San Antonio Medicine November 2018

SAN ANTONIO

THE OFFICIAL PUBLICATION OF BEXAR COUNTY MEDICAL SOCIETY

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NOVEMBER 2018

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VOLUME 71 NO. 11

MEDICINE SAN ANTONIO

TA B L E O F CO N T E N T S

Women in Medicine

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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By Sean Price, Texas Medical Association .....................12

By Jessica Rutstein, DPM..............................................14

Education is the Key to Better Healthcare for Women

By Troy Robbin Hailparn, MD ........................................16

Taking Care of Others While Taking Care of Yourself

MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org

By Laura Huete, MD, MBA, FACMQ, CMQ ....................20

Fighting on Two Fronts

SUBSCRIPTION RATES: $30 per year or $4 per individual issue

By Nancy Semin, Texas Medical Association .................22

Physician Burnout: Breaking the Cycle

By Emmalind Aponte, MD..............................................26

The Challenging Complexities of Treating Breast Cancer. What does Google Say?

By Sharon T. Wilks, MD .................................................................................................................28

BCMS President’s Message........................................................................................................................8 BCMS Legislative News ............................................................................................................................10 BCMS News ............................................................................................................................................11 Air Pollution and Asthma By Theodore M. Freeman, MD ...........................................................................30 BCMS 165 Anniversary New Member Welcome........................................................................................34 BCMS Circle of Friends Directory ..............................................................................................................36 In the Driver’s Seat ....................................................................................................................................41 The Swarm, Part 3 of 4 By Allen Cosnow, DVM ........................................................................................42 Auto Review: 2018 Kia Stinger By Steve Schutz, MD ..............................................................................44

PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net BUSINESS MANAGER: Vicki Schroder

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San Antonio Medicine • November 2018

VOLUME 71 NO. 11

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Editor: Mike W. Thomas Email: Mike.Thomas@bcms.org

Work hard. Set priorities. And never give up.

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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.

The State of Women in Medicine

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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 or its staff.

San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Sheldon G. Gross, MD, President Gerald Q. Greenfield Jr., MD, PA, Vice President Adam V. Ratner, MD, President-elect Leah H. Jacobson, MD, Immediate Past President Kristi G. Clark, MD, Secretary John Robert Holcomb, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Jenny Shepherd, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Charles Mahakian, MD, Military Representative Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Manuel Quinones, MD, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member

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

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Pavela Bambekova, Medical Student Darren Donahue, Medical Student Carmen Garza, MD, Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member Austin Sweat, Medical Student J.J. Waller Jr., MD, Member

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San Antonio Medicine • November 2018

PRESIDENT’S MESSAGE

MEDICINE BENEFITS AS MORE WOMEN JOIN THE RANKS

By Sheldon Gross, MD, 2018 BCMS President

Dear Colleagues,

The theme for this month’s San Antonio Medicine is “Women in Medicine.” In the spirit of full transparency, my oldest daughter,

Leah, is a Cardiothoracic Anesthesiologist. I am immensely proud of her and the work she has done. This obviously affects my attitude

of women in medicine.

One of the great pleasures of my work week is having fellows in child psychiatry come and visit my office on Friday afternoons. I

have been doing this for over 20 years. Greater than 50 percent of these individuals are women. Without fail, I find them to be enthusiastic, attentive, and smarter than I am. I am sure that the same can be said for women in every aspect of medicine.

The Bexar County Medical Society has a long history of having a banquet every year honoring specific women in medicine who

have made outstanding contributions to our community. This year’s banquet is at the Witte Museum. I encourage all to attend, although

I am concerned they may already be sold-out.

The face of medicine has changed over the last 50 years as our culture and society has changed. My Aunt Winnie attended medical

school and trained as an anesthesiologist 70 years ago. She was one of a small number of women at that time allowed into medical

school. As any profession opens its doors to a wider array of applicants, what follows is a more effective use of human potential. I can only hope that this trend will continue.

Medicine benefits when we attract the best and the brightest. I am happy to add that the current President of the American Medical

Association, Dr. Barbara L. McAneny, is an oncologist from Albuquerque, New Mexico who is doing an exceedingly good job as one

of many women who have served as President of the American Medical Association. Of historical note, the first woman to ever serve

in this capacity at the AMA was a Texan, Dr. Nancy Dickey. I am also encouraged to see that an increasing number of women have become more actively involved with the Bexar County Medical Society in recent years.

Women make up more than 50 percent of the leadership group we have been training this past year. They have the same charac-

teristics of the child psychiatry fellows that I mentioned earlier. They are enthusiastic, focused, and they are smart.

I hope everyone has a nice Thanksgiving. As always, your thoughts and comments are always welcome at San Antonio Medicine.

Sincerely,

SHELDON GROSS, MD

President, Bexar County Medical Society

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San Antonio Medicine • November 2018

BCMS LEGISLATIVE NEWS

BCMS LEGISLATIVE NEWS TOBACCO 21 ORDINANCE EFFECTIVE AS OF OCT. 1 On Monday, Oct. 1, the day the new Tobacco 21 Ordinance went into effect, SA Metro Health hosted a press conference, including participating supporters (of which BCMS is a member) at the William R. Sinkin Eco Center at San Antonio College. Among the speakers were: Dr. Colleen Bridger, SA Metro Health Director and District 7 Councilwoman Ana Sandoval, chair of the City of San Antonio Health Equity Committee. San Antonio becomes the first city in Texas to pass and implement an ordinance to raise the age to purchase tobacco products to 21.

For more information on the new ordinance, go to: www.sanantonio.gov/Health/HealthyLiving/Smoking

PETE FLORES BECOMES THE NEW SENATOR FOR SENATE DISTRICT 19 The special election for Senate District 19 took place on Sept. 18 and the new Senator who will represent the people of this district is retired game warden, Pete Flores. This was a historical election in that Sen. Flores won a seat held by Democrats for the last 139 years.

His Democrat opponent was former state and U.S. Representative Pete Gallego. In addition, Sen. Flores becomes the first Hispanic Republican Senator in the Texas Senate. I stopped by the campaign watch party to congratulate Mr. Flores on behalf of BCMS. For local discussion on this and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

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San Antonio Medicine • November 2018

BCMS NEWS

TMA Regional Telephone Town Hall Hundreds of South Texas physicians joined the Texas Medical Association’s regional telephone town hall meeting on Oct. 3 which was held at the offices of the Bexar County Medical Society.

TMA President Doug Curran, MD, BCMS President Sheldon Gross, MD, and TMA lobbyist Dan Finch led the discussion, laying out the basics of the association’s 2019 legislative agenda.

“We’re about taking care of Texans, and we’re about figuring out how to best do it,” Dr. Curran said as he launched the event, which was hosted by the Bexar County Medical Society.

The telephone town halls encourage a conversation between TMA leaders and physician members across the state. At 7 pm (CT) the evening of the event, TMA called members at the home phone number on file in their membership record. Physicians simply had to answer the phone to join the call.

visit us at www.bcms.org

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WOMEN IN MEDICINE

The State of Women in Medicine

By Sean Price, Texas Medical Association

O

nce a male-dominated field,

medicine is changing as women

make up a growing part of the

physician population. Women physicians

also are rising to leadership roles, and the

Texas Medical Association is dedicated to

helping them. TMA’s Fall Conference recently featured an event on women in

medicine. For more information, visit

TMA’s

Women

in

Medicine

www.texmed.org/WomeninMed/.

page,

Below are some areas where women are

reaching equality with men in medicine — and areas where there's still work to do.

Copyright 2018 Texas Medical Association. Used with permission.

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San Antonio Medicine • November 2018

WOMEN IN MEDICINE

Pay

In 2017, female physicians earned 27.7 percent less (or $105,000) than their male counterparts; in 2016, female doctors earned 26.5 percent less (or $91,284).

