San Antonio Medicine March 2020

S A N A N TO N I O

IN THIS ISSUE Primary Care Physician Issues - From MDs & DOs • BCMS Legislative Reception Honoring State Senator Jose Menendez • 2020 GMC Acadia

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Primary Care Physician Issues – From MDs & DOs

The Evolution of the Primary Care Physician

By John J. Seidenfeld, MD .................................12 The Future of Primary Care

By Ramon Cancino, MD, MS .............................16 Recruiting Internal Medicine Residents to Primary Care

By Ambili Ramachandran, MD, MS, FACP .........20 Do Healthy People Have a Meaningful Relationship with their PCP?

By Arti Thangudu, MD........................................24 Primary Care for All By Alexa Arastoo, DO, Medical Resident, UIW School of Medicine .....................26 “Nannie’s Story” - One Doctor’s Journey to Addressing Health Disparity

By Melissa A. Walker, DO.....................................28

BCMS President’s Message ........................................................................................................................8 BCMS Alliance ..........................................................................................................................................10 BCMS Legislative News ............................................................................................................................30 Book Review: The Swerve: How the World Became Modern By Stephen Greenblatt, Review by J.J. Walker, MD ......................................................................................................................32 BCMS Circle of Friends Physicians Purchasing Directory............................................................................34 Recommended Auto Dealers......................................................................................................................39 Auto Review: 2020 GMC Acadia By Steve Schutz, MD ............................................................................40

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San Antonio Medicine • March 2020

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MARCH 2020

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VOLUME 73 NO. 3

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

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

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San Antonio Medicine • March 2020

Jayesh B. Shah, MD, TMA Trustee Ramon S. Cancino, MD, Medical School Representative Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Stephen C. Fitzer, CEO/Executive Director (ex-officio)

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

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

PRESIDENT’S MESSAGE

Taking the Physician Out of Primary Care

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

In the hierarchy of medicine, primary care physicians (PCPs) are the point of the spear. Included in this group are those with a pureoffice practice, hospitalists, and those who work in an office and make hospital rounds on their admitted patients. These are the physicians who guide the care of patients by providing direct patient care and by arranging for appropriate consultation by others, including specialists in a number of different fields. In popular culture they are depicted as doctor Marcus Welby, or more recently, as Dr. Gregory House in the series House. They represent the consummate physician; one who has knowledge of not only the patient’s medical condition, but also their psychology and their social situation.

Traditionally, PCPs are the leaders of the patient care team. They are the first to collect historical data on the patient including symptoms, medications, past medical history, and a review of systems.

These physicians perform the first physical examination and collect appropriate radiologic and laboratory data. This information then provides the basis for the treatment program. PCPs are linchpins in the patient’s medical experience; they provide a buffer from the sterile aspects of in-hospital care; they are the conduit through which all aspects of the patient’s medical care are funneled. Not only does the primary care physician admit the patient to the hospital, but their diagnostic workup is the basis for the program of care provided. All medication orders, laboratory data, radiologic studies, and consultant reports should be reviewed by the primary care physician in order to assure that appropriate care for the individual patient is being provided. If surgical intervention is necessary, the PCP is often an assistant in the operating room.

Recently however, the letters “PCP” no longer stand for primary care physician. Their meaning has now been altered to mean primary care provider. This alteration represents a decrease in the importance and stature of the primary care physician. Much of what 8

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these highly-trained physicians do is now being done by nurse practitioners and physician assistants. A further variation in this job title dilutes the necessity of medical knowledge even more as these physicians may even be called primary care managers. Thus, the medical aspects of this position may be reduced when the “manager” must incorporate business into the delivery of medical care.

If this trend is allowed to continue, those who provide primary care will no longer need to be physicians. They will morph into someone who provides a recommendation for patient care. That recommendation will be modified and then instituted in its new form by the actual primary care manager.

If we as physicians do not preserve our role as leaders in the direction of the medical care of each patient, we will be relegated to a responsibility of suggesting medical care. Even now the payors seek to replace primary care physicians with other lesser trained medical professionals. While this is only a change in title at this point, there is the risk of a real change in qualifications in the near future. Even now, the bedside nurse often has more contact and direction from so called mid-level providers. All physicians are now seen as less valuable by payors, while those who provide primary care are at the greatest risk. In the future, even those physicians who perform procedures may be at risk. If we as physicians are to continue to provide the highest level of care to our patients, we must be the leaders in the decisions regarding that care.

The Bexar County Medical Society and the Texas Medical Association fight for physicians every day to ensure the best medical care for all patients. Every physician should join the effort to educate patients, the public and the legislature of what is best for patient care.

Gerald Greenfield, MD is an Orthopedic Surgeon in Bexar County and is the 2020 President of the Bexar County Medical Society.

BCMS ALLIANCE

By Jennifer Lewis

Cannon and I, along with our 4 children, settled back in San Antonio in the summer of 2012, after 14 years of service in the Air Force. Between his medical training and Air Force assignments, we moved from residency in San Antonio to Connecticut, Mississippi, back to San Antonio, overseas to Italy and finally to Virginia. With all of our extended family living throughout Texas, we decided San Antonio was home and made arrangements to begin civilian life here.

When it was time for us to transition away from military life, I felt lost as to how to make connections without the military bond.

We immediately signed the children up for our neighborhood swim team. Through one of those neighbors, I met Rena Baisden, who immediately told me about the Bexar County Medical Society Alliance, and began inviting me to luncheons and socials. I’m eternally grateful to Rena for being bold and inviting me. And I’m glad I said “yes”.

As I would come to find out, Rena has encouraged many medical spouses to join our organization over the years. She has served in many leadership roles within the Alliance. In 2013, she was on the Nominating Committee and called to ask if I would consider taking a position on the Executive Board. I said “yes”, and was slated to Vice President of Civic and Philanthropic, our community health committee. I can’t imagine my life in San Antonio, or in Texas for that matter, without the connection and encouragement that comes 10

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from my association with the Alliance.

Because of Rena’s influence, I have made it my habit to reach out and invite medical spouses who may not know the full benefit of membership. Often, it takes multiple invitations, or invitations by more than one of our members, before a person realizes the potential for themselves in our organization. That’s okay. I feel confident that what we have. The work that we do for our community, the effect we have on legislation that impacts the way medicine is practiced and valued in Texas, and the bonds of friendship because of our common mission are invaluable and timeless. I believe that if your family member (spouse, mother or father) is a physician, then, like military family members, you also serve the community through your sacrifices and support of that medical provider.

So, to all of the families in the Family of Medicine, I want to say “Thank you for your service.” The Alliance is here for you. If you are not a member, consider this your invitation. Please say “yes”.

If you are a member, be bold! Extend an invitation to others to join us at a social, general membership meeting, or community service project. Ask more than once. You never know when the timing will be just right.

Jennifer Lewis BCMSA Past President, 2016 TMA Alliance VP Membership, 2019-2020

PRIMARY CARE PHYSICIANS

The Evolution of the Primary Care

Physician

By John J. Seidenfeld, MD

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PRIMARY CARE PHYSICIANS Max Z (for Zenith) Cahan was a big pleasant man. He was a pharmacist for a time before he trained as a doctor. His office was on the poor side of the town I grew up in. The waiting room was small and always crowded with patients of all colors, sizes, and shapes.

Along the walls were pictures of the hundreds of infants he had delivered over many years of practice. My picture was among those. At the reception desk sat his wife Ida who was also patient, polite, pleasant, efficient, and helpful. Though we went to the office for care, he also came to our house with his black bag in times of need or we met him at his house where he had a basement office. His care got me through strep throat infections, sinusitis, pneumonia, and other illnesses and injuries. When my father had a near fatal heart attack, Dr. Cahan consulted with other doctors and got him back to health before the days of catheterizations and CABG. We were privileged to be treated by him and blessed to know him and his family as friends.

When I became interested in medicine, he allowed me to follow him on rounds to observe as he performed minor procedures such as suturing lacerations. On first witnessing such a procedure, he noticed when I became faint and got me into a chair without commenting on my feeble behavior. He was always a respected, trusted, and loyal advisor but he rarely spoke unless asked a specific question and then he only gave the answer requested without euphemism or belittling. Lives such as his in solo practice were later idealized on television shows such as Marcus Welby (if you are under 50, Google it).

