San Antonio Medicine September 2019

SAN ANTONIO

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Public Health

Herbalism: Garlic and Ginger Show Promise Combined with Gentamicin

By Abdullah Ghali, MSII ..........................................10 Street Medicine in San Antonio: Medical Student Perspectives and Experiences

By Matthew Hennessey, Alvin Boyd Newman-Caro, Kaleigh Longcrier, Hans Bruntmyer, DO..................12 My Journey with Alzheimer’s

By Sherman Macdaniel ..........................................16 Fighting an Epidemic of Amputations in Bexar County By Lyssa Ochoa, MD................................18 Lyme Disease: Diagnosis and Cure

By Alfred Miller, MD ................................................22 BCMS President’s Message ........................................................................................................................8 BCMS Legislative Mixer..............................................................................................................................24 BCMS & SAMGMA Working Together to Improve Medical Practice Management

By Tom Tidwell, CMPE, SAMGMA President ..........................................................................................26 The Making of My MD, MBA ......................................................................................................................28 UTHSA: Youth Onset Type 2 Diabetes

By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio ............30 Using Helmets to Limit Motorcycle Accident Fatalities from Head Trauma

By Ammar Navid Saigal, MPH ................................................................................................................32 BUSINESS: Network Diagnostics: Cyber Security for Medical Businesses By Maria Martinez, ChFC ..........34 BCMS Circle of Friends Directory ..............................................................................................................36 In the Driver’s Seat ....................................................................................................................................43 Auto Review: 2019 Volkswagen Atlas By Steve Schutz, MD ....................................................................44 PUBLISHED BY: SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net BUSINESS MANAGER: Vicki Schroder

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San Antonio Medicine • September 2019

SEPTEMBER 2019

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VOLUME 72 NO. 9

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

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

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

DIRECTORS Michael A. Battista, MD, Member

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

Vincent Paul Fonseca, MD, MPH, Member

BCMS SENIOR STAFF

Michael Joseph Guirl, MD, Member

Stephen C. Fitzer, CEO/Executive Director

David Anthony Hnatow, MD, Member

Melody Newsom, Chief Operating Officer

Gerardo Ortega, MD, Member

Alice Sutton, Controller

Manuel M. Quinones Jr., MD, Member

August Trevino, Development Director

David M. Siegel, MD, JD, Member

Mary Nava, Chief Government Affairs Officer

Rajeev Suri, MD, Member

Phil Hornbeak, Auto Program Director

Kelly King, Alliance Representative

Mary Jo Quinn, BCVI Director

George Rick Evans, Legal Counsel

Brissa Vela, Membership Director

Col. Charles Gregory Mahakian, MD,

Al Ortiz, Chief Information Officer

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San Antonio Medicine • September 2019

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

John D. Edwards, MD, Member

Military Representative

PUBLICATIONS COMMITTEE

J.J. Waller Jr., MD, Member

PRESIDENT’S MESSAGE

Welcome Stranger

By Adam Ratner, MD, 2019 BCMS President

Almost all of us have taken care of a family member with dementia or know someone who has or will. Many of our patients are also such caregivers and often look to us for day-to-day guidance whether we can provide it or not.

Approximately two years ago, in my capacity as Chairman of The Patient Institute, I was introduced to Mr. Sherman Macdaniel. Sherman is a retired financial service professional and is one of the most thoughtful, cordial, and well-spoken individuals I have had the pleasure of meeting. He also happens to be the grandson of a past president of the BCMS who served us approximately 100 years ago.

Sherman’s wife of 57 years, Kendall, was diagnosed with Alzheimer’s dementia after 53 years of marriage. The next four challenging years provided Sherman incredible practical and spiritual insights about coping as a caregiver to a spouse with Alzheimer’s dementia. After Kendall’s passing, Sherman collected his thoughts and collaborated with a few of his friends who had also taken care of their spouses with dementia and wrote a monograph titled Welcome Stranger.

Welcome Stranger is a heartfelt and practical guide for anyone taking care of a loved one with dementia in an easy-to-read format. It contains insights and tips to adapt caregiver communication and behavior which can make both the patient’s and caregiver’s lives much easier and less stressful.

Sherman’s mission in this phase of his life is to help those who find themselves taking care of dementia patients. Partnering with The Patient Institute, Sherman wants to freely distribute his book to those who will benefit from reading it. As a member of the BCMS, upon request, The Patient Institute will send you up to 10 free copies for you to read and distribute to your patients in need. If you find you need more, please let The Patient Institute know. To request your free copies, please contact Janet Poole at janet@patientinstitute.org.

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

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San Antonio Medicine • September 2019

PUBLIC HEALTH

HERBALISM Garlic and Ginger Show Promise Combined with Gentamicin

By Abdullah Ghali, MSII

he World Health Organization reports an alarming increase in pathogenic bacterial antimicrobial resistance. This has prompted the need for new versions of antibiotics but also has diverted a portion of the population’s attention away from antibiotics and towards Herbalism.

This clinical therapy aspect has been on the rise and stems from old traditions such 10

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as Chinese medicine that have been associated with treating bacterial infections and providing pain relief. This prompted me to conduct an experiment in 2012 to assess the potency of these extracts when combined with an antibiotic – gentamicin. This was designed to answer the question of “Do natural plants increase the antimicrobial strength of antibiotics?”.

I used the disk diffusion method to as-

sess potency against staphylococcus epidermidis by measuring the zones of inhibition. The experiment concluded that the efficacy of gentamicin showed a positive increase in inhibition when combined with garlic and ginger.

Traditional Chinese medicine is derived from the application of several therapeutic agents extracted from various plants that are grown in the wild and which are univer-

PUBLIC HEALTH Graph 1 Graph 2

sally used as spices considered fit for human consumption.

Plant extracts are also popular for their low toxicity and rare complications, compared with some medications. The lower number of adverse effects make them safer.

Garlic possesses a material called Allicin, which is a strong oxidizing component that disables the bacterial associated enzymes (that are necessary for infections to occur) by altering the membrane of the bacterium.

As for Ginger, the mechanism of action involves inhibition of enzymes essential for fatty acid metabolism.

References

1. Agu V, Jibo S, Adeshina G. 2012. Antibacterial Susceptibility Pattern of Pathogenic Bacteria Isolates from Vegetable Salad Sold in Restaurants in Zaria, Nigeria. Journal of Microbiology Research 2(2): 5-11 p.

2. Astrographics, 2005. E. Coli Bacterium. www.astrographics.com/GalleryPrintsIndex/G P2144.html. Accessed 2013 July 17.

3. Drugs, 2012. Common Side Effects, Allergies and Reactions to Antibiotics. www.drugs.com/ article/antibiotic-sideeffects-allergiesreactions.html. Accessed 2013 August 22.

4. Feldberg R, Chang S, Kotik A, Nadler M, Neuwirth Z, Sundstorm D, Thompson N. 1988. In Vitro Mechanism of Inhibition of Bacterial Cell Growth by Allicin. Antimicrobial agents and chemotherapy 32(12): 1763-1768.

5. Keen P, Montforts M. 2012. Antimicrobial Resistance in the Environment. Hoboken, New

Graphs 1 and 2 display the enhanced efficacy against s.epidermidis when plant extracts are combined with Gentamicin,.

Certain concentrations may double the zone of inhibition, which shows great potential. It is evident that garlic and ginger enhance the effect of Gentamicin, with their bacterial growth inhibition becoming stronger. An important extension of this study would be to investigate the molecular mechanism that allows Gentamicin to display a larger zone of inhibition. This would then indicate whether the combination of Gentamicin and garlic/ginger produces an

additive or synergistic combination.

Therefore, while it is important to recognize the importance of pharmaceutical therapy in specific diseases, it is important to stress the importance of a good diet as an additive to rather than a replacement for certain treatments. This is clearly illustrated when adding raw garlic and ginger to one’s diet regime when taking an anti-biotic.

Jersey: Wiley-Blackwell. 179 p.

