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HEALTHY EATING Healthy Eating and the Gift of Imperfection By Robin Eickhoff, MD, MPH.........................................14 Precision Nutrition: The Merger of Nutrition and Medicine By Tim Hlavinka, MD............................16 The Diet Puzzle By Janice Tapp, MSN, RN ...................18 Gardening & Farming: Examining the San Antonio Food Bank’s Farming Effort By Michael Guerra, San Antonio Food Bank..................20

Early Establishment of Health Eating Habits in Childhood By Jocelyn Wey, Cynthia Bogran, Yi Fang, Darwin Nguyen and Adeel Sajid................................................30 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................12 The History of Food Safety in America By David Alex Schulz, CHP.........................................................................32 Health Insurance Company Chicanery By Neal S. Meritz, MD................................................................................34 Why You Should Trust the COVID-19 Vaccine From Texas Medical Association......................................................36 Life Burns: A Poem By Emily Sherry ......................................................................................................................37 Respite Care for San Antonio’s Homeless By Tori Brucker, Ryan Daly, Thomas Damrow, Thelmari Raubenheimer....38 BCMS Alliance Teams with BCMS to Hold Doctors’ Day Blood Drive ....................................................................39 Circle of Friends Directory ......................................................................................................................................40 Auto Review: 2021 BMW 530e By Stephen Schutz, MD ........................................................................................44

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SAN ANTONIO MEDICINE • May 2021

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS. EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

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

DIRECTORS

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

BCMS SENIOR STAFF

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

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

SAN ANTONIO MEDICINE • May 2021

PRESIDENT’S MESSAGE

Coaching in Medicine: The Physician Coach and The Executive Coach By Rodolfo “Rudy” Molina, MD, MACR, FACP, 2021 BCMS President and Nora Vasquez, MD

Some of you are already familiar with the role of a coach and most of you have heard about coaching, in general. Yet when I have asked my colleagues to define what a coach is to them, I am confronted with a puzzled look as though the answer lies in plain sight but not tangible at the moment. As I began to look into what the role of a coach is, I became further confused after I saw a TED video by Atul Gawande entitled, “Want to get better at something? Get a coach.” After watching it, I found what he called a coach, I called a mentor. And yet in Gregg Thompson’s book, The Master Coach, he clearly states that the role of a coach is not a mentor but something different. As it turns out, there are different types of coaches. We will discuss the roles of at least two different types. The first is the Physician Coach and then next month’s article will explore the role of an Executive Coach. Both, I believe, are very important to us as physicians who are often asked to wear different “hats.” The format is Q & A, and we start with Dr. Nora Vasquez, a Physician Coach. I remember reading a JAMA article1 describing the Physician Coach as a new normal. With that in mind, here is what I found out. Part 1. The Physician Coach 1. How were you introduced to physician coaching? What is a physician coach? I was first introduced to physician coaching while attending a medical conference that discussed the benefits of coaching. The panel of speakers discussed how coaching can help physicians create a better work-life balance and also help them reach their professional goals. As an Internist, I had enjoyed leading and serving in multiple university and community health clinics for over a decade. At that time, I had started feeling the symptoms of burnout and I also wanted to pursue new leadership opportunities. However, I was feeling uncertain as to what the next step should be in my career. It was then that I decided to hire my first physician coach which was one of the best decisions of my life. Physician coaching helped me clarify my values and priorities. It helped me fine-tune my vision for how I wanted to fuse leadership and

SAN ANTONIO MEDICINE • May 2021

advocacy in medicine. In fact, physician coaching made such a profound impact on me that I decided to certify as a professional coach. I now coach and guide my fellow physician colleagues on their own journey of wellness and career fulfillment. My mission is to “Empower and Heal the Healers.” I coach medical students, residents and attending physicians at premier universities, organizations and hospitals in the United States and Canada. I also enjoy coaching individual doctors and other health care professionals, including physician assistants and nurses. As a professional coach, I help empower physicians to realize their full potential. I use high-performance coaching to teach my clients how to elevate their personal and professional growth so they can reach their goals quickly. I coach on a variety of topics, such as overcoming burnout, imposter syndrome, perfectionism, enriching relationships, time management and leadership development. When I coach, I also utilize the Maslach Burnout Inventory tool. This tool is a survey that measures and compares burnout among health professionals nationwide. The analysis from this data reveals that coaching mitigates burnout by decreasing emotional exhaustion and improves the sense of personal accomplishment and self-efficacy. Many of the testimonials from my participants state that they have learned to “love and value their work.” They have also stated that coaching helped them create a “better work-life balance.” Most importantly, they gain further insight and strategies to overcome the barriers that prevent wellness, growth and fulfillment in their lives. 2. How does a coach improve physician wellness? Wellness has been defined as “the complex and multi-faceted nature of physicians’ physical, mental and emotional health and well-being.” While physician wellness has often evoked images of yoga and mindfulness, we now recognize that adding a professional physician coach is a game changer. In a recent randomized clinical study published in the Journal of the American Medical Association,1 professional coaching was determined to be an effective intervention that reduces emotional

PRESIDENT’S MESSAGE

exhaustion and overall burnout. It was also determined to improve quality of life and resilience for physicians. While coaching is not therapy or counseling, it is an effective strategy that promotes wellness and is supported by an increasing body of evidence. A physician coach is uniquely capable of fostering an atmosphere of trust and understanding due to their shared experience of medical training. Now, more than ever, physicians need the support and guidance of an ally who has their best interests in mind. 3. What are the benefits of having a physician coach? The benefits of having a physician coach are tremendous. A coach can help you identify limiting beliefs, or those false beliefs that hold you back from taking action toward your goal. A coach can also expand your vision and provide accountability to help you reach your goals quicker. Over many decades, C- suite executives, athletes and professional sports teams have invested in the power of effective coaching to enhance performance, and to set and accomplish goals. Now, physicians have the same opportunity to invest in themselves and reach their full potential in their professional aspirations. 4. What are the benefits of a business coach in medicine? Coaching can help physicians enhance their business skills. Unfortunately, medical education does not provide the entrepreneurial training necessary to help new physicians start their own practices or innovative endeavors. In medicine, doctors are conditioned to be riskaverse because any misstep could lead to a life-or-death outcome. In business, however, it is important to be willing to try new ideas, risk failing and trying again until you succeed. Thus, a business coach can teach physicians how to develop a business mindset and apply these principles in a health care setting. These executive and management skills can also help doctors lead more effectively in their clinics, hospitals and business endeavors.

5. When should I consider seeking a coach? Physicians should consider seeking a coach if they want to achieve a goal, evolve into the best version of themselves or if they are experiencing burnout. Ideally, every medical student should begin their career in medicine with a physician coach. The physician coach can help them develop a growth mindset that enhances their medical education to weather the challenges of a career in medicine. The most common sentiment I hear from my clients is that they wish they had received coaching at the beginning of their medical career, as they believe it would have mitigated their burnout. The COVID-19 pandemic has increased burnout, making a detrimental impact on overall health care delivery. Many health professionals are feeling the emotional strain of the pandemic, prompting many physicians to reduce their hours or retire early and leave medicine altogether. While coaching is not a substitute for psychiatric care or therapy, many find having another physician colleague to talk to about the daily challenges they face in the workplace normalizes their experience. Interestingly, many physicians often prefer speaking with a coach because there is less stigma as compared to seeking mental health services. Prominent leaders at universities, hospitals and institutions nationwide recognize the importance of investing in physician coaching and are now promoting physician wellness programs. These coaching programs Continued on page 10 Visit us at www.bcms.org

PRESIDENT’S MESSAGE

Continued from page 09

are critical to support a healthy physician workforce that can continue to provide effective leadership and high quality of care. 6. What should I expect from a coach? You should expect a coach to partner with you to enhance your awareness, identify your values and help you achieve your goals. A skilled coach also creates the opportunity for you to discuss your concerns openly and without judgement. An effective coach helps create the momentum to achieve your goals and helps you realize your full potential. 7. What is the difference between a coach, a mentor and a psychiatrist. Coaching is not counseling, mentoring or psychiatric therapy. In fact, there are key differences that one needs to consider when hiring a coach. A coach guides a high-functioning client to trust their own inner wisdom so they can entertain new possibilities that create personal and professional fulfillment. A coach is “future focused” and helps the client accept the past and then focus on the present to answer the question, “Now what do you want to do or create going forward?” A mentor provides guidance and wisdom from their own personal experience and perspective. The mentor often advises the mentee to take specific actions to reach the mentee’s objectives. A psychiatrist focuses on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders. A psychiatrist often works with low-functioning patients who are having problems with daily activities or selfcare. They focus on the past and any underlying mental health issues. 8. How does one become a coach? There are many ways to become a coach. While some coaches draw from their personal experience to coach, there are many who also choose to seek additional professional training to develop their coaching skills. There are many types of coaches, including physician and non-physician coaches who focus on different niches. These niches include general life coaching, leadership, business, marriage, career and executive coaching. Coaching is an unregulated industry and there is no federation with sole authority to regulate the coaching profession. There are many different styles of coach training programs, so it is important to do your research and find a training program and coach that will meet your needs. In summary, a professional physician coach enhances self-awareness, up-levels strengths and guides participants to discover solutions. Furthermore, physician coaching mitigates burnout, fosters resilience and

SAN ANTONIO MEDICINE • May 2021

helps clients create personal and professional fulfillment. A professional physician coach offers an effective and strategic opportunity to empower physicians and medical teams to not only survive but also thrive, even in the midst of a pandemic. I would like to thank Dr. Nora Vasquez (www.renewyourmindmd .com) for her thorough review on this topic and for being a contributing author. Rodolfo (Rudy) Molina, MD, MACR, FACP is a Practicing Rheumatologist and the 2021 President of the Bexar County Medical Society. Nora Vasquez MD is a member of the Bexar County Medical Society. References: 1. Dyrbye, Liselotte N., Shanafelt T. "Effect of a professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial." JAMA internal medicine 179.10 (2019): 1406-1414. 2. Shanafelt T, Goh J, Sinsky C. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017;177(12):1826– 1832. doi:10.1001/jamainternmed.2017.4340 3. Palamara K, Kauffman C, Stone VE, Bazari H, Donelan K. Promoting Success: A Professional Development Coaching Program for Interns in Medicine. J Grad Med Educ. 2015 Dec;7(4):6307. doi: 10.4300/JGME-D-14-00791.1. PMID: 26692977; PMCID: PMC4675202. 4. McGonagle AK, et al. Coaching for primary care physician wellbeing: A randomized trial and follow-up analysis. J Occup Health Psychol. 2020 Oct;25(5):297-314. doi: 10.1037/ocp0000180. Epub 2020 Apr 16. PMID: 32297776. 5. Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016;50:132–149.

