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THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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PREVENTATIVE MEDICINE Helpful Tips on How to Prevent Joint and Back Pain By Gerardo Zavala II, MD, FAANS ......................................12 Key Asthma Management Strategoes to Prevent Asthma Attacks By John F. Freiler, MD...........................................14 Q&A: Understanding Risk of Gynecological Cancers By Jason Mark, MD.............................................................16 Skin Cancer Prevention By Fatima Raza, OMS-III, Faraz Yousefian, DO and Daniel Fischer, DO ...............................................................18 Prevention and Management of HIV in the 21st Century By Moses Alfaro, BSA and Colton Blinka, BSA ......................20 Prevention through Health Equity Training at the Long School of Medicine By Garrett Kneese and Samantha Driscoll .............................22

BCMS President’s Message .................................................................................................................................................8 BCMS Alliance: Nutrition Tips for a Healthy Summer By Taylor Frantz, RDN, LD ................................................................10 Bexar County Medical Society Building Named Stephen C. Fitzer Building.........................................................................26 Patient Safety, Burnout and COVID-19 By Prachi Shah and Desiree “Dez” Ojo...................................................................28 Art in Medicine: Artistic Expression in Medicine By Ravjot Vridi and Contemporary By Winona Gbedey ..............................31 Physicians Purchasing Directory.........................................................................................................................................32 Auto Review: 2022 GMC Yukon By Stephen Schutz, MD...................................................................................................36 Recommended Auto Dealers .............................................................................................................................................38

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SAN ANTONIO MEDICINE • June 2022

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JUNE 2022

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VOLUME 75 NO.6

San Antonio M edicine is the officialpublication of Bexar C ounty M edicalSociety (BC M S). Allexpressions of opinions and statem ents of supposed facts are published on the authority ofthe w riter,and cannotbe regarded as expressing the view s of BC M S. Advertisem ents do not im ply sponsorship oforendorsem entby BC M S. EDITORIAL CORRESPONDENCE: BexarC ounty M edicalSociety 4334 N Loop 1604 W ,Ste.200 San Antonio,TX 78249 Em ail:editor@ bcm s.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 peryearor$4 perindividualissue ADVERTISING CORRESPONDENCE: Louis D oucette,President Traveling Blender,LLC . A Publication M anagem entFirm 10036 Saxet,Boerne,TX 78006 w w w .travelingblender.com

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS RajeevSuri,M D,President BrentW.Sanderlin,DO,VicePresident Ezequiel“Zeke”SilvaIII,M D,Treasurer AliceGong,M D,Secretary John J.Nava,M D,President-elect Rodolfo“Rudy’M olina,M D,ImmediatePastPresident

DIRECTORS VincentFonseca,M D,M PH,Member W oodson "Scott"Jones,M D,Member LubnaNaeem ,M D,Member LyssaN.Ochoa,M D,Member JenniferR.Rushton,M D,Member RaulSantoscoy,DO,Member John Shepherd,M D,Member Am arSunkari,M D,Member LaurenTarbox,Member Col.Tim Switaj,M D,MilitaryRepresentative M anuelM .QuinonesJr.,M D,BoardofEthicsChair GeorgeF.“Rick”Evans,GeneralCounsel Jayesh B.Shah,M D,TMABoardofTrustees M elodyNewsom ,CEO/ExecutiveDirector TaylorFrantz,AllianceRepresentative Ram on S.Cancino,M D,MedicalSchoolRepresentative LoriKels,M D,MedicalSchoolRepresentative Ronald Rodriguez,M D,PhD, MedicalSchoolRepresentative CarlosAlbertoRosende,M D, MedicalSchoolRepresentative

BCM S SENIOR STAFF M elodyNewsom ,CEO/ExecutiveDirector M onicaJones,ChiefOperating Officer YvonneNino,Controller M aryNava,ChiefGovernm entAffairsOfficer BrissaVela,M em bership Director PhilHornbeak,AutoProgram Director AugustTrevino,Developm entDirector BettyFernandez,BCVIDirector AlOrtiz,ChiefInform ation Officer

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SAN ANTONIO MEDICINE • June 2022

PRESIDENT’S MESSAGE

Preventative Medicine in 2022 – A Renewed Push By Rajeev Suri, MD, MBA, FACR, 2022 BCMS President

Preventative (or Preventive) medicine are terms that have been used interchangeably since the 17th century and consist of measures taken for disease and disability prevention to ultimately improve disease outcomes. Each year, millions of people die of preventable deaths which are more often due to preventable behaviors (lifestyle choices) and exposures (environmental factors and disease agents). Leading causes of preventable deaths include chronic cardiovascular and respiratory disease and diabetes, while others include cancer, unintentional injuries and infectious diseases. We know the value of preventing disease; however, we live in a time when our knowledge and actions don’t always match up. In fact, our knowledge of the value of preventing disease and disability far exceeds our investments in public education and public health infrastructure that could support our taking advantage of that knowledge.1 The COVID-19 pandemic has exposed inadequacies of the current healthcare system, and as the US healthcare system defines the new normal in the evolving post COVID-19 era, it needs a new approach to providing sustainable preventive care for our populations. Failure to do so will worsen the long-standing disparities in health care that have been underscored by the pandemic. Preventive care has traditionally focused on face-to-face annual exams and labs/tests. This low-efficiency and low-efficacy model suffered during the pandemic due to decreased overall in-person patient visits, and disparities in race, ethnicity and socioeconomic status among those who utilized these in-person visits. The US healthcare system could shift the focus of preventive case from face-to-face exams to a strategy that focuses on population health: clinical registries to identify preventive services needed, annual prevention kits to facilitate widespread home-based testing, shared decision making, self-scheduling of screening tests and procedures at approachable community settings, and community-based strategies with navigators to overcome health disparities in underserved populations.2 Robust comprehensive registries that track all USPTF (US Preventive Services Task Force) grade A and B preventive services for patient populations are urgently needed to track the current versus targeted status. Integration of such registries with EHRs (electronic health records) to improve patient communication, and interoperability of these smart registries across EHRs and diverse health settings is key to analyzing utilization population patterns and health conditions by linking patients and clinicians to achieve the best prevention methods. Targeted annual prevention kits for addressing the USPTF grade A and B preventive services would be needed for every patient to allow POC (point-of-care) at-home testing along with easily-accessible questionnaires to facilitate personalized risk assessment and shared decision-making for chronic conditions. The pandemic has confirmed to us that virtual encounters with primary care providers (PCPs) work, and self-scheduled visits with PCPs can facilitate shared decision-making between patients 8

SAN ANTONIO MEDICINE • June 2022

and their providers. Any immunizations or preventive procedures can be scheduled at community-based clinics through patient navigators, thus aiming to close the gaps that adversely affected underserved patients and populations living in medical deserts. These programs may not eliminate the social determinants of health such as poverty and food insecurity, but could make access to the preventive services more equitable. In Bexar County, San Antonio Metro Health is leading the charge with the ‘SA Forward Plan’ to improve the health of our community. The strategic plan over the next five years plans to invest in preventive care and focus on six priority areas: Access to Care; Data and Technology Infrastructure; Food Insecurity and Nutrition; Health Equity and Social Justice; Mental Health and Community Resilience; and Violence Prevention. Further investments to promote comprehensive population health objectives that support preventive care are coming via the planned Public Health Division within University Health created in partnership with Bexar County. Nationally, however, challenges still exist to implementing this paradigm shift in preventive healthcare to a population-based strategy. These include payment reform for evidence-based preventive care delivery with demonstrable commitment to addressing disparities. The reform is needed not only for providers but also for community-based preventive healthcare delivery systems. Patient and clinician acceptance is a major hurdle, but a bigger hurdle is the acceptance from the overall healthcare system. A major challenge is federal and state level funding. Rather than increasing the growing health debt, what is needed is a change in focus of healthcare investments to prevention and health promotion. A large-scale shift in population-based prevention strategy is long overdue. Maybe the uncovering of the chronic pandemic by the recent acute pandemic/crisis will be the much-needed impetus that can drive this change. References 1. Hoffman D. Commentary on Chronic Disease Prevention in 2022. https://chronicdisease.org/wp-content/uploads/2022/04/ FS_ChronicDiseaseCommentary2022FINAL.pdf 2. Horn DM, Haas JS. COVID-19 and the mandate to redefine preventive care. NEJM 2020; 383; 1505-1507 Rajeev Suri, MD, MBA, FACR is the 2022 President of the Bexar County Medical Society, Tenured Professor and Interim Chair of the Department Radiology at UT Health San Antonio, and Chief of Staff at University Hospital San Antonio.

BCMS ALLIANCE

Nutrition Tips for a Healthy Summer By Taylor Frantz, RDN, LD

Summertime brings relaxation and adventure. Here are some quick nutrition tips to keep in mind this summer!

Hydration: Daily water loss is normal and requires replacement. During times of physical activity, illness, sweating or alcohol intake, fluid intake should be increased. For an average adult, fluid needs are between 3035 ml/kg of body weight. One classic way to check if you are hydrated enough is by looking at the color of your urine. You can consider yourself hydrated if your urine is a pale, yellow color. o Foods that fight dehydration include watermelon, berries, grapes, oranges, salad greens and fat free milk. o Freezing fruit, such as grapes, can make for a refreshing summertime snack that keeps you cool and hydrated. Try them instead of ice cubes! o Carrying a marked, reusable water bottle with you serves as a visual reminder to drink, as well as providing convenient access to a drink. o Try adding different flavors to your water for variety. Citrus, cucumbers, mint or strawberries add a twist to plain water. See recipe below for a refreshing summertime beverage. Meal planning: Summer is filled with busy schedules and trips that often lead to eating at restaurants more frequently. The right planning can set you up for nutrition success. o Create a weekly menu so you can easily prepare meals without too much thought. o When eating out at restaurants, look for key terms that clue you into a leaner choice such as grilled, baked, boiled, roasted or steamed. o Packing a meal to go in an icebox can help you avoid trips through the drive-thru for convenience foods. Self-care: Remember that everybody is a beach body and everybody has the right to wear shorts, dresses and bathing suits. Making memories that last a lifetime is so much more important than worrying about how you will look poolside. Appreciate your body for all it can do. Summer strawberry star-cube refreshers Recipe created by Michele Sidorenkov, RDN at mymillennialkitchen.com Ingredients 8 oz strawberries 1 cup blueberries 1 1/2 tablespoons lemon zest (1 medium lemon) Sparkling water 1 1/3 tablespoon sugar Optional garnish: lemon slices and mint sprigs 4 medium mint leaves Preparation: In a food processor, blend trimmed strawberries, lemon zest, sugar and mint leaves until it becomes a smooth puree (about 30 seconds). Spoon your strawberry puree into an ice cube tray or mold shapes and freeze overnight. Lay your blueberries out flat on a freezer-safe surface and freeze overnight as well. Keep the strawberry puree and blueberries frozen until you are ready to serve. Prepare the glasses by adding ice, star-cubes and frozen blueberries to the drink, then topping off the top with sparkling water and garnish. Add about 2-4 strawberry star-cubes to each 8 oz glass, adjusting the amount depending on your desired flavor strength. Enjoy! Taylor Frantz, RDN, LD is a registered dietitian and the 2022 President of the BCMS Alliance.

