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Mental Health Challenges
Grief, Mourning and Acceptance By Fred H. Olin, MD.......................................14 Poetry By Judy Jordan, MD ......................................16 Geriatric Depression and It’s Treatment By Frederick Brown, MD................................17 Caring for the Caregiver By Carol L. White, RN, PhD ...........................22 Depression and Pain By Somayaji Ramamurthy, MD.......................26 BCMS President’s Message ........................................................................................................................8 BCMS Legislative News ............................................................................................................................10 BCMS News ..............................................................................................................................................12 Presidential Reminisces from Jose M. Benavides, MD, FACP ....................................................................29 UTHSCSA: Accelerating the Pace of Biomedical Research By William L. Henrich, MD, MACP, President and Professor of Medicine, John P. Howe III, MD, Distinguished Chair in Health Policy at UT Health San Antonio ......................31 BCMS Honorees: Manuel Quiñones Jr., MD ..............................................................................................32 Feature: Inclusion is a Responsibility of Both Parties By Alex Kenton, MD ..................................................34 BCMS Circle of Friends Directory ..............................................................................................................36 In the Driver’s Seat ....................................................................................................................................43 Auto Review: 2019 Mercedes G63 AMG By Steve Schutz, MD ................................................................44 PUBLISHED BY: SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net BUSINESS MANAGER: Vicki Schroder
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San Antonio Medicine • May 2019
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VOLUME 72 NO. 5
San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.
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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 Adam V. Ratner, MD, President Rodolfo “Rudy’’ Molina, MD, Vice President John W. Hinchey, MD, Treasurer John J. Nava, MD, Secretary Gerald Q. Greenfield Jr., MD, PA, President-elect Sheldon G. Gross, MD, Immediate Past President
DIRECTORS Michael A. Battista, MD, Member John D. Edwards, MD, Member Vincent Paul Fonseca, MD, MPH, Member Michael Joseph Guirl, MD, Member David Anthony Hnatow, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones Jr., MD, Member David M. Siegel, MD, JD, Member Rajeev Suri, MD, Member Kelly King, Alliance Representative George Rick Evans, Legal Counsel Col. Charles Gregory Mahakian, MD, Military Representative Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robert Richard Leverence, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Brent W. Sanderlin, DO, Medical School Representative Alice Kim Gong, MD, Board of Ethics Chair
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, Chief Information Officer
PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Carmen Garza, MD, 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 J.J. Waller Jr., MD, Member
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San Antonio Medicine • May 2019
PRESIDENT’S MESSAGE
Innovative Leadership/Business Program:
BCMS is Fighting for You By Adam Ratner, MD, 2019 BCMS President
Ignorance is Not Bliss
Over the past several weeks, I’ve been watching the political
signed a personal loan guarantee for a financially unstable prac-
allied specialty society advocacy teams as they fight for us in
mately failed, and the hapless employee physician had to help
from our ability to practice medicine and our TMA/BCMS and
tice in which he wasn’t even a shareholder. The practice ulti-
Austin. Most of us take for granted the physicians and medical
bail out the partners.
with as few impediments and as much freedom as possible.
business, cultural, and leadership skills, many of us have become
sues reminds me how poorly prepared most of us are not only to
work ethic, compassion, and too often, our ignorance.
an individual, day-to-day, level. Very few of us likely received ad-
diate past-president, Dr. Sheldon Gross, and Executive Director,
ness of medicine.
ership program. This program has received rave reviews from our
society staff who are fighting for our ability to heal our patients The complexity of these existential political and economic is-
fight these political battles but also to advocate for ourselves on
equate practical training in the real-world, rough and tumble, busiIn this context, the knowledge of the business of medicine
includes basic leadership, professionalism, financial literacy, the creation and maintenance of desirable practice culture, legal
and human resource basics, ethics, and basic negotiation and
Because we have not been properly trained in these practical
relatively easy marks for those who want to take advantage of our
Under the visionary leadership and stewardship of our imme-
Steve Fitzer, BCMS last year created a successful physician lead-
first class of participants. Although there is a nominal fee for the
course, it compares favorably with courses costing thousands of
dollars more. One of the current class members was so excited
by the BCMS course that he will be enrolling in a formal MBA
political skills.
program.
ments with outrageously unfavorable terms to the physician with-
ditional business skills will be taught. If you’re interested in sign-
It astounds me how many physicians sign employment agree-
We are planning to extend and expand this program where ad-
out consulting with an appropriately specialized attorney or even
ing up for the next course starting in the fall or have any specific
the employment contract. Why would an otherwise intelligent
Steve Fitzer, know (steve.fitzer@bcms.org).
reading it. The true culture of practices is often first reflected in
physician believe that a corporation that offers an unfair employ-
ment agreement would somehow be a great place to spend most of one’s working and waking life?
Even if we can avoid a practice with an unfavorable culture,
most physicians don’t realize we have more bargaining power than
we realize but haven’t been trained to negotiate effectively. Along
the same lines, many of us practice leaders are not trained to find
optimal win-win solutions when we negotiate with potential hires,
vendors, hospitals, and third-party payers.
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Another amazing example, I just learned of a physician who
battles between the forces that are trying to control and profit
San Antonio Medicine • May 2019
topics you want addressed, please let our Executive Director, Dr. Adam Ratner is President of the Bexar County Medical Society and
serves as Professor and Assistant Dean of the University of the Incarnate
Word School of Osteopathic Medicine and Chair of The Patient Institute.
BCMS LEGISLATIVE NEWS
APRIL FIRST TUESDAYS A HUGE SUCCESS
Many thanks to all the BCMS members, Alliance members and medical students who attended the April First Tuesdays visit to the Capitol on April 2. Attendees included: Physicians – David Henkes, MD; Jim Humphreys, MD; Alex Kenton, MD; Sanjiv Kumar, MD; John Nava, MD; BCMS President Adam Ratner, MD; Ninza Sanchez, MD; Jayesh Shah, MD; John Shepherd, MD; and Zeke Silva, MD. Alliance members in attendance, were: Danielle Henkes and Jenny Shepherd. In addition, the following medical students from UT Health and UIW School of Medicine (UIWSOM) attended and joined the physicians and Alliance members on visits with the Bexar County legislators and their staffs. From UT Health – Phil Acosta; Nnamdi Akabogu; Scott Anderson; Daniel Carlisle; Jessica Davis; Trevor Dickey; Jasmine Gill; John Hintz; Glory Hughes; Frank Jing; Samiya Khan; Swetha Maddipudi; Rishi Malhotra; Sharon Mathai; Jen Nordhauser; Sid Pradeep; Irma Ruiz; Ahmed Shoola; Sabi Shrestha; Vanessa Trivino; Ryan Wealther; David Wilcox; Chelsea Wu and from UIWSOM – Sara Buckley, Jessica Gale; and Marc Ghosn. At the time of this writing, there are just over 50 days left in the 140-day legislative session. Many of medicine’s bills are moving through the process and a number of topics were covered during the First Tuesdays visits, including: Medicaid; state budget; mental health; surprise billing; pharmacy benefit managers (PBMs); prior authorizations; scope of practice; vaccinations; and Tobacco 21. For local discussion on these and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bms.org.
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San Antonio Medicine • May 2019
1. Jim Humphreys, MD (in dark jacket) leads a group of physicians and medical students during the April First Tuesdays visit to the Capitol. Here, they visit with Rep. Ray Lopez (District 125 – in white shirt). 2. On April 2, Armando Vendrell-Velez, legislative assistant in the office of Sen. Pete Flores (District 19) visited with BCMS First Tuesdays attendees (l-r): John Shepherd, MD; Vendrell-Velez; UIW medical student, Marc Ghosn; John Nava, MD and BCMS Alliance member, Jenny Shepherd. 3. Rep. Leo Pacheco (District 118) listens as Jim Humphreys, MD and medical students discuss issues of importance to medicine during the April 2 First Tuesdays visit to the Capitol. 4. BCMS physicians and medical students pause for a photo with Alec Mendoza, legislative staffer in the office of Sen. Jose Menendez (District 26) during the April 2 First Tuesdays visit to the Capitol. 5. Rep. Roland Gutierrez (District 119 – center) visits with BCMS physicians, Alliance members and medical students during the April 2 First Tuesdays visit to the Capitol. 6. During the April First Tuesdays, physician members from Travis and Bexar CMS met with Addison Reagan, policy analyst in the office of Sen. Donna Campbell (District 25).
BCMS NEWS
2019 BCMS
Wine Tour On March 23, the Bexar County Medical Society hosted its 2nd Annual Wine Tour.
Participants took a bus trip to Johnson City, Texas where they took part in several wine tasting events, toured local art galleries and enjoyed local shopping and dining opportunites.
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San Antonio Medicine • May 2019
MENTAL HEALTH CHALLENGES
Grief, Mourning and Acceptance Fred H. Olin, MD
Back in medical school, we were told about someone’s multiple levels of grieving. I am intentionally not looking them up… but I might after I finish this, have it proofread by my daughter (who is an excellent writer), and have it submitted to San Antonio Medicine. My wife, Sondra, died about 9½ months before this writing. It hasn’t been the most fun time of my life. As I reflect on my course of missing the woman I loved beyond reason and was married to for almost exactly 57 years, I realized that, so far, there have been three stages, which I will call “acute grief,” “mourning” and “acceptance.” Grief lasted perhaps eight or 10 weeks. Every minute of every day consisted of trying to control the external signs of my emotions. I wasn’t very good at it.
