San Antonio Medicine April 2021 by Traveling Blender

S A N A N TO N I O

Physician Retirement

SAN ANTONIO, TX PERMIT 1001

PAID

NON PROFIT ORG US POSTAGE

COVID-19 VACCINATION UPDATES

visit us at www.bcms.org 1

SAN ANTONIO

TA B L E O F C O N T E N T S

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

•

WWW.BCMS.ORG

•

$4.00

PHYSICIAN RETIREMENT Getting Paid for Your Practice at Retirement By Mike Kreager, Attorney & Author ..............................12 Physicians Upon Retirement By Texas Medical Board ................................................15 The Financial Basics of Preparing for Retirement By Michael Clark ...........................................................16 My Retirement from Academic Medicine By Rajam Ramamurthy, MD ..........................................18 Life Segmented: Did I Do Something Useful? By John J. Seidenfeld, MD and Adam Ratner, MD.........20 Retirement: Now What? By Stephen C. Fitzer, BS, MIM ......................................22 Retirement from Medicine in Stages: Slow Descent From the “Mountain” By Jaime Pankowsky, MD, FACS ..................................24

BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10 The COVID-19 Vaccination Game By Melody Newsom, BCMS Chief Operating Officer ..........................................26 To Vaccinate or Not to Vaccinate? By Jaime Pankowsky, MD, FACS ......................................................................28 Ten Things to Know to Administer COVID-19 Vaccines By David Doolittle ..............................................................29 BCMS NEWS: Melody Newsom Receives Distinguished Service Award .................................................................30 BCMS NEWS: Betty Fernandez, the New Director of Operations, Retiring: Thank You Mary Jo Quinn....................31 GOLF is a Four-Letter Word By John J. Seidenfeld, MD .........................................................................................32 Pandemic Story Telling from the Internal Medicine Residents at UT Health San Antonio .........................................33 Circle of Friends Directory ......................................................................................................................................34 Recommended Auto Dealers .................................................................................................................................38 PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com

SAN ANTONIO: Madeleine Justice madeleine@travelingblender.com Gerry Lair gerrylair@yahoo.com PROJECT COORDINATOR: Amanda Canty amanda@smithprint.net

For more information on advertising in San Antonio Medicine, Call Traveling Blender at 210.410.0014 in San Antonio and 512.385.4663 in Austin.

SAN ANTONIO MEDICINE • April 2021

•

APRIL 2021

•

VOLUME 74 NO. 4

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

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

SmithPrint, Inc. is a family owned and operated San Antonio based printing and publishing company that has been in business since 1995. We are specialists in turn-key operations and offer our clients a wide variety of capabilities to ensure their projects are printed and delivered on schedule while consistently exceeding their quality expectations. We bring this work ethic and commitment to customers along with our personal service and attention to our clients’ printing and marketing needs to San Antonio Medicine magazine with each issue.

BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

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

DIRECTORS

Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member David Anthony Hnatow, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member John Shepherd, MD, Member Ezequiel “Zeke” Silva III, MD, Member Amar Sunkari, MD, Member Col. Charles Mahakian, MD, Military Representative Manuel M. Quinones Jr., MD, Board of Ethics Chair George F. “Rick” Evans, General Counsel

SAN ANTONIO MEDICINE • April 2021

Jayesh B. Shah, MD, TMA Board of Trustees Stephen C. Fitzer, CEO/Executive Director Nichole Eckmann, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Katelyn Jane Franck, Student Alexis Lorio, Student

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 John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member Antonio J. Webb, MD, Member David Schulz, Community Member Donald Bryan Egan, Student Member Teresa Samson, Student Member Alexis A. Wiesenthal, MD, Member Neal Meritz, MD, Member Jaime Pankowsky, MD, Member Stephen C. Fitzer, Editor

PRESIDENT’S MESSAGE

Health Literacy: Toolkit for Physicians

By Rodolfo “Rudy” Molina, MD, MACR, FACP, 2021 BCMS President

In the January and February issues of this journal I wrote about Health Literacy; some of the history behind it, it’s working definition and gave examples on some of the challenging issues we face on achieving a more equitable healthcare system. With this article I wish to provide some simple steps; a toolkit that we can all use as clinicians to address one of these issues. I first did a literature search on “toolkits” on health literacy available for physicians. My first hit came from a government website1. Now this is a wonderful site with numerous ideas and suggestions. It can be downloaded into a 227-page PDF and if you have “all” the time in the world or have been awarded a hefty grant to do research in this field I would highly recommend a download. For most of us, we haven’t the time or the resources to carefully study this. So, as I continued my search I came to a more practical site; 8-ways to Improve Health Literacy from the Institute for Healthcare Improvement2. This was an easy two-page read that dealt primarily with how we speak to our patients. It had some valuable suggestions on choice of words we use when speaking to them. An example as listed in their number 5 of the 8 points suggested, choosing a word like “swallow” instead of “take”, or say “harmful” instead of “adverse”, or say “belly” instead of “abdomen”. The other seven suggestions were also helpful. As I mentioned, this was a fast and easy read. I then came to an even better, or I should say shorter, site with the title: Four Simple Strategies for Improving Your Patients’ Health Literacy – Advance Care Planning (ACP) Decisions3. This site also provides other links, all designed to improve how we as providers interact with our patients. As my search continued, I realized that COMMUNICATION was the underlying theme of these websites and of their toolkits. The 227page PDF government site, as well as the abbreviated 8- and 4-point strategies, were all about communicating our thoughts to our patients. Our ability to communicate is linked to the patients’ education. Educating our patient has been linked to improved medication adherence as reported by many different authors4. This was published September 11, 2020, and underscores the enormous importance of, yes you guessed it, communication. Okay, reality check, a study printed in a 2018 article in The Permanente Journal found that nearly 70% of health outcomes are “driven by factors beyond health care and that poverty is associated with more years of lost-life than smoking and obesity combined”. I recognize there are factors affecting healthcare outcomes beyond our

SAN ANTONIO MEDICINE • April 2021

control. So, by acknowledging this, we can and should admit we control the way we communicate with our patients. This April article, as I mentioned earlier, is meant to address what we can do in our offices. It’s a privilege to be a physician and yet one that is earned through diligence. It comes with its own vernacular, customs, symbols and uniforms. We use that vernacular (medical jargon) to more clearly and precisely communicate with each other about our patients. However, that is not the language of our patients. To communicate effectively with our patients, we then must step out of our world and enter theirs. An old friend and former elementary teacher, now deceased, told me that the mark of intelligence was measured on how well one can communicate with people on all levels from the very smart to the very ignorant. As physicians, we are smart and educated. I feel we can and should be able to communicate with all. I leave you with the following piece of information. The root of the word doctor comes from the Latin docere, meaning to teach. So, let us continue our teaching as our title defines us. Rodolfo (Rudy) Molina, MD, MACR, FACP is a Practicing Rheumatologist and 2021 President of the Bexar County Medical Society. References 1. https:www.ahrq.gov/sites/default/files/wysiwyg/professionals/ quality-safety/quality-resources/tools/literacy-toolkit/healthliteracytoolkit.pdf. 2. http:www.ihi.org/communities/blogs/8-ways-to-improve-healthliteracy 3. https://acpdecisions.org/four-simple-strategies-for-improvingyour-patients-health-literacy/ 4. https://www.medicaleconomics.com/view/patient-education-canimprove-medication-adherence

BCMS ALLIANCE

Planning for More Than Just Your Financial Health By Sue Bernstein, MS

We spend a lot of time and effort working towards a financially stable retirement, but in doing so, we often neglect the very thing that retirees cherish the most – their health. It’s already a struggle to keep up with the demands of work, family and community, but we can’t discount the importance of actively investing in both our short-term and long-term health. A proven strategy for making healthy lifestyle changes is to focus on modifying daily habits. Small adjustments in routines or activities can result in large, long-term gains. While we all know that habits can be difficult to break, here are a few tips: 1. Talk to your future self. What would you say about your current path? What are you currently doing or not doing that your future self would regret? What should you be doing now to thrive instead of just survive? 2. Figure out which things in your life you want to change and most importantly, why you want to change them. Knowing why it’s important to make a change and how that change will impact your life overall will help motivate and inspire you to get past tough moments. As you encounter distractions, focus on your motivation. 3. Tackle one habit at a time. Making small but consistent changes in one area will strengthen both that habit and your confidence in your ability to be successful. When you’re ready, tackle the next habit. 4. Count your wins, not your failures. Focus on making progress rather than aiming for perfection. 5. Use your missteps as lessons. If you go off track, ask yourself what happened and what you could do differently next time. This will guide you to future successes. 6. Connect with your emotions. Contemplate how your emotional states are propagating bad habits such as unhealthy eating, excessive drinking and poor sleep. 7. Have a support system. Find others with whom to join forces; an accountability partner, community group or coach can help you stay focused on your ultimate goals. Just as with financial planning, working on long-term wellness is best started early and worked on consistently. Small steps can lead to great gains. Fortunately, good habits are just as strong and hard to break as bad ones. As healthcare providers and health advocates, we play an important role in helping people develop healthy lifestyles. Your personal changes are likely to motivate others and as a positive role model, you are also more likely to remain on your own health path. Sue Bernstein, MS is a Health Transformation Coach and Consultant and the Recording Secretary of the Bexar County Medical Alliance

SAN ANTONIO MEDICINE • April 2021

PHYSICIAN RETIREMENT

Getting Paid for Your Practice at Retirement By Mike Kreager, Attorney & Author

Every day 10,000 Americans turn 65 (AARP website). As of the end of 2018, 28% of Texas’ physicians were over age 60 compared to 19% who were under age 40 (AMA Physician Masterfile 2019 n=64,382). A large bolus of physicians is approaching retirement. If you are among those physicians who want to retire, how do you get paid for your medical practice?