Later encounters with primary care doctors have gone well because of my early experience. When I tore the right medial meniscus during Internal Medicine internship due to a basketball injury, the orthopedist at the University of Iowa advised that he had a similar injury and would have an operation only if the pain was unremitting, the swelling persistent over a long period, or the knee locked into place. That was “primary care advice” which I follow to this day.

Years later when I noted severe hip pain, my internist, Dr. Heberto Garza Jr., found evidence of aseptic necrosis of the femoral head. Hip replacement surgery was planned after risk assessment. Dr. Garza was with my family and me throughout the procedure and lined up an excellent surgeon and post op resources.

Physical therapy and occupational therapy were advised and led to a very good outcome. We respect and trust the doctor because he listens to our questions, offers helpful advice, and shares concerns and recommendations. He skillfully cares for our problems. He exhibited the basics of primary care by following the progress and

treatment of my condition from start until this day. It is a tremendous help and consolation to know that a skilled professional will be with you in difficult times.

Traits which I value and admire as a practitioner and patient are a focus on the patient’s concerns, ethical decision making, use of guidelines in care recommendations, and use of artificial intelligence to supplement diagnostic and therapeutic acumen. The concepts of a medical home or primary care doctor who oversees and coordinates care, a focus on prevention and interest in community health, and a socially, just perspective are essential to consider.

Detrimental events

Since the middle of the 20th century in America certain events have greatly affected delivery of care. These include the use of the electronic medical record as a claims payment tool as opposed to the chronological complete medical record and work tool that was originally suggested and envisioned. Often the doctor and nurse of today are turned from the patient to watch a nearby video monitor rather than listening and watching during the all-important patient history. By facing away from the patient, we may lose the eye-toeye contact along with critical information of gestures and “body language”. Most records are not interactive so that consultants and primary care doctors are unable to share historical information.

How many times have you filled in a medical history form?

The cost of health care and methods of payment have reached crisis levels. According to some experts, more than 80 million Americans are under-insured, uninsured, or have significant coverage gaps today1. Regular switching of health plans by employers leads to discontinuous care and loss of a regular trusted primary care doctor.

Fraud and abuse have become constant additions to medical costs.

Medical care expenses are the primary cause of bankruptcies today2.

Even for those with insurance, the cost of procedure and pharmaceutical copayments and deductible expenses are excessive. Uwe Reinhardt3, a noted health care economist when asked what was wrong with our health care system famously replied, “it's the costs, Stupid”. When we look at Wennberg’s atlas4 and compare Medicare charges around our country, one is bewildered to make sense of economic variation.

The industrialization of medical care tells us to see patients faster and more often. Instead of doing two procedures in one visit, the incentives favor two visits. Instead of taking a complete medical history, we are encouraged to rush patients through. Time pressure may work for widget production but is rarely successful in developing respectful trusting relationships and getting a complete medical evaluation. Doctors are urged to do what they do best by continued on page 14

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continued from page 13 fragile doctor-patient relationship. Possible interventions to consider include mandatory community service for recent allopathic and osteopathic medical graduates in exchange for tuition assistance, regional health care resource allocation, fair drug pricing, incentives for graduates to choose primary care careers, payor reform aimed at reducing cost siphoning, negotiation of drug pricing by large providers such as Medicare and Medicaid, and a more socially just approach to our current system.

Conclusion

administrators whose main interest is not in doctor-patient relationships and who are judged by the bottom line they produce.

The current system promotes duplication of services, duplication of facilities such as hospitals in urban areas, over-utilization of expensive laboratory and diagnostic facilities, and enumeration of procedures which had been bundled together in the past. Recently, Medicare noted that the state with the most expensive comparative procedures was Louisiana (a fine state but unexpected in this category as basic costs are much lower than in more populous states)5.

Hospitals down the street from one another compete for the highest technology while rural hospitals go out of business. While rural areas have few practitioners, the cities have duplication in nearly every specialty.

Baby boomer retirements are at a high point and the number of primary care doctors “birthed” each year are inadequate to handle the patient load. Primary care residency programs often recruit foreign medical graduates because US graduates seek higher paying specialties in order to repay loans and improve lifestyles. Our incentives favor this imbalance and will only worsen as costs for medical education rise.

What suggestions do I have to improve health care in the US? We must get involved in organized medicine and push for solutions to problems which impair patient care. As our “primary care home” burns, we must seek alternative “fire quenching” approaches. We must add our voices to those calling for a solvent medical care system with fair distribution of resources, a prevention and community focused approach, and a rebuilding of the 14

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Dr. Cahan and his wife have both passed at this time. I visit their graves whenever I visit those of my parents and family. Memories of their kindness has not faded. It hardly seems fair that “indispensable people” die but they do. The graves are marked by simple stones and in no way would a casual viewer know of the greatness buried there.

I am a hopeful person. As a medical student recently told me, the way to the future is through “donating, voting, and volunteering”. These actions may not lead to revolutionary change, but incremental change is a more lasting alternative. My fervent hope is that all my colleagues, current students, and aspiring doctors will donate, vote, and volunteer in a way that leads to a return to primary care as the medical home it should be for our patients.

John J. Seidenfeld, MD is a board-certified specialist in pulmonary diseases and internal medicine, is an Associate Professor of Clinical and Basic Sciences Education at UIW School of Osteopathic Medicine, is currently the Co-Chair of the BCMS Publications Committee, and is a long-standing member of the Bexar County Medical Society and the Texas Medical Association.

References

1. https://www.commonwealthfund.org/publications/issuebriefs/2019/feb/health-insurance-coverage-eight-years-after-aca 2. https://www.debt.org/bankruptcy/statistics/ 3. Uwe Reinhardt, PhD. What Level of Health Spending Is “Affordable”?JAMA. 2017;318(19):1869-1870. doi:10.1001/jama.2017.16187 4. Wennberg, JE. Tracking Medicine: A Researcher’s Quest to Understand Health Care. Oxford. Oxford University Press.

2010. November 21, 2017 5. https://www.healthinsurance.org/louisiana-medicare/

PRIMARY CARE PHYSICIANS

The Future of

Primary Care

By Ramon Cancino, MD, MS

ince its inception, primary care focused on patient-centered treatment and prevention. From the “generalist” of the 1800s who made house calls on horseback, to the 1960s post-WWII era primary care physician working alongside subspecialties, to this generation’s health care and population health experts, primary care, more than any other specialty, has been consistently both the product of and the solution to the period’s health care needs.

Today’s primary care physicians have seen major changes in both health care structures and incentives. Compared to the past physicians who focused on episodic care for acute issues, primary care physicians mainly focus on chronic disease management and prevention. Nationally, there is movement towards innovative care delivery and alternative payment models, such as value-based contracts.

Health care spending is part of the daily national conversation.1 There is emphasis now on both productivity as well as high-value outcomes. Patients can instantaneously give feedback about their health care experiences. As a result of both political involvement and feats of technological innovation, primary care is evolving rapidly.

Cultural, technological, and political shifts in medicine are often magnified in Texas and felt first in the medical specialty of primary care. San Antonio’s primary care physicians are experiencing the effects of the nation’s shift towards high-value care; a movement that originated from the earliest days of the primary care disciplines.

When there is both emphasis and incentive to increase high quality care and decreasing avoidable unnecessary health care costs, care delivery models are not the only ones that change; cultures, values, and practice models change. As a result, the future for primary care looks both bright and challenging at the same time.

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More team-based care and collaboration. The Patient-Centered Medical Home initiatives emphasize the importance of team work towards common goals and there is strong evidence that teambased care can improve outcomes for patients and decrease burnout among clinicians.2,3 Many value-based contracts will drive practices to allocate more physician time towards managing highly complex patient populations. Depending on patient need, more team members, such as physician assistants, nurse practitioners, case managers, nutritionists, and behavioral health consultants, are needed to manage these patient populations in partnership with physicians. Licensed professionals such as physician assistants and nurse practitioners are likely to play a greater role in diagnosing and treating patients. Delegating more tasks to well-trained staff will also save time and improve efficiency.4 At the same time, primary care physicians will need to partner and align incentives with specialist colleagues in order to deliver truly high-value care to patients.

