San Antonio Medicine October 2020

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ELDER CARE

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Elder Care

The Cariños Approach: Integrating Comprehensive Care of Older Adults into Your Primary Care Practice By Neela K. Patel, MD, MPH, CMD and Angelica E. Davila, MD, MS ...........................................12 The Psychological Impact of COVID-19 on the Elderly By Nikoleta Golemi ...........................................16 Elder Care During the Pandemic

By Miguel Ayala, MD .....................................................18 Through the ICU Darkly: Transparency and the Texas Advance Directives Act

By John J. LoCurto, JD.................................................20

BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10 Parents – Talk to Your Teens About Vaping Before School Starts By Lindy Upton McGee, MD ...............................22 The Space of Indifference By Marvin Forland, MD, MACP ......................................................................................24 Diagnosis and Treatment of Peripheral Arterial Disease: A Word of Caution

By Boulos Toursarkissian, MD, FACS, RVT, RPVI, and Jorge Alvarez, MD, FACC, FCSAI.....................................26 Thyroid and Hormonal Health By Arti Thangudu, MD..............................................................................................28 The Business of Medicine: How to Dispose of Storage Devices Containing PHI and Other Sensitive Date

By Laura Hale Brockway, ELS .............................................................................................................................30 Art in Medicine: JFK By Jonathan Espenan ............................................................................................................31 Artificial Intelligence and Informed Consent By Laura M. Cascella, MA ..................................................................32 BCMS Circle of Friends Physicians Purchasing Directory........................................................................................34 Auto Review: 2021 Mercedes E350 By Steve Schutz.............................................................................................38 Recommended Auto Dealers .................................................................................................................................40 PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com

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San Antonio Medicine • October 2020

OCTOBER 2020

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VOLUME 73 NO. 10

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

DIRECTORS Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member Danielle Hilliard Henkes, Alliance Representative David Anthony Hnatow, MD, Member Lyssa N. Ochoa, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones, Jr., MD, Member John Milton Shepherd, MD, Member Richard Edward Hannigan, MD, Board of Ethics Co-chair Nora Lee Walker, MD, Board of Ethics Co-chair Charles Gregory Mahakian, MD, Military Representative George Rick Evans, Legal Counsel Jayesh B. Shah, MD, TMA Trustee

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San Antonio Medicine • October 2020

Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Stephen C. Fitzer, CEO/Executive Director (ex-officio)

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

PUBLICATIONS COMMITTEE Kristy Yvonne Kosub, MD, Chair John Joseph Seidenfeld, MD, Vice Chair Louis Doucette, Consultant Charles Hirose Hyman, MD, Member Tzy-Shiuan B. Kuo, MD, Member Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member David Schulz, Community Member Alexis A. Wiesenthal, MD, Member Tyler Adams, Student Member Chinwe Anyanwu, Student Member Darren M. Donahue, Student Member Donald Bryan Egan, Student Member Christopher Hsu, Student Member Aishwarya Devesh Kothare, Student Member Anirudh Madabhushi, Student Member Anjali Surya Prasad, Student Member Teresa Samson, Student Member Cara Jillian Schachter, Student Member Stephen C. Fitzer, Editor

PRESIDENT’S MESSAGE

Physician Leadership in Elder Care

By Gerald Q. Greenfield Jr., MD, 2020 BCMS President

Advances in medical care have ushered in a new era of increased longevity and longer quality of life. Physicians, both clinicians and researchers, have a major leadership role in laying the groundwork for a future of increased lifetimes. These areas include direct patient care, development and adjustment of medications, development of new surgical techniques and the development of new instruments and appliances. but they also include leading in attitude, empathy and respect.

The changes in lifestyle and economic demands in America have now forced the separation of what was earlier an extended family.

In this extended family, members of the younger generation cared for and protected older family members. Now younger family members are working outside of the household; especially the female members who in the past provided ongoing care for the elderly members. This has forced older members to go to facilities such as elder daycare or to a nursing home or extended care facility.

There they receive a level of care which does not approach that level of care and concern which would otherwise be provided by members of their own family. As younger family members move out of the household, their parents, now "empty-nesters", may relocate to senior living communities. Sometimes these are in the same community as their younger family members. but they may be quite distant. This change in American society may force older family members to leave the homes and communities in which they have lived for many years in order to relocate close to a grown child or other family member.

The recent pandemic of COvId-19 threatens both life expectancy and quality of life for all members of our society. However, older members of our society are much more frequently and severely impacted by the virus. Indeed, the coronavirus poses an especially difficult situation to the nursing home population where the infection is difficult to control and is frequently deadly. In addition to the physical stresses posed by the virus, forced family separations impose a new mental stress for our elderly population.

The politicization of the response to the coronavirus pandemic has led to an increased infection rate in all members of our society.

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San Antonio Medicine • October 2020

While the hospitalization mortality rate for younger patients is low, that of the elderly population is high and poses a severe risk to life. There are, nevertheless, patients over 100 years of age who have survived coronavirus infection. What some might consider to be minor cautions or changes in behavior can have significant impacts on the health and longevity of all of the members of our society. This is especially important to older members of our society. Often their physiologic reserve will not allow them to survive even a minor infectious insult.

As physicians, our society depends on us to provide accurate and timely information on health care. We must have the intestinal fortitude to speak truth to power; and in doing so, improve the health and the lives of the population. This is our moral, ethical and fiduciary responsibility. It is only with a healthy populace and the continued prospect of a long and fulfilling life that a society can regain the economic power on which its survival relies.

Gen. douglas MacArthur once said, "Old soldiers never die they just fade away." As physicians, we must strive to preserve the health and dignity of all members of our society whether they are soldiers or not. We cannot allow our seniors to languish in a swamp of poor health and neglect. They deserve both the possibility and the probability of a secure and healthy future. We, the health professionals, must care for our elderly as aggressively and as ethically as possible. All of us hope someday to be one of them. Just as they hope to remain healthy for as long as they live, we to must lay the groundwork so that we may have that same hope.

Gerald Greenfield, MD, is an Orthopedic Surgeon in Bexar County and is the 2020 President of the Bexar County Medical Society.

BCMS ALLIANCE

The Party of Medicine

By Jenny Shepherd I found a new hero the afternoon I heard San Antonio Alliance member June bratcher speak for the first time. dissatisfied with how her state representative, a trial lawyer, was leading she concluded that it was time for a change. “I didn’t feel like he was responding to the community that he lived in, which included a large number of physicians, so I decided that maybe it was time that we got a new representative,” Ms. bratcher said. She launched a grassroots campaign, rallied the medical community and got to work. While her chosen candidate did not get elected in that race, it was just the beginning for June who not only did remarkable work in San Antonio but led the way for physician spouses to become leaders in the political advocacy arena.

First Tuesdays and First Tuesdays in the district, both alliance-initiated programs, have been instrumental in bringing the needs of medicine to the attention of legislators, but the question still loomed for me: Why are only 337 bexar County physician families involved in advocacy and members of TexPac? One answer came in the form of my husband John’s operating room conversations that began with “let me tell you about the cool thing my wife is doing” and ended with “She’d love for you to get involved too; we’ll have to have you over.” As he began telling others about my advocacy experiences, it became apparent that many physicians and their spouses had no idea of the importance of advocacy, of the necessity for telling our stories. For those who did understand the importance, there was often uncertainty if they had a place in the process or how to be involved. It was in those conversations, those moments of expressed interest that the Party of Medicine was born. John and I honored all those extended invitations and hosted the first Party of Medicine in our home, sharing our stories of why we advocate, our top ten reasons why every physician and spouse should join us in the legislative fight for medicine and dispelled the myth of party politics in medical advocacy: we fight for only one party and that party is medicine.

For me, what began with June’s inspiration to become involved ended up in the creation of an award-winning peer-to-peer advo-

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cacy recruiting program being used by alliances not only across the state of Texas, but throughout the country. Our alliance and the Party of Medicine has been awarded the legislative Education and Awareness Promotion (lEAP) award given by the American Medical Association Alliance in recognition of innovative ideas in advocacy in addition to the TMAA Mary Ann Homer legislative & Political Action Award.

It’s an election year and never before have party lines been so apparent or the need to stand up for science and medicine been so necessary. Advocacy isn’t about politics though: It’s about being the voice of what’s right for medicine, for patients and for public health. So, as we begin this legislative session, I urge you to find your own inspiration for advocacy and get involved. Form a legislative relationship. Serve on an alliance or society committee. Talk with a legislator during First Tuesdays in the district.

