San Antonio Medicine April 2022

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MATERNAL HEALTH Neonatal Intensive Care Unit (NICU) in the 21st Century

By Alice K. Gong, MD .........................................................12 US Infant Mortality Rate Ranks Lower Than You Might Predict By Kathryn Markham and Samantha Bailey...........14 Adolescent Reproductive Health: A Global Concern

By Allison Foster and Cara Schachter..................................16 The Impact of Maternal Skin Conditions on Mental Health By Moses Alfaro, BSA, Adriana Ibañez, BSA and Morgan Fletcher, MD ....................................................18 Postpartum Alopecia

By Faraz Yousefian, DO, Sujitha Yadlapati, MD and Jennifer Krejci-Manwaring, MD, FAAD .................................21 Pregnancy, Breastfeeding and the COVID-19 Vaccine

By Cara Schachter and Allison Foster ..................................22 Mommies and Postpardum Depression (PPD)

By Holly Miller ......................................................................23 San Antonio’s POPs (Progestin-Only Pills) Project

By Theresa Heines, Isha Patel and Michaela Lee ...................24 The Children’s Association for Maximum Potential (CAMP)

By Azreena B. Thomas, MD, FAES ..........................................................................................................................26

BCMS President’s Message .................................................................................................................................................8 BCMS Alliance President’s Message ..................................................................................................................................10 Artistic Expression in Medicine By Sammar Ghannam........................................................................................................28 In Memoriam: Charles A. Rockwood, Jr. MD and Arthur Allison, MD ..................................................................................29 PRN - Take as Needed: Reviewing Offerings of Interest By David Alex Schulz, CHP...........................................................30 Physicians Purchasing Directory.........................................................................................................................................32 Auto Review: 2022 Lexus ES 350 By Stephen Schutz, MD................................................................................................36 Recommended Auto Dealers .............................................................................................................................................38

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SAN ANTONIO MEDICINE • April 2022

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APRIL 2022

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VOLUME 75 NO.4

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

Rajeev Suri, MD, President Brent W. Sanderlin, DO, Vice President Ezequiel “Zeke” Silva III, MD, Treasurer Alice Gong, MD, Secretary John J. Nava, MD, President-elect Rodolfo “Rudy’ Molina, MD, Immediate Past President

DIRECTORS

Vincent Fonseca, MD, MPH, Member Woodson "Scott" Jones, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member Jennifer R. Rushton, MD, Member Raul Santoscoy, DO, Member John Shepherd, MD, Member Amar Sunkari, MD, Member Lauren Tarbox, Member Col. Tim Switaj, MD, Military Representative Manuel M. Quinones Jr., MD, Board of Ethics Chair George F. “Rick” Evans, General Counsel Jayesh B. Shah, MD, TMA Board of Trustees Melody Newsom, CEO/Executive Director Taylor Frantz, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Lori Kels, MD, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative

BCMS SENIOR STAFF

Melody Newsom, CEO/Executive Director Monica Jones, Chief Operating Officer Yvonne Nino, Controller Mary Nava, Chief Government Affairs Officer Brissa Vela, Membership Director Phil Hornbeak, Auto Program Director August Trevino, Development Director Betty Fernandez, BCVI Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member David Schulz, Community Member Taylor Sullivan, DO, Member Faraz Yousefian, DO, Member Neal Meritz, MD, Member Jaime Pankowsky, MD, Member Winona Gbedey, Student Member Cara J. Schachter, Student Member Niva Shrestha, Student Member Danielle Moody, Editor

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SAN ANTONIO MEDICINE • April 2022

PRESIDENT’S MESSAGE

Addressing Maternal Health Inequities

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

Maternal health inequities exist in the US, and the statistics are strik-

diverse

provider

ing – Black and American Indian/Alaskan Native women are 2-3 times

workforce, so that

more likely to die from pregnancy-related causes than white women,

patients and com-

and black women are twice as likely to experience serious perinatal

munities can trust

complications. Various public/private/academic partnership initiatives

their providers. For communities who struggle to understand English,

have been launched nationwide to address the inequities in maternal

and for culturally diverse populations, cultural health navigators at

health care, with successful outcomes.

many clinics have helped them navigate cultural and language barriers,

B’more for Healthy Babies (BHB) is one such initiative. In 2011,

and interpret the nuances of heath care in the US.

this initiative was developed in partnership with the local Baltimore

Data often speaks better than words, and Stanford University’s mul-

community, University of Maryland Medical Center and University

tistakeholder initiative – California Maternal Quality Care Collabo-

of Maryland. This city-wide initiative supports mothers and babies in

rative (CMQCC), has been a key initiative to analyzing raw data on

neighborhoods of West Baltimore where 92% of residents are black

maternal health care for hospitals in California. CMQCC provides

and 66% of children live below the federal poverty line. It provides

feedback to hospitals and providers as to how their outcomes are af-

prenatal education, smoking cessation, rental assistance, access to sup-

fected by race and ethnicity. CMQCC has also used the same data to

port groups and a range of social services, and has already reduced in-

create step-by-step provider toolkits for key causes of perinatal com-

fant mortality rates by 75%.

plications, in order to reduce disparities in care and take away provider

Healthy Families Network (HFN) is a similar initiative in Bexar

subjectivity. As a result, California’s maternal deaths have dropped by

County founded in 2011 by San Antonio Metro Health’s Healthy

65%. Ongoing initiatives to have patients more involved with

Start Program in partnership with 40 academic and private organiza-

CMQCC will help the program achieve even better results.

tions from Bexar County. HFN has continued to positively impact

Maternal health care inequities exist, but I believe what is needed

various aspects of maternal and child health in Bexar County through

is a comprehensive multisector improvement of the health of vul-

its four workgroups – health outcomes through perinatal education

nerable people before, during and after childbirth at a

and support; cultural awareness, respect and empowerment; data re-

city/county/state and national level – supported by actionable data

sources, utilization and management; and reproductive life planning.

to providers and hospitals. Initiatives as mentioned above have

As we address maternal health inequities, it is important to realize

worked, and we need to enhance public, private and academic part-

that it’s not just the financial and educational background disparities

nerships for future initiatives that will be the harbingers of the much-

that are the cause. A college-educated black woman is at a 60% greater

needed change in maternal health.

risk of maternal death than a white woman with no high school diploma. The causes of such discrepancies include the effects of racism

Rajeev Suri, MD, MBA, FACR is the 2022 President of the Bexar

and weathering – the biological fallout of an accumulation of ongoing

County Medical Society, Tenured Professor and Interim Chair of the De-

stress through life that can cause premature aging and associated health

partment Radiology at UT Health San Antonio, and Chief of Staff at

issues. Another factor is the concern that their health concerns are

University Hospital San Antonio.

often overlooked. What is needed is a continued push to create a more

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SAN ANTONIO MEDICINE • April 2022

BCMS ALLIANCE

Mothering During the Pandemic

By Taylor Frantz, RDN, LD

I had my third child in late August 2020. Nearly my entire pregnancy was during the hectic and uncertain beginning months of the COVID-19 pandemic. Now, so many women have had to navigate the joy and excitement of pregnancy, coupled with uncertainty and isolation (both literally and figuratively) of the pandemic, but this is my story.

During those oft repeated ‘uncertain times,’ there were rumors of birthing alone and babies being taken from their COVID positive mothers. I was terrified. No matter how much I quarantined at home, I was potentially being exposed to COVID every time my emergency physician husband came home from work. While the anticipation of meeting my baby never subsided, it was always tempered with anxiety of the unknown.

My pandemic pregnancy and delivery were a much different experience than my previous two births. I could no longer share the experiences of OB appointments and prenatal ultrasounds with my husband, something that I felt left him feeling somewhat disconnected from the experience. Also, my mother, who is a retired labor and delivery nurse and was a huge help in my previous two births, was unable to attend that birth due to the restrictions. I felt a huge void in the room without her loving guidance and encouragement. I was confined to laboring in my hospital bed instead of walking the halls to progress labor. My boys also could not visit their new baby brother in the hospital.

I found myself lost in a place that felt familiar, but now looked very different. I leaned on my OB, Dr. Mallory Thompson, to guide me through the many questions and shifting concerns I had for myself and my baby. As the spouse of a physician, I am uniquely attuned to the fact that physicians are people too, a fact I feel is overlooked by so much of the public. Dr. Thompson was just as concerned about her own safety and the safety of her family as I was, but also had the added worry of her patients’ well-being, all while acting as a stable medical resource for her patients.

Now that time has passed, I can reflect on the many positive ways the pandemic impacted my pregnancy. It was a time where I was forced to slow down and enjoy each day with my growing belly and two young children. It forced to me to change the way I mothered; I grew creatively and became very intentional with my time. I still have fond memories of our family’s daily walks through the neighborhood, drawing messages with chalk as we went, or doing made up scavenger hunts. Pregnancy and parenting toddlers often feel like they will never end, but when I look back, they pass all too quickly. The pandemic allowed me time to soak in the frantic moments of motherhood that meant the most.

While I recognize these struggles pale in comparison to the hardships and heartbreaks I know others have experienced since March 2020, I still mourn the loss of the experience I had hoped for. But, I am forever grateful for the true heroes of medicine that braved that same uncertainty, and continued to show up for their patients as a source of wisdom and comfort.

Taylor Frantz, RDN, LD is the 2022 President of the BCMS Alliance.