Pre-Planning Selling your practice needs to start with the development of an exit plan, with target dates matched to key milestones. At the outset, identify your advisory team. The team consists of your CPA, financial planner and an attorney familiar with selling medical practices. Depending on your circumstances, a business broker may need to be added to the team. Often, a retiring doctor will engage a business appraiser to value the practice. There are many appraisers available at reasonable costs. Practice Income Assessment Ask your CPA to review your practice tax returns and financial statements. More specifically, ask the CPA to “normalize” the income statement to remove, or separately state, the costs associated with your employment and ownership. This exercise removes your salary, benefit costs (health insurance and retirement contributions), profit distributions, payments to your spouse and any extraordinary items that have been expensed, e.g., Spurs tickets, etc. The normalized income statement will show how much net income the practice generated in the prior three years. If depreciation, taxes and interest are added, you will have “EBITDA”, the practice’s earnings before interest, taxes, depreciation and amortization. EBITDA is a proxy for the practice’s free cash flow, an important indicator for pricing the practice, as discussed below.

SAN ANTONIO MEDICINE • April 2021

Buyers Who are the target buyers? The answer to this question is very specific to your practice and its subspecialty. If you have associates or younger owners, the first choice for buyers are these folks. If there are none, then a possible universe are physicians coming from training. However, in the last fifteen years, these folks may no longer be good candidates due to student loans and their desire for income stability and an aversion to risk. Other practices similar to yours are potential buyers but usually they have a similar aversion to adding debt and may be facing the same impending need to exit. Non-physician buyers include hospital systems, managed care systems and management companies (many backed by private equity). Much has been written about the cost containment goals of the hospital systems and managed care systems (those backed by the insurance companies). The former desires to capture the referral base of patients needing inpatient and outpatient care of hospital facilities and the latter desires to control provider costs to enhance profitability. Subspecialties are very attractive to non-physician buyers. If you have not already been previously approached, you can easily contact these buyers to gauge their interest in your practice. They will have standardized checklists for detailed information to be provided for their analysis.

PHYSICIAN RETIREMENT

Pricing There is no formula that will define your selling price. Gone are the per chart or multiple of revenue models. The best predictor of price is EBITDA. This number shows the income that the practice can produce. In large part, this cash flow is the “goodwill” of the practice, meaning it represents the reliable income stream associated with the practice as a business. From this amount, a buyer can subtract the cost to replace you and possibly the cost to convert to electronic records, which gives a net EBITDA. The net EBITDA will represent the return on the buyer’s investment. If your practice produces $100,000 net EBITDA annually, asking a purchase price of $1 million, means the buyer must wait five years before showing a return on its investment, ignoring possible economies of scale the buyer can add to the practice.

pital’s appraiser values the “hard” assets and possibly the value of a reduction in physician compensation, but there is no value attached to the goodwill of the practice—the recurring net revenue associated with it. Other non-physician buyers do not have the Stark Law concerns of a hospital system.

Beware of hospital system buyers Unless your practice is in high demand, the hospital buyer will often offer the least amount for your practice. This shortfall is attributable to their penchant to hide behind the Stark Law and erroneously conclude the hospital cannot offer a payment for your practice’s goodwill. It is true that the hospital cannot legally offer a purchase price based on your prior referrals to the hospital, but it is entirely legal to pay for the goodwill of your practice, as explained above, the recurring net EBITDA. Unfortunately, a history of sales to hospitals shows the hos-

Management Companies Management companies offer more complex payment terms designed to leverage the purchase price and to tie the practice to the management company. In this purchase arrangement, a portion of the purchase price, twenty percent is not uncommon, is reinvested into shares of the management company. The reinvestment leverages the purchase price since it is not paid and the risk of eventually monetizing the investment is deferred. These offers can be facially attractive with the promise of a potential IPO, but the details of the agreements gov-

Payment Terms Of course, you would like to receive the purchase in a lump sum at closing. On the other hand, the buyer will want to temper the risk associated with the possible future loss of recurring revenue by paying the purchase price in installments over three to five years. The deferred payments may also be contingent on the practice sustaining a level of annual revenue to earn the deferred payment, i.e., a milestone.

Visit us at www.bcms.org

PHYSICIAN RETIREMENT

erning the management company often show that the investment can be deflated upon separation, e.g., death, cessation of practice. Moreover, the investment is subject to exclusive control of the company’s management as well as the management of the PE fund backing the management company. In sum, the date when your reinvested purchase price will become money in your pocket cannot be predicted with any certainty. Post-Sale Retention Buyers are aware of your motivation to retire from active practice. However, they want your patients to stick with the purchased practice to sustain its ongoing value. They secure patient linkage by requiring the selling physician to remain with the practice, typically up to three years but sometimes as short as one year. The terms of your retention are negotiable. Your post-sale involvement can be at a reduced level compared to before the sale. You can also negotiate a requirement that the buyer immediately look for your replacement. Concurrent with the sale, you will enter into a new employment agreement with the buyer or its affiliated entity that may legally employ physicians. The terms of this employment agreement will be rigorous, which is to say one-sided in favor of the employer. Your compensation under the new employment agreement will influence the purchase price and vise versa. In other words, if your compensation is less, then the net EBITDA will be higher and justify a higher purchase price. You may also ask for incentive compensation for achieving productivity thresholds. Non-Compete You can expect a rigorous non-compete covenant. Both your selling entity and you individually will agree not to compete with the practice after its sale to the buyer for five years. In addition, your personal noncompete will continue an additional two years after the end of your services. In other words, if you continue working for the buyer for five years and then quit, you will still have two years you cannot compete, for a total of seven years. The duration and restricted territory of non-competes must be reasonable to be enforceable. The reasonable duration associated with the sale of a practice is generally five years and the restricted territory is a radius of fifteen to thirty miles from the practice’s location or locations. If you truly plan to retire, the terms of the non-compete become less of a concern. However, you should ask for “carveouts” to permit you to act as a locum tenens or a part-time faculty or VA clinician. Taxation Your CPA will be able to estimate the amount of taxes that must be paid on the proceeds of the sale of the practice. These taxes can vary widely if you own the practice in an entity. The buyer will buy the assets

SAN ANTONIO MEDICINE • April 2021

of the entity and not the ownership interests, e.g., stock or PLLC interests. The purchase price will be allocated to the assets purchased in a descending order of priority prescribed by IRS rules. Under these rules, the accounts receivable and hard assets are allocated an amount of the purchase price equal to their fair market value. The remaining purchase price will be allocated to goodwill and the non-compete. If the selling entity is a C corporation, it will pay corporate tax on the gain recognized from the sale and the remaining amount distributed to you will be a taxable dividend. The impact of this “double taxation” can be minimized by selling personal goodwill associated with you. Conclusion Plan not for just the date you retire but for the sale of your practice. It takes a team of advisors to assist you and an execution plan with defined objectives that includes prospective buyer identification and pricing guidance. Mike Kreager is a San Antonio business attorney at Kreager Mitchell. He has represented physicians and physician practices for over forty years and has advised on practice sales to all types of buyers. His last book “What’s My Practice Worth? A Comprehensive Guide to Practice Valuations and Sales” was published by the Texas Medical Association in 2016. Kreager Mitchell is a Gold Sponsor of the BCMS Circle of Friends Program.

PHYSICIAN RETIREMENT

Physicians Upon Retirement Transfer and Disposal of Medical Records When a physician retires, terminates employment, or otherwise leaves a medical practice, he or she is responsible for: • ensuring that patients receive reasonable notification and are given the opportunity to obtain copies of their records or arrange for the transfer of their medical records to another physician; and • notifying the board when they are terminating practice, retiring, or relocating, and therefore no longer available to patients, specifying who has custodianship of the records, and how the medical records may be obtained. Employers of the departing physician are not required to provide notification, however, the departing physician remains responsible for providing notification consistent with the rules under §165.5. Under Board rule 165.5, other licensed physicians remaining in the practice may not prevent the departing physician, required to provide notice, from posting notice and the sign. A physician, physician group, or organization (professional association, non-profit health organization, etc.) may not withhold information from a departing physician, required to provide notice, that is necessary for notification of patients. Patient Notification The physician shall provide notice to patients of when the physician intends to terminate the practice, retire or relocate, and will no longer be available to patients, and offer patients the opportunity to obtain a copy of their medical records or have their records transferred.