In reality, I don’t remember much about the first four weeks or so, only momentary visual vignettes, occasional snippets of conversation and not much else. The support of family, friends, and even acquaintances was gratifying and amazing. I had no choice but to interact with them, which was what saved me from withdrawing too far from the world around me. I discovered that there was a multitude of people who knew her, some only from relatively short contact. Many
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San Antonio Medicine • May 2019
called, emailed and showed up to tell me how she had made them feel good about something. Here’s an example of her influence: When I was in my late teens, I belonged to one of the nationally competitive junior drum and bugle corps in the Chicago area. In 2008, the corps, The Cavaliers (which creates very loyal alumni), reached 60 years of existence. For the anniversary they organized an alumni corps in which I played. We gave only one performance of significance, which was preceded by about 10 days of intensive music and drill rehearsals in the Chicago suburbs and around Bloomington, Indiana, where the Drum Corps International final contests were held that year. I posted her obituary on The Cavaliers’ alumni site. Dozens of the other members (there were about 180 of us) sent me notes via the site telling me how they had introduced themselves to her as she accompanied me to many of the rehearsals. She had asked them about their families, their schooling (some of the guys were still in college) and their lives in general and generally made them happy they had talked with her. I never knew. Anyway, as I regained contact with the world around me, I still mourned. I felt that I should be able to walk into a room in our home and say “Hey, Sonnie…” but I couldn’t. I started reminiscing to myself about not only the 57 years of marriage, but all the way back to college days when I first met her. There aren’t many
MENTAL HEALTH CHALLENGES
fine details in my memory, which is largely visual, but it would take only a word from someone or a glimpse of something around the house to cause me to remember and choke up a bit. After another two months or so, my control of the expressions of grief got better and better. At some point, someone sent me the illustration that accompanies this little essay. I don't recall who sent it and have been unable to find a source for it. Let me say that it absolutely describes what I was going through. At about six months after her death, my two daughters pushed (“nagged”) me to seek counseling. I was outwardly fine when I was with people, but sank into a morose gloom when alone, particularly at home. They were convinced I was clinically depressed. One of them came up with the name of a local psychiatrist and I did go see him. At our first session he said, “You aren’t depressed, you don’t need medications, you’re mourning normally.” My four times talking with him helped… although I must admit, I’m not sure why. Over those nine-plus months, I was essentially totally unable to start working on clearing out our much-toolarge home so that I could move to somewhere smaller, with less than 2.25 acres of grass, weeds and trees to care for. Then, somehow, a corner was turned and I started working on that problem. I guess I have reached the stage of acceptance. I called a woman Sondra and I had known for some years and have been hanging around with her a bit. It has been good for me: I never realized how much I needed female companionship. Do I still miss my wife? Oh, my, yes! Has missing her ceased to be the center of my existence? Yes to that, too. Do I feel that I am somehow disrespecting her or minimizing our relationship? Absolutely not. I am privileged to keep on living, and now realize what a privilege it is. Dr. Fred Olin is a retired orthopedist and a member of the BCMS Publications Committee.
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Poetry
MENTAL HEALTH CHALLENGES
By Judy Jordan, MD
The Wound Do you see it? It’s there, right here. People don’t get it. What do they think we do? Do they even have a clue? I doubt it. Sometimes I think they’re the lucky ones. I know that’s not really true but You see theirs; people get theirs. Here it is again. You still can’t see it? It’s the misplaced anger The harsh look The tense-fired reply The unbridled rage The rigid stance The misunderstanding The lack of compassion The blind eye to…. It’s easier for them. They’re finished with all of this. They can look down and remember Without pain. My pain is endless My pain will never be finished. Does it get better? Better than what? I’ve endured this pain for years. It becomes more difficult each time because It mixes with the past The past anger, the past hurts, The past rejections, the past pains 16
San Antonio Medicine • May 2019
It’s all so complicated The dream, where did it go? The shrapnel pierced the helmet. The IED pierced the armor. The bullet pierced the head. A family mourns. A father is dead. You still don’t see it? A-MAzing. I give up. SO fresh. SO obvious. To ME. It’s the wound in my heart.
The Pain What do you do with the pain? What do you do with the grief ? Where do you put it? On a shelf, high up, out of reach Or face to face, in front of you, swallowing you Or on a schedule, an agenda, I’ll think about it later Will there be a later for me; there wasn’t for them. Put it away; the pain’s too deep, too vast, too unfathomable, Too heavy, too crushing, too unbearable, Too impossible to deal with Put it where it’s safe, where it can’t touch me Hide it, from me, from them, then it goes away Out of sight, out of mind, right? It begins to smolder, to burn, to be transformed Do I recognize it? Will I recognize it? I must cry for them; only then can I cry for me.
MENTAL HEALTH CHALLENGES
Geriatric Depression and Its Treatment By Frederick Brown, MD
INTRODUCTION
My most important message is, “depression is not a normal part of aging.” All of us have had days when we feel “down” or “depressed.” Having this feeling/mood of “depression” is not the same as “depressive illness.” Depressive illness deserves treatment, whether found in a child, adolescent, adult or older person. Since this article deals with geriatric depression, “geriatric” should be defined. There was a time for me when “geriatric” referred to that slow-moving, gray-haired grumpy person in the reception area. Now that I am gray-haired, older and slower moving, I had to reevaluate what “geriatric” means. Late onset depression (LOD) or late life depression (LLD) means depressive illness with first appearance at ages 60 to 65, although that age is somewhat arbitrary; as one can find white matter changes (markers of aging) in patients only 55 years old who are depressed. In general, LLD has a worse prognosis then early onset depression, probably because of the inflammatory, vascular, and neurodegenerative processes which have been occurring for 60 years or so. Nonetheless, accurate diagnosis and treatment is beneficial to the patient, appreciated by the family and gratifying to the physician. There are some factors which make the diagnoses of LOD or LLD harder to make in geriatric patients. These patients should be treated because it will decrease serious consequences such as suicide, poor compliance with medical treat-
ment recommendations, increased need for home nursing and admission to long-term care facilities. The pharmacological treatment is fairly similar to that of depressive illness in younger patients, although non-medical approaches assume more importance.
EPIDEMIOLOGY
Prevalence and incidence percentages reflect the criteria for diagnosis and the setting/context of the survey. In community settings, the percent of individuals with onset of new depressive illness (incidence) in late life is relatively low, between 1 – 2.5% (for major depressive disorder, with another 1 – 3% having less severe depressive conditions.) These less severe depressive conditions can still cause significant impairment, are associated with higher health costs, and usually should be treated. Often however, there is not a formal diagnosis made nor treatment offered for many individuals with depressive illness surveyed in the community. The prevalence depends on the population being studied. In general, as in a younger population, approximately 10% of men and 15% of women have late life depression. In a community population the prevalence varies from 14 – 20%. Among hospitalized patients the prevalence is 12 – 45% and may be as high as 40% in long-term care facilities. continued on page 18
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MENTAL HEALTH CHALLENGES continued from page 17
ASSESSMENT DIAGNOSIS There are nine different types of “depression” listed in the current diagnostic manual (DSM 5.) I will not attempt to elaborate upon the distinctions. With LLD, there are often numerous somatic symptoms present. Their presence should not detract from focusing on the same primary symptoms one uses in younger patients for a proper diagnosis. The major issue is that we do not diagnose depressive illness only because of “depression,” a mood change. In fact, some individuals with a correct diagnosis of “depressive illness” actually deny a feeling of depression. There may be cultural factors which make it difficult or “wrong” to admit/discuss emotional issues, and/or neurobiological reasons why some individuals may have numerous symptoms of depressive illness and yet deny the mood of depression. However, it is mandatory to have either a feeling of “depression” or anhedonia (inability or decreased ability to experience pleasure,) for a two-week period for proper diagnosis. In addition, an accurate diagnosis would require four of the six following symptoms to be present during the same two-week period:
• decreased/low energy. The issue of decreased/low energy is quite subjective, and requires some time and skill to elicit properly. Decreased/low energy means there has been a significant decrease in energy from that person’s normal functioning, taking into account their typical activities. For example, a person who goes to the gym for 20 minutes twice a week may be having a significant decrease in energy if last month they went for 45 minutes four times per week, and now they are “too tired” to go more frequently. The key issue is whether or not their energy decrease prevents them from being involved in activities which they want to do.
• psychomotor changes, observable slowed (or agitated) speech or behavior, • impairment in concentration (or indecisiveness) in areas of interest, and
• changes in appetite is another important symptom to be considered for a diagnosis of depressive illness. Appetite changes usually involve a decrease in appetite and weight loss, but it is possible to have increased appetite as one becomes more depressed. • feeling worthless or guilty are common symptoms, and
• thoughts of death, suicide, or suicide attempts are important symptoms whose presence or absence should be evaluated.