6. Kim SO, Kundu JK, Shin YK. 2005. [6]-Gingerol inhibits COX-2 expression by blocking the activation of p38 MAP kinase and NF-kappaB in phorbol ester-stimulated mouse skin..

US National Library of Medicine National Institutes of HealthSearch database [Internet].

[2012 Mar 14, cited 2013 Oct 14] 24(15):255867. Available from: www.ncbi.nlm.nih.gov/ pubmed/15735738 7. Nievergelt A. 2011. In vitro immunopharmacological profiling of ginger (Zingiber officinale Roscoe).[Internet]. [Cited 2013 Sep 11].

Available from: https://e-collection.library. ethz.ch/eserv/eth:4650/eth-4650-01.pdf 8. Peter, K. 2004. Handbook of Herbs and Spices. Volume 2. Cambridge: Woodhead publishing. 33 p.

9. Sharma A, Bajpai V, Baek K. 2013. Determina-

tion of antibacterial mode of action of Allium sativum essential oil against foodborne Pathogens using Membrane permeability and surface characteristic parameters. J. Food Saf 33(2): 197-208 10. Sihota R, Tandon R. 2011. Parsons' Diseases of the Eye. Haryana: Elsevier BV. 148 p.

11. World Health Organization, 2004. Antimicrobial Resistance. www.who.int/mediacentre/ factsheets/fs194/en. Accessed 2013 October 27.

12. Ziarlarimi A, Irani M, Gharahveysi S, Rahmani Z. 2011. Investigation of antibacterial effects of garlic (Allium sativum), mint (Menthe spp.) and onion (Allium cepa) herbal extracts on Escherichia coli isolated from broiler chickens.

African Journal of Biotechnology 10(50): 10320-10322 p.

Abdullah Ghali is a second year Medical Student at the University of Texas Health Science Center in San Antonio.

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PUBLIC HEALTH

San Antonio medical students share their perspectives and experiences

By Matthew Hennessey, Alvin Boyd Newman-Caro, Kaleigh Longcrier, and Hans Bruntmyer, DO

Matthew Hennessey The medical field has a call to help those in need, but in a day and age where there is an increasing focus on the business of medicine, there can often be gaps in the system that leave certain populations wanting for care. Street Medicine aims to fill one of those gaps by going directly to the streets to treat a group that is often marginalized and undertreated, the unsheltered homeless population.

The field of Street Medicine is one that has grown out of the need to simply meet people where they are and lend a hand; but this type of care is more than going out and performing first aid. Above all, Street Medicine is about creating relationships with others, entering the patient’s world and interacting with them as equals. It’s not about 12

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asking “what can I do for you” it’s about asking, “what is your story.” It’s about going out into the patient’s world with no preconceived notions but with listening ears. There are many days spent on the street just talking to people, asking their name, listening to their story. Street medicine exists even on days when there are no medical needs but simply just conversations.

Alvin B. Newman-Caro Traditionally, medical education features a considerable emphasis, the first two years, on the science of medicine. This emphasis is understandable given the complexity of the human body and the increasingly complex means by which physicians seek to treat diseases. But the scientific regard for patients, emphasized over and over again in

the cases and vignettes with which students learn in those first two years, promote student’s conceptualization of patients as biologic puzzles rather than people. My experiences in Street Medicine-San Antonio have helped me to counter this dehumanizing habit of thinking. Through these experiences I have been able to remind myself of the calling that drew me to medicine – caring for persons who are suffering, rather than solving a biologic puzzle.

When I befriended a homeless gentleman who refused to seek medical treatment for his serious leg wound, I learned the importance of caring for a person holistically, as opposed to remedying something that is broken in the body. His leg was severely necrotized, likely due to a venomous spider bite and the wound was already infected. If

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he didn’t seek treatment immediately, he risked having to have his leg amputated, or die from sepsis. Although he allowed me to clean and bandage his wound, he refused to go to the hospital. However, that did not stop Street Medicine from visiting him weekly to check the status of his leg and reemphasize the paramount importance of receiving treatment at the hospital. Over time, the gentleman developed a trusting relationship with us and finally decided to go to the hospital.

When I asked him what finally motivated him to seek treatment, the man shared a humbling story with me. He was exploited by a local gang to test their newly synthesized drug products. All his life he was surrounded by bad people, manipulating him to do bad things for their benefit. It wasn’t

until he met Street Medicine volunteers that he finally had people tell him to do the right thing. All he had ever known were people that deceived and mistreated him.

It took him some time to understand that the people of Street Medicine are different.

We wholeheartedly cared about him, thought about him, prayed for him. When he realized this, he was inspired to seek treatment, as well as pursue a life absent of drugs with the ultimate goal of rising out of homelessness.

I no longer perceive health as simply the absence of disease. Health is intertwined with body and spirit. It was obvious that our friend was physically injured and required an immediate fix. However, it wasn’t until his spiritual wellness was cared for that he was able to be physically healed. Street

Medicine is an out-of-the-classroom learning experience that is highlighting this important aspect of medicine and provided me with eye-opening experiences that I will continue to build upon throughout my medical career.

Kaleigh Longcrier You can’t really understand what Street Medicine is like unless you get out and go yourself. As a student, Street Medicine has been an incredible opportunity to observe medical skills that I have not learned yet and practice the limited skills that I have learned thus far. As a future physician, I am learning valuable insight into the multidimensional entity that we call health. I’m learning that health and well-being are much more than numbers on lab tests but include intimate continued on page 14

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Her failing deep blue eyes were sunken into her face, highlighted by her dark, weather-worn, leather-like skin. She held my hand with a gentle yet intent grasp, looking into my heart, peering into my soul.

She began speaking to me, and, I couldn’t help but feeling that I was hearing from God.

“Never lose your sight” she told me.

The rest of her words seemed to flood over me – with one central message –

don’t stop seeing.

I squeezed her cold hands in assurance that I would not, and looked into her sweet blue eyes before I got up from the pile of her blankets and belongings and stepped out of her tent.

— Kaleigh Longcrier

details of our personal lives. I’m also learning about the importance of compassion and the impact that caring and believing in someone can have on their health. This experience is shaping me into the future physician I hope to be and the type of student and person I want to be, now. It reaches beyond my experience as a medical student and influences my interactions with people on a daily basis. It wouldn’t be exaggerating to say that it is life-changing.

Hans Bruntmyer, DO Most of us went into medicine to care for others; however, if you practice medicine long enough, you’re likely to get burned-out due to many factors. The way I found to regain my zeal for medicine was to care for those who have been marginalized by society. Being able to take the classroom to the streets and help future physicians learn empathy, compassion, and

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professionalism has been very rewarding.

As noted above, the impact has been real for our students. Matthew describes how asking our patients their story helps us, but more importantly this helps the patient know we care when the rest of society seems to have turned their backs on them.

As Boyd and Kaleigh mention, understanding that caring for a patient holistically can be ‘life-changing’, not just for the patient, but also for us, the providers.

When you actually hear the marginalized patient’s stories you see the daily struggle of trying to climb out of the ‘crab bucket’ and yet get pulled back down. You see firsthand the intense hold addiction and mental health issues have on a person’s life.

Is it worth going out on the street and caring for the ‘throw-aways’ of our community?

I believe we are all made in the Image of God and therefore should honor God by caring for the least of these… this work is ‘life-changing.’

Matthew Hennessey, Alvin Boyd NewmanCaro & Kaleigh Longcrier are osteopathic medical students at the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas.

Dr. Hans Bruntmyer is an assistant professor at the University of the Incarnate Word School of Osteopathic Medicine, the Director of Rural/Underserved Medicine and a member of the Bexar County Medical Society. His current medical practice consists of providing general health care at free mobile clinics for the marginalized in his community as well as street medicine for his homeless friends.

