San Antonio Medicine December 2022

MEDICAL YEAR IN REVIEW

How Hospital Staff Shortages Contribute to Physician Burnout By Sowjanya Mohan, MD 14

An Observation on the Evolution of Community Oncology

By Shruti Sharma, DO 16

Translating Discoveries into Healthier Patients at UT Health By Robert Hromas, MD 17

San Antonio Food Bank A National and International Spotlight During COVID-19 Pandemic

By Michael Guerra, San Antonio Food Bank 18

The Dangers of Social Media Trends and Misinformation By Fareen Momin, Bahar Momin and Tue “Felix” Nguyen 20

The New Dean and Chief Academic Officer of the University of the Incarnate Word, School of Osteopathic Medicine (UIWSOM): John T. Pham, DO ..............................22 World AIDs Day By Moses Alfaro and Tue Felix Nguyen 23

Medicare Disadvantaged: A Raft of Lawsuits Exposes Fraud in Medicare Part C By John J. LoCurto, JD 24

Medical Students and Storytelling: HIV Out Loud By Yolanda Crous and Joshua Carrasco 26

The Interstate Medical Licensure Compact: Balancing Licensure Portability and State Autonomy

By Lori H. Kels, MD, MPH and Charles G. Kels, JD 28

Peripartum Depression: Clinical Medical Students’ Reflections

By Abby O. Lozano, MD, Kristin Park and Emily Liu 30

Undergraduate Medical Education: Developing Empathy for Patients with Substance Use Disorders by Attending an Alcoholics Anonymous Meeting By Lori Kels, MD, MPH and Madeline Kundler 33

Letter to the Editor 8

BCMS President’s Message 10

BCMS Alliance Message 12

36th Annual BCMS Auto Show 35

Tax Stragegies for Physicians By Jeffrey W. Bryson, Attorney 36

Many Hands, Many Masks, One Mission By Christopher Ruano 38

BCMS Vendor Directory 40

Auto Review: 2022 Cars By Stephen Schutz, MD 44

Recommended Auto Dealers 46

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

rajeev Suri, Md, President Brent W. Sanderlin, do, Vice President Ezequiel “Zeke” Silva iii, Md, Treasurer Alice Gong, Md, Secretary John J. nava, Md, President-elect rodolfo “rudy’ Molina, Md, Immediate Past President

DIRECTORS

vincent Fonseca, Md, MpH, Member Woodson "Scott" Jones, Md, Member lubna naeem, Md, Member lyssa n ochoa, Md, Member Jennifer r rushton, Md, Member raul Santoscoy, do, Member John Shepherd, Md, Member Amar Sunkari, Md, Member lauren tarbox, Member Col. tim Switaj, Md, Military Representative Manuel M. Quinones Jr., Md, Board of Ethics Chair George F. “rick” Evans, General Counsel Jayesh B. Shah, Md, TMA Board of Trustees

Melody newsom, CEO/Executive Director taylor Frantz, Alliance Representative ramon S. Cancino, Md, Medical School Representative lori Kels, Md, Medical School Representative ronald rodriguez, Md, phd, Medical School Representative Carlos Alberto rosende, Md, Medical School Representative

BCMS SENIOR STAFF

Melody newsom, CEO/Executive Director Monica Jones, Chief Operating Officer Yvonne nino, Controller Mary nava, Chief Government Affairs Officer Brissa vela, Membership Director phil Hornbeak, Auto Program Director August trevino, Development Director Betty Fernandez, BCVI Director Al ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE

John Joseph Seidenfeld, Md, Chair Kristy Yvonne Kosub, Md, Member louis doucette, Consultant Alan preston, phd, Member rajam S. ramamurthy, Md, Member Adam v. ratner, Md, Member david Schulz, Community Member

Faraz Yousefian, do, Member neal Meritz, Md, Member

Jaime pankowsky, Md, Member Moses Alfaro, Student Member Winona Gbedey, Student Member tue Felix nguyen, Student Member niva Shrestha, Student Member nancy Salas, Editor

September 15, 2022

To the Editor, October Issue 2022

First, The American College of Physicians is to be commended for maintaining its position concerning a single payer system for two years. Dr. Seidenfeld accurately portrays our healthcare as “broken.”

But it must be recognized that all the defects he accurately notes have been known and identified by the most ethical healthcare econ omists in the United States and the remainder of the world for DECADES. The problem is in the United States, due to tremendous pres sures and lobbying from all the parts of the system, there is a desire to maintain the status quo. Unfortunately, there are economic gains provided through that broken system. The question is “How many more decades will it be before the other physicians’ organizations, the insurance industry, the pharmaceutical companies, the legal profession, the medical equipment manufacturers, etc., etc. will join in to a plan that benefits our citizens?”

Beyond that, there is an even greater defect in our system. While spending multiple times per person that the other countries of the world, we end up with the worst statistics of the entire western world.

Why? For years, those benefiting from the status quo have put forth the misinformation that the dichotomy between cost and quality of care was the unfortunate insufficient level of care provided to the underprivileged. They claimed that an examination of the remainder of society would demonstrate much better results. It is not and has never been true. The most recent evidence, only the last in a line of re search papers revealing the dishonesty in that claim, was revealed in the newest data on maternal deaths. Our maternal death rate was the only one of the industrialized countries to be rising. Every other country’s rate is falling. Even more horrifying, if all the underprivileged are taken out of the mix, the maternal death rate for the more affluent Americans is still the worst in the world.

The explanation is very simple. In the U.S. we do so many excessive operations and procedures, deemed unnecessary elsewhere, the normal rate of complications from these activities raises our complication rate to levels that are unconscionable.

The introduction of a single payer system will cut back on the costs to our healthcare system and provide other advantages. But to com pletely correct our broken system we must find a way to limit the abuse to the system caused by the medical community itself. It will prob ably be the most difficult challenge we will have to face. It will be a battle between the Hippocratic Oath and greed in a portion of our medical community.

By Herbert H. Keyser, M.D.

If you would like to send a letter to the editor of San Antonio Medicine magazine, please email editor@bcms.org.

BCMS in 2022 –

A Year to Remember or a Year to Forget

By Rajeev Suri, MD, MBA, FACR, 2022 BCMS President

2022 will always be remembered as the year we fought our way out of the COVID-19 pandemic and recreated a semblance of what is the new normal or almost back-to-normal. The year saw us finally get a control over the disease with more available vaccines/boosters and better treat ments but saw the challenges of its effect on the healthcare supply chains, and workforce redistribution. At the local and state level in organized medicine, effects included exacerbated challenges with revenue sources, but also opportunities like more interaction. We also have started seeing downstream effects of passage of some major legislation from last year (prior authorization) and ongoing challenges with surprise billing.

With billions of COVID-19 vaccines administered worldwide, the pandemic response has proved what collaborative revolutionary science can do, and how a historic global effort to develop, distribute and pro vide access to COVID-19 vaccines is making an impact. Equitable ac cessibility and distribution are however still a challenge due to local and global socioeconomic factors. Of the 3.47 billion vaccines administered globally, 49.6% of inhabitants in high income countries have received at least 1 dose, compared with only 1% in low-income countries. As the vaccine production is being ramped up to an additional 10-14 billion doses, challenges with supply chains will need to be addressed.

What has changed in 2022 compared with 2021 is more availability of proven treatments for COVID-19 – ritonavir-boosted nirmatrelvir (Paxlovid), remdesivir, monoclonal antibodies (mAbs) including Evusheld, bebtelovimab and/or combination treatments. Again, wide spread availability is still a challenge due to local and global socioeco nomic factors.

COVID-19 shone a bright light on the cracks and weaknesses in the healthcare supply chain (PPE, iodinated contrast, tracheostomy tubes, needle biopsy guides, to name a few). The root cause for this is the in tent of US healthcare systems to reduce supply costs, thus pushing many medical manufacturers offshore and increasing dependency on these offshore sites. This coupled with transport bottlenecks, global/local economic changes affecting workforce, and lack of trans parency of supply and demand can and did create severe disruptions in patient care. Systems are learning to cope with this with diversification and targeted inventories but the underlying root cause still persists.

Since its inception in March 2020, the $2.2 trillion CARES Act has helped healthcare systems weather the pandemic storm, but many sys tems did not survive. With the CARES Act support to health systems winding down and still with persistent challenges of increased cost of healthcare (supplies, decreasing reimbursements and high inflation),

health care systems are at an even higher risk of closing down with dele terious effects on patient care, and add to that the redistribution of workforce due to the great resignation/retirement, higher wages (com petitive wages, locums), a smaller healthcare workforce and a looming recession, the end is not near.

At a regional level, similar to other institutions, BCMS and TMA, have also emerged from the pandemic, slightly leaner with a reduced revenue source, though the last quarter has started showing a turn around. Organized medicine was not built for a remote environment and as we emerge into a social interactive medical society we were in tended for; we will morph back to who we were. The successful 2022 BCMS Women Leaders in Medicine awards ceremony was a classic ex ample of what the society needs to rejuvenate its members. Continued efforts in the coming years in this direction including leadership sem inars and partnership with healthcare focused pipelines in schools and colleges will be essential for BCMS to continue to have a voice for our physicians.

Laws passed last year are finally having an impact this year. H.B. 3459 or the “Texas Gold Card Act”, was passed as a law in September 2021 in Texas to establish continuous prior authorization exemption for physicians who earned 90% approval rate on prior authorization re quests for services over a period of six months. After an intense rule making process, certain provisions of the “Texas Gold Card Act” have started taking effect beginning October 2022, and have the capability of changing the healthcare environment for years to come.

So yes, 2022 is not a year we will ever forget. There were achieve ments, challenges and opportunities. Wishing you all the very best for 2023 for amazing opportunities for BCMS and its physician commu nity. Best wishes to a new leadership that will be at the helm starting the new year.

References:

1. FDA.gov. Medical devices shortages during the COVID-19 crisis public health emergency. https://www.fda.gov/medicaldevices/coronavirus-covid-19-and-medical-devices/medical-deviceshortages-during-covid-19-public-health-emergency#shortage

Rajeev Suri, MD, MBA, FACR is the 2022 President of the Bexar County Medical Society, Tenured Professor and Interim Chair of the De partment Radiology at UT Health San Antonio and Chief of Staff at University Hospital San Antonio.

BCMSA

A Year in Review

By Taylor Frantz, RDN, LD

2022 was a great year for the Bexar County Medical Society Alliance. We enjoyed getting back together and focusing on giving back to the community. Some of the organizations we partnered with include TMA Hard Hats for Little Heads, The Ronald McDonald House, San An tonio Food Bank, American Red Cross- Uvalde and Sleep in Heavenly Peace. We enjoyed social events such as new member coffee, dinner at the food truck park and “Sips and Dips” happy hours at our member’s homes. With funds granted to us by the TMA Foundation, we were able to provide $8,250 in scholarship funds to medical students and allied health students in Bexar County. We are looking forward to next year!

How Hospital Staff Shortages Contribute to Physician Burnout

By Sowjanya Mohan, MD

A

s we slowly emerge from the challenges the pandemic brought to heath care, one of the continuing struggles our hospitals are facing across the country is staffing. Nursing and physician shortages were already an issue before the pandemic. COVID has exacerbated the situation, resulting in physician burnout and affect ing not only how we provide care but also the patient experience while within our care.

A look at recent data warns of the increasing stress this is putting on our communities and care providers. According to physician staffing company CHG Healthcare, 43% of physicians changed jobs during the years of the pandemic, most to find work-life balance and avoid burnout, with 8% retiring and 3% moving into non-medical careers. Data pub lished in 2020 by the Association of American Medical Colleges esti mates that the U.S. could see a shortage of 54,100 to 139,000 physicians by 2033 in both primary and specialty care fields. Time Magazine pro filed the extent of the healthcare shortage in a July article noting several studies on the issue including a March 2021 survey conducted by Mer ritt Hawkins for the Physicians Foundation, which reported that 38% of physicians said they would like to retire in the next year.