Enhancements to traditional primary care visits and continued reliance on traditional primary care patient-physician relationships. Primary care’s focus includes preventing diabetes, hypertension, myocardial infarctions, and strokes. At the same time, we must all strive to help patients prevent avoidable urgent care, emergency room, and hospital utilization events. This activity is important to value-based contracts and can influence the total cost of care attributed to a practice. Primary care practices focus on population health and complex case management – proactively identifying patients at risk for avoidable hospital utilization and creating care plans to interact with them more often. At-risk patients often have a history of previous multiple hospitalizations, high social de-

PRIMARY CARE PHYSICIANS

terminants of health needs, or history of medication non-adherence. Practices also ensure access for patients is available when they need it. For example, many practices offer “same-day” appointments for patients for both convenience as well as to prevent patients from utilizing expensive emergency rooms for ailments that can be addressed better by the primary care physician (so called, ambulatory care sensitive conditions). Further, especially for older patients, population health management procedures ensure patients are regularly assessed to prevent avoidable hospitalizations – these procedures include annual wellness visits, chronic care management, and transitional care management encounters to prevent re-hospitalizations. As a foundation to these activities and in keeping with tradition, primary care physicians develop relationships with patients as a context for the care that is being provided. The patient-physician relationship is important and can lessen risk of medication nonadherence or loss to follow-up. However, patients are increasingly seeking primary care in non-traditional settings, such as in retail clinics and through app-based services such as Doctor on Demand.5 This generation’s patients often indicate ease of access, above all else, is a major component of what they look for in a health care provider.

Increasing number of employed physicians nationally but many are looking towards alternative models to deliver care independently. A 2015 report from the consulting firm Accenture forecasts that the percentage of physicians in independent practice would decline from 57% in 2000 to 33% by the end of 2016. Most are joining hospital practices, citing familiar reasons: reimbursement pressures and overhead costs. Other primary care physicians are

looking for ways to maintain autonomy. One method is the Direct Primary Care (DPC) model. This model utilizes a membershipbased alternative payment model in which patients, employers, or health plans pay primary care providers flat, simple, periodic fees directly for unlimited access to primary care and prevention services in a medical home environment.6 Today, about 1,000 DPC practices in 48 states provide primary care to over 300,000 American patients.

Similarly, an increasing number of physicians are forming concierge medicine practices; most are general internists and about 20% are family medicine physicians.7 Many community physicians, who want to remain independent, may choose to create loose affiliations with others to take care of patient populations in the form of an ACO and to negotiate contracts with payers.

Value-based care delivery models. Value-based care delivery models are being implemented across the country. This model of care delivery, different from productivity-driven fee-for-service models, align work with outcome, quality and cost metrics for specific patient populations. Often practices do this because commercial, state, and federal contracts provide value-based incentives for achieving quality, patient experience, and/or cost-saving thresholds.

The model relies on primary care done well in order to be successful. Thus far, the national accountable care models, though far from perfect, have demonstrated cost savings. For example, between 2013 and 2016, Medicare Shared Savings Plan ACOs saved CMS $2.66 billion dollars with a net savings of $665.8 million after accounting for incentive payments. Purchasers are also looking to primary care as a solution to employer-based health care.

Challenges primary care will face

Payments should support resources needed for successful value-based care delivery, including fully recognizing the value of non-face-to-face work. Many outpatient staffing benchmarks, such as MGMA, were determined by fee-for-service practice models that depended on face-to-face encounters to measure work. Preventive and population health management activities are often done without face-to-face visits but are of high value and the result of high cognitive activity. The challenge will be to measure and incentivize work based on true value rather than merely face-to-face visits and procedures.

Medical student debt and primary care shortages. Although not the only reason students choose other specialties, higher pay and lifestyle preferences lead many students to choose non–primary care fields even when their hearts are in primary care.8 One study demonstrated that graduates of public medical schools are deterred from choosing the primary care specialty due to high educational debt.9 This can result in a supply of primary care physicians that continued on page 18 visit us at www.bcms.org

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continued from page 17

will not meet the demands of many communities. Texas has significant shortages in primary care physicians, especially in many rural areas.10 Strong primary care physician mentorship and positive experiences in high-functioning primary care practices are the solution.

As value-based contracts link financial incentives to work done mainly in primary care practices, primary care compensation will need to increase proportional to this activity.

Burnout. One study has demonstrated that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent each clinic day on patient care-related electronic health record and administrative work. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.11 Between 40% and 50% of the primary care physician workforce are experiencing burnout.12 Many factors associated with burnout can be improved: lack of control over workload, inefficient teamwork, insufficient documentation time, chaotic work atmosphere, and excessive EHR time at home.13 This challenge will need to be tackled by health systems, physician leaders, and perhaps technology upgrades in years to come.

physicians will find themselves in positions of leadership because of their focus on patient-centered care, patient experience, and timely access. As a result, training physicians in leadership and management will be integral to the overall success of our health care system.

Technology and Innovation. Health care data volume has seen a growth rate of 878% since 2016.14 The number of medical practices that do not use some sort of electronic health record is shrinking. Mobile device capability to collect, store, and transmit health-related information is growing. For example, telehealth billing grew 53% from 2016 to 2017 and one estimate shows that, by 2024, 15% of all evaluation and management visits will occur virtually.15 A number of technology start-ups and large established technology leaders are getting into the health care field. Google Health recently partnered with Ascension, a large non-profit hospital system.16 Recently, leaders of Amazon, Berkshire Hathaway, and JPMorgan Chase formed Haven Health Care. Multiple organizations are taking medical dictation to new levels by including voice to text recognition in the exam room.17 Lastly, the next generation of health care users demand access and convenience in all services, including health care.

Surveys have demonstrated that 71% of millennials want to schedule appointments from phone apps and that 60% of this generation want virtual options for their health care.

Primary care practices, to stay ahead of the curve, need to assess how technology will help them meet future patient expectations.

Primary care is the past, present, and future of health care.

Opportunities

Primary Care physician leadership and mentorship in highvalue, patient-centered care. Primary care physicians will need to lead the discussion, planning, implementation, and evaluation of health care. The trust a patient will build with a practice or hospital system will be contingent upon the model that is developed to support that patient in maintaining his or her health. More primary care 18

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The primary care practice at UT Health Physicians uses evidence from the past to help us position ourselves well for the future. Utilizing a fully integrated electronic health record, the primary care physicians work closely with Health IT and Quality departments to make sure all patients receive high-value care. Many patients receive clinical pharmacy, behavioral health, and care management services based on their need.

If an ACO patient goes to the hospital, there is a smooth transition from hospital to home with care management services. In addition to a proactive primary care model which utilizes both centralized and embedded resources to ensure patients are receiving the best expert care possible, patients have access to an online patient portal where they can communicate directly with their medical home. Investment in future technologies such as video visits increases pa-

PRIMARY CARE PHYSICIANS tients’ ability to access primary care services from home. Increasingly, research and education efforts are being used to train the future leaders of primary care and medicine. For example, primary care residents at UTHSA learn about value-based care strategies in a month-long rotation. Our organization has a long-standing history of being at the forefront of primary care delivery, and we are training this community’s future physicians to carry on that legacy.

The stories of the doctor traveling house-to-house to see patients is not too far off from the reality of today, because the spirit of primary care remains true. Today’s primary care physicians, like those of the past, have a deep-seated interest in ensuring the full health of patients. To accomplish that goal is one of both art and science and built upon a trusting relationship that recognizes the uniqueness of each and every individual. The future of health care is primary care, because successful high-value care delivery very much depends on that focus.

Ramon Cancino, MD, MS is the Primary Care Center Director at UT Health Physicians and a member of the Bexar County Medical Society

References 1.

Hartman M, Martin AB, Benson J, Catlin A. National Health Care Spending In 2018: Growth Driven by Accelerations In Medicare And Private Insurance Spending. Health Aff (Millwood). 2019;39(1):8-17. doi:10.1377/hlthaff.2019.01451.

