San Antonio Medicine July 2019

SAN ANTONIO

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Cosmetic Medicine

Advocacy for the Aesthetic Patient – It’s Good Medicine By Christian L. Stallworth, MD...............12 Aesthetic Surgery and the Reconstructive Spectrum By Ted Ferguson, MD...........................16 Non-Surgical Fat Reduction Techniques

By Hope Shin, MD & Rodney Chan, MD.................18 The best way to maintain healthy skin is through prevention By Thushan DeSilva, MD.......22 Summer, sun, shades... oh, and don’t forget the sunscreen! By Pavela G. Bambekova...................24

BCMS President’s Message ........................................................................................................................8 BCMS Delegation ......................................................................................................................................10 The RSV Update Committee and its role in Physician Payment By Ezequiel “Zeke” Silva III, MD ................11 Opinion: The Doctor Shortage By Herbert P. Brown, MD ............................................................................26 UTHSA: Technology accelerator will prevent good ideas from going to waste

By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio ............28 UIW School of Osteopathic Medicine receives grant from Houston Osteopathic Hospital Foundation, allowing predecessors to invest in the education of future DOs By Katie Hennessey for UIWSOM ..........30 Art and Medicine: Submissions from Keerthana Pakanati, Amada Cruz, Alyssa Smith ..............................34 BCMS Circle of Friends Directory ..............................................................................................................36 In the Driver’s Seat ....................................................................................................................................43 Auto Review: 2019 Tesla Model 3 By Steve Schutz, MD ............................................................................44 PUBLISHED BY: SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net BUSINESS MANAGER: Vicki Schroder

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San Antonio Medicine • July 2019

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JULY 2019

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VOLUME 72 NO. 7

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

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

Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robert Richard Leverence, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Brent W. Sanderlin, DO,

DIRECTORS Michael A. Battista, MD, Member

Medical School Representative Alice Kim Gong, MD, Board of Ethics Chair

Vincent Paul Fonseca, MD, MPH, Member

BCMS SENIOR STAFF

Michael Joseph Guirl, MD, Member

Stephen C. Fitzer, CEO/Executive Director

David Anthony Hnatow, MD, Member

Melody Newsom, Chief Operating Officer

Gerardo Ortega, MD, Member

Alice Sutton, Controller

Manuel M. Quinones Jr., MD, Member

Mike W. Thomas, Director of Communications

David M. Siegel, MD, JD, Member

August Trevino, Development Director

Rajeev Suri, MD, Member

Mary Nava, Chief Government Affairs Officer

Kelly King, Alliance Representative

Phil Hornbeak, Auto Program Director

George Rick Evans, Legal Counsel

Mary Jo Quinn, BCVI Director

Col. Charles Gregory Mahakian, MD,

Brissa Vela, Membership Director

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San Antonio Medicine • July 2019

Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Carmen Garza, MD, Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member J.J. Waller Jr., MD, Member

John D. Edwards, MD, Member

Military Representative

PUBLICATIONS COMMITTEE

Al Ortiz, Chief Information Officer

PRESIDENT’S MESSAGE

Moral Injury, Patient Injury, and the Coroporate Practice of Medicine

By Adam Ratner, MD, 2019 BCMS President

Most of us practice within a corporate structure of some sort.

Formal organization is necessary for the sustainable pursuit of our healing missions particularly if more than one or two people comprise the organization. What’s most important is the culture of the corporate entity and its leadership.

Most of the physicians with whom I have had the pleasure of practicing, over my career, have been primarily driven by the interests of their patients. Oftentimes, as caring physicians, we spend more time and energy on a given patient than we will ever be financially compensated and accept that as part of our profession. Not infrequently, we expect to take a financial loss caring for certain patients as an inherent characteristic of our healing missions.

Publicly-traded companies and surplus-driven private forprofit and non-profit entities not truly controlled by practicing physicians aren’t set up this way. Their top leaders are typically rewarded based on the financial performance of their institutions, not on the “quality” of the care they provide, nor the number of lives improved or saved. The value of a life improved or saved, which does not contribute to the production of a financial surplus, is essentially considered either a direct loss or an opportunity cost which needs to be minimized. Corporate leadership of such an entity cannot both optimize patient care quality (which is difficult to measure anyway) and maximize surplus generation which is relatively easy to measure and likely directly impacts the corporate leaders’ personal income and perceived job performance.

The Patient Institute’s Conditions and Diseases of Healthcare Systems (CDHS) project calls this increasingly common situation, “incentive malalignment syndrome.” A condition where the stake holders, that is the patients, physicians, other health care professionals and systems, corporate practice leaders, etc., have competing and incompatible incentives.

Dr. Sheldon Gross, our BCMS immediate past-president, brought to my attention at the recent TexMed meeting that one of the largest health insurers is a major investor in a chain of pe-

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San Antonio Medicine • July 2019

diatrics clinics coming to our state. While it can be argued that direct integration of the payers into the delivery of health care may bring efficiencies and incentivize/force alignment between the payers and those who attempt to heal and provide healthcare, it certainly doesn’t necessarily align with the interests of the patients. Most insurers have a short time horizon with their insured patients because employers re-evaluate their health insurance provider annually and switch frequently. This inherent malalignment, at minimum, incentivizes a short-term, cost-cutting approach to health care delivery rather than a long-term prevention-oriented approach to patient care.

We physicians are adjacent to our patients at ground zero in this incentive malalignment danger zone. Financial and job security pressures burden physicians to make decisions that we know are not the best for our patients but are the best we can do given the constraints within which we are forced to work. How many of us believe that the RVU goals and patient scheduling and volume targets set by corporate masters optimize patient care?

We are aware of the increasing incidence of so-called physician “burnout” and too many of us are sick of suffering with it. Recent literature now speaks of “moral injury” to physicians as the primary cause. That is the damage we as physicians sustain because of the chronic and persistent requirement that we are forced to do the wrong things for our patients by the dictates of our corporate employers and payors.

Now that the 2019 regular legislative season is over, the BCMS leaders and staff will be reviewing the new political reality and seek to bring as many physicians as possible together to create a targeted and aggressive legislative program to address burnout, moral injury and their consequences on us and our patients. If you wish to participate, please let me know.

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

BCMS DELEGATION

BCMS DELEGATION TO TMA WRAPS UP HOUSE OF DELEGATES BUSINESS DURING TEXMED 2019 BCMS gains another member in the Texas Delegation to the AMA Congratulations to Ezequiel “Zeke” Silva, III, MD, who was elected as an alternate delegate to the Texas Delegation to the AMA. He was elected during the annual TexMed meeting on May 18 at the Hilton Anatole in Dallas. A board certified, practicing radiologist with the South Texas Radiology Group, Dr. Silva is a highly experienced member of numerous AMA committees and subcommittees, including: member of the AMA Specialty Society RVS Update Committee (RUC); chair of the AMA RUC Research Subcommittee; co-chair of the AMA Digital Medicine Payment Advisory Group (DMPAG); and member of the AMA RUC Health Care Professionals Advisory Committee. Dr. Silva joins the following physicians also representing BCMS on the Texas AMA Delegation: Drs. David Henkes, chair of the Texas Delegation to the AMA; Jayesh Shah, Delegate; and Jennifer Rushton, Alternate Delegate. Delegate and alternate delegate members in the Texas Delegation to the AMA represent TMA at AMA meetings.

The members of the BCMS Delegation to TMA also submitted two resolutions for consideration during the reference committee hearings including, Resolution 308, Regulation of Electric Scooters, and Resolution 416, Revising the Texas Department of Insurance Division of Worker’s Compensation Designated Doctor Training and Education Process.

Resolution 308 asks TMA to: (1) work with the Texas Department of Public Safety (DPS) to have electric scooters regulated as bicycles and require operators to follow traffic laws as bicycle operators; (2) work with DPS to place an age restriction on electric scooter operators to limit the use of these scooters by children too young to understand traffic laws and to allow only one operator per scooter; and (3) work with DPS to require the use of helmets when operating electric scooters and to add safety features so that car drivers can see them. The resolution was referred for study.

Resolution 416 asks that TMA work with the Texas Department of Insurance Division of Workers’ Compensation: (1) through the regulatory process to ensure that the TDI-DWC examination being given has questions that are accurate and have been validated; (2) to eliminate the requirement for physicians to repeat the course and exam process every two years; and (3) to develop less costly methods of obtaining and maintaining the appropriate level of education requirement to ensure that the Designated Doctors are using the Guides to the Evaluation of Permanent Impairment, 4th edition accurately and that injured workers are being evaluated fairly. The resolution was adopted.