SAN ANTONIO MEDICINE • June 2022

PREVENTATIVE MEDICINE

Helpful Tips on How to Prevent Joint and Back Pain By Gerardo Zavala II, MD, FAANS

f you've been searching for helpful tips on how to prevent or reduce joint and back pain, you have come to the right place. We will be discussing some of the best tips to maintain health within the joints, neck, back and spine. While this list is a great starting point, always consult your primary care physician for further analysis of your unique condition to establish a good starting point on your journey towards health and wellness. Starting with the basics The foundational aspects of health and wellness consist of many factors. Below is a breakdown of some of the first steps you can take to promote a healthier body. Maintain movement Maintaining movement is key to ensuring our joints, neck, back and spine remain healthy and mobile. Without consistent, steady movement throughout periods of the day, we will possibly begin to develop muscle atrophy. Through atrophy of the muscles, we will lose out on valuable core strength which helps support our neck, back and spine. Additionally, having leg strength developed through natural movement to support our body weight as we walk, run and exercise is crucial to maintaining safety while participating in various activities. Build strength and stamina Building strength and stamina across our entire body is ideal, yet it’s still beneficial to start slowly with your strength and stamina routine, then go from there. Without the proper amount of strength and stamina, one may be prone to injuring themselves while participating in everything from basic activities to intense sporting activities. Having the right amount of strength and stamina may help prevent injuries from occurring through core strength, balanced stability, quicker reaction times and muscle memory. Address ongoing problem areas through physical therapy Physical therapy is an amazing tool to help sort out problem areas within the body’s muscles, neck, back, spine and joints. One of the steps to take if you know you are suffering from 12

SAN ANTONIO MEDICINE • June 2022

PREVENTATIVE MEDICINE

tightness, aches, pains or stiffness from a past injury is to enroll the help of a qualified physical therapist. Physical therapy professionals have the ability to work with your body’s conditions in a non-invasive manner to promote blood flow, muscle movement, flexibility and regain strength over time. Stretching Stretching is a great activity to do at the beginning of the day. It certainly sets the tone for the rest of your day when you have a nice, relaxing stretching or yoga session. Stretching helps the body prepare for the day’s activities after a restful night of sleep. Stretching is also something your physical therapist will likely guide you on to best assist with the at-home care regimen portion of your physical therapy routine. Staying hydrated Staying adequately hydrated is crucial to maintaining a healthy lifestyle. Chronic dehydration is one of the leading causes of many conditions of the joints, neck, back and spine developing over time. Water helps our bodies maintain adequate hydration and in turn allows our bodies to have lubricated joints and functional processes throughout our entire bodily system. Below is a quick list of how water helps our bodies: • Aids digestion and rids the body of waste, • Helps lubricate your joints, • Produces saliva which helps you eat, • Balances your entire body’s chemical structure, • Helps your brain create the right hormones and properly send neurotransmitters, • Delivers oxygen throughout your body, • Cushions your bones, • Helps regulate body temperature. Healthy diet A healthy diet is vital to maintaining a healthy lifestyle. A diet rich in healthy vegetables, fruits, meats, nuts and grains will help you live a healthier, happier life. Eating organic, real foods is the best way to go when it comes to helping your body heal and remain on the right course to wellness once again. Foods rich in vitamins, nutrients and minerals may help your body form the right tools it needs to properly recover and internally resolve problems. Eating an anti-inflammatory diet is the right choice and this can be accomplished with the help of a certified nutritionist who specializes in anti-inflammatory diet regimens.

Reduce inflammation through better lifestyle choices Reducing inflammation is another great way to help with the prevention of neck, back, spine and joint pain. Alcohol and tobacco use contribute to inflammatory responses within our bodies. Eliminating those habits will not only reduce inflammation throughout the body, but it may also help you avoid other diseases later in life such as heart disease, cancer and arthritis. Reduce stress Reducing stress is easier said than done, yet it’s still important to recognize what really matters in life, and that is your health. If you’re constantly stressed out about something in your day-to-day life, you’re more than likely going to experience side effects of said stress over time. It is best to seek professional help if the stress becomes too much for you, and this may in turn allow you to relax and recognize the areas of your life that you can manage. Mental health is just as important as physical health. We tend to carry the weight of our stress throughout our back, neck, spine and joints. This can cause everything from poor posture to develop, tension throughout the lower and middle back to develop, or even our back to “give out” when we have high levels of cortisol and adrenaline running through our system. Learning to manage stress can make such a positive difference in all areas of our lives. Incorporate healthy lifestyle adjustments daily While this list is just the beginning of managing the prevention of joint and back pain, it’s important to discuss your various treatment options with your doctor. They can determine the next best step to take when it comes to successfully treating your condition(s). Making small steps in the right direction towards health and wellness is much easier than trying to accomplish everything all at once. Start incorporating healthy lifestyle choices day-by-day, week-by-week, month-by-month and year-by-year. You will most likely notice a compounding effect of the positive results over time. Joint and back pain is common, yet it doesn’t have to be when you start taking the appropriate action to best address your condition. I hope you have enjoyed reading this article and wish you the best in your journey towards healing. Gerardo Zavala II, MD, FAANS is a board-certified neurosurgeon serving San Antonio and surrounding cities since 2009. Dr. Zavala brings extensive training in minimally invasive spinal surgery, scoliosis correction, degenerative spinal stenosis and herniated disc disease. He is a member of the Bexar County Medical Society. Visit us at www.bcms.org

PREVENTATIVE MEDICINE

Key Ashtma Management Strategies to Prevent Asthma Attacks By John F. Freiler, MD

Asthma Fast Facts • More than 26 million Americans have asthma (1 in 12 children and 1 in 13 adults).1 • Each year, asthma accounts for more than 439,000 hospitalizations, 1.7 million emergency department (ED) visits and 13.8 million missed school days.1 • Asthma costs about $50 billion each year in healthcare costs.1 • Every day, about 10 people die of asthma. Black Americans are 2-3 times more likely to die from asthma than any other racial or ethnic group.1 • More than 60% of adults and 50% of children with current asthma have uncontrolled asthma.2,3 Asthma is a chronic respiratory disease requiring ongoing medical management. When controlled, asthma has a minimal impact on everyday living. Uncontrolled asthma with frequent and intense episodes of symptoms can have a significant cost to families and society because it may relate to an increased risk of an emergency department visit, hospitalization, and work and school absenteeism.2,3 Most people with asthma should be able to control their disease with proper care. Asthma education and self-management are essential components of successful asthma management. When healthcare providers deliver asthma care based on evidence-based asthma guidelines, patients can experience better health outcomes and quality of life.4 Asthma attack prevention Important strategies in asthma attack prevention include routine visits, recognition of symptoms, understanding the use of medications, proper inhalation technique, avoidance of triggers, monitoring and the use of premedication in certain situations. Routine follow-up care: Scheduling office visits every 6-12 months or more often if indicated is an essential part of caring for patients with asthma.4 • Assessing control should be incorporated into every routine asthma visit and is the basis for stepwise management of asthma medications. This can be done using a questionnaire that the patient completes prior to their visit. Standardized questionnaires, such as the Asthma Control Test and Asthma Control Questionnaire are informative and easy to use. 14

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• Periodic spirometry can also help assess progressive loss of lung function over time. • Incorporation of a written asthma action plan into routine visits can serve several functions such as daily asthma care, attack management and indications for emergency care. Read the American Lung Association: Create an Asthma Action Plan at https://www.lung.org/lung-health-diseases/lung-diseaselookup/ asthma/living-with-asthma/managing-asthma/create-anasthma-action-plan. Asthma symptoms: Patients should understand how to recognize early symptoms of a potential asthma attack, such as shortness of breath, wheezing, chest tightness and recurrent coughing. Role of medications: The differences between quick-relief medication and long-term controller medications should be discussed. Single Maintenance and Reliever Therapy (SMART) can be considered for select patients. Rather than an inhaled corticosteroid for daily

PREVENTATIVE MEDICINE

maintenance and an inhaled bronchodilator for exacerbations, SMART uses the same inhaler for both prevention and rescue therapy. This strategy, delivering a corticosteroid and long-acting beta agonist together, allows for a lower regular steroid dose, with additional doses as patients use the inhaler to relieve asthma symptoms. Only formoterol-containing formulations should be used, as it has a rapid onset bronchodilator effect, like albuterol.

incorporation of asthma management strategies based on evidencebased guidelines for asthma attack prevention.

Correct inhaler use: Provide skills training in using each type of inhaler prescribed. It may be helpful to have pictures of commonly-used inhalers to confirm which inhaler the patient is using. Also discuss spacer devices and nebulizers if used.

