San Antonio Medicine December 2020

S A N A N TO N I O

2020

MEDICAL YEAR IN REVIEW

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2020 MEDICAL YEAR IN REVIEW COVID-19 Pandemic & Public Health in San Antonio

By Sandra Guerra, MD, MPH ........................................12 Pandemonium 2020

By John J. Seidenfeld, MD ............................................18 Testing for Evidence of the COVID-19 Virus

By Alan Preston, MHA, ScD ..........................................22 Face Mask to Face Medicine

By Madeline Ruszala, UIWSOM, OMS-IV ......................24 On the Other Side... What Ifs After the Pandemic

By Timothy C. Hlavinka, MD..........................................26 COVID-19 Survivor Stories – It’s a Lonely Virus

By Cindy & Patricia (sisters) ..........................................28 BCMS Service to Our Members and Community in Need!

By Melody Newsom, BCMS Chief Operating Officer .....30 2020 Coronavirus Pandemic – A Year in Review

By Mary E. Nava, MBA .............................................................................................................................32 Your Medical Society By Your Side

By Brissa Vela ............................................................................................................................................34 COVID-19 and Pre-Clinical UME at UIW School of Osteopathic Medicine

By Adam V. Ratner, MD, FACR ..................................................................................................................35 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10 BCMS Circle of Friends Physicians Purchasing Directory........................................................................................36 Burnout: Symptom of Moral Injury at the Workplace or Something More? A Thought Analysis

By Rodolfo (Rudy) Molina, MD, MACR, FACP......................................................................................................40 The Business of Medicine: Consider These Year-end Financial Moves By Elizabeth Olney ......................................42 Recommended Auto Dealers .................................................................................................................................43 Auto Review: 2021 BMW X5M By Steve Schutz....................................................................................................44 PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com

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SAN ANTONIO MEDICINE • December 2020

DECEMBER 2020

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VOLUME 73 NO. 12

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS. EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

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

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS

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

DIRECTORS

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

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SAN ANTONIO MEDICINE • December 2020

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

BCMS SENIOR STAFF

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

PUBLICATIONS COMMITTEE

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

PRESIDENT’S MESSAGE

2020 – A Year of Tumult

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

First and foremost, it has been an honor and a privilege to serve as president of the Bexar County Medical Society for 2020. The staff and board of directors have been flexible and inventive in finding methods to provide services and guidance to all of the physicians in Bexar County. I am confident in the future of the Society as strong and sure hands continue to lead our organization.

2020 has truly been a year for the history books. Economically, the year began with the lowest unemployment rate and best stock market in recent history. The excess amounts of money in the accounts of high earners or those with a significant stock portfolio allowed them to pay for new cars, boats, RVs, or even airplanes. The entire country was flying high; drunk on a climate of cash, high stock returns and job security. However, when the coronavirus struck in February, the entire world changed and went into a downward spiral. Entire econåomies were placed on lockdown and medical care became secondary to societal recovery. The words and guidance of scientists were initially accepted, and the severity of the public health crisis was well-recognized.

But the patience of society decreased and eventually nearly evaporated. Cases of illness soared as various levels of leadership all over the world seemed to deny the entire situation. Racial and xenophobic slurs permeated reports and commentary regarding the virus. As would be expected, this resulted in increasing levels of infection. Emotion and politics changed the focus of the population and scientific objectivity was lost. In fact, many of the scientific thought leaders were maligned, belittled, ignored, and even turned into pariahs. Their jobs and careers were placed at risk. In some cases, their lives and the lives of their families were either threatened or put at risk.

In the United States, the national election took a backseat to the pandemic. Decisions by both the political and scientific leadership were often misrepresented, misinterpreted, or completely ignored. Chaos ruled as the lives of governors and other leaders including scientists were threatened. More than one plot was uncovered by law enforcement authorities and quashed. Political leaders selected their own truths and ignored or denied the recommendations of public health officials.

Those who were classified as essential workers became societal heroes as they fought both medical and economic battles. In an effort to reduce deaths caused by the virus, hospitals and nursing care facilities became fortified havens. Patients and family members were separated. Entry was at first curtailed, then denied. Intensive care and

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other hospital units became overloaded with patients suffering from coronavirus infections. Nursing staff, physicians and other caregivers placed their own lives at risk in order to provide life-saving services to patients. Even those who refused to follow recommended safety measures received the same level of care. Those patients exposed hospital staff to the risks of their own infection. Dying patients were separated from their family and loved ones and often expired with only hospital or nursing home staff members in attendance.

Due to civil and medical rules and regulations, patients were often prohibited or at least discouraged from standard office visits. Telemedicine became a way of life as patients and their problems had to be managed remotely. Masks or face coverings became mandatory. Gloves and other protective garments were necessary for the safety of caregivers; and were soon fashionable. Daily death tolls often exceeded those of recent military conflicts. Neighbors and families were split in their opinions and practices regarding use of personal protective equipment.

Shop and business owners were forced to police their own establishments in the face of an economic catastrophe and public ridicule.

The promise of a vaccine offers hope for a return to normal. But even this promise is cloaked in controversy and the hope is not universally accepted. What has, however, become clear is that with the specter of a worldwide economic and public health catastrophe, the world’s greatest scientific minds can set aside national pride and work together toward a common goal. A goal which could possibly rescue the soul of humanity. The overriding question is whether national leaders will be able to visualize the same goal. Perhaps the next several months will tell.

In spite of all of the setbacks in 2020, science and medicine remain the shining beacons to provide a society lost in the darkness of a worldwide pandemic. Those of us who provide medical care are expected to remain steadfast in our pursuit of health for the society, even as that same society places our own lives at risk. Just as we and our predecessors have always done, we will remain true to an oath which many of us took willingly many years ago. We will persevere. Even in the face of overwhelming odds, including our own deaths, we will continue to provide the best possible health care to those entrusted to us.

Gerald Q. Greenfield, MD is an orthopedic surgeon and is the 2020 President of the Bexar County Medical Society.

BCMS ALLIANCE

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2020 MEDICAL YEAR IN REVIEW

COVID-19 Pandemic & Public Health in San Antonio

By Sandra Guerra, MD, MPH

2020 was a year of unexpected events. The COVID-19 Pandemic disrupted life for so many this year, often in ways our community had not experienced since the 1918 influenza pandemic. Public health was placed in the spotlight instantaneously as the scientists with knowledge on combating a pandemic, the providers of scarce resources in testing, and the primary responders gathered information for public dissemination and education. Through these areas, San Antonio Metropolitan Health District served as the lead agency in responding to the pandemic.

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2020 MEDICAL YEAR IN REVIEW As a backdrop, the San Antonio Metropolitan Health Department was thrust into a response for which no agency in the United States could have adequately prepared. What the city had going for it were a few valuable gems that are rarely discussed, which ultimately saved lives. First, at the health department, the primarily female and diverse leadership team was highly experienced, educated, dedicated and widely respected. Under the leadership of the Assistant City Manager, Dr. Colleen Bridger, the team was crafted over years of smart hiring and trusted leadership during challenging times. Secondly, the city leadership chose to respect the health department’s guidance and regulations. Under Mayor Ron Nierenberg and Judge Nelson Wolff, the department was provided verbal, financial and political support.

Third, the most impactful professionals in our community during the pandemic were two doctors whose names are now recognized by the entire city.

The Local Health Authority, Dr. Junda Woo, came to the role 5 years ago as an OB/Gyn and former writer for the New York Times.

She was thrust into the spotlight, skillfully translating the science into practical terms that could be used by elected leaders, epidemiologists, school boards, business owners and the public. Through her legal authority under state law, Dr. Woo was able to help curtail outbreaks in long term care facilities and other environments. Another doctor, Dr. Anita Kurian, a former family physician in India and executive public health leader in Texas, was the ultimate leader of the response. Normally responsible for communicable disease programs, and as the pandemic exploded, Dr. Kurian quickly assumed the task of shepherding a public health workforce of over 520 people working all aspects of the COVID response. Physician leadership was a significant contributor in the race to beat the pandemic. I was honored to join this team of science leaders in July, almost 5 months into the pandemic. The lessons learned below are from the combined experiences of the amazing leaders of the San Antonio Metropolitan Health District.

HERE ARE THE TOP 10 LESSONS LEARNED IN THE PANDEMIC 1. Responding in a Public Health Crisis Requires a Multi-agency Emergency Response For San Antonio, the public health crisis of the pandemic required a Unified Command and multiagency response. San Antonio Metropolitan Health District, San Antonio Fire Department, South Texas Regional Advisory Council, City Manager’s Office, Mayor’s Office, Bexar County, University Health System, UT School of Public Health, the Bexar County Medical Society and many other crucial agencies became instrumental in ensuring the response was comprehensive, timely and robust. Most of the agencies dedicated a substantial portion of staff and resources to responding to the Pandemic, often

7 days a week, long hours, and in alternative work sites for most of the year. The agencies each responded in their areas of expertise and greatly expanded their impact. For instance, San Antonio Fire Department used their Mobile Integrated Health program to provide COVID testing at Skilled Nursing Facilities to control outbreaks.

This Emergency Response System had previously been used in responding to natural disasters, such as people evacuated from hurricanes to San Antonio. That experience, plus tabletop exercises in preparation for a pandemic, led to established roles and responsibilities of the same organizations in 2020. But beyond the textbook plans and ability to execute the plan, responding to a crisis required trusted relationships between organizations which took years to build during smaller events and even being partners during a non-event. The interagency relationships that public health depended on required the care that any relationship needs…communication, trust, dedication and mutual celebration for good work.

2. Public Trust in Science is Fragile Earning the public’s trust in science, medicine and evidence-based healthcare had been taken for granted by most for many years. What we learned this year is that when people’s health is threatened, they look for alternative plausible solutions and explanations. This is human nature and as physicians, we are accustomed to second opinions and internet searches when we give a challenging diagnosis. For many scientists, it was alarming to see the same reaction on a population basis; some blamed politics, others blamed the novel-ness of the virus, others blamed system failures or even competing views of scientists, but in the end, the result has been the same. The public’s trust in science is fragile.

Science is not immune to challenges and is built on testing assumptions. Yet that rigorous scientific process that we were trained on has come under scrutiny to respond in the speed needed when the threat is ubiquitous. The rigor was viewed as bureaucratic. The statistics were perceived to be gaming a system or advancing a political view. The recommendations on safety were seen as overbearing or not truly protective. The actions by the government officials to impose quarantines or close places of congregation were challenged as overreach and stifling civil liberties. Theories around public health hiding information were as abundant as the theories around hidden motives in inflating numbers or providing guidance. The work of public health was met with legal, social and intellectual push-back.

So, what does this fragility of trust in science mean going forward?

It means as scientists, we must recommit to having meaningful, honest conversations with patients, peers and the community on a regular basis, not simply in times of crisis. We must respect the decisions of people without condemnation or fault. We must educate to the best of our knowledge and give options when they are available. And we continued on page 14 Visit us at www.bcms.org

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must adapt to the environment around us to meet the needs of the person in their entirety, not just the physical; learn what drives their belief system and accommodate where they are in accepting the world as it has changed. And finally, recognize that the system used for rigor in science is the counterweight to the art of medicine.