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San Antonio Medicine • May 2019
EVALUATION OF SUICIDAL IDEATION As it is so important to evaluate depressed patients for suicidal risk, this concept will be discussed in detail. There is a myth that asking about thoughts of death or suicide may “cause” someone to consider suicide, and some providers will shy away from inquiry. Experienced clinicians know that asking these questions is appreciated by the patients and show the clinician’s concern. These are important symptoms to ascertain, as suicide may be a consequence of under or un-treated depression, and most patients who suicide have recently seen a health care provider. Patients should never be told, “you can trust me…this is just between you and me,” as the physician may need to involve family, friends, or law enforcement if suicidal risk is high. Lack of documentation of this suicidal ideation/plan/intent would not be seen favorably if litigation were to occur. In addition to the risk factors for depression, risk factors for suicide include: * relationship dissolution * death of spouse or partner * illness, especially if associated with pain, disability, or loss of independence * neurocognitive difficulty, (chronic/heavy alcohol abuse, TBI, Parkinson’s disease, dementia) * financial/ housing /legal difficulty (loss of residence, pension benefits, bankruptcy) * new lack of compliance with medical treatment * increase of risky behaviors (fast driving, substance abuse) * strange comments (“this is the last time you’ll see me” or “I won’t be coming back.”) * selling/giving away possessions * suddenly wanting to get affairs in order, writing a will. There is a continuum of questions one should ask elderly patients regarding their attitude toward life, even if not depressed, as 1550% of patients who successfully suicide do not have diagnosed depressive illness. The questions start off very generally and become more and more specific if previous answers are concerning. * How are things going? * Do you enjoy life? * Do you ever wish you were dead? * Do you ever consider killing yourself ? * What are your thoughts about what happens to you after suicide? * What specific plans do you have for suicide? * What steps have you taken to accomplish these plans? (purchased a gun, bought a rope, read about suicide on the Internet.)
MENTAL HEALTH CHALLENGES * Have you made any suicide attempts? (now or in the past?) * What is your intent regarding suicide now? If early questions show interest in life/living, there is no need to proceed with more questions. If there are specific plans, with intent, then definite action on the clinician’s part is indicated. Either involvement of family, emergency psychiatric consultation, emergency room evaluation, or involvement of police for an involuntary assessment are indicated. SPECIAL SUBTYPES OF DEPRESSION The absence of certain symptoms should be verified, as their presence indicates further diagnostic involvement and/or specific treatment. * Significant cognitive impairment may be a symptom of depression, and/or a symptom of a neurocognitive disorder such as dementia. This is difficult to ascertain in the early diagnostic process and is more of a “rule out” process than one based upon definitive factors. The term “pseudo-dementia” refers to a depressed patient with poor memory functioning, which clears upon treatment of depression. This is complicated as depressive symptoms may also accompany the onset of dementia. Collateral history from family may help clarify whether memory impairment or depressive symptoms came first. However, the important factor is whether cognition improves along with depressive symptoms; if it does, it was pseudo-dementia, if not the symptoms were indicative of early dementia. * Delusions – fixed, false beliefs which are not modified by rational discussion (i.e., believing you have a fatal illness in the absence of formal diagnosis) may be found in severe depression, bipolar illness and/or schizophrenia and will require treatment modification or specialty referral. * Visual hallucinations, which tend to imply more drug usage/withdrawal issues, brain structural disease, or delirium. * Auditory hallucinations, may be found in severe depression, bipolar illness and/or schizophrenia and will require treatment modification or specialty referral. LABORATORY STUDIES As every physician knows, certain illnesses may include depression among their presenting symptoms. In addition to a through physical examination, basic laboratory screening should include CBC, U/A, thyroid function, comprehensive metabolic profile, and levels of B12, vitamin D and folic acid. Borderline values of thyroid hormone, B12, folic, or Vitamin D levels may not “cause” depression but may impede improvement and should be normalized.
DIFFERENTIAL DIAGNOSIS
Medical causes are numerous, with vascular, metabolic and nutritional factors being at the top of the differential. As with younger patients, substance usage, primarily alcohol, is a common and often undiagnosed cause of depressive illness. Typically, one does not inquire about this in geriatric patients, and patents are often not forthcoming RE the amount of alcohol consumed daily. A high index of suspicion and laboratory testing is usually required. Especially in LLD, benzodiazepines and/or hypnotic use are commonly found, and frequently are depressogenic. Often, they are overlooked in importance as the patient has been taking the same dose for years, but because of a slowed metabolism their effect is much greater. Patients will routinely “fight” decreasing them, but almost always benefit from a slow reduction (over months.) If benzodiazepine dose is high, the decrease in fatigue and the improvement in mood is gratifying to both the patient and provider following slow tapering. Objective scales for diagnosing depression in the geriatric population There are three scales commonly used in geriatric setting for screening or for objective follow-up for treatment. * Geriatric Depression Scale with 30 questions. * Geriatric Depression Scale (short form) with 15 questions. These both have been found useful for research quantification but are not used frequently in clinics. * Patient health questionnaire (PHQ – 9) has only nine questions. This is the most commonly used of all the geriatric questionnaires. All of these questionnaires are self-administered, relatively easy to score, and in the public domain. They should not be used to make a diagnosis of depression, but rather to screen for the need for a more thorough clinical assessment. They all may be used at regular intervals to follow improvement following treatment.
RISK FACTORS
Although the presence of risk factors do not make the diagnosis, they serve as indicators for increased clinical attention. Usually, the more risk factors present, the more likely depressive illness will be found. Some risk factors in LLD are the same as risk factors for depression in younger individuals; such as being female, single, having chronic medical illness, substance abuse, and a personal or family history of mental illness. In the geriatric population; loss of a partner or family member, numerous medical illnesses, cognitive impairment, loss of significant sensory or motoric ability, loss of independence (driving, mobility, independent living) and social isolation are additional risk factors to be considered. continued on page 20
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MENTAL HEALTH CHALLENGES continued from page 19
TREATMENT
Approximately 80% of patients with LLD receive their treatment in a primary care setting, although surveys still show there is still significant underdiagnoses. The primary care setting is advantageous, as it provides continuity of care, access to medical and laboratory testing, and is free of the stigma of psychiatric referral. Treatment usually can be considered to be one of three common types, although a multi-modal approach with involvement of each type of treatment is often beneficial. * Environmental Encouraging or facilitating increased physical activity (physical exercise, walking, attendance at a senior center or gym) is very helpful, and there is increasing data about the benefit of physical exercise on depressive illness. Increased socialization is also helpful, whether at a neighborhood center, local church or with friends and family. Increased involvement of supportive family is very helpful. Not only can they provide support, but also supply important collateral history and family history, assistance in accepting and adhering to recommended treatment, and assistance in attending important appointments. Improvement of hearing, vision, and nutrition is universally recommended. The data now show that proper nutrition is as important in treating depression as in treating diabetes, hyperlipidemia and/or cardiovascular disease. * Psychotherapy Large-scale meta-analysis shows similar results comparing psychotherapy with medication treatment in depressive illness. However, psychotherapy is not recommended frequently enough, because of lack of physician familiarity with the benefits, the various methods available, and the lack of familiarity with referral sources. In addition, the value of psychotherapy is not emphasized enough 20
San Antonio Medicine • May 2019
in medical school, there are certainly no marketing representatives bringing meals to the office touting the benefits of psychotherapy for depression, and also physicians are not used to referring to LPCs, LMFTs, LCSWs or PhDs. * Medication As in younger patients, the initial treatment choices for depressive illness are the SSRIs, with some concern over fluoxetine because of its very long half-life. There is also some concern over paroxetine because of concerns of memory impairment secondary to its anticholinergic effects, however this has not been found during objective study. Sertraline, citalopram, and escitalopram are most useful, with minimal drug-drug interactions. There is some evidence that sertraline is especially useful for improving cognition. Other relatively well tolerated antidepressants are venlafaxine, bupropion, duloxetine and mirtazapine. Older antidepressants such as tricyclics (amitriptyline, nortriptyline) or MAOIs are not considered good choices, because of possible significant side effects. Current dosing recommendations have not changed from what I was taught in medical school 50 years ago, “start low and go slow.” There is no such thing as the “proper dose,” except as determined by adequate response in that individual patient. Dosing should be increased every 10-14 days until the patient begins to have some effect (side effects or improvement) and then the dose may be plateaued to ascertain how much improvement eventually will occur. The goal is to “treat to remission,” and not just to accept improvement. This leads to better functioning and less relapse. If the patient has not improved after a few months and the dose is approximately twice that of the “average” dose with normal thyroid, B-12, folate, and Vitamin D levels, then psychiatric referral is recommended. There are numerous choices available when a patient is not improving, but the subtlety of that is best handled by psychiatrists.
MENTAL HEALTH CHALLENGES A majority of patients will improve, especially if given environmental, psychotherapy and medication treatments. They will require appropriate psychiatric referral if they do not respond, or immediately if they are suicidal, or psychotic. For thoroughness, brief mention is given below to additional types of treatment available for those patients not responding to traditional psychiatric augmentation, psychiatric polypharmacy and dosing increases. * Neuromodulation Treatments If medication adjustment and augmenting strategies by a psychiatrist are not helpful, there are two types of “electrical” treatments given by psychiatrists, and a third which some patients pursue. * Electroconvulsive therapy (ECT) is still considered the “gold standard” for treatment resistant patients, although there is still some stigma attached to this treatment. This may be given as an outpatient, with 4-12 treatments initially over 3-5 weeks, and then tapering off frequency when improvement occurs. It is very safe, quite effective, but often has temporary memory impairment. The patient may not drive following a treatment session, and some psychiatrists prohibit driving for the entire course of treatment, as there is temporary impairment of memory and judgment.
to be useful for treatment in animal models of depressive illness. A few physicians started using ketamine in the 1960s, primarily for anesthesia. In the 1990s ketamine was being abused for it’s psychedelic properties and called “Special K.” Recent studies have found it a very useful treatment for depression, with a faster onset of action, including the decrease of suicidal ideation, than traditional antidepressants. Ketamine is administered IV, in outpatient settings, by anesthesiologists with close medical monitoring. The best dosing regimen is still being determined, and is expensive to use, because of the close monitoring required. However, just released in March 2019 is a nasal version of ketamine, Spravato, (intranasal eskeketamine,) which is not yet available to psychiatrists. It usually needs to be given three to four times over a eight week period, and the length of response for the average patient is still being determined. It is an exciting pharmacological advance. Both ketamine infusions and the intranasal Spravato approach will likely coexist for some time, until the exact pros/cons of each approach are better clarified.
