San Antonio Medicine July 2021

S A N A N TO N I O

Bexar County County Medical Medical Society Society Bexar CEO/Executive Director, Director, CEO/Executive

Melody Newsom

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COVID-19 UPDATE

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COVID-19 UPDATE A Year Like None Other: UT Health San Antonio Reflects on Lessons Learned from the COVID-19 Pandemic By Robert Leverence, MD ..........................14 COVID-19 Vaccination Overview: From Beginning to Present By Alan M. Preston, MHA, ScD......................16 COVID-19 in 2021: Vaccine Progress and Challenges

By Jan E. Patterson, MD, MS, MACP............................18 COVID-19 Vaccine Statistics in Bexar County Data from the Texas Depatment of State Health Services ........................................................................20 COVID-19 Statistics in Bexar County Data from the City of San Antonio Metropolitan Health District ............21 Vaccine Hesitancy By Diane Simpson, MD...................22 Will Flu Shots & COVID Vaccines Be Combined?

By Alvin Boyd Newman-Caro and Rebecca L. Sanchez, PhD .............................................26 COVID-19 Infectious Disease Virtual Outpatient Team: A Telemedicine Response to the Pandemic

By Emily Sherry ..........................................................................................................................................28 The Bexar County Medical Society COVID-19 Task Force: Our Next Move By John J. Nava, MD .....30 COVID-19: A Disease of Insufficient Nitric Oxide Production By Nathan S. Bryan, PhD.......................32

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JULY 2021

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VOLUME 74 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. EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

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BCMS President’s Message .....................................................................................................................................8 Bexar County Medical Society Names Melody Newsom as CEO/Executive Director...............................................10 BCMS Alliance President’s Message ......................................................................................................................12 Women Doctors and American Medical History: Trials and Triumphs in Service of the Most Needful

By David Alex Schulz, CHP .................................................................................................................................34 The Study of Life, Revisited By Winona Gbedey .....................................................................................................36 Artistic Expression in Medicine By Maggie Carroll, MD ...........................................................................................37 Impacting Recurrence in Non-Muscle Invasive Bladder Cancer Announcement by University of Texas Health Science Center San Antonio.....................................................................................................................38 BCMS Alliance: Congratulations to our Medical Student Scholars ..........................................................................39 Physicians Purchasing Directory.............................................................................................................................40 Auto Review: 2022 Ford F-150 Lightning EV By Stephen Schutz, MD....................................................................44

SAN ANTONIO MEDICINE is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, its members, or its staff. SAN ANTONIO MEDICINE the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS

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

DIRECTORS

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

BCMS SENIOR STAFF

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

PUBLICATIONS COMMITTEE John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member Antonio J. Webb, MD, Member David Schulz, Community Member Chinwe Anyanwu, Student Member Winona Gbedey, Student Member Teresa Samson, Student Member Faraz Yousefian, DO, Member Neal Meritz, MD, Member Jaime Pankowsky, MD, Member Danielle Moody, Editor

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SAN ANTONIO MEDICINE • July 2021

PRESIDENT’S MESSAGE

Leadership in Medicine

By Rodolfo “Rudy” Molina, MD, MACR, FACP, 2021 BCMS President

I’m a big fan of Winston Churchill who once said, “if you are going through hell, keep going.” As much as I admire his leadership skills as Prime Minister during World War II, I don’t think I would hire Mr. Churchill to run my outpatient rheumatology clinic.

How often in medicine have you heard the phrase, “we are all leaders”? Well, we are leaders. We are imbued with the expectation to lead a patient out of their illness and into health. The patient, nurses, staff, pharmacists and patient’s family are all expecting your guidance. We are thus required to understand the patient’s circumstances and communicate well with all team members.

The world of medicine is complex, existing in many different spheres. If we were to draw a Venn diagram where all circles converge on a patient afflicted with a malady, the existing circles would demonstrate a very complex system. Furthermore, within each of these circles exists a hierarchical framework requiring its own leader. So, when we speak of leaders in medicine, we should first define the circumstances and then ask what all great leaders have in common. I will provide you with three different scenarios where leadership was needed and then reflect upon the common variables found in each example.

Mulligan and Rehman describe the evolving role of the physician since the 1970s with the advent of corporate medicine in “The Evolving Crisis of Physician Leadership.” They describe that in the early ‘70s, physicians enjoyed unrivaled access to ‘legitimate authority.’ Subsequently, “the profession became less responsive to legitimate external critiques and blind to structural changes, such as hospital corporatization and market privatization.” In the 1980s, corporate medicine began influencing health care professionals to experiment with different payment models such as investor-owned health care corporations, multi-institutional alliances and popularized group practice instead of working solo. Mulligan and Rehman argue that “the real threat to physician sovereignty is corporate medicine” and that physicians have a moral obligation to insert themselves in institutional-political debates in order to preserve values understood by physicians as central to the practice of medicine and that best serve the interest of the patient. Leadership in this context requires transparency and a full understanding of the desired outcomes from all parties involved.

Dr. Hromas writes a very entertaining and insightful book titled “Einstein’s Boss.” Abraham Flexner hired Einstein to work at the Institute for Advanced Studies (IAS) at Princeton University, where it eventually became home to 33 Nobel Laureates, 38 Fields Medalists and many winners of the Wolf and MacArthur prizes. Despite not 8

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being a scientist or mathematician, Flexner’s early successes as an administrator at IAS inspired Dr. Hromas to create ten rules for leading geniuses. He emphasizes the importance of recognizing individuals’ strengths and connecting with team members with respect and empathy to achieve a common goal. I recommend this book to all those interested in this topic.

Doris Kearns Goodwin outlines the skills that defined four Presidents of the United States as great leaders during times of national crisis in her book “Leadership in Turbulent Times.” She asks the question, “are leaders born or made?” I was amazed to find how many differing opinions there are with a simple internet search. The overwhelming majority of authors I found believe that circumstances create opportunities to lead. Interestingly, the same is stated for the emergence of genius; circumstances allow for genius to be witnessed and appreciated. In a podcast, Goodwin argues that great leaders, whether they lead in a field of battle or a boardroom, have several things in common — empathy, ambition for self, ambition for something larger than self, resilience, to be nonjudgmental and the ability to communicate and tell stories.

I recognize that we are not all in a position of leading in the corporate world of medicine, leading geniuses or even leading a country in a crisis. Still, I do believe that we can all learn from these seemingly distinct scenarios. To counter some of the articles I alluded to earlier, it is important to consider that great leaders have the qualities and motivation before circumstances define them. Whether you are running a code blue or a clinic, successful leaders are team players. Furthermore, a great leader defines setbacks as learning opportunities and not as failures.

Yes, we are all leaders. I do believe that some have inherent skills that have been nurtured; however, we as physicians are proverbial students and should strive to become exceptional leaders. To that aim, your Bexar County Medical Society offers a leadership course that I recommend to all. This course is taught by Trinity University professors and besides describing leadership styles, it also gives insights on how to be a more effective leader.

Rodolfo “Rudy” Molina MD, MACR, FACP is the 2021 President of the Bexar County Medical Society.

BCMS CEO ANNOUNCEMENT

The Bexar County Medical Society Names Melody Newsom as its New CEO/ Executive Director

As of July 1, 2021, Melody Newsom, the current Chief Operating Officer of BCMS, will become the new Executive Director of the Bexar County Medical Society, replacing the retiring Steve Fitzer.

Many of you have come to know Melody during her 21+ years of employment at BCMS. Melody is a native Texan originally from Seminole, Texas. She has been married to her husband, Tommy, a retired dryland cotton farmer and racehorse breeder, since 1979.

Melody and Tommy now live in San Antonio with their two chihuahuas, Bode and Art. Prior to coming to BCMS, Melody worked for the Legislative Budget Board in Austin, Texas.

During her time with BCMS, Melody has had the opportunity to perform just about every operational task at the Society and has been responsible at one time or another for most departments in the organization. Since October of 2008, Melody has held the position of Chief Operating Officer (COO), wherein she has been responsible for all aspects of office operations. This includes direct oversight of administrative management, preparation and oversight of five departments’ budgets, management of membership and publications departments, 10

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research and writing bylaws for BCMS and our affiliate organizations, and has been responsible for Human Resources and the writing and implementation of policies and procedures.

Melody has managed many large projects that have had an impact on the San Antonio medical community, including the development of the Unified ID Badge, which Bexar County physicians carry today to access multiple hospitals where they have privileges.

When Katrina/Rita blew through, Melody was involved in recruiting and managing medical volunteers for hurricane evacuation shelters. During the COVID-19 pandemic, Melody has had direct oversight of the BCMS personal protective equipment (PPE) project through which much needed PPE was provided free to our medical community.

Most recently, she successfully spearheaded the efforts to get all physicians, their staffs and other medical professionals vaccinated as quickly as possible.

During her time as COO, Melody has represented BCMS in various capacities with the Texas Medical Association, San Antonio Metropolitan Health District, South Texas Regional Advisory Council on Trauma

(STRAC), San Antonio Federated Identity Management Governance Council and Texas Department of State Health Services.

Since the declaration of the pandemic, she has served on the City of San Antonio Testing Task Force, COVID-19 Community Response Coalition, COVID-19 Recovery Coordination Committee, COVID-19 Investigation/Contact Tracing Subcommittee, Vaccine Implementation Planning Committee, the STRAC Pandemic Medical Operations Workgroup, BCMS COVID-19 Task Force and the Task Force’s Communications Plan Subcommittee.

Melody expressed her enthusiastic acceptance of her new position this way: “It is now my great honor to be selected to take over the CEO/Executive Director position with this distinguished organization where I have dedicated most of my working life. I have always had the success of BCMS in my heart and have continually worked on behalf of our physician members! I would like to express my thanks to Steve Fitzer for all his leadership during his tenure as CEO/Executive Director. He has been a great mentor to me! I am blessed to be taking over BCMS as a very strong and prosperous organization.”

BCMS ALLIANCE

Past President Jennifer Lewis is Inducted as TMAA President

By Lori Boies, PhD

As the 2017 past President of the Bexar County Medical Society Alliance, I have the distinct honor of being surrounded by excellence. The 2018 President of the BCMSA, Jenny Shepherd, was honored at the 2021 TMA TexMed Conference with the June Bratcher Award for political action (named after another BCMS Alliance trail blazer, June Bratcher, who was the 1979-80 past president). At the same time, 2016 BCMSA President Jennifer Lewis was also taking her oath of office as the 2021-2022 Texas Medical Association Alliance President.