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SAN ANTONIO MEDICINE • April 2022

MATERNAL HEALTH

Neonatal Intensive Care Unit (NICU) in the 21st Century

By Alice K. Gong, MD

O

ver a century ago, Pierre Budin, Professor of Obstetrics and director of the Clinique Tarnier (the first medical facility dedicated to the treatment of premature infants), wrote of his experience and research in “The Nursling: The Feeding and Hygiene of Premature and Full-Term Infants.” He advised that treatment of weaklings, the product of premature labor should include: 1) prevention of chilling by use of an incubator; 2) careful feeding with mother’s milk, preferably; and 3) avoidance of exposure to contagious disease. Much has changed since then over the 20th century, and Neonatal Intensive Care Nursery (NICU) practices have spread worldwide.

Advances in perinatal care have notably contributed to tremendous reductions in infant morbidity and mortality over time, even as rates 12

SAN ANTONIO MEDICINE • April 2022

of prematurity and low birth rate newborns increased. In 50 years, the infant mortality rate of 22.4/1,000 live births in 1967 dropped to 5.7/1,000 live births. Through innovations in knowledge of pathophysiology, advances in technology, monitoring and skills, the NICU has evolved greatly in the care of sick newborns. Limits of viability have been pushed to as low as 22 weeks’ gestational age (GA). The latest report of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research network of 10,877 infants born at 22-28 weeks’ GA between January 1, 2013 and December 31, 2018, described survival among actively treated 22 weeks’ GA to be 30% and 23 weeks’ GA to be 55.8%. Although most think of the smallest and most fragile premature infant when one thinks of NICU

MATERNAL HEALTH

care, the rate of very low birth weight infants has not changed much with time. What has fueled the growth of NICUs is the larger, lower acuity of late-preterm newborns.

NICU care became expensive, common, possibly over-utilized and potentially harmful due to separation of mother and baby, thus interrupting normal development and breastfeeding. In Texas, the bulk of NICU care is publicly funded. Goodman et al. Dartmouth Institute for Health Policy and Clinical Practice, was commissioned by Texas Health and Human Services to evaluate the quality and value of newborn care in Texas in part due to the Texas Tribune article, March 20, 2011. Between 1998 and 2009, Texas NICU beds increased by 84%, while the birthrate growth was 18%. The Texas NICU project evaluated Medicaid newborns in the NICU; they found remarkable variations in NICU services and utilization across regions and hospitals despite adjustment for differences in health risks.

For late preterm singleton newborns (34-36 weeks GA), admission to NICUs range from 11.7% to 48%.

Along with the Texas NICU project, the 83rd Texas Legislature House Bill 15 created a Perinatal Advisory Council to develop and recommend criteria for designation of levels of neonatal and maternal care, including specifying the minimum requirements to qualify for each level designation (IV, III, II, I, with the highest level being IV) and a process for the assignment of levels of care. Central to all hospitals who apply for designation is the requirement for establishing and maintaining formal and highly effective systems of quality. Having Quality Assurance/Performance Improvement (QAPI) will be the hope: the way forward to establish a foundation for achieving the goal of systematically improving health outcomes of mothers and babies. All designated hospitals, regardless of level of care label, need to maintain an ongoing, data-driven program to evaluate and improve the provision of patient care. Hospitals that service maternal newborn care must be designated to receive Medicaid payments.

Babies who have spent months in a NICU are surviving in large numbers. Their health and well-being actually depend more greatly on care after the NICU. There is much brain development in the first three

years, and many are dependent upon therapies to help them develop to their full potential. There are also problems with malbehavior due to the trauma and isolation these babies experience as developing fetuses. We are also learning about the cardiovascular, metabolic and renal consequences of prematurity.

NICUs of the 21st century should have triple aims to improve neonatal health, improve the family’s experience and reduce cost. In my opinion, improving neonatal health should include health care coverage of the child who survives the NICU. Much like a cancer survivor, the child who endures the NICU may have many health sequelae that covers the life span. There is still much that we need to learn to help these children live a productive life.

References Budin P. The Nursling, translated

by William J. Maloney, 1907. Access Neonatology on the Web. http://www.neonatology.org/classics/ nursling/nursling.html Bell EF, Hintz SR, Hansen NI, et al. Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018.

JAMA. 2022;327(3):248-263. doi:10.1001/jama.2021.23580.

Goodman DC, Wasserman J, Murphy M, et al. Improving the Identification of Quality and Value in Newborn care in Texas. Final Report, Updated March 2019. For the Texas Health and Human Services Commission. Subcontract #UFTSP3010663. (Prime contract # 529-13-0046-0001). https://www.hhs.texas.gov/about/leadership/advisory-committees/perinatal-advisory-council Dance A. Survival of the Littlest. Nature. Vol 582. 4 June 2020. https://media.nature.com/original/magazine-assets/d41586-02001517-z/d41586-020-01517-z.pdf Alice K. Gong, MD is a William and Rita Head Distinguished Chair in Developmental and Environmental Neonatology and Professor of Pediatrics at the UT Health San Antonio Long School of Medicine. She is a member of the Bexar County Medical Society.

Visit us at www.bcms.org

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MATERNAL HEALTH

US Infant Mortality Rate Ranks Lower Than You Might Predict

By Kathryn Markham and Samantha Bailey

H

ealth indicators are important statistics used to gauge the health of a country. Infant mortality is particularly important as a health indicator due to its sensitivity to socioeconomic factors and basic living conditions in a country. The CDC defines infant mortality as the death of an infant before his or her first birthday.1 The United States (US) infant mortality rate ranks 33 out of 36 countries who are a part of the Organization for Economic Cooperation and Development.12 The US infant mortality rate in 2019 was 5.60 deaths per 1,000 live births, only a slight decline from 5.67 in 2018.3 Many aspects contribute to infant mortality. These vary based on maternal, fetal and infant factors, as well as location and access to resources. Although this statistic is an all-time low for America, it is still high compared to countries with a similar GDP like France and the UK with a rate of 3.8 per 1,000 live births.4 In the US, top risk factors contributing to perinatal mortality include low birth weight (LBW) and prematurity, neonatal death due to maternal complications, congenital malformations or chromosomal abnormalities, sudden infant death syndrome (SIDS) and unintentional injuries.5 Race, ethnicity, access to care and socioeconomic inequality contribute immensely to these risk factors as outlined by the changing rates between states, let alone countries. By exploring the causes of infant mortality in the United States, we can better understand the health of the country as a whole and ways to lower this figure.

Prematurity plays a considerable role in neonatal and infant mortality. Mortality rates increase with decreasing gestational age in preterm infants (<37 weeks). Prematurity and LBW babies have a higher risk of complications that can ultimately lead to death. Their body systems are not able to fully develop and there is more potential for infection, brain damage, lung damage, hemorrhage and heart complications.6 These patients are considered together because they present similar challenges. In the US, while infants born before 32 weeks represent 14

SAN ANTONIO MEDICINE • April 2022

only 2% of all births, they contribute to one-third to one-half of infant deaths.5 When examining prematurity and LBW, it is important to consider the racial gap in the US. In 2006, nearly one-fifth of African American babies were born premature, compared with one-eighth non-Hispanic white babies.7 There are more socioeconomic factors, such as reduced access to health care, education, and nutrition linked to LBW and prematurity in African Americans. This contributes to African American babies dying at twice the rate of white babies. When comparing US prematurity rates with the rest of the world, the US falls below many other developed countries. This is thought to be because of the sheer increase in the number of babies being born in the US, more than the medical care provided.7 Maternal mortality and maternal pregnancy complications are also leading causes of infant mortality in the US. In 2017, the maternal mortality rate was 17.3 per 100,000 live births. This number has been on the rise since the year 1987.8 The leading causes of maternal mortality were hemorrhage, cardiovascular/coronary conditions, cardiomyopathy and infection.8 In order to examine maternal pregnancy outcomes, it is important to first address the differences in maternal mortality in the US by race and ethnicity. The maternal mortality rate between 2014-2017 was three times as high for black women compared to nonHispanic white women (41.4 and 13.4 per 100,000 live births respectively).

Maternal complications associated with infant mortality include infections, hypertension, eclampsia, diabetes and obesity. In the US, the CDC reports between 6-9% of women will develop gestational diabetes. Data also suggest that another maternal determinant that can increase infant mortality is maternal obesity. When infant mortality in the US is separated by maternal pregnancy weight, mothers whose body mass put them in the obese category according to the body mass index (BMI), had an infant mortality rate of 7.07 per 1,000 live births. Moth-

MATERNAL HEALTH

ers who had a pregnancy weight that fell into the normal category according to the BMI had an infant mortality rate of 4.57. It is also important to note that being classified as underweight also increased infant mortality rate compared to mothers in normal and overweight categories.9 Congenital and chromosomal abnormalities are another key factor in perinatal mortality. Punctual and precise recognition and diagnosis in the perinatal period can mitigate this risk factor which contributes to about 20% of neonatal deaths in the US.5 For example, vitamin supplementation with folic acid and niacin is critical in preventing congenital anomalies.

SIDS is the unexplained death, usually during sleep, of a seemingly healthy baby less than a year old. Factors that can put an infant at risk for SIDS include physical factors such as brain defects and LBW, sleep environment, race, family history and secondhand smoke. In the US, nonwhite infants and infants who sleep in the same bed as parents or siblings are more likely to develop SIDS.10 Currently, unintentional suffocation is the leading cause of unintentional infant mortality in the US. It is most common for this injury to happen when blankets obstruct the infant’s airway, or the infant becomes trapped between a mattress and a wall. Accidental suffocation accounts for three quarters of all unintentional infant injury deaths.

