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MENTAL HEALTH Medical Burnout: Breaking Bad By Dharam Kaushik, MD ...............................................14 How to Overcome Physician Burnout and Thrive By Nora Vasquez, MD ...................................................16 Recognizing Mental Health in Youth By Mrudula Rao, MD and Michael Arambula, MD ..........18 Destigmatizing Mental Health Among Physicians and Medical Students By Niva Shrestha...........................................................20 A Bridge Between the Mind and the Skin By Tue “Felix” Nguyen, Marie Vu and Caroline Zhu ........22 A Closer Look at the Medical Needs of San Antonio’s Homeless Population By Kaleigh Longcrier, OMS IV, Taylor Sullivan, DO and Hans Bruntmyer, DO, MPH ....................................24 The San Antonio Refugee Health Clinic: Addressing Barriers to Refugee Mental Health By Emily Liu, Melissa M. Donate, Zeba Bemat, Anuradha S. Helekar, MD and Blake A. Harrell, DO .........28 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance President’s Message ......................................................................................................................10 The Bexar County Medical Society Names Monica Jones as its New Chief Operating Officer .................................12 BCMS Spotlight: Phil Hornbeak, Auto Program Director.........................................................................................13 Post-COVID Complications and Neurological Sequelae: PM&R Perspective By Monica Verduzco-Gutierrez and Carol Li, MD .................................................................................................................................................32 How Social Determinants of Health Impact Wellness Programs By Roxanne Leal...................................................34 Book Review: Chicken Soup for the ICU: A Review of “Kitchen Table Wisdom – Stories that Heal” By David Alex Schulz, CHP ................................................................................................................................36 Letter to the Editor By Neal S. Meritz, MD .............................................................................................................36 Physicians Purchasing Directory.............................................................................................................................38 Recommended Auto Dealers .................................................................................................................................43 Auto Review: 2021 Ford Bronco Sport By Stephen Schutz, MD.............................................................................44 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 2021

OCTOBER 2021

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

For advertising rates and information Call (210) 410-0014 Email: louis@travelingblender.com SAN ANTONIO MEDICINE is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, its members, or its staff. SAN ANTONIO MEDICINE the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

SmithPrint, Inc. is a family owned and operated San Antonio based printing and publishing company that has been in business since 1995. We are specialists in turn-key operations and offer our clients a wide variety of capabilities to ensure their projects are printed and delivered on schedule while consistently exceeding their quality expectations. We bring this work ethic and commitment to customers along with our personal service and attention to our clients’ printing and marketing needs to San Antonio Medicine magazine with each issue.

BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

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

DIRECTORS

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

SAN ANTONIO MEDICINE • October 2021

Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Katelyn Jane Franck, Student Alexis Lorio, Student

BCMS SENIOR STAFF

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

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

PRESIDENT’S MESSAGE

Mental Health in Our Elderly: Personal Anecdotes By Rodolfo “Rudy” Molina, MD, MACR, FACP, 2021 BCMS President

With aging comes changes that we are not prepared for. It’s not as though we have done it before, readjusting our current aging process by experience. Rather, our physician experience with aging comes as witnesses to our patients, parents or both. This month’s topic covers mental health, and I thought I would provide just a few words on my experience dealing with it, specifically in the elderly. I’m reminded by some of the lyrics in the song “Sunrise, Sunset,” which state, “I don’t remember growing older,” and that is exactly how I feel as I near retirement. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It is reported that one in five older adults experience a mental health concern. The most common mental illnesses reported are anxiety and depression. An under-reported mental health problem is loneliness. Dealing with issues such as depression, anxiety and loneliness among others can lead to suicide. The highest rate of suicides in this country are in the elderly, with those aged 85 and older having the highest suicide rate. Risk factors for suicide include not just those three mentioned, but also include a previous suicide attempt, substance abuse, family history of suicide, chronic pain, physical illness, declining physical function and impaired cognitive function. Recognizing these risk factors is key to successfully preventing suicide. It is also known that most of these mental health issues respond well to therapy. I bring up this topic because it is important to know and understand. I am fortunate to say that suicide in my elderly patients has been a rare occurrence in my 40+ years in practice. In my practice, the biggest concern expressed to me from the elderly is loss of memory. I find it interesting, since most are confusing their at8

SAN ANTONIO MEDICINE • October 2021

tempts at multitasking for forgetfulness. We are all guilty of multitasking. How many times have you walked into a room or opened a cabinet drawer and forgot the purpose of the action? That is because we are thinking about one, two, three, maybe four or five things that we need to do. We are still thinking of our last task when we find ourselves in the middle of completing our first thought. I tell my patients that no one does multitasking well, despite their convictions that they were good at it when they were younger. The other major source of loss of memory is lack of sleep or poor sleep hygiene, which is associated with increased pain and forgetfulness. Once we identify the problem and address it, they feel a lot better about themselves. Another recurrent topic in my office that creates both anxiety and depression is patronization by patients’ children. I assure them that their children’s actions are born out of love and concern. Love and concern are what I consider two sides of the same coin. How can we not love one another without a “protective” concern as part of that love? I had one gentleman in his late 80s express his frustration to me about his adult children characterizing them as “all wanting to be his doctor.” I merely told him that he would feel much worse if they didn’t care about him at all, which made him pause and think. On a personal note, my children are all medical doctors, so I will just wait my turn to experience the same. This month, as mentioned, we dedicate our magazine to discuss the topic of mental health, and I hope you will enjoy reading the excellent work presented in it. Rodolfo “Rudy” Molina, MD, MACR, FACP is the 2021 President of the Bexar County Medical Society.

BCMS ALLIANCE

De-Stress to Minimize Distress By Sue Bernstein, MS

Life can be stressful, particularly for medical professionals and their spouses, as each day can bring many unexpected challenges. In just his first two working hours, my husband had to deal with several stressful situations, including having an emotional discussion with a patient and family about a terminal cancer diagnosis, the news that a critical employee tested positive for COVID-19, a frustrating conversation with a high-risk patient who did not want to take the vaccine and having to resolve issues with office equipment. When he finally got home in the evening, he was greeted with only an unrefreshing dribble of water in the shower and yet another issue to deal with. Sometimes it just feels like too much. I’m sure most of you can relate! We can all be burdened by long hours, heavy workloads and tight deadlines. The current pandemic has made staying calm and focused even more difficult, as change and uncertainty seem to magnify our normal daily challenges. While we hope and anticipate that things will get easier, the stress continues to take a toll on both our minds and bodies. It’s time to stop waiting for life to calm down and proactively tackle the things that cause us stress. A good way to start is by making a formal plan. Try composing a list of the top ten stressors in your life. While you can’t wave a wand and magically eliminate everything that overwhelms you (how cool would that be?), just getting a list on paper can help you feel a sense of power. Next, take a careful look at your list and determine which items are within your control. If something is not changeable, take 10

SAN ANTONIO MEDICINE • October 2021

your pen and scratch it out! Let those things go! Focusing on issues that you have the ability to improve will give you positive momentum, and your life will feel more manageable. Tackle your list one item at a time. Choose an issue on which to focus and be 100% committed to attacking it. You can choose the stressor that upsets you the most or simply start with the easiest to conquer. Just move forward. When you feel one issue has been satisfactorily resolved, check it off your list and choose your next challenge. If you start to feel overwhelmed, take a deep breath, pull out your list and refocus. As you continue to address your list items one-by-one, try becoming a role model. Exuding positivity will help you stay focused and may inspire others to improve their own outlooks. Instead of letting friends or co-workers draw you into their negative banter, move conversations into a better direction. Telling a joke or funny story can quickly change the atmosphere. Stress is an inevitable part of everyone’s lives, but there are strategies you can implement to make your own life more manageable. Instead of allowing bad habits and excuses to become parts of your identity, try proactively eliminating or reframing your challenges while becoming a positive force for those around you. Sue Bernstein, MS is a Health Transformation Coach and Consultant and the Recording Secretary of the Bexar County Medical Society Alliance.

SAN ANTONIO MEDICINE

The Bexar County Medical Society Names Monica Jones as its New Chief Operating Officer

Meet Monica Jones, the new Chief Operating Officer of Bexar County Medical Society. Monica is excited to be working with such a strong group of professionals with such diverse backgrounds. Monica adds perspective and benefit to the organization from her more than 25 years of involvement in primarily nonprofit organizations. Born at a naval base in Pensacola, Florida, Monica’s family are native San Antonians. She attended Catholic school throughout her academic education, earned a Business Administration degree from Our Lady of the Lake University and holds a certification in Mediation. Before BCMS, Monica was the director of Human Resources and Administration at the Southwest Texas Regional Advisory Council for Trauma (STRAC) for thirteen years. Monica states working with Eric Epley, Dr. Ronny Stewart and the dynamic team at STRAC was one of the most challenging positions in her career, but the most rewarding and educational. Monica led the

SAN ANTONIO MEDICINE • October 2021

team to the first-ever Regional Emergency Healthcare Systems Conference held at the Alamodome in 2011. Monica also played a big role in the first-ever Regional Medical Operations Center (RMOC) activation and was involved in many Hurricane deployments such as Katrina, Rita, Gustav and Ike, not to mention the H1N1 RMOC activation and monitoring. “STRAC will always be part of my heart as they continue to be a leader in the Texas Trauma System.” After STRAC, Monica went back to her Alma Mater, Providence Catholic School, as the Director of Admissions. “It was time to give back to the community that supported me as a young woman.” Under her leadership, Providence increased enrollment and once again proved to be a leader in private school education, leading all other catholic schools in college scholarships earned. When COVID-19 hit, Monica took the health and well-being of her family seriously, taking a break from the workforce to care for her two sons: Michael Carter and

Christopher, who is disabled (autistic, epileptic and nonverbal). Monica and her husband Michael Sr. have been married for 14 years. She notes that Mike (a University of Texas Football Alum) has always been by her side during tough situations and is excited about her opportunity with BCMS. Monica states one of her greatest gifts is her team player mentality. Monica was a college athlete, playing basketball for the University of Dallas. “I bring my love of the game into my day-to-day work environment. You can depend on me as a team player, and I look forward to working closely and successfully with each of you. I am most excited to be working alongside Melody Newsom. We first met back in 2003 during my days at STRAC. We have stayed connected all these years. I am so proud of her accomplishments here at BCMS and look forward to learning from her. I have big shoes to fill!”

