SAN ANTONIO
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VOLUME 70 NO. 3
MEDICINE SAN ANTONIO
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ALLERGIES
Treat allergic rhinitis before it makes you feel miserable By Patricia Gomez Dinger, DO ..16 Asthma management in 2017 is highly effective when patients are compliant with prescribed treatment By Jeffrey S. Hallett, MD ....................20
Urticaria and Angioedema – Diagnostic and Therapeutic Options By Chris Christodoulou, MD.........................................................................................24 BCMS President’s Message ..........................................................................................................8 Executive Director’s Message .......................................................................................................10 BCMS Legislative News ..........................................................................................................................12 BCMS News.............................................................................................................................................26 Feature: 55 Words ...................................................................................................................................28 UT Health San Antonio By William L. Henrich, MD..................................................................................30 Financial: Plan for your future: Retirement savings for medical practices By Gil Castillo, CPRC ...........32 BCMS Officer Installation.........................................................................................................................34 BCMS Circle of Friends Services Directory .............................................................................................36 In the Driver’s Seat...................................................................................................................................43 Auto Review: 2017 Volvo XC 90 By Steve Schutz, MD ...........................................................................44
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Vital Stats: Allergies, Mountain Cedar and the perfect petri dish By David Schulz, CHP ..........22
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Food Allergy & Intolerance remains a gray area of medicine By Victor Estrada, MD .....................18
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Wheat Allergy: Diagnostic Confusion and Challenges By Michael P. Vaughn, MD, PhD ....14
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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.
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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Leah Jacobson, MD, President Adam V. Ratner, MD, Vice President Sheldon Gross, MD, President-elect Jayesh B. Shah, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary John Robert Holcomb, MD, Treasurer
DIRECTORS Rajaram Bala, MD, Member Lori Boies, PhD, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member Arthur D. Cortez, MD, Board of Censors Chair George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Bradley A. Lloyd, MD, Military Rep. Rodolfo Molina, MD, Board of Mediations Chair John Joseph Nava, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Carmen Garza, MD, Community Member Kristi Kosub, MD, Member Lauren Michael, Medical Student Sara Noble, Medical Student Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Adam Ratner, MD, Member David Schultz, Community Member J.J. Waller Jr., MD, Member Jane Yoon, Medical Student
6 San Antonio Medicine • March 2017
PRESIDENT’S MESSAGE
Our Local Government and the Medical Society How do we work together for the betterment of the citizens of San Antonio and Bexar County? By Leah Jacobson, MD, 2017 BCMS President
This May, the citizens of San Antonio and surrounding areas
elimination of health and health care disparities.”1 We must
will elect mayors and city council members. As physicians, it is
keep these ideals in mind when we and our local leaders make
important that we have a good knowledge of where they stand,
important decisions for our community.
especially on community health care issues. We hold them ac-
As one of the largest cities in the United States, San Antonio
countable for other issues, such as education/libraries, taxes and
does not have a health and human services advisory committee
public works improvements. Those are definitely important is-
to help educate and guide our local city leaders on these matters.
sues. These priorities are on the ballot this May with the pro-
We do have a great group of health visionaries through the
posed $850 million 2017-2022 Bond Project for the city of San
Health Collaborative of Bexar County, but I believe that local
Antonio (http://www.sanantonio.gov/2017Bond).
leaders would benefit from a group of advisors as these leaders
Local leaders impact health care both directly and indirectly.
deal with health-related issues. We, at the Medical Society, feel
It is imperative that we also hold them accountable for health is-
privileged to have been invited to participate in the selection of
sues that affect our patients and the community. In order to help
the next Metropolitan Health Director. It is collaborative efforts
facilitate this, the Medical Society has issued a challenge to the
such as this that will allow our members to have a bigger voice
candidates running for positions in San Antonio. We have sub-
in this community. The Medical Society will continue to work
mitted a series of questions to the candidates asking about topics
on various efforts to increase our presence and involvement in
including healthy eating, transportation, violence, mental health,
our community — be it with the city of San Antonio, Bexar
access to health care, and others. We will be posting their replies
County, or surrounding cities/municipalities.
on our social media sites for all our members to read. We hope
I look forward to meeting and working with county and city
that this will allow you to make a more informed decision when
leaders on health care issues that affect us and our patients. If
it comes to casting your vote.
there are particular topics that you feel are important for the
An informative report with regards to these issues is the 2016 Bexar County Community Health Needs Assessment (2016 Bexar County Community Health Needs Assessment: Full Report (PDF, 160 pp) ). The 2016 Assessment sought to
Medical Society to know about, please contact us leahjacobson.bcms2017@gmail.com. We are a GREAT city, but we have room for improvement. Remember — every vote counts. Let's help make a difference!
"support Bexar County partners in moving from knowing about local health needs and outcomes to changing those out-
Sincerely yours,
comes. " Healthy People 2020 defines "health equity" as the
Leah Jacobson, MD
“attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the
8 San Antonio Medicine • March 2017
1. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2010). Healthy People 2020. Washington, D.C. https://www.healthypeople.gov/2020/about/ foundation-health-measures/Disparities
FROM THE EXECTIVE DIRECTOR
The New BCMS Membership Phone App is Here! By Stephen C. Fitzer, BCMS CEO/Executive Director
As a BCMS member, have you ever found yourself looking for information about the medical society and had no idea how to go about getting that information? Maybe you are trying to find out who the president is and how to contact him/her, or you need to know who heads a committee, or who the staff person is that handles something, or where an event is being held and when and how to get there? Your eyes roll back in your head and you start thinking you will either have to try and navigate the website or call someone at the society for help. Those needs are what inspired the new BCMS phone app. Most of us have our smart phone with us at all times. It is our lifeline to everything we do these days. The invention of apps for smartphones initially had you downloading every app you could find that had any applicability to your life. But as time went on, you found yourself deleting apps you never used and you settled down to a page or two of apps that you use almost everyday, or at least very regularly. That is another thought behind the introduction of the new BCMS app. One app concentrates all the information about BCMS including leadership, calendar, staff, maps, and how to contact other docs. The first version of the app displays the tabs shown in the picture above, which provide you with the following information: Calendar/Events — Events included on the calendar include com10 San Antonio Medicine • March 2017
mittee meetings, board meetings, BCMS special events, medical community special events, deadlines, Spring Break dates, special seminars, etc. Besides listing the day and time of the events, it allows you to download the event and its details directly to your phone calendar and, in most cases, includes a map of the location of the event. Physician Leadership — Photos of BCMS elected leaders and committee chairs along with their contact information is displayed. You can even send emails, texts or make calls from the app. BCMS Staff — Photos of BCMS managers along with their contact information is displayed, and you can contact them directly from the app. BCMS Committees — BCMS has a large number of boards and committees. You can read about the functions of each committee as well as see the names and functional contact information of both the committee chair and the staff liaison for each committee. Auto Program — BCMS has a oneof-a-kind concierge automobile program to help physicians, their staffs and families find, buy, lease and finance (or refinance) cars and trucks. With the app, you can fill out a form to specify what kind of vehicle you want and let Phil Hornbeak know so he can already have the information together when he contacts you, or you can just call Phil and he will populate the form for you and ask you the questions necessary. You can also send Phil an email from the app. It is by far the easiest car-buying app there is and you have the option of having Phil hold your hand throughout the entire process. BCMS Publications — BCMS publishes the monthly San Anto-
FROM THE EXECTIVE DIRECTOR
nio Medicine magazine and the Weekly Dose electronic newsletter. Many current and past issues of both publications are available for review via this app. You also have the option of contacting the magazine editor, Mike Thomas, via email or phone call. It even has the cool feature of being able to flip the pages of the magazine just like you would if you held it in your hands. Circle of Friends — BCMS is fortunate to have many corporate supporters who donate to our Circle of Friends program. On this app you can access a directory of donors that we recommend our members consult when considering the purchase of such products or services. For potential donors, we outline a list of levels and benefits of our Circle of Friends program. If you need to contact the manager of the program, August Trevino, his phone and email are also functional from this tab. DocBookMD — If you are a member physician, this can be an encrypted way to communicate with other members of the Bexar County Medical Society. Once members have enrolled in this service (free of charge), they can see information about other members including where and when they graduated from medical school, their address and contact information, their specialty, practice name, etc.