Renew your TexPac membership. And while you’re at it, ask a friend to come along as you join us at the Party of Medicine.

Jenny Shepherd serves as the 2018-22 VP of Legislative Affairs for Texas Medical Association Alliance. She was President of Bexar County Medical Society Alliance in 2018.

ELDER CARE

The CARIÑOS Approach

*

Integrating Comprehensive Care of Older Adults into Your Primary Care Practice

By Neela K. Patel, MD, MPH, CMD and Angelica E. Davila, MD, MS

The UT Health San Antonio Geriatrics and Supportive Care Practice is an academic, interprofessional team of geriatric and palliative care primary care clinicians, pharmacists, care managers and other health care members. The group cares for over 3,000 patients ≥ 65 years of age and younger complex patients (e.g., AlS patients, down’s syndrome, multiple sclerosis, early onset dementia) in an NCQA-recognized, Patient-Centered Medical Home (PCMH) and geriatric care medical neighborhood. like most other primary care practices, the patient’s are frail with multiple comorbidities, social concerns, increased acute and post acute care needs.

This team developed the CARIÑOS (Compassion, Advocacy and Respect Intended to Nurture Older Adults with Supportive Care) Approach as: • patient-driven (i.e., practice that provides care that facilitates collaboration of patients and clinicians, when clinicians are considered colleagues and advisors)1, • comprehensive, • coordinated, and • multi-site to optimize primary health care delivery to older 12

San Antonio Medicine • October 2020

adults in South Texas.

Our approach focuses on quality and safety and integrates the care of complex older adults in multiple clinical settings. The patients’ medical home, the ambulatory clinic, systematically connects to the geriatric care medical neighborhood of specialists, emergency departments, hospitals, post-acute rehabilitation facilities, long-term care facilities, home health, hospice services, durable medical equipment agencies, the local Alzheimer’s Association, senior centers, social services including transportation assistance, adult protective services and area agency for aging to provide continuity of care and meet the patients’ healthcare needs.

The CARIÑOS Approach (see Figure 1) represents a highly complex set of related activities that can occur alone or be integrated to meet the patients’ needs. This approach avoids “silos” of care and facilitates shifting to patient-centered-care that results in value-basedcare and improved outcomes.

The clinic, the heart of this approach, is where all the coordination and relationship building with the patients and the health team occurs. Relationship building and continuity of patient care is intentional and continuous. It starts each clinic day during the morning

ELDER CARE FIGURE 1

huddle when the entire clinic team meets to discuss work flows for the day; caregiver support updates, patients who visited the Ed or were admitted to the hospital; discussing after-hours calls and follow-up needs; coordinating care with consultants; post-acute and long-term care calls, home health, dME, hospice, and any other social needs.2 This daily communication is the basis of the CARIÑOS approach.

The UT Geriatrics and Supportive Care team has made many changes throughout the years to build this model and believe that even a few changes in a primary care practice can begin the journey to a more patient-centered, comprehensive model. Some options to adapt and implement in your practice include: 1. Ambulatory Practice • Schedule longer appointment times: 30 minutes for follow-up and transitional care management visits and 60 minutes for new patients.

• Accommodate patients who sometimes come later or earlier than their appointment times or walk-in for acute visits.

• Have lvNs and/or RNs triage phone calls to assess for same-

• • •

• • • •

day visits, transitional care management, chronic care management and follow-up.

Manage your patient panels with an Md/NP dyad: Have a mechanism to schedule appointments that alternate between the physician and NP/PA to maintain continuity and oversight.

Have the lvNs schedule more frequent nurse visits for frail elders to manage blood pressure and INR checks.

Invest in a pharmacist: Make a Pharmd an integral part of your team to assist with deprescribing, reducing polypharmacy and to help control patients at high risk for uncontrolled blood pressure and uncontrolled diabetes and in transitional care management.

Urgent Care & Emergency departments: Collaborate and partner with one health system in your local area where most patients go after hours.

Give each facility a list of the names of your team’s clinicians (e.g., Mds, NPs, PAs). designate one team member as a point of contact during office hours.

Identify your practice’s after-hours point of contact as the person on call. continued on page 14

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ELDER CARE continued from page 13

2. Acute Care Hospitals • Collaborate with hospital partners where your patients generally get admitted and tell your patients the preferred hospital(s) to go to because you collaborate with the hospitalists there.

• develop a relationship with one hospitalist service and have your patients admitted to that service.

• Clarify expectations in the relationship: be notified of admissions on the day of admission and have a process to get daily updates, discharge, handoff and follow-up information.

• Assign a care manager from your practice or a NP to round in the hospital where your patients are admitted or attend the interdisciplinary team rounds of the hospitalist group(s) to get updates on your patients.

• Ensure your ambulatory practice calls the patient within 24 hours of patient discharge to coordinate care and follow up.

*Cariños is Spanish for fondness, affection, tenderness, and love.

The CARIÑOS* Approach is characterized by: • Comprehensive, coordinated, compassionate care across various clinical settings that meets the older adults’ needs beyond the office walls.

• Advocating for patients and families by collaborating and maintaining relationships with other clinicians and health care partners.

• Respecting what matters most to your older patients (e.g., meals, mobility, 3. Post-Acute Care Facilities money, and medicines5).

• Collaborate with select acute rehabilitation or skilled facilities for • Intentional activities and processes in your practice that are specific to meet your patients who need rehabilithe needs of older adults. tation.

• Nurtured relationships with families, social service agencies, and commu• Use the same hospitalist group if they also go to the post-acute fanity partners. cility to enable continuity of care.

• Older adults are wise and know what they want: Listen to what they say.

If this is impossible, identify a group of post-acute doctors and • Supportive Care for focus on quality of life establish a relationship with them so you can coordinate better care • Record each agency’s office hours to drop-off documents for of your patient. Have the physician inform you when your pasigning and get updates on patients they are serving. tients are admitted, handed off or discharged.

4. Home Health & Hospice Services • Partner with select home health and hospice agencies based on feedback on their quality and service from patients you have referred. Having a few collaborating agencies streamlines and extends your culture of care and makes them an extension of your geriatric care medical neighborhood. Institute a process to communicate and provide access to their services for timely and prompt patient care.

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5. Durable Medical Equipment (DME) and Supplies • Partner with dME companies and supplies to allow your patients to obtain the dME (e.g., walkers, wheel chairs, beds, 3 in 1 commode) they need in a timely manner. Partner with agencies that are more proactive and have a system that meets CMS guidelines with an eye to limit back-and-forth paperwork to lower your documentation burden.

ELDER CARE 6. Area Agency for Aging • Have a member of your team develop a relationship with the local area agency on aging to keep your practice informed about the resources available for your older adult patients.

• They are able to connect your patients to all or any services that they may need.

7. Alzheimer’s Association • Most patients with dementia and related disorders are seen and managed in primary care offices that partner with the Alzheimer’s Association.

• Have some of your office staff trained to lead caregiver support groups.

• designate a team member to know the resources available to assist your patients and families with such needs.

8. Social Services • Identify the local transportation services available for older adults who do not drive.

• designate one team member to contact Meals on Wheels.

• Identify a Senior Center in each ZIP Code and know the services they offer.

• Identify local professional caregiver services and personal care homes based on your patients’ experiences and feedback.

• Identify local caregiver support services.

• designate one person from your practice to maintain the contact information for Adult Protective Services in case your patients need their services for neglect or abuse.

9. Consultants • Maintain a list of consultants in the different specialties (e.g., cardiology, nephrology) your patients may need if you belong to an independent private practice group, based on the relationship you have with them and feedback from your patients.

Make the list available to your patients.

• Educate your patients about the value of having all their healthcare team members within one system if you work for a health care system or an academic practice.

The CARIÑOS Approach to care for older adults offers these benefits: • Encourages your patients and families to express their needs; • Helps coordinate your patients’ care across different clinical settings and the various services they use now and in the future; • Makes your care patient-driven, and • Enhances patient outcomes and satisfaction.

home health agencies that most of your patients use and rate highly.

Continue to examine the most important needs and building the community relationships to help provide improved patient centered care. Always remember that your clinic and the patient form the heart of the approach. Form a patient and family advisory council (PFAC)4 of your older adult patients and engage its members to help develop a patient-driven CARIÑOS Approach adapted to your practice. Finally, strive to continue improving your process since the CARIÑOS Approach is a journey, not a destination, in meeting your older patients’ health care needs.