3. Counting in a Pandemic is Tough Being transparent is essential during a crisis. The pandemic was no exception. Many governments turned to data as a presumed unmitigated source of truth and a community impact index. Yet, during the COVID Pandemic in San Antonio, the situation was like Americans watching football games; the community looked to daily number updates of cases, deaths and outbreaks on television, radio and other media channels. Government agencies were quick to share what they knew of the case counts and overall impact in multiple formats from social media, local news and even the Mayor’s “Daily Briefing” on television (and other broadcast modalities). The desire to be transparent is the culture of the San Antonio government to make sure citizens make informed decisions.

Yet with the commitment to transparency, the challenge public health officials faced to account for cases became the focus, instead of the message of safety. For instance, though COVID-19 was a reportable condition, recognizing laboratories were overwhelmed in the early days of the pandemic, meaning sometimes a result was available 10-12 days after collection. This delay in confirmatory diagnosis added to a delay in reporting to public health. As lab capacity improved, the official definition of a COVID case continued to evolve in public health, so some persons were able to be included in official counts, while others were pending further investigation. Simultane14

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ously, determining which COVID tests could be used based on the condition of the patient also added complexity to the case counting. Finally, due to the testing surge, some large laboratories and hospitals were reporting cases in batches, often weeksto-months delayed.

Then, there was the challenge in death reporting. Sadly, many people in San Antonio have died with COVID ever since the pandemic began. The complexity of “cause of death” reporting was not different during a pandemic, but the public rightfully wanted the information faster than the normal death records process would allow. This led to accepting unofficial reports from facilities or the coroner to show severity of illness to our community but had to await official confirmation weeks-to-months later, after a death certificate was available to review.

The reconciliation process added fuel to the conspiracy theories saying numbers were inflated to increase payments from the government or to sabotage a political candidate.

The reality was simply this: counting cases during a pandemic is not clean due to the complex health care and public health systems we have in Texas that existed prior to the pandemic. There is a lag time between when people get care and how that information is shared. It is not like going to the ATM and pulling out cash where your bank account is updated instantaneously. I wish it was! But sadly, think of it like the days when you wrote a check for a purchase and never knew when it would be cashed; your account could be flush with money and then suddenly overdrawn. Ideally, our community would see the statistics as a gauge more than a definitive marker for COVID in the community.

4. Contacting Contacts Has Always Been Difficult The role of public health has always been to confidentiality notify contacts of reportable communicable diseases. There are different tactics that have been employed by public health experts over the years based on the disease, the environment, and the next steps the “contact” must take. For instance, a person who has been diagnosed with tuberculosis would identify the places where they spent more than 8 hours with others while indoors. For measles, which is more easily transmitted, a sick person would describe every environment they were in over 2 days prior to symptom onset. For a sexually transmitted infection, a person would share the information they knew of intimate partners they had in the last 2 months. But when it came to COVID-

2020 MEDICAL YEAR IN REVIEW 19, the asymptomatic or pre-symptomatic person posed a problem in spreading the disease. Though many clinicians know this attribute is not unique to the coronavirus, public health becomes concerned when a silent spreader may be unknowingly exposing persons at higher risk.

Public health, with their partners, took on the daunting task to notify people who were exposed to a confirmed case. They made phone calls that were unanswered half the time. They waited for return calls.

Based on the situation, some employers or schools were notified. Long term care facilities were notified to stop admissions if a resident was found to be positive. Universities suspended team games when members got sick. The work of notifying was a tremendous undertaking that included education, resource sharing and empathy.

The contact tracers heard stories of the loss of loved ones, job loss, home displacement and theories galore.

For some, the burden of hearing heartbreaking tales of families separated, and unaccompanied hospitalizations or video-call, final good-byes, brought the public health worker to tears. Contacting people during a pandemic and hearing how it has impacted them was emotionally challenging.

5. The Waiting Game The other reason an asymptomatic or pre-symptomatic person is of concern in contact tracing is because once someone was identified as a contact to a confirmed case of COVID, the contact needed to quarantine and wait for test results or symptom onset. Ideally, a person who was exposed would be in quarantine for 14 days, which seemed like an eternity for most. The waiting game was a cornerstone to the COVID-19 pandemic in 2020. “Act as if you have it” was the mantra preached to people who had been exposed and even the public.

After someone was exposed to COVID, or if they had mild symptoms that could be consistent with the virus, the next step was to get a test done. That process was not easy either. Early in the pandemic, the test locations were fraught with long lines (albeit, by car). People hoped they could access the test (“do you have symptoms?”), wanted to know which test would be used and the speed in getting a result.

Sure, everyone wanted the rapid test which came about later in the year, but it was challenging to find testing locations and the results were not definitive. Despite knowing a test result should not clear someone to resume normal activities since the virus could still manifest within 14 days after exposure, the community was filled with anec-

dotes of people using a negative test as a short cut in quarantine requirements. The waiting game was lost.

6. What to DO: Social Responsibility on the backdrop of changing guidelines As the COVID-19 pandemic spread across the globe, watching other countries shut down in ways that current memories had not experienced was mesmerizing. Limiting travel, shuttering businesses, closing schools, changing behaviors in greeting each other…Americans’ watched and waited. Within a few weeks, the United States grappled with the same dire measures and drastic decisions. Travel as we knew it ceased, schools indefinitely suspended the Spring Break tradition, universities emptied dorms, temporary hospital beds were created, rationing of personal protective equipment became symbolic of a country reeling from the impacts of a deadly virus. Health care workers were the front line of defense and grocery store employees risked their well-being to ensure food and supplies were available to all. Hording of essential items and shortages were often a combination of a fragile justin-time supply chain and human psychology in a crisis.

As national public health guidance changed (“masks don’t work well” to “wear a mask all the time”, “test again to see if the virus is cleared” or “don’t test again for 90 days”), the public and clinicians grappled with what to do exactly. People were asked to stay home, limit outings to essential actions like grocery shopping. Over a short time, the list of essential activities increased, the economic strangle-hold impact on business and families emerged, the issues of unsafe home environments, holiday traditions and changing recommendations caused a quick slide back toward a false normalcy. This led to a COVID surge in the middle of summer, when respiratory illnesses rarely spike. The spike in cases, hospital capacity and deaths across the state, led to a statewide mask mandate which ultimately led to a reduction in the number of cases. People eventually settled into a risk-acceptance level that was mitigated by wearing a mask, staying six feet apart and hand washing.

Some risk-taking was inevitable in a population that had grown weary of the changes in life as we knew it. Young people suddenly felt a sense of immunity to the virus and attended college parties or went to bars. Older people missed grandchildren and opted to visit. continued on page 16 Visit us at www.bcms.org

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Schools recognized challenges with virtual learning and gave in-person classes a try. Long term care facilities were able to allow visitors under certain conditions. Religious services resumed with precautions.

We, as a community, re-learned that shaming people into social responsibility was met with resistance and non-conformity. Positive role modeling was more effective. We re-learned, as a community, that privacy of health information was still important in a pandemic, so efforts to blame the sick was fruitless. We recommitted, as a community, to find ways to protect the vulnerable and recognize how to care for our loved ones in new ways. We, as a community, found out how interdependent we are and how tenuous the relationship between our personal health and the health of those around us are connected.

7. The Speed of Science is Slower Than Some Expected Americans have long lived with the belief that ingenuity would bring a speedy solution to any health threat, especially one that the rest of the world had failed to halt. Yet, what the pandemic has reminded our country is that a solution is not a singular action, medication or vaccine, but an arsenal of smaller steps to success. Those of us in health care and public health know science does not occur at the speed of a one-hour episode of CSI. Instead, science is calculated from known experiences with similar viruses, previous pandemics and technology. Where we did advance…testing capabilities, medications, treatment modalities, innovation in ventilators and mobilization of human resources to hot spots, it seemed as if we were constantly trying to get there faster; rightfully so. There were experimental treatments and need for recovered donors. People across the globe tried home remedies promising protection only to add another health risk that public health had to inform people to avoid. Science was moving, but not nearly at the speed people wanted.

In San Antonio, the city was able to be involved in vaccine clinical trials, treatment trials and gave birth to an innovative testing center that promised to return COVID results in 24 hours for a fraction of the cost. The city was home to the first cases of COVID that were evacuated from cruise ships early on in the pandemic and later helped sister communities across Texas with patients when they experienced surges. These experiences helped build out the robust capabilities that San Antonio was able to leverage in the treatment of people in our hospitals and in the community. Science was not occurring as people expected, but it was occurring every day.

8. Spotlight on Social Determinants of Health The COVID-19 pandemic had many visuals that will be emblazoned in our minds for decades. Some of those images captured the national media of what was occurring in San Antonio, such as the arena parking lots filled with cars waiting for food assistance from the San Antonio Food Bank. Yet what those in health care already knew before 16

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the pandemic, is health is not only what occurs in a doctor’s office but it is driven by social factors such as food insecurity, social isolation, lack of transportation and other issues of inequity. The pandemic highlighted the populations that are disproportionately impacted by the social determinants of health. The ability to access food was often tied to places that were closed or the loss of work pushed families into poverty. Suddenly, the social determinants of health were visible, and palpable. Public health was keenly aware of the magnification of needs since they were speaking to people in the community daily.

We also will not know for years how some decisions such as discontinuing a medication so that you can buy food instead, will impact the productive life expectancy after COVID. What about the decisions to postpone childhood immunizations or the family who lost health insurance when the job was lost? We are unable to predict the long

2020 MEDICAL YEAR IN REVIEW

term sequalae of COVID due to these developing social determinants of health. What we as a community learned is the need to fortify around social determinants of health in San Antonio during “normal� times (yes, we will get there someday) to protect against the push over the cliff in another crisis.

9. Civil Discord and Pandemics Public health experts were not surprised by the civil discord during the pandemic.

History has taught us this is a common finding, though the impetus was unique and heartbreaking for our country.

What was surprising was the personal nature of the attacks on our Pandemic leaders. Racism was declared a public health crisis in San Antonio during the COVID-19 pandemic. We know generational disproportionate negative treatment of people of color has resulted in tremendous hardships that impact the health of the community. COVID was another example of a crisis with inequity in health outcomes often based on race. Hispanics were more likely to die of COVID in San Antonio than their peers.

And though it is also true that Hispanics have a higher rate of diabetes and other co-morbidities in the city, the question should remain on our minds: why? As public health professionals, COVID has taught us all the factors that led to a lack of equity in health are once again driving health disparities. It is incumbent on all fields of science, health, business and social justice to look at racism as its own health driver and commit to finding solutions.

One of the questions raised during the civil discord was if demonstrations led to more cases of COVID in San Antonio. There were no clear links between peaceful protests occurring outside in masked and socially distant events and known transmission of COVID.

get the vaccine, such as health care workers in long term care facilities and first responders. We know there will be people who cannot or will not be able to get immunized. We also know there is a risk of other shortages such as supplies. Treatments will continue to improve and more will be known about risk factors for severe illness. I am optimistic we will overcome this pandemic, but we are still too early to tell the long term sequalae of infection and overall health costs. The solution is not singular but a combination of all the lessons we have learned so far and those yet to come.

The way forward and out of the pandemic is to remain steadfast in our commitment to the health of our community in large and small ways. I am a strong believer that public health is not the responsibility of a city department, but instead it rests on the shoulders of all of living in San Antonio.