In addition, members can send encrypted information (including test results and x-rays) to each other. Contact Us — This tab gives you the general phone number and email address for the medical society, the physical location of the society building, mapping capabilities to show the building’s location and how to get there from where you are, and the BCMS website address. You can download the app from the app store onto your smart phone. The app is there now and it’s free. Just type in Bexar County Medical Society. You will recognize the logo when you see it. As time goes on, we will be adding features to the app and we are open to any suggestions you might have. Please download the app and check your contact information on DocBookMD to make sure it’s correct. If it’s not, send an email to the Membership Director, Brissa Vela, and she will make sure it is updated. We hope you enjoy this new app. It is a lot easier than navigating a website or looking something up in a book. To our physicians, we thank you for being members of the Bexar County Medical Society, and to our supporters we extend a special thanks for your contributions to the field of medicine.
visit us at www.bcms.org
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BCMS LEGISLATIVE NEWS
FIRST TUESDAYS VISITS TO THE CAPITOL
OFF TO A GREAT START By Mary E. Nava, MBA, Chief Government Affairs Officer and lobbyist Many thanks to the following physician and Alliance members who participated in the Feb. 7 First Tuesdays visits: Physicians – Leah Jacobson, MD, BCMS President; Daniel Deane, MD; David Holck, MD; James Humphreys, MD; Thomas Kaspar, MD; Alex Kenton, MD; Robert Kruger, MD; John Nava, MD; Raymond Osbourn, MD; Ryan Van Ramshorst, MD and David Shulman, MD; Alliance members – Lisa DeArmand; Danielle Henkes; Jennifer Lewis and Jennifer Shepherd. The group visited with 13 offices of state representatives and senators from Bexar County. Among the topics discussed were: surprise billing; Medicaid reimbursement; vaccinations; GME and the prescription drug monitoring program. For more information on the 2017 TMA Legislative Priorities, visit www.texmed.org. To register for First Tuesdays, go to www.texmed.org/firsttuesdays.
PHOTO CAPTIONS: TOP: (l-r) Jennifer Lewis; Ryan Van Ramshorst, MD; Jenny Shepherd; Jim Humphreys, MD and Daniel Deane, MD, gather to discuss agenda items prior to visits with legislators during the Feb. 7 First Tuesdays. CENTER: During the Feb. 7 First Tuesdays, BCMS physicians and Alliance members discussed a number of medicine’s issues with Carmen Tilton, Health and Human Services Policy Analyst (holding folder) for Sen. Carlos Uresti (Senate District 19). BOTTOM: (l-r) Daniel Dean, MD; Jim Humphreys, MD and Ryan Van Ramshorst, MD discuss medicine’s issues with Rep. Tomas Uresti (House District 118) during the Feb. 7 First Tuesdays.
12 San Antonio Medicine • March 2017
ALLERGIES
Wheat Allergy: Diagnostic Confusion and Challenges By Michael P Vaughn, MD, PhD
Allergy to wheat caused by antigen specific allergic antibodies (IgE) is a relatively straight forward diagnosis with a preponderance of scientifically validated studies to support a cause and effect hypothesis. A reliable diagnosis is made by the correlation of a clinical history suggestive of wheat allergy with the positive results of either blood testing (RAST) or skin prick testing. Non-IgE mediated allergy to the wheat protein gliadin (gluten), commonly referred to as Celiac disease (CD), has also been scientifically validated as being caused by gluten contained in several cereal grains (wheat, barley, rye and spelt). However, because up to 50 percent of those with CD have few or no symptoms, it has been estimated that up to 80 percent of persons with this disease remain undiagnosed. Estimates of the prevalence of CD have been as high as 1 in 100 people. Celiac disease (CD) is a serious autoimmune disorder with an
14 San Antonio Medicine • March 2017
identifiable underlying genetic predisposition (HLA-DQ2 and DQ8 alleles). More than 200 different symptoms have been reportedly attributed to this disease and per the World Gastroenterology Organization, CD can be divided into two basic types: classical and non-classical. The classical form of CD has features that are predominantly suggestive of malabsorption such as diarrhea, bloating, weight loss and failure to thrive (in children). In the non-classical form, gastrointestinal symptoms are often milder or absent and other symptoms may be of greater concern to the patient such as: chronic fatigue, migraine headaches, peripheral neuropathy, pruritic skin lesions (Dermatitis herpetiformis), unexplained infertility, or depression. A third type of CD has also been described in which the biopsy of the small intestine demonstrates the “diagnostic� histologic asso-
ALLERGIES
ciated findings of atrophic villous damage and lymphocytic infiltration, however, the patient is clinically asymptomatic. In all forms of CD, adverse outcomes from continued gluten consumption can result in unexplained iron-deficiency anemia, osteopenia, transaminitis, B12 and folate deficiency, and dental enamel defects. Most of the physicians who first encounter patients with CD lack the training and expertise to perform intestinal biopsies (the “gold standard” for CD diagnosis) however, in persons who are not IgA deficient and who are on gluten-containing diets, the diagnosis of this disease can also be made by serologic screening for IgA reactive to tissue transglutaminase (tTG-IgA). This test has been reported to have a sensitivity of 95-98 percent and specificity of 95 percent. Although less reliable, in persons with IgA deficiency, testing to detect IgG reactive to deaminated-gliadin peptide and tTG can be performed. Besides IgE-mediated wheat allergy and CD, the differential diagnosis for wheat-exacerbated gastrointestinal symptoms includes: immune activation from non-gluten wheat proteins and the nonimmune mechanism of bowel distention caused by gas producing bacteria that feed on the fermentable “oligo-di-mono-saccharides
and polyols (FODMAPs), present in wheat. The relatively newly described disease entity, commonly referred to as “non-coeliac wheat sensitivity” (NCWS), can present with a spectrum of signs and symptoms that mimics celiac disease including IBS problems as well as many other extra-intestinal manifestations (malaise, fatigue, skin rash, headache, paresthesias, fibromyalgia, depression, asthma, rhinitis and confusion/concentration problems “brain-fog”). In a recent report, it was found that NCWS causes quantifiable evidence of “systemic immune activation” and can result in “compromised intestinal epithelium” (Gut 2016; 65(12); 1930-37). The diagnosis of NCWS can be made in patients who are unresponsive to FODMAP-restricted diets, are negative for celiac associated antibodies and anti-wheat IgE, and yet continue to report symptoms that occur shortly after wheat ingestion and resolve within a few hours (or days) after withdrawal. *For more details see: De Giorgio, R “Sensitivity to Wheat, Gluten and FODMAPs in IBS” Gut. 2016:65(1) 169-178. Dr. Michael Vaughn is a board-certified allergist practicing in North Central San Antonio since 1999.
visit us at www.bcms.org
15
ALLERGIES
TREAT ALLERGIC RHINITIS Before it makes you feel miserable By Patricia Gomez Dinger, DO
Allergic rhinitis is a chronic inflammatory condition involving the nasal airway creating symptoms of sneezing, runny nose, itchy ears, watery eyes, post nasal drainage, nasal congestion, cough, and sinus pressure. It has been said to affect between 10 to 30 percent of adults and children in the United States. It accounts for at least 2.5 percent of all clinician visits, 2 million lost school days, 6 million lost work days, and 28 million restricted work days per year. It can be characterized as seasonal or perennial depending on the type of allergen to which the patient is sensitized and the duration of symptoms. A genetic predisposition and a high enough exposure to an allergen is generally what will predict whether a patient has allergies. Patients with allergic rhinitis will often suffer from allergic conjunctivitis, asthma, or atopic dermatitis. It is imperative to identify a patient’s triggers in order to begin instituting environmental controls and appropriate treatment. Patients will often misdiagnose their symptoms for an infectious illness or a common cold. Some key differences are that when the symptoms are due to allergic rhinitis it is usually not accompanied by a fever, it has a seasonal pattern to the recurrent symptoms, and it is typically characterized by itching and sneezing. A very common mistake patients make is to start treating symptoms too late after they are already feeling miserable. The best allergy treatment is to have identified the allergic trigger and begin treatment before the patient’s peak allergy season (if seasonal). I often explain this to patients as putting on your body armor before going into battle. If the symptoms are perennial, then using allergy medication year-round may be inevitable. These patients are also candidates for allergy immunotherapy. A very frequently asked question is: what are the best allergy med-
16 San Antonio Medicine • March 2017
ications to treat allergic rhinitis? Steroid nasal sprays are first line in the treatment of the condition. There are several now available over the counter. When these medications are used properly coupled with an antihistamine nasal spray it is possible to achieve ninety percent symptom improvement. Sinus rinsing can also be beneficial particularly when the patient has spent time outdoors during their peak season. Lack of treatment can severely impact a patient’s quality of life and has been associated with sleep disturbances, poor concentration, absenteeism/presenteeism, and generalized fatigue. It is important that patients understand that relying on corticosteroids orally or by injection is not the preferred treatment for allergies. This should be used as a last resort when proper allergy medications have failed. If allergic rhinitis is left untreated, it can result in a sinusitis and exacerbate asthma or cause bronchitis, thus requiring antibiotics. It is important to note that patients complaining of shortness of breath, wheezing or chest tightness in association with allergic rhinitis may be experiencing allergic asthma and should undergo pulmonary function testing. Patients whose nasal and respiratory symptoms are severe or refractory to therapy should be referred to an allergy specialist for a more definitive evaluation. Dr. Patricia Gomez Dinger is a board certified allergist with Advanced Allergy, Asthma and Immunology Center in San Antonio. She is a member of Texas Allergy, Asthma & Immunology Society, San Antonio Allergy, Asthma & Immunology Society, Bexar County Medical Society, American College of Allergy, Asthma, & Immunology, American Academy of Allergy, Asthma, & Immunology, and the Joint Council of Allergy, Asthma, & Immunology.
