SAN ANTONIO
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MAY 2018
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VOLUME 71 NO. 5
INFECTIOUS DISEASES
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A conversation with Barbara Taylor, MD, PhD Interview by Michelle Vasquez........................................14
By Mike W. Thomas .......................................................16
Cranial Asymmetry Versus Microcephaly By Sophia Tsakiri, MD; Nikolaos Zacharias, MD;
Immunizations and The Luxury to Choose
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By Travis Bias, DO .........................................................22
Improving the National Infectious Disease Strategy By David Lakey, MD....................................25 BCMS President’s Message ...............................................................................................................8 BCMS News .............................................................................................................................................10 Delegation News .......................................................................................................................................12 Commercial Real Estate: How to Profit During Inflation By Ari Rastegar.....................................................28 Trauma Tourism By Fred H. Olin, MD................................................................................................................30 Comparing the BCMS Auto Program to a Buying Service By Phil Hornbeak .............................................32 History: San Antonio’s Earliest Settlers Overcame Many Hardships to Make a Better Life for All of Us By Alfonso Chiscano, MD ......................................................................................................................34 San Antonio’s Tricentennial By Julie Catalano............................................................................................36 BCMS Circle of Friends Directory ..............................................................................................................38 In the Driver’s Seat ....................................................................................................................................42 Auto Review: 2018 BMW 230i coupe By Steve Schutz, MD ...................................................................44
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San Antonio Medicine • May 2018
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San Antonio Infectious Disease Consultants see the worst cases
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Infectious Diseases
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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.
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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Sheldon G. Gross, MD, President Gerald Q. Greenfield Jr., MD, PA, Vice President Adam V. Ratner, MD, President-elect Leah H. Jacobson, Immediate Past President Kristi G. Clark, Secretary John Robert Holcomb, MD, Treasurer
DIRECTORS Rajaram Bala, MD, Member Jenny Shepherd, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Manuel Quinones, MD, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member
BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, IT Director
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Pavela Bambekova, Medical Student Darren Donahue, Medical Student Carmen Garza, MD, Community Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member Austin Sweat, Medical Student J.J. Waller Jr., MD, Member
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San Antonio Medicine • May 2018
PRESIDENT’S MESSAGE
BCMS ALLIANCE IS ONE OF OUR MEDICAL SOCIETY’S STRENGTHS By Sheldon Gross, MD, 2018 BCMS President
Dear Colleagues,
I would like to discuss the importance of a group of individ-
uals who are seldom mentioned. These are individuals who do-
nate their time, have a great deal of creativity and dedication, and work hard to support physicians and improve healthcare in
our city and our country. I am referring to the Bexar County
encourage
them
to
learn about the alliance
and hopefully become
active at some level. If
one hears of a program
Medical Society Alliance.
sponsored by the al-
PAC. I met several individuals who were representing the alliance
physicians to support it. There have been several members of
My first exposure to alliance members was related to TEX-
at our TEXPAC board meetings. These were some of the
liance, I encourage all
our state legislature that have been alliance members from dif-
smartest, sophisticated, and insightful individuals on the entire
ferent parts of our state. I am hopeful that at some point we will
ing alliance member with an honor and recognition by the entire
state representative. One of the characteristics of a healthy or-
board. TEXPAC eventually decided to award a single outstandorganization. This honor was named after a San Antonio Alliance member, Ms. June Bratcher. I quickly came to learn that
have an alliance member from San Antonio as a state senator or
ganization is that it recognizes its strengths. Bexar County Med-
ical Society has a tremendous strength in the form of our alliance
alliance members are very bright individuals who want to help
membership.
Alliance, there is a social component to it. It is an organization
remind our membership that the Texas Medical Association
new friendships. However, it is much more than that.
dation will have its annual gala that Friday evening. As the host
in any way they can. When one thinks of the Medical Society
that enables people to meet other physician spouses and develop
In addition to supporting our alliance, I would again like to
meets in San Antonio on May 18th and 19th. The TMA Foun-
The alliance is constantly trying to develop new programs to
city, I would hope that many San Antonio physicians will attend.
viding helmets for children to wear while riding bicycles or trips
number of outstanding causes. I hope to see many of you there.
they play an invaluable role.
Sincerely, SHELDON GROSS, MD President Bexar County Medical Society
improve public health in San Antonio. Whether it involves proto Austin to lobby our state representatives and state senators,
As President of Bexar County Medical Society, I want to en-
courage all member physicians to speak with your spouses and
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San Antonio Medicine • May 2018
This money goes directly to the foundation where it serves a
BCMS NEWS
NEW COMMITTEE
SEEKS TO BE A BRIDGE BETWEEN MEDICAL STUDENTS IN SAN ANTONIO By Jessica L. Gale
The BCMS Academic Collaboration Committee (ACC) was created in the fall of 2017 to initiate collaboration with students from the University of the Incarnate Word School of Osteopathic Medicine and Joe R. and Teresa Lozano Long School of Medicine at UT Health San Antonio. The committee’s mission is to involve, advocate for, and support the medical students of Bexar County. This committee was founded with the intention of creating connection between the two groups of students. The ACC recently planned and participated in their first service outreach event. On Easter weekend, 8 members gathered at Brackenridge Park to provide families with blood pressure screenings and information from the Patient Institute. So far this year, the committee has met at each school and has been an effective channel for getting students involved in other BCMS Committees. Upcoming, the ACC’s Military Liaison is planning an early clinical leadership development event, and the Social Chairs are planning an easy get together. Later this year, the Committee hopes to host a new student mixer at the beginning of the school year for the first and second year medical students at each school. We are also looking forward to facilitating a presentation by the Student American Academy of Osteopathy group from UIWSOM for Long SOM students on Osteopathic Manipulative Treatment.
First and second year medical students in the BCMS ACC meeting at UIWSOM.
If you would like to be involved with the BCMS ACC please reach out to one of the student leaders, Jessica Gale, OMS-1 at UIWSOM jgale@student.uiwtx.edu, or Patricia Machado, MS-1 at the Long SOM at UTHSA, machadop@livemail.uthscsa.edu.
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San Antonio Medicine • May 2018
First and second year medical students in the BCMS ACC after a meeting at the Long School of Medicine.
DELEGATION NEWS
BCMS DELEGATION TO TMA ANNOUNCES TWO CANDIDATES FOR HOUSE OF DELEGATE POSITIONS The BCMS Delegation to TMA has announced the names of two physicians who are running for elected positions in the TMA House of Delegates. The candidates are: Jayesh Shah, MD, for TMA Board of Trustees and Alexander Kenton, MD, for AMA Alternate Delegate. Elections are set for Saturday, May 19 during TexMed 2018, TMA’s annual meeting, which takes place here in San Antonio this year at the JW Marriott Hotel. For more information about TexMed 2018, visit the TMA website at www.texmed.org. To learn more about how you can get involved with the BCMS Delegation to TMA, contact Mary Nava, chief government affairs officer at mary.nava@bcms.org.
TOP 5 REASONS TO VOTE
ALEXANDER B. KENTON, MD for AMA ALTERNATE DELEGATE • Engaged leader in organized medicine at the state and local level; “I treat my roles with the TMA as a second full time job.”
• Knowledgeable and perceptive when advocating for the House of Medicine’s state and federal issues
• Currently is a key contact with many elected officials and TEXPAC-supported candidates • Proven hospital staff leader in pediatric (neonatal/perinatal) medicine combined with previous experience and work in Internal Medicine
• Will fight to keep physicians as the lead voice for healthcare policy
“I respectfully ask for your vote and support!” - Alex
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San Antonio Medicine • May 2018
DR. JAYESH B. SHAH for
TMA BOARD OF TRUSTEES LEADER IN ORGANIZED MEDICINE • Alternate Delegate to AMA from TMA (7 years) • Past President, BCMS • Past Chair, AMA IMG Section • Past President, American Association of Physicians of Indian Origin • President, American College of Hyperbaric Medicine • Past Chair, American College of Certified Wound Specialists • Vice Chief of Staff, Southwest General Hospital • Chief of Staff, Uvalde Memorial Hospital • Market Physician Advisor, Tenet Health EXPERIENCE WITH TMA • Gala Co-chair TMA Foundation Gala 2018 • TMA Council on Healthcare Service Organization (3 years) • TMA Membership Committee (6 years) • Chair, TMA IMG Section • Chair, BCMS Delegation to TMA • Texas Delegate to American Medical Association • Chair & Member of numerous TMA Ad Hoc Committees • TMA Council on Health Promotion (1 year) ACTIVELY PRACTICING PHYSICIAN • Full-time, Actively Practicing Physician • Practices in a multi-hospital system with a Very High Percentage of Medicare, Medicaid & Uninsured patients • Directly involved in the unique issues that affect the Delivery of Health Care along the Texas border • Knowledgeable of issues caused by Uninsured, Underinsured, Medicaid & Medicare • Finishing Master of Healthcare Administration 2018 PHYSICIAN RIGHTS ADVOCATE • Active on Medical Issues at the national & state levels • Vice Chair of TEXPAC, District 21
INFECTIOUS DISEASES
A conversation with Barbara Taylor, M.D., Ph.D. Interviewed by Michelle Vasquez
What is your area of expertise? What drove you into this specific area?