Sandra Guerra, MD, MPH is the Interim Deputy Public Health Director of the San Antonio Metropolitan Health District and is a member of the Bexar County Medical Society.

10. There is no silver bullet The COVID-19 pandemic will end slowly over time. Many are hoping a vaccine will be the solution. What we know is there is no singular silver bullet to stop the pandemic. In previous pandemics, vaccines slowed the spread, but a widely available, safe and effective vaccine is months away. At first, certain groups will be prioritized to Visit us at www.bcms.org

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2020 MEDICAL YEAR IN REVIEW

Pandemonium 2020

By John J. Seidenfeld, MD

As I recap the year 2020, months seem like waves coming ashore, each one bigger than the last. At the time of this writing, more than 230,000 people have died from COVID 19 in the U.S. causing anxiety and grief (numbers in addition to expected deaths in prior years’ statistics).

So many wise and wonderful people have been lost. What happens now and what lessons have we learned?

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January 2020 We discovered that the vaping lung injury epidemic was attributable to a West Coast company selling vitamin E oil to rogue marijuana growers for inclusion in vaping pods. The oil received in barrels by the distributor, had a warning label “not for inhalation”. It was repackaged into smaller containers without labels and resold to cut THC put into vaping pods. Once off the market, the electronic vaping associated lung injury (EVALI) epidemic ended. Rare cases from toxic inhalants have been reported over the past ten years and will continue to dribble in.

Reports of a deadly strain of Coronavirus causing pneumonias and other serious illness were received from Chinese authorities and front-line doctors beginning in December of 2019 (after an initial coverup which often greets bad news). Life in the U.S. continued as before with no travel restrictions, but the CDC (Centers for Disease Control) went on alert and began sending out regular reports by early February for the period between December 2019 and February 2020. As I now teach at the University of the Incarnate Word School of Osteopathic Medicine (UIWSOM) and discuss topics such as Coronavirus with osteopathic medical learners, many felt no alarm and were confident that the CDC and WHO (World Health Organization) would contain the outbreak. I made plans to get together with friends in the coming months, to travel to meetings and to make reservations for summer travel. Face-to-face work continued.

February 2020 More concern was raised as reports from the outbreak appeared in the New England Journal of Medicine and Mortality and Morbidity Weekly Report from the CDC. We felt concern about

SAN ANTONIO MEDICINE • December 2020

2020 MEDICAL YEAR IN REVIEW the reports of a novel virus with severe health consequences for the elderly and rapid transmission but continued to feel confident that it would be contained. I traveled to San Francisco for a medical meeting early in the month. There I stayed with family in Oakland and traveled each day on public transportation to the meeting. I began to be concerned about seasonal influenza from people near me coughing and sneezing but took no precautions beyond cringing. As the month went on, a few cases were identified in the U.S. and some precautions were taken, but travel was not banned.

March 2020 I left the office to work from home in mid-March. I turned off the lights, closed the door and thought of Pompei. Cancelled: leave requests for weddings of nieces, a weekend with out of town friends in the Hill Country, homeowner’s association meeting with neighbors, golf with friends, gym workouts, grandchildren’s schools and haircuts.

My older brother died suddenly and catastrophically in a California nursing home, was buried in Chicago next to his wife, and we have delayed the memorial. We do not know but wonder about the infectious cause of his death.

We stocked up on toilet paper, hand sanitizer, canned foods, cleaning supplies, dried beans, rice, and nuts to prepare for the great unknown. Religous services and classes left the buildings and transferred to video conferencing. The virtual world has become more complex.

We see images of people, hear familiar voices, but are not as coordinated as we were; a new asynchrony.

People are infected and dying in greater numbers but the death rate, testing, protective equipment, and ethical decisions as to who gets ventilators are unclear. One of my older mentally capable friends voiced concerns about whether he would receive ventilator management if needed or whether he would be a “low priority”. The national approach is to let each state respond in their own way, but is this the best or most equitable approach? Other countries have had national coordinated responses. Travel is unlikely for a long time. Those at greatest risk are living or working at nursing homes, homeless shelters, prisons and jails, meatpacking plants, and anywhere one is unable to social distance, wash hands, or take other precautions to prevent airborne spread.

Clean water, soap and sanitizer, nutrition, safe housing and access to medical care have become essential to prevent infection; these are clearly the social determinants of health. Containment now is an unlikely goal.

tually to friends and family, or do other things, online of course. I am not making trips out and am sheltering in place as we have no idea of the time course or seasonal pattern of this virus. Bexar County Medical Society (BCMS) meetings are online, so no more fighting rush hour traffic around 1604. Friends are” Zooming” 2-3 times a week to check in, and grocery stores are going online for store pickup or delivery.

Small businesses and restaurants are closed and in a panic. People are losing their paychecks, jobs are shutting down and Congress is meeting emergently. Death and infection rates are rising as the U.S. becomes a major world focus, a title dubiously given by monthly infection and death tallies. A global pandemic has been declared by WHO. Travel

April 2020 Basketball tournaments are cancelled, pro sports are halting as players turn COVID-19 positive, and my sports viewing habits are changing as I wean off televised games. On the plus side, I have freed up 10-20 hours each week to read, watch dramas and mysteries, talk vircontinued on page 20 Visit us at www.bcms.org

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is blocked into and out of many areas and countries. Travelers from the U.S. are not welcome in certain common European and Asian destinations. Students are heading home from universities and living with families again. ‘Should we wear masks?’ has become a matter of political and scientific debate and people are sewing their own with “YouTube” guidance.

May 2020 At virtual work, we are examining each hour of curriculum content for four years of osteopathic medical studies. Online meetings start in the morning and fill the screen all day. We figure out how to eat meals and schedule personal need times around the ever present virtual audiovisual meeting. Telemedicine has come of age and my wife, a nurse practitioner with a VA affiliated clinic (Veterans Administration), is “seeing” patients virtually. Political parties and figures are blaming one another but solutions are in short supply. Violence against children and women, violence in the streets pitting citizens against citizens, and tensions borne of long containment are erupting. The pandemic is exposing inequities in the health care system. Memorial Day will be remembered as a time that incubated new cases as people partied like the end of the world was near and protested for and against many causes. Are we at war with ourselves? Are NIH and CDC leaders and our public health doctors our only great leaders? Are we for ourselves alone? Who will speak for those who are unable? Work on vaccines continues at a fast pace never seen before.

June 2020 A “White Coats for Black Lives” rally was held peacefully and prayerfully at UT Health Sciences Center field to raise awareness of the killing of black men and women and promoted the diversity of our medical learners. Participants kneeled, mostly holding signs displaying their own feelings but also referencing the Black Lives Matter (BLM) movement. After breaking a self-imposed quarantine for the first time in three months, I attended along with my wife, daughter, and grandchildren outdoors and distanced.

We learn now that 380,000 unscreened people came to the U.S. from China before a travel ban was put in place. Who knows how many came in from elsewhere in the world? Transmission rates of this virus are high and contact tracing is often impossible as test results return a week or more later unless you play in the NBA or work in the Administration.

July 2020 A granddaughter was in Dallas for healthcare and I did not travel to see her. It made me sad not to be with the family. Friends have been sending articles written by doctors and therapists dealing with pandemic sufferers; there is so much anguish as we are losing so many peo20

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ple and health care providers. The survivors are exhausted and often ill-equipped to deal with people who have multiple organ systems failing. Burnout is a rising problem. In many states, hospitals and intensive care units are at full capacity, all available ventilators are in use, and morgues are overflowing. Tents have been set up in parking lots for patients and testing, and “morgue” trucks are brought in to store the bodies of those that have died.

August 2020 School is set to start soon with confusing messages. Some state and federal leaders want everyone face-to-face but the teachers, mayors, some governors, parents, and bus drivers are balking. The CDC is sending recommendations for spacing and alternative plans including audio/video classrooms. Although operating room protocol still includes hand washing and mask wearing, some people do not understand that these measures are proposed to keep them and their families alive and do not trust the science. A few desperate people are threatening public health officials with violence if regulations such as mask wearing are not rolled back.

September 2020 A third niece is married, and the ceremony is on Zoom. I watch the beautiful bride known since her childhood through a camera broad-

2020 MEDICAL YEAR IN REVIEW casting from behind her father’s shoulder. Labor Day festivities and back to college seem to have fanned the COVID-19 flames so cases are rising again in many places. The yearly dentist, dermatologist, ophthalmologist, and audiologist visits will be delayed but I was able to get the flu shot at HEB. The politicians are blaming each other for COVID-19 blunders and deaths as the November election nears.

Many worry that profit and not science will dictate the delivery of a vaccine, but drug manufacturers have banded together to assure the public that trial results will dictate the vaccine delivery. Mail-in ballots, popular because of COVID-19, are debated by partisans as being discriminatory or making the vote more secure. Politicians are questioning the ability of the postal service to carry out its duties, but I remain confident in the system.

Wildfires, gun violence, hurricanes, and rude political discourse have all contributed to high anxiety. The natural disasters, violent deaths, and social media “bots” and fear mongers have reached a level I have never encountered. Faith is being tested daily. In the Northwest, people are choking on the smoky air and in the Gulf Coast people are losing their roofs and their lives due to hurricane related flooding. Our medical learners continue to respect one another, pursue their studies and give me hope for a better day.

cially just and kind world are offered this Thanksgiving. Once again, crisis is disaster plus opportunity.

October 2020 I plan to venture out to get the driver’s license renewed, to visit Pompei (as I think of the office) to collect artifacts and to drive to north Texas to visit family and support them for a critical surgery. These excursions are some of my first to the “badlands” since March. Have most of us envisioned scenes from “Mad Max” since the lockdown and pandemic threat? Continuing education and air travel may wait until an immunization is available and this has been a catastrophe for that important travel industry. Many are questioning whether they will take a vaccine if one is offered. Meanwhile, the numbers of people infected and dying are rising once again in a third wave since February and hospitals are again nearing capacity.

December 2020 This month, as all Decembers, could easily be sixty days long and still not have enough time for all to be done. Work project completions, school tests and deadlines, virtual family gatherings, Christmas celebrations, and end of the year elective procedures (which must be done in 2020 to avoid deductible expenses in the new year) are only a few goals to be accomplished. The influenza season has started but hopefully will be milder as people are wearing masks and social distancing. COVID-19 has infected millions in the US and the world.

Clinical trials are promising for an effective vaccine and by the spring we hope to be immunizing many Americans. Vaccine efficacy and those who oppose immunizations are still concerns.

As we look back please reflect on those we have lost, those whose lives are irrevocably altered, how we might improve our methods of care, and the blessing of having chosen a profession which allows us to care for those in need.

November 2020 It is expected that late fall will bring cooler temperatures to Texas and renewed college football brought crowds together. COVID-19 infections are expected to rise and deaths continue in areas where social distancing is not possible or abandoned for social proximity. A President and Congress were elected to face a COVID-19 recession, environmental change, the COVID-19 and health care disparities, social unrest and inequality, immigration challenges, internal and international relations, security concerns both physical and virtual, aging infrastructure, and more. There is much work to be done, and we will all need to pull together to get it started. Prayers for better health, greater understanding, solutions to deep-seated problems, and a so-

John J. Seidenfeld, MD, MSHA, FACP is a member of the Bexar County Medical Society and its Publications Committee; Alexandra G. Bailey is a Biomedical Engineering Student at The University of Texas at Austin.

