San Antonio Medicine March 2018

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VOLUME 71 NO. 3

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Is there a way to get really good prices for prescriptions? Yes, there’s an app for that.

BCMS President’s Message ...............................................8

BCMS Legislative News.........................................................12

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Medicine: Redifining HER2 Equivocal Breast Cancers: Lessons Learned from Genomic Pathology

By Shelly Gunn, MD, PhD ..................................................18 Medicine: Non-surgical alternatives for female incontinence By Dr. Timothy Hlavinka ...............................24 Business: Why companies should help employees retire on schedule By Gil Castillo .................................26 Book Review: Before I go to Sleep By S.J. Watson Revieded by Fred Olin, MD........................................28 In Real Time: VII: There is no real ending. It is a pause. By Rajam Ramamurthy, MD..................................30 Legal Ease: Do you have somebody workinig for you who isn’t a U.S. citizen?

By George F. “Rick” Evans, General Counsel, BCMS .............................................................................32 UT Health San Antonio president announces new medical school dean

By William L. Henrich, M.D., MACP, President and Professor of Medicine ......................................34 BCMS Circle of Friends Directory ..............................................................................................................38 In the Driver’s Seat ....................................................................................................................................42 Auto Review: 2018 Mercedes X560 convertible By Steve Schutz, MD .....................................................44

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VOLUME 71 NO. 3

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EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Editor: Mike W. Thomas Email: Mike.Thomas@bcms.org

By Stephen Fitzer, BCMS Executive Director..................14

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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.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Sheldon G. Gross, MD, President Gerald Q. Greenfield Jr., MD, PA, Vice President Adam V. Ratner, MD, President-elect Leah H. Jacobson, Immediate Past President Kristi G. Clark, Secretary John Robert Holcomb, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Jenny Shepherd, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Manuel Quinones, MD, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Pavela Bambekova, Medical Student Darren Donahue, Medical Student Carmen Garza, MD, Community Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member Austin Sweat, Medical Student J.J. Waller Jr., MD, Member

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PRESIDENT’S MESSAGE

Focusing on the youth to avoid “physician burnout”

By Sheldon Gross, MD, 2018 BCMS President I have now been in private practice for 34 years. I am happy to say that I still enjoy coming to work and feel great satisfaction from working with patients. I have observed many colleagues in the process. Some have maintained their enthusiasm, energy, and love of their career. Others have developed “physician burnout.” There has been a great deal of attention devoted to this recently. Numerous articles and lecture series have been dedicated to this. From a societal standpoint, the reason is obvious. Our country needs more physicians. In particular, we need physicians with many years of experience. From an individual standpoint, the reason is even more compelling. All of us have devoted a huge amount of time and energy to becoming physicians. As is the case in so many different careers, physicians typically get better with age. With our experience and knowledge over the years, we can reach a diagnosis more quickly and oftentimes can avoid mistakes that we have witnessed in the past. The main challenge is to keep up with new developments in our fields. This is the obvious advantage of being recently trained.

During one of my more pensive moods, I reflected on what differentiates those who remain enthused about medicine and those who don’t. One particular experience in my own practice stood out.

A fourth-year medical student was visiting my office and shadowing me for the day. I have always enjoyed this and found this refreshing and stimulating.

We went into the exam room to see a new patient. This was a 7year-old boy who had new onset Bell’s palsy. Over 34 years, I have lost count of how many patients I have seen with Bell’s palsy. However, for this medical student it was the first patient he had ever seen with this condition. I observed his enthusiasm about finally seeing something he had only studied previously. I witnessed his eagerness to learn more about it and discuss my past experience with Bell’s palsy. At the end of the day, he thanked me profusely for a stimulating afternoon. As I witnessed this student’s response to seeing his first case of Bell’s palsy, it reminded me of the enthusiasm I had during medical school and postgraduate training. It reminded me of why I became a physician in the first place. It reminded me of how fortunate I am to have a career that stays challenging and fascinating throughout one’s lifetime. I know that in every field of medicine there are practicing physicians who not only have a great deal to teach medical students, residents, and fellows, but would also

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benefit immensely from a personal standpoint. It is hard to become burned out if you are surrounded by people who are enthusiastic and eager to learn. Clearly, we are looking at a symbiotic relationship. Medical students and residents are hungry to learn from the experience of more seasoned practitioners. Seasoned practitioners benefit immensely from sharing in the enthusiasm and love of medicine displayed by our younger colleagues.

San Antonio now has two medical schools. The University of Texas Health Science Center is welcoming a new Dean, Dr. Hromas. The University of the Incarnate Word School of Osteopathic Medicine is now accepting students for its second class. I encourage practitioners to contact one of these two institutions and let them know if you are interested in working with medical students.

I have never regretted time spent teaching and sharing experiences with my younger colleagues.

At the same time that we focus on teaching students and residents, we have to maintain our focus on being in control of our own practice. We have to maintain focus on ensuring that the bureaucratic non-clinical burden on physicians does not overwhelm us. This is why I am constantly encouraging people to become active in organized medicine. One of the many goals of the TMA and AMA is to maintain as much physician control as possible.

For those of you that have had other experiences that renewed your enthusiasm about medicine, I welcome letters to the editor.

Sincerely, SHELDON GROSS, MD Bexar County Medical Society

Editor’s note:

Letters to the Editor are welcome and should be addressed to BCMS Editorial Dept., 4334 N. Loop 1604 W., San Antonio, Texas 78249 or send email to mike.thomas@bcms.org.

BCMS NEWS

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BCMS LEGISLATIVE NEWS

RECEPTION HELD HONORING CONGRESSMAN WILL HURD On Feb. 12, Christy and John Hinchey, MD hosted a reception in their home in honor of U.S. Representative Will Hurd (TX-23). Guests in attendance included members of the physician and dentist community, in addition to members of the business community. Many thanks to all who attended and to the Hincheys for hosting the event.

For more information contact Mary Nava, chief government affairs officer at BCMS, at 210-301-4395.

Congressman Hurd provides remarks during the reception held in his honor on Feb. 12.

(standing l-r): Congressman Will Hurd, John Hinchey, MD and Christy Hinchey pause for a photo at the reception on Feb. 12.

Congressman Hurd addresses attendees on Feb. 12 on all the latest happenings on The Hill, including taxes, cybersecurity and DACA.

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EXECUTIVE DIRECTORS MESSAGE

IS THERE A WAY TO GET REALLY GOOD PRICES FOR PRESCRIPTIONS? Yes, there’s an app for that.

By Stephen Fitzer, BCMS Executive Director hysicians are often asked by patients “how much will that medicine cost?” or “where should I go to get the best price on that medicine?” Physicians are normally not pharmacists. Without knowing the pharmacy prices of drugs, a physician could be prescribing drugs that the patient cannot afford. Wouldn’t it be great to have a free and reliable source that both physicians and patients could use to find that information? I’m going to tell you about one in this article.

If patients do not know how much a medicine costs, are afraid a medicine is too expensive, have been quoted a high price by a pharmacy, or do not have the time or ability to call around or visit pharmacies to find the best price, they may either pay too much or not have the prescription filled at all. When the prescription is not filled, the patient becomes non-compliant, may suffer unnecessarily, may wind up back in the doctor’s office or worse, winds up in an emergency room somewhere.

For patients that have insurance covering prescription meds, this issue is not so severe. The insurance company has usually pre-negotiated prices with pharmacies so the patient doesn’t have to haggle or shop around. The patient in those cases will usually have a copay that is manageable. But what about patients that don’t have any insurance to cover their medications and are left to themselves to find the best prices for their medicines? How about when a patient has Medicare coverage (like I do), where Medicare prescription coverage is optional for an extra fee? I did the math and, for me, it didn’t make sense to sign up for Medicare Part D (prescription coverage). The cost benefit just wasn’t there.

Getting back to the main point, when a patient doesn’t have prescription insurance, what do they do?

I found myself in that situation and started looking into various drug discount programs. Some charge a fee, some have a small network, some are only mail order, some can’t tell you how much the discount will be on a medicine, and some are just outright scams. Then I found something that made the process a lot easier.

P

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I’m telling you about it because I think it will make life a lot easier for both you as a physician and for your patients.

