San Antonio Medicine April 2019

SAN ANTONIO

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MEDICINE SAN ANTONIO

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Medical Technology

San Antonio’s Lifesaving Germ-Killer Robots

By David Alex Schulz .....................................12 Video Gaming: Harmless American Pastime or Public Health Crisis?

By Tristan C. Fielder.......................................16 Why patients worry about cybersecurity and patient-generated data

By Andis Robeznieks .....................................20 BCMS President’s Message ..................................................8 BCMS Legislative News ......................................................10 BCMS Honorees David P. Green, MD – Hand Surgeon to the World By Mike W. Thomas ..........................22 BCMS News ..............................................................................................................................................24 BCMS News: Active Shooter Exercise By Tim Tong, MD ............................................................................26 Feature: The Weather Down Here is Unique

By John Seidenfeld, MD ..........................................................................................................................26 UTHSCSA: Following a Different Model of Care: Accountable Care Organizations focus on improving patient health, experience while reducing costs

By Ramon Cancino, MD, MSc, Directory of Primary Care, UT Heatlh Physicians ....................................31 BCMS Circle of Friends Directory ..............................................................................................................36 Perception-Altering Plants: Valid Medicine? Book Review: “How to Change Your Mind” By Michael Pollan Review by David A. Schulz ......................................................................................................................42 In the Driver’s Seat ....................................................................................................................................43 Auto Review: 2019 Bullitt Mustang By Steve Schutz, MD ..........................................................................44 PUBLISHED BY: SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net BUSINESS MANAGER: Vicki Schroder

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San Antonio Medicine • April 2019

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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 Adam V. Ratner, MD, President Rodolfo “Rudy’’ Molina, MD, Vice President John W. Hinchey, MD, Treasurer John J. Nava, MD, Secretary Gerald Q. Greenfield Jr., MD, PA, President-elect Sheldon G. Gross, MD, Immediate Past President

DIRECTORS Michael A. Battista, MD, Member John D. Edwards, MD, Member Vincent Paul Fonseca, MD, MPH, Member Michael Joseph Guirl, MD, Member David Anthony Hnatow, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones Jr., MD, Member David M. Siegel, MD, JD, Member Rajeev Suri, MD, Member Kelly King, Alliance Representative George Rick Evans, Legal Counsel Col. Charles Gregory Mahakian, MD, Military Representative Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robert Richard Leverence, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Brent W. Sanderlin, DO, Medical School Representative Alice Kim Gong, MD, Board of Ethics Chair

BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Carmen Garza, MD, Member Leah Jacobson, MD, 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 J.J. Waller Jr., MD, Member

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San Antonio Medicine • April 2019

PRESIDENT’S MESSAGE

The Bad, The Ugly and The Good

By Adam Ratner, MD, 2019 BCMS President

The Bad

I’m writing this more than a month before you will read this. I hope by the time your copy of San Antonio Medicine lands on your desk in April, we’ll have some good news about Senate bill 1264, the so-called “surprise billing” bill. Many of us who pay attention to the happenings in Austin were expecting something like this to emerge. Here is a key excerpt from the bill regarding physicians who provide emergency services or are facility-based as it is published on March 2, 2019: A non-network physician or provider may not bill a patient described by this section in, and the patient has no financial responsibility for, an amount greater than the patient's responsibility under the patient's health care plan, including an applicable copayment, coinsurance, or deductible.

The Ugly

Those of us who have had the “privilege” of negotiating physician services contracts with third party payors will immediately grasp that should Sb 1264 and a proposed companion house bill become law, it will eliminate virtually any remaining incentive for any payor to negotiate contracts fairly with a physician who is facility-based and/or provides emergency services.

As it has been for years, the root of this problem is the lack of motivation of many third-party payors to work with willing and cooperative physicians to create and maintain adequate networks to serve our patients. Whether you practice solo or in a small, medium or large multispecialty private, corporate or academic group, almost all physicians who provide emergency or facility-based care will be adversely affected.

There is another ugly side. There are a few doctors whose practices are sending patients outrageous bills. I’m not sure whether all of the practices that send these bills realistically expect to be paid these huge sums, but on occasion some patients have been sent to collection agencies for inadequate payment. Proponents of Sb 1264 are using these outlier instances to attack the rest of us. Enough said.

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San Antonio Medicine • April 2019

The Good

Organized medicine in Texas has met and defeated similar bills in the past. Sb 1264 will be met by the full force of the TMA and bCMS advocacy teams in an effort to defeat it, as well.

Physicians are brilliant and hard-working and have the intellectual firepower to work around challenges and threats to our patients and our practices. Perhaps it’s time to think seriously about changing your relationships with third-party payors and deal one-on-one financially with your patients, if you can in your specialty.

Allying with the Alliance

We physicians in the bCMS are not alone. We have our bCMS Alliance. because of the joint vision and leadership of the immediate past presidents of the bCMS and the bCMS Alliance last year, Sheldon Gross and Jenny Shepherd, Kelly King, the current bCMS Alliance president, and our bCMS and Alliance Executive Committees, all of us are beginning to see the benefits.

Within a couple of days following the recent bCMS Executive Committee’s approval of developing a physician mental health/suicide prevention program (modeled after Travis County Medical Society’s program), three Alliance leaders volunteered to work on the program. during this same time period, three Alliance leaders stepped up to help advise our bCMS library Philanthropy board headed by dr. Gerry Ortega. Finally, two Alliance leaders signed up to participate in the 2019-2020 second annual Physician leadership development Program.

For the majority of bCMS members who have not had the privilege of working with the Alliance or participating in their social and philanthropic events, you and your spouse are missing out. The events are fun! The Alliance leaders and active members are passionate individuals who are making a major difference in the lives of those they touch, within the Alliance and bCMS as well as the greater community.

The Alliance leadership has come forward to work with the

PRESIDENT’S MESSAGE bCMS leadership and staff to better coordinate and market joint events so that more of us can participate and have fun despite our busy schedules.

Moving forward…

There has historically been active participation of Alliance members in the bCMS legislative/Socioeconomic Committee as well as representation on the bCMS board of directors. We would all benefit from Alliance representatives participating in other standing bCMS committees including the Communications/Publications, International Relations, and Public Health/Patient Advocacy committees.

An opportunity to gain new members for both organizations, while also providing needed service to our younger members, is for us to reach out to residents and fellows and their spouses and families in our community. When completing their training, the vast majority of residents and fellows stay in the general area of their programs. Each year dozens of these physicians finish their programs and many settle in our vicinity, yet most don’t become bCMS members and their spouses don’t join the Alliance.

Prior to becoming Alliance presidents, lori boies and Kelly King were active leaders in a spouses’ organization for UHS residents.

Unfortunately, after they left, this resident spouse organization has subsequently folded leaving a void. My hope is that working with bCMS, the Alliance can create and run a trainee spouses’ group which can truly address the needs of trainee spouses and families.

Such a project will not only improve the difficult lives of trainees, their spouses and families but also increase awareness and ultimately long-term membership in the Alliance and bCMS. Growing the breadth, loyalty, enthusiasm and value of membership of the bCMS and the Alliance are critical to our future ability to effectively advocate for physicians and our patients in these contentious and trying times.

We are continuously looking for new ways to add value to your membership. What would add value for you? Please let me know (adam.ratner@bcms.org).

Dr. Adam Ratner is President of the Bexar County Medical Society and serves as Professor and Assistant Dean of the University of the Incarnate Word School of Osteopathic Medicine and Chair of The Patient Institute.

visit us at www.bcms.org

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BCMS LEGISLATIVE NEWS

BCMS PHYSICIANS AND ALLIANCE MEMBERS HARD AT WORK DURING MARCH FIRST TUESDAYS last week, bCMS physicians and Alliance members participated in several meetings with legislators and staff during the March 5 First Tuesdays visit to the Capitol. In addition, this event hosted the young physicians and residents from around the state. With the legislative session now in full swing and committee hearings taking place, a number of topics were discussed, including: Medicaid; graduate medical education (GME); physician loan repayment; Medicaid reimbursement; scope of practice; surprise billing; insurance network adequacy; prior authorizations; maternal mortality; vaccinations; and raising the tobacco age to 21.

Many thanks to the attendees, who made our visits at the Capitol a success: Physicians – Michael battista, Md; Pam Hall, Md; bill Hinchey, Md; leah Jacobson, Md; Alex Kenton, Md; Sanjiv Kumar, Md; Jesse Moss, Jr., Md; John Nava, Md; James Saucedo, Md and Jayesh Shah, Md and Alliance members – James duerr and Jenny Shepherd.

The next First Tuesdays visit to the capitol is on April 2. We encourage all our members to get involved and participate in at least one First Tuesday this session. To register, please visit: www.texmed.org/FirstTuesdays

SAN ANTONIO HAS A NEW STATE REPRESENTATIVE last Tuesday, March 12, former City Councilman Ray lopez became the winner in the runoff election for Texas House district 125, the seat recently vacated by former state representative Justin Rodriguez, who is now a County Commissioner representing Precinct 2.

Once representative-elect lopez is sworn in, he will begin work in the 86th legislative session, which at the time of this writing, is fast approaching the half-way mark. Now that the district 125 seat is filled, bexar County is back up to full representation in the Texas legislature - 10 state representatives and 4 senators.

For local discussion on this and other advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org 10

San Antonio Medicine • April 2019

MEDICAL TECHNOLOGY

San Antonio’s Lifesaving

GERMKILLER ROBOTS

By David Alex Schulz

Killer Robots from San Antonio

are saving lives across the globe.