References 1. Control Asthma, 6|18 Initiative, Centers for Disease Control and Prevention: https://www.cdc.gov/sixeighteen/asthma/index.htm accessed 4/9/2022 2. AsthmaStats: Uncontrolled Asthma among Adults, 2016, Centers for Disease Control and Prevention: https://www.cdc.gov/asthma/ asthma_stats/uncontrolled-asthma-adults.htm accessed 4/9/2022 3. AsthmaStats: Uncontrolled Asthma among Children, 2012–2014, Centers for Disease Control and Prevention: https://www.cdc.gov/asthma/asthma_stats/uncontrolled-asthmachildren.htm accessed 4/9/2022 4. Strategies for Addressing Asthma for Healthcare Providers, American Lung Association: https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/diagnosing-treating-asthma/str ategies-for-addressing accessed 4/9/2022 5. Asthma Triggers and Management, American Academy of Allergy, Asthma and Immunology: https://www.aaaai.org/Tools-for-thePublic/Conditions-Library/Asthma/Asthma-Triggers-and-Management-TTR accessed 4/9/2022

Identification of triggers: Explain how to identify, avoid, eliminate or control asthma "triggers." It is important to stress that treatment measures without environmental control may be ineffective. Common asthma triggers:5 • Common allergens include house dust mites, animal dander, molds, pollen and cockroach droppings; • Tobacco smoke; • Air pollution, strong odors or fumes; • Exercise-induced bronchoconstriction; • Medications such as aspirin or other non-steroidal anti-inflammatory drugs such as ibuprofen and beta-blockers; • Emotional anxiety and stress; • Viral and bacterial infections such as the common cold and sinusitis; • Exposure to cold, dry air or weather changes; • Acid reflux, with or without heartburn. Monitoring: Patients should understand the importance of monitoring their asthma daily, recognition of early asthma symptoms and in treating their symptoms quickly. Encourage keeping diaries of medication use, peak flow rates, environmental exposures, symptoms and actions taken, as these can be used in planning attack prevention and management strategies. Premedicating to prevent onset of symptoms: Instruct patients on medication measures to take when triggers cannot be avoided. For example, premedication with beta-agonist agents prior to exercise, irritants or exposure to known allergens, such as animal dander, may prevent onset of asthma symptoms. Conclusion: While it can be challenging to incorporate patient-focused asthma education into routine care visits, busy clinicians can identify the most important points to discuss with each patient. Collaboration with an asthma specialist, such as an Allergist or Pulmonologist, can use useful to develop a comprehensive plan for

Recommended patient education resources Allergy & Asthma Network: https://allergyasthmanetwork.org American Lung Association: Asthma https://www.lung.org/lunghealth-diseases/lung-disease-lookup/asthma.

John F. Freiler, MD is the founder of Premier Allergy of Texas. A decorated Air Force Allergist-Immunologist, Dr. John F. Freiler retired from the military in the grade of Colonel in 2021 with 22 years of active-duty military service to serve the San Antonio community. Dr. Freiler’s distinguished military career is notable for having served as the Chief Consultant to the USAF Surgeon General for both Allergy & Immunology and Internal Medicine. Additionally, he was selected to serve as core teaching faculty for the Air Force’s sole Allergy and Immunology Fellowship Program. Dr. Freiler has published numerous peer-reviewed manuscripts and has been active in the mentorship and education of healthcare professionals throughout his career. He is board certified by both the American Board of Allergy and Immunology and the American Board of Internal Medicine. Dr. Freiler is a member of the Bexar County Medical Society. To learn more about Premier Allergy of Texas, please scan the QR code above, or visit their Facebook page at https://www.facebook.com /profile.php?id=100069842199659.

Visit us at www.bcms.org

PREVENTATIVE MEDICINE

Q & A: Understanding Risk of Gynecological Cancers By Jaron Mark, MD

1.) What is the importance of “knowing your risk”? a.) Family History: Family history is an important risk factor for ovarian, fallopian tube and primary peritoneal cancer, as well as for endometrial cancers. It’s important to know if multiple members of your family are affected by certain cancers, such as having two or more family members with breast cancer, pancreatic cancer, ovarian, fallopian tube, primary peritoneal or prostate cancer, as this may be a sign of having a hereditary syndrome and should prompt family members to undergo genetic counseling for consideration of genetic testing. Some endometrial cancers are related to a genetic predisposition related to Lynch syndrome (also known to increase the risk of ovarian cancer). If multiple members of the family have been affected by colon cancer or endometrial cancer, this should be a red flag to discuss genetic testing with your doctor. b.) Obesity: Obesity is associated with increased risk of ovarian cancer as well as endometrial cancer, with over 50% of endometrial cancers being attributed to obesity. c.) Age: Increased age is a risk factor for ovarian, fallopian tube and primary peritoneal cancers. d.) HPV: HPV causes over 95% of cervical cancers which highlights the importance of regular, routine pap tests to detect for cervical precancers so they can be treated before transforming into cervical cancer. HPV is also associated with development of vulvar and vaginal cancers. 2.) What is the available testing, screening and prevention? a.) Pap tests: Pap tests are used to screen for cervical and vaginal dysplasia caused by HPV in order to prevent untreated lesions from progressing into cancer. Testing is usually started initiated when women become 21 years of age. Women with a history of highgrade cervical dysplasia and those who have undergone a hysterectomy should still have vaginal pap tests to screen for vaginal dysplasia which, if high grade, can progress into vaginal cancer. b.) HPV vaccines: HPV vaccines have been around since 2006 and are approved for both boys and girls. These vaccines are very effective at reducing the risk of cervical, vulvar and vaginal cancers, as they immunize patients against the high-risk subtypes of HPV responsible for causing these cancers. In 2018, the FDA approved these vaccinations in adults up to age 45. 16

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c.) Healthy diet and lifestyle: Living a healthy lifestyle by eating a healthy well-balanced diet supports a healthy weight which in turn decreases the risk of ovarian and endometrial cancers which are associated with obesity. Living a tobacco-free life is not only important to prevent lung cancer but it is also a risk factor for cervical, vulvar and vaginal cancers. d.) Genetic testing: Genetic testing is indicated for all patients with a new diagnosis of ovarian, fallopian tube or primary peritoneal cancer. There are many different genetic testing companies and large multi-gene panels that can be used to assess for hereditary breast and ovarian cancer syndromes. Pathogenic mutations discovered on testing may warrant genetic testing on other immediate family members. Patients with endometrial cancer should also undergo genetic testing if the cancer is known to have defective mismatch repair genes which are routinely tested for while undergoing pathological evaluation after surgery. 3.) What are the differences between these cancers? What are the common/potential signs and symptoms? a.) Cervical cancer: Cervical cancer often presents with thin, clear or bloody vaginal discharge, painless vaginal bleeding or bleeding after intercourse. As the cancer progresses, symptoms can include flank pain, low back pain, leg pain, leg swelling, hematuria, rectal bleeding and vesicovaginal or rectovaginal fistulas. b.) Endometrial cancer: The majority of endometrial cancer presents with abnormal uterine bleeding such as vaginal bleeding or pinkish vaginal discharge in the menopausal period. A minority of endometrial cancer cases present with signs of uterine cavity enlargement such as pelvic pressure or pelvic pain. c.) Ovarian cancer: Ovarian cancer is the most lethal gynecologic cancer with no effective screening strategies. Most patients are diagnosed at an advanced stage because the symptoms are very subtle. Often called a “silent disease” since symptoms include decreased appetite, early satiety, bloating, increasing abdominal girth, increased urinary frequency, urgency, back pain and eventually abdominal pain or pelvic pain which most people experience at some point in their lives.

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d.) Vaginal cancer: Often presents like cervical cancer with painless vaginal discharge, vaginal bleeding or bleeding after intercourse. With disease progression, these symptoms can include urinary symptoms such as dysuria, urinary retention or hematuria. Continuing disease progression can lead to gastrointestinal issues such as colonic obstruction or bloody stools. e.) Vulvar cancer: Vulvar cancer often presents with an enlarging vulvar bump or lump that can be pigmented, or ulcerated and it can itch, burn or bleed. 4.) Can cancer risk be reduced, if so, how? Women with a strong family history of breast and/or ovarian cancer who have genetic testing and found to have a high-risk genetic mutation (such as BRCA1/2, Lynch syndrome, RAD51C/D, BRIP1) can undergo risk reducing surgery with removal of the ovaries and fallopian tubes to markedly reduce the risk of developing ovarian, fallopian tube or primary peritoneal cancer. Patients with obesity and irregular periods can reduce the risk of developing endometrial cancer by losing weight and taking contraceptives that promote regular periods. Certain patients, such as those with Lynch syndrome should undergo risk reducing surgery to remove the uterus and cervix, along with the ovaries and fallopian tubes when they are done with childbearing but usually no sooner than age 35-40 to reduce the risk of endometrial and ovarian cancer. HPV vaccination of young girls can reduce the risk of developing cervical cancer, vaginal cancer or vulvar cancer as these are often associated with HPV infection. References 1.) ACOG Practice Bulletin on Hereditary Breast and Ovarian Cancer Syndromes 2.) ACOG Practice Bulletin on Lynch Syndrome 3.) Onstad MA, Schmandt RE, Lu KH. Addressing the Role of Obesity in Endometrial Cancer Risk, Prevention, and Treatment. J Clin Oncol. 2016;34(35):4225-4230. doi:10.1200/JCO.2016.69.4638 4.) Eskander, R. N., & Bristow, R. E. (2014). Gynecologic Oncology: A Pocketbook (2015th ed.). Springer. Jaron Mark, MD is a Gynecologic Oncologist Surgeon with the START Center. He is a member of the Bexar County Medical Society.