Neela K Patel, MD, MPH, CMD is the Joe R. and Tereza Lozano Long Chair in Community Geriatrics and Senior Care, leads the Division of Geriatrics & Supportive Care where she supervises care across all clinical settings and is a member of the Bexar County Medical Society.

Angelica E. Davila, MD, MS is the Medical Director of the Division of Geriatrics & Supportive Care’s outpatient practice and is a member of the Bexar County Medical Society.

Acknowledgements Patients and families, staff, clinicians, our partners in the continuum of care, our department and UT Health leadership.

References 1 Norquist G. Patient-driven research will lead to better health.

Health Affairs blog, May 19, 2016. dOI: 10.1377/hblog 20160519.054923 2 Patel NK, Jaén CR, Stange KC, et al (2015). Patient-centered medical home: a journey not a destination. In Malone Ml, Capezuti E, Palmer RM (Eds), Geriatrics Models of Care (pp 156162). Switzerland: Springer International Publishing.

3 Epstein RM, Mauksch l, Carroll J, Jaén CR. Have you really addressed your patient's concerns? Fam Pract Manag. 2008 Mar;15(3):35-40.

4 Sharma A, Angel l, bui Q. Patient Advisory Councils: Giving patients a seat at the table. Fam Pract Manag. 2015 Jul-Aug;22(4)-7.

5 Fulmer T. discovering the 4 Ms: a framework for creating agefriendly health systems. The John A. Hartford Foundation blog, August 2018.

Consider how you can adapt and implement this approach in your practice. First, start by focusing on one issue that will address your older patients’ most pressing needs and priorities. For example, if home health is their most important need, building relationships with visit us at www.bcms.org

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ELDER CARE

The Psychological Impact of COVID-19 on the

Elderly

By Nikoleta Golemi

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San Antonio Medicine • October 2020

ELDER CARE

Senior citizens make up one of the most at-risk populations for developing complications from COvId-19. The CdC states that 8 out of 10 COvId-19 deaths reported in the U.S. have been among people aged 65 and older. This scary statistic can be attributed to several factors, including an increased number of comorbidities among older adults and the impact of aging on the immune system.

Further evidence is that the virus has had detrimental effects on nursing home residents and staff members across the country. The rapid spread of COvId-19 in nursing homes has shut down entire facilities and left family members scrambling to find at-home care for their loved ones. This information is terrifying for elderly individuals, a high-risk population.

The psychological impact of COvId-19 on the elderly can be easily overlooked even though it is a serious issue. To prevent the spread of the virus, precautions have been implemented such as limiting interactions with others and self-quarantining. While beneficial and important to maintain, these preventative measures can be very isolating, leading to feelings of loneliness and depression. Poor mental health can cause widespread health problems, such as increased blood pressure, heart disease and a decline in cognitive function.

(Wu, 2020).

The CdC suggests that even before the pandemic, older adults were an at-risk group for developing depression and feelings of loneliness because they have a higher likelihood of living alone, often have lost family members or friends, or are battling chronic illness.

Elderly immigrants are at an even higher risk of social isolation. The National Academies of Sciences, Engineering, and Medicine [NASEM] notes that latino immigrants have “fewer social ties and lower social integration levels than US-born latinos.� Monitoring of immigrant populations for arising mental health issues becomes increasingly important for them as the pandemic continues.

To combat social isolation and depression, older adults are encouraged during the epidemic to socialize from afar and participate in virtual social activities. Unfortunately, this requires the elderly to navigate technology, which can be very challenging. We have all experienced frustrations with technology in our everyday lives, but a generation of individuals who are not as well-accustomed to video conferencing or the use of social applications on mobile devices can become even more frustrated and discouraged.

These same difficulties of using technology apply for accessing virtual physician checkups. According to a recent study, in 2018, adults aged 65 and older in the United States were not ready for video visits, primarily due to inexperience with technology. So, where do the elderly who do not have access to or knowledge of computers or technology end up? Older adults who find themselves in that sit-

uation often must find other ways to manage the mental health effects provoked by COvId-19. Strategizing on how to overcome social isolation and depression, or even recognizing the symptoms by themselves, can be daunting for elderly patients.

This is where healthcare providers can play an essential role in identifying older adults who may be experiencing isolation. The CdC reports that adults aged 50 and older interact with the healthcare system at some point, with patients who are dealing with chronic diseases requiring multiple doctor visits. during these visits, clinicians can evaluate patients for symptoms of depression, anxiety, or social isolation. The NASEM suggests asking about the strength of an individual’s relationships, living arrangements and psychosocial functioning. If in-person clinic visits are not optimal, then perhaps a phone call to the patient can still help determine if they face social isolation or need assistance with daily living.

COvId-19 provides many challenges and hazards to the elderly.

As new issues arise, we must be able to adapt to assist them in our community. Even when socially distanced, we all need to continue to care for one another.

Nikoleta Golemi received a Bachelor of Science in Biochemistry from Texas Wesleyan University and is currently an Osteopathic Medical Student at UIWSOM and a member of the Bexar County Medical Society.

Works Cited: Older Adults and COvId-19. (n.d.). Retrieved August 27, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/need-extraprecautions/older-adults.html Wu, b. Social isolation and loneliness among older adults in the context of COvId-19: a global challenge. glob health res policy 5, 27 (2020). https://doi.org/10.1186/s41256-020-00154-3 loneliness and Social Isolation linked to Serious Health Conditions. (2020, May 26).

Retrieved August 27, 2020, from https://www.cdc.gov/aging/publications/features/lonely-olderadults.html National Academies of Sciences, Engineering, and Medicine.

2020. Social Isolation and loneliness in Older Adults: Opportunities for the Health Care System. Washington, dC: The National Academies Press. https://doi.org/10.17226/25663 lam, K., lu, A. d., Shi, Y., & Covinsky, K. E. (2020, August 3).

Assessing Telemedicine Unreadiness Among Older Adults in the United States during the COvId-19 Pandemic. Retrieved August 27, 2020, from https://jamanetwork-com.uiwtx.idm.oclc.org/journals/jamainternalmedicine/fullarticle/2768772?resultClick=1.

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ELDER CARE

Elder Care During the Pandemic

By Miguel Ayala, MD during this seemingly endless pandemic, it has become a challenge to continue delivering the care to our elderly patients. Some of it has been related to our inexperience with telehealth services, but also linked to the challenges our patients may have that impact their ability to seek medical care. Speaking with a colleague, he was sharing the sad case of one elderly patient that lost his leg due to not seeking care early for a wound in his foot. His patient told him he was afraid of getting out of the house and becoming infected with the COvId-19 virus. Many cases like this happen all over our city, and we need to find a way to prevent it.

We as physicians are all working to implement telehealth services in our clinics, and such will be the case as we continue using this type of visit to reach out to many of our patients, especially the elderly ones. It’s essential we continue reaching out to them and making sure they have medication refills, appropriate access to food, proper housing and transportation. Many of these social determinants of health can be addressed by the staff at our offices, but as clinicians, we also need to be aware of them since they will impact the outcome of any intervention we recommend.

In our clinic, we have implemented procedures and processes that have helped us improve the delivery and coordination of care for our elderly and most vulnerable population.

Below are some of them: • Staff are asked to identify our patients that haven't been seen for 3-6 months and make sure an appointment is scheduled for a routine visit or, at minimum, address the patient’s chronic conditions.

• Primary insurance companies we use have been asked to provide us with a list of our elderly patients with chronic conditions; conditions like COPd, Asthma, type 2 diabetes, or other chronic conditions that place our patients at risk. Insurances also are using risk stratification models to identify those patients as well.

• Personal Protective Equipment (PPE) is used in our offices following CdC and San Antonio Metro Health guidance, and chairs in our waiting room are appropriately spaced.

• Social media platforms are used to make our patients aware of our availability and to show that our offices are following all 18

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• •

• •

•

•

adequate protocols for their safety.

Resources provided by insurance companies, like social workers, disease management, and complex care are made available to patients.

Essential vital signs equipment like a thermometer, pulse oximeter and blood pressure meter are recommended for each of our elderly patients and/or their families to have at home so our medical office can obtain this essential information during a telehealth visit. Many insurances are providing this equipment at no cost to the patients.

No-show appointments are quickly rescheduled when one of our patients doesn’t show up for a scheduled appointment.