A special thanks to the following members of the BCMS Delegation to TMA, who were on hand throughout the weekend to conduct business in the House of Delegates meetings and elections, reference committees and Caucus Breakfast: Michael Battista, MD and Jayesh Shah, MD, chair and co-chair, respectively, of the BCMS Delegation to TMA; Brian Boies, MD, chair of the Reference Committee on Socioeconom10

San Antonio Medicine • July 2019

Top: Dr. Zeke Silva, candidate for AMA alternate delegate, at the podium presenting his nomination speech before the TMA House of Delegates during TexMed on May 17. Bottom: BCMS Delegates to TMA met during the Caucus Breakfast on Saturday, May 18 to discuss business of the House of Delegates.

ics; Chelsea Clinton, MD; John Edwards, MD; Harold Gaskill, MD; Alice Gong, MD; Anupama Gotimukula, MD; Prabhdeep Grewal, MD – member of the TMA Credentials Committee; Sheldon Gross, MD; William Hinchey, MD; David Hnatow, MD; James Humphreys, MD; Leah Jacobson, MD, served as Chief Teller of the TMA Credentials Committee; Alex Kenton, MD; David Lam, MD, chair of the Reference Committee on Financial and Organizational Affairs; John Menchaca, MD; Jesse Moss, Jr., MD; Lubna Naeem, MD; BCMS President, Adam Ratner, MD; Brent Sanderlin, DO; John Shepherd, MD; Ezequiel “Zeke” Silva, III, MD; Marc Taylor, MD; and Alexis Wiesenthal, MD. For local discussion or to learn how you can become involved with the BCMS Delegation to TMA, contact Mary Nava, chief government affairs officer and delegation liaison at mary.nava@bcms.org.

RVS UPDATE

The RVS Update Committee and its Role in Physician Payment

By Ezequiel “Zeke” Silva III, MD Since the early 1990s, physician payment amounts have been determined by a system called the resource-based relative value scale (RBRVS).

The RBRVS is maintained by the AMA Subspecialty RVS Update Committee, the RUC. I have been involved in the RUC process for over 11 years, eight as an advisor for the American College of Radiology and the last three as a member of the RUC panel. In this column, I describe how the RUC helps determine the amounts of physician payment and how all of us can contribute.

As the name suggests, the RBRVS is a scale of relativity and the currency of the RBRVS is the relative value unit (RVU). Services across the Medicare Physician Fee Schedule (MPFS) are assigned RVUs, based on the resources necessary to provide services to Medicare beneficiaries. The more resources there are, the more RVUs. The total RVU includes three components: work, practice expense and malpractice. Work RVUs are based on time; mental effort and judgment; technical skill and physical effort; and psychological stress, when an adverse outcome has serious consequences.

Practice expense RVUs are based on the resources needed in order to provide a specific service and are different for the facility, (the hospital) and nonfacility (the office). In general, physicians incur greater practice expenses in the office, where they pay for the necessary costs, which are defined as direct costs and indirect costs. Direct costs are specific to the individual service provided and include staff, supplies and equipment. Indirect costs are not specific to the service, such as utilities or the furniture. Work is sometimes referred to as the Professional Component (PC) and Practice Expense is referred to as the Technical Component (TC). Combined, the PC and TC constitute the global payment under certain circumstances, such as diagnostic studies. The third component of the total RVU, the malpractice RVU, is determined by specialty-specific malpractice insurance premium data.

The RUC includes approximately 29 members from multiple physician and qualified health provider specialties. The RUC meets three times per year – each time, over a three-to-four-day period.

Recommendations for valuation originate from the specialty societies, which randomly survey their members regarding the elements of physician work and, sometimes also, on the elements of practice expense. The specialty recommendation is based on relativity, which requires comparison to existing services within the MPFS. For example, a new procedure would be compared to an existing, but similar, procedure for relative comparison. This is often within the same specialty, but comparison is also made to services provided by other specialties, ensuring that relativity is multispecialty. The specialty recommendation is either approved or altered by the RUC, and the subsequent recommendation is then shared with the Centers for Medicare & Medicaid Services (CMS). CMS then internally vets the RUC recommendation and publishes its decision in the Federal Register as part of the MPFS-proposed rule around July 1 (and which allows public comment) and then as the MPFS final rule. The new valuations enter the MPFS in the subsequent calendar year.

We are fortunate that our AMA administers the RUC process and that physician specialties and individual physicians can contribute.

We are the ones who possess the clinical knowledge to inform these valuations. It is critical that we maintain our engagement. If not, there are others who may be willing to address valuation for us. For instance, the Affordable Care Act included provisions to create an Independent Payment Advisory Board, or the IPAB, to unilaterally value physician services with no guarantee of medical specialty or physician involvement. The IPAB was eventually eliminated by the Bipartisan Budget Act of 2018. As I have described, the RUC process is robust and requires the efforts our AMA, medical specialties and numerous physician volunteers. At the ground level, it is equally critical that individual community physicians participate in the survey process.

Dr. Ezequiel “Zeke” Silva III, MD, is with South Texas Radiology Group in San Antonio and was recently elected as an alternate delegate of the Texas Delegation to the AMA.

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COSMETIC MEDICINE

Advocacy It’s Good Medicine

for the Aesthetic Patient –

By Christian L. Stallworth, MD

Oct. 30, 2018, a Dallas resident and El Paso native visited a cosmetic center in Juárez, Mexico excited to undergo a rhinoplasty procedure. She would go on to sustain catastrophic neurologic sequelae and expire on November 24, 2018.

What events led to her death we may never know. But for the question of “why” she went to Mexico for this procedure, the answer may center around the same drivers that influence much of medicine today — cost and access.

According to Patients Beyond Borders, a consumer site focused on international medical travel, an estimated 1.9 million American medical tourists will travel abroad for medical care in 2019 alone, with Mexico serving as one of the largest destinations. Using United States-based procedural and pricing benchmarks, they report average savings throughout the world to range from 20-70%. And residing in a border state like Texas makes access to care south of the

On

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U.S. that much easier. Not surprisingly, cosmetic and dental procedures lead the list of medical services sought by these hopeful travelers who are perhaps more concerned with cost than safety and quality. So, despite living in a state with some of the world’s most renowned rhinoplastic surgeons, the family of this deceased former Texan reported she traveled to Juarez because the surgical cost was more affordable to her. Instead of obtaining the nose of her dreams, though, she paid the ultimate price of death. This is not to say there aren’t renowned rhinoplasty surgeons in Mexico. On the contrary, there are extraordinary surgeons in Mexico and throughout the world. The difference, though, may be in the lack of sufficient due diligence. In the absence of strong regulation, patients risk falling victim to inexperience, inadequate training, second-rate facilities and equipment, poor sanitation, embellished advertising and empty promises.

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One would hope incidences such as this only happen in a foreign country.

But look no further than our own local headlines to find similar cases in the U.S. In the summer of 2018, a doctor in Georgia made national headlines for her intraoperative rap and dance videos filmed while alleged unsuspecting patients were undergoing invasive medical procedures. In my opinion, the videos represent professional behavior that is egregious, unethical, and careless. But worse, still, are her patients’ outcomes.

In one representative case in February 2016, the self-described “nationally and internationally known cosmetic surgeon” performed liposuction and an open abdominoplasty on 54-year-old woman. After nine-hours under what was determined to be poorly monitored office-based anesthesia, with unlicensed and unsupervised care, the patient sustained anesthetic and anoxic complications leading to a year’s worth of ICU and LTAC admissions where she nearly expired. In addition, she accrued millions of dollars in medical expenses and lost her ability to walk, feed herself, and breathe on her own. I urge you to examine the details of this tragedy in “Verdict Magazine, The Journal of the Georgia Trial Lawyers Association.”

In recent years, Florida has also become a hotbed of rogue cosmetic surgery by ill-qualified and often unlicensed physicians. And as deaths and disfigurement have mounted, Florida lawmakers have finally begun to pass legislation to hopefully limit such practices and to aid in transparency for patients. With society caught in the traps of social media and screen magic, all that glitters can appear to be gold, tempting patients to seek care where they often shouldn’t.

Since 2014, an annual survey by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) has consistently highlighted an ever-growing increase in cosmetic procedures performed, particularly in the millennial, under-30 demographic. This is posited to be driven by the advent of the “selfie.” The same survey found procedure cost to be the primary driver for 10% of respondents.

In response, the AAFPRS continues to stress that patients maintain safety as their primary goal and approach their search for competent surgeons based on skill, qualifications, and outcomes instead of cost. Similarly, annual survey data released by the American Society

of Plastic Surgeons (ASPS) demonstrate a continued, steady rise in the number of cosmetic procedures performed annually over the last decade with more than a quarter million procedures performed in 2018 over 2017 alone. Of the 1.8 million surgical cosmetic procedures performed in the U.S. in 2018, breast augmentation, liposuction, nose reshaping, eyelid surgery, and tummy tuck were the most common. Far greater, though, were botulinum toxin and soft tissue filler injections, hair removal, and skin resurfacing procedures which accounted for the majority of the 15.9 million minimally invasive procedures performed in 2018. Now, more than ever, the social stigma of cosmetic surgery interventions is waning as affordability and accessibility increase.