To be clear, I am not a physician; I am a patient. My intention with this article is to tell you about a nocost phone app that saved me and others lots of money on prescriptions. Sometimes AMAZING amounts of money. Disclaimer: I receive no compensation for telling you about this, nor does anyone I know receive any compensation. BCMS is not endorsing this plan, has no relationship with the app provider and receives no compensation from this company.

This is purely my experience that I believe will really help physicians and patients on a regular basis.

The service I am talking about is a free phone app called GoodRx. It is available from both the Apple and Android app stores by typing in the name. Using the app is as simple as entering the name of the medicine, the dosage and the count, and letting the app tell you the price that is charged by most major pharmacies in town. In the case of San Antonio, it will normally list Walmart, Costco, Walgreens, CVS and Target (Sam’s Club and HEB are noticeably absent from the list). Upon entering a brand name medicine, it will usually list the price of the generic, if available. It lists the pharmacies in order of price, with the cheapest at the top of the list. It also tells how far away the pharmacy is from where you are at the time you look it up. The listed price will usually say “cash” or “coupon.” If it says “coupon,” touching the “coupon” box will bring up the codes the pharmacy will need to confirm and approve the price. Sometimes the price the pharmacy charges will be slightly different from the price listed by GoodRx, but the price is usually quite accurate. Sometimes GoodRx may not reflect a pharmacy’s current price because something has changed (prices change frequently on drugs). Patients can call ahead and confirm the price

EXECUTIVE DIRECTORS MESSAGE

with the pharmacy before making a trip there.

The app also has the feature of adding up the costs of all the patient’s medications and telling the patient which is the best pharmacy to use if they want to purchase all medications in one place. Other features of the app include: reminder of when each prescription needs to be refilled, health news tips, and information on the medicine’s use, dosing, side effects, drug interactions, etc.

I could see a physician using the app on his/her phone to record all the medications they normally prescribe, thus having information on pharmacies and their prices available to show patients. In the

eyes of the patients it would be viewed as good customer service.

The physician would obviously have to caution the patient on how to use any information about pharmacies, the quoted prices, drug information and such. Patients should also be reminded that any dosages, uses, etc., may be different in the app from what the doctor has prescribed. So, use the app knowing its limitations.

In my research of GoodRx, I reviewed their website (GoodRx.com), I checked with the Better Business Bureau, I checked Quora.com, and datafox.com. While most feedback about GoodRx is very positive, the most common complaint was about

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EXECUTIVE DIRECTORS MESSAGE continued from page 15

some pharmacies not honoring the price or the price being different than that listed on GoodRx. Sometimes that was due to the fact that prices change so often, while at other times the pharmacist had not been advised or trained on the use of GoodRx.

One of the most common questions about GoodRx is “How do they make their money?”

GoodRx has posted the following in response: •

• •

We provide services to businesses and insurance plans who want to help their employees/members save money on prescriptions.

We display third-party ads on our website.

Some pharmacies pay us a referral fee when we send new customers their way.

GoodRx offers a free kit for physicians that includes businesscard sized takeaways for patients. You can get the kit free of charge by going to the GoodRx site at www.goodrx.com/doctors.

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Personally, I have been using GoodRx for six or seven years with very good results. I thought everyone knew about the app. However, in my last two doctor’s office visits I asked if the doctors knew about GoodRx and they said no. When I demonstrated it to them, they could see the application to their patient care. With that experience, I figured I should tell BCMS members about it so they can look at the app and make their own decisions.

I hope this will help you as a physician and be good for your patients. There is no cost for the app. GoodRx has an upgrade they offer for a fee, but I have never used it. I use the free app and find it very helpful. I have saved thousands of dollars using it over the years. It tells me where to go to save the most money and how much I will pay for prescriptions. I also love reading more about the drugs I am taking. Try it for yourself and let me know what your experience is.

MEDICINE

Redefining HER2-Equivocal BREAST CANCERS:

Lessons Learned from Genomic Pathology

By Shelly Gunn, MD, PhD

Introduction

It has been three decades since the human epidermal growth factor receptor 2 (HER2) was identified as an oncogenic driver of human breast carcinomas.1 Now, as medical oncology enters the era of precision medicine, HER2 is still the most important predictive and prognostic biomarker in breast cancer.2 The HER2 status of a patient’s tumor can be analyzed at the protein level by immunohistochemistry (IHC) to visualize cell-surface receptor targets for anti-HER2 directed therapy. Additionally, HER2 status can be evaluated at the chromosome level by in situ hybridization (ISH) techniques to determine the HER2 gene copy number within the cell nucleus. Yet despite these two FDA-approved methods for HER2 testing and the many biotechnological advances in clinical pathology laboratory medicine, there remains a subset of high-risk patients with breast cancer (>20%) whose HER2 status is reported (often after multiple rounds of testing) as “equivocal.”

Classifying a patient’s tumor as HER2 equivocal gives clinicians no insight into the tumor’s HER2 biology, nor does the word provide any useful information about how to treat the patient. In the Merriam-Webster dictionary, the adjective “equivocal” is defined as “subject to two or more interpretations and is usually used to mis-

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lead or confuse.” Certainly, clinicians and patients who have received breast cancer prognostic marker reports with HER2 equivocal results would agree that this term is both misleading and confusing.

In my pathology consultation practice, many such cases have been referred to me, including this recent example:

Case History

A 69-year-old woman presents with a grade 2, <2 cm, node negative, strongly estrogen receptor–positive (ER+)/progesterone receptor–positive (PR+) tumor with HER2 initially reported as negative based on IHC score of 1+. The case was reflexed to FISH [fluorescence ISH] due to “histopathologic discordance” and reported as equivocal. The HER2/D17Z1 (chromosome 17 centromere) FISH ratio was 1.4 (negative) “to be interpreted with caution” due to the average copy number signals per cell of HER2 4.6 and D17Z1 3.2 (equivocal). The case was further reflexed for chromosome 17 “alternative probe” FISH where the results were reported as positive based on the HER2/TP53 ratio of 2.3 and HER2/SMSCR ratio of 2.0 [TP53 and SMSCR are chromosome 17 regions].

Is it any wonder that oncologists often feel misled and confused by pathology reports for HER2 status in breast cancer? The above

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case is just one example of why incalculable numbers of hours and healthcare dollars are continually spent on HER2 testing methods to “resolve” equivocal HER2 breast cancer into clearly actionable HER2-positive or HER2-negative categories. The collective effort to create a binary, two-tier framework around HER2 status in breast cancer is understandable given that oncology clinical practice guidelines have clearly actionable treatment directives only for unequivocally positive or negative HER2 results. High-risk tumors with a combination of low HER2 protein expression and nonamplified HER2 gene copy number fit neither of these categories. Yet tumors with low HER2 protein expression represent a significant subset of breast cancer cases. Could these tumors be trying to announce their biological reality by consistently showing 1 to 2+ protein and <6 copy numbers after repeated rounds of testing?

Since the term “equivocal HER2” was introduced as part of the first College of American Pathologists/American Society of Clinical Oncology (CAP/ASCO) guidelines published in 2007, the term has become synonymous with a third category of breast cancer.3 Following implementation of updated CAP/ASCO guidelines in 2013, the number of breast cancer cases falling into the equivocal category has increased, along with the number of additional tests that must be performed to resolve equivocal results.4, 5 Within this equivocal category, clinicians often end up with a collection of results from repeated and alternative testing methods used to attempt to resolve the equivocal HER2 status of the tumor. These test results often disagree as to whether the tumor is HER2-positive, HER2-negative, or something in between. The discordant test results may arise from IHC, ISH, alternative chromosome 17 probes, RNA multigene expression arrays, 21- gene recurrence score assays, DNA microarrays, and serum HER2 protein analysis, but only 2 of the aforementioned tests — IHC and FISH — are actually FDA approved for reporting HER2 status in breast cancer!

by IHC and FISH using comparative genomic hybridization, also called chromosomal microarrays (CMAs).6-10 CMAs provide a DNA-based approach to chromosome analysis with the capability of producing a high-resolution view of the HER2 gene on chromosome 17. The chromosome “ratio plot” allows simulated visualization of the p arm, q arm, pericentromeric region, and HER2 gene within the 17q12 amplicon. These high-resolution CMA images of HER2 gene status on chromosome 17 in multiple types of breast cancer have revealed the following interesting findings: • CMA studies provide confirmation that ISH is a reliable method for determining HER2 gene copy number independent of a ratio as long as formalin-fixed paraffin-embedded tissue handling is within CAP/ASCO guidelines for formalin fixation times.