PUBLIC HEALTH

MY JOURNEY WITH ALZHEIMER’S

By Sherman Macdaniel

Most trips and vacations are planned in advance and in many cases some benefits are received prior to commencing. The thought of a change in climate, scenery, architecture, food, and activities brings one pleasure and possibly relief. Thinking about a pending trip may even be therapeutic. There are occasions when just the reverse prevails and the timing comes as a huge surprise. That was my introduction to experiencing Alzheimer’s disease as a caregiver and I was completely unprepared for my journey!

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dear wife of 57 years, Kendall, was diagnosed with dementia in 2009, after 53 years of the most enjoyable and pleasant years imaginable. A year later she was upgraded to Alzheimer’s disease by a neurologist. When she was diagnosed with Alzheimer’s, I was given very little information pertaining to the disease and virtually nothing as to what to expect as a caregiver. I had virtually no experience with the disease either in my family or that of my friends. I did not know what to expect going forward. Trial and error was the script, so to speak. After quite a few months, when things were getting worse, I purchased a copy of The 36 Hour Day. It contained hundreds of pages regarding the disease but few dealing with caregiver stress, none of which were helpful to me. The urologist spoke only briefly as to what laid ahead for Kendall and suggested we consider entering a drug trial, which we did. So, for the next eighteen months we saw both Kendall’s neurologist and the trial neurologist every 90 days. The oral evaluations were rather brief and in Kendall’s presence, I was asked “How are you doing Mr. Macdaniel?”

Not wanting to create a possible confrontation, my reply always was “OK”. Actually, I was anything but OK! Caring for Kendall had become the most stressful, frustrating, exasperating experience of my adult life. Boundaries that had worked for fifty plus years were no longer recognized. “Thank you” evaporated from her vocabulary. Traditional hugs and kisses became offensive to her.

She lost interest in her broad network of friends, choosing not to attend the several monthly lunch- bunch groups she previously enjoyed for many years prior. Leaving the house for an appointment became a battleground for confrontation. What to wear to an event outside of the house became an irreconcilable issue, sometimes resulting in not attending. When for years

we both supported occasional suggestions (sometimes constructive criticism), early on this became verboten! No longer could I suggest that she left her glasses on the kitchen table, when asked their whereabouts… she would often slam the door or throw a magazine stating, “You are no help.” The inability to predict patient behavior and responses overwhelms each and every caregiver, for which there is little preparation or resolution.

I carried forward that which worked well in earlier parenting years, not realizing that what was successful with my children was unexpectedly rejected by my dear spouse of fifty plus years!

Could it be that I was doing numerous things wrong in my care for Kendall? It took me a lengthy period of time to come to the realization that I was contributing to the stress which I found so unbearable! I had frequent telephone conversations with my very dear and oldest long term friend Merton Minter Jr. His wife Ann was diagnosed with Alzheimer’s over a year prior to Kendall and we had frequent phone conversations relating our experiences and the overwhelming stress we encountered caring for our wives… a new and unexpected phenomenon. We both began looking for something in print that addressed the matter and frequently complained that we were unable to find anything helpful. Our commiserating with one another was beneficial, but did little to actually reduce the incessant stress. It did permit us to each make some modest changes in our communication and behavior with our wives, which was helpful.

However, it was not until both of our wives passed away that we realized how much we contributed to the very burdensome stress that we had experienced.

After a number of phone conversations both Merton and I felt we owed our fellow caregivers a favor by identifying many of the mistakes we made, some of which were

repeated over long periods of time. One of the predominate reasons I became a stockbroker in 1968 was that the position did not require writing reports or lengthy guidelines. However, Merton commissioned me to begin the task of compiling our thoughts. It was frustratingly futile until I asked God to intervene and assist me. His response came surprisingly quick and for several months, I was awakened at night and told what to say and how to do so… hence Welcome Stranger, the only publication I know of that suggests the communication and behavior of the Alzheimer’s caregiver has an enormous influence on the patient and can actually contribute to a more tranquil patient and in so doing reduces caregiver stress.

Bexar County has an estimated 34,000 or more Alzheimer’s patients and over 100,000 unpaid caregivers. Those caregivers have a 63% higher mortality rate than non-caregivers, stark testimony as to the stress associated with the service. Additionally, 25% of those Alzheimer’s caregivers are ‘sandwich caregivers,’ caring for an Alzheimer’s patient and one or more persons 18 years of age or younger. It is estimated that an additional 1,000 persons in Bexar County will be diagnosed with Alzheimer’s disease in 2019, and more in the years ahead.

It is hoped this manual, Welcome Stranger, will be made available to physicians in Bexar county, enabling caregivers to receive help beginning at the time of diagnosis, or soon afterwards. Much has been written and documented about the array of changes the patient makes in their behavior over the course of the disease but virtually nothing has been written suggesting the caregiver(s) must also make commensurate changes in their communication and behavior in order to reduce stress and rejection.

Sherman Macdaniel is the grandson of an early BCMS president who served about 100 years ago.

visit us at www.bcms.org

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PUBLIC HEALTH

Fighting an Epidemic of Amputations in Bexar County Let’s Toe-and-Flow, San Antonio!

By Lyssa Ochoa, MD, Board-certified Vascular and Endovascular Surgeon; The San Antonio Vascular and Endovascular Clinic

ver 2,000 Bexar County residents will lose a limb to amputation due to diabetes and peripheral arterial disease this year alone. San Antonio has nationally-high rates of diabetes (13.3% of adults) and obesity (38.4% of adults) which are major contributors to this problem1.

Furthermore, San Antonio’s economics creates uniquely challenging barriers to preventing amputations related to diabetes and obesity. In fact, data from the Texas Department of State Health Services shows that the diabetic amputation rates are highest in zip codes that also rank highest in the Hardship Index, which aggregates six socioeconomic factors to identify relative difficulty in daily living.

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PUBLIC HEALTH form the necessary consultations and diagnostics on a same-day to next-day basis.

These circumstances indicate that we need a wide-reaching amputation prevention program that specifically targets areas with both the highest clinical need and strongest socioeconomic barriers. Thankfully, much of the groundwork for the clinical component has already been established. In a 2010 edition of the Journal of Vascular Surgery, the “Toe-and-Flow” model of collaborative amputation prevention was born3. The article stipulated that the amputation prevention team should include foot specialists and vascular surgeons at a minimum, along with infectious disease, general surgery, plastic surgery, diabetology, and primary care, to essentially wrap each at-risk patient in a proactive bubble of resources. Of course, this combination of resources and requisite collaboration is more practical in a major academic center than a lower-socioeconomic area encompassing over 200 square miles, but modifications can tackle both the logistics and the socioeconomics.

app to alert all other specialists on the team to the presentation, pictures and all. This simple action launches immediate collaboration toward amputation prevention. With a few descriptive texts, an entire plan of care arises. One benefit of communitybased practices is autonomy over clinical schedules. It is not unfathomable that a committed team of practitioners could per-

Transportation Patients that face the combined dilemma of clinical amputation risk and socioeconomic barriers frequently cite transportation as a primary barrier to care.

However, many private insurance plans and Medicare Advantage plans offer transportation as a benefit. Medicaid will soon provide transportation for all beneficiaries through all managed and traditional carriers. A little energy from office staff can go a long way to help patients acquire the “free” transportation included in their plan. Many of the transportation arrangements will include multiple stops if multiple offices must be visited in a single day.

Furthermore, non-profit organizations, such as Ride Connect Texas, offer transportation to those in need at no cost.

Eliminating the transportation barrier is a major step toward a community-based amputation prevention program.

Diagnosis and Availability of Care Diagnosis of the at-risk patient may occur in any practitioner’s office, ranging from ischemic changes of a toe to obviously infected, non-healing foot wounds.