I’m an infectious diseases physician, and the focus of my clinical practice and research is the care of people living with HIV. I started learning about HIV in college, and when I started medical school in 1996, there was still no effective treatment, but that changed quickly. In 1996, the physician who would become my mentor at Columbia University, Scott Hammer, and others working with the AIDS Clinical Trials Group, discovered a combination of antiretroviral medications that would suppress the virus. This transformed HIV from a deadly infection to a chronic one. During residency, it was clear to me that HIV clinical care and research would allow me to pursue a field that challenged me intellectually while also allowing me to work with underserved populations on the social justice issues that were most important to me.
What unique challenges or opportunities do you have as a physician in San Antonio?
There are so many opportunities. The entire community has come together to end the HIV epidemic, giving us an amazing opportunity to have an impact. The challenges are the things we all know as physicians: San Antonio has high levels of income disparities and many people are uninsured. Transportation is difficult for many of our patients. Unfortunately, in my field, people with HIV still face a lot of stigma. I have patients whose friends are afraid to hug them or share dinner plates with them. Even some providers still think of HIV like we did two decades ago. They don’t realize that, with treatment, people with HIV can live long and healthy lives and do not pass the virus on to others. This is a challenge, but one we’re all working hard to overcome. Barbara Saatkamp Taylor, M.D., M.S. Epidemiology, FIDSA Associate Professor of Infectious Diseases Assistant Dean for the MD/MPH Program
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San Antonio Medicine • May 2018
What professional accomplishment are you most proud of?
In clinical work and research, there are never any individual ac-
INFECTIOUS DISEASES
complishments — everything is a part of work with a team. I am very proud of the work that we’ve done in the Dominican Republic, helping to understand the challenges people with HIV face there and the results of antiretroviral treatment expansion in the country. Right now, I’m incredibly proud to be a part of the End Stigma End HIV Alliance here in San Antonio. We’re a diverse group of people living with HIV, activists, social workers, nurses, physicians and public health professionals who came together last year in response to rising rates of HIV in young people in San Antonio — a trend that unfortunately is occurring across the Southern U.S. and Texas. San Antonio Mayor Ron Nirenberg and Bexar County Judge Nelson W. Wolff support our efforts, and on Nov. 30, 2017, San Antonio became the first “Fast Track City” in Texas, a part of an international effort to end the HIV epidemic. The mayor committed to specific goals for the epidemic in San Antonio by 2030: 90 percent of people in San Antonio with HIV should know their diagnosis, 90 percent of those should be on treatment and 90 percent of those should be virologically suppressed. We’re working with every HIV service organization in the community to help reach these goals, and in the past few months, we’ve set metrics and targets for 2018. It is exciting to be a part of such a dynamic and passionate group. I believe we can end the HIV epidemic in our community.
What drove you or inspired you to go into medicine?
As a kid I loved science. Science fairs, physics class, volunteering in a lab on the Texas A&M campus, even science fiction, were all things I enjoyed. When I went to college, I was sure I would get a Ph.D. and become a laboratory scientist, but two things happened to change that. First, I was studying molecular biology and took a virology course. It was 1993, and our understanding of HIV changed monthly. There was no treatment, and the virus mutated so rapidly that the human immune system and vaccines
couldn’t keep up with it. I remember sitting on my dorm room floor reading about it and feeling overwhelmed, but so impressed by the scientists who were working to stop the epidemic. The second game changer was that I went to Mexico to study indoor air pollution and fuel-efficient stoves as a part of my senior thesis project. That project then became a Fulbright Scholarship. I came back from Mexico fluent in Spanish and committed to working with underserved populations. It clarified that for me, my passion was to practice medicine and serve, rather than work in a lab.
What do you want patients to know about you? That I care about them as human beings and will listen.
What makes UT Health San Antonio a special place to practice?
Everyone is incredibly collaborative. I can pick up the phone and speak with surgeons, dentists or cardiologists about my patients and they all want the best for my patients.
What is special about practicing in Bexar County?
In talking to my colleagues in other places, it is unusual for an entire community to be willing to collaborate to end the HIV epidemic, which gives us the tools to make a difference. Working with the community here is one of the most rewarding things that I do.
What do you do to relax outside of the office, lab or clinic?
I still read a lot of science fiction. I have two daughters, so I spend time watching them do the things they love: soccer, ballet folklorico, track and piano. Finding time for fitness is important to me. I do CrossFit, run on the southern reach of the River Walk near my home and do yoga.
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INFECTIOUS DISEASES
San Antonio Infectious Disease Consultants see the worst cases By Mike W. Thomas
ounded in 1982, San Antonio Infectious Disease Consultants has grown into one of the largest practice groups of its kind with 11 physicians specializing in infectious disease and internal medicine operating out of six locations in San Antonio. Dr. Nicolas Melgarejo joined the practice seven years ago after completing a residency at UT Health M.D. Anderson in Houston. He was attracted to the practice, he said, because of its strong reputation for providing quality care. “They have a lot of experienced people who have been with the practice for many years and who are known for having achieved the best results,” Melgarejo said. One of the biggest challenges facing the infectious disease field today is the increasing anti-bacterial resistance of many diseasecausing organisms. This is due in part to the overuse of anti-biotics to fight common diseases, he said. As more and more resistant strains develop, the job of infectious disease doctors becomes increasingly difficult. “We believe the organisms are getting resistant faster and we are running out of tools to deal with them,” Melgarejo said. San Antonio Infectious Disease Consultants deal with a lot of the most serious cases including patients whose immune systems have been damaged by cancer treatments and those who are HIV positive. As for the AIDS crisis, Melgarejo said that most cases are now caught early enough so that it can be treated. There is still no cure, but the disease can be managed. However, this bit of good news may also be contributing to the steady rate of infections as people have become more comfortable with risky behavior, he said. The doctors in the practice only see the most serious flu cases as well as serious cases of pneumococcal disease and shingles. “Flu season was bad this year with a large amount of cases, but we only see the very worst ones,” he said. “The flu is unpredictable and a lot depends on conditions. We are always having to try and catch up with the latest mutations. The paradigm of the flu vaccine
F
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San Antonio Medicine • May 2018
Dr. Nicolas Melgerejo, San Antonio Infectious Disease Consultants
is not perfect. There is no complete immunity, but if we are lucky we can stay ahead of the curve.” San Antonio Infectious Disease Consultants has continued to grow over the years, Melgarejo said, and is constantly looking for new physicians to add to the practice. “We have plenty of patients and are looking for more doctors,” he said. “We look for quality over quantity and seek out the best and brightest.”
INFECTIOUS DISEASES
Cranial Asymmetry Versus Microcephaly: Implications for Practice During the Zika Virus Epidemic By Sophia Tsakiri, MD; Nikolaos Zacharias, MD; Jose Garcia, MD, SM; and Lynnette Mazur, MD, MPH
ongenital microcephaly can be the result of genetic, teratogenic, mechanical, infectious, and other factors affecting the fetal brain. Transient craniofacial asymmetries and cranial molding can mimic congenital microcephaly caused by brain abnormalities or neurotropic infectious pathogens, including Zika. We present two neonates who were born with head circumference at or below the 3rd percentile for gestational age, and had improving head measurements at discharge from the nursery and resolution of the microcephaly by the second month of life. The diagnostic workup of the first patient revealed congenital cranial bone asymmetry and molding, and the second patient's workup revealed cranial molding. Other etiologies for their microcephaly were excluded. These two cases
C
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San Antonio Medicine • May 2018
highlight the importance of standardized serial head circumference measurements as part of the workup for neonatal microcephaly. Clinical exclusion of transient congenital craniofacial asymmetries and cranial molding could be a cost-effective first step in the diagnostic workup of microcephaly.
Introduction
Anthropometrics are used prenatally and postnatally to assess fetal and neonatal growth. Head size is a proxy for brain growth. Microcephaly may originate in utero and can be the result of genetic, teratogenic, mechanical, infectious, and other factors affecting the fetal brain. Congenital Zika virus (ZIKV) syndrome is a leading cause of microcephaly in endemic areas.