Visit us at www.bcms.org

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2020 MEDICAL YEAR IN REVIEW

Testing for Evidence of the COVID-19 Virus

By Alan Preston, MHA, Sc.D.

Ever since COVID-19 was present in the USA, the challenge was to determine how fast would it spread and what harm could it cause, and to whom? In the world of epidemiology, we look at the incidence rate of a disease as the first onset of the disease. The prevalence of a disease is the number of people who have already acquired the disease. Capturing the rate of transmission of any given communicable disease requires an understanding of both.

Early this year (i.e., February 2020), the news agencies reported the number of cases every day based on those tested. The problem, in the beginning, was that the correct number of cases in the general population was at least ten times more than the number of cases being reported. This created two significant problems; one underestimated the number of infected individuals and overestimated the death rate (i.e., case fatality rate CFR) since the death rate is based on the number of infected cases. And not until midMarch did the testing begin in earnest to more accurately determine how many people may be infected. The number of tests before mid-March was less than 60 per day, which increased to 127,000 per day on March 18, 2020. As of November 2020, there have been over 1,327,000 per day in the U.S., or 156,318,000 COVID-19 cumulative tests performed. The more people tested, the more people will test positive; however, as a percentage of tested individuals, it will hold steady and predictable, as it has for a while at 6 to 10% tested positive. That suggests that those who think they are infected with COVID-19 find out that 90 to 94% of that population are COVID-19 negative.

Why would someone get tested, and what kind of test are they receiving? The CDC suggests that anyone with influenzalike illness (ILI) or COVID-like illness 22

(CLI) should be tested to rule in/out COVID-19. When over 90% of the tests are negative, that suggests the public has a high degree of fear and desire to understand whether they are infected. Their ILI symptoms may be related to allergies, a superficial sinus infection or a postnasal drip that causes a cough or sneezing unrelated to COVID19. The challenge for many healthcare professionals is when to perform a test and what kind of test should they perform?

There are primarily two categories of COVID-19 tests; the PCR test and the Antibody test. The PCR test is appropriate for current diagnosis for the most part, which I will explain in a bit, and the Antibody test is used to determine if someone had COVID19 in the past.

The challenge with the PCR test is that the results are binary; positive or negative. As most physicians understand, a laboratory test often has ranges. The ranges help physicians understand the acuity of the patient based on a lab value range. The PCR test also has a range. The range is based on a cycle threshold (CT). The current cutoff on most PCR tests is close to 40 CT. Suppose the CT is over 40, which suggests a negative test. If the CT is under 40, that means positive. However, most PCR tests for other types of viruses are closer to 30 to 35 on the high end. What are the implications of allowing a PCR CT of 30

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to 40 to indicate a positive COVID-19?

The implication is many people are labeled positive for COVID-19 when they should be labeled negative. They should be labeled negative because of the viral load. The PCR test amplifies genetic matter from the virus in cycles. If you find a high amount of viral load in a person, fewer cycles are required. The greater the viral load, the more likely the patient is to be contagious. And if it takes 40 cycles to detect a small amount of viral load, then the likelihood that the "infected" person can pass the virus is significantly negligible.

Unfortunately, the number of amplification cycles needed to find the virus is never included in the results sent to doctors. If it were, doctors could tell how infectious the patients are. It is difficult to estimate the number of tests suggesting a patient is positive when, in fact, they are, for all practical purposes, negative. A September 2020 NY Times article looked at three sets of testing data that include cycle thresholds. What they found was astonishing; in Massachusetts, New York and Nevada, up to 90 percent of people testing positive barely carried any virus. Tests with cycle thresholds so high detect genetic fragments that pose no particular risk to the public. Yet the public policy mandates have enormous economic consequences when data is overstated, and politicians rely on data (overstated or otherwise) for man-

2020 MEDICAL YEAR IN REVIEW dating more public restrictions.

Another reported positive test is the Antibody test. This test looks for antibodies to the COVID-19. Antibodies are proteins your immune system produces to fight off a foreign invader, such as a virus. A COVID-19 antibody test cannot diagnose active coronavirus infection. All it tells you is whether you have been infected at some point in the past, even if that occurred months ago. Unfortunately, often these tests, when applied and reported as positive, gives a false impression that a person is positive today. In fact, we do not know how long ago a person was infected. If the person was infected three months ago yet is reported as an infected case the day the result was discovered, then we are inflating the number of "positive" COVID19 cases. This might explain why the "spikes" of reported cases and the number of deaths are inversely correlated.

Trying to understand the impact of COVID-19 is further exacerbated by reporting cases that are not confirmed and cases that are lumped in a number of deaths related to, but not the cause of, COVID-19. According to the CDC, case and death counts include both confirmed and probable cases and deaths. And the definition for probable cases is: • Meeting clinical criteria AND epidemiologic evidence with no confirmatory laboratory testing performed for COVID-19 • Meeting presumptive laboratory evidence AND either clinical criteria OR epidemiologic evidence • Meeting vital records criteria with no confirmatory laboratory testing performed for COVID19

Additionally, COVID-19 death counts include pneumonia and influenza-like illness (ILI). Collectively, it is reported as one metric called PIC. (Pneumonia & Influenza & COVID). Therefore, the 237k deaths as of

November 7, 2020, includes the flu and pneumonia and not specifically COVID-19.

Again, setting public policy decisions to limit businesses from operating at full capacity based on inflated numbers may not be the best course of action. When we analyze who is vulnerable to COVID-19, it is compelling.

The elderly with co-morbidities are those who are likely to die from COVID-19.

Those who are over 60 years old account for 80% of COVID-19 deaths. Those over 50 accounts for over 95% of all COVID-19 deaths. And if testing were conducted on all suspected COVID-19 deaths and we differentiated between those who died FROM COVID-19 vs. WITH COVID-19, the number of FROM COVID-19 deaths would be substantially less than reported.

COVID-19 tests are important; however, we need to understand the implication of how we use the test and what conclusions are

derived from the results. Physicians should demand that the PCR test include the Cycle Threshold in every PCR test so the results received can then be appropriately managed.

Overstating the problem is not helpful to patients, physicians, or policymakers that rely upon the data to make policy decisions about our livelihood. We need to make sure these distinctions are addressed for all involved.

Dr. Alan Preston works in the area of Population Health Management and has a doctorate in Science in Epidemiology and Biostatistics from Tulane University and has spent his entire career in the healthcare space.

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2020 MEDICAL YEAR IN REVIEW

Face-Mask-to-Face Medicine

By Madeline Ruszala, UIWSOM, OMS-IV

Knock, knock. The door swings open and I’m nervously thrust into the exam room. Out of habit, I reach out to shake the patient’s hand as I introduce myself, “Good morning, I’m Student Doctor Ruszala. It’s nice to meet you.” The patient raises his eyebrows in a look of confusion as I pull my hand back unshaken. I realize in that moment that I’m not learning to practice medicine in the same world I was in just a few months ago. I smile and wonder if he can see the smile in my eyes because the rest of my face is hidden behind my mask and under my shield. This mask may be only one millimeter thick, but it feels like a concrete wall between the patient and me in that moment.

Ten weeks prior, cases of COVID-19 began to surge in the United States and medical students across the country were pulled out of hospitals and clinics as a protective measure to reduce exposure and conserve the personal protective equipment supply. We were told that it would be a two-week pause in clinical rotations as we attempted to “flatten the curve” across the country. Fourteen days quickly turned into six weeks and then ten weeks. I had spent the past two months at home, avoiding the grocery store, completing coursework on Zoom, trying to explain to my one-year-old daughter why the park was closed, and worrying about what the future would hold. How would this af24

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fect my medical education? Would I have the opportunity to learn everything I needed to know to become a physician? Would I be able to graduate on time? Questions such as these raced through my mind day and night.

Being taken off my rotation due to a global pandemic was a paradox.

I had chosen to pursue medicine because I wanted to help people when they were unwell. I understood that being around patients with communicable diseases would be a risk to myself and my family. I knew that I would likely get sick more frequently than others. However, I never considered I would live to see a pandemic like this. I surely never expected to be told that when the healthcare needs of the country were at their peak, I should stay home. The level of internal conflict this brought was painful. I wanted to be there to help. I wanted to put my training to good use. I knew that I was not quite ready to treat patients on my own, but there had to be some way I could be helpful when the hospitals and doctors were overtaxed. And yet, what I was being asked to do was “stay home and stay safe.”

My part in helping to control the spread of this illness was not in the clinics; it was in my own home. My role was staying out of public places and encouraging my loved ones to do the same, especially in the

2020 MEDICAL YEAR IN REVIEW midst of constantly changing public information. It was learning about They went from learning on campus in large and small group sessions, the disease from cutting-edge case reports and online didactic sessions as well as hands-on learning in the anatomy and clinical skills labs, to rather than seeing it firsthand. For my classmates and me, being sidelearning online via Zoom overnight. Many students reported that the lined was difficult, but the order encouraged us to be creative and find transition was difficult as they had to learn to use new technology and other ways to help. Students from UIWSOM helped in the COVIDto focus in their home environment which can be very distracting.

19 pandemic by donating PPE to local drives, delivering PPE to local Our third-year students were preparing to take their board exams physician’s offices, making and donating face shields, helping with conwhen the “Stay at Home” order was put into place in March. Many tact tracing, providing childcare for physicians whose daycare had had their exams canceled or postponed for indefinite amounts of time. closed, and much more!

Some still have not had the opportunity to complete these important In addition, when we could not be on our scheduled rotations, we assessments. They were forced to be resilient and to adjust to changes were able to complete a Telemedicine elective rotation. I learned about at a moment’s notice as no one could predict where this pandemic was many important facets of telehealth, including billing and HIPAA going to take us. practices, and even practiced doing patient visits via Zoom. I foresee The members of the Class of 2024 began their medical education telehealth being an important part of the future of medicine and I will in July and have not yet been able to travel to campus for full-time be more prepared to help my patients in this way. All the time I have learning. This has been an incredible feat for these students who have spent learning to use Zoom will surely prove useful as we enter into been forced to adjust to the rigor and pace of medical school in this the first ever virtual residency application season. Stuunprecedented time. The faculty and staff have redents in the Class of 2021 are prepared to do “meet and sponded by trying to bring the learning to the students I foresee telehealth greets” with residents, interview, and rank programs in in the best way possible given the circumstances. Stubeing an important hospitals and cities that we have never visited. Through dents are currently experiencing all the typical coursepart of the future of it all, we came together to help each other and our comwork, but in a virtual format and they have only been medicine and I will munity endure one of the most difficult times that we able to meet their classmates and professors via Zoom. be more prepared to have faced and I’m confident we will continue this.