There was no specialty in which women earned more than men.

visit us at www.bcms.org

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WOMEN IN MEDICINE

WORK HARD.

SET PRIORITIES. AND NEVER GIVE UP.

By Jessica Rutstein, DPM

is an honor to be a part of the medical community in San Antonio and contribute to the November 2018 issue of San Antonio Medicine, focusing on Women in Medicine.

When I decided I wanted to be a doctor, I did not really understand all of the challenges that lay ahead of me. I had grown up with doctors in the family; one aunt a pediatrician, another aunt a neonatologist, and my father a rheumatologist. I recall thinking it was an amazing job in every way. I wanted in.

So, I went the “pre-med” route upon entering University of Texas at Austin. I remember calling my father after the first week of engineering calculus at UT close to tears. “Dad, why do I need to know how to figure out the area underneath a roller coaster if I want to be a doctor?” I was only one of a handful of women in the class, and I had never taken calculus. My father replied: “It is just a game.

They are trying to weed out students who can handle medical school classes and those who cannot. Play the game and win.” It was a wake-up call. Work hard, get an “A”. So, I did.

After college I applied to all of the Texas medical schools and I was wait-listed at UTMB Galveston. During that time, I discovered Podiatry School. I shadowed with two San Antonio podiatrists, Dr. Larry Harkless and Dr. Richard Pollak, and realized it was a great fit for me.

Looking back now, becoming a podiatrist is one of the best choices I have made in my life. An added bonus: I met my husband, Dr. David Hughes, in podiatry school. It truly is a great field for women in medicine, one that I consider the best kept “secret” in medicine.

What is also fortunate about choosing my career as a doctor is that it can be flexible. This is essential in being successful with raising young children, having a family and a life! I have known several female physicians who simply quit their job because it is too stressful to try to “do it all”. Don’t quit! Make it work for you.

Currently, I work part-time and my husband works full-time.

It

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San Antonio Medicine • November 2018

When my kids get older, I will likely work more. For me, being there to pick my kids up from school and taking them to and from their after-school activities is important. Even though it is exhausting, it allows us to catch up and connect.

Another essential is exercise! Every day I wake up and force myself out of bed to exercise. If I did not sleep well (which is about every night) I will do gentle pilates or yoga. My goal is to jog daily and do weights. Sometimes I just walk the dog with my husband.

Keep moving. It clears the mind and keeps all the endorphins going.

I feel strongly about this: exercise first thing in the morning. You know you won’t go after clinic. Your energy has been sucked out of you after a long day and you are tired. You have to make dinner, walk the dog, and do your 7th grade science project. You have to get kids’ lunches ready for the next day and get the coffee ready for the morning.

Taking care of yourself includes whatever it is that you love doing, and doing that as often as possible. I love to travel, and we try to go on family trips a few times a year. I try to get a pedicure once a month and get my hair done at least once every two months.

Maybe 1-2 times a year I will treat myself to a massage. It is fun for me to feel like a woman, since most days I am in scrubs, no jewelry, and a ponytail. It is easy to forget yourself because most of your time is dedicated to taking care of everyone else. So, don’t feel guilty!

I also find a lot of joy from watching my kids participate in their activities. My daughter swims and my son plays golf. I try to go to all of my daughter’s swim meets and most of my son’s golf tournaments. This means saying “no” to other events, but at this time in my life my kids are my top priority.

That brings me to the other thing we need to do more: just say “no”. It is okay to not commit to every dinner, lecture, fundraiser, volunteer opportunity if you are already overwhelmed with what is on your plate. Life changes, and kids get older. You will have time for all of that stuff once the kids are grown up. I think it is great to

WOMEN IN MEDICINE

try to participate in what you can, but make good choices for you, your family, and your own sanity.

Another sanity saver is the Crockpot or pressure cooker! Food prepping has been really important and having everything ready to cook is key to a decent dinner. On my long days I prep the night before and then throw it all into the Crockpot in the morning. The pressure cooker is also ready to go for side dishes. Both are worth every penny. If all else fails, take-out works too! The time used in prepping is time saved during the week.

My other daily time saver has been utilizing technology to help me with completing my progress notes. I never go to bed without at least getting the same day’s dictation done. I try to sign off the same day, but at the latest, the next day.

I have been fortunate that I am working for The San Antonio Orthopedic Group. They have been continually improving technology utilized in the group to improve patient care and also help the doctors streamline their practices. We are currently using an App called “Entrada” which is a dictation service I have downloaded onto my cell phone. It syncs with my patients’ progress notes directly into the EMR. I am able to dictate my notes anytime and anywhere on my cell phone and then send it to the chart. This has worked out well, and is a real time saver. TSAOG has wonderful staff dedicated to helping me and all of the group’s physicians with our website and social media.

The challenges are vast in any career as a woman, but there is something very special about being a woman and a doctor. The secret to success is figuring out how to balance it all and also taking care of yourself. Letting go of perfection has been a learning process. Even though I always strive for an “A+” in all that I do, I am learning that if I am happy, my kids and husband are happy, and the patients are happy, an “A-“ is okay too!

Jessica Rutstein, DPM Podiatrist, The San Antonio Orthopedic Group

Dr. Jessica Rutstein credits her father, a rheumatologist, for encouraging her to get her medical degree.

Dr. Rutstein says it is important to make time for your family.

visit us at www.bcms.org

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WOMEN IN MEDICINE

EDUCATION

IS THE KEY TO BETTER HEALTHCARE FOR WOMEN

By Troy Robbin Hailparn, MD

hile in medical school at the Albert Einstein College of Medicine in New York, I found myself leaning towards a career in the field of Ob/Gyn. I’ve always been an advocate for women and women’s rights so it seemed to be a natural fit. When I moved to San Antonio and opened my own practice, Complete & Compassionate Ob/Gyn Care, I truly enjoyed being a part of creating families but also performing surgery and guiding women about their healthcare. Every patient received the time and care they deserved, and it was a pleasure watching the babies I delivered grow up over the years. Seeing women of all ages allowed me to counsel the younger ones on topics such as safe sex and reassure them their journeys through puberty were normal; while for my mature patients, helping them navigate their bodily changes through pregnancy, after birth and through menopause, let me see some of the more intimate concerns they were experiencing.

With the growing popularity of women seeking procedures to improve comfort, function and appearance changed by puberty, childbirth and aging, coupled with the questions my own patients were asking, I knew there was an increasing need for gynecologists to become more familiar with these physical issues.

As I sought to educate myself further with research and surgical training in labiaplasty, vaginal “rejuvenation,” mons liposuction, and more recently the non-surgical use of radiofrequency (ThermiVa) and platelet-rich plasma (PRP or the O-Shot) my journey gave me the opportunity to work with Drs. Marco Pelosi, David Matlock, Adam Ostrzenski and Red Alinsod — all leaders in the cosmeticplastic gynecological (CPG) field. While studying under world renowned gynecologic surgeon, Prof. Ostrzenski, I helped him to publish multiple articles on CPG procedures as well as participated in the very first two scientific sessions in CPG at international conferences that helped bring recognition and validation to women’s gynecological problems that weren’t being properly addressed. In 2011, I was one of three invited speakers to present at the 15th

W

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San Antonio Medicine • November 2018

Patient Vicki Filoteo with Dr. Hailparn and Shelly Miles on News 4’s SA Living.

World Congress in Controversies in Obstetrics, Gynecology and Infertility (COGI) in Hainan, China. The following year I participated in the first historic scientific session in CPG at the most reputable Ob/Gyn meeting in the world, the XX International Federation of Obstetricians and Gynecologists (FIGO) which recognized CPG for the first time as part of Gynecology. For the last few years, I have continued to lecture and offer courses to teach physicians here in San Antonio and abroad.