BCMS SPOTLIGHT

BCMS Spotlight:

Phil Hornbeak, Auto Program Director Phil Hornbeak came to the BCMS Auto Program from a career in Finance and Automotive management. In his early career, he learned to floorplan for dealerships and make bulk purchases of accounts receivable to gain new customers for the retail side of lending. He progressed into managing multi-franchise dealer groups to include inventory control, personnel and sales management. It was as though all of his previous experience prepared him for the job of BCMS Auto Program Director in 2004. Since the inception of the BCMS Auto Program in 1983, thousands of physicians, their families and staff have used our service. What is the BCMS Auto Program? The BCMS Auto Program is a benefit of BCMS membership. It is a free “concierge” service for locating and pricing vehicles. You don’t have to do anything other than tell us what you want. We do the legwork to find the make, model, color and equipment that suits you. Our participating dealers support the program by ensuring you get the best price on the car or truck of your dreams. In turn, we support the dealers with our business. We have many dealers to assist our program without taking up your precious time, invading your privacy or space. Currently we have financing as low as 1.65% up to 60 months with approved credit. We can have your loan pre-approved, so all you have to do is sign the title forms at the dealership and drive away. As a comparison, we tested a popular online vehicle “buying service,” and here is what we found. Your name, phone number, email and any other data given is shared with dealers and salespeople. We tested the service by going online and completing an inquiry form. We received six phone calls and four text messages. The salespeople on the other end refused to provide any pricing information unless we went to a dealership. We also went to a dealership to test that as well, and wasted over two hours before somebody gave a price. It was higher than the posted internet price for the same unit! If you want to window shop and test drive various vehicles, BCMS will connect you with a sales representative who understands our program and will make sure you get the best price the first time,

never pestering you like the service noted above. You can join the thousands of very satisfied BCMS Auto Program users by going to www.bcms.org and clicking on the Auto Program where you can request a vehicle and apply for financing pre-approval. You can also call (210) 3014367 to speak to Phil Hornbeak or email phil@bcms.org.

Another fun member benefit and part of the Auto Program is the

BCMS Auto Show,

which is held the third Thursday in October every year. This year is our 35th Annual Auto Show. It will be held at the BCMS headquarters on October 21, 2021. This is a fun family outing with a wide variety of beautiful vehicles, live music, and free food and drink. You don’t want to miss it, so save the date!

Visit us at www.bcms.org

MENTAL HEALTH

MEDICAL BURNOUT: BREAKING BAD By Dharam Kaushik, MD

*This article first appeared in AAMCNews and is reprinted with permission.

s the threat of COVID-19 wanes, health care workers are burned out and suffering. Here’s what one surgeon thinks should be done. The year was 2007, and I was a surgical resident at the University of Nebraska Medical Center. Joseph Stothert, MD, PhD, was the chief of trauma service. “Dr. Kaushik, did you see the consult in the ER?” Dr. Stothert looked into my eyes as if staring into my soul. “Not yet, Dr. Stothert,” I replied, picking up the patient’s chart. “They paged me two minutes ago.” Dr. Stothert shook his head and headed to the ER, where he saw the patient even before I did. Joseph Stothert was a phenomenal trauma surgeon, the medical director of the Omaha Fire Department and a brilliant leader who saved countless lives throughout Nebraska. He died by suicide in March 2021 after spending more than a year on the front lines in the war against COVID-19. For me and countless other residents that Dr. Stothert trained, his death will never be just a tragic statistic among so many during this pandemic. Rather, he will be remembered as one of the finest surgeons in the country, whose skill was matched only by his kindness and compassion. A recent Washington Post/Kaiser Family Foundation survey of 1,327 front-line health care workers in the United States during the COVID-19 pandemic revealed that medical burnout has reached epidemic proportions. An overwhelming 55% of front-line health care workers reported burnout (defined as mental and physical exhaustion from chronic workplace stress), with the highest rate (69%) among our youngest staff — those ages 18 to 29. That same age group also reported the highest negative impact of the pandemic on their mental health (75%), though a majority of all health care workers (62%) reported some mental health repercussions. Multiple survey data now show that health care workers responsible for providing direct care for COVID-19 patients are more likely to have depression, anxiety and mental distress. These mental health issues may be related to psychological distress from witnessing COVID19-related deaths, extra-long work hours and work-life imbalance. Health care workers have been working nonstop without a full appreciation of their sacrifices. Many have suffered financial distress as well, including salary cuts and furloughs.

SAN ANTONIO MEDICINE • October 2021

Furthermore, systemic racism, violence against Asians and child care crises for women in medicine have taken a tremendous toll on the mental and physical health of these minoritized groups during the pandemic. For women in medicine, there has been no respite from work, whether it’s on the front lines with COVID-19 or solving their child care challenges. When experienced in such a sustained and extreme form, burnout can have devastating consequences — not only on the workforce, but also on patients. Burned-out doctors and nurses can even threaten patient safety and the quality of health care delivered. The Washington Post/Kaiser Family Foundation survey found that 26% of health care workers in hospitals are angry and 29% have considered leaving the medical field. These are the warning signs of a smoldering epidemic of burnout among front-line medical professionals. National, institutional and departmental leadership should not put the burden squarely on staff to “do meditation apps, practice mindfulness, get 10% off on gym memberships or count your steps for wellness.” Instead, they must recognize the insidious nature of burnout and develop the necessary tools to prevent and treat it. Five practical changes we can implement rapidly 1. Recognizing burnout is the first step toward finding solutions. We need to have a mindset of “we are all in this together.” It can start at the departmental level with peer-to-peer coaching sessions during which faculty, residents and trainees have an opportunity to voice their feelings and get advice from peers and mental health experts on coping with burnout and promoting wellness.

MENTAL HEALTH

It is ingrained early on in medicine to “keep doing what you are told and never complain.” If you complain, you are seen as not resilient. This mindset is harmful and can create feelings of despair and selfjudgment. How can we be compassionate toward our patients when we are so critical of ourselves? By developing a bond through shared experience, peer-to-peer coaching can assist someone going through feelings of loneliness and isolation. This strategy can also remove the hierarchy typically seen in medicine, especially in surgical specialties. I am a urologic cancer surgeon with a focus on surgery for advanced kidney cancer. Depending on the complexity of the cancer, these are long, tedious surgeries — sometimes taking eight to 12 hours. I have experienced burnout on multiple occasions. Acknowledging and discussing it is the first step. We as health care workers should understand that it is okay to be vulnerable, and a system of peer-to-peer coaching can help us understand these vulnerabilities. There is good data that people who experience adversity or a traumatic event often find a sense of personal growth as they work through their trauma. This phenomenon is called “post-traumatic growth.” We see this in world-class endurance athletes who have psychological support and can build upon their strengths to surpass perceived physical and emotional limits. The only difference between health care workers and endurance athletes is that the latter have support from their peers, coaches and psychologists. Health care workers, by contrast, often grapple with their trauma isolated and alone. We can change that. 2. A mental health resources page on each department’s website with a list of outreach programs and contact information for anonymous psychological health support would be the next step. A recent Medscape report found that almost 40% of U.S. physicians had no workplace support to deal with grief and trauma. Health care workers are working extra-long hours, and some of them may not have the time or feel safe discussing their emotional and mental health with peers. For them, an anonymous method of accessing mental health resources is critical. 3. Program directors, associate program directors and faculty members should be offered training on supervising with empathy and fostering a genuine dialogue with their trainees (medical students, residents and fellows) on burnout and wellness. We need to move away from the perfunctory “How are you doing? — I’m fine” model to an active engagement in conversation. Trainees deserve our full attention toward their emotional and mental health, even if it is for only a few minutes. Being “present” in conversations with trainees is a genuine act of kindness, as it demonstrates that their well-being is our priority. “Tell me how you are really doing through this pandemic? You have my undivided attention” is a powerful open-ended question and can help

trainees feel an immediate bond with their faculty. Providing trainees a safe place by actively listening and then following through with action is the single most critical thing we can do as mentors. 4. Institutional leadership needs to implement a comprehensive action plan to promote wellness and prevent burnout. This may require a culture change from dealing with acute mental health issues to promoting programs to improve physician wellness and resilience. In 2019, the American Medical Association launched the “Joy in Medicine Recognition Program,” which encourages institutional leadership to improve physician wellness and reduce burnout by implementing workplace changes that improve practice, teamwork and peer support efficiency. 5. Hospital leadership should establish a provider wellness committee from different departments and include physicians and advanced practice providers. Each department could potentially have one “wellness champion” who could discuss issues specific to that department but who could also be the wellness contact for other faculty and residents in the department. Hospitals can work with the provider wellness committee on prioritizing space — a dining room, small gym or meeting room — for wellness-related conversations. If these minor changes are meaningful and enhance health care workers’ wellness, hospitals should investigate the creation of electronic-free environments. These can be modeled after airport sleeping/nap pods. Federal, state and city governments should support such programs and promote research into optimizing health care worker wellness. Such collaborative efforts could even advance the science of burnout during this pandemic. In the first year of the pandemic, more than 3,600 U.S. health care workers died. Anthony Fauci, MD, chief medical advisor to the Biden administration, said it best: The deaths of so many health care workers due to COVID-19 are “a reflection of what health care workers have done historically, by putting themselves in harm’s way, by living up to the oath they take when they become physicians and nurses.” Health care workers are an indispensable and resilient part of the nation’s workforce — and have saved countless lives, before the pandemic and during it. Understanding medical burnout and having strategies at the organizational level to prevent it will help avoid future catastrophes. We need to get the system of “preventing burnout and promoting wellness” up and running before the next pandemic happens. It will also be an authentic tribute to those “COVID-19 warriors” like Dr. Stothert. Dharam Kaushik, MD is an associate professor in urology and the program director of the urologic oncology fellowship in the Department of Urology at UT Health San Antonio and the Mays Cancer Center at UT Health San Antonio MD Anderson. He is a member of the Bexar County Medical Society.

Visit us at www.bcms.org

MENTAL HEALTH

HOW TO OVERCOME PHYSICIAN BURNOUT AND THRIVE By Nora Vasquez, MD

re you feeling the effects of physician burnout? If you answered yes, then you are not alone. In fact, for years we have known that occupational burnout affects over 50% of physicians in the United States. What exactly is burnout? Burnout is defined by the World Health Organization as feelings of overwhelming exhaustion, increased cynicism and negativity related to one’s job and reduced professional efficacy. Burnout is an occupational hazard that is expressed due to prolonged exposure to chronic stressors. Occupational stressors that drive physician burnout include, but are not limited to, increased workload, increased charting, lack of staff or resources, loss of autonomy and loss of community. That is to say that even the most resilient physicians are susceptible to burnout due to the demands, challenges and responsibilities placed upon them. Unfortunately, the COVID-19 global pandemic has exacerbated burnout and is contributing to an exodus of highly skilled and talented medical professionals leaving medicine at alarming rates. Hospitals and medical institutions are struggling to retain their workforce or even recruit new staff to alleviate the workload strain. It’s estimated that the cost to replace one physician ranges from $250,000 to $1,000,000. We know that burnout also has a detrimental 16

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cost for physicians personally and professionally. A Mayo study in 2017 revealed that when physicians are burned out, the overall quality of health care delivery suffers. There are more medical errors, decreased satisfaction scores, decreased morale and productivity. Most notably, the personal cost of physician burnout is devastating, as it often leads to depression, substance abuse, broken relationships and even suicide. Alarming data reveals that women physicians’ suicide rate is 130% higher than females in the general population. This is a tragedy that must be addressed at both the medical institutional level as well as on the individual level. As a Board-Certified Internal Medicine Specialist, I experienced the effects of burnout throughout my training and career, but I didn’t even know it at the time. At the height of my burnout, I started noticing that my usual optimistic thoughts were being replaced with dread and more negative thinking. I also recognized that I was feeling less fulfilled at work and so exhausted that resting on the weekends didn’t rejuvenate me. It was then that I knew something had to change. After exploring my options, I decided to hire a physician coach who helped me overcome my burnout and transformed my life for the better. This pivotal experience inspired me to become a Certified Physician

