had to adapt quickly. There was so much uncertainty and our days of connecting with other people were now via Zoom sessions. Physician families were extra nervous with what was to follow: days of worry-on-end, wondering if the physician in the household would get infected and come home and infect the rest of the family. How serious was this? Was the entire family at risk? There were so many questions and not many answers. This was when the members of the Bexar County Medical Society Alliance really banded together and were there for one another. We shared our fears, our tears and our worries and just asked for guidance from one another to make it through this difficult time. We all realized how important it was to stay connected even if it was via Zoom sessions. It was a blessing to know that each and every one of our members REALLY understood what we were feeling. We eventually realized that the best way to deal with the uncertainty and worry was to continue to do what we do best: reaching out to the community and giving back. We continued to meet and create ideas for reaching out to our members and our community while setting an example of masking and social distancing. This will likely continue into much of 2021, but 2020 has shown us that if we stay connected, we can get through this! I’ve said it before and I’ll say it again: the medical life is one of a kind; one that you don’t understand unless you are living it. Luckily the BCMS Alliance and its members DO get it and we are excited to conquer the unknown TOGETHER! Nichole Eckmann is the 2021 President of the BCMS Alliance.

SAN ANTONIO MEDICINE • January 2021

SOCIAL DETERMINANTS OF HEALTH

Social Determinants By Carlos Roberto Jaén, MD, PhD, FAAFP

Health

There is a light at the end a long tunnel as we celebrate the arrival of safe and effective vaccines for the COVID-19 pandemic. A magnificent miracle of modern medicine, considering that the first confirmed case in the United States was identified on January 21, 2020. 12

SAN ANTONIO MEDICINE • January 2021

SOCIAL DETERMINANTS OF HEALTH Figure 1 Many of our colleagues offer life-saving procedures and devices that alter dramatically the life course of our patients and many offer innovative therapies that prolong life and enhance the quality of life of our patients. Medicine in 2021 is bright and full of promise for those who can have access to it. We need to celebrate with pride the nobility of our profession and what is being achieved. We also need to face with humility the reality that what we do in medicine is but a small fraction of what drives health in the patients, families and communities we serve. According to recent estimates, clinical care contributes 20% to health outcomes, with social and economic factors, health behaviors and the physical environment accounting for the rest (see Figure 1). 1 The World Health Organization (WHO) defines social determinants of health (SDH) as “the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” 2 As articulated by the AMA Declaration of Professional Responsibility, we commit ourselves to “educate the public and polity about present and future threats to the health of humanity…[and] advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being” 3. So practically speaking, if we profess “a common heritage of caring for the sick and suffering” how do we address health disparities in Bexar County today by tackling the social determinants of health? A report from the National Academies of Science, Engineering and Medicine in 2017, Communities in Action: Pathways to Health Equity 4, presented a conceptual model that is included in Figure 2. It emphasizes the importance of increasing community capacity to shape health outcomes, of making health equity a shared vision and value, and of multi-sector involvement.

This model lists nine social determinants of health: 1) education 6) public safety 2) employment 7) the social environment 3) housing 8) transportation 4) income and wealth 9) health systems and services 5) the physical environment Stated in a different way, community-wide problems such as poverty, unemployment, low educational attainment, inadequate housing, lack of public transportation, exposure to violence, and neighborhood deterioration (social or physical) impact health and contribute to health inequities. The proposed multi-sector collaboration can include partners from agriculture, banking/finance, economic

2015 County health rankings: model, measures and years of data Source: County Health Rankings. Rankings Methods. 2015

development, education, health care, housing, human/social services, justice, labor, land use and management, media, workforce development, public health, transportation and others. The report also includes specific examples of communities tackling health inequities.4 Bexar County residents have an excellent resource in The Health Collaborative, an organization that has provided comprehensive health needs assessments since 1997, most recently published a report with details on many of the social determinants of health in 2019. The reports provide easily accessible and actionable data in graphic format. The organization has evolved to become a powerful network of citizens, community organizations and businesses committed to “improve the health status of the community through collaborative means”. Full disclosure, our Department of Family and Community Medicine is a member. In addition, the City of San Antonio Council has a committee dedicated to Community Health and Equity led by Council Member Ana Sandoval. It could be overwhelming to contemplate action on these SDH factors. Is there a way to focus on specific issues? Adler and colleagues offer us 3 pathways for action: 1) Addressing “upstream” SDH 2) Fostering health promoting resources and reducing healthdamaging risk factors throughout the life course 3) Improving access to, effects of, and the value of, clinical health services.6 continued on page 14 Visit us at www.bcms.org

SOCIAL DETERMINANTS OF HEALTH continued from page 13

Figure 2

Examples of the first pathway include home visiting programs for pregnancy and for parents of young children, the earned income tax credit, efforts to increase the federal minimum wage, and increased protections for job safety/worker protection (e.g. PPE) particularly during the pandemic among essential workers or expanding the Family Medical Act to cover smaller employers and add paid leave or criminal justice and sentencing policies. The evidence for the effectiveness for these approaches is robust.6 Examples of the second pathway include nutrition assistance in federal programs like Supplemental Nutrition Assistance Programs (SNAPs), local direct assistance by the San Antonio Food Bank, and direct assistance for specific patients who screen positive for food insecurity in our clinics. Also in this pathway are programs that promote children’s cognitive and social skills by expanding access to high-quality child-care and preschool (e.g., PreK for SA) as well as those that promote high quality primary and secondary schools. Regulations that incentivize healthy behaviors such as limiting tobacco and electronic nicotine delivery systems (ENDS) in multiunit housing, making healthy food options more salient and affordable, increasing the price of sugar-sweetened beverages that may reduce overweight and obesity, and promoting firearm safety. In terms of the third pathway, health care financing strategies to reduce health disparities, to allocate resources with the best effectiveness to improve patient outcomes are needed. The current fee-for-service payment system prioritizes “doing things to people rather than for people”, an emphasis on volume rather than on outcomes. Examples in this pathway include payment systems that value intervention and services that improve access and patient trust (e.g., transportation assistance and trust bridges by community health workers with clinical teams). Global capitated payment systems or value-based payments modeled on shared savings or accountable care organizations are examples of these innovative payment approaches. All these changes are not accessible to those most in need without expansion of health insurance coverage. Efforts to expand coverage need to be included along with changes to current policies to reduce further barriers to care among those who have coverage. The task to reduce health inequities in Bexar County requires that we stray from the comfort of our exam rooms, hospitals, procedure rooms and executive suites. We need to reclaim the healing mission that inspired us to get into our profession. With tenacity and enthusiasm, let’s engage with partners to address the other 80% that drives the health of the patients, families and communities we serve. We can do this together. Carlos Roberto Jaén MD, PhD, FAAFP is the Chair of Family and Community Medicine at the Long School of Medicine and a member of the Bexar County Medical Society and the National Academy of Medicine. 14

SAN ANTONIO MEDICINE • January 2021

Conceptual Model for Community Solutions to promote health equity Source: National Academies of Science, Engineering, and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. Doi:10.17226/24624.

References 1. Hood, C. M., Gennuso, K. P., Swain, G. R., & Catlin, B. B. (2016). County health rankings: relationships between determinant factors and health outcomes. American Journal of Preventive Medicine, 50(2), 129-135. 2. WHO (World Health Organization). 2012. What are the social determinants of health? Available at: https://www.who.int/ health-topics/social-determinants-of-health#tab=tab_1 (accessed December 6, 2020). 3. AMA (American Medical Association) 2001. AMA Declaration of Professional Responsibility Available at: https://www.amaassn.org/delivering-care/public-health/ama-declaration-professional-responsibility (accessed December 6, 2020) 4. National Academies of Science, Engineering and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. Doi: 10.17226/24624. 5. The Health Collaborative. (2019). 2019 Bexar County Community Health Needs Assessment Report. San Antonio, TX: The Health Collaborative. Available at: http://healthcollaborative.net/wpcontent/uploads/2019/10/Community2019_CHNAReport_compressed.pdf (accessed December 6, 2020) 6. Adler, N. E., Cutler, D. M., Fielding, J. E., Galea, S., Glymour, M. M., Koh, H. K., & Satcher, D. (2016). Addressing social determinants of health and health disparities: A vital direction for health and health care. NAM Perspectives.