• CMAs have revealed that tumors with gains of entire copies of chromosome 17 (polysomy 17) occur in <10% of breast cancers even though the HER2/cep 17 ratio used in dual- probe FISH is intended to correct for this biological phenomenon (cep 17 is another area of chromosome 17 used as a denominator in ratios). Instead of polysomy, many tumors contain segmental gains on chromosome 17, particularly on the long arm.11,12 A standard definition of HER2 “amplification” by genomic copy number analysis (including CMA) has not yet been established.

• CMA allows visualization of relative gains or losses of chromosome 17 regions used as the ratio denominator (cep17, TP53, SMSCR, RARA), causing the ratio to skew towards false negative or false positive.

• Although CMA provides more detailed information about chromosome 17 status in breast cancer than do conventional cytogenetics or FISH, the complexity of the method and interpretation make it impractical for routine use by the clinical laboratory. Thus, IHC and FISH will remain, for the foreseeable future, the mainstay of testing for HER2 status in breast cancer.

Given then that there are two excellent HER2 assays (IHC and ISH) readily available in the clinical laboratory, the currently confused state of HER2 testing in breast cancer is perplexing and raises some questions: • Are IHC and 2-probe ISH giving wrong answers 20% of the time, consistently, requiring alternative testing methods to resolve discrepancies?

• Alternatively, could IHC and ISH be giving correct answers, but we misinterpret the data and thus miss the true HER2 biology of HER2 “equivocal” tumors?

The above observations from genomic pathology help explain many of the primary problems with current HER2 testing, and they suggest strategies that could potentially improve results reporting.

1. Is it time to move away from dual-probe testing and the HER2/cep17 ratio to a single-probe approach? Beginning with the first Southern blots used to identify HER2 gene amplification in breast carcinomas, HER2 gene testing has historically been reported as a ratio. In the initial studies, HER2 gene DNA was compared with DNA of other genes such as ARG1 as a nonamplified internal control.1 In the era of FISH, a ratio of HER2 gene copy number per nucleus to chromosome 17 centromere copy number per nucleus is used as an internal control to “correct for” polysomy 17. However, from CMA studies we know that

Seeking answers to these questions, multiple genomic pathology groups have analyzed breast cancers that have been characterized

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single-probe ISH is giving the correct answer, and it is the ratio that can introduce instability by skewing the result toward a false positive or a false negative. This ratio skewing is a result of the segmental gains or losses within chromosome 17 that are more com- mon than polysomy 17 in breast cancer.7 In addition, the process of interchanging alternative denominator probes does not alter the gene copy number of the numerator. According to current CAP/ ASCO guidelines, a tumor with 4 to 6 copies of the HER2 gene will be called “HER2 equivocal” provided the denominator generates a ratio less than 2.0. Although reporting average HER2 gene copy number would thus seem to be the most straightforward approach, substantial supporting data do not yet exist for making such a change. Therefore, pathologists will need to continue to critically evaluate FISH results based on the numerator, denominator, IHC findings, and the patient’s clinical presentation.

2. How can we create an unequivocal reporting system? The current strategy of trying to fit all breast cancers into 2 HER2 categories for protein expression and HER2 gene copy number may not be represen- tative of the true biological spectrum of HER2 results. A 3-tier system including a borderline amplified group was described by Ross and colleagues in 1998 using data from multivariate analysis of a subset (n =220) of node-negative breast cancers derived from 324 cases reported by Press and colleagues in 1997.13-15 A more recent retrospective study by Press et al re-interpreted enrollment and outcomes data from the Breast Cancer Research Group clinical trials using 2013 CAP/ASCO guidelines for FISH. Findings from more than 10,000 patients enrolled in the clinical trials support the original FDA-approved criteria (in which there is no equivocal category) to be strongly predictive of treatment response.16 In this authors’ opinion, and based on these previous studies, a 3-tier system for HER2 reporting, one that recognized 3 categories of HER2 biology, could be considered an unequivocal reporting strategy: tumors showing high-level gene amplification with high (3+) protein expression would be HER2-positive, tumors 20

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with borderline gene amplification (<6 copies) and low-level protein expression would be HER2-low; and tumors with no gene amplification and no protein expression would be HER2-negative.

Response to Herceptin in the HER2-low category of tumors is currently being studied in the National Surgical Adjuvant Breast and Bowel Project (NSABP)-B47 trial. This randomized phase III trial is comparing chemotherapy alone with chemotherapy plus trastuzumab in more than 3,000 women with node-positive or highrisk node-negative HER2-low invasive breast cancer.17 The specific aim is to determine whether the addition of trastuzumab improves invasive disease–free survival in women with high-risk breast cancer reported as HER2-low by IHC and FISH. Eligibility for the trial is determined by an IHC score of 1 to 2+ and by a HER2-to-chromosome enumeration probe ratio of <2.0, which, together, document the presence of HER2 target receptors on the tumor cell surface and lack of HER2 gene amplification in the cell nucleus.

3. Are there currently any treatment recommendations for the HER2-low category of breast cancer? The NSABP-B47 trial began in January 2011, and its estimated primary completion date is in 2017. Although there are no current treatment recommendations for HER2-low tumors, identifying this subtype in high-risk patients will give clinicians insight into the HER2 biology of their patients’ tumors and provide unequivocal categorization of the HER2 status.

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In summary, it may be time to replace ratio reporting with single-probe ISH, and to categorize breast tumors with average HER2 gene copy number <6 and 1-2+ protein expression as HER2-low.

Recognizing this distinct genomic subtype on pathology reports will give a clinician critical information about a patient’s HER2 biology, while saving time and healthcare dollars that are currently being spent trying to transform HER2-low tumors into those that can be definitively called HER2-positive or HER2-negative.

We must await the results of the NSABP-B47 trial for guidance as to how to best treat this subset of high-risk patients, but to recognize this genomic subtype now would at least identify the HER2low tumors and “give them their seat at the table,” as one of my pathology colleagues has eloquently stated.

Affiliations: Targeted Genomics and Precision Pathology Services, San Antonio, Texas.

Send correspondence to: Shelly Gunn, MD, PhD, Targeted Genomics and Precision Pathology Services, 711 Navarro St, Ste 406, San Antonio, TX 78209. E-mail: gunns@targeted-genomics.com.

Disclosures: Dr Gunn discloses that she has been a speaker for Roche/Genentech.

cancers submitted for FISH testing: experience of a reference laboratory using US Food and Drug Administration criteria and American Society of Clinical Oncology and College of American Pathologists Guidelines. J Clin Oncol. 2016;34(29):3502-3510. doi: 10.1200/ JCO.2015.61.8983.

6. Chin SF, Wang Y, Thorne NP, et al. Using array-comparative genomic hybridization to define molecular portraits of primary breast cancers. Oncogene. 2007;26(13):1959-1970.

7. Yeh IT, Martin MA, Robetorye RS, et al. Clinical validation of an array CGH test for HER2 status in breast cancer reveals that polysomy 17 is a rare event. Mod Pathol. 2009;22(9):1169-1175. doi: 10.1038/modpathol.2009.78.

8. Gunn S, Yeh IT, Lytvak I, et al. Clinical array-based karyotyping of breast cancer with equivocal HER2 status resolves gene copy number and reveals chromosome 17 complexity. BMC Cancer.

2010;10:396. doi: 10.1186/1471-2407-10-396.

9. Hansen TV, Vikesaa J, Buhl SS, et al. High-density SNP arrays improve detection of HER2 amplification and polyploidy in breast tumors. BMC Cancer. 2015;15:35. doi: 10.1186/s12885015-1035-1.

References

10. Geiersbach KB, Willmore-Payne C, Pasi AV, et al. Genomic copy number analysis of HER2-equivocal breast cancers. Am J Clin Pathol. 2016;146(4):439-447. doi: 10.1093/ajcp/aqw130.