Hospital portals are continually monitored to identify those patients that are either admitted or going to the ER for any reason. Those patients are then scheduled at our clinics within seven days to prevent readmission and to perform reconciliation of medications.

Palliative care and Hospice services are contacted and worked with for Home Health and other ancillary services as we identify those elderly patients who are at high risk for complications and have chronic conditions that need to be monitored closely even though they are unable to come to the office for care.

Preventative tests, like breast and colon cancer screening and immunizations like flu and pneumonia vaccines are proactively suggested and scheduled for our elderly patients that are in need of such tests.

Our elderly patients, along with other most vulnerable patients, need us now more than ever; but we can't do it alone. We need the help of the patient's family, our office staff, community resources and ancillary services like home health, social services, etc., to provide the essential health care services to these patients. This pandemic doesn’t have an expiration date and we will need to continue working with resilience, compassion and energy because, as physicians, we have always been there for our patients. This time will not be an exception!

Dr. Miguel Ayala, MD is an internal medicine physician with the South Alamo Medical Group and is a member of the Bexar County Medical Society.

ELDER CARE

Through the ICU Darkly:

Transparency and the Texas Advance Directives Act

By John J. LoCurto, JD

Conflicts arise when a physician deems life-sustaining interventions futile, but a patient or surrogate presses for treatment to continue. The Texas Advance directives Act uses a procedural approach to resolve these disputes. The Act’s multi-step scheme is nationally recognized, yet the public knows little about how it works. The Texas legislature should fix this by requiring hospitals to report how they use the Act’s dispute resolution mechanism.

The Texas Advance directives Act (TAdA) creates a statutory framework for end-of-life decisions. It empowers Texans to (1) give instructions for their care should they experience critical illness or injury, including whether to forgo life-sustaining medical treatment (lSMT), and (2) execute a medical power of attorney appointing an agent to make decisions when they cannot.

TAdA makes positive contributions to advance care planning. but the law is better known for its “futility” provision, which applies when “an attending physician refuses to honor a patient’s advance directive or a health care or treatment decision made by or on behalf of a patient . . .” This provision establishes a process for handling disputes arising when a physician concludes lSMT is medically inappropriate and should be withheld or withdrawn but a patient or surrogate objects and demands lSMT (below).

TAdA’s critics maintain the law grants hospitals absolute and unilateral power over life and death. Their rhetoric is overheated.

TAdA endeavors: to resolve challenging end-of-life conflicts in a balanced way; mitigate the moral injury that futile care inflicts on health care workers; and conserve resources that futile care would otherwise consume. Still, the law does have some shortcomings.

One is lack of transparency.

TAdA periodically flares into the headlines when an emotionally wrenching case spills from the privacy of a hospital room into the glare of a courtroom. The public often learns about futility cases from media coverage. TAdA does not require hospitals to keep or report information about how they use the law’s futility mechanism. Thus, neither regulators nor the public has data showing: • how often physicians attempt to override advance directives or treatment decisions; • how many disputes the parties resolve by agreement and how many reach committee review; • how frequently committees affirm versus overrule physician decisions; • the number of patient transfers and involuntary terminations of lSMT under TAdA; • who is affected by TAdA; • where the law is invoked, and which facilities trigger it most/least.

Comprehensive data would provide insight and foster accountability. data would reveal how TAdA works and could inform development of protocols to avoid and deescalate futility disputes. data would allow us to evaluate whether committee review is a real safeguard or a formality that gives TAdA the sheen of due process. And data might

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ELDER CARE

reveal whether the law is applied disproportionately; for example, against people of color, older persons, patients lacking health insurance, or other disadvantaged groups.

If we had baseline data, we could compare how hospitals ordinarily use TAdA to usage in specific contexts, like the ongoing pandemic. A spike in futility cases during COvId-19 could indicate that de facto rationing is occurring. Overwhelmed physicians and hospitals may be quicker to deem lSMT medically inappropriate for current patients, thereby freeing ventilators, ICU beds, and staff for COvId-19 patients. A trend like this would warrant scrutiny to ensure futility determinations are fair, equitable, and based on sound medicine rather than rationing or bias.

The Texas legislature should enact a reporting requirement and delegate authority to the Texas Health and Human Services Commission to develop, with industry and public input, a rule governing the form, frequency, and metrics for reporting deidentified data. The data should be publicly posted and subject to regulatory oversight. Reporting would illuminate when, how often, and for whom physicians and hospitals use TAdA to terminate lSMT. Transparency leads to accountability, which is essential given the stakes.

John J. LoCurto, JD is Assistant Professor of Medical Jurisprudence and Health Policy at the UIW School of Osteopathic Medicine.

References Texas Health & Safety Code §§ 166.001 to 166.209.

Id. § 166.046(a).

See Pope, T.M. (2016). Texas Advance directives Act: Nearly A Model dispute Resolution Mechanism for Intractable Medical Futility Conflicts. QUT law Review, 16(1), 22-53.

Tinslee lewis’s case is emblematic. born with life-limiting

heart defects, she requires mechanical ventilation, artificially administered nutrition and hydration, sedation, and serial surgeries. Her physician deemed lSMT futile and invoked TAdA on September 27, 2019. The case is still pending in court and the media. T.l. v. Cook Children’s Medical Center, 2020 Wl 4260417 (Ct. App.—Ft. Worth July 24, 2020); Mitchell, M. (July 24, 2020). A Fort Worth Appeals Court Grants A Terminally Ill baby a New Trial, An Extended life. Fort Worth StarTelegram.

Retrieved August 18, 2020, from https://www.star-telegram.com/news/local/fort-worth/article244479422.html. limited historic data exists. See Pope, supra note 3, at 42-43.

This is no idle concern. See Schmidt, H. (April 15, 2020).

The Way We Ration ventilators is biased. The New York Times. Retrieved August 16, 2020, from https://www.nytimes.com/2020/04/15/opinion/covid-ventilator-rationingblacks.html.

Resource allocation is fraught because of the tendency to portray rationing as medical futility. It is easier to tell a family that a loved one will not receive treatment because it is futile than it is to say the hospital will not provide care because ventilators and ICU beds are scarce or other patients have priority because they are more likely to survive. I express no position on rationing, other than it should be discussed openly and not blurred into medical futility. See Young, M.J., et al. (2012). Rationing in the Intensive Care Unit: To disclose or disguise?

Critical Care Medicine, 40(1), 261-66.

Rationing could disproportionately impact older patients.

Italy, for example, responded to COvId-19 by acknowledging that “[a]n age limit for the admission to the ICU” and exclusion of “frail elderly” may be necessary. Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments, in Exceptional, Resource-limited Circumstances at pp. 3, 5. (March 16, 2020). Retrieved August 16, 2020, from https://vtethicsnetwork.org/wp-content/uploads/2020/03/SIAARTICovid-19-Clinical-Ethics-Recommendations.pdf. visit us at www.bcms.org

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SAN ANTONIO MEDICINE

Parents – Talk to Your Teens About Vaping Before School Starts

By Lindy Upton McGee, MD

As a pediatrician-mother of two teenagers, I am adding new topics to my “back to school” conversations with my kids and patients this year: wear masks, social distance, do not ignore any symptoms of illness. In this conversation, I will also be stressing how critically important it is not to vape or use e-cigarettes.

When in-person school ended abruptly last year, we know that 27.5 percent of high school and 10.5 percent of middle school students reported using e-cigarettes in the past 30 days. We do not have any data to know what happened with e-cigarette use after that. Public health experts are hopeful that time spent at home meant time spent away from e-cigarettes, but when school starts again the pressure to vape will be there. Now is the perfect time for parents to intervene to turn this tide.

There are several great resources to help parents have this talk with their teens. The American lung Association (AlA) has a handout “The vape Talk” to help educate parents and guide them through the conversation. The Centers for disease Control and Prevention (CdC) also has a good “Tip Sheet for Parents." both of these guides provide useful advice, including how to get started.

Approach the conversation in a non-confrontational way. Congratulate your teen if they have not been vaping so far, but listen with understanding if they have. discuss why you are concerned about e-cigarettes, mentioning that almost all e-cigarettes solutions contain nicotine, which is highly addictive in teens and has been tied to impulsivity and mood disorders, as well as long term effects on attention, learning, and memory. There is no safe level of nicotine exposure for teens. Educate your teen that contents of an e-cigarette solution are known causes of lung disease, cardiovascular disease, immune suppression, and cancer. After your talk, continue the conversation by pointing out all of the ways the tobacco industry is spending millions to target young adults to addict a new generation to their product. draw attention to social media advertising, flavors designed to appeal to kids and paid endorsements. Encourage your kids to rebel against these attempts at manipulation.