Recent changes to Board rule 165.5 have expanded the options for notification to patients. Notification shall be accomplished by: • either: o posting such notice on the physician's or practice website; or o publishing notice in the newspaper of greatest general circulation in each county in which the physician practices or practiced and in a local newspaper that serves the immediate practice area; and • placing written notice in the physician's office; and • notifying patients seen in the last two years of the physician's discontinuance of practice by either: o sending a letter to each patient; or o sending an email to each patient, in a manner that is compliant with state and federal law. A copy of the posted notices shall be submitted to the board within 30 days from the date of termination, sale, or relocation of the practice. Notices placed in the physician's office shall be placed in a conspicuous location in or on the facade of the physician's office, a sign, announcing the termination, sale, or relocation of the practice. The sign shall be placed at least thirty days prior to the termination, sale or relocation of practice and shall remain until the date of termination, sale or relocation. Notification to the Board When a physician retires, terminates employment, or otherwise leaves a medical practice, he or she is responsible for notifying the board when they are terminating practice, retiring, or relocating, and therefore no longer

available to patients, specifying who has custodianship of the records, and how the medical records may be obtained. Board rule 165.5 states that a copy of the posted notices shall be submitted to the board within 30 days from the date of termination, sale, or relocation of the practice. The Notification of Departure/Closure of Practice Form is available to assist with the submission of this information to the board. Exceptions Recent changes to Board rule 165.5 have expanded the exceptions to providing notice to patients. A physician is not required to provide notice of his or her discontinuation of practice to patients if the physician: • treated the patient while in a locum tenens position at a practice location for a period of no longer than six months at that location. For the purpose of this section, "locum tenens" is defined as a position in which a physician is employed or contracted on a temporary or substitute basis to provide physician services; or • only treated the patient in the following settings: o a hospital, as defined under Texas Occupations Code Section 157.051(6); o an emergency room; o a birthing center; or o an ambulatory surgery center; or • only provided the following: o anesthesia services in a setting described above; or o radiology services based on an order by a treating physician or in a setting described in above; or o pathology services in a setting described above. Visit us at www.bcms.org

PHYSICIAN RETIREMENT

The Financial Basics of Preparing for Retirement By Michael Clark

How we spend our retirement is an extremely personal and emotional matter. We’ve seen the television commercials of the gray-haired couple retiring to their vineyard or sailing in their yacht on the beautiful Mediterranean Sea. While appealing, those are really not the goals of most hard-working Americans. However, regardless of your unique goals, there are very specific steps that almost everyone should take in the years leading up to the transition to retirement. We are going to lay out these steps in bullet format below but want to provide you with a warning first. Many people will feel inadequately prepared or overwhelmed by how much there is to consider when reviewing these bullets. Instead, maybe you can be encouraged by the steps you have already taken and be glad to learn about other important steps that will help you further prepare for retirement now rather than once you’ve already hung up your spurs. So, here goes… Save enough money – this seems abundantly obvious but the process for determining the appropriate amount can often be ambiguous. There are certain analytical tools available that incorporate historical market performance, inflation, varying income streams such as pensions and inheritances, different account types such as IRAs and Trusts, to help determine the mathematical prob-

SAN ANTONIO MEDICINE • April 2021

ability of achieving your goals. Adjustments can then be made in how much you save or how you are investing to increase your probability of success. Adjust your portfolio to the right risk level – finding the comfortable balance between risk and reward can be challenging. We all want lots of upside without the risk of big losses. Some investors think they shouldn’t own stocks once they retire but they forget their time horizon doesn’t end on the day of retirement but goes for the rest of their life. There are now many strategies and investments designed to provide access to meaningful returns while protecting your irreplaceable capital from catastrophic losses. Consider tax diversification – generally, we all agree that diversification of investments in a portfolio is wise but not many people consider tax diversification. If future tax rates are unknown, then it may make sense to have some taxable investments (taxable now), some taxdeferred investments (taxable later) and some tax-free investments (taxable never). Understand your insurance – a thorough audit of your insurance coverage may help you eliminate unneeded policies, reduce your costs

PHYSICIAN RETIREMENT

and customize the coverage to your changing needs. Two of the most common questions we hear are: 1. When is the right time to buy long term care insurance? and 2. How much life insurance should I have in retirement? A complimentary, in-depth audit of your existing coverage can help answer these questions. Optimize your Social Security and your Pension – amazingly, there can be up to 95 different ways to claim social security benefits for a husband and wife. There are tools available to help define the best way for you, based on life expectancy, cash flow needs and age differences between spouses. For those fortunate enough to still have a pension, we can help identify the factors that allow you to decide if a lump sum rollover or a monthly paycheck is the better choice for you and your family. Check your Beneficiaries – one of the most common mistakes we’ve seen when working with new clients is that their beneficiary forms (for IRAs, 401ks, life insurance, and annuities) are out of date. Major life events such as marriages, divorces, births and deaths are the perfect time to ask your financial advisor to review your beneficiary designations. Additionally, most people don’t realize that their beneficiary designations override the wording in their wills so it’s vitally important to get these right. There is great peace of mind in knowing that your assets will be distributed exactly as you desire upon your passing. Minimize taxes on your Required Minimum Distributions from your retirement account – the rules have changed recently and the current tax code provides some creative ways to reduce taxes on your required distributions. Get your estate in order – clients often think that putting a will in place is all that’s needed to check this off of their “To Do List”. However, there are several other important documents to consider adding such as a Durable Power of Attorney, a Healthcare Power of Attorney, HIPAA authorization, and an Advanced Directive. Several important moments in time to consider a review of your documents are Major Life Events (marriage, divorce, birth, death) and moving to a different state which may have different rules and requirements. Other items to ponder… • Is your spouse engaged in the process? If your spouse prefers not to participate in the planning process, he/she should at least be familiar with the names and contact information of your advisors (financial planner, attorney, accountant, insurance agent). • What about those special items? Many families find it helpful to dis-

cuss with their loved ones, who will want/inherit special items such as jewelry, antiques, pictures and family heirlooms. Putting these wishes down on paper can save a lot of squabbling in the future. • Where are the important papers? Do your spouse and eventual executor know where you have your safety deposit box/safe, life insurance policies, car and home titles and other important items? Consider your Life Purpose during retirement – it is one thing to “retire from” a job or profession that you may or may not truly enjoy. In our experience, it is often important for high achieving professionals to have something to “retire to” when they leave behind the responsibilities of a high stakes and rewarding professional role. Maybe that purpose would involve charitable or community board service, mentoring of promising younger colleagues and friends, or some other form of “giving back.” The personal gratification that accompanies being a valuable contributor to the success of other individuals or organizations can be a meaningful consideration, as life often slows down significantly in retirement. Of course, for many it can be just as rewarding to enjoy the fruits of your labor… an active country club lifestyle, gourmet food and wine experiences, international travel or spoiling the grandkids. In any case, you’ve earned it. Preparing wisely for retirement goes far beyond the accumulation of a big investment portfolio. By incorporating these other vitally important steps into your planning process, you can remove much of the uncertainty and anxiety that families face as they enter this new stage of life. As long time Circle of Friends members, the professionals at Aspect Wealth Management would consider it a privilege to discuss your personal situation to see if there is a way we can help you have a successful retirement. We can be reached at 210-268-1500. About Michael Clark: In addition to graduating from the U.S. Air Force Academy and earning a Masters of Science from George Washington University, Mr. Clark holds the professional designations of Certified Investment Management Analyst and Certified Retirement Counselor. He specializes in working with physicians and business owners to simplify their financial lives by addressing the complicated planning issues faced by these professionals. Aspect Wealth Management is a long-time sponsor of the Circle of Friends Program.

Securities and advisory services offered through Cetera Advisor Networks LLC, member FINRA/SIPC, a Broker/Dealer and a Registered Investment Adviser. Cetera Advisor Networks LLC is under separate ownership from any other named entity. CA insurance license #0C82856. Advisors with Aspect Wealth Management are not tax or legal professionals. Please consult an attorney or CPA for legal and tax advice or opinions.