Jennifer is the 10th BCMSA member to serve as president of the Texas Medical Association Alliance. The 9th BCMSA member to serve was Martha Vijjeswarapu, who called Nueces County (Corpus Christi) her home for many years before moving to San Antonio in 2019. Martha finished a strong year as president and swore Jennifer in during a virtual ceremony due to the COVID-19 pandemic. Martha – thank you for your inventive and compassionate leadership during such unprecedented times. You showed us all how to lead with patience and grace; you strengthened the TMAA with pioneering ideas to engage members while, as medical spouses, we navigated uncertain and trying circumstances.

Jennifer’s installation speech was inspiring as it relayed a riveting story about having to evacuate from Hurricane Katrina while her husband, Cannon, was stationed at Keesler Air Force Base Hospital. In the end, while Hurricane Katrina made landfall two miles south of their home, this stressful time had a silver lining of bringing the Lewis family to Texas, and ultimately to San Antonio, where Jennifer found her tribe with the BCMSA. As physician families, many of us may relate to the allegorical parallels of evacuating a home with Hurricane Katrina barreling towards the coast, as well as many of the uncertain emotions that have consumed the past year, with the COVID-19 pandemic. I extend the same invitation to both physician spouses and physicians that Jen-

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nifer extended in her speech – let the Alliance be the group where you can find kindred friendship from others in similar positions who understand the unique struggles of the physician family.

Jennifer – I had the honor of following you as BCMSA President.

You were an inspiration and you truly showed me that we are all in this together; we all get by with a little help from our friends! I know that your year as TMAA President will have a brilliant vision as you lead the way with novel ideas to direct us forward in the post-COVID era. From the entire BCMSA: Congratulations! We are proud of you!

Lori Boies, PhD is a Bexar County Medical Society Alliance (BCMSA) past president (2017) and currently a presidential advisor. She also serves on the TMA Alliance Board as the Bylaws Chair for 2021-2022. Lori is an Instructor of Biological Sciences at St. Mary's University.

COVID-19 UPDATE

A Year Like None Other:

UT Health San Antonio Reflects on Lessons Learned from the COVID-19 Pandemic

By Robert Leverence, MD

Although COVID-19 is destined to become a part of our lives like influenza, it appears its pandemic days are numbered. So, the temptation for us is to block it out of our minds and look forward to brighter days. However, in the wake of what came to be a devastating public health crisis and the fact experts say it surely will not be our last, it will be important for us to record the lessons learned from this first modern-day world pandemic.

UT Health San Antonio was privileged to play a role in the COVID-19 pandemic, as I believe any academic health science center should. Not only do these institutions harbor the expertise needed to help direct care, but they also behold the clinical resources and capacity for testing, vaccinating and caring for large populations. They also have the research talent to discover effective treatments and the educational and marketing support to help communicate the needed behavior changes inherent in any pandemic.

Perhaps the most important lesson learned during the COVID pandemic was that nothing in my medical or administrative training prepared me for the crisis management it demanded. I do not recall even a single class or lecture on the topic. Before COVID-19, I was not even familiar with basic terms like EOC or Crisis Standards of Care.

Fortunately, I had access to the resources of the UTHSA Military Health Institute which quickly educated me on these vital concepts.

However, this type of support is not widely available. Consequently,

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maybe it is time to add pandemic preparation to the growing list of preventive health services now embedded in our health care system.

In brief, here are the lessons learned as I helped direct the clinical COVID response at our academic health center.

1. Know the purpose and structure of an Emergency Operation Center (EOC). EOCs can take on many forms and ours took on a “wheel and spokes” structure with health science center leaders at the hub meeting on a regular basis. Regular cross talk with other partners such as University Hospital (UH), Metro Health, South Texas Regional Advisory Council (STRAC)/Regional Medical Operations Center (RMOC) and the VA Medical Center formed the spokes and were essential to achieving our mission. The nature and frequency of these meetings and communication venues also constantly evolved as circumstances changed.

2. Understand the significance and role of Crisis Standards of Care.

These protocols are something one never hopes to use, but are essential in supporting the frontline health care worker in the event of an overwhelming number of casualties. Thanks to STRAC and faculty from UT Health Center for Medical Humanities and Ethics, we were able to put these protocols together early in the pandemic.

Fortunately, they were never needed here in San Antonio.

COVID-19 UPDATE

3. Be prepared to stand up a cross-department deployment program.

I was once told directing physicians is like leading an army of generals and nowhere was that more evident than during this pandemic. Physicians are inherent problem solvers, so they do not generally take orders without questioning them. Consequently, regular effective communication was vital in directing our group of over 1,000 physicians working at multiple sites. Crises have a way of drawing the best from people, and I was privileged to witness this among our faculty and staff. Radiologists volunteered to place central lines and psychiatrists volunteered to work on the palliative care service. Trauma surgeons, anesthesiologists and pediatricians who trained in critical care worked alongside our other intensivists to serve our critically ill COVID patients. Subspecialty physicians were quickly trained on modules prepared by our hospitalists and then placed on standby until deployed to care for COVID patients.

I was greatly inspired. Likewise, we worked closely with our hospital partner UH to coordinate the opening of additional COVID units and assignment of nurses. When it was my turn to attend to the care of COVID patients, without exception, a nurse would help me with the tedious ritual of donning and doffing my PPE. Fortunately, a good amount of trust had already been built with UH leadership which helped maintain smooth relations and operations

during this constantly changing crisis.

4. Appreciate the need for positive, steady, yet flexible leadership during a sustained operation, particularly in a stressful and everchanging environment such as a pandemic. Ensuring self-care and the physical and emotional wellness of your teammates is essential.

Simply taking the time to ask how they’re doing and encouraging a brief break from the action goes a long way.

This list is not all inclusive. A plan for Predictive Modeling, innovative use of Health IT, dispersing personal protective equipment and recovery were all important as well. The one silver lining from this pandemic is that I will forever be inspired and thankful for having worked with such outstanding faculty, staff, as well as partners throughout the city. Despite the shadow cast on 2020 by this pandemic, my memories will forever be framed by the impressive work I witnessed by these individuals. Good job San Antonio.

Robert Leverence, MD is Chief Medical Officer of UT Health San Antonio and is a member of the Bexar County Medical Society.

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COVID-19 UPDATE

COVID-19 Vaccination Overview: From the Beginning to Present

By Alan M. Preston, MHA, ScD

The virus that causes COVID-19 is related to other coronaviruses. The good news is that scientists have been studying coronaviruses for years and there is a lot we have learned.

Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) are not new, and vaccinations have been developed for previous strains. Nevertheless, each strain requires a specific vaccine to combat the RNA makeup of such strain in order to be an effective vaccine. Currently, there are three approved vaccines: 1. Pfizer-BioNTech: for ages 12 years and older and needs 2 shots given 3 weeks (21 days) apart.

2. Moderna: for ages 18 years and older and needs 2 shots given 4 weeks (28 days) apart.

3. Johnson & Johnson’s Janssen: for ages 18 years and older and needs 1 shot.

Vaccines go through three phases of clinical trials to make sure they are safe and effective. For other vaccines routinely used in the United States, the three phases of clinical trials are performed one at a time and do not overlap, which is why the standard process is so lengthy. The third phase usually takes the longest. During the development of COVID-19 vaccines, these phases have overlapped to speed up the process. No trial

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phases have been skipped. These three preliminary clinical trials must be performed to obtain approval from the FDA:

the candidate vaccine and determine the type and extent of immune response that the vaccine provokes.

1. Phase I Vaccine Trials This first trial involves a small group of adults, usually between 20-80 subjects. If the vaccine is intended for children, researchers will first test adults and then gradually step down the age of the test subjects until they reach their target. This is one reason that the age limits for children are in place. The goals of Phase 1 testing are to assess the safety of

2. Phase II Vaccine Trials A larger group of several hundred individuals participates in Phase II testing. Phase II testing aims to study the individual vaccine’s safety, efficacy, proposed doses, schedule of immunizations and delivery method.

3. Phase III Vaccine Trials Successful Phase II candidate vaccines

COVID-19 UPDATE

move on to more extensive trials, involving thousands to tens of thousands of people.

One Phase III goal is to assess vaccine safety in a large group of people. Specific rare side effects might not surface in the smaller groups of subjects tested in earlier phases.

Recall that the J&J vaccination was suspended for a short period when some people developed blood clots. At the time of the discovery, J&J had administered over 7 million vaccinations, and six of those people vaccinated presented with a blood clot. As in all clinical trials, there are often reported side effects. The question, which takes time to answer, is whether or not the side effects were the cause of the vaccination or simply a coincidence after taking the vaccination. Furthermore, even if the vaccine "caused" a potential side effect in a small population (.00008571% of the J&J population indicated a blood clot after the vaccine), the number of lives saved by providing the COVID-19 vaccine may be seen to outweigh the preventable side effect seen in the J&J vaccine. The FDA will continue to monitor the efficacy and production of the vaccine.

Results from these trials have shown that COVID-19 vaccines are effective. They have also demonstrated no serious safety concerns after many weeks following vaccination. This is an important milestone, as it is unusual for adverse effects caused by vaccines to appear after this amount of time.

Myths of the vaccine exposed Anytime there is a new drug or vaccine, people are skeptical as to the long-term effects. There is no shortage of conspiracy theories about the new vaccines. One of the more prevalent myths is that the Pfizer and Moderna vaccines introduce the RNA of the virus, which will alter the DNA of the host.

According to the CDC, mRNA vaccines work by instructing cells in the body how to make a protein that triggers an immune re-

sponse. Injecting mRNA into your body will not interact nor do anything to the DNA of your cells. Human cells break down and get rid of the mRNA soon after they have finished using the instructions.

The manufacturing ability of our cells extends beyond human proteins. When we are infected with a virus, including relatively harmless viruses like those that cause the common cold, these invaders inject their genetic material into our cells, resulting in pieces of mRNA encoding viral proteins being sent to our protein-making machinery.

Doing so enables the virus to assemble new viral particles out of these proteins and spread. Although mRNA vaccines are a relatively new technology, they are based on the same ancient premise: delivering mRNA into our cells, which they will use to manufacture a viral protein. mRNA vaccines don’t carry enzymes like an HIV virus, so there is no risk the genetic material that the SARS COVID19 virus contains could alter our DNA. The delivery systems of both the Moderna and Pfizer vaccines are brilliant. Here is how it works. First, the scientist takes a lipid nanoparticle to introduce the mRNA into a protective casing. To maintain the integrity of the lipid nanoparticle, the manufacturing process must keep it very cold (between -76 and -112 degrees Fahrenheit); otherwise, the efficacy is lost in a few days of the vial of the vaccine. This creates a transport vehicle to introduce to the human hosts. The COVID19 S-Protein is contained in the lipid nanoparticle. Once it gets into the host cell, the good news is that it does not enter into the cell's nucleus, where the cell's DNA is located. It is a brilliant transport mechanism and, in my opinion, safe.

entails unbiased observations and systematic experimentation." In general, science involves a pursuit of knowledge, and there are always limitations present when studies are performed. And, as new data become available, the conclusion of the observations may change slightly, significantly or not at all.