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SOCIAL DETERMINANTS OF HEALTH

Access to Healthcare: Threats & Opportunities Requiring Physician Action By Lyssa Ochoa, MD

Introduction I’ll never forget the first time I was told by a PhD epidemiologist and San Antonio staple, Dr. Anil Mangla, that clinical care accounted for only 20% of patient outcomes. In the year 2014, after 16 years of education and training to become a vascular surgeon, and another 3 years in private practice in San Antonio, this claim felt outrageous. However, my experience is San Antonio was being filled with examples of extremely disparate outcomes, and I was looking for an explanation. Covering a territory that stretched from Northeast San Antonio to both corners of the southside, the differences were obvious. To use diabetic lower extremity amputations as an example (of course this outcome was present in both the north and south areas of town) the magnitude of difference in disease state and age at presentation, I thought, must be correlated to education, literacy, and socioeconomic factors that I had not been trained thoroughly to understand nor to intervene upon. If I really wanted to make a difference, I needed more tools in my toolbox than scalpels, wires and catheters. This began my dive into Social Determinants of Health. With topics ranging from historical racist segregation policies to investment in neighborhood sidewalks and availability of fresh produce, I was clearly in the deep end of an unfamiliar pool. My tendency as a sur16

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geon to want to fix a problem right now led me to explore the one component I and my physician colleagues could impact at our own discretion: access to care. Threats Facing Access to Care Even as I accepted that clinical care accounts for about 20% of outcomes, I remained convinced that it is a huge 20% (imagine having access to 20% of Bill Gates’ fortune, for example)! Therefore, making sure patients had access to clinical care became an obvious place to start. I needed to answer the question: Why don’t more patients have easier access to care? Transportation was an obvious answer, with so many wrinkles within itself. Some patients don’t have their own vehicle; others share a vehicle within the family; still others, such as children and the elderly, may have no control over their own transportation. Some ride bikes, some ride the bus, some call friends to help, others Uber or rely on insurance-provided options which are frequently challenging to logistically navigate. There are dozens of situations our patients face other than what we assume to be the baseline of: “When I need to access care, I get into my car and drive to the care at my convenience.” Additionally, the physical distribution of health care resources

SOCIAL DETERMINANTS OF HEALTH

Figure 1

can limit access to care. A geographic review of National Provider Identification numbers (see Figure 1), makes it clear where healthcare physical resources are located. We are at a deficit of over 150 primary care providers south of downtown. There are two southside hospitals compared to 30 downtown and north (reference) and, as of today, zero Medicare-accredited ambulatory surgery centers south of downtown compared to 40 downtown and on the north side (reference). There are many logistical concerns of all healthcare providers that quickly become threats to access to care, even if they are common practice. For example, standard 8am-5pm Monday-through-Friday business hours mean that many patients cannot access care when they are done working. Also, because so many of our healthcare providers are already overworked and understaffed, the typical “next available appointment” may be many weeks out. Then there is the black swan event we are experiencing right now: COVID-19. The COVID-19 pandemic’s impact on access to care will certainly be studied for years to come, and I am sure we would all agree it has been significant. Trying to find a silver lining, we ought to able to learn from, appreciate and respond to patient access to care that truly originates from completely external, large-scale forces of nature.

Opportunities for the Practicing Physician Thankfully, we physicians have a lot of latitude in addressing the issue of access to care. I’ve found the best way to focus my assessment of the issue is to hone in on the common thread that intertwines patient access to care most frequently - transportation. Like many, I first viewed transportation as the how patients get around: by car or bus, etc. Broadening transportation to include the components of when patients can access care and where they will be accessing care allows us to design solutions that solve real access problems in ways that are within our control. Regarding how patients get around, a common barrier we can intervene upon is insurance-assisted transportation. We can train our schedulers to understand how insurance-assisted transportation works, including limitations such as 72-hour notice, the patient identifiers needed to schedule on a patient’s behalf and other logistics that may help us help the patients. Chances are, if a patient’s circumstances require them to rely upon insurance-assisted transportation, they probably also need assistance navigating the ins-and-outs of setting up such transportation. Another way to intervene upon how patients access care is to familiarize our staffs with non-profit transportation resources in our area. RideConnect Texas and Jefferson Outreach are continued on page 18 Visit us at www.bcms.org

SOCIAL DETERMINANTS OF HEALTH continued from page 17 Figure 2

two examples of organizations that help patients access medical care through flexible transportation. Others can be found at the San Antonio Community Resource Directory at www.sacrd.org. When patients are able to access care is another variable we have a lot of flexibility to control. There’s the option for us to keep our practices open even an hour later into the evening or perhaps conduct one evening clinic per week or per month. Keep in mind that ANY deviation of our practice hours that extends beyond the normal 8am-5pm Monday-Friday schedule CREATES access to care. A Saturday clinic makes an enormous impact on access to care. Consider reducing or closing a clinic on a Monday following a Saturday clinic to offset your additional stress. This may feel like a zero-sum game with regard to our own personal time, but the positive impact of a Saturday clinic available to our patients can far outweigh the loss of a subsequent weekday. Another variable within the when patients access care is being more flexible with our “next-available-appointment” definitions. For example, if a new patient has an acute problem or an established patient has an urgent change of their symptoms, consider allowing them to come in at their next convenience instead of the office’s next convenience. I frequently remind my staff that satisfying our patients’ needs far outweighs the acute inconvenience we may feel by adding a patient to a full schedule. Finally, we can review the where component of the patient access problem. Investment in physical healthcare facilities has largely followed the same overarching trends of housing and commercial investment: that is to say mostly north and far-west sides of town. That leaves a large geography of densely populated urban San Antonio with a dis18

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proportionate lack of healthcare facilities. As practicing physicians, one strategy we can deploy is that of satellite offices. These timeshare or part-time leasing options allow for a low risk, low incremental cost opportunity for a large return in terms of patient access. Using my practice as an example, we rent part-time space in 5 different offices throughout San Antonio, conducting 2 to 4 clinics per month within each. There are logistics to consider for this “pack-in, pack-out” model for transportation of supplies and staff, but these are easily customizable for the needs of any given office. Conclusion There’s no doubt that the course of history has stacked the deck against the utopian desire for equitable access to healthcare for all of our people. This history, however, should not discourage us from using our collective resources as physicians to initiate the changes we desire. For as much as the current status of patient access to care is the result of both the intended and unintended consequences of deliberate and purposeful historical planning (i.e. segregation, redlining, etc.). We must deliberately and purposefully invest in correcting the status quo. Thankfully, our chosen profession as physicians often allows us both the professional and financial latitude to make such investments. Access to healthcare is a problem we can solve together if we each take steps toward this goal. Lyssa N. Ochoa, MD is board certified in Vascular Surgery and General Surgery and is an elected member of the Board of Directors of the Bexar County Medical Society.

SOCIAL DETERMINANTS OF HEALTH

Location, Location, Location: Associating Physical Environment with Health Outcomes By Teresa Samson, OMS-III at UIWSOM

Less than twenty years ago, the completion of The Human Genome Project galvanized a deeper understanding of the human genetic code and became a cornerstone in medicine. Applications of this knowledge, such as genetic screening for disease, gene therapies and CRISPR-Cas9 gene modifications have revolutionized approaches to healing disease. Yet, science remains far from discovering a panacea. Strikingly, it is now well-known that a person’s ZIP code may be a better predictor of health outcomes than their deciphered genetic code.1 Despite scientific advances, health continues to be a multifaceted concept and healthcare practitioners now must consider what external factors affect patient outcomes. Housing, parks and playgrounds, safety, transportation, walkability and ZIP code are all aspects of one’s physical environment that have an important role in determining community health.2 Housing conditions became a focus of health maintenance in the 1990s as the U.S. Department of Housing and Urban Development took initiative in lowering the incidence of acute lead encephalopathy in pediatric patients. Their efforts have since resulted in a 70% reduction in lead cases. Older or ill-maintained homes provide the primary exposure to lead, which, even at low blood levels, has been shown to negatively impact cognitive and behavioral development in children. Other poorly regulated aspects of the home include exposure to carbon monoxide, tobacco and radon through the air as well as the absence of heating and cooling systems, poor water quality, mold, and ambient noise. These aspects are known to have similar deleterious effects on childhood neurological development and also jeopardize respiratory and immunologic health.3 Housing conditions are similarly an important factor in the health of the San Antonio community, where almost 50% of houses were built prior to the reduction of lead use in paint and gasoline, and where inadequate waste removal in certain neighborhoods compromises the health and safety of the area.4 Without regular maintenance, renovation, and imposition of building standards, homes could become the most dangerous place for San An-

tonio children to grow up. The outdoor aspects of neighborhoods have a similarly profound effect on community health. Parks and playgrounds provide safe outdoor areas for all age groups to exercise, socialize, or for leisure; activities that all have known health benefits. It is therefore unsurprising that areas with fewer recreational spaces have increased rates of cardiovascular disease.5 An intriguing study revealed a strong relationship between residential greenspace and childhood behavioral outcomes, correlating exposure to greenspace with decreased risk for conduct disorder-like behaviors at age 7 and anxiety, depression, and somatization-like behaviors at age 12.6 In the entire USA, 54% of Americans live within a 10-minute walk of a park, while only 38% of Bexar County residents have this luxury.7 Most of these green spaces are concentrated within Loop 410 and are primarily located near the more pedestrian-friendly areas of San Antonio, thus potentially decreasing the physical and psychological wellbeing of the other half of San Antonians without easy park access. Accordingly, access to safe, well-maintained parks and playgrounds are a commodity for the wellbeing of San Antonio residents and should remain a priority for city planners. Beyond neighborhood infrastructure, the safety of a neighborhood can alter community health outcomes in both direct and indirect ways. While an individual’s feeling of “safety” may be influenced by a number of subjective factors, crime and traffic fatality rates are measures that can help quantify the objective safety of a neighborhood.8 Beyond induction of stress, crime – most notably gun-related crime – has been shown to reduce park use, potentially decreasing rates of physical activity up to one year after each incident.9 Simple adjustments, such as increasing street lighting, could be redeeming. Such changes have been associated with increased physical activity, decreased apprehension, and fewer traffic accidents.10 Furthermore, awareness and fear of local crime has shown a 40% increase in probability of respiratory illness.11 With this in mind, crime reduction is continued on page 20 Visit us at www.bcms.org