ALLERGIES
Food Allergy & Intolerance REMAINS A
OF MEDICINE
By Victor Estrada, MD
If there ever has been a gray area of medicine, it is food allergy and/or food intolerance. Even the definition of "food allergy" varies from allergist to allergist. For some, it is an allergic reaction caused by a food that is specifically IgE mediated (positive skin test or positive IgE mediated blood test, such as ImmunoCap IgE, or the old Rast test). For others, it is an immune mediated reaction, not necessarily IgE mediated, that occurs after ingestion of a food. Approximately 12 million Americans suffer from food allergies and 1 in 12 children have food allergies. People can be allergic to any food, but 90 percent of food allergic reactions are caused by the following: • Milk • Peanuts • Eggs • Tree Nuts
• Wheat • Fish • Soy • Shellfish
18 San Antonio Medicine • March 2017
The highest risk foods for anaphylaxis include peanuts, tree nuts and seafood, with cow's milk and eggs in young children.
Food Allergy versus Intolerance Food allergy symptoms typically begin soon after eating the food and can occur with even tiny amounts ingested. Reactions can be cutaneous, such as urticaria and angioedema, gastrointestinal, such as vomiting and diarrhea, respiratory, such as wheezing and shortness of breath, as well as anaphylactic, involving any of the above, in addition to larygeal edema and/or hypotension, In contrast, food intolerance symptoms take longer to appear than food allergy symptoms and small amounts may be tolerated without any reaction. Symptoms are varied, and can include intestinal such as gas, abdominal bloating, pain, or diarrhea, as well as cough, runny nose, headaches, migraine headaches, skin problems such as eczema or urticaria, joint pain, lethargy, etc. Symptoms can be vague and difficult to diagnose.
ALLERGIES
A food allergy is caused by an immune reaction to a normally harmless protein in the food. The protein is called an allergen due to the fact that it can cause an allergic reaction.
Food intolerance may be due to various factors, including: • Enzyme deficiency, such as lactose intolerance • Chemicals that are produced naturally in foods such as salicylates in plant foods like fruit, vegetables and spices, amines in protein foods like chocolate, cheese, less-than-fresh meats and seafood, and histamine in improperly stored fish (Scombroid poisoning) and in foods like strawberries, chocolate and ripe cheese. Also, there are chemicals in foods that may affect people who suffer from allergic contact dermatitis. For example, foods high in nickel, such as chocolate, cashews, kidney beans and spinach, may cause dermatitis, especially hand dermatitis, in people who suffer from contact dermatitis to fake jewelry, belt buckles, etc. • Food additives, artificial sweeteners, colorings or flavorings, preservatives, emulsifiers and antioxidants. Some examples of preservatives are benzoates, nitrates, MSG, as well as, sulfites. • Autoimmune disease, celiac disease is both an autoimmune disease and a gluten intolerance.
DIAGNOSIS: Skin Testing/Serum IgE testing: In diagnosing a food allergy or intolerance, a good history is vital, as the story must correlate with the lab test. The most commonly used food allergy testing mechanisms include skin testing and ImmunoCap IgE blood testing. It is extremely important to remember that both methods can produce false positive reactions. A patient with a positive food test, who has been consuming that food without any symptoms, should not be advised to avoid that food. Also, remember that false negatives occur if the reaction is not a Type 1 hypersensitivity reaction or IgE mediated. Many times, a food diary documenting all foods eaten, plus all symptoms experienced, are required. This may require the assistance of a registered dietician. Other times, if a patient is motivated, a very restrictive elimination diet, such as chicken, rice and water only, for several days, may be more appropriate. If the symptoms improve, then one new food every 5 - 7 days, can be re-introduced.
usual IgE testing discussed above. Patch testing is typically used to diagnose allergic contact dermatitis to a variety of chemicals, metals etc., which are a delayed or Type 4 hypersensitivity reaction. This involves applying the food (or chemical) to the back for 48 hours, and then checking for an allergic response over the next several days.
Other Tests: There are other food allergy tests on the market, e.g. measuring IgG levels to foods, or white blood cell reactions to foods, however, neither have been scientifically proven and therefore are not covered by insurance. These tests have a high number of false positives, especially if that food is frequently eaten. Avoiding common foods, such as gluten and dairy, may lead to overall improvement in how one feels and maybe even weight loss, but that does not prove that a person is truly allergic to those foods.
Preventative Treatment: Unfortunately, the only recommended preventative therapy for food allergy is avoidance. Oral and sublingual food desensitization are both being investigated, but there are some practitioners who are currently offering the service in their clinics. A topical patch for peanut allergy is also being studied, as well as Xolair injections and a mixture of herbs named Chinese Herbal Formula. In patients with multiple food allergies, especially infants and growing children, the help of a registered dietician and nutritionist, to ensure proper nutrition, is encouraged.
Patch Testing: In infants and young children diagnosed with eczema or atopic dermatitis, some centers are adding patch testing of foods to the
Victor Estrada, MD, MPH is board certified in allergy and immunology, with over 27 years of experience treating children and adults.
visit us at www.bcms.org
19
ALLERGIES
Asthma Management By Jeffrey S. Hallett, MD
Asthma now affects more than 300 million people worldwide and its prevalence is rising, particularly in underserved populations. In the past, asthma was viewed as a disease of bronchoconstriction and was treated predominantly with bronchodilators. More recently it has been viewed as an inflammatory disease with a focus on antiinflammatory treatments. Inhaled corticosteroids (ICSs) have revolutionized the management of asthma, leading to better control of symptoms, a reduction in hospitalization, and reduced mortality. Current management of asthma is highly effective. Most patients are well controlled if they take regular ICSs with or without longacting β2-agonists (LABAs) in combination inhalers. Yet despite the availability of effective therapies, many patients with asthma appear to be poorly controlled largely due to poor compliance. Most surprising is the fact that over 80 percent of patients with difficult-totreat asthma have poor compliance with regular inhaled combination therapy. Even in patients with corticosteroid-dependent asthma, only half take oral corticosteroids regularly. As a result, there is increasing emphasis on not only newer and more effective
20 San Antonio Medicine • March 2017
controller medications, but also on newer concept therapeutics such as ultra-LABAs, dissociated steroid agonists, cytokine modulators, mast cell inhibitors, monoclonal antibodies, and improved forms of allergen immunotherapy. Bronchodilators are important for preventing and relieving bronchoconstriction and the major advance has been the introduction of the LABAs salmeterol, formoterol, and vilanterol, which last for over 12 hours. These drugs have complementary actions to corticosteroids and fixed combination inhalers with a corticosteroid are now the most effective available therapy for asthma. There are now several even longer acting β2-agonists ("ultra-LABAs") coming to market, including indacaterol, carmoterol, and olodaterol, which have a duration of action greater than 24 hours and are suitable for once-daily dosing. A once-daily muscarinic antagonist, tiotropium bromide, is less effective as a bronchodilator in asthma than β2-agonists and is used predominantly in chronic obstructive pulmonary disease (COPD) but appears to be a useful add-on therapy in some patients with se-
ALLERGIES
vere asthma. Several other once-daily long-acting muscarinic antagonists (LAMAs) are also in development. ICSs are currently the most effective anti-inflammatory therapy for asthma and work in almost every patient. However, all currently available ICSs are absorbed from the lungs and thus have the potential for systemic side effects. This has led to efforts to find safer ICSs, with reduced oral bioavailability, reduced absorption from the lungs, or inactivation in the circulation. Dissociated steroids attempt to separate the side-effect mechanisms from the anti-inflammatory mechanisms. This is theoretically possible because side effects are largely mediated via transactivation and the binding of glucocorticoid receptors to DNA, whereas anti-inflammatory effects are largely mediated via transrepression of transcription factors through a nongenomic effect. Dissociated steroid agonists have a greater effect on the transactivation than transrepression and thus may have a better therapeutic ratio. Monoclonal antibodies that block IgE are now used in the treatment of selected patients with severe allergic asthma. Both omalizumab and mepolizumab are expensive, so patients must be selected carefully for a trial of therapy. More potent anti-IgE antibodies that
may have a broader spectrum of effects are in development. Allergens bind to a low-affinity IgE receptor (FcÎľRII, CD23) as well as the high-affinity receptor FcÎľRI on several immune cells, including T- and B-lymphocytes and so more targeted monoclonals have potential. Specific allergen immunotherapy by subcutaneous injection (SCIT) is effective in controlling allergic asthma and will often lesson the need for other pharmaceuticals. High dose sublingual immunotherapy (SLIT), although still an off-label treatment, is becoming a more convenient and safer alternative to injections and is showing great promise with selected allergens, particularly dust mites; however, longer-term studies and comparison with ICSs and with SCIT are needed. Asthma therapy has always been, and will continue to be, a challenge for both the physician and the patient. But we are continually seeing profound advancements in asthma therapy, which is an encouraging sign for all of us. Jeffrey S. Hallett, MD, is a board certified allergist with Certified Allergy and Asthma of San Antonio.