SUMMARY
* Transcranial magnetic stimulation (TMS) is a newer electrical treatment, which is painless, does not require general anesthesia and does not produce a generalized seizure. Treatment is given 5 days a week for 3-6 weeks, and the patients can usually drive themselves to/from treatment. Often in medication treatment failure, ECT or TMS are covered by insurance. * Transcranial direct current stimulation (TDCS) is a third type of neuromodulation treatment. This is not a physician prescribed or directed treatment, but one about which physicians should be aware, as patients may inquire about it. Individuals purchase the instruments for $160-$600, and they are used at home. A common treatment protocol would be 20-30 minutes/day, for 2-6 weeks. Comparison studies to ECT and TMS are lacking, and TDCS would not be used for treatment resistant depression. Some patients report they are quite useful for mild-moderate depression, but are rarely physician recommended.
The new onset of depression in late life is less common than in younger individuals, but the total prevalence is quite high, from 1440%. Numerous risk factors are known, which would raise one’s suspicion about the need for more in-depth assessment. Although elderly patients may have many somatic symptoms, the same criteria are used for diagnosis as in younger patients. It is important to screen for suicidal ideation and intent, and to take appropriate steps. Various laboratory studies can rule-out medical causes, although the formal diagnosis of depressive illness is still clinical. Treatment of geriatric depression is usually done in a primary care setting. The medical treatment of depressive illness is similar to that of younger patients, although environmental and psychological treatments are also often indicated. If improvement does not occur, specialty referral and complex medical or neuromodulation methods (ECT, TMS) are often useful. Successful treatment results in a better quality of life, less morbidity from medical problems, and prolongation of independent living. Accurate diagnosis and treatment is beneficial to the patient, appreciated by the family and gratifying to the physician.
* Newest treatments. The first “really new” approach in 60 years is that of ketamine. The MAOIs, tricyclics, and SSRIs and “mixed action” antidepressants all putatively affect the production, release, or reuptake of dopamine, norepinephrine, and/or serotonin. In reality, alteration of brain neuroplasticity is the more likely mechanism. In the early 1990s, NMDA receptor agonists were found
Dr. Frederick Brown is a psychiatrist in general outpatient practice with an interest in comprehensive treatment of adult and geriatric patients. He is well versed in medication treatment, and various types of psychotherapy, He believes psychotherapy is often useful, and prefers to combine psychotherapy with medication in the treatment of most patients. visit us at www.bcms.org
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MENTAL HEALTH CHALLENGES
Caring for the Caregiver By Carol L. White, RN, PhD
Caring for a family member, partner, or friend with limitations in physical, mental, or cognitive functioning is nearly universal today. There are over 44 million Americans, family caregivers, characterized by their personal relationship with their recipient of care rather than by financial remuneration.1 Family caregivers provide care that may be episodic, daily, or of short or long duration. They provide over 80% of the necessary care for their family members, assisting with activities of daily living and household tasks, providing emotional support, and helping to navigate a complicated and increasingly fragmented health care system. Over 50% of family caregivers are delivering skilled nursing and medical care at home that was once provided by healthcare professionals.1 Despite the critical role that families take on for their loved
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ones, their own needs for support continue to be under-recognized. A seminal publication in 1979 referred to elderly women caring for their disabled husbands as the ‘hidden patients’.2 There have since been numerous studies highlighting the consequences of the role on the caregiver’s physical, emotional, social, and financial health.3-5 Yet, almost 40 years later, the results of a recent study conducted by AARP6 suggest that family caregivers are still ‘hidden patients’. In response to a survey conducted among family caregivers who had recently visited a health care provider (n=1,248), only 16% were asked about their own health and what support they needed as family caregivers and almost all caregivers (84%) reported needing more information to support them in the caregiving role. We can do better.
MENTAL HEALTH CHALLENGES
Family caregivers are the most important resource for their loved one living with dementia. These caregivers are particularly impacted by the disease, not only related to the emotional impact of the diagnosis, but also by their role in providing care. Compared with family caregivers of persons without dementia, they are more likely to take on multiple responsibilities including assisting with activities of daily living, coordinating health care services, and managing finances as well as other instrumental activities of daily living.7 In Texas, the number of individuals providing unpaid care for persons with Alzheimer’s disease grew from 690,058 in 2005 to over 1.4 million in 2018. These caregivers provided an estimated 1.6 billion hours of care, valued at $20.5 billion.7 Although some caregivers report positive benefits associated with the caregiving role, such as a closer relationship with the recipient of care or an opportunity to assist others, there is an extensive body of evidence showing negative consequences. The physical and emotional health effects experienced by family caregivers led to approximately $11.7 billion in higher health care costs for caregivers vs. non-caregivers nationally in 2018, including $903 million in higher health care costs in Texas.7 There are 5.8 million Americas diagnosed with Alzheimer’s disease. As the proportion of U.S. population age 65 and older continues to increase, the number of Americans with Alzheimer’s or other dementias will escalate rapidly. There is a pressing need to implement programs of support for families caring for their members with dementia. Our current systems of support for caregivers, particularly those who are caring for persons living with dementia, are limited and fragmented, with few evidence-based interventions translated into routine clinical care, thus remaining inaccessible to the majority of family caregivers. Specifically, caregivers in San Antonio have described the limited information they received at the time of diagnosis (“He was diagnosed…. We were not really told anything. He had a memory problem. And you’re just kind of thrown out there. “Now, go figure it out.”), the difficulty they have in accessing resources (“I never ap-
preciated how hard it was for families to find good quality home health care in this community until I had to do it myself. And I thought I knew how to do it and it was a nightmare.”), and the lack of guidance for planning for the future (“I didn’t get hospice in early enough – didn’t know to look at this – it was a god-send when it happened.”). Caregivers without support are much more likely to experience negative outcomes and prematurely institutionalize their family member.
The Caring for the Caregiver program, School of Nursing, UT Health San Antonio
The Caring for the Caregiver program supports family caregivers of people living with dementia through a model of education, research, and community engagement. As such, the program strives to support family caregivers in five key ways: preparing the caregiver to take on the caregiving role, offering anticipatory guidance, providing the caregiver with information to make plans as the disease progresses, recommending strategies to cope with care challenges, and supporting opportunities for socialization with their loved one with dementia. Family caregivers have participated in all stages of planning and implementing the program through their membership on our community advisory board. Family caregivers describe the need for information about the dicontinued on page 24
visit us at www.bcms.org
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MENTAL HEALTH CHALLENGES continued from page 23
agnosis, the progression of dementia, and community resources. The “Essentials of Caregiving” is a six-week course provided in a discussion format that focuses on understanding a diagnosis of Alzheimer’s disease or a related dementia, transitioning into the caregiving role, care planning including aspects of legal, financial, and medical care, and self-care for the caregiver. Although over 50% of family caregivers take on medical and nursing care, few receive training for this care and most learn by trial and error. We provide “Skills Training Workshop”, a hands-on-workshop facilitated by a team of healthcare professionals, to provide family caregivers with information and opportunities to practice care techniques that include fall prevention, transfers, communication, medication management, oral hygiene, and home safety. This is a unique resource offered to family caregivers in San Antonio. Although the workshop is focused on family caregivers of people with dementia, these workshops are also attended by caregivers who are providing care for a family member with stroke, Parkinson’s disease, or other neurodegenerative disease. We also provide the Virtual Dementia Tour (Second Winds DreamTM) as part of these workshops and to specific groups on request. This is a simulated experience of living with dementia for 8 minutes, followed by an opportunity to discuss and explore the experience with a trained facilitator. It is intended to build empathy among family caregivers and the community, potentially influencing increased patience and understanding when interacting with a person living with dementia. To counter the social isolation often experienced by those living with dementia and their families, the Caring for the Caregiver program hosts several community events, including a memory café and Grace Notes, a community choir for people living with dementia and their families. Memory cafes provide an environment where persons living with dementia and their family caregivers can learn and socialize with others on the same journey. While we often include a short educational component, the memory café is tailored to the interests of the participants and tends to focus on socialization with games, art activities, and music. The Caring for the Caregiver program, School of Nursing collaborates closely with the Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases at UT Health San Antonio to provide comprehensive care for persons with dementia and their family caregivers across the trajectory of the disease. All programs are provided free of charge to family caregivers. For more information about the Caring for the Caregiver program and support for family caregivers, please visit https://utcaregivers.org/ Community awareness is the bedrock of a comprehensive ap24
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proach to dementia and family caregiving. As awareness in the community is increased, opportunities for supporting people with dementia and their family caregivers are also increased. The invisible role of the family caregiver contributes to the difficulty caregivers experience in navigating and accessing available resources and support when needed. As shared by a community partner, “One of the things that we’ve recognized is that many caregivers don’t recognize themselves as caregivers. So education, I think, is extremely important to get the word out.” Our goal is to transform care for family caregivers of persons with dementia in San Antonio and South Texas so that they have their own health and well-being assessed and addressed. Recognition and support for family caregivers is among the most significant overlooked challenges facing the aging U.S. population, their families, and society.1 Our systems of care must ensure that family caregivers have up-to-date health information and support that they need, when they need it, as caregiving changes and evolves. We must strive to recognize the uniqueness and diversity of family caregivers in our city and in supporting family-centered care, consider their caregiving preferences, needs, and strengths as the foundation for care planning and services.