No, it’s not a reboot “Terminator” film, but a remarkable story about reducing health-care associated

and hospital acquired infections

(HAIs) with 21st Century technology. It marks the biggest advance in eliminating nosocomial infections, deaths, suffering and pain since Joseph lister introduced

hand-scrubbing and instrument sterilization.

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San Antonio Medicine • April 2019

MEDICAL TECHNOLOGY

before lister sprayed carbolic acid in the operating theater, a patient could as likely undergo a successful procedure only to die from ‘ward fever.’ Yet in the century between lister’s death and the release of XENEX lightStrike robots, disinfection has relied on 19th Century chemistry, with only incremental improvements. A 2012 Florida study concluded that little had changed since a similar study four decades prior.

Now, two young inventors and a San Antonio businessman have made a quantum leap (quite literally) in technology that is proven more effective than manual cleaning in killing pathogens as tough as Clostridium difficile (C.diff) spores, not to mention bacterium and viruses.

Not that one replaces the other, but together, according to XENEX CEO Morris Miller, “We give hospital environmental services workers the one-two punch needed to really make a difference.”

A difference documented in 26 peer-reviewed studies and now seen locally in University Health System, baptist Orthopedic Hospital, brooke Army Medical Center (bAMC), and Audie l. Murphy vA Hospital – all using lightStrike technology to disinfect rooms.

XENEX robots are in about 450 hospitals, surgery centers, long term care and skilled nursing facilities in the U.S., U.K., Europe, Asia, Africa, Middle East and South America.

Two infectious disease epidemiologists, dr. Julie Stachowiak and

dr. Mark Stibich, their doctorates from Johns Hopkins University, founded XENEX in 2008. After learning about the use of pulsed xenon bulbs overseas to combat airborne tuberculosis, they knew the technology had potential application in environmental disinfection of healthcare spaces.

XENEX grew from a concept in the Houston Technology Center. Early on, San Antonio’s Morris Miller was introduced to Julie and Mark. Miller, a co-founder of Rackspace, was eager to invest after he heard the clarity with which the two doctors expressed their mission.

“That’s always a critical question for me: What’s the mission? If it’s ‘to build a big company and make money,’ it’s the wrong answer.

Julie and Mark, on the other hand, had a passionate reason: ‘We want to stop the needless deaths caused by HAIs and reduce the pain and suffering caused by these infections.’”

They also explained the size of the issue, and its costs to society.

“In the U.S. alone, two million patients get them each year after going to the hospital,” recalls Miller, “and a hundred thousand die.”

That’s approximately the same number of deaths as from AIdS, breast cancer and auto accidents combined in the U.S., and as antimicrobial resistance increases, HAIs become even more life threatening and costly. The impact on the economy is estimated to be between $32 billion up to $40 billion, just in out-of-pocket healthcontinued on page 14

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MEDICAL TECHNOLOGY continued from page 13

care costs, not to mention lost wages, pain and suffering.

Marketing an expensive innovative technology, regardless of journal results, takes innovative approaches. Morris Miller was precisely the right partner. His record of accomplishment for identifying, using, and fostering adoption of new technologies goes back to when he first digitized Texas legal case law to make it available on Cd-ROM before anyone else saw the promise. The development of Rackspace from a basic Internet access and web hosting company to become an essential aspect of the cloud hosting industry is also a story in Miller’s wake. but marketing such a radical change in HAI-control to an industry as stolid as healthcare meant proving to hospitals that return-on-investment would be guaranteed.

So XENEX partnered with hospitals instead of just selling, and provided the same “extreme stewardship” to its clients that Rackspace fostered. Initial results from many of those first hospitals were encouraging: Cooley-dickinson Hospital (MA) reported an 86 percent drop in rates of C.diff infections; and Cone Health, whose MRSA infections plummeted in the first six months of using XENEX, saved over $2 million.

The results have continued to make headlines. “When a New Orleans hospital needed 24 robots, we said let us put them in at no cost to you, and unless your infections drop below a benchmark, there won’t be a bill, let’s say if they don’t go down 15 percent. So three months later, they announced a nearly 50-percent drop!”

Just a year ago, XENEX teamed with Norman Regional Health System to stem an expected flu epidemic at Norman Oklahoma Public Schools. Norman Regional’s Environmental Services team disinfected five schools using Germ-Zapping Robots from XENEX. The results were so impressive, XENEX has continued to partner with Norman Regional Health to support community events and raise awareness of disease transmission.

Clyde brawner, director of Environmental Services at Norman Regional Health System, said Norman Regional purchased four XENEX Germ-Zapping Robots in 2016 and two more in 2017, to 14

San Antonio Medicine • April 2019

assist with keeping patients safe, and in turn reducing hospital acquired infections and conditions.

"In the first year of having the robots, we noticed a 34 percent decrease in hospital acquired infections. The robots are a great investment," he said to The Norman Transcript, "I would like to see the hospital consider purchasing additional robots to further assist in sanitizing and disinfecting areas of the hospital." brawner said their efficiency and speed caught his eye. "It only takes about 10 minutes to completely disinfect a hospital patient room," he said. "It's very impressive."

While altruistic, the partnerships also have a strategic effect, says Miller. “It’s a new technology, and we’re trying to get around the price elasticity curve by working with hospitals, with their environmental services, saying, ‘let us help you save the money first, then you can pay us.’ Otherwise, it takes too long for the price to fall to have the technology as widely used as we want.”

And the need for these robots appears to be increasing. “For every infection that doesn’t occur, that’s one less use of antibiotics, and one less opportunity for antibiotic-resistant pathogens to develop. Thanks to the XENEX lightStrike technology, we can stop that cycle in its tracks,” Miller concluded.

David A. Schulz is a member of the BCMS Publications Committee.

MEDICAL TECHNOLOGY

VIDEO GAMING:

Harmless American Pastime or Public Health Crisis?

By Tristan C Fielder People of all ages and walks of life across the United States have drastically increased the amount of time they spend in front of screens in recent years.1 These increases in screen time have led many to question if at some point or threshold excessive screen time can have pathologic effects. Screen time can come in many flavors such as traditional television, video streaming, social media, gaming, internet surfing, and more. The breadth and depth of the internet and its associated entertainment modalities continue to grow and evolve around us every day. One area of particular interest to me is internet gaming and how it may affect our youth. data from the Pew Research Center suggest that in 2015, 59 percent of female and 84 percent of male teens surveyed (ages 13-17) indicated that they play video games online or on their phone.2 This study was repeated in 2018, and this time 83 percent of female and 97 percent of male respondents reported playing video games reg16

San Antonio Medicine • April 2019

ularly.3 video game playing is an enjoyable pastime that acts as a healthy source of entertainment for many young Americans. Although gaming does bring joy to many, the scientific community has been finding increasing amounts of evidence to suggest that video game use has the potential to negatively affect gamers’ lives.

In some cases, these negative effects manifest themselves as a sort of addiction. This addiction, termed Internet Gaming disorder (IGd), was listed in the diagnostic and Statistical Manual of Mental disorders 5th edition (dSM-v) in 2013 as a “Condition for Further Study.”4 It is important to note that the American Psychiatric Association (APA) has stated that “there was not sufficient evidence to determine whether the condition is a unique mental disorder or the best criteria to classify it at the time the dSM-5 was published in 2013.”5 Since the APA’s 2013 designation of IGd, many studies have been performed and published in an attempt to better under-

MEDICAL TECHNOLOGY stand the phenomenon. despite the mounting acknowledgment and investigation of IGd, some researchers suggest that this “push to pathologize video games” may be unfounded.6 In June of 2018, the World Health Organization (WHO) released the newly proposed 11th Revision of the International Classification of diseases, which designates IGd as its own unique disorder.7

The WHO defines IGd as “…a pattern of gaming behavior (“digital-gaming” or “video-gaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.

For gaming disorder to be diagnosed, the behaviour pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months.”7 A 2009 survey by Gentile reported that 8.5 percent of children and adolescents (8 to 18 years of age) who play video games in the United States display signs of pathological addiction.8 If we combine this proposed statistic with the recent Pew Research Center data on gaming prevalence, it can be said that about one in thirteen United States teens are likely experiencing some kind of pathological effects related to the use of video games.

One of the first stories of video game addiction came in 2011, when The Guardian published an article telling the story of dr.

Ryan van Cleave, a Ringling College of Art and design creative writing professor whose life was almost totally consumed by the online game World of Warcraft (WoW).9 According to The Guardian, dr. van Cleave was playing upwards of 60 hours of WoW per week at the height of his addiction.9 More recently, since debuting in late September of 2017, the online game Fortnite has absolutely dominated the video game world.

As of November of 2018, there are now over 200 million registered players.10 Fortnite’s creator Epic Games reportedly earned over $3

billion in profits in 2018.11 What makes that earnings statistic particularly interesting is that Fortnite is completely free to download and play. by simply creating an account for free you can join 99 other players from across the world in a battle royale. Your character is dropped onto an island with the other players where you have to gather weapons, medical supplies, and building materials while fighting your way to victory. This can be done alone or in a squad of up to four players. Epic Games has made Fortnite such a lucrative business by offering aesthetic upgrades to players’ virtual characters which they can purchase in-game. These virtual costumes, referred to as “skins”, range from eight to twenty dollars each and provide absolutely no advantage or change to the base gameplay aside from making your character look super cool.