Coach to help medical professionals mitigate burnout so that they too could enjoy the life they worked so hard to create. Since then, I have worked with hundreds of physicians throughout the United States and Canada. As such, I understand the daily challenges physicians struggle with as they lead and serve their patients, while also taking care of their family responsibilities. What is remarkable is that most physicians don’t realize how untreated burnout is preventing them from experiencing true fulfillment in their personal and professional lives. Once they learn the effective skills to overcome burnout and how to implement evidencebased strategies, they can create a work-life balance that allows them to enjoy their life more fully. The good news is that premier leaders at medical schools, hospitals and medical institutions nationwide now recognize the importance of investing and promoting physician coaching and wellness programs. Wellness has been defined as “the complex and multifaceted nature of physicians’ physical, mental and emotional health and well-being.” Every medical student, resident and attending physician deserves to have access to a physician coach. Professional physician coaching is an effective strategy that promotes wellness and is supported by an increasing body of evidence. According to a JAMA article pub-

MENTAL HEALTH

lished in 2019, a randomized controlled trial showed that just six sessions of professional coaching led to a statistically significant decrease in emotional exhaustion and overall burnout. There was also a statistically significant increase in quality of life and resilience scores. Therefore, we must promote and make these coaching programs easily accessible so that physicians can get the support they need. The Bexar County Medical Society (BCMS) is committed to supporting physicians and have charged me to lead and develop the BCMS Physician Coaching and Wellness Program. This program consists of a free monthly Physician Wellness Webinar Series where you can learn effective tips to help you improve your well-being at work and at home. You can register and learn more

about joining these monthly webinars by visiting the BCMS Calendar of Events at www.bcms.org. In summary, the detrimental effects of burnout can be mitigated by participating in the BCMS Physician Coaching and Wellness Program. This program will enhance your awareness, develop your strengths and help you create the work-life balance you desire so that you can achieve your personal and professional goals. Please share this article and invite your physician colleagues to join us so that we can better support our physician leaders through these challenging times.

a pilot randomized clinical trial." JAMA internal medicine 179.10 (2019): 1406-1414. Nora Vasquez, MD is a Certified Physician Coach and a BoardCertified Internal Medicine Physician with over a decade of experience. She developed the Physician Wellness Webinar Series for BCMS physician members to empower physicians with evidence-based coaching strategies to decrease burnout and enhance physician well-being. You can learn more about Dr. Nora Vasquez at www.renewyourmindmd.com. Dr. Vasquez is a member of the Bexar County Medical Society.

Reference: 1. Dyrbye, Liselotte N., Shanafelt T. "Effect of a professional coaching intervention on the well-being and distress of physicians:

Visit us at www.bcms.org

MENTAL HEALTH

Recognizing Mental Health in Youth By Mrudula Rao, MD and Michael Arambula, MD

uicide is the second leading cause of death in young people, ages 10-24 in the United States (CDC, 2020). Approximately 19% of all high school students (grades 9-12) seriously considered suicide during the past year (YRBS) and 9% actually made a suicide attempt during the past year (CDC, 2020). Not far from home, suicide is the second leading cause of death in young people, ages 10-24 in Texas (CDC, 2020). In 2020, the total number of suicide deaths in Bexar County youth were 20, compared to 10 total deaths in 2014, 6 in 2012 and 3 in 2010. The data shows that suicides in youth have gone up in Bexar County over the past 10 years. Similarly, 19% of all high school students seriously considered suicide during the past year and 10% made a suicide attempt during the past year (CDC, 2020). Autopsy studies have further shown that 90% of young people who died by suicide had a mental health condition, of which most were untreated, under-treated or undiagnosed. More recently, clinical research has shown that the COVID-19 pandemic has substantially undermined the emotional well-being of all our citizens. The need for mental health and suicide awareness is now more important than ever. The onset of more serious and chronic mental illnesses typically occurs during childhood and adolescence, during a time when students spend most of their lives in the classroom. Our students learn about science, mathematics, history, language and art to better prepare them for life as a young adult, whether it be at work or in college (or both), and starting a family. The time our students spend in the classroom is also a fertile opportunity for physical and mental health education as well. In the recent 87th Texas Legislative Session, the Texas Medical Association urged state legislators to make mental health education and awareness part of mandated school curriculum in Texas from elementary through high school. However, the legislators only “encourage” and “recommend” actions be done. Adolescents who receive physical and mental health education will better understand what their minds and bodies are going through as they develop; and they are more likely to seek assistance from the people who surround them in their lives (like a friend, teammate, teacher or parent). They are more likely to notice a change in the emotional 18

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well-being of their school friends too. The iron is hot at the moment, and the time to invest a few classroom hours in mental health education and awareness in our children’s lives would be a timely, productive and long-lasting health policy. To see a complete mental health resource guide for schools, please visit https://www.fitcitysa.com/mental-health-resource-guide-forschools/. To see the TMA’s policy on mental health education in schools, visit https://www.texmed.org/Template.aspx?id=57369. To see the AMA’s policy on mental health education in schools, please visit https://policysearch.ama-assn.org/policyfinder/detail/D-345. 994%20Increasing%20Detection%20of%20Mental%20Illness%20an d%20Encouraging%20Education?uri=%2FAMADoc%2Fdirectives.x ml-0-1165.xml. Supporting Organizations: American Foundation for Suicide Prevention, Bexar County Psychiatric Society, Bexar County Juvenile Probation Department, Psychiatrists, Pediatricians, Parents, City of San Antonio Mayor’s Fitness Council Executive Committee, NAMI, PBS/KLRN, Humana, Texas Association for Health, Physical Education, Recreation, and Dance, Bexar County Medical Society, Texas Schools Teachers/Superintendents and various other medical entities. Mrudula Rao, MD is an Adjunct Assistant Professor in the Division of Psychiatry at the University of Texas Health Science Center San Antonio. Dr. Rao is in private practice, specializing in the treatment of adult, adolescent and child psychiatric disorders. She is the past President of the Bexar County Psychiatric Society and is a member of the Bexar County Medical Society. Michael Arambula, MD is the current President of the Texas Society of Psychiatric Physicians and the immediate past President of the Texas Medical Board. Dr. Arambula practices General and Forensic Psychiatry. He is a member of the Bexar County Medical Society.

MENTAL HEALTH

DESTIGMATIZING MENTAL HEALTH AMONG PHYSICIANS AND MEDICAL STUDENTS By Niva Shrestha

“I regret that only now, in my last annual meeting speech, am I telling you about my own struggles. My anxiety and depression were on the verge of derailing my career aspirations. My fear of being judged negatively and the dark shadow of stigma nearly kept me from seeking help.” – 2018 AAMC President’s Address by Darrell G. Kirch, MD7

n the pursuit of helping others, physicians and medical students often forget to take care of themselves. Physicians make a lifelong commitment to medicine, and good mental health is imperative to sustain that commitment. It is crucial to acknowledge that “suicide is the only cause of mortality that is higher in physicians than nonphysicians.”1 Historically, this is not a new phenomenon. Documentation dating back to the nineteenth century indicates that suicide rates among physicians has always remained higher than that of the general public.1 For decades, however, physicians have been taught to “power through” and “tough out” the most mentally demanding times of their lives. This unwillingness to acknowledge and address mental health fuels personal, professional and intuitional stigma surrounding physician mental health. By destigmatizing mental health among physicians and medical students, the medical profession can create a more inclusive, healthy community that can better serve one another and their patients. A myriad of reasons exists as to why physicians may feel uncomfortable seeking or asking for help. This fear often begins with the intense personal and professional pressure doctors put on themselves, beginning in medical school. Medical education is often the source of many mental health issues. Chronic, prolonged stress leads to anxiety, 20

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burnout and depression with potentially permanent consequences, such as suicide or compromised medical care. Sometimes this pressure stems from other responsibilities, personal factors or psychiatric illnesses. Whatever the cause of stress, addressing physician mental health starts in medical school. A recent meta-analysis discovered the prevalence of depression or depressive symptoms among medical students was 27.2% and suicidal ideation was 11.1%.2, 3 Fortunately, many medical schools are now taking steps to normalize student mental health discussions, making it culturally acceptable for medical students to ask for help. Providing staff clinical psychologists, having access to peer support groups, promoting Mental Health Awareness Week— which is October 3 through October 9 this year—and increasing transparency on the psychological struggles associated with medical school are ways in which modern medical schools are helping destigmatize mental health. Providing medical students with comprehensive mental health training and resources will set a solid foundation for competent, healthy future physicians. In a study of more than 9,900 programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) during 2000-2014, suicide was found to be the second leading cause of death among resident physicians.4 Barriers to care have led to

only 1 in 4 trainees who wanted mental health treatment actually seeking care. Reportedly, the biggest barriers to care were “lack of time (77%), concerns about confidentiality (67%), concerns about what others would think (58%), cost (56%) and concern for effect on one's ability to obtain licensure (50%)”.4 These barriers are similar for attending physicians. These statistics demonstrate how doctors face not only professional but also personal and institutional stigma regarding mental health.5,6 As an institution, the AGEME in 2011 implemented an 80-hour resident work week and eliminated extended duration shifts for first-year residents. This is a small step in the right direction, acknowledging that all doctors have physical and mental limitations. However, to influence continued pr ogressive institutional change, the people who are a part of the health care system— physicians, other health care professionals, health care administrations and health care students— must first address their own biases about themselves and their colleagues seeking mental health treatment. Implicit biases about personal welfare as a physician can be so ingrained, that the person who needs help may not understand or recognize they need it. Some believe staying up all night to study or feeling chronically tired is a badge of honor—a reflection of their dedication to the medical profession—but it is not. There-

MENTAL HEALTH

fore, it is important to continue the conversation of mental health in all aspects of medical training, especially in continuing medical education. As medical knowledge evolves, so too will understanding of mental health and the vast resources available to physicians. Workplace policies should also evolve to recognize and support the pressing issue of physician mental health. In the past, physicians who struggled with mental health lived in fear: fear of being labeled as weak or incompetent, or fear of professional consequences after the admission of receiving professional help. Lack of professional support negatively impacts a physician’s critical thinking and ability to help patients. Therefore, destigmatizing and supporting mental health among all health care professionals is vital to the welfare of current and future generations of providers and patients. The stigma of mental health is not something that will disappear within a generation. While the stigma improves with each decade, there are still strides to be made. That can only happen if the medical community continues to prioritize mental health amongst themselves. Good mental health not only benefits the physician but also benefits their loved ones, colleagues and the patients they care for.