References
1 National Academies of Sciences, Engineering, and Medicine. Families Caring for an Aging America. Schulz R, Eden J, editors. Washington, DC: The National Academies Press; 2016. 2 Fengler AP, Goodrich N. Wives of elderly disabled men: The hidden patients. Gerontologist. 1979;19(2):175-83. 3 Brodaty H, Donkin M. Family caregivers of people with dementia. Dialogues in Clinical Neurosciences. 2009;11(2):217-28. 4 Brodaty H, Woodward M, Boundy K, et al. Prevalence and predictors of burden in caregivers of people with dementia. American Journal of Geriatric Psychiatry.22(8):756-65. 5 Lim JW, Zebrack B. Caring for family members with chronic physical illness: A critical review of caregiver literature. Health and Quality of Life Outcomes. 2004;2(1):50. 6 National Alliance for Caregiving and AARP Public Policy Institute. Caregiving in the U.S., 2015. 7 Alzheimer's Disease Facts and Figures. Alzheimer's & Dementia. 2019;15(3):321-87.
Carole L. White, RN, PhD is the Professor and Nancy Smith Hurd Chair in Geriatric Nursing and Aging Studies in the School of Nursing at UT Health San Antonio and also the director of the Caring for the Caregiver Program (https://utcaregivers.org/).
MENTAL HEALTH CHALLENGES
Depression and Pain By Somayaji Ramamurthy, MD
Headache, abdominal, chest and joint pain complaints are commonly reported by patients with depressive symptoms in a primary care setting and in nursing homes.
Pain is the most common symptom in patients seeking care at a physician's office. Depression is the most common mood disorder in patients seeking management of their mental health. There is a significant bidirectional correlation between depression and pain. This comorbidity significantly impacts diagnosis, the severity of symptoms and negatively influences clinical outcomes and treatment. Comorbidity results in lower functioning compared to depression or pain alone. The prevalence of the combination of these two conditions is greater than when depression or chronic pain are individually considered. They both share common neurobiological pathways and neurotransmitters. Many of the pharmacological, psychological and other treatment modalities are effective in treating both conditions. Unrecognized depression in pain patients contributes to treatment failure, increased medication use, interventional procedures and related complications, drug dependence, addiction and increased disability. Simultaneous assessment and treatment of both conditions are necessary for better outcomes.
Depression was prevalent in 60% of the patients with chronic pain (continuous or intermittent pain lasting greater than 3 months). The incidence of depression was even higher in patients with facial pain and medically unexplained pain. Patients with multiple pain complaints are more likely to be depressed than patients without pain. Patients with two or more different pain complaints are six to eight times more likely to meet depression criteria. As the pain severity and duration increase, depression increases. If depression increases, pain complaints also increase. Fear of pain leads to avoidance of activity with decreased activity leading to deconditioning. Decreased ability to participate in pleasurable activities leads to increased depression which further aggravates the problem.
Prevalence of Pain symptoms in patients with depression
Effect of pain on recognition and treatment of depression
The prevalence of pain in depressed patients ranged from 15 to 100% with a mean of 65%. Depressive symptoms predict future occurrence of back, shoulder and other musculoskeletal pain. Individuals with depressive symptoms were twice as likely to report back pain when compared to individuals without depressive symptoms. 26
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Prevalence of depression in pain patients
The diagnosis of depression was missed in a primary care setting in 50% of the patients who were later treated for depression. This was because the patients presented with somatic complaints, predominantly pain rather than dysphoric mood and or anhedonia (Inability to feel pleasure). In pain patients with unrecognized
MENTAL HEALTH CHALLENGES
depression, the associated fatigue and insomnia were attributed to the pain originating from the organic disease process. Unrecognized depression even in the presence of organic disease increases the pain severity and duration and inadequate pain relief. More opioids were prescribed than antidepressants in patients with pain and depression. This further leads to polypharmacy, substance abuse (opioids and benzodiazepines). Unrecognized depression can result in failure to control the pain even with invasive procedures leading to further complications. Patients are also reluctant to accept that depression could be contributing to their pain experience or treatment failures because of the social stigma attached to the diagnosis of depression. The patient may say, “pain is in my back, not in my head.” In such instances, patients go doctor shopping in search of a “real doctor or an expert or magical cure.” After the delayed recognition of depression physicians also feel absolved of the responsibility for the treatment failure. Early recognition of depression and concurrent management of both depression and pain is likely to result in better outcome. In a busy primary care practice, it is difficult to identify mild to moderate depression.
The increasing use of patient health questionnaire (PHQ-9) increases the recognition of depression and suicidal ideation
Explaining the following facts to the patient is likely to increase patient acceptance and referral to a mental health professional. 1. Chronic pain and decreased ability to participate in pleasurable activities can lead to depression. 2. The treatment of depression, with certain kinds of anti-depressants, may significantly decrease pain. 3. Concurrent management of both pain and depression is likely to result in better outcome.
Influence of pain on depression treatment outcome
Many studies assess the incidence of pain with depression or the influence of depression on the pain treatment outcome and not the outcome of the treatment of depression. Some studies indicate that Pain in multiple sites, increasing severity and greater than 6 months duration were associated with poor outcome including increased depression. Pain related decreased ability to participate in activities results in increased doctors’ visits, multiple pain medications including opioids, unemployment, all of which can lead to more depression and poor depression treatment outcome. Continuing pain increases treatment failure and relapse rate of depression. Presence of pain also increased the cost of medical care. Patients whose pain
was significantly relieved also had a significant resolution of their depressive symptoms.
Effect of depression on pain treatment outcome
Preexisting depression is associated with increased postsurgical pain and longer hospital stays. Most of the studies found that comorbid pain with depression was associated with poor outcomes with pharmacological and interventional procedures, more severe pain intensity, increased disability, lower quality of life, higher unemployment, more investigations and treatments, and higher cost. High copays and inadequate insurance coverage discourage depression treatment.
Overlapping neurobiology, neurochemistry and related treatment options
Pain sensory input reaching the somatosensory cortex via the lateral thalamus helps with the assessment location and intensity. The sensory input reaching the limbic system via the medial thalamus results in affective-emotional response such as suffering and hurting. This area of input into the limbic system including prefrontal, anterior cingulate insular cortex and amygdala overlaps the areas involved in depressive mood. The processing of both mood and pain are controlled by the same neurotransmitters, serotonin, norepinephrine, and glutamate. Pharmacological treatments affecting these neurotransmitters are likely to reduce both pain and depression. Descending pain inhibitory systems activate pathways to reduce pain impulse transmission from the dorsal gray matter of the spinal cord. These pathways are activated by serotonin, norepinephrine and endogenous opioids. Optimizing the treatment with antidepressants reduces both pain and depression. The addition of patient self-management cognitive behavior therapy (CBT) and brief intense psychotherapy result in further outcome improvements. A few studies report SSRIs (sertraline and paroxetine) were effective in reducing both pain and depression. Majority of the studies confirm better success with TCAs (amitriptyline, nortriptyline and imipramine) and SNRIs (venlafaxine, duloxetine and milnacipran) in reducing the comorbid pain in depressed patients. SNRIs and TCAs act on both the serotonin and norepinephrine receptors, unlike SSRIs which act only on serotonin receptors. Duloxetine is better tolerated than the other drugs even in the elderly. TCAs have the worst side effect profile especially in the elderly (a common cause of fall and fractured hip). The pain reduction starts earlier (one week) than the reduction of depression (two weeks). Duloxetine is approved for use in patients with fibromyalgia and diabetic neuropathy. These drugs can precipitate a manic episode in patients with bipolar depression. continued on page 28
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MENTAL HEALTH CHALLENGES continued from page 27
The effectiveness of opioid use in chronic pain is under scrutiny because of the current opioid epidemic. Comorbid depression has a higher incidence of abuse. Concomitant use of benzodiazepines significantly increases deaths from opioid overdose during the first 90 days. Inflammation: Cytokines released secondary to peripheral or CNS inflammation are known to produce pain and depression. Depression and pain secondary to the cytokines in patients receiving interferon for the treatment of Hepatitis C and multiple myeloma could be reduced by treatment or pretreatment with anti-depressants especially duloxetine. Ketamine a potent NMDA (glutamate) antagonist is also likely to reduce glutamate related inflammation in the central nervous system of patients with pain and depression. Ketamine, an old anesthetic is shown to be effective in reducing post-operative and chronic pain. It also regulates the connectivity between brain centers involved in both depression and pain. There is increasing evidence that ketamine is effective in rapidly reducing both pain and depression. Oral nasal and intravenous ketamine preparations are used. Dysregulation of the endocannabinoid system is present in patients with pain and depression. The cannabinoids were effective in reducing depression and especially comorbid pain. Mindfulness-based stress reduction (MBSR) is an eight-week evidence-based program that offers secular, intensive mindfulness training to assist people with stress, anxiety, depression and pain. 28
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Significant reduction in pain and depression was evident even at the end of 1 year. MBSR was as effective as CBT in reducing pain but CBT was more effective in reducing comorbid depression. Brain stimulation with implanted electrodes has effectively reduced pain and depression. Noninvasive transcranial magnetic stimulation reduces depressive symptoms and has the potential to reduce comorbid pain.