IGd has long been associated most with adolescent male gamers, so I figured I would find one to talk to about all of this.12 I didn’t have to go far. My 15-year-old brother has been playing increasing amounts of Fortnite for a year now. When he isn’t playing the game, he is usually watching YouTube videos of other people playing the game, studying how to perform better in the next battle he enters. Our parents strongly limit his time spent gaming, only allowing him to play on the weekends. because his urges to play Fortnite are constantly constrained, when he gets the chance to finally play on the weekend it can turn into an allnight binge session and a very disordered sleep schedule. by hording birthday and Christmas money, and through a bit of deception, he has spent somewhere around $500 on skins for his Fortnite character. In the podcast linked below, when asked if it was worth the $500 spent, he tells me that the added enjoyment that comes from having the rarest and most sought-after skins for his character has been well worth the cost. My brother goes on to reveal how playing Fortnite allows him and others to escape from the problems or negative feelings plaguing them in their real lives. We talk about how young video game players sometimes choose to spend time in the virtual world at a real cost to their lives back on earth. For young Americans, this cost can materialize in the form of worsening school grades, failure to maintain daily responsibilities, or even sacrificing the quality of relationships with others. When I ask my brother if his Fortnite use has ever had real negative effects on his life he tells me “there are definitely times where I do let [my video game consumption] slip and it does get away from me.” This seems pretty alarming, doesn’t it? Are our teens’ lives being ravaged by addictions to modern technology like video games and social media? continued on page 18

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MEDICAL TECHNOLOGY continued from page 17

Fortnite Gameplay: This is a screenshot taken just before my brother shot down this unsuspecting enemy (gliding away via umbrella) with Fortnite’s Heavy Snipe Rifle. It’s moments like these that Fortnite players live for.

In our discussion, my brother and I ultimately come to the conclusion that what seems to be a true pathological addiction, may be something more nuanced. At the conclusion of our talk, I ask him directly if he thinks he has an actual addiction to Fortnite: “I think I have an addiction. I’m not so sure if it’s a problem all of the time…

Honestly, you have to weigh the positive and negatives. For me personally, I think the positives outweigh the negatives… Instead of going out and doing a bunch of bad stuff, or stuff that’s bad for you like alcohol and drugs, I stay at home and play Fortnite with my friends. I live a good life, I just play a lot of Fortnite.”

He makes an interesting suggestion there. Could it be that playing video games all of the time might actually be a good thing? Schmitt and livingston, in their study of video game addiction and college performance among males, reported that male first year college students who were most addicted to video games had lower numbers of drug and alcohol violations when compared to the other students in the study.13 However, these same students were more likely to have lower first year Grade Point Averages (GPA), after controlling for high school GPA, when compared to the other students in the study.13 As my brother was arguing, perhaps there is a more complicated arrangement of positive and negative effects associated with playing games like Fortnite.

Whether you think video games present a public health crisis or a harmless good time, this is something that the vast majority of us and our patients interact with daily. does my brother’s story remind you of your children? do you see negative effects of gaming in your patients or their families? Will our children suffer in the future be18

San Antonio Medicine • April 2019

cause of their years spent staring at screens? do we, as a society, have a pathological problem with the way we consume social media and other technologies?

Many American families try desperately to limit their children’s screen time in an effort to prevent proposed negative effects to little avail. Perhaps modern technology has already woven itself into our society to an extent that makes removing it impossible. Try as we may, we continue to navigate closer and closer to our screens. To my knowledge, no one has a solution to this perceived problem. If there really is a problem with this technology wave that we are living in, learning more about how we interact with these advances may allow us to tailor our consumption to avoid the consequences of this new kind of addiction. While I am not advocating for foil hats and Nokia flip phones, I am interested in learning more about these things with you all.

If you find yourself in need of a break from the stress of writing notes, complying with federal regulations, and dealing with insurance companies anytime soon you can download Fortnite to go on a free island vacation complete with automatic rifles and awesome field surgeon costumes: Check out my discussion on IGd and Fortnite on the Apple Podcast App or Soundcloud by searching “Investigative Inquiries”, or by searching “Tristan C Fielder”.

Jump to 13:50 to catch the best part, where we hear from the expert (my brother). For those that crave efficiency, the Apple Podcast App allows you to play podcasts at up to 2X speed.

References List:

1 Heid M. There's Worrying New Research About Kids' Screen Time and Their Men-

tal Health. Time. http://time.com/5437607/smartphones-teens-mental-health/.

Published October 29, 2018. Accessed February 25, 2019.

2 lenhart A. Teens, Social Media & Technology Overview 2015. Pew Research Cen-

ter: Internet and Technology. April 2015. http://www.pewinternet.org/

2015/04/09/teens-social-media-technology-2015/. Accessed February 18, 2019.

3 Anderson M, Jiang J, Anderson M, Jiang J. Teens, Social Media & Technology 2018.

Pew Research Center: Internet, Science & Tech. http://www.pewinternet.org/

2018/05/31/teens-social-media-technology-2018/. Published November 30, 2018.

Accessed February 25, 2019.

4 American Psychiatric Association. diagnostic and Statistical Manual of Mental disorders. 5th ed. Washington d.C.: 2013

5 Internet Gaming. American Psychiatric Association. https://www.psychiatry.org/patients-families/internet-gaming. Accessed February 18, 2019.

6 bean AM, Nielsen RKl, van Rooij AJ, Ferguson CJ. video game addiction: The push to pathologize video games. Professional Psychology: Research and Practice.

2017;48(5):378-389. doi:10.1037/pro0000150.

7 Gaming disorder. World Health Organization. https://www.who.int/features/ qa/gaming-disorder/en/. Published Sept. 14, 2018. Accessed Feb. 18, 2019.

8 Gentile, d. Pathological video-game use among youth ages 8 to 18 A National Study.

Psychol Sci. 2009, 20, 594–602.

9 lush T. At war with World of Warcraft: an addict tells his story. The Guardian.

https://www.theguardian.com/technology/2011/aug/29/world-of-warcraft-videogame-addict. Published August 29, 2011. Accessed February 21, 2019.

10 Phillips T. Fortnite now boasts 200 million registered players. Eurogamer.

https://www.eurogamer.net/articles/2018-11-27-fortnite-now-boasts-200-million-

registered-players. Published November 27, 2018. Accessed February 22, 2019.

11 Kain E. 'Fortnite' Creator Epic Games Reportedly Earned $3 billion In Profits in 2018. Forbes. https://www.forbes.com/sites/erikkain/2018/12/27/fortnite-developer-reportedly-earned-3-billion-in-profits-in-2018/#28e5bf6e1c79. Published de-

cember 27, 2018. Accessed February 22, 2019.

12 Kuss, d. J., & Griffiths, M. d. (2012). Internet Gaming Addiction: A systematic re-

view of empirical research. International Journal of Mental Health and Addiction.

2012. 10, 278–296. http://dx.doi.org/10.1007/s11469- 011-9318-5

13 Schmitt Zl, livingston MG. video Game Addiction and College Performance Among Males: Results from a 1 Year longitudinal Study. CyberPsychology, behavior

& Social Networking. 2015;18(1):25-29. doi:10.1089/cyber.2014.0403.

Tristan Fielder is a first-year student at the Joe R. and Teresa Lozano Long School of Medicine. If you would be interested in talking about an issue related to public health on the Investigative Inquiries Podcast, Tristan can be reached at tfielder405@gmail.com.

visit us at www.bcms.org

19

MEDICAL TECHNOLOGY

Why patients worry about

cybersecurity

and patient-generated data

By Andis Robeznieks Patient-generated health data (PGHd), from wearables and other remote devices, represents an exciting opportunity to more deeply engage patients and families in care and offer robust data streams of objective information to better guide treatment plans. Yet, federal health IT experts note, one big factor that stands in the way of advancement on this front are fears about the cybersecurity of this sensitive information.

The AMA is committed to making technology an asset in the delivery of health care, not a burden. Efforts in this area include creation of the digital Health Implementation Playbook to speed the adoption and scaling of innovative solutions.

The Office of the National Coordinator for Health IT (ONC) has released a white paper that outlined some of the opportunities, 20

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challenges and security concerns that PGHd add to the digital health picture.

Security and privacy protections applied to PGHd are “uneven and do not establish a consistent legal and regulatory framework,” according to the ONC report, “Conceptualizing a data Infrastructure for the Capture, Use, and Sharing of Patient-Generated Health data in Care delivery and Research through 2024.” like all data, PGHd “may be at risk for security breaches that could affect the integrity of the data and expose the data to access for malicious purposes because they are not subject to the same security regulatory framework as HIPAA-regulated entities. Concerns include insecure points of data collection and insecure data movement that potentially expose the device or the clinician’s information

MEDICAL TECHNOLOGY system to pollutants, such as malware,” the ONC report stated.

“There is growing potential for risks related to unauthorized access, including cyber threats.”

The AMA participates in the Health and Human Services Health Sector Coordinating Council (HSSC) that recently released a fourvolume publication offering practical cybersecurity guidelines for small, medium and large health care organizations for focusing on major threats, identifying vulnerabilities, and prioritizing resources.

It also provides resources and templates that can be customized for an individual practice or organization’s use.

Another security concern cited by the ONC is the privacy risk of reidentifying deidentified data as it is collected and integrated from a variety of different sources. ONC, however, also identified several opportunities that PGHd provides for improving health.

According to the ONC, patient-generated health data:

• Empowers patients to capture, use and share PGHd to better manage their health and to participate in their care.