“But an extraordinarily empathic student affairs dean steered me to the treatment I needed. As a result, I am blessed to stand here today. Many of you have a story like mine. We need to tell our stories and beat back the stigma that causes so many of our learners and colleagues to suffer in silence. Speaking out and erasing the stigma around seeking help is a most worthy mountaintop to reach.” – 2018 AAMC President’s Address by Darrell G. Kirch, MD7 References 1. Albuquerque J, Tulk S. Physician suicide. CMAJ. 2019;191(18):E505. doi:10.1503/cmaj.181687 2. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016;316 (21):2214-2236. doi:10.1001/jama. 2016.17324 3. Dyrbye LN, Thomas MR, Shanafelt TD. Medical Student Distress: Causes, Consequences, and Proposed Solutions. Mayo Clin Proc. December 2005;80(12):1613-1622 4. Aaronson AL, Backes K, Agarwal G,

Goldstein JL, Anzia J. Mental Health During Residency Training: Assessing the Barriers to Seeking Care. Acad Psychiatry. 2018 Aug;42(4):469-472. doi: 10.1007/s40596-017-0881-3. Epub 2018 Feb 14. PMID: 29450842. 5. Gerada C. Doctors, suicide and mental illness. BJPsych Bull. 2018;42(4):165168. doi:10.1192/bjb.2018.11 6. Henderson M, Brooks SK, Del Busso L, et al. Shame! Self-stigmatisation as an obstacle to sick doctors returning to work: a qualitative study. BMJ Open. 2012;2(5):e001776. Published 2012 Oct 15. doi:10.1136/bmjopen-2012-001776 7. Kirch DG. AAMC President’s Address 2018 “The Mountaintops”. November 4, 2018. Niva Shrestha is a second-year medical student at the University of Incarnate Word School of Osteopathic Medicine (UIWSOM) and a member of the BCMS Publications Committee.

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MENTAL HEALTH

A BRIDGE BETWEEN THE MIND AND THE SKIN By Tue “Felix” Nguyen, Marie Vu and Caroline Zhu

Introduction Like many medical disciplines, dermatology intersects with other specialties to coordinate patient care optimally. An overlap that has been emerging for years is the relationship between the skin and the mind. Since both systems are inherently complex, medical professionals are continuing to investigate this association to better understand how it impacts our patients. Psychodermatology, a multidisciplinary subspecialty, focuses on integrating the principles of dermatology, psychiatry and psychology to approach patients holistically. The origins of psychodermatology can be traced throughout history. Hippocrates (460 - 370 BC), the father of modern medicine, recorded how stress affects the skin and described a hair-pulling disorder later to be known as trichotillomania.1 The book, Diseases of the Skin, written by English dermatologist and surgeon William James Erasmus Wilson in 1846, highlights various skin conditions such as alopecia areata, pruritus and hyperhidrosis which are strongly influenced by the human psyche.1 In modern medicine, dermatologic patients continue to have additional mental burdens. The incidence of psychiatric disorders in dermatologic patients is about 30-60%.2 Recognizing the psychosocial implications in skin disease is important; patients with refractory skin disease may have an underlying psychiatric disorder that needs to be addressed in order to improve therapeutic outcomes. In this article, we will explore the following three categories encompassed by psychodermatology: 1. Psychophysiologic disorders 2. Psychological problems caused by skin disorders 3. Primary psychiatric disorders with dermatologic symptoms Psychophysiologic Disorders Psychophysiologic disorders are dermatologic diseases that are worsened by stress or other emotional states. Examples of these conditions include eczema, acne, alopecia areata and hyperhidrosis. When interviewing patients about their chief complaints, patients may be unaware of how stress and anxiety can impact the skin. Thus, physicians should investigate any recent stressors for exacerbating factors. The percentage of patients reporting emotional disturbances accompanying their skin condition varies, but the range is estimated to be around 50% to greater than 90%.3 22

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In conjunction with treating the skin condition, counseling patients to adopt various stress-relieving and relaxation techniques may be beneficial to reduce the number of acute flares. If conservative management is insufficient, psychological pharmacotherapy such as benzodiazepines, SSRIs or other psychotherapies may be needed.4 Psychological Problems Caused by Skin Disorders Skin diseases are often associated with secondary psychological comorbidities such as depression and anxiety, as well as what some have termed “subsyndromal morbidities”: embarrassment, shame and low self-esteem.5 This association has also been demonstrated through several well-designed studies. In 2004, a group of investigators conducted a life-quality study on a population of over 18,000 Norwegian adults with a self-reported skin morbidity. The group found significant impacts on social problems and a strong association with depression in patients with skin disease.6 Similar findings were reported in a survey study of 8,000 adults, which identified a sustained association between skin problems and poor emotional health, despite adjusting for psychiatric diseases.7 Additionally, an analysis on patients with psoriasis discovered a correlation between psychiatric disturbances and severity of skin findings. The authors noted that even with clinical improvement, psychological suffering could persist.8 The pediatric population is also greatly affected by this relationship between skin disorders and secondary psychological problems. For instance, acne severity in adolescents has been correlated with depression and anxiety, and has even been suggested to increase suicide risk.9,10 Through the demonstration of the relationship between skin diseases and secondary psychiatric disorders, these studies highlight the importance for clinicians to consider evaluation for and concomitant management of psychological comorbidities in patients with skin disease. Primary Psychiatric Disorders with Dermatologic Symptoms Patients with primary psychiatric disorders can also present with skin manifestations. However, any observable skin lesions are not of dermatologic etiology and are usually self-induced. Two disorders that fall under this category are discussed: delusions of parasitosis and trichotillomania. Delusions of parasitosis11 is a condition in which an individual has delusions of parasitic infestation on the skin from mites, lice, fleas, spi-

MENTAL HEALTH

ders or other organisms. The cause of this condition is unknown and most commonly occurs in middle-aged white women; however, all individuals can still be affected. Characteristic symptoms of delusions of parasitosis include sensations of itching, burning, crawling and biting that may lead to extensive excoriation of the skin. Additional signs include a patient history of frequently visiting different physicians with no resolution of symptoms, as well as keeping specimens in a small container or bag with clinic visits. Such specimens typically include fragments of hair or skin with no clear evidence of the inciting organisms. A diagnosis is made through exclusion of other true infestations or conditions that may induce the sensation of itchiness, such as drug abuse. Treatment of patients with delusions of parasitosis should involve dermatologists, psychiatrists and entomologists, as patients are often convinced of the existence of their infestation. It is important to gain patient trust before initiating any pharmacotherapy, which may occur over repeated visits. Antipsychotics have been used to treat delusions of parasitosis, but not as solo therapy. Patients should receive additional support and attention in order to properly manage their condition. Trichotillomania12 is an obsessive-compulsive related disorder characterized by urges to repeatedly pull one’s hair, resulting in subsequent hair loss especially in areas such as the scalp. An associated phenomena includes trichophagia, in which affected individuals ingest their own hair. The cause of trichotillomania is not well-understood; however, individuals with this condition experience significant emotional distress, often impairing social and occupational functioning. In many cases, it usually occurs in adolescence and symptoms may occur in a cyclic manner. The two main forms of treatment for trichotillomania include pharmacotherapy and psychotherapy. While there are currently no FDA-approved drugs for trichotillomania, there is preliminary evidence that shows beneficial treatment effects with clomipramine, n-acetyl cysteine and olanzapine.13 Of these different medications, n-acetyl cysteine is the most well tolerated with fewer significant side effects. Psychotherapy in the form of cognitive behavioral therapy aims to treat individuals through habit reversal, awareness training and stimulus control. Conclusion Dermatologic diseases and psychiatric disorders work synergistically to impair our patients’ quality of life. Although it is easy to overlook any present mental disorders when interacting with dermatologic patients, physicians are encouraged to anticipate psychiatric comorbidities. For the future of dermatology, psychodermatology may play a more prevalent role in patient care as it acknowledges the bridge between the mind and the skin. References 1. França K, Chacon A, Ledon J, Savas J, Nouri K. Pyschodermatology: a trip through history. An Bras Dermatol. 2013;88(5):842-843.

2. Korabel H, Dudek D, Jaworek A, Wojas-Pelc A. Psychodermatologia: psychologiczne i psychiatryczne aspekty w dermatologii [Psychodermatology: psychological and psychiatrical aspects of dermatology]. Przegl Lek. 2008;65(5):244-248. 3. Cotterill JA. Psychophysiological aspects of eczema. Semin Dermatol. 1990;9(3):216-219. 4. Jafferany M. Psychodermatology: a guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry. 2007;9(3):203-213. 5. Magin P, Sibbritt D, Bailey K. The relationship between psychiatric illnesses and skin disease: a longitudinal analysis of young Australian women. Arch Dermatol. 2009;145(8):896-902. 6. Dalgard F, Svensson A, Holm JO, Sundby J. Self-reported skin morbidity among adults: associations with quality of life and general health in a Norwegian survey. J Investig Dermatol Symp Proc. 2004;9(2):120-5. 7. Bingefors K. Lindberg M, Isacson D. Self-reported dermatological problems and use of prescribed topical drugs correlate with decreased quality of life: an epidemiological survey. Br J Dermatol. 2002;147(2):285-90. 8. Sampogna F, Tabolli S, Abeni D. The impact of changes in clinical severity on psychiatric morbidity in patients with psoriasis: a follow-up study. Br J Dermatol. 2007;157(3):508-13. 9. Kilkenny M, Stathakis V, Hibbert ME, Patton G, Caust J, Bowes G. Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms. J Paediatr Child Health. 1997;33(5):430-3. 10. Xu S, Zhu Y, Hu H, Liu X, Li L, Yang B, Wu W, Liang Z, Deng D. The analysis of acne increasing suicide risk. Medicine (Baltimore). 2021;100(24):e26035. 11. Chamberlain SR. Trichotillomania. NORD (National Organization for Rare Disorders). 2021. https://rarediseases.org/rarediseases/trichotillomania/. Accessed on August 27, 2021. 12. Ngan V. Delusions of parasitosis. DermNet NZ. 2005. https://dermnetnz.org/topics/delusions-of-parasitosis/. Accessed on August 27, 2021. 13. Baczynski C, Sharma V. Pharmacotherapy for trichotillomania in adults. Expert Opin Pharmacother. 2020;21(12):1455-66.

Tue “Felix” Nguyen, Marie Vu and Caroline Zhu are medical students at UT Health San Antonio who are interested in dermatology. They all serve as officers for the medical school’s Dermatology Interest Group.