The reasons are of course many, and the consequences far reaching. To begin with, the pipeline that feeds our physician population is pinched from the start. There are not enough Graduate Medical Edu cation spots for internships, residencies and training. To help address

the problem, in 2021 congress introduced the bipartisan Resident Physi cian Shortage Reduction Act of 2021 (S. 834/H.R. 2256) to help open more spots for residency training.

Cost is another barrier for many. The Association of American Med ical Colleges reports that in 2021-2022, the average yearly cost for first year medical students is approximately $51,433 (without living ex penses), extrapolated to $205,734 for a four-year medical degree, in ad dition to undergraduate education costs. Many young physicians entering practice are under significant stress to pay student loans as well as establish practices and start their post education lives.

Hospital staffing issues have an impact as well. As hospitals work to overcome shortages in clinical staffing, physicians often become a buffer, still having to provide optimal patient care, being responsible for out comes and being the “face” of the organization to the patients and fam ilies. Yet, they have little control over staffing levels or utilization of resources within an organization. Physicians want to feel valued by the organization and administrative partners, not just a replaceable cog on a wheel. They want to work in a setting where they can take good care of their patients, have time to engage the staff they work with, and still have time to spend time with their families and enjoy hobbies and in terests outside of work. New and temp staffing for ancillary roles make it harder to form a team mentality when working in the clinical setting. That lack of a sense of community can also lead to stress and burnout.

Pandemic pressures in hospital care changed how many physicians practice medicine. Physicians took locums opportunities during the pandemic because of the higher pay and flexibility of schedules, which added to the cycle of shortages within practices and additional stress for full-time physicians. The advent and increase in Telehealth have allowed providers to work remotely, creating a barrier to recruitment in a num ber of hospital specialties.

Repercussions from physician burnout can include poor access to care, longer wait times and delayed care. This becomes especially perti nent in our primary-care network. A 2021 report by the Kaiser Family Foundation found that more than 83 million people in the United States live in a designated primary-care health professional shortage area (HPSA), and more than 14,800 practitioners are needed to remove the HPSA designation. This primary care shortage can result in patients de laying their care until they are in crisis, resulting in a stressed Emergency Department with a domino effect in other areas of the hospital.

Is there a solution to physician shortages and burnout? It is evident that a multipronged approach is needed, starting with changes to how we educate our future physicians, providing more opportunities and less expensive options. We must be more flexible in how physicians practice in the hospital, offering incentives that incorporate lifestyle balance for

physicians for whom this is a priority. Giving physicians a voice in op erations, and increased recruitment initiatives for all staffing needs in our hospitals are also potential solutions that could help to address shortages and burnout. In the meantime, hospitals will have to make difficult decisions on what services they can offer depending on physi cian availability. Flexibility, the willingness to adapt and change how we deliver care and ultimately continued dedication to our patients, can and will overcome any challenge we are faced with. Our physicians have persevered through one of the greatest healthcare challenges of our time. The COVID pandemic has made us stronger as a profession and we continue to advocate for improvements in the care for our patients and for each other as colleagues with the help of organizations like the Bexar County Medical Society.

Thank you to all our physicians for all you do every day to advocate for patients, staff and our communities.

Sowjanya Mohan, MD is the Chief Medical Officer at Baptist Health System. She is a member of Bexar County Medical Society.

An Observation on the Evolution of Community Oncology

By Shruti Sharma, DO

The practice of community oncology has evolved significantly in the last ten years. The general focus of community oncology was primarily to bring accessibility of cancer care treatment to patients while academic oncology focused largely on specialty and sub-specialty oncology services, research and being the powerhouse for education and training programs. We largely associated clinical trial availability with academic oncology and looked to them for additional resources, including research laboratories, libraries and access to exclu sive research databases.

It has been stimulating to see the evolution of community on cology to include procedures that were traditionally observed only at academic institutions. Many on cologists have started to develop “special fo cuses” instead of remaining as a general oncology physician. Furthermore, com munity hospitals have started investing in graduate medical education pro grams, which subsequently has allowed for the development of communitybased hematology and oncology fel lowships. Lastly, clinical trials and research protocols have been investi gated and implemented avidly in the com munity setting.

The mesh between community oncology and academic oncology has been beneficial to both parties. Some community hospitals have decided to es tablish an affiliation to an academic center. Other organizations have decided to remain independent but incorporate academic proce dures within their structure. Is one structure better than the other? Not necessarily.

Establishing an affiliation to an academic center allows for increased access to numerous clinical trials and research already established by the academic institution, not necessarily available to independent standing community programs. Furthermore, the reputation obtained upon affiliation to an academic institution helps increase awareness of the community program itself. In addition, this relationship allows di versification of enrollment into various trials. Gender, age, race and so cioeconomic status of individuals are all factors that need to be

considered upon enrollment of clinical trials. Academic centers can also provide increased supportive services to patients more readily at their community site.

Independent organizations have also flawlessly implemented aca demic procedures and have continued to provide rich resources for pa tients. As we continue to learn from the research being conducted by these clinical trials, independent organizations have continued to en courage community oncologists to become private investigators and establish leadership roles to ensure that patient care is never compro mised and remains inclusive. Some comprehensive cancer cen ters also consist of surgery and radiation services within the same organization, which allows for continu ity of care and accessible communication among patient treatment teams.

As research continues to produce re sults, the knowledge gained from these studies keeps academic oncologists, community oncologists and pharma ceutical companies busy, so we can continue to understand the mecha nisms of malignant hematology and solid tumors and manufacture new drugs that can help combat these disease processes. With all this vast knowledge, is it better for patient care, then, to “subspecialize” in oncology or remain a generalist in the community going forward? Currently, some community practices en courage oncologists to pick a few focuses to mold their practice into, while many others still leave this decision up to the physician.

Conclusively, we have observed significant change in this last decade regarding the structure of academic oncology and community oncol ogy. As the relationship between community and academic oncology continues to evolve, the goal of both, however, remains unified: to pro vide the best cancer care for our patients as close as possible to them.

Shruti Sharma, DO. She is a Medical Oncologist and Hema tologist at Texas Oncology, San Antonio Medical Center and a member of Bexar County Medical Society.

Translating Discoveries into Healthier Patients at UT Health

By Robert Hromas, MD

UTHealth is a remarkable engine for biomedical discovery that is offering hope for previously incurable diseases. Translating these discoveries into clinical trials right here in San Antonio contributes greatly to the burgeoning biotechnology industry here. We highlight here three drugs and one device that will make lives better for patients with complex and difficult to treat diseases.

First, Director of the Center for Innovative Drug Discovery, Dao hong Zhou, MD and I have developed a degrader of the cancer sur vival protein BCL-XL. This drug, termed DT2216 is in phase 1 clinical trials at the UT Health San Antonio, Mays Cancer Center. Phase 2 trials will start after the first of the new year in T-cell lym phoma, pediatric liver cancer and myelofibrosis, all diseases that are difficult to cure. Dr. Zhou was the first to use the proteolysis targeting chimera (PROTAC) technology to overcome the on-target and doselimiting toxicity of BCL-XL inhibitors. DT2216 targeted cancer cells by converting a previously toxic BCL-XL inhibitor into a PROTAC that targets BCL-XL to an E3 ligase minimally expressed in platelets but highly expressed in tumors. This makes DT2216 specific for many tumors, limiting its toxicity.

Second, Associate professor of Neurosurgery, Ali Seifi, MD never thought he would be on Shark Tank, but his discovery, Hiccaway is so effective at getting rid of hiccups, even in cancer patients who suffer from chronic debilitating hiccups, that he won a spot on the show. Shark Mark Cuban liked his invention and invested in the company, which now markets Hiccaway in HEB and Amazon. Seifi thought the first emails from ABC for Shark Tank were fake and ignored them. It was not until the main producer emailed him directly that he paid at tention and accepted the invitation to be on the show. He had pub lished a study proving Hiccaway’s efficacy in JAMA, and he had strong patent protection, which made him an attractive participant for Shark Tank. The fact that hiccups is the third most common health search on Google combined to make an investment in Hiccaway much less risky for Cuban.

Third, Jim Lechleiter, PhD, Professor in the Department of Cell Sys tems and Anatomy, found that a novel small molecule, AST-004 pro tected astrocytes from death after stroke or brain trauma. The surviving astrocytes were able to protect other central nervous system tissue, and recovery from the brain events was quicker. AST-004 holds promise for multiple other indications besides stroke and concussions. His team discovered another possible use for the drug, preventing hearing loss after explosions. “The inner ear has a lot of the same neural structure

as the brain” Lechleiter said, and AST-004 is also effective at preventing inner ear cell death after trauma from pressure blasts. AST-004 is in phase 1 trials in Europe, with phase 2 planned for the University Hos pital Trauma Center.

Fourth, Ratna Vadlamudi, PhD, Professor of Obstetrics and Gyne cology at the LSOM discovered a small molecule that was highly active against resistant breast cancers, ERX-41. He discovered that ERX-41 had robust activity against multiple Triple Negative Breast Cancer mo lecular subtypes. Vadlamudi identified a novel therapeutic vulnerability in these and other resistant cancers that can be targeted to kill these hard-to-treat cancers in culture and animal models. His studies showed that when ERX-41 hit its target, the LIPA protein, it induces endo plasmic reticulum stress in cancer cells, leading to cell death. He showed that targeting LIPA and causing ER stress in cancer cells may be an ef fective therapeutic strategy for resistant breast cancer and other difficult to treat solid tumors.

The LSOM research teams have made many other discoveries re cently that can ultimately impact many chronic diseases, such as dia betes, steatorrhea hepatitis, dementia and muscle wasting in aging. We are developing these interventions in San Antonio, which will markedly grow the biotechnology industry here, helping make San Antonio a hub for translating medical discoveries into patient care.

Robert Hromas, MD, Dean of the Long School of Medicine at UT Health San Antonio.

San Antonio Food Bank: A National and International Spotlight During COVID-19 Pandemic

By Michael Guerra, Chief Development Officer, San Antonio Food Bank

The last few years have put the San Antonio Food Bank in the national and international spotlight as it innovated and flexed to meet the humanitarian crisis brought on by the COVID19 pandemic. The Food Bank will be remembered for meeting the emergency food needs of the local community, that for so many were a first-time experience. The images of parking lots filled with cars wait ing for food, coupled with heroic volunteers serving alongside Food Bank staff to fill trunks with emergency food, will be forever etched in the minds and hearts of residents. Now, as the Food Bank pivots on the backside of the pandemic, the organization has been able to once again focus less on leading an emergency response and more on getting back to its core work of equitable distribution of nutritious food across a 29-county region of Central and South Texas.

Under CEO Eric Cooper’s leadership, the Food Bank has launched a comprehensive response to food insecurity for the region, a response that leads with food but also highlights education, employment and housing. The framework is titled “Secure San Antonio.” Here is a brief overview of the components.

FOOD: This year San Antonio Food Bank will source and redistribute nearly $150,000,000 in food, the majority of which is perishable, healthy food aimed at setting dinner tables for households facing hunger. The Food Bank allocates its food with an equity model that ensures communities that are historically underserved are given priority and their fair share of food.

EDUCATION: Realizing that the way out of poverty is through ed ucation and a living wage, the Food Bank has helped place food pantries in all local colleges and universities. In addition, the organi zation has placed full-time staff at each of the five campuses of the Alamo Colleges District. These staff help students navigate a variety of social needs they might encounter during their studies, and for these students, the biggest barrier to graduation is not flunking out, but rather poverty.

EMPLOYMENT: For nearly two decades, the Food Bank has led job training and placement programs (culinary arts and warehouse

logistics), graduating nearly 100 classes in those years. Building on this past success, the Food Bank strengthened its commitment to helping food insecure households with workforce training by adding a dozen case managers to support those who are undertrained and need work that pays a living wage. The change also added a suite of more than fifty training programs to the two the Food Bank runs in house.