BCMS ALLIANCE

Focus

on Fiber

By Taylor Frantz, RDN, LD BCMS Alliance President-Elect

One of the first things people ask me when they find out I am a registered dietitian is “what’s the best diet out there” or “how do I lose weight?” While it is nearly impossible to give one simple answer, as nutrition is highly individualized, one of my favorite nutrition tips is to eat fiber. Put simply, fiber is all the parts of plant-based foods that the body cannot break down and use for energy. Fruits, vegetables, legumes and whole grains all contain fiber. Although it provides no energy, vitamins or minerals, fiber is essential for optimal gut health, and is a very underappreciated nutrient. Fiber blocks absorption of dietary cholesterol and reduces serum LDL levels, which experts believe may help prevent heart disease. Additionally, fiber helps slow the overall process of digestion. This makes you feel fuller for a longer period of time and can prevent the urge to overeat. It also can prevent unnecessary snacking, which can lead to weight gain and obesity. This slowing of digestion also helps control spikes in blood sugar levels which is key in the prevention and management of type 2 diabetes. But, let’s not forget fiber’s most well-known contribution to digestive health. Fiber is what keeps you regular. Fiber comes in two forms: insoluble and soluble, but both help with stool consistency and motility. While it may not be the most glamorous topic, constipation prevention is so important. Chronic constipation can lead to hemorrhoids, anal fissures, incontinence, colonic and urologic disorders, to name a few. To add even more to fiber’s list of accomplishments, several studies have even shown a preventative relationship between the adequate consumption of dietary fiber and the development of several types of cancer. Sadly, most Americans do not eat anywhere close to the recommended amount of fiber every day. In general, women should consume a minimum of 25 grams of fiber per day and men should aim for 38 grams per day. Tips for increasing your fiber: • Consume fruits with the peel on. A medium apple with the skin on has double the fiber of a peeled one. • Enjoy smoothies instead of juice. Smoothies blend the fruit or vegetable and retain valuable fiber. Juice strains out the fiber, leaving just the sugar. • Add ground flaxseed to oatmeal or cereal for a fiber boost. • Add beans to salads or soups. • Add oats to your baked goods. • Try whole grain breads rather than white bread. Easy changes or additions to your diet can make a big difference in your gut health and overall quality of your life. Get into the habit of creating more-plant based meals, and you will start to enjoy the many benefits of fiber. Taylor Frantz is the President-Elect of the BCMS Alliance.

SAN ANTONIO MEDICINE • May 2021

HEALTHY EATING

Healthy Eating and the Gift of Imperfection By Robin Eickhoff, MD, MPH

My entire life, I have battled weight. My mother says she named me after a bird because I always had my mouth open for food. It makes me smile, because I know there is truth to it. I love food. I love thinking about it, reading about it, cooking it and definitely eating it. The downside is the false perception that I must decide between being overweight and enjoying my life the way I want, because there is no middle ground. This is the battle many fight every day: “It’s all or nothing.” As with most things in life, when we try to be perfect and inevitably fail, we quit. Healthy eating and nutrition is not an all-or-nothing proposition. We must give our patients and ourselves the gift of imperfection. The topic of healthy eating can fit in two buckets: metabolic (nutrition) and behavior (dietary). The two buckets are on each end of a continuum with a myriad of conditions that may (or may not) be influenced by intervention. I will address each and how pathology can influence them, including information on eating disorders. I will then offer suggestions for interventions in an office setting that I believe improves patient outcomes. Nutrition, the metabolic bucket, requires the balance of macronutrients and micronutrients to maintain and manage good health. Macronutrients are carbohydrates, proteins and fats. Micronutrients generally refer to vitamins and minerals, which come with a balanced diet. Media influence has led many to believe that carbohydrates are bad, proteins 14

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are good and with fats, it depends. In reality, we need all three for normal metabolic function, or disease ensues. Chronic diseases, particularly in more advanced stages, can result in deficiencies and inadequate nutrition. Sometimes, however, it is the treatment of those diseases that can cause the malnutrition. Medications can cause weight loss and malnutrition (chemotherapy) or weight gain and over-nutrition (antipsychotics, insulin). When malnutrition is due to a disease state, it is rarely desired, so patients strive to correct the deficiencies to the best of their abilities. When a patient is suffering from malnutrition, I am more inclined to tell them to eat whatever they prefer until their nutrition has improved. Success depends on the cause. End-stage diseases are more likely to result in the catabolic state of cachexia, which rarely improves. Intended weight loss resulting in malnutrition is more commonly caused by an eating disorder, making it much harder to treat. DSM 5 defines eating disorders as mental health disorders, “characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning.” These fall more into the behavior or dietary bucket, but can cross over into the metabolic bucket affecting nutritional status when not responsive to treatment. The most common eating disorders seen in a primary care setting are anorexia nervosa, bulimia nervosa and binge-eating disorder. These disorders tend to have higher prevalence in post-industrialized, higher-income countries. Risk of developing anorexia or bulimia tends to be more likely in

cultures that appear to value thinness. As one would expect, higher risk exists in occupations such as modeling or elite athletics that focus on being thin as healthy. Going into specifics about each of these eating disorders is well worth its own article and will hopefully be addressed in a future edition. Most patients we encounter do not have an eating disorder, but instead struggle with being overweight or obese. This often comes with a sense of shame and personal failure. We want to help patients overcome these barriers by empowering them with knowledge and tools about nutrition and healthy eating. How do we do this? There are recommended nutritional guidelines, but each person must be individualized. There are numerous eating plans, but no one-size-fits-all plan. No matter what the recommendation, it needs to be sustainable. The science of nutrition changes based on new data and studies. The benefits of quality, whole, natural food do not. We need carbohydrates, but ice cream and broccoli are not created equal. Fats are necessary for living, but unsaturated fats are best. Complete proteins are required. The daily American diet typically contains more protein than neces-

HEALTHY EATING

sary, but protein can be obtained from many surprising sources. For example, mushrooms have the same amount of protein per gram as carbohydrates. Recently, the USDA released updated Dietary Guidelines for Americans and overall, recommendations appear to be reasonable. Guidelines focus on the intake of nutrient-rich, high-value foods and minimal amounts of sugar and processed foods, while acknowledging the need for customization and moderation. Up to 15% of daily calories may include saturated fats and/or sugar-rich foods and beverages. This allowance is more likely to result in long-term success for changes in diet and improved nutrition. I have tried just about every diet out there. I have tried Green Smoothie diet, Weight Watchers®, pre-made meal plans like Jenny Craig®, Atkins®, South Beach® and my last and most successful diet: counting daily macronutrients. This worked for me because I had choices, and maybe more importantly, an accountability coach that I reported to weekly with my successes and challenges. I was never shamed or made to feel inadequate, only asked possible reasons for why I made a poor choice and how to prevent it from hap-

pening again. In other words, I was given permission to be less than perfect. My best effort was enough. If we want to ensure success in our patients, we need to provide them with accountability. That can be difficult when working in a busy clinic, managing schedules and keeping up on documentation and billing. Accountability can take many forms, however. It can be weekly weights and measurements with an MA, or even just a phone call from staff obtaining home readings and reviewing the weekly successes and challenges. Patients, just like us, want to be successful. Information is important, but as I am finding in my own life, accountability is what motivates me to change. Once progress is seen, motivation often becomes internal. Being accountable and supportive, however, can be the pivotal factors to push success. Over time, less external accountability is needed, because personal accountability develops. How we provide that accountability will be up to us and our patients. A healthy diet includes balance between the metabolic component (nutritional) and the behavioral component (dietary). Each of

these, when not in harmony, adversely affects the other. Poor dietary choices can cause undesirable nutritional outcomes that can cause disease or influence existing disease. Disease, whether chronic or acute, physical or mental, can adversely affect metabolic state and require dietary changes to minimize poor outcomes. Considering this when advising and treating patients, along with placing an emphasis on personal preferences, moderation of less nutritional foods and providing supportive accountability, can help patients be successful. Most importantly, when helping patients with an eating plan that will result in permanent change, give them permission to be less than perfect. It is important to do the same for yourself in the changes you want to make in your own life, dietary or otherwise. After all, we are all human. Robin Eickhoff, MD, MPH is a Family Medicine physician with WellMed and is a member of the Bexar County Medical Society. (For more detailed resources on Dietary Guidelines for Americans, including infographics, visit: dietaryguidelines.gov/resources) Visit us at www.bcms.org

HEALTHY EATING

Precision Nutrition:

"Let food be thy medicine, and medicine be thy food." – Hippocrates

The Merger of Nutrition and Medicine By Tim Hlavinka, MD

It was the Spring semester of 1979 and I needed another "hard science" class to fulfill medical school application requirements. I’d had enough of Organic and Biochem for one pre-med lifetime, so I perused the class handbook and stopped at Nutrition Science 101. Why not? It qualified and I wanted to learn about nutrition, as my career plan at that time was to become a pediatric surgeon. I thoroughly enjoyed learning about calorie requirements and vitamins and minerals and

SAN ANTONIO MEDICINE • May 2021

their physiology and impact on metabolism. Nutritional therapy at that time was directed toward easily phenotyped diseases such as phenylketonuria, or classic deficiency states such as pernicious anemia. It was fortuitous to have that background knowledge in med school as I went through Biochem and Pharmacology. In residency, nutritional advances such as TPN and enteral feedings were being developed and I tackled those with alacrity. Physicians' approach to nutrition seemed to

stop at disease states and not approach healthy eating and a healthy lifestyle. I propose that nutritional and dietary advice should be incorporated into all of our therapeutic interventions—this is not the future but the present. The concept of Precision Nutrition has been coined to designate the use of personalized nutritional approaches for prevention and management of disease. The discipline is in its infancy. Much work remains to create an integrated, interdisciplinary framework that in-

HEALTHY EATING

corporates clinicians, nutritionists, exercise physiologists, food resource personnel and life coaches, but much has been done. The bioinformatics pillars of precision nutrition include genetics, dietary habits, food behavior, physical activity, metabolic variance and the gut microbiota. The goal is the design of tailored nutritional recommendations to prevent and treat. Although large design trials have been few in the field, they are not lacking, and much observational research has been collected. Numerous genetic variants and polymorphisms have been identified to be active in the heterogeneous metabolic response to nutrients and specific diets. With the explosion of at-home genetic screening, many private sector laboratories offer customized dietary recommendations based on genetic markers. While this approach is straightforward, it fails to recognize the complexity of the contributing factors to our variance in metabolism. The individual genome remains a target for personalized approaches to nutrition, but solutions based simply on genetic codes are few. The interplay between genetics and environment is axiomatic. Dietary habits may seem self-evident, but for the discipline of precision nutrition, it refers to the quantity and variety of nutrients; macro- and micronutrients. Limitations of quantification of intake have perplexed nutritionists for decades. Research instruments are few and cumbersome and face the dilemma of self-reporting bias. Similarly, adherence to dietary measures remains a difficult-to-quantify behavior. If dietary habits are "what" we eat, then food behavior is "how" we eat. This field looks at frequency, timing and relative proportion of total intake over a given time cycle. It is also known as "food style monitoring." Included in this field is the concept of Circadian rhythms and their impact on metabolism, highlighted by the search for the optimal manner of intermittent fasting.