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MENTAL HEALTH

A Closer Look at the Medical Needs of San Antonio’s Homeless Population By Kaleigh Longcrier, OMS IV, Taylor Sullivan, DO and Hans Bruntmyer, DO, MPH

n January 2020, there were approximately 2,932 people experiencing homelessness in the San Antonio area, which is a 2% increase from 2019.1 In the state of Texas, 27,229 people are living either sheltered or unsheltered on a single night, which is a 5% increase from 2019.2 A growing homeless population comes with an increase in demand of health needs. Lack of primary care establishment can lead to progression of chronic diseases, such as diabetes or hypertension, leading to a downward spiral of complications. This often leads to ER visits and hospital admissions.3 These visits ultimately contribute to the overall financial burden that plagues the American health care system today.4 The first step in decreasing the burden of disease and creating a holistically healthy and more cost-effective health care system begins by identifying the types and prevalence of diseases in the homeless population. Helping our community can take many forms and facets, but if the needs are unknown, our attempts would be futile. Knowing the most pressing and prevalent health conditions among the homeless in a particular region is a springboard to create programs or protocols to address these issues. 24

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The motivation behind caring for San Antonio’s homeless population can be multifactorial. It can be argued that helping the homeless in Bexar County can improve overall health outcomes of the city and can decrease the financial burden of disease. Restoring the health of the homeless could create opportunities for labor intensive or physically demanding work, and thus theoretically decrease the incidence of homelessness itself.5 It can also be argued that in general, taking care of those less fortunate is an altruistic duty of society and a sacred ideal held in many religions. Christian Medical and Dental Association (CMDA) and Church Under the Bridge (CUB)6,7 are two of several organizations in San Antonio that have this layered and multifactorial motivation behind caring for the homeless population. The authors of this paper have conducted a retrospective review (University of the Incarnate Word Institutional Review Board Approval Number 21-02-004) from four free clinics provided to homeless patients by CMDA and CUB during March 2019 to January 2020. The following results were obtained on an intake form completed by patients and from history & physical elicited by students (with oversight by physicians and dentists) during the free clinics.

MENTAL HEALTH

Results Demographics: Fifty five percent of patients were male and 45% were female. There was a nearly even distribution of age among our patients; the majority ranged from 18-60. Nearly half listed a home address and twenty percent reported living at a shelter. Less than a third of patients reported having a primary care physician and 1/3 of patients had been hospitalized in the preceding 3 years. Figure 1

Of the patients with hypertension, 16% were on medication and the average systolic blood pressure reading was 136 mmHg. Nine percent of patients were on diabetic medications and the average glucometer reading was 132 mg/dL. Nearly three quarters of our patient population were overweight, obese or severely obese. Figure 3 displays body mass indices of homeless patients. Fifty six percent had a BMI greater than or equal to 30 and thirty percent with a BMI greater than or equal to 35 (classified as extremely obese). Figure 3

Figure 1 describes the distribution of health needs during the clinics. On the dental side of the clinic, the most common intervention was extractions (46%), followed by dental hygiene (30%) and 16% of patients had dental restorative procedures. On the medical side of the clinic, the most common chief complaint was musculoskeletal, including knee, shoulder, neck, back, and foot pain, and tendonitis. Following musculoskeletal complaints, the rest of the patients did not have a specific complaint, but rather requested a physical exam (i.e., a checkup) or needed a refill for a known medical condition. Several patients had chronic medical conditions needing attention, exhibited below in Figure 2.

Discussion Table 1 displays a comparison of 2016 Bexar County prevalence rates of various health conditions to the homeless patients in our free clinics.8,9 As seen, these numbers are significantly higher amongst homeless patients than the general population. Lack of health education, financial support and access to primary care could be some of the main reasons why homeless patients’ rates are higher than county rates.

Figure 2

Table 1

Figure 2: The most common medical problems seen at our free clinics. Hypertension, Arthritis and diabetes were the most prominent conditions seen.

Figure 3: Visual representation of homeless patients’ BMI. Only 3% of our patients were underweight.

Table 1: Comparison of the most common medical conditions seen in the homeless patients compared to local rates. As seen, the prevalence is dramatically increased in the San Antonio homeless population than the general population.

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MENTAL HEALTH

continued from page 25

cluding back pain, foot pain and neck pain. Additional interventions included cupping, counseling on ergonomics, home therapy and occasionally prescribed anti-inflammatories. We encouraged regular attendance at our clinic for subsequent OMT treatments. Future Considerations According to 2020 Point in Time Count, 21% of individuals experiencing homelessness are suffering from some form of mental illness in Bexar County.1 However only 4% of our patients disclosed as much during the clinics. Including mental health on our intake form could prompt the interviewer to elicit a psychological history. Additionally, future collaboration could include psychology and therapy students from local universities to participate in our clinics and provide counseling to this marginalized population. Presenting the most common conditions from our clinics was the first step in our pursuit to highlight and bring care to San Antonio’s homeless patients. We intend to follow these patients over many clinics once they start back up again (currently halted due to the COVID19 pandemic) to determine if our interventions are making a positive benefit to this population.

Obesity was frequently encountered. Despite the common association of homelessness with underweight individuals, we found 56% of our patients to be obese or extremely obese, and this number increases to 76% when we include overweight individuals. According to a study completed by Tsai, et al. in 2013,11 57% of surveyed homeless adults across the United States were overweight or obese. This statistic is further demonstrated in another study which cited 67% of the homeless populations they surveyed were overweight or obese.12 This raises many questions about a hunger-obesity paradox, and what can be done in clinical settings to educate patients about diet and nutrition. It could also be an area further developed in public health campaigns and policy formation to increase the availability of healthy food access to this demographic. The most prevalent chronic diseases we came across during our clinics were obesity, diabetes and their complications (i.e., self-reported nephropathy, neuropathy, Charcot foot). These remain more of a challenge to treat, as medical treatments require pharmacologic intervention and necessitate follow up. Having regular, frequent clinics (i.e., monthly rather than quarterly), even if hosted by other ministries, could provide consistent care. The most common chief complaint we encountered was musculoskeletal pain. University of the Incarnate Word School of Osteopathic Medicine medical students performed osteopathic manipulative treatment10 on several of the patients’ complaints, in-

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Acknowledgements The authors would like to thank Scott Philips and Mitzi Roberts of CMDA San Antonio, Diane Talbert of Church Under the Bridge San Antonio and Dr. Arunabh Bhattacharya of UIWSOM for their support and assistance on this project. References: 1. South Alamo Regional Alliance for the Homeless (Ed.). (2020). 2020 Point-in-Time Count Report San Antonio and Bexar County. SARAH Homeless. https://www.sarahomeless.org/wpcontent/uploads/2020/05/2020-PIT-Report-_5.14.pdf 2. 2020 Annual Report. Texas Homeless Network. (2020, December 17). https://www.thn.org/2020-annual-report/ 3. Garrett, D. G. (2012, January). The business case for ending homelessness: having a home improves health, reduces healthcare utilization and costs. American health & drug benefits. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046466/ 4. Hwang, S. W., Weaver, J., Aubry, T., & Hoch, J. S. (2011). Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Medical care, 49(4), 350–354. https://doi.org/10.1097/MLR.0b013e318206c50d 5. Integrate Health Care. Integrate Health Care | United States Interagency Council on Homelessness (USICH). (n.d.). https://www.usich.gov/solutions/health-care 6. Christian Medical & Dental Associations. (2020, July 23).

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7. 8.

10.

11.

12.

Healthcare for the Poor. Christian Medical & Dental Associations. https://cmda.org/healthcare-for-the-poor/ San Antonio Help for the Homeless. CUB Church Under the bridge. (n.d.). https://cub-sa.org/ City of San Antonio Metropolitan Health District (2016). Bexar County Data Report https://www.sanantonio.gov/Portals/ 0/Files/health/News/Reports/BRFSSReport2016_5-3118.pdf ?ver=2018-06-04-155732-877 Centers for Disease Control and Prevention. (2020, December 8). PLACES: Local Data for Better Health. Centers for Disease Control and Prevention. https://www.cdc.gov/places/ American Osteopathic Association. (n.d.). OMT: Osteopathic Manipulative Treatment. American Osteopathic Association. https://osteopathic.org/what-is-osteopathic-medicine/osteopathic-manipulative-treatment/ Tsai, J., Rosenheck, R. (2013) Obesity among Chronically homeless adults: Is it a problem? Public Health Reports. https://pubmed.ncbi.nlm.nih.gov/23277657/ Koh, K.A., Hoy, J.S., O’Connell, J.J., Montgomery, P. Hungerobesity paradox: Obesity in the Homeless. Journal of Urban

Health. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3531350/ Kaleigh Longcrier is a fourth-year medical student at UIWSOM applying to Family Medicine residency. She is also CMDA’s Texas Student Leader Representative and Student Trustee to the Board of National Trustees. Taylor Sullivan, DO is graduate of the inaugural class at UIWSOM, current General Surgery resident at UTHSCSA and member of Bexar County Medical Society Publications Committee. Hans Bruntmyer, DO, MPH graduated from Texas College of Osteopathic Medicine in 1994. After completing residencies in emergency and aerospace medicine, Dr. Bruntmyer retired from the U.S. Air Force in 2015. His current medical practice consists of providing Osteopathic Manipulative Medicine (OMM) and general health care at a free clinic for the marginalized in his community. He is a member of the Bexar County Medical Society.

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MENTAL HEALTH

The San Antonio Refugee Health Clinic: Addressing Barriers to Refugee Mental Health By Emily Liu, Melissa M. Donate, Zeba Bemat, Anuradha S. Helekar, MD and Blake A. Harrell, DO

he United Nations Refugee Agency defines a refugee as someone who has been forced to flee their country because of persecution, war or violence.1 In 2020 alone, 82.4 million people were forcibly displaced.2 This is an increase from past years, even with the COVID-19 pandemic slowing the rate of new displacement. Furthermore, the U.S. has historically resettled more refugees than any other country, with Texas often resettling the highest number of refugees compared to other states.3,4 Since 2010, more than 10,000 refugees have resettled in San Antonio as permanent residents.5 Though the specifics of refugee experiences vary widely, many of these individuals 28

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have had an arduous path, including forced displacement, a difficult journey away from their home country and the struggles associated with resettling in a new, unfamiliar country. Thus, an important consideration to make when characterizing the health needs of refugees is to examine the trauma they experience preflight, during flight and in resettlement.6 These stressors put refugees at an increased risk for mental health disorders.7,8 On average, one in every three refugees experience depression, anxiety or PTSD, with prevalence rates ranging between 20-80%, depending on the population.9 Despite the high prevalence of mental health concerns, many refugees do not seek out mental health

care. Common structural barriers include lack of access to health insurance, logistical barriers (transportation, child care needs, access to care, etc.) and language or other communication barriers.10,11 Of note, refugees admitted to the United States are provided short-term health insurance called Refugee Medical Assistance for eight months.12,13 However, after that expires, up to 50% of refugees may be uninsured, even with policies which allow for immediate access to Medicaid, CHIP and the health care marketplace. Language and communication barriers complicate all stages of health care, through filling out health insurance forms, scheduling appointments and filling prescriptions.11