INFECTIOUS DISEASES We present two neonates who were born with head circumference (HC) at or below the 3rd percentile for gestational age and had improving head measurements at discharge from the nursery. Case 1: A symmetrically growth-restricted, small for gestational age singleton female infant was born vaginally at 38 weeks and 3 days of gestation to a Hispanic mother who had traveled to El Salvador during her fourth month of pregnancy. Prenatal sonography at 13 weeks and 4 days demonstrated an embryonic crown-rump length at 27 percent for age and was otherwise unremarkable. Prenatal sonography at 21 weeks and 2 days of gestation demonstrated a fetal HC at 39 percent for age, a fetal weight at 37 percent for age, and was otherwise unremarkable. The birth weight was 2206 grams (0.6th percentile) and the HC was 29 cm (0.2nd percentile). The forehead was flattened, and cranial molding was present. The infant was hospitalized for 3 days because of microcephaly. Cytomegalovirus (CMV), toxoplasmosis, and rubella serologic studies were negative. A brain magnetic resonance imaging showed flattening of the frontal bone. Maternal Zika immunoglobulin M enzyme-linked immunoassay was negative. Neonatal serum real-time reverse transcription polymerase chain reaction was negative for ZIKV, dengue, and chikungunya viruses. During the hospitalization, the HC increased to 31 cm (1st percentile) by the third day of life. The patient was discharged with a diagnosis of frontal bone flattening and resolving congenital cranial molding. Her HC at 14 days of life was 32 cm (2nd percentile) and at 39 days of life was 36 cm (35th percentile). Case 2: A singleton male infant was born vaginally at 36 weeks and 1 day of gestation to a Hispanic teenager with limited prenatal care. The mother reported no history of exposure to ZIKV. Prenatal sonography at 23 weeks and 2 days of gestation demonstrated a fetal HC at 53 percent for age, a fetal weight at 50 percent for age, and was otherwise unremarkable. The birth weight was 2600 grams (35th percentile), the HC was 30 cm (3rd percentile), and molding was present. The infant was hospitalized for prematurity, respiratory distress, head growth restriction, and feeding difficulties. Serologic studies CMV, toxoplasmosis, and rubella were negative. A neonatal brain ultrasound and magnetic resonance imaging were unremarkable. Maternal and neonatal ZIKV testing were declined by the local Department of Health due to lack of maternal exposure to ZIKV. During the birth hospitalization, the HC increased to 32.5cm (27th percentile) by the seventh day of life. The patient was discharged home on the 11th day of life with a diagnosis of improving congenital cranial molding. His HC at day 13 was 33 cm (26th per-
centile), at day 50 was 37 cm (60th percentile), and at day 63 was 38 cm (66th percentile), increasing parallel to body growth.
Discussion
Accurate assessment of the fetal and neonatal head size and growth is essential for the diagnosis of microcephaly or of head growth restriction. A rapid growth phase is expected in the last half of the pregnancy, in the absence of nutritional, medical, economic, or care-related constraints. Early growth patterns of term infants are similar across human populations. Preterm growth generally follows intrauterine growth rates and shows a unique acceleration during the weeks before birth. The Society for Maternal-Fetal Medicine recently published the criteria and standard reference for diagnosing fetal microcephaly, when the HC by prenatal ultrasound is 3 standard deviations or more below the mean for gestational age. Preterm and term newborn growth standards obtained from population-based studies were most recently revised by Fenton and Kim in 2013 and by the International Fetal and Newborn Growth Consortium for the 21st century (INTERGROWTH-21st) in 2015. The US National Birth Defects Prevention Network published prevalence estimates for microcephaly from 30 participating births defects databases for the period 2009 to 2013, studying more than 11 million live births. They described a pooled prevalence for microcephaly of 8.7 cases per 10,000 live-born babies. Prevalence of microcephaly was higher among newborns of Hispanics, mothers younger than 20 years, mothers older than 40 years, preterm babies, low-birth-weight babies, and multiple pregnancies. Though specific prevalence data for cranial molding and craniofacial asymmetries were not reported, molding was recognized as a factor complicating the accuracy of diagnosing microcephaly. The authors acknowledged finding variation of the definition of microcephaly across the databases, with common cut-offs for the HC at lower than the 3rd, 5th, or 10th percentile for age. In our practice, we define microcephaly as a HC smaller than the 3rd percentile for gestational age, according to the 2013 Fenton growth charts for neonates. Due to the known risk for neurodevelopmental delays among infants with asymmetric head growth restriction, we also offer comprehensive evaluation of newborns who have HC measurements significantly smaller than their weight measurement, as had our second patient. Infections of CMV, toxoplasmosis, and rubella during pregnancy can cause fetal and neonatal microcephaly. Suspicion of an epidemiologic link between ZIKV maternal infection and fetal embryopathy occurred in 2015 during the ZIKV epidemic in Central and South continued on page 20
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INFECTIOUS DISEASES continued from page 19
America. Congenital ZIKV syndrome is characterized by microcephaly, cerebral ventriculomegaly, cerebellar hypoplasia, central nervous system (CNS) calcifications, arthrogryposis, or other CNS, ocular, and musculoskeletal abnormalities. On the most recent report from the US Zika Pregnancy Registry (USZPR), among 442 pregnancies with possible ZIKV infection, 26 fetuses or infants were found to have birth defects potentially related to ZIKV, 18 of whom (4 percent of possibly infected pregnancies) had microcephaly. Microcephaly, thus, was markedly more prevalent in the USZPR than in the general population. Practicing in Texas with documented ZIKV travel-associated disease and with gravid travelers from Central and South America, we often take care of pregnant women and newborns with potential exposure to ZIKV during pregnancy, namely a travel history to endemic areas, clinical disease, asymptomatic exposure of the mother, or exposure of her sexual partner(s). Prenatal care providers now routinely screen pregnant women for such history to identify fetuses and infants at risk for ZIKV embryopathy, per the Centers for Disease Control and Prevention guidelines. Current algorithms for the diagnostic workup of newborns born to mothers with potential ZIKV exposure are based on newborn findings consistent with congenital ZIKV syndrome, including microcephaly. Transient neonatal craniofacial asymmetries can lead to self-resolving microcephaly. Craniofacial asymmetries are common at birth. Most are the result of in utero or intrapartum molding, subcutaneous or subperiosteal cranial hematomas, torticollis, and deformational asymmetries. They are diagnosed by a careful examination of the neonatal head. Some can be suspected prenatally by ultrasound or can be expected due to the presence of prenatal factors such as extremes of fetal position, uterine crowding, uterine leiomyomata, or oligohydramnios. 20
San Antonio Medicine • May 2018
The incidence of cranial molding in full-term and preterm neonates is unknown. Such molding is considered a physiologic, transient, selflimiting deformation of the skull and is related to prolonged labor forces applied to the fetal head, regardless of mode of delivery. An older study described 38 newborns with molding at birth and increasing diameters of their heads in the first 3 days of life. Although we know that cranial molding improves in the first days of life, the natural course of molding is unknown. Detailed day-by-day head measurements of molded neonatal heads are lacking from the medical literature. Resolution of cranial molding was evident at 1 month of life on our first patient and at 1 week on the other. Neonatal microcephaly deserves comprehensive workup for underlying brain abnormalities or neurotropic infectious pathogens, including ZIKV, according to published algorithms. Craniofacial asymmetries and molding can mislead medical practitioners to underestimate the newborn head size and to overestimate the risk for congenital infection-induced microcephaly. Pediatricians are advised to perform standardized measurements of the fetal head with nonstretching measuring tape. When available, fetal ultrasonography can provide information on the prenatal head growth pattern. This information combined with the pregnancy history, the results of prenatal testing, a thorough physical examination of the newborn, and serial HC measurements in the first week of life may be critical to confirming or ruling out microcephaly or head growth restriction. Newborns with abnormal prenatal screens or fetal head growth patterns or with physical characteristics of Zika-associated or other embryopathy will be candidates for early advanced testing. Newborns with normal prenatal screens, normal prenatal growth and ultrasound findings, benign postnatal examination, and steadily improving HC may be candidates for targeted screening and longer observation. Neonatal blood and urine specimens as well as placen-
INFECTIOUS DISEASES tal specimens can be preserved within 48 hours of birth for later ZIKV testing, according to the CDC recommendations, while the medical team is weighing the clinical evidence for congenital microcephaly or symptomatic infection and while the maternal testing is in progress. Even if the laboratory and radiologic workup is delayed for a few days until the determination of microcephaly can be made, it ought to be offered to candidate neonates before the initial discharge from the birthing facility. Transient craniofacial asymmetries and molding can be self-resolving, whereas ZIKV and other fetal and neonatal CNS pathogens may lead to nonreversible or progressive microcephaly and to progressive and lifelong disabilities. Early detection of infection, reliable follow-up, and access to specialty resources give the pediatrician and the parents an explanation for the microcephaly and aim at enhanced quality of life for the patient. Utilization of resources is becoming pronounced in known ZIKV endemic areas, such as South and Central America, in areas of travel-associated exposure, and in areas of emerging local transmission, such as Florida and Texas. Before the ZIKV epidemic, the median hospital charge estimate for congenital microcephaly in Texas was $22,754, and the median hospital length of stay was 5
days. The incremental cost of comprehensive ZIKV-associated microcephaly workup, including advanced brain imaging, laboratory testing, prolonged hospitalization, and specialty care costs, is projected to be even higher. The emotional toll to families and the burden to human and laboratory resources is likely significant, too, though difficult to quantify. The clinical exclusion of transient congenital craniofacial asymmetries and cranial molding, via serial HC measurements, is a possible cost-effective first step in the diagnostic workup of microcephaly. We conclude that standardized serial circumference measurements of the newborn head are integral to the workup of transient neonatal craniofacial asymmetries mimicking infection-induced congenital microcephaly. Drs. Tsakiri, Garcia, and Mazur are with the Department of Pediatrics at UTHealth at Houston; and Dr Zacharias is with the Department of Obstetrics and Gynecology at UTHealth at Houston. Send correspondence to Sophia Tsakiri, MD, Lyndon Baines Johnson General Hospital, 5656 Kelley Street, Suite 2NT-91-002g, Houston, TX 77026; email: Sophia.Tsakiri@uth.tmc.edu.