While some may argue the frivolity of such procedures, cosmetic surgery procedures can have profound impacts on patients’ lives.

Restorative procedures like face, eyelid and body lifting have been shown to improve quality of life metrics, increase patient personal confidence in the workplace and social circles, and can even help promote healthy lifestyle changes like diet, exercise, and smoking cessation. Reconstruction of congenital defects can decrease social isolation, minimize bullying, enhance earning potential, and promote greater perceptions of self-worth, thereby elevating one’s concontinued on page 14

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COSMETIC MEDICINE continued from page 13

tributions to society. Transformative procedures like rhinoplasty and breast reduction can not only change someone’s outward appearance, but also provide improved functional outcomes of enhanced nasal breathing and diminished musculoskeletal pain, respectively.

Taken as a whole, aesthetic surgery and aesthetic medicine can enhance quality of life.

A motivating influence to pursue a career in medicine is the promise of being able to make a positive impact on the health of patients. It’s no wonder, then, that many choose to focus their training and careers in plastic and reconstructive surgery. As the number of patients seeking aesthetic interventions increases, so too do the number of physicians offering these services. Concomitantly, diminishing reimbursements, the stranglehold of government and institutional oversights, and physician burnout can also contribute to the allure of providing cash-pay aesthetic care. While there is no fault in this alone, the attraction can entice a slip down the proverbial slope further and further from the purpose and safety of their training. As reported in the New York Times, this trend is growing and poses confusion and risk for patients. In the United States, we ensure our collective expertise through licensing exams, board certifications, accredited training programs and maintenance of certification. Yet how these safeguards and accreditations are promoted to the public through YouTube, Instagram, Facebook and the internet can be both perplexing and misleading. To practice many aesthetic procedures, a hospital setting is not necessary, thereby eliminating the added layer of patient protection found in operative credentialing and privileging. In an outpatient venue, professional oversight can be lax. Patients, then, may find care, no matter how invasive, in a setting like those previously mentioned in Mexico, Georgia, Florida, or even here in Texas. In addition, there is a growing threat of counterfeit drugs and equipment. For example, the FDA has cautioned about some improperly manufactured injectables and toxins masquerading as legitimate pharmaceuticals in the U.S. marketplace. FDA warning notices have been issued to over 1000 physicians nationwide who are known to have administered fraudulent injectables. Ultimately, patients may access care that is hazard laden if they haven’t performed adequate due diligence.

Without proper oversight and guidance from the medical community at large, they may find easy access to treatment that promises great outcomes for reduced expense. In these cases, if it seems too good to be true, it probably is.

Today, the increasing accessibility and acceptability of cosmetic surgery procedures is greater than for any previous generation. But while the rewards of this burgeoning medical industry can be great for both patients and physicians alike, so too can be the risks.

Whether home or abroad, to seek treatment based solely on cost 14

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and easy access without vetting the surgeon can tip the scales away from safety in favor of cost. It is my hope that as a healthcare community, we physicians will recognize the potential positive impact of cosmetic and reconstructive procedures for our patients and help guide individuals seeking this care toward safe and favorable outcomes. Extending the same accepted advocacy for patients’ rights, education, and safety to the realm of aesthetic surgery and aesthetic medicine as we do for all other aspects of healthcare is tantamount for optimal outcomes. In this way, stories like that of our fellow Texan will become infrequent or even only in the past.

Dr. Christian Stallworth is dually board certified by both the American Academy of Facial Plastic and Reconstructive Surgery and the American Academy of Otolaryngology – Head & Neck Surgery. He is a Clinical Associate Professor and Director of the Division of Facial Plastic and Reconstructive Surgery for UT Health San Antonio / The University of Texas Health Science Center at San Antonio.

He also works part-time in private practice. He is a member of the Bexar County Medical Society.

Disclaimer: The views and opinions expressed here are those of the author and not meant to represent those of UT Health San Antonio or The University of Texas Health Science Center at San Antonio.

Resources:

1. RhinoCenter - https://www.facebook.com/pages/Rinocenter/1744481225832343?__tn__=K-R&eid=ARCtSp2Lpj42PpnPqcNLuQdFjmglJ0hm1EI7EHTYv0qZV0xkzym2QoBmZgje9G wb20Gk4yZgYdbxdeZ8&fref=mentions 2. https://www.dallasnews.com/news/news/2018/11/24/dallaswoman-dead-after-botched-nose-job-mexico 3. https://patientsbeyondborders.com/medical-tourism-statisticsfacts 4. https://www.washingtonpost.com/news/to-yourhealth/wp/2018/06/05/a-doctor-who-rapped-and-danced-duringplastic-surgeries-was-negligent-lawsuits-say/?noredirect=on&utm_t erm=.36c222ed0ebe 5. https://verdict.gtla.org/2018/12/06/the-tale-of-the-dancingdoctor-and-disturbing-lessons-learned-about-the-current-state-ofsurgical-practices-in-georgia/ 6. https://www.usatoday.com/story/news/investigations/2019/ 05/01/florida-passes-strict-controls-plastic-surgerycenters/3617669002/?fbclid=IwAR3uf9JjFAoxAlObToqVO5R26Gua6E121ZrdzBW1iE9OLkYFYTZeZpYdlc 7. https://www.aafprs.org/media/stats_polls/m_stats.html 8. https://www.plasticsurgery.org/documents/News/Statistics/ 2018/plastic-surgery-statistics-report-2018.pdf 9. https://www.nytimes.com/2006/11/30/us/30plastic.html 10. https://www.fda.gov/media/90808/download

COSMETIC MEDICINE

AESTHETIC SURGERY AND THE RECRONSTRUCTIVE SPECTRUM

By Ted Ferguson, MD

I have long felt that transitioning into a full-spectrum civilian practice after retiring from the Air Force was a painless move. The comprehensive exposure to every imaginable deformity that a military surgeon encounters is unrivaled in even the busiest trauma centers. As a result, I’ve never had reservations about my ability to transition into a more aesthetically inclined practice. I never experienced any anxiety with doing procedures that are not everyday16

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fare in the military world. I believe the reason for that is straightforward: plastic surgery is essentially a spectrum of reconstructive procedures.

In the military, we become accustomed to performing complex reconstructions. During my deployments to Iraq and Afghanistan, I was easily one of the busiest surgeons at each location. When the casualties would start rolling in, I would help with the initial triage,

COSMETIC MEDICINE

exploratory laparotomies, tracheostomies, etc. Once lifesaving maneuvers were complete, general surgeons, orthopedic surgeons, neurosurgeons, otolaryngologists, ophthalmologists and anesthesiologists would get to the grim task of putting the victims (and sometimes the assailants) back together. In most cases, this was a salvage operation designed only to stabilize the patients for the next echelon of care. I would cover bowel in one room, bone in another, and brain in the next, until all of the vital structures were protected and the dust had settled. For those who were not being shipped out in the next six to eight hours, we would often spend several weeks fine tuning the reconstructions, sometimes rebuilding lips, noses, ears and anything else that was missing or damaged.

During winter when fighting slowed, we would often direct our efforts to restoring local civilians to good health. This was an excellent way to win the hearts of the resident population and was also a rewarding endeavor for the physicians. We typically corrected traumatic injuries, severe burns, or even congenital anomalies such as cleft lip and palate. Suffice it to say that there is never a shortage of people needing a specialty-trained surgeon in a war-torn country.

These were some of the most difficult cases that I have ever come across, but like most things in medicine, if you apply the principles that you were taught in the earliest stages of your training, you can work through most any circumstance.

It is the application of those general principles that brings me to the broader point that I mentioned above: plastic surgery is a reconstructive spectrum. Reconstructive surgery is just that, building something out of nothing, or almost nothing. Aesthetic surgery is the enhancement of existing structures. Of the two, it is apparent which is the more difficult. I have no doubt that without my reconstructive foundation, my comprehension of complex anatomy and the ability to integrate that knowledge into a successful cosmetic outcome would be severely hampered.

We have entered into an era in which newly minted plastic surgeons — as well as many other specialists — are choosing to forego the foundational years as a reconstructive surgeon to plunge headlong into the cosmetic realm. I question whether one can effectively manage unexpected anatomic anomalies in the operating

room or unfavorable outcomes post-operatively without the proper building blocks in place. Like any other medical specialty, experience is of paramount importance in surgery. The combination of shortened training programs and a lack of hard-earned clinical experience is concerning.

Then again, maybe I’m just old fashioned about these things.

When I finished my general surgery residency, my plan was to go directly into a plastic surgery residency. The Air Force had other plans and I ended up working three years as a general surgeon. I was admittedly bitter and angry at the time, but in retrospect, those three years as a staff general surgeon made me a sharper plastic surgeon. I was better prepared for my residency and entered with confidence that I could tackle most anything. General Surgery may not have had a direct correlation with what most people would consider the core of plastic surgery, but it laid the foundation in much the same way as reconstructive surgery laid the foundation for aesthetic surgery.