MENTAL HEALTH

Differences in cultural beliefs surrounding health care is another social barrier that must be addressed.11 Due to previous health care experiences, refugees often have different expectations of health care compared to native U.S. citizens. For instance, some refugees are not accustomed to preventative care or having providers who are a different gender from themselves.11 This can contribute to negative perceptions of medical care. Finally, stigma around mental health disorders may deter seeking care due to fears of hospitalization, alienation from their community, being seen as “crazy” or loss of confidentiality.14 Finally, the detection of mental health problems in refugees can be challenging due to differences in mental health conceptualization.10,15 For example, mental health presentations in refugees may not adhere to the norms of what is considered a “symptom” of a mental health disorder. For example, previous trauma experienced by refugees can present through somatic symptoms which cause

distress, a phenomenon known as somatization.16 Furthermore, some refugees may believe their symptoms and/or mental health concerns have no treatment.14 Others may also think that talking about mental health problems can worsen their condition, and thus, it is best not to discuss it.14 There is still much to do regarding the appropriate treatment for refugees and asylum seekers. Providers can open meaningful discussions and provide education to destigmatize symptoms and mental health services, as well as make refugees more comfortable during visits with the use of direct questions and trained interpreters.17 Another potential solution is through a holistic approach focusing on collaboration with local community partners to decrease risk factors for adverse mental health outcomes. An evidence-based intervention to detect ongoing mental health concerns for the purpose of connecting with care is through the use of culturally competent screenings for refugee mental health, such as the Refugee Health Screener 15-item questionnaire (RHS-15). The RHS-15 is a sensitive, validated instrument for screening various refugee populations for emotional distress and mental health considerations.18 The RHS-15 has been translated and validated for use in several languages. The translated screeners have language-specific semantics to ensure the meanings are accurate in their own language. The screener is only recommended for use if there are adequate resources available for the conducting and scoring of screenings, as well as the method of referral for further evaluation and treatment.18 Program Overview: The San Antonio Refugee Health Clinic (SARHC) is a collaborative effort of students and faculty from medical, nursing and dental schools at the University of Texas Health Science Center San Antonio. The clinic is held weekly at a local church, within

walking distance of an area where a significant portion of the city’s refugee community has settled. The SARHC provides free preventive and acute medical, psychiatric and dental care to uninsured and underinsured members of the refugee community. On-site interpreters help facilitate communication between providers and patients. In addition to health concerns, patients can consult the Center for Refugee Services (CRS). The center often has representatives on-site for social needs, including employment opportunities, ESL classes and citizenship applications. The SARHC has made additional efforts to be community- and patient-centered by allowing walk-in services and providing prayer mats as needed for religious practices. In 2018, SARHC began working with UT Health Psychiatry residents and faculty to provide mental health care in response to community-expressed need, titled “Wellness Nights.” At weekly SARHC clinics, patients can request to be seen or referred by their medical provider to psychiatry staff, who see patients monthly. Additionally, medical student coordinators have implemented screening with the RHS-15. Once someone is identified as potentially benefitting from referral to wellness resources, medical student coordinators are the first point of engagement, normalizing the need to request help for their mood and/or physical symptoms, while also providing context around psychiatric services. Patients who consent to being seen will then be scheduled for a future Wellness Night appointment by a psychiatrist. Since April 2019, 35 patients have received both acute and long-term, follow-up care through Wellness Night. Common diagnoses seen include depression (57%), PTSD (34%) and anxiety (26%), with many patients having comorbid disorders. Medications are provided on-site via a pharmacy stocked through the Center for Medical Humanities and Ethics at UTHSCSA. Labs can also be performed through University Health. continued on page 30 Visit us at www.bcms.org

MENTAL HEALTH continued from page 29

Future opportunities for growth include expansion of mental health services outside of psychiatric care. Some patients express reluctance to see a psychiatrist, but would potentially be open to approaches such as talk therapy or support groups. In addition, as student coordinators, we hope to engage student volunteers more meaningfully through Wellness Nights. Recently, Wellness Night staff held a training session for RHS-15 survey administration, trauma-informed care and handling challenging patient encounters. This also allows student volunteers from multiple disciplines to participate in screening. Our work would not be successful without the years of trust that the SARHC and CRS have built within this community. It has been inspiring to see the relationships 30

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built through the dedication of faculty, residents and students. Furthermore, the experience of engaging our patients in these vulnerable conversations has been a privilege, and this opportunity has been invaluable to practice trauma-informed care and psychological first aid. We look forward to drawing on these experiences in our future practice as students and physicians. References: 1. What is a REFUGEE? Definition and Meaning: USA for UNHCR. Definition and Meaning | USA for UNHCR. https://www.unrefugees.org/refugeefacts/what-is-a-refugee/. Accessed September 6, 2021. 2. Refugee statistics. USA for UNHCR. https://www.unrefugees.org/ refugee-

facts/statistics/. Accessed September 6, 2021. 3. Fact sheet: U.S. refugee resettlement. National Immigration Forum. https://immigrationforum.org/article/fact-sheet-u-s-re fugee-resettlement/. Published November 5, 2020. Accessed September 6, 2021. 4. Krogstad JM. Key facts about refugees to the U.S. Pew Research Center. https://www.pewresearch.org/fact-tank /2019/10/07/key-facts-about-refugeesto-the-u-s/. Published August 20, 2020. Accessed September 6, 2021. 5. Center for Refugee services located in San Antonio, Texas. Center For Refugee Services. https://sarefugees.org/. Published August 20, 2021. Accessed September 6, 2021. 6. Mental Health. Refugee Health Technical Assistance Center. https://refugee-

MENTAL HEALTH

healthta.org/physical-mental-health/mental-health/. Accessed September 6, 2021. 7. Schlaudt VA, Miller AB. Refugee communities. APA PsycNet. https://psycnet.apa .org/record/2019-70450-017. Published 2019. Accessed September 6, 2021. 8. Peterson C, Poudel-Tandukar K, Sanger K, Jacelon CS. Improving mental health in Refugee Populations: A Review of intervention studies conducted in the United States. Issues in Mental Health Nursing. 2020;41(4):271-282. doi:10.1080/0161 2840.2019.1669748 9. Turrini G, Purgato M, Ballette F, Nosè M, Ostuzzi G, Barbui C. Common mental disorders in asylum seekers and refugees: Umbrella review of prevalence and intervention studies. International Journal of Mental Health Systems. 2017;11(1).

doi:10.1186/s13033-017-0156-0 10. American Psychological Association, Presidential Task Force on Immigration. (2012). Crossroads: The psychology of immigration in the new century. Retrieved from http://www.apa.org/topics/immigration/report.aspx 11. Morris MD, Popper ST, Rodwell TC, Brodine SK, Brouwer KC. Healthcare barriers of refugees post-resettlement. J Community Health. 2009;34(6):529538. doi:10.1007/s10900-009-9175-3 12. Health insurance. The Administration for Children and Families. https://www.acf.hhs.gov/orr/pro grams/refugees/health. Accessed September 6, 2021. 13. Refugee populations. Centers for Disease Control and Prevention. https://www.cdc .gov/coronavirus/2019-ncov/need-extraprecautions/refugee-populations.html# :~:text=Underlying%20medical%20conditions%20and%20lower%20access%20t o%20care&text=However%2C%20after %20their%20short-term,of%20 refugees%20may%20be% 20uninsured. Accessed September 6, 2021. 14. Shannon PJ, Wieling E, Simmelink-McCleary J, Becher E. Beyond stigma: Barriers to discussing mental health in refugee populations. Journal of Loss and Trauma. 2014;20(3):281-296. doi:10.1080/ 15325024.2014.934629 15. Song S. Mental Health Facts on Refugees, Asylum-seekers, & Survivors of Forced Displacement. https://www.psychiatry. org/File%20Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-Refuge es.pdf. Accessed September 6, 2021. 16. Rohlof HG, Knipscheer JW, Kleber RJ. Somatization in refugees: A review. Social Psychiatry and Psychiatric Epidemiology. 2014;49(11):1793-1804. doi:10.1007 /s00127-014-0877-1 17. Shannon PJ. Refugees' advice to physicians: How to ask about mental health. Family Practice. 2014;31(4):462-466.

doi:10.1093/fampra/cmu017 18. Hollifield M, Verbillis-Kolp S, Farmer B, et al. The refugee Health SCREENER15 (RHS-15): Development and validation of an instrument for anxiety, depression, and PTSD in refugees. General Hospital Psychiatry. 2013;35(2):202-209. doi:10.1016/j.genhosppsych.2012.12.002

Emily Liu and Melissa M. Donate are medical students at the UT Health Long School of Medicine and serve as Wellness Coordinators at the San Antonio Refugee Health Clinic (SARHC). Zeba Bemat is a medical student at the UT Health Long School of Medicine and served as a previous Wellness Night Coordinator. Anuradha S. Helekar, MD and Blake A. Harrell, DO are Wellness Night Resident Coordinators and resident members of the Bexar County Medical Society.

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Post-COVID Complications and Neurological Sequelae: PM&R Perspective By Monica Verduzco-Gutierrez, MD and Carol Li, MD

To date, millions of Americans who have been affected by COVID19 have residual symptoms that result in a heterogenous post-infectious condition referred to as “long COVID syndrome,” or Post-Acute Sequelae of SARS-CoV-2 infection (PASC). The CDC has now defined this as persistent symptoms after initial infection with a lack of return to usual state of health that lasts more than four weeks. Severity of acute illness correlates with post-COVID complications, as 36.4% of patients with severe COVID had a higher probability of neurological symptoms, such as acute disseminated encephalomyelitis, ischemic stroke and Guillain-Barre syndrome,1,6 compared to those with mild to moderate disease.2 However, persistent symptoms can also occur after noncritical COVID-19 infection. A recent prospective study reported 66% of patients with mild-moderate course had at least one symptom that persisted beyond 60 days.3 Management of this patient population has yet to be standardized, but a comprehensive and multidisciplinary approach is necessary. Since physiatry has a strong focus on medical complications impacting function, and many of PASC symptoms can have significant implications on quality of life and functional status, a multi-disciplinary PM&R led outpatient clinic for post-COVID recovery has been suggested.5 A Physiatric Approach to Care for Post-COVID Conditions: A Brief Overview The most common PASC symptoms include fatigue, post-exertional malaise and decreased endurance. There are different therapeutic approaches when addressing these symptoms. Some patients may respond very well to a structured, progressive return-to-activity program with physical therapy. A proposed protocol for this progressive reconditioning is described in the Salman study,7 as well as by other resources such as ‘Couch to 5K’ put forth by National Health Service – England. For others who present more like myalgic encephalomyelitis/chronic fatigue syndrome, slower paced physiotherapy to address breathing pattern disorders and education on pacing and energy conservation are more helpful. For patients with persistent dyspnea with minor activities, pulmonary rehabilitation can be considered, especially for patients with respiratory failure requiring ICU admission.8 More research is needed for pharmacologic interventions, but amantadine and duloxetine have shown some benefits for improving central fatigue in the right patient population. 32