This is hard for me to comprehend because I know how help my patients When we finally received the news that we would be difficult the acclimation process is, but they have in this way. able to return to clinical rotations, I was excited to condemonstrated an extreme amount of flexibility, which tinue my education and, at the same time, apprehensive will be incredibly valuable in their future careers. to return to the “real world” knowing how much had changed. My deIn the end, no one can predict exactly what the future months will sire to serve had not faltered and my interest in learning to be an effechold regarding the COVID-19 pandemic, but I know for sure that I tive physician was still there, but there was also the fear of being will continue smiling behind my mask and consider this time in my edexposed and becoming ill. We’ve seen that most cases in previously ucation abundantly valuable. One of my preceptors told me that she behealthy individuals are mild to moderate. However, that does not dislieves we have lost sight of humanity amidst this pandemic and I think count those who experienced severe symptoms and are now living with that in many ways that is true. We need to remember that the human potentially lifelong consequences of the disease. Either way, I suited race has faced many difficult periods. The way we will make it through up and headed back out to finish my rotation in Internal Medicine. I this is to unite ourselves and work together to keep everyone healthy. was surprised to realize that with the new guidelines in place, I saw As future physicians, we play an important role in this pandemic. very few sick patients in the outpatient clinic.

Our role involves learning how to handle difficult situations and how Most patients I saw were coming in for annual wellness exams or to to adjust. Communicable diseases surround us every day, but controlfollow up on chronic conditions. No one who had a fever or cough ling and slowing the spread of a pandemic is not new. We need not rewas allowed in the clinic. Again, I saw the paradox unfolding before member this time for all the things that were taken from us in our me. Sick patients were not allowed to see their physician—the one education, but for all the new opportunities that were presented. 2020 person they are supposed to turn to when they are ill. We’re still learnhas been a year filled with proverbial lemons for medical students ing how to respond to the challenges set forth by this pandemic and across the country, but we will continue making lemonade. We’ll just attempting to keep those who are well away from those who are sick have to sip it through our masks. should be prioritized to control the spread of disease. Still, we need to find a way for patients to access their physicians and the care they need.

Madeline Ruszala is a fourth-year medical student at the In talking to students who are still in their pre-clinical years, they have University of the Incarnate Word School of Osteopathic Medishared the impact the COVID-19 pandemic has had on their education. cine and is a member of the Bexar County Medical Society.

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2020 MEDICAL YEAR IN REVIEW

On the Other Side...

What Ifs After the Pandemic

By Timothy C. Hlavinka, MD

In late January, I received a frantic call from a good friend; she was in Daegu, South Korea teaching English as a second language.

Many of her students were from the Church that suffered the early outbreak of contagion. She was scheduled to come back home in early February and sought my advice.

At the same time, a colleague received an email from a friend in Wuhan sharing conclusive evidence of the unpreventable spread of this new plague.

The next day, the Chief Scientific Officer of a microbial genetics lab for which I consult called to ask if I had any connections with research facilities that could provide the viral genetic sequences for COVID19. He had called the CDC and offered to turn his lab into a COVID19 testing facility, promising 100,000 tests a week within three weeks.

To paraphrase a milder version of the conversation, he was told to “go jump off a cliff ”.

My friend was to arrive home from South Korea via DFW in a few days. I made calls to the CDC and Texas State Department of Health Service (DHS) to find out what protocols were being put in place for travelers. No one had any answers; no one seemed to know anything.

Our own, San Antonio Metro Health Department was the only source of reliable information; they suggested my friend quarantine in Dallas.

She got off her plane in DFW with 348 other passengers, all in masks, and no one even asked where she had been traveling. The stage for the inevitable spread of this virus had been set.

I illustrate my story as I imagine we all have stories similar to this.

That gut-check moment when you first realized that we were on our own, that our most esteemed institutions were failing us. We did what we always do; we rolled up our sleeves and went to work.

In every town all across America, hundreds of healthcare workers manned the front lines, risking their health, their lives and the health and lives of their families. Others went to work on strategy and execution. Many of us had to go back to medical school, devouring a mountain of new information daily. Our younger colleagues received years of maturity in a few months. We relied on our knowledge and experience, our wits and our guts in high-risk, high-stakes moments from the bedside to the virtual situation rooms. Once again, the public will never know the magnitude of our sacrifice. This is our solemn obligation, and we met it again. No one had to recruit or cajole; we just showed up.

We as front-line workers see certainty and uncertainty in our future.

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Changes such as telehealth and virtual education are a certainty to become fixtures in our practice environment; innovation and ingenuity will still be rewarded and utilized. We are uncertain that we will see adequate support for these changes, or if once again we will be asked to bear the burden of the changes in healthcare.

Fundamental challenges to the acquisition of scientific knowledge will have to be overcome. Indeed, the concept of the randomized clinical trial is under scrutiny. My MRI of the future is no more accurate than yours, but I offer some thoughts based on my first virtual CME. Susan L. Prescott, MD PhD, a pediatrician/epidemiologist in Western Australia offers bold ideas. Her research basis is termed "local projects with a global vision." In her ORIGINS Project, she seeks 10,000

2020 MEDICAL YEAR IN REVIEW families to evaluate the impact of changes in the first five years of life on the health of a community. She encourages medicine to act locally, in small Beta testing projects, so that cost and fear of failure are minimized. More importantly, she encourages medical workers to change the moral imperative of our time, focusing on one that is led by empiricism. The intended result being that healers be the leaders of our future.

Dr. Prescott offers that medicine should lead the charge to a paradigm shift in institutional reform, beginning with the most exigent – healthcare. She argues that we are uniquely positioned in this industry, with a knowledge of science and technology and the wisdom and vision to apply them to become the leaders of this new paradigm.

And why not? We are truly multidimensional professionals. When it comes to medicine, we are apolitical and global. We have shared the same frustration, anger and personal harm from the failure of our institutions as our colleagues did around the world. No one asked or cared which political party you belonged to when you were figuring out how to split a vent four ways. We share the same sorority and fraternity of never being able to say "no." Our sense of collegiality is unmatched. The moral imperative that drives each of us to do the most good for the most human beings has been beautifully illuminated across the globe in our most recent crisis.

Now it is our turn to take the moral high ground gained by sacrifice, and we must not yield this time! The public trust is a largesse that must not be wasted. There has never been a better time to be in medicine.

Let us all choose this time to restore our rightful place in its hierarchy.

Dr. Prescott encourages us to engage a colleague in conversations about policy and practice, and not to fear the grandest of ideas. I close with her final message:

"Humans have always emerged from crisis by simply putting one foot in front of the other and building on the lessons of the past. We owe it to our ancestry to all be willing to take that first step."

Here's to that first step. I look forward to taking it with my esteemed colleagues.

Timothy C. Hlavinka, MD is a Urologist and a member of the Bexar County Medical Society.

Visit us at www.bcms.org

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2020 MEDICAL YEAR IN REVIEW

COVID-19 Survivor Stories It is a Lonely Virus

By Cindy & Patricia (sisters)

Patricia’s story It was Tuesday, June 9th. I developed a headache, but didn’t think anything of it, since I suffer from migraines anyway. Tylenol wouldn’t even touch my pain. The headache continued through Wednesday and Thursday, along with a slight sore throat and a light dry cough. I developed a low-grade fever of 99.5. Even with these signs, I still didn’t think it was COVID. The symptoms were so subtle!

Because I was working from home that week, I was able to keep to myself. I was scheduled to work in the office the following week, when on Friday the 12th, I woke up feeling worse. Since I work for one of the hospital systems, we had a hotline number we could call if we had symptoms. I called the number that morning and had an appointment that afternoon to get tested. I still didn’t think it was COVID. But just to be careful, I quarantined myself. My mask was on at all times and I didn’t leave the room unless I had too. As Friday wore on, I felt worse.

Finally, I left to go get tested and was told if it was positive, I would get a call on the weekend. Saturday came and I still felt really bad so I didn’t leave to go anywhere. The headache was the worst, even though I was taking Tylenol and Advil every couple of hours. On Sunday morning, I went to the store to buy some more meds. My head hurt so much that I cried all the way home. My body aches continued to get worse. When I got home, my daughter asked me how I was feeling and I told her my headache was unbearable. As she was massaging my head, my phone started to ring. I noticed it was from the hospital, so I answered.

The nurse proceeded to tell me that I was 28

COVID positive! My heart sank, but everything made sense; you know, how I was feeling and the intensity of my symptoms. I told my family. Thankfully my son, daughter and my parents tested negative that following week. The house was cleaned and sanitized.

My food was left on a table outside the room.

If I was going to leave my room, I let everyone know that I was stepping out.

Over the next couple of days, I got worse.

I have never felt anything like this before. The headaches, body aches and difficulty breathing. I knew I should have gone to the hospital but I didn’t want too. One evening, I went

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outside because I wanted to see my son who had been staying at a friend’s house. We sat outside at safe distances and with masks on.

I started to shake and sweat so much; I was very dizzy but didn’t want to alarm my family and scare my son. So, I went to my room very quickly and as soon as I shut the door, I passed out and woke up a few minutes later.

It was a very scary time. I literally prayed that I wouldn’t die.

I lost my senses of taste and smell. To this day, my taste is different. This virus is a lonely one. I made myself walk outside in the middle of the day to warm up. Thankfully, with a

2020 MEDICAL YEAR IN REVIEW

lot of support and prayers, I was cleared after ten days to go back to work. The fatigue and shortness of breath continued for weeks after going back to work.

Meanwhile, as I was going through this, my sister Cindy and her family were just about to get started with this nightmare.

Cindy’s story It was Sunday June 14 when I got the call from Patricia that she had tested positive. She let all of us know and we were in shock. So, the whole family avoided being around my sister as well as to my parents’ home. But it was too late.

The next day, Monday, I had my sons tested with their pediatrician. The doctor had them sit outside in the back of the office where the nurse came to do a nasal swab and checked their lungs. All was clear. Wednesday we got the news all the boys were negative. I was very relieved.

I decided to get checked too by my mother’s doctor on Wednesday. After a week, I received the results - negative. Again relieved, we let our guard down. But it turned out we made the same mistake many have made; we got tested too soon after exposure.

We are supposed to wait eight days after exposure to be tested. The symptoms started when one of my young boys started with a low-grade fever, body aches and head hurting. I just thought it was the flu or something else, not COVID. I had the mentality of “it won’t happen to us”. Then I noticed my 14-year-old sleeping more, being tired and developing black eyes.

He was on the couch, tired. I cut up some pineapple for him and he got up to get some.

He asked me if I could taste the pineapple, and I said yes, it’s sweet. He couldn’t taste or smell it. That’s when I started to get really worried.

The next morning, I called the kids’ pediatrician again for them to get tested and the doctor’s office scheduled them in right away.

This time I only took the two youngest boys

to the doctor. My youngest one was wheezing and, when we got the results of the test, they both tested positive. I was told that the whole family should use masks and keep our distance in our home. When I got back, I had everyone distance from each other and quarantine. I washed all the clothes and bedding.

I had them all clean/sanitize everything, including door handles. I sprayed down the couches and mattresses with Lysol and then continued to spray down everything else. I washed dishes as soon as they were used. I washed the bedding every other day. My two oldest sons stayed in their room, since they didn’t present any symptoms.

I had started walking almost every day in the summer heat to get myself in better health. I noticed by body was hot but I thought it was because of the outside heat in June. But it turns out I had started with a low fever. Then one day I was just tired, my body ached and my fever started getting a little higher. My husband walked in from work looking tired; he said his body ached. He didn’t want to eat and said his nose “burned”.