As I move along this road, I am grateful for the struggles and conflicts that I have been privileged to experience. They have all played a role in shaping me into the surgeon that I am today. I make it a point to share these experiences with my patients whenever possible, as I believe that it reinforces their confidence in my ability to handle any situation that may arise during their care. When they ask me how many noses I have done, I also tell them how many I have built from scratch. When they ask me how many breast augmentations I’ve done, I also tell them how many breast reconstructions I’ve done. Patients appreciate that experience and perspective and our rapport is strengthened because of it.

We all like the compensation that comes with the cosmetic end of our craft, but hopefully we won’t forget the path that got us here.

It is truly the most rewarding part of our profession.

Earl E. Ferguson III, MD is a board-certified plastic surgeon who practices in San Antonio and a member of the Bexar County Medical Society. He retired from the military after finishing his career as Chief of Plastic Surgery for the Air Force and continues to do a mix of aesthetic and reconstructive surgery. visit us at www.bcms.org

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COSMETIC MEDICINE

NON-SURGICAL FAT REDUCTION TECHNIQUES

By Hope Shin, MD & Rodney Chan, MD

ody contouring has grown significantly more popular in the United States within the last several years, and the demand is only increasing. In 2018, liposuction was the second most common cosmetic plastic surgery procedure with over 300,000 cases performed¹. However, newer technologies that are less invasive with quicker recovery, fewer side effects, and less complications have increasingly become more appealing. A number of treatments have been FDA-approved to achieve gradual and modest fat loss without surgical incisions. These non-invasive fat reduction technologies all specifically target adipocytes by using different types of energy, such as cryolipolysis, laser, high-frequency ultrasound, and radiofrequency.

B

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San Antonio Medicine • July 2019

Optimal patients that would benefit from these devices are near their ideal body weight with specific areas of excess fat that cannot be eliminated by diet and exercise. The main benefits of non-invasive body contouring include no incisions or scars, no need for anesthesia, minimal side effects, and early return to normal activities. In addition, results last as long as the patient does not gain weight.

However, the limitations include a modest reduction of localized fat, minimal sculpting ability, and many treatments are needed for desired results.

Cryolipolysis (CoolSculpting®) is one of the more novel techniques that uses cold exposure to selectively reduce subcutaneous

COSMETIC MEDICINE

fat. Although the mechanism of action is not fully understood, the cold exposure is thought to create an inflammatory reaction within the adipocytes leading to apoptosis2. CoolSculpting® is FDA-approved for reduction of fat in the abdomen, flank, thighs, back, arms, upper buttock, and submental region. During the procedure, a vacuum applicator is attached to the targeted area which draws tissue into an applicator cup, and this is gently held between two cooling panels. The procedure usually takes between one to three hours depending on the number of areas addressed. Studies have demonstrated that average reductions in the subcutaneous fat layer range from 14%-25.5%,3,4,5. The most common side effects include localized erythema, bruising or swelling, and decreased sensation that can last one to eight weeks. After therapy, cryolipolysis has not found to increase serum lipid levels or liver function tests6.

Laser fat reduction (SculpSure®, Zerona®) is another technology that use laser therapy to target subcutaneous adipose tissue without affecting the dermis. SculpSure® uses a laser at 1060nm to increase the temperature of the adipose cells between 42 and 47 to damage the adipocytes and disrupt their structure. Over the next three months, the lymphatic system eliminates them7. Sculpsure® is FDAcleared for the abdomen, flanks, bank, thighs, and submental area.

Treatment takes approximately 25 minutes per area and requires multiple sessions, and it can take up to 12 weeks to see optimal results. In contrast, Zerona® uses low-level laser technology at a wavelength of 635nm to penetrate fat and create a temporary pore in the cell membrane of the adipocyte through which lipids are re-

leased. The lipids are released into the interstitial space and removed by the lymphatic system. Therefore, there is volume reduction in fat without inducing cell death.

On average, patients undergo six to 12 treatments every 48 hours for a period of two weeks8.

Emerging technologies are on the horizon that promise greater agility with a smaller “footprint.”

The eonFR is a cart-based system using a 1064 nm laser. It is a platform meant to be used for multiple aesthetic indications including body contouring among others. It uses a powered articulated arm to deliver the laser energy and cool the skin simultaneously without any skin contact. The surface area is significantly larger due to this capability and the set-up time is minimal with has no post-treatment required. The physician determines the treatment zone, selects it, reviews it with the visualized light and implements treatment with the push of a button. It is currently pending FDA clearance.

Another technique for noninvasive fat reduction is high frequency ultrasound (UltraShape®) which emits acoustic waves of focused ultrasonic energy to target only subcutaneous fat at a controlled depth. The energy is transmitted through pulsed ultrasound to mechanically target the adipocytes without increasing the temperature in the surrounding tissues. Only areas with at least 1.5cm of fat thickness should be treated, and it is recommended that patients undergo a series of three treatments spaced two weeks apart to see optimal results. The maximum fat thickness reduction is usually seen between 15 and 30 days after the final treatment9.

Radiofrequency energy devices (Thermage®, Velashape®) use either monopolar or bipolar radiofrequency energy to deep-heat fat cells, connective tissue, and dermal fibers. The mechanism is dual action by causing immediate collagen contraction and remodeling, as well as increasing the adipocyte’s metabolism and accelerating the triglyceride egress from the cell. Thermage® is a monopolar radiofrequency device that is mostly used for skin tightening and cellulite but also has a modest reduction in fat. It is FDA-approved only for the periorbital rhytids but can also be used in different areas of the body. VelaShape® combines 700nm-2000nm infrared light and suction coupled bipolar radiofrequency to mechanically manipcontinued on page 20

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COSMETIC MEDICINE continued from page 19

Treatment

Energy Source

Mechanism of Action

Efficacy

Side Effects

CoolSculpting® Cryolipolysis

Cold induced inflammatory reaction to cause apoptosis of adipocytes

Fat thickness reduction of 14%-25.5%

Erythema, bruising, swelling, decreased sensation

SculpSure®

1060nm laser

Increases temperature to disrupt adipocyte structure

Fat thickness reduction of 21%-24%

Mild tenderness

Zerona®

635nm laser

Transitory pore in cell membrane opening allows fat to leak out

3-9 inch fat thickness reduction

Thermal skin injury

UltraShape®

Ultrasound

Mechanical motion to produce cellular membrane disruption

2-4cm circumferential fat reduction

Bruising

Thermage®

Monopolar radiofrequency

Deep heat fat cells, connective tissue, and dermal fibers

Improvement scores of 30-70% for cellulite with modest fat thickness reduction

Erythema, minor swelling

Velashape®

Bipolar radiofrequency, infrared light, and vacuum

Mechanically manipulate fat and thermally injure the dermis

5.4cm ± 0.7cm circumference fat reduction, 40% cellulite improvement

Erythema, minor swelling

ulate fat and thermally injure the dermis9. It is FDA-approved for cellulite and thigh and abdominal fat reduction. Velashape® has been found to have an overall mean circumference reduction of 5.4cm ± 0.7cm when the abdomen, buttock and thighs were treated over five weeks10.

Noninvasive fat reduction is an attractive therapy to enhance specific areas that would benefit from body contouring. All of the technologies described above have been proven to be safe with minimal side effects. However, it is crucial to not only choose the correct patients that would benefit from these modalities, but also educate patients that there will only be a modest improvement in body contour.

References

1) National, S., & Bank, D. (2018). Cosmetic Surgery National Data Bank Statistics. Aesthetic Surgery Journal, 38(suppl_3), 1–24. https://doi.org/10.1093/asj/sjy132 2) Avram MM, Harry RS. (2009) Cryolipolysis for subcutaneous fat layer reduction. Lasers Surg Med; 41(10):703–8.

3) Dover J, Burns J, Coleman S, et al. (2009) A prospective clinical study of non-invasive cryolipolysis for subcutaneous fat layer reduction: Interim report of available subject data. Lasers Surg Med. 41:43.

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4) Coleman SR, Sachdeva K, Egbert BM, Preciado J, Allison J. (2009) Clinical efficacy of noninvasive cryolipolysis and its effects on peripheral nerves. Aesthetic Plast Surg. 33:482-488 5) Shek SY, Chan NPY, Chan HH. (2012) Non-invasive cryolipolysis for body contouring in Chinese – A first commercial experience. Lasers Surg Med. 44:125-130 6) Klein KB, Zelickson B, Riopelle JG, et al. (2009) Noninvasive cryolipolysis for subcutaneous fat reduction does not affect serum lipid levels or liver function tests. Lasers Surg Med; 41(10): 785–90.

7) Decorato, J. W., Chen, B., & Sierra, R. (2017). Subcutaneous adipose tissue response to a non-invasive hyperthermic treatment using a 1,060 nm laser. Lasers In Surgery And Medicine, 49(5), 480–489.

8) Afrooz, P. N., Pozner, J. N., & Dibernardo, B. E. (2014). Noninvasive and Minimally Invasive Techniques in Body Contouring.

