San Antonio Medicine November 2019

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VOLUME 72 NO. 11

MEDICINE SAN ANTONIO

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Immunizations

Vaccinations are Gifts By Lindsay Irvin, MD .....................10 San Antonio Metro Health Update on Children’s Vaccines By Lynna Agado and Megan Miller .................12 Measles: More than Just a Rash

By Woodson Scott Jones, MD .......................................14 You’re a Doctor, Should I Vaccinate My Precious Child? By Melissa Garcia, MD.......................................18 The Effect of Vaccinations on the Prevalence of HPV

By Abigail Cain, MD, MPH .............................................20 The Story of San Antonio’s First Vaccines

By Jacob Canfield ........................................................22 How Social Media Fuels Anti Vaccination Sentiment By Isabela Baker.............................................24 Cartoon: Mom Goes to the Doc! By Christian Jacobsen....................................................................27 BCMS President’s Message ........................................................................................................................8 The Transition — Special Needs Patients Become Adults By Ruchi Kaushik, MD, MPH ............................28 How a Pass/Fail Curriculum Has Changed My Approach to Medicine By Teresa Samson, OMS-II..............29 Happy Patient; Happy Doctor Model By Uchenna L. Umeh, MD ................................................................30 Cancer Expert, Patrick Sung, D.Phil Joins UTHSA

By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio ........31 Teaching Technology to Seniors Helps Ease Social Isolation By DeAnne C. Cuellar ....................................32 BCMS News - Election Results and Calender of Events ............................................................................34 BCMS News - Leadership Course, First Tuesdays, New Member Welcome, Auto Show ............................35 BCMS Circle of Friends Directory ..............................................................................................................40 Recommended Auto Dealers......................................................................................................................47 Auto Review: 2019 Volkswagen Jetta GLI By Steve Schutz, MD ..............................................................48 PUBLISHED BY: SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net BUSINESS MANAGER: Vicki Schroder

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San Antonio Medicine • November 2019

NOVEMBER 2019

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VOLUME 72 NO. 11

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

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

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

DIRECTORS Michael A. Battista, MD, Member

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

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

John D. Edwards, MD, Member Vincent Paul Fonseca, MD, MPH, Member

BCMS SENIOR STAFF

J.J. Waller Jr., MD, Member

Michael Joseph Guirl, MD, Member

Stephen C. Fitzer, CEO/Executive Director

David Anthony Hnatow, MD, Member

Melody Newsom, Chief Operating Officer

Teresa Samson, OMS-II, Member

Gerardo Ortega, MD, Member

Alice Sutton, Controller

Manuel M. Quinones Jr., MD, Member

August Trevino, Development Director

David M. Siegel, MD, JD, Member

Mary Nava, Chief Government Affairs Officer

Rajeev Suri, MD, Member

Phil Hornbeak, Auto Program Director

Kelly King, Alliance Representative

Mary Jo Quinn, BCVI Director

George Rick Evans, Legal Counsel

Brissa Vela, Membership Director

Col. Charles Gregory Mahakian, MD,

Al Ortiz, Chief Information Officer

Military Representative

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San Antonio Medicine • November 2019

Sneha Aidasani, MD, Member Stephen C. Fitzer, Editor

PRESIDENT’S MESSAGE

Advocating for Yourself: Don’t shoot yourself in the employment contract!

By Adam Ratner, MD, 2019 BCMS President It is the express mission of the Bexar County Medical Society to advocate for you and your patients in Bexar County and to advocate together with TMA throughout the state. That said, there is only so much that organized medicine can do. You must also advocate for yourself!

The theme of the October 2019 issue of San Antonio Medicine was the corporate practice of medicine, dealing with its impact on us physicians and our patients. There are many powerful forces vying for the power and money inherent in the practice of medicine. With both good and evil intentions, these forces are trying to control our working lives and practices as much as they can.

The initial and arguably the most important interaction many of us have with these powerful forces comes in the form of our employment contracts. These legal documents are typically created by attorneys expert in employment law and reflect the cultures, values, and motivations of the employers who offer them to us.

An employment contract is truly a legal window into the culture of a practice. Although most contracts understandably reflect the asymmetrical power between a corporate practice and an employed physician, some contracts are more asymmetrical than others. It is one sign of a well-run practice for its employment contract to contain provisions to protect itself whenever it can, within reason.

That said, some physician employment contracts purposely include draconian provisions that may not even be legal and enforceable. Why do otherwise intelligent physicians think that an employer presenting such a poor contract would have any motivation to provide an attractive working environment for its physicians? Furthermore, disentangling from one of these contracts might require a potentially costly and personally disruptive legal challenge for a victim physician, yet many of us routinely sign these instruments of servitude and bondage.

Many physicians are simply unwilling to take the time to read and understand the consequences of each provision in a contract. Most of us are clearly out of our areas of competence in interpreting these documents. If confronted with a medical problem out of our specialty, we routinely get a consult from an appropriate specialist we trust. Why don’t we all do the same thing with our employment

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contracts and hire an attorney with expertise in medical employment contract negotiation? Simple. It costs money from our own pockets, scarce personal time, and many of us don’t think we can negotiate a favorable change in a contract anyway.

So, how much money is it worth to you to avoid a miserable working environment which might ultimately cost several hundred thousand dollars to escape?

Many physicians feel that we have no negotiating power and would be unable to convince an employer to alter their employment contract. Certainly, if we begin with this negotiating attitude, we won’t get far. The reality is that some employers will alter their contracts, and some won’t. Never forget that we, as physicians, have the ultimate power to simply walk away if we don’t like a contract. No one can force us to sign one against our will. This is truly our ultimate power as individual physicians.

If a physician has only one job prospect and no other options, it is harder to walk away from a bad contract. Most of us need to make a living but still need to be able to walk away from a contract negotiation; we must seek out and cultivate multiple employment options for ourselves prior to signing a contract. This takes time and effort but usually pays off.

For more than a decade I’ve been teaching business of medicine courses to medical students, residents, fellows and practicing physicians. I’ve recently started asking those in my classes to take a short and simple oath which I hope they will recall when it is their time to evaluate and sign an employment agreement. You might want to do the same.

“I promise that I will never sign an employment contract that I have not read and understood in its entirety. I will seek wise and experienced counsel as needed as the decision to sign such an agreement will likely impact me for the rest of my life.”

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

IMMUNIZATIONS

By Lindsay Irvin, MD

“Whoever saves one life, saves the world entire.” – The Talmud

In October of 2017, my husband and I went to parents’ weekend at Brandeis University in Waltham, MA, where our youngest son Joseph had just started his freshman year. We had an early morning stroll around Walden Pond, where we watched the sunrise, balanced stones on a cairn honoring Henry David Thoreau, and tried to come to terms with the reality of being empty-nesters after focusing most of our energy on our two children for the previous two decades. Then we dried our tears and headed to Concord, MA for pancakes.

We ended up in the beautiful Old Hill Cemetery near the Concord town center, which was decorated for Halloween. As I wandered around the old grey granite headstones, many of which were scoured by time and weather into being almost illegible, I was struck by how many of the graves – most from the 1700s – were for children, and 10

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how tenderly and lovingly they were remembered.

In New England in the 1700s, according to the Plimoth (sic) Plantation and New England Genealogical Society, the mortality rate for children in that era was high: A cumulative total of 36% of children died before the age of six, and another 24% between the ages of seven and sixteen. In all, of 100 live births, 60 would die before the age of 16.

Causes of death were numerous, including tetanus due to unsanitary conditions surrounding childbirth. Other prominent diseases included: whooping cough, diphtheria, dysentery, tuberculosis, typhus, typhoid fever, rickets, chicken pox, measles, scarlet fever, smallpox and plague under their period names.

I came away from that morning feeling grateful. I recognized the

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historically relevant miracle that 100% of our two children had, quite literally, survived their childhood. And that I have had the privilege of raising our children, and practicing pediatrics, in a chapter of human history that allows us to expect our children to avoid diseases that killed their predecessors by the millions.

The number of lives saved by vaccines since they were introduced is impossible to quantify. The World Health Organization on their website estimates that more than 10 million lives have been saved by vaccines alone between 2010 and 2015.

While much of the progress over the past century in childhood survival has been part of a broader public health initiative (and we have far to go), immunizations are one of those human achievements that can only be appreciated by looking in the rearview mirror.

When we lose our historical perspective on immunizations, we cease to see them as the incredible step forward that they have been in our collective human journey on this planet. I find it interesting talking to young parents who have been so protected by vaccines all their lives that they have the luxury of doubting the basic science that supports them.

It is difficult to communicate the impact of vaccines on the human race and all the lives saved in a twenty minute visit with young parents who have never seen a case of mumps or measles, much less of polio or diphtheria. Feeling like something of a fossil, I try to communicate to them a more immediate sense of what these diseases we try to prevent can do to the human body.

Like anyone who grew up in a time when we were all still being immunized for smallpox, I have my stories. My parents both had younger sisters who died of polio. I wonder sometimes about the cousins I might have had if my aunts had survived into adulthood.

My first code, on the 5th floor of the old Santa Rosa Children’s Hospital as a pediatric intern, was an infant with pertussis. (I will never forget that tiny baby turning blue and struggling to breathe as another intern and I scrambled to save his life, which he owes now to an experienced nurse who pushed us both out of the way and began CPR.) And then there were all the patients with pneumococcal meningitis in the PICU at University Hospital when we were residents in the 1990s who went from being healthy children to being neurologically devastated or dead in a matter of hours.

Immunizations aren’t perfect. With escalating drug prices (particularly when vaccines are produced by pharmaceutical companies that have a monopoly on a particular product), purchasing, storing and accepting the liability of offering vaccines can be an untenable financial risk or just bad business – especially for a small practice. (If you would like an example of just how stressful stocking vaccines can be, just ask any pediatrician about the price of Prevnar 13 and watch them go red in the face.)

There are purchasing groups such as CASA or Cook’s Children’s Hospital’s PedsPal that can make vaccines more affordable. Our office has been using a new purchasing model called VaxCare for over a year that has reduced both the financial and logistical headaches of keeping vaccines available. Or, you can use the model I used for years – save your pennies till they squeak and try to keep up, all on your own, with the burgeoning and unexplained escalations of price. (I don’t recommend this. Currently, the prices pediatricians in the United States pay for immunizations are disproportionately high and are increasing compared to the cost of vaccines in other countries.)