• Shows a more holistic picture of a patient’s health over time, “increases visibility into a patient’s adherence” to a treatment plan, and enables timely interventions.

• Strengthens the patient-physician relationship by facilitating the creation of an individualized care plan and fostering shared decision-making.

• Provides researchers access to a larger pool of data.

Aside from the big cybersecurity concern, the ONC noted other challenges. Among them:

• Practices may lack the technical infrastructure and workforce capacity to integrate PGHd into functional workflows.

• Evidence demonstrating clinical benefit of PGHd “is still limited and inconclusive.”

• There are liability concerns about using potentially inaccurate PGHd in clinical decisions or if PGHd is not acted on or reviewed.

• The lack of technical standards limits secondary research and clinical trial uses for PGHd.

The ONC also identified technical challenges patients face:

• As of 2016, 34 million Americans still lacked access to broadband internet.

• 36 percent of Americans do not own a smartphone.

• Use or ownership of smartphones could be challenged by a patient’s low income, cognitive or physical impairments, or language barriers.

EHRs purchased or upgraded in 2019 will include the capability to capture PGHd. Physicians should ask their EHR vendors to provide comprehensive education on this new feature. EHR vendors should provide best practices on the use, security and integration of PGHd into physicians’ workflows.

Patients may also be distrustful about how their information will be used. The ONC cited a survey conducted by the patient information-sharing website PatientslikeMe which found that, among patients with an existing medical condition, 72 percent believe data from personal health records can be used to deny them health benefits, while 68 percent felt they could be denied job opportunities.

Andis Robeznieks is a senior news writer with the American Medical Association.

visit us at www.bcms.org

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BCMS HONOREES

bCMS Honorees

David P. Green, MD Hand Surgeon to the World before he became a world-renowned hand surgeon, dr. david P. Green, 82, spent time as a medic at March Air Force base in Riverside, Calif., treating wounded soldiers returning from the vietnam War. It was there that his interests first turned towards hand surgery because he saw so many veterans coming home with grievous hand injuries.

“We were getting all these hand cases from vietnam and I didn’t think we knew enough about how to treat them,” Green said. So, at the first opportunity he went back to school at Columbia Presbyterian Medical Center in New York to study orthopedics.

After his graduation, Green was presented with an opportunity to get in on the ground floor at the new department of Orthopedics at the Medical School in San Antonio. A native Texan who grew up in El Paso and graduated from baylor College of Medicine, Green was more than happy to return to his home state. For the next eight years he served as the coordinator of resident training and then chief of the hand surgery service.

While at the medical school, Green met dr. Charles A. Rockwood, one of the school’s first faculty members and chair of the department of Orthopedics. Together, Green and Rockwood co-authored a twovolume textbook on fractures that is now in its 8th edition. Today the textbook is considered a standard reference on the subject and is used in orthopedic residency training throughout the country.

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By Mike W. Thomas In 1977, Green came to another crossroads in his career when he was offered the opportunity to become the chair of orthopedics at UT Southwestern Medical Center in dallas. “It was a big decision,” Green recalls, “I had to decide whether I wanted to be in academics my whole career or if I wanted to be a hand surgeon.”

The next year, Green left the medical center and became the first surgeon in San Antonio to devote his practice entirely to hand and upper extremity surgery. before long he was joined by other doctors and became a founder of the San Antonio Hand Center. Over the years he has served as the hand surgery consultant for the San Antonio Spurs and has treated numerous professional athletes including members of the dallas Cowboys, world class gymnasts, professional rodeo cowboys, and golfers on the PGA tour.

Green wrote another textbook in 1980 called “Operative Hand Surgery,” which went on to become one of the definitive textbooks on hand surgery. It was published by a british company with American subsidiaries and Green was surprised to learn that it became very popular all around the world. The book is now in its 7th edition and has afforded him the opportunity to travel all over the world. but after a while, Green said he tired of writing only about medicine. “I was constantly writing and editing my books,” Green said. “As soon as I would finish updating one book it would be time to update the other one. by the fifth edition, I decided it wasn’t fun

BCMS HONOREES

anymore so I retired from medical writing and began pursuing other topics.”

Green’s love of history led him to write several history novels on World War II including “Hitler’s Money Trail: How he acquired it, How he squandered it”; “Rudolph Hess’ Mission: The Flight That Might Have Changed History”; and “Plague in the Pacific: How Japan’s Unit 731 Might Have Won the War”. but his best-selling book was one he just did on a lark by researching the origins of the names of streets and places around San Antonio called “Place Names of San Antonio”. His latest book is a collection of mini-bios about people who lost a presidential election, ranging from Wendell Willkie in 1940 to Hillary Clinton in 2016. All of these books can be found on his author page on Amazon.com.

Green calls writing his therapy and he is tickled when he is invited to speak on topics other than hand surgery. but, of course, hand surgery is still what he is best known for and he has received many honors and recognitions over the years. In 1997, he was named the distinguished Alumnus of his own residency training program, The New York Orthopaedic Hospital. He was also named the 2016 distinguished Alumnus of his alma mater, baylor College of Medicine. In 2019, the bexar County Medical Society honored him with their Golden Aesculapius life-

time Service Award.

Ten years ago, Green joined the board of SAMMinistries, a non-profit that helps families facing homelessness, and was inspired by a woman he met on the board who had been abandoned by her husband, left homeless but was still able to overcome these obstacles and put herself through law school. Green decided to launch the Helping Hands Fund which raises money to help people like the woman he had met to go back to school. The entity has so far raised more than $300,000 and works closely with SAMMinistries.

Green has seen many advancements in medicine over the years, but one that he is most excited about is micro-vascular surgery that makes it possible to restore blood supply to severed limbs and other transplanted tissues. Green is optimistic about the future because of the people he sees going into medicine every year.

“Every generation is smarter than the one before because they start out at a higher level,” he says. While dr. Green has been responsible for training well over 100 hand surgeons during the past 30 years, he does not like to take credit for their success.

“I think the role of a teacher is to provide a proper environment and point them in the right direction,” he says. “That is maybe 5 or 10 percent while the rest is their hard work. So that is why I think it is arrogant for me to say that I trained so-and-so.” visit us at www.bcms.org

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BCMS NEWS

ACTIVE SHOOTER TRAINING AT BCMS

A full-scale Active Shooter Exercise was held March 9, 2019, at the bexar County Medical Society (bCMS) headquarters. The training was put on by the bexar County Office of the Constable Precinct 2 at the request of the bCMS Emergency Preparedness Committee and the Alamo Area Medical Reserve Corp (MRC). Fifty-five people from all over San Antonio were in attendance to take the training which included bCMS physician members, and representatives from Health Careers High School, Methodist Healthcare Ministries, Aspect Wealth Management and others.

Our thanks to Captain Marc Garcia, who instructed the training and oversaw the exercise, Constable Michelle barrientes vela and her excellent team of officers that made the Active Shooter exercise so realistic. Our thanks also goes out to Shavano Park Police, Fire and EMS for their cooperation with the event.

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San Antonio Medicine • April 2019

BCMS NEWS

visit us at www.bcms.org

25

BCMS NEWS

ACTIVE SHOOTER EXERCISE

By Tim Tong, MD Society on a local, national, and international level is experiencing an increasing number of mass shootings. The etiology and root causes of this phenomenon are too numerous to be addressed in this article. While the likelihood of any one individual being caught up in such a tragic and terrifying experience is still low, all of us still need to practice awareness and preparedness. After all, we have all been warned since childhood not to stand in an open field during a thunderstorm. likewise, we are always hearing public service announcements advising one to look around the parking lot for potential danger when going to and from our vehicles.

What can I do to protect myself and those around me from becoming a victim of a mass shooting? The answer is that all of us can be an important part in limiting the damage inflicted by a mass shooter. To help address this, a full-scale active shooter exercise was held on the grounds of the bexar County Medical Society headquarters on March 9th. This exercise was organized by the bexar County Medical Society, Alamo Area Medical Reserve Corps/Metro Health and bexar County Constable Precinct 2.

This was a half-day event that started with a breakfast generously provided by our medical society followed by introductions and orientation. A video that covered the key elements of the “before, during and after” was viewed.

The “before” is having a plan. This includes having situational awareness and actively practicing it. When going into a building, know where the exits are. Wherever you are, does something seem amiss? If you see something, say something to an authority immediately and be aware of one’s environment and any possible danger.

The “during” includes the three parts of RUN and escape, if possible; HIdE, if escape is not possible; and FIGHT as a last resort.

Getting away is the top priority. do not go back to your desk or locker to retrieve your phone or other belongings! Hide out of the shooter’s view and preferably somewhere where there is a barrier to bullets. lock and block doors, draw shades, be quiet, and silence devices. Attempt to silently communicate with authorities and stay 26

San Antonio Medicine • April 2019

in place until the all clear is given by the authorities. Helpful information includes location of the shooter, number of shooters, physical description, number and type of weapons, and number of potential victims. Fight as a last resort and fight as if your life depended on it, because it does. Recruit others who are willing and swarm the shooter using makeshift weapons such as chairs or scissors.

The “after” is knowing how to respond after law enforcement arrives. The scene is chaotic and law enforcement is not necessarily clear on who the perpetrator, or perpetrators are. Keep your hands visible and empty and follow all commands and instructions. do not be afraid of seeking professional help to cope with the aftermath of the events.

The video was followed by the full-scale inter-agency exercise.