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INFECTIOUS DISEASES
Immunizations and The Luxury to Choose By Travis Bias, DO
he 82-year-old woman lay on her mat, her legs powerless, looking up at the small group that had come to visit her. There were no more treatment options left. The oral liquid morphine we had brought in the small plastic bottle had blunted her pain. Nonetheless, she would be dead in the coming days. The cervical cancer that was slowly taking her life is a notoriously horrible disease if left undetected and untreated, and that is exactly what had happened in this case. We had traveled hours by van along dirt roads to this village with a team of health workers from Hospice Africa Uganda, the country’s authority on end-of-life care, to visit the woman. She was the second patient of a similar condition I would see that afternoon. Back home, seeing an 80 year-old woman with advanced cervical cancer, let alone two in the same day, was exceedingly rare. In highincome countries, cervical cancer is a largely treatable disease, especially when caught in the early stages. And it is now preventable thanks to Gardasil, a widely accessible vaccine against Human Papillomavirus (HPV), the infectious agent that causes most cervical cancers. Physicians and other health care experts recommend the vaccine for all pre-teens in the United States. “If only she had had access to Gardasil,” I thought to myself. Just months earlier I was busy in my private primary care practice in Austin, Texas. In one of the richest countries on the planet that spends more on health care per person than anywhere in the world, I was putting forth my best effort to explain to a mother why her 14-year-old daughter, who had never before had any sexual contact, needed the series of three shots against HPV. “So this HPV is sexually-transmitted, and she still needs the vaccine even though she is
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not sexually active? And she does not need this shot to attend school?” Gardasil was a difficult sell in the conservative state that was careful about adopting what government, or anyone for that matter, recommended an individual do for the sake of public health. It is now February 2018 and news reports are sounding the alarm about the strain of influenza making its way around the U.S., causing remarkably high rates of hospitalization and death. This disease can be easily prevented by one vaccine each flu season, yet patients decline this vaccine due to any number of excuses. “Won’t I be sick or sore for several days after?” “I am very careful about what I put in my body.” And the online “anti-vax” echo chamber encourages this behavior, turning one anecdote of a less-than-desirable reaction into several stories of harm attributed directly to a single shot in the arm. What a luxury to choose from a menu of technological advances to protect one’s health. What a luxury to have an employer or taxpayer fund these ubiquitous means of preventing disease; whether it is a vaccine, a blood test, or a basic treatment. High-income societies have at times taken for granted life-saving resources. All to the detriment of their communities. What a luxury. Considering the Centers for Disease Control and Prevention’s list of the top 10 greatest public health feats of the last 100 years, we are on an incredible backslide to the year 1899. Measles was declared eliminated from the United States in 2000 thanks to widespread immunization, yet we now have outbreaks at Disneyland and anticipated future outbreaks due in part to conscientious objectors to the vaccine. Thanks to advancements in water treatment we no longer have major outbreaks of diarrheal disease, yet we now have continued on page 24
INFECTIOUS DISEASES continued from page 22
entrepreneurs selling “raw water.” What a luxury. It is a cruel reality of inequality and resource mismatch across the globe when those without resources are clamoring for them, while those with resources refuse. Whether based on religious or individuality protests in conservative communities or “natural” ways of life in more liberal communities, the result is the same ignorance of science and reason. What a luxury. But a heavily and densely populated globe interconnected by the increasing ease of international travel means that one person’s declined influenza vaccine might mean another person’s influenza death. The case of Ebola virus disease transported from Liberia to Dallas, Texas in 2014 highlighted how quickly and easily infectious diseases can spread across borders.
In a world of finite resources (yes, even in America) when does the conversation about personal responsibility turn to individuals implementing what is available to them to benefit their global community? In a decade as a family medicine physician in the U.S., I had never before seen a death due to cervical cancer. With our suite of widely used screenings, diagnostic technology, and range of surgical solutions, cervical cancer-related deaths are exceedingly rare. And now that we have deployed the vaccine, Gardasil, cervical cancer rates worldwide have been cut in half. “If only this woman had had access to Gardasil,” I thought to myself. Instead, the 82-year-old matriarch tried to maintain her dignity in the face of a spreading cervical cancer, urinating on a plastic tarp in her niece’s concrete open-air house and controlling her pain with ibuprofen and oral liquid morphine. If only she had had access to that luxury to prevent her cancer. With a little public will, perhaps her great-granddaughters — and mine — will. Travis Bias, DO, is a family medicine physician who once practiced in Texas and now practices in California. He also is a medical and public health educator. Dr. Bias was an active member of the Texas Medical Association while in the Lone Star State. Connect with him at his blog, The Global Table, or on twitter @Gaujot.
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INFECTIOUS DISEASES
By David Lakey, MD
know dangerous infectious diseases are coming, or coming back, and they have the potential not just to cause tragic loss of life and health but to threaten public safety and order. We often forget they have the potential to change history. It might be an influenza pandemic caused by a human-adaptive avian flu or a hemorrhagic fever virus such as Ebola. Or it could be something totally unexpected, as Zika virus was last year. There's no question. We'll be confronting serious infectious disease threats in the future. History, biology, epidemiology, political science, and common sense all point to it. Transcontinental flights occur multiple times a day. The 7.4 billion people on this planet are expanding into previously uninhabited areas and being exposed to potentially new infectious diseases. A large outbreak anywhere in the world is a direct threat to the United States. Our primary tools to control infectious disease are either overused (antibiotics) or underused (vaccines). We have to expect that new and harder-to-treat bacteria, viruses, and fungi will emerge and will be rapidly transported worldwide.
We
What can we do to better prepare?
Good answers to that question include more research on vaccines and diagnostics, more refined models for tracking and predicting the spread of disease, reducing the unnecessary use of antibiotics and increasing immunizations, better training and guidelines for health care workers who are on the front lines of treating infectious disease, and better support of the essential public health infrastructure.
None of these answers, however, address the political and organizational challenges of being able to respond faster than the disease spreads. One lesson I have learned from being in the middle of multiple recent events is that our federal, state, and local response systems do not ramp up as quickly as needed. We saw this with U.S. Ebola cases in 2014, and we saw it last year with Zika. Without the ability to rapidly invest in targeted prevention, our response against infectious disease outbreaks will remain too slow. Politics at multiple levels frequently prevents this rapid, targeted response from occurring. I agree with U.S. Centers for Disease Control and Prevention Director Tom Frieden, MD, and many other public health officials that it is time for a Federal Emergency Management Agency (FEMA)like resource for rapid responses to rapidly emerging infectious diseases of national consequence. FEMA, which assists states in responding to natural disasters, has proven an invaluable structure for dealing with potentially catastrophic events that require responses that are fast, efficient, and massive. FEMA isn't perfect, but it's a good starting place for imagining a better structure for managing our national response to infectious diseases of national consequence. FEMA has streamlined the ability for states to request and receive aid from the federal government in a natural disaster, and it has taken a lot of the partisan politics out of the equation. Funds are made available early enough to mitigate and respond effectively to the event, and controls are in place at the state and federal levels to ensure this resource is not abused. As a nation, we've recognized that exceptional circumstances call for exceptional processes and structures and that natural disaster continued on page 26
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INFECTIOUS DISEASES continued from page 25
doesn't have a party or an ideology. In the case of infectious disease, we should do the same, perhaps with even more urgency and more hope. Potential epidemics are sensitive to human response. If the response is quick and effective, the disease can be contained. If the response is lacking, the result may be an actual epidemic, with rates of transmission and spread that are exponential. Infectious diseases have been major actors in the course of human history. Words like plague, smallpox, consumption, and pestilence strike a deep fear inside us. We like to think of those diseases as something of the past. We feel protected by modern sanitation, vaccines, and antibiotics. But inside us that fear remains. There are a few things we can do with that fear. We can suppress it and hope for the best. We can be its victim and jump from crisis to crisis, developing ad hoc responses and finding scapegoats when the responses fall short. Or we can put the fear to good use and think constructively and with foresight about how to manage future threats. David Lakey, MD, is associate vice chancellor for population health and chief medical officer for The University of Texas System. He served as commissioner of the Texas Department of State Health Services during 2007–15.