2. Nelson KM, Helfrich C, Sun H, Hebert PL, Liu C-F, Dolan E, Taylor L, Wong E, Maynard C, Hernandez SE, Sanders W, Randall I, Curtis I, Schectman G, Stark R, Fihn SD. Implementation of the Patient-Centered Medical Home in the Veterans Health Administration: Associations With Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and Emergency Department Use. JAMA Intern Med. 2014;174(8):1350. doi: 10.1001/jamainternmed.2014.2488.

3. Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaen CR. Journey to the Patient-Centered Medical Home: A Qualitative Analysis of the Experiences of Practices in the National Demonstration Project. Ann Fam Med. 2010;8(Suppl _1):S45-S56. doi:10.1370/afm.1075.

4. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21(6):23-29.

5. Where is the future of primary care headed? Medical Economics. https://www.medicaleconomics.com/medical-economics/news/where-future-primary-care-headed.

Published January 10, 2017. Accessed January 31, 2020.

6.

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Direct Primary Care. direct-primary-care. https://www.dpcare.org. Accessed February 2, 2020.

Dalen JE, Alpert JS. Concierge Medicine Is Here and Growing!!

Am J Med. 2017;130(8):880-881. doi:10.1016/j.amjmed.

2017.03.031.

Zabar S, Wallach A, Kalet A. The Future of Primary Care in the United States Depends on Payment Reform. JAMA Intern Med. 2019;179(4):515-516. doi:10.1001/jamainternmed.

2018.7623.

Phillips JP, Petterson SM, Bazemore AW, Phillips RL. A Retrospective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States. Ann Fam Med. 2014;12(6):542-549. doi:10.1370/afm.1697.

Section 1: Ensure an Adequate Health Care Workforce. https://www.texmed.org/Template.aspx?id=24400. Accessed February 2, 2020.

Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, Westbrook J, Tutty M, Blike G. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.

Ann Intern Med. 2016;165(11):753-760. doi:10.7326/M16-0961.

Advisory Board. Physician burnout in 2019. http://www.advisory.com/daily-briefing/2019/01/18/burnout-report. Published January 18, 2019. Accessed February 2, 2020.

Olson K, Sinsky C, Rinne ST, Long T, Vender R, Mukherjee S, Bennick M, Linzer M. Cross-sectional survey of workplace stressors associated with physician burnout measured by the Mini-Z and the Maslach Burnout Inventory. Stress Health J Int Soc Investig Stress. 2019;35(2):157-175. doi:10.1002/smi.2849.

HITInfrastructure. Organizations See 878% Health Data Growth Rate Since 2016. HITInfrastructure. https://hitinfrastructure.com/news/organizations-see-878-health-datagrowth-rate-since-2016. Published May 8, 2019. Accessed February 2, 2020.

Telehealth up 53%, growing faster than any other place of care.

American Medical Association. https://www.amaassn.org/practice-management/digital/telehealth-53-growingfaster-any-other-place-care. Accessed February 2, 2020.

Ascension News. https://www.ascension.org/News/News-Articles/2019/11/11/19/51/Ascension-and-Google-working-together-on-healthcare-transformation. Accessed February 2, 2020.

Kumah-Crystal YA, Pirtle CJ, Whyte HM, Goode ES, Anders SH, Lehmann CU. Electronic Health Record Interactions through Voice: A Review. Appl Clin Inform. 2018;9(3):541-552. doi:10.1055/s-0038-1666844. visit us at www.bcms.org

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Recruiting Internal Medicine Residents To

Primary Care

By Ambili Ramachandran, MD, MS, FACP

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here is a well-known looming shortage of primary care physicians. The American Association of Medical Colleges estimates that the US will face a shortage of up to 55,200 primary care physicians by 2032. Internal medicine physicians are well-trained to provide primary care to adults with complex medical conditions and the aging baby boomer population will supply plenty of such patients. However, fewer internal medicine residents are choosing to practice as primary care physicians.

Studies have examined why fewer internal medicine residents are choosing primary care careers. Residents are more likely to enter primary care if they reported good continuity of care with their patients in their resident clinic and satisfaction with their continuity clinic experience. Unfortunately, many internal medicine residency clinics struggle with insufficient healthcare resources while trying to care for low-income, underserved patient populations with medically and socially complex conditions. Continuity of care can be challenging to achieve due to the intricacies of resident training schedules and residents often are burdened with trying to complete administrative tasks on their own. A survey of residents found that a poor resident continuity clinic experience can eliminate interest in general medicine that previously existed during their intern year.

Residents are also more likely to choose primary care if they had primary care role models among their attendings. Conversely, a lack of role models can make residents, who were initially inclined toward primary care, reconsider their choice. In academic settings, there are few physicians who practice full-time primary care since most general medicine faculty physicians have other academic responsibilities such as teaching, precepting, and administrative roles.

Resident training opportunities in the community, rather than exclusively in the academic medical center, are associated with a greater likelihood of entering primary care.

Additionally, residents cite having expended, dedicated outpatient time and a variety of outpatient experiences in non-resident clinics as reasons why they maintained an interest in primary care. They also acknowledge the importance of primary care mentors and a peer group of residents who share an enthusiasm for primary care as important encouragements to remain in primary care.

One approach residency programs have used to recruit and retain residents in primary care career paths is through primary care training programs (PCTPs). PCTPs are options within categorical internal medicine residency programs where residents gain additional training in primary care by way of resident schedules and curricula. PCTPs emphasize outpatient medicine and preparation for primary care practice, and graduates of PCTPs are consistently more likely to pursue careers in general medicine than graduates of categorical programs.

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Description of the UT Health San Antonio (UTHSA) Ambulatory Track

In 2017, the UTHSA residency program launched its Ambulatory Track to prepare more residents for careers in primary care. Residents apply to the Track at the midpoint of their second year of residency (before many residents start preparing applications for specialty fellowships) and then spend the majority of their final year of residency in the outpatient setting, giving them extended, dedicated time in clinic instead of the hospital. It was designed to address some of the reasons why residents do not pursue careers in general outpatient medicine.

Increased time in primary care: This categorical residency program is structured on a 4+1 schedule where residents are on a rotation such as hospital wards for 4 weeks followed by outpatient clinic for 1 week. Such X + Y schedules are increasingly popular among residency programs and succeed in removing the competition between inpatient and outpatient responsibilities on a single day. Still, they can make continuity between resident PCPs and their patients more challenging since patient needs do not arise neatly every 5 weeks. The schedule also makes it harder for residents to develop that sense of ownership of their patient panel that comes from being in clinic on a weekly basis. In contrast, in the Track, residents come to their continuity clinic 2-3 half-days every week. Residents can develop better longitudinal relationships with their patients and can accommodate a larger panel of patients since they offer more appointments. Residents also have more opportunities to see same-day or urgent care visits, which is an important skill for a primary care provider to develop. Overall, residents gain practice and more “reps” at taking care of patients in a primary care setting, allowing them to develop greater ability and confidence in general outpatient medicine.

Alternate primary care sites: In addition to their resident continuity clinic site, residents have a second continuity clinic at least half of the year. The goal is to expose them to different practice models that exemplify the qualities of a high-functioning, patientcentered medical home. The program partners with a Medicare managed-care group in San Antonio that demonstrates the principles of team-based, high-value care. It also places residents in the VA’s community-based outpatient clinics (CBOCs) to work with a different patient population and health care system. Physicians in these practices also serve as role models who have chosen a career in primary care in non-academic settings and are professionally satisfied and successful.

Primary care clinical knowledge: By the end of residency, most residents are well-versed in inpatient management skills and feel ca-

pable of starting work as a hospitalist upon graduation, if they choose not to specialize. Conversely, many of the concerns that patients bring to their PCPs are not covered thoroughly in a typical internal medicine residency curriculum and residents lack confidence that they could adequately manage a rash, shoulder pain, or contraception. Therefore, all residents in the Track rotate through specialty clinics to equip them with the clinical knowledge they would need as PCPs: sports medicine clinic, skin clinic, gynecology clinic, and diabetes clinic. These rotations give residents a greater volume of exposure and more in-depth training from expert physicians than can be offered in the standard resident continuity clinic.