Upon such suspicion, the practitioner can use a free HIPAA-compliant smartphone continued on page 20

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Intervention Designing the appropriate clinical intervention strategy for amputation prevention is truly a patient-by-patient endeavor. The breadth of the available toolbox is determined by the combined skill sets of the team taking care of each patient. Primary infection control is commonly obtained through surgical intervention by incision and drainage, debridement, or digital amputation. Diabetic foot infections may harbor treatment-resistant bacteria, requiring the infectious disease specialist to initiate appropriate infection control therapy and guide long-term, culturespecific antibiotic therapy. In many cases, arterial insufficiency is an underlying factor which could require revascularization ranging from distal arterial bypass to pedal artery angioplasty. Optimal wound healing may also require the wound specialist to administer hyperbaric oxygen therapy, requiring 5-dayper-week treatment for up to two months. A significant proportion of patients will have comorbidities involving any mix of heart disease, kidney disease, hyperlipidemia, and hypertension, adding additional layers of specialists that need to be consulted and informed along with a major juggling act by primary care physicians.

The interventional mix described above would be daunting to most people facing such issues, but even more so to those with limited resources of finances, time, transportation, and health education. How can a single, stay-at-home grandmother with an 8th grade education raising two grandchildren on a fixed income without a vehicle be expected to make all of the appointments requisite to amputation prevention, let alone understand each step of the way? This is where an emphasis on Social Determinants of Health by all members of the amputation prevention team can make the most significant impact. Coordinating resources in today’s smartphone-connected world is not as challenging as it may seem. Vascular and 20

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foot specialists, for example, can be scheduled to see patients inside a hyperbaric oxygen facility in conjunction with the wound specialist. An alternative could be that the patient’s transportation for the day be coordinated to visit multiple specialists at their independent facilities on a single day.

The Dream: Upstream Prevention All of us healthcare professionals understand that diabetic amputation prevention cannot begin at the presentation of a diabetic foot ulcer. Amputation prevention begins in childhood, with the establishment of healthy nutritional and exercise habits. Amputation prevention continues at every step through life, regardless of whether one is rich or poor, white or Hispanic, more educated or less educated. We cannot ignore, however, that risk factors for diabetic amputations have a tendency to creep into our lives with varying degrees of disproportionality. This opens a complicated Pandora’s box. What are the roles of government, educational systems, parenting, community resources, housing, transportation infrastructure, and safe environments? All of these and more undoubtedly have an impact on health outcomes, as described by countless studies of Social Determinants of Health. As a community of healthcare providers, we must optimize the care we provide to our patients, but we must also challenge ourselves to help our patients in ways that extend beyond the four walls of the exam room. Only then will we begin to

see diabetic amputation rates fall, along with improved health outcomes at every turn.

Together, We Can Make a Difference The collective challenges we face in San Antonio which lead to diabetic amputations may be unique to our city, but a wide range of possible solutions can be found by applying a little creativity to adapt existing models to our community. Collaborative amputation prevention can be the future of San Antonio by leveraging the well-established Toe-and-Flow model, and trading a bricks-and-mortar medical tower for a technology-enabled, passionate pool of community-oriented resources who are willing to tackle Social Determinants of Health with our patients. Achieving this vision would undoubtedly create a new model that may benefit cities throughout the United States, but it has to start somewhere. Let’s Toe-and-Flow, San Antonio!

Resources

1. Centers for Disease Control, 500 Cities: Local Data for Better Health, 2018; https://chronicdata.cdc.gov/500-Cities.

2. Economic Innovation Group, Distressed Communities Index Report, 2016; https://eig.org/ wp-content/uploads/2016/02/2016-DistressedCommunities-Index-Report.pdf.

3. Rogers, et al, Toe-and-Flow: Essential components and structure of the amputation prevention team, Journal of Vascular Surgery, September 2010; 3www.jvascsurg.org/article/ S0741-5214(10)01325-X/pdf.

PUBLIC HEALTH

LYME DISEASE: Diagnosis and Cure

By Alfred Miller, MD

here is a saying, “live and learn.”

I have practiced medicine for over fifty years. I have lived and I have learned. I had a private practice in Internal Medicine/Rheumatology from 1968-2008 in San Antonio, TX. While keeping a full schedule, I also taught Rheumatology at the UTSA Rheumatology Clinic one afternoon a week at the Robert B. Green Hospital, providing care to the underserved population.

Then my daughter-in-law in Boston became ill. Top hospitals in Boston and even the Mayo Clinic, where I trained, thought she had MS and then ALS. Her symptoms were varied, extreme, and debilitating.

There was no offered cure; she was given four months to live. Given no hope, I began to search for something, anything, to explain her symptoms. Because she had lived in Westchester, NY, and then in Boston,

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San Antonio Medicine • September 2019

Ma., I wondered if her diagnosis could be Borrelia Burgdorferi infection or, as it is commonly known, Lyme Disease. A Borrelia infection could produce the exact same clinical presentation. My daughter’s illness put me on a path of investigation and knowledge. Once properly tested, her diagnosis of Lyme disease was undeniably clear.

I am truly amazed by the results of objective testing to confirm the etiology of Neurodegenerative Diseases. For many years I erroneously excluded Borrelia infections by adhering to the standard testing method. The tests measure the antibodies in the patient's blood in response to exposure to the antigens on the spirochete. In the chronic infection, the spirochete becomes cystic and sequestered resulting in a muted or absent immune response.

Furthermore, many of the Neurodegenerative Diseases are considered “auto-im-

mune”, so the patients are treated with immunosuppressive medications prior to testing. These prevent the antibody response resulting in a negative test result. The standard Western Blot omits Outer Surface Protein “A” (Band #31) and Outer Surface Protein “B” (Band #34). These omissions are very unfortunate, forcing an invalid exclusion of Borrelia infection.

Intellectual honesty is the basis of all science.

I have encountered numerous patients who have been diagnosed with MS, ALS, Lewey Body Dementia, CIDP, Parkinson’s Disease, Alzheimer’s Disease, and other MND who are testing positive for Borrelia infection when properly tested. Prior to testing, the patient's immune system must be exposed to the spirochete in order to

PUBLIC HEALTH

produce antibodies.

I recommend 21 days of “Provocative Antibiotics� - i.e. Flagyl 500mg (to open the cyst allowing the antibiotic to penetrate) plus Zithromycin 500mg. Then after the completion of the provocative antibiotics, a Western Blot or Immunoblot containing Bands #31 & #34.

I have no connection with any labora-

tory; I have relied on a lab that is dedicated to tick borne diseases. All patients I have encountered (100%) have tested positive after the course of the provocative antibiotics. It is noteworthy that some of these patients have initially tested negative, then after the provocative antibiotics, the exact same tests become positive.

I have recommended these patients be treated with "pulse" antibiotics, i.e. three consecutive days on medications followed by four days off medications (additional information can be provided). Always included in the regimen is Flagyl or Tindamax in order to allow the antibiotic to penetrate the cyst; IV Rocephin 2gms BID for three consecutive days via a "butterfly IV" which is removed and reinserted the following week. So far, the results have been gratifying.

Recently, one patient was treated with this regimen for six months. Her illness be-

came stabilized, then liposuction harvested her mesenchymal Stem Cells. These Stem Cells were expanding in culture over an eight-week period, then the Stem Cells were injected back into this patient. The results, to date, have been remarkable! She had been very debilitated and is now walking and even using an Exercycle.

I am convinced the concept of "autoimmune" disease must be modified and an infectious etiology included in the Differential Diagnosis of all Neurodegenerative, Rheumatological, and Mental Illnesses.