This was a live and realistic scenario of an active shooter event. The civilian participants had the opportunity to practice the mental and physical skills they just learned about preparing, running, hiding, fighting and coping with the aftermath. Understanding the challenges faced by our first responders and some of the tactics deployed in such a scenario gave us all a better appreciation of what they do and how to keep ourselves and others safer. The involved agencies had an opportunity to practice and hone their responses to such an event. There is an incredible amount of critical and realtime communication and coordination that has to happen in the milieu of a highly charged environment.

While there is no “typical” active shooter scenario, being aware and prepared, whether one is a civilian or in law enforcement can help mitigate the damage caused by a mass shooter. Part of that preparation includes familiarizing yourself with your workplace standard operating or safety plan.

If you are interested in holding an active shooter exercise at your practice, church or school, feel free to contact Office of the Constable bexar County Precinct 2 or your local law enforcement agency. The more people that are trained on how to react the better off our community will be.

Dr. Tim Tong is a pediatric intensivist at The Children's Hospital of San Antonio and vice-chair of the BCMS Disaster Preparedness Committee.

FEATURE

Texas and Texans, You All Listen Up –

The Weather Down Here is Unique

on the roster to fill time between reports on disasters and sporting events but listened to in the rare event of inclement weather. Also remember to start taking them seriously whenever tornadoes or hurricanes threaten or strike. like the weather radio, they should be brought out of the drawer on unusual occasions.

By John Seidenfeld, MD Please, please let me explain a little-known but very important concept. It has come to my attention that some people believe that one set of seasons is adequate for all Americans in this great and geographically vast country. While one set might be enough for a smaller nation, it is inadequate, unhelpful, and irritating to Texans who garden, work, wear clothing or go without, or for one reason or another spend time outdoors. I will concentrate on weather related information, and the environment the weather creates. let me propose a more helpful set of seasons for all Texans and especially the unmet expectations of those who are from other regions and got here as soon as they were able. Television weather reporters should be considered eye candy often blocking important maps and radar displays. They should be ignored as irrelevant and only kept

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There are four seasons in Texas.

• • • •

Fallwinterspring Early-Summer Mid-Summer late-Summer

december 23 to March 22 March 23 to June 22 June 23 to September 22 September 23-december 22

The most memorably unpleasant season in South Texas from the Hill Country to the border with Mexico is Mid-Summer, unless you are a scorpion. What are your memories? Would you share them with me? This is the season which brings certain concerns to mind.

First and foremost, the Uv Index, a guide to future dermatologic misadventures is often 12 on a scale of 1-10 for much of one’s waking hours leading to the most important adaptive behavior, the

FEATURE siesta. Man’s best friend is often heard snoring along with the master during the early afternoon post prandial hours. No worries about hobby gardening as most everything is now dead. Spiny slimy ochre flourishes along with basil, but master gardeners as well as mad dogs and Englishmen may persist and even flourish during these months.

Tomatoes leave this world near the beginning of the season in green garb and charred shriveled ash. Scorpions, poisonous snakes, venomous spiders, cacti, and the chiggers flourish in this yearly threemonth solar storm. The chigger, for those novitiates, is a nearly microscopic bug that hops on people’s legs, crawls laboriously up to their warm, moist, intertriginous private parts, and bites. The insect dies due to scratching, but the secretions it deposits results in itching the equivalent on an itch scale to the habanero pepper on the Scoville heat scale. Unfortunately, the itch continues until a week has passed, you have removed the offending skin, or you have passed to the next world. Forget about sleeping during this period unless medicated with heavy doses of corticosteroids. less sadistic societies might consider this as a form of torture that if used would lead one to spill the proverbial beans for every question asked. Adventurous Texans who want to foolheartedly be outdoors during these months seek a river, lake, reservoir, or man-made water hole for relief. Advice to the wise and solarphobe is that between the hours of 9 a.m. and 7 p.m. stay indoors, and work on crafts such as soap or candle making, reading, writing, board games, sewing, painting pictures, repairs and maintenance, cooking without heat, irritating your pertinent other or sib, and any other activity best done in slow motion. Would you let me know what your favorite is?

If the pet wants to go outdoors, open the door occasionally but this is not a time for the leisurely walk. If the pet insists, limit your walking to before 7 a.m. and after 7 p.m., and go no further than necessary for their bladder and alimentary relief. Months of days with daytime temperatures over 100 degrees Fahrenheit are common, and months of days without rain are also the rule. despite

the lack of rain, you will find that the habit of sprinkling precious water over the ground is so pervasive in suburban yards, that humidity levels will remain intolerable, and you will suffer from drenching sweats, yeast infections, and insect bites from every unscheduled moment outside. I strongly advise staying inside and putting a large faced thermometer and hygrometer outside an often-viewed window to realize the miraculous importance of air conditioning, prepare a disaster plan in the event of air conditioning failure, and check for meteorological records which in this day of rapid climate change are plentiful and commonplace rather than extraordinary as in the past. If the elderly or infirm live nearby and an awful stench is noted, it is wise to call the authorities for them to investigate the source and bring in the proper assistance. Just when you think you live in a desert, the skies open and provide tons of rainwater to overwhelm streets, houses, ball fields, streams, bridges, and reservoirs. These downpours may last minutes or days and occur without pattern. Of course, this bounty comes from and is lost to the Gulf of Mexico when rivers overflow their banks and water seeks its level.

If for some reason you are caught outside during hours of solar index greater than 1, be careful while driving. These temperatures cause many drivers to exercise their hand gestures, vocal cords, car horns, weaponry, and automobile maneuverability resulting in confrontations, dangerous driving situations, and inappropriate rage. Every inch of road becomes contested as if privately owned, and anger becomes murderous with minimal provocation. What would easily be forgiven in Fallwinterspring, becomes a matter of intense outrage, and a personal afront leading to respect and honor vendettas.

Hot heads lead to bad decisions and illogical thought, and temperatures inside vehicles without AC often rise to intolerable levels such that children should never be left unattended particularly if they are driving. driving should be avoided during the heat of the day along with talking, meeting, arguing, any confrontation or possible confrontation, appointments of any kind, and decisions of any import. I often break this rule during Mid-Summer but what do you expect when you are not thinking rationally? In fact, if hibernation is at all possible during this period, nestle down in a nice cool cavern.

One of the few blessings of this season is fruit such as peaches, watermelons, papayas, mangos, and pineapples. These wonders start to appear in Early Summer and may persist until late Summer. Make sure you take advantage of this bounty continued on page 28

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FEATURE continued from page 27

and sample local offerings at farmer’s markets, roadside stands, or grocery stores. The handy chef will preserve these marvels as jams, fruit soups, sherbets, or for use in ice creams. Even more adventurous people may choose cactus fruits, agarita berries, napolitos, or other exotic finds to make jam or pickles. Sun tea is favored at this time of year although devotees of sweetened and unsweetened varieties claim their favorites, and edentulous smilers give evidence to their preference. To avoid squabbles most restaurants and chefs keep both possibilities open for most of the three summer seasons, and for all four seasons for natives. Served quantities often exceed 36 ounces and 48 ounces is favored by those who drive trucks and spend much of their waking hours outdoors.

Late-Summer

The transition between Mid-Summer and late-Summer may be gear like in progression and delayed into October some years. Rarely is it a smooth reduction of temperature and humidity. late-Summer brings a gradual lowering of temperatures into the 90’s and even lower eventually, a return to the hobby garden for fall adventures, a chance to hang wash outdoors without getting third degree burns, chances of rain at times, and all the holidays such as black Friday, etc. that we all seem to look forward to even without the cold white stuff from the sky. What does this season recall to you? This is truly a time of Thanksgiving akin to the deliverance of the Israelites from Egyptian bondage. brains begin to function again after MidSummer addling. One even starts to think of venturing outdoors during the daylight hours although the critters are still active until late in this season and the Uv index remains high.

If you want a fall garden, you may be too late. brave souls venture out in late Mid-Summer with crops such as second plantings of tomatoes, peppers, and eggplants but these tempters often will not have enough daylight hours later in the season to mature and produce in the backyard. They will need a lot of attention and water to survive the planting and may not make it to the finish line with produce even if they survive the first month of torturous heat. The price of any produce gained will be many times the cost of supermarket or farmer’s market comparables. leafy crops may produce if started in late-Summer, but they also may burn up early. Whatever you choose, you will develop great empathy with and respect for Texas farmers, and realize a few of the risks they take. This process should help you revere farm to table restaurants and appreciate that farmer’s markets though pricey may cost less than backyard production. late in late-summer, say late October you may be able to once again venture off road for a hike in the woods. laundry may be hung on the line during late and Early Summer but avoid mid-day Uv rays. The pet may get longer walks, and you may even enjoy 30

San Antonio Medicine • April 2019

these later in the season. The chigger may be lurking so remember to use dEET, high boots, gloves, hats, and long pants and longsleeved shirts. The little devils, once gone, will not be back until the end of Fallwinterspring in mid-March or later. Towards the end of late-Summer, you may regain a sense of adventure, a welling up of energy, and the maintenance desire resurfaces so that the chain saw, tractor, four-wheel drive, and mower get attention for the approach of Fallwinterspring. One day you will walk into the morning, the temperature at 6 am has dipped below 70 degrees F for the first time in three or four months, and your legs feel rejuvenated. More often these feelings will be rewarded with a resurgence of humidity and heat to keep smugness at bay. Eventually it will be as if you had to carry a hundred-pound sack over your shoulders any time you left an air-conditioned home, and suddenly the sack emptied or otherwise mysteriously disappeared. Your body regains elasticity, energy, adventure, and faintly remembered strength. The seasons clearly change from Mid to late-Summer sometime before Fallwinterspring.