HOUSING: The final component of a Secure SA framework is actu ally the place where low-income households spend the majority of their income. The Food Bank is strengthening its work across the region with affordable housing partners, sending food on mobile units to apartment complexes to minimize mobility barriers and increase participation. The Food Bank is also building the Apple Seeds Apartments, adjacent to their New Braunfels Food Bank satellite facility. The Apple Seeds Apartments, opening in 2023, will have 50 units and will target families with an adult working in the area who is not currently able to afford housing near their work.

Food remains focal for the Food Bank, but the future of health and equity has meant a pivot to solutions beyond mere food for the organ ization. More information about these programs and how to get in volved can be found at www.safoodbank.org

Michael Guerra is a Chief Development Officer at San Antonio Food Bank

Photographs copyright San Antonio Food Bank.

The Dangers of Social Media: Trends and Misinformation

By Fareen Momin, Bahar Momin and Tue “Felix” Nguyen

O

ur world has been increasingly reliant on social media; whether it be for entertainment or knowledge, many of us use multiple social platforms to gain information and inter act with others globally. Since the beginning of the COVID-19 pan demic, many individuals have increased their use of social media platforms, including Facebook, TikTok, Instagram and Twitter. During the first COVID-19 wave in 2020, 70% of users reported an increase in social media use, and during the second wave, 89% of users reported an increase in social media use.1 Although these platforms have allowed us to connect with individuals in real-time, many of us forget the power so cial media may hold to negatively impact our communities.

With the increased use of social media, some users have relied on these platforms to research ways to improve their physical appearance and com plexions. Dermatologic therapies, including microneedling, have gained interest in the beauty community to help improve skin texture. These in terests have brought about multiple trends on social media, including “DIY Microneedling” and “Sunscreen Contouring,” to capitalize on peo ple’s insecurities.2 Dermatologists and other licensed professionals per form microneedling by minimally traumatizing the skin to promote collagen and elastin production, which helps reduce the appearance of fine lines, wrinkles and pitted acne scars. To obtain similar results, users shared “DIY Microneedling” techniques at home, unaware of the in creased risk of infection when performed incorrectly or when using un sanitary needles and instruments.

Another dangerous trend on TikTok was “Sunscreen Contouring,” where users applied sunscreen only to certain portions of their face, such as the nose bridge and cheekbones, to elicit a tan that made their face look “sculpted” without makeup.2 Sun exposure to unprotected areas of

the skin can increase the risk of skin cancer, including melanoma, squa mous cell carcinoma, and basal cell carcinoma. In addition, long periods of chronic sun exposure can also lead to early photoaging and hyperpig mentation triggered by ultraviolet radiation damage from the sun.

Along with the dangerous trends on social media, the amount of mis information has increased. The COVID-19 pandemic brought the issue of social media misinformation to the forefront.3 Conspiracy theories rapidly spread across platforms, such as COVID-19 being synthesized in a lab and microchips in vaccines for governmental tracking. Studies found that beliefs in COVID-19 conspiracies lead to reduced compli ance with health guidelines and protective behaviors, posing a danger to public health.3

The use of social media as a source of information is evident in topics surrounding health and nutrition. A popular example is the promotion of a drink called “adrenal cocktail,” a beverage composed of orange juice, peeled oranges, coconut water and sea salt to help alleviate “adrenal fa tigue.”4 It was developed by functional nutritionists who claim that elec trolyte-rich drinks will “replenish” the adrenal glands and promote electrolyte homeostasis. The term “adrenal fatigue” describes an alleged condition caused by chronic stress that leads to overuse of the adrenal glands. The adrenal glands are tightly-regulated, small organs positioned superiorly to each kidney, and are responsible for synthesizing various hormones that help regulate blood pressure, blood sugar, response to stress and electrolyte balance. A systematic review found no substantial evidence of “adrenal fatigue” as a medical condition.5

The increased use of social media by physicians can help combat many of these dangerous trends. A survey conducted on more than 4,000 physi cians found that over 90% of them utilize social media and that 65% of

them use their platform professionally.6 The misinformation published by social media influencers on these platforms is unregulated and can have dangerous public health consequences. Therefore, increased physician and educator presence on social media may help dispel any false circulating information and increase accessibility to evidence-based medicine.

With modern advancements in the digital era, social media platforms can be an excellent source of knowledge and continued learning when used mindfully. We encourage patients and the general public to only trust content produced by professionals when seeking reliable informa tion to reduce exposure to potentially hazardous information.

References

1. Aldrich AZ. Finding Social Support Through Social Media During COVID Lockdown. UConn Today. June 24, 2022. Accessed Septem ber 25, 2022. https://today.uconn.edu/2022/06/finding-social-sup port-through-social-media-during-covid-lockdowns/#

2. Dellner A. 5 TikTok Trends That Make Your Dermatologist Cringe. PureWow. May 7, 2021. Accessed September 23, 2022.

3. Xiao X, Borah P, Su Y. The dangers of blind trust: Examining the in terplay among social media news use, misinformation identification, and news trust on conspiracy beliefs. Public Underst Sci.

2021;30(8):977-992. doi:10.1177/0963662521998025

4. Walsh K. What Is the “Adrenal Cocktail” — and Is It Healthy (or Nec essary)?. EatingWell. August 4, 2022. Accessed September 23, 2022. https://www.eatingwell.com/article/7991890/what-is-the-adrenalcocktail-is-it-healthy/

5. Cadegiani FA, Kater CE. Adrenal fatigue does not exist: a systematic review [published correction appears in BMC Endocr Disord. 2016 Nov 16;16(1):63]. BMC Endocr Disord. 2016;16(1):48. Published 2016 Aug 24. doi:10.1186/s12902-016-0128-4

6. Ventola CL. Social media and health care professionals: benefits, risks, and best practices. P T. 2014;39(7):491-520.

Fareen Momin is a medical student at UTMB. She is interested in dermatology and serves as the Vice President of the UTMB Dermatology Interest Group.

Bahar Momin and Tue “Felix” Nguyen are medical students interested in dermatology at the UT Health San Antonio Long School of Medicine. They all served as clinic coordinators for the local student-run dermatology free clinic.

The New Dean and Chief Academic Officer of the University of the Incarnate Word, School of Osteopathic Medicine (UIWSOM):

Dr. John T. Pham

Dr. John T. Pham is the new Dean and Chief Academic Offi cer of the University of the Incarnate Word School of Os teopathic Medicine (UIWSOM), he started his deanship in June 2022. He formerly served as Vice Dean of Western University of Health Sciences College of Osteopathic Medicine of the Pacific Northwest in Lebanon, Oregon.

“I am excited to get a chance to be a part of a very talented team who will oversee the growth and expansion of UIWSOM not just now, but in the years to come. We are located in the heart of a medically underserved area of San Antonio, on the Southeast side and as we grow, so will the services we can provide to this community and the surrounding rural areas. This will be a great opportunity for our students to live the Mission of the University of the Incarnate and our founders, The Sisters of Charity of the Incarnate Word… to get out in the community and serve those who need it the most.” Says Dr. Pham.

As a child, Dr. Pham settled in Portland, Oregon with his parent and younger brother after emigrating from Vietnam in 1975. He is the eld est of three sons and the first in his family to attend medical school.

He graduated with his Bachelor of Science, Cum Laude, from Ore gon State University, Corvallis, Oregon. After graduating from Oregon State University, he left the state for the first time since arriving in Ore gon to attend medical school at Des Moines University in Iowa. Dr. Pham completed his residency in family medicine at the East Moreland Hospital.

After graduating from residency, his ambition and motivation to give back to his community were embedded in his fiber. He became an en trepreneur and opened a solo practice clinic in Portland, where he prac ticed for almost ten years before joining Western University COMP-Northwest in 2011. Being fluent in Vietnamese, Dr. Pham’s practice served many first- and second-generation Vietnamese. Throughout his time in private practice, he mentored countless numbers of medical students and pre-med students at his clinic.

Dr. Pham has been recognized for mentoring both locally and na tionally. These acknowledgments have earned him D.O. of the Year from the State Association in 2010 and Mentor of the Year from the AOA in 2007. His love of teaching led him to Western University COMPNorthwest, where he began educating as an Assistant Professor of Family Medicine for the inaugural class in 2011. When the opportunity arose for him to give back to the community and train future compassionate and competent physicians, he did not hesitate. He now brings his pas

sion for education and mentoring to the University of the Incarnate Word School of Osteopathic Medicine (UIWSOM) as Dean.

“Where will our next generation of doctors come from if we do not lead by example? Mentoring and being mentored is a gift. Observing physicians in practice gives premedical and medical students a sense of the rigors of medicine – the day to day realities of caring for patient after patient, ad ministering medical records, consulting with other health professionals and managing support staff. These are all factors that are critical in fostering those who will follow in our footsteps.”

At UIWSOM, Dr. Pham leads a community that is committed to improving the health and well-being of our local, national and global communities. UIWSOM brings together world-class researchers and faculty from diverse health-related fields to train our future osteo pathic physicians.

The curriculum at UIWSOM is forward-thinking and distinctive. UIWSOM graduates complete medical school with the tools to effec tively communicate with patients, diagnose, treat diseases and lead with compassion and empathy.

UIWSOM’s mission is to empower all members of the medical edu cation community to achieve academic, professional and personal suc cess and develop a commitment to lifelong learning through excellence in learner-centered, patient-focused education, justice-based research, and meaningful partnerships of osteopathic clinical service across the spectrum of undergraduate, graduate and continuing medical education.

The development and application of osteopathic principles of medicine across four years of physician training will promote culturally, linguistically and community responsive care for all patients to enhance patient safety and improve patient outcomes are core principles of our mission.

The UIW School of Osteopathic Medicine operates four state-ofthe-art facilities on the UIW Medical Campus at Brooks on San An tonio’s southeast side. These buildings formerly comprised the U.S. Air Force School of Aerospace Medicine. In total, the buildings consist of approximately 155,000 square feet of educational and administrative space on 16 acres.

UIWSOM currently has 661 learners and is preparing for its third grad uation. They are also now accepting students for their 7th academic year.

Dr. John T. Pham, Dean and Chief Academic Office at the University of the Incarnate Word School of Osteopathic Medicine (UIWSOM).

World AIDs Day

By Moses Alfaro and Tue Felix Nguyen

It was only 41 years ago when the United States (US) reported the first cases of an unusual and mysterious illness that would soon be later known as acquired immune deficiency syndrome (AIDs). The AIDs epidemic of the 1980s disproportionately affected people of the LGBTQIA+ community, specifically gay and bisexual men and other men who have sex with men and transgender women. In the US, there are estimated to be 1.2 million individuals living with human immunod eficiency virus (HIV), and around 13% of those individuals are unaware of their HIV status.1 From the start of the epidemic, over 700,000 people have passed away from AIDs in the US.2 While there have been down ward trends in HIV transmission and mortality rates over the years due to the introduction of novel antiretroviral drugs, this disease still per vades. Currently, great efforts are being made to ensure that this disease is eradicated in the near future.

On December 1st of each year, people worldwide come together to spread awareness regarding HIV and remember those who have passed away from AIDs. This day, known as Worlds AIDs Day, was founded in 1988 and serves to garner support and funding to combat HIV. Globally, it is estimated that 38 million people are HIV positive, so im proving public awareness and support is crucial.3 Numerous interna tional and national organizations host various events and spearheaded programs targeting the HIV/AIDs education disparity, such as UN AIDS, which has an “Education Plus Initiative” that aims to reduce the rising HIV transmission among adolescent girls and young women in sub-Saharan Africa. These initiatives are vital to fighting against HIV/AIDs, and without the support of millions of people across the globe, we would not have our current life-saving innovative therapies.