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Skin Cancer Prevention By Fatima Raza OMS-III, Faraz Yousefian, DO and Daniel Fischer, DO

kin cancer is the most common cancer in the United States, followed by lung cancer, prostate cancer and breast cancer. According to American Academy of Dermatology estimates, one in five Americans will develop skin cancer in their lifetime, and approximately 9,500 people in the United States are diagnosed with skin cancer every day.1 In Texas, the odds are even more grim: the state ranks third in the nation for incidence of malignant melanoma, with 5,020 cases projected to be diagnosed in 2022.2 In the United States, skin cancer represents 20-30% of all neoplasms in Caucasians, 2-4% in Asians and 1-2% in the Black population.3 Of the types of skin cancer, non-melanomatous skin cancers (NMSCs), namely basal and squamous cell carcinomas, are the most commonly diagnosed.4 Both of these cancers have overlapping risk factors, including tanning bed usage and ionizing radiation. However, the most significant risk factor is UV radiation, principally UVB radiation from sunlight exposure. In particular, occupational UVB exposure, as in the agricultural and construction industries, is a major risk factor as compared to nonoccupational risk factors. UVB radiation is thought to be more carcinogenic than UVA radiation due to its complete absorbance by skin and resultant increased ability to mutate tumor suppressor genes. Of the tumor suppressor mutations resulting in skin cancer, p53 is the most common, with mutations found in up to 50% of basal cell carcinomas.4 While the risk factors and pathogenesis of skin cancers are well studied, there remains no consensus on screening guidelines for skin cancer. The USPTF has not published screening recommendations, citing insufficient evidence for its benefit.5 Diagnosis of skin cancers is therefore heavily reliant on clinical examination of the skin lesion. Clinical diagnosis of NMSCs commonly includes aspects of patient history, including raised lesions which bleed and crust. Dermatoscopic evaluation and biopsy can often aid with clinical diagnosis. In melanomatous disease, the importance of early clinical recognition and diagnosis is paramount, as the cancer grows first horizontally and then vertically in stages, with stage correlating to depth. In 1985, researchers at NYU implemented the acronym ABCD, now commonly used in practice − A (asymmetry), B (border irregularity), C (color variegation), D (diameter >6mm) and E (evolving or changing) for clinical diagnosis of melanoma.6 18

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In the absence of routine screening, preventive measures become all the more important. The American Academy of Dermatology has published multiple guidelines regarding skin cancer prevention: seeking shade particularly between the hours of 10 am and 2 pm, wearing sunprotective clothing and using broad-spectrum, water-resistant sunscreen with SPF 30 or higher, reapplying every two hours. The AAD additionally recommends regular skin self-exams to detect cancer early.7 In short, these guidelines essentially encourage patients to become their own healthcare advocates. Perhaps the bedrock of skin cancer prevention is the regular use of sunscreen. While most of the population may at least be aware that sunscreen is protective in some form, the wide varieties and types of sunscreens may overwhelm the common consumer. Sunscreens are largely organized into two categories based on active ingredients: organic (physical) and inorganic (chemical). Organic filters include active ingredients such as oxybenzone, while inorganic filters include titanium dioxide and zinc oxide. Organic filters, however, have shown in some studies to have systemic effects in subjects including hormonal imbalance. In addition, negative environmental impacts of the active ingredients may potentially concern consumers.8 Inorganic sunscreen filters are considered alternatives to organic filters, and are present in sunscreens at sizes of <100nm. This size difference is cosmetically preferable to consumers, as the sunscreen is much less visible on the skin. Based on currently available data, inorganic filters are less harmful to the environment and pose minimal health risk due to low levels of absorption across the skin barrier.9 While as of yet, there is no clear consensus as to which type of sunscreen provides superior UV protection, empowering patients with information about sunscreen choices as well as education on how and when to apply sunscreen may improve patient initiative and participation in skin care and prevention. The utility of preventive methods such as sunscreen, however, is limited by other aspects of dermatologic care, such as physician constraints. A 2011 survey of primary care providers, internists and dermatologists reported that of all responding physicians, time constraints, competing comorbidities and patient embarrassment or reluctance were reported as the top three major barriers to performing full body skin examinations on patients; these factors varied by specialty. Family physicians responded with time constraints as the primary hindrance, while dermatologists re-

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ported patient embarrassment as the major barrier.10 As such, patients arriving at their physician’s office without a specific skin concern may not receive a full skin examination or appropriate skin care education. Other factors to be considered regarding skin cancer prevention are behavioral − employees in the construction and agricultural industry are at increased risk due to occupational hazard and UV exposure, and as a result, preventive measures in these populations are paramount. However, a recent survey found that more than half of agricultural workers in the United States reported never using sunscreen while outside on a sunny day. While the use of at least one type of recommended protective clothing was significantly higher in agricultural workers, the regular use of pants was almost twice their use of wide-brimmed hats, leading to prolonged direct sunlight exposure of high-risk areas such as the face and neck.11 This further elucidates the challenges in skin cancer prevention, especially for rural and migrant worker communities. According to data from the National Center for Farmworker Health, there are over three million migrant workers in the United States, with 83% identifying as Hispanic, and 77% feeling most comfortable conversing in Spanish.12 Barriers to health care and access for these patients, such as scarcity of Migrant Health Centers, lack of education, language barriers and cost of medical care pose a significant challenge to agricultural workers. To this end, the focus on improving skin cancer prevention is vital, especially in vulnerable populations. For migrant workers, the AAD has implemented the Latino Outreach Program to provide skin cancer education and screenings to migrant workers in California, Texas and Arizona. These types of initiatives could be especially beneficial in South Texas, where regular screening may be more difficult to access outside of large urban settings. In the future, it is our hope that UIWSOM and UTHSCA can organize systematic skin cancer screening clinics, not just in San Antonio, but in its suburbs with lesser access to preventive screening and education. References 1. Stern RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol. 2010 Mar;146(3):27982. doi: 10.1001/archdermatol.2010.4. PMID: 20231498. 2. Siegel, RL, Miller, KD, Fuchs, HE, Jemal, A. Cancer statistics, 2022. CA Cancer J Clin. 2022. https://doi.org/10.3322/ caac.21708 3. Gloster HM Jr, Neal K. Skin cancer in skin of color. J Am Acad Dermatol. 2006 Nov;55(5):741-60; quiz 761-4. doi: 10.1016/j.jaad.2005.08.063. PMID: 17052479. 4. Brandt, MG, Moore, CC. Non Melanoma Skin Cancer Facial Plastic Surgery Clinics of North America, 2019-02-01, Volume 27, Issue 1, Pages 1-13 5. US Preventive Services Task Force. Screening for Skin Cancer: US Preventive Services Task Force Recommendation Statement.

JAMA. 2016;316(4):429–435. doi:10.1001/jama.2016.8465 6. Glazer, AM, Rigel, DS, Winkelmann, RR, Farberg, AS. Clinical Diagnosis of SkinCancer Dermatologic Clinics , 2017-10-01, Volume 35, Issue 4, Pages 409-416, Guidelines of care for the management of basal cell carcinoma 7. Bichakjian, ChristopherKim, John Y.S. et al., Journal of the American Academy of Dermatology, Volume 78, Issue 3, 540 - 559 8. Schneider, SL, Lim, HW. Review of environmental effects of oxybenzone and other sunscreen active ingredients, Journal of the American Academy of Dermatology, Volume 80, Issue 1,2019, Pages 266-271, ISSN 0190-9622, https://doi.org/10.1016/ j.jaad.2018.06.033. 9. Schneider, SL, Lim, HW. A review of inorganic UV filters zinc oxide and titanium dioxide. Photodermatol Photoimmunol Photomed. 2019; 35: 442– 446. https://doi-org.uiwtx.idm.oclc.org /10.1111/phpp.12439 10. Oliveria SA, Heneghan MK, Cushman LF, Ughetta EA, Halpern AC. Skin Cancer Screening by Dermatologists, Family Practitioners, and Internists: Barriers and Facilitating Factors. Arch Dermatol. 2011;147(1):39–44. doi:10.1001/archdermatol.2010.414 11. Ragan, KR, Buchanan, LN, Thomas, CC, Tai EW, Sussell A, Holman DM. Skin Cancer Prevention Behaviors Among Agricultural and Construction Workers in the United States, 2015. Prev Chronic Dis 2019;16:180446. DOI: http://dx.doi.org/ 10.5888/pcd16.180446 12. National Center for Farmworker Health. 2017 Agricultural Worker Population Estimates [Private Data Source].; 2020. http://www.ncfh.org/population-estimates.html Fatima Raza, OMS-III is a third-year medical student at the UIW School of Osteopathic Medicine. She is planning to apply to Internal Medicine residency this year, and takes particular interest in hematology/oncology, cardiology and health disparities in South Texas. Faraz Yousefian, DO is an intern at the Texas Institute for Graduate Medical Education and Research (TIGMER) in San Antonio, Texas. He is very passionate about mentoring nascent physicians and educating the general population about skin diseases and the steps they can take to prevent them. Dr. Yousefian is a member of Bexar County Medical Society. Daniel Fischer, DO is a PGY-2 Dermatology resident at St. John’s Episcopal Hospital in Far Rockaway, New York. He has conducted close to 30 clinical trials and contributed to over one dozen publications in the field of both clinical and cosmetic dermatology. He enjoys teaching and mentoring students and residents and plans to continue to do so beyond residency. Visit us at www.bcms.org

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Prevention and Management of HIV in the 21st Century By Moses Alfaro, BSA and Colton Blinka, BSA

nce thought to be an untreatable disease, HIV is now largely preventable and manageable with new therapeutics that have been developed since the AIDs epidemic in the 1980s. While society has made great strides in developing treatments that allow people living with HIV to lead normal lives, there are still clusters of individuals who go untreated and mistakenly transmit this disease. Our article explores the numerous ways to prevent transmission of HIV and what options are available for treatment if one is to contract this disease.

In addition to these prevention tips, there are some medications available to aid in prevention like PrEP (pre-exposure prophylaxis) or PEP (post-exposure prophylaxis). PrEP is a prescribed medication that is taken as a pill and can reduce the risk of contracting HIV by 99% when taken as prescribed.3 It’s generally recommended to keep using a condom with PrEP to prevent other sexually transmitted diseases (STDs), as PrEP only works against HIV.3 As for PEP, this is used whenever you have been possibly exposed to HIV and should be used within 72 hours of the expsoure.4

Transmission and prevention The way HIV is transmitted plays a crucial role in how to prevent contracting it. HIV is transmitted through bodily fluids like blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids and breast milk.1 In the United States, the most common activities that lead to transmission are having sex with someone who has HIV, sharing injection equipment (e.g., needles), or from mother to child during pregnancy or birth through breastfeeding.1 Not sharing needles, using condoms during anal or vaginal sex, or practicing abstinence by not having sex help in the prevention of HIV.2 Some individuals might not be aware that these activities can post a high risk of contracting HIV, so its paramount to spread this awareness.