Recommended reading:
1. Pain and Depression: A Systematic Review: W.W.IsHak et al www.harvardreviewofpsychiatry.org Volume 26 • Number 6 • November/December 2018 2. Chronic pain and mental disorders: Shared neural mechanisms, epidemiology and treatment. W.M.Hooten, 2003Mayo clin proc.2016;91(7):955-970 3. Depression and Pain Comorbidity. Matthew J. Bair et al ARCH INTERN MED/VOL 163, NOV 10, 3. 3. 4. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy for Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial Cherkin et al JAMA; 2016 315(12) 1240—1249 Somayaji Ramamurthy, MD, is a retired professor of anesthesiology and former director of the Pain Medicine Fellowship program at UT Health San Antonio.
PRESIDENTIAL REMINISCES
PRESIDENTIAL REMINISCES
Jose M. Benavides, MD, F.A.C.P.
Past-Presidents of our beloved County Medical Society have been asked to reminisce a bit to the times when they were at the helm and try to write something that might have impacted their lives during the time they were in office. I am absolutely sure that everyone that occupied the top position has a lot to remember from the hundreds of hours we were involved in medical, local state or national activities related to our presidency. The archives of our organization have plenty of information as to what went on during our years as president. My case is not different, however, what impacted me the most was our society’s involvement with the tragic events that occurred in Mexico City as a direct consequence of the earthquake in September 1985. In addition to the thousands of lives lost and the horrendous physical destruction, the earthquake affected two of the largest hospitals there at one of the worst times possible. It hit at 7:20 a.m. on Sept. 20, 1985, just at the time when many physicians were making their rounds or in the surgical or OB suites and the tragedy killed hundreds of people including healthcare personnel, patients and 114 physicians as well as injuring dozens of young doctors. Many Mexican, American and world-wide organizations immediately got involved to help, to rescue the injured and to recover the victims. That event touched many of us here in San Antonio. I got several calls from concerned colleagues who were trying to find a way to get involved in helping. I particularly remember calls from Doctors Jake Meadows, Al Thaddeus and J. B. Gonzalez and we all tried to devise means to organize a plan to help our brothers and sisters in Mexico City, those who were injured and to find a way to get in touch with relatives of those who perished and manifest somehow our deep condolences. Needless to say, that with each phone call we all cried and perhaps my colleagues might have thought that I was a graduate from Mexico City Medical School. My good fortune was to receive another call, this one from my beloved friend and colleague Dr. Albert Sanders (left). He helped by making the connections with an orthopedic specialist as himself who was very familiar with the organizations of the hospitals involved and we developed a two-prong plan: A: We were able to bring to San Antonio
some of the injured young physicians and all the local hospitals offered free care for the six of them that we brought. B: I started to gather donations/funds with the purpose to deliver personally to the young widows, parents or other immediate relatives of the 114 physicians killed. Lots of work and time was involved and I am proud to say that I delivered into the hands of those relatives 110 checks in a very emotional event in Mexico City and with so many people helping us here and in Mexico City. The coordination worked very well. I’m proud to say that our medical society and the presidents in turn for 1985 and 1986 assisted me and Ms. Carole Ancelin from our society and it was a great help. Anyone who wishes additional information in regards to the above, I suggest to check the annals of our society or to give me a call. I am very happy that our society got involved and that we were able to provide a little help to our brothers and sisters to the south. Thank you, Al Sanders. Dr. Jose M. Benavides was president of the Bexar County Medical Society in 1984. visit us at www.bcms.org
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UTHSCSA
Accelerating the Pace of Biomedical Research By William L. Henrich, MD, MACP, President and Professor of Medicine, John P. Howe III, MD, Distinguished Chair in Health Policy at UT Health San Antonio
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Better understanding the diseases that most affect our region and nation will enable us to provide patients with improved diagnosis and treatment. With that goal in mind, UT Health San Antonio will strengthen critical research platforms and accelerate the pace of biomedical research through the creation of a centralized biobank. The biobank, made possible by a $2.5 million gift from the J.M.R. Barker Foundation, is part of a comprehensive UT System effort to support a federal biobank infrastructure of resources, along with best practices, to collect bio-specimens linked to the medical records of each donor. It is essential to have a bio-repository that reflects the region’s unique population. In the United States, the majority of clinical trials and medical research has been conducted on non-Hispanic Caucasians, and evidence shows that many discoveries and resulting treatments may not be relevant to other populations. San Antonio’s patient base is 63 percent Hispanic — a population that is significantly underrepresented nationally in biomedical research and clinical trials. The centralized biobank will allow for increased focus on collecting, processing and analyzing specimens from patients with diseases that disproportionately affect the South Texas population, with special emphasis on Alzheimer’s disease, cancer, diabetes and heart disease.
UTHSCSA Plans for the biobank include a repository specifically for brain specimens, providing essential resources for neuroscience researchers and faculty as they seek to understand how the brain functions. It also will create additional avenues for collaborative research on a national level in Alzheimer’s and neurodegenerative diseases. The biobank will have a profound impact on research being conducted at our nationally recognized Sam and Ann Barshop Institute for Longevity and Aging Studies, as well. The institute is the only aging research center in the country to achieve the distinction of having both a Nathan Shock Center of Excellence and a Claude D. Pepper Older Americans Independence Center, through two National Institute on Aging grants. Maintaining these prestigious designations at the Barshop Institute is a top priority for our university, and the biobank will play a vital role as it facilitates translational studies and extends observations made in animal models to elucidate relevant determinants of human diseases that require the availability of human tissue samples. In the area of cancer research, the biorepository will have an emphasis on tumor specimens from cancers that disproportionately occur in Hispanics in South Texas. This will not only impact research at our National Cancer Institute-Designated Cancer Center, but will also support investigators at the university’s Greehey Chil-
dren’s Cancer Research Institute, with its special focus on addressing the unique challenges of childhood cancer. It is only through relentless efforts to achieve enhanced understanding of the biology of the world’s most complex diseases that we will eventually find ways to prevent them or eradicate them. This biobank will help us do just that. This is an exciting time in biomedical research, when a confluence of events is multiplying possibilities for new breakthroughs in medicine. The Barker Foundation’s support is critical in advancing a strategic initiative that will allow us to significantly contribute to scientific knowledge that will impact researchers worldwide. The University of Texas Health Science Center at San Antonio, now called UT Health San Antonio, is one of the country’s leading health sciences universities. With missions of teaching, research, healing and community engagement, its schools of medicine, nursing, dentistry, health professions and graduate biomedical sciences have produced 36,500 alumni who are leading change, advancing their fields and renewing hope for patients and their families throughout South Texas and the world. To learn about the many ways “We make lives better,” visit www.uthscsa.edu.
visit us at www.bcms.org
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BCMS HONOREES
Manuel Quiñones Jr., MD From young patient to experienced doctor, a medical success story By Mike W. Thomas
In 1966, a 10-year-old boy found himself lying in a hospital bed in San Antonio with a fractured arm and third-degree burns on his legs. His family had been involved in a head-on collision earlier that day while driving home from his uncle’s ranch and his mother was also there with a fractured hip. But rather than being scared, the inquisitive young boy watched wide-eyed at all the things that were going on around him that day. He was intrigued by the doctors and nurses who were rushing about taking care of him and other patients. And out of that traumatic experience grew a lifelong love of medicine for the young Dr. Manuel Quiñones Jr.
“My experience as a child is what led me to become a doctor,” Quiñones says. “It was my dream from that time on to go into medicine.” One of the doctors who treated him that day, Dr. LeRoy Bates Sr., would go on to practice medicine into his 80s and would eventually become a patient of Dr. Quiñones. A native San Antonian, Quiñones graduated from Holy Cross High School and went on to be the first one in his family to attend medical school, graduating first from St. Mary’s University and then from Baylor College of Medicine in Houston. After a three-year residency in family practice, Quiñones stayed in San Antonio and settled down and has been ever since. Board certified in family medicine, Dr. Quiñones has a special interest in treating adult patients with hypertension, diabetes and high cholesterol – common ailments in San Antonio and South Texas. For years, he was in private practice, but 25 years ago he decided that the future of medicine would require most doctors to work in groups. “I realized that it would be almost impossible in the future for solo doctors to survive,” he said. “The only way to maintain control and not have to sell to a hospital organization or insurance company was to work in groups.” Together with Dr. Rowland Reyna and Dr. Richard Reyna, Quiñones helped to found HealthTexas Medical Group LLC in 1994. Today, the physician-owned medical group has over 60 physician and mid-level providers working out of 16 clinics across San 32
San Antonio Medicine • May 2019
BCMS HONOREES
At left, Dr. Quiñones receives the BCMS Golden Aesculapius Award from Dr. Leah Jacobson. Below, supporters of "Dr. Q" wear fake mustaches to celebrate his award.