Clin Plastic Surg 41, 789–804.

9) Mulholland, R. S., Frcs, C., Paul, M. D., & Chalfoun, C. (2011).

Noninvasive Body Contouring with Radiofrequency, Ultrasound, Laser Therapy, and low level laser therapy. Clin Plastic Surg 38, 503-520.

10) Winter ML. (2009) Post-pregnancy body contouring using a combined radiofrequency, infrared light and tissue manipulation device. J Cosmet Laser Ther; 11(4):229–35.

COSMETIC MEDICINE

“But first, let me take a selfie.

Can you guys help me pick a filter? I don’t know if I should go with looking tan, skinny, removing wrinkles…”

kin care, cosmetic procedures, lasers and other devices are continually being enhanced in order to keep up with the demands of the aging person to look and feel younger. The prominent influence of social media has dramatically increased self-awareness and the ways people seek to improve their appearance. Every blemish, wrinkle and flaw are scrutinized in an attempt to rejuvenate and satisfy their appearance.

With the growth of the ‘selfie generation,’ people are now seeking instant gratification more so than ever. Procedures such as botulinum toxin and fillers have increased in popularity due in part to the rise of social media. Even for patients who don’t fall into that category, there are a host of other options for wrinkle reduction, skin tightening, lifting and brightening as well as other devices and treatment regimens.

Short of a surgical procedure, what can be done for the aging face?

The best method is prevention. There are three main components that age our skin: ultraviolet (UV) radiation, pollutants/cigarette smoking and time. UV radiation (obtained by sun and/or tanning beds) is best treated with avoidance, protective covering and sunscreen. Remember the shadow rule; if your shadow is shorter than you, it’s best

The best way S to maintain healthy skin is through prevention

By Thushan DeSilva, MD

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San Antonio Medicine • July 2019

COSMETIC MEDICINE

to stay indoors. Peak hours are typically 10 a.m. to 2 p.m., although in Texas the sun can remain pretty intense until well past 5 p.m. Protective covering includes UV-protected clothing such as long-sleeved shirts, broad-brimmed hats (that cover the ears), UV-protected sunglasses (to help prevent cataracts), and darker and tighter weaved clothing. You can seek shade with umbrellas and trees as well. The best advice regarding sunscreen is that any sunscreen you will wear consistently is better than nothing. In general, you should look for SPF of 30 or more, ideally with zinc oxide as an active ingredient.

No matter which sunscreen you use, while outdoors you should reapply every two hours; more frequently if you get wet or sweat.

The appropriate amount to use is one ounce for whole body application. Most bottles are 4-8 ounces, which means a bottle should only last for 4-8 applications‌ not all summer long! As for pollutants, you can certainly try to live greener, but will still be exposed to environmental pollutants. The best thing you can do is use skin care that has good anti-oxidant benefits; the most common being products containing vitamin C. If you currently smoke cigarettes, either stop for the many health reasons beyond skin aging or stop reading this article any further. Time is the only variable we have no control over, but there are several options to try and reverse some of the aging effects of time.

If sunscreen is not part of your daily regimen it’s time to start making it a priority, not only for skin cancer prevention but also for premature skin aging. There are several options to combat skin aging and achieve skin rejuvenation. The first step is retinoid application.

Retinoids have been proven to normalize keratinization of the epidermal layers and increase collagen and elastic fibers for firmer, tighter skin. The higher the concentration, the better the results, however you may experience more irritation and side effects. Next, you can utilize different combinations of antioxidants and growth peptides. In addition to collagen and elastic fiber breakdown, brown spots and dilated capillaries age our skin. There are many skin brighteners and lighteners such as hydroquinone, kojic acid and azaleic acid, just to name a few. There are also several medical grade skin care products available on the market that provide patients improvement in the appearance of brown spots. Capillaries are most improved with vascular lasers.

Repetitive movement will eventually add lines and wrinkles to certain areas of the face. The main areas are the vertical scowl lines between the brows, the horizontal lines of the forehead and radiating crows feet on the sides of the eyes. These are best addressed by botulinum toxin. Not all botulinum toxins are equal and not all injectors are equal so be sure and do your research.

Gravity keeps us on the ground but also causes some facial features to go south, creating deepened nasolabial folds, marionette

lines and jowling. Non-surgically we can correct this by refilling lost volume in the midface/cheek and/or directly into the nasolabial folds and marionette lines.

Fillers can be generically divided into hyaluronic acid (HA) based or nonHA based. Although one advantage of the HA-based fillers is that any unforeseen side effects or asymmetries can be reversed with hyaluronidase. Ask your injector whether they have the hyaluronidase on site. If not, go elsewhere.

When it comes to devices, it seems there is always something bigger and better on the horizon. The perfect device that tightens tissue with no pain and no downtime doesn’t exist as of now. What does exist are ablative and non-ablative lasers. Ablative (such as CO2 or Erb:YAG) lasers give better results but with some pain and downtime. Newer technologies include radiofrequency devices, microneedling with or without PRP, combination radiofrequency with microneedling, focused ultrasound, electromagnetic impulses, and IPL (photofacials). Old school chemical peels can be very effective for skin tightening as well but are limited due to downtime from peeling/sloughing and pigmentary issues during summer months.

Clearly there are numerous options available in the quest for the fountain of youth. The ideal answer is a combination of approaches including prevention with sunscreen, a good skin care regimen involving a tolerable retinoid and other modalities such as botulinum toxin, fillers, lasers or other skin tightening devices. The limitations include the starting canvas, downtime and budget. Patients should seek out a board-certified physician to help customize a treatment strategy based on desired outcomes, timeline and budget.

Dr. Thushan DeSilva is a board-certified dermatologist practicing since 2000 and a member of the Bexar County Medical Society. He is a member of the San Antonio Dermatology Society and served as president from 2009 to 2011.

Dr. DeSilva opened DeSilva Dermatology in Boerne in 2017.

visit us at www.bcms.org

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COSMETIC MEDICINE

Summer, sun, shades… oh, and don’t forget the sunscreen!

By Pavela G. Bambekova

lot has changed about the notion of beautiful skin throughout the years. Despite Coco Chanel’s inspiration for tanning in the 1920s and the craze of tanning beds in the ‘70s, the notion of beautiful skin seems to have turned 180°, and sun-blocking agents that help reduce wrinkles, leathery skin, and brown spots associated with long-term sun exposure appear to be more appealing to people who appreciate skin beauty. But whether one spends time at the pool with friends or travels to the beach with family this summer, it can be easy to forget the sunscreen.

As the sun gets brighter and stronger, dermatologists are encouraging patients to apply sunscreen on a regular basis. May was Skin Cancer Awareness month, which serves as an annual reminder that routine sunscreen use helps reduce the risk of developing skin cancer. Applying sunscreen daily can also prevent sunburns and decrease signs of skin aging, thus leaving skin to look and feel younger, more radiant, and healthier.

Despite the well-studied benefits of sunscreen, regular sunscreen use has generated a lot of attention lately, especially after an article

by Matta et. al. was published in the May issue of JAMA.1 The investigators conducted a randomized clinical trial of 24 healthy volunteers who applied sunscreen four times per day for seven days.

A

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San Antonio Medicine • July 2019

The objective of the study was to determine the systemic exposure of sunscreen active ingredients (avobenzone, oxybenzone, octocrylene, and ecamsule) present in commercially available sunscreen products of different formulation types (cream, spray, and lotion) under maximal usage conditions. The authors determined that plasma concentrations of active ingredients were greater than 0.5 ng/mL (the threshold limit established by the U.S. Food and Drug Administration) in all four products after four applications on day one, and three of the four active ingredients remained above the threshold for the duration of the study. This study left many people wondering if wearing sunscreen is actually doing more harm than good. The media, which followed with headlines like “Sunscreen chemicals enter bloodstream at potentially unsafe levels” and “High levels of sunscreen ingredients enter blood after just a day of use” helped generate a scare among consumers.

“It is important to keep in mind that the plasma concentration found within the study participants does not necessarily equate to a toxic level,” says Dr. Faryal Siddiqui, a dermatology resident at UT Health San Antonio. “I wouldn't want this to deter any of my patients from practicing good sun safety.”

Demonstrating that active ingredients are systemically absorbed

COSMETIC MEDICINE

in the bloodstream is not new information. In the late 90s, a similar finding was shown by Hayden et. al. and published in the Lancet.2 Since then, the FDA, which regulates sunscreens in the U.S. as over-thecounter drugs, has issued guidelines that encourage sunscreen maximal use clinical trials to demonstrate systemic absorption of active ingredients and to see if that is above 0.5 ng/mL; if systemic absorption is more than this threshold, the FDA requires further studies on toxicology. Thus, the study by Matta et. al. supports the need for further investigations to determine the clinical significance of the findings.