These deaths are largely considered preventable. Other unintentional causes of infant death include motor vehicle accidents, drowning, fires and other unspecified causes.11,12 In the year 2018, more than 21,000 infant deaths were reported in the US. The infant mortality rate in 2018 (rate of 5.67) was a historic low in the US, but compared to other developed countries, the US infant mortality rate remains one of the highest. This is an established public health issue and there have been many changes made to mitigate the risk factors mentioned above that have led to preventable deaths.

Prematurity and LBW prevention start in the prenatal period along with prenatal care. This emphasizes the importance of access to quality OB/GYN care and education regarding general health and well-being for mothers even before conception. Some states have begun extending Medicaid up to one year after a woman gives birth in order to improve access to appropriate health care during these vital periods of development.4 A multidisciplinary approach is the only way to decrease the infant mortality rate, as health care is only one aspect. Interventions targeting at-risk populations need to go beyond, identifying all barriers causing these health disparities including access to food, health care, job security, family stability and education.1 References 1. Willis, E., MD, MPH, Majnik, A., PhD, Johnson, S., PhD, Magallanes, N., BSc, & McManus, P., PhD, RN. (2014). Conquering Racial Disparities in Perinatal Outcomes. Retrieved from Research Gate.

2. 12. America’s Health Rankings annual report, 2019. Retrieved from https://www.americashealthrankings.org/learn/reports/2019-annual-report/international-comparison 3. Infant mortality. (2021, September 08). Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm 4. Cohen, J. (2021, August 01). U.S. maternal and infant mortality: More signs of public health neglect. Retrieved from https://www.forbes.com/sites/joshuacohen/2021/08/01/us-maternal-and-infant-mortality-more-signs-of-public-healthneglect/?sh=180db8b83a50 5. Zacharias, N., MD, FACOH. (2020, June 10). Perinatal Mortality (L. Weisman MD & L. Wilkie MD, MS, Eds.). Retrieved from UpToDate.

6. Premature babies. (2019, October). Retrieved from https://www.marchofdimes.org/complications/prematurebabies.aspx 7. P. (2009, December 15). Premature births help explain higher U.S. Infant Mortality Rate. Retrieved from https://www.prb.org/resources/premature-births-help-explain-higher-u-s-infant-mortality-rate/ 8. Pregnancy mortality surveillance system. (2020, November 25). Retrieved from https://www.cdc.gov/reproductivehealth/maternalmortality/pregnancy-mortality-surveillance-system.htm 9. Ely, D., PhD, Gregory, E., MPH, & Drake, P., MS. (2020, August 21). Infant Mortality by Maternal Prepregnancy Body Mass Index: United States, 2017-2018 (Rep. No. Volume 69, Number 9).

10. Sudden Infant Death Syndrome(SIDS). (2020, May 20). Retrieved from https://www.mayoclinic.org/diseases-conditions/sudden-infant-death-syndrome/symptoms-causes/syc-20352800 11. 10 Leading Causes of Injury Deaths by Age Group Highlighting Unintentional Injury Deaths, United States- 2011 [Digital image]. (n.d.). Retrieved from https://www.cdc.gov/injury/wisqars /pdf/leading_causes_of_injury_deaths_highlighting_unintentional_injury_2011-a.pdf 12. Accidental suffocation and strangulation during infant sleep. (n.d.).

Retrieved from https://safetosleep.nichd.nih.gov/resources/ providers/downloadable/ASSB_SafeSleep_txtalt#:~:text=Among %20babies%2C%20accidental%20suffocation%20is,and%204%20 months%20of%20age Kathryn Markham is a second-year medical student at the University of the Incarnate Word School of Osteopathic Medicine.

Samantha Bailey is a third-year medical student at Midwestern University CCOM.

Visit us at www.bcms.org

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MATERNAL HEALTH

Adolescent Reproductive Health: A Global Concern

By Allison Foster and Cara Schachter

P

regnancy and childbirth-related complications remain the leading cause of death for 15-19-year-old girls globally, making adolescent reproductive health a global concern. The number of pregnancies that occur each year in girls aged 15-19 is estimated around 21 million, with at least 10 million being unintentional. Teen pregnancy is associated with a significantly increased risk of eclampsia, puerperal endometritis and systemic infection compared to women aged 20-24. Infants of adolescent mothers are also at higher risk for prematurity, low birth weight and severe neonatal conditions. In addition to lifethreatening health issues, there is a large concern for the social and economic impacts on a young mother, including higher rates of school dropout and intimate partner violence. The repercussions of pregnancy during adolescence continue to propagate further research into contributing factors and potential changes that can be effective in promoting adolescent reproductive health.

There are numerous factors that contribute to high rates of adolescent pregnancy, such as health service-related issues, socioeconomic status and cultural expectations. A prominent contributing component is lack of comprehensive sex education occurring in schools or homes.

Insufficient knowledge hinders adolescents from taking the proper precautions or seeking out the needed health care to prevent unplanned pregnancy. While economic disadvantage likely plays an important role, young females who seek reproductive health services may perceive judgment from health care workers and be deterred from receiving care.

In many cultures, sex and reproductive health are unwelcome topics of conversation, creating an environment in which adolescents may feel uncomfortable approaching their family with questions or concerns.

Additional factors to consider include cultures with early marital expectations or unequal gender power relations. Aside from cultural barriers, substance abuse and decreased level of self-esteem are also frequently associated with an increase in pregnancy during adolescence.

Empowering adolescent girls through education, community and policy are all shown to reduce the incidence of adolescent pregnancy.

Through these initiatives, young women are provided with the proper tools and cognizance needed to make informed decisions in many aspects of their lives, with an emphasis on their sexual and reproductive health. For example, comprehensive sex education is a critical component to promote safe sex practices in young women. Evidence supports the effectiveness of required sex education, as well as an increased fre16

SAN ANTONIO MEDICINE • April 2022

quency in which sexual health information is presented to students. A supportive environment that allows students to ask questions freely is also an important component of effective sex education. Equipping adolescent women with accurate information dismantles any misconceptions or fills in any knowledge gaps the teen may have, thus increasing their ability to take control of their reproductive health. In addition to education, studies show that cultures that allow young women to play more active roles in their societies have decreased numbers of risky sexual encounters. Forward-thinking policies, such as adolescent-directed health care services and affordable access to contraception, have the ability to further empower adolescents to seek proper medical attention and preventative measures.

In an attempt to combat the adverse effects associated with pregnancy at a young age, it is important to understand the factors contributing to high rates of adolescent pregnancy. Lack of knowledge, community support and approachable health care services continue to propagate high rates of pregnancy in adolescence. The empowerment of young women through comprehensive sex education and policies fashioned to provide accessible reproductive health services are pivotal to the reduction of adolescent pregnancy. A tailored approach to each unique culture and community must be established. Identifying prominent influences in adolescent lives and understanding what drives their decisions will continue to help guide the most effective approaches for the future.

Allison Foster and Cara Schachter are third-year medical students at the UT Health San Antonio Long School of Medicine. Cara is a member of the BCMS Publications Committee.

Visit us at www.bcms.org

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MATERNAL HEALTH

The Impact of Maternal Skin Conditions on Mental Health

By Moses Alfaro, BSA; Adriana Ibañez, BSA and Morgan Fletcher, MD

W

hen a woman becomes pregnant, there are numerous physiological changes that occur in the body. Some of these changes become physically apparent and can be emotionally distressing for some individuals. Our article explores the relationship between a woman’s body image and some common skin conditions that arise as a result of pregnancy, as well as some possible solutions to improve overall body image after pregnancy.

Polymorphic Eruption of Pregnancy Polymorphic Eruption of Pregnancy (PEP), formerly known as pruritic urticarial papules and plaques of pregnancy (PUPPP), is a common benign gestational skin dermatosis.5 This condition presents with raised, edematous papules coalescing into plaques, usually beginning on the abdomen with potential spread to the extremities.6 While this condition can be distressing to pregnant women, it tends to resolve after pregnancy. PEP commonly presents in primiparous women with multi-gestation pregnancies.

Pruritic Folliculitis Pruritic Folliculitis is a gestational skin condition that presents clinically as erythematous follicular papules and sterile pustules during the second and third trimesters of pregnancy.7 Women should be aware that this condition can often be misdiagnosed as bacterial folliculitis and that resolution of pruritic folliculitis can occur after pregnancy with or without medication.7 This condition is benign, but can pose psychological effects to a woman’s overall body image.

Image: American Family Physician13

Image: American College of Osteopathic Dermatology6

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Striae Gravidarum Striae gravidarum (SG), also known as stretch marks, is one of the most common skin conditions that arises after pregnancy, affecting roughly 55%-90% of women.1 It commonly presents on the abdomen, breast or thighs as linear atrophic plaques which may be hypopigmented, erythematous or hyperpigmented.3 SG is thought to occur due to the hormonal changes that occur during pregnancy. Weight gain is not thought to be a significant indicator for the development of SG.2

MATERNAL HEALTH

ative emotional path that can affect their everyday behaviors and social interactions.9

Image: American Family Physician Journal7

How To Improve Body Image After Pregnancy The emotional toll that skin conditions have on a woman’s mental health after pregnancy can be substantial, but there are some methods and resources that can aid in creating a healthy and positive self-image.