2 Schmidt KT, Chau CH, Price DK, Figg WD. Precision oncology medicine: the clinical relevance of patient-specific biomarkers used to optimize cancer treatment. J Clin Pharmacol.

2016;56(12):1484- 1499. doi: 10.1002/jcph.765.

11. Curtis C, Shah SP, Chin SF, et al. The genomic and transcriptomic architecture of 2,000 breast tumours reveals novel subgroups.

Nature.

2012;486(7403):346-352. doi: 10.1038/nature10983. Cancer Genome Atlas Network. Comprehensive molecular portraits of human breast tumours. Nature.

2012;490(7418):61-70. doi: 10.1038/nature11412.

1. Slamon DJ, Clark GM, Wong SG, et al. Human breast cancer: correlation of relapse and survival with amplification of the Her2/ neu oncogene. Science. 1987;235(4785):177-182.

3. Wolff AC, Hammond ME, Schwartz JN, et al; American Society of Clinical Oncology; College of American Pathologists. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol.

2007;25(1):118-145.

4. Wolff AC, Hammond ME, Hicks DG, et al; American Society of Clinical Oncology; College of American Pathologists. Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists clinical practice guidelines update. J Clin Oncol. 2013;31(31):3997-4014. doi: 10.1200/JCO.2013.50.9984.

5. Shah MV, Wiktor AE, Meyer RG, et al. Change in pattern of HER2 fluorescent in situ hybridization (FISH) results in breast

12. Press MJ, Bernstein L, Thomas PA, et al. HER-2/neu gene amplification characterized by fluorescence in situ hybridization: poor prognosis in node-negative breast carcinomas. J Clin Oncol.

1997;15(8):2894-2904.

13. Ross JS, Muraca PJ, Jaffe D, et al. Multivariate analysis of prognostic factors in lymph node negative breast cancer. Eur J Cancer.

1998;34(suppl 5):S102.

14. Ross JS, Fletcher JA. The HER-2/neu oncogene in breast cancer: prognostic factor, predictive factor, and target for therapy.

Oncologist. 1998;3(4):237-252.

15. Press MF, Sauter G, Buyse M, et al. HER2 gene amplification testing by fluorescent in situ hybridization (FISH): comparison

continued on page 22

visit us at www.bcms.org

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MEDICINE continued from page 21 of the ASCO-College of American Pathologists guidelines with FISH scores used for enrollment in Breast Cancer International Research Group clinical trials. J Clin Oncol. 2016;34(29):35183528. doi: 10.1200/JCO.2016.66.6693.

16. Fehrenbacher L, Jeong J-H, Rastogi P, et al. NSABP B-47: a randomized phase III trial of adjuvant therapy comparing chemotherapy alone to chemotherapy plus trastuzumab in women with node-positive or high-risk node-negative HER2-low invasive breast cancer. Poster presented at: 2013 ASCO Annual Meeting.

J Clin Oncol. 2013;31(suppl; abstr TPS1139).

Abstract

In the era of precision medicine, human epidermal growth factor receptor 2 (HER2) is the most important predictive and prognostic biomarker in breast cancer. The HER2 status of a patient’s tumor can be analyzed at the protein level by immunohistochemistry (IHC) and at the chromosome level by in situ hybridization (ISH) techniques to determine the average HER2 gene copy number. Yet, despite these two complementary methods for HER2 testing, there remains a subset of high-risk breast cancer patients (>20%) whose HER2 status is reported as “equivocal,” an assessment that provides no useful information about how to treat the patient.

Given there are 2 FDA approved HER2 assays readily available in the clinical laboratory, the currently confused state of HER2 testing in breast cancer is perplexing and raises the following questions: are IHC and dual-probe ISH giving the wrong answer 20% of the time, or alternatively, could these tests be giving the correct answers and we are misinterpreting the data? For the past decade, genomic pathologists have used chromosomal microarrays (CMAs) as a DNA-based approach for obtaining high-resolution images of HER2 gene status on chromosome 17. These studies provide confirmation that ISH is a reliable method for determining average HER2 gene copy number, and it is the HER2 ratio denominators (cep17 or alternative probes) that can introduce instability into the final results. However, even though CMA provides more detailed information about chromosome 17 status in breast cancer than conventional cytogenetics or FISH, the complexity of the method and interpretation make it impractical for routine use by the clinical laboratory as a HER2 testing method. Thus, IHC and fluorescence in situ hybridization will remain for the foreseeable future, the mainstay of HER2 testing in breast cancer. The current challenge is thus not to introduce a new HER2 assay into the clinical laboratory but rather to develop a strategy for reporting unequivocal, biologically accurate results using existing FDA-approved testing methods.

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San Antonio Medicine • March 2018

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23

MEDICINE

NON-SURGICAL ALTERNATIVES FOR

FEMALE INCONTINENCE

By Dr. Timothy Hlavinka

medicine, rapid technological advancement is commonplace. As less-invasive treatments evolve into non-invasive ones, it is much less common for a new treatment to turn our heads as clinicians.

But as non-invasive alternatives become more pervasive and effective, demand for them becomes patient driven. More than ever, the answer to the universal question, "Doctor, are there any options besides surgery?," is returned with an emphatic, "yes!"

In

New solutions to female incontinence

Take urinary stress incontinence, for example.

Women now have a wide range of non-surgical options powered

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San Antonio Medicine â&#x20AC;˘ March 2018

by breakthrough technologies that can produce impressive results, no scalpel necessary. In an historically challenging arena for urologists and gynecologists, this is a welcome change.

The American Urological Association estimates 30-50 percent of females experience significant urinary incontinence, with prevalence increasing with age. An American College of Obstetrics and Gynecology impact survey projects that more than 40 million American women will have urinary incontinence over the next three decades, associated with staggering economic and quality of life loss.

Many women avoid discussions of bladder problems with their doctors either out of embarrassment or fear that that there are no alternatives to surgery. Indeed, the recent vaginal mesh controversy

MEDICINE

has further fueled that avoidance.

But for women who have already tried behavioral training, Kegel exercises and other non-surgical solutions without success, surgery may seem the only alternative. Until now, when the march of technology has produced a female incontinence treatment based on high-intensity focused electromagnetic technology (HIFEM).

HIFEM technology uses electromagnetic energy focused directly on the pelvic floor, inducing electric currents that target neuromuscular tissue resulting in supramaximal contractions of the entire pelvic floor muscle compartments. A single HIFEM session brings the equivalent of thousands of these supramaximal contractions at a rate that results in a high degree of muscle re-education in incontinent patients through restoration of neuromuscular control.

This FDA-approved technology is now available through a device called Emsella – essentially a chair the patient sits on for about 30 minutes per session, or a total of six sessions for most women. The patient doesn’t even have to change clothes or disrobe. And clinical research shows 95 percent of Emsella-treated patients reported significant improvement in their quality of life. More than two-thirds report becoming dry or using significantly fewer pads.

New approaches to improving sexual well-being

Female sexual health also is a major issue and another where rapid technological change is dramatically altering the treatment landscape. Ablative laser resurfacing not long ago was the leading-edge technology for labiaplasty and vaginal rejuvenation, a means of greatly enhancing female intimate aesthetics and sexual satisfaction, especially useful as women age.

But an innovative new technology has emerged, using a combination of radiofrequency and ultrasound to stimulate new collagen and elastin synthesis in the vagina and external genitalia. This combination results in the capacity to deliver more intense energy to the targeted tissues in a shorter time span with greater histological and clinical benefits while preserving patient comfort. Each session requires only a few minutes, is done without even local anesthesia, and requires little or no recovery time.

Women are seeing impressive results from this completely noninvasive, non-surgical treatment methodology. Again, the march of technological progress never stops.

Embracing new technologies

Patient care shouldn’t be limited to what we, as physicians, already know. Those of us who’ve spent thousands of hours perfecting our surgical skills must always be open to new approaches and new technologies, knowing that our goal is an optimal patient outcome, even when new technologies disrupt the usual way we

care for our patients.

In short, when new technologies bring valid improvements to healthcare, we can either ignore them or embrace them. We believe embracing them is the way to go.

This philosophy is a major theme of the practice I share, The Urology Place, with Dr. Naveen Kella. We believe the relentless progress of technology has the potential to reinvent the way we care for patients and to produce results never previously possible.