By Dr. Alfred Miller, Retired Mayo Clinic trained physician. Private Practice Internal Medicine/Rheumatology 1968-2008. Full Professor, Clinical Faculty, University of Texas Medical School San Antonio, Texas, 1968-2008.

visit us at www.bcms.org

23

BCMS MIXER

BCMS POST-SESSION LEGISLATIVE MIXER A HUGE SUCCESS

By Mary E. Nava, BCMS Chief Government Affairs Officer Over 80 guests attended the BCMS 86th Session Legislative Wrap-up Mixer held on Tuesday, Aug. 13 at Peripheral Vascular Associates (PVA) Main Avenue Medical Plaza in downtown San Antonio. A special thank you to PVA President of the Board, Demetrios Macris, MD and the PVA leadership team for partnering with BCMS to host and sponsor the Mixer. The Mixer was done as a post-Session thank you to all our state legislators to honor them and thank them for their time and attention to medicine’s issues during the recent 86th Legislative Session. Attendees enjoyed visiting with several members of the Texas Legislature, along with legislative and congressional staff members. Elected officials and staff members in attendance were: Sen. Pete Flores, District 19; Rep. Philip Cortez, District 117; Rep. Leo Pacheco, District 118; Rep. Steve Allison, District 121; Cynthia Cabral, Communications Director, Office of Sen. Jose Menendez, District 26; Clarissa Rodriguez, Chief of Staff, Office of Rep. Cortez; JD Pedraza, Chief of Staff, Office of Rep. Barbara Gervin-Hawkins, District 120; James Rodriguez, Communications Director, Office of Rep. Ray Lopez, District 125 and MaryEllen Veliz, Deputy Chief of Staff and District Director, Office of Congressman Lloyd Doggett, TX Congressional District 35.

During the event, Alex Kenton, MD, BCMS Legislative and Socioeconomics Committee Chair, offered remarks to attendees and stressed the importance of working with all members of the Legislature on behalf of all patients. Additionally, Dr. Kenton announced an upcoming new program, in conjunction with the Texas Medical Association (TMA) and TMA Alliance, First Tuesdays in the District. In a similar fashion as our First Tuesdays at the Capitol, beginning Oct. 1, we plan to rollout a series of meetings and activities with each of our legislators, that will take place here in San Antonio, in the districts – as a way to continue our dialog during the interim. Other county medical societies from around the state will also be participating in this new initiative.

More details to follow in the coming weeks and months as meetings and activities are scheduled.

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

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San Antonio Medicine • September 2019

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BCMS MIXER

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1. From (l-r): UT Medicine medical student Frank Jing visits with BCMS members Rudy Molina, MD, BCMS Vice President of the Board; Sam Morale, MD and Brian Davis, MD during the BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza on Aug. 13.

2. Enjoying the Aug. 13 BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza were (standing l-r): Jesse Moss, Jr. MD, Darlene Metter, MD and Rep. Philip Cortez (District 117).

3. From (l-r): PVA staff Tammy Windsor, director of business development and Rebecca Martinez, director of communications, pause for a photo with Clarissa Rodriguez, chief of staff in the office of Rep. Philip Cortez and Rep. Cortez (District 117) during the BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza on Aug. 13.

4. Sen. Pete Flores (District 19), (center), pauses for a picture with Gerardo Ortega, MD (left) and Jesse Moss, Jr., MD on Aug. 13 during the BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza in downtown San Antonio.

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5. Alex Kenton, MD and Michael Battista, MD, (standing center l-r) chair and co-chair, respectively, of the BCMS Legislative and Socioeconomics Committee, visit with Sam Morale, MD and Cynthia Cabral, communications director in the office of Sen. Jose Menendez (District 26), during the BCMS 86th Legislative Session Wrap-Up Mixer held Aug. 13 at PVA Main Avenue Medical Plaza.

6. Alex Kenton, MD, chair of the BCMS Legislative and Socioeconomics Committee, provided remarks during the Aug. 13 BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza.

7. Members of the Texas Legislature and staff members were guests of honor during the Aug. 13 BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza. Standing l-r: Rep. Steve Allison (District 121) and James Rodriguez, Communications Director in the office of Rep. Ray Lopez (District 125).

8. PVA vascular tech, Brian Hembling, screens Jayesh Shah, MD, who took advantage of a free carotid artery screening offered during the Aug. 13 BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza.

9. UT Medicine medical students participate in the free carotid artery screenings offered during the BCMS 86th Legislative Session Wrap-Up Mixer held Aug. 13 at PVA Main Avenue Medical Plaza.

10. During the BCMS 86th Legislative Session Wrap-Up Mixer held Aug. 13 at PVA Main Avenue Medical Plaza, Cynthia Cabral, Communications Director in the office of Sen. Jose Menendez (District 26) pauses for a photo with John Nava, MD, chair of the BCMS Public Health and Patient Advocacy Committee.

11. On Aug. 13, during the BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza, Rep. Leo Pacheco ( District 118), (left), listens as PVA President of the Board, Demetrios Macris, MD and PVA physician, Gerardo Ortega, MD explain the role of PVA in the care of patients facing peripheral vascular disease.

12. Jesse Moss, Jr., MD (left) and Alex Kenton, MD (right), chair of the BCMS Legislative and Socioeconomics Committee, visit with Rep. Steve Allison (District 121) during the Aug. 13 BCMS 86th Legislative Session Wrap-Up Mixer held at PVA Main Avenue Medical Plaza.

visit us at www.bcms.org

25

SAMGMA

The Bexar County Medical Society & The San Antonio Medical Group Management Association Working Together to Improve Medical Practice Management

By Tom Tidwell, CMPE – SAMGMA President The Bexar County Medical Society and San Antonio Medical Group Management Association leadership meet quarterly to discuss issues that affect physicians and medical practice management.

Each quarter the senior staff of BCMS (Steve Fitzer, Melody Newsom, Mary Nava and Brissa Vela) meet with the current SAMGMA Board of Directors (Tom Tidwell, Randy Becker, Shameka Moore, Tom Duran and Tina Turnipseed). BCMS and SAMGMA have been working together for years to support our physicians with a common goal… ensuring their success!

Similar to the Bexar County Medical Society and the Texas Medical Association, SAMGMA is the local affiliate of Texas MGMA. SAMGMA currently has over 100 members locally and BCMS has over 5,000 members.

The SAMGMA Board of Directors appreciates the physician leadership at each practice for supporting their medical practice management team by allowing them to attend SAMGMA membership meetings and lunch connections, which typically provide a 1hour education program. And in February of each year, SAMGMA hosts a day-long practice management education conference to present “hot topics” in medical management.

If you haven’t heard about SAMGMA, please check us out at www.samgma.org and encourage your medical practice manager to become a member. Just as the physician’s professional association is important to them, SAMGMA provides educational and networking opportunities for our members.

If your medical practice manager isn’t getting their information from SAMGMA, it may be worth asking “where is he/she getting current information about successes and changes in medical practice management?”

We do need the help of physician leaders. We have missed many of our medical practice managers attending our meetings this past year. Please encourage your medical practice manager to attend all SAMGMA meetings, and to become active in their association.

Your practice managers need your support to protect your practice!

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San Antonio Medicine • September 2019

FEATURE

The Making of My

MD, MBA “Adult Ed is a Mother, but it’s also a Keeper!” … Dr. Lulu

By Uchenna Umeh, MD After my term as a Lt. Col in the United States Air Force, I had the opportunity to join the Air Force Reserves, go back to school, or work as a pediatrician. I chose school and work. I had no specific “why”, since I earned the VA educational funds, it was more like “why not?” My friends and family had mixed reactions. Never one to dwell on a thought, I jumped in before I lost my nerve.

Coincidentally, I was in great company since my son and spouse were both students as well.

I wondered how I would manage work, school and “mommying.” I initially wanted the combined MBA/MPH program, but fear and doubt discouraged me, so the MBA it was. I put my best Naija Igbo Woman foot forward and started the regular MBA. The first semester was a breeze (or was it?). I was going back to school in the tech age! What? Reminding me of when I first came to the USA, attending an American school was full of new experiences.

I was the oldest student in a class with millennials. What struck me was their attitudes towards the work. They showed up late and didn’t often do their portion of the schoolwork. This bothered me so much that, I considered disenrolling. Luckily my adviser suggested the Executive MBA program instead. Once I understood what an Executive MBA was, I was sold! However, some “friends” queried the “executiveness” of it… “Is it a watered-down MBA? “Is it an online/electronic E-MBA?” “Are you going to have a real MBA degree afterwards?” and, “Why are you going back to school, aren’t you tired?” Hmm…how does one respond to all that love?