A study focusing on PEP and its relationship to the social media app, Instagram, revealed that mothers experiencing PEP posted under a hashtag #PUPPP, where they would seek out advice from other users on how to manage this condition.10 This study shows that a sense of community and awareness can help improve a woman’s overall perception of their skin condition and provide relief through shared experiences. Some women may wonder how they could accept and love their pregnant and postpartum body; thankfully, there are some coping strategies and methods to arrive at that mindset.

Other Notable Pregnancy-Related Dermatoses Many other dermatologic conditions present during and shortly after the period of pregnancy. These include, but are not limited to, pemphigoid gestationis (an autoimmune disorder), atopic eruption of pregnancy (a version of eczema), melasma (darkening of the skin), hirsutism (increased hair growth), hair loss and many more. Some of these conditions may indicate maternal or fetal morbidities, and all of them have the ability to negatively impact a woman’s mental health. It is important to seek advice from a health care provider regarding skin conditions that present during pregnancy.

The Effects on Women’s Mental Health In recent years, there has been an increased emphasis on the link between skin and mental health, a field of interest known as psychodermatology.9 Psychodermatology emphasizes that effective management of skin conditions involves recognition and treatment of the mental health impacts of these conditions.14 The onset of SG in women during pregnancy can pose negative effects on a woman’s body image, as stretch marks are unlikely to go away on their own.2 Some of these effects on body image include anxiety, self-consciousness, embarrassment and depression.4 These changes in self-perception can impact how a woman interacts in her social life or cause her to refrain from wearing the clothes she loved before.4 When it comes to PEP and pruritic folliculitis, these conditions tend to be more noticeable because of their pronounced redness and raised borders, causing emotional distress and feelings of discomfort in a woman’s public sphere. In a society that promotes unrealistic beauty standards of women, these skin conditions can have a significant negative effect on how women view their bodies and can decrease their quality of life.8 In our culture, there can be immense pressure to strive for perfection, especially since the onset of social media. Stigmatization of skin conditions can lead women down a neg-

SOME STRATEGIES INCLUDE: Focus on the positive work your body is doing and manage the pressures.

Your body is changing to help your baby grow and develop, so keep in mind this is normal and part of the process of motherhood.11 While you may feel pressure to look a certain way, it is important to view pregnancy within this realistic context.12 Get regular physical activity.

An example of physical activity is yoga, where you focus less on how you look and more on the link between your body and mind.11 Keep it all in perspective.

Pregnancy is a time to focus on your physical and mental health, so spend time eating well, exercising sensibly and being aware of your expectations around body image.12 Seek mental health support if you need it.

There is never shame in reaching out to professionals for help.11 Continued on page 20 Visit us at www.bcms.org

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MATERNAL HEALTH Continued from page 19

Conclusion While pregnancy is an extraordinary time in a woman’s life, it can pose some unexpected changes to the body, many of which may result in altered body image perceptions. This can negatively affect mental health and lead to a decreased quality of life. It is important for women to seek out support from their loved ones, mental health experts, and commit to the practice of coping strategies to learn to love their bodies and develop healthy self-images.

References 1. Farahnik, B., Park, K., Kroumpouzos, G., & Murase, J. (2016). Striae gravidarum: Risk factors, prevention, and management. International journal of women's dermatology, 3(2), 77–85. https://doi.org/10.1016/j.ijwd.2016.11.001 2. Staff, H. (2020, October 8). Pregnancy: Stretch marks, itching, and skin changes. Michigan Medicine. Retrieved February 23, 2022, from https://www.uofmhealth.org/health-library/aa88316#aa88316-sec 3. MacGregor, J. L.; Wesley, N. O. (2019, October 22). Striae distensae (stretch marks). UpToDate. Retrieved February 23, 2022, from https://www.uptodate.com/contents/striae-distensae-stretchmarks 4. Fromson, N. (2021, November 9). Pregnancy stretch marks cause stress and emotional burden, study finds. University of Michigan.

Retrieved February 23, 2022, from https://labblog.uofmhealth.org /body-work/pregnancy-stretch-marks-cause-stress-and-emotionalburden-study-finds 5. Chouk, C. (2021, August 6). Pruritic urticarial papules and plaques of pregnancy. StatPearls [Internet]. Retrieved February 23, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK539700/ 6. Pruritic urticarial papules and plaques of pregnancy. American Osteopathic College of Dermatology. (n.d.). Retrieved February 23, 2022, from https://www.aocd.org/page/PUPPP 7. Tunzi, M.; Gray, G. R. (2007, January 15). Common skin conditions during pregnancy. American Family Physician. Retrieved February 23, 2022, from https://www.aafp.org/afp/2007/0115/p211.html#: ~:text=Pregnancy%2Dspecific%20skin%20conditions%20include,a nd%20pruritic%20folliculitis%20of%20pregnancy.

8. Karhade, K., Lawlor, M., Chubb, H., Johnson, T., Voorhees, J. J., & Wang, F. (2021). Negative perceptions and emotional impact of striae gravidarum among pregnant women. International journal of women's dermatology, 7(5Part B), 685–691. https://doi.org/10.1016/j.ijwd.2021.10.015 9. Evans, M. (2020, February 6). How do skin conditions impact

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10.

11.

12.

13.

14.

mental health? Patient.info. Retrieved February 23, 2022, from https://patient.info/news-and-features/how-do-skin-conditionsimpact-mental-health Payton, A., &amp; Woo, B. K. (2021). Instagram content addressing pruritic urticarial papules and plaques of pregnancy: Observational study. JMIR Dermatology, 4(1). https://doi.org/ 10.2196/26200 Body image in pregnancy. COPE. (2021, October 25). Retrieved February 23, 2022, from https://www.cope.org.au/expecting-ababy/staying-well/body-image-in-pregnancy/ Pregnancy and body image. Pregnancy and body image | Office on Women's Health. (2018, August 28). Retrieved February 23, 2022, from https://www.womenshealth.gov/mental-health/body-imageand-mental-health/pregnancy-and-body-image Walters, J.; Clark, D. C. (2005, April 1). Pruritic rash during pregnancy. American Family Physician. Retrieved February 23, 2022, from https://www.aafp.org/afp/2005/0401/p1380.html Jafferany M. (2007). Psychodermatology: a guide to understanding common psychocutaneous disorders. Primary care companion to the Journal of clinical psychiatry, 9(3), 203–213. https://doi.org/10.4088/pcc.v09n0306 Moses Alfaro and Adriana Ibañez are medical students at the UT Health San Antonio Long School of Medicine.

Morgan Fletcher, MD is a resident-physician in the department of dermatology at the UT Health San Antonio Long School of Medicine. She is a resident member of the Bexar County Medical Society.

Postpartum Alopecia

MATERNAL HEALTH

By Faraz Yousefian DO, Sujitha Yadlapati MD and Jennifer Krejci-Manwaring MD, FAAD

T

he phenomena of postpartum alopecia, or postpartum telogen effluvium (TE), in women during the postpartum period is a well-known consequence that can cause significant psychological distress, especially to a first-time mother. During pregnancy, an increased number of hair follicles remain in the anagen phase (growth phase) for a longer period of time as a result of hormonal changes.

However, within three to six months of delivery, these hairs synchronously return to the telogen phase (resting/ shedding phase) as a result of the sudden drop in hormone levels. Postpartum hair loss is largely attributed to this, however, we cannot discount other contributing factors, including emotional and physical stress associated with childbirth.1,2 Even though exact statistics are difficult to obtain, some large multicenter studies and organizations such as the American Pregnancy Association estimate that 40-50% of new moms will experience hair loss after childbirth.3 Our purpose in writing this article is to shed light on this common experience and bring attention to the importance of recognizing and reassuring affected mothers. As for treatment, an excellent prognosis exists in the majority of cases since the condition is completely reversible, therefore reassurance is a powerful therapeutic tool.4 In this regard, active listening to a new mother's concerns during a stressful time can be an invaluable part of the therapeutic process. Additionally, this is a great time to recognize and treat undiagnosed hair and scalp conditions such as seborrheic dermatitis and scalp psoriasis together to improve overall scalp health.2 Sometimes postpartum TE will unmask underlying alopecia that had gone unnoticed: typically female pattern hair loss (androgenic) or other contributing factors to hair loss like thyroid disease, or nutritional deficiencies like Vitamin D or iron. The American Academy of Dermatology provides educational and management resources for the public that can be of great assistance.5 Other important counseling for patients is to discuss healthy hair care practices such as gentle brushing, limiting hot ironing or blowdrying, and avoiding tight hairstyles which can reduce breakage and traumatic hair loss. Haircuts and volumizing shampoos can make the hair appear fuller. Hair health may be improved by foods high in iron, Vitamin C, Vitamin D, Omega-3s, magnesium and beta-carotene. Topical minoxidil is available over-the-counter as a solution or foam and is a common medication recommended for treating hair loss. Minoxidil is FDA approved for both male and female pattern hair loss (androgenetic alopecia). It is actually the only medication approved for hair loss in females, however, limited safety data exist for breastfeeding mothers.6 Minoxidil is an effective treatment option for many hair disorders because it increases the anagen phase and hastens hair follicle turnover from the telogen to the anagen phase. So in the case of TE, it can help return the hair cycle to its normal phase faster.