That’s why Naveen invested the time and energy to become one of the pre-eminent robotic prostate surgeons in the country. And why I have devoted decades to research in sexual health – because I know there is always a better way as long as we are open to discovering it.

Dr. Timothy Hlavinka is a board-certified urologist who specializes in both general urology and lifestyle medicine. He is an expert in women’s sexual medicine and the only MD Fellow of The International Society for the Study of Women’s Sexual Health in Texas. He also specializes in hormone replacement therapy in both men and women. Hlavinka and Dr. Naveen Kella lead The Urology Place in San Antonio. visit us at www.bcms.org

25

BUSINESS

Why Companies Should Help Employees Retire on Schedule

By Gil Castillo hen it comes to retirement readiness, the numbers are not encouraging: according to investmentnews.com, more than half of our fellow Americans do not have enough retirement savings to cover their living expenses after they leave the working world.

Have you considered how this lack of planning and funding might affect your business?

Retaining older, near-retirement workers can certainly offer big benefits to your business and employees. After all, highly experienced workers have a lot of knowledge and wisdom to share with younger colleagues, and it's tough to find good workers of any age.

However, what about the other side of the coin? As with most things, there are trade-offs. First, the greater the number of older, more experienced workers in your employ, the fewer opportunities exist for younger workers looking to learn and make their mark.

Second, retaining older workers who would prefer to retire is likely to result in increased costs for your business.

W

Following the career life cycle

Most employees have certain expectations in their careers. Often, these expectations involve a steady progression up the career ladder and wage scale, along with the accumulation of knowledge that comes with those career moves and experiences. This natural career life cycle depends on a predictable pattern of young workers entering the full-time workforce after completion of school and older workers exiting the workforce at or around traditional retirement age. But with over half of workers unable to support themselves in retirement, how will this lack of preparation and funds affect this established pattern and life cycle? Older workers staying on the job create a ripple effect: • When an employee stays at work past the expected retirement age, that employee's position is not available to a younger, more inexperienced worker.

• Since promotions are generally based on knowledge and experience, each employee working past expected retirement affects numerous others down the management chain. Now employees must wait longer to be promoted into roles they had thought would be available upon another employee's retirement.

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San Antonio Medicine • March 2018

• Employees who must wait to receive the promotions and raises they feel entitled to will likely look elsewhere for their next career step, costing your company valuable resources plus actual costs in turnover and hiring.

Addressing employee benefits costs

When workers stay on your payroll past traditional retirement age, they often also stay on your health insurance, which costs your company money. While every additional employee costs your company to insure, in the case of an older worker, the cost is usually quite a bit more. Insuring a young individual costs about one-third what you'd pay to insure an older person.

Let's say you employ Mary, who's 67 years old. Mary doesn't have the retirement savings she needs to quit working, so she decides to stay in her job for several more years. If she retired, she would use Medicare for her health insurance, but since she's still employed, she decides to retain your company's insurance, which she feels allows her more flexibility in choice of doctors and services. Just this one employee undoubtedly costs your company thousands in medical benefits alone. When large numbers of employees make the same choice as Mary, the altered employee lifecycle can make your company's health care costs skyrocket.

Related reading: Why More Americans Are Delaying Retirement

Ensuring productivity

Over the years, many studies have suggested that engaged employees are more productive. That may signal a problem with certain past-retirement-age workers, since an employee who has no choice but to continue working past his preferred retirement age is unlikely to be fully engaged. According to a Prudential report, "employees who are not able to retire when they wish may experience financial stress, a lack of engagement, and lower productivity." An employee who knows he didn't save enough to retire comfortably may be preoccupied with money worries and unable to give his work as much concentration as he could without those stresses.

Encouraging employees to retire on schedule

Now that we've addressed some of the negative consequences

BUSINESS

of employees working past retirement age, how can you improve the situation? Of course, you don't want all your older workers to retire at once, and as we discussed earlier, your company and younger employees greatly benefit from older employees' experience and knowledge. Therefore, you want to consider what the best plan would be for your company.

• Establish what you think is the best employee life cycle for specific departments, groups, and positions. Once you have an idea of an optimal life cycle, you can work with your management team to determine plans that would enable older employees to occupy positions where they transfer knowledge to younger workers and still retire in time to enjoy their golden years, freeing spots for younger workers to learn and grow in their careers.

• Encourage employees to save for retirement through education and access to appropriate savings vehicles.

• According to the Employee Benefit Research Institute, 73% of workers who are currently not saving for retirement report that

they would be more likely to do so if their employer provided a matching contribution. Given this powerful number, consider whether your company could start or increase matching retirement plan contributions.

• In the same report, 66% of respondents say they'd be more likely to save if their investments were automatically deducted from their paycheck. Setting up payroll deduction is often free to your company, so it's an easy way to encourage employees to save.

Helping your employees properly prepare for retirement is a responsibility that business owners take seriously, and for good reason.

Remember to take the employee lifecycle into account when deciding on the best way your company can support employees in saving for retirement. For personalized assistance with your business and retirement planning, consult a financial advisor that specializes in employer retirement plans, or you can contact me at 210-321-7258 or gcastillo@swbc.com.

visit us at www.bcms.org

27

BOOK REVIEW

BEFORE I GO TO SLEEP

BY S. J. WATSON

Reviewed By Fred Olin, MD Christine Lucas is a woman in her 40s, but she doesn’t know that. She’s married and lives with her husband in North London, but she doesn’t know those facts either. When she awakens each morning, she has no idea where she is or who that man is who’s in bed with her. She wakes up thinking she’s in her 20s, because that’s what her memories tell her. She’s frightened by not recognizing anything she sees, but gets up and goes into the bathroom, where the mirror horrifies her. Her face has lines and wrinkles and sags that a 20+ year-old woman doesn’t have…but, but it’s her face nonetheless. Pasted up around the mirror are pictures of her older self with a man, and it’s the man in the bed. The pictures are labeled “Christine and Ben.” The two of them appear to be affectionate and connected to one another. She looks at her body: it’s not the way she remembers, either.

After a bit, the man wakes up and the story commences. He calms her down and tells her that she had some trauma about 20 years ago, and that she’s 47 now. He says that she was struck by a hit-andrun driver and was comatose with a head injury for a long time.

When she finally regained consciousness she was found to have lost the ability to form new memories that would persist through a period of deep sleep, so each day is truly a new world for her. Early on she had a psychotic break and spent some time in a psych ward, then more time in a nursing home before Ben brought her home to care for her himself.

There are only four characters in this entrancing novel: Christine, her husband Ben Wheeler, a neuropsychologist, Dr. Nash, and Claire, her best friend from before her accident. She hasn’t had contact with Claire for many years, and Ben tells her that Claire moved to New Zealand years ago.

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Dr. Nash had been attempting to help her regain both her memory and her ability to retain new memories by having her write in a journal that she was to keep secret from Ben, because he had refused Nash’s request to try and help her after he heard about her from a colleague. Each morning after Ben had gone to work Dr. Nash would telephone Christine, tell her where she had hidden the journal, and ask her to find it and read it. Then he asked find time at the end of the day to write all that had happened and hide the journal in the same spot.

What follows is a quotation from a review of the book in the Los Angeles Times by Jonathan Shapiro: I tried to write this but couldn’t put the thoughts together half as well.

“This is life beyond mere confusion or disorientation. Watson presents a character existing in a condition of perpetual nowness, a present without context, a life without history. It is a kind of hell — an intellectual and emotional state devoid of meaning or emotion. It is what we fear when we fear the nothingness produced by Alzheimer's, perhaps, or some other condition that robs one of mind and memory.”

BOOK REVIEW The story is carried forward by the daily entries in Christine’s journal. They cover a two-week period in November of an unnamed year. Reading them is like living in Christine’s brain: you discover real truths about her through her interpretation of events and conversations, and it slowly becomes evident that Ben isn’t exactly what he professes to be and the situation isn’t necessarily what he says it is. The emotion, suspense, terror and horror of the lies and manipulation was spellbinding for me, and I found myself reading on at every opportunity, no matter what else I was supposed to be doing.