There is also emerging evidence that e-cigarette users are at greater risk for COvId-19 diagnosis and symptoms. Teens who vape may reduce their immunity and put themselves at risk of severe COvId-19 disease due to known effects of vaping on the lungs, heart and the overall immune system. vaping also produces an aerosol, which is a perfect way to spread the virus.

Make sure that you communicate to your teens that not only should they not vape, they should also avoid being around anyone who is vaping.

E-cigarette use in adolescents is a public health catastrophe that cannot be ignored. One silver lining of this horrible pandemic may be that it has, at least temporarily, put the brakes on this vaping crisis that was speeding out of control. let’s not lose the opportunity to reverse course and lead our teens to a healthier future.

Lindy Upton McGee, MD is a member of Texas Pediatric Society, Texas Medical Association, and Associate Professor of Pediatrics at Baylor College of Medicine and Pediatrician at Texas Children’s Hospital.

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SAN ANTONIO MEDICINE

THE SPACE OF

Indifference

By Marvin Forland, MD, MACP

I have long been fond of aphorisms – highly condensed distillations of wit, wisdom, or experience, encapsulated in readily recalled form. Considering aphorisms as a teaching aide, or ancillary to one’s moral compass, I recall a metaphor from Mother Teresa: “I alone cannot change the world. but I can cast a stone across the waters to create many ripples.” I see aphorisms as pebbles, tossed in our pond of thought, generating sequences of ripples, widening and deepening our range of consideration.

In these recent months of contemporarily unprecedented universal engagement in seeking protection from and combating a potentially life-threatening onslaught, a simple aphorism frequently roars, rather than ripples, through my mind.

“The absence of love is not hate, but indifference.”

Where to begin? In our daily activities, to see the resistance to the simple gesture of wearing a face mask as possible protection for those one may encounter. In feckless and mendacious national leadership unable to articulate a simple message of compassion. In industries with multibillion-dollar reserves sequestering federal assistance programs while the struggling retailer attempts to keep fulfilling our daily needs. More recently and blatantly, a police officer’s sustained neck hold, and another’s pistol firing.

The fragility of the basic foundations of our democratic society has been revealed as we witness employee-based health insurance provisions disappear with the frightful levels of unemployment.

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This is coupled with the ideological resistance of our state legislators to take advantage of available Federal health support programs. We have become aware of the consequences of the decades-long growth in the disparity in work-related remuneration between the management level and lower and lowest rungs of employees. “Food insecurity” is the polite term in realizing our neighbors or colleagues have been exhausting their weekly pay-checks without monetary reserve, nor able to avoid the threat of housing eviction.

This cycle of poverty, abetted by racial inequities, is equally reflected in what is now further revealed about our criminal justice system and access to quality education.

Why have we not been more fully engaged individually or collectively in addressing these issues in our decades of relative prosperity and seeming equanimity? Each of us has been guided by our individual moral intuition – a complex, long-studied blend of nature and nurture. A relevant, positive response manifest through our resultant values, and guiding our degree and nature of engagement, has been characterized by a variety of terms – empathy, compassion, sympathy, caring, beneficence, etc.

In specifically considering these issues in the last fifteen-plus years of my long career as a medical educator, I have witnessed what cognitive psychologist Steven Pinker states has been a recent “empathy craze.” Consulting my local University library, I confront a list of 115 relevant book titles.

However, Columnist david brooks, in the New York Times, warns us “Empathy makes you more aware of other people’s suffering, but it’s not clear it actually motivates you to take moral action,

SAN ANTONIO MEDICINE or prevents you from taking immoral action.” Neurophilosopher Patricia Churchland is afraid it may lead to incapacitation: ”We falter under empathy fatigue.” Citing his own and other’s work, CUNY’s eminent moral philosopher Jesse Prinz summarizes, “These studies suggest that empathy is not a major player when it comes to moral intuition. Its contribution is negligible in children, modest in adults, and nonexistent when costs are significant.”

We turn to sympathy, only to be warned it may be a form of personal detachment. Compassion may be too individually directed, resulting in lessened ability to consider community issues. do I give up my search for the common quality to calibrate my moral compass, to emulate and inspire the virtue of Aristotle, which he characterized as compassion, to define everyday operational values? Hardly – but I find a way to emphasize engagement by parsing the lyrics of a Johnny Mercer 1940’s tune.

Rather than “accentuate the positive(s)”, we must gain engagement by “eliminating the negative. Yes – indifference is the opposite of love and the major distractor.

Nobel Peace Prize winner Elie Wiesel, as chronicler of the Holocaust and a moral guardian, is often the referent in love/hate/indifference considerations. This is based on his powerful framing of the relationship in an interview published in US News and World Report, december, 1986: “The opposite of love is not hate, it’s indifference. The opposite of beauty is not ugliness, it’s indifference. The opposite of faith is not heresy, it’s indifference. And the opposite of life is not death, it’s indifference. because of indifference, one dies before one actually dies. To be in the window and watch people being sent to concentration camps or being attacked in the street and do nothing, that’s being dead.”

Scholars of aphoristic expression have traced the apparent earliest published version of this insight to dr. Wilhelm Stekel, a Ukraineborn, Austrian psychologist, who was one of the earliest followers of Sigmund Freud. Indeed, he has been described as “Freud’s most distinguished pupil.” Freud himself acknowledged Stekel as teaching him a “truer estimate of the extent and importance of symbolism in dreams.”

Stekel’s conclusion was based on extensive reflections on his early applications of Freud’s psychoanalytic techniques. In a publication translated into English by Rosalie Gabler in 1921, “The beloved Ego: Foundation of the New Study of the Psyche”, Stekel wrote: “The opposite of love is not hate, but indifference; the absence of feeling can only be the absence of feeling. disinclination, which is coloured by feeling, often serves the purpose of concealing and protecting oneself against an inclination.”

Stekel and Freud had a falling-out in 1912, with Freud writing an associate “ Sketel is going his own way.” He died in london in 1940,

with an autobiography published posthumously in 1950.

An earlier aphoristic version, slightly differently worded, appears in George bernard Shaw’s 1897 play, The devil’s disciple: “The worse sin toward our fellow creatures is not to hate them, but to be indifferent to them: That’s the essence of inhumanity.”

Eudora Welty, in her distinguished mid-twentieth century short stories and novels, well-characterized our concern. She wrote “I knew this, anyway: that my wish, indeed my continuing passion would be not to point the finger in judgment but to part the curtain, that invisible shadow that falls between people, the veil of indifference to each other’s presence, each other’s wonder, each other’s human plight.”

More contemporaneous, in 1961 psychologist Rollo May wrote in love and Will “Hate is not the opposite of love; apathy is.” John leCarre, in 1968, noted in A Small Town in Germany: “The opposite of love isn’t hate; it’s apathy.”

John Updike, in a short story, Trust Me, sensitively described a father adjusting his young daughter’s displaced dental brace with a mouth-nose plier: “The gaiety in his voice revealed a crucial space, a gap between their situations: it would be his blunder but her pain. Another’s pain is not our own. Religion, he supposed, seeks to close this gap, but each generation’s torturers keep it open. Without it, compassion would crush us: the space of indifference is where we breathe.”

In his essay, later play and film, ”The Odd Couple” Alan bennett describes his fifteen year relationship with a homeless woman living in a van parked in his alleyway, - noting “…by unfeeling we are saved.”

As we ponder which resources we must muster so that we as individuals, members of society and citizens of a nation, can close the “space of indifference’, I choose the words of Rabbi Abraham Joshua Heschel, who walked through the South with his arm linked to dr. Martin luther King’s, and authored the magisterial volume, The Prophets:

“…morally speaking, there is no limit to the concern one must feel for the suffering of human beings, that indifference to evil is worse than evil itself, that in a free society, some are guilty, but all are responsible.”