The next day I called my mom’s doctor’s office to get tested again. By then my boy’s symptoms had gone away. For my boys, it lasted about a week and they were back to “normal”. But I struggled for about 2 weeks with fever, tightness in my chest and I was wheezing. I also had a dry cough that would act up at night. My husband would ask me if I was ok. He wanted to take me the hospital, but I didn’t want to go. I noticed my sense of

smell was gone and I had lost my appetite, but I still had some taste.

I used all of my son’s inhaler and that seemed to help a little. I was really scared with everything that I had heard on the news.

My husband had all the symptoms but never got tested. He said he didn’t feel the need to if I had already tested positive; he was sure he also had it. Because he worked by himself outside, he just kept working. He would come home and just sleep. In the evenings, he would tell me to walk and get moving so I wouldn’t just be in bed. I would walk about half-a-block and I couldn’t take it. I felt so tired and out of breath.

Finally, my fever broke and the wheezing stopped, my chest felt so sore. My employer helped me get an appointment to get tested again to go back to work. The test results were negative for COVID. I hoped that meant everything would be back to normal, but it took week s for my sister and I, walking in the evenings, to build our strength back.

We both struggled with our breathing. For several weeks I couldn’t catch my breath.

Now I’m doing much better, breathing “normal”. All six of us in my family still don’t have our full sense of smell and taste back.

My faith in God is what got us through it; praying and believing we would all get better.

We still take all the necessary precautions including masks when we’re out and we use hand sanitizer. We hope we don’t ever get COVID again.

Visit us at www.bcms.org

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2020 MEDICAL YEAR IN REVIEW

BCMS Service to Our Members and Community in Need!

By Melody Newsom, BCMS Chief Operating Officer

When the novel coronavirus pandemic was declared in March of 2020, no one had an idea of just how this would affect our community or physician members of the Bexar County Medical Society! Early on, the lack of a multitude of items needed to respond to the pandemic in our community was great.

From the lack of specimen collection kits and supplies (swabs, viral transport medium (VTM), etc.) to personal protective equipment (PPE), the needs of the medical community became rapidly apparent.

When responses to the emergency needs of our community were identified, BCMS reached out to our physician members to help. The physicians stepped up and donated countless test collection kits and supplies so our city could maintain testing capacity of our first responders and medical staffs as the virus was entering our community.

The world-wide demand for PPE resulted in major shortages of PPE. Early on, governmental agencies and national stockpile supplies of PPE were mostly earmarked for in-patient settings such as hospitals and nursing facilities. As a result, primary care and out-patient clinics were left with few to no avenues to obtain PPE. The lack of PPE put 30

the physicians, their staff and patients at risk of, and the fear of, contracting COVID-19.

In mid-March, a passionate and concerned medical student reached out to BCMS alarmed about the lack of appropriate PPE for the medial professionals where she was working. She and a group of dedicated medical student volunteers, later forming the Strategic Alliance for Emergency Response (SAFER Texas), started soliciting donations of PPE and other supplies. Donations were solicited from multiple sources in the community that had closed their businesses due to the community lockdown and to their being categorized as “non-essential”. The construction industry, distilleries, nail salons, the Vietnamese community and physician practices that were more “elective-procedurebased” were solicited to donate PPE. These donations got the PPE project going and allowed BCMS and SAFER Texas to provide the much-needed PPE to the medical professionals deemed “essential” so they could continue to serve their patients.

The response was amazing! Construction companies donated non-medical grade N95s, shoe coverings and overalls. Distilleries, especially Garrison Brothers, donated hundreds

SAN ANTONIO MEDICINE • December 2020

of gallons of isopropyl alcohol for use as hand sanitizer. Nail salons donated gloves and got the Vietnamese community organized to make face shields and cloth masks. You get the picture! Many other individuals, companies and non-profits came together to help the physicians and our medical community.

When the supply chains began to open, practices that were not already established PPE customers of reputable PPE suppliers could not obtain the needed PPE. Even when other potential suppliers were identified and contacted, supplies were still very limited and prices were inflated.

Since that time, the BCMS/SAFER Texas PPE Project has grown into a full-fledged PPE distribution system to serve the medical community. BCMS’ longstanding relationship with the Southwest Texas Regional Advisory Council (STRAC) has allowed the Society to be the conduit of PPE provided from the Texas Division of Emergency Management (TDEM) to the physicians, not only in Bexar County, but in south Texas. Because of this collaboration, we have been able to help many hundreds of physicians to be able to continue to see patients while keeping their staff, patients and themselves safe.

2020 MEDICAL YEAR IN REVIEW

A few of the numerous comments we have received are: “We are really desperate for gloves (nonsterile). Our normal vendors are telling us they are backordered. And those you can purchase have gone up more than 600%. It is so frustrating! I thank you all again for always coming through for us small practices! You all have been a life saver.”

“Thank you for providing us the opportunity to receive PPE as we struggle to take care of patients during this pandemic while protecting ourselves. It is much appreciated.”

“Thank you for all of your donations; they have made a difference in our practice.”

“We are so appreciative of the assistance; we are seeing many more sick/exposed children every day.”

“We have opened up another department of our practice and are having to use more PPE for employees and patients who do not have the appropriate masks. Thank you for your continued help.”

“This PPE has been a life-saver!

Thank you!”

“Thank you for supporting our medical community!”

“Thank you for coordinating these donations. The masks are less necessary (although desired as we are reusing standard surgical masks and have no N95/KN95 available). The biggest need is gloves which are in short supply and are needed for proper patient care. Trying to find items through our usual distributors is harder with each order. Thank you again.”

Since March, over 275,000 pieces of PPE have been distributed through our PPE project. The impact to the physicians and their practices has made a huge difference in keeping the medical community and our community safe.

If you are still in need of PPE, please visit the BCMS COVID-19 Resources page and click on the Request PPE button on the lefthand side, or click the link in The Physicians Link, BCMS’ electronic newsletter.

BCMS is committed to serving our physicians, not only through the PPE Project but with all the other services available to our members! If you have a need, please let us know. We are here for you! Thank you for being a BCMS member and making a difference in your patients’ lives and our community.

Melody Newsom is the Chief Operating Officer for BCMS and the staff liaison to the BCMS Emergency Preparedness Committee. She has been with BCMS since October 1999.

Visit us at www.bcms.org

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2020 MEDICAL YEAR IN REVIEW

2020 Coronavirus Pandemic –

A Year in Review

by Mary E. Nava, MBA

At the time of this writing, our country is in the eighth month of the 2020 Coronavirus Pandemic and has elected a new U.S. President.

It is not surprising that the pandemic figured prominently in this year’s elections. For the most part, San Antonio and Bexar County have fared well, considering all the challenges associated with the pandemic.

Nationally and world-wide, at the front and center of this pandemic were the physicians and medical professionals caring for coronavirus patients and the challenges they faced each day in their clinics or in hospitals. Sadly, the Pandemic is still with us and although there is no cure, vaccine trials continue and two vaccine manufacturers are expected to apply for emergency use authorization (EUA) in November.

Members of the BCMS COVID-19 Task Force (herein Task Force) and its four subcommittees: Communications Plan, Community Mitigation, Hospitals and Workforce and Pediatrics and Schools have been hard at work since March, and until recently, met weekly to discuss how physician members could assist our government leaders and community around the myriad of issues and concerns with COVID19. The Task Force continues to monitor the situation now that cases in Texas, the nation and in other countries are increasing yet again and at the time of this writing, Texas had the highest number of daily COVID-19 cases in the U.S. Bexar County case numbers have been holding steady in recent weeks, although a slight uptick has been registered in the number of local COVID-19 cases and the positivity rate. This development is not necessarily unusual since many students have returned to in-person instruction, business establishments have been allowed to open and/or expand the number of people they serve and, of certain concern, is that some people continue to congregate in spite of the COVID-19 threat. Nevertheless, this increase in cases is important to monitor and also tracks increase in hospital admissions. Suffice it to say, this activity has the attention of the Task Force and the Hospitals and 32

SAN ANTONIO MEDICINE • December 2020

Workforce Subcommittee. Ezequiel Silva, III, MD, chair of the Hospitals and Workforce subcommittee, stated, “The role of the subcommittee has been to closely follow trends in hospital admissions and how those admissions have impacted our healthcare system stress scores, including staff and hospital bed availability. By tapping into leaders in the various hospital systems, we achieved a collaborative understanding of our county's needs. This allowed meaningful interactions with the Southwest Texas Regional Advisory Council (STRAC) and the Department of State Health Services (DSHS) where appropriate.”

Working in collaboration with the Communications Plan Subcommittee, members of the Task Force, Pediatrics and Schools Subcommittee and Community Mitigation Subcommittee developed several video public service announcements (PSAs), which were posted to the BCMS website and social media platforms. The PSAs covered such topics as: following the protocols, answering the call (from the health department), when to access the emergency room and wearing a mask properly. Diane Simpson, MD, chair of the Community Mitigation Subcommittee, stated, “The purpose of the Community Mitigation subcommittee is to determine the most relevant public health practices to control the spread of coronavirus. The committee seeks to encourage the adoption of these practices by the public through social media messaging.”

Lubna Naeem, chair of the Communications Plan Subcommittee added, “In a crisis like that of COVID-19, when the stakes are high in a politically charged environment, stepping aside is not an option.

Engaging physicians, the community and stakeholders is necessary, now more than ever. Whether making universal mask wearing a community standard or promoting contact tracing awareness, expanding the reach of communication is critical to continuing to educate our citizens on the importance of all of us working together to help combat

2020 MEDICAL YEAR IN REVIEW

this coronavirus.” The Communications Plan Subcommittee is responsible for reviewing all communications pieces submitted by the Task Force or other subcommittee members to ensure consistency of message.

Members of San Antonio and Bexar County elected leadership, along with MetroHealth, attribute San Antonio’s success with earlier reaching a plateau in overall cases and a lesser impact on schools than previously expected to the fact that San Antonians have taken the necessary steps to adhere to the guidelines for wearing masks, proper handwashing and practicing social distancing. "The COVID-19 pandemic uniquely affected children with regards to their education, socialization, and overall health. The Pediatrics and Schools Subcommittee worked diligently to act as a resource for providers, parents, and school systems about the Sars CoV2 virus, and to help provide useful resources for these groups,” said Leah Jacobson, MD, chair of the Pediatrics and Schools Subcommittee. Although the wearing of masks became a political issue, it is evident that the people of San Antonio did their part to help slow the spread of COVID-19 by following the recommended protocols.

John Nava, MD, Chair of the Task Force said, “The Task Force cannot stress enough the importance of continuing to follow the science

and maintaining adherence to the recommended protocols. Task Force members realize that people are getting COVID fatigue, but we by no means are in a position to let our guard down. People must continue to be vigilant, especially now that flu season has arrived and we are in the fall and fast-approaching winter and holiday seasons.” Plans call for the Task Force and Subcommittees to continue to meet every two weeks for the foreseeable future.

BCMS extends a big THANK YOU to all the members of the Task Force and subcommittees for their support and dedication. The work of the Task Force has been a huge undertaking and BCMS appreciates all the members who have stepped forward to help in this endeavor.

Additionally, THANK YOU to the BCMS leadership for their care and concern in keeping us (employees of BCMS), safe during this pandemic, by allowing those who could work from home effectively, to do so. This included providing a safe environment for those employees who continued to work in the BCMS offices.