Preparation for practice: Residents entering primary care practice need to understand the changing landscape of health care financing and delivery. Therefore, all residents in the Track participate in a Health Improvement System rotation run through the UT Health Primary Care Center. Residents are introduced to topics such as value-based care, population health, patient experience, and accountable care organizations, and they contribute to an ongoing clinic-based quality improvement project. At the end of the rotation, residents have stated that they better understand how a healthcare organization is run and are more prepared to be physician leaders in their future roles. They are able to effectively compare future jobs knowing what resources they should expect to support their practice and how their performance will be measured and compensated.

Electives: When practicing the full breadth of primary care, it is essential to be familiar with the diagnosis and management of the wide spectrum of medical conditions. This breadth can be intimidating to residents otherwise drawn to this career. It can also be interesting for a primary care physician to develop a niche area of expertise, such as treating chronic hepatitis C infection or substance use disorders. The Track therefore offers many elective rotations in the traditional medical specialties, such as pulmonology, hepatology, and HIV and infectious diseases. Track residents can even design their own elective. For example, this year a resident designed a rotation in jail medicine through the Detention Health Care Services of the Bexar County adult detention center.

Results: Last year, all three of the graduating Track residents chose careers in full time primary care in Texas. This year, another four residents are taking jobs as primary care physicians while the remainder are pursuing fellowships in geriatrics, endocrinology, and addiction medicine. Another four residents will start the Track next year. By comparison, only one resident entered outpatient general medicine in 2017 at the Track’s inception. The personal and professional success of the graduates has enhanced the desirability and respect of outpatient general medicine as a career option, and is creating a comcontinued on page 22

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continued from page 21

munity of primary care-bound residents. Primary care is now becoming an acceptable norm, rather than the exception, for residents interested in general medicine in our residency program.

Ongoing needs: Although being part of a PCTP increases the likelihood of entering primary care, it is not enough. Residents in PCTPs reported that they may not pursue primary care because of feeling ill-equipped to address the psychosocial needs of their patients, needs that are higher in populations typically served by resident continuity clinics. Residents therefore need to train in clinics with adequate interdisciplinary support from social services and behavioral health. The VA PACT (Patient Aligned Care Teams) model exemplifies efforts to provide team-based care that addresses the broad range of needs patients bring to primary care. The program needs to continue to improve this resident continuity clinic experience for all residents, not just those inclined toward primary care.

Broader improvements are needed to our health care system overall. The American College of Physicians recently published recommendations for reforming many aspects of the US health care system, including addressing social determinants of health and health insurance coverage. Improvements are needed to how physicians are compensated, to the administrative burden of primary care, and to documentation requirements. By improving the professional lives of established PCPs and by improving how primary care is delivered everywhere, primary care can be an attractive career option for motivated residents and address the workforce needs of our society.

Ambili Ramachandran, MD, MS, FACP is an Assistant Professor of Medicine and Interim Division Chief of General Medicine in the Department of Medicine at UT Health San Antonio.

She directs the Ambulatory Track for internal medicine residents, co-directs the General Medicine Clinic where many residents have their continuity practice, and is board certified in Internal Medicine and Preventive Medicine.

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References

1. American Association of Medical Colleges. The complexities of physician supply and demand, 2019. https://www.aamc.org/ data-reports/workforce/data/2019-update-complexities-physician-supply-and-demand-projections-2017-2032 Accessed 3 Feb 2020 2. Long T, Chaiyachati K, Bosu O, et al. Why Aren't More Primary Care Residents Going into Primary Care? A Qualitative Study. J Gen Intern Med. 2016;31(12):1452–1459 3. Peccoralo LA, Tackett S, Ward L, et al. Resident satisfaction with continuity clinic and career choice in general internal medicine.

J Gen Intern Med. 2013;28(8):1020–1027 4. Nadkarni M, Reddy S, Bates CK, Fosburgh B, Babbott S, Holmboe E. Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors. J Gen Intern Med. 2011;26(1):16–20 5. Stanley M, O'Brien B, Julian K, et al. Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine?. J Gen Intern Med. 2015;30(9):1333– 1338.

6. Long T, 2016 7. Peccoralo LA, Callahan K, Stark R, DeCherrie LV. Primary Care Training and the Evolving Healthcare System. Mount Sinai Journal of Medicine. 2012;79(4):451-463. doi:10.1002/msj.21329.

8. Long T, 2016 9. O’Rourke P, Tseng E, Levine, R, et al. The Current State of US Internal Medicine Primary Care Training. Am J Med. 2016; 129(9):1006-14 10. Stanley M, 2015 11. Long T, 2016 12. Better is Possible: The American College of Physicians’ Vision for the U.S. Health Care System. Ann Intern Med 2020; 172(2 Supplement)

PRIMARY CARE PHYSICIANS

Do Healthy People Have A Meaningful Relationship With Their PCP?

By Arti Thangudu, MD

early half of people younger than 30 years old, and nearly a third of people 30-49 years old, do not even have a primary care doctor. And guess what? I’m one of them. As an endocrinologist, I often feel guilty about not having a PCP, because I remember condoning the lack of an established PCP all the time I was in residency. Then I remember the rest of the story. We wanted to keep our high-risk patients healthy; those who overutilized the ED and hospital due to lack of primary care.

Most of us are not high risk overutilizers. We are simply people with lives, jobs and families who want to invest our time meaningfully. Primary care for many of us feels like a significant time investment for minimal gain.

Whenever I get close to choosing a primary care for myself, I ask “what will a PCP do for me”? My gynecologist does my well-woman exams, my children’s pediatrician gives me my yearly flu shot and, 24

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as an internist/endocrinologist myself married to an internist/intensivist, I just cannot see what a PCP would add to our home’s cumulative five board certifications. I have yet to be able to justify sitting in a waiting room for two hours to be told my labs look good by a midlevel. So, I fight back my resident conscience and I save the headache and $40 co-pay year after year.

For me and many healthy adults, primary care visits are a waste of time. Before starting my direct care endocrinology and lifestyle medicine practice, I was a physician who worked in a busy outpatient setting, and I remember the relief of seeing a healthy person without many questions in the middle of a jam-packed clinic schedule. The insurance-based, sick-care model of medicine we are living with forces providers to borrow time from straightforward patients to donate to their sick, complicated patients. The only way to get the time you deserve in this model is to get sick. It is a misaligned

PRIMARY CARE PHYSICIANS reimbursement structure developed by insurance companies that minimizes the importance of both patients and physicians and deteriorates the doctor-patient relationship.

In 2019, I ventured into the world of Lifestyle Medicine and received my third board certification in it last October. This field opened my eyes to a major void in our medical system - evidencebased strategies for lifestyle optimization and disease prevention.

Traditional medical schools and residencies do not adequately teach preventative medicine, so it is no surprise that now nearly 90% of our country’s healthcare costs are on chronic preventable diseases.

As we continue to throw pills, injections and expensive tests at problems that can be prevented or solved by thorough history taking and by targeting nutrition, exercise, sleep and unhealthy habits, our population continues to get sicker.

Since primary care does little for healthy people, most people enter the healthcare system after their health has escaped them.

What if it was different? Most people could stand to have something fixed about their lifestyle, even if their labs and imaging are perfectly normal. These lifestyle tweaks could set them up for better long-term health.

What if primary care shifts gears?

What if we are able to move into a world of medicine where patients are engaged and empowered to make healthful diet, exercise and other lifestyle modifications before they fall ill? With prevention in mind, primary care physicians have the opportunity to support our community to better health.