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San Antonio Medicine • May 2018
BUSINESS OF MEDICINE
Commercial Real Estate: HOW TO PROFIT DURING INFLATION By Ari Rastegar Founder and CEO of Rastegar Equity Partners
Uncertainty in the public markets continues to cause unrest among global and domestic investors, with inflation being one of the main economic theories circulating amongst financial analysts about the cause of the next market crash.
What exactly is inflation?
The economic definition of inflation is “a general increase in prices and fall in the purchasing value of money.” In reality, this translates to ordinary expenses, like groceries or gas, are going to cost more — and in some instances much more than one is accustomed — without a relative increase in work related income. Investing in “hard assets” such as gold or other precious metals, oil or other natural resources, and even art have historically been protective investment vehicles to both protect against inflation, and in some instances, turn a future profit. When an economic shift happens, investors seek alternative investments like commercial real estate to their traditional public stock, bond and cash portfolios. 28
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In every investment there is always risk.
When considering alternatives, it is even more important to find the right managers to work with — those who have a strong track record and a system in place to manage the risks in a less regulated environment. As a general rule, alternative investments are typically held in the portfolios of institutional and high net worth investors. Investors seek alternatives because when done right, they offer other attractive benefits in a turbulent economy. These investments are said to be “non-correlated” to the public markets, which essentially means that their value changes according to variables not directly related to the public markets. As investors are considering their options, they should be reminded that that any income generated from bonds or other fixed income instruments should factor in the inflation rate to determine their “real return” or “real interest rate.” Essentially, this is the gross return. For example: If you earn a 5% return from a bond, and the inflation rate is 2%, then the real return / real interest rate is 3%.
When you factor this into an environment at high risk for inflation, investments that can generate higher yield are more attractive if they can be done in a lower risk environment. When sourcing investments — whether in residential or commercial real estate — professionals will always have the competitive advantage in finding opportunities that that will generate strong risk-adjusted yield.
Historically, having an insulated alternative portfolio in a time of inflation has helped create a more balanced portfolio to counteract inflation. Although all “hard asset” options can be effective (and have been in the past) there is one critical element that, when coupled with hard assets, can have an exponential effect in not only defending against inflation, but generating more real-time profit: income. Real estate, namely, income-producing
BUSINESS OF MEDICINE
real estate, is a popular choice because rising prices increase the resale value of the of property. In addition, certain types of real estate can be used to generate income, specifically from rent paid by tenants. There are many options for investors to seek current income in real estate, but the question that investors need to ask themselves is:
How much risk am I taking or willing to take, and how much time and energy do I have to devote to these investments?
specialized profession that requires specialized knowledge and hard work. There are many steps that must be taken in a particular way before purchasing a rental property. This includes sourcing the property, conducting due diligence, budgeting for repairs, marketing the property to find a tenant, ensuring the tenant has the financial viability to lease the property, and a slew of other managerial tasks to maintain the property. On top of that, one must manage the financial risks associated with purchasing the property, not to mention personally guaranteeing a mortgage. And even if that laundry list of tasks is completed, one the biggest risk factors is that the property is either 100% occupied or 0% occupied.
What does that mean?
Residential Real Estate VS Commercial Real Estate
Many novice investors elect to buy residential real estate and rent it out to generate income. On paper, this seems like a very attractive opportunity, but upon closer analysis, the risk may not outweigh the reward. To begin with, real estate investing is a
The vast majority of residential properties are single-tenant assets, so if they decide to vacate the property early, no income is being generated to offset the costs associated with owning the property, and the investment quickly turns into a massive liability. In order to protect against the 100% / 0% risk profile, owning multiple houses to create a portfolio can help diversity the risk — which also incrementally increases the work and the capital outlay for purchase and upkeep. In effect, this is not a passive investment like investing in the stock market; real estate requires active participation. On the other hand, commercial real estate refers to any non-residential properties used for commercial purposes — most commonly, apartment complexes, shopping centers, and office buildings. The properties in these instances are multi-tenant, so the risk of default is spread out considerably and not reliant on a single tenant for rental income. In some cases, there are single-tenant commercial properties as well, but the solvency
of the tenant is based on the business itself, often a corporation with more locations to secure the lease. One of the stark differences with investing in commercial real estate vs. residential is that the vast majority of the opportunities available to investors are done by professionals that specialize in real estate investing. This does not mean that there is not risk, there is always risk. Compare this to the large portion of rental property owners who are using their own, non-professional skills to determine which properties to purchase for investment, and you can see the increased risk of loss immediately.
Barring any undisclosed risks, the diligence, management, and operations of commercial real estate should be handled by a professional company, which allows the investor to receive passive income, allowing their money to work for them instead of signing up for another job. Ari Rastegar is the founder and CEO of Rastegar Equity Partners, a Dallas-based private equity real estate firm. Rastegar is a Platinum Sponsor of the Medical Society. He can be reached at 917-7035027 or email: ari@rastegarep.com.
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FEATURE
TRAUMA TOURISM Fred H. Olin, M.D.
When I was in full-time orthopaedic practice I did my part by taking trauma calls at the private hospitals in the Medical Center. Most of the calls were, of course, the usual things orthopaedists see; little old ladies with hip fractures, kids with distal radius fractures, victims of car wrecks, part-time athletes with sprained, strained or torn this and that and so on. However, sometimes geography made a difference and we would have some international excitement. If you look at a map of Texas and Mexico you’ll see that San Antonio is the closest U.S. big city with a medical center to almost all of the Mexican beach resorts. Flying time from them to S.A. is shorter than to other cities because the air-ambulance servicers didn’t like flying over water, in this case the Gulf of Mexico. Over the years those facts led to some interesting adventures. I’ll try to remember the details of a few. One afternoon I was called and told that a jet air-ambulance was coming in from Cancun with a 40-ish-year-old man with several fractures. It would land in a short while, and he would then be transferred over to what is now Methodist Specialty and Transplant Hospital, where I was on call. His story was this: The gentleman was an accountant who lived in the Maryland suburbs of Washington, D.C. He and his girlfriend were on a motor scooter when they were crushed against a low wall by a bus. The woman was killed. He sustained femoral and clavicular 30
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fractures and was all bruised up. Something about his chest made our ED physician nervous, although he couldn’t really define it, so he called in a thoracic surgeon. An aortagram showed a small tear in the thoracic aorta where the ductus arteriosus attached, with a contained hematoma in the mediastinum. He was taken to the OR where his aorta was repaired. I did a closed nailing of the femur when that was done. The patient did pretty well under the circumstances and was sent to the ICU after recovery. That is, he did well …until a couple of days later, when his wife came to visit him. The nurses said it was an “interesting” interaction. He was ultimately discharged and we never saw or heard anything more. Another time I received a call from Methodist about an airambulance coming in, this time from Cozumel. The patient was an elderly woman with a hip fracture. Her story extended over the better part of a week. As she and her early-20’s granddaughter were entering their hometown Stavanger (Norway) airport for a flight to London, a door had somehow knocked the older lady down. She was able to get up and hobble on. In London they stayed at an airport hotel until their flight to Miami the next day. She was so sore that she needed a wheelchair to get to the flight. In Miami, they went straight to the cruise ship for the main event of their trip. She now was unable to even stand, and for some reason there wasn’t the usual physician on board, only a nurse, and the X-ray machine was allegedly non-functional. By
FEATURE
the time they got to Cozumel she was bed-bound. The ship didn’t dock, so she was transferred to the island by boat, where a displaced intertrochanteric fracture was diagnosed. She had purchased trip insurance from the Norwegian Postal Service, and when the situation was reported to the Service, they arranged for the transfer to San Antonio. Besides the fracture she was in pretty good shape, so the next morning I fixed he hip. Although her granddaughter spoke fluent English, Grandma spoke only Norwegian, which set up one of the more humorous moments. After the surgery, my wife had insisted that I bring the exhausted granddaughter home to our house to let her rest. She had stayed overnight the first night at the hospital, sitting with her grandmother. I went to the hospital from my office later that day to check on the patient. I came out of the room to the nurses’ desk and told the staff I needed a translator. Several of the Hispanic folks volunteered, which wasn't much help since none of them spoke Norwegian. We ended up using the bedside phone to call my house and the granddaughter translated for us. Anyway, she did well, we got her up and moving a bit, and when she was ready for discharge after almost a week, the Norwegian Postal Service sent a physician and a nurse to accompany them back home, everyone in first-class seats all the way. The third one I can recall right now came in the same way, but this time from Mazatlan. The patient was a middle-aged Hispanic
gentleman whose family had run a small neighborhood grocery store in Mazatlan for many years. He was an American citizen, but had gone down there to help his siblings run the store after their parents had died. I don’t recall the exact circumstances, but somehow he got crosswise, to his detriment, with a man who had a machete. He sustained several large but mostly superficial lacerations here and there, which had been given good first-aid, and a both-bone fracture of his left forearm, thankfully closed. It was a fairly classic defensive injury. We got everything sutured up, I fixed the fractures and we got him started on rehab for his shoulders, which had taken most of the cutting injuries. He was discharged to his home in Gilroy, California, known far and wide as “The Garlic Capital of the World.” A year or two later my wife and I were in the San Francisco area and we visited him and his wife at their home. I didn’t charge him for the post-op home visit. Fred H. Olin, M.D. is a semi-retired orthopaedic surgeon who doesn’t miss taking trauma call one bit…although sometimes it did get interesting. visit us at www.bcms.org
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AUTO PROGRAM
Buying a Car or Truck? Let’s Compare the BCMS Auto Program to A Buying Service By Phil Hornbeak, BCMS Auto Program Director
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Buying Service
When you use a buying service to find a vehicle, you start by filling out the pop-up window which gives them your contact information. You will enter information about a particular year, make, and model, following which they provide you with a price range or current advertisement and give your personal information to some dealers. That is when the race begins; every contacted dealer wants to be the first one to contact you to lock you in on a vehicle before the other dealers get a chance. You will receive more calls than you ever imagined. It is like a dam breaks and the water starts washing over you; call after call, text after text.