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of specific importance in improving the health of the San Antonio community, where crime rates tend to surpass the state average. The 2017 Bexar County Community Health Improvement Plan reported that violent crimes were 1.4 times the 2016 Texas rate, with both family crimes and child abuse/neglect crimes 14% higher than the 2016 Texas rate, all with expected increases in coming years. In light of this data, one may assume that increasing crime rates may contribute to a further reduction in neighborhood physical activity, yielding predictably poorer health outcomes for San Antonio residents. Traffic fatality rates are indeed a reflection of neighborhood safety, and they also impact the walkability of an area. In a highly car-dependent city such as San Antonio, where traffic fatalities have been shown to be higher than the state rate, prioritizing safe, wellmaintained walking areas is essential to community health.8 This is especially true for the areas outside of Loop 410, where there are fewer walkable areas and generally poorer health outcomes.7 It may be less intuitive that limited public transportation can compromise numerous aspects of community health. Interestingly, access to public transportation is linked with a stronger sense of community, better mental health and increased physical activity, which enhances cardiovascular outcomes.10 San Antonio’s Metropolitan Transit (VIA) is the only city-wide public transportation system in a city that is otherwise deemed “highly cardependent, with low walkability,” and many would suggest the transit system is inadequate to support movement across one of the nation’s largest-by-area cities.4 In fact, data from the 2019 Bexar County & Atascosa County Community Health Needs Assessment Report suggests that public transportation use may routinely double commuting times for residents.4 These findings will hopefully prompt San Antonio to improve its connectivity through enhanced public transportation and community efforts, and thereby curb related health outcomes. Possibly the most important health indication of the physical environment is ZIP code. Studies have supported the predictive capacity of ZIP code on population health. One study performed in Missouri analyzed both hospital and census data to identify strong associations between Community Health Rankings and the health outcomes of

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residents within particular ZIP codes.1 Proper application of these findings may improve approaches to healthcare by enabling providers to better understand variables in patient health, and prompt governing bodies to address the underlying causes for poor health outcomes. This data application is of high importance in San Antonio, a city where residents on the north side have a life expectancy 20 years longer than residents living in the south side, which is primarily home to minority and low-income families.8 This finding is consistent with the distribution of other health outcomes in the San Antonio area. Compared to north-central areas, residents of the south, west, and east sides of town are more likely to describe themselves as “fair or poor health versus better health” (29.1% of Southwest residents versus 12.9% and 17.5%

SOCIAL DETERMINANTS OF HEALTH

of Northside and Near Northside residents, respectively), have confirmed child abuse cases (20 to 70 per 1000 on the Near Westside versus 0 to 15 per 1000 in Northside and Near Northside), and have a diagnosis of diabetes (17% for residents on Near Westside versus 7.7% on the Far Northside).4 With further investigation, similar health outcomes may be associated with housing conditions, transportation, safety, walkability and public transportation of areas outside of the north-central region. Addressing the innumerable associations between physical environment and health outcomes remains a seemingly insurmountable challenge for our public health officials, city council members and law enforcement. Government initiatives seek to dissemble factors upstream of poor health outcomes such as poverty, infrastructure, trauma, while also pursuing a more direct approach by connecting and empowering community members. With time and further study, understanding the effects of physical environment on health will yield a stronger, healthier San Antonio, and transform San Antonio into a home that is suitable for all. Teresa Samson is an OMS-III at University of the Incarnate Word and is a member of the Bexar County Medical Society Publications Committee. References 1. Nagasako, E., Waterman, B., Reidhead, M., Lian, M., & Gehlert, S. (2018). Measuring Subcounty Differences in Population Health Using Hospital and Census-Derived Data Sets: The Missouri ZIP Health Rankings Project. Journal of public health management and practice : JPHMP, 24(4), 340–349. https://doi.org/10.1097/PHH.0000000000000578 2. Artiga, S. (2018). Beyond Healthcare: The Role of Social Determinants in Promoting Health and Health Equity. Kaiser Family Foundation. https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determi-

nants-in-promoting-health-and-health-equity/ 3. Weitzman M, Baten A, Rosenthal DG, Hoshino R, Tohn E, Jacobs DE. Housing and child health. Curr Probl Pediatr Adolesc Health Care. 2013 Sep;43(8):187-224. doi: 10.1016/j.cppeds.2013.06.001. PMID: 23953987. 4. The Health Collaborative. (2016). 2016 Bexar County Community Health Needs Assessment Report. San Antonio, TX: The Health Collaborative. 5. Bhatnagar A. (2017). Environmental Determinants of Cardiovascular Disease. Circulation research, 121(2), 162–180. https://doi.org/10.1161/CIRCRESAHA.117.306458 6. Madzia, J., Ryan, P., Yolton, K., Percy, Z., Newman, N., LeMasters, G., & Brokamp, C. (2019). Residential Greenspace Association with Childhood Behavioral Outcomes. The Journal of pediatrics, 207, 233–240. https://doi.org/10.1016/ j.jpeds.2018.10.061 7. 2019 Impact Report. (2019). SA2020. San Antonio, TX: SA2020. 8. 2017 Healthy Bexar Plan. (2017). Community Health Improvement Plan. San Antonio, TX: Metropolitan Health District; San Antonio, TX: Health Collaborative. 9. Han, B., Cohen, D. A., Derose, K. P., Li, J., & Williamson, S. (2018). Violent Crime and Park Use in Low-Income Urban Neighborhoods. American journal of preventive medicine, 54(3), 352– 358. https://doi.org/10.1016/j.amepre.2017.10.025 10.Bird EL, Ige JO, Pilkington P, Pinto A, Petrokofsky C, BurgessAllen J. Built and natural environment planning principles for promoting health: an umbrella review. BMC Public Health. 2018 Jul 28;18(1):930. doi: 10.1186/s12889-018-5870-2. PMID: 30055594; PMCID: PMC6064105. 11.Arthur, K.N., Spencer-Hwang, R., Knutsen, S.F. et al. Are perceptions of community safety associated with respiratory illness among a low-income, minority adult population?. BMC Public Health 18, 1089 (2018). https://doi.org/ 10.1186/s12889-0185933-4.