Diagnosis and symptoms Early diagnosis of HIV is paramount because it can aid in receiving treatment that can prevent any complications or unwanted symptoms, and it can help in reducing the spread of the disease to any other individuals. A common way that HIV can be diagnosed is through the ELISA (enzyme-linked immunosorbent assay) test, which can detect antibodies to the virus through a blood draw.5 However, antibodies to the HIV infection aren’t produced immediately when you are infected, so there can be a window of a couple of weeks where ELISA cannot detect an infection due to the lack of antibodies produced, causing a false negative.5 If the ELISA is positive for antibodies, a western blot test will be ordered to confirm the results because it is very sensitive to

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the antibodies produced against HIV.5 Another test, called a nucleic acid test (NAT), can look for the actual virus in the blood.6 Although this test can detect HIV sooner than other tests, it is a very expensive test and can only be used after a patient has had a high risk exposure or are presenting with symptoms of the disease.6 Symptoms of HIV can usually be mistaken for another viral disease, so this further emphasizes the importance of getting tested to ensure you do not have an infection. Usually, early HIV symptoms can occur within a couple weeks or months from the time of infection.7 Symptoms can include fever, headache, fatigue, swollen lymph nodes, rash, sore throat, or sore muscles and joints.7 These symptoms are nonspecific so it can be challenging for people to recognize that it can be due to an HIV infection. If you are at risk for contracting HIV, it is recommended to get tested and be aware of any viral symptoms that might arise. Treatment When it comes to HIV, treatment is prevention. By reducing the viral load of an individual with HIV, the risk of future transmission drops precipitously. Current standard of care calls for the treatment of a newly diagnosed HIV patient with highly active antiretroviral therapy (HAART) regardless of that patient’s CD4 count or symptoms.8 HAART is a regimen of three to four drugs, each of which target a different stage of the viral life cycle to ensure that resistance to any one drug won’t cause the treatment to be unsuccessful. With proper patient adherence, HAART has been shown to reduce morbidity, mortality and transmission of HIV.9 Adherence, though, can be a significant challenge to people being treated with HAART. Whenever possible, a HAART regimen should be chosen that consists of a single co-formulated tablet taken orally once a day. However, certain patients may have contraindications to the currently available co-formulated tablets and have to take as many as three to four pills twice a day, instead.10 In situations such as these, it is paramount for the interprofessional care team to stress the importance of adherence, and provide strategies to improve adherence. These strategies include patient education, seven-day pillboxes, and downloadable phone applications and alarms. Conclusion HIV is not once what it was in the late 1900s. With a plethora of options to treat the disease, and with new drugs in the works, people living with HIV can lead relatively normal lives. It's important for healthcare leaders in the community to educate and spread awareness of how to protect yourself from contracting HIV, how to test for it and what options are available for treatment.

References 1. Content Source: HIV.govDate last updated: June 24, 2019. (2021, January 26). How is HIV transmitted? HIV.gov. Retrieved April 8, 2022, from https://www.hiv.gov/hiv-basics/overview/abouthiv-and-aids/how-is-hiv-transmitted 2. Centers for Disease Control and Prevention. (2021, May 25). Pep. Centers for Disease Control and Prevention. Retrieved April 8, 2022, from https://www.cdc.gov/hiv/basics/pep.html 3. Centers for Disease Control and Prevention. (2021, May 13). Prep effectiveness. Centers for Disease Control and Prevention. Retrieved April 8, 2022, from https://www.cdc.gov/hiv/basics/prep /prep-effectiveness.html 4. Centers for Disease Control and Prevention. (2021, May 25). Pep. Centers for Disease Control and Prevention. Retrieved April 9, 2022, from https://www.cdc.gov/hiv/basics/pep.html 5. HIV diagnosis. ucsfhealth.org. (n.d.). Retrieved April 9, 2022, from https://www.ucsfhealth.org/conditions/hiv/diagnosis# :~:text=ELISA%20Test%20ELISA%2C%20which%20stands,in %20one%20to%20three%20months. 6. Centers for Disease Control and Prevention. (2022, April 19). Types of HIV tests. Centers for Disease Control and Prevention. Retrieved April 9, 2022, from https://www.cdc.gov/hiv/basics/ hiv-testing/test-types.html 7. Mayo Foundation for Medical Education and Research. (2020, November 21). Early HIV symptoms: What are they? Mayo Clinic. Retrieved April 9, 2022, from https://www.mayoclinic.org/ diseases-conditions/hiv-aids/expert-answers/early-hivsymptoms/faq-20058415 8. Eggleton JS, Nagalli S. Highly Active Antiretroviral Therapy (HAART) [Updated 2021 Nov 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554533/ 9. Kemnic TR, Gulick PG. HIV Antiretroviral Therapy. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513308/ 10. Justiz Vaillant AA, Gulick PG. HIV Disease Current Practice. [Updated 2021 Dec 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534860/ Moses Alfaro, BSA and Colton Blinka, BSA are medical students at UT Health San Antonio Long School of Medicine. Moses is a member of the BCMS Publications Committee.

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Prevention through Health Equity Training at the Long School of Medicine By Garrett Kneese and Samantha Driscoll

s medical education continues to advance beyond Flexnerian practices (Flexner, 1910), so does the focus of these educational methods to include the charges of today’s physicians. One of these charges, highlighted by the disparate impacts of the COVID-19 pandemic (Kim et al, 2020) and based in the historical segregations of our American society (NCRC, 2020), is the inequities within the social determinants of health (SDoH). “As the United States contends with the effects of the COVID 19 pandemic, health inequity, and a long overdue reckoning of institutional racism, transforming primary care is essential to meet the moment…” – V.J. Dzau, National Academy of Medicine Over the last decade SDoH literature has expanded enormously, beginning at a measurement and identification stage (ie what social factors determine health, and how might we calculate, quantify and measure them?), and continuing onward to where we are today with respect to implication and intervention (ie what do these determinants tells us about our communities and what can medical society do to respond within this newfound lens?).

Modified figure from Family Medicine Team Care Session, February 2022. (Kneese et al, 2022)

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Reaching back to the educational framework, there are now efforts nationwide at the undergraduate (UME) and graduate medical education levels leveraging this lens to empower medical trainees and those of other health professions as well to work towards not only providing higher quality health services based on a socially-derived understanding of their patient, but also advocating for and working towards reductions in the disparate outcomes that unequal distributions of negative social determinants can cause. Much of this education at the UME level is course-based in pre-clinical years, and occasionally integrated at an elective-only level during fourth-year coursework. Ultimately, we conclude alongside most other global and national health organizations that socioeconomics and health behaviors as influences by social determinants are the primary driving factors that can be modified for prevention of disease across populations (Hood et al, 2016). At UT Health San Antonio, the Department of Family and Community Medicine’s undergraduate medical education division, led by Dr. Nehman Andry, has been hard at work in the post-pandemic setting to bring SDoH education to all medical students at the university in hopes of facing the challenge of health disparities headon. The teams for this article’s highlighted programs comprise of clinical faculty, students, community health workers (promotores) and consultants with the American Board of Family Medicine. With help from several leaders in the department, they have facilitated both longitudinal and interventional programs at the third-year medical student level to improve SDoH clinical competencies in all students and inspire them to advocate for the communities they serve from a foundational understanding of health equity. With additional time available due to limited clinical scheduling for the third-year family medicine clerkship in intra-pandemic education, an impetus to leverage that time for a novel educational experience arose. The idea to create a longitudinal experience over the 6-week rotation framed the pairing of medical students with both a promotore (community health worker, or CHW) from the Department, and a patient well-established with the promotore for an interactive SDoH community-clinical journey.

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mary care access, health disparities in San Antonio, community engagement practices, etc. that are foundational to family medicine practice. This year’s spring session was inter-professionally designed and delivered by three faculty and one medical student to capitalize on the momentum of the clerkship curriculum previously described, acting as either a capstone workshop session for those who had already completed the clerkship, or as an educational primer for those yet to enter the clerkship that year. Based in competencies of place and equity, a patients circle of support, establishing trust between doctor and patient, and addressing societal challenges to these concepts, this case-based workshop follows the story of a patient in small-group format to bring SDoH-oriented tools to students in a competency-driven and practical manner. BeHealth Disparities 6-Week Curriculum Overview as Developed for 2021-2022 Clerkship Students ginning with a review of San Antonio’s own history of housing segregation that have led to measurable health Over the course of the rotation, students spend time each week getting inequities between neighborhoods of the city, students then learn how to know their patient on a more socially-derived level via independent to work with patients experiencing these disparities in a relationallyinvestigation using both electronic health records and geospatial social centered way through empathic communicative and psychosocial indeterminant data tools such as the American Board of Family Medicine’s tervention tools that build trust with patients sometimes considered Population Health Assessment Engine (PHATE) (Bambekova et al, forgotten by medical society. 2020), direct meetings with their partnered promotore, guided visits to the patient’s community, and ultimately a personal meeting with the patient in their own home. While innovative tools, such as the ABFM’s PHATE, allow for neighborhood-specific understandings of patients’ social vulnerabilities, it also directly links providers to zip code-specific resources and services designed to rectify these vulnerabilities (such as travel vouchers, food assistance programs and other social services). Then, by placing students physically into the environment of their patient, we extract them from the medical education bubble that could possibly detach them from the realities often faced by many of their most vulnerable BATHE Clinical Communication Technique as presented in the Family Medicine Team Care patients. Finally, these experiences culminate with a report to their peers Session, February 2022 in the form of an artistic rendition that encapsulates what they’ve learned and the relationships they’ve built along the way (see next column, top). While implementing these psychologically-driven approaches, stuAltogether, this student-patient-promotore engagement experience dents also learn to establish a circle of care for their patient along the provides a holistic look at health disparities as SDoH are implicated way, possibly consisting of behavioral psychologists, nutritionists, psyright here in the San Antonio advanced primary care environment. Ad- chotropic specialists and social work to name a few of what are entailed ditionally, it highlighted the importance of an interprofessional team in an advanced primary care model. These competencies are finally to fully address complex issues and lower the barriers to care for our framed by the ethical and moral challenges posed by our medical-inpatients by leveraging the skills and trust built by promotores and other dustrial complex, charging students to recognize the moral determiancillary service team members. nants of health (Berwick, 2020) in practice and community presence. The Long School of Medicine’s Team Care curriculum is a longitu- A final charge to students is made to go beyond the recognition of and dinal experience over the third medical school year that focuses on attempt to resolve in clinical practice the disparities in SDoH that their themes that span across all specialties (UTHSA LSOM, 2022). The patients face, through recognizing the necessity to look upstream at Family and Community Medicine Department is charged with one the structures and systems in place that lead to these disparities at-large. session each spring, which has often focused on topics surrounding priMeasuring the outcomes of these educational interventions is tancontinued on page 24 Visit us at www.bcms.org