Because I am so passionate about taking care of women, my practice evolved, and 15 years ago I opened the Cosmetic Gynecology Center of San Antonio in the Stone Oak area. Having performed more than 4,000 vaginal procedures and well over 800 labiaplasties, I know that many women have comfort, sexual function and appearance concerns that are not being properly handled at routine Ob/Gyn visits. Some physicians are uncomfortable discussing sexual

(continued on page 18)

WOMEN IN MEDICINE (continued from page 16)

function problems and are resistant to learning these new procedures because they are set in their ways. They also don’t give women the time and care they deserve due to insurance constraints and the use of Electronic Medical Records.

Women who may need surgery for incontinence can end up with a hysterectomy as well because of the two lines doctors use that I strongly dislike: “While we are in there” and “You don’t need it anymore.” Unfortunately, some doctors remove the uterus and cervix because they make more money without letting their patients know that it doesn’t always need to come out. It is important to understand that the uterus is still useful after childbirth because it contributes to orgasmic contractions and the cervix not only supports the top of the vagina but lubricates it as well. I am always surprised when a patient tells me she has had a hysterectomy but doesn’t know if she still has her ovaries or cervix. How can you let a doctor operate and not fully understand what is being done to you? Consents are signed but it seems that women are signing without fully understanding what procedure(s) they are having. Also, when you go to your doctor who has taken good care of you for many years, and s/he says you need surgery, you trust this person’s opinion and don’t know the questions you should be asking.

Too often women are being dismissed with comments like “it’s all in your head” or “you are normal,” or “squeeze your muscles” whereas I have patients who couldn’t keep a tampon in, couldn’t run around with their children due to leakage of urine, have intimacy problems with their spouse or partner, or can’t exercise, do routine activities or wear a bathing suit due to extra tissue getting in the way or making them feel self-conscious. So many of my patients come in with little or no knowledge about their bodies. Everyone should be taught about their anatomy and how their parts work to know when something is wrong. I have been trained in the newest technologies including heat application and PRP which are non-surgical no downtime options that can replace hormones for vaginal dryness and help with incontinence, vaginal tightness and orgasmic intensity. As a woman and a doctor, it is imperative to have both compassion and sensitivity to these issues and tell them about all the available treatment options – surgical and non-surgical – so they 18

San Antonio Medicine • November 2018

can make the most informed decisions for themselves.

Education is the key to better healthcare. I use various social media platforms to educate women and men and to answer questions including Facebook (I did my first live chat on Labiaplasty a few weeks ago), Instagram, and RealSelf, where questions are presented daily and reviews and before and after photos are available.

I was asked by the American College of Obstetricians and Gynecologists (ACOG) to create an online educational eModule on the Labia Minora and Labiaplasty procedures for my Ob/Gyn colleagues which they copyrighted and published at the end of 2015 and have a book on Amazon called “Beneath Your Pink Perfect: Everything You Ever Wanted to Know About Labiaplasty But Didn’t Know to Ask” for women seeking information about the extra tissue, why it has occurred, what questions to ask their doctors and what they can do about it.

I was privileged to be chosen to give a TedxTalk in San Antonio last November and picked the topic of Female Anatomy 101, which can be seen on YouTube. On Nov. 15, I will be giving a dinner presentation on “Life-Changing Issues Ob/Gyns Don’t Talk About but Should” at Scuzzi’s Italian Restaurant. Anyone who is interested can contact my office.

My years of experience in practice have allowed me to change women’s lives and give them back their self-esteem and self-confidence. I receive hundreds of letters and cards from women whose lives I have helped dramatically improve and who finally feel comfortable in their bodies.

Of course, like all women, juggling work and home-life can be challenging. I’ve been extraordinarily lucky in that my husband has been extremely supportive as has my son. I think it’s important for him to see his parents work hard to give him a foundation for independence and to be passionate about work and helping others.

Dr. Troy Robbin Hailparn is a board-certified Ob/Gyn focusing on Advanced Cosmetic-Plastic Gynecology and Reconstruction techniques. She can be contacted at info@cosmeticgyn.net or at (210) 615-6646, and has an informative website www.CosmeticGYN.net. Her office is located at 525 Oak Centre Drive, Suite 220, SA, TX 78258.

WOMEN IN MEDICINE

taking care of others while taking care of

yourself

By Laura Huete, MD, MBA, FACMQ, CMQ

ome kids just know what they want to do from an early age.

I’m one of those fortunate few. As a young girl, I knew I wanted to be a physician and to help others become well and live healthy.

I love practicing medicine. It combines my love for science with taking care of others. Nothing deterred me from my dream, not even the demands of training and the challenges of learning how to care for others. I honestly couldn’t imagine doing anything else.

I am the only physician in my family. My family gave me so much

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San Antonio Medicine • November 2018

support during my education, and I am always grateful to them for all the help they provided.

One of the most enjoyable aspects of medicine is teaching others, whether it be my own patients or with my colleagues. As Senior Medical Director at WellMed Medical Group, I have the opportunity to coach, lead and mentor in a way that is incredibly fulfilling. Having the chance to greatly impact our patient population by providing access to quality health care is an incredible privilege.

Through innovative technology, physicians like me have access

WOMEN IN MEDICINE

to nearly real-time information about how our patients view us and the quality of their care.

This kind of scalable instant feedback wasn’t imaginable more than a decade ago when I completed my medical training. With new rating systems, patients can see whether practices are rated 1 star or 5 stars, and review what other patients think of the service. It truly is the Age of the Consumer.

That is one reason I am particularly proud of my involvement last year in helping WellMed to earn the Gold Seal of Approval for Ambulatory Health Care from The Joint Commission, the nation’s oldest and largest independent standards-setting and accrediting healthcare body. Additionally, The Joint Commission awarded all WellMed clinics with a Primary Care Medical Home (PCMH) Certification. Fewer than 350 medical groups in the country have attained both distinctions from The Joint Commission.

The journey to achieve these recognitions was arduous. Rigorous preparation validated WellMed's compliance with federal, state and local regulatory policies and procedures, as well as safety policies set by our affiliated healthcare companies.

The hard work paid off in several ways. WellMed experienced an 18-point jump between 2015 and 2017 in the Optum annual Patient Health and Safety Assessment, from 79 percent in 2015 to 97 per-

cent in 2017. WellMed clinics achieved this high mark even with more rigorous standards added to the assessment each year. We also realized improved communication and collaboration between departments, such as credentialing, education and training, and clinic operations.

Most importantly, the process forced us to further improve to meet our goals to promote patient safety, quality of care and efficiency of care. Like most physicians, these benchmarks are impetus for why I got into medicine. Just as importantly, we improve the overall patient experience by continually striving to achieve these goals.

Caring for others also taught me the importance of caring for myself. How can I expect my patients to be healthy if I’m not serving as an example?

Running is one of my favorite ways to do just that. I’ve finished five half-marathons, and I am currently training for my sixth. I also raced in two sprint triathlons. I love the physical and mental challenges of pushing my limits, yet I have to accompany the rigorous training with a healthy diet.

Living a healthy lifestyle includes keeping a daily mindfulness and gratitude practice, as well. Running is a fantastic stress reliever, making me a better-rounded person and practitioner. It shows in my attitude. My daughter and my close friends can even tell when I am overdue for a good long run!

I also make time for my family and friends by planning at least a couple of vacations annually. Experiencing other cultures, places and foods makes for a relaxing and enriching vacation. The chance to unplug and recharge also makes me a better physician for my patients and my staff when I do return to “the real world.”