At this point, showing that active ingredients are absorbed systemically does not imply toxicity. Little is known about the toxicities of sunscreen ingredients. High systemic levels of oxybenzone are thought to be linked to hormonal changes in males,3 but more research focusing on such effects is needed.

In addition, it is important to know that the study investigators clearly stated their results do not indicate that individuals should refrain from using sunscreen. The authors also acknowledge the limitations of their study — it was conducted in indoor conditions without exposure to heat, sunlight, and humidity, which may alter the rate of absorption of sunscreen. Furthermore, the study was performed with healthy adult volunteers, which leaves room for investigating systemic absorption of sunscreen active ingredients in children and in people with chronic skin conditions.

With all of this, it is important to know that dermatologist still recommend using sunscreen on a regular basis. There are two kinds of sunscreen — chemical sunscreens that absorb sunlight and physical sunscreens that deflect sunlight. The former can contain oxybenzone, avobenzone, octisalate, octocrylene, homosalate, or octinoxate as their active ingredients, and they tend to be easier to apply to the skin; the latter contain titanium dioxide, zinc oxide, or both, and they are recommended for sensitive skin. The FDA has proposed that titanium dioxide and zinc oxide are “generally recognized as safe and effective.” Therefore, people worried about systemic exposure of sunscreen ingredients can consider this when making their selection.

“Physical blockers have been known to leave a white cast or feel greasier than their chemical counterparts, but there’s been such a

proliferation in brands and formulations that I think most people can find one that works for them,” says Dr. Siddiqui.

Protecting the skin from the sun is more than just sunscreen, however. Avoiding sun exposure at peak hours between 10 a.m. and 4 p.m. checking the UV index, which offers a snapshot of how likely one is to burn based on the amount of UVB light, wearing wide-brimmed hats, sunglasses, long sleeve shirts, and staying in shaded areas as also important to help keep skin looking younger and healthier.

“If sunscreens are not a realistic part of someone’s routine, I encourage patients to purchase sun protective clothing,” says Dr. Siddiqui. “I just bought an SPF 50 shawl myself!”

Resources

1 Matta, Murali K., et al. “Effect of sunscreen application under maximal use conditions on plasma concentration of sunscreen active ingredients: a randomized clinical trial.” JAMA (2019).

2 Hayden, Cameron GJ, Michael S. Roberts, and Heather AE Benson. “Systemic absorption of sunscreen after topical application.” The Lancet 350.9081 (1997): 863-864.

3 Janjua, Nadeem Rezaq, et al. “Systemic absorption of the sunscreens benzophenone-3, octyl-methoxycinnamate, and 3-(4methyl-benzylidene) camphor after whole-body topical application and reproductive hormone levels in humans.” Journal of Investigative Dermatology 123.1 (2004): 57-61.

Pavela G. Bambekova is a medical student at UT Health San Antonio.

visit us at www.bcms.org

25

OPINION

THE DOCTOR SHORTAGE

By Herbert P. Brown, MD

Have you tried to consult a physician for your own medical needs lately?

First, you find that it takes several more phone calls than you first thought.

Second, unless the problem is obvious the actual number of primary care physicians has dwindled so it may take you awhile to find help.

Recently, a collaboration between the Massachusetts Medical Society and Harvard School of Public Health did a survey of physician availability in New England resulting in a white paper that generated quite a bit of interest in the New England area and even nearby Canada. They found that the actual number of primary care physicians has dwindled so much so that there is a public health crisis as a result. The cause, physician burnout (much to their and the public’s surprise, but not ours because it hurts patients).

Our sister society, the Mass Medical Society, decided that some interventions were needed urgently: They determined that outside intervention was needed.

1. That key stakeholders be identified and moreover, they be made aware of their responsibilities, e.g. health insurers.

2. Impress upon governmental agencies that physician’s time spent on extensive documentation does not directly improve patient care.

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San Antonio Medicine • July 2019

3. Provide scribes so busy physicians can devote more time to direct patient care. If the Electronic Health Record is mandatory, minimize and reduce its check off level.

4. Improve compensation for primary care physicians for time and services spent. Present level is pitiful.

5. If you have the means, employ a concierge physician. This, of course, does not solve the larger problem which still merits our attention.

6. Consider physician wellness programs as integral to the clinical programs.

Those of us who enjoy the practice of medicine should not be discouraged for the sake of corporate benefit. We can and must fight back for our own as well as our patient’s sake.

Dr. Herbert Brown is a retired physician and a member of the Bexar County Medical Society.

UT HEALTH

TECHNOLOGY ACCELERATOR WILL PREVENT GOOD IDEAS FROM GOING TO WASTE

By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio Medical breakthroughs are the result of arduous research and great effort, but if they are never translated into new therapies, drugs or treatments, they benefit no one.

In the field of biomedical research, ideas are especially precious, for who knows which one could hold the cure for a vexing disease?

As a society, we cannot afford to lose possible solutions for cancer 28

San Antonio Medicine • July 2019

or diabetes or heart disease because of a complicated process to get them in the hands of physicians for the benefit of their patients.

Precious time lost could mean precious lives lost.

To this end, UT Health San Antonio in April announced TechNovum, a technology commercialization accelerator. TechNovum starts with the germ of an idea, and accelerates, or compresses, the

UT HEALTH

amount of time it takes to move the idea to the next stage, such as to a life science spinoff company in an incubator.

TechNovum will pair UT Health San Antonio faculty investigators with mentors from the business community and coach them through the market validation of their biomedical products, preparation of a business plan and pitching their technologies. The inaugural five to eight teams of inventors (known as Founders) will undergo a rigorous and structured entrepreneurial ideation program that includes weekly course sessions and guest speakers.

The accelerator program will run from June through October 2019, and wrap up with two days for the teams to demonstrate their products and present their business plans. One day will be reserved for accredited investors, the other will be open to the community.

This is a critical advancement for our community and the world beyond.

At the center of this commercialization accelerator is the promise of progress in science. Founders will build their business skills and gain knowledge of resources to translate ideas into products and companies. This will get new discoveries and technologies into the world faster, and could mean the difference between living with a disease and being cured.

For more than 50 years, UT Health San Antonio has provided an environment in which world-class scientists turn their discoveries into reality. One example is Jean Jiang, PhD, who occupies the

Zachry Distinguished University Chair in Cancer Research. She knows what it takes to start with an idea and navigate the early steps of patenting and licensing a new biotechnology.

Her scientific curiosity, her entrepreneurial spirit and her unwavering devotion to translating her discoveries to help patients led to the exclusive licensing of two unique biologic therapeutics by AlaMab Therapeutics Inc. in June 2017.

These biologics will be developed into novel, first-in-class therapies for spinal cord injury and breast cancer bone metastasis.

Had TechNovum existed while Dr. Jiang was first beginning her journey, it would have propelled her project into a more advanced level of development at a much faster speed. This is because, in addition to providing education and mentoring to researchers who are new to drug and product development, it will also teach investors how to seek financial support for very earlystage preclinical studies.

San Antonio has an increasingly robust and collaborative bioscience ecosystem that provides unlimited partnership opportunities. Because of the efforts of the faculty and staff at UT Health San Antonio, including Andrea Giuffrida, PhD, vice president for research; John Gebhard, PhD, assistant vice president for the Office of Technology Commercialization; and accelerator co-directors John Fritz and Sean Thompson, TechNovum will be collaborative and complementary to all that exists in the ecosystem and highly valuable to all investigators with an entrepreneurial spirit.

We are confident that, with support from the community, TechNovum will eventually reach out to investors and entrepreneurs, even those who are not affiliated with UT Health San Antonio.

Most importantly, ideas — concepts that can save lives — will be planted, watered and reaped for the betterment of human health.

The University of Texas Health Science Center at San Antonio, now called UT Health San Antonio, is one of the country’s leading health sciences universities. With missions of teaching, research, healing and community engagement, its schools of medicine, nursing, dentistry, health professions and graduate biomedical sciences have produced 36,500 alumni who are leading change, advancing their fields and renewing hope for patients and their families throughout South Texas and the world. To learn about the many ways “We make lives better,” visit www.uthscsa.edu.

visit us at www.bcms.org

29

UIW GRANT

PROTECTING OSTEOPATHIC HERITAGE AS PROFESSION RISES UIW School of Osteopathic Medicine receives a grant from Houston Osteopathic Hospital Foundation, allowing predecessors to invest in the education of future DO’s.

By Katie Hennessey for UIWSOM Dr. David Armbruster found an important synergy between the Houston Osteopathic Hospital Foundation (HOHF) and the Mission of the University of Incarnate Word School of Osteopathic Medicine (UIWSOM). Both organizations are deeply invested in the growth of osteopathic medicine, helping the practice expand and share its approach to care.

As the field grows, Armbruster, a political advocate for the profession, wanted to aid medical establishments committed to the mission of osteopathy. The HOHF Board of Directors was thoughtful in choosing UIWSOM as the recipient of the $200,000 Houston Osteopathic Hospital Foundation Grant at the beginning of 2019.