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Food Insecurity in a Post-COVID Bexar County By Olivia Chen and Dirk Wristers

SAN ANTONIO MEDICINE • January 2021

Food insecurity, defined by the USDA as “the limited or uncertain availability of nutritionally adequate and safe foods or limited/uncertain ability to acquire acceptable foods in socially acceptable ways”, has demonstrated consistent associations with the development of chronic diseases like diabetes, hypertension and obesity in numerous studies.1 According to Feeding America, the food insecurity rate of Bexar County was 14.1% in 2018, 2.6% percent greater than the national average.1 Furthermore, although Bexar County is among the top 15 US counties with the highest number of Supplemental Nutrition Assistance Program (SNAP) recipients, a significant proportion remain food insecure.2,3 Keep in mind, these statistics were collected prior to the COVID-19 pandemic. Many families in our community are sitting down for dinner without adequate meals to share. Other families are forced to skip meals completely. Food insecure patients may be hard to detect due to stigma surrounding food assistance. Questions such as “Have you had to cut the size of your meals or skip meals because there wasn’t enough money or food to go around?”. Additionally, the USDA offers a reliable, six-question screening tool that can be used to assess food insecurity in patients. Since the virus affected Texas early in March 2020, Bexar County residents have seen their unemployment rates skyrocket up to 13.5% in April 2020, according to the Texas Workforce Commission (TWC).4 For comparison, the unemployment rate in Bexar County was 3.0% in April 2019.5 As of September 2020, the unemployment rate in Bexar County remains quite high at 8.3%.6 Months of record-high rates of unemployment have caused community organizations like the San Antonio Food Bank (SAFB) to experience unprecedented surges in the number of clients they serve; between March 2020 and July 2020, SAFB saw their original client base double from 60,000 to 120,000.7 This massive increase in demand for services provided by local community organizations, in combination with a lack of current research regarding the impact of COVID-19 on food access, has highlighted the crucial need for research investigating the state of food security in Bexar County since the COVID-19 pandemic. In response to this major gap in public health research and in partnership with SAFB, an interprofessional team of students developed a community service and learning research project that will evaluate how food insecurity, food access barriers and purchasing behaviors have shifted in Bexar County since the COVID-19 pandemic began. This team is led by Dirk Wristers, a 4th year MD/MPH student at UT Health San Antonio, and consists of students from the UT Health San Antonio medical, dental, and nursing schools as well as a UTSA dietetics intern. COVID-19 has had a profound impact on the education of these medical students. Many were pulled out of the clinical learning environment and are being asked to learn in unconventional ways amidst an era that needs health care providers now more than ever. This team of students resolved to continue to make a positive impact on their communities despite their newfound distance from the patient pop-

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ulations they one day hope to serve. They are working together to uncover the details surrounding our food insecurity spike and are creating new solutions to this issue. This project has received funding from the UT Health Community Service and Learning MIDI Grant. These are unprecedented times that require careful analysis and novel reactions to a constantly evolving, novel situation. With a wellcrafted, mixed-method approach, which consists of both a quantitative survey distributed to SAFB clients living in Bexar County and qualitative focus group interviews for select survey participants, this team hopes to bring to light occult issues that are contributing to the larger trends we are seeing in a post-COVID Bexar County. Olivia Chen and Dirk Wristers are students at the UT Health San Antonio Long School of Medicine References 1 . Jo Weaver, L. and B. Fasel, C. (2018) A Systematic Review of the Literature on the Relationships between Chronic Diseases and Food Insecurity. Food and Nutrition Sciences, 9, 519-541. doi: 10.4236/fns.2018.95040. 2. Feeding America. 2020. Map The Meal Gap. [online] Available at: <https://map.feedingamerica.org/> [Accessed 28 August 2020].

3. Gundersen C, Waxman E, Crumbaugh AS. An Examination of the Adequacy of Supplemental Nutrition Assistance Program (SNAP) Benefit Levels: Impacts on Food Insecurity. Agricultural and Resource Economics Review. 2019;48(3):433-447. doi:10.1017/age.2019.30 4. Coleman-Jensen, Alisha, Matthew P. Rabbitt, Christian A. Gregory, and Anita Singh. 2019. Household Food Security in the United States in 2018, ERR-270, U.S. Department of Agriculture, Economic Research Service. 5. https://www.twc.texas.gov/news/texas-unemployment-rate-130percent 6. https://www.twc.texas.gov/news/texas-unemployment-rate-128percent 7. https://www.twc.texas.gov/unemployment-rate-83-percent-september 8. Talbot, S., 2020. SA Food Bank Officials Concerned Demand May Spike After Several Assistance Programs End This Week. [online] KSAT. Available at: <https://www.ksat.com/news/local/ 2020/07/27/sa-food-bank-officials-concerned-demand-mayspike after-several-assistance-pr ograms-end-this-week/> [Accessed 8 September 2020].

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Health Literacy Improves Women’s Health Care By Kalli R. Davis, OMS-II, Matthew D. Parker, MD, Ariana Lewis, MD, Kent Rohweder, MD

Health literacy affects the quality of healthcare provided to an estimated 80 million Americans. People experiencing low health literacy have difficulty obtaining and understanding information necessary to make decisions regarding their healthcare.1 Health illiteracy has been recognized as a major barrier to obtaining care for symptoms associated with uterine fibroids (UF).2 With UF affecting 70-80% of premenopausal women, it is important that the healthcare community address literacy challenges in helping patients understand UF.1 UF can significantly decrease the quality of life for affected women, prompting them to seek treatment for symptom relief. 3 Our focus is on combating low health literacy as a barrier to achieving shared decision making for selection of treatment in patients with UF, with particular emphasis on how collaboration between healthcare providers can help overcome this limitation to increase patient satisfaction and quality of life.2 24

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Treatment for symptomatic UF is far from one-size fits all, and is influenced by patient’s personal preference, fibroid size, number, location and numerous other factors.3 Physician communication of these assessed factors can help guide patient participation in the shared decision-making process. Patients may be overwhelmed by the amount of information disclosed during a consult, which is more frustrating to patients with limited health literacy. This is evident in studies showing hesitancy among patients with limited health literacy to ask questions that would facilitate greater comprehension and indicates a bias by providers to compensate with a paternalistic approach to care.4,5 A survey conducted by the Society of Interventional Radiology (SIR) found that 59% of women diagnosed with UF expressed that ‘knowing their doctor discussed all treatment options with them is the most important factor for selecting a treatment.’6 However, studies

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have shown that less than half of women that had undergone treatment for UF understood what a fibroid was or had heard of uterine artery embolization (UAE) as a treatment option, and that the majority of women who had heard of UAE learned about it outside of their provider’s office.6 These outcomes demonstrate an opportunity for better patient engagement in shared decision-making during treatment selection. It is important to remember that the average American adult reads at about a 7th-8th grade reading level. Studies demonstrate that most of the available resources, including some ‘reliable’ resources, fail to provide educational material at the appropriate level, despite recommendations from the American Medical Association that patient education material should be written at or below a sixth-grade reading level.7 Patient education material on the SIR website for UF was classified as ‘very difficult’ and ranged from 12th-17th grade reading level. An evaluation of available online materials for uterine UF concluded that only 6.7% (3 of 45) websites met all JAMA benchmarks to be classified as understandable reliable information.8 These studies point out the need for development of reliable and efficacious patient education (online and in-print) and shared decision-making tools for routine use during treatment consultation of women with uterine UF. Other ways to overcome health literacy as a barrier to shared decision-making in the treatment of UF include collaborative patient consultations between the gynecologist and an interventional radiologist. This collaborative effort between interventional radiologists and gynecologists has demonstrated benefits in facilitating patient decisionmaking by providing thorough exploration of all treatment options from providers who will be performing the procedures.9 These discussions are important to foster greater understanding of the advantages and, more importantly, the limitations of treatment options. Shared decision-making interventions have demonstrated significant benefits to disadvantaged patients, particularly those with limited health literacy.10 To provide optimal care for patients seeking treatment for symptomatic fibroids, gynecologists and interventional radiologists should work together to develop shared decision-making tools for use during patient visits for management of symptomatic uterine fibroids. Kalli R. Davis, B.S. / M.A. is a second-year medical student at UIWSOM in San Antonio, Texas and a member of the Bexar County Medical Society. Matthew D. Parker, MD is a Vascular and Interventional Radiology PGY-2 at UTHSC Long SOM and is the Co-Chair of the SIR RFS Research and Innovation Committee. Ariana Lewis, MD is a fourth year OBGYN resident at UTHSCSA. She is pursuing a career as an academic specialist in general obstetrics and gynecology.