PHYSICIAN RETIREMENT

My Retirement From Academic Medicine By Rajam Ramamurthy, MD

The Academic ‘Bug’ While explaining the total and differential WBC (White blood cell count) to the student who was assigned to me when I was a senior houseman in the General Hospital pediatric ward in Chennai, India, I turned around to see that a group of students and nurses had gathered behind me. One commented, “Thank you, Ma’am. No one explains simple things to us; it is taken for granted that we know those things and we are too shy to ask, fearing we will be judged as stupid.” That statement has stuck with me all my teaching life. During my pediatric residency at Cook County Hospital in Chicago, I was doing a newborn baby physical examination. It was customary for me to always request that the mom come and be with me so I could finish talking to her during my exam of the baby. The group of students who were assigned to neonatology would gravitate to where I was. Part of what I did and spoke was work, but part of what I did was showmanship, nicely said; role modeling. However, at some back corner of my conscience an image of myself was building, it was that of a teacher- ‘Guru’ in the Sanskrit language (Gu meaning darkness and Ru- light, literally a teacher who removes the darkness and shines the knowledge of light). A taste of this is intoxicating; it drives your career choice and is the most difficult one to withdraw from as one contemplates retirement from academic life. Bitten or smitten by the academic bug is no understatement. Decisions to enter and exit academia: The environment of one’s training greatly influences a physician’s career path towards clinical care, research or teaching. A person with an MD or DO degree who chooses an academic career balances on one leg of this so called ‘three-legged stool’. Teaching was the leg I stood on. One study shows that the primary reason women chose an academic career is an interest in teaching. The same study showed that women choosing academic medicine did so not as a planned decision but a serendipitous one realized almost at the end of fellowship. Silver et al, in a study involving 4,572 physicians, found that the average age at retirement for most physicians was 65 years, but women physicians tend to retire on the average 4.1 years earlier than men. Also, about 40% of the physicians reduced their activity by at least 10% for 3-4 years prior to retirement. This should enter the calculation when work force numbers are calculated based on the number of licensed physicians. Although there are several papers regarding pre-retirement preparation, there are very few studies addressing the period surrounding retirement and post-retirement. Factors affecting male and female 18

SAN ANTONIO MEDICINE • April 2021

physicians’ retirement decisions include: general environment at work, decreasing income, employment of spouse, income after retirement (Social security income, pension or annuity other sources like rental property) current age, the existence of dependents in the family, years of service as a physician, the health status of self and spouse, stress/burnout, personal interests and the availability of part-time jobs. Once the decision is made to retire, there is almost no road map for that physician, particularly in the psycho-social aspect, which has prompted this article. It was the last time I would give this lecture to medical students and residents which I did once a month. It was about skin conditions in the newborn baby. I had pictures of skin problems with a ‘wow factor’ of 10 on a scale of 1-10, as the students called it. I had mentioned that it was my last teaching session; I retired that week. At the end of the session the residents rushed to finish their work, the students rushed to the cafeteria to grab lunch. I sat down for what felt like a very long five minutes. Is that it? Forty-two years of a teaching career and no one in the institution cares? You just pack up, turn the projector off and walk away? It certainly seems like there could be something we do in recognition of a last teaching session, last surgery, last clinic patient, last day at work, to put closure to a lifetime of work for most physicians. Life after retirement Ideal retirement means something different for each physician. The most common statement I hear is that they are relieved that they do not have to follow any schedule. That was true for me. It was followed by using that unscheduled time in committing to unnecessary activities like listening to online webinars, attending lectures, book clubs and planning to have lunch with other retirees. Others plan vacations they should have taken at a much younger age when their stamina and agility would have allowed them to walk the long trek to Petra and back instead of staying back looking at the facade. Those who are grandparents among us overcommit to taking care of grandchildren, finding ourselves in the familiar place of playing the role of parents. However, this is among the things grandparents do that is probably the most pleasant engagement that infuses youthfulness and joy in one’s life. My retirement planning started two years before actual retirement. I was in my office preparing a lecture, an activity I thoroughly enjoyed. It occurred to me that I can do this forever. I love to write! I should do that while I have the clarity of thought and physical wellness. It was at that point I decided I will set a retirement date. I felt that my work environment was ready for that as well. I have written a lot since then,

PHYSICIAN RETIREMENT

but my book is still only in my head. After the honeymoon period, boredom sets in. Every physician friend who retired has expressed the desire to do some part-time work. Most academic retirees have not expressed financial reasons for wanting to work but just to be doing something to keep medicine in their life. Working as Locum Tenens, telemedicine, overseas volunteer work, volunteering in a clinic are among medical activities which attract physicians. Physicians who have a serious passion like gardening, golfing or mountain climbing have delved into these activities with gusto. This is a financial commitment as well and should be considered when planning finances. For me, it is teaching Indian classical dance. I spend twenty hours a week teaching, preparing lessons, organizing programs and other dance related activities. The financial perks are minimal but the physical and mental fitness aspects of it are great rewards. The Forest Dweller Some colleagues have delved into reading religious literature for an in-depth understanding their own religion and sometimes other world religions. In the Hindu way of thinking, humans go through four phases of life. The student (Bramacharya), Householder (Grihastha), Forest dweller (Vanaprastha) and Sanyasi (Renunciate). The first two stages are obvious, the third literally means retiring to the forest and trying to withdraw from a material world to spend more time on spiritual pursuits. In modern times, this is the stage of retirement when one gradually tends towards spiritual pursuits. Time spent in meditation or prayer gives a special kind of quietness as we get into the later stages of retired life. I have heard senior friends say that they achieve this while doing dishes, gardening, singing or listening to music. In English literature, life’s seven stages were eloquently described by Shakespeare in the play ‘As you like it’. All the world’s a stage, And all the men and women merely players; They have their exits and their entrances; And one man in his time plays many parts, His acts being seven ages. There are differences between male and female physicians in the manner they consider retirement.

Rajam Ramamurthy, MD is a member of the BCMS Publications Committee and is a past President of the Bexar County Medical Society. References: Key findings highlight perceived barriers to retirement planning at various career stages in addition to factors that can enhance physicians' retirement planning, including creating gradual and flexible retirement options, supporting ongoing discussions about financial planning and later career transitions, and fostering a culture that continues to honour and involve retirees. Medical institutions could foster innovative models for later-career transitions from medicine in ways that address physicians' needs at various career stages, support gradual transitions from practice and recognize the value of experienced, capable latercareer physicians and retirees. Planning for retirement from medicine: a mixed-methods study Michelle Pannor Silver 1, Laura K Easty 1 Affiliations expand • PMID: 28401128 • PMCID: PMC5378543 • DOI: 10.9778/cmajo.20160133 Free PMC article Implications: Strong work identity and tensions between different generations may confound concerns about retirement in ways that complicate institutional succession planning and that demonstrate how traditional understandings of retirement are out of date. Findings support the need to creatively reconsider the ways we examine relations between work identity, age, and retirement in ways that account for the recent extensions in the working lives of professionals. Gerontologist 2018 Mar 19;58(2):320-330. doi: 10.1093/geront/gnw142. Visit us at www.bcms.org

PHYSICIAN RETIREMENT

Life Segmented

Did I do something useful? By John Seidenfeld, MD and Adam Ratner, MD

If I am not for myself, who will be? If I am for myself alone, what am I? If not now, when? *

Seidenfeld: Life is usually lived in phases and today in pods. Transitions from privileged birth, to child living in a peaceful land, to camper in a faraway remote location, to public school student, to athlete, to awkward boyfriend, to college student distant from home, to trainee in a lifelong profession, to Army service, to husband, to father, to grandfather, and to remembered soul seems a condensed

SAN ANTONIO MEDICINE • April 2021

but fitting summary. Another way to view this life is that seen from a pod of medicine. Here the molt was from medical student, to intern, to resident in internal medicine, to fellow in pulmonary medicine, to faculty researcher and teacher, to mentor, to clinician, to administrator, to medical director, to clinician, and to faculty member.

PHYSICIAN RETIREMENT

We transition from unformed Potential to formed Professional with the help of teachers, mentors, genetic gifts, proper nurturing, nudging, questioning, telling stories and believing them, answering offers, invitations, and opportunities, overcoming obstacles and crises, and entering dialogue with friends, colleagues and acquaintances. Sometimes we push and sometimes we are pushed. As Bob Dylan has said, everyone serves somebody. As we go on there is lifelong learning. There is belief in science, literature, comradery, interprofessionalism, and advancement of society and culture. If we are fortunate, we reach out to others and they reach out to us. Two years ago, I was living the quiet life of a Hill Country gentleman learning about wild hogs, scorpions, snakes, and grandchildren when Adam Ratner asked if I would visit him at UIW (University of the Incarnate Word) School of Osteopathic Medicine to discuss the new school. What follows is Adam’s explanation as to what has happened in his life that led to this fortuitous meeting. Ratner: John is correct, life is segmented, particularly if lived fully. I didn’t really know and appreciate this early on. When I completed my residency and fellowship, I believed that was the end of my academic career. I returned to San Antonio where I grew-up and joined an active and growing private radiology practice. I found that I particularly enjoyed building new imaging centers and developing new practices with my partners. I enjoyed this for two decades until reimbursements changed in 2005-6 and I realized that we probably wouldn’t be building any more imaging centers. I “retired” from private practice with the plan to co-found a non-profit organization, The Patient Institute, to keep me busy and out of trouble. Unfortunately, I was not busy at first while we waited for the IRS 501(c)3 determination letter to get the organization funded and running. To fill the time, I was spending too much time at Costco and the garage was filling up. One morning, after a few weeks of retirement, our high-school aged daughter (now a psychiatry resident) came down the stairs, saw me in my bathrobe at the breakfast table (she never saw me at breakfast prior to retirement), pointed her finger at me and exclaimed, “Dad, you’re lazy!” I did not want to be a poor role model, and frankly I was bored. As soon as she left for school that morning, I contacted Darlene Metter, a friend and colleague at UT LSOM Department of Radiology, and my second career in academic medicine began. I enjoyed several years at UT and then transitioned to UIWSOM when I heard they needed a part-time radiologist. Both at UT LSOM and at UIWSOM, I have

found great joy guiding and mentoring the next generation of caring, effective and happy physicians. During my academic career, I became more active in BCMS. One of my favorite BCMS activities is serving on the Publications and Communications Committee. On this committee, we have fun discussing the contents of our excellent magazine, San Antonio Medicine. At one of these Publications and Communications Committee meetings, who should I see but John Seidenfeld. I remembered working with him decades ago when I was in private practice. Seidenfeld: And so, it began again. Adam was passionate and excited about a case-based learning method at the SOM. After watching this process and a more Socratic question and answer, large group process, I had found the next project along life’s path. That was some two years ago and since then I have been more involved with the learners in groups studying cases, in pre-clinical education, and in community engagement activities. The faculty has welcomed me and the ideas we are working on together. BCMS and the Publication Committee have provided a platform to discuss all aspects of medical practice. Steve Fitzer and the clinicians who volunteer as counselors and officers with the medical society are excellent role models. We are looking for others who still have a voice, an active mind, a heart flame, and interest in communicating with colleagues about big and small projects. Lifelong learners please contact Adam or me and we would be glad to share or hear of your interests. *Hillel the Elder John Seidenfeld, MD is the Chair of the Publications Committee. Adam Ratner, MD is a member of the Publications Committee and former President of the Bexar County Medical Society.