Marvin Forland, MD, MACP, is a Professor Emeritus at the UTHSC in 1999. Dr. Forland helped found the Center for Medical Humanities and Ethics in 2002, and continues to the present in an advisory position. Dr. Forland is a Lifetime Member of the Bexar County Medical Society.

visit us at www.bcms.org

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SAN ANTONIO MEDICINE

Diagnosis and Treatment of Peripheral Arterial Disease: A Word of Caution

By Boulos Toursarkissian, MD, FACS, RVT, RPVI, and Jorge Alvarez, MD, FACC, FCSAI Peripheral vascular or arterial disease (PAd) is very common in San Antonio and South Texas. This is in part due to the high prevalence of diabetes, a well-known risk factor for PAd. PAd can cause significant morbidity, including claudication, rest pain and ulceration, which can in some cases lead to limb loss. There has therefore been a significant push to identify patients with PAd; a worthwhile endeavor. However, that same effort can lead to misuse of some of the treatment modalities for PAd. It is important to identify patients with asymptomatic or symptomatic PAd so that appropriate treatment modalities can be initiated to prevent disease progression. This consists of lifestyle 26

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modifications and non-invasive medical measures. lifestyle changes consist of smoking cessation and a regular walking program. Medical measures include antiplatelet agents such as aspirin, adequate glucose control for diabetic patients, anti-hypertensive therapies and, if possible, the use of statins.

All of these measures have been proven in numerous large studies to be of benefit in reducing mortality and/or morbidity in patients with PAd. It is also prudent to have all patients with PAd appropriately screened for associated silent cardiac and cerebrovascular disease. Cardiac comorbidity is the number one cause of early mortality in patients with PAd (not PAd itself), while associated

SAN ANTONIO MEDICINE cerebrovascular disease can cause significant morbidity in terms of stroke. PAd patients should therefore seek care from medical providers willing to treat all associated problems or make the appropriate referrals. All these measures combined will stabilize a patient and may forestall the need for any invasive peripheral procedure for quite a while.

Identifying patients with PAd should not automatically lead to invasive interventions, no matter how “minimally” invasive such interventions might be. It has never been proven that subjecting patients with asymptomatic or minimally symptomatic PAd to peripheral revascularization procedures achieves any useful goal such as limb salvage or sustainable quality of life improvements; neither does prophylactic revascularization prevent further deterioration of the PAd. Quite to the contrary, unnecessary interventions can lead to a malignant cycle of restenosis and deterioration of peripheral runoff vessels which can increase the risk of limb loss.

Sadly, many stakeholders seeking increased volumes of interventions may choose to ignore these time-proven realities.

There are accepted indications for revascularization in PAd patients. These include significant claudication, ischemic rest pain, lower extremity ulcerations or gangrene. Unfortunately, for an unfamiliar or overeager practitioner, some of these indications may be misinterpreted. For instance, many diabetic patients have associated peripheral neuropathy manifested by sensory disturbances, which can be erroneously mislabeled as vascular rest pain. Treating PAd has once again never been proven to reverse neuropathy. Another confusion may arise with arthritic complaints, a common morbidity seen in elderly patients who make up a large segment of the PAd population. back issues can also be a cause of lower extremity discomforts at rest or with exercise and this should not automatically lead to a diagnosis of vascular rest pain. diagnosing PAd is not a straight-forward process. In addition to clinical acumen, it requires appropriate testing. In this same context, it is important to decry the overreliance seen today in many places on pure imaging modalities, as opposed to physiologic testing. For instance, a reliance on duplex ultrasound alone will lead to unnecessary procedures. An elderly diabetic patient will often have some sort of abnormality on duplex imaging that has no relationship whatsoever to his or her arthritic foot complaints. duplex ultrasound velocities alone and CT angio or MRA are anatomic tests.

They detect lesions, but don’t say much about the physiologic significance of those lesions. Appropriate physiologic tests such as ankle brachial index, toe brachial index or transcutaneous oxygen measurements are needed for true understanding of a lesion’s significance. For instance, a toe pressure of 90 mm Hg in a diabetic patient with foot tingling will readily tell that the symptoms are not PAd related, regardless of what a duplex may show.

In summary, early diagnosis of PAd is an important endeavor, but should not lead to immediate invasive interventions. The cornerstone for PAd treatment has always been aggressive lifestyle modification first and foremost. We encourage patients to seek the counsel of their trusted family physician or internist. A diagnosis of PAd does not imply imminent loss without revascularization, as some might think. Most importantly, scare tactics describing certain limb loss without immediate revascularization should not be used.

Boulos Toursarkissian , MD, FACS, RVT, RPVI, is with Peripheral Vascular Associates, is an Adjunct Professor at the UT Health Science Center, San Antonio, and is a member of the Bexar County Medical Society.

Jorge Alvarez, MD, FACC, FCSAI is board certified in Cardiology and Interventional Cardiology, is Director of Methodist Structural Heart Program and is a member of the Bexar County Medical Society.

visit us at www.bcms.org

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SAN ANTONIO MEDICINE

Thyroid & Hormonal Health

By Arti Thangudu, MD Hormonal health is a growing topic of interest for both patients and physicians. Unfortunately, the loudest voices in this space are those spewing non-evidencebased advice that is confusing for everyone. Physicians in primary care, gynecology and endocrinology are being inundated with questions on hormonal supplementation - pharmaceuticals, non-FdA approved therapies, as well as unregulated supplements that do not require a prescription.

Given the prevalence of thyroid hormone misunderstanding and mismanagement and adverse effects related to inappropriate use of thyroid hormones and supplements, as an endocrinologist, I hope to educate our community on this topic. We will start with a focus on hypothyroidism due to Hashimoto’s thyroiditis, since this is the most common thyroid disease treated by non-endocrinologists.

Symptoms of hypothyroidism are well known and include weight gain (~20 lbs or less if due to hypothyroidism alone), fatigue, constipation, cold intolerance, depressed mood, hair loss, dry skin.

These symptoms are non-specific and can be caused and exacerbated by lack of healthful lifestyle and other medical conditions.

The most helpful test in working up hypothyroidism is TSH; however, now patients are being tested with multiple thyroid tests and are under the impression that if they do not have a “full thyroid panel” their thyroid has not been evaluated thoroughly. This is simply untrue and leads to wasteful and confusing testing.

Let’s talk about the other tests.

Free T4 and total T3 are helpful in hyperthyroidism but not in hypothyroidism.

We do not have a good commercially available assay for free T3, so results from free T3 testing are unreliable and therefore not helpful in diagnosis or treatment of thyroid disease.

Reverse T3 (RT3) testing has been popularized by the invention 28

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of functional medicine in the 1990’s by discredited Phd Jeffrey bland. This is a subset of providers from acupuncturists to physicians who obtain certification with 18 hours of coursework that can be performed online (compared with > 8000 hours of hands on training completed by a board-certified endocrinologist). Functional medicine proposes that reverse T3, an inert thyroid hormone, competes with active T3. This is flawed reasoning. The T3 receptor has a 100x affinity for active T3 when compared to its affinity for RT3 and a 2018 meta-analysis of nearly 1400 studies concluded that there is little evidence to support wide use of RT3 testing. RT3 is on average six times the cost of TSH, so despite many functional medicine providers stating it is not problematic due to cost, it is not cost effective.

FTI or T7 can be helpful in rare cases of differentiating pituitary versus thyroid causes of hypothyroidism, but is not helpful in Hashimoto’s.

Often patients with Hashimoto’s thyroiditis have presence of thyroid peroxidase antibodies and thyroglobulin antibodies. Around 5% of Hashimoto’s patients do not have detectable antibodies.

Measuring these antibodies can be beneficial in making a diagnosis of etiology of hypothyroidism. Since presence of antibodies with-

SAN ANTONIO MEDICINE

out hypothyroidism are not indicative of disease, there is no indication for routine screening for Hashimoto’s antibodies in a euthyroid patient. Also, levels do not correlate with severity of disease, so these antibodies do not need serial monitoring. There are practitioners who tell patients that these antibodies should be reduced and that Hashimoto’s is reversible of modifiable. While there may be anecdotes of this, no strong, systematic data has demonstrated effective methods to reduce antibodies or correlated reduction in antibodies to disease improvement.

The dilemma is that many patients treated for hypothyroidism with normal TSH still report symptoms of hypothyroidism. There are even many patients with symptoms they believe are due to hypothyroidism with normal TSH off thyroid treatment. Given confusion amongst providers on appropriate thyroid management, many of these patients are being overtreated with thyroid hormone supplementation.

Symptoms of hypothyroidism are non-specific and overtreatment with thyroid hormone can lead to dangerous effects. Endocrinologists are seeing patients with insomnia, anxiety, tremors, rapid heart rate and osteoporosis in the clinic daily. More and more patients are being hospitalized with atrial fibrillation with rapid ventricular rate due to iatrogenic hyperthyroidism.