visit us at www.bcms.org
21
ALLERGIES
VITAL STATS Allergies, Mountain Cedar and the perfect petri dish By David Schulz, CHP
If there’s a number vital to the average San Antonio household,
Dr. Ratner began his studies in the treatment of allergies,
it’s the daily Mountain Cedar Pollen count, provided by Dr. Paul
asthma and immunology in children and adults in 1984, creating
Ratner and Sylvana Research to nearly every local weather fore-
Sylvana Research concurrent with the start of his practice. This
caster each morning. And for good reason. When San Antonio
research facility studies new investigational medications about to
developed, so did the perfect laboratory petri dish for studying
be introduced via Phase 1 through Phase 4 clinical drug trials;
allergens. Not just cedar, Dr. Ratner points out, but a broad range
and trials are not limited to allergy medications.
of allergen studies are conducted here, taking advantage of absence of any competing pollens during the height of winter season.
A graduate of The State University of New York at Stony Brook with a bachelor of science degree in biology in 1971, Dr. Ratner
“We made Mountain Cedar known to pharmaceutical com-
received his medical degree from the Albany Medical College of
panies,” he says about himself and his colleagues. “They knew
Union University and completed his residency in pediatrics at
nothing about it, but it was a pure season and a perfect labora-
Brooke Army Medical Center in San Antonio in 1978. He com-
tory for study.”
pleted a two-year fellowship in clinical allergy and immunology
22 San Antonio Medicine • March 2017
ALLERGIES at the University of Texas Health Science Center in San Antonio in 1984 and his course was set. A focus on immunology was natural, considering the heritage and name of Sylvana Research. “My mother died of leukemia at 42; the institute is primarily named for her, in her memory.” The focus of research, the identification of symptom relieving drugs, has shifted considerably over the last three decades. “There’s been a long cycle of drugs in development and they’ve grown very effective now … there’s little inducement to develop another multimillion dollar pharmaceutical when nasal steroids are sold over the counter for less than 20 dollars.” “Normally we’d be doing lots of cedar studies with hundreds of patients, but there’s been a trail-off of new developments,” he continued. But that can lead to monopolies on products as well … note the recent Epi Pen crisis. “We are conducting studies on peanut allergy right now. Unfortunately, the only treatment available now is the Epi Pen which is prohibitively expensive for most patients ($600!). Fortunately, there are two new products hopefully being approved in 2018.” For more information, or to be considered for a research study, contact info@sylvanaresearch.com … and keep the tissues handy! David Schultz, a certified HIPAA professional and CEO of Cyber Risk Associates LLC, is a member of the BCMS Publications Committee.
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ALLERGIES
URTICARIA AND ANGIOEDEMA Diagnostic and Therapeutic Options By Chris Christodoulou, MD
Urticaria refers to transient, very pruritic lesions that affect up to 20 percent of the population at some point in their life. They can be divided into acute cases lasting less than six weeks, and chronic cases lasting more than six weeks. The acute cases may be associated with an allergic reaction to a specific factor such as food, medication, insect bites, etc.(1, 2) In children, viral febrile illness is a frequent cause of acute urticaria. In contrast to acute urticaria, chronic urticaria is more commonly idiopathic and in most cases even extensive laboratory evaluations will not identify any relevant cause. Autoimmune diseases, malignancies and infectious etiologies have all been implicated in chronic urticaria.(3, 4) Urticarial vasculitis is an autoimmune skin lesion that may look like urticaria but has different features. For instance, it may last longer, it may resolve with residual hyper-pigmentation and can be associated with systemic symptoms.(5) The urticarial lesions are accompanied by intense itching, but usually there is no pain. They tend to last less than 24 hours and resolve without any residual hyperpigmentation. They may involve any part of the body, may appear at any time of the day or night and they may range in number from a few lesions to hundreds at any given time and in size from less than 1 mm to large plaques the size of a palm.(1, 2, 3) Angioedema frequently accompanies urticaria and as long as it does not involve the oral/respiratory tract (tongue, uvula, throat, lungs) it is not of major concern. In contrast to the urticaria that usually lasts a few hours, the angioedema may last up to 48 hours. The evaluation of urticaria should not be extensive as in the vast majority of patients there will not be any specific
24 San Antonio Medicine • March 2017
ALLERGIES
cause found.(4) Most authorities suggest CBC, ESR or CRP; often some more extensive laboratory work up may be suggested to include thyroid function tests, liver function tests and urinalysis. The main reason the laboratory evaluation is performed is not to identify the cause but rather to ensure there is no hidden cause. In case of suspected urticarial vasculitis, skin biopsy is necessary.(5) The cornerstones of treatment are the antihistamines which may be used at much higher doses than used for treatment of allergic rhinitis, often four times the usual dose.(6) Combinations of two antihistamines may be more effective for many patients than just doubling the dose of one. Short courses of oral steroids may be used in case of recalcitrant urticaria, although this is not a treatment recommended by all experts due to the adverse effects. One of the latest treatments of recalcitrant hives is omalizumab, an anti IgE monoclonal antibody that targets IgE. Several studies that have evaluated its efficacy suggest that this is a good therapeutic option in patients who have failed other standard treatment modalities. About 65 percent of patients resistant to antihistamines responded favorably to omalizumab and about 40 percent of patients were completely free of hives while on this drug. No major adverse effects were recorded although very rarely anaphylactic reactions were reported.