Either way, I got in, and I was already enrolled in the school of business, I only needed an intradepartmental transfer.

My Executive MBA cohorts were people closer to my age – adults. We had a lot in common. They were experienced and wanted to do their schoolwork. My kind of people. We were dif-

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San Antonio Medicine • September 2019

ferent, yet similar. There were veterans, foreigners, parents, divorcees, and one other one Black person, a Nigerian like me!

Awon Naija sha!

The school system was a challenge for me. Folks call their professors by their first names. Huh? Not in Nigeria, tufiakwa! I graduated in the early ‘90s. We had real chalkboards, not smartboards. Our blackboards were not virtual, they were black and present in the classroom. I had no concept of office-hours or what it meant to access library books online, and to “check them out” virtually. Really?

As the only physician and one of only two blacks of the cohort, I had no one else wearing my exact shoes. I had to weather statistics alone. (I had biostatistics in med school, sensitivity and specificity – not Anova or Covariance Analysis). Since I hate numbers, accounting and finance and Excel were nightmares.

They made for many a tear-filled day at the professors’ offices.

Every now and again, I felt lonely and left out, but my resilience and adaptability would kick in and I would win little battles.

Macro economics was good, but not Micro. The professor works for the FED, he is a kindly older gentleman with a thick Texan accent and a friendly smile. I spent many afternoons in his office at the Federal Building downtown San Antonio. Corporate restructuring was okay until we got into the calculations. As a wordsmith, organizational behavior was great, ethics was a bit confusing. Marketing, negotiations, business strategy and international business studies were easy. Executive coaching, an elective, was with one cool Chica who once worked for NASA. She is equal part brains, beauty, class and control.

I LOVE reading and discussions, so my favorite subject was leadership. Our professor was cool and soft-spoken, the cases were interesting and thought-provoking. I enjoyed learning about

FEATURE

exemplary leaders and about my own flavor of leadership. The TEDx talk we each had to give at the end of the class was the cake-icing. Mine was on The Power of the Word “NO”.

The highlight of the program was our 12-day international trip to South East Asia. The 17-hour flights only fueled the excitement I felt in seeing Singapore and Vietnam. I can’t quite articulate Singapore. Its clean streets, ultramodern architecture, eclectic suburbs, fine dining, high-end shopping, educated minds, and multiracial indigenes all living harmoniously despite differences in religion, language, customs and cultures. A hard lesson for all African countries to learn (sadly). Singapore welcomed me with open arms. I even sang Karaoke with a local band at a pub.

Vietnam was different. More real, dirtier, noisier, almost “happier” than Singapore. We visited the Crocs factory, dined with locals in a traditional Vietnamese home, and took a canoe ride on the river to the coconut village, where our senses were mesmerized by aromas of coconut. Since I am a Tropical Chic, this, was home! I ended the trip by finishing the final edits of my first book – How to Raise Well-Rounded Children on the plane ride home. It’s available online.

I shall miss school. I am proud to say that I completed the

MBA and can now print out my new business card with all five letters in their proper order: MD, MBA. I earned it; albeit 30 years post MD. I am hopeful for the doors it will open to me. I had no “why.” I did it because I could, because the funds were available, or simply because.

I’d like to end with this; follow your heart, try something new, push yourself. What is holding you back from following and fulfilling your dreams? Remember, life is what happens while you are busy planning…so get off your phone, get off your couch and just do it!

My name is Uchenna Umeh, MD, MBA, and I approve this message.

Dr. Uchenna Umeh aka Dr. Lulu the Momatrician, is a BC Pediatrician with nearly 30 year clinical experience. She quit clinical medicine last year to follow a calling to speak on child, teen and young adult depression and suicide. Her first book is an Amazon Bestseller. She is also host of Dr. Lulu's Parenting Your Teen Workshop and Host of Suicide Pages with Dr. Lulu, the Podcast. She lives in San Antonio with her family.

visit us at www.bcms.org

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UT HEALTH

YOUTH-ONSET TYPE 2 DIABETES

IS DERAILING THE LIVES OF YOUNG ADULTS

By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio

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San Antonio Medicine • September 2019

UT HEALTH

Jane Lynch, M.D., a pediatric endocrinologist at UT Health San Antonio, is truly on the front lines of San Antonio’s alarming increase of Type 2 diabetes in children.

Since 2005, more than 1,000 youth under the age of 18 have been diagnosed with the disease in her clinic at the Texas Diabetes Institute on South Zarzamora Street. The youngest was only 5 years old at the time of diagnosis.

Type 2 diabetes was once known as adultonset diabetes because of its usual manifestation when people are in their 40s or 50s, and often after years of struggling with being overweight or obese, poor diet and a lack of exercise. Increasingly, however, physicians are seeing much younger patients affected by the disease.

Heeding the warning signs, Dr. Lynch and collaborators nationwide initiated a study in 2004 called TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth). The study enrolled and treated adolescents with youth-onset Type 2 diabetes until 2011.

The study’s comparison of metformin, rosiglitazone and lifestyle intervention yielded underwhelming results. All participants declined in pancreatic function with each passing year.

At the conclusion of the study in 2011, all participants were invited to remain for an observational phase. It has followed 517 participants who have had the disease for an average of 12 years.

At annual patient visits, information was gathered using laboratory testing, echocardiograms, vessel function testing and eye examinations. Researchers also collected each participant’s medical history to chart any diabetes-related events. These data were presented at the 2019 American Diabetes Association meetings in San Francisco.

The researchers found the development of diabetes-related complications in indi-

viduals with youth-onset disease is often much more rapid than it is in individuals who develop the disease later in life. Now in their 20s, the TODAY participants are experiencing life-changing health consequences caused by Type 2 diabetes at the earliest stages of adulthood: • Five deaths have occurred in this young adult population.

• More than 50% of participants have abnormal lipids.

• More than 60% have high blood pressure.

• About 40% of participants have evidence of early diabetic kidney disease.

• Almost 50% of participants have evidence of diabetic retinal disease.

• Up to 33% of participants demonstrate signs of early diabetic nerve disease.

• 25% of pregnancies with known outcomes resulted in miscarriage or fetal death.

• 24% of these pregnancies were preterm births.

The findings suggest health care professionals need to aggressively treat young patients battling Type 2 diabetes to minimize the damage from serious diabetes-related complications. This intensive management depends on coordinated care by teams of expert providers. It also requires families’ commitment to continue to seek care, even if their child’s disease has stabilized.

Additionally, more medications are needed for this disease in children. Until recently, metformin and insulin were the only therapies approved by the Food and Drug Administration for Type 2 in children. Encouragingly, data from an international study in which Dr. Lynch and her colleagues assisted, called Ellipse, led to FDA

approval in June of a new injectable drug, liraglutide, for Type 2 diabetes in youth as young as age 10.

That is a bit of good news in an otherwise difficult landscape for these children and their families. Still, families must cope with aggressive symptoms, few medication options and challenging compliance. This is the hard reality on the front lines of this devastating epidemic.

However, research is the key to a better tomorrow. Dr. Lynch is part of a cadre of diabetes experts at UT Health San Antonio that is conducting visionary research and incorporating the latest findings into preeminent patient care. Lives will be changed as a result.

Young people are our greatest resource.

We will fight this scourge with all our might to keep it from further harming the lives of our children.

William L. Henrich, MD, MACP, a nephrologist and professor of medicine, has been president of UT Health San Antonio since 2009.

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

visit us at www.bcms.org

31

USING HELMETS

USING HELMETS

to Limit Motorcycle Accident Fatalities from Head Trauma

By Ammar Navid Saigal, MPH

The difference between life and death for a motorcyclist can be as simple as wearing or not wearing a helmet. The Eastern Association for the Surgery of Trauma writes in its article Helmet Efficacy to Reduce Head Injury and Mortality in Motorcycle Crashes that more than half of motorcycle accident- related deaths are due to head injury. These deaths can be prevented to a significant degree by wearing a safety helmet that will lessen the direct physical impact to the cranium and brain of a rider involved in a collision.