Balancing work and life is never easy, particularly for those of us devoted to the practice of medicine. Yet making that balance a priority is essential so we can be effective for our patients, our families, and ourselves.

Laura Huete, MD, MBA, FACMQ, CMQ, is Senior Medical Director for Clinical Quality and Patient Safety for WellMed Medical Group.

visit us at www.bcms.org

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WOMEN IN MEDICINE

FIGHTING ON TWO FRONTS

By Nancy Semin, Texas Medical Association

Nov. 18 will mark the centennial of when the armaments of World War I at last fell silent. An armistice had been declared, and the fighting that claimed more than 32 million lives had finally come to an end. reaking the war down by numbers can sometimes blunt the human scale of courage and sacrifice. Still, about 4 million Americans served in World War I. Of those, about 13,000 were women, and fewer than 100 of them were physicians.

B

Only one of those doctors was from Texas: May Agness Hopkins, MD.

Born on Aug. 18, 1883, Dr. Hopkins grew up in Austin. Her father Eugene was a bookkeeper for a coal company but died in an accident in 1893 at only 34 years old. To support her family, the widowed Martha Hopkins found work as a laundress at the State Lunatic Asylum.

Out of these experiences, Dr. Hopkins learned to be resourceful and self-reliant.

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San Antonio Medicine • November 2018

May Agness Hopkins, MD.

She enrolled at The University of Texas at Austin, where a zoology scholarship helped pay her tuition. She stayed busy in school, captaining the women’s basketball team and serving as president of the Zeta Tau Alpha sorority before graduating with a bachelor’s degree in science in 1906.

Next was medical school at The University of Texas Medical Department, now The University of Texas Medical Branch at Galveston. In the early 20th century, it was acceptable for middle- and upper-class women to attend college, but obtaining a professional degree beyond that was something else entirely. Almost certainly Dr. Hopkins faced prejudice for her efforts, but she graduated in 1911 as the only female in her class.

Dr. Hopkins then moved to Dallas to establish her pediatric prac-

WOMEN IN MEDICINE tice. While she did note in a 1957 interview with the Dallas Times Herald that some people initially scoffed at a “lady doctor” in town, the decision to relocate there proved to be fortuitous. The early 20th century was transformative for the city of Dallas, which evolved from a frontier town to a thriving urban center that offered women a broader role in its many cultural and commercial developments.

But just as Dr. Hopkins began to build her medical practice, war broke out. Like many of her generation, Dr. Hopkins felt the stirrings of patriotism and duty and wanted to serve. And like most women of her generation, she was shut out of many opportunities to do so.

For doctors who wished to serve, the most direct route to the European front was the Army Medical Reserve Corps, but women physicians were explicitly barred from enlisting. Women could serve as stateside military physicians, but there would be no rank, no promotion, no bonus, and no pension.

The American Red Cross provided another option. The organization placed women directly in France to staff the Children’s Bureau, where they could perform medical services for displaced women and children. This was not battlefield medicine, but it was an opportunity Dr. Hopkins eagerly accepted as it afforded her passage across the Atlantic to work near the war zone.

When Dr. Hopkins left for France in July 1918, she was 35 years old and had never traveled outside of the United States, as she noted on her passport application. But like most new recruits, she was excited to be of service and eager to jump into action.

Told she would first need to fill out a couple of forms, Dr. Hopkins was frustrated to discover this involved four days of repetitive paperwork. She then sat idle for two more weeks as she waited on official orders from the French government.

Battlefield medicine

When Dr. Hopkins at last received an assignment, she was paired

with a group of women from Smith College. In fact, four groups of women had arrived in France under the organization of a special Ivy League commission, including alumnae from Radcliffe College, Wellesley College, and Vassar College. The Red Cross broke up the other three groups, giving those women individual assignments.

Only the Smith group remained intact.

When Dr. Hopkins headed out to the front lines on Aug. 12, she was part of a coterie of 12 other women. At dusk, they arrived at Chateau-Thierry, a deserted town that only three weeks prior had been held by the Germans during the Battle of the Marne.

Locating the former Red Cross headquarters was the women’s first priority, but they discovered it was uninhabitable. The roof had partially collapsed, all the windows were blown out, and the walls were riddled with shell holes. The women found the garden more hospitable. They laid out their bedrolls underneath the starry skies and nervously awaited a German air raid, which they had been told happened on a regular basis. They were unexpectedly given a reprieve.

“The enemy was good to us the first night,” Dr. Hopkins told the Herald, “and let us sleep in peace.”

The next morning the women further explored the village, but found no buildings intact. The village was unlivable and offered no safe refuge, so the women pitched tents on a nearby hillside. They hardly had finished this task when American troops approached re-

(continued on page 24)

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23

WOMEN IN MEDICINE (continued from page 23)

questing assistance with wounded soldiers.

As the only doctor in the group, Dr. Hopkins was asked to provide medical treatment, while the other women set up a canteen to feed the soldiers. The patients were in transit after being evacuated from field hospitals for further treatment at facilities outside the war zone. At this stop-over point, Dr. Hopkins performed battlefield medicine: re-bandaging wounds, irrigating the eyes of men who had suffered gas burns, and keeping watch on shell-shocked patients.

For the next two weeks, the women spent their days assisting the wounded. But the nights offered no respite. The Germans had resumed nightly air raids, and under a full moon when visibility was better, attacks were all but guaranteed.

“How I have learned to hate the moon,” Dr. Hopkins told the Herald. The women quickly developed a nightly routine. After falling asleep from exhaustion they were usually awakened by planes, prompting them to put on their helmets and run to a nearby dugout.

Dr. Hopkins was supposed to be performing refugee work for the Red Cross. Now she was doing what she and other women physicians had hoped for all along — serving on the front lines of the war.

Eventually, Dr. Hopkins was asked to travel with a group of wounded soldiers to ensure their safe arrival at a nearby hospital.

The journey started at 4 am with Dr. Hopkins, five aides, and 106 patients traveling down the Marne River by boat. Their only provisions: a box of bandages the French had left behind. To sterilize her hands, Dr. Hopkins used boiled water.

The journey was arduous and nerve-wracking. When the group finally reached its destination 17 hours later, Dr. Hopkins burst with pride. “David might have slain his tens of thousands, but May Agness had brought through 106 injured men,” she later said of the experience.

Continued service

After her unscheduled duty with the U.S. Army ended, Dr. Hopkins began her service in the Children’s Bureau in France. By no means was this work any easier. The agency screened roughly 600 children a day for possible infectious diseases and other medical needs. Many of them arrived on convoys from German-occupied territories, released because they were too young to provide labor in the agricultural or industrial sector.

By November 1918 an armistice was declared and fighting between the Germans and Allies ceased. Dr. Hopkins’ work with the

Red Cross kept her busy well beyond that date, organizing post-war clinics and hospitals in Marseilles and Avignon. But the war was over, and the armies and the vast bureaucracy that supported them gradually dismantled.

Dr. Hopkins returned to Dallas and busied herself with a wide array of professional and civic commitments. In addition to resuming her medical practice, she served on the faculty at Baylor University College of Medicine (before it moved to Houston), and was a member of the Texas Medical Association and American Medical Association.

In 1927 she married Howard E. Reitzel, who also served in France with the 111th Division Corps of Engineers. In 1931 she cofounded the Lyceum Club of Dallas (an arts, literature, and social activism group for women only) and served as president of the Zeta Tau Alpha sorority as well as its umbrella organization, the National PanHellenic Congress.

As Dr. Hopkins transitioned to civilian medicine, “Dallas seemed a little tame” compared to her war experience, she told the Herald.

A colleague of Dr. Hopkins’, however, fondly remembered she often made house calls in her large Buick with a revolver tucked under the front seat.

Dr. Hopkins answered the call to serve and did so despite the limitations imposed on women of her generation.