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tamount to further adoption and integrations at an institutional level, and the Department’s work has shown promise in current evaluation. The SDoH Clerkship experience has significantly increased students’ SDoH knowledge, practical intervention competency and clinical practice intentions per 1st-year data collections, while the Team Care session was met with significant engagement and positive feedback from both students and other clerkship directors. What these results tell us is that with adequate time allowed at an organizational level and a committed and passionate interprofessional team available for initiative development, strides can be made in student SDoH training to meet our community’s needs in reducing health disparities in future practice. These are exciting times for the health equity movement in the medical education space, providing opportunities for students, faculty, interprofessional team members, and even patients to collaborate towards a brighter and healthier future for the city of San Antonio. Prevention of disease begins with an understanding of the real factors contributing to the development of those diseases, which today are unequivocally distributed largely on the basis of inequity in socially-derived drivers of illness, we find. We hope that this story will inspire others in academia to strive for the same at their institutions, but will also inspire all healthcare professionals in this network to see what the future of physicians is leaning into over the coming decade. As these endeavors continue to expand and improve their impacts on students at the Long School of Medicine, we welcome feedback, partnership and most of all, inspiration in our common efforts. 24

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Acknowledgements: -Nehman Andry, MD: For your incredible leadership, guidance and support to all of the teams, players and patients who have helped build these student experiences and patient support mechanisms. You are an inspiration to all who seek to be champions for innovation in medical education. -Carolina Gonzalez-Schlenker, MD: For your wisdom in care ethics, pride in the work of promotores and immense contribution to the moral frameworks of these programs that shaped the entire tone of what needed to be understood in these experiences. You are an inspiration to all who value the difficult and necessary conversations required to transform medical society in the coming decades. - Yajaira Johnson-Esparza, PhD: For your empathic expertise and collaborative contributions from clinical psychology that equipped these students to communicate in the direst of circumstances with their patients, and do so from a trustbuilding framework. You are an inspiration to all who seek to highlight the criticality of behavioral health in prevention, treatment and maintenance of wellness. -Robert Ferrer, MD, MPH: For your foundational efforts, historical contextualization and vast expertise in health inequities across our city of San Antonio and con-

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sistent support for this crucial learning at the medical student level. You are an inspiration to all who seek to be leaders and programmers in health equity and clinical fluency in the next generations of physicians. References 1. Flexner A. (2002). Medical education in the United States and Canada. From the Carnegie Foundation for the Advancement of Teaching, Bulletin Number Four, 1910. Bulletin of the World Health Organization, 80(7), 594–602. 2. Kim, E. J., Marrast, L., & Conigliaro, J. (2020). COVID-19: magnifying the effect of health disparities. Journal of general internal medicine, 35(8), 2441-2442. 3. Redlining and Neighborhood Health. NCRC. (2020). Retrieved 23 April 2022, from https://ncrc.org/holc-health/ 4. Hood, C. M., Gennuso, K. P., Swain, G. R., & Catlin, B. B. (2016). County health rankings: relationships between determinant factors and health outcomes. American journal of preventive medicine, 50(2), 129-135. 5. Bambekova, P. G., Liaw, W., Phillips, R. L., & Bazemore, A. (2020). Integrating community and clinical data to assess patient risks with a population health assessment engine (PHATE). The Journal of the American Board of Family Medicine, 33(3), 463-467.

6. Kneese, G. Andry, N. Gonzalez-Schlenker, C. Johnson-Esparza, Y. (2022). Beyond social determinants | Clinical approaches. UTHSA Team Care Curriculum Session. 7. Clinical Curriculum | UT Health San Antonio. (2019). Retrieved 23 April 2022, from https://www.uthscsa.edu/academics/medicine/education/ume/curriculum/clinical 8. Berwick, D. M. (2020). The moral determinants of health. Jama, 324(3), 225-226. Garrett Kneese is a graduating senior medical student at the Long School of Medicine's MD/MPH program and curriculum consultant/researcher for the UT Health San Antonio Department of Family and Community Medicine. He will be entering his Family and Preventive Medicine Residency program this summer and will continue to work towards advances in health equity training at the undergraduate & graduate medical education levels. Samantha Driscoll is a medical student at UT Health San Antonio pursuing Family Medicine.

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BCMS BUILDING DEDICATION

BCMS staff pose for a picture.

Fourteen BCMS Presidents and BCMS Real Estate Chairman, Buddy Swift, MD, were present to celebrate and congratulate Mr. Fitzer on this very special day.

Bexar County Medical Society Building Named

Stephen C. Fitzer Building

The Bexar County Medical Society (BCMS) on Saturday, May 14 held a ceremony honoring former CEO and Executive Director, Stephen C. Fitzer, who recently retired. The BCMS Board of Directors unanimously voted to name the BCMS headquarters the “Bexar County Medical Society Stephen C. Fitzer Building” after Mr. Fitzer. Mr. Fitzer served the Bexar County Medical Society for more than 13 years in two different terms. During his tenure, Mr. Fitzer led the efforts of BCMS to provide its 5,600-plus physician members with the advocacy and tools necessary to meet the healthcare needs of the citizens of Bexar County. Mr. Fitzer first joined BCMS in 2003 when 26

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the organization faced serious financial challenges, needing reorientation to better serve its members. Because Mr. Fitzer had 20 years prior experience as CEO of three different companies, including Inspectorate America, Inc., Professional Service Industries, Inc. and Smith Bucklin and Associates, he was able to bring to bear his operational, marketing and financial expertise to the fore to strengthen the organization and put it on solid financial footing. In Mr. Fitzer’s first term with BCMS, the old BCMS building was sold. That left BCMS in temporary offices with the intention of constructing or buying a new building, one that is closer to where physician members live and work. However, Mr. Fitzer chose to retire

from BCMS in 2008. In 2013, Mr. Fitzer was approached by BCMS to return and resume his role as CEO when the position again became available. Mr. Fitzer accepted the role. Besides managing the day-to-day operations, Mr. Fitzer was immediately challenged to find a new home for BCMS. Over a period of 24 months, Mr. Fitzer raised the necessary money, purchased a prime lot on Loop 1604 near NW Military Hwy, and constructed an award-winning building (“Project of the Year” by the American Subcontractors Assoc.) and did it all on budget and on time! For Mr. Fitzer’s outstanding management of the 8th largest county medical society in the

BCMS BUILDING DEDICATION

Rick Evans, BCMS legal counsel for 41-years, praises the leadership, years of service, dedication and successes of Mr. Fitzer with the crowd.

Jayesh Shah, MD; Mayor of Shavano Park, Bob Werner; Buddy Swift, MD; Steve Fitzer and Vijay Koli, MD pose for a picture.

United States, bringing financial and management strength to the organization, and for constructing this one-of-a-kind, award-winning building that will be the home of BCMS for the next 100 years or more, this beautiful building is named in his honor, to be known as the Bexar County Medical Society Stephen C. Fitzer Building. “When I learned about this great honor, I felt a genuine sense of appreciation and recognition for my years of service. I feel a bond with the Society, its members and my colleagues that will endure forever in my heart,” said Mr. Fitzer. Melody Newsom, the current BCMS CEO and Executive Director, said “By naming our

Rajeev Suri, MD gives remarks at the building dedication.

building in honor of our recently retired CEO and Executive Director, Stephen C. Fitzer, we celebrate his leadership, guidance and dedication to the physicians of Bexar County and as such, the patients in our community. The naming of this building in Mr. Fitzer’s honor will serve to remind us all of the past, current and future dedication that we exercise daily to serve our physician members and their practices.” Dr. Rajeev Suri, the current BCMS President, said “This building naming ceremony also speaks to the vision and mission of BCMS, which is to provide quality healthcare to the patients of Bexar County and make Bexar County a healthier community. Mr. Fitzer truly exemplified the skills of a leader

and has laid the groundwork for us to continue to support the future generations of physicians in times to come. Steve embodies the spirit of BCMS in his actions, his professionalism, and his commitment to the Society and for its ideals.” The Bexar County Medical Society is the oldest county medical society in Texas and eighth largest in the U.S. representing more than 5,600 physicians in and around San Antonio, Texas. The society seeks to promote high standards of medical care in the community, advocating on behalf of physicians and patients while providing beneficial services to its physician members. For more information about BCMS, visit www.bcms.org. Visit us at www.bcms.org

SAN ANTONIO MEDICINE

Patient Safety, Burnout and COVID-19

By Prachi Shah and Desiree “Dez” Ojo

This article will examine how COVID-19 contributes to burnout, the impact of COVID-19 on patient safety and changes that can take place in hospitals to help mitigate burnout and increase patient safety. What do patient safety, burnout and COVID-19 have to do with each other? They are intertwined. The pandemic increased the prevalence of burnout among healthcare professionals. Exhaustion and stress impact how patients are cared for in our hospitals and clinics. Recent studies have shown concerning increases in Methicillin Resistant Stahylococcus Aureus (MRSA), Central Line Associated Blood Stream Infections (CLABSI), Catheter Associated Urinary Tract Infection (CAUTI), and Skilled Nursing Facility (SNF) major injury fall rates and decubitis ulcers since the COVID pandemic began.¹ This area of research is especially important because it is likely that we will have to learn to live with COVID-19, new strains and periodic surges for the rest of our lives. Hospital administrators and hospital systems will need to figure out a way to take better care of their healthcare workers while also making our patients feel safe, happy and cared for in their hospitals. How is COVID contributing to burnout? Burnout is increasing among healthcare workers due to occupational hazards, systemic inconsistencies, financial instability and an increase in the volume of patients due to the pandemic.² A study that examined burnout among nurses during the pandemic found that 28

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34.1% of the participants experienced emotional exhaustion, 12.6% experienced depersonalization and 15.2% felt a lack of personal accomplishment.³ The AMA Coping with COVID-19 survey administered to assess stress among healthcare workers in the United States found that 25% of physicians experienced anxiety, 37.3% experienced work overload and 47.73% experienced symptoms of burnout.4 In a survey by Medscape, 47% of physicians said they were burned out − a 5% increase from the year before.5 Occupational hazards In the early stages of the pandemic, there was a lack of personal protective equipment (PPE) availability in many parts of the country and inconsistent data about the reliability of PPE. Healthcare workers were fearful of contracting the disease from work and spreading it to their families.² The AMA Coping with COVID-19 survey found that 61% of the healthcare workers felt fear of exposing the disease to their families.4 This led to many healthcare workers isolating themselves from their loved ones. The toll of having to see patients die from COVID-19 while not being able to have loved ones around contributed to the stress of working on the frontlines during the pandemic. There was also inadequate COVID-19 testing availability, uncertainty about whether healthcare workers would be supported if they contracted the infection and whether there would be access to childcare from the increased work hours. Increased work hours, decreased sleep and disrupted work-life balance led to fatigue and mental distress, which can lead to burnout.6