Physicians have numerous observations as to what appears to be effective and what appears to be less effective. True science allows conclusions that are based upon observations to be examined. We are still learning about COVID-19; however, we have millions of data points that we previously did not have.

The science should evolve to better understand COVID-19 and the vulnerable populations that are susceptible to it. Those over age 70 with comorbidities are far more vulnerable than those under 60 with minor health problems when acquiring COVID19. We should treat each person as an individual and determine which individuals need special protection. Individuals in a population are generally at very low risk of dying from such a disease and act accordingly.

Doctors should be given a broad latitude to practice medicine based on the evidence of each patient. As I always say, "be careful what conclusions you come to based upon a study or the underlying data." There are always limitations to all studies, and the generalization of any research also has limitations when one tries to generalize beyond the scope of the study.

Alan Preston, MHA, ScD works in the area of Population Health Management and has a doctorate in Science in Epidemiology and Biostatistics from Tulane University and has spent his entire career in the health care space.

Definitions of science According to one definition, "Science is any system of knowledge concerned with the physical world and its phenomena, and that

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COVID-19 UPDATE

COVID-19 in 2021: Vaccine Progress and Challenges

By Jan E. Patterson, MD, MS, MACP

Just a year ago, we were headed into a summer surge of COVID-19 hospitalizations and deaths. As we cared for sick patients and saw continued increases in hospitalizations and deaths, we worked to increase testing, improve public health measures and discover what therapies worked best. We could hardly envision that an even worse winter surge was coming, in which we would exceed 500,000 U.S. deaths from COVID-19.

It was also hard to imagine that by the year’s end, we would have effective vaccines against COVID-19, but vaccination of health care workers began in December. Even better, the vaccines were more efficacious than we could have imagined.

In clinical studies, mRNA vaccines (Pfizer/BioNTech, Moderna) were 94-95% effective against symptomatic disease and even more effective against hospitalizations and death. Real-world data after the FDA Emergency Use Authorization (EUA) has confirmed 94% effectiveness against symptomatic disease of the mRNA vaccines after two doses in health care workers, and efficacy in the general population appears to be similar. The single dose, replication-deficient adenovirus vector Johnson & Johnson/Janssen ( J&J) vaccine was 66% effective against COVID infection in clinical studies. Most real-world efficacy data is for the mRNA vaccines, and real-world data on the J&J vaccine is still being evaluated. Evidence is also accumulating that each of the FDA-authorized vaccines provide significant protection against asymptomatic infection. For all of these vaccines, the most protection was achieved two weeks after the final vaccination dose.

Effectiveness of a single dose of mRNA vaccine estimated from realworld data is 70-80% in health care workers. Long term data regarding mRNA vaccine single dose efficacy is unknown, and based on current data, people should receive two doses of the mRNA vaccine to obtain the most benefit from vaccination.

Vaccine breakthrough cases have occurred, including some cases of hospitalizations and deaths, but these are very rare. The CDC recently 18

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reported 0.001% breakthrough cases among 100 million people vaccinated and most of these cases did not result in hospitalization or death.

Review is still ongoing to see who may be most at risk of breakthrough cases, but it is likely to be elderly or immunosuppressed persons.

The safety record of the vaccines has also been good. Common side effects are typically within two days of the vaccine and include sore arm, headache, fatigue and less commonly, chills and fever. Reactogenic side effects such as chills and fever are more common after the second dose and in those < 55 years old. The Moderna vaccine can have a benign delayed local reaction at the site of injection 8-10 days after the vaccine, occurring in <1% of people.

A side effect to be aware of for mRNA vaccines is anaphylaxis, which occurs in about 4 per 1 million persons vaccinated, and has been treated successfully at vaccine sites during the post-vaccine observation period. This occurs more commonly in women and those with a history of allergic reactions. If a severe reaction occurs within four hours of the first dose of the mRNA vaccine, the second dose should not be given. While the cause of these severe reactions is not known with certainty, polyethylene glycol (PEG) is a constituent of mRNA vaccines and is a known potential allergen. Those with a history of PEG allergy should avoid mRNA vaccines. The J&J vaccine does not contain PEG, but contains polysorbate which has potential cross-reactivity. For persons with a history of polysorbate allergy, consider an Allergy/Immunology consult or contact the CDC Clinical Immunization Safety Assessment Center for guidance.

The detection of rare blood clots after the J&J vaccine demonstrates successful post-EUA surveillance with the Vaccine Adverse Event Reporting System (vaers.hhs.gov). The distinctive Thrombosis with Thrombocytopenia Syndrome (TTS) consists of a blood clot in an unusual location, such as the brain, in combination with thrombocytopenia, occurring within two weeks of the J&J vaccination. Women and those < 60 years old are at higher risk of this complication. An impor-

COVID-19 UPDATE

tant finding is that heparin antibodies are present in this condition, so other anticoagulants must be used for treatment of these clots.

Current recommendations are that persons who have already had COVID should still be vaccinated. The degree of natural immunity after vaccination varies, and reinfection can occur. There is not a recommended minimum interval for the vaccine after infection, but reinfection is uncommon before 90 days. Persons with COVID should defer vaccination at least until recovery from acute illness and criteria for discontinuing isolation is met.

At this time, the FDA recommends against the routine use of antibody testing for detection of vaccine antibody response. Many FDAauthorized antibody tests detect nucleoproteins that are the result of natural infection and not spike protein, which is what vaccines are directed against. Even with tests detecting spike protein antibodies, studies continue regarding the amount of antibodies that are protective against infection. Commercially available antibody tests do not detect neutralizing antibodies.

The need and timing for booster doses have not been established, but it is likely that a booster will be advised around the end of the year.

The vaccines currently authorized by the FDA appear to have efficacy against variants of concern, although responses may be diminished for some variants. As the virus continues to spread in areas around the globe, the development of new variants is concerning.

Early studies in immunosuppressed persons indicate that they may have less antibody response. Depending on the results of ongoing studies, earlier boosters in this population may be warranted, but as of this writing, this is not yet recommended.

The adenovirus vector Oxford/Astra-Zeneca vaccine, used widely in the United Kingdom and some other countries, is not yet FDA-authorized in the U.S. and has also been noted to be associated with TTS. In addition, studies show there are concerns with efficacy against the South African variant. Clinical trials with Novavax, a recombinant protein plus adjuvant vaccine, appear very promising, but FDA authorization is not expected until later this summer.

Influenza was virtually nonexistent this past winter season, but without masking and distancing next winter, it is expected to return.

A combination of flu/COVID vaccine could be desirable, and Novavax has announced promising preclinical data with a combination vaccine. Clinical trials with this combination vaccine are expected to begin before the end of the year.

The U.S. is on course to achieve the Biden administration’s goal of 70% of adults receiving at least one dose of vaccine by July 4, 2021.

By the third week in May, over 60% of adults have received one dose.

Around 40% of the total U.S. population is fully vaccinated. Several states have achieved at least one dose to 70% of their adult population.

See the CDC COVID Data Tracker for updated numbers.

At the time of this writing, more than 50% of Texans 12 years of age and older have received at least one dose of vaccine. Bexar County has exceeded 1 million doses given and the majority of seniors have been vaccinated. Among the total Bexar County population, more than half have received at least one dose and over 40% are fully vaccinated. See the COVID-19 page at sanantonio.gov for the most upto-date information from Metro Health.

This is encouraging news, and yet the pace of vaccination in the U.S. has slowed. Strategy has shifted from mass vaccination to mobile vaccination, pharmacies and physician offices to make vaccination more convenient. Vaccine hesitancy is more common in rural areas, and vaccination rates also vary a great deal by state. Most hesitancy is related to concerns about side effects. Surveys continue to show that a person’s most trusted source of information about vaccines is their personal health care provider, so physician discussions with their individual patients about the vaccine are key. Vaccination rates high enough to achieve herd immunity in all geographic areas of the U.S. may be elusive, however, and we may have to be prepared for another increase in cases next winter, since coronaviruses are typically a fall/winter seasonal virus.

Countries leading the world in vaccination rates include Israel, United Arab Emirates, Bahrain, Chile and the UK. Clinical study results of the efficacy and safety of vaccines used in many other areas of the world, such as Sinovac/Coronavac (inactivated virus technology; China) and Sputnik V (adenovirus vector technology; Russia) are not as well-known, and real-world data will be telling.

While vaccination rates in the U.S. are encouraging, the battle against COVID-19 is still fierce in most parts of the world. The current situation in India is an example. In the month of May, India reported more COVID-19 deaths in a single day than any other country during the pandemic.

The efficacy of vaccines authorized in the U.S. and the speed with which they became available is phenomenal and we are indeed fortunate to have had the government’s support, innovative technology, scientific expertise and willing study volunteers to achieve such success.

Because the virus knows no borders, however, we are not safe until we are all safe, and the U.S. can play an important role in controlling COVID-19 worldwide by making its plentiful supply of vaccines available to other countries.

Jan E. Patterson, MD, MS, MACP is a Professor of Medicine/Infectious Diseases at the Lozano Long School of Medicine. She has more than 30 years of experience in infection prevention and has been involved in the COVID-19 response for the South Texas Regional Advisory Council, UT Health, University Health and Metro Health. She is a member of the Bexar County Medical Society.

Visit us at www.bcms.org

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COVID-19 UPDATE

COVID-19 Vaccine Statistics in Bexar County Data from the Texas Department of State Health Services

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SAN ANTONIO MEDICINE • July 2021

COVID-19 UPDATE

COVID-19 Statistics in Bexar County Data from the City of San Antonio Metropolitan Health District

Visit us at www.bcms.org

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COVID-19 UPDATE

Vaccine Hesitancy

By Diane Simpson, MD

People who remain hesitant to receive a COVID-19 vaccine are receiving a great deal of attention in print and broadcast media. They are in effect the ‘swing votes’ on whether or when the United States can achieve herd immunity through vaccination and prevent the introduction and spread of new variants.

Not all eligible persons who remain unvaccinated in July 2021 are “vaccine hesitant.” Some are “vaccine opposed” and refuse or resist most or all immunizations and laws that mandate vaccines. Others are “vaccine challenged.” These are vaccine eligible persons who will take the vaccine when they can, but currently face barriers in time, transportation or other logistical factors.

The “vaccine hesitant” are those with unanswered concerns and questions that keep them from receiving the vaccine. Understanding the who and why of vaccine hesitancy can help inform the public health and medical provider on what to do.