New mothers are sleep-deprived and commonly stressed out or nervous about so many things related to caring for a new baby, and when hair loss occurs, it can add insult to injury. Physicians should continue

to reassure their patients that TE is reversible, but they have to give it time; up to a year may be necessary to return to “normal.” Emphasizing the need for healthy foods, obtaining adequate protein intake, maximizing sleep when possible and practicing gentle hair care practices can help them get through this stressful time.

References 1. Gizlenti S, Ekmekci TR. The changes in the hair cycle during gestation and the post-partum period. J Eur Acad Dermatol Venereol.

2014;28(7):878-881. doi:10.1111/jdv.12188 2. Schiff BL. Study of Postpartum Alopecia. Arch Dermatol.

1963;87(5):609. doi:10.1001/archderm.1963.01590170067011 3. Pregnancy and Hair Loss. American Pregnancy Association. Published April 27, 2018. Accessed February 25, 2022. https://americanpregnancy.org/healthy-pregnancy/pregnancy-health-wellness/h air-loss-during-pregnancy/ 4. Thom E. Pregnancy and the hair growth cycle: anagen induction against hair growth disruption using Nourkrin ® with Marilex ® , a proteoglycan replacement therapy. J Cosmet Dermatol.

2017;16(3):421-427. doi:10.1111/jocd.12286 5. Hair loss in new moms. Accessed February 25, 2022. https://www.aad.org/public/diseases/hair-loss/insider/new-moms 6. Suchonwanit P, Thammarucha S, Leerunyakul K. Minoxidil and its use in hair disorders: a review. Drug Des Devel Ther. 2019;13:27772786. doi:10.2147/DDDT.S214907 Faraz Yousefian, DO is an intern at the Texas Institute for Graduate Medical Education and Research (TIGMER) in San Antonio, Texas. He is very passionate about mentoring nascent physicians and educating the general population about skin diseases and the steps they can take to prevent them. Dr. Yousefian is a member of Bexar County Medical Society.

Sujitha Yadlapati, MD, is a PGY-2 dermatology resident at HCA Corpus Christi Medical Center - Bay Area Program. She is also a board-certified family medicine physician. Her professional interests include skin cancer prevention, cutaneous oncology, procedural dermatology and complex medical dermatology. Dr. Yadlapati is a member of the Texas Dermatological Society.

Jennifer Krejci-Manwaring MD, FAAD is the medical director of the Limmer Hair Transplant Center in San Antonio, Clinical Professor of Dermatology for UT Health Science Center and staff Dermatologist at Audie Murphy Veterans Hospital. She specializes in surgical hair restoration and hair loss treatment. She is a member of the International Society of Hair Restoration Surgeons, American Board of Hair Restoration Surgeons, Texas Dermatology Society, American Medical Association and Bexar County Medical Society.

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MATERNAL HEALTH

Pregnancy, Breastfeeding and the COVID-19 Vaccine

By Cara Schachter and Allison Foster

Introduction Maternal immunization has the ability to provide protection against many communicable diseases throughout pregnancy. Ideally, women are vaccinated prior to becoming pregnant in order to ensure the baby is protected from conception to delivery. However, in certain situations such as COVID-19, the data supporting the safety and efficacy was not made available until after the initial release of the first wave of immunizations. Many women have now become eligible to receive one or more doses of the vaccine at some point during their pregnancy. While the CDC continues to compile data on this population, it is essential to also consider the risks of abstaining from vaccination. The CDC categorizes pregnant women in Tier 1c, given that multiple studies have documented an increased risk to pregnancies that are exposed to COVID-19 infection when compared to exposure in the general nonpregnant population. Pregnant women have a higher likelihood of severe infection requiring hospitalization and intensive care, as well as preterm birth and stillbirth. National and global health institutions have deemed the COVID-19 vaccine safe for use during pregnancy and breastfeeding, and vaccination continues to be one of the most effective ways to prevent severe COVID-19 illness and related adverse events during pregnancy.

Use of the COVID-19 Vaccine During Pregnancy The COVID-19 vaccine is recommended for all women who are pregnant or planning to become pregnant. Data collected after the major vaccine trials shed light on the use of the vaccine in pregnant women and demonstrated no harmful effects on the pregnancy, as well as lower rates of maternal SARS-CoV-2 infection overall. The rate of spontaneous miscarriage (12.8%) did not vary significantly compared to that of the general population. The majority of the data currently available was collected by the CDC’s Vaccine Adverse Event Reporting System (VAERS), as well as the Vaccine Safety Datalink (VSD) and Clinical Immunization Safety Assessment (CISA). In total, over 40,000 pregnancies have been documented.

When considering choice of vaccine during pregnancy, studies have demonstrated greater efficacy among the mRNA vaccines as opposed to a vector-based vaccine. Both vaccines have proven to be safe and effective, but if an mRNA vaccine is unavailable, a vector-based vaccine is preferred to vaccine deferral. UpToDate recommends vaccinating pregnant women as soon as possible and administering boosters when appropriate. Gestational age does not impact the safety of the COVID22

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19 vaccines. Multiple studies have demonstrated that the COVID-19 vaccine does not increase adverse events during pregnancy and has no impact on fertility in those trying to become pregnant. In contrast, SARS-CoV-2 infection has demonstrated a transient decrease in male fertility with no proven effect on female fertility.

Use of the COVID-19 Vaccine During Breastfeeding The recommendation for COVID-19 vaccine use during breastfeeding is similar to the current guidelines for pregnancy. Because the available vaccines do not contain infectious virus, breastfed infants are not considered at-risk for infection from consuming milk from a mother who has been recently vaccinated. Although data is even more limited for this population because the FDA excluded pregnant women from early trials, some reports indicate the antibodies developed from mRNA COVID-19 vaccination can be passed to infants through breast milk. One study involving 84 women demonstrated a significant elevation in anti-SARS-CoV-2 specific IgA antibodies just two weeks after the initial immunization, with a subsequent increase in IgG antibodies during the four-week mark. By this time, 91.7% of samples tested positive for IgG antibodies. This study suggested strong neutralizing effects of the antibodies detected in breast milk with the possibility of providing passive immunity to infants. Future research may focus on the benefits provided to infants and the degree of passive immunity provided by breast milk after immunization.

Conclusion All COVID-19 vaccines currently available to the public have been proven to be both safe and effective for use during pregnancy and breastfeeding. Vaccination against COVID-19 infection decreases the risk of severe infection during pregnancy requiring hospitalization and intensive care. Emerging data also demonstrates the potential benefit of breastfeeding after vaccination through passive immunity for infants.

Women who are pregnant or planning to become pregnant and considering vaccination should also establish care with an OB/GYN to make informed and individualized decisions for their pregnancies and reproductive health.

Cara Schachter and Allison Foster are third-year medical students at the UT Health San Antonio Long School of Medicine. Cara is a member of the BCMS Publications Committee.

MATERNAL HEALTH

Mommies and Postpartum Depression (PPD)

By Holly Miller

The Postpartum Depression Project

T

he American Psychiatric Association (APA) estimates that 14.3% of women in the Unites States experience symptoms of postpartum depression (PPD). Any peripartum woman is at risk for PPD, but certain social factors can increase risk, including having stressful life events, having financial or employment problems and lacking social support. We work with two non-profit crisis pregnancy centers that serve clients with and without these risk factors. Our goal is to provide screening, education and resources to these women. To accomplish this, medical students contact women 2-4 weeks after their due date to screen them for PPD using a screening protocol that begins with the PHQ-2, followed by the Edinburgh Postpartum Depression Score if indicated. If the screening is positive, we provide free education on PPD and information on free community resources that can help with their symptoms. We also encourage women to talk to their obstetrician at their postnatal appointment. Since project initiation in October of 2020, nearly 150 women have been screened with 13% screening positive for PPD, which is consistent with the APA’s estimates. The women who screened positive encompassed a wide range of ages, had varied maximum education and had varied relationships to the father of the baby. Initial intentions were evenly split between determined to parent and considering abortion, and most women anticipated partner involvement for parenting. We found that combining the PHQ-2 and EPDS identifies women at risk for PPD in any population, and the variety of situations reported in women who screen positive suggests that PPD does not discriminate based on relationship status, intention to parent or education. We plan to continue working with our community partners to screen women in our community, and hope to expand to additional community partners in the near future.

Mommies on Methadone Education Due to the increasing opioid epidemic, The Center for Health Care Services (CHCS), University Health

System (UHS) and the Texas Department of State Health Services (DSHS) collaborated to create The Mommies Program, a specialized female Intensive Outpatient Program (IOP) substance abuse treatment center dedicated to providing prenatal care to expectant mothers with opioid addiction whose addictions are currently being treated with methadone, a synthetic opioid agonist that prevents opioid cravings and withdrawal symptoms. As students, our goal is to educate women on healthy nutrition during pregnancy, domestic violence, the safety and efficacy of methadone treatment during pregnancy, as well as the importance of achieving sustained abstinence peripartum, basic newborn preparation and postpartum depression. To accomplish this, medical students developed a four-part education curriculum to be administered during patient appointments at specific times pre- and postnatal based on identified needs. A basic knowledge survey is administered before and after education to evaluate intervention effectiveness based on overall understanding. Additionally, we hope to increase the compassion capacity and empathy experience in first- and second-year medical students by introducing them to a population of patients that is often on the fringes of society. Medical students involved in the project develop relationships with the women, and hopefully have a chance to sit down and hear one of the women’s stories.