However we manage to keep immunizations in our offices, and whatever misery that may cause us – misery that is pretty much impossible to describe to anyone who has not had their refrigerator full of vaccines lose power in a thunderstorm – just remember that any comprehensive list of human achievements that have changed the course of history puts vaccines in the top ten – up there with inventing the wheel and landing on the moon.

I am at that stage of practice where kids that I immunized as babies are bringing me their kids to immunize. Years of care have convinced them that I am not just whistling in their ear when I tell them I want them to receive vaccines so that they can be healthy 20, 30 or 40 years from now, when I am long gone, and they have grandchildren of their own.

I can only agree with Nelson Henderson that the true meaning of life, and specifically of pediatrics, is to plant trees under whose shade you do not expect to sit. When I think of the children in that quiet graveyard in New England who never had a chance to grow up and put down roots, I am thankful for all my own little sprouts who have received their vaccines.

Lindsay Rockwood Irvin, MD is a practicing pediatrician at Alamo Heights Pediatrics in and is a member of the Bexar County Medical Society. visit us at www.bcms.org

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SAN ANTONIO METRO HEALTH

UPDATE ON CHILDREN’S VACCINES Vaccination Rates, HPV and the Texas Vaccines for Children Program

By Lynna Agado and Megan Miller Bexar County, immunization coverage rates remain high but, with recent outbreaks and setbacks in coverage rates for some key vaccine preventable diseases, Bexar County must continue to increase its vaccination rates. The Texas Vaccines for Children (TVFC) program presents an opportunity for physicians in Bexar County to increase vaccination rates by eliminating barriers to offering and obtaining vaccines.

Based on the most recent data (2017) from the National Immunization Survey (NIS), 75.6% of children 19-35 months old in Bexar County have received the “4:3:1:3:3:1:4” vaccine series, a rate which is higher than the averages of 70.4% in the United States and 67.8% in the State of Texas (the 4:3:1:3:3:1:4 vaccine series is a marker reflecting coverage for seven key vaccine series including diphtheria, tetanus, pertussis, measles, mumps, rubella, hepatitis A, hepatitis B, polio, pneumococcal, and varicella).

However, the Bexar County coverage rate is still below the Healthy People 2020 target of 80%.

While the overall series rate has steadily increased since 2014, completion rates for hepatitis A and DTaP lag behind coverage for other vaccines in Bexar County.

Human Papilloma Virus (HPV) Vaccinations Unfortunately, in 2018 only 48.0% of Bexar County adolescents were up to date with the HPV vaccine, according to NIS data re12

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leased in August. This represents a slight increase over the 2017 rates (46.4%). Specifically, more males are up to date, with an increase from 37.2% in 2017 to 43.6% in 2018. In the case of females, the rates decreased from 55.6% in 2017 to 52.5% in 2018. These results highlight the need for continued efforts to ensure all boys and girls are vaccinated on time to ensure adolescents receive the best protection against HPV-related cancers. Additionally, physicians can help increase HPV vaccine uptake by doing the following: • Have an “HPV Vaccine: Same Way, Same Day” type discussion with all your 11-12 year-old patients.

• Understand that parents may have concerns about vaccinations and be prepared to address parents’ questions about all adolescent vaccines.

• Continue efforts to ensure all boys and girls are vaccinated on time.

• Follow up with adolescents who are due for additional doses by implementing a reminder-recall system.

Texas Vaccines for Children (TVFC) Program Another way to promote the HPV vaccine, as well as other vaccines, is by enrolling in the TVFC program. This federally funded program provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay. Participating in the TVFC program also saves physicians money, as they no longer have to buy vaccines for eligible patients. Eligible patients include children (birth through 18 years of age) who meet one of the fol-

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lowing criteria: Medicaid eligible, uninsured, American Indian or Alaska Native, underinsured, or enrolled in CHIP. The TVFC program gives all children a better chance of getting their recommended vaccinations on schedule. Being a TVFC provider helps children stay in their medical home and return to their primary provider for healthcare needs. The TVFC program provides the ability to bill non-Medicaid and non-CHIP clients an administration fee, as well as access to the vaccine ordering and reporting system. Physicians and staff receive training and resources to be a successful immunization partner.

This year is the 25th anniversary of the Vaccines for Children program, and it has provided great value to communities across the nation. In Bexar County alone, more than 150 TVFC providers served over 314,000 children through the age of 18 in 2018. You could help increase this number and provide services to children who otherwise may go without vaccinations.

A phone app called HPV Vaccine: Same Way, Same Day™ offers a brief, interactive role-play simulation designed to enhance healthcare providers’ ability to introduce the HPV vaccine and address hesitant parents’ concerns. The simulation was developed by the Academic Pediatric Association, the American Academy of Pediatrics, and Kognito. It is available from Google Play and the iPhone App Store.

If you are interested in learning more about TVFC enrollment and how to become a provider, please contact Lynna Agado, San Antonio Metropolitan Health District TVFC Coordinator, at 210-207-3965, or visit the Texas Department of State Health Service’s website for enrollment information.

Megan Miller is the Immunization Program Manager for the San Antonio Metropolitan Health District.

Lynna Agado is the TVFC/ASN Coordinator of the San Antonio Metropolitan Health District. visit us at www.bcms.org

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By Woodson Scott Jones, MD he year was 1997 and I was stationed as a relatively new Air Force Pediatrician at Aviano Airbase in Italy. I saw a 13-month-old toddler with a two-day history of fever to 102, cough, conjunctivitis, runny nose and bilateral ear infections. I started him on amoxicillin. He returned the next day more ill appearing with higher fevers to 104, worsening cough and conjunctivitis along with a new maculopapular rash that had started on the face and then spread down the trunk of his body to the arms and legs (see pictures). Due to poor hydration, appearing more ill and it being unclear if child was having a significant penicillin reaction, I admitted the child to our hospital.

Later that day, I had a second 13 month-old infant from the same day-care class present to the emergency room with very similar symptoms of cough, coryza, conjunctivitis, rash and fevers. I thought we were most likely dealing with a virus, perhaps measles.

The next day we learned that one of the day care workers from that daycare class, who was not fully vaccinated, had a low-grade fever and a rash that spread from head-to-toe, with cough, and mild conjunctivitis. Her breast fed, six-month-old infant also had the rash, cough and mild conjunctivitis but was otherwise relatively well. As it turned out, we were rightly suspicious of Rubeola, otherwise known as “measles”. We were able to obtain blood and urine samples from the infant which confirmed it to be Rubeola per the Centers for Disease Control and Prevention (CDC).

Looking back at this case, I am somewhat surprised by my lack of initial recognition of measles because of my prior academic interest in it. As a resident, stimulated by the 1992 measles outbreak in the United States, we had studied and published work on immunization rates in the military.1 Though I was well aware of the required high-herd immunity with measles (90 - 95%), I did not learn until after our cases that measles was endemic in northern Italy at that time. Why was that important? Had we known this, we would have been giving the measles vaccine at 12 months rather than at 15 months, which was the more common practice in the United 14

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States at that time due to higher efficacy rates. This would have perhaps mitigated this outbreak since the exposed classroom consisted of 12-to-18-month-old toddlers.

As a young officer and pediatrician, I learned a lot, fast, about public health intervention and communication, including implementation of base-wide measles immunization campaigns for all children 6-to-12 months of age, radio communications and developing a follow-up plans to ensure infants were reimmunized again after 12 months of age.

My career continued to intersect with the measles vaccine. I was part of the leadership of a military medical team a year later to Chad, Africa. We brought only one immunization vaccine as an intervention, the measles vaccine. At the time, it took significant effort to convince our military logisticians to take refrigerators and ice chests so we could sustain the necessary “cold chain” to preserve the vaccine. Why all this effort for this particular vaccine? At the time, the World Health

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HOW TO IDENTIFY

MEASLES Measles is an acute viral respiratory illness characterized by a prodrome of fever (as high as 105°F) and malaise; cough, coryza, and conjunctivitis – the “three C’s”; and a pathognomonic enanthema (Koplik spots), followed by a maculopapular rash. In some immunocompromised patients the rash is not evident.

Organization (WHO) was making good inroads into that region with the polio vaccine. It was the very need for the cold chain that impacted the ability to provide that sub-Saharan region with the measles vaccine. Further, over the next decade, we the faculty in the Military Medical Humanitarian Assistance Course stressed the measles vaccine as the primary emergent immunization intervention to be seriously considered in a refugee crisis. This intervention is necessary because measles is so highly infectious, especially when associated with camp overcrowding and even higher rates of morbidity and mortality in malnourished children. Measles-associated encephalitis can be particularly devastating. According to the WHO, there were 110,000 measles deaths globally in 2017; most were children under 5 years of age. This is despite the measles vaccine resulting in an 80% drop in measles deaths since 2000.

Fast forward 27 years to 2019, we are in the middle of another measles outbreak with more cases this year than we have seen since the outbreak in 1992 that launched my interest in immunizations.

There have been over 1200 cases in 31 states. We have had one confirmed case in Bexar County which is among the 21 cases in Texas in 2019. Similar to the 1992 measles outbreak, this outbreak in the United States is associated with a global outbreak due to under-immunization with over 360,000 confirmed cases, triple the number from the previous year

What is our role in the current global outbreak in measles as providers in Bexar County? Our first and foremost role is to “do no harm” by ensuring our staff are aware of the measles outbreak and are appropriately immunized or have evidence of immunity (remember the daycare worker above). Review and post in our offices, for staff and patients, the Texas Health and Human Services 2019 Measles Health Advisory and the Texas Medical Association Notice found in the references. Our second intervention is active surveillance to ensure our patients are immunized appropriately for measles according to CDC guidelines (Table 1). Ensure patients are receiving the second dosage and consider immunization between 6 and 12 months if planning to travel internationally. Third, we should use this outbreak to capitalize on the opportunity to further educate our patients and their families on the effectiveness of immunizations. Each year prior to the initiation of the measles vaccine in 1963, measles led to; three-to-four million infected people, resulting in 48,000 hospitalizations, 400-500 deaths and 1000 cases of encephalitis. The year after licensure, measles decreased by 95% and the episodic outbreaks ceased. The measles vaccine has a long history of being highly effective.