“We want to support institutions who are teaching Osteopathic Manipulative Medicine (OMM), and all the principles of the profession,” he said.

Noted for their manual treatment and whole-person approach, osteopathic medicine in the United States has seen a rapid growth in recent years. Medical schools graduated more Doctors of Osteopathy (DO) in 2018 than any year in history. In 2016, UIWSOM opened in San Antonio, Texas training primary care osteopathic physicians to meet the health needs of Central and South Texas, particularly in underserved and vulnerable populations. It is now one of 35 US osteopathic medical schools and the only faith-based medical school in Texas.

The grant reminded UIWSOM Founding Dean Dr. Robyn Phillips-Madson of the pioneers of the field, who designed a natural path towards health when medical practices of their time presented limitations. These new methods, which focused on the body’s ability to heal itself, were largely dismissed by mainstream medicine. However, the steady advocacy of leaders like Armbruster contributed to 30

San Antonio Medicine • July 2019

David Armbruster, DO and wife of 63 years, Elaine Armbruster remain in Pearland, Texas, where the Family Medicine Doctor treats patients in OMT techniques and osteopathic principles at the Armbruster Clinic.

UIW GRANT

greater acceptance of the medical profession as well as to the growth it has enjoyed today.

“These are the historians, they set this wonderful foundation for us to carry forward,” Madson said.

A Physician’s Mission to Defend the Field

Dr. Andrew Taylor Still, the philosopher and physician behind the preventative, whole-person methods of osteopathy, implored future physicians in the field to fight for the purity of the profession.

“Stand behind all legitimate research institutions,” Still said. “Give them your support.”

In 1963, Armbruster graduated from the first osteopathic medical institution named for the osteopathic founder, A.T. Still University - Kirksville College of Osteopathic Medicine. The calling to stand behind the field became his mission.

Family Physician and Proctologist, Armbruster and wife of 63 years, Elaine, moved to Pearland, Texas to establish a clinic in 1964.

The bustling metropolitan area that Pearland is today, was a small community on the outskirts of Houston at the time.

It didn’t take long for Armbruster to become locally known in the rural community as Pearland Schools’ team physician, City of Pearland health officer, and the doctor who sewed the local rice farmer’s fingers back on after he refused to go to the hospital.

Outside the city limits, Armbruster was turning over major stones in the American Osteopathic Association (AOA), working to assure that states across the nation gave full practicing rights to osteopathic doctors.

“We fought for equal rights for years,” Armbruster said, referring to the over 50 consecutive years that he has served as an active member of the AOA. “There was always one hot spot that we had to straighten out one way or another.”

One of the first hot spots was in the state of California, when leaders of the California Medical Association and the California Osteopathic Association met behind closed doors to discuss plans for

MDs and DOs to merge into one medical field. The contract agreement, approved in 1962, stated licensed DOs and recent graduates would be awarded a Doctor of Medicine degree. With only an MD accrediting system, osteopaths could no longer receive license to practice osteopathic medicine.

“Osteopathic medicine was known as a cult at the time,” Armbruster said. It took nearly two decades and numerous appeals from influential osteopaths for the California Supreme Court to rule against the refusal of osteopathic licensure, resulting in the formation of two medical board licensing associations, one for DOs, one for MDs. While Texas granted full practicing rights to osteopathic physicians in 1907, it would take nearly 70 years for osteopaths to be eligible for licensure in all 50 states.

Armbruster was on the frontlines, recommending resolutions and voting for the limitations and constraints placed on the practice to be broken down as part of his work on the AOA House of Delegates. “Over all the years of my practice, I’ve done nothing but advocate for full practice rights,” he said. “They’d have to eventually accept all of us.”

UIWSOM Plans to Utilize Grant to Foster Tomorrow’s D.O.s

The University of the Incarnate Word School of Osteopathic Medicine graduates their first class in 2021 and will send them out to residency programs. Madson aspires for UIWSOM learners to recognize the work their predecessors accomplished in building the profession, and continue in the philosophy, practice and science throughout their medical careers. The partnership with HOHF will help accomplish this goal.

The distinction between DO and MD accreditation is about to change. By 2020, The Accreditation Council for Graduate Medical Education, (ACGME) the system that accredits MD programs, will add DO residencies and fellowships, creating a single accrediting continued on page 32 visit us at www.bcms.org

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UIW GRANT continued from page 31

system and uniform pathway of preparation.

The Osteopathic Principle Committee will sit on the ACGME to ensure osteopathic skills and philosophies are distinguished and supported at the graduate medical education level.

“If we aren’t intentional about integrating osteopathic philosophy and osteopathy manipulation in all aspects of medicine, we are going to lose our heritage,” Madson said.

The Osteopathic Recognition Program, an added qualification residency that programs can obtain by offering residents osteopathic training and assessment, will help DOs receive specific training in their graduate medical education.

“I am hoping to use some of this funding from the HOHF to support a DO to work on Osteopathic Recognition Accreditation for the ACGME residency program we help start,” Madson said.

UIWSOM would have a DO faculty member develop requirements for the program and oversee the training for the osteopathic track.

“There would be osteopathic recognition in family medicine, internal medicine, psychiatry, all the specialties,” Madson said. “There would be certain qualifications they would have to meet to receive the recognition, like OMM and mindfulness with mind, body, spirit. … Funding from the HOHF helps us get this started earlier than

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we likely could have.”

Armbruster and Madson first realized their shared interest in fostering the tenets of the field through their work in health policy in the Texas Osteopathic Medical Association.

The HOHF has previously supported UIWSOM in 2018 with a $50,000 grant that helped make students’ attendance at developmental trainings possible. UIWSOM learners participated in medical conferences like the American Academy of Osteopathic Convocation, American College of Osteopathic Physicians, AOA annual conferences and Osteopathic Manipulative Treatment (OMT) trainings in fascial distortion.

“We are a young profession,” Madson said. “We have to do a lot of training in leadership development so that we can really have high quality schools [in the future].”

One of her methods for sustaining osteopathic principles throughout UIWSOM learners’ professional careers, is teaching them to naturally think in a way that fosters holistic patient treatment.

“Rather than treating osteopathic principles and OMT as a separate entity, I think integrating it throughout everything you learn about medicine, will show learners how to actually use it.” Madson said. “This grant allows us to do just that.”

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ART & MEDICINE

San Antonio Medicine is introducing a new monthly feature where we will showcase art submissions from member doctors and local medical students.

“Corazon del Flor” (Heart)

By Keerthana Pakanati – MS3 UT Health San Antonio, Long School of Medicine, Class of 2020

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San Antonio Medicine • July 2019

ART & MEDICINE

55 Word Stories Amanda Cruz – MS3 UT Health San Antonio, Long School of Medicine, Class of 2020

“An intimate view into some bowels.”

The scalpel slices her skin open.

I see liver, small intestine. Her heart beats rhythmically against her diaphragm. Her gallbladder is so green.

I am peering inside, into the deepest parts of her body, ones she’ll never even see. And I’ve never met her. I barely know her name.

I feel embarrassed, an intruder.

“I just want to eat good.”

A group of white coats shuffle into his room. “There is nothing more we can do.”

He understands he’ll die soon.

“Ya gotta help me eat, doc,” he tells me. “I can’t taste anything, and the cancer gets rid of my appetite.”

He will die in three weeks, but his wife makes the best tortillas.

“Worry about your weight, not nails.”

In the OR, the patient is asleep, ready to be cut open.

We have difficulty positioning her on the table; she is heavy. f inally “Her nails look so pretty,” I say. They’re acrylic.

But Nurse is frustrated. “She should worry more about her weight than her nails.”

The room laughs. But the patient doesn’t hear.

Poetry Alyssa Smith – MS3 UT Health San Antonio, Long School of Medicine, Class of 2020

“Stages of Grieving” today is a monday and i am existing on two cups of coffee and a cesspool of anxiety when mom calls. she says, "the cancer is back", and i hang up. decide if it were tuesday, i would be angry,

swear to god and doctors and break a few plates or something. if it were wednesday, cry in silent solitude until i forget i have ribs. thursday, make a bargain with god. or the devil. either would work. if it were friday, i would say, maybe this is okay. maybe this means no more suffering.

no more chemo. no more watching the woman who raised me srhink and shrivel. saturday or sunday, stay on the phone. talk about life, make the most of it. whatever mature adults do. but it's a monday so i close my eyes and pretend to sleep instead.

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

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

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

ACCOUNTING SOFTWARE

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

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

ATTORNEYS

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

Kathleen Barrow Partner 512-382-8796 kbarrow@constangy.com Ashlee Mann Ligarde 512-382-8800 aligarde@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com

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www.constangy.com “A wider lens on workplace law.”

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice.

Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector.

Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

Thornton, Biechlin, Reynolds, & Guerra (HHH Gold Sponsor) Worried about the TMB, government audit, or investigation? From how to avoid TMB complaints to

navigating the complex regulations of government agencies like Medicare and Medicaid, we stand ready to guide and protect our clients.