References: 1. Bernstein JA; Lang DM; Khan DA; et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol. 2014;133:1270-1277 2. Powell RJ, Du Toit GL, Siddique N, et al.; British Society for Allergy and Clinical Immunology (BSACI) guidelines for the management of chronic urticaria and angio-oedema. Clin Exp Allergy. 2007;37:631–650. 3. Grattan CE, Humphreys F; British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Guidelines for evaluation and management of urticaria in adults and children. Br J Dermatol. 2007;157:1116–1123. 4. Kozel MM, Bossuyt PM, Mekkes JR, Bos JD. Laboratory tests and identified diagnoses in patients with physical and chronic urticaria and angioedema: a systematic review. J Am Acad Der-
matol. 2003;48:409–416. 5. Chang S, Carr W. Urticarial vasculitis. Allergy Asthma Proc 2007;28:97-100 6. Staevska M; Popov TA; Kralimarkova T et al. The effectiveness of levocetirizine and desloratadine in up to 4 times conventional doses in difficult-to-treat urticaria. J Allergy Clin Immunol. 2010; 125(3):676-682 7. Gómez-Vera J Gutiérrez-Ávila SA Acosta-Gutiérrez DN, et al. Ann Allergy Asthma Immunol. 2016;117:204-206. Omalizumab in the treatment of antihistamine-resistant chronic urticaria in adults. 8. Kaplan AP; Therapy of chronic urticaria: a simple, modern approach. Ann Allergy Asthma Immunol. 2014; 112:419-425 9. Saini SS, Bindslev-Jensen C, et al. Efficacy and safety of omalizumab in patients with chronic idiopathic/spontaneous urticaria who remain symptomatic on H1 antihistamines: a randomized, placebo-controlled study. J Invest Dermatol. 2015;135:67e75 Dr. Chris Christodoulou completed his medical studies at the Semmelweis University of Medicine in Budapest, Hungary (1990). Thereafter he did his residency in Internal Medicine at Easton Hospital, PA (1992-1995), followed by a fellowship in allergy-immunology at the UTHSCSA, in San Antonio, TX (1995-1997). He then continued his education as a subspecialty fellow in Clinical Laboratory Immunology (CLI) at All Children’s Hospital, St. Petersburg, FL which was extended to a total of 2 years (1997-1999). After completing his education he returned to his home country Cyprus where he practiced allergy-immunology until 2015, when he returned to San Antonio and has been practicing here since then. Practice: MedCare Associates, 19260 Stone Oak Parkway, Suite 105, San Antonio TX 78258, tel: (210) 402-3456
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25
BCMS NEWS
BCMS Trip to Chennai, India A delegation of physicians from San Antonio traveled to Chennai, India from Dec. 24, 2016 – Jan. 4, 2017. San Antonio and Chennai became sister cities in 2007 and the Bexar County Medical Society signed collaborative agreements with its Chennai counterpart at the same time. Doctors who attended the trip included: Dr. Jayesh Shah Dr. Venkat Srinivasan Dr. Neela Patel Dr. Anupama Gotimukula Dr. Roberta Kruger Dr. John Harper Dr. Do/ Thuy Danh Dr. Muhammed Munir Dr. Farah Munir Dr. Sreedhara Akkhihebbalu Miss Viet Thi Hong MS Miss Prachi Shah Mrs. Mondragon Alejandrina Mr. Octavio Agular Mrs. Hamida Munir Mrs. Priya Srinivasan Miss Tarika Srinivasan Master Sankya Srinivasan Attendees visited Apollo Hospital in Delhi and MV Diabetic Hospital in Chennai where they attended and gave the following CME presentations: • Hyperbaric Oxygen Therapy: Clinical Applications – Dr. Jayesh Shah – Delhi • Mind Body Medicine: Dr. Venkat Srinivasan – Chennai • Diabetic foot update; Dr. Jayesh Shah – Udaipur • Geriatrics and Palliative Care: Dr. Neela Patel – Udaipur • Multiple CME’s at AAPI Global Summit – Udaipur • Symmedcon 2017: International Conference on Stress, Yoga and Mind-Body Medicine at Sri Ramachandra Univerity – Chennai • Dr. Neela Patel: Management of Pain and Suffering – Chennai • Dr. Sreedhara Akkhihebbalu: Role of Dance in Management of Stress – Chennai • Dr. Venkat Srinivasan: The Powerful Placebo – Chennai • Workshop on Stress management by Dr. Venkat Srinivasan • Workshop on Geriatric and Palliative care by Dr. Neela Patel Check out next month’s edition of San Antonio Medicine for more about the trip including pictures and feature articles. 26 San Antonio Medicine • March 2017
THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA
ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc. Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of February 19, 2017.
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27
FEATURE
55 WORDS The 55-word story is a “micro” literary form with a simple mission: tell a story in exactly 55 words—no more, no less. Not a poem, not an essay, but a story. This tight structure challenges the author to pack the most punch on a page as tiny as a Post-It note. Crafting these bite-sized stories exercises the creative muscle unlike other formats yet its brevity makes it approachable to even the most novice of writers. Purposeful reflection is imperative to mindful clinical practice and physician wellness, yet many of us struggle to find the time or the tools to do so. The 55-word story is perfectly suited for busy physicians looking for a powerful yet efficient method for reflection. The format has been adopted as an approach to narrative medicine, and collections of stories have been published in JAMA and other medical journals. Since July 2015, medical students at the UT Health Science Center have been participating in Project 6 -55, an hourlong guided reflective writing workshop where they write 55-word stories about their clinical experience and share with their peers. Though many students are initially apprehensive, they are impressed by the power of 55 words to bring a story to life and some have adopted this as a tool for their on-going reflection and professional growth. The following collection of stories was written by senior medical students at UT Health San Antonio and showcases their vast and rich experiences throughout their medical education. We are pleased to share our first quarterly 55 Words feature, and encourage you to try your hand at writing a 55-word story. Why Is It Morning?
Ceira Kaylynn Ward UTHSA School of Medicine, Class of 2017 He arrived with back pain, my first admission. He left with an inevitable fate, my first farewell. He loved the Salisbury steak, my first chuckle on wards. He asked me, “What if it isn’t cancer?”, my first difficult discussion. He will not see his grandchild born, my shoulder was cried upon. He was, my lesson.
The Ride Home
Lauren Michael UTHSA School of Medicine, Class of 2017 Full of ambition with a white coat and an instant promotion. “Take ownership of your patient.” Differentials explored and labs sifted. “She passed, you were out.” I leave didactics with more than my book bag and collapse into my car. I release what’s locked away. Am I strong enough? My thoughts overflow. “Same time tomorrow.”
28 San Antonio Medicine • March 2017
The Returning Patient
Amber Clapper UTHSA School of Medicine, Class of 2017 What brings you in today? I have chest pain. Not cardiac, you can go home. I have shortness of breath. Not pneumonia, you can go home. I have dizziness. Not dehydrated, you can go home. Why do you keep returning to the hospital? You have no medical problems we can treat. I have no home.
Prolonged
Shaoli Chaudhuri UTHSA School of Medicine, Class of 2017 We say he’s deluded. Whisper it in the workroom. He looks up experiments done on dead pigs, orders we reproduce them on his wife of 30 years. He tells us to save her, threatens to sue us. Agonal breathing. Cancer-ridden. She clings on, but she’s tired. She tells him to let her go. He won’t.
FEATURE
To learn more about the 55-word story or the Project 6-55 writing workshop, please contact Kristy Kosub, MD at kosub@uthscsa.edu.
She Never Said
Grace Cheney UTHSA School of Medicine, Class of 2017 Seventeen people gathered around the bed listening to the ventilator’s rhythmic hiss. “What would she want?” “She never said.” The green lines of life dance with the slow rhythm of her heartbeat. Yet the tearful glances are only answered with the impassiveness of anesthesia-induced sleep. “How did we get here?”
Code status confirmation.
Alexa Rodin UTHSA School of Medicine, Class of 2017 “DNI/DNR,” she replied. “Today is our anniversary,” he whispered, and I tried not to cry. “May you find as much love and joy as this marriage brought me,” she comforted both her husband and a stranger. They had five children, twelve grandchildren, twenty great-grandchildren, two great-great-grandchildren, and 38 years and one day of marriage.
Role Model
Ken Okons UTHSA School of Medicine, Class of 2017 Only six percent of medical school applicants are African American. This number is lower now than it was in 1976. Why? Role models show kids it’s possible. How will someone know they can be great if they see no examples of great people similar to themselves. It is our job to break the mold.
Bird’s-Eye View
Jennifer Leet UTHSA School of Medicine, Class of 2017 Doctors are people too right? Why is it the norm for doctors to be worn down so thin? There should be a balance between work and play. There needs to be a balance for the sake of maintaining sanity. How can we be healers if we’re damaged in the process?
Untitled
Anonymous UTHSA School of Medicine, Class of 2017 Mr. Mr is a something-5 year old with a past medical history of past medical histories that presents to the AEIOU-D with VD, ED, and PE on 3D CT. We can work him up or down for anything so long as we keep it nebulous and brief enough to heap it full of meaning.
Treating Both Mice and Men
Vinh Dao UTHSA School of Medicine, Class of 2017 Past three years filled with studying mouse cancers. Inject, grow, treat, cut, measure, analyze. Then repeat. Are these results meaningful in the real world? Then, infant diagnosed with refractory ALL. Life is cut short unless something is done. Chemotherapy kills indiscriminately. Experimental treatment induces response. Hope! Learning to treat both mice and men, worth it.
Paired Together
Bryan Brockman UTHSA School of Medicine, Class of 2017 A father in need, a daughter willing but unable. Few options, even less time. Without it he won’t last long. Two brothers across the country. One is in need and the other wants to give. But they’re not a match. Hope appears, paired kidney donor exchange. Two kidneys donated, two received, and two lives saved.
Awake
Chris Wilson UTHSA School of Medicine, Class of 2017 Laying in bed I saw a mind and body eroded; A (barely) living fossil containing only memories of experience and being, and perhaps not even that. For all I know, had he awoken and looked upon me, He would have envied my youth and potential. But I was without sleep, and envious of his slumber.