We need to redouble our efforts to educate families on vaccine safety. While this outbreak has created significant stress in some families, in others it has perhaps not created enough anxiety. In famcontinued on page 16

visit us at www.bcms.org

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IMMUNIZATIONS continued from page 15 ilies suspicious or firmly against immunization, I recommend trying to first understand their “why,” rather than presume it might be for reasons most commonly known. This helps direct counseling and demonstrates a willingness to listen. I have found it helpful to share my personal experience with measles and how I have seen it affect children. Sharing the current global and historical impact of the disease sometimes impacts some families.

As the 1992 and now 2019 global measles outbreaks subsequent spread to the United States demonstrates, families who fail to vaccinate cannot rely on the good will of those in the United States who do protect their families, particularly from measles. We must respectfully remind them how fortunate they are that so many others still do vaccinate, given that 9 of 10 unvaccinated people exposed to measles get the disease. Due to the highly infectious nature of measles, immunization rates as noted earlier need to be in the 90 - 95% range to protect the community. These factors mean the failure to vaccinate their children puts others, particularly the most vulnerable, severely immunocompromised children who cannot get the vaccine, at risk. The Immunization Action Coalition, the CDC and others provide remarkable resources to educate families (see references). The CDC has a summary resource to address Thimerosal concerns. The National Academies of Sciences, Engineering and Medicine has released multiple reports over the last two decades on vaccine safety, particularly related to concerns with autistic spectrum disorders and immunization.

In summary, measles is more than a rash. It is a highly infectious illness with its most significant impact on the most vulnerable in Bexar County and around the globe. Even though I had significant “academic” experience with measles, I was not abreast of what was happening in the surrounding community when I was stationed in Italy. We all have to stay informed about the current and future outbreaks in the United States and globally as Bexar County is an international community. This recent outbreak reminds us of our continued need for diligently educating and immunizing the patients we serve. We must not cease in our efforts to combat the misinformation leading families to make poor choices regarding immuniza16

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tion. Finally, we need to remain vigilant for recognizing the clinical symptoms and findings associated with measles to ensure isolation, testing, and appropriate post-exposure interventions.

Woodson Scott Jones, MD is a graduate of UT Medical Branch in Pediatrics. He is currently Vice Dean of Graduate Medical Education at UT Health San Antonio and is a member of the Bexar County Medical Society.

References

Jones WS, Hall BH, Smalley JR, Schelonka RL, Butzin CA, and Ascher DP. Immunization status of preschool children in a military clinic. Arch Pediatr Adolesc Med 1994;148:986-989 World Health Organization Key Fact Sheet: Measles. 2 May 2019. www.who.int/news-room/fact-sheets/detail/measles Center for Diseases Control and Prevention (CDC). Measles Cases and Outbreaks: Measles Cases 2019. www.cdc.gov/measles/casesoutbreaks.html Texas Department of State Health Services. Measles 2019. Organism, Causative Agent, or Etiologic Agent. www.dshs.texas.gov/ IDCU/disease/measles/Measles-2019.aspx.

2019 Measles Health Advisory. file:///C:/Users/jonesw3/Downloads/Measles%20 Health%20Advisory071019.pdf Center for Diseases Control and Prevention (CDC). Global Measles Outbreak. www.cdc.gov/globalhealth/measles/globalmeaslesoutbreaks.htm The Immunization Action Coalition Measles Handouts. www.immunize.org/handouts/measles-mmr-vaccines.asp National Academies of Sciences and Engineering: Vaccine Safety Publications: www.nationalacademies.org/hmd/Global/Search.aspx?q= measles+vaccine+safety

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“You’re a Doctor, Should I Vaccinate My Precious Child?”

By Melissa Garcia, MD

he overwhelming and only answer to this question should be YES! We all learned about immunizations in medical school, and most of us thought we would never see certain diseases again in our practice lifetime. I understood the immunology and the disease process, and I saw the pictures of the consequences of these diseases. I am not going to review the disease processes or statistics for vaccine efficacy and safety, but I will tell you vaccines work and they save lives and it is our responsibility as physicians to disseminate that information to anyone that will listen.

My mother’s generation can tell stories of lining up to receive the polio vaccine as well as knowing someone that was in an iron lung.

One of my greatest fears during training was encountering epiglotitis, because who really wants to face that in a child?

As a Pediatrician in the trenches, I can see that the anti-vaccination movement is alive and kicking. Our great state of Texas as well as local counties have some pockets of abysmal school vaccination rates. When combined with the prevalence of measles throughout the country, we stand to lose our “measles elimination status” if the cases of measles continue to rise. This is absolutely unacceptable in this day of modern medicine when readily available vaccines can prevent disease. I really never thought I would have to spend so much time convincing parents to vaccinate their child.

In my 20 years of medical practice, I can honestly say that I have never encountered a circumstance where a vaccine could not be administered due to vaccine safety or side effects, (with the exception of not giving live virus vaccines to an immunocompromised child, or when the vaccine is truly contraindicated, which is extremely rare). Full disclosure, I did not practice in the whole cell pertussis vaccine era; that is a lot of vaccines given through the years. I have never given a student vaccine exemption waiver except when live virus vaccines are contraindicated.

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We took an oath to first do no harm, and I value the opportunity to protect the health of our children. We must all answer the vaccine question with confidence and relay the message that vaccines are safe and essential in order to protect our children and those that surround us who truly can’t be vaccinated. Vaccines should be given on time and at the recommended intervals, otherwise the child continues to be at risk of vaccine preventable diseases. If you have questions about vaccines, please ask your friendly Pediatrician or Family Medicine physician.

We as colleagues need to take a stand against the misinformation that undermines the evidence-based medicine that we all practice on a daily basis. We must advocate to our legislators for elimination of the personal vaccine exemption in Texas to help ensure that the climbing vaccine exemption rates begin to decrease across our schools and in our great state of Texas. Even California has a more stringent vaccination policy than Texas. We can do better. We should all feel confident to answer the question, “Should I vaccinate my precious child?” with an overwhelming YES! Melissa A. Garcia, MD is a Pediatrician at ABCD Pediatrics in New Braunfels, Texas and is a member of the Bexar County Medical Society.

IMMUNIZATIONS

The Effect of Vaccinations on the Prevalence of

HPV

While it is well known by medical professionals that the human papillomavirus (HPV) causes nearly all cervical cancers (associated with cancers of the vagina, vulva, penis, anus and oropharynx), the general populace is largely unaware of this. Patients, often unknowingly, rely upon physicians for the awareness and education that leads to more patients receiving vaccinations.

The virus is prevalent in Texas, with 2510 cases of HPV-related cancer recorded between 2012 and 2016, including 830 cases of oropharyngeal cancer and 890 cases of cervical cancer. During this period in Bexar County, the incidence of cervical cancer was 10.6 in 100,000 people, with 28% of those succumbing to (dying from) the disease.

HPV vaccination, which has the potential to prevent most HPV related cancers, has been available for female adolescences, ages 926 years, since 2006, and has been available for male adolescents since 2011. Following the introduction of the vaccine, there has been a significant decrease in HPV type infections.

• Female Infections - Between 2013 and 2016, there was a decline in HPV related infections from 11.5% to 1.8% for ages 14-19 years, and from 18.5% to 5.3% among females aged 20-24 years old.

• Herd Effect - There have also been declines observed among unvaccinated women suggesting a herd effect.

• Male Vaccination Rates - Vaccination rates for males have generally been found to be lower than in females. However, concurrent HPV vaccination in males significantly lowers the rates of HPV infection in the female population as well.

The physician's role is critical in increasing the rates of HPV vaccination. A recent study evaluating the patient’s decision to be vaccinated, versus not being vaccinated, concluded that patients often were vaccinated at the urging of their physician. The study pointed out the following: • Physician Influence - of those who received the vaccination, 40% said that physician recommendation influenced their decision.

• Non-vaccinated patients - 36% stated they had never thought about receiving the vaccine.

• No Need for The Vaccination - 31% felt they did not need the vaccine.

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By Abigail Cain, MD, MPH The Healthy People 2020 target is for an 80% vaccination rate to ensure maximum community immunity. This vaccination series requires three doses of vaccine to provide protection against the virus.

In Bexar County, only 48% of targeted patients are completely up to date on their HPV vaccinations, with males being particularly low with only 25% of them receiving the required 3 doses of vaccine.

When the rates of HPV vaccination were compared between those who had received recommendations from a provider vs. those who had not, it was found that those that had been recommended to receive the vaccine were much more likely to be vaccinated. It is evident that in order to continue to decrease the rate of HPV infections and of HPV related diseases, physicians need to educate patients (both male and female) as well as the community about the importance of the HPV vaccine. Through broad-based community educational programs, as well as one-on-one patient centered care, we as physicians can raise awareness and reduce the stigma surrounding HPV, causing more individuals to become vaccinated.

References: • McClung NM, Lewis RM, Gargano JW, Querec T, Unger ER, Markowitz LE. Declines in vaccine-type human papillomavirus prevalence in females across racial/ethnic groups: data from a national survey. J Adolesc Health In press 2019.

• Oliver SE, Unger ER, Lewis R, et al. Prevalence of human papillomavirus among females after vaccine introduction – National Health and Nutrition Examination Survey, United States, 2003– 2014. J Infect Dis 2017;216:594–603 • J. Barrera, S. Greene, E. Petyak, S. Kenneson, E. McGill, H. Howell, D. Billing, S. Taylor, A. Ewing & J. Cull (2019): Reported rationales for HPV vaccinations vs Non-vaccination among undergraduate and medical students in South Carolina, Journal of American College Health. DOI 10.1080/07448481.2019.

1659279 Abigail Cain, MD, MPH is a resident at UT Health San Antonio and is a member of the Bexar County Medical Society.

IMMUNIZATIONS

The Story of San Antonio’s First Vaccines

By Jacob Canfield he San Antonio we are fortunate to live in today, with some exceptions, is largely free from the numerous infectious diseases that plagued the city when it was first founded.

Yellow fever, influenza, cholera, and smallpox all terrorized San Antonio at some point in its 300-year history. Smallpox, for instance, consistently claimed lives in the community until vaccinations began to be utilized in the early 19th century. Although many San Antonio residents nowadays may recognize vaccination as standard medical practice, this was not always the case. Only two centuries ago, the practice of vaccination was in its infancy. The citizens of San Antonio were some of the first people in the Americas to utilize, develop, and distribute vaccines only a few years after they had been proposed by Jenner in 1796.