THE WHO National Information Through a series of surveys and focus groups, the Kaiser Family Foundation monitors COVID-19 vaccination attitudes and experiences in the United States. Their latest results obtained in late May provide a national snapshot of the percent who are either receptive, hesitant, resistant or adamantly

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Figure 1: Kaiser Family Foundation COVID-19 Vaccination Attitudes

Figure 2: Vaccine Attitude by Class

By The New York Times, David Leonhardt | Source: Kaiser Family Foundation

SAN ANTONIO MEDICINE • July 2021

COVID-19 UPDATE

against receiving the COVID Figure 3: Vaccinations of Bexar County Residents by Race/Ethnicity vaccine (Figure 1).1 VA data included; DOD data not included The media has focused on the Republican vs. Democratic divide evidenced in these surveys.

However, a recent article published in the May 24, 2021 New York Times, “The Morning” online newsletter argues that the vaccination rate differences are more of a class divide between those with college degrees and Data provided by the San Antonio Metropolitan Health District, Division of Epidemiology those without, rather than politics or race.3 Figure 4: Vaccine Attitudes The data in Figure 2 shows a random survey of 2,097 adults conducted from April 15 to April 29, 2021. Not all rows total 100 percent. Some participants did not give an answer.

In Bexar County, results from focus groups conducted by the NIH-funded Project, Community Engagement Alliance (CEAL), concluded that vaccine hesitancy was high in the county’s communities of color. (CEALing the COVIDBy New York Times author Sema K. Sgaier of the Surgo Foundation, adjunct assistant 19 Loopholes Project CEAL (Bexar County). professor at the T.H. Chan School of Public Health, Harvard The work was completed as part of the CommuStudies on the effect of personal attitudes toward COVID vaccine nity Assessment Methods course offered at the UT Health School of uptake are taking place, although results must be viewed with caution.

Public Health and overseen by Drs. Valerio and Whigham and TeachMuch of our information on public perception comes from online ing Assistant Dennis O. Nyachoti. All work was completed during the and telephone surveys or focus groups which, while rapid, face chalSpring 2021 term. This conclusion is supported by recent county data lenges obtaining representative samples that allow scientists to quancollected from the state’s immunization registry, although ‘vaccine tify and understand with any certainty the extent of COVID-19 challenges’ remain another reason for lower vaccination rates. vaccine hesitancy. In an opinion article published by the New York THE WHY Times author Sema K. Sgaier of the Surgo Foundation and an adjunct The vaccine challenged remain unvaccinated, but for reasons other assistant professor at the T.H. Chan School of Public Health, Harvard than choice. At first, changing eligibility guidelines and the need for suggested that, based on telephone and online surveys of over 4,400 an appointment were confusing, time consuming and difficult to navadults conducted in late 2020/early 2021 and again in March 2021, igate. In addition, work, child care and transportation for either the those who were vaccine hesitant could be placed in one of four types vaccinee or the person transporting them can be barriers. These num(Figure 4): bers should decrease as the vaccines are more equitably distributed and vaccination sites are becoming more available around the county.

• Watchful – They are waiting to see what happens next.

The vaccine hesitant, who include some health care providers, have • Cost Anxious – They want the vaccine but can’t afford the time chosen not to be vaccinated right now. Prior COVID infections, conor cost. cerns over vaccine side effects, previous bad experiences with vaccines, • System Distrusters – They feel the health care system does not as well as historical vaccine abuses by governments are reasons why treat them fairly. some choose to wait. Other reasons include misinformation on factors • COVID Skeptics – They don’t believe the threat. such as costs, citizenship status requirements and medical risks assoThe remaining persons are “Enthusiasts.”4 ciated with the vaccine. continued on page 24 Visit us at www.bcms.org

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COVID-19 UPDATE continued from page 23

A third survey of 18,000 people conducted in English via Facebook in February through April 2021 developed state specific data.

Understanding these categories, the author argues, allows public health officials and medical providers to understand where they face the most challenges and respond more specifically to the concerns of the vaccine hesitant.

Figure 5: Percentage who says they are likely to turn to each of the following when deciding whether to get a COVID-19 vaccine2

WHAT THE PROVIDER CAN DO There is no one answer or technique to convince every vaccine hesitant person to accept the COVID-19 vaccine. But providers should know the facts and encourage vaccine uptake among eligible patients.

Earlier this year in a national poll, more people responded that they listen to their medical providers more than other sources for vaccine information.

DO • Ask why vaccine hesitant patients are concerned about the COVID-19 vaccine. Be respectful of their reasons.

• Explain your views.

• Offer to answer their questions. The BCMS has information on COVID vaccines available through The Physicians Link.

• Be honest about the limitations and side effects of COVID-19 vaccines.

• Recommend the vaccine to eligible unvaccinated patients.

• Have on hand and make available the most recent information on the site and time of COVID-19 vaccination clinics and nearby pharmacies that offer the COVID vaccine. If possible, post information in the waiting room.

DON’T • Jump into an argument without thinking.

• Argue, become angry and/or respond only with, “You are wrong.”

References 1. KFF COVID-19 Vaccine Monitor Dashboard. kff.org. (n.d.). https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid19-vaccine-monitor-dashboard/?gclid=Cj0KCQjwhr2FBhDbARIsACjwLo0LjHeLEbqaRCX0vz_sIb3hwuceWCsM5ZHyt_ 8pwhCXYgqUXY_lwt4aAimAEALw_wcB. 2. KFF COVID-19 Vaccine Monitor Dashboard. kff.org. (n.d.). https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-

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19-vaccine-monitor-dashboard/messages/messages/information#messengers.

3. Leonhardt, D. (2021, May 24). The Vaccine Class Gap. The New York Times. https://www.nytimes.com/2021/05/24/briefing/ vaccination-class-gap-us.html.

4. Sgaier, S. K. (2021, May 18). Meet the Four Kinds of People Holding Us Back From Full Vaccination. The New York Times. https://www.nytimes.com/interactive/2021/05/18/opinion/cov id-19-vaccine-hesitancy.html.

Diane Simpson, MD is a retired physician who is a member of the Public Health and Patient Advocacy Committee and the COVID-19 Taskforce of the BCMS.

Visit us at www.bcms.org

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COVID-19 UPDATE

Will Flu Shots & COVID Vaccines Be Combined?

What Would the Future Look Like?

By Alvin Boyd Newman-Caro and Rebecca L. Sanchez, PhD

The idea of combined vaccines is not a new one. There are several examples of combined vaccines currently utilized, such as Pediarix, ProQuad, Kinrix and Pentacel, all which protect against various combinations of diphtheria, tetanus, pertussis (DTaP), hepatitis B virus, poliovirus (IPV), measles, mumps, rubella (MMR), varicella virus (chickenpox) and Haemophilus influenzae type b (Hib).2 Not only have combination vaccines been proven effective, they also have the advantage of being an individually administered shot that protects against multiple diseases.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has produced 33,079,543 cases of coronavirus illness and taken 591,265 lives in the United States.1 When the outbreak began, prompt publication of the viral genome sequence allowed work to begin immediately on a vaccine solution. In groundbreaking fashion, vaccines for COVID-19 were created in less than one year. Up to this point, Pfizer/BioNTech has reported efficacy of 95%, while Moderna has set forth an efficacy of 94.5%.3,5 Nonetheless, it is unknown if current COVID vaccines will be protective against future COVID-19 strains. It is possible that SARS-CoV-2 will persist for some time and will potentially become a seasonal epidemic, like that of past influenza epidemics. Reasons for this are because we have yet to globally eliminate earlier strains of SARS-CoV-2, we are seeing novel viral variants emerge and the long-term protectiveness of current COVID vaccines remains unknown — calling into question the need for booster shots. Similar to the influenza virus, the SARS-CoV-2 viral 26

SAN ANTONIO MEDICINE • July 2021

variants could necessitate a modified yearly vaccine against it. Therefore, the next logical step in vaccine development would be the creation of a combined COVID and influenza vaccine. In addition, discussions involving COVID and influenza combination vaccines make sense right now, especially since the 2021-2022 influenza season is already upon us.

During this year’s typical influenza season, cases of influenza infections were significantly reduced. In May, the CDC reported on its website that from September 27, 2020, through May 15, 2021, only 250 (or 0.05%) of the 485,637 specimens tested and reported were positive for influenza viruses at U.S. public health laboratories, and only 1,874 (or 0.18%) of the 1,054,101 respiratory specimens tested and reported were positive for influenza viruses at U.S. clinical laboratories (compared with 10%-19% in recent years).6,7 However, now that mask and social distancing regulations are becoming more relaxed, a rise in both influenza and SARS-CoV-2 cases is predicted for the 2021-2022 season. Infection with influenza, SARS-CoV-2 or influenza/SARS-CoV-2 co-infection, presents a significant future public health threat, making a combination vaccine desirable.

While many are just starting discussions about future combination vaccines, Novavax, a biotechnology company developing a SARS-CoV-2 vaccine (NVX-CoV2373), released preclinical data in May 2021 using a combination hemagglutinin (HA) quadrivalent nanoparticle influenza vaccine (qNIV) and their COVID-19 vaccine candidate (NVX-CoV2373).4,5 The Novavax study

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stated the following: “The combination qNIV/CoV2373 vaccine produces high titer influenza hemagglutination inhibiting (HAI) and neutralizing antibodies against influenza A and B strains. The combination vaccine also elicited antibodies that block SARS-CoV-2 spike protein binding to the human angiotensin converting enzyme-2 (hACE2) receptor. Significantly, hamsters immunized with qNIV/CoV2373 vaccine and challenged with SARS-CoV-2 were protected against…and were free of replicating SARS-CoV-2 in the upper and lower respiratory tract with no evidence of viral pneumonia. This study supports evaluation of qNIV/CoV2373 combination vaccine as a preventive measure for seasonal influenza and COVID-19.”4 And while this early data is promising, human-based clinical trial studies of the combination vaccine are still imperative for the Novavax study.

As vaccine research continues to develop and trials increase in number, an immunization action plan needs to be considered. In addition, the cost and burden of individual shots as opposed to a combination vaccine requires evaluation, while also keeping in mind that citizens in rural areas and underserved populations would likely benefit from a combination vaccine due to its convenience and enhanced protection against both SARSCoV-2 and influenza viruses.

What would the future look like?

The future of any novel COVID/influenza combination vaccine is still undetermined; nevertheless, we can analyze past vaccination trends to predict future ones. Multiple scenarios can be proposed regarding a patient’s choice for vaccination: 1. Patients who get the influenza vaccine yearly will continue to receive the influenza vaccine and will more than likely also opt to receive the COVID vaccine.

In this scenario, the COVID/influenza

combination vaccine may be preferred since it is more convenient to receive one combined shot rather than two individual shots.