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UT HEALTH SAN ANTONIO
UT HEALTH SAN ANTONIO: ENDOWMENTS ARE CHANGING THE TRAJECTORY OF HEALTH SCIENCE EDUCATION By William L. Henrich, MD
Recently, The University of Texas Health Science Center (now known as UT Health San Antonio) announced the naming of the School of Medicine as a result of an extraordinary gift that significantly expands the educational legacy of philanthropists Joe R. and Teresa Lozano Long of Austin. The Longs initially gave $1 million to UT Health in 1999 to support scholarships for medical students from South Texas, and they followed this with a transformative $25 million gift in 2008 to expand scholarships for students from across Texas studying to be physicians, nurses, physician assistants or scientists. Last month the Longs the contributed an additional $25 million that will change the trajectory of health science education for Texas and beyond. Their previous gift of $25 million established the Joe R. and Teresa L. Long Scholarship Research and Teaching Fund, a permanent endowment that supports student scholarships in medicine, nursing, graduate and physician assistant studies; advances medical research in diabetes and other areas that affect the health of the population; and sustains faculty through perpetual funding of new endowed chairs that support efforts in priority areas of UT Health’s education, research and patient care missions. Two new endowed distinguished chairs have been established to date. 30 San Antonio Medicine • March 2017
Endowments deliver significant, sustained long-term impact as the Long Fund clearly has demonstrated. When considered in its totality, the impact of the Longs’ philanthropy, with their new gift of $25 million, now exceeds $61 million. In recognition and appreciation of the new gift and the collective impact of the Longs’ previous commitments to UT Health, the UT System Board of Regents enthusiastically authorized the naming of the School of Medicine at UT Health San Antonio as the Joe R. and Teresa Lozano Long School of Medicine. The Longs’ new $25 million gift will establish a $1 million distinguished chair endowment for the dean of the School of Medicine; a $4 million endowment to support scholarships for students from throughout Texas who are attending UT Health and studying to be physicians; and a $20 million President’s Endowment for Faculty Excellence in Medicine to support priority faculty recruitment in the School of Medicine. The Longs have supported more than 290 scholarships to more than 115 students. Today, 44 Long Physicians are practicing medicine in South Texas and beyond — graduates of the Long-funded scholarship programs that covered their medical school tuition for their entire
education at UT Health. “In continuing the missions of the Joe R. and Teresa Lozano Long School of Medicine, we are advancing our commitment to our community through excellence in patient care, education and research,” said Ronald Rodriguez, MD, PhD, interim dean of the School of Medicine. “The Long School of Medicine will never stop in its quest to be one of the best medical schools in our nation.” The Long School of Medicine consistently ranks among the top medical schools in the nation for graduating Hispanic physicians. Since state resources now support less than 10 percent of our School of Medicine’s budget, it will be increasingly important that philanthropic gifts, such as that provided by Austin’s Joe and Terry Long, fill the necessary gap to ensure the UT Health mission of educating the next generation of health care providers for our state continues into the future.
UT HEALTH SAN ANTONIO
Dr. William L. Henrich received his undergraduate degree from Columbia University and his doctor of medicine degree from Baylor College of Medicine. He then completed a residency in Internal Medicine at the University of Oregon Medical School and a fellowship in Nephrology at the University of Colorado School of Medicine. Dr. Henrich held many positions at UT Southwestern Medical School in Dallas, including Professor of Internal Medicine, Associate Chief of Staff for Research and Development at the VA Medical Center in Dallas and Attending Physician at Zale Lipshy University Hospital. From 1995 to 1999, he served as Professor and Chairman of Medicine at the Medical College of Ohio and Chief of the Medical Service, Medical College Hospital, in Toledo, Ohio. Subsequently, he served as the Theodore Woodward Professor and Chairman of the Department of Medicine at The University of Maryland School of Medicine in Baltimore from 1999-2006. Dr. Henrich served as the Dean of the School of Medicine and Vice President for Medical Affairs at the University of Texas Health Science Center at San Antonio prior to being named President in June 2009. PHOTO CAPTIONS: Opposite Page: Joe and Theresa Long with Dr. Henrich and students. This page: Joe and Theresa Long.
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FINANCIAL
PLAN FOR YOUR FUTURE:
RETIREMENT SAVINGS FOR MEDICAL PRACTICES By Gil Castillo, CRPC
Owning a medical practice allows you the freedom to plan your own future. While planning, don’t forget the importance of building your personal wealth, such as through retirement savings plans. Not surprisingly, retirement plans are often underutilized by owners and employees of small businesses when compared to benefits bestowed by large companies. With everything else required for your practice, you may be under-saving or have put off setting up a retirement plan entirely. Fortunately, there are a number of options that can jump-start your savings, with minimal fees. In addition to providing for your own retirement needs, many of these plans provide an easy way for you and your employees to contribute to retirement, which will help your practice hire and retain employees.
Options for you and employees Offering retirement plans and company contributions on behalf of your employees is a great way to attract and retain quality employees. Here are some options designed to make retirement account creation and funding easy for small businesses.
32 San Antonio Medicine • March 2017
401(k) With many large companies offering a 401(k) profit-sharing plan, current and prospective employees are likely to welcome saving in such a recognized plan. These are some of the highlights: • Employees can contribute up to $18,000 per year ($24,000 for those ages 50+) in pre-tax and Roth (after tax) money. • Deferred money goes into a separate account for each employee and is not taxed until employees withdraw funds. • As the employer, your practice can match employee contributions or make discretionary profit-sharing contributions to employee accounts.
Simplified employee pension (SEP) A SEP offers an easy and low-fee way to provide retirement plans to employees of your practice. Here are the basics: • You set up a SEP with a trustee or financial institution, which will open accounts for you and all other eligible employees. The trustee or bank takes care of financial and reporting details. • Your practice contributes to each employee's account. The con-
FINANCIAL
tribution must be the same percentage of pay for every employee. • Annual contributions may be quite generous, capped at 25% of an employee's pay or $54,000, whichever is less. • Contributions made to employees' accounts are taxdeductible for your practice.
Savings incentive match plan for employees (SIMPLE IRA) The SIMPLE IRA is designed for businesses with 100 employees or less. These are some highlights: • To be eligible for a SIMPLE IRA, your practice must not offer any other retirement plan. • Employees may choose to contribute a percentage of pay to their accounts, similar to a standard employer 401(k); your practice must contribute to all employees' accounts. • Employee contributions are capped at $12,500 per year ($15,500 per year for those ages 50 and older). • Your practice must either match employees' contributions by contributing up to 3% of their pay OR must contribute 2% of employee pay to every eligible employee account, regardless of whether the employee contributed. • Your company contributions are tax deductible.
Cash balance plan A cash balance plan added to your practice’s existing 401(k) plan provides a way to increase retirement savings while reducing taxes. Here’s how it works: • Pre-tax cash balance plan contributions are layered on top of existing 401(k) contributions, allowing you to double or triple pretax contributions. • Your practice sets specific contribution amounts by employee position or group. • Accounts are portable, and employees can roll over their accounts to an individual retirement account (IRA) or other qualified plan if they wish. • Plan assets are protected from bankruptcy and lawsuits.
Options for your own retirement When considering only your own retirement, think about a traditional or Roth IRA. Like most Americans, self-employed individuals are able to save up to $5,500 per year ($6,500 for those ages 50
and older) of earned income in an individual retirement account (IRA) or Roth IRA. Some things to keep in mind: • With an IRA, you contribute pre-tax dollars and pay tax when you withdraw the funds in retirement. You can set up an IRA to payroll deduct your pre-tax earnings. • With a Roth IRA, you contribute after-tax dollars, and you withdraw funds tax-free in retirement. The IRS imposes some income restrictions on Roth IRA usage; consult a wealth advisor for details. While running your own medical practice already involves a lengthy to-do list, saving for your future and helping employees do the same should be a priority. Luckily, with the plan options available, you can get started with a minimum of effort and expense. More good news: as with many activities the U.S. government wishes to encourage, the IRS offers small business owners an incentive to set up retirement plans for employees. As long as you contribute to the retirement of at least one employee who is not highly compensated, tax credits are available for establishing and maintaining a new retirement plan. To ask questions or learn more about any of these options, contact me at 210.321.7258 or gcastillo@swbc.com. Gil Castillo, CRPC, Wealth Advisor, SWBC Wealth Management.