FEATURE If you have children or grandchildren, you might be able to rejoin them outdoors. The little darling demons seem almost immune to seasonal variation, and like “mad dogs and Englishmen” or “blue lipped children at the beach” have been outside for months in pools, on ball fields, and getting ready for school.

Make sure you dust off your folding chairs, seat cushions, and manners as ball games, umpires’ decisions, coaches’ behavior, and the lurking solar exposure may overcome you as you deviate from polite, persistent, and patient behaviors to absolute moments of craziness very hard to explain in retrospect. You will want binoculars, bug spray, sun protection, a camera to capture fast moving objects or children, and comfortable field seating on these sojourns.

School will have restarted between Mid and late Summer. This is important to consider if you plan to walk alone or with dog, bicycle as a verb, or in any other way foolishly enter a roadway. Newly minted 16-year-old drivers may be hunching over steering wheels of over powered pickup trucks or SUvs and trying to impress their friends with their raceway skills while ignoring pedestrians. For this reason, never go outside without a light for darkened times, a reflective vest, a bag of dog poop to throw if necessary, and the righteous indignation of the elderly or infirm even for those much younger. brevity keeps me from further expounding on the innumerable bounty of this season after the scorching preceding season.

The fresh apple is a resurgent as is the pumpkin. both presage pies to come. dreams of cinnamon, nutmeg, and allspice create a nocturnal scent environment. What are your favorite memories of this season?

Fallwinterspring

Once again expect a gear like transition often characterized by a house air conditioned one day and heated the next. Heating, ventilation, and air-conditioning companies remain the primo businesses in this area with a welcome break and vacation saved for this period.

For the go getters who are intent on making their fortune, business is nonstop as heaters may need attention, and old air conditioning units may need to be replaced. This is the time of year when relatives and friends from other regions descend, roadside trailer parks flourish, beach communities come alive, and the chamber of commerce exudes confidence about the wineries, breweries, music festivals, fiestas, and San Antonio river activities. Hurricanes take a break and rest up for the next names storms to come. Flu shots are essential as no one wants to miss a day of this cooling off due to unnecessary illness. The pet walker revels in this season as walks lengthen, the air is usually felt deep and appreciatively in the lungs, and solar avoidance is less a concern. Most years follow a very pleasant and rewarding script, although occasionally we feel more Scottish, don woolen or other warm clothing, and may even wear long pants. Fireplaces, gas logs, and stoves light up, and friends gather round to watch the snow fall when northern games are viewed on audio video devices of choice.

Weather reports from northern cities produce crowd noises of approbation and feelings of schadenfreude. After Mid-Summer no continued on page 30

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FEATURE continued from page 29

season in Texas is truly predictable and beginning and ending season dates are fluid.

Migrating birds as well as “snow birds” are seen during this season. Our feathered friends take a break from the colder northern climes and have an extended beach party near the Gulf of Mexico, and further south. College students on vacation swell the population of some beach communities, and enjoy intemperance of food, alcohol, drugs, and sex probably because of watching sea turtles laying eggs and watching other animal signs of fecundity. One’s own children and grandchildren who live idyllic lives are excluded from the previous generalization.

This is the season to walk the woods with near abandon as the critters and most importantly the chiggers are on break. long boots, long pants, long sleeved shirts, and broad brimmed hats provide cover, the lower temperatures reduce sweating, and the lower solar index reduces skin damage. Now is the time to clean up the garden, mow the native grasses, and feel connected to those native peoples who came before us and preserved the land we roam. When the days are particularly cool, one only must remember days of MidSummer to warm up the soul. Native Texans, or those who have lived here more than twenty years, native Americans indigenous to this region, Mexicans, Spaniards, French Colonists, or other claimants to this soil often have trouble during this season making appropriate clothing choices. Those who dress warmly, or layer clothing are unable to teach natives the benefits of these behaviors resulting in devastating pneumonia and flu seasons among the shorts and tank top wearing populaces.

From the latter part of late Summer to the end of Fallwinter32

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spring the fruit offerings change to citrus, and the markets will sell ten-pound bags of grapefruits, oranges of all types for juice and eating, lemons, and limes.

These delights will also appear in back yards, trucks of road side vendors, and markets.

These tastes are supplemented by a sound image filled with shot gun blasts, rifle reports, and burning brush crackling in the country side.

More could be written, sounds and sights have been overlooked, scents will vary with environment, and explorations should be planned. I hope this simple guide adds to your enjoyment of this wonderful region and tempers your expectations if you have come from elsewhere where seasons are four and distinct. What would you like to add to this incomplete imperfect recollection? As the grands or little people might say this is only JJ’s opinion and he is older than dirt so discount the views expressed.

Dr. John Seidenfeld is a member of the BCMS Publications Committee.

UTHSCSA

Following a Different Model of

CARE

Accountable Care Organizations focus on improving patient health, experience while reducing costs

By Ramon Cancino, MD, MSc, Director of Primary Care, UT Health Physicians virgen Rodriguez-Perez, M.d., a UT Health Physicians family medicine physician, remembers a different time.

“In my other practice, we were seeing as many patients as possible because that was the way we made money,” she said.

Primary care physicians across Texas are used to practicing under this model. Traditional fee-for-service care incentivizes high patient visit volumes rather than high quality care. This type of medical practice is often not patient-centered and can lead to unnecessary and often redundant utilization of health care resources, disjointed care and poor patient outcomes. dr. Rodriguez-Perez now follows a different model, and her patients are benefiting, she said.

“Now, before many of my patients arrive, my medical assistant and I know what cancer screenings are due, whether or not they have recently been to an emergency room or hospital, and when their last diabetic foot exam was,” dr. Rodriguez-Perez said. “I can focus on prevention and, if my patient gets sick, our team can get that patient into the office the same day to avoid having to send that patient to the emergency room.”

The model she describes, value-based care, is one that focuses on achieving what is known as the Triple Aim, improving a population’s health and patient experience while controlling avoidable costs.

Quality is often measured using Healthcare Effectiveness and Information Set metrics and the patient experience. Costs are measured by factors such as avoidance of emergency room visits for ambulatory care, sensitive conditions and hospital readmissions. Incentives are based on their performance on these measures for specific patient populations. In the U.S., many more practices are now practicing both fee-for-service care and value-based care models.

The latter is the cornerstone principle around which Accountable Care Organizations are structured.

The value of ACOs

because the goals of value-based care are different from those of fee-for-service care, the structure through which care is delivered

must be different as well. Traditional fee-for-service care practices are designed to see a high volume of patients, while high-performing ACOs often collaborate with hospitals, have physician leaders focused on improving performance, utilize sophisticated information systems, provide effective feedback to physicians, and have embedded care coordinators.

The U.S. health care market was not always focused on value, but the U.S. has a history of attempting to restructure U.S. health care to decrease costs. Previous attempts to restructure care delivery have included the Health Maintenance Organizations of the 1980s and 1990s and the Medicare Physician Group Practice demonstration pilot program in the mid-2000s. Costs continued to rise. In 2011, the U.S. department of Health and Human Services, via Medicare program section 3022 of the Patient Protection and Affordable Care Act of 2010, created ACOs in an effort to contain rising U.S. health care costs by helping physicians, hospitals and other health care providers better coordinate care for patients.

The term ACO has had many definitions. The term “accountable care organization” was originally used by dr. Elliott Fisher in 2006 during a public meeting with the Medicare Payment Advisory Committee. The Centers for Medicare and Medicaid Services define an ACO as “groups of doctors, hospitals and other health care providers who come together voluntarily to give coordinated highquality care to their Medicare patients.” In general, the ACO framework focuses on ensuring that all patients, especially the chronically ill, receive the right care at the right time.

Since 2011, value-based purchasing contracts and ACOs have multiplied. As of 2015, there are about 744 ACOs in the public and commercial sectors. In the public sector, the Medicare Shared Savings Plan has nearly 480 participating organizations as of January 2017. This program rewards providers who deliver high-quality and low-cost care to Medicare patients. Similar contracts are being done in the commercial sector, such as blue Cross blue Shield’s Alternative Quality Contract in Massachusetts. In both examples, providers enter into an agreement with an insurer to take on financial risk ascontinued on page 32

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UTHSCSA continued from page 31

Ramon Cancino, M.D., M.Sc., is director of primary care for UT Health Physicians and medical director at UT Health Hill Country. He specializes in family medicine.

sociated with the care and outcomes of specific patient populations.

Although the structures can differ, the goals are the same: increase quality of care and aim to reduce unnecessary health care costs.

Important to ACOs are a focus on developing a shared mental model of care collaboration, data transparency and continuous improvement. Teamwork and collaboration are demonstrated through care management and integrated care across different care locations.

Organizations collect and share data on process and outcomes metrics via integrated health information technology, often a shared electronic health record. Teams use this data for continuous improvement using structured and standardized methods for improvement and continual self-auditing for improvement in goals.