Mary E. Nava, MBA is the Chief Government Affairs Officer for the Bexar County Medical Society.

Visit us at www.bcms.org

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2020 MEDICAL YEAR IN REVIEW

Your Medical Society

By Your Side

By Brissa Vela

We all had a vision for 2020. We thought that we would unveil a plan that set the path for our day-to-day operations, however, it all changed in a matter of days. Everything we had planned was changed. The path we thought we could follow took us on a big detour. That is when the Bexar County Medical Society (BCMS) and the Texas Medical Association (TMA) began refocusing our efforts. As we took our journey down this new road, we learned to adapt and find resources that would help our members navigate through the new way to practice medicine.

We, like you, could see that telemedicine and its usage were becoming the means of practicing medicine for many physicians, especially when involving such a serious contagion. As a result, several services were developed to assist the physicians navigate this under-used service, enabling it to emerge for the daily practice of medicine. The services developed for our members include free telemedicine contract review, telemedicine vendor evaluation criteria, assistance creating business service agreements with telemedicine platform vendors using HIPAAcompliant encrypted services, guidance on appointment scheduling and obtaining patient consent, and help with prescription and medication management through telemedicine platforms.

To ensure patients can find our physician members, the BCMS Find a Doctor referral service (available on the Bexar County Medical Society phone app or on the BCMS.org website) continues to provide online information that is updated continuously for the community and for our physician members. We encourage every physician to review their profile and make sure it is always up-to-date. This service allows new and existing BCMS members to provide the following referral information: • Physician primary and secondary specialties

• Insurance types accepted (subject to patient verification) • Physician photos

As COVID-19 was emerging, BCMS and TMA could see the need for Practice Viability Resources, including funding sources (SBA and others), liability insurance policy updates, payer, coding and documentation guidance (Medicare, Medicaid and Commercial Plans) and human resources guidance. If you are new to practice or to Texas, we can provide guidelines to open your practice and run your daily practice, financial and clinical operations, etc.

Besides business help, leadership help for physicians during this pandemic has been aweinspiring! Your medical Society has served the medical community in so many ways, spending countless hours giving guidance to the community leaders, not only locally but at the state level as well.

The Student Collaboration Committee has also stepped up for the benefit of all physicians during this pandemic. This group is made up of students from both medical schools (UT Health SA and UIW) who have been heavily involved supporting the BCMS COVID-19 Taskforce, PPE distribution, writing of articles about how the medical schools are adapting, and volunteering to support your medical society’s efforts.

The BCMS Task Force, in combination with medical students, developed public service announcements (PSAs) supporting the “Wear a Mask” campaign; developing the COVID-19 Pediatric Symptom Severity Chart; preparing Parental Guides in English and Spanish; and creating artwork for social media outreach.

They also lead a Give Back campaign to benefit the San Antonio Food Bank.

As we continue to work through these challenging times, we will always continue to focus on the needs of our members and their practices.

• Practice(s) information addresses, phone numbers and website links • Physician education history • Hospital affiliations 34

SAN ANTONIO MEDICINE • December 2020

Brissa Vela is the BCMS Membership Director.

2020 MEDICAL YEAR IN REVIEW

COVID-19 and Pre-Clinical UME at UIW School of Osteopathic Medicine

By Adam V. Ratner, MD, FACR

Medical school has surely changed since I was a student way back in the last millennium. Back then, in the first two years of medical school, we spent hours every weekday sitting in lectures while trying not to daydream. At night and on weekends we crammed and binged, trying to memorize the material that we would purge onto the next test and shortly thereafter, forget.

At the University of the Incarnate Word School of Osteopathic Medicine (UIWSOM), our case-based, team-oriented, student-directed learning curriculum is built on active engagement and interaction between medical students and faculty facilitators. Every Monday through Friday morning, first and second-year medical students work in small groups and larger teams with faculty facilitators to learn, discuss, and critically think through clinical situations, their basic science and socioeconomic underpinnings, and humanistic consequences.

This curriculum requires the presence and active engagement of students at a far higher level than just sitting in a classroom or watching a video screen. That said, since the inception of the school we had debated the merits of allowing students who were unable to attend a session for personal reasons or mild illness to be able to join sessions remotely. The founding leaders of UIWSOM had made the investments in the appropriate IT infrastructure to allow the use of technologies to support remote learning.

In early 2020, the leadership at UIWSOM began discussing the potential effects of a possible epidemic on our medical school. When it became apparent that the COVID-19 pandemic had reached San Antonio by the second week of March, we were prepared. Our office of Medical and Interprofessional Education trained the faculty, staff, and students in the art of Zoom teleconferencing. We converted our highly interactive live curriculum into a virtual one, literally over a single weekend.

I remember I was most concerned about adequate bandwidth and power of the Zoom servers, but my fears were unfounded. All things considered, the transition has been astoundingly successful but, of course, not perfect.

The lack of in-person interaction has created a myriad of challenges.

Without in-person guidance and oversight it’s not possible to convey the nuances of performing ideal history and physical examinations or osteopathic manipulative techniques. The good news is that students are learning practical telemedicine skills much earlier now than in the past.

Just as importantly, the lack of real person-to-person interaction adds to loneliness and isolation among medical students. Most medical students (and faculty) are able to develop strong camaraderie with colleagues. This camaraderie just isn’t quite the same on Zoom teleconferences.

From its inception, UIWSOM has always emphasized the humanism required to be a caring and effective physician. One way we support physician humanism is this through addressing the behavioral health needs of medical students and faculty. We have increased our behavioral health resources and created new programs to address these mental health challenges in the COVID-19 learning environment.

As of the time I write this (late October 2020), we are developing a thoughtful and controlled plan to bring our pre-clinical medical students back on campus for the hands-on clinical skills training they have missed in the past few months. We will continue to seek the best possible balance to continue our mission of creating the next generation of sorely needed, primary care physicians while seeing the resurgence of COVID-19 cases across the country and the world.

Stay tuned.

Adam V. Ratner, MD, FACR is Professor of Radiology, Health Policy, and Medical Humanities and Assistant Dean of Strategic Initiatives at UIWSOM. He is also Chairman of The Patient Institute and 2019 President of the Bexar County Medical Society

Visit us at www.bcms.org

35

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

ACCOUNTING FIRMS

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ACCOUNTING SOFTWARE

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ATTORNEYS

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.

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

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BANKING

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a

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SAN ANTONIO MEDICINE • December 2020

private banking team committed to supporting the medical community.

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DIAGNOSTIC IMAGING

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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.

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

FINANCIAL ADVISOR

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FINANCIAL SERVICES

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

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

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values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

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INSURANCE

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

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

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

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”

HEALTHCARE BANKING Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core

INFORMATION AND TECHNOLOGIES

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

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

OSMA Health (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians.

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

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,

continued on page 38 Visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY continued from page 37

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

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

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

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

dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL SUPPLIES AND EQUIPMENT

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.”

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.”

MEDICAL PRACTICE

MOLECULAR DIAGNOSTICS LABORATORY

MEDICAL BILLING AND COLLECTIONS SERVICES

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

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

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases.

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

PRACTICE SUPPORT SERVICES

MEDICAL PHYSICS INTERNET TELECOMMUNICATIONS

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

Clayton Brown Regional Sales Director 210-693-8025

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Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly!

Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460

SAN ANTONIO MEDICINE • December 2020

www.marpinc.com Keeping our clients safe and informed since 1979.

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly!

Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com

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

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

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

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

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

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

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

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

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 (HH Silver Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7.

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

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

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

The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center.

Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

Visit us at www.bcms.org

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SAN ANTONIO MEDICINE

BURNOUT:

Symptom of Moral Injury at the Workplace or Something More?

A Thought Analysis

By Rodolfo (Rudy) Molina MD MACR FACP

The word and concept of “burnout” is becoming better known and now more often written about in medicine. What is it? The Oxford Dictionary notes the first use of burnt out was in 1837 describing elder nobleman. In 1926, the term burnt out was used to describe a young woman’s demeanor.

So, I did a PubMed search using the terms burn out or burn-out from 1926 through 2020. There were no references to burn out up until the early 1970s. From 1970 through 1979, there were a total of sixty-five articles published that mentioned burn out. Thereafter, a steady increase in the number of articles mentioning burnout appear in our literature. A sampling of the number of articles published each in the following years gives us a sense of the continual increase and interest in this subject.

In 1980, 32 articles were published dealing with burnout; in 1990, 161 articles; in the year 2000, 329 articles were published; and in 2019, 1,644 articles were published. The concept of burnout has become so prominent, the World Health Organization (WHO) designated burnout with the ICD10 code of Z73.0. This code defines burnout as circumstances which influence the patients’ health status, but not a current illness or injury and one that is unacceptable as a principal diagnosis. The ICD -11 code, QD85, more clearly defines and characterizes burnout as a chronic workplace stress that has not been successfully managed. It refers specifically to this phenomenon in the occu40

pational context and states it should not be applied to other experiences in other areas of life. It goes further by describing three characteristics: 1. Feeling of energy depletion or exhaustion, 2. Increased mental distance from one’s job or feeling of negativism or cynicism related to ones’ occupation, and 3. Reduced professional efficacy.

The WHO recognizes these as symptoms arising from the stress of one’s occupation.

We have heard about burnout in other occupations such as policing, fire fighters, as well as field and service workers during the pandemic. The stress of constant re-entry into a hazardous job is considered a factor that leads to burnout.

If burnout is a description of a symptom complex associated with one’s occupation, then the root of the problem would be the stressors of that particular occupation.

Jonathan Shay began to talk about combat stress in October 1991, comparing it to what was described in Homer’s Iliad and the soldiers who returned from battle. He then wrote about the Achilles in Vietnam in 1994, discussing severe cases of Post-Traumatic Stress Disorder. These solders were trained to commit legal criminal acts and after they witnessed horrific battle scenes, they then returned to civilian life where they could no longer trust their leaders. Why? They were suffering from what he termed a “moral in-

SAN ANTONIO MEDICINE • December 2020

jury”, defined as “a betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation, so that there can be personality changes and complications in treating the post-trauma injury.” In the case of the Vietnam vets, there were frequent complaints of being issued M-16 rifles that malfunctioned, or being sent out on patrols where they felt like sitting ducks in difficult and unfamiliar terrain by commissioned officers corps. Moral injury has been applied to our medical profession as the root for burnout.

As I read through the literature, I thought the idea of moral injury should be expanded to more completely address the issue of burnout. Over my last forty-one years (nine in the military and 32 in private practice) that I’ve been practicing medicine and hearing my colleagues speak of their issues and problems with their practices, I’ve pondered the idea of burnout. This has led me to the following analysis of the problem. I believe there are three areas of activity that we have to be managed successfully to address and prevent burnout. And if any one of these areas fails, burnout is eminent for the other two cannot compensate. The three areas are: 1. Resilience (self-motivation), 2. Life balance, and 3. Control of the workplace.

I’ll discuss each individually. I do want to clarify that this analysis applies to the individual who continues to try working at 100%, despite failing in any one of these three areas.