“I couldn’t have dreamed in my wildest dreams how wonderful Dallas has been to me and to all women physicians,” she said in her Herald interview. “But now I know the doors are open. Many hospitals and schools now want the woman physician. There are more and more opportunities for us.”

Special thanks to Robert Gunby, MD, and his wife Elizabeth for bringing Dr. Hopkins to the attention of the TMA History of Medicine Committee.

Copyright 2018 Texas Medical Association. Used with permission.

24

San Antonio Medicine • November 2018

visit us at www.bcms.org

25

WOMEN IN MEDICINE

PHYSICIAN BURNOUT Breaking the Cycle

By Emmalind Aponte, MD

L

ike most female physicians, I have a busy life. Every day is

a rush of completed tasks, new ones to complete, and

some that I can never get to. It is very easy for any physi-

cian to forget about their health and wellbeing. It is very easy to suf-

flexibility to work from home. I have learned that this tool is a dou-

ble-edged sword that can perpetuate the cycle of non-stop working.

We are always connected somehow to work, it can be via e-mails,

texting, phone calls, or electronic records. It is my opinion that the

fer from burnout when we live in a cycle of work, home chores,

more accessible we make ourselves through our mobile devices, the

Survey of America’s Physicians: Practice Patterns and Perspectives

As a mom, I want to spend quality time with my son and I want

family, and everything else that can happen in a given day. The 2018

more likely we are of burning out.

reported that 78 percent of physicians at least often feel burned

to give him my utmost attention. I worry about his school perform-

to their full capacity or over extend it. (1)

grows out to be a well-rounded man. As a wife, I want to make sure

and myself. The electronic medical records have facilitated our work

keep our common goals.

out. This same survey reports that 80 percent of physicians work As a working mom, I struggle with finding time for my family

by making patient’s information more available and giving us the 26

San Antonio Medicine • November 2018

ance and his extra-curricular activities; I want to make sure that he that I am sharing the best of me with my life partner and that we As physician, I worry about my patients like I would worry about

WOMEN IN MEDICINE a sick relative. I worry about their overall wellness, including how their families are coping

at home.

As we all know, medicine is an everchanging

field where in just one blink, a recent development can be old news. Information flies as

quickly as light and your patient may be the

one updating you about a new finding in medical sciences; keeping up with all the data adds

to my already demanding calendar.

As you can see, I’m a worrier and it is hard

to stay focused when you have so many wor-

ries floating around your thoughts. How do I

stay focused and avoid burning out? How do

I break the cycle that can lead to burn out?

I have not mastered the ‘science’ of not

worrying (and I don’t think I want to com-

pletely master it), but I can share a few tips

that I have learned that help me keep a balanced life: •

I start my day with a positive attitude and

try to enjoy every single moment with my patients. At the end, they are the reason

• • • • • •

why I chose medicine.

I have learned to set limits and when to say no to not over bur-

I am not a therapist or intend to be one, these are just a few things

den myself and safeguard family time.

that work for me and may not work for everyone. Nevertheless, I

It is a rule that I cannot break, and this time I spend exercising

that it will help others find their own way of dealing with routine

I make it a point to take time for myself; I call it my selfish time.

just wanted to share how I break the cycle every day with the hope

which is something that I love.

and stress.

myself to work at home. I find that if I don’t set that limit, then

Resources:

I try to plan family activities for almost every weekend that I’m

perspectives. And examination of the professional morel, practice

Just like I limit my son’s screen time, I limit the time that I allow

I’ll just keep working or worrying non-stop.

1.) 2018 survey of Americus physicians: Practice patterns and

not on call.

patterns, career plans, and perspectives of today's physicians, aggre-

them months ahead because I enjoy the process so much.

owners/employees.

One of my greatest joys are family vacations. I start planning Connecting to the world outside of the office and hospital is

of extreme importance to me. It keeps me leveled and keeps

my focus away from work. I have friends outside of the medi-

cine environment to always be able to see the world through

other perspectives, and never forget how wonderful life is.

gated by H, gender, primary care/specialist and practice WWW.physiciansfoundation.org Dr. Emmalind Aponte practices Hematology and Medical Oncology in San

Antonio.

visit us at www.bcms.org

27

WOMEN IN MEDICINE

The Challenging Complexities of Treating Breast Cancer

What does Google say?

By Sharon T. Wilks, MD

R

ecently, a dear medical school friend of mine reached out

to me about her step daughter who is a 42-year-old premenopausal female who was diagnosed with a multifocal,

node positive stage III breast cancer. I was asked about management and prognosis and to talk with the young lady who I last met when

she was in college. She now is a mother of six, married, home schools her children, a strong believer in God and had been previ-

ously healthy.

As this young lady and I talked and as I had tracked her progress

on her online journal (this has been a wonderful way to keep all of

her friends and family up to date and current regarding her status), I have been reminded again about how complex treating cancer –

particularly, breast cancer – has become. Adding to the oncologist’s

efforts of best choice is the establishment of online web sources

Where does one begin?

not be done or offered.

the current opinion that when a person presents with a lymph node

breast cancer care:

burden may be improved by use of Neoadjuvant chemotherapy

and social media groups that can establish what should or should

This young lady’s case highlights a number of aspects in current

• She is young;

• The disease was inoperable at presentation;

• She is BRCA mutation positive ( this appears to be inherited

from her dad who just turned 70 and is a prostate cancer survivor and just learned he is BRCA mutation positive);

• Her initial chemotherapy did not reduce her tumor and she went

to surgery recently where a small residual primary tumor (mixture of ductal and lobular) but a lot of lymph nodes were still active with breast cancer at resection;

At initial diagnosis, she was deemed inoperable. This was due to

positive (nodes are involved with cancer), the prognosis and disease

(NAC). Another factor with this case is the multifocal nature of the

cancer. When NAC evolved, it was hoped that cases that were in-

operable due to unknown margin and tumor clearance would be

made operable and might improve a patient’s ability to have an op-

portunity for breast conservative approaches surgically with lumpectomy or partial mastectomy.

Today, though NAC is used frequently, many who present with

stage III breast cancers are usually offered mastectomy with radia-

tion (data now show that patients with large axillary lymph node in-

• She originally had an Estrogen (ER) and Progesterone ( PR )pos-

volvement and large tumors > 5 cm experience a 30 percent

Negative tumor but on mastectomy, the tumor is now HER 2

mastectomy irradiation). With the initial hormone positivity, one

itive and (Human Epidermal Growth Factor 2 ) HER 2 Neu Neu positive though still ER & PR positive.

28

San Antonio Medicine • November 2018

reduction of relapsed improved breast cancer survival with postcould have entertained use of estrogen blocked, but with such a

WOMEN IN MEDICINE

large tumor burden and her young age,

the decision for use of cytotoxic therapy

was given. She underwent an initial treat-

ment plan with dose dense chemotherapy (instead of a q 3-week schedule of ther-

apy, data now support treatment given

more frequently and in shorter intervals

including every two weeks and weekly schedules of therapy).

This patient’s tumor initially did not

appear to be responsive and so unlike some current approaches with use of an

alternate regimen, she was taken to sur-

gery and due to the BRCA mutation

presence, she underwent bilateral mastectomy. Since post mastec-

gist. She had researched her selection of her oncologist as she was

tomy irradiation to the right breast and axilla was to be performed

given many names based upon their online reviews, posted infor-

panders for a delayed reconstruction after all of her chemotherapy

Interestingly, though there were oncologists closer to home which

postoperatively, she was deemed a candidate for use of tissue exis done. She was not deemed a candidate for autologous reconstruction. Failure of achieving a pathologic complete response (PCR) is

a poor prognostic factor (unfortunately, she has many) but is not

mation about training and experience and location from her home.

was critical for her home-schooling efforts and provision of child-

care, she selected someone whose office was farther away based

upon the online reviews and word-of-mouth reputation regarding

uncommon to see in patients with Hormone receptor (HR)-positive

delivery of care.

tients receiving NAC achieve a PCR in the range of 20 to 40 percent

quick access to information today and though I have not seen this

comparison to HR negative breast tumors where PCR may be as

influenced by what is deemed acceptable. I have patients who had

breast cancer. Most recent estimates suggest HR +Breast cancer padepending upon the associated HER 2 Neu status of the tumor in high as 60 to 80 percent.