The necessity of motorcycle safety protocol has long been recognized. Legislative action intended to curb the number of deaths resulting from motorcycle accidents in general has been effective in reducing the number of deaths and the corresponding financial costs to society (such as medical bills from trauma as well as damage incurred by other parties involved in the collision). In fact, such action has re-

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peatedly been shown to prevent injury and death in lieu of rising contrary attitudes of motorcyclists.

The link between use of safety helmets among motorcyclists and the reduction of deaths due to head trauma in the event of a motorcycle collision has been established and corroborated by numerous epidemiologic studies. During an investigation entitled: A Population-Based Study of Motorcycle Injury and Costs, the following was revealed as consequential to being involved in a motorcycle accident: • The highest rates of death occurred among men aged 20 to 24 years (Connecticut, 1992).

• Total costs to society exceeded $29 million.

• Not wearing a helmet increased the chance of dying 3.4 fold.

The study concludes that injuries related to motorcycle collisions increased morbidity, mortality, and medical costs. It estimates that a “uniform helmet law” could save ten lives each year and save the state $5.1 million annually. They describe their data as “crucial in advocating re-enactment of motorcycle helmet laws.”

One particularly alarming investigation followed the repeal of legislation enforcing the use of helmets among motorcyclists in the state of Michigan and examined the corresponding effects for riders within that state. Entitled Motorcycle Crash Helmet Use and Injuries Following Repeal of Michigan's Motorcycle Helmet Law, this study examined the effects of repealing Michigan's law requiring the use of safety helmets. Data on helmet use and injuries both before and after the repeal were compared. It was concluded that “Helmet use among crash-involved riders decreased significantly after the repeal (74% vs. 98%)

USING HELMETS

and the fatality rate among non-helmeted riders was 2.8-times higher. An estimated 26 fatalities and 49 serious injuries that could have been prevented by helmet use.�

This clearly illustrates the preventative effect that wearing helmets has on the fatality rate of motorcyclists involved in collisions in which they suffered head injuries.

In summary, although nobody can change the fact that head injuries are the

leading cause of death in motorcycle accidents or that the relative danger of being involved in a motorcycle accident is much greater than that of being involved in a car crash (all else equal), deaths from motorcycle-accident-related head trauma have been shown to be prevented by putting helmets on society’s motorcyclists. With such a clear link having been repeatedly established by logically-sound methodologies, it should be strongly requested of state governments to enforce legislation mandating the use of helmets among motorcyclists, much the same as seatbelt laws exist for the other automobiles.

References: 1. An Evidence-Based Review: Helmet Efficacy to Reduce Head Injury and Mortality in Motorcycle Crashes: EAST Practice Management Guidelines

MacLeod, Jana B. A. MD; DiGiacomo, J. Christopher MD; Tinkoff, Glen MD, FACS, FCCM Journal of Trauma and Acute Care Surgery: November 2010 Volume 69 - Issue 5 - p 1101-1111 doi: 10.1097/TA.0b013e3181f8a9cc Clinical Management Update.

2. Ann Emerg Med. 1992 Mar;21(3):273-8.

A population-based study of motorcycle injury and costs. Braddock M1, Schwartz R, Lapidus G, Banco L, Jacobs L. 3. Am J Public Health. 2017 Jan;107(1):166172. Epub 2016 Nov 17. The Impact of Michigan's Partial Repeal of the Universal Motorcycle Helmet Law on Helmet Use, Fatalities, and Head Injuries. Carter PM1, Buckley L1, Flannagan CA1, Cicchino JB1, Hemmila M1, Bowman PJ1, Almani F1, Bingham CR1.

visit us at www.bcms.org

33

BUSINESS

Network Diagnostics: Cyber Security for Medical Businesses

By Maria Martinez, CLU, ChFC

In 2016, a hospital in California was the victim of a ransomware attack. Hackers shut down the internal computer system at Hollywood Presbyterian Medical Center for over a week, encrypting protected patient files, emails, billing, and other sensitive data.

The hackers were demanding $3.7 million in ransom before they would relinquish control of the information obtained from the hospital’s server. Tim Erlin, a spokesperson from the hospital, said that the attack “seriously degraded their ability to deliver care.”

Attacks like this are becoming increasingly common, and medical businesses are a big target. Cyber attacks can derail business operations, cost companies thousands of dollars, and damage brand images.

Cyber attacks and data breaches have become a recurring trend in today’s society, and the most valuable currency is customer data.

In the medical business world of sensitive medical records and HIPPA-protected patient files, virtually all patient and company data is prized by hackers and worth protecting for your practice.

As breaches become more common and destructive, organizations are still perplexed about coverage and, ultimately, uncertain about cyber insurance being a necessity. In this era of increasing regulation and public awareness of data security risks, you don’t

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San Antonio Medicine • September 2019

want to risk critical information falling into the wrong hands. Every practice should consider their exposure level in the event that sensitive data is compromised, but for the medical business community, cyber security needs to be a top priority.

Data Breaches Data is everywhere. We store it in our internal business systems and in the cloud. We collect it from our clients and share our data with business partners. Leaders need data, value it, and are able to amass it. We carry data with us and leave a digital footprint every day. Technology providers help us store it forever and share it globally. In the data breach era, leaders face greater risk if they fail to protect data throughout its lifecycle.

Email is an easy access point and hackers can deploy massive attacks by sending out blanket emails waiting for a bite – giving them access to your practice’s sensitive information – or worse, your patient’s personal information. Medical practices are more susceptible to cyber attacks because many of their employees have access to patient information and medical records. These employees constantly work over email sharing company data, and often times aren’t properly trained on how to recognize or re-

BUSINESS

spond to these types of incidents.

Data breaches can be expensive and are difficult to avoid. In a recent study, more than 50% of small to mid-sized businesses surveyed stated they faced a cyber-security attack, and the average cost of a data breach has increased to a staggering $5.9 million!

As data breach consequences grow, leaders must understand their data security risk. Companies face increased scrutiny from regulators, litigants, business partners, and their customers so leaders must make timely data security decisions. A data security strategy helps leaders make risk-informed decisions before their actions are reviewed after a breach.

Why Small & Mid-Sized Practices Are at Risk We hear about large-scale cyber incidents on the news all the time, but cyber criminals are focusing more and more of their efforts on small and mid-sized businesses. According to Chubb, 62% of all cyber breach victims are small and midsize enterprises (SME’s). Experts expect that this trend will continue to rise.

One reason that cyber criminals are increasingly hitting SME’s is that many smaller operations do not have dedicated cyber security teams, and mistakenly believe that the expense of onboarding a

cyber security expert is beyond their budget. This opens such businesses up to be an easy target for cyber criminals.

According to Patrick Theilen, SVP at Chubb, “Cyber criminals typically don’t target specific small businesses, but they increasingly use tools that target the vulnerabilities of small businesses.

Those vulnerabilities are sometimes technical, like unpatched software or poorly configured hardware. Even more commonly, those vulnerabilities are simply employees who may use weak or compromised passwords, or may inadvertently click something they shouldn’t have.”

All medical businesses face their own types of cyber risks, and while they may not be completely avoidable, having a prevention plan, educating your employees, and proper cyber liability insurance coverage can protect your practice from the financial and operational dangers of a cyber security breach.

Maria Martinez, CLU, ChFC is a cyber security specialist with SWBC and a Circle of Friends member. She can be contacted at (210) 376-3478 or maria.martinez@swbc.com.

visit us at www.bcms.org

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

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

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

ACCOUNTING SOFTWARE

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

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

ATTORNEYS

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

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

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San Antonio Medicine • September 2019

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

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

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

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

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

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

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

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

ASSETS ADVISORS/ PRIVATE BANKING

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

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

BANKING

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DIAGNOSTIC IMAGING

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

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

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

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

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

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

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

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

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

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

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

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

FINANCIAL SERVICES

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

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

achieve more in life.