2. Patients who get the influenza vaccine yearly will continue to receive the influenza vaccine but may refuse the COVID vaccine due to hesitation to receive a newly synthesized vaccine or the inconvenience of returning for a required second COVID vaccine dose, depending on the type of vaccine first administered.

3. Patients who decline both vaccines because of anti-vaccination sentiments, vaccine hesitations, lack of health care access or any number of barriers to health care.

4. Patients who choose only to receive the COVID vaccine because of pre-existing hesitations from past influenza vaccine experience (i.e., those who believe “the last time I received the influenza vaccine, I got the flu”).

Taken together, ongoing research is suggesting that influenza and SARS-CoV-2 present with many similarities. Both respiratory viruses demonstrate the need for a yearly vaccine based on variations in viral strains from past strains. They also manifest parallelism in symptoms, transmission and populations that are particularly vulnerable.

Therefore, a combination vaccine presents the optimal solution to curbing both infections. While research is newly emerging regarding a combination vaccine, past infection and vaccination trends also show a promising future for a combined influenza and SARS-CoV-2 vaccine. For these reasons, public health officials and members of the health care community should consider starting a conversation now around combination vaccine implementation.

References 1. “CDC COVID Data Tracker.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, covid.cdc.gov/covid-data-tracker/#cases_totalcases.

2. “Combination Vaccines – Fewer Shots Same Protection.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 1 Aug. 2019, www.cdc.gov/vaccines/parents/why-vaccinate/combination-vaccines.html.

3. Kim, Jerome H., et al. “Looking beyond COVID-19 Vaccine Phase 3 Trials.” Nature Medicine, vol. 27, no. 2, 2021, pp. 205–211., doi:10.1038/s41591-021-01230-y.

4. Massare, Michael J, et al. “Combination Respiratory Vaccine Containing Recombinant SARS-CoV-2 Spike and Quadrivalent Seasonal Influenza Hemagglutinin Nanoparticles with Matrix-M Adjuvant.” 2021, doi:10.1101/2021.05.05.442782.

5. Shinde, Vivek, et al. “Efficacy of NVXCoV2373 Covid-19 Vaccine against the B.1.351 Variant.” New England Journal of Medicine, vol. 384, no. 20, 2021, pp. 1899– 1909., doi:10.1056/nejmoa2103055.

6. Uyeki, Timothy M., et al. “Influenza Activity in the US During the 2020-2021 Season.” JAMA, 2021, doi:10.1001/ jama.2021.6125.

7. “Weekly U.S. Influenza Surveillance Report.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 28 May 2021, www.cdc.gov/flu/ weekly/index.htm.

Alvin Boyd Newman-Caro is a Fourth Year Medical Student at the University of Incarnate Word School of Osteopathic Medicine. He plans to specialize in General Surgery.

Rebecca L. Sanchez, PhD is an Assistant Professor of Microbiology at the UIWSOM. Visit us at www.bcms.org

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COVID-19 UPDATE

COVID-19 Infectious Disease Virtual Outpatient Team: A Telemedicine Response to the Pandemic

By Emily Sherry

Beginning with the COVID-19 pandemic, Long School of Medicine volunteers and medical students rotating on the Family Medicine clerkship had the opportunity to be a part of the COVID-19 Infectious Diseases Virtual Outpatient Team. As part of the team, we contacted patients via phone calls who had been diagnosed with COVID-19 after hospital discharge or after diagnosis at 5 days and 14 days. Our major goals included monitoring patients’ symptoms and a COVID-19 illness course, offering medical resources, escalating patient care to infectious disease specialists when needed, connecting patients with primary care and listening to patients’ other, nonmedical needs.

Through the experience on the COVID-19 Infectious Diseases Virtual Outpatient Team, I felt we all gained a more personal understanding of the needs of patients within our San Antonio and Texas communities, as well as the macrocosm of the pandemic. By contributing to phone follow-ups, we developed educational and clinical skills that better enabled us to serve the needs of patients right now. Not only has the experience been a chance for our outpatient team to reach a large number of people and maintain contact, but also the virtual person-to-person encounter has given us a foundation to reflect and build upon how we envision ourselves as physicians serving patients in the future.

We won’t always be caring for patients in a pandemic setting, yet certain themes transcend all medical work and time. For me person28

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ally, serving different roles as medical team member, educator, support system and advocate illuminated various timeless professional development questions. How will we care for patients when we don’t have all the answers for them? How will we educate patients during scenarios in which many unknowns surround their condition? And as our fellow medical communities fight for the human person, what will our response be as health care professionals? In reflecting, I was reminded of reverberating motifs that drew me to medicine in the first place. These motifs include the value of being truly present with the human person; bringing the passion, compassion and joy for medicine that carried me to this calling into every patient experience; and always respecting the dignity of the human person in how I advocate and care for them.

I think medical professionals have been adapting and growing to address this pandemic with creativity, courage, flexibility and teamwork, amidst uncertainty and unpredictability. Notably, we face the same question that we answered every day before COVID-19 through our actions, mindset and integrity that we bring to the clinical environment: How will we care for our patients today?

In the momentous crucible of COVID-19, the question has remained the same, but is textured to the rapidly changing circumstances of health care and our world. Currently, telehealth is playing a major role in making health care more accessible and safer for patients and clinic teams. Being a part of the COVID-19 Infectious Diseases Vir-

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tual Outpatient Team has been a meaningful way to learn about COVID-19 with an epidemiological perspective. I also enjoyed personally reaching out to those affected by COVID-19 on the community level. Listening to patients, answering their questions and showing them we cared by closely following up until patients returned to their baseline or felt comfortable was incredibly valuable for our clinical education. Moreover, I enjoyed developing the ability to host quality, effective virtual visits and establishing rapport and trust with the patient on the other side of the phone line.

In the fall of 2020, a time marked with a great deal of COVID-19 cases, hospitalizations and deaths, testing positive for COVID-19 was a distinctly vulnerable and frightening experience. In the voices of our patients diagnosed with COVID-19, I heard a range of human emotions, understandably weighted by confusion, frustration and fear. Our telemedicine calls were also met with great gratitude, as they provided patients the chance to discuss specifics of their illness course and receive reliable information based on current medical recommendations.

Patients inquired most about their symptoms, expected recovery and ability to safely return to loved ones and work after quarantine.

At times, however, people needed connection with additional medical care. I remember calling to check in on a woman who had been diagnosed with COVID-19 two months earlier. Initially, I expected her to respond with a recovery story, but quickly learned she had persistent and worsening COVID-19 symptoms that week that were im-

pairing her ability to function. She did not know at what threshold she should seek medical care, but described feeling like a “walking zombie.” She thanked me deeply for caring and addressing her change in condition, and I escalated her care to our infectious disease specialist for further medical evaluation and management. Working with this patient reminds me of the privilege we have as medical professionals to help patients feel seen and be heard. This conversation also underscores that simple actions such as phone check-ins can play important roles in good medical care. As physicians, we must recognize that sickness can equate to lost work time, medical bills and sizable inconvenience. And thus sometimes, we need to expressly give our patients the encouragement to pursue their health and to remind them that their well-being has immeasurable worth.

While virtual meetings are not typically a medical professional’s ideal for the health care experience, the pandemic has motivated a vivid response for the health care system and the provider as an individual to both embrace and evolve telehealth. I am also optimistic that our critical use of telehealth now will help improve the accessibility of health care for patients in the future, so that when in-person visits are safe enough to be the default, we will have bridged many gaps that existed before COVID-19. It is my hope that our system and its clinicians will be better trained, informed and prepared to apply telehealth not as the default, but as an option for individuals and communities who were previously underserved. In the post-COVID19 era, which we are pursuing with hope and motivation, how will health care be changed? Step-by-step, how are we approaching and seeing the question differently because of the environment we are embracing and responding to?

When I repeat the question again, “How will we care for patients today?” how do we answer? We will probably make more phone calls to patients than usual, we will sanitize our hands and instruments more than we ever thought to in the past and we will intentionally find new ways to connect with patients through the phone or through the mask. When we answer the question, “How will we care for patients today?” I think the context looks different, textured by the pandemic, but the answer is the same as it always was. We will stay true to the heart of medicine and answer by serving the human person placed in our care in whatever ways we can offer. For as long as the fire burns, as long as the world turns, we are here and that means one thing: we are caring for you today.

Emily Sherry is a Medical Student at the Long School of Medicine, UT Health San Antonio, Class of 2022.

Visit us at www.bcms.org

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COVID-19 UPDATE

The Bexar County Medical Society COVID-19 Task Force:

Our Next Move

By John J. Nava, MD

Fifteen months ago, the BCMS COVID-19 Task Force was formed by inviting members of the Public Health and Patient Advocacy, Emergency Preparedness, Executive, Legislative and Socioeconomics Committees of BCMS to combine their efforts. The intent was to examine the outbreak of COVID-19 in our community and to evaluate, recommend and communicate to BCMS leadership how BCMS could be involved in the fight against this deadly virus.

Four subcommittees were formed, each meeting separately and reporting back to the larger group at weekly virtual meetings. The combined emphases of the Task Force evolved from learning about this new virus to educating others about the virus, using PPE to protect oneself and understanding the logistics of vaccine administration. Together with the community of San Antonio, BCMS has worked to slow the spread of the COVID-19 virus; the numbers of vaccinated persons have increased and new cases have decreased.

We would like to recognize, congratulate and thank all those who helped in this effort. Each of the subcommittee chairs was asked to provide a synopsis of the activities of their respective subcommittees.

Their comments follow.

Lubna Naeem, MD Communication Subcommittee Chair We are in this together. In the year 2020, with a crisis like that of COVID-19 and when the stakes were high, the Communication Subcommittee’s role was outstanding in engaging the physicians, community and stakeholders, whether it was making public service announcements (PSAs) for making universal mask wearing a community standard or promoting contact tracing awareness.

We appreciate the overwhelming response from the community for the PSA initiative. We are proud of our team, integral committees, medical students, Alliance, BCMS members and the community partners for their aspiration to be part of this integral initiative. This wouldn’t be possible without the support of the BCMS leadership and the entire BCMS staff.

Thank you.

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Diane Simpson, MD Community Mitigation Subcommittee The Community Mitigation Subcommittee was formed to examine the most relevant public health practices to control the spread and encourage adoption. The committee members decided the use of social media messaging was the most practical means to disseminate correct information to the public.

This role was more important early in the pandemic, when the general population began to understand the scope and risks of COVID19 and to adopt effective prevention measures into their daily lives.

The committee members self-produced video messages to post on social media and the BCMS website, covering topics such as the need for cooperation with contact tracing and case investigation, the importance of going to the hospital in medical emergencies and voting safely in the 2020 elections. These messages provided correct information and demonstrated the support of BCMS in regards to good public health practices.