As you may have noticed in your professional reading, articles reporting studies of medications, surgical results, etc., now often have a paragraph where the first sentence reads something like “The shortcomings of our study are…” In the case of Before I Go To Sleep, the only development that left me unsatisfied was at the end: the dramatic climax was strong and gripping and I didn’t really expect it, but the part after that action was soft and mildly disappointing. You might love it, though: “Different strokes” and all that.

As of mid-November, the San Antonio Public Library had 15 copies of this book, as well as e-book and audio book versions

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29

IN REAL TIME

In Real Time – VII

There is no real Ending.

It is a pause.

By Rajam Ramamurthy, MD

seems like the hundredth time I am attempting to write this last chapter so I don’t leave you reader in limbo. I am on a flight to England, the first travel across time zones since N’s illness that started in January 2016. I want to share with you an incredible phase of recovery of which I had a fleeting glimpse in June 2016, that progressed rapidly like a fog was lifting off a valley. N was beginning to sleep better for long hours. I could also get him to sleep in the afternoons. As the fog lifted and his thinking became normal the realization of not

It

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working, not driving, not having computer access and many more restrictions began to weigh on him and he would sit quietly for long periods. One of the interventions that helped was a referral to a psychotherapist who was a specialist in helping with depression under these circumstances. I was at the first meeting with the therapist. She again invited me to sit in after few sessions she had just with N. She suggested that N needs more independence, he should drive, have computer access. There is a simulation driving test that was suggested which N took and passed with flying colors. The first

IN REAL TIME

place he drove by himself was to the psychotherapist appointment.

I relived the anxiety that we all go through when our teenage children have taken the car out. I worried and called him several times.

I am sure it was annoying for a grown man. His management both by the psychiatrist and the therapist was gentle and a lot of emphasis and trust was placed on his high functioning brain. He has no memory of the period from January till August 2016 even now except for somethings he remembers at random. Unless it benefitted him I did not want to try to make him remember.

Physical therapy for the shoulder was prolonged to a point where the therapist was at a loss as to what more to do. He still could not lift his left arm above his head. The mobility and strength improved exponentially when he started working out at home and after he started driving he worked out at the gym. Before the illness, N worked out regularly. He got back into the routine again and lost weight. For the past three years he was gaining weight relentlessly as his binge eating was out of control. N's attitude was heartwarming. He was very understanding, cooperative and went at his physical and psychological recovery process in the same methodical way he approached his work, gardening and relationships.

By December the medications were discontinued. At N's request one medicine was continued which he wanted to wean at a slower pace. The therapist insisted that he will benefit from having more control over accessing the computer and having a phone, in general having more control over his daily life, I wanted to introduce these gradually as placing the controls in place was not easy. It took him two months to say yes when I was going to give him the computer logging info. To this day he has not gone to any undesirable sites other than watching all the Trump escapades. I guess one has to choose between the devil and the deep sea.

One day I asked N if he remembered any of his behavior when he was ill. He said "awareness of what he did in itself is a deterrent to go that route again". What triggered the excessive behavior, lack of inhibition, poor judgement in spending will still remain a mystery to me. In reading about it, this type of behavior which was a textbook description of Fronto-temporal dementia could also be a part of bipolar disorder in its manic phase. "IT IS TREATABLE". This is something important for the readers to keep in mind.

N is back to his baseline which means he is functioning at his full potential. The tragedy is that his brilliant mind is wasted. It is my opinion that professionally he was cheated off his status, his earnings, and his future. If there is such a thing as a poetic justice I hope I live long enough to see it.

Now life seems to be on a fast track. What we were planning to do in two to four years has been brought forward. We delved into

decluttering the house. The clutter was artifacts collected over the years from all over the world. Furniture, artwork, statuary and many more that were given away or placed on estate sale. When it comes to estate sale you must be very careful in choosing the business. The one we had cheated us and to this day has not paid us. We had hundreds of plaques and trophies to deal with. The trophy companies will dispose them off for you they do not recycle. Books were the hardest to part with. I reluctantly gave them away thinking about space in a downsized home. The decluttering feels wonderful, it is as though your mind is decluttered. I advise my age peers to try it.

I am writing this closing chapter for you dear reader. You have been kind in empathizing, patient in waiting for this last chapter and a partner in the healing process. My heartfelt gratitude to you. I chose the title 'In Real Time' for writing, even during the peak of N's illness was an important part of my wellbeing and strength that helped me to care for N. Since January of 2017 I could not write. I did not want to remember 2016. But it is indelibly etched in my brain. I wish I had answers and explanations for what we went through. I will only be left with questions. Questions about things I could not write for legal, moral and compassionate reasons. They try to pull me into a black hole and I try to pull myself up like a gold nugget that is all the more shiny when taken out of the fire.

It is said that it takes a village to raise a child. It takes a world to heal a patient from a ginormous life event. First our children who stood like rocks with us. Our son a celebrity actor was trying to understand the working diagnosis FTD, he had more information thanks to google god, than I had at that point. Our daughter an internist and Psychiatrist bore the brunt of my constant questions. I shared N's illness with his siblings and mine. They cuddled us in their loving arms and eased the pain. We must have done something good in our life to have friends who surrounded us like a soothing blanket that uplifted the spirit and steadied the mind that was tossed around in despair. We owe our gratitude to the University Hospital and the staff and the UT physicians who saw N at his worse and nursed him back to health.

I bid you goodbye dear reader. Wish me luck, my story is still in the making.

Rajam Ramamurthy. MD Professor Emeritus, Department of Pediatrics UT Health in San Antonio

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31

LEGAL EASE

Do you have somebody working for you who isn’t a U.S. citizen?

By George F. “Rick” Evans, General Counsel, BCMS

dds are very high that, either now or in the future, you’re going to find yourself wanting the services of a person who isn’t a U.S. citizen. Think about all the times this happens. Maybe you need: A nanny? A yard guy? A home maid? Or maybe you need professional help in your office or side businesses? What risks are you taking if you hire somebody who isn’t a U.S. citizen? It happens every day, here and all over the nation. My guess is that you’ve done it many times already, right?

Look, the laws can be pretty intense on this subject. The web of federal regulations is intended to protect the U.S. work force and it does that by creating a lot of obstacles to hiring non-citizens. If you violate these laws, you can be subject to not only civil sanctions, but criminal penalties, too. So, what do you do?

First, you need to figure out if you’re actually hiring an employee

O

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San Antonio Medicine • March 2018

or hiring an independent contractor. The laws we’re talking about apply to employees; not independent contractors, so you need to know the difference. Also, if you hire an employee, there are a lot more implications including your responsibility to pay Social Security, Medicare, Federal Income, and Unemployment taxes. You may be subject to minimum wage requirements and the obligation to pay time and a half for more than 40 hours of work. You may be subject to the anti-discrimination laws regarding employees and the rules of the EEOC. In short, it makes a big difference if you’re hiring an employee or an independent contractor. How do you tell which is which?

The litmus test is whether you control the manner in which the work is done. In other words, if you control both (1) what work is to be done, and (2) how that work is done, you’ve got an employee.

Even if you don’t exercise your right to control how the work is

LEGAL EASE

done, if you simply have the right to do that, you’ve got an employee. And that’s true even if the person only works for you part time or you pay him by the job. An independent contractor is somebody who usually provides his own equipment or tools to do the job and offers his services to the public as part of his business. Or somebody who provides the services at his place of business rather than yours (i.e. a nanny who takes care of multiple babies at her house rather than coming to your house).

If you find that you’ve got an employee, then you need to determine if he is legally eligible to hire.

There are only four categories of people you can legally employ. They are (1) U.S. citizens, (2) noncitizen nationals of the U.S. which are people from American Samoa, people born abroad of U.S. nationals, and a few other, very limited exceptions, (3) lawful permanent residents, (4) aliens specifically authorized to work such as by having an EAD card. Now, note this well. It is your legal burden to verify the person is legally eligible to be hired. You and your new employee are also required to complete a U.S. Citizenship and Immigration Services form I-9 which you can get at www.uscis.gov/i-9.

The form has to be completed no later than the first day the employee works. You don’t have to complete this form if the employee is used just for occasional or irregular domestic work in your home (i.e. a babysitter). While not mandatory, if you are hiring an employee, you may want to consider having a written contract if for no other reason to make sure the relationship is “at will” so you can fire the person without proving cause.