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

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

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

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

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

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

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

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

continued on page 38

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

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

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

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

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

HEALTHCARE BANKING

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

Jeanne Bennett EVP | Private Banking Manager 210 343 4556

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San Antonio Medicine • September 2019

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

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

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

HEALTHCARE CONSULTING

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

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

Digital Telehealth Solutions (HHH Gold Sponsor)

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

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

HOSPITALS/ HEALTHCARE SERVICES

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

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

INFORMATION AND TECHNOLOGIES

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

Rana Camargo

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

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

INSURANCE

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

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

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

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

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

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

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

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

INSURANCE/MEDICAL MALPRACTICE

INTERNET TELECOMMUNICATIONS

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

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

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

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

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

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

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

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

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

LUXURY REAL ESTATE

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

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

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

MARKETING ADVERTISING SEO

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

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

MEDICAL BILLING AND COLLECTIONS SERVICES

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems William J. Trijullo Medical Services Representative 210-800-5500 wtrujillo@acumen.systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a checkup?

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

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

MEDICAL PRACTICE

UT Health Physicians (HHH Gold Sponsor) UT Health Physicians, the faculty

practice of UT Health San Antonio, features the region's most comprehensive array of specialists & sub-specialists. Now offering free, secure access to your patients’ records. Most health plans accepted.

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

MEDICAL SUPPLIES AND EQUIPMENT

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

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

MORTGAGE

PrimeLending (HHH Gold Sponsor) Doctor Loans, Construction Loans, VA Loans, Conventional and FHA Loans.

Cleo Garza Sr. Loan Officer NMLS#218858 210-483-4907 cleo.garza@primelending.com www.lo.primelending.com/cleo.garza Home Loans Made Simple

PRACTICE SUPPORT SERVICES

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Debbie Marino SWBC Employee Benefits, SVP Corporate Relations (210) 210-525-1248 DMarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems William J. Trijullo Medical Services Representative 210-800-5500 wtrujillo@acumen.systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a checkup?

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

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San Antonio Medicine • September 2019

“Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

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

REAL ESTATE SERVICES COMMERCIAL

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

RESIDENTIAL REAL ESTATE

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

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

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

RETIREMENT PLANNING

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

Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Ben Taylor Wealth Management Advisor 210-278-3802 ben_taylor@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

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

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

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive

provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Donna Bakeman Office Manager 210-301-4362 dbakeman@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELECOMMUNICATIONS ANSWERING SERVICE

TAS United Answering Service ( Gold Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7.

Dan Kilday Account Representative 210-258-5700 dkilday@tasunited.com www.tasunited.com “We are the answer!"

For questions regarding services, Circle of Friends sponsors or joining our program please contact August Trevino, Program Director at 210-301-4366, August.Trevino@bcms.org, bcms.org/COF.html

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

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

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

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

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

GUNN AUTO GROUP

11001 IH 10 W at Huebner San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Esther Luna 210-690-0700

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Ford 12300 San Pedro San Antonio, TX

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

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Marty Martinez 210-525-9800

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

David Espinoza 210-912-5087

Rick Cavender 210-681-3399

Gary Holdgraf 210-862-9769

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Subaru 9807 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

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

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

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Sandy Small 210-341-8841

James Cole 800-611-0176

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

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

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

AUTO REVIEW

2019 Volkswagen Atlas

By Stephen Schutz, MD

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San Antonio Medicine • September 2019

AUTO REVIEW In 2013, the Chairman of Volkswagen AG’s Supervisory Board, Ferdinand Piech, famously stated, “We understand Europe, we understand China and we understand Brazil, but we only understand the U.S. to a certain degree so far.” My interpretation of that statement at the time was that Dr. Piech was extremely frustrated that VW’s then-CEO Martin Winterkorn had missed the market shift in this country from sedans to SUVs and crossovers.

Someone at VW obviously listened, because six years later Volkswagen’s U.S. sales are rising quickly thanks to SUVs and crossovers.

I recently tested Volkswagen’s biggest and most important SUV, the Atlas, and concluded that the world’s second largest automaker (after Toyota) seems to understand our market a lot better than they did in 2013.

A direct competitor to the huge selling Toyota Highlander, Honda Pilot, and Ford Explorer, the Volkswagen Atlas is a midsize SUV that features a base price of around $32,000, three rows of seats, and plenty of space for the stuff American families need to lug around just driving to soccer practice.

The exterior design of the Atlas is pretty vanilla – as are the Highlander, Pilot, and Explorer designs – but appealing. Kind of clunky and chunky with a distinct Volkswagen flavor is my take, and for moms and dads anxious to be driving something other than minivans that’s probably a good thing.

Inside, things get more interesting thanks to Volkswagen’s unadorned but perfectly good infotainment system. There’s little in the way of flashy graphics that dazzle during the test drive but become annoying when you have to live with the car, and everything you need is where it’s supposed to be. The SatNav functions by punching in an address or saying your destination out loud using the voice recognition system, and working the audio system or HVAC is similarly easy: you either use the touchscreen or go with the buttons and knobs on the center stack. Thank you Volkswagen for making things so easy and low stress.

While the usability of the Atlas’ tech is excellent, the plastics and other materials in the cabin are not quite up to Highlander/Pilot standards, something to keep in mind.

Atlas pricing starts at just over $30,000 and can climb up to almost $50,000 if you check all the boxes, which is in line with the competition.

There are seven trim levels you can choose including, deep breath: S, SE, SE with Technology, SE with Technology R-Line, SEL, SEL R-Line and SEL Premium. The base S comes with a 235 horsepower turbocharged four-cylinder engine, while all other trim levels come with a 276HP 3.6-liter V6. My tester came with

the base engine, which struggled to move the 4528 lbs Atlas when I needed to hustle, so I’d recommend the V6. Front-wheel drive is standard, and V6 models can be ordered with all-wheel drive (AWD is standard on the SEL Premium).

All Atlases come with eight-speed automatic transmissions. Fuel economy figures are 20 MPG City/26 MPG Highway for the four cylinder engine and 18/25 MPG for the V6.

Atlas S models have cloth seating, a bench seat in the second row, and automatic headlights. Forward collision mitigation, blindspot monitoring, and rear cross-traffic alert are now standard across the line, as are Apple CarPlay and Android Auto. Upgrading to the SE adds keyless go, a power driver's seat, heated front seats, three-zone automatic climate control, a larger 8-inch touchscreen interface, and the option of captain's chairs in the second row. The SE with Technology adds remote engine start, power rear hatch, adaptive cruise control, lane keeping assist, and active blind-spot monitor. Selecting the SEL gets you a panoramic sunroof, LED taillights, heated steering wheel, hands-free rear hatch, and Volkswagen Digital Cockpit. Digital Cockpit is basically VW’s version of Audi’s (excellent) Virtual Cockpit, a configurable screen that replaces the standard gauge cluster.

As noted above, both the SE with Technology and the SEL are available with the R-Line upgrade, which adds 20-inch wheels, a few exterior tweaks, and some unique interior trim. An SEL Premium with even more doo-dads is also available.

Driving the Atlas is slightly more involving than its Japanese and American competitors, but this is not a big boxy GTI (or Tiguan for that matter). Hey, you’ve got a family now, so face reality if you haven’t already – your vehicles are all about your kids and their friends, not you. Got it? Good.

The Volkswagen Atlas is an excellent vehicle aimed at the heart of the most important automotive market niche in this country: the mid-size three-rows-of-seats family SUV. Given how good the Atlas is, I’d say that VW now understands what American customers want quite well. I suspect that somewhere in Germany Ferdinand Piech is smiling.

To get your best deal on a new Volkswagen, call Phil Hornbeak at BCMS at 210-301-4367.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 45 45 visit us us at at www.bcms.org

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San Antonio Medicine • September 2019