There are numerous ways to show your support and awareness on World AIDs Day. For instance, you can purchase a red ribbon from UNAIDS. The red ribbon’s funds are allocated to programs that com bat HIV/AIDs and support girls and women of the LGBTQIA+ com munity. The ribbon symbolizes solidarity with the millions of people living with HIV and serves as an opportunity to show your support and spread awareness to others. In San Antonio, organizations like Fi esta Youth put on a week’s worth of events starting on World AIDs

Day. This year’s theme is “Remembrance and Hope,” and you can par ticipate by attending events such as visiting the Fiesta Youth sponsored National AIDs Memorial Quilt by the Names Project, more informa tion can be found on their website at www.fiesta-youth.org.

While supporting campaigns and spreading awareness is crucial to ending HIV/AIDs and its associated stigma, we should also emphasize the importance of getting tested to know our HIV status. Getting tested significantly helps reduce transmission of this disease, and for tunately, testing is becoming more accessible in the US.

For more information about getting tested, visit www.gettested.cdc.gov to find a local center.

If you are at risk for contracting HIV, consider pre-exposure prophy laxis (PrEP) or post-exposure prophylaxis (PEP). These drugs can help minimize morbidity and reduce transmission rates of HIV.

If you are interested in learning more about them, please ask your primary care physician for more information.

References:

1. U.S. statistics. HIV.gov. (n.d.). Retrieved October 15, 2022, from https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics

2. Published: Jun 07, 2021. (2022, July 1). The HIV/AIDS epidemic in the United States: The basics. KFF. Retrieved October 15, 2022, from https://www.kff.org/hivaids/fact-sheet/the-hivaids-epidemicin-the-united-states-the-basics/#:~:text=The%20first%20cases %20of%20what,U.S.)

3. World AIDS Day. (2022, September 21). Retrieved October 21, 2022, from https://www.worldaidsday.org/about/

Moses Alfaro and Tue Felix Nguyen are medical stu dents at UT Health San Antonio Long School of Med icine and members of the BCMS Publications Committee.

Medicare Disadvantaged: A Raft of Lawsuits Exposes Fraud in Medicare Part C

By John J. LoCurto, JD

Healthcare fraud is a massive and stubborn problem. Perhaps the best way to confirm this is to examine the annual Health Care Fraud and Abuse Control Program Report that the United States Departments of Justice and Health and Human Services prepare. Year after year, the Report touts huge fraud recoveries. In Fiscal Year 2021, it boasted healthcare fraud judgments and settlements ex ceeding $5 billion and total collections approaching $2 billion.1 Of course, recoveries that big necessitate even bigger frauds.

Schemes directed at Medicare Part C – also known as Medicare Ad vantage – are an emerging concern. Losses are difficult to calculate pre cisely but are surely in the billions. The Centers for Medicare & Medicaid Services (CMS) estimates that Part C overpaid more than $15 billion in FY21.2 Other estimates range from $12 to $25 billion.3 With so much money at stake, it should come as no surprise that the Department of Justice designated Medicare Advantage an enforcement priority.4 The Department has filed or joined a raft of lawsuits against

major health insurance companies – e.g., Kaiser Permanente, United Health, Anthem – that allegedly bilked Medicare Advantage out of billions. To understand how fraud this big could have occurred, one must first understand Medicare Part C.

Medicare Advantage is an alternative to traditional Medicare, which comprises inpatient (Part A) and outpatient (Part B) services. Under Part C, private health plans (MA Plans) contract with CMS to cover Medicare beneficiaries who have opted out of traditional Medicare. MA Plans must cover all the services that beneficiaries would normally receive from traditional Medicare. Most plans also cover Medicare Part D (prescription drugs) and many offer additional coverages not avail able under traditional Medicare, including vision, hearing and dental, to attract beneficiaries. Enrollment in Medicare Advantage has ex ploded. According to the Kaiser Family Foundation, as of 2022, Medicare Advantage plans cover nearly 50% of the Medicare-eligible population – over 28 million persons.5

Medicare Advantage pays MA Plans a base monthly rate for each beneficiary they cover. The government makes this “per member, per month” payment irrespective of the services that patients actually receive or that Plans actually reimburse. The base rate that Medicare Advantage pays to MA Plans may increase due to risk factors that make caring for beneficiaries more challenging and costly. These risk factors include a beneficiary’s health status. If a beneficiary has a chronic illness or multiple diagnoses, a risk adjustment is made to augment the monthly base rate payment for that beneficiary. This creates a perverse incentive: MA Plans can earn more by making their beneficiaries seem sicker on paper than they are in person. This is exactly what the Department of Justice has accused the major MA Plans of doing. The Department’s allegations against Kaiser Perma nente (KP) are exemplary.

On October 25, 2021, the government intervened in a whistle blower lawsuit by filing a complaint against KP and its MA Plans. The complaint accuses them of perpetrating a billion-dollar fraud against Medicare Advantage.6 The suit contends that KP combined high-tech strategies (data-mining software and algorithms) and lowtech manual chart reviews to scour patient files for missed billing op portunities – diagnoses that were not made but could be added to patient files to justify upward risk adjustments and higher monthly payments. Once it identified new diagnoses, KP purportedly cajoled and pressured physicians to add them to patient records, which would then be submitted to the government, sometimes years later, for ad ditional reimbursement.

The following allegations from the government’s complaint against KP illustrate how the scam worked: 1) one of KP’s MA Plans directed radiologists to find evidence of calcium in the aorta and to interpret the evidence as atherosclerosis; 2) data miners subsequently searched patient files for the findings and key terms that the Plan had instructed radiologists to use; 3) the Plan then prompted physicians to review the findings, diagnose atherosclerosis of the aorta, and add the new diag nosis to their patient records to justify an upward risk adjustment and higher payment per patient.7 In this way, the Plan created an assembly line of fraud that cost Medicare Advantage millions.

The government’s claims against KP, UnitedHealth, Anthem and others are just that – claims. They have not been proven in court. What is more, it is tempting to focus exclusively on the MA Plans and their alleged misconduct, but that would be shortsighted. The government bears responsibility as well. Frauds this pervasive do not happen overnight. They take time, exploit programmatic flaws and depend on lax oversight. The government’s recent enforcement efforts are overdue and insufficient. The United States healthcare system cannot enforce its way out of its Medicare Advantage problem. It must instead adopt sensible healthcare policies that prioritize people, not profit.

References

1 Health Care Fraud and Abuse Control Program Report for Fiscal Year 2021. (2021, July). Retrieved from U.S. Department of Health & Human Services, Office of Inspector General: https://oig.hhs.gov /reports-and-publications/hcfac/index.asp.

2 Part C Improper Payment Measure (Part C IPM) Fiscal Year 2021 (FY 2021) Payment Error Rate Results. (n.d.). Retrieved from Cen ters for Medicare & Medicaid Services: https://www.cms.gov/ files/document/fy-2021-medicare-part-c-error-rate-findings-andresults.pdf.

3 Abelson, R., & Sanger-Katz, M. (2022, October 8). 'The Cash Mon ster Was Insatiable': How Insurers Exploited Medicare for Billions. The New York Times. Retrieved from https://www.nytimes.com/2022/10/08/upshot/medicare-advan tage-fraud-allegations.html.

4 Remarks of Deputy Assistant Attorney General Michael D. Granston at the ABA Civil False Claims Act and Qui Tam Enforce ment Institute. (2020, December 2). Retrieved from United States Department of Justice: https://www.justice.gov/opa/speech/re marks-deputy-assistant-attorney-general-michael-d-granston-abacivil-false-claims-act.

5 Freed, M., Biniek, J. F., Damico, A., & Neuman, T. (2022, August 25). Medicare Advantage in 2022: Enrollment Update and Key Trends. Retrieved from KFF: https://www.kff.org/medicare/issuebrief/medicare-advantage-in-2022-enrollment-update-and-keytrends/.

6 United States ex rel. Osinek v. Kaiser Permanente, No. 3:13-cv3891-EMC (N.D. Cal.) (#110).

7 Id. at ¶¶ 244-45.

John J. LoCurto, J.D., Assistant Professor of Medical Jurispru dence & Health Policy at The University of the Incarnate Word School of Osteopathic Medicine (UIWSOM)

Medical Students and Storytelling: HIV Out Loud

By Yolanda Crous and Joshua Carrasco

I

have always believed in the power of stories. I was an English major in college, and I spent my first career as a magazine editor in New York. So, when I began to consider my job to go to med ical school, I turned to the place I’ve always gone for life advice: the bookshelf. While I was shadowing physicians and volunteering in hos pitals, I was also devouring tomes by physician-writers like Paul Farmer, Rana Awdish, Abraham Verghese and Elizabeth Ford. Page after page, story after story, I searched for a line or a moment that would signal to me that applying to medical school in my 40s was not an absolutely disastrous idea. (Spoiler alert: It was the best decision of my life.)

What I did not know then was that I would never think more deeply about the power of storytelling than I have as a medical stu dent. I owe this gift to HIV Out Loud, a storytelling project dedicated to creating and preserving the oral history of HIV in South Texas, and a National Endowment for the Humanities-funded collaboration be tween the End Stigma End HIV Alliance of San Antonio (ESEHA) and the Center for Medical Humanities and Ethics (CMHE) at UT Health San Antonio.

In November 2019, Dr. Barbara Taylor, an infectious disease physi cian who was co-chair of ESEHA at the time, invited students to a live HIV storytelling event at the historic Guadalupe Cultural Arts Center. The theater was packed, but all conversation stopped the moment the first storyteller walked onto the stage. As a first-year medical student who still spent more time in the lecture hall than with patients, I was struck by how each narrator centered their story not on illness or the virus but on how living with HIV had reframed the way they were seen by the community—and the way they perceived themselves.

That night, those stories, jolted me into an awareness of how pro foundly a single sentence or gesture by a physician or staff member can change the trajectory of our patients’ lives and health. A growing body of research indicates that even subtle or unconscious judgmental tones when discussing a patient’s sexual history or lecturing a patient about missing a clinic appointment can negatively affect the patient living with HIV and can reduce the likelihood a patient will adhere to a lifesaving antiretroviral medication regiment.

In the months and years since that storytelling night in November, ESEHA and the Center for Medical Humanities and Ethics have joined forces to expand ESEHA’s storytelling program into HIV Out Loud, an oral history of HIV in South Texas. Under the leadership of pediatrician and writer Rachel Pearson, the project has three main

goals: 1) to create new spaces where those in the HIV community— not only people living with HIV, but also their loved ones, their physi cians, HIV advocates and anyone whose life has been touched by HIV—can tell their stories how they wish them to be told; 2) to ensure that these stories are preserved and easily accessible by the public, es pecially by those living with HIV; and 3) to establish an HIV Out Loud medical-school elective, co-led by the CMHE and people living with HIV, that will train students in oral-history interviewing tech niques. It is our hope that this elective will not only sustain the oral history project but help reduce HIV stigma in health-care spaces and encourage compassionate, collaborative patient-centered care among our future physicians.

The elective has not yet begun but HIV Out Loud has already trained two cohorts of medical students. We held our first mobile sto rytelling session at World AIDS Day in December, and several mem bers of the HIV community generously took time out of the event to entrust their stories and memories with us—an honor we do not take for granted. We are actively looking for members of South Texas HIV community to interview, so if you are interested in sharing your story for the oral history project, please reach out to HIVOutLoud@gmail.com.

As for me, I still hit the bookshelf when I need guidance on big life questions. But when it comes to figuring out what kind of physician I want to be one day, nothing will ever teach me more than the stories of my patients—and the stories of HIV Out Loud.

For ESEHA’s Anti-Stigma Guidelines, go to endstigmaendhiv.com/resources.

Yolanda Crous and Joshua Carrasco are medical students at the UT Health San Antonio Long School of Medicine, Class of 2023. They are leaders of the HIV Out Loud project.

The Interstate Medical Licensure Compact: Balancing Licensure Portability and State Autonomy

By Lori H. Kels, MD, MPH and Charles G. Kels, JD

2022 marked Texas’s first year as a member state of the Interstate Medical Licensure Compact (IMLC). On June 7, 2021, Texas became the 33rd state to join the IMLC when Governor Greg Abbott signed House Bill 1616 into law.1 On March 1, 2022, Texas compact licensing became operational, with Texas physicians able to apply for out-of-state licenses and out-of-state physicians able to apply for Texas licenses via the IMLC mechanism.