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There may also be exacerbations of chronic pain symptoms. Multi-joint arthralgias or generalized myalgias can be responsive to NSAIDs, given the inflammatory pathophysiology of PASC. New onset paresthesias involving upper extremities or unmasking of premorbid asymptomatic neuropathies may also occur. In cases where paresthesia symptoms fall within a certain nerve distribution or associated with focal weakness, electrodiagnostic and nerve conduction studies may be indicated to localize the lesion or look for myopathy. Further physiatric evaluation on how these symptoms can be managed to maximize patient’s functional ability with orthotics, PT/OT, steroid injections or nerve blocks can be done. “Brain fog” can manifest as cognitive impairment, behavioral changes, poor concentration and attention, short term memory deficits and psychological symptoms. A brief neurocognitive screen can be helpful. The mini mental status exam can be completed for inperson encounters. For patients with physical limitations where telemedicine platforms may be more effective, the Modified Telephone Interview for Cognitive Status can be useful in screening for mild cognitive impairment. Speech therapy can provide compensatory strategies and structured cognitive retraining, especially for patients who are experiencing cognitive symptoms that are functionally disruptive. The long-term effects on the central nervous system are poorly understood at this time, but because the inflammatory changes parallel that of accelerated intracellular aging exposed to multiple stressors over time,4 it has been suggested that the very persistence of this inflammation in the brain can potentially be associated with neurodegeneration. This may bring into light the potential role of incorporating a wellbalanced, anti-inflammatory diet and certain nootropic supplements in neuro-recovery. Other common PASC symptoms seen in PM&R clinic include headaches, autonomic dysfunction and anosmia. Episodic migraine management can mostly follow the AAN guidelines,9 depending on phenotype. For migraines occurring more than 15 times a month, a

SAN ANTONIO MEDICINE

combination of magnesium oxide, riboflavin and coenzyme Q10 can be a good prophylactic before considering other sedative pharmacologic alternatives. Advanced imaging should be considered in patients with new onset headaches with auras or focal neurologic deficits. Anosmia may persist for as long as six months post infection, and a trial of intranasal steroids in conjunction with olfactory training can be considered before consulting ENT, while simultaneously monitoring for malnutrition as the impact of anosmia can affect oral intake. In addition to evaluating cardiopulmonary status, assessing autonomic dysfunction with regards to volume status, orthostatic intolerance with sit to stand changes and need for compression garments may also be necessary. Adjustment post-COVID recovery can present as increased anxiety or depression. Patients with pre-morbid psychiatric conditions may be more at risk. This makes the collaboration with psychology and neuropsychology specialists invaluable. It is in this author’s opinion that managing neuropsychiatric symptoms can synergistically improve management of other symptoms of cognition, sleep disorders, headaches and fatigue, as they often coexist with each other. Most importantly, empowering patients with self-management strategies, appropriate coping strategies, educational resources about vaccination and data regarding the risk of re-infection is also important. The frequency of outpatient follow-up care is variable and individualized depending on when the decision about clinical resolution of PASC symptoms is made and the return to baseline function has occurred. Given the complexity and variety of presentations of PASC, a collaboration between PM&R, primary care, therapy teams and various subspecialties is essential to further deepen our understanding of how to best manage the unique needs of this patient population. The increasing prevalence of PASC suggests that even as the pandemic evolves and restrictions begin to decrease, the demand for longterm follow up and rehabilitation management for COVID-19 survivors will continue to increase. The end goal is learning how to balance the use of available public health resources to match this demand while optimizing a patient’s daily routine, lifestyle or work/school performance. References 1. Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kummerlen C, Collange O, Boulay C, Fafi-Kremer S, Ohana M, Anheim M, Meziani F. Neurologic Features in Severe SARS-CoV-2 Infection. N Engl J Med. 2020 Jun 4;382(23):2268-2270. doi: 10.1056/NEJMc2008597. Epub 2020 Apr 15. PMID: 32294339; PMCID: PMC7179967.

2. Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683-690. doi:10.1001/jamaneurol.2020.1127 3. Carvalho-Schneider C, Laurent E, Lemaignen A, et al. Follow-up of adults with noncritical COVID-19 two months after symptom onset. Clin Microbiol Infect. 2021;27(2):258-263. doi:10.1016 /j.cmi.2020.09.052 4. Lippi A, Domingues R, Setz C, Outeiro TF, Krisko A. SARS-CoV2: At the Crossroad Between Aging and Neurodegeneration. Mov Disord. 2020;35(5):716-720. doi:10.1002/mds.28084 5. Barratta JM et al. Post Acute Sequelae of COVID-19 Infection and Development of a Physiatry-Led Recovery Clinic. American Journal of Physical Medicine & Rehabilitation. 2021 6. Ellul MA, Benjamin L, Singh B, Lant S, Michael BD, Easton A, Kneen R, Defres S, Sejvar J, Solomon T. Neurological associations of COVID-19. Lancet Neurol. 2020 Sep;19(9):767-783. doi: 10.1016/S1474-4422(20)30221-0. Epub 2020 Jul 2. PMID: 32622375; PMCID: PMC7332267. 7. Salman D, Vishnubala D, Le Feuvre P, Beaney T, Korgaonkar J, Majeed A, McGregorA. Returning to Physical Activity after COVID 19. BMJ 2021;372:m4721. http://dx.doi.org/10.1136/bmj. m4721. Published: 08 January 2021 8. Al Chikhanie Y, Veale D, Schoeffler M, Pépin JL, Verges S, Hérengt F. Effectiveness of pulmonary rehabilitation in COVID-19 respiratory failure patients post-ICU. Respir Physiol Neurobiol. 2021 May;287:103639. doi: 10.1016/j.resp.2021.103639. Epub 2021 Feb 12. PMID: 33588090; PMCID: PMC7879818. 9. Update: Pharmacologic treatment for episodic migraine prevention in adults. American Academy of Neurology Summary of Evidencebased Guideline for Clinicians. American Headache Society. 2012.

Monica Verduzco-Gutierrez, MD runs the Post-COVID Recovery Clinic at UT Health San Antonio. Carol Li, MD is the medical director of outpatient neurorehabilitation services at the Polytrauma Rehabilitation Center of the Audie L. Murphy VA Hospital. Dr. Verduzco-Gutierrez and Dr. Li are members of the Bexar County Medical Society.

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How Social Determinants of Health Impact Wellness Programs By Roxanne Leal

There are many factors that affect our health. We know that eating well, exercising and seeing a doctor when we are sick are simple steps that we can take to keep ourselves healthy, but our health is also affected by access to social and economic opportunities. Social determinants of health include the following factors: • • • • • • •

Socioeconomic status Education Neighborhood (zip code) Physical environment Employment Social networks Access to care

According to the Centers for Disease Control, “Poverty limits access to healthy foods and safe neighborhoods and more education is a predictor of better health. We also know that differences in health are striking in communities with poor social determinants of health, such as unstable housing, low income, unsafe neighborhoods, or substandard education.” Addressing social determinants of health is important for improving health and reducing health disparities. Studies propose that health behaviors such as smoking, poor diet, lack of exercise and social and economic factors are the main drivers of health outcomes, and that social and economic factors can shape individuals’ health behaviors. Not only are social determinants of health important factors that affect overall health, but addressing them can also help reduce health disparities that are often rooted in social and economic disadvantages. Education is Key I grew up with my grandparents in a low-income community where nutrition wasn’t a high priority. As in the case with many low-income families, my grandparents did not really know enough about proper nu-

SAN ANTONIO MEDICINE • October 2021

trition or how to create a healthy living environment to equip me with the proper resources for leading a healthy lifestyle. How do we change this? I believe the key is education. When I was 18 years old, a friend took the time to show me how to eat healthy and the importance of exercise. I was able to change my nutrition and start engaging in regular physical exercise, which improved my overall well-being and enhanced my enthusiasm for living a healthy lifestyle. This friend is the reason I got into the corporate health world. Every time I make a nutrient-packed smoothie or go for a jog, I thank that friend. Thanks to that introduction to healthy living, I devoted my career to creating those opportunities for others. Reaching out to those individuals who need educational resources can create positive change in the health of any employee population. The most effective and successful benefits programs are only further enhanced by education—both for leadership and employees. Through regular communication, you can give your employees tips on leading a healthy lifestyle such as balanced nutrition, regular exercise and regular health screenings. Provide information on the effects of smoking, obesity, alcohol use and unhealthy practices that can lead to high blood pressure, high cholesterol, stress and depression. Understanding Your Employee Population The success of a targeted wellness program is defined by each organization’s unique employee population. Building a successful wellness program that positively impacts the health of your employees begins with understanding their demographic makeup, baseline health status, and overall health and wellness education. When creating wellness programs for your employees, it’s crucial to understand their living conditions, income and education levels and access to care. Un-

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derstanding the population is the first step to creating a successful targeted program. According to the Office of Disease Prevention and Health Promotion, “By working to establish workplace policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time.” Understanding the demographics of your workforce can help you determine what types of benefits will be most effective for your business and employees. Building the Best Wellness Program for Your Employees It’s important that you understand how your employees feel about the benefits you’re offering them so that you can continue to optimize your program over time. You can find out how your employees feel about your program by conducting surveys, analyzing provider reports, or studying provider and actuarial research. If you’re aware of what your employees like or don’t like about their benefits, you can make an effort to highlight those things in your regular communication. For example, if your plan includes a free annual biometric screening but your employees do not take advantage of it, you can include reminders in your communication program. Learning how your employees feel about their benefits will arm you with the information you need to revise your communications to

meet realistic goals and expectations, your employees’ needs, your communication plan objectives and your business’s requirements. Developing Healthy Partnerships By taking the time to develop partnerships with local health vendors such as dietitians, fitness trainers and mental health professionals, and making access to these services easy to access and understand, organizations can provide their employees with resources and services that will help them stay healthy. Whether your organization would like to add a corporate wellness program to your employee benefits plan, or would like to enhance an existing program, SWBC’s Employee Benefits Consulting Group can provide consulting services to help you design and maintain a plan that meets the requirements of your organization. SWBC can provide the analytical support, develop custom communication materials and assess the benefit to your company. Visit swb.us/custom-benefits to learn more. Roxanne Leal has been with SWBC since December 2019. As a Wellness Program Manager, Roxanne specializes in developing strategic wellness programs based on high-cost claims, survey data and aggregate reports. She has worked in the health & wellness industry for over 7 years. SWBC is a Gold Circle of Friends Sponsor of the BCMS. Visit us at www.bcms.org

BOOK REVIEW

Chicken Soup for the ICU: A Review of “Kitchen Table Wisdom – Stories That Heal” By David Alex Schulz, CHP

When Dr. Rachel Remen’s work was first published in 1996, it seemed a radical approach to healing. By its 10th anniversary reprint, it was seen as pioneering “new age” medical care and respected, if not fully adopted. Today, a quarter-century after its appearance, “Kitchen Table Wisdom” is doctrine. Call it “integrated,” call it “alternative,” call it “holistic,” Dr. Remen, as both a health care leader and long-time chronically-ill patient, invites us to consider wellness from a perspective that looks beyond diagnosis, increasing the scope to the widest angle possible. First as a pediatrician, later as a counselor, Dr. Remen began exploring the spiritual dimension of the healing arts. Her experiences have taught her that life is "coherent, elegant, mysterious, aesthetic,” she writes. “When I first earned my degree in medicine, I would not have described life in this way. But I was not on intimate terms with life then." Now, Clinical Professor of Family and Community Medicine at UCSF School of Medicine; Founder and Director of the Institute for the Study of Health and Illness at Wright State University Boonshoft School of Medicine in Dayton, Ohio; and author of The Healer’s Art, a groundbreaking curriculum for medical students, she is considered a leader of Relationship-Centered Care and Integrative Medicine. More than seventy vignettes comprise “Kitchen Table Wisdom,” stories related by patients, colleagues, seers, clergy, and her own professional and personal testimony. Not all are concise parables with beginnings, middles and ends; some are homilies, others fables, salted with a scattering of straightforward philosophical discussions of essence and being; of experience and its meaning.