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

ASSETS ADVISORS/ PRIVATE BANKING

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

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

BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability.

We work hard and together with our clients to accomplish great things.

Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking

210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

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

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

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

Joseph Bieniek Vice President Small Business Specialist 210-247-2985 jbieniek@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

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

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

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

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

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

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

Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com

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

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

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

DIAGNOSTIC IMAGING

Touchstone Medical Imaging (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity.

Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

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

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

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

Synergy FCU Member Service (210) 750-8331 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

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

help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection.

Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Rene Farret Wealth Management Advisor 210-278-3806 rene_farret@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Jon M. Tober SWBC Mortgage—Sr. Loan Officer NMLS #212945 (210) 317-7431 jon.tober@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

FINANCIAL SERVICES

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to

achieve more in life.

Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

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

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

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

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

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

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

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

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

Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth” Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small businesses and partnered with multiple financial institutions, to assist with financing of building acquisitions, construction projects, and machinery and equipment loans.

Cheryl Pyle Business Development Officer – San Antonio & South Texas 830-708-2445 CherylPyle@CapitalCDC.com www.capitalcdc.com “Long-term, fixed-rate financing for owner-occupied commercial real estate.”

HEALTHCARE BANKING

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

Jeanne Bennett EVP | Private Banking Manager 210 343 4556

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

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

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

HEALTHCARE CONSULTING

CareAllies (HHHH 10K Platinum Sponsor) CareAllies works side-by-side with health care providers to accelerate the transition to valuebased care, helping improve the quality, value and experience of care for patients and make health care better for everyone.

Sabina Moreno, Network Operations Senior Manager (713) 437-3088 X 523088 Sabrina.Moreno@careallies.com info@careallies.com https://www.careallies.com/ “For Better Health and Better Business”

Digital Telehealth Solutions (HHH Gold Sponsor)

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

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

HOSPITALS/ HEALTHCARE SERVICES

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

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time 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” Y&L Consulting (HH Silver Sponsor) We are an IT Consulting company that specializes in Software Managed Delivery, Business Process Outsourcing Managed Services, IT Staff Augmentation, Digital and Social Media with experience in the Medical industry.

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

INSURANCE

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

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY OSMA Health (HHH Gold Sponsor) Health Benefits designed by Physicians for Physicians.

Bill Brooks Senior Vice President (214) 329-4584 BBrooks@abadmin.com www.osmahealth.com/ “People you know Coverage you can trust”

ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

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

INSURANCE/MEDICAL MALPRACTICE

INTERNET TELECOMMUNICATIONS

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

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

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

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

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

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

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

MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com

LUXURY REAL ESTATE

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

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

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

We have served the buyers and sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country.

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

MARKETING ADVERTISING SEO

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

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

MEDICAL BILLING AND COLLECTIONS SERVICES Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL PRACTICE

UT Health Physicians (HHH Gold Sponsor) UT Health Physicians, the faculty practice of UT Health San Antonio, features the region's most comprehensive array of special-

ists & sub-specialists. Now offering free, secure access to your patients’ records. Most health plans accepted.

For referrals or questions, contact: Jose Gamez, Director, Physician Relations (210) 450 8347 GamezJ4@uthscsa.edu www.UTHealthcare.org “Offering daily grand rounds with no-cost CME to local physicians since 1969.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

PRACTICE SUPPORT SERVICES

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Debbie Marino SWBC Employee Benefits, SVP Corporate Relations (210) 210-525-1248 DMarino@swbc.com www.swbc.com

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

SWBC family of services supporting Physicians and the Medical Society

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

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

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

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

REAL ESTATE SERVICES COMMERCIAL

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

RESIDENTIAL REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Re-

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alty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

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

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

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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.

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STAFFING SERVICES

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For questions regarding services, Circle of Friends sponsors or Joining our program please contact August Trevino, Program Director at 210-3014366, August.Trevino@bcms.org, bcms.org/COf.html

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visit us at www.bcms.org

41

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

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

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

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

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

GUNN AUTO GROUP

15423 IH-10 West San Antonio, TX

11001 IH 10 W at Huebner San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Dale Haines 210-341-2800

Esther Luna 210-690-0700

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Ford 12300 San Pedro San Antonio, TX

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

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Marty Martinez 210-525-9800

Cavender Audi Dominion 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Rick Cavender 210-681-3399

Gary Holdgraf 210-862-9769

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Subaru 9807 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

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

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

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Sandy Small 210-341-8841

James Cole 800-611-0176

Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463

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

AUTO REVIEW

2019 Tesla Model 3

By Stephen Schutz, MD

44

San Antonio Medicine • July 2019

AUTO REVIEW

You’re at a cocktail party – nice company, delicious finger food,

good drinks – and the topic of cars comes up in conversation.

The person you’re talking with has bought a new vehicle, and they want to talk about it, describing the features and ownership expe-

rience with phrases like, “it’s so cool,” “I just love looking at it,”

and “I’m so glad I got it.”

Which vehicle brand is it likely to be? In the 1990s, those con-

versations frequently were about Lexus, in the 2000s, Mercedes,

quick, so zipping around town is lots of fun. I didn’t spend much

time on the highway with the model 3, but I’m told long trips are

quiet and pleasant (assuming you know where charging stations

are located).

Which, as it turns out, is a lot of places. The friend who

loaned me his Model 3 recently drove it from Boise, Idaho to

Ann Arbor, Mich. and had no trouble charging his car every 200

miles or so. He also told me that he could get plenty of juice in

BMW, or Audi, and now, Tesla. Isn’t it something that the only

about 20 minutes.

seem to talk about now is Tesla?

the country, and as battery technology improves, longer trips will

they are from other manufacturers, so I had to borrow one from

ternal combustion engine vehicles – which is to say very easy. Until

For starters, the Model 3, while good looking from some angles,

massive ongoing investments, most people will take the Suburban,

American automotive brand that people at upscale gatherings Regrettably, Tesla press vehicles are much less available than

a friend in order to write a review. It was quite an experience.

is not nearly as handsome as its Model S big brother. More narrow

As electric car charging points continue to proliferate around

be easier than they are now and will approach what they are in inthat day arrives, and I’d say it’s at least five to 10 years away despite Escape, or Highlander on the trip to Kansas to see the in-laws for

and upright than the S, the Model 3 looks less sleek, and from di-

Christmas.

tall for its size. If the model S is the jock of the Tesla family, the

five to 10 years? In five years, I’d say yes, but in 10 I’m leaning

rectly behind or in front of the car, the 3 looks too thin and too 3 is the nerd.

That same feeling extends to the interior, where, from the dri-

ver’s seat, you’re faced with the steering wheel, a big central screen,

OK the elephant in the room. Will Tesla even be around in

no. As cool as their cars are, the company remains stubbornly

unprofitable, and that’s before they’ve ever had to grapple with

the unsexy realities of fixing cars under warranty and covering

and, umm, not much else, really. It’s very strange. But it works be-

legacy costs.

screen is a breeze to navigate, configurable, and oh so cool. Every-

its vehicles is an online affair: you configure it, arrange or confirm

it was. If I were in charge of the user interface division at Audi,

arrives by truck, and that’s it. No test drives are possible, so Tesla

no automotive history could come up with a screen that is so su-

(there’s fine print, of course).

cause the screen is AWESOME. Intuitive like an iPad, the Tesla

thing you need is there, and I was surprised at how not distracting Lexus, or Cadillac, I’d be embarrassed that a new company with

perior to what the big budget OEMs could manage.

And Tesla offers over-the-air software updates too. OMG thank

you! Why doesn’t every manufacturer do this? I have been so frus-

trated over the years to send my car to the dealership for a software update, which I know my phone could do by itself while I

sleep. The next step is buying software upgrades from the screen,

and I understand Tesla will be launching that feature soon (think

buying the autopilot feature with a few clicks on the screen with-

Since Tesla has closed most of its showrooms, buying one of

the financials, and click “place order.” A week or two later the car allows you to return your new car after seven days with no penalty After driving a Tesla, I now understand why so many successful

people (including lots of BCMS members) are excited enough

about these cars to brag about them at cocktail parties. While Teslas are not my cup of tea, I now get it.

To get your best deal on a new Tesla, call Phil Hornbeak at

BCMS at 210-301-4367.

Stephen Schutz, MD, is a board-certified gastroen-

out taking your car anywhere).

terologist who lived in San Antonio in the 1990s

much regenerative braking (to charge the battery) every time you

He has been writing auto reviews for San Antonio

Driving the Model 3 is similarly impressive. Since there’s so

lift off the accelerator, you actually don’t use the brake pedal

much. As you’d expect from an electric car, acceleration is very

when he was stationed here in the U.S. Air Force.

Medicine since 1995.

visit www.bcms.org 45 45 visit us us at at www.bcms.org

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46

San Antonio Medicine • July 2019