We encourage every student on the project to then submit a reflective 55-word essay to Connective Tissue.

We found that education intervention based on identified needs within this population is effective at teaching new information and increasing understanding. This project will continue to be integrated with the Mommies Program at the Robert B. Green Clinic.

Holly Miller is a third-year medical student at UT Health San Antonio. She is a student leader for the Postpartum Depression Project and the Mommies on Methadone Education Project.

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MATERNAL HEALTH

San Antonio POPs (Progestin-Only Pills) Project

By Theresa Heines, Isha Patel and Michaela Lee

U

nintended pregnancy rates are higher in America than in most developed countries with disproportionately high rates seen in young, low-income and minority women. As of 2020, Texas has an unintended pregnancy rate of 30.4%, and the fifth highest teen birth rate among US states. These high rates of unintended pregnancies are likely due to an array of factors, including socioeconomic status, inadequate sexual education and affordable health care. Additionally, according to the American College of Obstetricians and Gynecologists, one-third of women in America have reported barriers to accessing birth control in their lifetime.

Using an over-the-counter (OTC) method, the San Antonio POPs Project provides progestin-only pills (POPs) to non-pregnant, uninsured females and studies the effectiveness of the OTC model while assessing reproductive health and contraceptive knowledge acquisition and retention with the aim of increasing accessibility to birth control for women in the San Antonio area. The project measures pregnancy rates, patient retention and compliance, and knowledge retention over a 12-month period.

At their first appointment, patients complete four surveys: a prescreening survey, demographic survey, pre-educational knowledge assessment, followed by a presentation on reproduction and contraception, and a post-education assessment consisting of the same questions as the first assessment. Patients return to the clinic after 3, 6 and 9 months where they retake the education assessment. They take 24

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the assessment one final time as part of their exit survey when they have either completed one year in the project or opted to leave early.

Demographic Analysis Analysis of the pre-screening and demographic surveys identified our typical clients as Hispanic females between 18 and 24 years of age with a high school diploma and an annual household income of under $10,000. 73% self-identified as Hispanic, 47% were under 24 years old and 43% had only a high school degree.

Furthermore, a majority of participants (54%) have previously been pregnant. Supplementary analysis demonstrates that the average number of pregnancies increases with older-age ranges and is the highest for the group that attained less than a high school diploma.

Plotting the home zip codes of participants showed that our participants come from throughout the San Antonio metropolitan area, with no striking predominance of participants living in lower income zip codes. 54% resided in north Bexar County and 46% in the southern half, with median household incomes ranging from $24,744 to $116,854.

Education Data from this project included pre- and post-education surveys as well as demographic data. The pre- and post-survey questions were grouped into contraceptive and reproductive health (RH) categories

MATERNAL HEALTH and responses from 60 patients were analyzed. The pre-education survey RH average was 39%; the post was 79%. The pre-survey contraception average was 54%; the post was 71%. There was a statistically significant difference in correct responses after the educational presentation (RH: p = 0.01, contraception: p = 0.02). Patients who completed the study showed a statistically significant difference in knowledge between the pre-education survey and exit surveys (RH: p = 6.75E-17, contraception: p = 0.008). This indicated that our study and educational presentation was impactful in knowledge acquisition and retention.

OTC Model & Retention Our project currently has 61 patients enrolled. Pre-survey data found the most common barrier to using contraception was cost. Although 69% of patients reported adverse effects, fatigue being the most common (38%), half of the participants interviewed indicated that they would use POPs again after the project. The project saw a drop in newly enrolled patients during 2020, most likely due to reduced clinic hours and fewer referrals during the pandemic. We hypothesize that the integration of remote follow-ups secondary to COVID-19 increased our patient retention, and these results are pending.

Conclusion The goals of this project are to help educate women on reproductive health, increase access to affordable birth control and decrease the rate of unwanted pregnancies and STIs in a vulnerable population within Bexar County. Our results indicate that patients reliably retained contraceptive education administered in the clinic, especially patients who completed the entirety of the study. We believe this is a worthwhile initiative for this population and have enjoyed participating in furthering our patients’ education. We plan for the project to continue next year and hopefully reach additional women in the Bexar County community.

References 1. America's Health Rankings analysis of CDC, Pregnancy Risk Assessment Monitoring System or state equivalent, United Health Foundation, AmericasHealthRankings.org, Accessed 2022.

2. Teen birth data. (2020, December 15). Retrieved March 24, 2021, from https://txcampaign.org/teen-birth-data/ 3. American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice, Isley, M., & Allen, R. H. (2019). Over-thecounter access to hormonal contraception. American College of Obstetricians and Gynecologists Committee Opinion, 134(4), e96–e105. https://doi.org/10.1097/aog.0000000000003473 Theresa Heines, Isha Patel and Michaela Lee are second-year medical students at the UT Health San Antonio Long School of Medicine. They represent the San Antonio POPs Project.

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MATERNAL HEALTH

The Children’s Association for Maximum Potential (CAMP)

By Azreena B. Thomas, MD, FAES

C

hildren’s Association for Maximum Potential (CAMP) started because a little boy “just wanted to ride a horse like John Wayne.”

In April 1979, three US Air Force pediatricians with a unique vision and an indefatigable determination − Dr. Chris Plauche Johnson, Dr. Fred McCurdy and Dr. Robert de Lemos − along with other health professionals brought 32 children with special needs together for a weekend camp. Previously these campers were not accepted at other camps – even those for children with special needs – due to the severity of their medical conditions or disabilities. Neither the severity of the children’s conditions nor the unpredictable Texas weather mattered at that first session of CAMP. After this first successful weekend, the group unanimously agreed that these camp sessions should continue and resolved that no child – regardless of severity of illness or disability – should be denied the opportunity to go to camp. Fast forward to today, and CAMP now alleviates medical, physical, developmental and intellectual barriers for more than 1,600 campers (ages 5-50), using a one-to-one camper to counselor ratio, with medical supervision for campers. CAMP serves individuals with mild to severe disabilities from medical diagnoses of intellectual and developmental disorders, Down's syndrome, cerebral palsy, traumatic brain injury, spina bifida, autism spectrum disorder, chronic medical illnesses, epilepsy, visual impairment and/or hearing impairment. CAMP accepts most Medicaid Waiver funding and strives to ensure that no camper is excluded based on disability or ability to pay. No other camping program in South Texas meets the physical, medical and emotional needs of this population.

CAMP is a place where individuals can… …ride a horse, even if they can’t walk; …float the slow river, even if they have severe respiratory issues; …make friends, even if they can’t speak; …hold a fuzzy chinchilla, even if they can’t see; …simply “be themselves” without fear of being judged or bullied; …experience independence and a sense of accomplishment.

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At CAMP’s 55-acre summer camp in the Texas Hill Country, campers participate in nine one-week residential sessions with traditional camping activities such as swimming, horseback riding, canoeing, archery, music recreation, arts & crafts, karaoke and the coveted CAMP “prom.”

Five specific populations are impacted by CAMP's mission: Campers (with mild to severe diagnoses), non-disabled siblings ages 5-13 (who can go to camp with the Camper in their family), caregivers, teenage and young adult volunteers, and healthcare volunteers.

During the 2019 program year, 493 volunteer counselors dedicated 115,000+ hours of service, while 137 healthcare volunteers administered 28,946 doses of scheduled camper medications and earned 743 CEUs. CAMP offers hands-on education for its volunteers and continuing education in select sessions for healthcare professionals (physicians, nurses, medical/nursing students, respiratory/physical therapists, etc.) who provide health care, treatment, medication and other care to campers, staff and volunteers − and who gain invaluable rewards in return.

The benefit for young volunteers, I can assure as a parent of an alumni volunteer, is as great or greater than that obtained by the camper. They learn compassion, responsibility, patience, empathy, and acquire maturity and a sense of gratitude for their own circumstances – all values we would want our children and/or grandchildren to embrace. For healthcare workers, the experience is unparalleled. No rotation can give the real-life training that is gained in the short time caring for those at CAMP by helping them reach their potential through various camp activities while dealing with their particular PEG tube or ventilator situation that day. The “Top Docs” Mark Holland Croley, MD (who specializes in Neonatal-Perinatal Medicine and is also a CAMP Board Member) and Head Nurse J. Dee Evans, MSN, APRN, FNP-C are very knowledgeable and mentor healthcare staff for career experiences that undoubtedly are unforgettable, fulfilling and appreciated for a lifetime.

CAMP’s original footprint was an old church camp facility with buildings and facilities built in the 1940s-1950s. The process of retrofitting and adapting these old buildings to meet the needs of its campers had been an ongoing struggle, until major advances were made in the 2010s with a state-of-the-art aquatic center and critical wastewater treatment

MATERNAL HEALTH

plant. And with the completion of the second phase of the Capital Campaign, three buildings are ready for campers: the Health Care Facility, Camper Cabin and Arts & Crafts Pavilion.

And as huge an undertaking as the summer camp is, CAMP does not stop there. School-year programming is available in both the Hill Country and in San Antonio. Monthly programs include Respite Weekends, Parents Night Out, Teen and Adult Day Adventures (TADA), life skills programs and family retreats.

Income is never a barrier to attend CAMP. For those needing financial assistance, CAMP offers a scholarship tier based on family income, and additional assistance may be provided upon request.