Known as “San Antonio de Bexar” or simply “Bexar” at the time, the area of modern-day San Antonio in the early 19th century was an agglomeration of three distinct communities consisting of the Franciscan missions, the military presidio of San Antonio, and the civil settlement of San Fernando de Bexar. Although these communities inevitably collaborated and integrated with each other, they were independent entities and often had incompatible interests. Despite their differences, they shared the common struggles that were a part of living on the frontier of New Spain and later Mexico after its independence in 1821. Being on the frontier meant these Bexareños (the period term for residents of San Antonio de Bexar) lived in geographic, economic, and social isolation. This isolation made Bexareños fiercely independent, but unfortunately did not make them immune to epidemics.

For most of the early 1800s, no hospital and few, if any, qualified doctors existed in the Bexar area1. This lack of medical infrastructure forced Bexareños to rely on their national government for medical aid. During the 1820s, the Mexican government attempted to provide smallpox vaccine shipments to communities throughout Texas whenever epidemics arose. In fact, the importance of vaccination was emphasized by government officials to a strict degree.

On February 21st, 1830, Ramón Músquiz, governor of “Coahuila 22

San Antonio Medicine • November 2019

y Tejas”, made vaccination compulsory in San Antonio de Bexar declaring that “everyone without exception was required to report to the municipal building where the operation will be performed free of charge”2. Furthermore, Músquiz, made clear to local administrators that “whenever the vaccine fluid is lost through your indolence, apathy, or carelessness, this office will make use of its legal power to apply to Your Lordship whatever punishment may be due in proportion to the gravity of the harm that may result to humanity from such neglect”2.

The importance the Mexican government placed on vaccination stemmed from Spain’s early embrace of the vaccine. In fact, Spain endorsed an unprecedented expedition led by Dr. Francisco Javier de Balmis in 1803 with the aim of vaccinating millions against smallpox in the New World and Asia. Although not quite accomplishing this aim, the expedition did help establish the practice of vaccination throughout the Americas. Regarding Balmis expedition, Jenner himself wrote: “I don't imagine the annals of history furnish an example of philanthropy so noble, so extensive as this”3.

Despite the Mexican government’s attempt to adequately supply Texas communities with vaccines, shipments were slow, never arrived, or if they did, were often spoiled and unfit for use. However, the ingenuity of the proudly independent Bexareños of San Antonio would find their own solutions to supply shortages. In 1831, after a smallpox epidemic sweeping through Texas finally hit Bexar, the townsfolk developed their own formulation of the smallpox vaccine from an infected cow udder1. Without medical experts present, it was up to the citizens of Bexar to create this vaccine based solely on written instructions. Although the historical account does not disclose the specifics of these instructions, it can be speculated it was accomplished through one of two popular methods of vaccination available at the time. The first, and most likely, involved harvesting cowpox virus (a member of the genus Orthopoxvirus) from the pustules on an infected cow and using that extract to directly vaccinate human individuals. In fact, Spanish governor Antonio Martinez a decade earlier in 1820 urged the utilization of this method in order to develop vac-

IMMUNIZATIONS cines for San Antonio de Bexar2. However, a cow with visible signs of cowpox may have not been readily available or too few in number to vaccinate all citizens. Therefore, it is possible that “retrovaccination” may have also been utilized by Bexareños to make vaccines. Developed in 1803 by Gennaro Galbiati and Michele Troja in Naples, this method involved infecting a healthy cow with lymph from a recently cowpox-inoculated human. Lymph was then harvested from the newly infected cow which supposedly functioned as an even more effective vaccine for human use4.

Regardless of the specific method employed, Bexareños were so successful at creating smallpox vaccines that shipments were sent to Nacogdoches from San Antonio when they began to experience a smallpox epidemic of their own. Evidence for the efficacy of these vaccines is scant, but Alcalde Manuel de los Santos Coy, early settler and politician of Nacogdoches, wrote in 1831 that “I have never seen more milder cases of smallpox than those of this epoch, only two have died from it”2. Furthermore, it seems the successful development and implementation of vaccines during the smallpox outbreaks of the early 1830s laid the groundwork for effective medical infrastructure in San Antonio de Bexar.

Only months after the epidemic of 1831, Bexar's first community health commission (“Junta de Sanidad”) was established1. Therefore,

it can be speculated that standards of healthcare practice in San Antonio today began in part due to the early adoption of the smallpox vaccine. In a time where some modern Bexar residents may question the utility of vaccination, it was clear that early San Antonians recognized the importance of this life-saving technology, embraced it in its infancy, and set the precedent for cutting-edge medicine still being practiced in the city today.

Jacob Canfield is a second-year medical student at the UT -LSOM in San Antonio.

References 1. De la Teja, J., & Wheat, J. (1985). Bexar: Profile of a Tejano Community, 1820-1832. The Southwestern Historical Quarterly,89(1), 7-34.

2. Nixon, Pat. (1946). The medical story of early Texas 1528-1853.

Mollie Bennett Lupe Memorial Fund. Lancaster Pa. 133-136.

3. Montes, Luis. (2018). Spain, A Global History. Global Square Editorial S.l. 362.

4. Buonaguro, F. M., Tornesello, M. L., & Buonaguro, L. (2015).

The XIX century smallpox prevention in Naples and the risk of transmission of human blood-related pathogens. Journal of translational medicine, 13, 33.

visit us at www.bcms.org

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IMMUNIZATIONS

How Social Media Fuels Anti Vaccination Sentiment

By Isabela Baker

“If other moms say vaccines are dangerous...�

Since their development, vaccines have proven themselves valuable by successfully treating preventable deaths since the early 19th century. Vaccines are used worldwide to combat infectious diseases like the flu, polio, and measles13. In recent years, misinformation has kept immunizations from achieving their fullest potential. Preventable diseases have had outbreaks in countries where they were previously eradicated, according to the Centers for Disease Control (CDC), then returned along with a rise in popular non-medical beliefs11.

Misinformation that leads to disease outbreaks is spread by groups who oppose immunization practices and who question the effectiveness of vaccines12. In the United States, 45% of adults report that they do not believe that the general public receives enough vaccine education from doctors6. This may be causal to the 71% of U.S. adults (without chronic health conditions) who reported using the internet for health-related searches16. Adults who opt out of traditional medical care and rely on virtual, often non-medical resources, are largely responsible for the contraction and spread of vaccine-preventable diseases10.

The Role of Social Media Social media sites are especially popular forums where users are likely to encounter anti-vaccination sentiment and frequent persuasion tactics3. Because of this, social outlets including Facebook, YouTube, and Instagram have taken steps to prevent dangerous anti-vaccination myths and misinformation from being promoted via hashtags and search inquiries14. Social media gives users the power to create, modify, and share whatever messages they please4. Internet users who do not seek reliable sources are subject to health misinformation that is potentially dangerous when disseminated quickly7.

Government and organized efforts have been developed to encourage regular vaccination practices in the name of public health and safety. These public health care campaigns aim to combat nonprofessional interpretations of published literature correlating vaccinations to the contraction of autism or cancer. In order to generate the most effective messages that alleviate vaccine hesitancy, studies have tested the persuasive strength of vaccine opposition websites on adult attitudes5, 8.

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IMMUNIZATIONS

Attitudes Versus Persuasion Attitudes can be changed using persuasion, or messages that combine aspects of power, emotion, and truth, as observed by Aristotle3.

Anti-vaccination messages utilize persuasive techniques to achieve the guise of a credible message while evoking empathy from the audience; sentiments that can be difficult to combat when considering our individual social identities and levels of attitude resistance9.

Close knit parenting communities are only one source of vaccine hesitancy and one related account found that “if other moms say vaccines are dangerous, whatever a public health official argues about the science might not hold much weight”2. As communities continue to make health-related decisions based on the distrust of professionals, growing health concerns will come to affect those beyond their own children.

To better understand the persuasive strength behind anti-vaccination attitudes, I performed a study to assess claims made about vaccination practices on Twitter. These anti-vaccination Twitter posts were grouped based on the hashtags under which they were found. Known persuasion theories were considered while examining the information and used to draw conclusions about the tactics behind the posts.

What Twitter Tells Us To test the idea that Twitter users promote vaccination hesitancy, I began by saving the first six posts related to pre-selected hashtags, including “Educate before you vaccinate”, “Don’t vaccinate”, “Vaccines don’t work”, “Antivax”, and “Vaccines”. These searches did reveal some pro-vaccination posts, however those were not considered in this study.

The five different anti-vaccination themes, among the 60 Twitter posts, were termed as Vaccine Safety, Personal Claims, Professional Claims, Derogation of Provaccination Institutions, and Lifestyle Alternatives. Four different theories of persuasion (Power of a Message, Peripheral Judgement, Source Credibility, and Cognitive Dissonance) were also considered and paired with a supporting theme. I would note that all textual data, tags, attached images, and hyperlinked sources were considered while developing conclusions about the content of the persuasive messages. Evaluation of the persuasive strength of individual posts was largely based on my own biases.

The Vaccination Safety information themed posts, informed

readers about potential harms from vaccination practices5. As I reviewed the posts, I came across both rewarding and coercive content and understood that the user intended to induce paranoia about vaccine “symptoms” in the reader. Posts under the Personal Claims theme took advantage of anecdotal evidence that connected antivaccine sentiment to moral values and emotion. I was most surprised to find that some posts included quotes by sources in medical and science fields; these were considered Professional Claims themed posts. Professional opinions were defined as input by sources called doctors, experts, government organizations, or hyperlinks to peer-reviewed studies. Statements that denied the credibility of professional opinions, health care authorities, scientific findings, and national or state legislature were placed under the Derogation theme. These posts in particular, incited suspicion among Twitter users, about other individuals, organizations, and offered claims providing rationale for mistrust. Lifestyle Alternatives were posts that referred to personal health choices and promoted specific health practices, wellness, parenting methods, and organic lifestyles.