By December 2020, information and professional messaging regarding COVID-19 had saturated the mainstream media. The need for this subcommittee lessened considerably and the group decided not to meet in 2021, although members continue to write occasional articles on COVID-19 and public health issues for San Antonio Medicine.

Leah H. Jacobson, MD, FAAP Pediatric and School Re-opening Subcommittee No one could have imagined back in March of 2020 that what started as the usual Spring Break would change the educational system dramatically for the next 15 months.

The Pediatric and School Re-opening Subcommittee worked diligently during this time to discuss issues related to the effects of the pandemic on children and their changes in schooling.

A few of the topics discussed included: 1) positivity rates and other metrics in the pediatric populations both locally and at the state level, 2) the need to follow closely ever-changing guidelines issued by

COVID-19 UPDATE

TEA (Texas Education Agency), UIL (University Interscholastic League) and the Center for Disease Control (CDC), 3) recommendations put forth by the American Academy of Pediatrics and the Texas Pediatric Society, and 4) varied special interests, such as special education, insecurities (food, internet access, child care), etc.

We were also involved with the local Metro Health preK-12 Consultation Group in an advisory role. I am very proud of the work of the members of this subcommittee. This group developed a Pediatric COVID-19 Symptoms Severity Chart (in both English and Spanish) which was printed in San Antonio Medicine magazine, then elevated to the state level through the Texas Medical Association (TMA). We also drafted a position statement on school face-to-face re-openings for BCMS last summer, and worked on a letter to the Governor concerning the state of education during the pandemic.

A personal thank you all subcommittee members, as well as staff person extraordinaire, Mrs. Mary Nava.

Zeke Silva, MD Hospital and Workforce Subcommittee Policymakers recognized early on that protecting our nation’s health care infrastructure was a key consideration in fighting the COVID19 pandemic. The BCMS COVID Task Force, therefore, included a Hospital and Workforce subcommittee to monitor our local health care facility status. The subcommittee was populated with physician leaders from our city’s various hospital systems.

The subcommittee monitored local data closely, particularly data from the Southwest Texas Regional Advisory Council (STRAC) Pandemic Medical Operations Workgroup, where BCMS had several representatives who participated on their calls several times a week. The STRAC data was tabulated daily and included specific numbers on the number of COVID-19 positive inpatients, new admissions, ICU, ventilated and ECMO patients. The data was also broken down by hospitals within Bexar County and those outside of Bexar County

and included a hospital stress score for each.

The subcommittee collaborated to share strategies which were successful for our respective health systems.

We followed national and state level trends closely and inquired how our local hospitals were being impacted by these trends. For example, how many staff were leaving San Antonio for other opportunities around the country? And how many supplemental staff were being received by the Texas Department of Health and Human Services?

Careful and continuous monitoring of hospital needs, staffing and collaboration between systems allowed the subcommittee to inform the broader BCMS on its communication and actions on behalf of our members and our patients.

Wrap-up As the taskforce winds down, the question has been posed, “What did we accomplish?” Well, our meetings maintained situational awareness of the status of the community response. Through posts on BCMS social media, The Physicians Link newsletter and articles in San Antonio Medicine magazine, we disseminated information to the larger society and San Antonio citizens. We were ever ready, waiting in the wings should our assistance be needed. Our willingness to serve was tangible evidence of the spirit of service of the Bexar County Medical Society.

During the last year, the pandemic exposed gaps in health coverage of certain vulnerable groups. Issues of health equity that were actually chronic became apparent as the community-wide response developed.

Community-wide concerns regarding food insecurity and unmet mental health needs persist.

Now we consider where we go from here, as a medical society and a larger service community. Many of the unmet needs remain, and the Public Health and Patient Advocacy Committee will continue to address these issues. Unaddressed needs and health equity issues offer the chance to respond as valued health care leaders to inform and guide our fellow residents of Bexar County.

I welcome any BCMS members who have an interest in participating, and extend an open invitation to become more involved.

In closing, I express my gratitude to all the members of the BCMS COVID-19 Task Force, the four subcommittee chairs, and all of the BCMS staff, without whom our efforts would not have been possible.

John J. Nava, MD was the Chair of this BCMS COVID19 Task Force and is the current Vice President of the Bexar County Medical Society.

Visit us at www.bcms.org

31

COVID-19 UPDATE

A Disease of Insufficient Nitric Oxide Production

By Nathan S. Bryan, PhD

COVID-19 is now a worldwide pandemic affecting millions of people around the world. As of mid-May 2021, over 160 million people have been infected, with over three million deaths. Early data coming out of China in January 2020 revealed that patients with underlying cardiovascular disease were more susceptible to infection, greater disease severity and ten times higher mortality. Among the patients studied, the median (range) age was 64 (21-95) years old, female (50.7%, and the median time to symptom onset was 10 days (interquartile range [IQR]), 1-30). Of this group, 82 (19.7%) had some type of cardiac comorbidity. It was apparent as the study went on that patients with cardiac morbidity and COVID-19 fared worse than the patients with COVID-19, but no history of cardiac morbidity. Patients with cardiac morbidity with diagnosed COVID-19, compared with patients without cardiac morbidity, had a higher mortality rate (51.2% vs 4.5%) and risk of death.1 In addition, over the past 18 months, reports from the U.S. database compiled by CDC report mortality from COVID-19 to have a racial disparity.2 A disproportionate number of COVID-19 fatalities among Hispanics and African Americans has been observed. This has been attributed to known disparities in health care, low economic resources and issues associated with social distancing: occupation, crowded residential spaces and transportation crowding. Additionally, Hispanics and African Americans have a high incidence of pre-existing and often 32

SAN ANTONIO MEDICINE • July 2021

untreated cardiovascular conditions.3 It is clear that older people with an underlying comorbidity such as high blood pressure, heart disease, kidney disease, obesity, smokers and patients with pulmonary disorders are at an increased risk of COVID infection. These are also the people that get the sickest and die from COVID. Additionally, abnormal blood clotting is an increasingly recognized complication of this disease, both systemically and within the pulmonary circulation.4 In fact, one of the greatest predictors of death is a serum blood test that indicates elevated clotting activity (D-dimer).

More recent clinical observations reveal endothelial cell infection and endotheliitis in COVID patients across vascular beds in multiple organs.5 The vascular endothelium is an active paracrine, endocrine and autocrine organ that is indispensable for the regulation of vascular tone and the maintenance of vascular homoeostasis.6 COVID-19-endotheliitis could explain the systemic impaired microcirculatory function in different vascular beds and their clinical sequelae in patients with COVID-19. Endothelial dysfunction and insufficient nitric oxide (NO) production is a principal determinant of microvascular dysfunction by shifting the vascular equilibrium towards more vasoconstriction with subsequent organ ischemia, inflammation with associated tissue edema and a pro-coagulant state. See illustration. Therefore, the people that are most susceptible and vulnerable to COVID infection are exactly the patients that have insufficient nitric oxide production in their body.

COVID-19 UPDATE

For more information, please visit www.nocovidstudy.com.

If patients meet the following criteria, then they will qualify to participate in the study: 1. Hispanic or African American 2. Aged 50-85 3. Diagnosed with COVID in the past 72 hours 4. Have at least one comorbidity such as hypertension, diabetes, heart disease, kidney disease, obesity or a smoker.

Restoring nitric oxide through drug therapy is reported to improve oxygenation,7,8 an action needed as the COVID-19 disease progresses and acute respiratory disease syndrome (ARDS) develops. NO decreases the propensity of blood to clot,9 a problem leading to multi-system damage in patients severely ill with the COVID-19 virus.

All these factors: decreased oxygenation, low NO levels in Hispanic and Africans American patients, decreased oxygenation in severely ill COVID-19 patients, increased clotting and increased inflammation, leads one to hypothesize that increasing NO levels in patients with COVID-19 would have a salutatory benefit. A Texas-based biotechnology company, Nitric Oxide Innovations, is conducting an FDAapproved Phase 3 clinical trial for a novel nitric oxide releasing drug therapy for Hispanic and African American patients aged 50-85 diagnosed with COVID in the last 72 hours. The clinical trial aims to investigate if restoring nitric oxide can prevent progression of disease and hospitalization, reduced need for ventilation and decrease death.

Early data from the clinical study reveals that nitric oxide can improve oxygenation in patients within five minutes of taking the drug. Hispanics and African-Americans are known to be nitric oxide deficient and respond favorably to nitric oxide-based therapies. Patients are needed in the clinical study. Subjects will be randomly assigned to receive either an NO active drug lozenge or a placebo for 30 days. The primary outcome measures rates of hospitalization, admission into the intensive care unit and death in patients on the drug compared to the placebo. A secondary endpoint will be the fractional oxygen saturation of patients receiving the drug compared to those on the placebo.

3.

4.

5.

6.

7.

8.

9.

References: 1. Shi, S., et al., Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol, 2020.

2. Yancy, C.W., COVID-19 and African Americans. JAMA, 2020.

Carnethon, M.R., et al., Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation, 2017. 136(21): p. e393-e423.

Connors, J.M. and J.H. Levy, COVID-19 and its implications for thrombosis and anticoagulation. Blood, 2020.

Varga, Z., et al., Endothelial cell infection and endotheliitis in COVID-19. Lancet, 2020. 395(10234): p. 1417-1418.

Bonetti, P.O., L.O. Lerman, and A. Lerman, Endothelial dysfunction: a marker of atherosclerotic risk. Arterioscler Thromb Vasc Biol, 2003. 23(2): p. 168-75.

Allen, B.W., J.S. Stamler, and C.A. Piantadosi, Hemoglobin, nitric oxide and molecular mechanisms of hypoxic vasodilation. Trends Mol Med, 2009. 15(10): p. 452-60.

Zhang, R., et al., Hemoglobin betaCys93 is essential for cardiovascular function and integrated response to hypoxia. Proc Natl Acad Sci U S A, 2015. 112(20): p. 6425-30.

Radomski, M.W., R.M. Palmer, and S. Moncada, The anti-aggregating properties of vascular endothelium: interactions between prostacyclin and nitric oxide. Br J Pharmacol, 1987. 92(3): p. 639-46.

Nathan S. Bryan, PhD is the Founder and CEO of Nitric Oxide Innovations, LLC. Nitric Oxide Innovations, LLC is a Gold Circle of Friends Sponsor of the BCMS. For more information, you can contact him at nathan@pneumanitricoxide.com.

Visit us at www.bcms.org

33

SAN ANTONIO MEDICINE

Women Doctors and American Medical History: Trials and Triumphs in Service of the Most Needful

By David Alex Schulz, CHP

The Age of Heroic Medicine was ending.