The role of physical activity in metabolic balance is also axiomatic. Precision nutrition, however, attempts to see beyond the obvious need for increasing the total level of METs. It attempts to arrive at the type and timing of physical activity and its relation to intake to achieve more metabolic bang for the exercise buck. It also explores the phenomenon of epigenetics and the relationship between exercise, diet and the expression of multiple atrisk genes for obesity.

Deep phenotyping is defined as the precise and comprehensive analysis of phenotypic abnormalities in which the individual components of the phenotype are observed and described. Assessment of the impact of a given nutritional intervention requires accurate and well-defined disease stratification. For instance, a trial looking at outcomes measuring only the traditional risk factors of hypertension, dyslipidemia, BMI and inflammatory markers would be better defined if body composition by DEXA, echocardiography, ocular pressures, fundus exam and spirometry were also included. Metabolic variance has on its surface the obvious reference to how and why individuals vary in their response to the same dietary measures. However, the field goes beyond to

include the rapidly emerging arena of metabolites of nutrients and the creation of biomarkers to identify the impact of these metabolites on the body's systems. From malabsorption syndromes to its impact on the immune system, gut microbiota has seen an explosion in research. The precise interplay between food intake and its effects on enteric microorganisms is further defined by studies that show specific dietary alterations changing the gut microbiome and leading to disease. Therapeutics for these entities have remained elusive. We live in an obesogenic society and changing diet and lifestyle has proven challenging for most of our patients. The wealth of literature that speaks to vast improvements in outcomes with weight loss is an overwhelming reminder to us that we are our patients' advocates in the journey to health. From Anesthesia to Vascular Surgery, all specialties have literature supporting this intervention. Carry this with you—the loss of a single Kg of weight decreases the relative risk of diabetes by 16%. It is possible to make that intervention with every patient at every visit and not change anything but the course of a human life. As more is recognized about the benefits of dietary and lifestyle changes, the need for an integrated, comprehensive approach utilizing the multiple stakeholders in the field of nutrition science looms large. We rely on our colleagues in nutrition, food resources, personal training and life coaching to produce the outcomes long sought by a nation suffering from an epidemic of obesity. Let us learn from our colleagues so that we can have the true "stakeholders," our patients, achieve the health outcomes they richly deserve. Tim Hlavinka, MD is a Urologist in San Antonio, and is Medical Director of Vidamor Medical in Boerne. He is a member of the Bexar County Medical Society.

Visit us at www.bcms.org

HEALTHY EATING

The Diet Puzzle By Janice Tapp, MSN, RN

Food is the energy source that keeps our body nourished. Food can promote our well-being or poor health. Eating the best possible choices and maintaining the correct portions and balance should be our goal. However, nutrition is the least understood subject by our society, including the professionals who treat our health and diseases. The most popular diets address weight loss, followed by diets to control diseases such as diabetes, high blood pressure, kidney disease and heart diseases. There are so many different diets and methods to lose weight, but track records for them remain poor. People still need to lose weight and continue to survive with chronic diseases. This article provides a positive and negative review of some of the most common eating patterns. Standard American Diet (SAD) reflects a general food pyramid or food plate. It has protein, vegetables, fruits, grains, oils and diary. It has no restriction on sodium amounts. Many of the calories are derived from excess fat, processed foods and sugar. Unfortunately, serving sizes are poorly understood by consumers. The sad outcome of this eating pattern is obesity, diabetes, heart disease, hypertension and cancers. Gluten-free options have become a popular choice. Typically, celiac 18

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disease or gluten sensitivities were the reason for this eating pattern, but claims of weight loss, gastrointestinal benefits and autoimmune disease relief have prompted so many to avoid wheat, barley and rye. Disadvantages may be lack of fiber, weight gain and lack of nutrients. Keto diets are a popular fad, claiming weight loss, lowering triglycerides, blood pressure and cholesterol by consuming mostly proteins and fats, and cutting the amounts of carbs. Along with decreasing carbohydrate intake, one can lose fiber, nutrients and even minerals. When in a state of ketosis, one may have less hunger due to fat and protein consumption. Eating unhealthy fats, especially saturated fats, is not a good option when elevated cholesterol may be a reason to choose this eating pattern. Some people claim up to 10 pounds of weight loss a month. A keto diet should not extend more than 3 months due to extreme amounts of fats and lack of carb nutrients like fiber. Kidney and heart damage may occur with these restrictions. Paleo includes lean meats, seafood, eggs, oils, fruits, low-starch veggies, seeds and nuts, but not grains, legumes, diary, sugary foods, processed foods and salty types of food. Many nutrients are lacking from the foods omitted and costs for this diet can be expensive. It is a

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poor choice for good health if one wants to eat like the early people or reduce inflammation with a slightly cleaner form of eating. Mediterranean Diet has been a successful choice that promotes a balanced choice of foods. It includes all food groups and it is well-balanced for nutrients. Fresh foods, nuts, olives, veggies, fruits, grains and fish are some of the highlights. The diet shies away from processed foods, sugar, refined grains and processed meat. Some dairy, like hard cheeses, yogurt and eggs are included. The downsides to the diet are costs, food prep time, weight gain and even low iron levels. In general, it can meet mostly all nutrition requirements and has been a better choice for many people. Whole food plant based (WFPB), or vegan diets do not include any animal products. A plant-based diet typically includes fruits, vegetables, legumes, grains, soy products and grains as the foundation. Oil and sugar may be used sparingly or not at all. A vegan may make dietary choices based on health or on animal welfare. Public awareness of poor treatment of animals and their environments has increased. The resources to raise these animals is not only expensive, but connected with global climate concerns. Animals and viruses have been linked to Ebola, influenza and SARS. Meat has been shown to cause many health issues from its fat content and additives. Meat and animal products have been altered for farming factories using antibiotics and hormones. Research available has shown that meat can increase cancer risks. On the other hand, a plant-based diet shows increased benefits to lessen chronic diseases. In addition, plant-based diets are preventive for many illnesses. Data now shows obesity causes increased mortality in COVID infections. Obesity is one of the ultimate dietary and health concerns for most of the population at any given time in their life. WFPB diets can reduce these staggering figures. Portions may not need to be addressed if one is faithful to dietary choices. In fact, many followers of the plant-based lifestyle have lost weight. In addition, the literature describes WFPB diet may lower incidence of many chronic diseases, including hypertension, type II diabetes, obesity and atherosclerosis. Many cardiologists recommend WFPB to patients with hyperlipidemia control. Some healthcare providers say the literature states that diet is unreliable and they would rather choose research-based pharmacology to control chronic disease. Changing to a WFPB diet with education and encouragement can pave the way to reducing the medications or eventually eliminating them. One question raised is: “What do I eat and how do I prepare it?” Providers ask for resources for their patients. When patients see the positive outcomes of a healthy lifestyle by reducing the side effects from pharmacology and disease symptoms, they are encouraged to continue. Can you imagine the energy patients have when they lose weight and no longer require the drugs that convey antihypertensive side effects?

When eaten correctly, a whole food diet balances out all the vitamins, minerals and nutrients. There is sufficient protein, carbs and natural low fats in this diet. Most vegans supplement Vitamin B 12. The pieces of the diet puzzle can all come together with this easy, simple diet which can be maintained with encouragement, education and coaching, if needed. There is not a need for weight loss diets with WFPB.

The solution to optimal health is prevention. Dr. Paul Dudley White from Massachusetts General Hospital promoted this when he recommended exercise and optimal nutrition back in the ‘60s. He saw the outcomes in his own lifestyle and recommended it to his cardiology patients and fellow physicians. Hippocrates quotes, “Let food be thy medicine and medicine be thy food.” Look at the equation: Optimal nutrition equals optimal health. There has never been a better time to eat a more wholesome diet as a plant-based diet. As a nurse, I have seen a huge increase in obesity and all the chronic disease connected with it. I learned how to practice a healthy lifestyle and preach what I practice. Preventive health is the best practice and a healthy lifestyle promotes optimal health for each person. In my career as an educator, I have passed on this knowledge with people concerned with their health and continue to do so in a consultation practice. Janice Tapp, MSN, RN has a Master of Science in Nursing Education from Grand Canyon University and a Bachelor of Science in Nursing from the University of the Incarnate Word. Coaching and consultation are available at Jmtapp55@msn.com. Visit us at www.bcms.org

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Gardening & Farming: Examining the San Antonio Food Bank’s Farming Effort By Michael Guerra

Since 1980, the San Antonio Food Bank has served the emergency needs of food insecure residents across 16 counties of Southwest Texas. Known for helping individuals with groceries and meals, the Food Bank sets the table for 120,000 people a week. The groceries and meals are the anchor for the Food

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Bank’s “food for today” strategy, the first rung of their 3-step effort to move individuals to self-sufficiency. The Food Bank’s second step up the ladder assists individuals with “food for tomorrow”: helping them enroll in public support programs (SNAP, WIC, etc.), and teaching

them all manners of healthy cooking and nutrition. Employing more than 30 people to help individuals navigate public benefits enrollment and more than a dozen registered dieticians and wellness experts, this is the largest effort of any food bank in these two program areas. The Nutrition, Health and Wellness Team works to promote healthy eating patterns and active lifestyles to improve the well-being of the community. This is done by educating the community through a variety of free classes and by promoting healthy eating through urban gardening and Farmers’ Markets. The Food Bank operates the largest Farmers’ Market Association in the region, conducting as many as 25 markets each month. Food is provided from Food Bank farming initiatives, as well as from local farmers. Individuals can use their Lone Star Card for produce. They can also get their produce purchase doubled by a special incentive program offered by the Food Bank. The markets offer seasonal fruits and vegetables. In addition, the farmers’ markets have nutrition demos showing attendees how to prepare healthy recipes from the items available in the market that day. The Health and Wellness team works in the community, teaching classes on a variety of topics: healthy cooking for kids, strategies for combating diabetes and obesity, effective grocery store shopping, extending your grocery budget and much more. Classes are free to participants and are offered in both English and Spanish, conducted in person and through virtual offerings. The Food Bank’s farming efforts take place

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at two farms and one teaching garden. Since 2007, the Food Bank has worked the soil at its main campus. That farming effort currently puts 40 acres under plow, cultivating fruits and vegetables that are then integrated into meals for kids and into distribution for those needing produce at home. Volunteers work side by side with staff to plant, maintain and harvest the items from the farm. The Food Bank also makes items from its West Side farm available to local restaurants as a part of a farm-to-table initiative. The effort is a win for local restaurants and helps provide earned revenue support to the Food Bank, with every $1 of income providing 7 meals to the community. The second Food Bank farm is located at historic Mission San Juan, and is an effort in partnership with the National Parks Service. The Food Bank maintains a MOU with the National Park, allowing them to farm 45 acres in exchange for maintaining and staffing a teaching garden at the Mission. The teaching farm at Mission San Juan shows historical farming as it would have occurred 300 years ago, including the use of flood irrigation from the local acequia. The Food Bank’s farming effort has multiple purposes. First, it is an effort to educate people about food and how it is grown. The farms host tours for schools on a weekly basis. Second, it is an effort to discuss sustainable farming and energy practices. Water and conservation are so key to the food economy. Farming gives the Food Bank a platform to discuss these practices. Finally, the Food Bank farms as a way to engage the community in giving back through volunteerism. To find out more information about the San Antonio Food Bank, visit www.safoodbank.org or follow them on all social channels #safoodbank. Michael Guerra is the Chief Resource Officer of the San Antonio Food Bank.