Kent Rohweder, MD is Associate Program Director for Diagnostic Radiology, Associate Professor of Radiology & Interventional Radiology and Associate Professor for Clinical Emergency Room Radiology at UTHSC Long SOM. His clinical interests include interventional approaches for treatment of vascular, genitourinary and hepatobiliary diseases; and trauma diagnosis and life-saving interventional radiology procedures. References 1 . Rikard, R. V., Thompson, M. S., McKinney, J., & Beauchamp, A. (2016). Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL). BMC public health, 16(1), 975. https://doi-org.uiwtx.idm.oclc.org/10.1186/s12889-016-3621-9 2 . Henry, C., Ekeroma, A., & Filoche, S. (2020). Barriers to seeking consultation for abnormal uterine bleeding: systematic review of qualitative research. BMC women's health, 20(1), 123. https://doiorg.uiwtx.idm.oclc.org/ 10.1186/s12905-020-00986-8 3. Marsh, E. E., Al-Hendy, A., Kappus, D., Galitsky, A., Stewart, E. A., & Kerolous, M. (2018). Burden, Prevalence, and Treatment of Uterine Fibroids: A Survey of U.S. Women. Journal of women's health (2002), 27(11), 1359– 1367. https://doi-org.uiwtx.idm.oclc.org/10.1089/jwh.2018.7076 4 . Keij, S. M., van Duijn-Bakker, N., Stiggelbout, A. M., & Pieterse, A. H. (2020). What makes a patient ready for Shared Decision Making? A qualitative study. Patient education and counseling, S0738-3991(20)30462-6. Advance online publication. https://doi-org.uiwtx.idm.oclc.org/ 10.1016/j.pec.2020.08.031 5 . Zeuner, R., Frosch, D. L., Kuzemchak, M. D., & Politi, M. C. (2015). Physicians' perceptions of shared decision-making behaviours: a qualitative study demonstrating the continued chasm between aspirations and clinical practice. Health expectations: an international journal of public participation in health care and health policy, 18(6), 2465–2476. https://doi-org.uiwtx.idm.oclc. org/10.1111/hex.12216 6 . Society of Interventional Radiology - The fibroid fix: What women need to know. (n.d.). Retrieved November 16, 2020, from https://www.sirweb.org/ patient-center/fibroid_fix2/fibroid-fix-report/ 7 . Hansberry, D. R., Kraus, C., Agarwal, N., Baker, S. R., & Gonzales, S. F. (2014). Health literacy in vascular and interventional radiology: a comparative analysis of online patient education resources. Cardiovascular and interventional radiology, 37(4), 1034–1040. https://doi-org.uiwtx.idm.oclc.org/ 10.1007/ s00270-013-0752-6 8 . Murray, T. E., Mansoor, T., Bowden, D. J., O'Neill, D. C., & Lee, M. J. (2018). Uterine Artery Embolization: An Analysis of Online Patient Information Quality and Readability with Historical Comparison. Academic radiology, 25(5), 619–625. https://doi-org.uiwtx.idm.oclc.org/10.1016/j.acra. 2017.11.007 9 . Zurawin, R. K., Fischer, J. H., 2nd, & Amir, L. (2010). The effect of a gynecologist-interventional radiologist relationship on selection of treatment modality for the patient with uterine myoma. Journal of minimally invasive gynecology, 17(2), 214–221. https://doi.org/10.1016/j.jmig.2009.12.015 10 . Durand, M. A., Carpenter, L., Dolan, H., Bravo, P., Mann, M., Bunn, F., & Elwyn, G. (2014). Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PloS one, 9(4), e94670. https:/doiorg.uiwtx.idm.oclc.org/10.1371/journal.pone. 0094670

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Underutilization of Total Knee Arthroplasty: Active Efforts and Proposed Solutions to Address this Locally By Katelyn Franck , Margaret Jonas, MS, Jaydee Foster, MA, Matthew Morrey, MD, and Roberto Fajardo, PhD

The south side of San Antonio is a medically underserved area with both a shortage of physicians and a significant amount of need. Total knee arthroplasty (TKA) is a common and successful treatment for end stage arthritis that significantly decreases pain levels and improves quality of life. The incidence of knee arthritis is similar among nonHispanic Whites, Blacks, and Hispanics, yet when compared to nonHispanic Whites (NHW), minority populations such as Hispanics utilize TKA 20-30% less despite a similar incidence of osteoarthritis (OA). This means approximately 25% fewer Hispanics with end stage knee OA (among all with end stage OA) seek out a TKA compared

SAN ANTONIO MEDICINE â&#x20AC;˘ January 2021

to non-Hispanic Whites. In San Antonio, this suggests that approximately several hundred to a thousand Hispanic individuals with endstage OA will likely not seek out a TKA to treat their disease (Zhang and Jordan 2010) in any one year. This number will only increase as demographic trends change and the Hispanic population, which has a large young population, ages more and more. The reasons for lower utilization are poorly understood. Lower utilization is documented in Hispanics even after controlling for education, income, geographic location, education, insurance status and/or medical comorbidities (Irgit and Nelson 2011). Patient preferences,

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expected outcomes, religion, patient and provider level factors, hospital distance and patient’s willingness to travel are among the factors that have been associated with disparities, but they fail to explain underutilization (Zhang 2016). Even among only Medicare recipients these disparities persist. It is essential to better understand the healthcare decision-making process in patients with OA of the local Hispanic population, especially those on the south, east, and west sides of town (underserved areas). Ideally, improved utilization rates will mean fewer individuals unnecessarily enduring life altering pain and discomfort and thus increased surgical volumes; essentially a win-win for community wellness and the healthcare industry. What are some solutions? An ongoing study conducted by a team from the UIWSOM and the private sector is investigating the overall patient healthcare experience and how it relates to underutilization of TKA in local minority populations. The survey study, led by Dr. Roberto Fajardo, strives to identify cultural, social, and socioeconomic factors that influence a person’s decision to pursue medical attention and undergo a surgical joint replacement procedure due to osteoarthritis (OA). This work, supported by the offices of city councilwomen Rebecca Viagran and Adriana Rocha Garcia, as well as Dr. Matthew Morrey with Ortho San Antonio, will better inform researchers and clinicians about the decision-making process of patients from the south, east, and west sides of San Antonio. So far, the research team has recruited over 120 people for their study. Subjects are being recruited at local senior centers and public events such as farmer’s markets, YMCA’s and other UIWSOM sponsored health events. In these interviews with southside residents, interesting patterns have emerged. Of our present sample of respondents, over 90% reported that they currently have health insurance and indicate they are comfortable with their current medical knowledge. Among patients that live with daily knee or hip pain, 47% indicated financial concerns would prevent them from pursuing surgery. Half believed joint replacement surgery is common and successful for knee and hip OA. But, 41 and 43%, respectively reported they would avoid a total joint arthroplasty due to fear or cost even though surgery could alleviate joint pain. This is an interesting result given that research overwhelmingly proves these highly successful procedures infrequently result in major complications. This study is ongoing, however it is coming to light that fear, finances and doubts about the benefit of the procedure appear to fuel decisions to forego surgery. A proposed solution is development of private and academic (privademic) partnerships that invest in the underlying causes of underutilization. These partnerships will allow researchers and clinicians to be able to address and rectify these concerns in a more timely and efficient manner. Small, upfront monetary investments by privademic

partnerships would result in a more targeted approach to addressing the specific needs of the patients in a specific community. This ultimately leads to improved wellbeing by many suffering from knee OA and an increase in surgeries that are needed. This increases patient access for private practices, an opportunity for mutual wins. Presently, outcomes are not as good in minority populations. An investment in understanding the reasons for this, as well, is needed to close that gap. In addition to socioeconomic factors, provider and patient factors are significant contributors to disparities observed in TKA (Perez 2020). Working as a privademic partnership, clinicians can get a more customized understanding about their patients’ concerns rather than combing through generalized population studies that may or may not fit the demographic in which they are working. Listening to the narratives of our patients and working collaboratively to better understand their perspective will take upfront effort on the physicians’ part, but investing time now will pay off in the future. This will help San Antonio achieve better health outcomes, increased patient satisfaction and improved community health as a whole. Katelyn Franck and Margaret Jonas are both third year medical students at UIWSOM and part of the research team studying health disparities and TKA underutilization. They are also members of the Bexar County Medical Society. Jaydee Foster, MA is a Clinical Research Coordinator at UIWSOM. Matthew Morrey, MD is an orthopaedic surgeon with Ortho-San Antonio and Clinical Associate Professor at UIWSOM and UT Health San Antonio. Roberto Fajardo, PhD is an Associate Professor of Anatomy at UIWSOM. References: Zhang, Y., & Jordan, J. M. (2010). Epidemiology of Osteoarthritis. Clinics in Geriatric Medicine, 26(3), 355–369. https://doi.org/10.1016/j.cger.2010.03.001 Irgit, K., & Nelson, C. L. (2011). Defining racial and ethnic disparities in THA and TKA. Clinical orthopaedics and related research, 469(7), 1817–1823. https://doi.org/10.1007/s11999-011-1885-z Zhang, W., Lyman, S., Boutin-Foster, C., Parks, M. L., Pan, T. J., Lan, A., & Ma, Y. (2016). Racial and Ethnic Disparities in Utilization Rate, Hospital Volume, and Perioperative Outcomes After Total Knee Arthroplasty. The Journal of bone and joint surgery. American volume, 98(15), 1243–1252. https://doi.org/10.2106/JBJS.15.01009 Perez, B. A., Slover, J., Edusei, E., Horan, A., Anoushiravani, A., Kamath, A. F., & Nelson, C. L. (2020). Impact of gender and race on expectations and outcomes in total knee arthroplasty. World journal of orthopedics, 11(5), 265–277. https://doi.org/10.5312/wjo.v11.i5.265

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COVID-19 & Education The GAP Year