Harrowing techniques of bloodletting, sweating and purging to balance the four “humors” were giving way to gentler treatments. By the 1850s, wealthy patients began expecting effective results without agonizing therapy. Scientific medicine was a frontier pioneered by new schools, infirmaries and hospitals. Surgery was performed anesthetically but hazardously – Lister’s antiseptics were still a decade away.

The Blackwell sisters blazed the frontier; Elizabeth was the first woman to earn a medical degree in the United States, and Emily, its first woman surgeon. Their story and that of institutions they founded informs “The Doctors Blackwell: How Two Pioneering Sisters Brought Medicine to Women and Women to Medicine” by Janice P. Nimura (2021; W. W. Norton & Company). The sisters’ aspirations, endeavors and eccentricities, portrayed in an epically-scaled history, is a story not only of people but of a time and place, and a profession in growth.

Elizabeth (the third of nine children) and Emily (her next younger sister) were raised in a religious family following a progressive “English Dissenters” faith. Their father was ironically a sugar manufacturer and fervently antislavery: paradoxes run rampant in the feisty family 34

SAN ANTONIO MEDICINE • July 2021

story. The siblings rarely attended school, educated at home by private tutors. Experiencing little real-world academic competition, Elizabeth set her sights on becoming the first woman accepted by an American medical college.

Elizabeth’s motivation was not compassion for the sick, or a sense of vocation, but to demonstrate that women were up to the era’s premier challenge. Nor would she be satisfied by her own acceptance alone. Proof-of-concept required Emily follow suit so together they could establish a thriving medical practice. The Blackwells were never satisfied by second best: Elizabeth attempted admission only at the most traditional, prestigious colleges.

Even the best medical schools were a far cry from the clinical training and residency now integral. Students were taught by rote in a series of lectures for which they had to purchase tickets. The entire course, from admission to graduation, was two 16-week semesters, repeated the following year. Students hoped to gain some practical experience during the summer.

“She sought interviews with Philadelphia’s leading physicians and sent letters of inquiry to medical colleges in both Philadelphia and New York. At the University of Pennsylvania, the oldest and most august American medical school, Dr. Samuel Jackson burst out laughing at her request.”

Rejected by every institution to which she had applied, Elizabeth sent off a flurry of applications to a dozen provincial medical colleges across New England. Lightning struck in the form of a rebellious student body at Geneva Medical College (later transferred to Syracuse

University in Syracuse, New York).

The Dean announced to faculty that “A young lady, studying privately with an eminent physician in Philadelphia, applied with her mentor’s endorsement for admission to their school.”

The faculty put the decision to the student body. The students recognized faculty skittishness and their power to make serious mischief.

Astounding the college, students approved and before long, Elizabeth Blackwell rose from a classroom curiosity to class-leader in academic achievement.

Elizabeth performed clinical work over break at Philadelphia’s refuge for the destitute, Blockley Alms House. “Blockley is the microcosm of the city,” wrote one observer. “Here is drunkenness; here is pauperism; here is illegitimacy; here is madness; here are the eternal priestesses of prostitution, who sacrifice for the sins of man; here is crime in all its protean aspects; and here is vice in all its monstrous forms.” Serving two thousand indigents in such a place offered a sense of clinical work that the lecture hall never provided.

In January 1849, she became the first woman to earn a medical degree in the United States. A year later, Dr. Elizabeth Blackwell moved to France for practical residency: she could enter La Maternité, France’s largest public maternity hospital, not as a qualified doctor but as a student.

At La Maternité, Dr. Blackwell saw a thousand cases — vastly more than she might see anywhere else — under the tutelage of Paul Antoine Dubois, a distinguished professor of

SAN ANTONIO MEDICINE

obstetrics. “In this one branch of medicine, there was no better practical education.”

La Maternité showed her that medical and social issues were inseparable, particularly in terms of hygiene and household. It was a philosophy she would carry throughout her life.

Unfortunately, the lesson left her the permanent loss of her left eye from an infection of purulent ophthalmia, an aggressive form of conjunctivitis related to gonorrhea.

For medical school, Emily Blackwell had greater choices and was less selective. She introduced herself to the president of Rush Medical College in Chicago. Previously, Emily had distinguished herself attending lectures at Bellevue Hospital given by Columbia faculty. “The endorsement of the Bellevue Brahmins made all the difference: it was easier for Rush’s leaders to act boldly on Emily’s behalf when they could point to men of large reputation who had already done so.”

The Doctors Blackwell found opening a prac-

tice more challenging than earning their credentials. In a time “female physician” equated to abortionist, patients were hard to recruit. Patrons were easier. Ever the institutionalists, Elizabeth and Emily opened the first hospital staffed by women in 1857, the New York Infirmary for Indigent Women and Children.

Decades of medical advancement and social turmoil are portrayed through the eyes and experiences of the Blackwells. They served both the indigent in the Infirmary and their Patrons in private practice until they reach the height of their combined efforts: The Woman’s Medical College of the New York Infirmary.

It was the first school entirely devoted to the medical education of women. The Doctors Blackwell ran it under a different and better philosophy. Students had to attend for three years instead of the standard two, and would have hands-on lessons. Their course of lectures would build progressively year to year, rather than simply repeating the same material. And

theirs would be the first medical school of any kind to feature a professor—Elizabeth herself—devoted to the subject of hygiene.

Janice Nimura paints these stories as if in companionship with the Blackwells, perhaps with an overzealous reliance on their own writings in letters and diaries. “The Doctors Blackwell” can be a reader’s challenge (“valetudinarian”?) and the principals not especially likeable characters, but stalwart readers will find themselves immersed in a pivotal time of health care and more aware of their heritage for the effort.

All quotes and images from: Nimura, Janice P. “The Doctors Blackwell: How Two Pioneering Sisters Brought Medicine to Women and Women to Medicine” (2021) W. W. Norton & Company. Kindle Edition.

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

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of June 23, 2021.

Visit us at www.bcms.org

35

SAN ANTONIO MEDICINE

The Study of Life, Revisited

By Winona Gbedey

I wanted to say something profoundly beautiful and philosophical about my experiences during quarantine, but when I sat down to write this, all I could think about was my cat.

She died in the spring of 2017, a few hours before my organic chemistry final. As I racked my brain, searching for the answers to complicated scientific principles that still elude me, my beloved pet of twelve years lay lifeless at the foot of our stairs. My parents told me what had happened when I returned home. It was quick, they said, unexpected, shocking. It was too much, so they didn’t want me to dwell on it while I was taking my exams. Grief, I soon discovered, could be all-consuming.

Reconciling my last memories of Tiger with the knowledge that she was gone was difficult. Sometimes it still is. Unlike my family, I didn’t see her wither away over a course of three days. I never got that time to flip the switch, to think maybe this is the end. To me, Tiger is still the vivacious little thing who loved to curl up next to me and vibrate my body with the force of her purr. Except she isn’t here anymore. I imagine this is what it’s like for most people who lose someone unexpectedly: disbelief and grief that indefinitely sticks to you like super glue.

Because of the pandemic, I find myself thinking about how fickle life is constantly—how it unexpectedly vanishes into the night while the rest of the world sleeps. After many hours in more quarantine-induced existential crises than I can remember, I’ve come to the conclusion that life is so fleeting because it is ruled by biology. Biology demands that all living things expire eventually, no matter how much they are loved. Despite the place I had carved in my heart for her, it was Tiger’s time to go. Biology didn’t care.

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SAN ANTONIO MEDICINE • July 2021

I am fortunate that when I think of death, I think of my cat. My family, my friends, they are all still with me—something I am even more grateful for now, as SARS-CoV-2 continuously sweeps across the country, claiming lives like the Grim Reaper. When I turn on the television or tap my news app, I am inundated by stories of families saying their goodbyes through an iPad screen while their loved one lays unconscious, alone, entangled in a mess of tubes and cords. Their stories remind me that I am one of the lucky few who does not yet know the pain of losing someone.

And then, all of a sudden, I begin thinking about my cat.

I cannot pretend that losing a beloved pet is the same as losing a beloved person. But I can say this: Tiger’s death still hurts because she was loved. In a strange turn of events, the pandemic has taught me that all grief is valid because all grief comes from a place of love. The way others describe their pain mirrors the way I speak of mine; in those moments, we are the same, mourning the loss of someone we loved.

When biology claims another piece of my soul, Tiger’s death will not ache any less than it does now. The parts of me that I gave to her may not be as large as the ones I give my parents, my brother, my best friends or my future partner, but she has a part of my heart nonetheless. One day I will know what it is like to lose someone. But for now, I think of my cat.

Winona Gbedey is a medical student at the Long School of Medicine, UT Health San Antonio, Class of 2023.

SAN ANTONIO MEDICINE

Artistic Expression in Medicine

By Maggie Carroll, MD

Top: Hand Bottom: Right Chest and Arm

Artwork created by Maggie Carroll, MD, Long School of Medicine, UT Health San Antonio, Class of 2021.

Visit us at www.bcms.org

37

SAN ANTONIO MEDICINE

Impacting Recurrence in Non-Muscle Invasive Bladder Cancer Announcement by University of Texas Health Science Center San Antonio

Bladder image from White Light Cystoscopy

Same Image from Blue Light Cystoscopy with /Cysview

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In the United States, more than 720,000 people are living with bladder cancer, and an estimated 83,730 people will be diagnosed this year.1 Mays Cancer Center at UT Health San Antonio is now offering Blue Light Cystoscopy with Cysview® for improved detection and management of non-muscle invasive bladder cancer (NMIBC), including carcinoma in situ (CIS) in an outpatient setting.

“Treatment of bladder cancer requires careful, meticulous detail and adherence to surveillance regimens,” said Dr. Robert Svatek, Urologic Oncologist at Mays Cancer Center and Chair of Urology at UT Health San Antonio. “It requires diligence in the administration of proper standardized therapy, but treatment regimens must also be individualized.”

Cystoscopy is the gold standard diagnostic tool for bladder cancer. Historically, this has been conducted using white light cystoscopy; however, some tumors may escape detection under white light alone.2,3 To increase detection and decrease recurrence for patients suffering from bladder cancer, Blue Light Cystoscopy with Cysview is employed.

“Although it is not a replacement for biopsy, Blue Light Cystoscopy with Cysview is an enhanced cystoscopy that helps us identify lesions that may not be visible using white light cystoscopy alone,” said Dr. Svatek. “This advanced approach helps us elevate our diagnostic capabilities and provide a higher standard of care for our patients.”

During a standard cystoscopy procedure, the bladder is examined using white light. During a Blue Light Cystoscopy with Cysview, both white and blue light are used. Cysview makes tumor cells glow bright pink in blue light, but it is not a dye. It is a hexyl-ester of aminolevulinic acid that results in an increased volume of porphyrins in cells. Unhealthy cells do not process out the porphyrins as quickly as healthy cells; the resulting accumulation creates a pink glow in blue light.