Dr. Arti Thangudu is a triple-board-certified MD who specializes in Endocrinology, Diabetes and Metabolism and Lifestyle Medicine. In her clinic, Complete Medicine, she focuses on optimizing lifestyle to prevent, treat and even reverse chronic metabolic diseases like diabetes, obesity and high cholesterol. She believes the patient-physician relationship is key to improving her patients' health and she builds this through thorough visits, convenient access and pricing transparency.

visit us at www.bcms.org

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PRIMARY CARE PHYSICIANS

Primary Care for All A Family Medicine Resident’s Allegiance to the Field

By Alexa Arastoo, DO, Medical Resident, UIW School of Medicine hard to get through a discussion about the future of American healthcare without facing the reality that Americans are disproportionately unhealthy compared to the amount of money and resources exhausted on patient care. Much like a medication reconciliation list with 28 prescriptions, fixing the health of our aging population often feels like a herculean feat. One partial solution that is often discussed is to provide more primary and preventive care to reduce cost and improve patient outcomes, which is a difficult task in its own right.

The Association of Medical Colleges’ (AAMC) 2019 update to The Complexities of Physician Supply and Demand reported a primary care physician shortage anywhere from 21,100 to 55,200 doctors by the year 20321. This problem has not gone unnoticed; 474 more family medicine GME positions were offered in the 20182019 Match than in the year prior2. As a family medicine resident finishing the seven-year-long chapter on my own medical education 26

San Antonio Medicine • March 2020

and training, I am only beginning to understand how many opportunities are out there for family medicine doctors, many of which do not entail being a primary care provider. Other than one’s own clinical interests, there are many factors that scare board-eligible family medicine residents away from primary care careers; productivity-based pay, long administrative hours charting and filling insurance requests, oversight over other practitioners, high risk for burnout, reduced salary potential compared to other specialties, sixfigure loan debt and the overwhelming aspect of juggling patients’ medical and social needs as the sole healthcare provider. All that said, as my certification exam approaches and emails – and texts somehow – from medical recruiters become a daily occurrence, I still envision myself working in clinic-based primary care, just like I did three years ago, verrucae and all.

Though I have a humble amount of experience in providing primary care, I do have a strong pull toward continuing in the field for

PRIMARY CARE PHYSICIANS one reason – longitudinal patient relationships. Sure, at any national family medicine conference, you can hear a rousing talk about primary care as the “front line” of medicine and primary care physicians as the champions of improving healthcare in America, but “championing” is not what gets you through the extra hours of charting after the last patient has left your office. When I work through a scheduled lunch break, opting instead to shove a bag of skittles into my whitecoat pocket – don’t tell my patients – to fill out some mundane insurance requests that take entirely too long, I do not draw strength from the larger call to reform healthcare and change the course of the future. I do it, simply because I like my patients. I cherish the opportunity I have as a clinic doctor to get to know my patients.

In a world based on productivity and the dreaded Relative Value Unit, the only thing that keeps me from feeling as though the daily grind of seeing eighteen patients a day has not reduced me into a cog in some complicated coding-billing machine is the occasional heartfelt “thank you” from a patient. It is not entirely an altruistic sentiment; I derive a selfish glee from being told I helped someone, and as a primary care provider, I get to follow up with patients to continue to help them, perpetuating a positive feedback loop. Hospitalists and urgent care doctors help patients too, but they miss out on following patients’ lives and developing inter-generational relationships with families.

There are intangible components to patient care that cannot be gleaned from the mere snapshot of a patient’s life that passes during one hospitalization or acute illness. Are there other important benefits to becoming a primary care physician? Sure. Do any of them feel as good as getting a hug from a patient who says that you changed their life? Honestly, probably not. It’s a lost opportunity that family medicine programs do not advertise this to applicants on their websites as a rewarding component of residency training, opting instead to describe call schedules and elective opportunities.

Even though I am passionate in my pursuit of primary care, I feel a lot more can be done to entice medical students and residents to choose this career – the most obvious but often overlooked thing being to train them in ambulatory primary care medicine. Residents split their time between the inpatient and outpatient settings, and depending on the inpatient workload, this can make time at clinic more of an afterthought. It is difficult to be attentive during clinic appointments while waiting for a page from the hospital or recovering from your last overnight call. It is even harder to do in halfday blocks once per week. There are specific skills that are crucial to success in the longitudinal ambulatory care setting, and not focusing on developing these abilities essentially relegates them to “on the job” training after graduation. This is a huge oversight and po-

tential barrier to residents pursuing primary care. Obviously, residents should still get some training in the hospital to develop clinical competency, but I feel that in order to truly make a dent in the primary care physician shortage, family and internal medicine programs will need to allocate extended periods of time for residents to put their undivided efforts into treating and developing relationships with their own panel of patients in the clinic setting.

Sticking more residents in continuity clinics is not the most glamorous way to improve our current healthcare landscape, but it could at least develop a more robust pool of those interested in pursuing primary care, which for the patients currently lacking access to medical services, is a great start.

Alexa Arastoo, DO, is a 3rd year Family Medicine Resident in the inaugural class of the Community Based Family Medicine Residency affiliated with UIW School of Medicine.

References

1. Dall T, Reynolds R, Jones K, Chakrabarti R, Iacobucci W. (2019) 2019 Update: The Complexities of Physician Supply and Demand: Projections From 2017 to 2032. Washington, DC: Association of American Medical Colleges.

2. Porter, S. (2019). 2019 NRMP Match Marks Decade of Growth for Family Medicine. Annals of Family Medicine. 2019 May; 17(3): 278-279. visit us at www.bcms.org

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PRIMARY CARE PHYSICIANS

“Nannie’s Story” One Doctor’s Journey to Addressing Health Disparity

By Melissa A. Walker, DO

annie, as she was known by her family and her rural Louisiana community, was truly a Saint among us. Although she married at the age of 14 and had the first of her nine children by the age of 15, the name Nannie was given to her because of her caring for other children of the community.

These were children who had been orphaned by their mothers’ untimely deaths or friends of her own children who just loved “Going to Nannie’s” after church, after school, or anytime she would allow them there – all were welcomed at Nannie’s.

Although her educational pursuits were cut short by her becoming a wife and a mother at such an early age, one could not discount her almost genius ability to handle financial matters and that she avidly read stories that would take her and the children away to worlds so much different than their rural community. Hence, she was sought out by the elderly and the unlearned of her town to as28

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sist them with completing their paperwork, paying their bills, contacting lawyers, or anything that was intimidating to them because of their limited reading abilities. Being a caregiver became Nannie’s defining greatness.

Nannie was, however, guilty of one thing that is true of most caregivers – she neglected her own health in the pursuit of helping others. Now, I could say that neglect led to her fate, but one cannot deny that the disparity of care that was so prevalent in her rural community contributed to the illnesses and early deaths of its residents. It was not perceived as disparity, however; it was “just the way things are.” Hearing children receive tasks like, “go down to your Aunt Ora’s and ask her to send me one of her high blood pressure pills,” was extremely common.

You may say, “This seems to be lack of education and not the distribution of services.” My response is, “Aren’t we responsible

PRIMARY CARE PHYSICIANS

www.cdc.gov

Poverty Environmental Threats Inadequate Access to Health Care Individual and Behavioral Factors Educational Inequalities

for both when it comes to healthcare?” At that time, a drug like Metoprolol was considered a rare commodity and one primary care physician would service nearly a nine-town radius. That’s disparity at its greatest.

Now we see Nannie as a 53 year-old empty nester. She should be so proud that all her children have graduated high school. Three have gotten at least a bachelor’s degree, five have served in a branch of the military. Not so! We see Nannie, as her medical chart review stated, “a 53 year-old woman appearing much older than her stated age….”. This mother wasn’t living her best life basking in the Louisiana sun. In fact, on one summer day in July 1992, it would be the Louisiana sun that contributed to her fate and to her daughter receiving a call from a frantic relative stating, “Missie, the ambulance just came to pick up your momma. She passed out in the kitchen and they think she had a heart attack or stroke or something. Y’all need to come to the hospital.” Indeed, Nannie had a stroke, a heat stroke. Upon arriving to the local hospital, her temperature was found to be 107 degrees.

More than two years of hospitalization would take her from that hospital, to a larger more advanced hospital in a neighboring city, to a Skilled Nursing Facility, and finally to a Nursing Home where she died from pneumonia and hypoxia within days of arriving there.