The most well-studied treatment for hypothyroidism is synthetic T4. Synthetic T3 also plays a role for some patients and should be

dosed carefully by an experienced physician. desiccated porcine thyroid extracts like Armour Thyroid and NP thyroid are generally not as safe given unpredictable dosing and supraphysiologic T3 concentrations. Armour has been recalled in the past and NP thyroid was recently recalled this year due to adverse effects. In my experience, I have seen many patients with iatrogenic hyperthyroidism and more variability in symptoms and thyroid levels with desiccated porcine thyroid extracts. Evidence does not support use of naltrexone for thyroid disease.

We have lost patients to due to quick visits, loss of trusting patient-physician relationships and perhaps a lack of compassion for the symptoms of hypothyroidism. This has led more and more patients to seek alternative methods of care - dr. Google and less credible providers selling unregulated, dangerous supplements and non-evidence based dietary restrictions such as gluten-free diet, elimination diets and avoiding cruciferous vegetables.

We must change our approach for our patient’s safety. We must demonstrate compassion first and remember that the patient’s symptoms are real even if they are misinformed about the cause.

It is incumbent upon us to validate their concerns, directly address the misinformation widely dispelled by the internet and the financial motives behind supplement pushers. We have to support our patients with education and resources on both thyroid health and on optimization of diet, exercise, sleep, stress and unhealthy habits for improvement of symptoms. We care for our patients so much that we train for years and take time away from our families to serve them, so let’s show them - I believe this will lead to better hormonal care.

Arti Thangudu, MD, Physician, Founder of Complete Medicine, is Triple Board Certified in Endocrinology, Diabetes & Metabolism, Lifestyle Medicine, Internal Medicine and Plant-Based Nutrition and is a member of the Bexar County Medical Society.

visit us at www.bcms.org

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THE BUSINESS OF MEDICINE

How to Dispose of Storage Devices Containing PHI & Other Sensitive Data

By Laura Hale Brockway, ELS

Improper disposal of electronic devices and media puts the information stored on those devices at risk for a breach. And when devices contain protected health information (PHI), it puts your patient’s data at risk. What can you do to protect PHI when you want to dispose of equipment such as desktops, laptops, tablets, copiers, servers, smartphones, hard drives, and USb drives? The Office for Civil Rights and the National Institute of Standards and Technology offer the following guidance. 1, 2 Paper destroy paper using cross-cut shredders that produce particles that are 1 x 5 millimeters in size or pulverize/disintegrate paper materials using disintegrator devices equipped with 3/32-inch security screen.

Microforms destroy microforms (microfilm, microfiche, or other reduced image photo negatives) by burning. When material is burned, residue must be reduced to white ash.

Cell phones, personal digital assistants, and other hand-held devices Shred, disintegrate, pulverize, or burn devices in a licensed incinerator.

Routers, copy machines, fax machines Shred, disintegrate, pulverize, or burn devices in a licensed incinerator.

ATA hard drives, SCSI drives, flash drives, and USBs Shred, disintegrate, pulverize, or burn devices in a licensed incinerator.

Floppy disks, zip disks Shred, disintegrate, pulverize, or burn devices in a licensed incinerator.

CDs, DVDs destroy in order of recommendations: Remove the Information-bearing layers of disc media using a commercial optical disk grinding device.

• Incinerate optical disk media (reduce to ash) using a licensed facility.

• Use optical disk media shredders or disintegrator devices Sources 1. Office for Civil Rights. Guidance on disposing of electronic devices and media. July 2018 OCR Cybersecurity Newsletter. Available at https://www.hhs.gov/sites/default/files/cybersecurity-newsletter-july-2018-disposal.pdf . Accessed August 23, 2018.

2. National Institute of Standards and Technology. Guidelines for media sanitization. September 2006. Available at https://ws680.nist.gov/publication/get_pdf.cfm?pub_id=50819 . Accessed August 23, 2018.

Laura Hale Brockway is Assistant Vice President, Marketing, Texas Medical Liability Trust and can be reached at laura-brockway@tmlt.org.

Reprinted with permission from Texas Medical Liability Trust.

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ART IN MEDICINE

Title:

JFK - "Ask not what your country can do for you—ask what you can do for your country."

Description: 30" by 40" Acrylic on Canvas. The painting was created using a minimalistic shading color scheme.

By Jonathan Espenan

This painting is personally significant to me because it was one of the first portraits that I started making. I created a series in which I paired paintings of famous people with quotes that demonstrated their knowledge that they shared with the world.

In hard times, or in times of pandemic, it is our immediate human nature to focus on survival. In the early months of COvId-19 we worried about the future, about death, about survival. We lived our lives from a place of fear. As the months went on, we remembered our core human values of helping others and of togetherness. We started focusing on what we could do to help other people. JFK's wisdom transcends the time and place of which he originally spoke it, and continues to apply to us today. Instead of focusing on what we can get from others, we must focus on how we can contribute to society and help our country during these hard times.

Jonathan Espenan is a medical student, Class of 2021 at the UT Health San Antonio Long School of Medicine, UT Health San Antonio.

visit us at www.bcms.org

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THE BUSINESS OF MEDICINE

Artificial Intelligence & Informed Consent

By Laura M. Cascella, MA

Informed consent, in its basic sense, seems like a fairly straightforward concept. A patient is informed about a proposed test, treatment, or procedure; its benefits and risks; and any alternative options. With this knowledge, the patient decides to either consent or not consent to the recommended plan. In reality, though, informed consent is a more complex process that involves nondelegable duties and varies in scope based on the type of test, treatment, or procedure involved.

When technology is introduced into the mix — particularly advanced technology — the informed consent process can become even more complicated because of additional information that the provider must convey to the patient and that the patient must weigh in his/her decision-making process.

As artificial intelligence (AI) surges into healthcare with applications such as machine learning, deep learning, neural networks, and natural language processing, new ethical and practical issues related to informed consent are emerging. When should patients be told that AI technologies are being utilized for diagnostic and treatment purposes? How much information about the technology needs to be disclosed? What are the best ways to explain the complexities of AI in understandable ways?

AI’s rapid momentum has, in many cases, eclipsed the ability of regulators, leaders, and experts to implement laws, standards, guidelines, and best practices that address some of these issues. Thus, healthcare providers should stay vigilant for ongoing developments related to their legal and ethical responsibilities for disclosing infor-

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San Antonio Medicine • October 2020

mation about AI during informed consent discussions.

Healthcare providers also must contend with how the media and popular culture might shape patients’ views of AI as well as their own views. An article in the AMA Journal of Ethics notes that “When an AI device is used, the presentation of information can be complicated by possible patient and physician fears, overconfidence, or confusion.” An example that might foreshadow this potential issue occurred with the emergence of robotic surgery. vigorous direct-to-consumer advertising and marketing was noted in some instances to overestimate benefits, overpromise results, and/or fail to define specific risks, which led to inflated patient perceptions or unrealistic expectations of the technology.

It is not difficult to see how media might also shape AI’s image, with persistent stories about how AI technologies will affect daily life in either fantastic or catastrophic ways. In a media-obsessed society, this inundation of information can have a significant impact on patients’ perceptions, potentially leading to idealistic or pessimistic views of AI. In turn, the need for thorough and appropriate informed consent discussions becomes even more pertinent.

To address issues related to patient knowledge and expectations of AI, healthcare providers must start with self-awareness and education about the technology. The authors of the aforementioned article explain that “for an informed consent process to proceed appropriately, it requires physicians to be sufficiently knowledgeable to explain to patients how an AI device works.”

Although acquiring extensive knowledge of AI coding, programming, and functioning is likely unrealistic for most healthcare providers, those who plan to use these technologies in practice should be able to:

THE BUSINESS OF MEDICINE

• Provide patients with an explanation of the basic way in which the AI program or system works • Explain the healthcare provider’s experience using the AI program or system • describe to patients the risks versus potential benefits of the AI technology (e.g., compared to human accuracy) • discuss with patients the human versus machine roles and responsibilities in diagnosis, treatment, and procedures • describe any safeguards that have been put in place, such as cross-checking results between clinicians and AI programs • Explain issues related to confidentiality of patient’s information and any data privacy risks Taking the time to provide patients with these additional details during the informed consent process and to answer any questions can help ensure that they have the appropriate information to make informed decisions about their treatment. Following the informed consent process, providers should document these discussions in patients’ health records and include copies of any related consent forms.