The challenges of providing such care are beyond the scope of

this writing because of the complexity of the disease and her poor

prognosis and the complexity of treatment. She will now complete

Use of social media and online sources is a common way for

influence a patient’s treatment plan completely, many patients are stayed with one provider just simply due to a perceived sense of a

more or less aggressive approach as dictated by friends or family. I

have many people tell me on their first visit that they knew about

me and had looked me up online to be sure that I was the right fit

a full year of HER 2 targeted therapy in addition to consideration

for them.

complete hysterectomy that will likely render her post-menopausal

and supporting a patient is the influence of right and wrong ap-

of what is the best strategy for estrogen blockade though a future which then provides an option for use of an Aromatase Inhibitor.

As she began her journey, the best sources of information were

other survivors, but she also checked websites that provided infor-

mation and she talked to me and other health care professionals. As

a result, which is common today, she had a sense of treatment op-

tions that should be offered prior to her first visit with her oncolo-

Along with all the complexities of treating a challenging disease

proaches and “established” approaches that influence patients’ care

and acceptance of care based upon social media.

Sharon T. Wilks, M.D., FACP is an oncologist working

for Texas Oncology. She specializes in hemotology and

medical oncology.

visit us at www.bcms.org

29

ASTHMA

Air Pollution Asthma

By Theodore M. Freeman, MD

A

ir pollution is due to a variety of contaminants in the air and can occur in both indoor and outdoor environments. Outdoor contaminants include carbon monoxide, lead, sulfur dioxide, oxides of nitrogen, ozone (O3) particulate matter and biologic agents.1 Indoor air pollution is often due to many of the same contaminants but for the purposes of brevity this discussion will be restricted to outdoor agents. The sources of outdoor air pollution are divided into point sources and mobile sources. Point sources are fixed in location and are usually factories and power plants that routinely emit gaseous and particulate matter when operating. Mobile sources include everything that uses internal combustion as a power source, most importantly motor vehicles. The Clean Air Act of 1970 as amended in 1990 30

San Antonio Medicine • November 2018

established the Environmental Protection Agency (EPA) to set and monitor National Ambient Air Quality Standards (NAAQS).

These standards can be found at https://www.epa.gov/criteriaair-pollutants/naaqs-table.

Asthma is reversible obstructive airway disease. Each of the contaminants above has been established to have a negative impact on asthma except for lead and carbon monoxide.2 Particulate matter (< 10 um in diameter) has been associated with asthma exacerbations in studies performed not only in the U.S. and Europe but also in Australia, Brazil, China, and New Zealand.1 One interesting study looked at particulates and incidence of respiratory disease in a valley in Utah before, during, and after a labor strike that temporarily shut down a steel mill in the valley.2 Both particulates and respiratory dis-

ASTHMA Figure 1

Figure 2

eases decreased during the strike and returned to prior levels when the mill re-opened.2 Diesel exhaust and diesel exhaust particles have been shown to have an immediate effect on lungs. Mast cells and neutrophils are increased.1 Studies have shown an increase in inflammatory markers and antioxidants like glutathione.3 More interestingly diesel exhaust has been associated with increased incidence of allergy, which is another trigger for asthma. This association was first noted in Japan.

In 1951 there were 20,000 diesel cars in Japan, by 1988 there were 7,600,000. Before World War II, allergy to Japanese cedar was very rare.4 By 1974 the overall incidence had risen to 3.8% and by 1981 was 9.4%.4 The highest incidence (13.2%) occurred in schoolchildren living in areas with cedar trees and heavy traffic.4 Further studies have shown that diesel exhaust particles are associated with a switch to a T helper cell type 2 (Th2) which is associated with increased IgE production.1 Ninety three percent of sulfur dioxide comes from point sources (factories) and while studies have shown it is a potent bronchoconstrictor, its affects are often difficult to separate from particulate pollution.2 Nitrogen dioxide is a potent bronchoconstrictor as well, but it is also a precursor of ozone.2

Ozone in controlled exposure studies has been shown to drop forced vital capacity (FVC) and forced expiratory volume (FEV1) rapidly probably due to a sensory neural reflex.1 Ozone also leads to increased neutrophilic inflammation within a few hours of exposure.1 Studies have shown that there are increased hospital admissions 24 to 48 hours after ozone exposure.1 Keeping track of these various pollutants and deciding when they are a significant threat to our respiratory health can be problematic as each one has separate values and times of exposure before they become significant (see NAAQS above). The EPA has conveniently developed an Air Quality Index (AQI) that integrates all the various pollutants (see Figure 1). They also explain what these values mean for different populations (see Figure 2). The information can be accessed at https://www.airnow.gov/index.cfm?action=aqibasics.aqi The actual values for San Antonio each day and the predicted values for tomorrow can be found at https://www.airnow.gov/index.cfm?action=airnow.local_city&map center=0&cityid=240 . The EPA also publishes an extensive document called the Menu of Control Measures which lists the things

(continued on page 32)

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31

ASTHMA (continued from page 31)

that can be done to reduce air pollutants (see https://www.epa.gov/ sites/production/files/2016-02/documents/menuofcontrolmeasures.pdf ). When these measures are employed systematically they can reduce emissions and reduce respiratory problems. Examples of this occurred at both the Atlanta and the Beijing Olympic games.

In 1996, Atlanta reduced ozone by reducing vehicle use and succeeded in reducing ozone levels and asthma morbidity during the games compared to both immediately before and immediately after the games.1 In 2008, Beijing implemented controls on both personal automobile use and industrial use of fossil fuels.1 Particulate matter smaller than 2.5 um fell from 72.3 ug/m3 before the games to 45.7 ug/m3 during the games and daily asthma events fell from 16.5/d before the games to 7.3/d during the games.1 It is apparent that improving our air quality is not only the responsibility of government and industry but of every one of us who use internal combustion engines.

Dr. Theodore Freeman is owner and practicing physician with San Antonio Asthma and Allergy Clinic at 2833 Babcock Rd. Suite # 304, San Antonio, TX 78229.

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San Antonio Medicine • November 2018

References:

1. Hernandez ML and Peden DB. Air Pollution: Indoor and Outdoor. In Middleton’s Allergy Principles and Practice. 8th edition.

Edited by Adkinson FN, Bochner BS, Burks WA et al. Elsevier.

Philadelphia PA. 2014. Pages 482-484.

2. Peden DB. Air pollution in Asthma: effect of pollutants on airway inflammation. Ann Allergy Immunol. 2001; 87 (suppl):1217.

3. Peden DB. The epidemiology and genetics of asthma risk associated with air pollution. J Allergy Clin Immunol. 2005; 115:213-9.

4. Ring J, Buters J and Behrendt H. Particulate and Pollen Interactions. In Middleton’s Allergy Principles and Practice. 8th edition. Edited by Adkinson FN, Bochner BS, Burks WA et al.

Elsevier. Philadelphia PA. 2014. Pages 497 – 505.