Visit us at www.bcms.org

PHYSICIAN RETIREMENT

Retirement: Now What? By Stephen C. Fitzer, BS, MIM, CEO/Executive Director of the Bexar County Medical Society

I am a baby-boomer. Like many of my generation, my entire life has been work-workwork. It is the way I was brought up and it is how many of my generational friends think. Baby boomers were raised with an attitude of personal responsibility and the value of hard work, and wore them as badges of honor. We took pride in earning and saving, providing for our families, paying the house off, funding the kids’ college accounts, and racing to retirement,

SAN ANTONIO MEDICINE • April 2021

a time when we would be able to take a rest. Once we win the race to retirement, then what? For Boomers, the race to retirement means wanting to retire early and have a comfortable life that allows for doing all the things that we would like to do, or just relax and enjoy life. So, I decided to give retirement a try, at the age of 52. I decided there was enough money accumulated to retire and took that giant retirement step. Selling the company I had invested in in

Illinois, my family and I moved back to Texas, built our retirement home and called Boerne home. Long story short, I was too young to retire and quickly figured that out. So after just six months, I started looking for another opportunity. Then, after working another five years (taking me up to the ripe old age of 57), I decided to give retirement another go. I learned a lot more the second time around, but ultimately failed that retirement test as well.

PHYSICIAN RETIREMENT

Everyone says you have to have hobbies or serious interests in your life in order to retire early and successfully. Athletics had always been my hobbies; basketball, baseball/softball, golf, running to stay in shape. I found that when I got older, I couldn’t keep up with the younger guys anymore when playing sports. I became too slow in basketball (I figured that out when I started fouling too much), couldn’t throw the ball as far or hit a ball as hard in baseball anymore, and found it hard to find golf partners who wanted to play as often as I wanted. Volunteering is also purported to be a good use of retirement time. Being very active in my church, I got very involved in helping others. Everyone has developed different skills they can share to assist others and therefore we should help in ways where we feel we can make a difference. My choice was to provide free counseling to those who lacked experience with business and “the system”. It is very fulfilling to see someone who is about to be deported, because of a vengeful husband, have the opportunity to stay in the country together with her three US citizen children. It was also fulfilling to teach non-financial people how to manage their lives better and find success. It was fulfilling to help business owners figure out how to better manage their business and not lose everything. Contrarily, it is demoralizing to see those who refuse to accept advice and as a consequence lose their livelihoods, their homes their jobs or their families. Traveling is what many who retire seek to do. What can be more fun than going to places one has never been before, experience other cultures, see the great wonders of the world. Some just want to get in their car or RV and travel this great country; others want to visit Europe, Australia, the islands, the home of their ancestors or other exotic locations. If one has prepared financially for the expenses of these joys and has the health to enjoy the travel, it is worth comparing what you know in life to what you have not known. However, in my case, I had traveled to 65 countries dur-

ing my business career and therefore travel felt a bit like a mailman taking a walk on his/her day off. It just wasn’t my first choice. Something that impacts everyone in retirement is learning to live on savings and investments; no more paychecks from an employer or proceeds from a business. Social Security does not fully compensate for this lost revenue. Like many, I had heard it said that it is cheaper to live as a retired person; well, IT’S NOT! Most expenses stay the same. Expenses such as property taxes, insurance, food, home maintenance are all still there. Plus, medical expenses tend to go up, leisure travel can be very expensive, some hobbies can add significant costs to the budget, and eating out becomes a regular form of entertainment. I met many people during my second retirement that had reached their seventies or eighties and had run out of money. They were embarrassed and ashamed. When they retired, they thought they had more than enough money. Then inflation, investment losses, bad economies, death of their partner, kids who provided support moving away, or the need for repairs to their home or for a new vehicle all hit them unexpectedly. Are you ready for retirement? Prepare and calculate carefully. My advice is stay close to family, get financial advice before and after retiring, live a healthy lifestyle, and do what you really enjoy. Stephen C. Fitzer BS MIM is the CEO/Executive Director of the Bexar County Medical Society References: 25 Things to Do When You Retire - By Phil Taylor, Contributor, June 15, 2020

Here are some ideas of what to do in retirement, printed by U.S. News & World Report: 1. First and foremost: Learn to live within your means. 2. Travel. 3. Remodel your home. 4. Move to the city. 5. Move to the country. 6. Get a part-time job. 7. Volunteer. 8. Spend time with friends. 9. Babysit. 10. Get educated. 11. Write a book. 12. Learn a new language. 13. Start a new hobby. 14. Nothing. 15. Join a fitness group. 16. Take up a new sport. 17. Buy a motor home. 18. Start a business. 19. Teach. 20. Go into public service. 21. Visit family. 22. Be a mentor. 23. Read. 24. Start a blog. 25. Learn to play music.

Visit us at www.bcms.org

PHYSICIAN RETIREMENT

Retirement from Medicine in Stages: Slow Descent From the “Mountain” By Jaime Pankowsky, MD, FACS

While in training and when in private practice, one does not think of retirement at any time. That thought and feeling enters in our mind as our circumstances, and sometimes our health, begins to change; but not for the better. Alongside the care of patients, duties in the hospitals where we practice and paying off rents and/or mortgages, we are concerned to care for our families and see that our children get the education they can obtain and accomplish. But sooner or later, events personal, professional, financial and social begin to exert their influence and make retirement a more immediate concern. The “when-and-how” is different for each doctor depending on the physician’s conditions in health, finances, family and age. Early on, when one’s practice becomes stabilized and settled, we begin investing in annuities, IRA’s and/or the stock market, thinking in a very distant future for retirement. Until then we continue humming along. And then, the children are grown up and educated, the house mortgage is paid up and changes are occurring in one’s profession or specialty that we did not expect and for which we were not trained. And then health changes occur and retirement is looking us directly on the face. I practiced general surgery for over thirty years in San Antonio and then changes began to creep on my complacency. First, general surgery began to be replaced by subspecialties, like colon and rectal surgery, bariatric surgery, breast preservation, etc. One is at that stage, or at an age, when returning to a training program is not an option. Second, I developed cryptogenic tremor in my left hand and this alone made operating less safe for the patient

SAN ANTONIO MEDICINE • April 2021

and unsightly for the staff. Finally, a spinal fusion made standing in the operating room for long hours more problematic. So, health issues and changes in the specialty demanded I stop doing surgery. Other than those problems (none of them potentially fatal), I was in good health and condition. But just doing nothing was not in my nature. I took on other activities. I volunteered as a member of the Committee on Continuous Medical Education of the Texas Medical Association and for a couple of years I used to go with the committee staff to evaluate the educational programs of hospitals in different cities in the state. It was interesting

and stimulating, but it required traveling and attending meetings in Austin. At one point they chose to not have me on the committee and I left. Also, I spent about 18 months evaluating medical claims for the Social Security Administration. I gave it up, because judges seldom had any use for our medical evaluation and it appeared to me to be a waste of time. I also saw how the system was being gamed and cheated by people with false diseases (myalgias) or insignificant injuries. I resigned. I decided to travel with my wife and, after learning to scuba dive, with a club of scuba divers. Trips as close as Cozumel and as far as

PHYSICIAN RETIREMENT

Tahiti and the Red Sea in Egypt were appealing and very interesting experiences. I also made a trip around the world by ship in a program called “Semester at Sea”, which at that time (1998) was sponsored by the University of Virginia (today it is led by the University of Colorado). Taking advantage of my familiarity with the hyperbaric chamber, I took courses in chronic wound care, one in Minneapolis and two in San Antonio. Our city’s population suffers from obesity and diabetes in large numbers and they, in turn, frequently develop chronic wounds in the extremities very difficult to treat. I joined a couple of clinics as staff and worked in those clinics for about twelve years. Finally, my age was becoming an issue. I was past my 80th birthday, and I was advised enough was enough, (to my family’s relief I quit completely around the year 2008).