In time, healthcare organizations and providers can use their experience with AI, lessons learned during the implementation of AI in clinical care, and evolving federal and state regulations and pro-

fessional standards to determine appropriate patient selection criteria for various AI applications and to hone informed consent processes.

Laura M. Cascella, MA is with MedPro. For more information about informed consent, see MedPro’s “Risk Management Strategies for Informed Consent”. To learn more about managing AI risks, see “Risk Tips: Artificial Intelligence”.

RESOURCES Schiff, d., & borenstein, J. (2019, February). How should clinicians communicate with patients about the roles of artificially intelligent team members? AMA Journal of Ethics, 21(2):E138-145. doi: 10.1001/amajethics.2019.138 langreth, R. (2013, October 8). Robot surgery damaging patients rises with marketing. bloomberg News. Retrieved from www.bloomberg.com/news/2013-10-08/robot-surgery-damagingpatients-rises-withmarketing.html Schiff, et al., How should clinicians communicate with patients about the roles of artificially intelligent team members?

This document should not be construed as medical or legal advice. because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PlICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and/or may differ among companies. © 2019 MedPro Group Inc. All rights reserved.

visit us at www.bcms.org

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

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

ACCOUNTING FIRMS

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

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

ACCOUNTING SOFTWARE

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

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

ARCHITECTURE LK Design Group, Inc. (HH Silver Sponsor) LK Design Group has over 24 years of experience designing various medical and hospital buildings. We have experience in both ground up developments and re-design of interior spaces for medical professionals.

Lynn Kuckelman Peters President 210-824-8825 Lynn.p@lkdesigngroup.com Kristin Savage Director of Business Development 210-824-8825 Kristin.s@Lkdesigngroup.com www.lkdesigngroup.com

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor)

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San Antonio Medicine • October 2020

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

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

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

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

ASSETT WEALTH MANAGEMENT

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

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

Mike Bertuzzi First Vice President Senior Financial Advisor

210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

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

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”

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.”

Synergy Federal Credit Union (HHH Gold Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

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

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

Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com BBVA Compass (HH Silver Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

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

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”

COMMERCIAL PROPERTY MANAGMENT

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"

FINANCIAL SERVICES Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton.

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

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

Elizabeth Olney with Edward Jones ( Gold Sponsor)

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

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

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

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

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/eliza-

beth-olney "Making Sense of Investing"

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

Jake Pustejovsky Commercial Relationship Manager (830)302.6336 Jake.Pustejovsky@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (512)226-0208 www.Regions.com

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society.

Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group and SWBC PEO, SVP Corporate Relations (210) 525-1241 DMarino@swbc.com 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 well-

served 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® CEO | Wealth Advisor 210.864.3350 eric@avidwp.com avidwp.com “Plan it. Do it. Avid Wealth”

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

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

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER GHA TECHNOLOGIES, INC (HH Silver Sponsor) Focus on lifelong relationships with Medical IT Professionals as a mission critical, healthcare solutions & technology hardware & software supplier. Access to over 3000 different medical technology & IT vendors.

Pedro Ledezma Technical Sales Representative 210-807-9234 pedro.ledezma@gha-associates.com www.gha-associates.com “When Service & Delivery Count!”

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor)

continued on page 36

visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY continued from page 35 With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

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

INSURANCE

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

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org 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 OSMA Health (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians.

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

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San Antonio Medicine • October 2020

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

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

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

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

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

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

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

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior).

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

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 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 check-up?

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.”

furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

MEDICAL PRACTICE

IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner.

Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.com Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “

MEDICAL 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.”

MEDICAL FURNITURE

MOLECULAR DIAGNOSTICS LABORATORY

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio provid-

ing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases.

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

OFFICE FURNITURE

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

PRACTICE SUPPORT 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 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 check-up?

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administra-

tion, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society.

Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group and SWBC PEO, SVP Corporate Relations (210) 525-1241 DMarino@swbc.com

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

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

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

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

offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

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 Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton.

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

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”

REAL ESTATE SERVICES COMMERCIAL

STAFFING SERVICES

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional

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

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!"

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

For questions regarding Circle of Friends Sponsorship or, sponsor member services please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366 www.bexarcv.com/secure/ bcms/cofjoin.htm

visit us at www.bcms.org

37

AUTO REVIEW

2021 Mercedes E350

By Stephen Schutz, MD

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San Antonio Medicine • October 2020

AUTO REVIEW

In the 1970s, when Mercedes lagged far behind Cadillac and lincoln in the US luxury automotive sales race, their most important products were the S-class sedan and Sl convertible. In the 1980s, as Mercedes grew their volumes and became a major player here, the E-class sedan, particularly the classic bruno Sacco W124 version, became the center of gravity for the brand.

Now Mercedes easily outsells those American brands and regularly competes for sales supremacy with bMW; and the E-class has become almost an afterthought, easily outsold by both the GlC and GlE SUvs (with the GlS flagship SUv not that far behind). Nevertheless, just as the 3-series will always be special at bMW because of all it did for the company, so the E-class is held in high esteem at Mercedes.

An all new E-class has just been launched with many important upgrades from the 2020 model, particularly in its powertrains and tech, and I was “fortunate” to be able to drive (COvId-19 is to blame for this, not surprisingly) a 2020 E350 press car. Naturally, I wanted the 2021 version, but lemons/lemonade I decided to couple information from other sources about the 2021 models with my driving experience in the 2020 E350, which, let’s be honest, is likely to drive a lot like the new model.

The 2021 E350 will feature the same turbocharged 2.0 liter four-cylinder engine that is in the 2020 model. That engine produces 255 HP, and, like all 2021 E-class models, is coupled with a 9-speed automatic transmission. A plug-in hybrid E350e is also available, and in this model the aforementioned four-cylinder engine works together with an electric motor to generate a total of 315 HP. The more upmarket E450, which used to have a turbo v6, is now powered by a turbocharged 3.0 liter inline 6cylinder engine with a 48-volt mild hybrid system that doubles as an electric supercharger. AMG E53 models come with the same inline six as the E450, but they use the electric supercharger, a turbocharger, and the 48 volt mild hybrid system to crank out 429 HP. An aside: bMW is famous for its wonderful inline 6-cylinder engines, but Mercedes also offered them until the late 1990s when they switched to v6s. Thank you Mercedes for bringing back the best 6-cylinder configuration and ditching your v6s!

For now I’d suggest the AMG E53 or E450 to get the extra power, but it shouldn’t be long before an AMG E63 with a v8 and tons of power is available, probably in sedan and wagon forms. That will be fun (but pricey).

Of note, Mercedes will be phasing out all E-class coupes and convertibles soon, so if you’re interested in one of those wonderfully stylish cars, call Phil Hornbeak before they’re no longer available (Mercedes hasn’t announced when they’ll be pulled from the market, but sometime in the next 9-12 months is a reasonable estimate). They don’t sell very well, but I for one will miss them.

While the two door E-class models will fade away, the wagon will continue on, and, interestingly, will morph into an SUv-ish

elevated thing called the All Terrain (available only as E450s).

Standard E-class wagons, available in the US for decades, have always appealed to well-heeled buyers because of their understated good looks. Will the butchy All Terrain be as attractive to those desirable customers, many of whom are bCMS members and their spouses? Only time will tell, but I’m going with no.

The new E-class will have better tech too. The clever MbUX technology system, already available on “lesser” Mercedes, is best known for answering to, “Hey Mercedes”, but it does a lot more than mimic Siri. MbUX includes bigger screens as well as Apple Carplay and Android Auto, and the new system will be touchscreen operated rather than using the previous rotary knob on the central console.

The driving experience of the 2020 E350 I tested was nice but not spectacular, as you’d expect from a Mercedes E-class. Pushing things resulted in mild understeer, but normal driving was uniformly pleasant. The car felt most at home on the open highway, but zipping around town running errands was also pleasurable.

The E-class has never been and will never be a sports car, but as an everyday driver it’s hard to beat (unless you choose a GlE, which drives similarly, sits higher for better visibility, and has more cargo space).

The 2021 E-class is a benchmark car that benefits from obvious attention from Mercedes engineers and executives who want to maintain the history of excellence that has marked it since it launched decades ago. like any Mercedes, it’s expensive but should provide years of value and happiness. There are other midsize luxury cars out there, but there are none better than this one.

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

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

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San Antonio Medicine • October 2020