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Hispanics and Liver Disease By Rita Lepe, MD

According to the 2019 U.S. Census, Hispanics make up 18.5% of the U.S. population (60 million). In Texas, 39.7% of the population is Hispanic (11.5 million) and they primarily live in large urban cities, including San Antonio (63.2%), Dallas (42.4%), Austin (35.1%) and Fort Worth (35%). Hispanics, by definition, are a heterogenous group descending from countries related to Spain, Spanish language and culture. Hispanics can be of any race, although the majority are classified as White, thus the distinction in the Census as Non-Hispanic Whites (NHW) for the Caucasian population. Chronic liver diseases are very prevalent in the Hispanic population and are a leading cause of death. In 2018, chronic liver disease ranked 7th as a leading cause of overall mortality in Hispanics and the 4th leading cause of death in Hispanic men ages 55-64. The most prevalent liver diseases are non-alcoholic fatty liver disease (NAFLD), chronic hepatitis C, alcoholic liver disease, cirrhosis and liver cancer. Health care disparities exist that are responsible for the increased mortality. It is important to address them to improve long-term health outcomes. Obesity affects 43% of Hispanics in the U.S. Obesity can lead to the development of NAFLD/NASH which can progress to cirrhosis and liver cancer. Metabolic syndrome affects 35% of U.S. Hispanics and is a risk factor for NAFLD/non-alcoholic steatohepatitis (NASH). A concerning fact is that Hispanic children have the highest rates of obesity at 25.8% compared to 22% of African American (AA) children and 14% of NHW children. Children can also develop fatty liver, 22

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which is currently the most common pediatric liver disease. If not addressed early, these children will go on to develop early onset of DM type 2, hypercholesterolemia and metabolic syndrome at an early age. Data from NHANES III reported that 2% of Hispanics have chronic hepatitis C. In Hispanics, cure rates of less than 95% are comparable to NHW and other races. Advanced liver disease due to alcohol abuse has a prevalence of 16% higher than that of other ethnic groups. Death due to alcohol-related chronic liver disease is two times higher than in NHW men. Rates for hepatocellular carcinoma and cholangiocarcinoma are 1.9/100,000 in Hispanics compared to 0.7 for NHW. The death rate is twice as high for Hispanics than NHW due to the fact that Hispanics tend to present with more advanced stage disease and are less likely to receive curative treatments. Many studies have looked at the effect of race/ethnicity on graft and patient outcomes in patients undergoing liver transplants. Hispanics have equivalent or improved graft and

orthotopic liver transplant survival compared to NHW and AA. Hispanics with end-stage liver disease (ESLD) should be promptly referred to transplant programs for evaluation. Chronic liver disease disproportionately affects Hispanics of all ages. Obesity is also affecting Hispanics at an alarming rate, suggesting that higher rates of NASH and liver cancer will lead to higher rates of mortality. Early intervention addressing the risk factors for chronic liver disease in Hispanics and prevention, especially in the pediatric population, is of extreme importance. Programs need to be developed at the public health level. Rita Lepe, MD is a Hepatologist with the Texas Liver Institute and is a member of many medical societies including the American Association for the Study of Liver Diseases (AASLD), American Gastroenterology Association (AGA), American Society of Transplantation (AST) and the North Texas Latin American Physician Association (NTLAPA).

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Bloating & Food Choices By Chirag Patel, MD

Belching, bloating and flatulence are some of the most common reasons why patients seek medical advice and dietary guidance. In many cases, this may be completely normal, but with increasing frequency and severity, symptoms can be rather distressing. Belching is a normal process that comes from accumulated air in the stomach related to swallowing. This can either come back up as belching, or moved forward into the remainder of the gastrointestinal tract, eventually passed as flatus. Flatulence results from a combination of this swallowed air and gas produced by colonic microbiota. Bloating is a sensation of fullness or distension, mostly at the upper abdomen. Food or gas in the stomach, especially in abnormal amounts, can contribute to this sensation. The gutbrain axis can play as a large factor with this sensation as well. It is important to note that symptoms like melena, hematochezia or weight loss should raise suspicion for more aggressive or life-threatening etiologies. In such cases, there should be a very low threshold to refer to a gastroenterologist for further evaluation. Otherwise, there can be a large amount of overlap between these symptoms. Similar lifestyle and dietary interventions can lead to clinical improvement. Everyone swallows air as a part of eating and drinking. Excess air can be swallowed with carbonated beverages like beer or soda and even with something as simple as chewing gum. In large amounts, this can lead to belching, bloating or flatulence. Eating large meals or eating rapidly can result in these symptoms as well. Avoidance can be helpful to mitigate some of these symptoms. Some carbohydrates, like cauliflower, broccoli, beans or cabbage can go undigested in the 24

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small intestine and eventually the colonic bacteria can metabolize them to gases leading to excess flatulence. Other foods that can increase flatulence include onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, alcohol and caffeine. When similar symptoms occur consistently with ingestion of dairy, lactose intolerance should be suspected early, especially given its high prevalence. The key to all of these is to identify the triggers and to use trial avoidance to seek symptom relief. Multi-day, food diary logging timing of types of foods ingested, along with timing and types of symptoms experienced, can be very helpful to identify potential dietary triggers. Constipation can sometimes contribute to these symptoms and can usually be detected upon further symptom review. Treatment can many times lead to resultant improvement in bloating or flatulence symptoms as well. Beyond these avoidances and constipation management when necessary, ongoing symptoms may indicate the need for a gastroen-

terology consultation. Imaging, laboratory testing, breath testing for small intestinal bacterial overgrowth and endoscopic evaluation can all play a further diagnostic role. The role of food allergy testing is unclear, and currently testing is not recommended for these symptoms in particular. As you can imagine, expansive workup can be quite costly and many may choose to seek further dietary modifications via specialized diets like Low FODMAP (low in fermentable oligo-, di-, and monosaccharides and polyols), elimination diets or a low residue diet. These specific diets are best executed by a consultation with a registered dietitian and with supportive data to suggest superior clinical outcomes versus physician consultation alone. Of these, a Low FODMAP diet is one of the most popular recommended diets from a gastroenterologist, especially when a case of Irritable Bowel Syndrome (IBS) is suspected. Patients with IBS have shown to be sensitive to even the slightest increase in intestinal gas and sometimes even a normal amount of gas. They may

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have additional symptoms of abdominal cramping, constipation and/or diarrhea. The Low FODMAP diet has shown to be an excellent cost-effective option as an initial “best step” in management and evaluation. This is especially true in younger and otherwise healthy patients without “red flag” symptoms like melena, hematochezia or weight loss. High FODMAP foods include other shortchain carbohydrates that are poorly absorbed in the intestine as well, leading to rapid for-

mation with gas production and often with resultant symptoms of bloating. Some examples of these are foods that contain fructose like honey, high-fructose corn syrup, apples, pears, mangoes, cherries and wheat. The FODMAP diet involves elimination of these foods for 6-8 weeks and then, upon symptom improvement, slow categorical reintroduction of foods helps to identify intolerances or triggers contributing to symptoms. Belching, bloating and flatulence are in-

credibly common. In the absence of red flag symptoms, initial management may involve avoidance of carbonated beverages, chewing gum and poorly digested carbohydrates. Constipation should not be overlooked, as it can be simple to treat in many cases. Diets like the Low FODMAP diet or elimination diets with consultation of a registered dietitian, especially in young and otherwise healthy patients, may be a reasonable next step. Otherwise, additional workup and medical management with a gastroenterologist can be helpful to diagnose and treat alternate etiologies like GERD, Helicobacter pylori, peptic ulcer disease, gastroparesis, bacterial overgrowth and more. Chirag Patel, MD is a Gastroenterologist in Bexar County and a member of the Bexar County Medical Society.

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Childhood Obesity: An Unresolved Public Health Problem By John Menchaca, MD

Childhood obesity continues to be a major public health problem for at least the past forty years and continues to worsen.1-2 Multiple approaches have been tested to prevent and treat obese children both at home, school, or both, though all with poor results. It is well recognized that many of the obese children will eventually become obese adults with several complications. These well-documented complications including diabetes, cardiovascular disease, liver disease, increased cancer, and dementia.2,3 Hence, there is a need to explore other therapeutic approaches. In the past two decades, attention has been focused on the role of the prenatal period on the development of childhood obesity. To the disappointment of many, interventions during the pregnancy have not yielded satisfactory results.2,3 In recent years, attention has turned to the periconceptional period, which is three months before conception to the end of the first trimester of the pregnancy. Animal studies are very encouraging.5 Furthermore, studies on the donor sperm in in vitro fertilization procedures have demonstrated that sperm from obese male donors are abnormal and are associated with obesity in the offspring resulting from the pregnancy.6 The role of maternal obesity has been likewise well documented.7 Preliminary clinical studies of interventions on obese mothers before conception are very encouraging.7 There are numerous studies underway to confirm that interventions that improve the weight and nutritional status of the obese mother will help minimize the risks for the offspring to become obese in their later years.8 The most difficult, if not impossible task, is to identify the mother before she gets pregnant so intervention measures can be initiated. One approach is contacting the mother after she has her first baby, initiating interventions to improve her weight and nutritional status before she gets pregnant with her second baby. Our obstetrical colleagues could stay in touch with the mother in-between the first and second pregnancies to hopefully improve her weight and nutritional status before she gets pregnant. This would hopefully minimize her offspring’s risk 26