The frequency of posts recorded were based on the five chosen themes. The most common post theme was Vaccination Safety, and offered personal interpretations of information, with weak persuasive strength, although much of the claims were found in published data with credible sources (43.3%). The Personal Claims posts utilized anecdotes to support the users claims (24.6%). Health care providers were quoted encouraging anti-vaccination sentiment and used statistics to justify their opposition to immunization practices continued on page 26 visit us at www.bcms.org

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as medical professionals (9.7%). Twitter users who shared their distrust of traditional doctors and government intervention also bolstered statements about their right as patients to choose individual treatment options and the ability to opt out as well (11.6%). Advocates for the use of alternative medicine, or homeopathy, supported vegan eating habits in addition to detoxifying and healing practices (10.5%).

The content analyzed throughout this study were all top results and remained fairly consistent. However, in most other cases, the nature of social media shows that the impact of any given post is constantly changing, as trends fluctuate and algorithms intervene. If health and safety outlets monitored large social media platforms, it may help officials be aware of anti-vaccination sentiments being shared given times.

The Common Good The presence of Vaccination Safety information bolstering found on Twitter gives insight to what type of content feeds anti-vaccination attitudes and ways the public is encouraged to undermine medical consensus. With an understanding of how online anti-vaccination rhetoric spreads, private health care officials, public health organizations, and pro-vaccination resources can improve vaccination compliance rates. This information will also aid our societal efforts to reduce infectious disease threats for the common good.

The use of social media to promote anti-vaccination sentiment and behaviors has made public spaces increasingly dangerous for immune-vulnerable populations and threatens our overall “herd immunity”, according to the CDC. This flu season (October through May), practice washing your hands, get your flu shot, or inform people if you will be opting out, and stay home if you are sick. It is important to note that receiving appropriate immunization services not only protects you, but the people you care about as well.

Isabela Baker is a psychology major at St. Mary's University in San Antonio, Texas References

1 Albarracín, D. & Vargas, P. (2010). Attitudes and persuasion: From biology to social responses to persuasive intent. The Handbook of Social Psychology (pp. 394-427).

2 Belluz, J. (2019). Why the Washington measles outbreak is mostly affecting one specific group. Retrieved from www.vox.com/2019/3/19/ 18263688/measles-outbreak-2019-clark-county 3 Borchers, T. A. (2013). Persuasion in the media age (3rd ed.). Long Grove, IL: Waveland Press.

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4 Broniatowski, D.A. et al. (2018) Weaponized health communication: Twitter bots and russian trolls amplify the vaccine debate. American Journal of Public Health. 108(10), 1378-1384.

5 Davies, P., Chapman, S., & Leask, J. (2002). Antivaccination activists on the world wide web. Archives of Disease in Childhood, 87(1), 22-25. doi: 10.1136/adc.87.1.1-a.

6 Fox, S. & Duggan, M. (2013). The Diagnosis Difference. Retrieved from www.pewinternet.org/2013/11/26/the-diagnosis-difference/ 7 Haase, N., Betsch, C., & Renkewitz, F. (2015). Source credibility and the biasing effect of narrative information on the perception of vaccination risks. Journal of Health Communication, 20(8), 920-929.

8 Hornsey, M. J., Harris, E. A., & Fielding, K. S. (2018). The psychological roots of antivaccination attitudes: A 24-nation investigation. Health Psychology, 37(4), 307-315.

9 Moran, M. B., Lucas, M., Everhart, K., Morgan, A., & Prickett, E. (2016). What makes antivaccine websites persuasive? A content analysis of techniques used by antivaccine websites to engender antivaccine sentiment. Journal of Communication in Healthcare. 9(3), 151-163.

10 Moxon, E. R., Das, P., Greenwood, B., Heymann, D. L., Horton, R., Levine, O. S., Plotkin, S., & Nossal, G. (2011). A call to action for the new decade of vaccines. The Lancet. 378(9788), 298-302.

11 Phadke, V. K., Bednarczyk, R. A., Salmon, D. A., & Omer, S. B (2016).

Association between vaccine refusal and vaccine-preventable diseases in the united states: A review of measles and pertussis. JAMA. 315(11), 1149–1158.

12 Pluviano, S., Watt, C., Della Sala, S. (2017). Misinformation lingers in memory: Failure of three pro-vaccination strategies. PLoS ONE. 12(7).

13 Research America & American Society for Microbiology (2018). Americans’ views on vaccines and infectious disease outbreaks. Retrieved from www.researchamerica.org/sites/default/files/MAY2018_VaccinePressRelease_final.pdf 14 Wagner, K. (2019). Facebook is finally cracking down on anti-vaccination hoaxes. Retrieved from www.vox.com/2019/3/7/18254941/facebook-anti-vaccination-hoax-crackdown-policy

IMMUNIZATIONS

visit us at www.bcms.org

27

FEATURE

The Transition –

Special Needs Patients Become Adults

By Ruchi Kaushik, MD, MPH Okay, all joking aside, this is truly a serious issue. At what point is it time for pediatricians to say to our families, “It’s time to move on. We both have different paths. I think we should see other people. I promise, it’s not you, it’s me”? At the same time, we deeply care for our patients and families and know they are not looking for a one-night stand in the emergency department, but, rather, a longterm, committed relationship with a new doctor.

So, why is this an issue? Well, the truth is that advancements in medical knowledge and technology have allowed us to improve outcomes for children and youth with special health-care needs. Over 85% of children born today with chronic medical conditions will live into adulthood.1 As of 2010, more than half of all individuals with cystic fibrosis were over the age of 18.2 Over the next decade, roughly 90,000 people with congenital heart disease are expected to enter adulthood.3 Indeed, there are currently 18 million young adults 18-21 years of age – one in five has chronic conditions.4 And yet, we pediatricians remain so attached to our patients. We are afraid to let go or afraid adult providers will not be comfortable caring for our patients; similarly, our patients are afraid of moving on and not ready to trust a new doctor.5 But it is time to face our fears. Evidence suggests that health outcomes improve for young adults with chronic conditions when they have smoothly transitioned into an adult model of care.6 So, why shouldn’t pediatricians continue to see young adults with disorders that begin in the prenatal or immediate postnatal period into adulthood? Well, while we are great at immunizing, developmental screenings, and discussing anticipatory guidance, we may not be so great at recognizing signs of diseases that typically present in adulthood, Pap smearing, discussing family planning, or recalling the timing of other important preventive screenings. Certainly, these are all topics we can brush up on, but what’s more important than transferring to adult care is transitioning to the adult model of care.

Fortunately, the National Alliance to Advance Child Health has developed “Got Transition”, a cooperative agreement with the Maternal and Child Health Bureau aimed to improve transition from pediatric to adult health care with new and innovative strategies for health professionals and youth and families via its website, www.gottransition.org. The site’s resources assist providers who are both transitioning out and accepting young adults with sharing transition policies, tracking and monitoring, assessing transition readiness, creating portable medical summaries and transferring care.

It is time for pediatricians to assert, “we need to talk…” to our patients and families, inform them of the expiration date of our relationship, but ensure they are mentally prepared to enter a new 28

San Antonio Medicine • November 2019

WANTED Forty-something pediatrician seeks adult providers interested in caring for young adults with special healthcare needs.

Hobbies/Interests: Crossword puzzles, baking, and children with medical complexity.

Fears: Snakes, Loop 410, and young adult patients with new-onset adult problems.

long-term relationship, not set them up for a date with the emergency department. It is time for us to elicit not only a parent’s understanding, but also a teen’s understanding of their problem list, medications, and symptoms requiring urgent medical care.

It is time to face reality; the reality is, however, that identifying adult health care providers can be challenging. In an ideal world, we would compile a list, a directory of sorts, of local and regional adult primary care and subspecialty providers who are interested in caring for young adults with chronic medical conditions, with insurance network information. We would create a transition seminar, a quarterly lecture series given by pediatric specialists to educate adult providers about childhood-onset disorders to prepare them for the millions of teens entering adulthood. We, the exes, would shake hands with the new “bride-to-be,” open the door and share all the secrets to foster a smooth, safe, and quality transition.

Ruchi Kaushik, MD, MPH, FAAP, Assistant Professor, Pediatrics, Baylor College of Medicine, Medical Director, ComPCaN (Comprehensive Peds for Complex Needs), Medical Director, The Children's Hospital of San Antonio Blog (CHofSAblog.org), The Children's Hospital of San Antonio, \ruchi.kaushik@bcm.edu References:

1. Reid GJ, Irvine MJ, McCrindle BW, Sananes R, Ritvo PG, Siu SC, Webb GD. Prevalence and correlates of successful transfer from pediatric to adult health care among a cohort of young adults with complex congenital heart defects. Pediatrics. 2004;113(3 Pt 1):e197-205.

2. Tuchman LK, Schwartz LA, Sawicki GS, Britto MT. Cystic fibrosis and transition to adult medical care. Pediatrics. 2010;125(3):566-573.

3. Warnes CA, Liberthson R, Danielson GK, Dore A, Harris L, Hoffman JIE, Somerville J, Williams RG, Webb GD. Task force 1: the changing profile of congenital heart disease in adult life. Journal of the American College of Cardiology. 2001;37(5):1170-1175.

4. Transition of PSHCNs to adult medical care webinar series. NYMAC. http://aapdc.org/event/transition-of-pshcns-to-adult-medical-care-webinar-series/2015-02-11/. Accessed March 15, 2019.

5. O’Sullivan-Oliveira J, Fernandes SM, Borges LF, Fishman LN. Transition of pediatric patients to adult care: an analysis of provider perceptions across discipline and role. Continuing Nursing Education. 2014;40(3):113142.

6. Tuchman L, Schwartz M. Health outcomes associated with transition from pediatric to adult cystic fibrosis care. Pediatrics. 2013;132(5):e847-853.

7. Got Transition. gottransition.org. www.gottransition.org/ index.cfm?.

Accessed March 15, 2019.

FEATURE

How a Pass/Fail Curriculum Has Changed My Approach to Medicine

By Teresa Samson, OMS-II at UIWSOM We have all seen it on one medical show or another: A patient in despair and unsure of whether or not to move forward with a highrisk, life-saving treatment is quickly assured: “There is no need to worry. This doctor is the best.” It is stated so factually and so confidently, episode after episode. Each time, that sentence rolls off the tongue of the medical team and transforms the atmosphere from one of doubt to one of resilience. As a medical student watching those moments, it is hard to resist the fantasy that one day I, too, will be… The Best… But will I? What defines “best,” and how can I reach that standard?