If you decide to work with one of the dealers who calls you, you will go to their dealership (in Texas a hot parking area) and likely spend several hours working through their sales process. Even though you asked for someone you will still go through some sales procedures:
THE QUESTIONING AT THE DEALERSHIP GOES LIKE THIS: • What’s your name? Alternatively, thanks for coming in Mr. or Mrs. Customer.
• What brings you in today?
• May I ask why you are thinking about buying a new car?
• Are there any specific makes or models you are interested in?
• What features does your current vehicle have that you would still like to have in your new one?
• What do you dislike about your current vehicle?
• What are the top thredd things you would love to see in your new vehicle?
• Will you be trading in your current vehicle?
• Who is going to drive the vehicle most of the time and for what purpose (business, pleasure, family)?
• What is your timeline? (Buying ASAP vs. browsing and waiting)
• Are you planning to pay cash or finance the vehicle?
• Did you finance your last vehicle? What was your monthly payment? One of the advertising tactics observed recently is to show you the picture of a car, a sale price, and offer very low financing rates. However, upon investing the time and effort to go to a dealership, you find the price listed is for a used or demo car (one-of-a-kind that has probably already sold), and the rates are for the top 1 percent of buyers. Teasing and tricky ads are designed to get you to register online or by phone. Are you overwhelmed yet? Now, let’s contrast the BCMS Auto Program 32
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AUTO PROGRAM
BCMS is your vehicle buying concierge.
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BCMS Auto Program THE BCMS AUTO PROGRAM IS FREE OF CHARGE, A CONCIERGE SERVICE WITH NO SALES PRESSURE.
The Auto Program can arrange to deliver a vehicle to you for a test drive, ease the paperwork, negotiate prices, advise on financing, leasing, warranty programs, models, deals, and so on. Since the Auto Program does not charge you for services and receives no commission on your purchase of a vehicle, you can always trust them to act in your best interest.
With the BCMS Auto Program, you have two options. • Call the Auto Program Director directly (210 301-4367) to discuss what you are looking for in a vehicle, • or go online at www.bcms.org and fill out a form about what kind of vehicle you want. The Auto Program will contact participating dealers, locate the exact make, model and color vehicle with the equipment you want. You will receive both the MSRP and the dealer’s lowest price. If you wish to test drive or look at the vehicle, you will be put in touch with a person at the dealership who is responsible for making your visit a comfortable and pleasant experience, and you already have the price. The Auto Program always has cooperating lenders offering options for low finance rates. The Auto Program Director is an expert on lease vs. purchase questions and has commercial contacts he can refer you to (leases are usually for those who use a vehicle for business more than 51 percent of the time). We can also get the details on the manufacturer’s sponsored mileage leases. So, now it is time to call the Auto Program (210) 301-4367, or email Phil@bcms.org and start the easy path to the vehicle of your choice.( However, if you love negotiating, call that buying service!) visit us at www.bcms.org
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HISTORY
San Antonio’s earliest settlers overcame many hardships to make a better life for all of us By Alfonso Chiscano, MD
Over the course of this, our Tricentennial year, city leaders, educators, artists, community activists and many others will be paying homage to the men and women whose blood, toil and tears founded and created San Antonio. Many of the city’s most recognizable landmarks, from the original Spanish missions to the San Fernando Cathedral, are a testament to the legacy of the founders of our municipal government. There is a modest symbol of remembrance that lies not too far from San Fernando. A plaque that honors 16 families – a total of 56 men and women. Hailing from the Canary Islands, these individuals came here in 1731 at the behest of King Philip V, who wanted to retain the territory for Spain. What these brave adventurers ultimately gave to our city, however, makes for a much greater story. It is, as the marker at Municipal Plaza states, the story of the “earliest civilian colonists of San Antonio.” Upon their arrival to the area, the Canarians joined with the Coahuiltecans – the earliest recorded inhabitants of the area – the mission friars and the Spanish presidio soldiers who were here to protect them and the mission lands for the Spanish crown. They founded a municipality, the Village of San Fernando de Bexar. 34
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The village was located on what was then the west side of the Plaza de las Yslas – or, as it is better known today, Main Plaza. Above all, they established our city’s system of law and order, the very foundations upon which civil government is based. The lives of these 56 civilian settlers are intertwined with the history of this city. For example, they accounted for the first 120 mayors of San Antonio. And later descendants, like Robert L. B. Tobin, would be integral to the cultural legacy of our city. An underwriter of operas and champion of the arts, Tobin would go on to fill an entire wing of the McNay Art Museum with his priceless collection of theater art and design. The contributions of the early Canarians to our system of government and our cultural heritage is immense. But theirs is also a story of bravery in the face of overwhelming hardships, a story that should continue to inspire each and every one of us, and one that is relevant to this day: The quest for a better life in a new land. They faced fantastic challenges, enduring a transatlantic voyage that would take them as far as Vera Cruz, Mexico. The last 1,000 miles of the journey would be traveled on foot. Think about that. After months at sea, the 56 Canarians still had to walk 1,000 miles to get to their new home.
HISTORY
So great was their desire for a new life, for themselves and their loved ones, that they walked 1,000 miles to seize the better life. What a lesson of love and dedication these colonists have shown us! Over time, the Canarians would establish ranches where they would raise crops and tend cattle. During the American Revolution, the Canary Islanders took part in cattle drives, providing beef to the colonists who were fighting for freedom from British rule. But in the tumultuous times of the Texas Republic, many Canarians would see their ranches taken from them. But even this heartbreak was not enough to diminish their humanitarian spirit. Their history and legacy cannot fit on a simple monument in Main Plaza. It can begin to be told by the five bronze statues that have been commissioned and will ultimately reside in front of the Bexar County Courthouse. Were it not for the passion for a better life that drove these “earliest civilian colonists in San Antonio,� our beloved city would not be what it is today. We owe it to our founders to have that same passion to create an even better city over the next 300 years. Dr. Alfonso Chiscano, a thoracic and cardiac surgeon, was born in the Canary Islands. He is a co-chair of the San Antonio Tricentennial Commission. visit us at www.bcms.org
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TRICENTENNIAL
SAN ANTONIO’S TRICENTENNIAL
By Julie Catalano Photography courtesy of www.visitsanantonio.com
The Alamo City’s 300th birthday is well underway, but there’s still plenty to experience during this once-in-a-lifetime happening.