The IMLC facilitates interstate practice, whether through telemed icine or in-person care such as locum tenens arrangements, by simplifying and easing the licensure application process between member states. The compact is also designed to enhance patient protection through additional layers of physician vetting, beginning with a re quirement for the applicant’s home state to verify their qualifications for IMLC participation.2 Additional state licenses obtained via the IMLC are neither special purpose licenses (such as limited telemedi cine licenses), nor new national or multistate licenses. They are unre stricted state licenses identical to the traditional (and historically more onerous) process of applying for multiple licenses directly. Accordingly, a physician’s practice in another state – whether in-person or virtual –remains subject to the oversight and regulation of the relevant state medical board based on the patient’s location.3 For qualifying physi cians already licensed in a member state, the IMLC offers an additional pathway for multistate licensure that seeks to minimize redundancies and centralize administrative functions; more conventional licensure avenues remain available and in place.4

Arguably the greatest strength of the IMLC is its balance between

streamlining physician mobility and preserving state regulation of med icine, which is a key tenet of federalism under US constitutional gov ernance. Medical licensing is a quintessential exercise of states’ inherent authority to protect the health, safety and welfare of their inhabitants.5 Yet licensure barriers to cross-state practice can pose problems of in equity, complexity and perceived obsolescence in an increasingly inter connected world, especially since pandemics and other disasters do not respect artificial boundaries. These challenges have led to growing calls for upending the current state-based system through national or federal licensure, or alternatively through defining the telemedicine site of care as where the physician, rather than the patient, is located.6 Either op tion would inevitably erode state primacy in verifying the competency, qualifications and character of physicians delivering care to the local population.

In addition to advances in telemedicine technology, one of the im petuses for the Federation of State Medical Boards (FSMB) to steer the development of the IMLC a decade ago was its recognition that an innovative state-based solution was essential to maintaining states’ historical and constitutional role in regulating the professions and protecting the public. Previous efforts, such as the Federation Cre dentials Verification Service and uniform licensure application, proved helpful but ultimately insufficient to meet the emerging chal lenge.4 The ingenuity and enduring promise of the IMLC is that it provides an expedited pathway for physicians to obtain multiple li censes while keeping the traditional regulatory authority of state medical boards intact.

Table

The IMLC addresses an identified barrier to access to care by leveraging, rather than enervat ing, a physician’s home state license through a clearinghouse function that streamlines multi state licensure while adding appropriate safe guards. The resulting licenses obtained by physicians seeking to expand their virtual or physical reach are full and separate medical li censes, reaffirming states’ jurisdiction over the conditions of practice impacting their communi ties but reducing unnecessary duplication and delay. Promulgated under the auspices of the FSMB and endorsed by the American Medical Association, the IMLC was designed to achieve license portability through voluntary mecha nisms compatible with state prerogatives and physician self-policing through medical boards.3 The Texas Medical Association (TMA) had advocated for Texas to join the compact for multiple legislative sessions before the efforts came to fruition last year.

Interstate Medical Licensure Nurse Licensure Compact (NLC) Compact (IMLC)

Participation 37 states, District of Columbia, 35 states (awating implementation in Guam OH and PA)

Texas Yes Yes membership

Mechanism Expedited pathway through IMLC Multistate license / Automatic Commission reciprocity

Process (1) Confirm eligibility Obtain multistate (compact) license (2) Apply through IMLC portal from primary state of residence (3) Receive letter of qualification (PSOR) in a compact state (LOQ) from state of principal license (SPL) (4) Select additional member states and pay state fees"

Result Additional state license(s) Multistate (compact) license

Engl J Med. 2015;372(17):1581-1583.

5. Dent v W Va, 129 US 114 (1889).

Although the IMLC model of expedited licensure is less robust than an automatic reciprocity system such as the Nurse Licensure Compact,7 its careful construction to obtain widespread buy-in among state capi tals remains integral to the venture’s lasting success (Table). Adoption of the IMLC by remaining US states and territories is both a test of the flexibility of time-honored licensure mechanisms to meet emerging needs and an imperative to address geographical physician shortages, both during and outside of crises such as the COVID-19 pandemic.2 Since Texas adopted the compact last year, it has been joined by four more states, bringing the current total to 37 states, the District of Co lumbia and Guam.8

Disclaimer: The views expressed are those of the authors and do not necessarily reflect those of the Department of Defense or any of its compo nents.

References:

1. Tex Occ Code Ann § 171.

2. Adashi EY, Cohen IG, McCormick WL. The Interstate Medical Li censure Compact: attending to the underserved. JAMA. 2021;325(16):1607-1608.

3. Steinbrook R. Interstate medical licensure: major reform of licensing to encourage medical practice in multiple states. JAMA. 2014;312(7):695-696.

4. Chaudry HJ, Robin LA, Fish EM, Polk DH, Gifford JD. Improving access and mobility: the Interstate Medical Licensure Compact. N

6. Slomski A. Telehealth success spurs a call for greater post-COVID19 license portability. JAMA. 2020;324(11):1021-1022.

7. National Council of State Boards of Nursing. Nurse Licensure Com pact. https://www.ncsbn.org/nurse-licensure-compact.htm.

8. Federation of State Medical Boards. Interstate Medical Licensure Compact. https://www.imlcc.org.

Lori Kels, MD, MPH is a board-certified psychiatrist and an Associate Professor at the University of the Incarnate Word School of Osteopathic Medicine, where she serves as the Psychi atry Clerkship Director. She is also a member of the Bexar County Medical Society (BCMS) and serves as the UIWSOM representative on the BCMS Board of Directors.

Lieutenant Colonel Charlie Kels is an associate general coun sel for the Defense Health Agency and a judge advocate (JAG) in the U.S. Air Force Reserve.

Peripartum Depression: Clinical Medical Students’ Reflections

By Kristin Park, Emily Liu and Abby O. Lozano, MD

Peripartum depression is defined by the Diagnostic and Statis tical Manual of Mental Disorders, 5th Edition, as a major de pressive episode during pregnancy or occurring in the four weeks after delivery. Clinical features include depressed mood or an hedonia, with four additional symptoms: sleep disturbances, excessive guilt, low energy, concentration difficulties, appetite changes, psy chomotor agitation or retardation and suicidal ideation. Postpartum depression affects approximately 10-15% of adult mothers yearly and rates are particularly high in adolescent (25%) and African American (35%) mothers.

Delayed medical and psychiatric care can exacerbate the symptoms of mothers with peripartum depression, which can impact infant devel opment. During pregnancy, depressed women are more likely to partic ipate in smoking or cocaine use and have poorer maternal weight gain, leading to low birth weight, maternal pre-eclampsia and premature de livery, amongst other complications. Furthermore, postpartum depres sion can impact maternal-infant interactions, which have been associated with negative effects on cognitive and behavioral develop ment of infants and may have long-term effects on child development. Therefore, it is critical to detect and treat peripartum depression as early as possible. However, pregnant and postpartum women face unique bar riers to seeking care. One study found that only 13.8% of women screen ing positive for peripartum depression, at obstetric visits, reported receiving any form of medication, psychotherapy or counseling.

Our first clinical rotation as medical students was with the obstet rics and gynecology (OBGYN) department. We expected to human ize the pathology we learned in our preclinical years and hone our clinical acumen. Neither of us imagined how much each patient would teach us. Here, we each reflect on how our respective encounters with our patients affected by peripartum depression grew our understand ing of patient care.

Kristin:

“A mother was brought to gynecology triage by a concerned social worker. The patient had come in for a social work appointment, but the social worker quickly realized that the mother’s sadness was beyond cir cumstantial. As she was triaged, the patient tried her best to answer ques tions, while crying and caring for her baby. A nurse stepped in to help the mother finish changing and feeding the infant. Then, the patient tearfully

shared that she was overwhelmed. Once we began the patient interview, the mother said she was constantly worried about her premature infant, especially since witnessing the baby having an apneic event. She reported that her partner recently became physically and emotionally abusive, re peatedly telling her that she should kill herself and that he no longer wanted to be with her. With this, she reported several concerning symptoms: feeling sad most of the time, having difficulty concentrating, lacking energy, wanting to sleep “forever”, and yet not sleeping more than a couple of hours for the last few weeks. Later that day, psychiatry diagnosed the patient with postpartum depression.”

Many factors can contribute to the development of postpartum de pression, including, but not limited to, biology, stressful life events, prematurity of infants, low income, poor marital relationships and ma ternal abuse. The mother I saw was exposed to several of these factors; elements of this mother’s story are not uncommon in those affected by peripartum depression. For example, domestic violence, before, during and after pregnancy, is associated with increased odds of peripartum depression. Additionally, mothers of preterm infants have an increased risk of postpartum depression compared to those of term infants. Women experiencing postpartum depression may normalize their symptoms. Similarly, this mother normalized her sadness. Although the circumstances of her life contributed to her depression, she did not realize she was struggling beyond a normal physiologic response. The social worker’s attunement to the patient’s situation and her symptoms, led to screening and treatment of the depression. Interacting with this mother served as a reminder of the importance of exploring a patient’s concerns beyond their “chief complaint.” I find that I pay closer atten tion when taking the social history to have a well-rounded view of what the patient is experiencing.

Emily:

“While at the prenatal clinic, I met a pregnant woman with gestational diabetes who had been started on insulin and was asked to keep a blood glucose log at her last visit. Her log had many entries missing, but meas urements recorded were in the 200s, well above what would be healthy for her and her growing baby. As the resident explored the lack of consis tency with checking her blood sugars, she described difficulty getting out of bed and making meals, feeling guilty that she wasn’t taking care of her self and difficulty focusing on household chores. We discussed the diagnosis of peripartum depression, how common the diagnosis was, and how ben eficial treatment could be. In response, our patient burst into tears. Once she composed herself she questioned: “How does this medication work? How long would I need to take this for? After my pregnancy, too? How would I know if it worked?” After a lengthy discussion, she verbally agreed to try the medication we recommended, but her body language remained guarded. When I returned to the room, I asked if she wanted to talk more about our recommendations from today’s visit. In the end, discussing her fears about whether psychiatric medication would change her personality was what seemed to put her most at ease. We also explored adjunctive ther apies, such as journaling and mindfulness, while she waited for available psychotherapy services.”

Significant barriers illustrated in this encounter included uncer tainty regarding psychotropic medication safety and efficacy, in addi tion to stigma about psychotropic medications. Counseling this mother taught me to understand medication safety and side effect pro files from the perspective of a patient, especially when working with

pregnant women. With this patient, I was struck by how much resist ance there was to readily available treatments when she was clearly suf fering. There is significant stigma associated with mental illness, and patients may forgo treatment to avoid label attachment. Stigma in peri partum depression patients can be exacerbated by society’s judgment of mothers’ care for their children. Finally, I learned that providing psy choeducation to patients regarding therapy in addition to medication management, can help build patient rapport. With this patient, sug gesting journaling as a way to process her emotions, in addition to tracking her thoughts and moods, provided comfort as she would be able to document the effect of the medications. I hope to improve my ability to assess what stage of change a patient may be at and tailor counseling based on a patient’s concerns. In this encounter, our con versation may not have fully influenced the patient’s preconceived no tions of mental health care, however, her openness to try different forms of therapy was enlightening.