Systemic inconsistencies Along with the challenges of working in the hospital with an increased volume of patients during the pandemic, there were rapid changes in protocols and policies varied by specialty and hospital.7 This caused confusion and frustration within healthcare teams. The differences in local and national responses along with inadequate planning for equipment availability, emergency management and triage also contributed to this frustration as the burden falls on healthcare workers. The pandemic put a pause on many parts of the US economy, which increased rates of unemployment and consequently added stress and anxiety on the population.² Exacerbated by the pandemic, the need for healthcare workers has increased while the supply is decreasing.8 Stress, burnout and more difficult working conditions from the pandemic have led many healthcare workers wanting to leave healthcare partially or completely.9 Hospitals and clinics had a decrease in staffing, more overtime work and decreased time spent during patient visits. Among the healthcare workers that kept their job, it was found that 31% have considered leaving, and 19% said they thought about completely leaving the healthcare field¹¹. Another study found that 55% of frontline doctors have reduced interest or ability to continue working in the field.8 By 2050, the predicted shortage of nurses will exceed 500,000, while the shortfall of physicians will top 139,000.9 How COVID-19 impacts patient safety To us at the Texas Patient Safety Initiative (TPSI), there are four big contributors to the lack of patient safety in the era of COVID-19: human error, misdiagnosis, delayed patient care and fear of transmission. Human error As human beings practicing the art of medicine, physicians are going to mess up. It’s a given. No one is perfect, not even a physician. Medicine has been historically known as a

SAN ANTONIO MEDICINE

profession that is above a certain “standard.” Whether it was intentional or not, we have been bred and conditioned to obtain perfection.¹0 From undergraduate science classes to the Medical College Admissions Test (MCAT) and medical school class rankings − we’ve been taught that perfection is what we should strive for.¹0 So, when human error occurs in the hospital, like it inevitably will, people play the name, shame and blame game.¹0 People are punished for their honest mistakes and these honest mistakes increase substantially when our healthcare teams are understaffed and healthcare workers are overworked and burnt out, which has increased due to the COVID-19 pandemic. Misdiagnosis According to the Agency for Healthcare Research and Quality,¹¹ the presence of COVID-19 in our communities increases the risk of misdiagnosis in patients with respiratory illnesses. For example, if a patient comes into the emergency room with a respiratory illness presenting with COVID-19-like symptoms and the hospital is unable to see that patient until they get a COVID test, that patient may experience a delayed diagnosis of a nonCOVID-19 condition. The COVID-19 pandemic has shifted the decision-making processes of the healthcare system: if a patient presents with COVID-like symptoms, it is assumed that they have COVID until proven otherwise.¹¹ Patients who present with COVID-like symptoms do not always have COVID.¹¹ Misdiagnosis perpetuated by the magnitude of the pandemic can delay patient care and inevitably lead to increased progression of non-COVID illnesses.¹¹ Delayed patient care/fear of COVID-19 transmission The COVID-19 pandemic has significantly impacted the delivery of health care in the United States. As we continue to fight to flatten the curve, healthcare administrators, healthcare workers and frontline staff have had

to redesign healthcare delivery by prioritizing the most urgent patients with the most acute conditions, and rescheduling patients with chronic conditions and elective surgeries for later appointment times and dates.¹¹ The fear of patient safety and COVID-19 transmission has facilitated delays in preventative care, general checkups and screening procedures.¹¹ We will feel the impact that COVID-19 has had on our healthcare system for a very long time. The effects will pop up in places we least expect. For example, the World Health Organization estimates that over 20 million routine preventive vaccinations will be missed due to the pandemic.¹¹ The fear of COVID-19 transmission and delayed patient care has not only increased the volume of patients in the intensive care unit but will continue to negatively affect patients looking for preventative care and patients with chronic health issues looking for continuation of care.¹¹ COVID-19 has unraveled the structure of our healthcare system and its processes. Without proper mitigation, structural changes and policy updates, our healthcare system and communities could suffer the greatest impact. What can be done to prevent and identify burnout? The following list is suggested from our literature review that expanded on how we can support healthcare workers to prevent and

identify burnout. • Hospital systems must integrate mental health services like counseling, chaplain services, accommodations in work schedules and community support for healthcare workers.¹² • Involve healthcare workers in the process of developing, integrating and evaluating measures to help identify burnout.¹² • Encourage reflection and blame-free environments for healthcare workers to share their experiences.¹³ • Eliminate the stigma associated with mental health-related illness.7 • Hospital leadership must show their appreciation, support and spread words of encouragement.¹² • Encourage healthcare team meetings or check-ins to facilitate constant communication, team building, trust and a stronger sense of support.¹² • Monitor fatigue, stress and sleep via mobile health tools. ¹² The pandemic has caused frustration, burnout and loss of passion among many physicians and other healthcare workers. A change must be made to decrease burnout and optimize patient care and safety. Happy, healthy physicians are more likely to deliver the quality care that patients deserve. continued on page 30 Visit us at www.bcms.org

SAN ANTONIO MEDICINE continued from page 29

References 1. Lee A. Fleisher, M.D., Michelle Schreiber, M.D., Denise Cardo, M.D., and Arjun Srinivasan, M.D. Health Care Safety during the Pandemic and Beyond — Building a System That Ensures Resilience. The NEW ENGLAND JOURNAL of MEDICINE Perspective, 386;7, 609-611 2. Sasangohar, Farzan PhD, SM, MASc*,†; Jones, Stephen L. MD, MSHI*; Masud, Faisal N. MD‡; Vahidy, Farhaan S. PhD, MBBS, MPH*; Kash, Bita A. PhD, MBA, FACHE*,§ Provider Burnout and Fatigue During the COVID-19 Pandemic: Lessons Learned From a High-Volume Intensive Care Unit, Anesthesia & Analgesia: July 2020 - Volume 131 - Issue 1 - p 106111 doi: 10.1213/ANE.0000000 000004866 3. Galanis P, Vraka I, Fragkou D, Bilali A, Kaitelidou D. Nurses' burnout and associated risk factors during the COVID-19 pandemic: A systematic review and metaanalysis. J Adv Nurs. 2021 Aug;77(8):3286-3302. doi: 10.1111/jan.14839. Epub 2021 Mar 25. PMID: 33764561; PMCID: PMC82 50618. 4. Prasad K, McLoughlin C, Stillman M, Poplau S, Goelz E, Taylor S, Nankivil N, Brown R, Linzer M, Cappelucci K, Barbouche M, Sinsky CA. Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: A national cross-sectional survey study, EClinicalMedicine, Volume 35, 2021,100879, ISSN 2589-5370, https://doi.org/10.1016/j.eclinm.2021.10 0879. 5. Physician Burnout, Depression Compounded by COVID: Survey - Medscape - Jan 21, 2022. 6. Leo CG, Sabina S, Tumolo MR, Bodini A, Ponzini G, Sabato E and Mincarone P (2021) Burnout Among Healthcare Workers in the COVID 19 Era: A Review 30

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of the Existing Literature. Front. Public Health 9:750529. doi: 10.3389/ fpubh.2021.750529 7. Song YK, Mantri S, Lawson JM, Berger EJ, Koenig HG. Morally Injurious Experiences and Emotions of Health Care Professionals During the COVID-19 Pandemic Before Vaccine Availability. JAMA Netw Open. 2021;4(11) :e2136150. doi:10.1001/jamanetworkopen.2021.36150 8. Cutler DM. Challenges for the Beleaguered Health Care Workforce During COVID-19. JAMA Health Forum. 2022;3(1):e220143. doi:10.1001/jamahealthforum.2022.0143 9. Wilensky GR. The COVID-19 Pandemic and the US Health Care Workforce. JAMA Health Forum. 2022;3(1) :e220001. doi:10.1001/jamahealthforum. 2022.0001 10. Classen, David C. MD, MS; Kilbridge, Peter M. MD The Roles and Responsibility of Physicians to Improve Patient Safety within Health Care Delivery Systems, Academic Medicine: October 2002 - Volume 77 - Issue 10 - p 963-972 11. AHRQ PSNET Annual Perspective: Impact of the COVID-19 pandemic on Patient Safety. Patient Safety Network. (n.d.). Retrieved March 7, 2022, from https://psnet.ahrq.gov/perspective/ahrqpsnet-annual-perspective-impact-covid19-pandemic-patient-safety 12. Rangachari, Pavani, and Jacquelynn L Woods. “Preserving Organizational Resilience, Patient Safety, and Staff Retention during COVID-19 Requires a Holistic Consideration of the Psychological Safety of Healthcare Workers.” International Journal of Environmental Research and Public Health., vol. 17, no. 12, 2020, pp. International journal of environmental research and public health. , 2020, Vol.17(12). 13. Leo CG, Sabina S, Tumolo MR, Bodini A,

Ponzini G, Sabato E and Mincarone P (2021) Burnout Among Healthcare Workers in the COVID 19 Era: A Review of the Existing Literature. Front. Public Health 9:750529. doi: 10.3389/ fpubh.2021.750529 Prachi Shah is an OMS-II at the UIW School of Osteopathic Medicine. She is a member of the Texas Patient Safety Initiative, Student Outreach for TDSR Public Health Talks and former Treasurer of the American College of Osteopathic Family Physicians Student Chapter (ACOFP). Desiree “Dez” Ojo is an OMS-II at the UIW School of Osteopathic Medicine. While pursuing her medical degree, Desiree is a Student Board Member for Texas Doctors for Social Responsibility (TDSR), a member of the Texas Patient Safety Initiative (TPSI), former 2021-2022 Treasurer for the UIWSOM Student National Medical Association (SNMA) and is a member of her school’s Learner Ambassador Program.

SAN ANTONIO MEDICINE

Artistic Expression in Medicine By Ravjot Virdi

For this project, I chose to make a twopart plaster mold of a medicine bottle. After the mold was made, I used it to create wax models of the bottle. My theme for this project was mental health. In society today, mental health is a topic that is not talked about enough. The medicine bottle I used for this project belongs to a close family member who uses it to contain anxiety medication. I have seen firsthand how individuals with mental health often feel the need to hide their illness. Mental health is considered a taboo topic in many societies, especially in South Asian culture. To highlight the topic in this project, each bottle is labeled with a medication used to treat a different mental illness. By creating a display that outwardly portrays this topic, I hope it will spark conversation and promote greater awareness on this important issue. Ravjot Virdi is a medical student at the UIW School of Osteopathic Medicne.