Nannie was my mother. I tell you this story, not to garner sympathy, but because I believe it needs to be told and telling it has helped me to heal and has helped to shape who I am as a physician. Why? It was after my mother’s death that my original desire to become a physician was reignited. I say reignited because it had never left my heart, even when I began to pursue other interests and had removed it from forefront of my mind.

Experiencing my mother’s illness and subsequent death at such an early age allows me to not only answer the question, “What if it were your mother?” in my medical decision-making processes; but, because it was my mother, I have a greater sensitivity and understanding of those who lack both education and resources.

Nannie was the smartest, kindest, most giving person I have ever

known. She should have been someone great. She would have been a great physician. Because her life was cut short, I have taken up her mantle of care and concern for “the least of these.”

Matthew 25:35-40 NLT For I was hungry, and you fed me. I was thirsty, and you gave me a drink.

I was a stranger, and you invited me into your home. I was naked, and you gave me clothing. I was sick, and you cared for me. I was in prison, and you visited me.

Then these righteous ones will reply, “Lord, when did we ever see you hungry and feed you? Or thirsty and give you something to drink? Or a stranger and show you hospitality? Or naked and give you clothing? When did we ever see you sick or in prison and visit you? And the King will say, “I tell you the truth, when you did it to the one of the least of these my brothers and sisters, you were doing it to me.”

Health Disparities

Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. Populations can be defined by factors such as race or ethnicity, gender, education or income, disability, geographic location (e.g., rural or urban), or sexual orientation. Health disparities are inequitable and are directly related to the historical and current unequal distribution of social, political, economic, and environmental resources.

Dr. Melissa Walker is a primary care physician and the owner and operator of The Carol Clinic for Family-Centered Healthcare in San Antonio, TX. Her practice is named after her late mother, Mrs. Carol Williams Walker “Nannie”.

Carol is also an acronym. C – Care; A – Attention; R – Respect; O – Oneness; L – Loyalty. These attributes were possessed by Dr. Walker’s mother and she strives to exemplify the same in the care of her patients. visit us at www.bcms.org

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BCMS LEGISLATIVE

Standing (l-r): BCMS President, Gerald Greenfield, MD; event co-hosts Adam Ratner, MD and Varda Ratner; Senator Jose Menendez; event co-hosts Jenny Shepherd and John Shepherd, MD pause for a photo during the TEXPAC-sponsored reception held in honor of Sen. Menendez on Jan. 30 at the Shepherd home.

Reception honoring State Senator Jose Menendez On Jan. 30, a TEXPAC-sponsored reception was held in honor of a good friend of medicine, State Senator Jose Menendez (District 26), at the home of Jenny and John Shepherd, MD. The reception was co-hosted by the Shepherds, along with Varda and Adam Ratner, MD. Senator Menendez was honored for his work in support of medicine’s issues during the 86th Legislative Session. Many thanks to the Shepherds and Ratners for hosting the event, which attracted physician members, BCMS Alliance members and medical students, along with members of the Jewish community, who attended to thank the Senator, in part, for the legislation he sponsored and successfully passed to recognize Holocaust Week in schools.

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

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San Antonio Medicine • March 2020

BCMS LEGISLATIVE

Enjoying the TEXPAC-sponsored reception honoring Sen. Jose Menendez on Jan. 30 at the home of cohosts, Jenny and John Shepherd, MD were (standing l-r): Richard Benedikt, MD; Ezequiel “Zeke” Silva, III, MD; co-hosts, Varda Ratner and Adam Ratner, MD; and Pam Hall, MD.

UIW School of Medicine medical student, Marc Ghosn (left) and Brian Boies, MD, (right), pause for a photo with Sen. Jose Menendez during the Jan. 30 TEXPAC-sponsored reception honoring Sen. Menendez held at the home of co-hosts, Jenny and John Shepherd, MD.

Sen. Jose Menendez (left) greets Jayesh Shah, MD and Neha Shah during the Jan. 30 TEXPACsponsored reception held in the senator’s honor at the home of co-hosts, Jenny and John Shepherd, MD.

visit us at www.bcms.org

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BOOK REVIEW

THE SWERVE: How the World Became Modern A Book by Stephen Greenblatt Summarized by J.J. Waller, MD

In the winter of 1417, a lone figure rode through the terrain of southern Germany. His name was Poggio Bracciolini. His home was in Italy (Rome), but he was a member of a group of “thinkers” calling themselves “humanists.” This movement, having arisen with Plutarch a century before, devoted themselves to discovering the literature of ancient Greece and Rome. Long buried in the monasteries of Europe through the Middle Ages, being copied by monks in the scriptorium with copy upon copy upon copy having been made over centuries of the ancient literature, the humanists sought these relics of antiquity with a fervor to regain not only the books and articles themselves, but also the philosophy and accomplishments of the ancient philosophers.

Poggio was born in the rural area around Florence and managed through hard work and diligence to achieve the status of a notary, a highly respected and regarded profession in those days. Not only was he a notary, but his handwriting was universally sought after because of his unbelievable handscript. This was before the development of the printing press, so all manuscripts had to be copied by hand.

He traveled to Rome, the home of the papacy to find work in the Curia (the Court of the Pope). After years of dedication he became the apostolic secretary to the Pope, the highest office for a non-ordained individual.

This was a tumultuous time for Catholicism because there were two Popes in office, each struggling to have the other defrocked.

When Pope John XXIII (his employer) was finally unseated, Poggio was without a job so he set off to satisfy his inner being, becoming a book finder (bibliophile). Therefore, he was in Germany; seeking after unknown pieces of literature, scrolls and codices of ancient work, the copies of which were found in the libraries of the many monasteries throughout Europe. This was where the language of the ancients was written in ancient Greek and Latin, the latter of which Poggio was an expert.

After months of searching the shelves of the various libraries and numerous monasteries, he was in the Abbey of Fulda located in Central Germany. While perusing the many copies of ancient literature he came upon a long text written about 50 BCE by a poet and philosopher named Lucretius. The title of the work was “De Rerum Natura” or “On the Nature of Things.” This was written and consisted of a five-book collection of 7400 lines in six codices of poetry.

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He remembered the name of the Greek philosopher and author and knew that this was a first copy to be seen in over 1000 years. It took two months for him to copy the entire book in his excellent handwriting.

What was so remarkable about this text, other than the beautiful poetry, was the arguments about life, death, philosophy and science. Some of the elements of which Lucretius wrote include the following: Everything is made up of invisible particles which he called “first things,” bodies of matter or atoms. Everything is formed from these seeds and in the end, nature returns them to their previous state. The particles are invisible, indivisible and infinite in number. Constantly in motion, they occasionally “swerve” in the course and collide with other matter to form new shapes, resulting in the matter of the universe; the stars, the moon, mountains, animals, etc. They eventually come apart and are again returned to their previous state. The total of matter remains the same and the balance of the living and the dead remain stable and is always restored.

All the particles (atoms) are in constant motion as is and in the infinite void. These are so existing that there is no beginning, middle or end. Later philosophers cite the idea of these basic forms that could be indestructible – the greatest thought that man has ever hit upon. The fact that it was proposed about 55 BCE had ramifications down throughout the centuries.

The universe has no creator or designer. The particles have not been made and cannot be destroyed. To quote Lucretius, “The constant motion and colliding of atoms has shifted countless ways, all types of experimentation has resulted in arrangements that have created and composed our world.”

Everything comes into being as a result of the “swerve” of the particles, which is attributed to the creation of the atoms colliding.

The constant and random swerving is the source of free will, for if all molecules were in long, predetermined chains there would be no possibility of free will.

Nature ceaselessly experiments. All living creatures have evolved through a long, complex process of trial and error, resulting in adap-

BOOK REVIEW tations that survive and prosper.

The universe is not created for us alone or about humans. Humans are not unique but are only a part of the universe’s existence. Human society did not begin in The Golden Age of Tranquility and Plenty but in the primitive battle for survival.

The soul dies because it is made of the same material as the human body. As a result, there is identical existence of the particles in the human, resulting in the existence of the soul being the same as that of the body.

As a result of the above argument, there is then no afterlife and death is nothing to us. As a result of the philosophy arose the epicurean vision of life. Life should be grounded in pleasure. In this source, pleasure is the opposite of pain in life. Epicurean thought is not based on the idea of a life of indulgence and debauchery, but one of moderation, study and enlightenment.