In both medical shows and in reality, being The Best often seems to filter down to two things: skillfulness and intelligence. In medical school, we categorize skillfulness and intelligence as measures of one’s Competency as a budding doctor. No doubt, these two are important qualities to develop for the day we encounter patients with complicated cases, but are they enough to make us The Best or even a good clinician?

In high school and undergrad, The Best were recognized by their ability to excel, shown through their rankings, stellar GPAs, honors society memberships, scholarships, and various awards at graduation. This sifting of the student body to select individuals led me to adopt the mindset that if I wasn’t The Best, I wasn’t good at all. It seemed that there was no worth in being “good enough” nor in doing my best, especially if my best wasn’t The Best.

You can imagine the difficulty in applying this mindset to medical school, where every person has more education, credentials, life experience, innovation, etc. than the next. There is no way to measure up to the people around me. To try to outdo them is an impossible task. This is where the Pass/Fail curriculum changes things. No

more rankings; no more scores. Just pray a lot, and pass.

By eliminating the numbers and rankings, having a Pass/Fail curriculum has encouraged an atmosphere of authenticity for me. I no longer judge my success (and self-worth, if we are being honest) on my numbers, because I never learn what my numbers are. I had always dreamed of becoming a renowned physician, but by eliminating the notion that any one person can be the best, this curriculum has guided me toward the encouraging realization that being The Best is not why I wanted to go into medicine in the first place.

My focus has shifted to what makes me My Best, and to me that means stepping away from my studies every so often and living my life through relationships, traveling, and spending time outside under the blazing Texas sun. Pursuing these activities has helped me reorient to who I am and what the fullness of my potential looks like. It looks a lot different than I had previously thought.

I do still hope to be great one day, but maybe not in a way that separates me out from others. I have learned so much more by sharing resources among my peers rather than studying alone. I have seen patients benefit more from a collaborative healthcare team than by quick interactions with one physician. Time and again, I have found my purpose through service to others rather than by serving myself.

Maybe, to be great, or to be The Best (whatever that is), is not a quality formed in isolation. Maybe it is something obtained by harnessing The Best – The Best of all of us – in the practice of healing.

Teresa Samson is a second-year medical student at the UIW School of Osteopathic Medicine in San Antonio, Texas, and is a member of the Bexar County Medical Society. visit us at www.bcms.org

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FEATURE

Happy Patient; Happy Doctor Model

By Uchenna L. Umeh, MD

Dear Doctor,

Since I quit my job so I could start speaking on youth depression and suicide, I have discovered a side of me that loves to write, speak and fight. That side lay dormant until the passion to save our youth through creating awareness was ignited, after my 7-year-old patient attempted suicide in May of 2018.

Over time, I have had to finally admit to myself that I miss seeing my patients. They are my "anti-kryptonite". However, I knew that I didn’t want to go back to what I call "assembly line" medicine; the kind that is run by CEOs with little knowledge of what it's like to have boots in the mines; the kind that has enslaved doctors and caused burnout to become a household word and put profits before patients and providers; the kind that we did not sign up for in medical school and unfortunately drives 400 of us to early deaths each year through suicide.

I decided that medicine that way was no longer for me. Neither Locums nor Hospitalist options fit. Then I discovered DPC Docs on Facebook. A 2K-strong community of doctors practicing medicine on their own terms. Direct Primary Care, three life-changing words for those of us who look further and farther outside the box saying "enough already" to the big bosses.

I happily jumped in with two feet. You see, Direct Primary Care is exactly what Dr. Universe ordered for me. A spin-off of Concierge Medicine, DPC allows doctors to practice medicine the old-fashioned way. I learned about DPC nearly 2 years ago through a podcast featuring one of its pioneers, Dr. Josh Umbehr of Atlas MD. I was intrigued by the model and got hooked. Yet it took me nearly 2 years to act on it, not because the process is hard, but because I needed the right mindset and stars to align.

Starting back into clinical practice had to be on my own terms. A quick check with the Texas Medical Board confirmed that I could attend to at-risk youth aged 8 years to 18 years, the population I speak and write about, that spun off my dream to open my own youth health center.

It took less than 6 weeks and less than $10,000 to set up. You see, I have a micro DPC practice model; a patient panel of <300, no fancy equipment, or staff. I see only 6-8 patients a day for up to 1 hour per visit, for three days a week. My monthly overhead is a fraction of what I paid when I owned a traditional practice, my EHR is user-friendly, my stress level is low, my patients are happy, and so am I. While this might not work for many, it works for me and my niche. Dr. Amber Price of Willow Pediatrics offers home visits and only sees newborns. Dr. Sara Sultz of the DOC group does

telemedicine, home visits, vaccines and IVF right in the patient's home! Such is the new way to practice medicine and I am proud to announce that I am the first and only pediatrician in Texas and the US with this niche, in this model.

So, what is DPC? Its primary emphasis is on affordable care. In its purest form, no insurance or third-party payer is accepted. That puts the first nail in the burnout coffin! No insurance means; I. Get. To. See. My. Patients. For. As. Long. As. I. Want. To! Yassss! Patients keep their health insurance and might even get reimbursed. A flat monthly fee is paid in exchange for; longer times with patients, intimate doctor-patient relationships, lower healthcare costs, unlimited direct access to doctors virtually, improved work-life balance for physicians (reducing burnout), reduced patient load, and reduced administrative costs. The increased time with patients is a huge win for me. Fees vary depending on location and market competition; for me, it’s less than a #Starbucks coffee!

It is a membership model, like Netflix. I also offer telemedicine, parent coaching and a teen support group. My patients have my cell number to call, text, or email me whenever they need to. They get as many visits as they like each month! When was the last time you had that kind of access to your doctor? Let’s say my 14 year-old patient is experiencing an emotional crisis at 2 pm and at school, they need to get to me right away, and not have to wait until they get home, inform their parent who calls the next day to get an appointment for the next week, take time off from work and school, wait for hours in the waiting room, only for the doctor to spend all of 10 minutes with them. They then wait another 2-3 months to get an appointment with the psychiatrist who may or may not accept their insurance or charge them 2 or 3 times my monthly fee for only one visit!

In conclusion, I believe I have found nirvana in medicine again.

You might also, if you try; think about it. You never know. These days I work smarter, not harder. I still have time for; blogging, speaking engagements, recording my podcast (Suicide Pages with Dr. Lulu) and finishing up my second book, a chronicle about Teen Life (buy my first book; a Parenting Guide, here). Once we conquer that voice in our heads telling us we can't do it, the rest will fall in place. Ultimately, Happy Patient: Happy Doctor is what we all seek, right? So, I ask again this time, dear doctor, will you DPC? “We can't be afraid of change. You may feel very secure in the pond that you are in, but if you never venture out of it, you will never know that there is such a thing as the sea or the ocean. Holding onto something that is good for you now, may be the very reason why you don't have something better.” — C. JoyBell C.

Uchenna L. Umeh, MD is a Board Certified Pediatrician, Teen Expert and National Keynote Speaker at "Ask Doctor Lulu", CEO at Teen Alive and is a member of the Bexar County Medical Society.

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San Antonio Medicine • November 2019

UT HEALTH

BRCA Expert, Patrick Sung, D.Phil., Joins UTHSA

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

America’s greatest research minds are hot commodities—the marketplace for their services is fiercely competitive. A pioneering life sciences researcher who pushes the envelope against disease can be a cornerstone of scientific attainment for any city, but especially our city, bolstering San Antonio’s position as a leader of science and medicine. And the researcher’s discoveries have the potential to be translated into tomorrow’s therapies.

One of San Antonio’s recently recruited stars, biochemist Patrick Sung, D.Phil., is making inroads into understanding the biology of inherited gene mutations that greatly increase the risk of cancer formation in both women and men.

Dr. Sung, a leading expert on BRCA1 and BRCA2 cancer biology, joined UT Health San Antonio in 2019 from Yale, where he was a professor of molecular biophysics and biochemistry, therapeutic radiology and epidemiology. A $6 million grant from the Cancer Prevention and Research Institute of Texas (CPRIT) supported his recruitment. Dr. Sung was actually re-recruited back to Texas; he and his wife formerly lived in Houston and San Antonio.

Dr. Sung is an expert in the molecular mechanisms by which BRCA1 and BRCA2 mutations give rise to cancers, which could

lead to new ways to treat them and possibly prevent their occurrence in the first place.

BRCA1 and BRCA2 are tumor suppressor genes. When these genes are mutated, the loss of function leads to cancer. Primarily known for increasing risk of breast cancer in women, BRCA1 and BRCA2 mutations also are associated with ovarian cancer, prostate and breast cancer in men, and a childhood cancer called neuroblastoma. A related gene is associated with aggressive pancreatic cancer.

Dr. Sung’s laboratory conquered a major technical challenge over several years—a feat that eluded all other labs worldwide. Using unique insect cell culture systems, the scientists were able to prompt the BRCA1 and BRCA2 genes to make their proteins. These are very elaborate human BRCA proteins expressed in insect cells. Now that this technical hurdle is overcome, the Sung lab is poised to figure out how these tumor suppressor proteins function.

Very few groups in the world are able to conduct this type of investigation. Like mechanics taking an engine apart and putting it back together, the team is analyzing the sequence of events that occur when a BRCA mutation leads to cancer initiation and progression.

Dr. Sung brought talented researchers with him, and since coming to San Antonio, the team in July received a $3.75 million translational grant from the Gray Foundation of New York to focus on drug resistance in BRCA-deficient tumors. UT Health San Antonio is the lead institution in a collaborative effort with the Dana-Farber Cancer Center in Boston and the University of Pennsylvania.

This fall, Dr. Sung was selected to receive a highly competitive National Cancer Institute (NCI) Outstanding Investigator Award.

He is the first faculty member in UT Health San Antonio history to capture this prestigious NCI award, which is bestowed only upon researchers with august track records, elite-level scientific impact, and ascending career trajectories and research goals. The award, which began Sept. 9, will provide $6.1 million through 2026. Dr. Sung also just received a $1.8 million Faculty STARs Award from The University of Texas System.

STARs stands for Science and Technology Acquisition and Retention.

The NCI Outstanding Investigator Award encourages risk taking. It provides freedom for an established investigator to come up with provocative ideas—paths of inquiry where the chances of being wrong are actually quite high, but also where, if the scientist is right, the impact will be tremendous.