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for obesity. Another option for the physicians involved with the mother’s first baby and its well-baby care is to become involved with the mother’s postpartum period. Obviously, there would have to be additional reimbursement for the physician’s involvement over the two to three years between the pregnancies. A final, third option, is more vigorous health education in middle and high school for both males and females. This would make it so when they move on to parenthood, both young mothers and fathers will be at optimum status at the time of conception. In summary, what we have done and are trying now has not succeeded. We must consider other approaches to help stem the tide of childhood obesity and, by default, adult obesity. John Menchaca, MD is a member of the Bexar County Medical Society. References 1. Ogden, C.L. et al: Trends in Obesity Prevalence Among Children and Adolescents in the United States 1988-1004 through 2013-2014 JAMA 2016 Jun 7; 315(21) 2292-2299 2. Al- Khudairy et. al: Diet, physical activity, and behavioral intervention for the treatment of overweight or obese adolescents aged 12 to 17 years. Cochrane Database Syst. Rev. 2017 (6) CDO 12691 3. Colquitt, Jill L. et. al. Diet, physical activity, and behavioral intervention for the treatment of overweight or obesity in preschool children up to age of 6 years. Cochrane Database Syst. Rev. 2016 May 2016 (3) CDO 12125. 4. Meyer, D.M. et al: Evaluation of Maternal Dietary n-3 LC – PUFA Supplementation as a Primary Strategy to Reduce Offspring Obesity; Lessons from the INFAT Trial and Implications for Future Research. Front. Nutri. 2020 7: 156 5. Nichols, L.M. et al: The Early Origins of Obesity and Insulin Resistance, Timing, programing, and Mechanisms. Int. J Obesity 2016 40: 229-238 6. Sultan, S. et al: Male Obesity Associated Gonadal Dysfunction and the Role of Bariatric Surgery. Front. Endocrinol. (Lausanne) 2020 vol 11 p 408 7. Catalano, P.: Reassessing strategies to improve pregnancy outcomes in overweight and obese women. 2019 vol 7: pp 2-3 8. Erickson, M.L. et. al: Rationale and Study Design for Lifestyle Intervention in Preparation for Pregnancy (LIPP): A Randomized Controlled Trial. Contemporary Clinical Trials 94(2020) 106024

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Can We Incentivize

Healthy Behavior? Each individual should be responsible for their own health and for shaping their own future. Obesity is one of the biggest drivers of preventable chronic diseases and associated health care costs in the United States. Health care costs in the U.S. are 20 percent more per capita than the rest of the world. More people are sick, making health care costs higher. Many have chronic conditions because of poor lifestyle choices (the problem of plenty). Even though people know maintaining a healthy weight and eating healthy are important, it is hard to put this thought into practice. If we can incentivize healthy behavior, we can control some chronic conditions and decrease health care costs. “Healthy Choice” was started by the Cleveland Clinic for its employees in 2010. The key idea was to give employees incentives to avoid six chronic medical conditions and in return, see a decrease in their insurance premium rates. This program has been a huge success. Cleveland Clinic showed a flat-lining of health care costs for the first few years, followed by a 2 percent decrease last year. The six major chronic diseases responsible for 75 percent of all health care costs are high cholesterol, high blood pressure, excess weight, diabetes, asthma and tobacco use. In the Cleveland Clinic program, workers saw a physician or a mid-level provider who monitored things such as weight and cholesterol. They also offered education and counseling for a healthy lifestyle. The Healthy Choice program was voluntary, but because incentives were huge (i.e. workers who met the goal could save 28 percent in health insurance premiums) many workers participated in the program. Since 2010, almost 66 percent of workers with one or more of the six major chronic conditions managed to get them

under control, with a majority of them continuing to keep them under control. The incentive system succeeded in changing behavior. Cleveland Clinic also made changes such as removing unhealthy options and reducing portion sizes in their cafeteria. They did this by removing sugary snacks and drinks from their vending machines, adding an onsite fitness center and providing yoga classes with other healthboosting activities. A few employers across the nation are following the program designed by Cleveland Clinic, developing workplace wellness programs for their employees to decrease health care insurance costs. Incentivizing employees by decreasing their health insurance premiums is in turn making employees healthier and happier. Can we implement Cleveland Clinic’s Healthy Choice program in all health care systems throughout the U.S.? Can we incentivize patients and change their behaviors? At some point, with health care costs skyrocketing and the Medicare system not able to handle the cost, is it fair to ask citizens to pay more for their healthcare if they do not choose to participate in healthy lifestyle choices? Once consumers of healthcare buy into this incentive system, people’s behavior will change and that will also change the food industry. The food industry will ultimately have to change and provide more healthy choices at affordable costs. In the same way Centers for Medicare & Medicaid Services (CMS) has developed in-

By Jayesh Shah, MD

centives for physicians to participate in quality measures, is it possible for CMS to develop incentives for patients to follow healthy lifestyle choices? The future of healthcare will require the redesign of primary care and development of incentives for healthy behavior. Jayesh Shah, MD, a wound care specialist certified in Internal Medicine and Undersea and Hyperbaric Medicine, is a member of the Board of Trustees of the Texas Medical Association. Cleveland Clinic program reference: http://www.mauldineconomics.com/frontlinethoughts/how-to-rebuild-healthcareright

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BOIL WATER ADVISORY Source: Centers for Disease Control and Prevention

If your local health officials issue a boil water advisory, you should use bottled water or boil tap water. This is because a boil water advisory means your community’s water has, or could have, germs that can make you sick. Advisories may include information about preparing food, drinks, or ice; dishwashing; and hygiene, such as brushing teeth and bathing. Boil water advisories usually include this advice: •Use bottled or boiled water for drinking, and to prepare and cook food. •If bottled water is not available, bring water to a full rolling boil for 1 minute (at elevations above 6,500 feet, boil for 3 minutes). After boiling, allow the water to cool before use. •Boil tap water even if it is filtered (for example, by a home water filter or a pitcher that filters water). •Do not use water from any appliance connected to your water line, such as ice and water from a refrigerator. •Breastfeeding is the best infant feeding option. If you formulafeed your child, provide ready-to-use formula, if possible. Handwashing •In many cases, you can use tap water and soap to wash hands during a boil water advisory. Follow the guidance from your local public health officials. •Be sure to scrub your hands with soap and water for at least 20 seconds. Then, rinse them well under running water. •If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol. Bathing and showering •Be careful not to swallow any water when bathing or showering. •Use caution when bathing babies and young children. Consider giving them a sponge bath to reduce the chance of them swallowing water. Brushing teeth •Brush teeth with boiled or bottled water. Do not use tap water that you have not boiled first. Washing dishes •If possible, use disposable plates, cups, and utensils during a boil water advisory.

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•Household dishwashers generally are safe to use if: o The water reaches a final rinse temperature of at least 150 degrees Fahrenheit (66°Celsius), or o The dishwater has a sanitizing cycle. •Sanitize all baby bottles. •To wash dishes by hand: o Wash and rinse the dishes as you normally would using hot water. o In a separate basin, add 1 teaspoon of unscented household liquid bleach for each gallon of warm water. o Soak the rinsed dishes in the water for at least one minute. o Let the dishes air dry completely before using again. Laundry •It is safe to wash clothes as usual. Cleaning •Clean washable toys and surfaces with: o Bottled water, o Boiled water, or o Water that has been disinfected with bleach Caring for pets •Pets can get sick from some of the same germs as people or spread germs to people. Give pets bottled water or boiled water that has cooled. •If bottled water is not available, bring water to a full rolling boil for 1 minute (at elevations above 6,500 feet, boil for 3 minutes). After boiling, allow the water to cool before use. •Boil tap water even if it is filtered (for example, by a home water filter or a pitcher that filters water). •Do not use water from any appliance connected to your water line, such as ice and water from a refrigerator. Caring for your garden and houseplants •You can use tap water for household plants and gardens. Reference: cdc.gov/healthywater

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From Cable into the Kitchen How the LSOM Food Network Inspired Me to Change the Way I Cook By Ana Moser

As someone who has always had a hearty appetite and a penchant for trying new food, when my medical school offered me the chance to partake in a cooking class, I did not hesitate to sign up. In partnership with the San Antonio Food Bank (SAFB), the Long School of Medicine (LSOM) offers the LSOM Food Network, an interactive cooking program aimed at teaching students how to prepare healthy, nutritious meals that are both time- and budget-friendly. SAFB’s Chef and Nutrition Education Coordinator, Raul Longoria, facilitates each session by guiding students step-by-step through recipes, answering any questions we have along the way. I have learned about kitchen safety, such as how to properly hold a knife and learned the best ways to cut an onion, head of cabbage and bell pepper. Participating in this program has encouraged me to be more creative in the kitchen. I learned that I don’t always have to follow recipes verbatim and that it’s okay to adjust recipes to my personal preferences and dietary needs. For instance, I can incorporate spices that I know I’ll enjoy or make small tweaks to recipes in order to utilize the ingredients I have in my pantry or refrigerator. Substituting ingredients with healthier alternatives, such as using brown rice instead of white rice, or incorporating vegetables into my go-to meals are just a few of the lessons I have learned through the LSOM Food Network program. Perhaps my biggest takeaway from the program is that healthy foods don’t have to be bland. Taste can easily be improved by mixing flavor profiles and incorporating seasonings and spices into one’s cooking. On top of all

that, the LSOM Food Network program has saved me time and money (two things that I, like most medical students, have a limited amount of ) because I am able to cook a large dish and freeze the excess for later. It’s much less tempting to go out and buy takeout when I know I have a flavorful, healthy meal at home that just needs to be heated up. Some of my favorite recipes I’ve made through the LSOM Food Network include Thai basil fried cauliflower rice, vegetable paella and apple carrot muffins. I had never eaten these dishes prior to participating in the program, and I was pleasantly surprised at how delicious all three tasted, even though they contained a lot of vegetables and other healthy ingredients. I now feel more comfortable in the kitchen and confident in my cooking abilities. The LSOM Food Network program has taught me that eating healthy and giving my body the proper fuel it needs is something that benefits both my overall physical health and personal well-being. Giving myself the nutrients I need by eating healthy helps me feel more energized, and therefore, better able to serve future patients. My experience with the LSOM Food Network has also influenced my professional development as a physician. Chef Longoria often shares stories about how the SAFB distributes large quantities of food to our communities in need. Understanding the many moving parts to the food distribution operation is eye-opening in understanding the needs of our community. I hope to pass along my new skills to future patients and motivate them to cook healthy meals that they look forward to eating.

My advice to future patients would be to conduct a quick search and find healthy recipes online that they would be excited in trying out. I would remind them not to get discouraged if the dish they cook does not turn out perfect. Like anything else, there is a learning curve to cooking; it takes experimentation and trial-and-error before finding what works. I want my future patients to know that eating healthy doesn’t mean sacrificing flavor— it just means getting a little creative in the kitchen and incorporating their preferred flavors into meals. Setting aside a little bit of time to cook may seem inconvenient, especially when fast food and takeout are so readily accessible. However, with so many serious diseases having a correlation with unhealthy eating, such as obesity, hypertension, diabetes and an array of cardiovascular diseases, it is well worth investing a little time to cook wellbalanced meals. Educating my patients on many lifestyle changes, such as choosing healthier alternatives to their favorite dishes, could lower their risk for morbidity and greatly improve their health. I’m grateful that my medical school offers this program because it has taught me practical skills in the kitchen, encouraged my culinary creativity and shown me that eating healthy meals not only benefits myself, but my future patients. Ana Moser is a Medical Student at the Long School of Medicine, UT Health San Antonio, Class of 2024.