By now you realize that hiring a non-citizen can be a hassle. It can be even more of a hassle if you want to work through the in-

sanely time consuming bureaucratic paperwork of trying to get them a “green card” or other legal document authorizing them to legally work here. So, what’s the take home lesson from all this?

What’s the easy way out? Here’s what you can do.

1.

Let’s not ignore the obvious. Just hire U.S. citizens or non-citizens who can demonstrate their legal authority to work here.

2.

The next easiest option is to make sure you’re hiring them as an independent contractor. That’s especially easy if you only need help sporadically and can show you’re just hiring them to get the job done but leaving the ins and out of how to do it to them.

3.

If none of the above works, then hire through a licensed agency. It will cost you a fair bit more, but they’ll handle all the paperwork, taxes, documentation, etc.

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33

UT HEALTH

UT Health San Antonio president announces new medical school dean

By William L. Henrich, M.D., MACP, President and Professor of Medicine

It gives me great pleasure to announce the appointment of Robert Hromas, MD, FACP as the Joe R. and Teresa Lozano Long School of Medicine Dean and UT Health San Antonio Vice President for Medical Affairs.

Dr. Hromas began his duties in February, earlier this year.

Dr. Hromas earned a B.S. in Biology at Wheaton College, Illinois and his medical degree at The University of Texas Medical School at Houston. He did a post-doctoral research fellowship in the regulation of immunoglobulin gene expression and a residency in Internal Medicine at the University of Iowa, followed by a post-doctoral research fellowship in transcriptional regulation of hematopoiesis at the University of Washington. He also was a hematology fellow at the University of Washington and the Fred Hutchinson Cancer Research Center. He is board certified in Internal Medicine with a subspecialty board certification in hematology.

Dr. Hromas also previously served as Chair of the Department of Medicine at University of Florida Health, where he was also the

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San Antonio Medicine â&#x20AC;˘ March 2018

Vice President of the University of Florida Physicians Clinical Practice Association and a member of the UF Health Shands Hospital Executive Board. The University of Florida's Department of Medicine has approximately 360 faculty, 210 residents and fellows, more than 600,000 patient encounters per year along with 24,000 annual hospital admissions. He has trained 29 graduate students or fellows, most of whom have entered academic careers, and 21 junior faculty, almost all of whom have obtained tenure, with three obtaining Hematology-Oncology Division Chief positions. He has served on editorial boards of Blood and Stem Cells and has won numerous teaching and patient care awards, including the Indiana University Humanism in Medical Education Award, the Indiana University continued on page 36

UT HEALTH continued from page 34 Board of Trustees Outstanding Teacher Award, and the People Living Through Cancer Caring Award. He has

served as Chair of Scientific Affairs for the American

Society of Hematology and as their congressional and media representative.

A seasoned investigator, Dr. Hromas has published over 160 scholarly research papers, has for two decades been continuously funded by the National Institutes of Health and has chaired several NIH and American Cancer Society study sections. His laboratory has isolated and characterized several novel DNA repair proteins that play crucial roles in both cancer chemotherapy resistance and in HIV integration. He currently leads a public-private drug development consortium that is creating new drugs and testing them for effectiveness in treating cancers resistant to chemotherapy.

Prior to his work at the University of Florida, Dr. Hromas served as Chief of Hematology-Oncology and Deputy Director of the Cancer Center at the University of New Mexico, assisting that institution in achieving its designation as a National Cancer Institute Cancer Center. Before that, he was Deputy Director of the Indiana University Cancer Center, also assisting it in obtaining its first NCI designation. Dr. Hromas has been elected to such honorific scientific organizations as the American Society of Clinical Investigation, the Association of Professors of Medicine, the American Clinical and Climatologic Association and the Association of American Physicians.

It is my strong belief that the Long School of Medicine stands at a crossroads of many exciting opportunities, and my sense is that Dr. Hromas, with the help of our talented faculty, staff and students, and many at UT Health and University Health System, will enjoy the brightest and most exciting of futures ahead.

I hope that you will join me in providing the warmest of welcomes to Dr. Hromas, his wife Shari, and their three adult children to UT Health San Antonio.

Sincerely, William L. Henrich, M.D., MACP President and Professor of Medicine

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Celebrating the Mays Family Foundation’s gift Tuesday are (seated) Peggy and Lowry Mays, (standing, left to right) Bill Johnson, Mays Cancer Center Director Ruben Mesa, M.D., UT Health San Antonio President William L. Henrich, M.D., MACP, Sen. José Menédez and UT System Chancellor William McRaven.

UT Health San Antonio President William L. Henrich, M.D., MACP (left) thanks Lowry and Peggy Mays for the Mays Family Foundation’s gifts to the UT Health San Antonio Cancer Center. The UT System renamed the cancer center as the Mays Cancer Center in their honor.

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37

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.

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Avid Wealth Partners (HHHH 10K Platinum 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 well-served 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® Founder & Wealth Management Advisor Specializing in Investment Management and Fee-Based Financial Planning 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank.

Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Manage-

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San Antonio Medicine • March 2018

ment in North America for 2017 by Euromoney."

ATTORNEYS

Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence.

Partner and Office Head Mark R. Flora 512-382-8800 mflora@constangy.com Partner William E. Hammel 214-646-8625 whammel@constangy.com Senior Counsel John E. Duke 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”

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.

Employment & Labor Mario Barrera 210 270 7125 mario.barrera@nortonrosefulbright.com Life Sciences and Healthcare Charles Deacon 210 270 7133 charlie.deacon@nortonrosefulbright.com Real Estate Katherine Tapley 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”

Strasburger & Price, LLP (HHH Gold Sponsor) Strasburger counsels physician groups, individual doctors, hospitals, and other healthcare providers on a variety of concerns, including business transactions, regulatory compliance, entity formation, reimbursement, employment, estate planning, tax, and litigation.

Carrie Douglas 210.250.6017 carrie.douglas@strasburger.com Cynthia Grimes 210.250.6003 cynthia.grimes@strasburger.com Marty Roos 210.250.6161 marty.roos@strasburger.com www.strasburger.com “Your Prescription for the Common & Not-So Common Legal Ailment”

ASSETS ADVISORS/ PRIVATE BANKING

U.S. Trust ( Gold Sponsor) At U.S. Trust, we have a long and rich history of helping clients achieve their own unique objectives. Since 1853, we've been committed to listening, building long-term relationships, and helping individuals and their families realize the opportunities they create for themselves, their children, businesses, communities and future generations.

SVP, Private Client Advisor, Certified Wealth Strategist® Christian R. Escamilla

210.865.0287 christian.escamilla@ustrust.com “Life’s better when we’re connected®”

BANKING

Amegy Bank of Texas (HHH Gold 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.

Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future.

Stephanie Dick, Vice PresidentCommercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees.

Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com “Working for a better future”

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans.

Rick Tatum richardt@ozonabank.com www.ozonabank.com

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

RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more.

Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org

Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals.

Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

Frost (HH Silver Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”

BUSINESS CONSULTING Alto Vista Enterprises, LLC (HH Silver Sponsor) We specialize in helping physicians grow their business according to the goals and timeline of the practice. Customized business development strategies are executed by an experienced and dedicated team of consultants.

Michal Waechter, Owner (210) 913-4871 MichalWaechter@gmail.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

BUSINESS SERVICES

New York Life Insurance Company (HHH Gold Sponsor) We believe that any great relationship starts with great core values: Attention, Accountability, Appreciation, Adaptability and Attainability Financial Consultant Doug Elley 210-961-9991 dougelley@financialguide.com www.newyorklife.com

CONTRACTORS/BUILDERS /COMMERCIAL

Cambridge Contracting (HHH Gold Sponsor) We are a full service general contracting company that specializes in commercial finishouts and ground up construction.

Rusty Hastings Rusty@cambridgesa.com 210-337-3900 www.cambridgesa.com

Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire employee life cycle. From online onboarding to certification tracking to payroll processing, manage your people anytime, anywhere.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"

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) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"

FINANCIAL SERVICES

Avid Wealth Partners (HHHH 10K Platinum 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 ommitted to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP, CIMA, AEP, CLU, CRPS Founder & Wealth Management Advisor Specializing in Investment Management and Fee-Based Financial Planning 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

EMPLOYEE MANAGEMENT

Beyond (HHH Gold Sponsor)

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!”