SAN ANTONIO MEDICINE • October 2021

She tells of three stonecutters: the first, who saw his effort as boring piece-work; the second, who delighted in the same piecework, as it enabled his family a secure life; and the third, who saw the integral role his stones would have in the great cathedral for which they were cut. He saw their meaning. “Meaning may become a very practical matter for those of us who do difficult work or lead difficult lives. Meaning is strength. Physicians often seek their strength in competence. Indeed, competence and expertise are two of the most respected qualities in the medical subculture, as well as in our society. But important as they are, they are not sufficient to fully sustain us,” reflects Dr. Remen. From the birth, through the span of life’s challenges (many selfimposed, such as an ‘urge to judgment’) to palliative care and beyond, Dr. Remen’s stories cross all borders and religions. “As St. Luke wrote in Acts of Apostles 4:11, the stone rejected by the builders may prove in time to be the cornerstone of the building. What we believe about ourselves can hold us hostage. Over the years I have come to respect the power of people’s beliefs. The thing that has amazed me is that a belief is more than just an idea—it seems to shift the way in which we actually experience ourselves and our lives. According to Talmudic teaching, ‘We do not see things as they are. We see them as we are.’ A be-

lief is like a pair of sunglasses. When we wear a belief and look at life through it, it is difficult to convince ourselves that what we see is not what is real,” writes Remen, who is equally conversant in Buddhist, Islamic and Hindu beliefs. “Kitchen Table Wisdom” finds its connective tissue in both how we affect one another, and the therapeutic effect of relating stories about healing. These narratives are about more than helping people embrace healthier lives: they lead to accepting the role that each person plays in others’ health, and understanding our own place in the cycle of life with serenity. I emphasize ‘our’ in the belief

BOOK REVIEW

that no health care professional can finish this book it without having found strong identification with at least one if not many of the situations, circumstances, conundrums, koans, or life-passages portrayed. For example, her recounting of visiting a parent in palliative care, when the author’s mother imagined her own mother, the author’s namesake and long-passed, was also visiting: “My mother began to tell her mother Rachel about my childhood and her pride in the person I had become. Her experience of Rachel’s presence was so convincing that I found myself wondering why I could not see her. It was more than a little unnerving. And very moving. Periodically she would appear to listen and then she would tell me of my grandmother’s reactions to what she had told her.” No one attending a parent in the end-transi-

tion would find this story in the least remarkable or unusual except in its lucidity. Dr. Remen is at heart an anti-reductionist, advocating that health simply cannot be explained in terms of its constituent parts and their interactions. She comments, “My tendency to tell stories had always been frowned upon by my medical colleagues and rejected as ‘anecdotal evidence.’ They preferred to measure truth in terms of hard data. So I had learned to keep my stories to myself.” Dr. Dean Ornish agrees in the book’s forward, “Anecdotal evidence — in other words, stories — is viewed with suspicion by scientists. There are too many confounding variables, so the facts are harder to prove, to replicate.” Now, a quarter-century later, “Kitchen Table Wisdom” continues to defy reductionist thinking, using deeply moving and

LETTER TO THE EDITOR

life-changing anecdotes, convincingly illustrating the remedial power of stories, from easing suffering and dispelling fear, to healing shame and restoring the sense of worth. The reason it has been continually in print is the author’s sincerity: “In the end, I write about something I know intimately: that every one of us matters. And that we have the power to befriend and strengthen the life in one another and to change the world, one heart at a time.” All quotes and images from “Kitchen Table Wisdom - Stories That Heal” by Rachel Naomi Remen, MD, Copyright ©1996, Penguin Publishing. David Alex Schulz, CHP is a community member of the BCMS Publications Committee.

The Bexar County Medical Society is proud to welcome a New Platinum Sponsor

It is with pleasure that I write to commend you for the exceptional quality of San Antonio Medicine magazine. I appreciate reading about the most recent COVID developments, the workings of the Bexar County Medical Society, and the goings-on of our two sterling medical schools: the UT Health San Antonio Long School of Medicine and the University of the Incarnate Word School of Osteopathic Medicine. The ‘Art in Medicine’ feature reminds me of those JAMA covers and essays that I enjoyed for so many years. Book discussions by David Schulz are very entertaining as well. Keep up the good work! Sincerely, Neal S. Meritz, MD Neal S. Meritz, MD is a retired Family Practice physician and a member of the BCMS Publications Committee. If you would like to send a letter to the editor of San Antonio Medicine magazine, please email editor@bcms.org.

Please support this sponsor with your patronage, thank you. Visit us at www.bcms.org

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Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

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SAN ANTONIO MEDICINE • October 2021

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

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking (210) 283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com 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 www.bbt.com/wealth/start.page "All we see is you" Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need. Synergy FCU Member Services (210) 750-8333

info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

BUSINESS CONSULTING

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210.846.9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210.557.9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

FINANCIAL ADVISOR

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community. Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner” Elizabeth Olney with Edward Jones (HH Silver Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

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

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

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

HEALTHCARE BANKING

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

First Citizens Bank (HHH Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com Danette Castaneda Business Banking Specialist 512.797.5129 Danette.castaneda@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise” Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private 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

human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension & topical wound care. info@NitricOxideInnovations.com (512) 773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options. Laura Kouba Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

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

Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent & treat

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the

Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

continued on page 40 Visit us at www.bcms.org

PHYSICIANS PURCHASING DIRECTORY continued from page 39

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

INVESTMENT ADVISORY REAL ESTATE

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates). Jon Wiegand Principal 210-241-2036

jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

MEDICAL BILLING AND COLLECTIONS SERVICES

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.” Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL PHYSICS

SAN ANTONIO MEDICINE • October 2021

shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL PAYMENT SYSTEMS/CARD PROCESSING

First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com Danette Castaneda Business Banking Specialist 512.797.5129 Danette.castaneda@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

MORTGAGES

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.

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

PRACTICE SUPPORT SERVICES

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org

sales, lease representation and financial restructuring (equity, debt, and partnership updates). Jon Wiegand Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate” Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management. Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease” The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center. Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

RETIREMENT PLANNING REAL ESTATE SERVICES COMMERCIAL

Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELEHEALTH TECHNOLOGY

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship, please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366

Visit us at www.bcms.org

AUTO REVIEW

SAN ANTONIO MEDICINE • October 2021

AUTO REVIEW

2021 FORD BRONCO SPORT By Stephen Schutz, MD

This is not a review of the new and long-awaited Ford Bronco. New Broncos are finally arriving at dealerships around the country to rapturous applause from anxious customers, many of whom put down hefty deposits over a year ago. But the Bronco Sport is not a Bronco. In fact, it’s so different that I wondered why it’s named, “Bronco” at all. The real Bronco is a direct competitor to the Jeep Wrangler, and for that reason is a legit off-road intending big tough truck. The Bronco Sport, on the other hand, is a much smaller crossover SUV with styling elements that connect it to its big brother, but has nothing else in common with it. It’s not wrong to think of the Bronco Sport as a rebodied Escape. A Ford Escape is a nice vehicle owned by many fine, hardworking Americans, but exciting it is not. Ford probably thought, “wouldn’t making a more ‘off-roady’ version generate some enthusiasm that the Escape can’t?” Yes, it would, and after driving the Bronco Sport for a week, I understand why it’s here—for that enthusiasm. Importantly, it looks way more like a Bronco than it does an Escape. Three people asked me what I thought of “the new Bronco” and were disappointed that it wasn’t that (all three said something like, “Oh that makes sense, it seems too small”). Bronco-esque styling cues on the Bronco Sport include a boxy profile, an upright grille with the name “Bronco” across it in big letters, a hefty clamshell hood, short front and rear overhangs, and big chunky door handles. I haven’t driven the Bronco yet—I very much hope to soon, by the way—but I’m certain that it will drive nothing like the Bronco Sport. The latter drives, no surprise, a lot like the Escape (and Toyota Rav4, Honda CRV and GMC Terrain), which is to say pleasant. Handling is reassuringly neutral, the ride is comfortable without being too cushy and acceleration is acceptable. A 181HP 1.5-liter 3-cylinder turbo are the guts of the Bronco Sport, but a 245HP 2.0-liter four-cylinder turbo is also available as an option. Both come with an eight-speed automatic transmission, and all versions come with AWD. The 3-cylinder gets you a 0-60 MPH time of 8.7 seconds, while the 4- does it in just 5.9. Fuel economy is 25 MPG City and 28 Highway for the 3-cylinder, and 21/26 for the 4-cylinder. The interior of the Bronco Sport is surprisingly good. The materials are nice to look at and touch, and the boxy shape of the vehicle provides a lot of space. In fact, there’s enough space in the configurable

cargo area for two mountain bikes (if you lay the rear seats flat). The screens, tech and what have you are as contemporary as anything from the competition. And like most new vehicles in 2021, the user interface is a central touch screen, which enables you to control the audio, phone and climate functions effortlessly without much distraction from the road. The overall impression from behind the wheel is that this is a tougher and (slightly) bigger Escape. The many Bronco-esque styling cues in and outside of this mainstream small SUV may make it seem a bit more adventurous than it really is. For instance, when you start the Bronco Sport, a little “movie” plays on the central screen, showing rolling boulders in a desert scene that suddenly come together to become a young horse (a Bronco!). I suspect the “real” Bronco will do the same thing. I get it, Ford wants to imbue Bronco Sport buyers with as much Bronco as they can, but it seems a bit like fans getting backstage passes to a rock concert—they feel almost like they're rock stars, but they’re not. For the record, the Bronco Sport does have some off-roading chops. While the upmarket Badlands edition sports an enhanced AWD system, stouter suspension components, and more ground clearance, even the base model Bronco Sport has been engineered for more off-road capability than the Escape. So, if off-roading is your thing, I’d go with the Badlands version. Pricing of the Bronco Sport is aggressive, with a base MSRP of just under $29,000. Badlands models, which I suspect BCMS members will be most interested in, start at around $35,000. This is 2021, the year of “no discounts,” so expect to pay right around MSRP (or more) for your Bronco Sport. The Bronco Sport is not a real Bronco, but it kind of looks like one, and it costs a lot less. While it can’t do what a Bronco can off road, onroad it’s a pleasant small SUV, and for many buyers these days, that’ll be just fine. 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 2021

San Antonio Medicine October 2021

Articles inside

By Emily Liu, Melissa M. Donate, Zeba Bemat, Anuradha S. Helekar, MD and Blake A. Harrell, DO

By Tue “Felix” Nguyen, Marie Vu and Caroline Zhu

By Niva Shrestha

By Mrudula Rao, MD and Michael Arambula, MD

By Dharam Kaushik, MD

By Nora Vasquez, MD

By Kaleigh Longcrier, OMS IV, Taylor Sullivan, DO and Hans Bruntmyer, DO, MPH