SAN ANTONIO MEDICINE

Resilience is our ability to overcome hardship. As physicians, or a healthcare provider such as a Nurse Practitioner or Physician Assistant, we have all spent long hours to get our degrees. Completing medical school, internship, residency (and in some cases fellowships) we have endured numerous hardships to get where we are today.

So, I would say that most of us have a healthy dose of resilience and self-motivation that empowers our ability to be the physicians and caretakers that we are. However, over time some of us might incur an illness, physical or mental, that could wear on our resilience.

Chronic pain or depression can and does impede our ability to continue treating patients successfully. And of course, there is age to consider. With aging comes slower response rates and less energy. Most of us who are older just cut down our hours in clinic or find another job that is less demanding to avoid the frustration of not staying on time with our clinical load. For my younger readers, I hope there are many, many years ahead of you before you can possibly (and never do) relate to what I just wrote about aging. If we lose our resilience, I believe burnout is imminent.

As an FYI, our medical society provides a free personal consultation for members who wish to discuss, in confidence, a personal matter with a licensed medical psychologist by linking to LifeBridge on our website.

Life balance speaks to our ability to find other outlets for our mental and physical well-being. For some, it’s raising a family and enjoying the time going to soccer games, talent shows and other activities. I’m always intrigued, but no longer surprised, to hear about our talented physicians that enjoy painting, playing an instrument, composing music, writing, hiking, bicycling, traveling, etc. The list of activities outside of medicine that my colleagues enjoy is long and, for me, gratifying to hear of their endeavors and ad-

ventures. We need that time to replenish and refocus our energies as we return to our demanding profession. Without these outlets we risk the development of burnout. However, having these other activities is not enough to avoid burnout. There is number three of my analysis.

Control of the workplace is a challenge and it starts on the day we see our first patient. For most of us, we spent almost a decade of training for this moment and our training was all about developing a doctor-patient relationship. Then, on that first day of seeing our patient, we are confronted with numerous barriers between us and the patient.

One, insurance companies that restrict testing have limited the resources for the patient including a limited list of providers in their network and, if it’s an HMO, a delay in treatment on the day of the office visit. Two, an EMR (electronic medical record) that will oblige you to become more proficient with its use in order to see the required number of patients needed to pay for your overhead and your salary. Three, regulatory demands for documentation in order to bill an acceptable level.

The number of metrics and type of metric are and continue to be a work in progress. The metrics are redundant in their need to be documented at each office visit and all too often arbitrary and superfluous to the actual care needed for that visit. Four, the dreaded priorauthorization (PA) required by the pharmacy benefits managers (PBMs). PBMs are the “unchecked” entities that profit the most from the kick-backs, termed as rebates, they get from the pharmaceutical companies.

Based on their rebates, they create a formulary unique and profitable to them and restrictive to our patients. PAs have been shown to delay or deny treatment and increase the administrative time and cost to providers. These four intrusive barriers can be and are a frustration we confront on a daily basis. Herein lies the

moral injury, the betrayal by the system that is supposed to allow us to give our patient the best care we can. The care that we have so diligently trained for and so desperately want to administer.

How did we get here? One possible explanation is the increasing regulatory laws that are well meaning but short-sighted. A PubMed search for the number of healthcare laws created over the last few decades revealed a steady increase in their number. In the decade of the 1970s, we have a total of seventy laws passed dealing with healthcare policy. Thereafter, the number of healthcare policy laws increase steadily and exponentially. In this last decade, from 2010 thru 2019, there were 1,271 laws passed. The curve for the number of healthcare policy laws passed matches the curve of the number of articles written about burnout. The control of our work place has been systematically striped from our hands and passed into the hands of administrators, law makers, insurance companies and PBMs. We, who take care of our patients, have lost control and therein lies the consequential burnout for some.

All three of these areas, resilience (self-motivation), life balance, and control of the workplace are equally important and, in my view, require examination if we recognize burnout in one of our colleagues. Regaining control of our doctor-patient relationship is a must and we should all feel obliged to develop a relationship with our policy makers.

I hope this “thought analysis” of burnout in our profession will lead to a broader conversation on this very important topic.

Rodolfo (Rudy) Molina MD MACR FACP is a Practicing Rheumatologist and 2021 President-elect of the Bexar County Medical Society.

Visit us at www.bcms.org

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THE BUSINESS OF MEDICINE

Consider

These Year-end Financial Moves

By Elizabeth Olney

We’re nearing the end of 2020 – and for many of us, it will be a relief to turn the calendar page on this challenging year.

However, we’ve still got a few weeks left, which means you have time to make some year-end financial moves that may work in your favor.

Here are a few suggestions: • Add to your IRA. For the 2020 tax year, you can put in up to $6,000 to your traditional or Roth IRA, or up to $7,000 if you’re 50 or older. If you haven’t reached this dollar limit, consider adding some money. You actually have until April 15, 2021, to contribute to your IRA for 2020, but the sooner you put the money in, the quicker it can go to work for you. Plus, if you have to pay taxes in April, you’ll be less likely to contribute to your IRA then.

• Make an extra 401(k) payment. If it’s allowed by your employer, put in a little extra to your 401(k) or similar retirement plan. And if your salary goes up next year, increase your regular contributions.

• See your tax advisor. It’s possible that you could improve your tax situation by making some investment-related moves. For example, if you sold some investments whose value has increased, you could incur capital gains taxes. To offset these gains, you could sell other investments that have lost value, assuming these investments are no longer essential to your financial strategy. Your tax advisor can evaluate this type of move, along with others, to determine those that may be appropriate for your situation.

• Review your investment mix. As you consider your portfolio, think about the events of these past 12 months and how you responded to them. When COVID19 hit early in the year, and the financial markets plunged, did you find yourself worrying constantly about the losses you were taking, even though they were just on “paper” at that point? Did you even sell investments to “cut your losses” without waiting for a market recovery? If so, you might want to consult with a financial professional to determine if your investment mix is still appropriate for your goals and risk tolerance, or if you need to make some changes.

• Evaluate your need for retirement plan withdrawals. If you are 72 or older, you must start taking withdrawals – technically called required minimum distributions, or RMDs – from your traditional IRA and your 401(k) or similar retirement plan.

Typically, you must take these RMDs by December 31 every year. However, the Coronavirus Aid, Relief, and Economic Stimulus (CARES) Act suspended, or waived, all RMDs due in 2020. If you’re in this age group, but you don’t need the money, you can let your retirement accounts continue growing on a tax-deferred basis.

• Think about the future. Are you saving enough for your children’s college education? Are you still on track toward the retirement lifestyle you’ve envisioned? Or have your retirement plans changed as a result of the pandemic? All of these issues can affect your investment strategies, so you’ll want to think carefully about what decisions you may need to make.

Looking back – and ahead – can help you make the moves to end 2020 on a positive note and start 2021 on the right foot.

Elizabeth Olney, is an Edward Jones Financial Advisor and is a member of the BCMS Circle of Friends. Edward Jones, Member SIPC

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SAN ANTONIO MEDICINE • December 2020

AUTO REVIEW

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SAN ANTONIO MEDICINE • December 2020

2021 BMW X5M

AUTO REVIEW

By Stephen Schutz, MD

In the 1950s and ‘60s sports cars with two doors like MGTDs, Porsche 911s, and muscle cars were all car enthusiasts wanted. Then in the ‘70s and ‘80s sports sedans such as the Mercedes 6.9, BMW M5, and Saab 9000 turbo (remember that?) grabbed our attention.

Now it’s SUVs. And why not? A Porsche Cayenne Turbo S can lap the Nurburgring as quickly as the 1980s supercar Porsche 959, and a Lamborghini Urus SUV can do it even faster. The combination of turbocharging, all-wheel drive, torque vectoring, and traction/suspension management software has resulted in the ability to make SUVs go really really fast.

Enter the 2021 BMW X5M, a hyper-SUV (I just made that up— give me credit if it catches on) which is pretty much an M5 sedan with a higher center of gravity and more space (and weight).

Driving the X5M is surprisingly similar to being behind the wheel of the M5. Explosive acceleration accompanied by a raucous V8 soundtrack is what happens when you hit the gas. And be careful when you do that, not because you’re approaching the X5M’s limits—they’re prodigious and much higher than yours—but because just five or so seconds after you nail the throttle at 60mph you’ll be going 120MPH. Despite a curb weight of 5425lbs (!), the X5M can handle almost as well as its M5 brother because of the aforementioned tech-enabled advancements. Cornering is neutral at any speed (at least any sane speed), and the big Bimmer is very stable on the highway as well. And thanks to a wide track and lowered suspension, the X5M isn’t “tippy”.

Nevertheless, that tuned suspension combined with bigger diameter wheels and low profile performance tires give the X5M a “sporty” ride, which borders on harsh if the pavement’s not smooth.

On the highway, on the other hand, everything’s wonderful. Not only is the ride comfortable and wind noise subdued, but the gearing is such that the engine is relaxed at any speed. I spent a lot of time between 75 and 90MPH and the X5M was quiet and very much in its element the whole time. And all that power and torque means that passing is a snap. In fact, the ability to pass quickly and effortlessly even at high speeds may be the best reason to buy an X5M (or M5 for that matter).

For the record, the X5M sprints from 0-60MPH in 3.6 seconds, but guzzles premium gasoline at a rate of 13 MPG City/18 Highway.

Naturally, driving the largest and heaviest BMW M-vehicle off road would be stupid. Would you hurt it? Probably not, but, even though it’s an SUV; this beast is about as much of an off-roader as a Ferrari.

It sure doesn’t look like a Ferrari though. Instead it looks like,

umm, an X5. That’s either good or bad depending on your point of view. If you want your neighbors to recognize instantly that you spent $120,000 (and possibly more) on your hyper-SUV, then you’re likely to be disappointed. On the other hand, if understatement is your thing, then you’ll like the X5M. There’s less understatement inside the X5M’s cabin where numerous M-badges and classic M blue and red accents serve as reminders that you own a special machine connected with such automotive icons as the M1 supercar, E30 M3, and wish-I-had-one E34 M5. I could do without the bold X5M badges on the seat backs (which light up at night), but the two tone seating surfaces with diamond stitching certainly look good.

Of course, at this price point there needs to be luxury, and there's plenty of that. The interior materials are first rate, and there’s tech galore easily accessible via the rotary iDrive knob on the center console. Rest assured, BMW makes sure buyers of the X5M will feel special when they drive it.

After close to 20 years of evolution the iDrive system is finally intuitive. Porsche and Audi have switched to touch screens, but they’re no better than this generation of iDrive.

Like all M-vehicles, the X5M can be had as the “base” model or the X5M Competition. For an extra $12,000, choosing the Competition version gets you 17 additional HP (for a total of 617, which is probably closer to 700 since BMW famously understates their power figures), blacked out badging and trim, and other enhancements. Frankly, the standard X5M is all you need (actually the nonM X5 50i is plenty fast), but if you want bragging rights and paying rock bottom prices isn’t that important to you, the X5M Competition is quite satisfactory.

It’s now the ‘20s, and performance SUVs have supplanted sports cars and sports sedans as “the” thing. I personally don’t like that reality much, but I can’t argue with the performance of vehicles like the X5M. It’s an amazing vehicle.

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

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

Visit us at www.bcms.org

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Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of November 18, 2020.

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SAN ANTONIO MEDICINE • December 2020