No one could have imagined what would happen to our education system at the start of the pandemic in March 2020. What initially was thought to be a “blip” in the education of our children and young people has turned in to an arduous ongoing journey with no end in our foreseeable future. Students, educators, administrators, staff and parents have all been affected. As a general pediatrician and a parent in our community, I quickly learned about the good and the not-so-good aspects of virtual/distance learning. I chose to get involved at both the local and State level to help educate myself, as well as other health care providers and the community about the ever changing aspects of the Sars-CoV2/ COVID-19 virus. More importantly, I wanted to know how it was affecting us. With regards to the current education situation, there are no winners. Everyone is struggling in their own way. That could be the student who chooses to stay home to keep her elderly grandparents safe, but suffers due to social isolation, or it could be the kindergartner who is losing out on basic education because his family does not have the economic means to afford high speed internet. Then there are the educators who are putting themselves and their families’ health at risk to teach our children. We are literally having to weigh health versus education. Recent statistics point to community positivity rates being high again, and the patience of students, teachers and parents are wearing thin. The Texas Education Agency (TEA) is applying pressure to schools to bring more students back for in-person education, which adds more stress to the situation. Fortunately, we know more about SARS-CoV-2. Global, national and local data provide some reassurance about in-school transmission (see additional information below for links). Bexar County has particular disparities associated with the issues brought about by the COVID-19 virus. A higher rate of infection has been found in certain areas/zip codes of the county. And it has been repeatedly stated that certain school districts’ students/families lack the means to provide essential technical infrastructure, such as high-speed internet, or provide basic necessities, such as food. There are reports of increased domestic abuse related to loss of job/income, added stress, etc., as well as mental health conditions (for all ages). Many students with special needs are suffering without schoolprovided services and therapies. These students are the ones that need to be present in school, but contrarily also need to be at home (as to not be potentially exposed to the virus). So, what is the answer? I do not think there is just one, but my personal thought is that this is a “Gap Year!” Everyone take the year off,

SAN ANTONIO MEDICINE • January 2021

By Leah H. Jacobson, MD, FAAP

get this pandemic under control, and start fresh next year. It does not mean we should not continue to educate and provide for our children and young people during this time, but we should take the pressure off of them, the parents, the educators, and the school systems during this very difficult period in our lives, and not expect perfect attendance, great test scores, or large academic achievements. Basic needs and health are the important keys at this time. Leah H. Jacobson, MD FAAP is a general pediatrician in private practice. She is Chair of the BCMS COVID-19 Task Force Subcommittee on Pediatrics and Schools, a member of the Metro Health PreK-12 Consultation Group, a member of the TMA School Reopening Work group, a member of the TMA Committee on Child and Adolescent Health, and was the 2017 BCMS President References and Information 1 . CDC guidance as of September 2020. 2 . State level data: https://dshs.texas.gov/coronavirus/schools/ texas-education-agency/ 3 . TEA/State level data: https://tea.texas.gov/sites/default/files/ covid/SY-20-21-Public-Health-Guidance.pdf 4 . Local data: https://covid19.sanantonio.gov/What-YOU-CanDo/Reopening-Safely/Information-for-Residents#RemoteLearning. Almost all cases represent out-of-school transmission (i.e. household, social circles). (But there are several studies that show that children do transmit to household members—and certainly adult staff do.) 5 . Additional local data (epidemiological reports): https://covid19.sanantonio.gov/About-COVID-19/Dashboards-Data/Epidemiological-Reports. Cases in children on p. 6 of November report, and hospitalizations on p.11. In a Previous Health Directive, Junda Woo of the San Antonio Metro Health defines Red/Yellow /Green (https://covid19.sanantonio.gov/files/assets/public/files/about/health-directives/healthdirective-schools-amended-20200903.pdf ).

SAN ANTONIO MEDICINE

On Becoming a Physician By Abeer Chohan

I believe that it is quite common on this journey, on which we have embarked together, to experience similar feelings and make likeminded connections. How we interpret these may differ for us individually and how we draw meaning from each encounter to relay it to our path again may be more personalized and sacred for each. I am unsure of the sentiments of the majority when it comes to deep reflection on past events but I personally find myself skipping this necessary step at the end of my days. I don’t know that I fully allow myself to ponder the nature of what it is that I am doing. I think that it is easier to go through the motions of care than the emotions of care. Of course, every patient has a story to tell, beyond the story of their chief complaint and their past medical history, beyond anything that physical scars and aches and sores can comprehend. It is not until you reach into the crevices and tap into the rich mines of the wounds that you will truly understand another's suffering, truly empathize with another’s pain. In “becoming” what it is we set to be, I think many of us will have noticed how “unbecoming” of our former selves we are. It is a dynamic change to be molded into one who is ready to serve. Each tribulation fragments you and sometimes even delivers a blow so strong it will wring and shake the very core of your being, causing the soft and malleable parts of you to shift and reform you once again. Not so much like a diligent sculptor who continuously chips away at the right corners and constructs the perfect image, but rather like a warrior tsunami that knows only destruction in its path, its winds and water forcing the pliable sand to shift and violently reassemble itself from amongst the remnants. I think many see the journey as a factory assembly line, and maybe that is what it seems from the outside. A naive bright eyed pre-med goes in and a hardened and wise physician comes out. But what it takes to get from point A to point B only few truly know. It is hard for me to imagine one single instance, one event that I can look back on and say “yes, that is when I knew I had become a doctor.” I think

it was not one big thing rather the collection of little ones. The little moments and the little interactions. The little girl who as a refugee ended up in my care, who looked up at me and saw a scarf that she could relate to, who told me she wanted to be me when she grew up. The little breaths of air, taken by a dying man surrounded by his family; one who knew life as a daredevil, who was used to breathing fire, now engulfed by it in a fever because the cancer cells had nested too long. The little steps taken by the aunt down what seemed to be a never-ending hospital corridor, who went from holding up her family to being propped up by a friendly OT in recovery from her stroke. The little triumphs and the little sorrows encompassing the vast experience of what it means to become. I think it dawned on me a little too late perhaps that being a doctor is not treating a disease, it is healing a person. A person with a story and a life and a soul and memories to share. I do recall when I first was let out onto the wards, an eager kid excited to see all the pictures I've spent so long staring at; jealous when a classmate recollected a stirring tale of what rare diseases and conditions they bore witness to; always forgetting that there is a life who now embodies that disorder, whose life has been molded and twisted and plunged, maybe by that same warrior tsunami that came for us, into becoming a patient. We are becoming together and in that becoming we find connection, meaning, unity and from that we heal, prosper, and become whole. Abeer Chohan is a 4th year medical student at UIWSOM, pursuing a residency in pediatrics. She is a proud member of the inaugural class at UIWSOM and a member of the Bexar County Medical Society.

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CDC EXECUTIVE SUMMARY

Centers for Disease Control

Implications of the Emerging SARS-CoV-2 Variant VOC 202012/01 Updated December 22, 2020

Executive summary A new variant strain of SARS-CoV-2 that contains a series of mutations has been described in the United Kingdom (UK) and become highly prevalent in London and southeast England. Based on these mutations, this variant strain has been predicted to potentially be more rapidly transmissible than other circulating strains of SARS-CoV2. Although a variant may predominate in a geographic area, that fact alone does not mean that the variant is more infectious. Scientists are working to learn more about this variant to better understand how easily it might be transmitted and whether currently authorized vaccines will protect people against it. At this time, there is no evidence that this variant causes more severe illness or increased risk of death. Information regarding the virologic, epidemiologic, and clinical characteristics of the variant are rapidly emerging. CDC, in collaboration with other public health agencies, is monitoring the situation closely. CDC will communicate new information as it becomes available. Does this variant have a name? At present, the variant is referred to as “SARS-CoV-2 VOC 202012/01” (i.e., the first variant of concern from 2020, December), or “B.1.1.7.” The press often uses the terms “variant,” “strain,” “lineage,” and “mutant” interchangeably. For the time being in the context of this variant, the first three of these terms are generally being used interchangeably by the scientific community as well.