This year is the perfect time to learn the history of San Antonio — a long, complex and compelling tale that begins when the city was named before there was a city, when indigenous peoples like the Payaya Indians occupied the area for many thousands of years. Spanish explorers arrived on June 13, 1691 on the feast day of St. Anthony de Padua, naming both the area and the river in his honor. It was 27 more years, in 1718, before the first mission — what we now know as the Alamo — and the first presidio were established at San Pedro Creek, populated by Spanish friars and Spanish soldiers, respectively. Although 1718 is celebrated as San Antonio’s birth, there was no official city government until 56 Canary Islanders arrived in March of 1731 by royal decree of the King of Spain, establishing law and order with a municipal government and city hall. Ranches and farmland were tilled with the help of Spanish presidio soldiers and the Native Americans — a full century before the Battle of the Alamo. That’s the short version. Hundreds of Tricentennial-themed events, performances, lectures, exhibits, concerts, films and festivals will fill in the gaps with everything from solemn remembrances to celebrations of art, music and dance, led by the San Antonio Tricentennial Commission in partnership with area organizations and institutions. 36
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WHERE TO START? RIGHT HERE: Commemorative Week, May 1-6
Packing as much Tricentennial as possible into six days, this week explores history, education, arts and much more. Many of the events are free, but for ticket and time info, go to www.sanantonio300.org.
May 1. Day of Reflection.
The week kicks off with interfaith services at places of worship across the city, headed by the Archdiocese of San Antonio and other religious leaders. A pilgrimMISSION CONCEPCÍON age from Mission Concepción arrives at Main Plaza, followed by a musical performance, healing ceremony, lighting of the Eternal Flame and a candlelight vigil. Free.
May 2. History and Education. Thousands of San Anto-
nio students will get a visit from historical performers touring area schools throughout the week to bring the city’s history to life. Special exhibits will also be on display at libraries, college campuses and museums.
Article Courtesy of Home Design Décor magazine
TRICENTENNIAL
May 3. Founders Day. A Founders Day Ball is a gala tick-
eted event at the downtown Henry B. Gonzalez Convention Center. Concurrent activities that are free and open to the public will be held at UTSA main campus, Texas A&M San Antonio, Our Lady of the Lake University, St. Philip’s College and Morgan’s Wonderland.
May 4. Arts for All. Complimentary admission to museums,
art venues, theaters and more, many of them offering Tricentennial-centric programming.
May 5. Legacy Day. Arts, entertainment, tours and celebrations pay tribute to the five San Antonio Missions — San Jose, Concepción, Espada, San Juan and the Alamo. The day ends with fireworks over every mission.
THE ALAMO
MISSION SAN JOSE
MISSION SAN JUAN
MISSION ESPADA
BY BOB HOWEN
CROCKET VIOLIN
served as a life source through the ages. This is a companion exhibition to Confluence and Culture: 300 Years of San Antonio History, through January 6, 2019. www.wittemuseum.org The San Antonio Museum of Art also does double duty with San Antonio 1718: Art from Viceregal Mexico, through May 13, that tells the story of San Antonio’s first century through more than 100 artworks; and Spain: 500 Years of Spanish Painting from the Museums of Madrid, from June 22-September 16, featuring more than 40 masterpieces from major collections, many of which have never been on display in the U.S. www.samuseum.org
BY BOB HOWEN
CRISTÓBAL DE VILLAPANDO (NEW SPAIN, 1645-1714), THE MYSTICAL CITY OF GOD, 1706
May 6. Military Appreciation. Designed to highlight the
city’s renowned military history, this day will focus on active duty military and Joint Base San Antonio.
MORE HIGHLIGHTS:
Two fascinating exhibitions at the Witte Museum bring to life a firstclass (and fun) history lesson. Through July 1, Gathering at the Waters: 12,000 Years of People explores how the San Antonio River
Confluence: Art at the Convention Center is an exhibition hosted by the City of San Antonio to showcase more than 20 new artworks by prominent local and regional artists at the newly expanded Henry B. Gonzalez Convention Center. Free. One of the most exciting Tricentennial offerings will endure far into the future — the “T” Public Art Garden, an ambitious project that will reinvent four acres along the River Walk into a walkable space for visitors to connect with inspiring public art. Works by local and international artists will grace the area to create an artistic destination combining art, culture, people and place in the heart of downtown. This multiyear art initiative is planned for a late 2018 launch.
WANT MORE?
The official San Antonio Tricentennial SA300 app is available for download in both iOS and Android, with information on the latest events and celebrations for the city’s milestone birthday. u
MARKET PLAZA BY THOMAS ALLEN
For a complete calendar of official Tricentennial events, visit www.sanantonio300.org. visit us at www.bcms.org
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us. ACCOUNTING FIRMS Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”
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”
ASSET MANAGEMENT
Avid Wealth Partners (HHH Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and well-served by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”
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San Antonio Medicine • May 2018
The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank. Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."
ATTORNEYS
Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence. Mark R. Flora Partner and Office Head 512-382-8800 mflora@constangy.com William E. Hammel Partner 214-646-8625 whammel@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”
Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell
210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”
Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”
Strasburger & Price, LLP (HHH Gold Sponsor) Strasburger counsels physician groups, individual doctors, hospitals, and other healthcare providers on a variety of concerns, including business transactions, regulatory compliance, entity formation, reimbursement, employment, estate planning, tax, and litigation. Carrie Douglas 210-250-6017 carrie.douglas@strasburger.com Cynthia Grimes 210-250-6003 cynthia.grimes@strasburger.com Marty Roos 210-250-6161 marty.roos@strasburger.com www.strasburger.com “Your Prescription for the Common & Not-So Common Legal Ailment”
ASSETS ADVISORS/ PRIVATE BANKING
U.S. Trust ( Gold Sponsor) At U.S. Trust, we have a long and
rich history of helping clients achieve their own unique objectives. Since 1853, we've been committed to listening, building long-term relationships, and helping individuals and their families realize the opportunities they create for themselves, their children, businesses, communities and future generations. SVP, Private Client Advisor, Certified Wealth Strategist® Christian R. Escamilla 210.865.0287 christian.escamilla@ustrust.com “Life’s better when we’re connected®”
BANKING
Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Stephanie Dick, Vice PresidentCommercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com
BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Mary Mahlie Global Wealth Management 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com “Working for a better future”
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”
Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans. Sam Fisher Vice President/Commercial Lender 210-319-3503 samf@ozonabank.com www.ozonabank.com
The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com
RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more. Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org
Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals. Synergy FCU Member Service (210) 345-2222 or
info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”
EMPLOYEE MANAGEMENT
Frost (HH Silver Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses. Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”
Beyond (HHH Gold Sponsor) Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire employee life cycle. From online onboarding to certification tracking to payroll processing, manage your people anytime, anywhere. Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"
BUSINESS CONSULTING Alto Vista Enterprises, LLC (HH Silver Sponsor) We specialize in helping physicians grow their business according to the goals and timeline of the practice. Customized business development strategies are executed by an experienced and dedicated team of consultants. Michal Waechter, Owner (210) 913-4871 MichalWaechter@gmail.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”
BUSINESS SERVICES
New York Life Insurance Company (HHH Gold Sponsor) We believe that any great relationship starts with great core values: Attention, Accountability, Appreciation, Adaptability and Attainability Doug Elley Financial Consultant 210-961-9991 dougelley@financialguide.com www.newyorklife.com
CONTRACTORS/BUILDERS /COMMERCIAL
Cambridge Contracting (HHH Gold Sponsor) We are a full service general contracting company that specializes in commercial finishouts and ground up construction. Rusty Hastings Rusty@cambridgesa.com 210-337-3900 www.cambridgesa.com
FINANCIAL ADVISOR
Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"
FINANCIAL SERVICES
Avid Wealth Partners ( Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's ommitted to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP, CIMA, AEP, CLU, CRPS Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”
Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than
money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”
Beyond ( Gold Sponsor) Beyond is a financial technology company offering a suite of business tools including payment processing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference. Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"
Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"
RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning). Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org
continued on page 40
visit us at www.bcms.org
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39
The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank. Carol Mani Johnston Senior Vice President – Wealth Management Senior Portfolio Manager 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."
GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A parttime, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time. Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration
HEALTHCARE TECHNOLOGY RubiconMD (HH Silver Sponsor) RubiconMD enables primary care providers to quickly and easily discuss their e-Consults with top specialists so they can provide better care - improving the patient experience and reducing costs Shang Wang Business Development (845) 709-2719 shang@rubiconmd.com Cyprian Kibuka VP of Business Development (650) 454-9604 cyprian@rubiconmd.com www.rubiconmd.com “Expert Insights. Better Care."