A multitude of factors can contribute to the development of peripar tum depression. During our pre-clerkship years, most of our curriculum focused on pathophysiology and treatments of conditions. However, a couple of interactions with patients affected by peripartum depression have already illustrated that the psychosocial aspects of our patients’ lives significantly impact their medical care. These experiences taught us to consider the biological, psychological, and social components of a pa tient, to screen for peripartum depression, regardless of whether we are in OBGYN, pediatrics, family medicine, psychiatry or other areas of medicine. Undoubtedly, these components will help us identify other ill nesses too. Thus, as we continue to grow our clinical skills, we hope to shape our ability to care for individuals, not just their conditions.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/ appi.books.9780890425596

Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, T. (2005). Perinatal depression: A system atic review of prevalence and incidence. Obstetrics and Gynecology, 106(5 Pt 1), 1071–1083. https://doi.org/10.1097/01.AOG.00001 83597.31630.db

Dinwiddie, K. J., Schillerstrom, T. L., & Schillerstrom, J. E. (2018). Postpartum depression in adolescent mothers. Journal of Psychoso matic Obstetrics and Gynecology, 39(3), 168–175. https://doi.org/10.1080/0167482X.2017.1334051

Moses-Kolko, E. L., & Roth, E. K. (2004). Antepartum and post partum depression: Healthy mom, healthy baby. Journal of the Amer ican Medical Women’s Association (1972), 59(3), 181-191.

Koire, A., Nong, Y. H., Cain, C. M., Greeley, C. S., Puryear, L. J., &

Van Horne, B. S. (2022). Longer wait time after identification of peri partum depression symptoms is associated with increased symptom burden at psychiatric assessment. Journal of Psychiatric Research, 152, 360-365. https://doi.org/10.1016/j.jpsychires.2022.06.046

Murray, L., & Cooper, P. J. (1997). Postpartum depression and child development. Psychological Medicine, 27(2), 253-260. https://doi.org/10.1017/s0033291796004564

Zuckerman, B., Amaro, H., Bauchner, H., & Howard, C. (1989). Depressive symptoms during pregnancy: Relationship to poor health behaviors. American Journal of Obstetrics and Gynecology, 160(5), 1107-1111. https://doi.org/10.1016/0002-9378(89)90170-1

Marcus, S. M., & Heringhausen, J. E. (2009). Depression in child bearing women: when depression complicates pregnancy. Primary Care: Clinics in Office Practice, 36(1), 151–ix. https://doi.org/ 10.1016/j.pop.2008.10.011

Howard, M. M., Mehta, N. D., & Powrie, R. (2017). Peripartum de pression: Early recognition improves outcomes. Cleveland Clinic Jour nal of Medicine, 84(5), 388-396. https://doi.org/10.3949/ ccjm.84a.14060

Marcus, S. M., Flynn, H. A., Blow, F. C., & Barry, K. L. (2003). De pressive symptoms among pregnant women screened in obstetrics set tings. Journal of Women’s Health, 12(4), 373-380. https://doi.org/ 10.1089/154099903765448880

Guintivano, J., Manuck, T., & Meltzer-Brody, S. (2018). Predictors of postpartum depression: A comprehensive review of the last decade of evidence. Clinical Obstetrics and Gynecology, 61(3), 591-603. https://doi.org/10.1097/GRF.0000000000000368

Norhayati, M. N., Nik Hazlina, N. H., Asrenee, A. R., & Wan Emilin, W. M. A. (2015). Magnitude and risk factors for postpartum symptoms: A literature review. Journal of Affective Disorders, 175, 3452. https://doi.org/10.1016/j.jad.2014.12.041

Alvarez-Segura, M., Garcia-Esteve, L., Torres, A., Plaza, A., Imaz, M. L., Hermida-Barros, L., San, L., & Burtchen, N. (2014). Are women with a history of abuse more vulnerable to perinatal depressive symp toms? A systematic review. Archives of Women’s Mental Health, 17, 343-357. https://doi.org/10.1007/s00737-014-0440-9

Howard, L. M., Oram, S., Galley, H., Trevillion, K., & Feder, G. (2013). Domestic violence and perinatal mental disorders: A systematic review and meta-analysis. PLoS Med 10(5), Article e1001452. https://doi.org/10.1371/journal.pmed.1001452

Vigod, S., Villegas, L., Dennis, C-L., Ross, L. (2010). Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: A systematic review. BJOG, 117(5), 540–550. https://doi.org/10.1111/j.1471-0528.2009.02493.x

Sword, W., Busser, D., Ganann, R., McMillan, T., & Swinton, M. (2008). Women’s Care-seeking experiences after referral for postpartum depression. Qualitative Health Research, 18(9), 1161-1173. https://doi.org/10.1177/1049732308321736

Pinto-Foltz, M. D., & Logsdon, M. C. (2008). Stigma Towards Men tal Illness: A concept analysis using postpartum depression as an exem plar. Issues in Mental Health Nursing, 29(1), 21-36. https://doi.org/10.1080/01612840701748698

Emily Liu is a medical student at UT Health San Antonio Long School of Medicine, Class of 2024. She is interested in Family Medicine and Psychiatry.

Kristin Park is a medical student at UT Health San Antonio Long School of Medicine, Class of 2024. She is interested in OBGYN.

Dr. Abby O. Lozano is a psychiatrist practicing at UT Health San Antonio and University Hospital.

Undergraduate Medical Education: Developing Empathy for Patients with Substance Use Disorders by Attending an Alcoholics Anonymous Meeting

By Lori Kels, MD, MPH and Madeline Kundler

The integrated curriculum at University of the Incarnate Word School of Osteopathic Medicine (UIWSOM) introduces learners to the topic of substance use disorders during their first year. The UIWSOM curriculum utilizes a spiral approach to the curriculum to reinforce key concepts. Formal substance use disorder teaching occurs during large group didactics, small group case-based discussions and a recovering physician patient panel during the preclerkship phase.

During the psychiatry clerkship in the third year, learners are re quired to attend an Alcoholics Anonymous meeting. Many medical schools across the country have a similar requirement, in part based on evidence that increased exposure to treatment of patients with sub stance use disorders during medical education is correlated with in

creased empathy towards their patients.1 At UIWSOM, learners write a reflection on their experience after attending the meeting. They often report having a more meaningful and positive experience than ex pected. Excerpts from some reflections are shared below, with permis sion from each learner.

“As most medical students, I learned the basic sciences through reading textbooks. For psychiatry, most of my time was spent trying to differentiate the dozens of antipsychotic medications or wondering why a psychiatrist would prescribe one SSRI over the other.

For Alcohol Use Disorder, I concentrated on the timeline of symp toms and knew there were many nonpharmacologic treatment strate gies. I read about cognitive behavioral therapy, patients can greatly

MEDICAL

improve with the use of support groups or maintaining current rela tionships. I could tell you to include those management options in the plan for my clinical notes, but I never knew how these groups and ther apies truly helped and impacted patients.

During my psychiatry clinical rotation, I observed an Alcoholics Anonymous Meeting, I walked into a small house filled with around 20 people. Each person shared their history of addiction and each story vastly differed.

At the meeting, I introduced myself as a medical student and I came to learn about Alcoholics Anonymous (AA). Each member shared their stories without hesitating. They trusted me with their vulnerability. After the meeting, I was individually greeted by most members that wanted to share more with me and even thanked me for my openness. My overall experience while attend ing these meetings as a medical student changed my view of Alco holics Anonymous. It deepened my understanding of the chronic disease of alcoholism and it encouraged me to continue learning and observing all the possible treatments for addiction, and now that I’ve not only read but seen the benefits of Alcoholics Anony mous, I can confidently recommend it for my future patients.”

“It was nothing like I was expecting… It was empowering for me to see how these people wanted to give back to the community that did so much for them. Overall, I was blown away of the stereotypes that were broken by me going to this AA meeting and how many people need to experience these meetings to understand the hard ships people are going through.”

“I had a lot of respect and developed more empathy for my group… I learned to challenge my bias I had for individuals who are suffer ing from substance abuse, I learned it was not a moral dilemma but one that included environmental trauma and hardships which are not always apparent at first glance. I am more humbled and grateful for all the opportunities I was given and the family support I am given. I become more understanding and I know I will be a more compassionate physician from this experience.”

“Being a family member of someone with alcohol use disorder is exhausting and heartbreaking, but attending this AA meeting re minded me just how heartbreaking and exhausting it is to be a per son with alcohol use disorder.”

“I learned that many of the members had a daily struggle to fight the urge to use, especially when life got tough.”

“I was reminded of the importance of always extending grace to people, because you never know what someone may be going through. The stories that these men and women shared were sober ing and they opened my eyes to not be so quick to judge.”

“The thing I learned that was the most compelling for me was the way each woman described their compulsion to drink. They each took turns explaining their experience, but they all had a sim ilar theme. Even when they knew that their lives were going awry and faced with serious consequences, they could not stop the craving and compulsion to drink. This made me realize how debilitating this disorder is, and how sad it is that there are still people who think it’s simply a will-power issue.”

We thank the learners for their willingness to share their experiences and reflections with San Antonio Medicine Magazine readers.

References

1 Kastenholz, K.J., Agarwal, G. A Qualitative Analysis of Medical Students’ Reflection on Attending an Alcoholics Anonymous Meeting: Insights for Future Addiction Curricula. Acad Psychiatry 40, 468–474 (2016). https://doi.org/10.1007/s40596-015-0380-3

Lori Kels, MD, MPH is a board-certified psychiatrist and an Associate Professor at the University of the Incarnate Word School of Osteopathic Medicine, where she serves as the Psychiatry Clerk ship Director. She is also a member of Bexar County Medical Society (BCMS) and serves as the UIWSOM representative on the BCMS Board of Directors.

Madeline Kundler is a medical student interested in Psychiatry at University of the Incarnate Word School of Osteopathic Medi cine, Class of 2024.

36th Annual BCMS Auto Show

BCMS held our 36th Annual Auto Show on Thursday, October 20th. Over 300 BCMS physicians and family members attended. It was a lovely evening filled with food, drinks and music by "The Elvis Impersonator”, Travis Hudson. Thank you to our Sponsors: Genesis Care, San Antonio MGMA, Nolan, Fogo De Chao, Hard Rock, Enrique Thomas Experience, Sustenio, and Teppan Tx. Big Thanks to the fol lowing Dealerships: GUNN Acura, Audi, Blue Bonnett Dodge, Northside Ford, Northside Honda, North Park Lexus, North Park Lincoln, Northside Mercedes-Benz and North Park Subaru for displaying your alluring vehicles, making the night so spe cial. Save the date for next years’ Annual Auto Show, October 26, 2023.

Tax Strategies For Physicians

By Jeffrey W. Bryson, Attorney

With calendar year 2022 quickly coming to an end, now is the opti mal time to develop a strategy for maximizing permissible year-end de ductions in order to minimize tax exposure and ensure a tax-efficient outcome. Too often physicians either overlook some of their personal and business tax deductions or misunderstand how best to take full ad vantage of the deductions available to them. This article describes some year-end tax planning strategies for 2022 and later years.

Background

The Tax Cuts and Jobs Act of 2017 (TCJA) made several significant changes to the individual income tax, including reforms to itemized deductions, an expanded standard deduction and lower marginal tax rates across brackets.

One significant change made by the TCJA was an increase in the standard deduction to $25,900 for 2022 and $27,700 for 2023 for mar ried taxpayers filing jointly. Itemized deductions can only be claimed

if all itemized deductions add up to more than the standard deduction. The most common expenses that qualify as itemized deductions in clude mortgage interest and charitable giving (discussed below).

Maximizing Charitable Donations

In order to claim a tax deduction for a charitable contribution, gen erally it is necessary to forgo the standard deduction in favor of item ized deductions. Physicians who previously utilized charitable donations as part of their overall itemized deduction planning, may not be able to benefit from making smaller charitable donations in 2022 as a result of changes made by the TCJA.

One possible workaround is to “stack” charitable donations in a sin gle tax year. For example, assuming married physicians wish to donate $15,000 annually to a favorite charity and wish to maximize the benefit of these deductions. Instead of giving $15,000 in 2022, the couple may consider giving $15,000 of the cash bequest on January 1, 2023 and

another $15,000 on December 31, 2023. This stacking strategy will allow the full gift to be claimed as an itemized deduction in 2023 which may reduce their taxable income.