Religions are invariably cruel because of the demand they place on individuals by insisting that either we are doomed to a beautiful life or one of a hell.

In 1417, Poggio rediscovered this great poem. He realized it was strictly against the teaching of the Catholic Church. After copying the books, he sent them to a friend in Rome where he returned

shortly. It was 10 years before this was released and further copies were made. Multiple copies were made by hand-copying before the printing press came into being in 1451.

The poem, after the printing started, soon became widespread.

The subjects of Lucretius’ poem started a resurgence of thinking. It was not the only factor instituting the Renaissance but certainly an important one. It became widely distributed and naturally was vigorously denounced by the Catholic hierarchy. It could be condemned, but it could not be suppressed.

Poggio finally returned to Rome, once again becoming an apostolic secretary to several Popes in the ensuing years. He wrote several articles on many subjects. In his later years he returned to Florence and died in 1459.

The philosophy of Lucretius resulted in the involved thinking of Copernicus, Galileo, Newton, Hunter, Darwin and even Thomas Jefferson, plus many other giant thinkers of the next centuries.

J.J. Waller, MD is a member of the Bexar County Medical Society and an avid historical researcher.

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PHYSICIANS PURCHASING DIRECTORY Brought to you by the BCMS Circle of Friends

By supporting these sponsors with your patronage, you are supporting the BCMS. ACCOUNTING FIRMS

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ARCHITECTURE Sol Schwartz & Associates P.C. (HHH Gold Sponsor) With This Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being.

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

ASSETT WEALTH MANAGEMENT

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

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

ATTORNEYS Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life.

We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning.

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ACCOUNTING SOFTWARE

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

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com

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San Antonio Medicine • March 2020

Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence.

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

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

Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com

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

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

ASSETS ADVISORS/ PRIVATE BANKING

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

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

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

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

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

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

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

BANKING

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

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

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

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

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

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

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

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

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

Synergy Federal Credit Union (HHH Gold Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

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

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

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

COMMERCIAL PROPERTY MANAGMENT

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

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

DIAGNOSTIC IMAGING

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

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

FINANCIAL ADVISOR

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

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

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“Get what you deserve … maximize your Social Security benefit!”

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

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

FINANCIAL SERVICES

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

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.

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

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

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

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

Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing" Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and well-

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visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY continued from page 35 served by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

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

HEALTHCARE BANKING

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

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

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

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

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San Antonio Medicine • March 2020

HEALTHCARE CONSULTING

INSURANCE

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

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

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.”

HOSPITALS/ HEALTHCARE SERVICES

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

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

INFORMATION AND TECHNOLOGIES

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

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

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.

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

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

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 en-

dorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

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

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

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

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

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

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

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

MEDICAL BILLING AND COLLECTIONS SERVICES

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

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

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

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

MEDICAL FURNITURE

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

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

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

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

MEDICAL PRACTICE

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

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

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

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

OFFICE FURNITURE

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

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

PRACTICE SUPPORT SERVICES

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth

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

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

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

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

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

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

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

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

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

KW Commercial (HHH Gold Sponsor) We specialize in advising Medical

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visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY continued from page 37

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

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San Antonio Medicine • March 2020

STAFFING SERVICES

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

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

TELECOMMUNICATIONS ANSWERING SERVICE

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

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

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

RECOMMENDED AUTO DEALERS • • • •

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

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.

11001 IH 10 W at Huebner San Antonio, TX Esther Luna 210-690-0700

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

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Marty Martinez 210-525-9800

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Honda 9100 San Pedro San Antonio, TX 78216

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

Sean Beardsley 210-988-9644

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Subaru 9807 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

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

Mark Castello 210-308-0200

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Justin Boone 210-635-5000

Sandy Small 210-341-8841

James Cole 800-611-0176

Cavender Toyota 5730 NW Loop 410 San Antonio, TX Gary Holdgraf 210-862-9769

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

San Antonio, TX Ed Noriega 210-561-4900

Porsche Center 9455 IH-10 West San Antonio, TX Matt Hokenson 210-764-6945

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

AUTO REVIEW

2020 GMC Acadia

By Stephen Schutz, MD

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San Antonio Medicine • March 2020

AUTO REVIEW

general, I’m into the substance of cars. What the car, truck, SUV, or crossover is matters, and options, especially tech options, don’t count that much. When I drive a new car like the S-class Mercedes, I want to know how its essence compares to its competitors and the previous generation S-class. Its design, the way it drives, and how it makes me feel behind the wheel are important, but options like atomized scents or lane departure warnings aren’t. In fact, it’s rare that any feature of a vehicle that I drive makes much of an impact on me.

Having said that, GM just introduced something that got my attention: an audible and visual alert that tells you to check the rear seat after you turn the car off. I recently drove a GMC Acadia crossover and was reminded to check the rear seat every time I shut the car down and prepared to get out. I’m an empty nester and don’t have kids at home, but thank you General Motors for this potentially lifesaving feature!

Approximately 40 people die every year from hyperthermia that results from being left behind in a hot car. That’s not a big number, but since almost all of the 40 are infants and toddlers strapped in car seats, every one of those deaths is especially upsetting. It almost doesn’t matter that an average of around 40 people die in traffic accidents on our roads and highways every 8 hours, most of us wish we could do something, anything, to prevent a baby from roasting to death in a hot car. And the fact that GM has done something about it is to be applauded.

Anyway, the Acadia is a mid-size family crossover that competes with the market leaders, Toyota Highlander and Honda Pilot (and two serious new contenders from Korea, the Hyundai Palisade and Kia Telluride). Sized and outfitted the way it needs to be, the Acadia is a legitimate competitor in this competitive market segment.

The Acadia’s exterior design is attractively mainstream without being annoying, but it certainly doesn’t take any chances.

Inside the Acadia, things are similarly nice but not groundbreaking, although it’s worth mentioning that customers in this market segment are not looking to be shocked or awed. Consistent competence with no surprises is what works with these buyers, and the Acadia delivers in that regard with soft surfaces, comfortable seating, and usable tech. Everything’s easy to see and right where you want it, which is how it should be. As I drove the Acadia I could imagine being a busy working parent rushing from work to school to piano or soccer practice, with the Acadia helping me by

decreasing my stress level, not increasing it. Of course, the same can be said of the Acadia’s competitors, but at least the GMC product isn’t falling behind here.

Interestingly, the steering wheel volume controls sit behind the wheel where the right sided paddle shifter would be, not on the wheel somewhere facing you; it’s weird but functional. In fact, the only real negative of the Acadia’s interior is the third row of seats, which is tight. No third row is roomy, but this one is particularly not roomy.

Powering the Acadia Denali is a version of the ubiquitous 310HP direct-injected 3.6-liter V-6 that GM places in everything from the Chevy Colorado pickup to the Cadillac CT6 sedan, now connected to a 9-speed automatic transmission. A turbocharged four-cylinder engine is available in lesser Acadias, but I’d avoid it given the crossover’s 4,399 lb. curb weight. Both FWD and AWD versions of the Acadia are offered.

Driving the Acadia is as exciting as you’d expect a mid-size luxury crossover to be; fine but not fun. But when you’re ferrying your kids and their friends to a basketball game or dance rehearsal, you don’t need or even want fun, so it’s all good.

I would expect many, if not most, BCMS members and their spouses to be interested in the loaded Denali version of the Acadia, which adds a lot of luxury to an already nice vehicle. Ticking the Denali box adds about $15,000 to the $34,000-ish base price of an Acadia (that’s retail, and our Phil Hornbeak will get you a much better deal if you call him, as I hope you already know), and for that extra sum you get quite a bit.

The GMC Acadia, especially one in Denali trim, is a nice midsize crossover with an extra dab of luxury, and if you need something in this class, this vehicle will work nicely. It’s unlikely that the Acadia’s reminder will save you from forgetfully leaving your young child behind on a hot day; but if it does, thank God and GM. Their reminder to check the rear seat is a good thing.

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

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

visit us at www.bcms.org

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