HOSPITALS/ HEALTHCARE SERVICES
Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor)
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San Antonio Medicine • May 2018
Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”
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”
Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”
INSURANCE
SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships. Deborah Gray Marino VP Community Relations 210-525-1241 DMarino@swbc.com Wealth Advisor, Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Kristie Arocha, Mortgage 210-255-0013 karocha@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services
TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”
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 products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair. Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com
INTERNET TELECOMMUNICATIONS
INSURANCE/MEDICAL MALPRACTICE
Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice
Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”
MEDICAL BUSINESS CONSULTING
Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations. Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."
MEDICAL BILLING AND COLLECTIONS SERVICES
From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”
PAYROLL SERVICES
SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits. Kristine Edge, Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.
Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com
PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”
REAL ESTATE SERVICES COMMERCIAL
PRACTICE CONSULTANTS Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations. Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice." Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”
MEDICAL SUPPLIES AND EQUIPMENT
Henry Schein Medical (HHH Gold Sponsor)
New York Life Insurance Company (HHH Gold Sponsor) Our Goal, increase patient & employee satisfaction, generate more free time for practitioners and mitigate both business and personal financial risk. (No Cost Financial and Business consulting including HIPAA audit evaluations, BCMS members only). Doug Elley 210-961-9991 dougelley@financialguide.com www.newyorklife.com “20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”
PRIVATE EQUITY
Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation. Kellie Rastegar 818-800-4901 kellie@rastegarep.com
Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation. Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com
SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment. Shane Brown, Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”
STAFFING SERVICES
Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley, Branch Director 210-301-4362 bwhitley@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.” United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"
TOXICOLOGY LABORATORY TESTING
Diagnostic Solutions, LLC (HHH Gold Sponsor) Partnering with Diagnostic Solutions allows providers to incorporate the industry’s best practices into drug compliance testing and clinical decision-making with accurate and timely results for UDT quantitation and identification. Jana Raschbaum, MBA, BSN, RN 210-478-6633 janelleraschbaum@gmail.com Donald Nelson, MD 928-529-5110 dhnelson@citilink.net www.trustedtox.com For questions regarding services, Circle of Friends sponsors or Joining our program. Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html
visit www.bcms.org 41 41 visit usus atatwww.bcms.org
RECOMMENDED AUTO DEALERS AUTO PROGRAM
• • • •
We will locate the vehicle at the best price, right down to the color and equipment. We will put you in touch with exactly the right person at the dealership to handle your transaction. We will arrange for a test drive at your home or office. We make the buying process easy! When you go to the dealership, speak only with the representative indicated by BCMS. GUNN AUTO GROUP
Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Cary Wright 210-558-1500
Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900
Ancira Chevrolet 6111 Bandera Road San Antonio, TX
Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX
GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154
Jude Fowler 210-681-4900
Esther Luna 210-690-0700
Bill Boyd 210-859-2719
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Honda 14610 IH 10 W San Antonio, TX
GUNN Acura 11911 IH 10 W San Antonio, TX
GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209
Pete DeNeergard 210-680-3371
Coby Allen 210-625-4988
Abe Novy 210-496-0806
Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216
Cavender Audi 15447 IH 10 W San Antonio, TX 78249
David Espinoza 210-912-5087
Sean Fortier 210-681-3399 KAHLIG AUTO GROUP
Cavender Toyota 5730 NW Loop 410 San Antonio, TX
Northside Ford 12300 San Pedro San Antonio, TX
Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX
Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX
North Park Subaru 9807 San Pedro San Antonio, TX 78216
Gary Holdgraf 210-862-9769
Wayne Alderman 210-525-9800
William Taylor 210-366-9600
James Godkin 830-981-6000
Mark Castello 210-308-0200
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Mazda 9333 San Pedro San Antonio, TX 78216
North Park Lexus 611 Lockhill Selma San Antonio, TX
North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX
North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211
Scott Brothers 210-253-3300
North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257
Jose Contreras 210-308-8900
Justin Blake 888-341-2182
Stephen Markham 877-356-0476
Justin Boone 210-635-5000
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Lincoln 9207 San Pedro San Antonio, TX
North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257
13660 IH-10 West (@UTSA Blvd.) San Antonio, TX
Porsche Center 9455 IH-10 West San Antonio, TX
Barrett Jaguar 15423 IH-10 West San Antonio, TX
Sandy Small 210-341-8841
James Cole 800-611-0176
Ed Noriega 210-561-4900
Matt Hokenson 210-764-6945
Dale Haines 210-341-2800
15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800
Land Rover of San Antonio
AUTO PROGRAM
Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org
visit us at www.bcms.org
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AUTO REVIEW
2018 BMW 230i coupe By Stephen Schutz, MD
In its ongoing effort to span the entire automotive spectrum, BMW sells the modestly priced 230i coupe in this country. Good for them. With their 7-series sedan, upcoming X7 luxury SUV, and — can you believe they’ve owned this company since 1998? — Rolls Royce, they have the high end covered. It’s worth a moment to consider how far BMW has come in 40 years. In 1978 BMW sold just three models in this country: the 320i and 633i coupes and 533i sedan. This year they offer, deep breath...the 7-series sedan, X1, X3 and X5 crossovers, X2, X4 and X6 crossover coupes, i3 electric coupe, i8 and Z4 sports cars, 2- and 4-series coupes, and 4- and 6-series Gran Coupes. In addition, there are convertible versions of the (non-Gran) coupes as well as M versions of seven of their offerings. Based on the not-sold-here 1-series hatchback, the entry level 230i is intended to entice young professionals and others with some but not lots of disposable income to the brand (and, of course, introduce them to BMW’s pricier offerings as their incomes rise). In this country, the 2-series can be had in either coupe or convertible forms, rear- or all-wheel drive, and either of two engines,
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the base 2.0L four-cylinder motor with 248HP or 3.0L in-line six with 335HP. As is the case with every engine in non-electrified 2018 BMWs, both 2-series powerplants are turbocharged. In case you care in these days of cheap gas, fuel economy figures are 24 MPG city/35 highway for the 230i coupe and 21 city/32 highway for the M240i coupe. In keeping with their athletic natures, both the 230i and M240i are available with either an 8-speed automatic or—thank you BMW!!—six-speed manual transmission. (If you choose AWD, the manual is no longer available.)
The exterior design of the 230i is best described as conservative. Most modern BMWs have understated styling, but the 2-series’ is probably the most low-key. I drove it all over my area during my week with it and not a single person gave it a glance. Still, its relatively long hood, stubby rear end, and wedgy stance give the 230i a nicely sporty look. And the many character lines along the sides and hood add personality. Nevertheless, my usual critique of contemporary
AUTO REVIEW BMW styling--too many trees and not enough forest--also applies to the 2-series. The 230i’s interior is monochromatic and uninspiring with materials that generally disappoint. But while the interior will not impress owners of higher end luxury cars, it is unmistakably BMW, and given the 230i’s modest price point—it starts at around $34,000 — will please its intended audience. Naturally, the 230i’s cabin is small. There’s little elbow room in the front, let alone in the cramped rear seats, and there’s not much space for luggage etc even if you fold the rear seats down. But the 230i isn’t about interior cushiness or space for rear seat passengers, it’s about driving pleasure, and on that score it does very well. Almost 250HP is more than enough to provide brisk acceleration, and BMW engineers are to be commended for minimizing turbo lag. In the early days of turbocharging, lag was an annoying reality of spirited driving. Now power is delivered as soon as you hit the throttle. Given its small size and low weight, the 230i handles very well with reassuring neutrality through corners but also good stability on the highway. Twisty B-roads are where the 230i is most comfortable, and that’s where the diminutive Bimmer and I bonded. My tester had RWD, which lessens weight over the front axle, and a manual six-speed, which maximizes driver involvement, and it was nothing but fun when I took it up my favorite curvy mountain road. My test car did not have the $2300 Track Handling package, which includes two-mode adaptive dampers, variable-ratio steering, and Michelin Pilot Super Sport summer tires on 18-inch wheels, and I didn’t miss it. If I were configuring my own 230i I’d be tempted by this option but would worry about ride quality. Standard features in the 230i include push-button starting, rainsensing windshield wipers, and dual-zone automatic climate control. Interestingly, no 2018 2-series model offers blind-spot protection or adaptive cruise control, features found on numerous less prestigious cars. Nevertheless, load a 230i up with options ¬— and there are many — and you can find yourself paying more than $50,000, which is 4-series money. As always, a conversation with BCMS’ Phil Hornbeak before you choose your next new car is recommended.
BMW sells an amazingly wide variety of vehicles these days, and I’m happy that they haven’t neglected the lower end of the market. The 230i coupe is fun to drive and satisfying to own, which is what BMWs have historically been. And it’s more accessible than its pricier siblings. If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 45 45 visit us us at at www.bcms.org
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