As the 2022 calendar year end approaches, another tax planning strategy for physicians who do not want to donate cash is to consider donating appreciated securities instead. Donating appreciated securities has two major benefits. First, the amount of the charitable donation will be the fair market value (FMV) of the security on the date of con tribution. For example, stock purchased in 2017 for $100 may today be worth $400 which is the FMV of the stock. A donation of the stock to a favorite charity will be eligible for a deduction of $400.

Another benefit to donating appreciated securities is the avoidance of taxable gain on its sale. Normally when a security is held over a year and sold for a gain, capital gains taxes are owed on the gain at a rate as high as 20%. If the charity subsequently sells the security, even for a substantial gain, no capital gains taxes are owed.

Mortgage Interest Deduction

As mentioned above, the home mortgage interest deduction is one of the most common expenses that allows high-income taxpayers to itemize their deductions. Unfortunately, the TCJA decreased the avail able interest deduction to the first $750,000 of mortgage debt for a pri mary home, down from $1,000,000 before the passage of the TCJA. The limitation on home mortgage interest applies to loans taken out or refinanced after December 15, 2017.

For example, a physician who takes out a mortgage loan for $900,000 in 2017 can probably deduct all of the interest on the loan on his tax return. On the other hand, interest on the same mortgage taken out in 2022 may be restricted by the TCJA and limited to interest on the first $750,000 of principal value.

Refinanced mortgage loans are also subject to the limited interest deduction. With mortgage interest rates rising, the demand for refi nancing loans may be less common but it is still a good strategy to check with a CPA prior to refinancing a home loan to avoid inadvertently los ing a portion of the interest deduction.

In addition to the itemized deductions for charitable contributions and mortgage interest, physicians may further reduce their taxable in come by claiming the following personal deductions which are often overlooked or underutilized:

Retirement Plan Contributions

Pre-tax salary deferral contributions are a deduction that can often be overlooked by physicians. Retirement plans for physicians em ployed by a hospital or medical group can include a 401(k), 403(b) or 457 plan and allow a physician avoid taxes on the compensation de ferred under the plan. For example, if a physician who earns $300,000 per year defers the maximum amount to an employer sponsored

403(b) Plan ($20,500 for 2022 and $22,500 for 2023) for the 2022 calendar year, the physician will only be taxed on $279,500 for 2022. Deferrals and earnings on the deferrals are generally not taxable until withdrawn from the plan.

Small physician groups can benefit by implementing a 401(k) plan. A 401(k) plan works much like a 403(b) plan and permits pre-tax salary deferral contributions to the plan, subject to certain annual limitations.

For self-employed physicians, a SEP-IRA allows for a pre-tax deferral of up to 25% of earnings not in excess of $61,000 for 2022. The catch with a SEP-IRA is contributions must be made to the plan at the same rate for all eligible employees.

The benefit of implementing these types of retirement plans is a cur rent deduction for plan contributions and tax-deferred growth on plan investments.

Tax Loss Harvesting

Tax loss harvesting is the practice of selling some underperforming investments at a loss in order to offset gains realized on the sale of other investments. Under IRS rules, taxes are only owed on the net gain re alized, so offsetting investment gains with investment losses can reduce taxable income and create a tax savings for the physician.

Tax loss harvesting must be completed by the end of the calendar year. Accordingly, in order to utilize this tax planning strategy for 2022, the transactions must be completed by December 31, 2022.

Something to keep in mind when utilizing this strategy is the rules for tax loss harvesting preclude recognizing a loss on the disposition of stock or securities when a substantially similar stock is purchased within the 61-day period commencing 30 days before and ending 30 days after the date of sale. In other words, a taxpayer cannot sell a stock at a loss to claim the tax benefit and repurchase the stock the next day at the lower price. Known as a “wash sale,” the IRS may disallow realization of the artificial tax loss and the taxpayer will be unable to utilize the re sulting tax break.

These are just a few year-end tax planning steps that can be taken to save on taxes. We encourage physicians and other high-income taxpay ers to discuss these year-end tax planning strategies with their personal tax advisors to determine what works best for them.

Jeffrey W. Bryson is an Attorney at Kreager Mitchell, PLLC a BCMS Circle of Friends sponsor.

Many Hands, Many Masks, One Mission

By Christopher Ruano

It was January 21, 2020, and I vividly recall reading an online article about our Nation’s first case of SARS-CoV-2 (COVID-19). It was a day unlike any other – this one felt strangely ominous, somewhat distant, but quite real. I began to think about how we as a people would respond to this invisible, rapidly spreading pathogen that was spiraling into what would soon become a global pandemic. I began to rationalize these rapidly unfolding events through the lens of our shared American experience: I knew that we would rise to this occasion and help one another, because we have done it so many times before throughout his tory. After all, we are the people who reached the Moon, who liberated the oppressed in World War II, and who, despite our many growing pains and stumbles along the way, are at our core, decent and honorable people. Once again, Americans from all walks of life stood up and an swered the call, but this time it would be different. Much different. This time we would face down an invisible enemy that knew neither bound aries nor limitations. To borrow the famous words of Apollo 13 Com mander, James "Jim" Lovell, “Houston, we’ve had a problem”.

My name is Christopher Ruano – I am a US Army veteran and pres ent-day Threat Intelligence Advisor with over 20 years of global opera tional experience. Although, I have been with the BCMS PPE Donation Program since its inception in early April 2020 and have since directed and worked in every facet of the program as a contractor, this short story is not about me. Rather, it is about how public and private community stakeholders banded together to respond to what would soon become a national emergency and felt more locally as a critical shortage of PPE supplies for underserved medical clinics, and the public at large. Further, it is a first-hand account that seeks to properly recognize the countless people who have helped to make this program a model in public-private emergency response cooperation in a time of great need.

The BCMS PPE Program was started in April 2020 by a small group of bright, ambitious and publicly focused medical students, who saw the immediate need to get involved in the COVID-19 response. Of noteworthy mention: Gwendolyn Quintana (now MD), Yvette Lopez and Kayla Pineda, who went on to form the Student Alliance

for Emergency Response (SAFER Texas). Working directly with pri vate sector donors, the team quickly gathered significant personal pro tective equipment (PPE) contributions from the home improvement and construction industries, thus setting the stage for what was to be come a large donation influx from various private sources in the coming weeks and months ahead.

The SAFER team also spent a great deal of time coordinating large pallets of PPE from the Texas Division of Emergency Management (TDEM), by way of the Southwest Texas Regional Advisory Council (STRAC). The first few weeks of the program also saw a steady stream of medical student volunteers, who donated their free time away from classes and exams, to deliver hundreds of boxes of PPE to medical clin ics across the greater San Antonio area. It is fair to say that this critically timed coordination saved countless lives and protected hundreds of frontline medical personnel, who individually on many occasions, warmly thanked the students in person, by phone and by email for their strenuous efforts.

The first several months of the program were incredibly busy, and this meant that the BCMS conference room would soon be repurposed as a storage facility for N-95 masks, surgical masks, Level IV gowns, coveralls, eye protection and other protective equipment. Thanks to Melody Newsom, present-day CEO (then Chief Operating Officer) of BCMS, the timely decision to take in one million PPE articles into storage was made, and as a result, the program’s sustainability was etched into stone – this time at scale. We were now truly ready, willing,

and able to meet the many challenges that lay ahead, but how would we manage it all? What systems would we use? How would we account for the donations and accurately report them to state and local agen cies? How would we stay in constant contact with stakeholders, dona tion sources and clinics? These important questions led us to the creation, design and implementation of a proprietary emergency man agement PPE database that would serve as the center point for the pro gram’s entire operations from end to end.

The PPE database took two weeks of around-the-clock efforts to first conceptualize, correctly build and then test under pressure (and did I mention test it some more?) Like any database technology project, there was a continuous need for the refinement and optimization of the records, the formatting and the reporting processes. Ours was no excep tion to this rule. After one month of real-world application (also known as bumps in the road), the system kinks were finally ironed out, the crit ical processes were clearly identified, and what emerged soon after grew to become a repeatable, scalable, and ultra-effective emergency manage ment database that has successfully accounted for 100% of all PPE ar ticles and their destinations across South Texas and beyond.

Fast forward to today, the program has successfully donated and de livered over 650,000 items of PPE, effectively meeting the PPE needs of BCMS members and thousands of medical practitioners alike. Ad ditionally, BCMS donated almost 6 million PPE articles to the San Antonio Food Bank, over 300,000 to the Texas Med Clinic, Haven for Hope, Catholic Charities and dozens of community sources such as

Sunshine Cottage School for the Deaf, San Antonio

School District, UTHSCSA Nixon Library, IDEA

Corazon de San Antonio and the BCMS Alliance. BCMS’s final donation of PPE went to the government of Namibia, Africa. The PPE donation consisted of 5 pallets of KN95s, cloth masks, disposable surgical masks and liquid hand sanitizer. It was an honor to help the citizens of Namibia with our donation of PPE to help fight the COVID-19 pan demic which is still going on.

In closing, I would like to recognize the staff of BCMS and medical students who helped with the difficult work of delivery, pick-up, sorting and shipping out PPE. No easy feat by any measure, so my thanks go out to this dedicated group of people. A special acknowledgment for the heroism of our frontline medical personnel, who truly deserve our deepest gratitude and appreciation for their continued contributions to the health and well-being of our communities. As for me, I will be with the program until the last request for PPE is received and its last mask is dispatched. And so, the work continues . . .

Christopher Ruano is a U.S. Army veteran, and a 20+ year intelligence practitioner who specializes in Continuity of Oper ations (COOP), Critical Infrastructure Protection (CIP), Joint Targeting, C4ISR, Human Terrain System (HTS), Foreign Internal De fense (FID) and Security Force Assistance (SFA).

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Oakwell Private Wealth Management (HHHH 10K Platinum Sponsor) Oakwell Private Wealth Manage ment is an independent financial advisory firm with a proven track record of providing tailored finan cial planning and wealth manage ment services to those within the medical community.

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Managing Partner, Physician Liai son

(210) 503-0003 (Phone) yulia@genicslabs.com (Email) Kevin Setanyan Managing Partner (210) 503-0003 kevin@genicslabs.com Artyom Vardapetyan

SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

Elizabeth Olney with Edward Jones (HH Silver Sponsor)

We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney, Financial Advisor 210-858-5880

Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

Denise C. Smith

Vice President | Private Banking 210-343-4502

GERIATRICS / PRIMARY CARE

Bertuzzi-Torres-Fernandez

Wealth Management Group ( Gold Sponsor)

We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solu tions for discerning healthcare professionals, including asset pro tection, 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

Will C. Fernandez, CEPA Senior Portfolio Advisor Financial Advisor 210-278-3812 wfernandez@ml.com https://fa.ml.com/texas/san-an tonio/bertuzzi-torres-fernandez

Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HOSPITALS/ HEALTHCARE FACILITIES

Nexus Neurorecovery Center (HHH Gold Sponsor)

A post-acute rehabilitation facility focusing on brain injuries. Pro gramming provides individual and group physical, occupational, cog nitive, and speech therapy. We help residents return to lives of productivity and meaning.

Sydney Kerr Liaison 346-339-2654 skerr@nhsltd.com Caitlyn Tewksbury ctewksbury@nhsltd.com

Justin Sanderson CEO 210-854-4732 jsanderson@nhsltd.com

Nexus Neurorecovery Center 227 Lewis St, San Antonio, TX 78212

Conviva Care Center (HHH Gold Sponsor)

Conviva’s value-based care model allows physicians to deliver high quality, personalized care and achieve better outcomes, while feeling free to focus on health equity and patient outcomes.

Kim Gary

Senior Physician Recruiter (812) 272-9838 KGary4@humana.com www.ConvivaCareers.com “Fuel Your Passion & Find Your Purpose”

INFORMATION AND TECHNOLOGIES

dream deserves a well-crafted plan.