Cysview® (hexaminolevulinate HCl) is an FDA-

SAN ANTONIO MEDICINE • July 2021

approved optical imaging agent indicated for use in the cystoscopic detection of NMIBC including CIS among patients suspected or known to have lesion(s) based on a prior cystoscopy or undergoing surveillance cystoscopy for carcinoma of the bladder.

Cysview is instilled in the patient’s bladder at least one hour before the procedure and used with the KARL STORZ Photodynamic Diagnostic system to perform Blue Light Cystoscopy as an adjunct to White Light Cystoscopy.4 “Expertise in the management of advanced bladder cancer requires proper timing and coordination of multiple treatment modalities available to treat the disease including surgery, radiation therapy and chemotherapy.” To that end, Dr. Svatek has developed a collaborative care pathway that provides exceptional precision in the pre-operative and post-operative management of patients with bladder cancer.

References: 1. National Cancer Institute. SEER Stat Facts: Bladder Cancer 2017. https://seer.cancer.gov/statfacts/html/ urinb.html. Accessed January 25, 2019.

2. Hermann GG, Mogensen K, Carlsson S, Marcussen N, Duun S. Fluorescence-Guided Transurethral Resection of Bladder Tumours Reduces Bladder Tumour Recurrence Due to Less Residual Tumour Tissue in Ta/T1 Patients: A Randomized Two-Centre Study. BJU Int. 2011;108(8b):E297-E303.

3. Daneshmand S et al. Efficacy and safety of blue light flexible cystoscopy with Hexaminolevulinate (HAL) in the surveillance of bladder cancer: A phase III, comparative, multi-center study. J Urol. 2017 Dec 2.

4. Cysview [prescribing information]. 2018:1-14. Chang SS, Boorjian SA, Chou R, et al. Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline. J Urol. 2016;196(4):1021-1029.

Mays Cancer Center is the first and only center in the region to offer Blue Light Cystoscopy with Cysview® in an outpatient setting for improved detection and management of non-muscle invasive bladder cancer.

SAN ANTONIO MEDICINE

Congratulations to our Medical Student Scholars!

For decades, the BCMS Alliance has rewarded excellence in allied health fields in Bexar County. This year, the 104-year-old organization began a new medical student scholarship program, presenting awards to two exceptional students, one at each of Bexar County’s medical schools.

BCMS Alliance funds were matched by the TMAF Medical Student Scholarship and Grant Trust Fund of Dr. Roberto J. and Agniela (Annie) M. Bayardo and the TMAF Hispanic Medical Student Scholarship Trust Fund of Dr. Roberto J. and Agniela (Annie) M. Bayardo.

VICTORIA FAHY BCMS Alliance Hispanic Medical Student Scholarship UIW School of Osteopathic Medicine | Class of 2023 A graduate of Mary Hardin-Baylor with a BS degree in Cell Biology, Victoria was presented the coveted Loyalty Cup for exemplifying the ideals, traditions and spirit of the University. During medical school, Victoria has served others through community immunization drives, leadership roles with the Student Government Association and Academy of Pediatrics and as peer mentor as an Office of Admissions learner ambassador. “I want to thank the Bexar County Medical Society Alliance for selecting me for the inaugural BCMS Alliance Hispanic Medical Student Scholarship. With this gift, I will be able to continue to pursue my passion for both medicine and outreach within our local community. I would also like to thank the donors for investing in not only my future, but also other medical students within the Bexar County area. I am truly honored to receive this award and I will strive to enact positive change within our community. As a Latina and first-generation graduate student, I hope to inspire other students like me to pursue their dreams and passions.”

RYAN WEALTHER BCMS Alliance Medical Student Scholarship UT Health San Antonio Long School of Medicine | Class of 2022 Prior to graduating summa cum laude from Drake University with a BS degree in Biochemistry, Cell and Molecular Biology and a BA in Chemistry, Ryan earned his nurse aide certification working as a CNA to hone his clinical skills. Heavily involved in research, his recent studies focus on palliative care, COVID-19 prevalence and vaccine hesitancy. A leader, peer mentor and student physician advocate for medicine on the national, state and local level, Ryan is also committed to serving others, especially at-risk communities. “I am very grateful to accept the inaugural BCMS Alliance Medical Student Scholarship. As a medical student advocate, I strive to serve my community and use my voice to advocate for patients in San Antonio, the state of Texas and across the nation. As the newly elected Chair of the TMA Medical Student Section, I look forward to increasing medical student advocacy throughout the state of Texas over the upcoming year. This award is especially meaningful to me because its financial support will allow me to continue pursuing my passions and endeavors, including conducting research, attending advocacy events and participating in away rotations as I apply to dermatology programs. Thanks again to the BCMS Alliance and to the TMA Foundation for supporting me in my endeavors and helping me achieve my goals.”

Visit us at www.bcms.org

39

PHYSICIANS PURCHASING DIRECTORY Support the BCMS by supporting the following sponsors.

Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed.

ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being.

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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.

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ATTORNEYS

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

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

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

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

ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life.

We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning.

Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

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

FINANCIAL ADVISOR

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

Shawn P. Hughes, JD Senior Vice President, Private Banking (210) 283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”

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

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

Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

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

BANKING

BB&T (HH Silver Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services -- BB&T offers solutions to help you reach your financial goals and plan for a sound financial future Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com https://www.bbt.com/wealth/star t.page "All we see is you"

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

Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help

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Physicians get the banking services they need.

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

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning.

Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

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

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

Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services.

Mary P. Mahlie Vice President Wealth Advisor (512)787.2488 Mary.Mahlie@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (210)385.9326 Fred.Kelley@Regions.com www.Regions.com

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

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

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

First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking.

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210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

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”

OSMA Health (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians.

Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians.

Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians.

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

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

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options.

Laura Kouba Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications

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

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

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

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

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

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment

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

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PHYSICIANS PURCHASING DIRECTORY continued from page 41

for our insureds. ProAssurance Group is A.M. Best A+ (Superior).

Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience.

Clayton Brown Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

MEDICAL BILLING AND COLLECTIONS SERVICES

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

Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.”

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

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

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MEDICAL PHYSICS

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly!

Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL SUPPLIES AND EQUIPMENT

“BCMS members receive GPO discounts of 15 to 50 percent.”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases.

Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

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

Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare.

Elevate the Level of Remote Care.

Enhance the Patient Experience.

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

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com

SAN ANTONIO MEDICINE • July 2021

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly!

Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

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 CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions.

Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate” Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management.

Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease” The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center.

Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELEHEALTH TECHNOLOGY

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties.

For questions regarding Circle of Friends Sponsorship, please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366

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

Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare.

Elevate the Level of Remote Care.

Enhance the Patient Experience.

Visit us at www.bcms.org

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AUTO REVIEW

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SAN ANTONIO MEDICINE • July 2021

AUTO REVIEW

2022 Ford F-150 Lightning EV

By Stephen Schutz, MD

Ford recently unveiled the coming-in-2022 all-electric F-150 Lightning pickup truck, and it was, as they say, kind of a big deal. It looks a lot like the current F-150—which we’ll get to in a minute— but with numerous futuristic styling touches, particularly in the lighting department.

Interestingly, Ford is positioning the Lightning as a tough pickup for commercial fleet buyers first, presumably thinking that if those demanding customers can be won over, then retail customers should be relatively easy to satisfy.

It makes sense. On the one hand, commercial buyers put many more miles on their trucks and are much harder on them than everyday owners—think hauling stacks of drywall to 12 different job sites in one day—but on the other, if Ford can make them happy, then people who use their trucks for more mundane activities like Costco runs will likely be satisfied too.

As with most things in life, easy to say, hard to do.

Anyway, the Lightning includes some highly innovative features such as the ability to use its battery pack as a power source in case of a power outage in your house, and a huge lockable “frunk” storage space located under the hood in the place where the engine used to be.

Base F-150 Lightnings are expected to start at around $40,000, but no other details about pricing have been provided. It’s reasonable to expect all the trim levels we’ve become accustomed to with internal combustion engine (ICE) F-150s (XLT, Lariat, Platinum and the like), but with an extra cost for the electric versions. And it’s easy to predict that average transaction prices will be much higher than $40,000.

I have neither driven nor seen an F-150 Lightning, but I did spend a week with a gasoline powered version of what Automotive News calls Ford’s, “crown jewel.” It was a pleasant experience, as you’d expect, given the fact that the ICE F-150 has been the best-selling vehicle in the U.S. for more than four decades.

My test vehicle came with the loaded Limited trim and had a V8 engine, which used to be ubiquitous and is now quite unusual (most F-150s today come with the more efficient and torquier 3.5L EcoBoost V6).

Driving the F-150 Limited reminded me that some versions of this truck are almost Lexus-like from inside the cabin. The ride is comfortable, noise is limited, passenger space is generous, even in the back seat and most materials are soft and very attractive. Nevertheless, this is a Ford and not a Lexus, so many buttons and knobs (and a few surfaces) are more reflective of a base model $40,000

truck than a $80,000 luxury vehicle (an F-150 Limited lists for about that much money, FYI).

While driving an F-150 around town and (especially) on the interstate is invariably pleasant, and it’s always nice to have room to put almost anything, this is not a perfect vehicle. Parking one can be difficult, and fuel economy is generally disappointing (16 MPG City/22 MPG Highway for the V8 and 18 City/23 Highway for the 3.5L EcoBoost V6).

By the way, only my favorite engine, the 3.0L turbo-diesel V6, gets respectable fuel mileage: 20 MPG City/27 Highway.

Interestingly, the most recent F-150—updated just last fall—includes some retro styling touches that harken back to the 1970s, particularly the egg crate grilles found on most trim levels. The overall design is of course completely modern, but it’s surprising to see an icon like the F-150 tip its hat to a decade marked by automotive designs that are not remembered fondly. Vehicles from that decade are derisively called “malaise era” cars, as then-new emissions regulations and back-to-back oil embargoes rocked the industry, resulting in underpowered and ugly products.

The F-150 can be configured in an almost infinite number of ways, but BCMS members will likely be drawn to the higher-end models with four doors, especially the Platinum and King Ranch versions. While those two trim levels have much in common, they use different styling elements and interior materials to appeal to more urban and rural buyers, respectively. The Limited sits above those trim levels at the very top of the F-150 food chain.

For the next year or so until it actually launches, the all-electric F150 Lightning will be the darling of automotive publications across the country, but for the time being, the less cool ICE F-150 remains a pickup you can count on. It can tow, haul and get you to the hospital in any weather condition. Plus, it does so with a level of comfort and luxury that surpasses what even some expensive cars can provide.

It’s easy to see why it’s so popular.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

Visit us at www.bcms.org

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