SAN ANTONIO MEDICINE • January 2021

Why has this variant been in the news recently? Since November 2020, a variant strain of SARS-CoV-2 has become prevalent in the southeast of England, reportedly accounting for 60% of recent infections in London. This variant has a mutation in the receptor binding domain (RBD) of the spike protein at position 501, where amino acid asparagine (N) has been replaced with tyrosine (Y). The shorthand for this mutation is N501Y, sometimes noted as S:N501Y to specify that it is in the spike protein. This variant carries many other mutations, including a double deletion (positions 69 and 70). Why has this variant emerged in the UK? We do not know. By chance alone, viral variants often emerge or disappear, and that may be the case here. Alternatively, it may be emerging because it is better fit to spread in humans. This rapid change from being a rare strain to becoming a common strain has concerned scientists in the UK, who are urgently evaluating the characteristics of the variant strain and of the illness that it causes. Have we seen this variant in the United States? The VOC 202012/01 variant has not been identified through sequencing efforts in the United States, although viruses have only been sequenced from about 51,000 of the 17 million US cases. Ongoing travel between

the United Kingdom and the United States, as well as the high prevalence of this variant among current UK infections, increase the likelihood of importation. Given the small fraction of US infections that have been sequenced, the variant could already be in the United States without having been detected. What do we know already about variants containing N501Y? Prior work on variants with N501Y suggests they may bind more tightly to the human angiotensin-converting enzyme 2 (ACE2) receptor. It is unknown whether that tighter binding, if true, translates into any significant epidemiological or clinical differences. In one laboratory study of transmission of the virus between ferrets, this mutation (and one other) spontaneously arose in the ferrets during the experiment. The significance of this observation remains to be elucidated. VOC 202012/01 so far has no known association with animals or animal contact. What about the other mutations in this variant of SARS-CoV-2? SARS-CoV-2 mutates regularly, acquiring about one new mutation in its genome every two weeks. Many mutations are silent (i.e., cause no change in the structure of the proteins they encode) because they produce a three-letter codon that translates to the same amino acid (i.e., they are “synonymous”). Other mutations may change the codon in a way that leads to an amino acid change (i.e.,

CDC EXECUTIVE SUMMARY

the G614 variant spreads more quickly than viruses without the mutation. • Ability to cause either milder or more severe disease in humans. There is no evidence that VOC 202012/01 produces more severe illness than other SARS-CoV2 variants.

they are “non-synonymous”), but this amino acid substitution does not impact the protein’s function. VOC 202012/01 has 14 non-synonymous (amino acid [AA] altering) mutations, 6 synonymous (non-AA altering), and 3 deletions, notably including, • 69/70 deletion: this double deletion has occurred spontaneously many times, and likely leads to a change in the shape of (i.e., a conformational change in) the spike protein. • P681H: near the S1/S2 furin cleavage site, a site with high variability in coronaviruses. This mutation has also emerged spontaneously multiple times. • ORF8 stop codon (Q27stop): This mutation is not in the spike protein but in a different gene (in open reading frame 8), the function of which is unknown. Similar mutations have occurred in the past. In Singapore, one strain with this type of mutation emerged and disappeared. What implications could the emergence of new variants have? Among the potential consequences of these mutations are the following: • Ability to spread more quickly in humans. There is already evidence that one mutation, D614G, has this property to spread more quickly. In the lab, G614 variants propagate more quickly in human respiratory epithelial cells, out-competing D614 viruses. There also is evidence that

• Ability to evade detection by specific diagnostic tests. Most commercial polymerase chain reaction (PCR) tests have multiple targets to detect the virus, such that even if a mutation impacts one of the targets, the other PCR targets will still work. • Decreased susceptibility to therapeutic agents such as monoclonal antibodies. • Ability to evade vaccine-induced immunity. FDA-authorized vaccines are “polyclonal,” producing antibodies that target several parts of the spike protein. The virus would likely need to accumulate multiple mutations in the spike protein to evade immunity induced by vaccines or by natural infection. Among these possibilities, the last—the ability to evade vaccine-induced immunity— would likely be the most concerning because once a large proportion of the population is vaccinated, there will be immune pressure that could favor and accelerate emergence of such variants by selecting for “escape mutants.” There is no evidence that this is occurring, and most experts believe escape mutants are unlikely to emerge because of the nature of the virus.

What is CDC doing to track emerging variants of SARS-CoV-2? In November 2020, CDC officially launched the National SARS-CoV-2 Strain Surveillance (NS3) program to increase the number and representativeness of viruses undergoing characterization. When fully implemented in January 2021, each state will send CDC at least 10 samples biweekly for sequencing and further characterization. In addition, CDC’s COVID-19 response is actively seeking samples of interest, such as samples associated with animal infection and, in the future, samples from vaccinebreakthrough infections. Data from these efforts are continuously analyzed at CDC, and genomic data are rapidly uploaded to public databases for use by researchers, public health agencies, and industry. To coordinate US sequencing efforts outside of CDC, since early in the pandemic, CDC has led a national coalition of laboratories sequencing SARSCoV-2 (SPHERES). The SPHERES coalition consists of more than 160 institutions, including academic centers, industry, nongovernmental organizations, and public health agencies. Of the approximately 275,000 full-genome sequences currently in public databases, 51,000 are from the United States. (The UK currently has the most sequences, with 125,000). Last Updated Dec. 22, 2020 Content source: National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases

Is this new variant related to the newly emergent variant in South Africa? On December 18, 2020, the South African government announced that it had also seen the emergence of a new strain in a scenario similar to that in the UK. The South African variant also has the N501Y mutation and several other mutations but emerged completely independently of the UK strain and is not related to it.

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SAN ANTONIO MEDICINE

Interdependence and Positive Psychology: Using our Shared Experiences to Flourish in Challenging Times By Jon Courand, MD

The COVID-19 pandemic has served as a dramatic demonstration of our human interconnectedness, encompassing individuals beyond our families and local communities to nations and the world as a whole. At times, this interconnectedness has been viewed as a great risk factor prompting physical distancing, quarantine or even sheltering in place. More than a few times I have walked through a store or my workplace and viewed my friends, neighbors and colleagues as threats to my personal health, or grew angry at those who chose to gather in large groups or deliberately chose not to wear masks. Along the way, however, many of us sensed with increasing unease the isolation and lack of human interaction. We missed the physical connection of shaking hands, embracing loved ones or sitting down with friends to share a meal. Despite that isolation we have witnessed, perhaps for the very first time true in-

SAN ANTONIO MEDICINE • January 2021

ternational collaboration as teams of researchers, hospital systems, healthcare workers, innovators, policy makers, manufacturers, epidemiologists, pharmaceutical companies and others come together in a global effort to address the immense challenges of the Coronavirus pandemic. We are not just interconnected; we are also interdependent. That interdependence far from being a threat is actually a critical strength which opens in each of us a space for gratitude, shared experiences and a focus for compassion. Sharon Salzburg wrote in Real Love: The Art of Mindful Connection “The combination of realizing our distinctiveness along with our unity is seeing interdependence”. The insight emanating from this realization of our distinctiveness along with our unity can be profoundly transformational. Beneath the layers of unease and distress, there is the strength that keeps us going, the lessons

learned, the hopes, the skills that have supported our survival and, in many occasions, our success. These “things” are the focus of Positive Psychology (PP), a scientific approach to the study of what enables individuals and communities to thrive. PP was “founded on the belief that people want to lead meaningful and fulfilling lives, to cultivate what is best within themselves, and to enhance their experiences of love, work, and play.” (1). Researchers and theorists in PP have studied human thoughts, emotions, and behaviors from a strengths’ perspective. In other words, PP is dedicated to the study and promotion of “what makes life most worth living” (2). This is often at odds with the health care approach which operates through the lens of a disease mode looking for the pathological and dysfunctional. PP relies on research and scientific methods to identify then strengthen what works in our lives to promote wellbeing. This

SAN ANTONIO MEDICINE

children, helping friends, working for a greater cause, or expressing themselves in creative ways. For physicians, staying connected to your WHY, understanding the immense impact of your work, and remembering why you chose to do what you do may help you find fulfillment, even in everyday tasks.

difference between a pretend happiness or a real sense of wellbeing is what makes it so appropriate in the times of COVID-19. We need not forget the pain and suffering the world is experiencing. But we can take some time to explore and promote what is helping us survive, better yet flourish, through it. PERMA At the heart of PP is the PERMA model, the five core elements of psychological wellbeing: Positive Emotion, Engagement (or a state of flow), Relationships, Meaning, and Accomplishment (3). These five elements can help us move towards a life of fulfillment, happiness, and meaning. Positive Emotions Focusing on positive emotions is the ability to remain optimistic and view our experiences from a constructive perspective. Optimism is a big component of PP since it postulates that joy, meaning, creativity and happiness can be developed through consistent work. As a therapist (AD), I sit all day with difficult emotions. I accompany others in their pain and suffering day-in and day-out. I must constantly remind myself that many people are thriving, that even my own clients can feel very different and happy in other moments of their lives. I just don’t get to witness them. I find that this perspective helps me reclaim control over my

emotional life. Engagement Engagement is our ability to remain present and integrate into our lives the activities where we find calm, focus, and joy. Activities that meet our need for engagement rush positive neurotransmitters and hormones to our body, infusing us with a sense of well-being. When we are interested, focused and enjoying what we do, we are in “the flow.” Incorporating mindfulness, the practice of being fully present in the here and now might be the key to feeling fully engaged, and a powerful antidote to burnout. Relationships PP is based on the concept of humans as social beings, with a deep need for physical and emotional interactions with others. These interactions promote connection, love, and intimacy. Hence, interconnectedness and the relationships it creates are crucial to meaningful lives. Meaning Another key element that can promote fulfillment and life satisfaction is the understanding of “why am I on this earth?” Mark Twain said, “The two most important days of your life are the day you are born and the day you find out why”. Many people find the answer through religion or spirituality, raising their