Antonio, New Braunfels and Boerne. “One of the biggest challenges in medicine is transitioning with all the changes,” Quiñones says. “The only ones who do well with constant change are business consultants and wet babies. But by working together in groups we can keep one another from being overwhelmed as we adapt to new situations.” Quiñones said there is a lot to keep up with, especially for general practitioners, so it is challenging from year to year with the wide variety of problems you must face. When you add in additional work brought on by regulatory requirements and the advent of electronic medical record keeping it is easy for physicians to become consumed with their work and lose the balance they need to maintain between their personal and professional life. Working in a group environment with other doctors gives the physician the flexibility they need to maintain their sanity. Quiñones says it is important for him to be able to spend time with his family and be able to play as hard as he works. He enjoys spending time at their Flying Pig Ranch in Medina County near D’Hanis with his wife and their two Jack Russell Terriers. He also takes one or two vaca-
tions a year to see the world. Last year found them in South America cruising the Amazon River and climbing Machu Pichu and this year they were in Iceland and had a chance to see the Northern Lights. It also gives him time for other activities such as serving on the Texas Medical Board to which he was appointed by the governor for a six-year term that will be up in 2024. “My fellow doctors have been very patient with me allowing me the time to travel to Austin for frequent meetings,” he said. Dr. Quiñones served as President of the Bexar County Medical Society in 2008 and this year was awarded its highest honor, the Golden Aesculapius Lifetime Service Award. He has also been named one of the Best Doctors in San Antonio among many other honors. Now 63, Quiñones says he is having way too much fun to consider retirement any time soon. He said he has at least another 10 years of medical practice in him before he will consider retiring. “I love taking care of my patients,” he said. Quiñones, who currently works out of the group’s Leon Valley Clinic, said he is planning to move his practice to open a new location for HealthTexas in Helotes later this year – a challenge he embraces. visit us at www.bcms.org
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LEGISLATIVE ACTION
INCLUSION IS A REPSONISBILITY OF
BOTH PARTIES By Alex Kenton, MD
A few weeks ago, I was asked, “What does inclusion mean to you?” Because I was only allowed two minutes to give my definition of inclusion, I wish to expand on it here, as I think my definition has direct relative impact on what the Bexar County physicians face today. Inclusion is a dual responsibility held by both the leaders of an organization and its membership or its employee base. Organizations can only be characterized as inclusive if the leadership wishes to be inclusive of others in the participation of the leadership, structure, and culture of the organization AND if those individuals who make up the organization step up and PARTICIPATE to be included. Inclusion is a responsibility of leadership and those who are being led. Indeed, the most effectively inclusive organizations will have individuals who can be seen both as part of the leadership and part of the individual make-up of the organizational infrastructure. These are truly the most successful organizations. Too often inclusion focuses on many other factors. Some consider inclusion solely to be the responsibility of leadership. Leaders should ensure all others are included in the benefits of a particular organization, regardless of race, religion, gender, etc. Leaders should include others in the decision-making process. The term inclusion has been used to ensure that no specific group of people is excluded from decisions, benefits, or other specific char34
San Antonio Medicine • May 2019
acteristics of the organization or group. Webster’s dictionary defines inclusion as a relation between two classes that exist when all members of the first are also members of the second. Many people latch on to these concepts and demand inclusion or claim an organization is not inclusive enough. If those individuals who request that leadership include them in decision-making don’t participate in all aspects of the organization, then they are not meeting their responsibility and the organization will fail; the loss of the expectation of dual responsibility leads to failure. No larger example of this failure is exemplified than what has happened at TEXPAC. I have heard many physicians complain that TEXPAC was not inclusive enough. When I joined TEXPAC leadership, I found myself inundated with accusations that TEXPAC was only interested in endorsing conservative candidates. There were accusations that the process of endorsing or giving money to candidates was neither balanced nor transparent. In the last four years, we restructured the entire assessment process. A scoring system including objective votes on legislation favorable or unfavorable to the House of Medicine as well as a subjective scoring system, which solicits direct input from the county medical societies and lobbyists was put into place. At the same time, we sought out more physician participation on the board and the Candidate Evaluation
LEGISLATIVE ACTION Committee (CEC), and in terms of monetary contribution, without which, we cannot effect change or impact. There is change, yet the same physicians who criticize TEXPAC still do not participate. It becomes a self-defeating cycle. More will be done by TEXPAC for outreach in the next two years, but I ask each of you reading this to fulfill your role to participate if you wish to be included. Please come to our meetings, even if you are not a board member or a CEC chair, and watch the process and suggest ways to make it better. You should help to make our organization stronger because without that strength, policies the TMA makes will be spits in the wind. TEXPAC brings your TMA lobby team access to the legislators who make the bills. I commit to you that we will include you if you stand up to be included. Another recent example is the recent actions surrounding House Bill 29, filed by our own Bexar County Representative Ina Minjarez. This bill gives a patient access to physical therapy without any physician evaluation and referral. This can become a safety issue for our patients. Imagine patients with undiagnosed fractures, sprains, or tumors going straight to a physical therapist for therapy and potentially worsening the condition or allowing it to
exacerbate. We responded with a letter to the representative expressing our concerns with this legislation, signed by many physician members. We, as a physician advocacy organization cannot be successful without your leadership being inclusive and without the physician rank and file stepping up to participate. It will follow that many of you who participate to be included will quickly become leaders as well. The path is a fluid dynamic. I was thinking of all these issues when I answered my interviewer on his question. I informed him I have seen great organizations succeed when the culture of inclusiveness is met with a culture of engagement. I have seen large organizations fail when either component is missing. Indeed, in today’s complex world, physician organizations must structure themselves to be transparent and inclusive of others in the decisions made, but this culture is only effective if physicians are engaged to participate at every level of the organization. Otherwise, failure looms. Dr. Alex Kenton is the chairman of BCMS Legislative and Socioeconomic Committee.
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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”
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. Kathleen Barrow Partner 512-382-8796 kbarrow@constangy.com William E. Hammel Partner 214-646-8625 whammel@constangy.com John E. Duke Senior Counsel 512-382-8800
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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”
Thornton, Biechlin, Reynolds, & Guerra (HHH Gold Sponsor) Worried about the TMB, govern-
ment audit, or investigation? From how to avoid TMB complaints to navigating the complex regulations of government agencies like Medicare and Medicaid, we stand ready to guide and protect our clients. Robert R. Biechlin, Jr., Partner (210) 581-0275 rbiechlin@thorntonfirm.com Michael H. Wallis Partner (210) 581-0294 mwallis@thorntonfirm.com Kevin Moczygemba, Associate 210-377-4580 kmoczygemba@thorntonfirm.com https://thorntonfirm.com “Protecting Physicians and Their Practices”
ASSETS ADVISORS/ PRIVATE BANKING
BB&T (HHH Gold Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services — BB&T offers solutions to help you reach your financial goals and plan for a sound financial future. Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com www.bbt.com/wealth/start.page "All we see is you"
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 EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley
Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”
BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle. Moses D. Luevano Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Joseph Bieniek Vice President Small Business Specialist 210-247-2985 jbieniek@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com
BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services. Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"
Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com Daniel Ganoe Mortgage Loan Originator 210-283-5349 www.broadwaybank.com “We’re here for good.”
The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com
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
www.synergyfcu.org “Once a member, always a member. Join today!” First National 1870, a division of Sunflower Bank, N.A. (HH Silver Sponsor) First National 1870 is a regional community bank dedicated to building long-term relationships founded on sound principles and trust. Jamie Gutierrez Business Banking Officer 210-961-7107 (Direct) Jamie.Gutierrez@firstnational1870 .com www.FirstNational1870.com “Creating Possibility For Your Medical Practice”
BUSINESS CONSULTING Waechter Consulting Group (HH Silver Sponsor) Want to grow your practice? Let our experienced team customize a growth strategy just for you. Utilizing marketing and business development tactics, we create a plan tailored to your needs! Michal Waechter, Owner (210) 913-4871 Michal@WaechterConsulting.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”
DIAGNOSTIC IMAGING Touchstone Medical Imaging (HH Silver Sponsor) Touchstone Medical Imaging provides a wide range of imaging services in a comfortable, service oriented outpatient environment while utilizing state of the art equipment, the most qualified radiologists and superior customer service. Patrick Kocurek Area Marketing Manager 210-614-0600 x5047 patrick.kocurek@touchstoneimaging.com www.touchstoneimaging.com/ locations "We provide peace of mind, giving compassionate care to our community with integrity"
FINANCIAL ADVISOR 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) 750-8331 or info@synergyfcu.org
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"
Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society
FINANCIAL SERVICES
Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection. Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Rene Farret Wealth Management Advisor 210-278-3806 rene_farret@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”
SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Jon M. Tober SWBC Mortgage—Sr. Loan Officer NMLS #212945 (210) 317-7431 jon.tober@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Tom Jordan SWBC Investment Services,
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!”
BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle. Moses D. Luevano Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”
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"
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37
HEALTHCARE BANKING
New York Life Insurance Company (HHH Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace. Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”
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 Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small businesses and partnered with multiple financial institutions, to assist with financing of building acquisitions, construction projects, and machinery and equipment loans. Cheryl Pyle Business Development Officer – San Antonio & South Texas 830-708-2445 CherylPyle@CapitalCDC.com www.capitalcdc.com “Long-term, fixed-rate financing for owner-occupied commercial real estate.”