Contemporary

By Winona Gbedey

Every three months, it’s the same dance. There’s more to this choreography, but we never advance.

I know what they say about patients like me. “Uncontrolled,” “non-compliant,” and “nonadherence” makes three.

We begin when she tells me my A1c is high. I pretend and tell her I don’t know why.

They don’t try to understand my life. They don’t know my triumph, my toil, my strife.

“Are you taking your meds?” she always says. “Sometimes,” I concede, “but I wish they cost less.” Then she asks about diet and exercise. We talk about cutting out tortillas and fries. She concludes with a little encouragement. I smile and nod, yet wonder if this is time well spent.

I like her because she knows me and tries To listen and understand why I always buy fries. So we finish our dance, and then part ways. We work and wish for better days.

Author’s note: “Contemporary” was inspired by a patient interaction I had during my Family Medicine clerkship. Written from the patient's point of view, this poem was made to be a reflection of the unknown social and economic factors that contribute to our patient's adherence to our treatment plans and to serve as a love-letter to practitioners who take the time to take these factors into account.

Winona Gbedey is a medical student at the UT Health San Antonio Long School of Medicine and a member of the BCMS Publications Committee.

Every three months, we do this dance. But at least she tries to give me a chance. Visit us at www.bcms.org

PHYSICIANS PURCHASING DIRECTORY Support 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) Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness. 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”

ASSETT WEALTH MANAGEMENT

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

BANKING

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

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 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

SAN ANTONIO MEDICINE • June 2022

suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

FINANCIAL ADVISORS

Synergy FCU Member Services 210-750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community. Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

BUSINESS CONSULTING

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210-846-9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor) Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for health care entities. Betty Fernandez Director of Operations 210-582-6355 Betty.Fernandez@bexarcv.com www.BexarCV.com “Proudly serving the medical community since 1998”

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

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

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Michael Clark, President 210-268-1520 mclark@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Michael Leos, Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318 mleos@swbc.com swbc.com

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

Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent and treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension and topical wound care. info@NitricOxideInnovations.com 512-773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

HEALTHCARE BANKING

First Citizens Bank (HHH Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise” 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

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 Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you. Wendell England Director of Member Benefits 512-370-1776 wendell.england@tmait.org 800-880-8181 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Guardian (★★★ Gold Sponsor) Live Confidently. Every financial dream deserves a well-crafted plan. Ned Hodge 210-332-3757 ned@nedhodge.com www.nedhodge.com | www.Opesone.com “Take care of today then plan for tomorrow”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through

coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) 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 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’s rating is AM Best A (Excellent). Mike Rosenthal Senior Vice President,

continued on page 36 Visit us at www.bcms.org 33

PHYSICIANS PURCHASING DIRECTORY Business Development 800-282-6242 MikeRosenthal@ProAssurance.com www.ProAssurance.com

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. Aron Sweet , Account Director 210-788-9515 aron.sweet@upnfiber.com Jim Dorman, Account Director 210-428-1206 jim.dorman@upnfiber.com Tammy Carosello, Account Director 210-868-0420 tammy.carosello@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

INVESTMENT ADVISORY REAL ESTATE

MEDICAL BILLING AND COLLECTIONS SERVICES

Medical Financial Group (★★★ Gold Sponsor) Healthcare and Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller and past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210-846-9415

information@medicalfgtx.com Linda Noltemeier Jones, Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals” 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 PAYMENT SYSTEMS/CARD PROCESSING

continued from page 35

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

MORTGAGES First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

MEDICAL SUPPLIES AND EQUIPMENT 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.”

SAN ANTONIO MEDICINE • June 2022

SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Jon Tober, Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! Kevin Barber, President 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

San Antonio Medical Group Management Association (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. Alan Winkler, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates). Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com CARR Realty (★★Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 210-573-6146 Brad.Wilson@carr.us www.carr.us “Maximize Your Profitability Through Real Estate” Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management. Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease”

RETIREMENT PLANNING

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.”

Visit us at www.bcms.org

AUTO REVIEW

2022 GMC Yukon By Stephen Schutz, MD

SAN ANTONIO MEDICINE • June 2022

AUTO REVIEW

The 2022 GMC Yukon is an updated version of one of GM’s fullsize SUVs, and it’s very good. For the record, all of GM’s updated full-size SUVs, the Chevrolet Tahoe/Suburban, GMC Yukon/Yukon XL and Cadillac Escalade/Escalade ESV, are very good, and all have been selling strongly since they were launched in 2020. In addition to the usual changes you’d expect when a vehicle is updated — refreshed styling, nicer interiors and more efficient power-

So, the Yukon is noticeably better than it was on school runs, and incrementally improved on the open road. Two V8 engines are offered: a 355HP 5.3L and a 420HP 6.2L. For Diesel enthusiasts like me, GMC also offers a 3.0L Turbo-Diesel inline-six that pumps out 460 lbs-ft of torque. All models come with a 10-speed automatic transmission operated by a push-button panel on the dashboard, and all can be had with either rear- or all-wheel drive. Fuel economy is a bummer, as you’d expect. The 5.3L V8 gets you

trains — the big news with this generation of GM’s full-size SUVs is that the “smaller” versions are now larger. One persistent complaint about the Tahoe, Yukon and Escalade was that, for full-size vehicles, they didn’t provide all that much second- or third-row seating space. That’s been remedied with the addition of five inches to the wheel-

16 MPG City/20 MPG Highway, the 6.2L V8 drops that to 14/19 and the Diesel makes everyone feel less guilty at 21/27. For the record, the 5.3L V8 isn’t as comfortable lugging the big Yukon around as the 6.2L. One of my business partners has owned Yukons with both engines, and he told me, “I’d never get the 5.3

base, which has resulted in much more rear passenger space. In fact, things are so much better in that regard that I would imagine many buyers who would have ordinarily purchased longer wheelbase models like the Suburban will get the shorter versions instead and be pleased. Another major enhancement for the big GM SUVs is a new independent rear suspension. Not only does that improve ride quality, but it also allows for a lower floor, which further expands storage space. And it improves the third-row seats as well. In previous generations of the Yukon, the third-row seats were just okay. Now the “way back” in the standard wheelbase Yukon is a comfortable place to be, even for 6’2” me. Instead of feeling like my knees were right in front of my face, in the new third-row seat I felt pretty much like I was sitting in the

again.” As noted above, I’d choose the Diesel. All Yukon models come with a large infotainment display with GMC's latest user interface, which is nice to look at and easy to use. The base SLE, mid-range SLT, and off-road AT4 models all feature a display that sits in the center of the dashboard and looks good, but the Denali's is embedded in the dashboard and surrounded by chrome for a more upscale look. Apple CarPlay/Android Auto integration and a WiFi hotspot are all standard; navigation and Bose audio are optional. I don’t have space to go into all of the options and packages, but the Yukon starts at just over $52,000 and goes up from there. The top shelf Denali costs about $17,000 more and is popular with BCMS mem-

previous generation Yukon’s second-row seat, which is a significant upgrade from before. The exterior design of the new Yukon is evolutionary, not revolutionary, so you’ll be forgiven for not noticing the new versions as they drive by you on Bandera Road. Given the Yukon’s popularity, it’s not surprising that GM took the, “if it ain’t broke don’t fix it” approach to the styling. Nevertheless, there are changes. The grille is bigger than it was, and the headlight housings are more stylized. And the rear lights are similarly sculpted, switching from rectangular shapes to something kind of oblong and more dramatic. Also, there’s a Range Rover-ish tapering of the rear end of the SUV that wasn’t there before. Maybe it’s “slimming”? Driving the new Yukon is similar to driving previous versions, but better. The ride and handling − if that’s the right noun when we’re talking about a 6000 lb SUV − are obviously improved thanks almost entirely to the independent rear suspension. And the Yukon’s best-inclass highway manners, which enable the gobbling up of interstate miles, remain unchallenged.

bers for a reason. It’s a very nice truck. GM has done an excellent job updating their full-size SUVs, and the 2022 GMC Yukon is proof. If you need the space and can afford the fuel, you’ll love it. Note for readers: A trauma surgeon friend and I have launched an automotive podcast that may interest you. It’s called, “Cars on Call,” and it features discussions about a myriad of automotive subjects from two physicians’ perspective. It’s available on Apple, Spotify and other platforms, and I hope you give it a listen. 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

11911 IH 10 West San Antonio, TX 78230

Audi Dominion 21105 West IH 10 San Antonio, TX 78257

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX

Coby Allen 210-696-2232

Rick Cavender 210-681-3399

Charles Williams 210-912-5087

William Boyd 210-859-2719

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave. New Braunfels, TX 78130

Northside Ford 12300 San Pedro San Antonio, TX

Northside Honda 9100 San Pedro Ave. San Antonio, TX 78216

14610 IH 10 West San Marcos, TX 78249

Matthew C. Fraser 830-606-3463

Marty Martinez 210-477-3472

Paul Hopkins 210-988-9644

Mark Hennigan 832-428-9507

Kahlig Auto Group

Land Rover San Antonio 13660 IH 10 West San Antonio, TX

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 25131 IH 10 W Dominion San Antonio, TX

North Park Lincoln 9207 San Pedro San Antonio, TX

Cameron Tang 210-561-4900

Tripp Bridges 210-308-8900

James Cole 210-816-6000

Sandy Small 210-341-8841

North Park Mazda 9333 San Pedro San Antonio, TX 78216

Mercedes Benz of Boerne 31445 IH 10 West Boerne, TX

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

9455 IH 10 West San Antonio, TX 78230

John Kahlig 210-253-3300

James Godkin 830-981-6000

Al Cavazos Jr. 210-366-9600

Douglas Cox 210-764-6945

Kahlig Auto Group

North Park Subaru 9807 San Pedro San Antonio, TX 78216

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

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

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

Raymond Rangel 210-308-0200

Phil Larson 877-356-0476

Gary Holdgraf 210-862-9769

Justin Boone 210-635-5000

Kahlig Auto Group

San Antonio Medicine June 2022

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