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Early Establishment of Healthy Eating Habits in Childhood:

A Preventative Measure Against Childhood Obesity By Jocelyn Wey, Cynthia Bogran, Yi Fang, Darwin Nguyen and Adeel Sajid

Obesity in childhood has both immediate and long-term consequences. Preventable diseases, usually associated with adulthood, are occurring more frequently in the pediatric population, largely due to obesity.3 For example, type II diabetes mellitus, a disease usually associated with the older population, is now being seen more regularly in some settings, contributing to almost half of new pediatric diabetes cases.3 Obese children also have an increased risk for asthma, sleep apnea and even cardiovascular disease.10 Furthermore, obese children are also more likely to also be obese as adults, which is associated with similar health problems such as hypertension, gout, cardiovascular disease and stroke.3,10 While development of childhood obesity is multifactorial, major contributory factors such as dietary choices and parental influence 30

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on eating habits are impactful and tend to be established early in childhood.1 Additionally, the role of different eating patterns among racial and ethnic groups may also influence the development of obesity in childhood.1 In San Antonio specifically, there is a disproportionately high rate of pediatric obesity among the Hispanic community. A great percentage of these children reside in the south and central regions of the city, corresponding to lower socioeconomic status communities.2 This is important to keep in mind during office visits and while counseling parents and patients on healthy eating habits, as some studies have also found parents of lower socioeconomic status tend to engage in poor eating habits which are then transferred to their children.5 What, how and when food is consumed matters. Lindsay et al., found that children

tend to develop their food habits early on through “exposure and repeated experiences.”4 Early exposure to healthy, nutrientrich foods, such as vegetables, fruits and whole grains increases the odds these types of foods will be eaten more often both in childhood and adulthood. Another key factor in establishing healthy eating habits at an early age relies on parents serving as role models. A number of studies have shown how the perceptions, beliefs, emotional status and even the BMI of the mother substantially influence dietary practices and weight of children.6,7,8 Early in development, children have a tendency to model and eat what their parents consume, especially developing preferences for what their mothers eat.4 Preschool-aged children tend to have a strong dislike of new foods. Low consumption of fruit and vegeta-

HEALTHY EATING

bles with high intake of calorically-dense foods in this age group corresponds to “weight status in later childhood stages.”1 There is a caveat to this, however; kids should not be made to ‘clean their plates’ or have extremely stringent control placed over their diet by their parents. Several studies have shown high maternal food control leads to a higher likelihood of the child becoming obese.9 Rather, children should be given healthy options to choose from and be allowed to decide for themselves how much food to eat from what they are given.4 Just as it is important what a child eats, it is also important how and when a child eats. Behaviors related to poor diet, including excessive snacking, frequent eating out, fast food consumption and eating while watching television, have been found to be associated with an increased risk of gaining weight.1 Conversely, eating dinner as a family throughout adolescence helps promote consumption of healthy food intake and reduces consumption of calorically dense foods.4 Although there have been several studies highlighting the importance of establishing healthy eating habits at an early age, there needs to be an active involvement of the parents in forming these behaviors which can then be continued into adulthood. Children’s dietary habits, food preferences and even physical activity levels are greatly influenced by their parents and home environment.10 It is crucial that parents acknowledge the importance of healthy eating and the ways in which they can contribute meaningfully to their children’s understanding of the same. Additionally, cultural habits and beliefs need to be considered when discussing pediatric dietary guidelines with parents, ensuring they have factual information regarding what a healthy weight and diet entails for the corresponding age of the child.10 These are important factors which should be addressed by pediatricians in an effort to fur-

ther attenuate the risk associated with childhood obesity. Authors left to right: Adeel Sajid, Darwin Nguyen, Yi Fang, Cynthia Bogran and Jocelyn Wey are Second-year Osteopathic Medical Students at the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas.

References 1. Sharon Kirkpatrick, PhD, MHSc, RD, Amanda Raffoul, MSc, Measures Registry User Guide: Individual Diet. National Collaborative on Childhood Obesity Research. May 2017. http://nccororgms.wpengine. com/tools-mruserguides/wp-content/uploads /sites/2/2017/NCCOR_ MR_User_ Guide_Individual_Diet-FINAL.pdf 2. Byron A. Foster, Trevor M. Maness, Christian A. Aquino. Trends and Disparities in the Prevalence of Childhood Obesity in South Texas between 2009 and 2015. Journal of Obesity, vol. 2017, Article ID 1424968, 7 pages, 2017. https://doi.org/ 10.1155/ 2017/1424968 3. Goutham Rao, MD. Childhood Obesity: Highlights of AMA Expert Committee Recommendations. Am Fam Physician. 2008 Jul 1;78(1):56-63. https://www.aafp.org/afp/ 2008/0701/ p56.html#afp20080701p56-f1 4. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 2006;16(1):169-186. doi:10.1353/ foc.2006.0006 5. Lindsay A, Wallington S, Lees F, Greaney M. Exploring How the Home Environment Influences Eating and Physical Activity Habits of Low-Income, Latino Children of Predominantly Immigrant Families: A Quali-

tative Study. International Journal of Environmental Research and Public Health. 2018;15(5):978-995.doi :10.3390/ ijerph15050978 6. Vollmer RL, Mobley AR. Parenting styles, feeding styles, and their influence on child obesogenic behaviors and body weight. A review. Appetite. 2013;71:232-241. 7. Kalinowski A, Krause K, Berdejo C, et. al.:Beliefs about the Role of Parenting in Feeding and Childhood Obesity among Mothers of Lower Socioeconomic Status. Journal of Nutrition Education and Behavior. 2012;44(5):432-437. 8. Jang M, Owen B, Lauver DR. Different types of parental stress and childhood obesity: A systematic review of observational studies. Obesity Reviews. 2019;20(12):1740-1758. doi:10.1111/obr.12930 9. Innella N., Breitenstein S., Hamilton R., et. al.: Determinants of Obesity in the Hispanic Preschool Population: An Integrative Review. Public Health Nursing. 2016;33 (3):189-199. 10. Etelson, Debra, Donald A. Brand, Patricia A. Patrick, Anushree Shirali. Childhood obesity: do parents recognize this health risk? Obesity Research. 2003;11:1362– 1368. https://onlinelibrary.wiley.com/ doi/pdf/10.1038/oby.2003.184

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The History of Food Safety in America: A Tale of Deceit, Scandal and Poison By David Alex Schulz, CHP

From milk to meat, we assume food from the market represents sanitary production, quality ingredients, truth in labeling, and if not, healthful nutrition at least—not poison. This complacency comes only at the end of hard-fought battles … and the war is not over. Indeed, it was a postmortem of the SpanishAmerican War that brought the nation’s abysmal state of food preparation and adulteration into sharp focus. At the dawn of the 20th Century, the War Department was accused of killing more soldiers than did the enemy, poisoning with tainted food. The army’s commanding general called for an in-

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vestigation into the quality of the food supplied to his troops, accusing the military of feeding his men “embalmed beef.” While standard practice at the time to preserve canned meat with formaldehyde, the army sought the Department of Agriculture Chemistry Division to analyze a can of corned beef that left a 19-year-old private convulsing and a day later, dead. “The analysis showed that the contents of the can had been saturated with the neurotoxic metal lead, which had apparently seeped out of the container itself. Lead was also found in his body.” The fight to keep “poisons sold as food”

from public knowledge is dramatically documented in Deborah Blum’s “The Poison Squad” (2018, Penguin Publishing Group). Blum recounts the single-minded focus of Agriculture Department Chemist Harvey Wiley in his obsessive pursuit of the landmark Pure Food and Drug Act of 1906, and the battles resulting from its implementation.

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At the time, a typical day’s meals contained overly ample amounts of borax, alum, salicylic acid (not acetylsalicylic), sodium sulfite, coaltar-dyes, benzoic acid, saltpeter, sulfuric acid, formaldehyde, copper, methyl alcohol and boracic acid. More than forty doses of unregulated chemicals and dyes would be consumed in a day. No food was untainted: “Dairymen, especially those serving crowded American cities in the nineteenth century, learned that there were profits to be made by skimming and watering down their product. The standard recipe was a pint of lukewarm water to every quart of milk—after the cream had been skimmed off. To improve the bluish look of the remaining liquid, milk producers learned to add whitening agents such as plaster of Paris or chalk. Sometimes they added a dollop of molasses to give the liquid a more golden, creamy color. To mimic the expected layer of cream on top, they might also add a final squirt of something yellowish, occasionally pureed calf brains.” “Flour” was routinely extended with crushed stone or gypsum. Brown sugar contained ground insects. “Coffee” was anything but: More than 80-percent of ground coffee tested was adulterated. “One sample contained no coffee at all.” Wiley’s team also found that processors had devised a way to make coffee-free “beans” by pressing a mixture of flour, molasses, and occasionally dirt and sawdust into molds. Counterfeit foods were a major concern in the spice industry, where a ground product may hide a high-proportion of adulterant. “One New York firm—a purveyor of pepper, mustard, cloves, cinnamon, cassia, allspice, nutmeg, ginger, and mace—purchased five thousand pounds of coconut shells a year for grinding and adding to every spice on that list.” America is synonymous with ample meat supplies, but Upton Sinclair’s “The Jungle” dispelled any belief in hygiene or sanitation on

the butcher’s floor. The meatpackers’ fight to keep it from publication is a turning point in the struggle. They focused on accusations of “fake news,” threatening to sue publishers. Doubleday and the Chicago Tribune launched their own investigation, much to the meatpackers chagrin: it showed the book was understatement. “Both men returned disgusted and horrified by what they’d seen.” The case for regulation is also seen as a drive to limit freedoms, an immensely powerful argument. It took an equally powerful organization and unlikely hero to assure the passage of the 1906 Pure Food and Drug Act, also known as “Wiley’s Law” – the American Medical Association (AMA). The AMA was determinedly nonpolitical and less interested in food safety than in the problem of snake-oil medicines, but the two issues were bonded together in the law which was bottled in committee. The AMA threatened Finance Committee-chair Senator Nelson Aldrich to rally all 135,000 physicians in the country, “including all of those located in the senator’s home state, to get the bill passed. The doctors would, if need be, contact every patient, county by county.” In the end, it was by virtue of President Theodore Roosevelt’s Rough Rider experience in Cuba that he politically championed Chief Chemist Wiley and his team of “taste testers,” AKA, the Poison Squad. We can read labels of ingredients with some assurance today in large part because of Teddy’s Bully Pulpit and his belief that Americans deserved honest food. But times change, and rules must adapt: A year after the book’s publication, standards for labeling “organic” were finally established. * All quotes from. The Poison Squad – One Chemist’s Single-Minded Crusade for Food Safety at the Turn of the Twentieth Century, by Deborah Blum, Penguin Publishing Group, 2018, Kindle Edition.