Beyond ( Gold Sponsor) Beyond is a financial technology company offering a suite of business tools including payment processing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"

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) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning).

Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org

continued on page 40

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank.

Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."

GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time.

Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration

HEALTHCARE REAL ESTATE SAN ANTONIO COMMERCIAL ADVISORS (HH Silver Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

HEALTHCARE TECHNOLOGY RubiconMD (HH Silver Sponsor) RubiconMD enables primary care providers to quickly and easily discuss their e-Consults with top specialists so they can provide better care - improving the patient experience and reducing costs Shang Wang Business Development

40

San Antonio Medicine • March 2018

(845) 709-2719 shang@rubiconmd.com Cyprian Kibuka VP of Business Development (650) 454-9604 cyprian@rubiconmd.com www.rubiconmd.com “Expert Insights. Better Care."

HOSPITALS/ HEALTHCARE SERVICES

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

Miranda Peck 210-482-3000 mipeck@selectmedical.com Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

INFORMATION AND TECHNOLOGIES

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”

INSURANCE

SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships.

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor, Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Mortgage, Kristie Arocha 210-255-0013 karocha@swbc.com SWBC Mortgage www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services

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 John Isgitt 512-370-1776 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

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

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.”

The Doctors Company (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com.

Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY today’s medical environment with greater ease—that’s only fair.

Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET TELECOMMUNICATIONS

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”

MEDICAL BUSINESS CONSULTING

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Owner – Lettie Cantu 210-363-1735 Lettie@progressivebilling.com Administrator - Richard Hernandez 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

MEDICAL BILLING AND COLLECTIONS SERVICES

210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

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 SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold 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 percent to 50 percent.”

PAYROLL SERVICES

SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits.

Kristine Edge, Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.

BCMS members only).

Doug Elley 210-961-9991 dougelley@financialguide.com www.newyorklife.com “20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”

PRIVATE EQUITY

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.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, non-profit, R&D, healthcare delivery, professional services and more!

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Program Coordinator Valerie Rogler 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

REAL ESTATE SERVICES COMMERCIAL

PRACTICE CONSULTANTS Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Owner – Lettie Cantu 210-363-1735 Lettie@progressivebilling.com Administrator - Richard Hernandez

New York Life Insurance Company (HHH Gold Sponsor) Our Goal, increase patient & employee satisfaction, generate more free time for practitioners and mitigate both business and personal financial risk. (No Cost Financial and Business consulting including HIPAA audit evaluations,

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar

818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment.

Shane Brown, Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”

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.

Brody Whitley, Branch Director 210-301-4362 bwhitley@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients Physician Recruiter MSgt Robert Isarraraz Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"

For questions regarding services, Circle of Friends sponsors or Joining our program.

Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html

visit www.bcms.org 41 41 visit usus atatwww.bcms.org

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

We will locate the vehicle at the best price, right down to the color and equipment.

We will put you in touch with exactly the right person at the dealership to handle your transaction.

We will arrange for a test drive at your home or office. We make the buying process easy!

When you go to the dealership, speak only with the representative indicated by BCMS. GUNN AUTO GROUP

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Cary Wright 210-558-1500

Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX

GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

Bill Boyd 210-859-2719

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 IH 10 W San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209

Pete DeNeergard 210-680-3371

Coby Allen 210-625-4988

Abe Novy 210-496-0806

Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Sean Fortier 210-681-3399 KAHLIG AUTO GROUP

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Gary Holdgraf 210-862-9769

Wayne Alderman 210-525-9800

William Taylor 210-366-9600

James Godkin 830-981-6000

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX

North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211

Scott Brothers 210-253-3300

North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257

Jose Contreras 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257

13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Barrett Jaguar 15423 IH-10 West San Antonio, TX

Sandy Small 210-341-8841

James Cole 800-611-0176

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Dale Haines 210-341-2800

15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org

visit us at www.bcms.org

43

AUTO REVIEW

2018 Mecerdes S560 Convertible

By Steve Schutz, MD

The Mercedes S560 convertible is one of the most impressive vehicles I’ve ever driven. It does everything well, and I respect it tremendously. It’s not much fun though, which may or may not matter to you. But if it does, maybe buy a Porsche 911 turbo S instead.

There's a lot to say about this car, but it seems appropriate to start with the one word that kept coming to mind as I drove it: heft. The S560 is a large car that looks imposing, and the interior leathers and metals look like they came from a Hermes boutique. The doors close with a reassuring thunk, and you just know that this car will look and feel almost as solid in 20 years as it does now.

The exterior design is modern Mercedes Benz, which is to say sleek with noticeably rounded edges. The head- and taillights are all LED with jeweled detailing, chrome accents abound, and large Mercedes emblems adorn the front grille and trunk lid. As I've noted 44

San Antonio Medicine • March 2018

previously, all of those styling elements are must-haves for the Chinese market, and as long as our friends across the Pacific like these kinds of designs, that's what we are going to see because that market and not the U.S. dictates what luxury cars look like.

Interestingly, the S560 convertible comes with a cloth top. Ten years ago I would have predicted that by now all luxury brand convertibles would have folding steel roofs that stow in the trunk, but in fact cloth tops seem to have taken over. While saving weight explains some of the move back to fabric tops, most of the reason for going back is styling and the fact that engineers have been able to manufacture cloth tops with enough sound deadening that steel tops are no longer quieter.

Naturally, as Mercedes’ flagship the S560 is loaded with technology. Yes there's lane departure warning, blind spot protection, and

AUTO REVIEW fact, Mercedes, like most automotive manufacturers, is already testing cars that can drive themselves on public roads. They're not doing that much here because our laws don't allow it, but other countries do. My son has a friend who works as an engineer for Mercedes in Germany, and that friend has taken many trips between Berlin and Stuttgart during which he has sat in the driver’s seat doing nothing more than watching movies on his iPad. While the appearance and feel of the materials in the S560 are good enough to make you stop what you're doing and just enjoy them, and the tech is the most advanced you can get in any vehicle currently for sale, this is not an exciting car to drive. Certainly it's very quick, as a zero-to-60 MPH time of 4.3 seconds will attest, and it can gobble up interstate miles at super-legal speeds without breathing hard. But the experience of driving the S560 is clinical and almost sterile. If piloting a Ferrari 388 is a 10 when it comes to driver involvement, I'd give the S560 a 7. It does everything you need and does it well, but the big Mercedes keeps you at arms-length, as if the car knows what to do better than you do.

Which I guess it does.

The engine that enables that impressive performance is Mercedes’ latest twin-turbo 4.0 liter V8 that produces 463 HP. While that's a lot of power, and the S560 convertible weighs a weight watcher-ish 5,000 lbs or so, its fuel economy numbers aren't as terrible as you might expect: an estimated 16 MPG city 25 highway. As future Mercedes incorporate cutting edge hybrid technologies, especially plug in capability, expect those figures to improve.

The S560 convertible is a top shelf luxury car that does everything well. Luxury, technology, and safety are all there beyond what you'll experience in almost any other vehicle for sale today. And while this plush Mercedes isn't much fun to drive, it has a lot of heft, that je ne sais quoi that makes well-heeled customers feel special every time they get in it and drive away.

(Author’s note: This review was based on driving the 2017 S550 convertible, which is no longer for sale. The 2018 S560 is mostly unchanged except for the powertrain and some detailing, and therefore is expected to provide a very similar ownership experience. I attempted to describe what owning the S560 would be like based on my time with the S550, and I incorporated information that is available about the S560 in order to make it relevant for prospective purchasers.) smart cruise control, as there is in many vehicles that cost much less than this car, but that's just the beginning.

Where the S560 creates separation from more pedestrian vehicles is in autonomous driving, and the S560 takes things as far as you can get in 2018 with a smart cruise control that automatically adjusts its speed for curves, intersections, changes in the speed limit, and toll plazas. (Its knowledge of the terrain is based on GPS data.) In

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 45 45 visit us us at at www.bcms.org

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San Antonio Medicine â&#x20AC;˘ March 2018