Ned Hodge 210-332-3757 ned@nedhodge.com www.nedhodge.com | www.Opesone.com

“Take care of today then plan for tomorrow” Humana (HHH Gold Sponsor)

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

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

Express Information Systems (HHH Gold Sponsor)

INSURANCE/MEDICAL MALPRACTICE

Aspect Wealth Management (HHH Gold Sponsor)

We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Michael Clark, President 210-268-1520 mclark@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

HEALTHCARE BANKING

Amegy Bank of Texas (HH Silver Sponsor)

We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett

EVP | Private Banking Manager 210-343-4556

Jeanne.bennett@amegybank.com

Karen Leckie

Senior Vice President | Private Banking 210-343-4558 karen.leckie@amegybank.com

Robert Lindley

Senior Vice President | Private Banking 210-343-4526 robert.lindley@amegybank.com

https://nexushealthsystems.com

“To return patients to lives of pro ductivity and meaning”

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor)

UT Health Physicians, the faculty practice of UT Health San Anto nio, provides our region with the most comprehensive care through expert, compassionate providers treating patients in more than 140 medical specialties at locations throughout San Anto nio and the Hill Country.

UT Health San Antonio Physicians

Regina Delgado

Business Development Manager (210) 450-3713 delgador4@uthscsa.edu

UT Health San Antonio MD Anderson Mays Cancer Center

Laura Kouba Business Development Manager (210) 265-7662 norriskouba@uthscsa.edu Cancer.uthscsa.edu

Appointments: 210-450-1000

UT Health San Antonio MD Ander son Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

With over 29 years’ experience, we understand that real-time visi bility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimen sional reporting that helps you accommodate further growth and drive your practice forward.

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

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor)

TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a compli mentary insurance review. It will be our privilege to serve you.

Wendell England

Director of Member Benefits 512-370-1776 wendell.england@tmait.org 800-880-8181 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor)

With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) pro vides malpractice insurance and related products to physicians. Our purpose is to make a positive im pact on the quality of health care for patients by educating, protect ing, and defending physicians.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org

Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor)

We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insur ance for the medical community.

Katy Brooks, CIC 210-807-5593

katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

Guardian (★★★ Gold Sponsor)

Live Confidently. Every financial

MedPro Group (HH Silver Sponsor)

Rated A++ by A.M. Best, MedPro Group has been offering customized

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insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze 512-658-0262

Kirsten.Baze@medpro.com www.medpro.com

ProAssurance

(HH Silver Sponsor)

ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group’s rating is AM Best A (Excellent).

Mike Rosenthal Senior Vice President, Business Development 800-282-6242

MikeRosenthal@ProAssurance.com www.ProAssurance.com

INVESTMENT ADVISORY REAL ESTATE

Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com

“Make us the solution for your account receivables.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (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.”

PRACTICE MANAGEMENT

Wave Online

(★★★ Gold Sponsor)

Our team of professionals will act as your extended AR office en hancing your revenue through our proprietary metrics and claim management systems. In addition, you keep 100% control of your RCM. Contact us today for a no cost evaluation.

Saranraj (Raj) Venkatesh Vice President – RCM | Sales and Client Relations 726-228-1097 saranraj@wavemt.com https://rcmwave.com/ “Innovation towards Solutions”

PROFESSIONAL ORGANIZATIONS

The Health Cell (HH Silver Sponsor)

Alamo Capital Advisors LLC

(★★★★ 10K Platinum Sponsor)

Focused on sourcing, capitalizing, and executing investment and de velopment opportunities for our in vestment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and fi nancial restructuring (equity, debt, and partnership updates).

Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Wave Online

★★★ Gold Sponsor)

Our team of professionals will act as your extended AR office en hancing your revenue through our proprietary metrics and claim management systems. In addition, you keep 100% control of your RCM. Contact us today for a no cost evaluation.

Saranraj (Raj) Venkatesh

Vice President – RCM | Sales and Client Relations 726-228-1097

saranraj@wavemt.com https://rcmwave.com/ “Innovation towards Solutions”

Commercial & Medical Credit Services

(HH Silver Sponsor)

A bonded and fully insured San

MILITARY

San Antonio Army Medical Recruiting office (★★Silver Sponsor)

Mission: Recruit highly qualified and motivated healthcare profes sionals for service in the Army Reserves or Active Duty Army, in support of Soldiers and their families.

1LT Thomas Alexandria 210-328-9022 Alexandria.n.thomas12.mil@army. mil

https://recruiting.army.mil/mrb/ “Service to Country, Army Medi cine, Experientia et Progressus”

MOLECULAR DIAGNOSTICS LABORATORY

“Our Focus is People” Our mis sion is to support the people who propel the healthcare and bio science industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! Kevin Barber, President 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 Medical Group Man agement Association (SAMGMA) (HH Silver Sponsor)

nancial restructuring (equity, debt, and partnership updates).

Jon Wiegand, Principal 210-241-2036

jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

CARR Realty

(HH Silver Sponsor)

CARR is a leading provider of commercial real estate for tenants and buyers. Our team of health care real estate experts assist with start-ups, renewals, reloca tions, additional offices, pur chases and practice transitions.

Brad Wilson Agent 210-573-6146

Brad.Wilson@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

RETIREMENT PLANNING

Oakwell Private Wealth Management (HHHH 10K Platinum Sponsor) Oakwell Private Wealth Manage ment is an independent financial advisory firm with a proven track record of providing tailored finan cial planning and wealth manage ment services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113

SERVICE@OAKWELLPWM.COM www.oakwellpwm.com

“More Than Just Your Advisor, We're Your Wealth Management Partner”

iGenomeDx

( Gold Sponsor)

Most trusted molecular testing laboratory in San Antonio provid ing FAST, ACCURATE and COM PREHENSIVE 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, Pharma cogenomics”

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SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Lindsey Herman Nolan, MHR, CMPE, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor)

Serving the Texas healthcare commu nity 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.

Alamo Capital Advisors LLC

★★★★ 10K Platinum Sponsor)

Focused on sourcing, capitalizing, and executing investment and de velopment opportunities for our in vestment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and fi

Cindy M. Vidrine

Director of Operations- Texas 210-918-8737

cvidrine@favoritestaffing.com

“Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

2023 New Cars

By Stephen Schutz, MD

Autumn is traditionally the time when automotive manufacturers introduce new cars, trucks, and crossovers so I’m going to use this space to discuss some new 2023 vehicles that I think may be of interest to BCMS members. In no particular order, here they are.

Cadillac Escalade V - Escalades are popular with Texans in general and BCMS members in particular, and that’s certainly true for the lat est generation, which launched two years ago with more interior space and a game changing independent rear suspension. The 2023 V ver sion provides suspension upgrades and a supercharged V8 good for 682HP in an effort to “make an elephant dance”, as they say. Given its $155,000 starting price, I’d say, “pass”.

Alfa Romeo Tonale - Joining the Guilia sedan and Stelvio SUV, the Tonale aims to democratize Alfa with a smaller and cheaper crossover (think BMW X1 and Lexus UX competitor). Alfa sells around as many vehicles in a year as Ford sells F150s in a week, so I hope the Tonale succeeds (in case you’re wondering, it’s pronounced “toe-nah-lay” not “toe nail”).

Audi RS3 - The late-great Ferdinand Piech’s beloved 5-cylinder en gine soldiers on in its 5th decade to power this joyously raucous sports sedan, which is surely on its last legs as Audi moves resolutely into the BEV (Battery Electric Vehicle) future. Get ‘em while you can.

Audi e-tron GT RS - Audi’s version of the BEV Porsche Taycan manages to both look better and have a nicer interior than its Porsche cousin. I’m not ready to trade my 911 for an electric car yet, but if I were, this is the one I’d buy.

BMW XM - Like the Escalade V, the XM is BMW’s attempt to sell a big and heavy SUV that’s also “athletic”. And like the 50-year-old obese man who shows up at your gym in early January, the XM seems likely to fail. It features a brawny twin-turbo V8 augmented by plugin hybrid technology. Its 0 - 60MPH time is around 3.5 seconds, so it has some undeniable pluses. But many will find its styling and $160,000 price tag to be challenging.

BMW M2 - while the new M2’s styling has also been described as challenging, I’m going to embrace this four-seat sports car because of its wonderful 453HP turbocharged in-line six-cylinder engine and standard six-speed manual transmission. As with the aforementioned RS3, get ‘em while you can.

Ford F150 Raptor R - Tired of getting sand kicked in its face by the completely OTT 700HP Ram TRX pickup, the badass Raptor R now offers a competitive V8 engine (borrowed from the Shelby GT500). I think the standard Raptor has plenty of power, but if you don’t, Ford now has you covered.

Jeep Wagoneer/Grand Wagoneer - longer wheelbase L versions of these popular Suburban/Escalade competitors are now offered. These full-size family haulers are proving to be popular in part, because they have best-in-class interiors.

Lexus RZ - A BEV counterpart to the perennially best-selling RX attempts to do for electric luxury crossovers what the original RX did for internal combustion engine (ICE) luxury crossovers—make Lexus the default choice. BEVs are so different from ICE vehicles that I have doubts this approach is best, but with Lexus’ impressive track record they very well may be right.

Mercedes EQS/EQE - BEV equivalents of the standard Mercedes models we know and (mostly) love, the EQ line looks quite different visually, with exterior designs that are all teardrops and jelly beans. This is BEV.1 time, so expect rapid evolution as engineers learn and innovate. To avoid getting stuck with obsolete technology (or styling) when it’s time to trade in your BEV, I’d recommend leasing over buying for now.

Nissan Ariya - The successor to the affordable Leaf BEV looks a lot like its predecessor, but delivers much more range (250mi vs around 100). If you want a BEV and are on a budget, this and the Chevy Bolt are pretty much your only choices.

Nissan Z - The legendary Nissan sports car lives! Essentially a re bodied 370Z, the 2023 model is full of retro styling elements that re mind you of the original 240Z from the early 1970s. It’s an excellent choice for enthusiasts, but expect to wait a bit if you want one—it’s sold out for now.

Range Rover Sport - The go-to vehicle for 40-ish moms in upscale zip codes gets many enhancements for its third generation. It’s hard to tell it apart from the last one just by looking, but it’s all new, and, like the “big” Range Rover, the Sport has a nicer interior. In case you’re wondering. . . yes, the new one’s significantly more expensive.

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 magazine since 1995.

11911 IH 10 West San Antonio, TX 78230

Coby Allen 210-696-2232

Kahlig Auto Group

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave. New Braunfels, TX 78130

Matthew C. Fraser 830-606-3463

Audi Dominion

21105 West IH 10 San Antonio, TX 78257

Rick Cavender 210-681-3399

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

Charles Williams 210-912-5087

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX William Boyd 210-859-2719

Northside Ford 12300 San Pedro San Antonio, TX

Marty Martinez 210-477-3472

Kahlig Auto Group

Land Rover San Antonio 13660 IH 10 West San Antonio, TX

Cameron Tang 210-561-4900

North Park Lexus 611 Lockhill Selma San Antonio, TX

Tripp Bridges 210-308-8900

Northside Honda 9100 San Pedro Ave. San Antonio, TX 78216

Paul Hopkins 210-988-9644

Kahlig Auto Group

14610 IH 10 West San Marcos, TX 78249

Mark Hennigan 832-428-9507

Kahlig Auto Group

North Park Lexus at Dominion 25131 IH 10 W Dominion San Antonio, TX

James Cole 210-816-6000

North Park Lincoln 9207 San Pedro San Antonio, TX

Sandy Small 210-341-8841

North Park Mazda 9333 San Pedro San Antonio, TX 78216

John Kahlig 210-253-3300

Mercedes Benz of Boerne 31445 IH 10 West Boerne, TX

James Godkin 830-981-6000

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

Al Cavazos Jr. 210-366-9600

9455 IH 10 West San Antonio, TX 78230

Douglas Cox 210-764-6945

Kahlig Auto Group

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Raymond Rangel 210-308-0200

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

Phil Larson 877-356-0476

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Gary Holdgraf 210-862-9769

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

Justin Boone 210-635-5000