Amegy Bank of Texas ( Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”
BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services. Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"
HEALTHCARE CONSULTING
Digital Telehealth Solutions (HHH Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible
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Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program. Dr. Jorge Arango CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”
HOSPITALS/ HEALTHCARE SERVICES
Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com
INFORMATION AND TECHNOLOGIES
Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903
ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting” Y&L Consulting (HH Silver Sponsor) We are an IT Consulting company that specializes in Software Managed Delivery, Business Process Outsourcing Managed Services, IT Staff Augmentation, Digital and Social Media with experience in the Medical industry. David Stich Senior VP of Strategic Partnerships 210-569-3328, David.stich@ylconsulting.com Marisu Frausto Account Executive 210-363-4139, Marisu.frausto@ylconsulting.com www.ylconsulting.com/ “Your success is our success.”
INSURANCE
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
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY INSURANCE/MEDICAL MALPRACTICE
Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” 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
Digital Telehealth Solutions ( Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program. Dr. Jorge Arango, CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”
LUXURY REAL ESTATE
Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients. Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"
Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage. We have served the buyers and sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country. Craig Browning
MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”
MARKETING ADVERTISING SEO
Veerspace (HHH Gold Sponsor) We're a nationwide digital advertising agency that specialize in growing aesthetics practices through videography and social media. Office contact number is 210-969-7850. Michael Hernandez President/ Founder 210-842-3146 Michael@veerspace.com Anna Hernandez Marketing Specialist 210-852-7619 Anna@veerspace.com
MEDICAL BILLING AND COLLECTIONS SERVICES Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”
MEDICAL PRACTICE
UT Health Physicians (HHH Gold Sponsor) UT Health Physicians, the faculty practice of UT Health San Antonio, features the region's most comprehensive array of specialists & sub-specialists. Now offering free, secure access to your patients’ records. Most health plans accepted. For referrals or questions, contact: Jose Gamez, Director, Physician Relations (210) 450 8347 GamezJ4@uthscsa.edu www.UTHealthcare.org “Offering daily grand rounds with
no-cost CME to local physicians since 1969.”
MEDICAL SUPPLIES AND EQUIPMENT
Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”
PRACTICE SUPPORT SERVICES
SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Debbie Marino SWBC Employee Benefits, SVP Corporate Relations (210) 210-525-1248 DMarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society
PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bio-
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science industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org
REAL ESTATE SERVICES COMMERCIAL
KW Commercial (HHH Gold Sponsor) We specialize in advising Medical Professionals on the viability of buying & selling real estate, medical practices or land for development Marcelino Garcia CRE Broker Assciate 210-381-3722 Marcelino.kwcommercial@gmail.com Leslie Y. Ayala Business Analyst/ CRE Associate 210-493-3030 x1084 Leslie.kwcommercial@gmail.com www.GAI-Advisors.com “Invaluable Commercial Real Estate Advice for The Healthcare Professional”
RESIDENTIAL REAL ESTATE
Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients. Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499
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nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"
Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage. We have served the buyers and sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country. Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”
RETIREMENT PLANNING
Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection. Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Ben Taylor Wealth Management Advisor 210-278-3802 ben_taylor@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”
New York Life Insurance Company ( Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace. Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares, Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”
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.”
TELECOMMUNICATIONS ANSWERING SERVICE
TAS United Answering Service ( Gold Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7. Dan Kilday Account Representative 210-258-5700 dkilday@tasunited.com www.tasunited.com “We are the answer!"
For questions regarding services, Circle of Friends sponsors or Joining our program. Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html
THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA
ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Eye Center, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA The San Antonio Orthopaedic Group Urology San Antonio, PA
Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of April 24, 2019.
visit us at www.bcms.org
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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
GUNN AUTO GROUP
15423 IH-10 West San Antonio, TX
11001 IH 10 W at Huebner San Antonio, TX
GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154
GUNN Honda 14610 IH 10 W San Antonio, TX
Dale Haines 210-341-2800
Esther Luna 210-690-0700
Bill Boyd 210-859-2719
Eric Schwartz 210-680-3371
GUNN Acura 11911 IH 10 W San Antonio, TX
Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216
Cavender Audi Dominion 15447 IH 10 W San Antonio, TX 78249
Cavender Toyota 5730 NW Loop 410 San Antonio, TX
Coby Allen 210-625-4988
David Espinoza 210-912-5087
Rick Cavender 210-681-3399
Gary Holdgraf 210-862-9769
GUNN AUTO GROUP
KAHLIG AUTO GROUP Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX
Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX
North Park Subaru 9807 San Pedro San Antonio, TX 78216
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
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 Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257
Scott Brothers 210-253-3300
Tripp Bridges 210-308-8900
Justin Blake 888-341-2182
Stephen Markham 877-356-0476
Northside Ford 12300 San Pedro San Antonio, TX Marty Martinez 210-525-9800
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211
North Park Lincoln 9207 San Pedro San Antonio, TX
North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257
Justin Boone 210-635-5000
Sandy Small 210-341-8841
James Cole 800-611-0176
Porsche Center 9455 IH-10 West San Antonio, TX
Barrett Jaguar 15423 IH-10 West San Antonio, TX
Matt Hokenson 210-764-6945
Victor Zapata 210-341-2800
Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.) San Antonio, TX Ed Noriega 210-561-4900
Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463
Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org
AUTO REVIEW
2019 MERCEDES G63 AMG By Stephen Schutz, MD
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San Antonio Medicine • May 2019
AUTO REVIEW
The Mercedes Gelandewagen, all new for 2019, though you’d never know it by looking at it, is a triumph of old over new. It’s completely old school, with nary a hint of interest in what comes next, let alone what’s going to happen in 20 years. In fact, it’s not wrong to say that the 2019 G-wagen is the automotive past giving the future the middle finger. Take the exterior design for starters. Looking just like the box it came in, the G63 AMG I tested begged the question of just how much time Mercedes’ styling team spent on it. Every body panel is new, and yet even seasoned car spotters will have trouble telling the new “G” from the old one, despite the fact that the 2019 version is slightly longer and a whopping 5 inches wider. It’s unapologetically unaerodynamic in a way that seems to say, “I don't care what the price of gasoline is. Ever.” But it’s visually unique and gets noticed, which is undoubtedly most of its appeal. The original Gelandewagen was introduced in 1979 as a military vehicle tweaked for civilian use, and it quickly joined the Land Rover Defender and Toyota Land Cruiser as go-anywhere utility vehicles destined for places like the Australian Outback and Scottish sheep farms. Mercedes continually enhanced and refined it expecting that the G would stop selling as more modern SUVs arrived in the scene, but it never did. Instead it became cool, appearing in countless rap videos and becoming a regular sight in tony locales like Nantucket, Aspen, and Bel Air. So, in order to conform with ever tightening safety requirements and make it more comfortable, Mercedes engineered a new ladder frame platform and created the first truly modern G-wagen in 40 years. Available in either just-wow G550 or completely over-the-top G63 AMG versions, the Gelandewagen is fast. The G550 provides a 416 HP 4.0 liter twin-turbo V8, good for a 0-60 MPH time of 5.4 seconds, while the 577 HP version of the same engine does the deed in just 4.4 seconds. All G-wagens come with a 9-speed automatic transmission. Fuel economy is as dismal as you’d expect: 13 MPG city/17 MPG highway for the G550 and 13/15 for the G63 AMG. Those are not surprising numbers, of course, but they are certainly discouraging. Another sobering number is $148,495, the base price of the 2019 G63 AMG. And that’s without options, which seemingly every buyer of German luxury cars these days adds. The G550 starts at “just” $125,495, and I doubt any reader will be shocked to learn that most G-wagen buyers choose the AMG version. The G550 and G63 AMG look very similar, but the AMG version has a more aggressive grille, slightly flared fenders, and side exhausts.
Mercedes took care to ensure that both the G-wagens can handle off-roading even better than their sure-footed predecessors by including five on-road driving modes and three for off-road. While I can’t imagine American owners subjecting their G-wagens to anything worse than bad weather, serious capability is there when you need it. The interior of the previous G-wagen was that of an old SUV with modern parts and pieces added on, but the 2019 interior is all new, completely modern, and similar to what you’ll find in an E- or S-class. The gauges are all electronic, and welcome Mercedes niceties like beautiful round air vents, soft leather, and nice-totouch buttons and knobs are all there. A configurable double screen infotainment system like the one in my test vehicle is optional (and recommended at just $850), but even the standard set up is contemporary and attractive. The larger footprint of the 2019 G-wagen results in more space for up to five passengers including six additional inches of rear foot room. Oddly, Mercedes made sure the G-wagen still has the world's loudest central locking system. Weird. Driving the G63 AMG is not bad. The ride is much better than it was in the previous G-wagen – though it’s not as good as in its sibling, the GLS – and the big brute handles surprisingly well. The engine is loud though, and the experience of being behind the wheel becomes a little tiring after a while. Give me a GLS any day, although more extroverted buyers will be drawn to the G-wagen’s undeniably rakish personality. As noted above, many options and packages are available to personalize your vehicle, and a conversation with Phil Hornbeak will help you get the right G (or any other car) for you. The surprisingly popular Gelandewagen is all new for 2019, bringing many modern features to what remains an old school vehicle. It drives better, is faster and more spacious, and now includes modern Mercedes technology. It’s anything but understated, and therefore won’t appeal to many customers, but for those who appreciate the G-wagen life, it entails far fewer compromises than the previous one did. As always, call Phil Hornbeak at 210-301-4367 for more information and to get your best BCMS deal. 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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San Antonio Medicine • May 2019