In 2019, CAMP distributed $466,358 in scholarships to families bridging the gap in what families can afford to pay, as well as filling the gap in the amount Medicaid Waiver programs pay.

How can you help?

You can volunteer your time as a healthcare professional for just one week at the summer camp. Or, let your high school or college-aged children know about volunteer counselor opportunities. You can also learn more about CAMP during Valero’s Champions Fore Charity (formerly Birdies for Charity) or during the Big Give.

Or just Spread the Word... so that the people we can serve; the people who can volunteer; the caretakers that need respite; the people who can donate; and the people who need us...can find us.

Learn more about CAMP by visiting www.campcamp.org, or calling (210) 671-5411.

We would love to give you a tour.

Azreena B. Thomas, MD, FAES is a neurologist specializing in the diagnosis and treatment of those with epilepsy, and has been in solo private practice in San Antonio since 2001. She also serves as a member of the CAMP Board of Directors and is a member of the Bexar County Medical Society.

Visit us at www.bcms.org

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ARTISTIC EXPRESSION IN MEDICINE

Artistic Expression in Medicine

By Sammar Ghannam

Mammography, Watercolor Many images in radiology remind me of art that I create. I challenged myself to create a mammogram using watercolor and salt to represent the texture of breast tissue.

Sammar Ghannam is a PGY-1 preliminary resident in the UT Health San Antonio Internal Medicine Residency program and will start Radiology residency in July 2022.

Goodnight Kiss: A study of Mary Cassatt’s “Mother and Child,” Oil on canvas Ever since I started oil painting, I have been inspired by the Impressionism movement.

Mary Cassatt was one of the few women in the Impressionism movement. I love her art and the themes of mother and children. This is a study of Mary Cassatt’s painting titled “Mother and Child.”

Sammar Ghannam is a PGY-1 preliminary resident in the UT Health San Antonio Internal Medicine Residency program and will start Radiology residency in July 2022.

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SAN ANTONIO MEDICINE • April 2022

IN MEMORIAM Charles A. Rockwood, Jr., MD

SAN ANTONIO MEDICINE

Submitted by Will Sansom Renowned orthopaedic surgeon Charles A. Rockwood Jr., MD, died on February 1 at age 92 after a 60-year career in San Antonio. Joining the UT medical school faculty in San Antonio in 1966, he was one of the medical school’s founding faculty members, retiring just two years ago. The medical school today is called the Joe R. and Teresa Lozano Long School of Medicine and is part of The University of Texas Health Science Center at San Antonio (UT Health San Antonio). As the head of orthopaedics at UT Health San Antonio for more than 20 years, Dr. Rockwood trained nearly 300 orthopaedic resident physicians. Later specializing in shoulder surgery, he became an internationally known consultant and mentored numerous shoulder fellows both stateside and abroad. He co-edited three major textbooks during his career still in use by orthopaedists worldwide, including the sentinel “Fractures,” now in its 11th edition. As an innovator, he devised several groundbreaking prosthetic devices for shoulder surgery while at UT Health San Antonio, and as a lecturer traveled worldwide for more than 40 years. He was the president of several national orthopaedic associations, always with a special emphasis on education and research. In the early 1970s, Dr. Rockwood was the driving force in organizing the Emergency Medical Services (EMS) program in San Antonio. Serving as its first medical director, this forever changed the landscape of emergency care in the city. Dr. Rockwood was a life member of the Bexar County Medical Society. The BCMS extends sympathy to the family and friends of Dr. Rockwood. To read more information, please visit https://news.uthscsa.edu/in-memoriam-charles-a-rockwood-jr-md-legendaryorthopaedic-educator-and-ems-founder/.

IN MEMORIAM Arthur Allison, MD Arthur Allison, MD was born in Kerrville, Texas on January 8, 1933. He was a graduate of Tivy High School and played football for their high school team. He was known to have lifetime tickets to all University of Texas football games. He went by the nickname of “Speedy” because of his deliberate approach to both dining and dressing. Dr. Allison was skilled at playing the piano and also sang in his church choir.

Dr. Allison went to the University of Texas for his undergraduate and then gained early admission into the University of Texas Medical Branch in 1953. He graduated in 1957 and then interned at Robert B. Green Hospital in San Antonio. He was a surgery resident at St. Joseph’s Hospital and the VA Hospital in Little Rock, Arkansas. He joined the Bexar County Medical Society in 1961. Dr. Allison began in Family Practice but then transitioned into Emergency Medicine in 1974. He served as the President of the Texas College of Emergency Medicine in 1980. Dr. Allison also saw and treated a large number of patients in the Yucatan, who would have otherwise not have received care.

Dr. Allison was a member of the Texas Cavaliers, which included his annual participation in the San Antonio River Parade. He passed away on January 24, 2022 after battling a terminal illness for two years.

The Bexar County Medical Society extends sympathy to the family and friends of Dr. Allison.

Visit us at www.bcms.org

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SAN ANTONIO MEDICINE

PRN – Take as Needed: Reviewing Offerings of Interest

by David Alex Schulz, CHP

"Sometimes reality is too complex.

Stories give it form." − Jean Luc Godard “Tell me, O Muse, of that ingenious hero who travelled far and wide.”

– Homer We are in a new era of narrative media, and this column’s focus on the written word deserves broadening. The Oral Tradition is essential to entertain, instruct, debate, inspire and testify. Today’s desktop technology makes audio production inexpensive, and podcasts abound, ranging from the profound to the profoundly silly. If the form is unfamiliar and you’re reluctant to dive deeper for fear of timewaste, I urge taking the chance.

Podcasts are today’s salon, combining experts, topics of interest and inspiring hosts.

“WarDocs,” a weekly discussion of medicine practiced by current and former military physicians, produced by three BAMC-related San Antonio doctors, both entertains and inspires.

“WarDocs” honors the legacy and preserves the oral history of military medicine told from the perspective of the healthcare heroes 30

SAN ANTONIO MEDICINE • April 2022

who’ve lived it. It grew out of a simple Facebook page built by Dr. Doug Soderdahl, urologist at Fort Sam Houston.

“As I become more senior in rank, I discovered our ability to communicate was not really optimal, and that we weren’t taking advantage of social media,” said Dr. Soderdahl. “So, I started a Facebook page for Army Medical Corps officers in a private ‘group’ to share information.”

That’s when surgeons Drs. Wayne Causey and Kevin Kniery, experienced with medical podcasts, suggested adapting to an interview format to more fully address issues of interest to Army doctors.

“It began as a more focused, technical podcast,” said Dr. Soderdahl, “targeted just for Army physicians out of training, how to manage their career and other advice. But having practiced medicine in uniform for thirty-plus

years, I met so many people who had great stories from all services, and often wished there was some way that those stories could be preserved. They taught great lessons learned and provided insights that are applicable to people in the military, people in medicine, people’s lives in general.

“And there simply isn’t a whole lot of knowledge out there dealing with physicians in warzones, doing things that normal physicians don’t do, what really happens when doctors are in the military and deployed across the globe. We began with physicians but are now expanding to the whole healthcare team, talking with nurses, with medics, dentists, what is involved with being in the military and doing some of these crazy things that these healthcare heroes get a chance to do.”

Crazy, like when your medic’s kit includes mortar rounds along with morphine and IVs.

SAN ANTONIO MEDICINE

It’s not a typical house call when retired Command Sergeant Major Rudy DelValle, Ranger Weapons Platoon medic, parachutes into Panama in Operation Just Cause.

He describes, “I had the door position in the fourth C141. Now, you’re all camoed-up, your rucksack weighs a ton and the big green light comes on, you’re out the door on a 500foot jump. I landed in a runway light, and had to drop into the elephant grass, screwed up my elbow but it is what it is; you put your weapon into action and link up with other Rangers.”

In “WarDocs,” DelValle describes how medics serve throughout the military medical system from operational units to assignments within Military Medical Treatment Facilities, and the lessons he learned to train medics to be their best, sharing examples of how medical providers should train for the battlefield. Deployed in Operations Desert Storm, Desert Shield, Haiti, the Panama Invasion and with a Special Forces group in support of drug interdiction operations, his battlefield experiences prepared him for the DC Beltway when he was selected for the role of Command Sergeant Major of the Walter Reed National Military Medical Center.

“Nothing really prepares you to be in the middle of the ocean with about a thousand primary care patients under your care,” US Navy Capt. Christine Sears, MD said in a recent “WarDocs” episode.

A Navy urologist now serving as the Command Surgeon of SOUTHCOM, Dr. Sears describes how Navy medical personnel are able to provide quality medical care while at sea, often with limited resources and direct support. Dr. Sears had the unique opportunity to command the Military Treatment Facility aboard the Navy Hospital Ship USNS Comfort. The Comfort is designated role three (definitive surgery hospitals) in the case of combat, but primarily used in humanitarian assistance for disaster relief.

“Getting to be a doctor, a leader and a naval officer at sea, all at the same time, was wonderful. We went to 12 different ports and helped many, many people,” she said, even when there wasn’t a port, like in FARC-controlled Colombia, sending triage missions on speedboats to land, returning with patients.