If I had to summarize some of the reasons to retire, I can think of at least three (although I am sure many colleagues could find many more): First, one’s health. One cannot jeopardize the well-being of patients, family, hospital and office staff by practicing in a state of wobbly well-being, either physical or mental. This does not need further clarification. Second, family. If in good health, the doctor should try his best to ensure that his family (widow if he dies first) have the means to support and live relatively free of economic distress if possible. Also, one has to see that the children have reached their maximum capacity in learning to lead an independent life on their own. Third, one should be financially free of major debts and with reserve funds to be able to lead a normal life even if it be a more mod-

est one than when we were at maximum capacity to work. The United States government has been indulgent and understanding to most middleclass citizens by allowing us to create growth retirement funds that are tax sheltered while growing. For fruitful investment most of us need a financial advisor, but we need to be cautious here, and avoid those who claim they can make us rich in a short time. A steady, diversified plan will work most of the time if we start early and keep the goal of retirement with a peace of mind always in front. Jaime Pankowsky MD FACS is retired and a Life member of the Bexar County Medical Society.

Visit us at www.bcms.org

COVID-19 VACCINATION

The COVID-19 Vaccination Game By Melody Newsom, BCMS Chief Operating Officer, Community Liaison

Vaccinations (and a plethora of questions about them) are all the rage these days! How on earth do I get one? Which brand should I get? Should I even get vaccinated when it’s available? How do I get vaccine for my practice to give to my patients? The list goes on! The hardest one for the physicians, their staff and other medical professionals in the Phase 1A category is the “How on earth do I get one?” Physicians that do not have privileges at a hospital along with their staff were left out of the mix during the initial rollout of the vaccine in Texas. This became even more of an extreme challenge when the State of Texas opened up the vaccination priorities to the 1B population, leaving the doctors and other medical professionals in the same boat as the rest of the community, having to struggle to find an opportunity to get vaccinated! H-E-B had been designated as the place for Phase 1A’s to get vaccinated, yet they only received 100 doses at each pharmacy in San Antonio for a total of 1,400 doses for our entire medical community. I have dedicated nearly all of my time at BCMS, since the pandemic was declared, focused on all things COVID-19. I’ve served on various pandemic related committees such as the BCMS COVID Task Force, Metro Health Testing Task Force, Testing and Lab Reporting Workgroup, the Community Response Coalition, the Regional Medical Operations Center (RMOC) and monitored multiple conference calls each week such as UT Health, Southwest Texas Regional Advisory Council (STRAC) and the Department of State Health Services (DSHS). At each of these committees on which I participate I continually mention the plight of our physician members who, along with their staffs, are without hospital privileges and therefore have no path to get the vaccine. So, when a hospital has a small quantity of vaccine available, they would call me – “there are 300 doses at this location for doc-

SAN ANTONIO MEDICINE • April 2021

tors only; 200 doses at that location for doctors and medical staff; 35 doses RIGHT NOW at this location”, and so on! (I have likened the situation to a game of “Whack-A-Mole” on steroids!) As you recall from previous articles in San Antonio Medicine, BCMS in conjunction with H-E-B held a 1st dose vaccine event at the BCMS building on Sunday, January 10 and the follow-up 2nd dose event Saturday, February 6. I knew that was still just a drop in the bucket of the medical community needing to be vaccinated, so the vaccine Whack-A-Mole game continued. Vaccine opportunities became few and far between. UT Health reached out and had a limited number of vaccine doses to dedicate to the 1A group. I collected names and phone numbers and UT Health personnel called to schedule appointments. Still a very cumbersome scenario for all involved, but it was still progress. Finally, on Thursday, February 25 at 4 p.m., UT Health called to let me know they were going to designate 1,000 doses for the doctors and other medical professionals on Saturday, February 27. Wow! Short notice again but, hey, “We’ll see what we can do”. UT Health had been internally testing a program that would allow the ability to upload the contact information for those needing to be vaccinated so they could self-schedule. BCMS became the beta test to the large population of physicians. Despite a few glitches, we were able to get over 700 uploaded into the system by Saturday. The glitches seem to be minimal now and, the great news is, UT Health has been designated a vaccine hub and continues to make vaccination appointments available to our physician members and other medical professionals. I want to say I finally won at the Whack-a-Mole game. (At least for now!) “Which brand should I get?” With three vaccines receiving the Emergency Use Authorization (EUA) – the Pfizer and Mod-

COVID-19 VACCINATION

erna mRNA vaccines and the newest vaccine from Janssen/Johnson & Johnson – discussions, phone calls and questions abound. The consensus from experts is you should get whichever COVID-19 vaccine is offered to you. Each of the three currently authorized COVID-19 vaccines prevents severe disease and death. Now that the Johnson & Johnson one-dose vaccine is out, the main question I receive now is, “How do I get vaccine for my practice?” If this is you, links to all the information you need are available on the BCMS COVID-19 Resources page under the COVID-19 Vaccine Resources section on the BCMS website www.bcms.org. This includes the COVID-19 Pandemic Vaccine Provider Registration as well as links to COVID-19 Vaccination Training Programs and reference materials for healthcare professionals. We have worked throughout the pandemic to make the BCMS COVID-19 Resources page an all-inclusive place to go for information. According to the DSHS website, vaccine supply remains limited as manufacturers build capacity. It will take time for Texas to receive

enough vaccines for priority populations. Supply will increase in coming months. More vaccines are in clinical trials now and may be authorized for use soon. If you are interested in seeing where the vaccine allocations are going each week, the information is available on the DSHS COVID-19 Vaccine Allocations webpage. Both State and Federal Allocations are available on that page. Throughout the pandemic, the Bexar County Medical Society team has worked diligently to communicate valuable information, provide easy to access needed resources, distribute FREE Personal Protective Equipment (PPE), and gain access to vaccinations for our members and the medical community! Always know, we are here for you and want to help you and your practice during the difficult as well as the good times. Melody Newsom is the BCMS Chief Operating Officer and Liaison with Community, Emergency Preparedness Entities.

Visit us at www.bcms.org

COVID-19 VACCINATION

To Vaccinate or Not to Vaccinate? By Jaime Pankowsky, MD, FACS

Often in the news media one reads of people refusing or doubting whether to be vaccinated against COVID-19 or not. Reasons given appear at first sight reasonable enough, including worry about allergic reaction, fear of secondary infections (because of or in spite of the vaccine, etc.), or that vaccines may cause Autism. These and other reasons given varied from the improbable to the outlandish. Ever since Dr. Jenner introduced the cowpox vaccine at the end of the XVIII century and the British Parliament passed a law to vaccinate school children, the news media has come out with questions and even opposition to such vaccine obligation. “Punch”, the sarcastic magazine, published a number of cartoons showing people growing cow tails behind their bodies, or horns on their heads as a consequence of being vaccinated. Other dreadful consequences to vaccination were presented and in response many Britons tried to refuse the vaccination lest they develop such complications. In the meantime, smallpox epidemics were still killing or deforming millions of people, a fact that was waved away as part of life like rain and snow. Today, because of this effective vaccine, smallpox has all but disappeared. Since the times of the invention of smallpox vaccines, we have seen the development of vaccines against rabies, diphtheria, tetanus, influenza, poliomyelitis, etc. In other words, vaccines have had an enviable record of success in preventing or reducing the effects of infectious disease that in the past were scourges of humanity. It would be safe to dare any business enterprise or world government to match similar successes in all their decisions. And yet, some people will trust the advertisements and propagandas placed in newspapers and on television before they would trust the COVID-19 vaccine. Joseph Goebbels, Hitler’s minister of propaganda, is reputedly to have said that “a lie, repeated frequently and persistently enough, will be believed more than the truth”. And the regime he represented was an example of perhaps he being right since it happened in Germany, a country that prior to the Nazis was the most educated, most scientifically advanced country in Europe. That said, those were bad times in Germany. It was suffering terrible post-war inflation and bad economic times after World War I, when they also felt the humiliation of defeat and the people were in the mood to receive the messages of those false Messiahs. Today, and since the end of World War II, the United States has been at the apex of scientific advancement while at the same time enjoying an enviable economic position in the world. Our medical centers are a Mecca for medical education and new scientific discoveries and developments. So, why are some of our people showing such stubborn disregard for true science and embracing persistent ignorance? 28

SAN ANTONIO MEDICINE • April 2021

In times past, newspapers like “Punch” and many other more serious publications, were the purveyors of news, some factual, some speculative, some dubious and some flat-out lies. But, the public had the choice of buying them or not. With the inventions of the telephone, radio, television, movies and now, the internet and the electronic platforms to cast opinions, speeches and ideas up into the clouds to be captured (willingly or unwillingly) by the public, we are now inundated with unverified opinions, voices, fantasies, conspiracies and, yes, some verified facts as well. The goal is not always evil as with Herr Goebbels’, but nevertheless, the spread of unverified information can cause what our military calls collateral damage or unintended results. As an example, we learned that no less than a representative to Congress from Georgia, postulated that the fires in California were caused by a laser ray projected from outer space by Monsieur Rothschild, who happens to be French and, of course Jewish, and normally is known to be more interested in producing high quality wines. What caused Monsieur Rothchild to want to burn California is not explained. My problem is this: that there are enough people in the state of Georgia who thought this person, who probably should be under psychiatric care, should be elected their representative to Congress. The only explanation is the diffusion of outlandish stories, pseudo facts, and conspiracies in the media mentioned above. It is worrisome, because Americans think of themselves as practical, factual individuals. However, since the appearance of unverified, mis-information in the media and its persistent repetition, it has begun to appear believable to a portion of our citizens. Even television commercials seem to be promising fantastic possibilities that seldom if ever come true, but their constant repetition are making them believable. One should not be surprised, therefore, that vaccinations have also been endowed with mysterious evil properties. Even minor reactions to injections are magnified by the news media, making them appear as dreadful complications by their televised megaphone. The media thrives financially and politically in panic mongering. When children receive routine vaccinations, and coincidentally, some of those children turn out to autistic, it is immediately assumed that one caused the other, instead of just coinciding with one another. I think its time to teach more science to our children in school, at least it should be given the same importance we now give to sports and social activities…perhaps more. Jaime Pankowsky MD FACS is a retired physician who is a life member of the Bexar County Medical Society.