Dr. Sung’s decision to leave the Northeast and return to South Texas was indicative of San Antonio’s growing attractiveness to the nation’s top researchers. He joins many other excellent scientists in San Antonio, a fact that contributed to his decision to return. We are glad to have in our fold this outstanding biochemist whose discoveries promise to push the envelope in treating BRCA-deficient cancers.

William L. Henrich, M.D., MACP, is president of UT Health San Antonio and professor of medicine in the university’s Joe R. and Teresa Lozano Long School of Medicine. With missions of teaching, research, healing and community engagement, UT Health San Antonio is one of the country’s leading health sciences universities. www.UTHealthSA.org.

Dr. Henrich is a member of the Bexar County Medical Society. visit us at www.bcms.org

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FEATURE

Teaching Technology to Seniors Helps Ease Social Isolation

By DeAnne C. Cuellar All sorts of things can affect our health, but not all of them require treatment by someone wearing a stethoscope. Adequate food, relationships, transportation and safety, to name a few, are called social determinants of health, and they play a major role in an individual’s health risks and outcomes, often acting as a barrier to good health.

Among those determinants, strong social connections are particularly important as we age. Having people we care about, and who care about us, is a necessary component to healthy aging. That doesn’t bode well for 73% of seniors in Texas who are at risk for social isolation, which is known to lead to depression and lessen quality of life.

Today, much of the contact we have with others revolves around technology, from smart phone features to social media. Older adults who lack digital know-how are bound to become more isolated, depriving them of relationships they need.

Seniors living in rural areas of San Antonio have an even harder 32

San Antonio Medicine • November 2019

time connecting with others. Some travel long distances to get basic needs met at community organizations, like food pantries and churches, and to find some sense of emotional connectedness, making their need for digital competence more urgent.

Senior Planet San Antonio, a project of the nonprofit Older Adults Technology Services (OATS), is directly tackling this issue, helping seniors live more connected lives. The programs at Senior Planet, which are free for adults aged 60 and over, are based on 15 years of successfully teaching seniors how to best use technology and social platforms to improve their lives. The program’s non-intimidating, but highly effective methods have been proven to not only improve social engagement and relationships, but also significantly boost health and wellness, financial security, advocacy and civic engagement and creative expression.

OATS was one of two organizations in San Antonio who received investments from Humana Foundation for their focus on addressing social determinants of health. The Humana Foundation

FEATURE seeks out organizations to help reach a Bold Goal of helping communities become 20% healthier by 2020 and beyond. In San Antonio, these efforts have included the formation of the San Antonio Health Advisory Board and working with various community partners like OATS to impact what’s called “Healthy Days” – a measurement used by the Centers for Disease Control and Prevention.

Social isolation is one of the factors that can affect this measure.

What makes Senior Planet unique is the approach. It teaches technology to seniors at their pace with hands-on teaching, and individual mentoring. It creates an environment where seniors feel at home among their peers who are there for many of the same reasons. Because of this senior-centric approach, they absorb knowledge and enjoy the process.

Through multi-week, group courses offered in both English and Spanish, senior students choose from a variety of classes, like ‘Connecting in the Digital Age’, where they learn to get comfortable with email, social media, video chat, and other digital tools that foster connection. Once learned, these skills become a lifeline for older adults, bridging them with family and friends, both old and new. Being connected also enables seniors to shop and bank online, to meet virtually with doctors through technology like telemedicine, and to gain access to information and entertainment

that was once out of reach.

OATS and its flagship program, Senior Planet, have taught more than 35,000 older adults across the country. In San Antonio, there has been great success since the program rolled out in October. Over 37% of participants reported making three or more friends after just one month of class; seniors reengage in the community, interact on social media, and even use dating apps to meet companions.

Together, we can pull back the technology curtain separating some seniors from the modern, digital world. And in doing so will help change the way San Antonio ages – while increasing the community’s “Healthy Days”.

DeAnne C. Cuellar; Texas State Director, Older Adults Technology Services (OATS)/Senior Planet San Antonio and Gloria Rodriguez, Vice President, South & West Texas, Senior Products, Humana Inc. To find out more about OATS, visit www.oats.org; to find out more about Senior Planet, visit www.seniorplanet.org/ san-antonio; To learn more about Humana’s Bold Goal efforts in San Antonio, visit populationhealth.humana.com.

visit us at www.bcms.org

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BCMS NEWS

Bexar County Medical Society

ELECTION RESULTS FOR 2020 ELECTED POSITIONS PRESIDENT-ELECT Rodolfo “Rudy” Molina, MD

VICE PRESIDENT Rajeev Suri, MD

BOARD OF DIRECTORS

Vincent Fonseca, MD

TREASURER John J. Nava, MD

SECRETARY Brent Sanderlin, DO

Lyssa Ochoa, MD

John Shepherd, MD

BOARD OF ETHICS

Alice Gong, MD

Jesse Moss, MD

Manuel Quiñones, MD

Note: All TMA Delegate and Alternate Delegates were elected.

2019 CALENDAR OF EVENTS Women in Medicine, Mays Family Center at The Witte . . . . . . . . . . . . . . . . . . . . . . . .November 21 Thanksgiving Holiday, BCMS Office Closed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .November 28-29 BCMS Board Appreciation Dinner, Brasao Brazilian Steakhouse . . . . . . . . . . . . . . . .December 10 Christmas Holiday, BCMS Office Closed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .December 24-25

2020 CALENDAR OF EVENTS New Year’s Day, BCMS Office Closed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .January 1 Installation of Officers, Mays Family Center at The Witte . . . . . . . . . . . . . . . . . . . . . . . . January 25 34th Annual Auto Show, BCMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .October 15 Women in Medicine, Mays Family Center at The Witte . . . . . . . . . . . . . . . . . . . . . . . .November 19

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San Antonio Medicine • November 2019

BCMS NEWS

THANK YOU!

BCMS Members, Band, Car Dealers, Sponsors, & Performers of the 33rd Annual Bexar County Medical Society Auto Show The Automobile Dealers: Cavender Audi at Dominion, Cavender Toyota, Gunn Acura and Honda, Northside Ford, Chevrolet and Honda, MB of San Antonio and Boerne, North Park Lexus, Mazda, Volkswagen, Subaru, and Lincoln, Bluebonnet Chrysler Dodge/Ram, Porsche of San Antonio, Land Rover San Antonio, and Ken Batchelor Cadillac.

The Restaurants: Bob’s Steak & Chop House, La Madeleine, The Historic Menger Hotel at the Alamo, Firehouse Subs, Maggiano’s Little Italy, University Bowl, Drury Hotels, Zoe’s Kitchen Sponsors: Acumen, SWBC, Synergy FCU, Favorite Staffing, TMLT, Nolan Healthcare Solutions The BCMS Members (and the weather)

visit us at www.bcms.org

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BCMS NEWS

BEXAR COUNTY MEDICAL SOCIETY

2019-20 LEADERSHIP COURSE The second annual BCMS Leadership Course kicked-off on September 21 in the BCMS conference room, taught by professors from the Trinity University Masters of Healthcare Administration program. The goal of the BCMS Leadership Course is to teach physicians the leadership and management skills that can be used to manage their practices, businesses, community involvement, organized medicine and their personal lives. The subjects of the first session of the course were: Setting the Stage The Evolving Health Care System Blurring of the Lines in Health Care Building Credibility Everyone is a Leader Leadership Progression Model Competence & Compassion Accountability & Kindness The Leadership Course will continue for three more Saturday morning sessions over the coming months. Contact Brissa.Vela@bcms.org for more information.

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San Antonio Medicine â&#x20AC;˘ November 2019

FIRST TUESDAYS IN THE DISTRICT OFF TO A GOOD START On Oct 1, BCMS physician members, Alliance members and medical students participated in visits with four of our members of the Texas House of Representatives during the launch of First Tuesdays in the District (FTID), an extension of First Tuesdays at the Capitol. Locally, the goal is to have participants who either live or work in each of the legislative districts attend the visits with their respective legislator. Attendees met with Rep. Barbara Gervin-Hawkins (District 120); Rep. Steve Allison (District 121); Rep. Lyle Larson (District 122); and Rep. Ray Lopez (District 125). Attendees thanked the legislator and their staff for all their work in support of medicine during the 86th Legislative Session. Additionally, the groups presented plaques to the legislators on behalf of the Texas Medical Association (TMA), in honor of their work on medicine’s issues.

More visits are being planned with the rest of the Bexar County delegation between now and the first week in December.

Many thanks to the following individuals who attended the visits: Physicians – Isabel Basaldu-Prado, MD; David Henkes, MD; Leah Jacobson, MD; John Shepherd, MD; Alliance members – Lori Boies; Aleida Colen; Danielle Henkes; Jennifer Lewis; and Medical students – Katelyn Franck and Marc Ghosn from the UIW School of Medicine (UIWSOM).

If you want more information on how you can join the legislative visits with our legislators, email your contact info to mary.nava@bcms.org.

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

BCMS LEGISLATIVE NEWS

Standing (l-r) in the district office of Rep. Barbara Gervin-Hawkins (District 120) on Oct. 1 are: BCMS Alliance member Aleida Colen; Gervin-Hawkins; Mary Nava, BCMS chief government affairs officer; and Marc Ghosn, UIWSOM medical student. The group presented Rep. Gervin-Hawkins with a plaque on behalf of TMA during the First Tuesdays in the District visits.

Rep. Lyle Larson, center, (District 122) is presented with a plaque on behalf of TMA by BCMS Alliance member, Jennifer Lewis (left) and Leah Jacobson, MD (right) during the Oct. 1 First Tuesdays in the District visit in Rep. Larson’s district office.

On Oct. 1, during the First Tuesdays in the District visit in the district office of Rep. Ray Lopez, center, (District 125), attendees presented him with a plaque on behalf of TMA. Standing (l-r) are: Mary Nava, BCMS chief government affairs officer; John Shepherd, MD; Lopez; Isabel Basaldu-Prado, MD and BCMS Alliance member, Lori Boies.

Attendees representing District 121 met with Rep. Steve Allison in his district office on Oct. 1 and presented him with a plaque on behalf of TMA during the First Tuesdays in the District visits.