Dr. Sears served as the Command Surgeon of the 7th Fleet during the start of the COVID-19 pandemic, on the USS Blue Ridge. “I got on the Blue Ridge in September, and we were scheduled to have a very robust mission doing partnership work throughout the Pacific. Fast forward a few months, and we began hearing about this coronavirus, and wondered what impact it might have. We quickly stood up a team to look at the Diamond Princess, and at various cruise ships around the world, asking what this would mean as an operational concern on a Navy ship that didn’t have staterooms but crew quarters instead. We rapidly began to work with the cruise line industry to share information with me to help face the unique challenges of the Navy balancing public health and operational readiness,” said Dr. Sears, who continued her role managing COVID-19 as a SOUTHCOM surgeon.

“We want to put the pandemic in the rearview mirror,” laments Col. (R) Dr. Matthew Hepburn, “And then when it happens again – and it certainly will happen again – we won’t be ready. So, I am hell-bent that we don’t let it happen again.”

Bold words, but it’s hard to naysay Dr. Hepburn, a military infectious disease physician uniquely prepared for Operation Warp Speed and the global pandemic response. Dr. Hepburn currently serves in the White House Office of Science and Technology Policy (OSTP).

In WarDocs, he shares stories and insights from his decades of experience as an Army infectious disease physician including lessons

learned from his time as a program manager at the Defense Advanced Research Projects Agency (DARPA), preparing him for his critical role in Operation Warp Speed, responding to the COVID-19 pandemic. He offers a fascinating behind-the-scenes look into the partnerships between the DoD, HHS and private industry that shattered the normal timelines for vaccine development, testing and implementation.

Each of more than 40 “WarDocs” resonate the authenticity of firsthand witnessing of history. It is here that Drs. Soderdahl, Causey and Kniery are achieving their implicit goal. The hosts frequently quote Aldous Huxley, “That men do not learn very much from the lessons of history is the most important of all the lessons of history.”

These interviews, available freely on Google, Apple and Spotify podcast sites, will eventually be vital to historians’ understanding of our times; now, they make wonderfully compelling listening for anyone interested in either military or medical stories told by leaders in both fields.

David Alex Schulz, CHP is a community member of the BCMS Publications Committee.

Visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY Support 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) Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness.

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”

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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 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.”

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

SAN ANTONIO MEDICINE • April 2022

groups and individual physicians.

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

Brandi Vitier 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com Synergy Federal Credit Union (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!”

BUSINESS CONSULTING

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems.

Jesse Gonzales, CEO CPA, MBA 210-846-9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor) Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for health care entities.

Betty Fernandez

Director of Operations 210-582-6355 Betty.Fernandez@bexarcv.com www.BexarCV.com “Proudly serving the medical community since 1998”

FINANCIAL ADVISORS

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner” 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

“People Bank with People” “Your Practice, Our Promise” Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

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

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying.

For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies.

SWBC’s services supporting Physicians and the Medical Society.

Michael Leos, Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318 mleos@swbc.com swbc.com

HEALTHCARE BANKING

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”

First Citizens Bank (HHH Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking.

Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick

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

Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

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

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

INSURANCE Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent and treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension and topical wound care. info@NitricOxideInnovations.com 512-773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options.

Laura Kouba, Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu

TMA Insurance Trust (HHHH 10K Platinum Sponsor) TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you.

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

Guardian (★★★ Gold Sponsor) Live Confidently. Every financial dream deserves a well-crafted plan.

Ned Hodge 210-332-3757 ned@nedhodge.com www.nedhodge.com | www.Opesone.com “Take care of today then plan for tomorrow”

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

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

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

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

continued on page 34 Visit us at www.bcms.org

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

Mike Rosenthal Senior Vice President, Business Development 800-282-6242 MikeRosenthal@ProAssurance.com www.ProAssurance.com

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 Vice President of Sales,San Antonio 210-693-8025 clayton.brown@upnfiber.com Aron Sweet , Account Director 210-788-9515 aron.sweet@upnfiber.com Jim Dorman, Account Director 210-428-1206 jim.dorman@upnfiber.com Tammy Carosello, Account Director 210-868-0420 tammy.carosello@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

INVESTMENT ADVISORY REAL ESTATE

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates).

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

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MEDICAL BILLING AND COLLECTIONS SERVICES

Medical Financial Group (★★★ Gold Sponsor) Healthcare and Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller and past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems.

Jesse Gonzales, CEO CPA, MBA 210-846-9415 information@medicalfgtx.com Linda Noltemeier Jones, Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals” 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 PAYMENT SYSTEMS/CARD PROCESSING

First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking.

Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

MEDICAL SUPPLIES AND EQUIPMENT Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals

SAN ANTONIO MEDICINE • April 2022

continued from page 33

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”

MORTGAGES

SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying.

For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies.

SWBC’s services supporting Physicians and the Medical Society.

Jon Tober, Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober

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!

Kevin Barber, President 210-308-7907 (Direct) kbarber@bdo.com

Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Medical Group Management Association (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.

Alan Winkler, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates).

Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com CARR Realty (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions.

Brad Wilson, Agent 210-573-6146 Brad.Wilson@carr.us www.carr.us “Maximize Your Profitability Through Real Estate” Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management.

Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease”

RETIREMENT PLANNING

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

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.”

Visit us at www.bcms.org

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AUTO REVIEW

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SAN ANTONIO MEDICINE • April 2022

2022 Lexus ES 350

AUTO REVIEW

By Stephen Schutz, MD

Sedans are dying. I’ve written about this phenomenon previously and still believe that it’s true. Despite that reality, however, there are many good sedans out there to buy, if you're interested.

Before we talk more about sedans, let’s quickly review SUVs, which are the main reason that sedans are dying. 25 years ago, SUVs were utilitarian vehicles that combined usefulness with (some) luxury, in a package that wasn’t an, OMG-no-one-will-ever-respect-me minivan.

Now SUVs have evolved from popular family haulers into serious players in almost every market segment, including expensive sports cars, as the Lamborghini Urus, Aston Martin DBX and BMW X5M

sole is still there, but now it’s supplemented by a redundant touchscreen that allows you to just push on that to get what you want. Thank you, Lexus, this is now a good system.

Driving the ES 350 is generally a quiet and comfortable experience.

In fact, the 2022 ES 350 is probably the modern Lexus that most reflects the spirit of the original 1990 LS 400 — an athletic drive isn’t happening no matter where you’re going, but a soothing experience is.

I’ve made this point before, but it’s worth repeating: I’m all for a rapid and immersive drive along a winding backroad in a V8 Mustang or BMW M3, but after a long and stressful day at work, I’m happier

demonstrate.

And SUVs sell well because of the significant pluses they offer buyers: a high seating position that lets you see over normal cars, more space for cargo than you get with comparable sedans, and added safety due to the extra metal between you and any vehicle that you might collide with.

But before we bury sedans, it’s worth noting that they are actually good vehicles to own. They are more enjoyable to drive than most SUVs, can generally carry up to five passengers and have a trunk which can hold a lot, even if not as much as an SUV. And in these supply chain limited times, sedans are more available to purchase than SUVs.

to sit in a quiet car listening to music and making a few phone calls.

I’ll bet I’m not the only busy physician who feels that way.

The Lexus ES comes with one of three powertrains. The base ES 250 is powered by a 203 HP 2.5-liter four-cylinder engine with all-wheel drive. ES 350s like my test car include a 3.5-liter V6 that generates 302 HP coupled with an eight-speed automatic transmission and front wheel drive. ES 350h models feature a hybrid powertrain that puts out 215 HP; a continuously variable automatic transmission—I’m not a fan, as regular readers know—and front-wheel drive are standard.

Fuel economy figures are 25 MPG city/34 MPG highway for the ES 250, 22/32 for the ES 350 and 43/44 for the ES 350h.

Pricing starts at just under $42,000 for the ES 250 and climbs to

I recently drove a very nice luxury sedan, the Lexus ES 350, and was reminded of why sedans still, “got some game.” For one thing, the ES is good-looking. While neither as quietly elegant as an Audi A6 nor as obviously upscale as a Mercedes E-class, the ES manages to look both luxurious and understated at the same time.

It helps that Lexus has finally learned how to integrate the assertive grilles of their vehicles with the sides and rear ends, resulting in more harmonious designs than they had five or so years ago. And they’ve minimized the size of their head- and taillights, which also helps.

Pulling all that together is difficult but important because tasteful design in the luxury space is important. Ultimately, buyers want a premium vehicle to whisper, “I’m successful,” not yell, “I’ve got lots of money!”

The interior of the ES is undoubtedly nice, but a little less lux than

around $52,000 if you select the ES 350 with the Ultra Luxury Package. Since that package adds attractive 18-inch wheels, upgraded leather upholstery, a hands-free power trunk lid, power rear sunshade, wood-and-leather steering wheel and adaptive suspension, I would check that box if I were buying one.

The ES 350 is a comfortable and well-crafted luxury sedan that is a very reasonable alternative to an SUV. It may give up some utility to a comparable SUV, but it drives better and will provide a Lexus ownership and driving experience that you’re likely to enjoy for years to come.

any of Lexus’ German competitors. The seats are comfortable and the materials upscale, but somehow the whole thing lacks the “je ne sais quoi” that Audi and Mercedes have.

At least Lexus’ infotainment system has caught up with the Germans. The old use-your-finger mini-me touchpad on the center con-

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

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

Visit us at www.bcms.org

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Audi Dominion 21105 West IH 10 San Antonio, TX 78257

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

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX

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Cameron Tang 210-561-4900

Tripp Bridges 210-308-8900

James Cole 210-816-6000

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Kahlig Auto Group

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