COVID-19 VACCINATION

Ten Things to Know to Administer COVID-19 Vaccines By David Doolittle

State health officials have begun distributing COVID-19 vaccines across the state, based on guiding principles that prioritize essential health care workers and vulnerable populations. There are numerous requirements and steps physicians and health care facilities must adhere to in order to administer vaccines. Below are 10 things to know about administering the vaccines that have received an EUA from the FDA so far. • State Registries: In order to administer a vaccine, you must be enrolled in Texas' immunization registry, ImmTrac2. Enrollment in ImmTrac2 is part of the registration process at EnrollTexasIZ.dshs. texas.gov. • Ordering and Inventory: You will be required to submit requests, accept your allocation, and report inventory for the COVID-19 vaccine via the Texas Vaccine Allocation & Ordering System (VAOS). Be sure to check your email spam folder and accept your allocation within 48 hours. Resources: o COVID-19 VAOS – How to Access the System (PDF) o COVID-19 VAOS – Provider User Training Guide (PDF) o More Department of State Health Services (DSHS) Resources and Video Demonstrations • Records and Reporting: You will need to report patient information for each vaccine administered to ImmTrac2 within 24 hours of administration. COVID-19 vaccination records must be preserved for at least three years following vaccination, and will need to be made available to any federal, state, local, or territorial public health department to the extent authorized by law. You also need to submit a daily report of the doses administered into the Texas Department of Emergency Management (TDEM) Therapeutics and Vaccine Reporting Portal and report any unused or wasted doses specifically into VAOS. • Payment: You cannot sell or seek payment for COVID-19 vaccine and any accompanying supplies provided free by the federal government. Administration fees may be applied; however, you must administer the vaccine regardless of whether the recipient can pay the fees. If you are enrolled in Medicare or plan to enroll to administer the vaccine, you need to keep up to date on coding, billing, and payment requirements from CMS. • Temperature Monitoring: You must have a digital data logger to closely monitor and record the refrigerator and freezer temperatures that store the COVID-19 vaccine. These records must be preserved for at least three years. Find more information on the requirements of digital data loggers on the DSHS website. • Ancillary Supplies: COVID-19 vaccine shipments will come with

•

all ancillary supplies, including needles, syringes, alcohol prep pads, surgical masks, face shields, diluent (if applicable), and COVID19 vaccination record cards for patients. For the Pfizer/BioNTech vaccine, you may receive these supplies in a separate shipment. Time Limitations: The vaccines come in multi-dose vials and need to be completely used within a limited period of time after the vial is removed from the refrigerator or freezer. The Pfizer/BioNTech vaccine requires reconstitution with saline. More details on administration, dilution (if applicable), and time limitations are available in these Pfizer/BioNTech, Moderna, and Janssen/Johnson&Johnson fact sheets. Patient Education: Before you give the shot, you have to provide to the patient an approved Emergency Use Authorization (EUA) fact sheet or vaccine information statement (VIS). The current EUA fact sheets for recipients of the Pfizer/BioNtech, Moderna, and Janssen/Johnson&Johnson vaccines are available on the BCMS website. After the first dose, you must give your patient a COVID19 vaccination record card, which is included in your vaccine shipment. For Pfizer/BioNtech and Moderna, the card is to ensure the first dose and second dose are from the same vaccine manufacturer. If the patient’s card is lost, you can look up which first dose the patient received in ImmTrac2. You cannot give a patient doses from different vaccine manufacturers. Safety: You must administer a COVID-19 vaccine in accordance with all requirements and recommendations of CDC and CDC’s Advisory Committee on Immunization Practices (ACIP). The ACIP’s recommendations for the Pfizer/BioN Tech,Moderna, and Janssen/Johnson&Johnson vaccines, as well as CDC’s Interim Considerations for Use of mRNA COVID-19 Vaccines are available on the BCMS website. Adverse Events: You must input any moderate and severe adverse events following vaccination to the Vaccine Adverse Event Reporting System (VAERS). Note that you should report adverse events only to VAERS, which is co-managed by the CDC and the U.S. Food and Drug Administration (FDA). You also must promote to recipients V-Safe, a smartphone-based tool that uses text messaging and web surveys to provide personalized health check-ins.

CDC also has published Interim Considerations: Preparing for the Potential Management of Anaphylaxis at COVID-19 Vaccination Sites. Find more tools, resources, and information on TMA’s COVID19 Resource Center, which is continually updated.

BCMS NEWS

Melody L. Newsom Distinguished Service Award Recipient

For tireless, successful efforts during the COVID-19 crisis organizing the distribution of donated personal protective equipment (PPE) to medical professionals in Bexar County; For creating and maintaining awareness of the need for prioritization of Phase 1a vaccinations and arranging, in combination with other community organizations, COVID-19 vaccinations for medical professionals throughout Bexar County; For continuing loyalty to the Bexar County Medical Society and its physician members; Melody L. Newsom, you are recognized with this Distinguished Service Award from the Bexar County Medical Society, its leaders, members and staff.

SAN ANTONIO MEDICINE • April 2021

BCMS NEWS

Betty Fernandez – New Director of Operations Bexar Credentials Verification, Inc.

Thank you, Mary Jo Quinn! God be with you in your retirement

The Bexar County Medical Society is pleased to announce the appointment of Ms. Betty Fernandez as the new Director of Operations of its subsidiary, Bexar Credentials Verification, Inc. (BCVI). Ms. Fernandez was previously trained and worked as a credentialing specialist under Mary Jo Quinn, the departing Director of Operations at BCVI. After 11 years of service as a credentialing specialist under Ms. Quinn, Ms. Fernandez left BCVI and accepted an opportunity to work for a neuromonitoring practice for 3 years where she gained the experience of how primary source verification information is used by a medical practice. This completed her training/exposure and made Ms. Fernandez the right candidate to assume the role formerly held by Ms. Quinn. Ms. Fernandez expressed her acceptance of the new position by declaring “I am truly honored and excited to accept the position of Director of the Credentialing Department at Bexar Credentials Verifications, Inc. (BCVI). I am very thankful for being given this opportunity. Ms. Mary Jo has been the director for 20+ years and has paved the road for me to come and continue her legacy. I am proud to return to be part of such a great organization and it is my deep belief that working together with physicians’ medical practices, our clients and staff, we will meet our mutual goals.” In order for a medical provider or allied professional to be able to practice at a hospital, clinic or surgery center they need to be credentialed. BCVI is a credentialing authority organization (CVO) certified by the National Committee for Quality Assurance (NCQA) that provides direct contact with primary sources for the verification of healthcare providers’ qualifications. Primary Source Verification (PSV) is the process of making sure to verify where the provider received their degree in medicine and had their training to confirm their credentials, including the PSV of boards, licensing, sanctions, medical staff and work experience.

After more than 20 years of service to the Bexar County Medical Society and Bexar Credentials Verification, Inc. (BCVI), its subsidiary, Ms. Quinn has decided to begin officially enjoying the journey as a retired person. Mary Jo Quinn is a native of San Antonio and has worked in the health care field for over forty years in Texas, Kentucky and Ireland. She worked in San Antonio area hospitals (Christus Santa Rosa, University Hospital, and Humana Hospital) and for health care plans. For eighteen years prior to joining BCVI, Ms. Quinn was directly involved with credentialing and compliance for hospitals, health care plans and CVO’s. Ms. Quinn was the first Director for Bexar Credentials Verification, Inc. when it started up in the 1990’s. Ms. Quinn felt a higher calling and left the company for three years to be a missionary with the Presentation Sisters of the Blessed Virgin Mary in Zambia, Africa for two years, living with the people and teaching reading and English to children and setting up a special needs class for Zambian children who had never been able to attend school. Upon return home to San Antonio, Ms. Quinn worked with the Incarnate Word Sisters as Director of Volunteers at Sisters Care, a personal care agency. Then in 2005, she returned as the Director of Bexar Credentials Verification, Inc. Ms. Quinn will be sorely missed by her staff, Bexar County physicians, and all the companies with which she has worked in her many years of service. Ms. Quinn leaves us with this comment, “Working for BCMS has been a delight.”