BCMS NEW MEMBER WELCOME

BCMS 165th Anniversary New Member Welcome

Lâ&#x20AC;&#x201C;R from top left: Dr. Sheldon Gross, BCMS President, with Dr. Leo Profenna, who won a drawing for a $250 gift certificate. Attendees mingle at the event. Dr. Gerardo Ortega visits with UT Health medical student Carlos Ontiveros. Attendees engoy treets from the Menger Hotel.

34

San Antonio Medicine â&#x20AC;˘ November 2018

BCMS NEW MEMBER WELCOME

L–R from top left: Dr. Kenneth Yu (at right) talks with John Bains, CEO of Magnolia Diagnostics LLC. August Trevino, BCMS Development Directory, poses with attending Circle of Friends members. Dr. Adam Ratner, BCMS President-Elect, poses with medical students from University of Incarnate Word. Patty Spann of TMLT visits with Dr. John Nava.

THANK YOU TO THE WONDERFUL FOOD SAMPLING SPONSORS Fogo de Chao Brazilian Steakhouse • La Quinta Medical Center • Menger Hotel Piatti’s Italian Restaurants • Corporate Caterers

THANK YOU TO OUR BCMS 165TH ANNIVERSARY EVENT SPONSORS PRESENTING SPONSORS

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San Antonio Medicine • November 2018

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

Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

First National 1870, a division of Sunflower Bank, N.A. (HH Silver Sponsor) First National 1870 is a regional community bank dedicated to building long-term relationships founded on sound principles and trust.

Jamie Gutierrez Business Banking Officer 210-961-7107 (Direct) Jamie.Gutierrez@firstnational1870 .com www.FirstNational1870.com “Creating Possibility For Your Medical Practice”

BUSINESS CONSULTING Waechter Consulting Group (HH Silver Sponsor) Want to grow your practice?

Let our experienced team customize a growth strategy just for you. Utilizing marketing and business development tactics, we create a plan tailored to your needs!

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

DIAGNOSTIC IMAGING Touchstone Medical Imaging (HH Silver Sponsor) Touchstone Medical Imaging provides a wide range of imaging services in a comfortable, service oriented outpatient environment while utilizing state of the art equipment, the most qualified radiologists and superior customer service.

Patrick Kocurek Area Marketing Manager

yond (HHH Gold Sponsor) Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire employee life cycle. From online onboarding to certification tracking to payroll processing, manage your people anytime, anywhere.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"

FINANCIAL ADVISOR

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

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

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

FINANCIAL SERVICES

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR ad-

ministrative tasks, from payroll services to securing employee benefits and P&C Insurance.

Leslie Barnett SWBC Mortgage lbarnett@swbc.com Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Cleo Garza SWBC Mortgage – Sr. Loan Officer 210-386-0732 cleogarza@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Avid Wealth Partners ( Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's ommitted to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP, CIMA, AEP, CLU, CRPS Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

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!”

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visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

HEALTHCARE CONSULTING Beyond ( Gold Sponsor) Beyond is a financial technology company offering a suite of business tools including payment processing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"

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

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

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

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

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

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San Antonio Medicine • November 2018

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

Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small businesses and partnered with multiple financial institutions, to assist with financing of building acquisitions, construction projects, and machinery and equipment loans.

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

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

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

HOSPITALS/ HEALTHCARE SERVICES

critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

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

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

INSURANCE

HEALTHCARE BANKING

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

Jeanne Bennett EVP | Private Banking Manager 210 343 4556 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”

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

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

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is

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

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

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY INSURANCE/MEDICAL MALPRACTICE

INTERNET TELECOMMUNICATIONS

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

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

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

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

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

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

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

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

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

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

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

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

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

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

Country.

Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

MARKETING ADVERTISING SEO

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

Michael Hernandez President/ Founder 210-842-3146 Michael@veerspace.com Genevieve Pineda Business Development Director 210-386-7853 Genevieve@veerspace.com Anna Hernandez Marketing Specialist 210-852-7619 Anna@veerspace.com

MEDICAL BUSINESS CONSULTING

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

MEDICAL BILLING AND COLLECTIONS SERVICES

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and com-

passion while remaining in compliance with the laws and regulations that govern our operations.

Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

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 SUPPLIES AND EQUIPMENT

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

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

PHYSICIAN SERVICES

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance.

Leslie Barnett, SWBC Mortgage lbarnett@swbc.com Gil Castillo, SWBC Wealth Management, 210-321-7258 gcastillo@swbc.com Kristine Edge, SWBC PEO – Professional Employer Organization 830-980-1207

continued on page 40

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

kedge@swbc.com Cleo Garza, SWBC Mortgage Sr. Loan Officer 210-386-0732 cleogarza@swbc.com Debbie Marino, SWBC Insurance & Benefits, 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

PRIVATE EQUITY

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

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

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

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

Tina Turnipseed, President Tom Tidwell, President-Elect info4@samgma.org www.samgma.org

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San Antonio Medicine • November 2018

REAL ESTATE SERVICES COMMERCIAL

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

RESIDENTIAL REAL ESTATE

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

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

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

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

Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com

www.phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

www.airforce.com/careers/ "Caring For Those Protecting The Nation"

RETIREMENT PLANNING

TELECOMMUNICATIONS ANSWERING SERVICE

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

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

STAFFING SERVICES

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

Brody Whitley, Branch Director 210-301-4362 bwhitley@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677

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

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

TOXICOLOGY LABORATORY TESTING

Diagnostic Solutions, LLC (HHH Gold Sponsor) Partnering with Diagnostic Solutions allows providers to incorporate the industry’s best practices into drug compliance testing and clinical decision-making with accurate and timely results for UDT quantitation and identification.

Jana Raschbaum, MBA, BSN, RN 210-478-6633 janelleraschbaum@gmail.com Donald Nelson, MD 928-529-5110 dhnelson@citilink.net www.trustedtox.com

For questions regarding services, Circle of Friends sponsors or Joining our program.

Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html

RECOMMENDED AUTO DEALERS AUTO PROGRAM

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

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

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

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

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Rudy Solis 210-558-1500

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GUNN Honda 14610 IH 10 W San Antonio, TX

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Eric Schwartz 210-680-3371

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Abe Novy 210-496-0806

Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Gary Holdgraf 210-862-9769

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KAHLIG AUTO GROUP

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North Park Mazda 9333 San Pedro San Antonio, TX 78216

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

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

Scott Brothers 210-253-3300

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

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

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KAHLIG AUTO GROUP

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North Park Lincoln 9207 San Pedro San Antonio, TX

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

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Porsche Center 9455 IH-10 West San Antonio, TX

Barrett Jaguar 15423 IH-10 West San Antonio, TX

Sandy Small 210-341-8841

James Cole 800-611-0176

Ed Noriega 210-561-4900

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15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

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

FEATURE

The Swarm

Part 3 of 4

By Allen Cosnow, DVM

one knows whether the swarm has a leader. It has been suggested that there might be some worker, indistinguishable from the others, who carries out that function. At any rate, if there is a leader at all, it certainly it isn't the queen herself; she is often one of the last to leave the hive, and besides, she doesn't see well.

Generally, swarming begins between 10 a.m. and 2 p.m. A few workers fly out, but they don't go far. They fly around close to the hive, back and forth, while they await the others. More and more bees come out, and the swarm continues to enlarge until it fills a sphere about twenty feet in diameter in the air around the hive. This takes about 15 minutes. Somewhere in this cloud of twenty or thirty thousand bees – 40 to 60 percent of the population – is the queen.

When all that are going to take part in the swarm are present, the swarm leaves.

The swarm starts to move slowly through the air, while each individual bee flies back and forth inside it. Those who are unfamiliar with the life of bees are often frightened by the sight of a swarm in the air (thinking it must be an attack squadron), but in reality, this is the time when bees are least inclined to sting. A bee stings only when her body is handled roughly or when she "thinks" she needs to protect her home. Bees in a swarm are just travelers; they are temporarily without a home to protect, and if a bee in a swarm is not physically threatened, it is improbable that she will sting. I have stood in the middle of a swarm in flight and had bees bump into me, bounce off, and continue as though nothing had happened.