Accomplishments It is probably redundant to tell you how important it is to feel accomplished. I will dare to say that had you not had clear goals and a sense of satisfaction and achievement when you arrived to them, you would not have succeeded through medical school and residency. Having goals and accomplishments in life is important to stay in the path of thriving. Reexamine your accomplishments and your goals, set new ones if need be, and celebrate your achievements. Conclusion We work in an increasingly complex system made more intense by the current pandemic, yet through our Interdependence, we have the opportunity to forge a shared vision, express our gratitude for those on this same journey, and act with compassion for those who are suffering. We are all here to bring our unique talents to this wider effort. Positive Psychology through PERMA provides a useful roadmap to help guide us beyond a state of enduring one’s life to flourishing within it. Jon Courand MD, FAAP is Professor and Vice Chair for Education and Training in Pediatrics and Assistant Dean of Wellness Programs for GME at UT Health San Antonio. Resources 1. https://ppc.sas.upenn.edu/ 2. Peterson, et al. Group Well-Being from a Positive Psychology Perspective. Int Assoc. Applied Psych, (57) pp.19- 36, 2008 3. https://positivepsychology.com/what-ispositive-psychology-definition/

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PHYSICIANS PURCHASING DIRECTORY Support the BCMS by supporting the following sponsors. Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed. ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

BANKING

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a

SAN ANTONIO MEDICINE • January 2021

private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com https://www.bbt.com/wealth/star t.page "All we see is you"

BUSINESS CONSULTING Synergy Federal Credit Union (HHH Gold Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need. Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

Waechter Consulting Group (HH Silver Sponsor) Want to grow your practice? Let our experienced team customize a growth strategy just for you. Utilizing marketing and business development tactics, we create a plan tailored to your needs! Michal Waechter, Owner (210) 913-4871 Michal@WaechterConsulting.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

DIAGNOSTIC IMAGING

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com BBVA Compass (HH Silver Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services. Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities" BB&T (HH Silver Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services -- BB&T offers solutions to help you reach your financial goals and plan for a sound financial future

Touchstone Medical Imaging (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity. Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

FINANCIAL ADVISOR

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

management and mortgage products and services. Jake Pustejovsky Commercial Relationship Manager (830)302.6336 Jake.Pustejovsky@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (512)226-0208 www.Regions.com

Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President | Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society. Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group, Insurance Services, SWBC Wealth Management and PEO (210) 525-1241 DMarino@swbc.com Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® CEO | Wealth Advisor 210.864.3350 eric@avidwp.com avidwp.com “Plan it. Do it. Avid Wealth”

GHA TECHNOLOGIES, INC (HH Silver Sponsor) Focus on lifelong relationships with Medical IT Professionals as a mission critical, healthcare solutions & technology hardware & software supplier. Access to over 3000 different medical technology & IT vendors. Pedro Ledezma Technical Sales Representative 210-807-9234 pedro.ledezma@gha-associates.com www.gha-associates.com “When Service & Delivery Count!”

INFORMATION AND TECHNOLOGIES

HEALTHCARE BANKING Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth

Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA),

the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com OSMA Health (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians. Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

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PHYSICIANS PURCHASING DIRECTORY continued from page 35

MEDICAL BILLING AND COLLECTIONS SERVICES The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.” Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL PRACTICE

IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner. Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.com Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “

MEDICAL PHYSICS

SAN ANTONIO MEDICINE • January 2021

shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL SUPPLIES AND EQUIPMENT

Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

PRACTICE SUPPORT SERVICES CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-434-2713 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience. Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor)

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society. Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group, Insurance Services, SWBC Wealth Management and PEO Relations (210) 525-1241 DMarino@swbc.com

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org

glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Donna Bakeman Office Manager 210-301-4362 dbakeman@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELEHEALTH TECHNOLOGY

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship or, sponsor member services please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366 www.bexarcv.com/secure/ bcms/cofjoin.htm

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service." The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center. Gay Ryan Property Manager 210-559-3013

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-434-2713 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.

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AUTO REVIEW

SAN ANTONIO MEDICINE â&#x20AC;¢ January 2021

AUTO REVIEW

2021 Chrysler Pacifica Hybrid By Stephen Schutz, MD

By the time you read this, Fiat Chrysler Corporation (FCA) will have been acquired by Peugeot SA (PSA), joining Peugeot, Citroen, DS, Opel, and Vauxhall in an ever expanding stable of automotive brands. It seems like a rare win-win in the automotive M&A world. PSA has been ably led by CEO Carlos Tavares since 2014, and they have successfully integrated the venerable Opel and Vauxhall companies that they purchased in 2017. So they were ready for their next acquisition when they proposed a merger with FCA in early 2019, and FCA needed a partner with scale who could take their good parts and make them even better. Nevertheless, PSA was actually FCA’s second choice as a partner. Carlos Tavares’ former boss and mentor, Carlos Ghosn, former CEO of Renault-Nissan, was deep into negotiations with FCA in 2018 when he was arrested in a Japanese sting operation orchestrated by Nissan, ending a deal that would have created the biggest automaker in the world. Two-plus years after the Ghosn arrest, which I still believe was one of the stupidest corporate decisions ever, Nissan and Renault continue to shed market share, and both brands seem destined to be absorbed by competitors—Nissan by Toyota and Renault by PSA (just my opinion FWIW). Anyway, FCA will undoubtedly help PSA, and not just because absorbing FCA gives PSA ownership of perennially profitable Jeep and Ram, but also because FCA has some excellent products unrelated to those brands. Like the Chrysler Pacifica Hybrid minivan I just tested. The Pacifica is the latest Chrysler minivan, and it’s a good one. Featuring numerous innovative features and storage solutions (although the famed “Stow N Go” second row seats are unavailable in the Hybrid because that’s where the battery pack is located), the Pacifica is perfectly designed for parents and grandparents who have to lug kids and their paraphernalia around hither-and-yon. Not only is the Pacifica’s interior cleverly designed, but it’s big— big enough for 7 people and their gear—which reminds me to quickly get this off my chest: vehicles this cavernous inside should not be called “mini”. They’re just not. The Pacifica, despite its many clever storage innovations, can’t reasonably be called premium inside. Even in its highest trim it’s nice and comfortable but no GMC Denali wannabe with materials throughout the interior and dashboard that are good but not great. Of course, any Denali will be significantly more expensive than the Pacifica Hybrid, which starts at just over $41,000, but the Pacifica

will remind you of the price differential every time you get in it. Driving the Pacifica is also good but not great, but it’s better than a GMC Denali because minivans (sorry, FWD-based vans) have less mass and lower centers of gravity than large SUVs. Obviously, the Pacifica is no sports car, but it is pleasant to drive around town and on the highway. (It’s especially good on the highway, by the way.) One change I would make, if I could, would be to lose the continuously variable transmission (CVT). The CVT is more fuel efficient, to be sure, but it drones under acceleration and just feels not quite right. A standard automatic like the 9-speed included in nonHybrid Pacificas would be better. Speaking of fuel efficiency, the Pacifica Hybrid gets 32MPG City, 33 Highway, and gas-electric combined 84MPGe. Much of the credit for those good numbers goes to the plug in part of the Hybrid. Because of that, the Pacifica Hybrid can go all-electric for around 30 miles on a full charge, which for me meant that I ended up going back and forth to work without using any gasoline at all since I have a short (7 mile) commute. An owner who plugs in every night and uses their Pacifica Hybrid mostly to zip around town running errands and taking kids here and there could easily go about their lives hardly ever going to a gas station. Battery Electric Vehicle (BEV) enthusiasts encourage everyone to ditch internal combustion engines (ICEs) right now, but with recent electric power outages in California and a stretched grid elsewhere it seems prudent to retain an ICE backup in case your local utility runs short on electricity. The Pacifica Hybrid takes care of that. Nevertheless, the additional complexity of a battery pack, electric motor, and a lot of extra software means that there’s more in the Hybrid that could go wrong. The PSA-FCA merger is likely to provide the strong Jeep and Ram brands a more robust foundation on which to build, but PSA is gaining more than just those two makes, as my time with the Chrysler Pacifica Hybrid proved. As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

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Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of December 23, 2020. 42

SAN ANTONIO MEDICINE â&#x20AC;¢ January 2021