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BCMS OFFICER INSTALLATION
2017 INSTALLATION OF OFFICERS Dr. Leah Jacobson was sworn in as the 2017 BCMS President during the Installation of Officers ceremony on Jan. 28 at the Witte Museum. PHOTO CAPTIONS: 1. 2017 BCMS Officers (Back Row) Dr. Gerald Greenfield, secretary; Dr. John Holcomb, treasurer; Dr. Adam Ratner, vice president; Mr. Stephen Fitzer, executive director. (Front Row) Dr. Sheldon Gross, president-elect; Dr. Leah Jacobson, president; Dr. Jayesh Shah, immediate past president.
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2. Past and Present Presidents of BCMS Back row – Dr. John R. Holcomb (1993); Dr. Donald Gordon (2010); Dr. Roberto San Martin (2009); Dr. Gerardo Ortega (2001); Dr. Leah Jacobson (2017); Dr. Delbert Chumley (2007); Dr. Jayesh Shah (2016); Dr. Marc Taylor (2002) Front row – Dr. Vijay Koli (2000); Dr. Rajam Ramamurthy (2004); Dr. Stephen Gelfond (1994); Dr. Albert Sanders (1991); Dr. Jose Benavides (1984); Dr. Neal Gray (1992); Dr. Jesse Moss (2011). 3. BCMS members met in the new Mays Family Center at Witte Museum.
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34 San Antonio Medicine • March 2017
4. Special Award Winners Bernard “Buddy” Swift, DO, MPH; Charles “Chuck” Bauer, MD; Vijay Koli, MD; Mr. Stephen Fitzer. Swift and Fitzer each received the Distinguished Service Award for their work in building a new permanent home for the Bexar County Medical Society. Drs. Bauer and Koli received the Golden Aesculapius Award for a lifetime of distinguished service to medicine.
BCMS OFFICER INSTALLATION
3 6
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5. Mrs. Cathy Ortega, Dr. Gerardo Ortega, Dr. Leah Jacobson and Dr. Rajam Ramamurthy. 6. Dr. Neal Gray getting a plate of food at the hors d’oeuvre bar.
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7. Dr. Charles Bauer, the 2016 recipient of the Golden Aesculapius Award, greets Dr. Albert Sanders, who won the award in 2006.
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.
ACCOUNTING FIRMS RSM US LLP (HH Silver Sponsor) RSM US is one of Texas’ largest, locally owned CPA firms, providing sophisticated accounting, audit, tax and business consulting services. Vicky Martin, CPA 210-828-6281 Vicky.Martin@rsmus.com www.rsmus.com “Offering service more than expected — on every engagement.” Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”
ACO/IPA
ASSET MANAGEMENT
Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives. Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management”
ATTORNEYS IntegraNet Health (HHHH 10K Platinum Sponsor) IntegraNet Health is an Independent Physician Association that helps physicians achieve higher reimbursements from insurance companies whereby some of our higher performing physicians are able to achieve up to 200% of Medicare FFS. Executive Director Alan Preston, MHA, Sc.D. 1-832-705-5674 Apreston@IntegrNetHealth.com www.integraNetHealth.com
ARMY HEALTHCARE 5th Medical Recruiting BN (HH Silver Sponsor) We recruit quality men and women who would like to be a part of our team. SFC Cherie Kirk 210-692-7376 Cherie.k.kirk.mil@mail.mil www.youtube.com/watch?v=kweqi 3TelO8 "Serving to heal, Honored to serve"
36 San Antonio Medicine • March 2017
Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”
BANKING
Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability,
Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Stephanie Dick Vice President- Commercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com
BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Commercial Relationship Manager — Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future”
Broadway Bank (HHH Gold Sponsor)
Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”
Frost (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses. Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”
IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC BankSan Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area. Markham Benn 210-518-2500, ext. 26921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”
Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans. Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY www.rbfcu.org Regions Bank (HHH Gold Sponsor) VP Physician Lending Group Moses D. Luevano, 512-663-7743 phone moses.luevano@regions.com
The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com
SSFCU (HHH Gold Sponsor) Founded in 1956, Security Service provides medical professionals with exceptional service and competitive rates on a line of mortgage products including one-time close construction, unimproved lot/land, jumbo, and specialized adjustable-rate mortgage loans. Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology? Expanding your office space? We offer loans to meet your business or personal needs. Competitive rates, favorable terms and local decisions. Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org RBFCU (HH Silver Sponsor) 210-945-3800 nallen@rbfcu.org
CONTRACTORS/BUILDERS /COMMERCIAL
Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer. Our model allows you to own your own office space as opposed to leasing. Steve Huffman shuffman@huffmandev.com 210-979-2500 Shawn Huffman shhuffman@huffmandev.com 210-979-2500 www.huffmandev.com
RC Page Construction, LLC (HHH Gold Sponsor) Commercial general contractor specializing in ground-up & interior finish out projects. Services include conceptual & final pricing, design-build & construction management. Single-source management from concept to completion ensures continuity through all phases of the project. Clay Page 210-375-9150 clay@rcpageconstruction.com www.rcpageconstruction.com
FINANCIAL SERVICES
Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor) Our mission is to help you enjoy a lifetime of financial security with greater certainty and clarity. Our outcomebased planning approach involves defining your objectives, creating a plan to maximize potential and inspiring action towards your goals. Fee-based financial plans offered at discount for BCMS members. Eric Kala CFP®, AEP®, CLU®, ChFC® Wealth Management Advisor | Estate & Business Planning Advisor 210.446.5755 eric.kala@nm.com www.erickala.com “Inspiring Action, Maximizing Potential”
Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@ aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”
e3 Wealth, LLC (HHH Gold Sponsor) Over $550 million in assets under management, e3 Wealth delivers truly customized solutions to individuals and businesses while placing heavy emphasis on risk minimization, tax diversification, proper utilization and protection for each client's unique financial purpose. Managing Partner Joseph Quartucci, ChFC® 512-268-9220 jquartucci@e3wealth.com Senior Partner Terry Taylor 512-268-9220 ttaylor@e3wealth.com Senior Partner Jennifer Taylor 512-268-9220 jtaylor@e3wealth.com www.e3wealth.com
Frost Leasing (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses. Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com “Commercial leasing for a doctor’s business equipment and vehicle.”
Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the
things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives. Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management” First Command Financial Services (HH Silver Sponsor) Nigel Davies 210-824-9894 njdavies@firstcommand.com www.firstcommand.com
GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time. Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration
HEALTHCARE REAL ESTATE SAN ANTONIO COMMERCIAL ADVISORS (HH Silver Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”
continued on page 38
visit us at www.bcms.org
37
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37
HOME HEALTH SERVICES Abbie Health Care Inc. (HH Silver Sponsor) Our goal at Abbie health care inc. is to promote independence, healing and comfort through quality, competent and compassionate care provided by skilled nurses, therapists, medical social worker and home health aides at home. Sr. Clinical Account Executive Gloria Duke, RN 210-273-7482 Gloria@abbiehealthcare.com "New Way of Thinking, Caring & Living"
HOSPITALS/ HEALTHCARE SERVICES
Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years. Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery. Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 www.swgeneralhospital.com “Quality healthcare with you in mind.”
Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com
38 San Antonio Medicine • March 2017
Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”
INFORMATION AND TECHNOLOGIES
Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system. Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.
INSURANCE
SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships. VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com SWBC Mortgage Jon M. Tober 210-317-7431 JTober@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services
TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”
Frost Insurance (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses. Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com “Business and personal insurance tailored to meet your unique needs.”
Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com
INSURANCE/MEDICAL MALPRACTICE
Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar
County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” The Doctors Company (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com. Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best.
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair. Keith Askew Market Manager kaskew@proassurance.com Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com
INTERNET/ TELECOMMUNICATIONS
Spectrum Business Class (HHH Gold Sponsor) When you partner with Spectrum Business Class, you get the advantage of enterprise-class technology and communications that are highly reliable, flexible and priced specifically for the medical community. Sales Leader Medical Market Rick Garza 210-582-9597 rick.garza@charter.com “Spectrum Cable Business Class offers custom pricing for BCMS Members.”
MARKETING ADVERTISING SEO
Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system. Rainey Threadgill 210-647-6350 Rainey.Threadgill@rainman.com www.henced.com Henced offers BCMS members custom pricing.
MEDICAL BILLING AND COLLECTIONS SERVICES Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San
Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”
MEDICAL SUPPLIES AND EQUIPMENT
Henry Schein Medical (HHHH 10K Platinum 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 percent to 50 percent.”