Visit us at www.bcms.org

SAN ANTONIO MEDICINE

GOLF is a Four-Letter Word By John J. Seidenfeld, MD

It pains me to say this, but my younger self sees my older self as elderly. Though some people start golf at a younger age to enjoy the game for a lifetime, even those who start later should look forward to camaraderie, a nice walk and help with tracking errant balls. Two years ago, a friend asked me to join him on the links. Some history of our relationship is important to better understand my response. We were once a tennis doubles team and always had an enjoyable time playing. We also played softball and made a formidable shortstop to first base connection. This was mostly because of his excellent fielding at shortstop and pinpoint throws to first base. Occasionally I connected well with pitches while at bat and would drain the bases. I still remember, fondly, patients we cared for as doctors over the years. For these reasons one could only say yes to his invitation. A few words of caution as to why you should or should not say yes to such a proposition. Reasons to say “yes” are that when we play golf, we walk for one-totwo hours and pull carts with our clubs around a par three, nine-hole city course. We discuss life events and plans, ask questions about all aspects of life, speak spontaneously without inhibition, suggest new streaming shows and books, marvel at good shots but do not keep score unless we are doing well, often drop another ball if we mishit or lose one, and never feel the need to lie or cover up if many shots are taken. The formula we use to rate the day is that the walk and talk get a grade of 85% and any good shots add to the total. Anger and frustration are discouraged, and we agree that this is a difficult game. My friend is a good golfer, and this beginner is open to his suggestions. Reasons to say “no” to the golf proposition include other things you might do with your time, the cost of equipment and greens fees, the 32

SAN ANTONIO MEDICINE • April 2021

long learning curve, frustration and anger as emotions that arise in some, and physical maladies which a grandfather explained as complaint categories after forty years of age, “asses and elbows.” We might have our new car columnist write about the costs of golf equipment depending on how seriously one is about the game. These might be anywhere from a used Chevy to a new Beemer in his parlance. The way to get from a used Chevy to a new Beemer might include regular lessons from a professional for many years, the latest clubs by tailor made (Taylor Made?), golf tourism once the pandemic abates although this is what we sometimes imagine as we play at all San Antonio’s courses, shoes and outfits to match the course and weather, golf carts and other paraphernalia, psychoanalysis to work on swings and competitive urges, and public courses known as the Alamo Golf Trail versus country club membership and fees. Some describe golf as “a good walk spoiled” (attributed to Mark Twain and John Feinstein) but your frame of mind and reasons for playing temper a hasty condemnation. Medical professionals do serious work and need down time to balance the difficult encounters. Because of our historically mild weather in South Texas, we have played almost each week in 2020 and plan to continue in 2021 despite the one week of winter in February this year. Other four-letter words to consider are “love” of the “game”, “mate” to share the day with, and the “walk” that is part of it. I hope your outing brings you more joy than pain. John J. Seidenfeld, MD is the Chair of the BCMS Publications Committee.

SAN ANTONIO MEDICINE

Pandemic Story Telling Internal Medicine residents at UT Health San Antonio participated in Project 6 -55, a guided reflective writing workshop, during which they wrote and shared 6-word and 55-word stories about how the COVID-19 pandemic has impacted their clinical work. Sharing with their peers offered a powerful understanding of the experience of caring for patients during a pandemic and some collective healing. Here are their stories…. Learning to smile with my eyes. Emotions hidden underneath a mask. It has changed human interaction, challenging us to adapt. Non-verbal communication has always prevailed over words. Now, how can I tell a patient, I’m happy? How can I tell them, I’m sorry? When can we go back to seeing a smile and smiling back? ~ By Ariadna C. Perez Sanchez, MD, PGY-1 Transferred from an outside hospital hanging on to your life. On a nasal cannula, switch to comfort care, away from home. His wife said she can only come the next day. He said, “Please, help me, Doctor.” Morphine ordered. But before it got there, he was gone. Family never got a chance to say goodbye. ~ By Jane Lee, MD, PGY-2 Agony while waiting for a phone call. Hours are longer, waiting. For every ring, my heart skips a beat; hoping to hear the doctor’s voice. Hoping for good news, yet any news will suffice. It’s difficult to hang up. Time shortens. So much to ask. I forget everything I planned to ask during that call. ~ By Juan Carlos Ulloa-Rodriguez, MD, PGY-2 Lying in bed, a painstaking three months now. Ventilated, hypotensive; a victim of the pandemic. Family and physicians holding on to hope, no visible light on the horizon.

He lays there, visibly struggling, appearing emaciated and fatigued. All options explored, losing faith. His last breath; he gives a sigh of relief. Now, finally at peace. ~ By James Gnecco, DO, PGY-2 You can’t see the microscopic. The apolitical plagues that baffle us. Empathy is the oracle that reveals the unseen suffering. Fake news. The previously healthy gentleman. Now plugged into a new reality. Winner of an unfortunate lottery, where attention is the consolation prize. Someone needs to call the family. Ignorance is bliss. Especially when sedated. ~ By Andrew Gonzalez, MD, PGY-3 Overwhelmed being an adult and doctor. I love the hospital, COVID and all. It’s when I come home that I cry. I’m not alone at work, find comfort in sickness. Surrounded by friends and family for years. Suddenly being an adult, a doctor, and alone is overwhelming. I’m growing, but it is exhausting and lonely. ~ By Saatchi Kuwelker, MD, PGY-1 Another month passes. 200,000 dead. Surrounded by ventilators and isolation. Yet, some still pretend. “I heard it’s like the flu.” “I want things to be normal again.” The more time passes, the less things change. We could have been there by now. We tried to warn you. If only you had listened. It marches on. ~ Anonymous

Palliative care during COVID. MICU full. Calling to update their families daily. I dread picking up the phone. Always bad news to give. The hopefulness in their voices fades with each call. Husbands, wives, sons, and daughters. All wanting to see their loved ones one last time. I have nothing but kind words to offer. ~ By Edward Pierce, MD, PGY-1 “Will I ever get to see my mom? Why is she coughing so much? Things have been tough. Grandma started coughing too and was taken to the hospital today. I just lost my sense of taste this morning and am having muscle aches. Tell me everything is going to be okay, Doctor. I need it.” ~ By Sanjay Prasad, MD, PGY-1 I told her over the phone, without a ventilator he would not make it through the night. A long hard sob. We both knew his wishes. I told her it was time to say good-bye. They had been in love for 50 years. They cried together through a screen. He passed peacefully in the night. ~ By Grace Hopp, MD, PGY-3 First impression: young, healthy, strong. Yet, fighting for breath. A few hours later: sick, unstable, drowning. Yet, calm and smiling. Photo of her family beside her head. “Need air!” “I will put you to sleep, help you breathe. But first, tell me a good memory.” “Me, my two kids on a beach.” The end, agony. ~ By Mahmoud Samy Ahmed, MD, PGY-2 Visit us at www.bcms.org

PHYSICIANS PURCHASING DIRECTORY Support the BCMS by supporting the following sponsors. Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed. ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) 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.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

ASSETT WEALTH MANAGEMENT

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. 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

BANKING

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country

SAN ANTONIO MEDICINE • April 2021

Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking (210) 283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”

sound financial future Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com https://www.bbt.com/wealth/star t.page "All we see is you" Synergy Federal Credit Union (HH Silver 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!”

DIAGNOSTIC IMAGING

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 BBVA Compass (HH Silver 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. Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities" BB&T (HH Silver 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

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 (HH Silver Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society. Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group, Insurance Services, SWBC Wealth Management and PEO (210) 525-1241 DMarino@swbc.com

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® CEO | Wealth Advisor 210.864.3350 eric@avidwp.com avidwp.com “Plan it. Do it. Avid Wealth”

HEALTHCARE BANKING Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services. Jake Pustejovsky Commercial Relationship Manager (830)302.6336 Jake.Pustejovsky@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (512)226-0208 www.Regions.com

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable” Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett

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

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER GHA TECHNOLOGIES, INC (HH Silver Sponsor) Focus on lifelong relationships with Medical IT Professionals as a mission critical, healthcare solutions & technology hardware & software supplier. Access to over 3000 different medical technology & IT vendors. Pedro Ledezma Technical Sales Representative 210-807-9234 pedro.ledezma@gha-associates.com www.gha-associates.com “When Service & Delivery Count!”

INFORMATION AND TECHNOLOGIES

INSURANCE

physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com OSMA Health (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians. Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps

continued on page 36 Visit us at www.bcms.org 35

PHYSICIANS PURCHASING DIRECTORY continued from page 35

MEDICAL BILLING AND COLLECTIONS SERVICES The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.” 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 PRACTICE

IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner. Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.com Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “

MEDICAL PHYSICS

SAN ANTONIO MEDICINE • April 2021

shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL SUPPLIES AND EQUIPMENT

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience. 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.”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

PRACTICE SUPPORT SERVICES

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society. Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945

(210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group, Insurance Services, SWBC Wealth Management and PEO Relations (210) 525-1241 DMarino@swbc.com

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org

The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center. Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

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. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship or, sponsor member services please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366 www.bexarcv.com/secure/ bcms/cofjoin.htm

TELEHEALTH TECHNOLOGY

REAL ESTATE SERVICES COMMERCIAL

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

Visit us at www.bcms.org

San Antonio Medicine April 2021

Articles inside

By Jaime Pankowsky, MD, FACS

Getting Paid for Your Practice at Retirement

My Retirement from Academic Medicine

The Financial Basics of Preparing for Retirement

Life Segmented: Did I Do Something Useful?

Physicians Upon Retirement