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

“I WONDER WHAT’S IN IT” We sit at a table delightfully spread And teeming with good things to eat. And daintily finger the cream-tinted bread, Just needing to make it complete A film of the butter so yellow and sweet, Well suited to make every minute A dream of delight. And yet while we eat We cannot help asking, “What’s in it?” Oh, maybe this bread contains alum or chalk Or sawdust chopped up very fine Or gypsum in powder about which they talk, Terra alba just out of the mine. And our faith in the butter is apt to be weak, For we haven’t a good place to pin it Annato’s so yellow and beef fat so sleek Oh, I wish I could know what is in it. The pepper perhaps contains cocoanut shells, And the mustard is cottonseed meal; And the coffee, in sooth, of baked chicory smells, And the terrapin tastes like roast veal. The wine which you drink never heard of a grape, But of tannin and coal tar is made; And you could not be certain, except for their shape, That the eggs by a chicken were laid. And the salad which bears such an innocent look And whispers of fields that are green Is covered with germs, each armed with a hook To grapple with liver and spleen. The banquet how fine, don’t begin it Till you think of the past and the future and sigh, “How I wonder, I wonder, what’s in it.” HARVEY WASHINGTON WILEY, 1899 Read aloud by the author to Congress at hearings on the Pure Food and Drug Act Blum, Deborah. The Poison Squad (pp. xi-xii). Penguin Publishing Group. Kindle Edition.

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Health Insurance Company Chicanery By Neal S. Meritz, MD

The health insurance industry utilizes many tactics, some overbearing and some more subtle, but doctors and patients are invariably the victims. Physicians have always had a love/hate relationship with health insurance companies. This is the result of decades of dishonorable treatment of doctors, hospitals and patients in policy making and payment considerations. Health insurance companies have become multibillion dollar industries in part by refusing to pay physicians, care centers and hospitals fairly. Denying and delaying claims is the foundation on which the health care industry reaps those enormous profits. Coding Medical coding is how the physician’s practice turns services provided into billable revenue,1 and if that coding is deemed inaccurate by the insurer, reimbursements will be delayed, denied or only partially paid. The ICD system is complex and confusing with claims most frequently rejected due to alleged billing and coding errors. Medical coding is predominately payment related; it has almost nothing whatsoever to do with patient care. Any claim that results in non-payment or delay results in increased revenue for the insurer, and ICD considerations further that aim. Denying Valid Claims Healthcare insurers routinely make the business decisions to deny the claim and hope that the patient does not pursue the appeal.2 Faced with a denial, most patients and doctors will accept the insurer’s decision and pay the bills themselves, thus increasing the insurer’s profits.3 According to healthcare.gov, in 2019, 181 major ACA (Obamacare) medical insurers reported 232.2 million in network claims received, with 40.4 million denied, an average of 17.4%. Less than 60,000 of these denials were appealed, an appeal rate of less than 0.2%.4 34

SAN ANTONIO MEDICINE • May 2021

The insurer agreed to overturn about 40% of that 0.2%. Former Kansas Insurance Commissioner Sandy Praeger states, “We think some companies are probably denying claims, counting on the hassle factor, so that people will just go ahead and pay out of their own pockets.” 5 COMPLEXITY Consumer Reports The complexity of our health care structure is the reason that we have the most expensive, inequitable, inefficient and unpopular health care system of any developed country, with poor to mediocre outcomes. Reimbursement, with its mind-boggling payment rules, creates an enormity of administrative costs as well as many perverse incentives. Physicians and hospitals are insurance company prey. The system, with its intentional confusion, is designed to wear physicians down. An insurance company has nothing to lose and everything to gain by placing barriers in the physician’s path. The percent of premiums that an insurance company spends on claims and expenses that improve health care is called the “Medical Loss

Ratio.”6 Thus, actually paying doctors and providing health care to patients are considered financial losses by an insurer. Other Tactics Health insurers employ many other deceptions to avoid paying doctors. They might claim that the procedure is experimental or cosmetic. Insurers have been found guilty of canceling, illegally and retroactively, policies of people whose medical conditions are too expensive to treat. Many denials are for procedures judged to be “not medically necessary.” Insurance companies rely on technicalities such as improper coding or demographic errors to deny valid claims. Insurers now perform what they refer to as “audits,” utilizing software known as “denial engines” because the programs are designed to purposely decrease payments to doctors and hospitals. Multiple industry sources have reported the automatic downcoding or denial of high-level evaluation and management services.7 And, of course, there is the hassle factor from: prior authorizations, exclusion of medications and intentional confusion.

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The Float According to Warren Buffet, “The Float” is the money the insurance company gets to hold onto between the time patients pay premiums and the time the insurer must pay out claims on their policies.8 Insurers receive premiums up front and pay claims much later, leaving large sums to be invested. If premium income exceeds the total of expenses and eventual losses, the insurer registers an underwriting profit that adds dramatically to the investment income produced by The Float.9 High volume denials based on idiosyncratic edits, made-up rules and contrived audits are commonplace. The rationale for insurance companies to not pay claims is obvious.

most revealing a doubling of profits in 2020 compared to 2019. Meanwhile, premiums have increased 57% since 2009. United Healthcare reported a Medical Loss Ratio (their phrase for The Float) of 70.2%, accounting for record profits in 2020 during the pandemic.10 There is no dominant entity to set administrative standards because the U.S. health care system is so fragmented. Meanwhile, insurers run amok, minimally regulated, collecting overwhelming profits at the expense of physicians, hospitals and patients. This dishonorable behavior has long been characteristic of the health insurance industry, and the likelihood is great that these deceitful practices will continue indefinitely.

Conclusion Many in the U.S. are struggling as a result of the pandemic, but health insurance companies are thriving. Multibillion dollar profits are reported by all the large insurers, with

Neal S. Meritz, MD is a retired Family Practice physician and a member of the BCMS Publications Committee.

References 1 “A Brief History of Medical Coding” by Ben Castleberry 5/11/16 Aviacode 2 “How to Fight Back When An Insurer Denies Your Claim” 1/17/17 McKennon Law Group California Insurance and Life, Health, Disability Blog 3 “Six Ways to Avoid Having a Healthcare Claim Denied” by Orly Avitzur MD Consumer Reports 12/14 4 “Transparency in Coverage for 2020 Plan Year” 1/20/21 by Karen Pollitz and David McDermott Kaiser Family Foundation 5 Sandy Praeger Kansas Insurance Commissioner 2003-2015 LA Times 1/17/17 6 “How Insurers Deny Legitimate Claims” McKennon Law Group PC California Insurance Litigation Blog 7”Software Helps Insurers Profit From Denials” by David Rosenfeld 6/14/17 Pacific Standard/Grist 8 “Warren Buffet Explains the Genius of the Float” by Jacob Goldstein 3/1/20 Texas Public Radio NPR 9 “Are Healthy Care Companies Profiting From The Float?” By Milt Treudenheim 4/17/97 The New York Times 10 “Transparency in Coverage for 2020 Plan Year” Kaiser Family Foundation 1/20/21

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SAN ANTONIO MEDICINE • May 2021

SAN ANTONIO MEDICINE

Life Burns By Emily Sherry

Good morning, and hot sauce flew into my eye from the breakfast I had tried to spice up. Thankfully, it didn’t burn. Good afternoon, and walking into the VA I received the daily COVID-19 screen. Fortunately, I have no fever or signs for concern. It’s time to get handoff for our shift and learn, our guy who’s supposed to go home on antibiotics, Is now on hospice, with DNR and prn narcotics. From serving in Vietnam to working at the zoo, and running a business in horticulture too, He lived a flavorful and naturistic life, loved his work, family, and late wife. Last shift I’d said, let’s get you home, you’ve got a lot more life to live. He agreed, let’s not let this infection be a deflection. We’d chatted about all things - religion, politics, and living, Jokingly, I said, just in time to prep for what’s taboo at Thanksgiving. He’d even shared his burial plans to eventually rejoin his wife in the urn. We just never knew that week would be his turn. From man we are dust, and to dust we shall return. And oh boy, did that day fervently burn.

Reflection I wrote the following poem, "Life Burns," from caring for one of our veterans from his initial presentation at the hospital to the end of his life. I write about this experience with the specific allegory of burning in order to juxtapose the actual “nonburning” events (of the day I walked into shift and learned of a 180º turn of events) with the heat of raw human emotions I experienced in learning that my patient now faced the end of his life in the coming days. This man never struck me as a “dying” or even an at near “risk-ofdying” patient when he presented to the ED with pneumonia. Maybe it was because he didn't enter the hospital looking very sick, because he was relatively young, because he was conversing expressively and vividly, or because my clinical acumen is still developing, but he just didn’t fit my picture of someone in their final days. With that being said, I’m reminded that the time one has left on earth doesn’t look the same on everyone, and not everyone receives an advance notice. My goal in this poem was to embody the things that were important to him as a person. In particular, he told me that he did not believe he would be remembered past his adult kids. He was disheartened that he would not "leave a legacy." Because of this, I wanted at the least to create something concrete, to put something on paper, if you will, that would remind me of our work together. I wanted to capture a piece of our time, including our expansive conversations on traditionally avoided topics—per his free-spirited personality—as well

as some of the things that made him the person he was. In this way, I honor his memory, the time we shared, and maybe a little legacy too by sharing the poem with others. Importantly, I also carry the lessons he taught me into caring for future patients: the impetus for strong patient communication, the power of stopping by the patient’s room again before going home, and the gravity that even a medical student’s advocacy can make for respecting end-of-life wishes. He walked into our hospital never expecting a days-left prognosis, and his dying wish was to make it home one last time to say goodbye to his family, feel the sun and fresh air, hug his dogs. After life only handed him this “daysnotice,” I saw tangible change in his eyes and voice in how he encountered every ounce of life. Going home had many steps, such as establishment of an oxygen tank at the house and a 24hour nurse. Hours and hours passed; he held onto life by the bridge of maximum flow oxygen. We didn’t leave his side until they brought the transport stretcher. At this point, our team didn’t know if he’d survive the drive. We cared for our other patients, and we kept praying… Thanks be to everyone who fought for his wishes: he spent the final hours with his granddaughter and son at home. He died surrounded by the nature in which he’d made a living. A Poem and Reflection by Emily Sherry, Medical Student, Class of 2022, UT Health, Long School of Medicine.