MERCHANT CARD/CHECK PROCESSING Firstdata/Telecheck (HH Silver Sponsor) We stand at the center of the fastpaced payments ecosystem, collaborating to deliver nextgeneration technology and help our clients grow their businesses. Sandra Torres-Lynum SR. Business Consultant 25 years of dedicated service 210-387-8505 Sandra.TorresLynum@FirstData.com ‘The true leader in the payments processing industry’
OFFICE EQUIPMENT/ TECHNOLOGIES
210-326-8054 WParker@dahill.com Major Account Executive Bradley Shill 210-332-4911 BShill@dahill.com Add footer: www.dahill.com “Work Smarter”
PAYMENT PROCESSING/ PAYROLL & HR SOLUTIONS Heartland Payment Systems (HH Silver Sponsor) Exclusively endorsed by 250 business associations, we strive to be your true business partner, offering simple solutions with simple pricing and a 3-yr rate lock. Territory Manager Merchant Service DeLisa McNair 210-215-0321 delisa.mcnair@e-hps.com Territory Manager Payroll/HR Rhonda Chadwick 210-421-7436 rhonda.chadwick@e-hps.com www.heartlandpaymentsystems.com
PAYROLL SERVICES
SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits. Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.
REAL ESTATE/ COMMERCIAL Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes. Major Account Executive Wayne Parker
SAN ANTONIO COMMERCIAL ADVISORS (HH Silver Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com
www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”
SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment. Shane Brown Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”
STAFFING SERVICES
Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”
To join the Circle of Friends program or for more information, CALL
210-301-4366 or email August.Trevino@ bcms.org VISIT www.bcms.org
visit us at www.bcms.org
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42 San Antonio Medicine • March 2017
RECOMMENDED AUTO DEALERS AUTO PROGRAM
• • • •
We will locate the vehicle at the best price, right down to the color and equipment. We will put you in touch with exactly the right person at the dealership to handle your transaction. We will arrange for a test drive at your home or office. We make the buying process easy! When you go to the dealership, speak only with the representative indicated by BCMS.
Ancira Chevrolet 6111 Bandera Road San Antonio, TX
Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX
Jude Fowler 210-681-4900
Esther Luna 210-690-0700
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Honda 14610 IH 10 W San Antonio, TX
GUNN Infiniti 12150 IH 10 W San Antonio, TX
GUNN Acura 11911 IH 10 W San Antonio, TX
GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209
Bill Boyd 210-859-2719
Pete DeNeergard 210-680-3371
Hugo Rodriguez and Rick Tejada 210-824-1272
Coby Allen 210-625-4988
Abe Novy 210-496-0806
Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216
Cavender Audi 15447 IH 10 W San Antonio, TX 78249
Cavender Toyota 5730 NW Loop 410 San Antonio, TX
Northside Ford 12300 San Pedro San Antonio, TX
David Espinoza 210-912-5087
Sean Fortier 210-681-3399
Gary Holdgraf 210-862-9769
Wayne Alderman 210-525-9800
Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230
Ancira Nissan 10835 IH 10 West San Antonio, TX 78230
Jarrod Ashley 210-558-1500
Jason Thompson 210-558-5000
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154
Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900
Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX Alan Henderson 210-681-6300 KAHLIG AUTO GROUP
Ingram Park Auto Center Dodge 7000 NW Loop 410 San Antonio, TX
Ingram Park Auto Center Mazda 7000 NW Loop 410 San Antonio, TX
Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX
Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX
North Park Subaru 9807 San Pedro San Antonio, TX 78216
Daniel Jex 210-684-6610
Frank Lira 210-381-7532
Richard Wood 210-366-9600
John Wang 830-981-6000
Mark Castello 210-308-0200
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257
North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211
North Park Mazda 9333 San Pedro San Antonio, TX 78216
North Park Lexus 611 Lockhill Selma San Antonio, TX
North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX
Stephen Markham 877-356-0476
Justin Boone 210-635-5000
Scott Brothers 210-253-3300
Jose Contreras 210-308-8900
Justin Blake 888-341-2182
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Lincoln 9207 San Pedro San Antonio, TX
North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257
Sandy Small 210-341-8841
James Cole 800-611-0176
Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.) San Antonio, TX
Porsche Center 9455 IH-10 West San Antonio, TX
AUTO PROGRAM
Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org
AUTO REVIEW
2017 Volvo XC 90 By Steve Schutz, MD
North American Truck of the year, Motor
Billion, if they had kept the original XC 90
ular upstarts keep their proverbial heads
Trend SUV of the year, Sunday Times Top
platform, updated the engines and transmis-
down.
SUV and 4x4, IIHS Top Safety Pick, and on
sions, and completely re-done the interior.
As hinted at above, the previous XC 90
and on. And that’s just in the U.S. The latest
My sense was that there wasn’t anything
had an unimpressive interior. While the lay-
Volvo XC 90 has also wowed the automotive
wrong with the old XC 90 that those
out and tech were fine, the materials left
press in Europe and around the world since
changes wouldn’t have fixed.
something to be desired. I owned a first gen
it launched spectacularly in 2015. Still, while
Still, while the new XC is bigger and has
XC 90 for many years and loved it, mostly,
I know it’s kind of a big deal, as they say, I
very attractive and sleek styling, it doesn’t
but intermittent rattles and continual inte-
needed to experience it to see what all the
look that much different from the old one.
rior material degradation were very discour-
fuss was about.
The proportions are similar, as are the very
aging. Owners of the new XC 90 will
Candidly, at first I thought it was just a
Volvo-esque grille, bulbous beltline, and
experience neither of those downers. From
reskin of the original XC 90, which it’s not.
(highly) vertical taillights that extend up to
the headliner to the dashboard to the gauges,
Instead it sits on an all new platform that
the roofline. Designwise, the new XC 90
everything you see in the XC 90 is high
adds 5 inches in wheelbase, 6 inches in
doesn’t take any risks, instead following the
quality. And it features materials that feel as
length, and 4 inches in width to the origi-
Audi Q7 into the land of understatement.
substantial as they look. Obviously, Geely
nal’s dimensions. Given how expensive
Which is OK with me, by the way. As luxury
heard the feedback from owners of the old
things are these days, I wouldn’t have blamed
crossovers push past luxury sedans in the
XC 90 and made corrections. Lots of them.
Geely, the Chinese conglomerate that
hearts and minds of well-heeled customers,
Naturally, the larger platform means
bought Volvo from Ford in 2010 for $1.8
it probably makes sense to have those vehic-
there’s more space for people and gear in the
44 San Antonio Medicine • March 2017
AUTO REVIEW
XC 90. The extra width provides a less
gine that produces 250 HP and is available
call to BCMS’s own Phil Hornbeak will get
“cozy” seating experience behind the wheel,
with either front- or all-wheel drive (AWD).
you all the information you need.
and the longer wheelbase translates into
All XC 90s come with an eight-speed auto-
The new Volvo XC 90 is a thoroughly
some additional foot room for backseat pas-
matic transmission, and all models above the
modern luxury crossover SUV that deserves
sengers. The third row is more spacious too,
T5 have AWD. The XC 90 T6 comes with
the many awards it has won. Good looking
but honestly, anyone over 12-years-old
a clever 316 HP 2.0-liter four-cylinder en-
and boasting an elegant Scandinavian inte-
should probably avoid going back there. At
gine that is both supercharged and tur-
rior, Volvo’s best-selling vehicle should be
least Volvo has made moving the second row
bocharged(!). The XC 90 T8 Plug-In Hybrid
considered by any BCMS member looking
seats out of the way easier so the kids can get
utilizes the same engine as the standard T6
for something with three rows of seats and
back there more quickly.
but adds an 87 HP electric motor for a total
excellent safety.
The XC 90 comes with safety and driver
of 400 HP. With a 240-volt charging station,
assistance features galore, as you’d expect in
fully recharging the battery takes only about
any Volvo. Frontal collision detection with
2.5 hours.
If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.
automatic braking is standard, and that sys-
The T8 is undoubtedly very high tech,
tem is sophisticated enough to brake when
but upgrading to that version of the XC 90
Steve Schutz, MD, is a
a driver tries to turn into the path of an on-
costs an additional $19,000 more than a
board-certified gastroenterolo-
coming car. Auto-steering is there to help
comparable T6 model (which starts at
gist who lived in San Antonio
keep the XC 90 in its lane, and Pilot Assist
around $50,000). I predict a low take rate
in the 1990s when he was sta-
II, new for 2017, provides semi-autonomous
for the T8.
tioned here in the U.S. Air
driving at speeds up to 80 mph.
Space constraints preclude me from dis-
The base model XC 90 T5 is powered by
cussing the various option packages and
a turbo-charged 2.0-liter four-cylinder en-
other add-ons available for the XC 90, but a
Force. He has been writing auto reviews for San Antonio Medicine since 1995.
visit us at www.bcms.org
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46 San Antonio Medicine • March 2017