Standing (l-r) are: David Henkes, MD; BCMS Alliance President, Danielle Henkes; Allison; Katelyn Franck, UIWSOM medical student; and Leah Jacobson, MD.

visit us at www.bcms.org

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BCMS NEW MEMBER WELCOME

Bexar County Medical Society September 10, 2019

1

2

3

4

5

6

1 – (L to R) Brian Davis, MD; Gerald Greenfield, MD, 2020 Elected BCMS President; Christian Jacobsen, MS LSOM; Perry Jacobsen; Bob Ferry, MD. 2 – Rick Cavender Band.

3 – Rick Cavender hosted the New Member Welcome event at his Audi Dealership near the Dominion (Phil Hornbeak, BCMS Auto Program Manager, and others look on)

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San Antonio Medicine • November 2019

4 – (L to R) Brian Boies, MD; Cannon Lewis, MD; John Shepherd, MD. 5 – (L to R) Phillip Voltz, MD – 1995 BCMS President; Geneva Voltz; Delbert Chumley, MD, 2007 BCMS President; Louise Chumley, 2000-2001 BCMS Alliance President.

6 – (L to R) Rick Cavender, Audi Dominion Owner and host of the New Member Welcome; Adam Ratner, MD, 2019 BCMS President, welcomes the crowd.

New Member Welcome Event

BCMS NEW MEMBER WELCOME

Cavender Audi

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8

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7 – Audi R8 Spyder, with a V10 engine (doctor worthy) at the center of the action.

8 – (L to R) Veronica Vasquez, MD; Nora Vazquez, MD; Leah Jacobson, MD, 2017 BCMS President.

9 – (L to R) Leo Profenna, MD; William Albright, MD.

10 – (L to R) Swetha Maddipudi; Frank Zelun Jing; Jaswanth Kintada; Connor Breinholt (& baby ); Ryan Wealther; Marc Ghosn (UIW School of Osteopathic Medicine); Vinh-Son Nguyen 11 – Connor Breinholt, MS LSOM, thinking “Someday!”.

12 – Banks Breinholt (son of Connor Breinholt, MS LSOM), thinking “Booster seat, please!”

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

Please support our sponsors with your patronage; our sponsors support us.

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

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

ACCOUNTING SOFTWARE

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

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

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

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

ATTORNEYS

Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on

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San Antonio Medicine • November 2019

workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence.

Kathleen Barrow Partner 512-382-8796 kbarrow@constangy.com Ashlee Mann Ligarde 512-382-8800 aligarde@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”

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

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

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

Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 na-

tional ranking for healthcare law according to US News & World Report and Best Lawyers”

ASSETS ADVISORS/ PRIVATE BANKING

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

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

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

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

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

BANKING

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

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

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

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

Moses D. Luevano Market President

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

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

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

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

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

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

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

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

James Murry, Associate Realtor 210.314.7835 murry@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

DIAGNOSTIC IMAGING

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

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

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

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

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

COMMERCIAL PROPERTY MANAGMENT

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

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com

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

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

Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor

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

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

specialized products and services to meet the challenging demands of their career and lifestyle.

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

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

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

Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing" Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

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

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

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

BankMD (HHH Gold Sponsor) We believe Physicians deserve

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

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 41

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

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

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

HEALTHCARE CONSULTING

recovery through education and research.

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

INFORMATION AND TECHNOLOGIES

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

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

INSURANCE

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

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

HOSPITALS/ HEALTHCARE SERVICES

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

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San Antonio Medicine • November 2019

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

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

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

Jon Buss: 512-338-6167

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

OSMA Health (HHH Gold Sponsor) Health Benefits designed by Physicians for Physicians.

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

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

LUXURY REAL ESTATE

INSURANCE/MEDICAL MALPRACTICE

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

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

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

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

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

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

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

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

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

MARKETING ADVERTISING SEO

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY MEDICAL BILLING AND COLLECTIONS SERVICES

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

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

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

MEDICAL FURNITURE

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

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

MEDICAL PRACTICE

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

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

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

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

MORTGAGE

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

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

OFFICE FURNITURE

CBI Group (HHH Gold Sponsor) From reception to waiting rooms

to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

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

PRACTICE SUPPORT SERVICES

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Debbie Marino SWBC Employee Benefits, SVP Corporate Relations (210) 210-525-1248 DMarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems William J. Trijullo Medical Services Representative 210-800-5500 wtrujillo@acumen.systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506

cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up?

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

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

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

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

REAL ESTATE SERVICES COMMERCIAL

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

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com James Murry, Associate Realtor 210.314.7835 murry@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, inno-

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 43

vative solutions, value added services, unparalleled service."

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

RESIDENTIAL REAL ESTATE

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

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

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

RETIREMENT PLANNING

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

Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813

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San Antonio Medicine • November 2019

Tiffany_briggs@ml.com Ben Taylor Wealth Management Advisor 210-278-3802 ben_taylor@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

STAFFING SERVICES

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

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

TELECOMMUNICATIONS ANSWERING SERVICE

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

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

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

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

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

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

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

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

GUNN AUTO GROUP

11001 IH 10 W at Huebner San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Esther Luna 210-690-0700

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Ford 12300 San Pedro San Antonio, TX

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

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Marty Martinez 210-525-9800

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

David Espinoza 210-912-5087

Rick Cavender 210-681-3399

Gary Holdgraf 210-862-9769

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Subaru 9807 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

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

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

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Sandy Small 210-341-8841

James Cole 800-611-0176

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

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

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

AUTO REVIEW

2019 Volkswagen Jetta GLI

By Stephen Schutz, MD

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San Antonio Medicine â&#x20AC;¢ November 2019

AUTO REVIEW The seventh generation Volkswagen Jetta, introduced in the U.S. last year, is VW’s latest attempt to demonstrate with product that the company takes our market seriously. Together with the new Atlas and redone (and larger) Tiguan SUVs, the new Jetta is, presumably, intended to make us forget all about the Eos and Routan.

As has always been the case, the GLI is to the Jetta as the GTI is to the Golf. And the GLI and GTI are very similar under the skin—they share a platform and drivetrain, after all—but with different body styles and interiors.

Size-and-price-wise, the GLI competes with the Honda Civic and Toyota Corolla, but it’s more engaging to drive (unless you chose the Civic R, which is tons of fun but much pricier). Zippy around town and eager to hit your favorite curvy road, the GLI will please any enthusiast under most circumstances; it makes going to work or the grocery store an event rather than drudgery.

On the other hand, long trips on the interstate are not the GLI’s forte thanks to a droning engine that’s cool during short drives but somewhat annoying on the open road.

For the record, the GLI’s powerplant is a 2.0 liter turbocharged 228HP four-cylinder engine mated with your choice of either a six-speed manual transmission or a seven-speed dual clutch automatic. That translates to a 0-60MPH time of 5.6 seconds with the automatic, which is quite good for a sporty compact sedan (the manual is slightly slower but certainly more involving and fun).

Fuel economy is 25MPG City/32MPG Highway.

The interior is very Volkswagen, which is to say pretty spartan

but easy to sit in and use. There’s decent space in either the front or rear seats, and the cabin feels more special than a standard Jetta.

Nevertheless, the materials are not luxurious and don’t even measure up to those in the GTI. Still, they’re fine for the price point and competitive with the aforementioned Civic and Corolla.

The tech is likewise not fancy, but it works well and is very intuitive. A larger screen with more bells and whistles can be had for more money, but I don’t really see the point. The standard infotainment system is fine. Oh, the steering wheel, borrowed from the GTI, is fantastic.

The Jetta GLI is about a foot and a half longer than the GTI, and it looks substantially different too, so it makes sense that few people will cross shop these mechanically identical vehicles. They have completely different personalities, which leads me to conclude that parents of young children will gravitate more to the GLI, while single “dude bros” and empty nesters would likely prefer the hatchback GTI.

Jetta GLI pricing starts at a budget friendly $26,850, and, in another effort to capture American hearts and wallets, all Volkswagens now come with a 6yr/72,000 mile warranty.

An important aside: the great Ferdinand Piech died in August, four years after stepping down as the singular leader of Volkswagen AG. And, make no mistake about it, for 22 years Piech led Volkswagen much as Steve Jobs led Apple—he led it completely.

When Dr Piech became VW’s CEO in 1993, the company was losing money despite selling 3 million vehicles per year, and they had a lousy reputation for quality. In 2018, VW sold over 10 million cars, was solidly profitable, and had no more quality concerns than any of its competitors, including Toyota.

Like Steve Jobs, Ferdinand Piech was difficult. He was immensely intelligent, demanding to work for, and almost impossible to please. Yet engineers who worked under him at VW say they did their best work while working on challenging projects for Piech.

The Audi A2, VW XL1, and Bugatti Veyron are good examples of “impossible” cars that VW produced at Piech’s insistence.

I’m not going to list the other legendary street and racing cars that happened while Dr Piech was the boss, since they’re numerous and have been outlined elsewhere, but I am going to say that he was the most influential person in the automotive world over the past 50 years, and he made Volkswagen AG into the juggernaut that it is today, almost single handedly. And he did it with otherworldly vision, determination, and taste, just like Steve Jobs.

RIP Ferdinand Piech.

Anyway, the Jetta GLI, which Dr Piech would doubtless see as a good but not great car, is fun to drive and a happy alternative to a boring Corolla or Civic.

Nobody really wants a low-to-mid-priced compact sedan, but if your circumstances require that, getting a GLI will at least provide some fun behind the wheel. And it’s more proof that Volkswagen is finally taking the U.S. market seriously.

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

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

visit us at www.bcms.org

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THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA

MEDNAX

Clinical Pathology Associates

Peripheral Vascular Associates, PA

Dermatology Associates of San Antonio, PA

San Antonio Eye Center, PA

Diabetes & Glandular Disease Clinic, PA

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ENT Clinics of San Antonio, PA

San Antonio Infectious Diseases Consultants

Gastroenterology Consultants of San Antonio

San Antonio Kidney Disease Center

General Surgical Associates

San Antonio Pediatric Surgery Associates, PA

Greater San Antonio Emergency Physicians, PA

South Alamo Medical Group

Institute for Women's Health

South Texas Radiology Group, PA

Lone Star OB-GYN Associates, PA

The San Antonio Orthopaedic Group

M & S Radiology Associates, PA

Urology San Antonio, PA

MacGregor Medical Center San Antonio

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of October 19, 2019.

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San Antonio Medicine â&#x20AC;˘ November 2019