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Respite Care for San Antonio’s Homeless By Tori Brucker, Ryan Daly, Thomas Damrow, Thelmari Raubenheimer

The emergency room is a community’s medical safety net, often caring for the uninsured with no guarantee of payment. Low-income populations, including our city’s homeless population, increasingly rely on the emergency department for basic primary care. Healthcare needs of the homeless are comparable to those of the general population, however, their circumstances often result in more acute presentations and require advanced measures to be taken during their treatment and continuation of care. The American Hospital Association found that hospital admission rates are five times greater amongst the homeless, and that these patients remain in the hospital for an average of four days longer.1 These extended stays result in increased costs without subsequently improved healthcare outcomes. A study measuring hospital readmission rates amongst the homeless found that homeless individuals have a 30-day readmission rate of 22% as compared to 7% among matched control patients from low-income backgrounds with similar primary reasons for admission.2 Significant contributors to the poorer outcomes amongst this population are a return to adverse living conditions, a lack of patient follow-up and difficulties with care coordination that collectively decrease compliance resulting in many patients “falling through the cracks.” With the discouraging information about readmission rates and costs of care in mind, the question arises as to what hospitals and communities could do to mitigate this burden and improve health care outcomes for our homeless neighbors. The current approach to discharging homeless patients is both challenging and complex. The tasks of securing patient funding, establishing follow-up connections and locating stable housing places significant burden on hospitals and their staff. Many local shelters are already operating at maximum capacity and few are properly equipped to house and care for homeless individuals, post-discharge, who typically require more attentive care and specific follow-up services. To add to these difficulties, some shelters have acceptance criteria, such as physical ability and medical clearance, that excludes a significant number 38

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of discharged patients who may not have alternative housing options. Cumulatively, these factors frequently prevent the orchestration of a safe and cost-effective discharge plan for the homeless patient. As a result, hospitals typically are forced to absorb the costs of medical care and the patient is often left with no options other than a return to the streets. There is a consequent high likelihood of readmission due to inadequate healing. Fortunately, many cities are beginning to explore new ways in which the homeless community can be helped after discharge. Programs such as respite care are an example of an intervention showing promising results. Respite care stands apart from traditional shelters in that it provides post-hospital care to homeless patients who are not sick enough to remain in the hospital, but still require monitoring and basic healthcare services.3 Medical respite programs have been shown to reduce future hospital admissions, 90-day hospital readmissions and hospital length-ofstay among homeless patients.4 Many also offer social services and housing placement assistance that eases these patients’ transition from the streets to stable housing situations. While respite programs alone are not a solution to the challenges the homeless population faces on discharge, they present a clear opportunity to improve health outcomes, mitigate healthcare costs and transition homeless individuals into reliable housing. Currently, San Antonio community organizations work tirelessly to provide food and housing to the nearly 3,000 homeless individuals living within Bexar County.5 Despite these efforts, post-hospital discharge care for the homeless remains extremely challenging. Implementation of new projects to tackle homeless healthcare have the potential to drastically improve the health of our local homeless population and help the city progress towards decreasing homelessness here in San Antonio. In December of 2020, the city released its 5-Year Strategic Plan to Respond to Homelessness in San Antonio and Bexar County. This plan outlined a broad expansion of homeless aid programs with specific focus on

identifying ways to assist those “high-utilizers” of behavioral and medical health systems, follow-up with patients recently discharged from a hospital setting and providing dedicated respite/recovery beds and step-down facilities for chronically ill individuals.6 This call to address the issue of homeless healthcare comes at an important time as the city of San Antonio works to allocate the influx of local and federal funding resources towards tackling homelessness. Given the success and benefits of respite care programs, the city's exploration of this method of homeless care could greatly contribute to their future strategy. References: 1. Health Research & Educational Trust. (2017, August). Social determinants of health series: Housing and the role of hospitals. Chicago, IL: Health Research & Educational Trust. Accessed at www.aha.org/housing 2. Saab, D., Nisenbaum, R., Dhalla, I., & Hwang, S. W. (2016). Hospital Readmissions in a Community-based Sample of Homeless Adults: a Matched-cohort Study. Journal of General Internal Medicine, 31(9), 1011–1018. doi: 10.1007/s11606-016-3680-8 3. Tomita, A., & Herman, D. B. (2012). The Impact of Critical Time Intervention in Reducing Psychiatric Rehospitalization After Hospital Discharge. Psychiatric Services, 63(9), 935– 937. doi: 10.1176/appi.ps.201100468 4. Doran, Kelly M, et al. “Medical Respite Programs for Homeless Patients: a Systematic Review.” Journal of Health Care for the Poor and Underserved., vol. 24, no. 2, pp. 499–524. 5. South Alamo Regional Alliance for the Homeless (SARAH). (2019). Retrieved from https://www.sarahomeless.org 6. Strategic Plan to Respond to Homelessness in San Antonio and Bexar County. December 2020. Retrieved from https://www.sanantonio.gov/Portals/0/Files/HumanServices/Ho melessServices/StrategicPlan.pdf

(L-R) Tori Brucker, Thomas Damrow, Thelmari Raubenheimer and Ryan Daly are all OMS III’s at UIWSOM.

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BCMS Alliance Teams with BCMS to Hold

Doctors’ Day Blood Drive In honor of Doctors’ Day, the Bexar County Medical Society and the Bexar County Medical Society Alliance held a blood drive with the South Texas Blood & Tissue Center. The event was held on April 6 at the Bexar County Medical Society headquarters. The drive ended up with a total of 34 units of blood collected, far surpassing their goal of 25 units. The 34 units collected will help save the lives of 102 patients in South Texas. Special thanks to the volunteers and team who made it possible! Above: Nichole Eckmann and April Chang with the Bexar County Medical Society Alliance and Raymond Hampton with the South Texas Blood & Tissue Center help with the blood drive.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of April 19, 2021. Visit us at www.bcms.org

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

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

ACCOUNTING SOFTWARE

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

ATTORNEYS

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

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

ASSETT WEALTH MANAGEMENT

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

BANKING

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country

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Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking (210) 283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”

sound financial future Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com https://www.bbt.com/wealth/star t.page "All we see is you" Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need. Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

DIAGNOSTIC IMAGING

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

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

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

FINANCIAL SERVICES

HEALTHCARE BANKING

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

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

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!”

Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services. Mary P. Mahlie Vice President Wealth Advisor (512)787.2488 Mary.Mahlie@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (210)385.9326 Fred.Kelley@Regions.com www.Regions.com

Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President | Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

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

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options. Laura Kouba Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu

INFORMATION AND TECHNOLOGIES

“We offer BCMS members a free insurance portfolio review.”

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

INSURANCE/MEDICAL MALPRACTICE 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”

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org www.tmait.org

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593

continued on page 42 Visit us at www.bcms.org 41

PHYSICIANS PURCHASING DIRECTORY continued from page 41

katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com

ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

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

MEDICAL BILLING AND COLLECTIONS SERVICES

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice.

Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.” Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL PRACTICE

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

MEDICAL PHYSICS

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

SAN ANTONIO MEDICINE • May 2021

MEDICAL SUPPLIES AND EQUIPMENT

www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

PRACTICE SUPPORT SERVICES CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.

Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

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”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com

PROFESSIONAL ORGANIZATIONS

San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of health-

care real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate” The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center. Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.

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

The Bexar County Medical Society is proud to welcome a Renewing Platinum Sponsor to our Circle of Friends program.

TELEHEALTH TECHNOLOGY

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713

Please support this sponsor with your patronage, they support us.

Visit us at www.bcms.org

AUTO REVIEW

SAN ANTONIO MEDICINE • May 2021

AUTO REVIEW

2021 BMW 530e By Stephen Schutz, MD

Electric cars are coming. Like for real. They’re going to hit us from all directions, most notably China, and they are going to change our lives. This is an inevitability, and the only question is when it’s going to happen. Sandy Munro, a well-regarded automotive industry consultant, predicts that battery electric vehicles (BEVs) and plug-in hybrids will begin outselling internal combustion engine (ICE) powered cars and light trucks in 2028. I have been and continue to be a BEV skeptic—BEVs comprised 2% of the U.S. automotive market in 2020, about the same as in 2015, so I’m not completely off base with my skepticism—but I’m starting to see how things may change quickly. If you’re a true believer, you already have a Tesla, Nissan Leaf, Audi e-Tron or Porsche Taycan, but if you’re not, you are probably wondering how this big transformation is going to happen. I think it will happen gradually at first, and then quickly. As for the gradual part, consider the BMW 530e. It is a plug-in car that does everything—an “almost BEV” that gives you most of the pluses of a BEV with few of the minuses. Here is what I mean: Fully charged, the 530e will give you about 25 miles of all electric driving. For most people, that is enough to get you to work and back plus a couple of stops along the way (Starbucks, the store, soccer practice or yoga). If you have a charger at work, which increasingly people do, you can do even better on electric power alone. For example, my GI practice just built a new endoscopy center and we installed two charging ports in the parking lot. Imagine never (or rarely) going to a gasoline station. That’s what my week with the plug-in hybrid 530e was like. I drove to work at 7 every morning, did my doctor thing all day, ran a few errands, drove home, plugged in and then did it all again the next day. There was no “driving excitement,” and let’s face it, with any car you plug in there rarely is. Nevertheless, it was all very pleasant. Road trips with the family or other long drives, which are generally exercises in range anxiety in BEVs, are no problem with the 530e thanks to its conventional four-cylinder engine and eight speed ZF automatic transmission. Both are there to back you up when you can’t charge. The exterior design of the 530e is sleek and contemporary, exactly what you would think the BMW 5-Series would look like in 2021. In fact, I found myself glancing over my shoulder to admire it several

times. The reason for this was its attractive design, but part of it was the Phytonic Blue Metallic paint which was eye-catching on its own. (I would not recommend getting your new 5-Series in white or silver, please. You’ll regret it). It must be said, however, that BMW has regrettably gone back to its 1990s ways with its sedans by making “one sausage in three different lengths.” It takes a trained eye to tell the 5-Series from the 3 or even the 7, and I wish that weren’t the case. Having said that, if everyone is buying SUVs and crossovers, does it really matter anymore? The interior of the 530e is a very nice place in which to spend time, as is the case with any new Lexus, Audi or Mercedes. As with those brands’ interiors, screens have replaced all of the gauges. Everything you need information-wise is either right in front of you or just a few taps on a touch screen away. All that tech can be overwhelming at first, but with a little study and practice it becomes easy. (Note to Lexus: study BMW and Audi’s user interface and make some changes.) The cabin of the 530e is a quiet and comfortable cocoon that is as relaxing as any 1960s Cadillac. No, it is not as involving as its epic 535i predecessor of the 1980s, but after a long day cathing, operating or sitting down with 24 patients, doesn’t a quiet cocoon sound good? Nevertheless, I miss cars that were “involving.” As always with vehicles from Germany, many options and option packages are available to help you personalize your ride. My wellequipped tester carried a sticker price of just over $70,000, and I think that’s about where most transaction prices will end up. As BEVs and plug-in hybrids begin to take over the market, I’d make a case for going with the latter over the former, at least for now. Plug-in hybrids give you the benefit of using just electricity most of the time, but won't leave you stranded if you can’t find a charger on a long road trip. And the 530e is an excellent plug-in hybrid. As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

Visit us at www.bcms.org

San Antonio Medicine May 2021

Articles inside

Early Establishment of Health Eating Habits in Childhood

CDC Boil Water Advisory

From Cable into the Kitchen: How the LSOM Food Network Inspired Me to Change the Way I Cook By Ana Moser

Healthy Eating and the Gift of Imperfection

Gardening & Farming: Examining the San Antonio Food Bank’s Farming Effort

The Diet Puzzle By Janice Tapp, MSN, RN

Childhood Obesity: An Unresolved Public Health Problem By John Menchaca, MD

By Chirag Patel, MDBloating & Food Choices

Can We Incentivize Healthy Behavior?

Hispanics and Liver Disease

Precision Nutrition: The Merger of Nutrition and Medicine By Tim Hlavinka, MD