Most importantly, the success of an ACO hinges on practice engagement at all levels, especially in primary care. The reimbursements an ACO receives are highly contingent on quality and cost outcomes, which can be leveraged by a patient population that is adherent, loyal and engaged in their own care. As a result, the longitudinal relationships patients develop with primary care clinicians are often the reason patients adhere to medical advice (such as receiving a colonoscopy, seeing a clinical psychologist, joining a 34

San Antonio Medicine • April 2019

weight-loss program or consulting with a surgical specialist) as well as the reason they follow up. Success in the Medicare Shared Savings Plan is contingent upon not only demonstrating value, but also on demonstrating patient attribution through consistency of visits and utilization of resources within a single Medicare Tax Identification Number. Furthermore, it is often the frontline staff—schedulers, front desk workers, benefits coordinators, nurses and medical assistants—who are interacting with patients and providing the initial patient experience. Therefore, on-site physician and staff engagement in making key clinical operations decisions as they relate to ACO metrics is critical.

At the forefront

UT Health San Antonio aims to be the leading ACO in Central and South Texas. The organization is forming an ACO, the UT Health San Antonio Regional Physicians Network, in July 2019. In doing so, it has worked to engage all its physicians and staff in a two-year process driven by physician leadership focused on the Triple Aim. “As a physician-led organization, we wanted to be sure all our

UTHSCSA

leaders and stakeholders were involved in this process,” said Carlos Rosende, M.d., executive director of UT Health Physicians.

“We continually engage all our medical directors and clinical leaders in our decision-making,” said bob leverence, M.d., chief medical officer for UT Health Physicians.

The focus on clinician and stakeholder engagement resulted in an enhanced, integrated patient care experience that builds on the practice plan’s experience as a patient-centered medical home. Patients have their own personal primary care physician and can interact with their medical home virtually through an online portal, which allows patients the ability to see test results, medications and their visit histories.

Another layer of personal care exists for ACO patients.

“Our primary care and specialist teams and leaders helped develop workflows, which we use in daily interactions with patients either in person or virtually,” said Kenyatta lee, M.d., chief quality officer for UT Health Physicians. local and central teams work together to review every patient with a daily emphasis on identifying gaps in quality metrics. In addition, each afternoon, representatives from all primary care prac-

tices discuss care gaps. To ensure gaps are addressed either in person or virtually by members of the team, personalized care plans are developed for each patient. Every morning, a practice access teleconference ensures patients with acute needs are seen in a timely fashion. All this activity is supported by a health information technology infrastructure that collects and reports data on care gaps in real-time.

“We worked closely with our clinical leaders to develop our electronic health record workflows and dashboards that allow us to deliver value-based care to our patients seamlessly,” said Timothy barker, M.d., chief medical information officer at UT Health Physicians.

The integrated local and central workflows allow clinicians time to deliver patient care.

“We feel we have a lot of support around us, which allows us to focus on caring for the patient in front of us,” said david Cadena, M.d., a UT Health Physicians family medicine clinician.

The model of care the ACO will deliver has attracted interest from non-UT Health San Antonio physicians as well. The UT Health Physicians group is developing relationships with community physicians; many are attracted to the Regional Physicians Network model of care and will join it as ACO participants. ACO participants will have the opportunity to utilize the same patient care resources, have direct access to UT Health Physicians specialists, as well as have access to ACO educational events. The participants will also have the opportunity to receive a portion of any of the shared savings that the Regional Physicians Network would gain.

What lies ahead

Ultimately, the goal of all this work is to make sure patients receive the best evidence-based care at the right time. The value-based care model (and the ACOs that will deliver this care to patients) is a step toward this goal. value-based care aligns actions that make sense to physicians and patients—such as improving blood pressure and decreasing hospital readmissions—with incentives. While the U.S. has a long history of restructuring itself and its health care to meet the Triple Aim, recent evidence that suggests billions of dollars were saved by the Medicare Shared Savings Plan ACOs may mean that we are closer than we have ever been to the goal.

Ramon Cancino, M.D., M.Sc. is director of primary care for UT Health Physicians, the medical practice of the Long School of Medicine at UT Health San Antonio, and medical director at UT Health Hill Country. As an assistant professor and primary care physician, he also is part of the UT Health Regional Physicians Network. He can be reached at cancinor@uthsca.edu. visit us at www.bcms.org

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

ACCOUNTING FIRMS Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets.

Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ASSET MANAGEMENT

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection.

John M. Albert |The Farret Team | Financial Advisor 210.278.3816 john.albert@ml.com www.fa.ml.com/farretgroup “Life’s better when we’re connected®”

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San Antonio Medicine • April 2019

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.

Kathleen Barrow Partner 512-382-8796 kbarrow@constangy.com William E. Hammel Partner 214-646-8625 whammel@constangy.com John E. Duke Senior Counsel 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.

Mario Barrera Employment & Labor 210 270 7125

mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

Thornton, Biechlin, Reynolds, & Guerra (HHH Gold Sponsor) Worried about the TMB, government audit, or investigation? From how to avoid TMB complaints to navigating the complex regulations of government agencies like Medicare and Medicaid, we stand ready to guide and protect our clients.

Robert R. Biechlin, Jr., Partner (210) 581-0275 rbiechlin@thorntonfirm.com Michael H. Wallis Partner (210) 581-0294 mwallis@thorntonfirm.com Kevin Moczygemba, Associate 210-377-4580 kmoczygemba@thorntonfirm.com https://thorntonfirm.com “Protecting Physicians and Their Practices”

ASSETS ADVISORS/ PRIVATE BANKING

BB&T (HHH Gold Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services — BB&T offers solutions to help you reach your financial goals and plan for a sound financial future.

Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com

www.bbt.com/wealth/start.page "All we see is you"

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

BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle.

Moses D. Luevano Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”

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.

Joseph Bieniek Vice President Small Business Specialist 210-247-2985

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY jbieniek@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com Daniel Ganoe Mortgage Loan Originator 210-283-5349 www.broadwaybank.com “We’re here for good.”

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

while utilizing state of the art equipment, the most qualified radiologists and superior customer service.

Patrick Kocurek Area Marketing Manager 210-614-0600 x5047 patrick.kocurek@touchstoneimaging.com www.touchstoneimaging.com/ locations "We provide peace of mind, giving compassionate care to our community with integrity"

FINANCIAL ADVISOR 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) 750-8331 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

First National 1870, a division of Sunflower Bank, N.A. (HH Silver Sponsor) First National 1870 is a regional community bank dedicated to building long-term relationships founded on sound principles and trust.

Jamie Gutierrez Business Banking Officer 210-961-7107 (Direct) Jamie.Gutierrez@firstnational1870 .com www.FirstNational1870.com “Creating Possibility For Your Medical Practice”

BUSINESS CONSULTING Waechter Consulting Group (HH Silver Sponsor) Want to grow your practice? Let our experienced team customize a growth strategy just for you.

Utilizing marketing and business development tactics, we create a plan tailored to your needs!

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

DIAGNOSTIC IMAGING Touchstone Medical Imaging (HH Silver Sponsor) Touchstone Medical Imaging provides a wide range of imaging services in a comfortable, service oriented outpatient environment

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

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection.

John M. Albert |The Farret Team | Financial Advisor 210.278.3816 john.albert@ml.com www.fa.ml.com/farretgroup “Life’s better when we’re connected®”

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee

benefits and P&C Insurance.

Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Jon M. Tober SWBC Mortgage – Sr. Loan Officer NMLS#212945 210-317-7431 Jon.tober@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

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!”

BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle.

Moses D. Luevano Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”

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

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visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

makes sense for you.

Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

New York Life Insurance Company (HHH Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace.

Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

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 Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small businesses and partnered with multiple financial institutions, to assist with financing of building acquisitions, construction projects, and machinery and equipment loans.

Cheryl Pyle Business Development Officer – San Antonio & South Texas 830-708-2445 CherylPyle@CapitalCDC.com

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www.capitalcdc.com “Long-term, fixed-rate financing for owner-occupied commercial real estate.”

HEALTHCARE BANKING

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

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

HEALTHCARE CONSULTING

Digital Telehealth Solutions (HHH Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program.

Dr. Jorge Arango CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

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

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visi-

bility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting” Y&L Consulting (HH Silver Sponsor) We are an IT Consulting company that specializes in Software Managed Delivery, Business Process Outsourcing Managed Services, IT Staff Augmentation, Digital and Social Media with experience in the Medical industry.

David Stich Senior VP of Strategic Partnerships 210-569-3328, David.stich@ylconsulting.com Marisu Frausto Account Executive 210-363-4139, Marisu.frausto@ylconsulting.com www.ylconsulting.com/ “Your success is our success.”

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org 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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INSURANCE/MEDICAL MALPRACTICE

INTERNET TELECOMMUNICATIONS

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

Digital Telehealth Solutions ( Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program.

Dr. Jorge Arango, CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) 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 today’s medical environment with greater ease—that’s only fair.

Keith Askew, Market Manager kaskew@proassurance.com

LUXURY REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage.

We have served the buyers and sellers of premier Texas properties

for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country.

Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

MARKETING ADVERTISING SEO

Veerspace (HHH Gold Sponsor) We're a nationwide digital advertising agency that specialize in growing aesthetics practices through videography and social media. Office contact number is 210-969-7850.

Michael Hernandez President/ Founder 210-842-3146 Michael@veerspace.com Anna Hernandez Marketing Specialist 210-852-7619 Anna@veerspace.com

MEDICAL BILLING AND COLLECTIONS SERVICES 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 to 50 percent.”

PHYSICIAN SERVICES

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance.

Gil Castillo, SWBC Wealth Management, 210-321-7258 gcastillo@swbc.com Kristine Edge, SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Debbie Marino, SWBC Insurance & Benefits, 210-525-1241 dmarino@swbc.com Jon M. Tober SWBC Mortgage – Sr. Loan Officer NMLS#212945 210-317-7431 Jon.tober@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio.

Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to

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medical practice managers and support charitable fundraising.

Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

KW Commercial (HHH Gold Sponsor) We specialize in advising Medical Professionals on the viability of buying & selling real estate, medical practices or land for development Marcelino Garcia CRE Broker Assciate 210-381-3722 Marcelino.kwcommercial@gmail.com Leslie Y. Ayala Business Analyst/ CRE Associate 210-493-3030 x1084 Leslie.kwcommercial@gmail.com www.GAI-Advisors.com “Invaluable Commercial Real Estate Advice for The Healthcare Professional”

RESIDENTIAL REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage.

We have served the buyers and sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate

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firm in San Antonio and the Hill Country.

Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

RETIREMENT PLANNING

New York Life Insurance Company ( Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace.

Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares, Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

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.”

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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

THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA

ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Eye Center, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA The San Antonio Orthopaedic Group Urology San Antonio, PA

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of March 22, 2019.

visit us at www.bcms.org

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BOOK REVIEW

Perception-Altering Plants: Valid Medicine?

Book Review: “How To Change Your Mind” by Michael Pollan

By David A. Schulz Michael Pollan is obsessed with food.

Not the cooking and eating, although his books contain mouthwatering descriptions, but the social and anthropological plenum that provides humans sustenance, pleasure, confusion, and ill-health. beginning with The botany of desire, Pollan examines how humans and plants adapt and fulfill each other’s appetites to suit their own survival, from control (potatoes), beauty (tulips), to sweetness (apples), and intoxication (cannabis). The question remains, who is really domesticating whom?

The Omnivore's dilemma, Pollan’s most frequently cited work, examines today’s agricorp production, proving that Americans have become “People of the Corn,” more than any civilization, with Zea mays’ structure forming the foundation for more supermarket products than we imagine. He traces the origin of each part of a Chicken McNugget, from the chick’s feed to the binder to the coating to the frying oil, to a particular industrially engineered corn plant.

Cooked, his penultimate work and a Netflix series, tracks the author mastering a single classic recipe using one of the four elements: Fire, Air, Water, and Time (fermentation). The lessons move beyond the practical (although four recipes are offered and taught) to examine how cooking involves us in a web of social and ecological relationships.

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San Antonio Medicine • April 2019

Now, Pollan turns his attention to recent research into the long-banned and Westernshunned practices of imbibing fungi as a means of enlightenment, with some fascinating application to the maladies of PTSd, addiction, even for use in palliative care.

“How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, dying, Addiction, depression, and Transcendence documents the ongoing work by scientists on therapeutic application of two substances: psilocybin, and lysergic acid. Memory is short, but history records that in the 1950s and early ‘60s, many in the psychiatric establishment regarded both as miracle drugs. Only after these compounds were linked to the counter-culture as a rite of passage, and their uncontrolled use spread, did the scientific establishment lose interest in the possible benefits of drug-induced altered states of consciousness.

2006 saw a cracking of the ice and the beginning of a renaissance of interest. Albert Hoffman, discoverer of the ergot lysergic Acid, celebrated his centennial with a massive three-day symposium attended by two thousand people and two hundred journalists in basel. Unrelated, a month later here in the US, the new chief justice, John Roberts, ruled that a small religious sect’s import and use of a hallucinogenic tea containing dMT was covered under religious freedom. “The Supreme Court seems to have opened up a religious path — narrow, perhaps, but based on the bill of Rights — to the federal recognition of psychedelic drugs, at least when they’re being used as a sacrament by a group deemed a religion by the government,” says Pollan. The turning point came that summer with publication by the Journal of Psychopharmacology (Oxford, England), of a Johns Hopkins study, “Psilocybin can occasion mystical-type experiences having substantial and sustained

personal meaning and spiritual significance”

by R. R. Griffiths & W. A. Richards & U. McCann & R. Jesse. The research continued, with the publication in 2016 by Griffiths, et al, “Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial” also in Psychopharmacology.

Pollan describes the history of psychotropic drug use, pointing out that the only society in which they aren’t utilized, now or historically, are the ones in geographic regions they simply don’t grow, the Inuit, for example. He goes on to cover the research currently being accomplished in various therapies, particularly in palliative care. but it wouldn’t be a Pollan book or a classic in the school of New Journalism, without personal testimony. He takes the reader on a travelogue of three trips: lSd, Psilocybin, and dMT. As the author describes: “A molecule had launched me on each of these trips, and I returned from my travels intensely curious to learn what the chemistry could tell me about consciousness and what that might reveal about the brain’s relationship to the mind. How do you get from the ingestion of a compound created by a fungus or a toad (or a human chemist) to a novel state of consciousness with the power to change one’s perspective on things, not just during the journey, but long after the molecule has left the body?”

With the FdA approving phase 3 trials of MdMA, and psilocybin not far behind – just this August, it approved psilocybin trial for treatment-resistant depression – these questions may open an entirely new chapter in understanding consciousness, mysticism, and modern medicine.

(All quotes from Pollan, Michael. How to Change Your Mind (p. 291). Penguin Publishing Group. Kindle Edition.)

David A. Schulz is a member of the BCMS Publications Committee.

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

AUTO REVIEW

2019 BULLITT MUSTANG

By Stephen Schutz, MD

before taking a trip to San Francisco recently, I called the company that provides press cars and asked what they had available.

As usual, there was a nice assortment of cars to choose from, but when the voice on the phone said, “We also have a bullitt Mustang”, I blurted out, “I’ll take it”.

And why wouldn’t I? The car chase scene through San Francisco in the 1968 Steve McQueen movie “bullitt” was absolutely epic – check it out on YouTube if you haven’t seen it already – so the chance to drive a new bullitt Mustang on some of those same streets was something I couldn’t say no to.

In that classic car chase, Steve McQueen’s Frank bullitt pursues two hit men in a black dodge Charger R/T with his Highland Green v8 Ford Mustang. It’s an intense scene, highlighted by numerous jumps and slides, and by the time the chase ends – badly for the hit men, as you might expect – the Mustang has become iconic.

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San Antonio Medicine • April 2019

Not surprisingly, Ford decided to capitalize on the enduring iconicity of Frank bullitt’s ‘Stang, and 51 years later there’s a bullitt Mustang that we can buy from any dealer.

For the record, the current 2019 version is not the first bullitt Mustang and almost certainly won’t be the last. The first one launched in 2001 and featured a choice of either Highland Green paint or Shadow black, similar wheels to the original, and discreet bullitt badges on the trunk lid, but very little ornamentation anywhere else. The second version (of the next gen Mustang) came out in 2008 and featured similar enhancements.

There’s now another generation of Mustang – launched in 2015 – and a bullitt version will be offered for the 2019 and 2020 model years. The bullitt Mustang is indeed a special car. Available, once again, in either Highland Green or Shadow black, the newest bullitt looks menacing and certainly gets noticed. There’s no badging on the grille or sides of the car, which, combined with the black five-

AUTO REVIEW

spoke wheels, makes the car look badass. I would get this car in green, but getting it in black like my test car wouldn’t be a mistake.

Inside the bullitt, things look very Mustang GT, except for the steering wheel, which has the word, “bullitt”, spelled out in big block letters on the hub, and the shift knob, which is a white cue ball. Otherwise the interior is standard Mustang fare, which is to say good. While the plastics and other materials you see and touch are uninspiring, the central screen that controls most features is easy to see and navigate, and there are plenty of buttons and knobs to push and twist if you’d prefer (e.g. volume and tuning are easily controlled by twisting a knob, the way they should be).

I’m meh on the bright red “Start” button, but overall the bullitt’s interior looks and feels like a sporty car’s cabin should, with enough special bits to help justify the higher price.

For those buyers who prefer to forgo the beefy six-speed manual transmission and cue ball shift knob, Ford offers, ummm... other cars. Hallelujah, all 2019-2020 Ford Mustang bullitts will be manual only!

To make things more special, Ford added 20HP to the normally aspirated Mustang GT V8 (460 to 480HP), and, it seems, more sound too. As I’ve written previously, the standard 5.0 liter V8 Mustang sounds great when you rev it, but the Bullitt sounds even better.

Not surprisingly, this Mustang is a delight to drive. Running errands in town is all about practicing your 1-2 shifts and listening

to the engine, but twisty b-roads and open highways with long sweeping turns are a true pleasure. No matter what you drive or where you drive it, driving a bullitt Mustang will almost certainly provide a more intense and visceral experience than what you are used to. That’s true for me, and my everyday driver is a manual 2018 bMW M3.

Cold shower time: the base price of a bullitt Mustang is $47,590 and fuel economy is a sobering 15 MPG City, 24 Highway. On the plus side, 0 - 60 MPH sprints take just 4.2 seconds.

Unlike German sports cars, the bullitt Mustang offers just three options, magnetorheological shocks ($1,695), leather Recaro seats ($1,595), and an Electronics package ($2,100) featuring a b&O stereo, blind spot protection, and navigation.

We are nearing the 51st anniversary of the Steve McQueen movie “bullitt”, and, while that seems like an awful long time ago, I’m OK celebrating it as long as the celebration includes a drive in the 2019 bullitt Mustang. This is a special car, and I would urge anyone who buys one to keep it. like the Hemi ‘Cuda, this car will inevitably die, and owners who sell it will probably wish they hadn't.

As always, call Phil Hornbeak at 210-301-4367 for more information and to get your best bCMS deal.

Stephen 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 • April 2019