No

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San Antonio Medicine • November 2018

The swarm advances this way for a few yards, or for hundreds of yards, until it comes to some object (as far as anyone can tell it is a random choice) – a limb or trunk of a tree, a shrub, a post, the eaves of a house – and one at a time each bee lands there. Finally, a cluster weighing as much as six pounds is formed. It may be that the immediate purpose of forming the cluster is to be sure that the queen is present; sometimes for one reason or another it happens that she is not. In that case the bees soon become aware of it, break up the cluster, and return to the hive. But most of the time she is with them, and the swarm remains clustered there with the bees clinging to one another. Mean- while, scouts are sent to explore the area to find a suitable place to start a new home. The rest remain there tranquilly waiting.

This is another time when people become frightened – seeing a big cluster of bees hanging from a branch – but again, having no real home, the bees have little propensity to sting. Moreover, before leaving the hive each bee had filled her stomach with enough honey to last for as much as seven days if necessary, and having a stomach full of honey it is difficult for her to assume the curved position necessary to insert her stinger, at least if the cluster hasn't been there for more than three or four days. Bees in a cluster can often be gently picked up by the handful like so many berries. It is during this time that a beekeeper, if he discovers the cluster, can gather up all those workers and the queen and transfer them to an empty hive, thus obtaining for himself the start of a new working colony.

(There is no point in trying to return them to the hive that they

FEATURE came from; it was overpopulated to begin with, and they will leave again in a couple of days.) We beekeepers are always on the lookout for these swarm clusters in late spring and early summer. There is not much danger to the beekeeper of being stung when collecting a cluster. The danger comes in hastily going up a ladder or climbing a tree to gather it, and then falling and breaking his neck.

But much of the time no one recovers the cluster. The scouts return, and in some way – still not well understood – they compare opinions as to the advantages and disadvantages of the different places they have investigated. (Their preferred habitation would be a cavity about 15 feet up in a hollow tree, but they can't always be so selective.) After a period ranging from a few hours to a week they come to an agreement, and the clustered swarm leaves its waiting place in the same way that it left the hive, this time more purposefully.

The first workers to arrive at the new habitation – whether a natural one they discovered themselves or an empty hive prepared by the beekeeper – remain at the entrance with their back ends toward the outside. They fan their wings, diffusing to the others the specific pheromone that calls them to enter. Some of the bees enter flying,

but most land several feet in front of the entrance and walk in by the thousands, as though marching. The queen enters this way as well. Every beekeeper will tell you that even if he sees this arrival a thousand times, he will be thrilled every time he sees it.

Once they are inside, they are no longer "berries." Now they have a home. Guards are quickly posted at the entrance to defend the colony. Within a few hours work begins. Some of the workers leave to look for flowers, and others begin to secrete wax and construct combs; as soon as the combs have some cells available, the queen lays her first eggs in the new home. Soon there will be a beautiful new city of wax, full of industrious workers, and the life of the bees will go on as it has done for millions of years.

But we have left the original colony, now nearly deprived of adults, nearly defenseless. What about them?

To be continued…

Allen Cosnow, D.V.M. is a retired small animal veterinarian who keeps his several bee colonies on a city lot in Glencoe, Il, a lake-shore suburb of Chicago. He is a veterinary school classmate of Fred H. Olin, D.V.M., M.D.

visit us at www.bcms.org

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AUTO REVIEW

2018 Kia Stinger

By Stephen Schutz, MD The 2018 Kia Stinger is a good car. Surprisingly good. It’s a RWD performance sedan that actually performs, and it’s the first Kia I would recommend to my friends (and readers).

Of course, Kia will need more vehicles as good as the Stinger if they want to move out of the automotive bargain basement and into the world of Toyota, Ford, and BMW. In fact, they’ll need desirable crossovers that drive well and are attractive to look at along with SUVs that exude quality. But a sports sedan that’s legitimately sporty is a good start.

Creating a new RWD platform to underpin the Stinger was bold and probably necessary. RWD cars inevitably handle better than their FWD brethren because balanced weight distribution and propulsion from the back end of the car prevent understeer. It should be noted that the Kia engineer in charge of developing the Stinger was Albert Biermann, formerly VP of engineering for BMWs M–division, and presumably he pushed for RWD. Nevertheless, developing a new platform is expensive, and kudos to Kia for signaling their seriousness by making one.

Not surprisingly, the Stinger handles very well. At 190 inches long 44

San Antonio Medicine • November 2018

with a 114-inch wheelbase, the Stinger is hardly a turn-on-a-dime hot-hatch. But those dimensions mean that Stingers are stable on the interstate and confident through high-speed sweeping turns. Still, twisty A- and B–roads are no problem for Kia’s for sports sedan, which really impressed me with its driving chops.

Plenty of power helps. Like seemingly everything these days, the Stinger uses turbochargers to maximize output. In this case twin turbos coax 365 horsepower from the 3.3-liter V6 in the GT version I tested (the standard engine makes do with 255 horsepower from a 2.0-liter turbo inline four.) Fuel economy is 19 mpg city/25 highway for the GT and 22/29 for the lesser Stinger.

For the record, selecting the GT model, which would be the choice for enthusiasts, gets you Brembo brakes and 19-inch wheels with sticky Michelin low-profile summer tires. AWD is an option that includes torque vectoring, but I’d probably go with RWD for cost and weight reasons.

The exterior design of the Stinger is different from anything else out there. While Chrysler made cab-forward designs famous in the mid-1990s, the Stinger is all about being cab-backward. Naturally,

AUTO REVIEW

the hood is relatively long – duh – but the rear end with its long hatch is well integrated, and overall the look works. I especially like the demonstrative front end highlighted by an assertive grille (two, actually, one upper and one lower) and large air intakes lateral to those grilles, as well as high door sills and short side windows. It’s all kind of Gangsta, which I suspect is not accidental.

There’s nothing Gangsta about the interior though, which is pretty standard fare for Kia. Yes paddle shifters are there to remind you that this is a sports sedan – no manual is available – nice colored accents are scattered around generously, and the console and dash are tilted towards the driver as they are in sports cars. But overall the sense from behind the wheel is that you’re in a Kia, not an Audi.

Pity, Kia had an opening there.

Of course, an Audi-esque interior costs money, and that would’ve caused the Stinger to have a higher price. As it stands, the Stinger starts at around $33,000 with base GTs going for just under $40,000.

Adding AWD costs $2,200 regardless of which model you add it to.

As always, call Phil Hornbeak to get the best price on a Stinger or any other vehicle.

Which brings me to the elephant in the room: this is a performance car that legitimately performs, a RWD/AWD car that could’ve been FWD, and it looks seriously good. But it’s a Kia. For not much

more cash you can get into a Lexus IS200t or BMW 320i, and you don’t have to explain your decision to your neighbors. And that’s a problem that won’t go away until Kia establishes itself as a consistent producer of luxury and performance vehicles like those aforementioned brands (and others) have. Once that happens, transaction prices and resale values will rise, and the virtuous cycle that has made Mercedes, Lexus, and Audi into international cash cows will take Kia into the automotive heavens. Easy to say, hard to do.

The 2018 Kia Stinger is a good performance car for all the reasons listed above, and kudos to Kia for going the extra mile by putting their first performance sedan on a RWD/AWD platform. Here’s hoping they continue to feed the enthusiast market. If they do, I predict good things for both sales and resale values.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

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

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San Antonio Medicine â&#x20AC;˘ November 2018